At the beginning of the Covid-19 pandemic in many countries around the world; the worry has always been that countries’ health services will be overwhelmed. In Italy and New York in the United States, there was a stage that the hospitals could not cope with the influx of critically ill patients leading to difficult choices being made of who will be treated and who will die. In Wuhan in China and in London in the UK, the authorities have been able to respond quickly by building large hospitals and providing Intensive Care Units. As Covid-19 cases increase in South Africa, the big question is; will our health services cope? Professor Emeritus at Wits University in Critical Care Guy Richards who is advising at the Charlotte Maxeke Johannesburg Academic Hospital told Biznews that Cape Town is already under pressure and he says private hospitals are going to have to be brought on board if the public hospitals are overrun. He also comments on whether it is safe for children to go back to school and whether there are effective treatments for Covid-19. – Linda van Tilburg
Cases of Covid-19 are increasing in South Africa, with some predictions that the worst-case scenario is a million cases with 40,000 deaths. BizNews asked an expert in critical care in South Africa, professor emeritus at Wits University professor, Guy Richards, who is advising the university’s academic hospital on critical care about these predictions and what can be expected in the coming months. Professor Richards also weighs in on the treatments like hydroxychloroquine and remdesivir, which he is not excited about, and about whether school children are at risk of Covid-19.
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I’m not an auditor or an actuary or anything else like that, I don’t know how they calculate the figures but that would indicate that they would be looking at approximately a million infections by the time November or whenever it comes around. That would mean that we would be having one-fifth of the current world’s population infections. To me, that sounds very unlikely but I’m not going to make pronouncements on it because they are very clever mathematical people and they’re using models and they’re deciding on how it is going to work. I also don’t think that they’ve taken into account factors like wearing masks and whether that’s going to decrease the transmission rate but it seems unlikely but I’m not going to discount it and say that it isn’t going to occur.
Critical Care is your speciality. Is there a possibility of shortages of critical care and ICU units going forward?
Certainly, there will be. Cape Town is currently undergoing this surge, Gauteng hasn’t yet started the surge. Cape Town is under huge pressure from an ICU point of view. Remember that in South Africa we’ve got very few actual intensivists, mostly the ICU is managed either by anaesthetists or by general physicians and so a lot of the expertise is not there. I would foresee that when the ICU use is completely full then one would have to perform some form of triage which would mean that you would have to be selecting patients that are most likely to survive or should I rather say deselecting those that are least likely to survive.
I listened yesterday to a US expert Dr William Haseltine, there used to be almost a 90% mortality rate if you were on a ventilator, but they’ve managed to bring that down to about 30%.
That was because of the fact that they immediately ventilated or put patients onto a mechanical ventilator as soon as they were hypoxic or their oxygen levels were low, that was thought to be the ideal practice initially. In fact what we’ve been doing is seeing if we can avoid putting the patients on mechanical ventilation so we will be starting therapy on them and we will be at the same time giving them other options like high flow nasal cannula, CPAP or even just a plain nasal cannula initially to see whether they can maintain their oxygenation. At the same time we get them to turn themselves over into the prone position which also improves oxygenation and in many cases we can avoid the necessity for ventilation. The whole idea is to try and get on top of the hyper-inflammatory response, the hyper-inflammatory phase before it leads to a situation where you require mechanical ventilation and if you can, well then you’ve got a much better prognosis.
Are some people actually dying of heart attacks and cancer that are reported as Covid-19 cases?
I’m sure that people are dying of heart disease and cancer because they’re not prepared to come to hospital worrying about catching it. I think that a large number of patients with non-communicable diseases are not being adequately treated at the moment. Certainly in South Africa, a large number of patients are not coming to a hospital to collect their HIV medicine for example. Those patients, both HIV and TB, there’s an urgent search for those patients to go out and find them to make them come and get their therapy. Remember that from the other point of view that Covid-19 can actually precipitate a heart attack because it does have an effect on the heart and on your coagulation system. So it could itself cause heart attacks. There’s no evidence that it causes cancer. I would doubt very much that people are having their deaths recorded as being Covid if they happened to come in with cancer. When we get a patient who comes in and dies we would swab them and assess to see whether in fact they were positive or not positive. I think that there are very few that are being mislabeled.
A lot has been written recently about the various treatments of Covid-19. What is being used in South Africa, what are your views on these different treatments?
Lots of people are still using our hydroxychloroquine because it does have efficacy in the lab. It’s been shown in the lab to inhibit the growth of the virus, but that’s looking at a non in-vitro situation, in other words not when it’s being given to humans. There was a lot of excitement by that French investigator who performed a study which showed that there was a benefit in terms of outcome and mortality but that was a very poorly performed study and certainly has not been reproducible. Now, there have probably been at least 5 studies that say that hydroxychloroquine is of no value either in patients who have severe disease or even in mild disease. Some people have been taking it like Donald Trump as prophylaxis, there is also no evidence at all that it works as prophylaxis and certainly, patients who have been on it have been recorded as having caught Covid-19 anyway. I’m not at all excited about hydroxychloroquine. I don’t think it’s of value. Its primary use in engagement is as a disease-modifying agent in auto-immune conditions and there may well be a shortage of it in that setting. I don’t think that there’s good evidence at all that it works, and two recent studies published in The BMJ also showed exactly the same thing. I want to mention remdesivir, it is an American drug made by Gilead. The FDA authorised it for emergency use prior to the publication of the study which we still haven’t seen, we are still waiting and we don’t know whether it showed benefits or not. The one published by Wang which was from China in Lancet recently had 437 people that were planned to be enrolled and they only managed to enrol 237 because the epidemic had decreased so they couldn’t find enough patients to actually put it in. It was therefore underpowered to make any sort of qualified statement about its efficacy. It took subgroups which made even smaller numbers and then they looked to see whether it was given before or after 10 days after the onset of symptoms. They then set down a non-significant trend towards benefit in patients who took it before or within the 10 day period after the onset of symptoms. Very unexciting, no mortality difference or anything. It’s expensive, it’s got to be given intravenously and unless the study comes after and show something really spectacular, I don’t think it’s going to be an important benefit in terms of therapy.
There’s no miracle cure or treatment right now?
Nothing as yet.
If we can look into the future, where are we in South Africa with critical care, are we going to cope, when is the peak coming? What are you expecting?
The peak is going to come at different times in different areas. As I said, Cape Town is already undergoing this surge. Currently, they are running at about maximum, one has to hope that patients will get better at the same rate as new admissions are coming in. Otherwise yes they will be overwhelmed and then there’s going to be a major problem. Certainly, private hospitals are going to have to be brought on board from the public hospital point of view that when they are overrun private hospitals will have to be taking in patients as well. We just have to then manage as other countries have done, even though the health services have been overwhelmed. For example in New York and in Italy, we’re just going to have to close. We’re a big believer in the use of corticosteroids, at the time that patients present with pneumonia they shouldn’t receive corticosteroids if they have the early phase of the disease. If they do come in with pneumonia and they’ve got hypoxia, their oxygen levels are low, we start corticosteroids early. There have been two studies now which have demonstrated benefit and a reduction in mortality. That we feel is the way to go in order to try and decrease progression to the inflammatory phase which is the phase at which most of the mortality actually occurs. Thereafter, we are using a monoclonal antibody directed against a specific aspect of the inflammatory response. Monoclonal used for rheumatoid arthritis and we’ve seen quite a bit of success using it in that setting as well. There are therapies that will treat the actual response that the patient has. Whereas we don’t, as far as I believe any have any effective antiviral therapies.
Now, with lockdown being lifted, are you expecting more cases?
I mean certainly Cape Town, I doubt is going to come out of Stage 5. They’re going to be kept there because they’re really surging and we’re going to move to a stage 3, which is really not a massive lift. Some of the schoolchildren will be going back but we don’t believe that that’s actually going to cause a major problem either to the schoolchildren or to the other people involved. In other words, it’s very unusual for a child to bring home the virus to the parents or to the grandparents. Older people are still going to be encouraged to stay at home. We are still going to be using masks, only certain people are going to be allowed to go to work. It’s not a full lifting of lockdown. It’s going to be staged or a gradual lifting.
