At least eight doctors in Gauteng have succumbed to Covid-19, which angry healthcare workers have blamed on shortages of good quality personal protective equipment. They are among the 181 health workers who have died from the virus, according to figures revealed by Health Minister Zweli Mkhize. Mkhize said 24,000 healthcare workers had been infected with Covid-19. How vulnerable healthcare workers are during the pandemic was highlighted when Professor Emeritus in Critical Care Guy Richards at Wits University, who is advising at the Charlotte Maxeke Johannesburg Academic Hospital, announced that he was one of the infected health workers. Prof Richards, who has been hailed by the medical community for the Covid-19 treatment regime that he and other Wits doctors devised, told BizNews in a podcast that hundreds of health workers in his hospital were infected but he regarded it as one of the hazards of his occupation. He also slammed the government’s decision to allow taxis to fill up to 100% and to allow religious gatherings, saying they were ‘a major means of transmission’ of Covid-19. – Linda van Tilburg
Guy Richards: I tested positive on the 20th of July.
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Were your symptoms severe?
Pretty bad. I mean, I had quite bad respiratory symptoms. I was quite short of breath. My saturations did go down at one stage but in conjunction with some of the people I trained, we managed myself quite well. I still managed to carry on, teaching webinars and all those sorts of things during it, but fortunately didn’t end up needing ventilation or anything. I’m in the recovery phase of Covid-19, I have come back to work after it.
You knew exactly what the right treatment was, is that it?
Ja.
Prof are you okay now?
I still feel a bit tired and dry and run down, but that’s all improving.
Do you think you contracted Covid-19 in the hospital?
Yes, I think it obviously is a hazard, an occupational hazard of being a doctor or a health care worker at the moment. The issue is that even if you’re not directly in contact with patients, your colleagues are likely also to have the disease and transmission occurs quite easily in the hospital. So, yes, I contracted it, but fortunately, I am well on the recovery phase at this stage.
You’ve been praised by Dr Ryan Noach from Discovery Health for using dexamethasone as a treatment quite early on, in March. Is that what you treated yourself with?
Yes, but now you have to be cautious about this. First of all, it wasn’t me alone, it was certainly protocols that we developed as an ICU group here in Gauteng. Myself and Prof. Mervyn Mer, we had previously treated certain viral pneumonias, particularly chicken pox pneumonia, those are severe that occur in adults, with corticosteroids and it had demonstrated a very good response at that stage. We also had treated various forms of pneumonia with corticosteroids if they were severe enough at that stage. So, we were fairly confident that with this disease, if you use the corticosteroids at the appropriate time, would also be of benefit.
Corticosteroids
So, now that’s a very critical issue, is that if you take the corticosteroid whilst you still do not have the pneumonic phase, in other words, the pneumonia that is secondary to the Covid-19, then it will often make you worse. So, prescribing corticosteriods by GPs in the early phases of the disease, is bad and it actually leads to worse outcomes. This is why there was some controversy in terms of whether cortisone was a benefit or not. In patients who develop the pneumonia phase, the virus infiltrates the lungs, which are associated with low oxygen levels, then that is the phase at which you would start the corticosteroids and co-existent with that low oxygen level, is a high level of inflammation that we measure with a blood test called the C-reactive protein, which shows the extent of the inflammation in the lungs. So, with that situation, where there is a combination of pneumonia and high C-reactive protein, corticosteroids are going to be of benefit. And I did take them, but only when my oxygen levels dropped, and my C-reactive protein had elevated significantly as well and then I started the corticosteroids at that stage.
Did you ever need oxygen?
No, I didn’t need oxygen. My saturations remained sort of in the region of 90 to 91, which is down, but not at the level that actually requires oxygen.
And how do you feel now?
I feel much better. It leaves you with a certain degree of debility. You feel run down and tired and a lot of people have exhaustion, which is ongoing. I’m not too bad. I climbed a number of stairs today going up to the ward and I managed them but I’m going to step it up and increase the amount of exercise I do gradually.
The fact that you contracted Covid-19 is an indication that health workers are particularly at risk.
Of course, yes. There are hundreds of health care workers who have contracted this disease in our hospital alone. Fortunately, we have not lost any, but there have recently been eight doctors or so who died in one of the hospitals north of us. Who knows, ultimately, in total, the number of health care workers who have demised as a consequence of this disease?
We hope you will get better soon. If we look at critical care in South Africa at the moment, is the health system coping?
Yes, it is actually doing remarkably well. Obviously, in Gauteng, we are somewhat spoilt. We are the smallest in geographical area, but the biggest in population. But along with that, we have more ICU beds, both in public and in private, than the other provinces put together. We had the facilities available to treat very ill patients. We are far better off than under-served provinces like the Eastern Cape and so on, where they have been completely overwhelmed in terms of the availability of facilities. So, yes, we’ve been managing and it’s a testament to the doctors and nurses here, that they have managed to do so and to treat the patients effectively in so doing.
One of the major means of transmission would be in a closed taxi, even if you are wearing masks…
It seems that the peak is now behind us, especially in Gauteng. Is that what you see in your wards?
Yes, so the numbers actually are declining at the moment. We still have a huge number of patients, but the numbers definitely are going down and that obviously makes it easier to manage, as we go ahead. Obviously, if you’ve got less pressure on beds, it becomes easier to manage the patients. Of course, the numbers are declining and that’s it what we said would actually occur and what has happened all over the world? Of course, secondary peaks are always possible. I think that we’re not going to be rid of this disease until such time as a vaccine, an effective vaccine, is available. So, at any point we could get an increase again in the numbers we’d be seeing in the hospital. It just depends upon how well people follow the social distancing protocols and wearing their masks and all the rest of it.
Are other provinces expecting peaks now? Some provinces do not seem to be hit that hard.
Yes, I think that’s the same all over the world. If you look at the United States, the state or the situation in various states vary significantly, and people will achieve their peak or get to the peak numbers at differing times. But that’s just a temporal difference and each province will rise to similar levels, not similar levels in terms of absolute numbers, because we’ve got a much bigger population, but they will have a similar peak that occurs relative to their population in whatever province you happen to be and they will occur at different times.
I see that the World Health Organisation is also sending a ‘surge team’ to South Africa to help with the hospitals that are not coping.
I see no benefit of that whatsoever. I can’t see what a WHO surge team would do to help us in terms of managing these patients.
What have you learnt about the treatment of patients with Covid-19?
So, the two primary things that actually kill people are the pneumonic or the pneumonia that occurs in the lungs with low oxygen levels and requires ventilation. The other thing is the coagulation abnormalities. In other words, people clot at an abnormal rate in different sites. A number of people have died from clots going to the lungs or clots going to the brain or clots in the heart and even clots in the lungs, in the small vessels in the lungs themselves. So, part and parcel of our therapy has been the use of anticoagulant agents, which has definitely made a difference, and particularly heparin-like products, there are other ones that work but heparin-like products are the best ones that one should be using along with the corticosteroids at the appropriate time.
In some patients who despite corticosteroids and anticoagulation and certain of the nutrients, which can make a difference in terms of progression to the inflammatory phase, if despite that they still are elevating their C- reactive protein and their lung function is getting worse, then we use an agent known as Tocilizumab, which is an anti-IL-6 monoclonal antibody, that has anti-inflammatory effects. In a large study, again, that was not shown to be a benefit, but that’s not surprising because in that large study, it was not used in the appropriate patients anyway.
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So, it should only be used in those patients who are declining despite all the other appropriate therapies at that time. Remdisivir is available now. It’s already being used incorrectly in the majority of patients. It’s best if it is used early in patients when they are first admitted to hospital. Used later, there’s no good evidence that it makes any difference whatsoever. So, in other words, it is an antiviral. Once the inflammatory response has occurred from the virus, you’re going to get less response from the antiviral. So, the idea would be to treat that virus as early as you possibly can, in order to abort or prevent the development of the secondary inflammatory response that occurs after you’ve had the viral infection.
You contracted Covid-19. I know you’re more exposed, but this means nobody is safe from Covid-19, are they?
No, they’re not and which is why social distancing and mask wearing and all the rest of it, is so important. It is also why it’s so disappointing that the government backed down as far as the taxis are concerned, because one of the major means of transmission would be in a closed taxi, even if you are wearing masks or not wearing masks. The fact that the government backed down from that point of view is a real pity and that they still have certain restrictions on visiting people, yet they allow people to go to weddings and funerals with 50 people. That’s completely ridiculous in terms of the spreading. So, I was disappointed that religious services were allowed to resume, and I was particularly disappointed that the government backed down from the taxi industry.
If we look at the fatality rate in South Africa, it’s still relatively low compared to the rest of the world. What do you ascribe that to?
Well, I think that there are factors that might be involved. I think that in some of the under-served provinces like the Eastern Cape, I think, we might be under-calling the number of people who are dying. I think that in Gauteng in particular, where we had a lower mortality, that harks back also to what I said earlier in terms of the availability of ICU beds and hospitals that are capable of treating patients. And thirdly, I think that our protocols for therapy that we initiated early, as early as the beginning of March, end of February, have made a difference in terms of the outcomes as well. So, I think that there are probably a number of factors involved in the lower mortality
You mentioned under-calling – do you think some people might be dying from it and their families don’t even know that it is from Covid-19?
I think it’s possible. But I mean, when people do get sick, although it is possible that cancer patients may die very suddenly, when people do get critically ill, they don’t just lie around at home. They either go to or will be brought to the hospital. Whereas, I’m sure that there are some people who might die suddenly, and it might not be recognised, I think the vast majority of people who have Covid-19 related disease would attend a hospital before they die. So, it would actually be recognised. I think that probably is not the case.
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I think that some people are dying from diseases like heart disease and diabetes and things like that, because they’ve been too scared to come to the hospital for their normal therapy. I think we’ll see some excess deaths of non-Covid-19 diseases because of people not attending their regular chronic therapy and now we’re going to see a big increase in tuberculosis because people are not coming to be tested for their tuberculosis and the testing facilities have been converted to test for Covid rather than TB. So, all those non-Covid-19 diseases are going to be associated with increasing mortality as well.
