🔒 WORLDVIEW: Covid-19 will hit SA hard – and BCG shots may not help

Some have argued that SA has a good chance of avoiding the worst of Covid-19 thanks to its early lockdown, rapid testing rollout, and widespread BCG vaccination.

While I hope they are correct, here’s why they may be wrong.

1. SA has many immunocompromised individuals

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There are nearly 8 million people in SA living with HIV and AIDS. SA is also home to a staggering 20% of the world’s tuberculosis cases, with nearly 450,000 new cases every year (around 230,000 of whom are also living with HIV).

Both HIV and TB leave people more vulnerable to serious illness from the coronavirus. HIV attacks the immune system, so those living with HIV are more susceptible to infections. And TB attacks the lungs, leaving them weaker and more predisposed to the respiratory ravages of Covid-19.

An outbreak of Covid-19 among such a vulnerable population could result in a frightening mortality rate. Failing to protect these vulnerable people would be a morally reprehensible act. It would also pile further devastation on South Africa’s most vulnerable families.

This is part of the reason why SA has one of the world’s harshest lockdowns – according to data from Oxford University, few countries are imposing stricter restrictions than we are. The government hopes that by doing so, it can protect the immunologically weak from exposure to the virus and potentially save millions of lives.

Hale, Thomas, Sam Webster, Anna Petherick, Toby Phillips, and Beatriz Kira (2020). Oxford COVID-19 Government Response Tracker. April 2020.

2. Many South Africans live in crowded and unsanitary conditions

South Africa’s crowded townships could become major Covid-19 hotspots if the coronavirus gets a foothold in them. Many South Africans live in crowded conditions, and as the outbreak in New York City has shown us, density is a key factor in the spread of the virus. It would be almost impossible for those living in a small house or shanty to properly isolate themselves if they fell ill, meaning that the disease would easily spread through families and beyond.

Further, some South Africans lack access to clean running water, making hand washing impossible. Exacerbating the personal hygiene problem, many municipalities have failed to provide proper rubbish collection services, meaning that infected waste – such as used tissues from a coronavirus-positive household – could end up lying on the street, posing an infection risk.

Thus, South Africa’s townships represent an almost ideal breeding ground for a devastating coronavirus outbreak. Were the virus to make its way into some of the poorer communities in SA, it would be almost impossible to stop.

3. The BCG vaccine is unproven

There is a reason that so many scientists have cautioned that there is no definitive evidence for the BCG vaccine’s efficacy against coronavirus – there is no hard evidence that it is effective.

Consider, for example, the epidemiological studies that have suggested BCG efficacy by comparing death rates in, say, India with those in Italy.

There is a very clear problem upfront – while Italy has a world-class health system and a sophisticated registry of the causes of death for everyone who shuffles off the mortal coil, India’s health system and record keeping are a little patchier. It’s very possible that India is failing to record deaths from Covid as such, and India certainly isn’t conducting as much testing as Italy is. We must compare countries with similar health systems, record quality, and populations for the comparison to be vaguely meaningful or reliable.

It also doesn’t make any sense to compare fatality rates. As you know by now, the fatality rate for Covid-19 in a population is the number of deaths divided by the number of cases. But testing rates vary wildly across countries. In every country, more testing has revealed more cases, so it’s clear that coronavirus infections are widespread but often undetected. Therefore, fatality rates are more a measure of how much testing is being done than anything meaningful about Covid-19.

It’s more helpful to compare deaths – the thing that is probably most accurately being recorded in countries with well-developed health and recordkeeping systems – per million of population. This gives us a sense of how many people are dying of Covid-19 adjusted for population – for example, it puts some perspective on the claim that the US outbreak is the most devastating – America has a lot of people in it, so it’s actually quite low on the rankings at this point. This data can be viewed in the table below – it’s based on reported death counts, UN population data, and WHO vaccine information.

As you can see, there is not really a clear pattern of BCG vaccine efficacy. France had a programme roughly comparable to Irelands, but French death rates are much higher than Irish ones. The US, with no programme, has relatively few deaths per million of population, as does Germany. There are many factors at play – the US has a very spread out population, Germany has a lot more nurses per 1,000 people than anywhere else (which seems to be even more important than doctors or hospital beds). Ireland has a younger population. The BCG vaccine may be helpful, but it’s no miracle. (Admittedly, programs vary – some focus on immunising new-borns, others on schoolchildren, some include boosters, others don’t. The point is, we really don’t know how much, if any, protection the BCG vaccine really offers).

Furthermore, even if the BCG vaccine does prove helpful – clinical trials will tell us soon – consider the fact that vaccination coverage in South Africa hovers around 70%-80%, compared to 99% in Bangladesh. If 15% of South Africans are not vaccinated, that’s over 8 million people – more than enough for a serious problem.

There are no magic bullets for the coronavirus crisis. The road out of lockdown and back to normality may be a long one.