UPDATED 14/03/2020
HEALTH SOUTH AFRICA’S inability to detect a Covid–19 patient incoming from a red zone (Italy) is cause for alarm. Health Minister Zweli Mkhize characterisation of so-called ‘patient zero’ as ‘no big deal’ amidst a rush to give South Africa the ‘all clear’, the failure of his department to pre-empt and stall the arrival of the country’s first patient, is most definitely A BIG DEAL.
Unlike South Africa, Senegalese scientists are on the forefront of testing. In partnership with the UK-based Mologic, scientists at Dakar’s Pasteur Institute are helping to develop a handheld coronavirus test kit that could diagnose COVID-19 within 10 minutes. Lab-on-a-Chip PCR testing exists today, and can detect Covid-19 incubation within 10 minutes. An industry journal describes the method for creating PCR tests on ‘microfluidic devices’.
It is abundantly obvious that our Dept of Health (DOH) lacks the technology to test for Covid-19 during the 5.1 day incubation period and that Dr Mkhize has absolutely no idea how to go about treating patients other than via self-quarantine. There are currently no plans it seems, to acquire portable PCR Kits for all South Africans. The PCR acronym is short for Polymerase Chain Reaction, the method by which a very small sample of DNA can be amplified to an amount sufficient to study in detail.
Given South Africa’s previous experience with the HIV pandemic, it is particularly galling that our own science sector appears to not have received any previous funding to produce portable PCR–testing and the dept of Health is unable to provide any answers to the problem of incubation detection, other than to reiterate that pathology labs exist and stock-outs have occurred with PPE.
It appears incoming arrivals are being tested purely on the basis of a symptomatic case-definition which includes high temperatures and ignores the incubation period.
Remarkably, in media briefings reminiscent of the HIV-denial era, Dr Mkize disingenuously claimed over the weekend, ‘there is nothing overly infectious’ about Covid-19, and South Africans are thus in ‘no immediate danger’ from the pathogen. This viewpoint gained support from ‘religious leaders’, as the Minister of Health (MOH) announced the so-called patient zero had been miraculously cured, Sunday, after being admitted on Thursday.
Nevertheless, an event which had necessitated the activation of ‘tracer-teams’ to locate other members of a group of 10 who had visited Italy.
Sending patient zero back home may be premature, given the likelihood of reinfection.
Several persons related to the group of South Africans who traveled to Italy was also found to have the Covid-19 virus. A school was closed down yesterday, due to an educators ‘close proximity to a positive Covid-19 patient’. The DOH meanwhile called for calm, but stopped short of calling the closure, ‘irresponsible’.
Reports of the country‘s first ‘community transmission‘ in the Free State yesterday were retracted by the DOH. There are currently 16 confirmed cases,
Instead of announcing stringent testing protocols on incoming flights Dr Mkhize has moved to give South Africans the all clear. Our Minister of Tourism has meanwhile outlined three possible scenarios, the worst being presumably internal travel restrictions. This contrasts with the UK which this week announced a robust ‘containment and delay strategy’.
During the 2003 coronavirus outbreak of the severe acute respiratory syndrome (SARS), a passenger aboard a flight from Hong Kong to Beijing infected people well outside the WHO’s two-row boundary. The New England Journal of Medicine noted that the WHO criteria “would have missed 45 percent of the patients with SARS.”
The Harvard Business Review published an article Feb 28, on the need for cheap Covid-19 diagnosis, stating: “Testing at a broader, global scale may be necessary, .. would require a point-of-care “rapid” diagnostic kit. We made the same case for combating the less-widespread albeit tragic Ebola and Zika crises. Such broad testing cannot depend on specialized equipment and a relative handful of centralized labs; people need to be tested in clinics and perhaps even at their doorsteps. Our most recent models indicate that in order to control coronavirus within a year, 80% of symptomatic patients would need to be tested and isolated within a day of symptoms appearing.”
Am therefore not reassured at all by the approach outlined by the Minister, and totally agree with Dr Anthony Fauci of the Whitehouse Covid-19 task-team that ‘millions of diagnostic tests are needed’, and thus ‘a more robust approach to testing‘. Over-reliance by our own department of health on a symptomatic approach and post-infection ‘tracer-teams’ presents many dangers, including the possibility of community infection.
Karl Greenfield, the author of a book on SARS writes “I noticed a pattern in how the media, governments, and public-health systems respond to infectious-disease outbreaks. There are four stages of epidemic grief: denial, panic, fear, and if all goes well, rational response”.
A comparison between the experience of Hong Kong and Italy is useful. “In Hong Kong”, says first-responder Michael Coston, “they assumed the disease was already in the community, and they not only continued to work to prevent further entry, they put very tough measures in place to prevent its spread. Italy, on the other hand, has been mostly reactive. Waiting for community spread to become obvious, and then dealing with each outbreak as if it were a limited event, rather than a systemic problem.”
We cannot afford to simply wait for patients to present themselves to doctors. Let’s not become like Mauritania where several patients fleeing a red zone were apprehended, or Iran, where failure to quarantine has lead to a massive public health disaster.
Even Zimbabwe, with limited resources has a better policy than our own Health Dept in demanding persons entering Zim supply a Covid-19-free certificate. Have we forgotten about yellow fever? I should hope not. The global spread of the virus appears to have outstripped plans outlined in a presentation by Kerrigan McCarthy of the DOH. They involve development of a single questionnaire for travelers from China, and ‘provision of additional thermometers and staff to support screening.’
The latest announcement of a lowering of the threshold of surveillance of pneumonia cases in both public and private health systems is unlikely to impact on future case numbers, however expanding the definition of suspect cases to include persons with pneumonia or severe respiratory infection with breathlessness, as Singapore has done, will offer many benefits.
Coronoviruses are a family of hundreds of viruses that can cause fever, respiratory problems, and sometimes gastrointestinal symptoms too, and include Middle East respiratory syndrome (MERS) and Severe Acute Respiratory Syndrome Coronavirus 2 (SARS).
Covid-19 with a reproduction number or R0 of 1.4–3.8 is bound to turn into a community disease extremely quickly if we all carry on pretending, like Iran, that the science doesn’t matter, it does. To give an indication, SARS had an r0 of 2-5, while MERS was 0.3-0.8. Anything greater than 1 is able to spread, with Measles at the top of the list of airborne diseases with a whopping R0 of 12-18. Reports carried by South Africa’s PE Herald appear to confuse Covid-19 with MERS, and consequently are based upon a lower R0!
The virus is several more times infectious than the Flu, and has a high mortality rate, according to Dr Richard Hatchett, who heads up the UK Coalition for Epidemic Preparedness Innovations. However a piece in MIT Technology Review suggests a different rate of infection: “The flu has a shorter incubation period (the time it takes for an infected person to show symptoms) and a shorter serial interval (or the time between successive cases). Coronavirus’s serial interval is around five to six days, while flu’s gap between cases is more like three days, the WHO says. So flu still spreads more quickly.“
A comparison between the seasonal flu and Covid-19 shows that while average mortality rate for seasonal flu is just 0.1%, mortality spectrum for the novel coronovirus is anywhere between 1%-18% depending upon age group. This is an order of magnitude greater! For the common flu the spectrum is just 0.01-0.83%. Our DOH has its decimals in the wrong place! The official WHO average Covid-19 mortality rate is 3.4% Italy is reporting a 4.2% apparent mortality rate. (see How Deadly is the Coronovirus?) and (Covid-19 Facts Checked).
If one uses German Chancellor Merkels estimates that 40%-60% of the population will invariably be infected: South Africa with a population of 52 million must plan for some 20 800 000 to 31 200 000 cases of which 1.8 – 3.4 % will be critical. In other words we stand to lose 561 600 to 1 060 800 and 374 400 to 707 200 people during the course of the epidemic.
Extrapolating stats from the North presents certain difficulties, the least of which is our country has many informal settlements and an under-resourced public health system. The figures therefore need to be corrected by a factor of 3, — we could end up shedding anywhere between 1 200 000 and 3 million people.
South Africans must demand better screening technology and protocols now! “The clinical picture suggests a pattern of disease that’s not dissimilar to what we might see in influenza,” according to a report carried by online news site Bloomberg, as to why the disease turns deadly.“The progression from mild or moderate to severe can occur “very, very quickly,” says Bruce Aylward, a WHO assistant director-general who co-led a mission in China that reviewed data from 56,000 cases”.
A doctor on the front line of Italy’s fight against coronavirus has described the epidemic as a “disaster” and warned the public is underestimating the threat posed by the disease because of a “war on panic”.
By some accounts, Covid-19 also appears to operate as a ‘Flu-like Malaria’ in effect, resulting in similar respiratory complications and according to a paper published via Pubmed,treatable by chloroquine phosphate. Anti-virals such as lopinavir-ritonavir have also proven effective in Spain, as have the use of protease inhibitors. Some have therefore also likened the disease to a form of ‘HIV Flu’, but this is an overstatement and predicated upon the use of effective viral disruptors. A more accurate description would be ‘viral pneumonia’, but how to explain the reports of fever?
The virus can live on surfaces for up to three days.
We therefore need to demand evidence-based decision-making and rollout of at very least, a nation-wide hygiene and hand-washing programme. A political sermon from Minister Mkhize on how to go about treating the victims, given the current low numbers in our country, is inappropriate in the absence of answers to the problem of incubation and Red Zone arrivals at our ports-of-entry. So too, is the prejudice shown against persons of Chinese origin, by those who also ignore the fact that patients are also recovering.
Now is not the time however to be sacrificing public health in the quest for individual patients rights, yes all humans have rights and yes, we need to defend them vigorously, but we also need to ask our Minister of Health: who decides who is going to live or die if our public health system is flooded to over capacity by government inaction and negligence? Without sufficient preemptive intervention as opposed to post-infection mitigation, the pandemic will in all certainty, escalate and impact our nation.