File picture: Parenting Upstream/Pixabay
File picture: Parenting Upstream/Pixabay

Covid-19: These are the top questions SA GPs were asked last week

By Opinion Time of article published Feb 15, 2021

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Dr Sheri Fanaroff

Last Sunday evening, Health Minister Dr Zweli Mkhize and a panel of leading experts hosted a media briefing to outline new developments in South Africa’s Covid-19 vaccine acquisition and rollout programme.

The briefing came promptly after new studies showed that the Oxford/AstraZeneca vaccine, of which South Africa had procured one million doses from the Serum Institute of India, may not have the same efficacy (or effectiveness) against the mutated Covid-19 501Y.V2 variant – which is predominant in South Africa.

We were told that much of the antibody induced by this particular vaccine was not actually active against the variant circulating in South Africa – but that would not deter our vaccine rollout efforts as sights would now turn toward Johnson&Johnson whose vaccine has proven more effective.

As a general practitioner, these developments have sparked many questions from my patients and colleagues, which I will seek to address for anyone who may have similar queries.

The first, and most prominent question, is whether I am still choosing to take a vaccine when it becomes available. Unequivocally, yes - as will my family. I have registered on the healthcare worker database and will hopefully be in line to receive a vaccine as soon as possible.

While different vaccines have different efficacies against the virus, what remains critical is that the same vaccines have all shown a nearly 100% reduction against severe Covid, hospitalization and death – which is much more important.

At this stage, there are a lot of unknowns about the vaccine rollout. Like many other general practitioners, I have registered my practice to be a vaccine site, and therein completing the online vaccination course through the Department of Health to be registered as a certified vaccinator by February 15.

The electronic national registry has just launched. This will collect personal data and will allocate individuals to an allocated vaccination site, which may be a pharmacy, local clinic or a general practice. At the moment, the electronic database is only open for healthcare workers to register, but this will hopefully soon be extended to include the rest of the population.

During Phase 2 Rollout, adults over 60 years, essential workers and patients over 18 years with comorbidities should be able to receive vaccines. During Phase 3 Rollout, all adults over 18 years will be eligible.

There are so many more questions about vaccine side effects and safety that are beyond the scope of this article. There are many sceptical anti-vaxxers and a lot of misinformation.

Vaccines may not be a “magic bullet” to end the pandemic, and it’s true that we will still need to practice mask wearing, social distancing and hand sanitizing for some time after; however, achieving herd immunity through vaccination is our best chance of returning to pre-pandemic social life, work and school.

Another topic of contestation is the use of Ivermectin.

SAHPRA recently authorized Ivermectin for compassionate use, as part of a “controlled compassionate program” due to pressure from various groups, stating (as have FDA and NIH) that there is not enough evidence either for or against its use.

“Compassionate use” implies each patient who wants to take it needs to apply via their doctor on a Section 21 form to SAHPRA and it may or may not be approved. It’s not as simple as writing a script. SAHPRA is likely to only approve drugs under Section 21 if there are no other treatment options. On February 3, the Gauteng High Court ruled in favour of Afriforum, giving doctors permission to treat Covid-19 using Ivermectin on an urgent basis, without waiting for the outcome of an application from SAHPRA. There are no clear guidelines as to when exactly Ivermectin should be administered and it is still unclear whether prophylactic use is allowed.

Another issue is the procurement of Ivermectin. There is a large black market in South Africa for Ivermectin, and we have no way of knowing if what is on offer, smuggled into the country, is real and safe. It may be just aspirin or even something harmful that has been packaged and labelled as Ivermectin. Most of the mainstream physicians and Johannesburg-based critical care senior doctors are still not advocating for its use at this stage. Although some of the trials look promising, there is no unequivocal proof that it works.

There have also been some serious reported side effects, mainly neurological. There are many patients who have ended up in hospital with serious Covid-19 infection despite taking Ivermectin, either for prevention or for treatment. And also many anecdotal good news stories.

If you are taking Ivermectin, I urge you to check that it is from a reputable source, preferably a pharmacy and not a veterinary preparation; that you don’t exceed the very small recommended dose; and that you check the 20-page list of drug interactions if you are on any other medications.

The recent publication of the Colcorona study gave results of non-hospitalized patients treated with colchicine (a medication that reduces inflammation, mainly used to treat gout). This was a randomized controlled trial and concluded that the use of colchicine “significantly reduces hospitalizations by 25%, the need for mechanical ventilation by 50%, and deaths by 44%.”

While this sounds impressive, unfortunately if you look at it closely, the findings are actually not as significant as we would like. The absolute reduction in mortality was very small (from 0.4% to 0.2%.). The conclusions are that one would need to treat 500 people with risk factors with colchicine to save 1 life, and to treat 83 people to prevent one hospitalization.

The 25% risk reduction in hospitalization given in the study’s conclusion is only a relative risk reduction. (The risk of hospitalization is 6% without colchicine and 4.6% with colchicine.) So, the absolute risk reduction is only 1.4%. In other words, if you treated 100 patients, you would stop 1.4 of them from being hospitalized and dying.

Nonetheless, colchicine is a fairly harmless medication, with the main side effect being diarrhea, and will definitely be a treatment consideration going forward.

We have learnt from the pandemic: that there is no single magic medication for either the treatment or prevention Covid-19. However, there is much that has been learned over the last few months, and despite the massive second wave and unpredictable new strain, treatment protocols are in place and doctors have better knowledge on how to treat it.

While we hold out for vaccines, we need to continue safe practices and continue responsible behaviour to protect our families and our community.

* Dr Sheri Fanaroff is a Johannesburg-based GP.

** The views expressed here are not necessarily those of IOL.

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