By Dr Sheri Fanaroff
OPINION - It is difficult to comprehend that it is one year since the first COVID-19 case was diagnosed in South Africa. Last year this time, we could not predict the massive changes that were about to permeate our daily existence. Twelve months have been a massive learning curve for the global medical community and have permanently changed the world as we knew it.
One year ago, when I wrote my first “Coronavirus Update” on 15th March 2020, we had 61 confirmed cases of COVID-19 in the country, nearly double the previous day. There was not yet community spread in South Africa. People were fearful of getting ill and everyone was desperate for knowledge on how to keep safe. Six months ago, I wrote an update called “Reflections”, documenting events of the prior six months. At this time, on 15 August 2020, there were 583 653 cases in South Africa and 11 677 deaths. Just over a year after our first South African case, we are at the end of the second wave and have identified 1 526 873 positive cases and 51 179 deaths due to COVID-19. The number of cases has tripled and deaths have gone up nearly five times in the last six months.
WHAT DO WE KNOW IN MARCH 2021 THAT WE DIDN’T KNOW IN MARCH 2020?
IT’S A MARATHON, NOT A SPRINT
At the beginning of the first lockdown, the impression was that if we could hold out for the three weeks of lockdown, we would “flatten the curve” and life could go back to normal. As three weeks became five weeks of level five lockdown, followed by months of extended restrictions, school closures and ongoing lockdowns, we realised that we were going to have to live with and adapt to the “new normal”. In March 2021, as we go about work and school in Level 1 lockdown, we need to be aware that the question is not “Will there be a third wave?”, but “When will the third wave be?”. With vaccines rolling out at an excruciatingly slow pace, we will need to continue to observe COVID protocols until we have reached herd immunity. This is daunting, because we don’t yet know the exact length of the marathon - however, like with all viruses that have afflicted past generations, “This too shall pass”.
MASKS
In March 2020, the WHO, the CDC, the SA Department of Health and all global authorities were advising that masks were not necessary for the general public, but should only be worn by sick people. This was partly due to the shortage of masks and PPE for healthcare workers, partly because the transmission of the virus by asymptomatic individuals was not yet fully understood, and partly because there was a concern that masks worn incorrectly could get contaminated. It was only in April 2020 that “Masks for all” became policy. Recommendations for cloth masks for the public have been thought to be one of the most effective ways of reducing transmission of spread of COVID-19, and together with social distancing and hand hygiene, was responsible for aborting the winter influenza season. While several groups continue to protest the use of masks as unnecessary, unhealthy or unconstitutional, recent recommendations in March 2021 in fact promote the use of TWO masks as studies show that “double masking” is superior to prevent infections.
QUARANTINE AND ISOLATION GUIDELINES
These have shortened from 14 days in March 2020 to 10 days in 2021. The US gives the option for an early end to quarantine in people who have been exposed (a negative test on Day 5 to 7 means they can return to work on Day 8). This however, comes with the risk of a 5 to 12 percent infection rate on day 8 to 10, whereas after the full 10 days of quarantine, there is only a 1% risk of infection. The South African Department of Health and NICD have stuck to a ten day quarantine period both for quarantine (contacts) and isolation (infected people).
GROCERIES AND SHOPPING
In March 2020, we were more worried about the risk of picking up the virus from infected surfaces than we are this year. At that time, we were advising people to wipe down and sterilize all parcels brought in from outside. In March 2021, we know that although the virus survives on surfaces for hours to days, there has not been documented transmission from touching surfaces or food. However, stringent hand hygiene remains important, and washing hands well after touching surfaces and before eating or touching your face remains prudent.
Last March with the threat of lockdown and toilet paper shortages, people were urged to “stock up but not stockpile” so that they would have enough to sustain them through lockdown without contributing to shortages. In March 2021, despite not being free to buy alcohol after curfew, the panic has passed and most products are available.
SOCIALISING, VISITING AND GATHERINGS
Last Easter and Pesach, doctors were urging people not to visit at all outside of their immediate family circles. This year, with case numbers relatively low, it seems reasonable that families share these special holidays together WITH CAUTION. I would still advise socialising within a restricted bubble, maintaining social distance, keeping masks on and eating outside and at a distance of two metres. Gatherings where families are eating together should not be more than two or three families, family units should sit together to eat, and food should preferably be served by one person with sanitised hands. Large functions still carry a high risk of infection. Older and vulnerable people need to do a risk/ benefit analysis and decide whether they can attend safely if all COVID protocols are in place.
TRAVEL AND EATING OUT
Last March, these were prohibited, but now they are possible. I often repeat that “It’s people that are the problem, not places”. The COVID risk is much the same wherever your location, and if the basic principles of social distancing, mask wearing, staying in ventilated spaces and hand sanitising are observed, risks can be kept to a minimum. Travel in aeroplanes and taxis needs to be done with strict protocols in place. International travel has changed and one now needs a negative PCR test in order to travel overseas. Some countries have introduced Immunity passports or green passports where only vaccinated people can access travel, restaurants or even beach chairs. In South Africa, we are a long way from this reality.
SCHOOLS
We now know that children are much less likely than adults to develop severe COVID illness, are less likely to transmit it and are seldom the index case in a family outbreak. As such, children are encouraged to attend school in person rather than online, with all the social, medical and physical benefits that school entails. Children under the age of 6 are no longer required to wear masks in public. Schools have made major progress in using blended learning and online platforms to educate students, and have become adept at mitigating students’ risks by applying COVID protocols.
TESTING
One year ago, COVID PCR swabs were the only tests available and were limited to people with symptoms who had travelled or been exposed, due to testing shortages. There is no shortage of tests and thus the criteria for who can get tested is less strict. Contacts of positive patients are encouraged to test on day 7 or 8 even if they remain asymptomatic. March 2021, although the PCR test remains an expensive gold standard, we now have a broader spectrum of tests available, including rapid antigen tests,and antibody tests (NB antibody tests can only show exposure after about ten days and cannot diagnose new infections). Last year this time we were waiting four to seven days to get PCR tests back, while now we receive results in 6 to 24 hours. Rapid antigen and antibody tests can give results in ten minutes.
TREATMENTS
A year into the pandemic, doctors are much more knowledgeable and better prepared to treat COVID-19. The speed of development of medications and sharing of information, both locally and internationally has been unprecedented. Multiple trials of old and new drugs continue to be done on a large scale around the world. Medications like Remdesivir, convalescent plasma, cortisone, anticoagulants and colchicine are now widely accepted and used. Vitamins are routinely used, although only Vitamin D shows definite benefits in trials. Other medications like chloroquine, initially thought to be promising, have proved disappointing. Still others, like Ivermectin, remain controversial as although small studies and anecdotal results have shown good results, the bigger randomised trials that have been completed are not showing the expected benefits.
VACCINES
In March 2020, few doctors would have believed that it would be possible to have vaccines available within the space of one year. Although our country has been frustratingly slow in the initial rollout, the healthcare workers trial at least means that we have started.
I attach a link to a South African vaccine calculator, that allows you to see how many people are in front of you in the vaccine queue and when you can expect to be vaccinated.
IF all goes according to plan, elderly people or those with comorbidities can expect to be vaccinated by the end of July. Of course this hinges on vaccines that have been purchased from various sources arriving in the country on time and an ability by the government to set up and manage vaccine venues where these can be delivered. It does seem like an impossible task, but I remain optimistic that the pace will pick up and we will get going soon.
https://www.omnicalculator.com/health/vaccine-queue-sa
FLU VACCINES
This is one thing that hasn’t changed from last year. I highly recommend that both children over six months and adults get vaccinated against Flu again this year. We expect a third wave of COVID in Winter (following patterns from the Northern hemisphere). Influenza can present very similarly to COVID-19 with high fevers, body pains and a cough, and having a flu vaccine massively diminishes this risk. Flu vaccines are expected to be available at the end of March or the beginning of April. Elderly people or those with respiratory illness can also consider Pneumovax and Prevenar if they haven’t had them. Please discuss these with your doctor.
NEW STRAINS
In March 2020, we were just starting to learn about what the coronavirus was. Unfortunately, coronaviruses mutate, and there are now multiple new strains around the world, including the highly transmissible 501.V2 variant attributed to South Africa. Last week two more new strains were identified in South Africa. The months ahead will reveal the effects that these will have on infections and vaccines.
One year ago, I quoted Michael Leavitt , a former US Health and Human Sciences secretary, who wrote in 2007, “Everything we do before a pandemic will seem alarmist. Everything we do after will seem inadequate.” While it sometimes feels like the South African response has vacillated between “alarmist” and “inadequate”, I do think that, on balance, we have handled the pandemic better than most countries. The next six months, which include Winter, will be critical as we endeavor to keep the inevitable 3rd wave under control while we steadily increase the number of vaccinated individuals. If we continue to be careful, I am hopeful that I won’t be writing these updates in March 2022.