Cape Town — More than 34,000 cases of COVID-19 have been confirmed in Africa in the two months since the first confirmed case of the disease on the continent, with over 1,500 lives lost. Dr Matshidiso Moeti, World Health Organization (WHO) Regional Director for Africa, said physical distancing and national lockdowns are some of the measures used to mitigate the spread of the novel coronavirus, reducing the total number of cases when combined with increased testing.
South Africa is one of the countries with the most confirmed cases and tests. Its Minister of Health Dr Zwelini Mkhize, of South Africa, offered insight into how his country sought to confront the pandemic during the WHO briefing hosted by the World Economic Forum (WEF).
"We have approached this as a national campaign led by the president together with various cabinet ministers, business, civil society and members of the opposition parties. We all agreed on one approach as a coherent unit." Mkhize said, shared statistics of South Africa's infection and death rates.
"Since the first confirmed case on the 5th of March, we have had 5,350 reported cases. Of those, we have had 2,073 recoveries and 103 deaths. This gives us a mortality rate of around 1.3% ."
Mkhize said that the government's approach was based on projections that the eventual number of cases would be too large for the nation's hospitals to treat adequately. "We needed to take containment measures to flatten the curve. There had to be a proactive approach to determine the number of positive cases before they reached hospitals, (and) deal with them in time so that we didn't wait for an avalanche to descend on our health facilities."
The South African government trained and deployed 60,000 health workers who have been supported by non-governmental organisations including The President's Emergency Plan For AIDS Relief (PEPFAR) and the Global Fund. "At this point, six million people have been screened for symptoms and temperatures ."
Mkhize said infections arose from "cluster outbreaks" - when church meetings, factories and shops can results in groups of people being infected together.
Speaking from Accra, epidemiologist and former director of the Noguchi Memorial Research Institute, Professor Kojo Ansah Koram, said Ghana's modus operandi was to quarantine individuals suspected of having the disease, particularly travellers, from the beginning.
"I think this was good because at that point we were not sure what was happening. But for a group of roughly 1,000 travellers, the decision was made to quarantine and test them. We then found that more than 10% were positive." Prof. Koram made particular note of the fact that the infected travellers were asymptomatic which determined Ghana's way forward. "From that experience, the decision was made to track suspected cases, including contacts of people who had been to hospitals, and to test as widely as possible."
Koram said Ghana's mortality rate stands at about 1% . "At the start, we underestimated our testing capacity so we were a little overwhelmed but we managed to overcome this. We have now done more than 110,000 or 120,000 tests.
"Since 12 March we've had 1,671 positive cases. Unfortunately, we've lost about 16, and we've had about 190 recoveries … We have 1,483 cases under active observation. Most of them are in isolation centres without symptoms."
Accra is the epicentre of the outbreak in Ghana, Koram said, with more than 80% of cases in the nation's capital. The disease also spread to Kumasi with people in other regions of the country apparently becoming infected contact with people who had been to the southern Ghanaian city. "When the decision was taken to lock down Accra, a grace period was given. Some people left Accra, a sizable portion of which went to other regions."
Question and answer session
Recent reports suggest serious problems in Dar es Salaam. No figures have been released. How concerned is the WHO about the situation in Tanzania?
Moeti: "Before I speak on Tanzania specifically, we are observing countries taking an approach to the response at different speeds. The main measures include identifying cases, contact tracing, isolation and quarantine where necessary. In addition to that, the physical distancing measures that have been put in place more broadly in cities and countries. What we have observed is that Tanzania took some time to implement these measures, particularly physical distancing. For example, while schools were closed, places of worship were kept open so the gathering of people continued to happen in close spaces as well as in shopping areas and markets, which is an aspect of our countries that has been very difficult to impose. In addition to that, after Dar es Salaam was recognised as being the epicentre prevention of travel from there took some time to regulate which means, as Prof. Koram mentioned, when Ghana announced that Accra was being locked down, there was a grace period in which people travelled out of the city and there managed to spread the virus. This, we believe, was happening in Tanzania. In addition, we observed and had reports from neighbouring countries that truck drivers - people travelling by road carrying cargo from across Tanzania - have been found in a number of neighbouring countries to be positive. So, we continue through our country team and working with technical partners on the ground to advise the government, to provide them with the knowledge that the WHO has with the guidelines that we have and with the experience that we have from other countries in order to have those policy decisions taken based on data that will enable the government to get on top of the situation and hopefully start to see a bending of the curve."
South Africa and Ghana have a roughly similar mortality rate. These are low figures compared to the rest of the world. What do you think are responsible for Africa's low mortality rates?
Mkhize: "I think for us in Africa what would be useful would be for us to go all out and use our health workers and field operators to reach out and find people with suspicious symptoms, test them early before any complications and then in the process we could isolate them if they are found to be positive. That, I think, is going to be very helpful in reducing the numbers of people who could overwhelm our system. We also find that there are many people who are asymptomatic, particularly younger people, and so it is important for us to always have a sense of the prevalence of the infection in the community. In relation to mortality, I think it's a bit early for us to explain what this could be but we think that Africa largely has been behind the rest of the world in the onset of the outbreak. It might be early days for us. Secondly, we've noticed younger, healthier people tend to handle the infection better. Most of the patients who have succumbed have had co-morbidities and underlying cardiovascular, pulmonary and renal diseases or HIV and immunocompromised situations due to cancers. We think this is a major factor and most deaths were of people over the age of 60. I think our preparedness needs to be on creating more triage centres in every hospital and every clinic so people who walk in with symptoms must be separated from the rest of the patients. Also, we have to create field hospital beds so that someone who is asymptomatic cannot go back to their community where it is overcrowded and they cannot be isolated. At the moment we have very few people in the ICU (intensive care unit) - about 30 of them, and about 15 are on ventilators, so most of the people who were able to be isolated at home are being treated at home because of the ability to contain the infection. So I think we have to learn as we go."
Tanzania's president recommended the use of steam inhalation to combat the novel coronavirus. As an epidemiologist, what is your experience in providing scientific advice to political leaders, and what is the best way political leaders can communicate ... when it comes to offering advice on the pandemic Prof. Koram?
Koram: "Well, for me, and probably for those I will be working with, you work from the position of strength - what you know and you try to make sure your recommendations are based on what is known, so we need to collect data and see what is true and what is not true in our population. If, for example, you said, based on the epidemiology, 'let's lock down the place, let's track everybody', it's sound, but if you're in a place like Accra where there's a large majority of people in the informal sector, for example, then that advice has to be taken in addition to what will happen with that population who have to go out on a daily basis to get their daily bread. So you can make pure scientific advice but you have to be aware that it has to be managed in context and I think those who have to take the decision - ministers and presidents - have a really tough job on their hands."
Now that South Africa is easing the lockdown in phases, what is your metric of measurement to decide how to move from one phase to the next?
Mkhize: "The lifting of the lockdown was mainly due to the scientific focus that indicated that the five weeks we had would give a maximal shift in the peaking of the curve, that if we were to move the lockdown by another month or two months, it would hardly change that trajectory. The phasing of the lockdown has to take into account two major issues. The first of those is the rate of transmission. The second is the readiness of health services to respond to the burden of positive patients in any particular area. This means every part of the country has a different rating that we will be assessing and, of that, the metro areas are the ones we are concerned have a high transmission rate, therefore, we have to balance the extent to which we are going to ease off certain restrictions, vis-à-vis the need for us to contain the spread of the infection. When we talk about a risk-adjusted return to normality, it means that we are going to start from areas where there's a high transmission rate and the poorest level of preparedness of the system. Anywhere where there is such a situation, we will therefore not ease economic activities and social activities that much, but slowly as we build up our capacity to respond, we will then find it's easier to open up slowly to various other areas. So, for example, areas with a huge rise in the rate of infection like Mangaung, in the past three weeks they have been able to stall that rate to very few numbers of cases which means that their level of response and level of transmission has shifted from being very high to being moderate and therefore it allows a different response than, if you were to compare, Cape Town where the rate of transmission is very high and still rising. The numbers of beds, staff and tests that we have to do have to be pushed to a level where they can match to be able to start containing the rise of numbers of infected people. So the balance is going to be on a case-by-case, district-by-district, area-by-area basis."
With regard to the spread of COVID-19 in conflict zones, particularly in DRC, Libya, Somalia, but especially Burkina Faso, is there anything you, Dr. Moeti, or Dr. Yao can add about the situations there?
Moeti: "We are very concerned about people living under conflict conditions, refugee camps and other precarious situations, which is the case in some of the Sahel countries like the Central African Republic and South Sudan where we are working with our humanitarian partners and governments to support the response, mainly to prevent the virus from getting into these communities, some of which are in remote areas."
World Health Organization Emergency Operations Manager in Africa, Dr. Michel Yao: "The main challenge is access. We recall what happened in eastern Congo with Ebola. Access is a critical element for teams on the ground to stretch out their response, mainly the surveillance component as well as setting up facilities for testing and treatment so this is a major challenge and as mentioned by Dr. Moeti, it's where partnership is required - working closely with all the humanitarian partners to access these areas."
How will the focus of resources and attention on COVID-19 affect the fight against other diseases that health ministries (and) governments are trying to tackle? Do you expect upticks or fresh outbreaks in other disease areas?
Mkhize: "I think that's an interesting question because we grapple with that matter every day. The reality is that we have to mount an immediate response to the COVID-19 challenge but at the same time, we do understand that unless our health services are able to balance other comorbidities, then we have a challenge. A huge number of our people who have diabetes, hypertension, chest infections, tuberculosis, HIV/Aids and cancers - all of these need to be managed while we are dealing with this. That is the reason why there has been an additional allocation of resources to actually help the department to get additional human resources so that we don't have COVID-19 patients displacing other patients in need, and also so we end up with a situation where the triage at the entry of hospitals must allow people to be treated for other conditions while at the same time we have to manage the rising tide of COVID-19 infections. So we have to keep a balance because in our case we are concerned that over five million people are on antiretroviral treatment - they cannot be taken off that treatment and their treatment program cannot be undermined because it will create a new problem on the side. It is a very difficult balance but we have to try and manage it."
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Yao: "Other conditions are critical in the African context. Our summation, like the honourable minister Mkhize said, is to ensure proper triage so that services are ongoing on the COVID side of the challenge and to also ensure health workers can be repurposed so that we keep these services going. We also need to ensure supply chains are maintained."
Are there any projections of what the mortality rate will be in South Africa when infections reach the estimated peak in September?
Mkhize: "We have not publicised any focus of deaths, as such. We just issued a general awareness that if we don't manage to reduce the numbers of cases, the death toll might increase and we have to make preparations for that. We have a number of focus groups working on this matter and in the process, you realise their figures are varied so we have avoided publishing figures because they could also be used for sensational purposes. We believe the numbers that will be coming in at the beginning of winter when the co-infection with influenza virus is going to give us a better sense as to whether we are going to look at a much more pessimistic scenario with a rapid rise in number of people who are infected or it's going to be possible to manage it until we get the peak later on in September. We are going to prepare for any eventuality but we will avoid issuing numbers because if you looked at the first focus, we would actually have been at a much higher level but interventions changed the course, so we must work for the best scenario possible even though we have a sense for how bad things can be."
South Africa has been moving to universal healthcare for a few years. Do you think, Dr. Mkhize, that the response to the outbreak has broken down walls where moving to NHI (National Health Insurance) will become easier?
Mkhize: "A very interesting question because we all agreed we need to face the COVID-19 outbreak as a health sector, meaning we don't make a distinction between private and public (health insurance). For example, the first few cases were diagnosed by the private sector, the patients admitted to private hospitals with testing initially in the public sector and then the private sector. So there's a huge collaboration between laboratories. At any one time, there's any backlog at any one of the laboratories, the government can step in, take over the specimens, do the tests and make sure that there's no backlog as such. In the private sector we actually sat down, compared the numbers and agreed we are going to share the burden and at the moment we are negotiating the terms of engagement so that where there are facilities available in the private sector, we will use them. So I think COVID-19 will make collaboration much closer between public and private. As to the attitudes towards universal health coverage, I believe there is still work to be done. I believe a lot more will be achieved out of the COVID-19 response than there has been before, but it still requires a lot of engagement because the interest in the private and public sector can never be aligned completely but if we can fund a mechanism where we can co-exist in a model that allows us to be able to settle each other's concerns, we will actually be much closer to universal health coverage."
