COVID-19; SA’s ability to handle patient load doubtful – Prof Shabir Mahdi

A leading epidemiologist and respiratory infectious diseases expert, Professor Shabir Mahdi, has expressed deep concern that the fast-approaching COVID-19 peak in the Western Cape will overtake bed occupancy thresholds in the province’s major tertiary public hospitals. The anchor guest in a webinar hosted by Discovery Health in conjunction with the SA Medical Association in early June and attended by over 1 500 clinicians and other healthcare workers, Prof Mahdi said it was “frightening,” that the Western Cape’s main hospital ICU’s were already full of COVID-19 patients when the epidemic was not even at a third of its projected upward trajectory. The province is the country’s worst-affected, carrying over half of the estimated C-19 infection and mortality burden. Professor Mahdi said winter medical ward bed occupancy in State hospitals was usually 90% due to seasonal influenza. Citing Italy and Spain’s overwhelmed facilities, he said lower income countries had, ‘far lower bandwidth,” when it came to a confluence of the coronavirus peak and the usual winter influenza surge.

“We won’t be able to cope in spite of our valiant efforts to increase bed capacity. It takes an entire generation to rebuild a healthcare system. The lockdown enabled us to begin identifying symptomatic cases and begin testing and tracing – but we fell short, because this wasn’t in place at the start of the lockdown,” he warned.

Predicting that the epidemic would peak in the Western Cape at the end of July, he said the rest of the country would, on average, peak around a month later.

“The lockdown won’t eliminate the virus. Lockdown only works with aggressive testing of cases, tracing and isolation and/or quarantine. That has to happen very early on to prevent community transmission. That opportunity passed us by even before even the Level Five lockdown. With the first 20 imported cases, you need to trace up to 90% of all contacts – not just those in same household,” he stressed.

The hard truth on SA’s testing and tracing

He said South Africa’s claim to have a 90% tracing success rate almost certainly referred to only household contacts.

“I’m not talking about that. I’m talking about anyone who’s been in contact for 15-30 minutes, within a meter and a half radius. In high income countries they talk about one person having 20 contacts per day. We have, on average, as many at 70 contacts per day, research done in the Western Cape shows.”

Prof Mahdi said ideally, it took about three days from the time an individual showed symptoms to entering isolation. Calculating from the time of infection to signs of symptoms, to isolation, added up to six days. Assuming a conservative 20 contacts per person, that meant 120 contacts needing follow -up.

“So, when you’re diagnosing 100 new cases per day, that comes to 120 000 contacts to follow up. The research so far shows 70% of these need tracing before you can begin containing the virus. It’s just not feasible. The countries that succeeded, like South Korea and Singapore, used high-technology, (cell phone location), to trace contacts – and had already developed this plan from their MERS coronavirus outbreak in 2012,” he added.

He was at pains to dispel the myth that because of the urgency of the pandemic it was acute and would dissipate fairly quickly.

Prepare for a two-year pandemic

“Some naively believed the lockdown would contain the virus. We’re going to have waves of outbreaks for about two years. This is not a 100-metre sprint, but an ultra- marathon. With the 1918 “Spanish flu” pandemic, the second wave was actually more severe than the first, and they had four waves, up to 1920. That’s pretty much where we’re headed globally. We either develop herd immunity and it becomes a seasonal problem with some people. However, the only thing that will shorten the time period and render this a more of a nuisance virus will be a vaccine,” he warned.

It was ‘biologically implausible’ that the decrease in cases in the first week of SA’s lockdown had anything to do with lockdown. In truth, this represented people infected before lockdown.

“Our testing actually decreased during the first week of lockdown, compared to the week before. Over the five-week lockdown, the average number of cases per day was 30-40 in the first week, rising to close on 400 during the last week. That came with a ten-fold increase in testing,” he added.

Non-pharmaceutical’ intervention, (individual risk-reduction behaviour-change) was no guarantee against infection – it’s main value was to slow the spread rate of the virus; and this was now critically important, time-wise.

“We need a vaccine sooner than 60% of the population are infected. It’s at that point in time that we expect herd immunity to kick in. Now, whether natural infection actually induces sufficient immunity for herd immunity to kick in is a completely different story,” he stressed.

It was at this point in time that the (viral) reproduction rate dropped below one new case for every new person infected (by changing the percentage of the population susceptible to the virus).

SA’s case fatality risk compares well

He said the case fatality risk in South Africa for hospitals stood at 12% (compared to 2% in the general population) and this compared very favourably

to Italy and the United Kingdom, where the common denominator used was hospital case fatality.

Of every 1000 adults over a two to three-year period, about 25 would be hospitalised, with five dying. About 80% of those over 65 years old could die, he said, using multiple graphs and spread-sheets to illustrate.

Yet in South Africa, in contrast to many older populations in the northern hemisphere, there was a disproportionate number of people under the 65-year old threshold carrying high-risk co-morbidities, such as hypertension and diabetes, which changed the picture dramatically. Yet in the 18-45 age grouping, among those with no co-morbidities, none of the 1000 would die, while for children under 18 years old, it would be ‘unfortunate” if even one child was hospitalised, let alone died, he added.

Of Italy’s death-peak of 30 000 on May 5th this year, none were children, he emphasised.

“I’ve been doing respiratory viruses in South Africa for 25 years and this is the first one I’ve come across where I see kids being spared the severe effects of a virus,” he observed.

He said comparing statistics by country was a dangerous and inaccurate occupation.

The Centre for Disease Control (CDC) estimated that 1,3 million C-19 tests had been done in Africa, with just over half in South Africa. This pointed to an overall lack of capacity, with many countries relying on a single laboratory. (Lesotho relies on SA labs – for example). He cited the 2009 Swine flu pandemic which initially showed that the fewest number of confirmed global cases were from Africa. Yet then the final data were probed, more than 50% of all deaths were from Africa and South East Asia.

Prof Mahdi said South Africa had the capacity, but not the capability, and urged for testing to be focussed where risk priorities existed such as hospital patients and healthcare workers.

“We need testing results in 12-24 hours. Otherwise our healthcare workers will unknowingly be exposed and infect patients. Testing needs to be urgently goal-directed. Getting results up to seven days later makes testing a meaningless exercise, because people are far less infectious by then,” he stressed.

He said the NHLS had the capacity to get 36 000 tests done within 24 hours, but couldn’t do it because of a global shortage of testing kits.

Testing kit relief imminent

President Cyril Ramaphosa announced subsequent to Prof Mahdi’s webinar, that SA was sourcing the urgently-needed kits from 15 million being secured monthly from mid-June by the African Level Platform, while Health Minister Dr Zweli Mkhize’s lead advisor, Prof Salim Abdool Karim, said that after ‘disappointing’ initial test times, the NHLS was by June 20th, starting to trim backlogs down to a turn-around time of between 48 and 72 hours.

Quizzed by his audience on progress with a vaccine and general immunity after infection, Prof Mahdi said that while immunity was protective against severe disease and illness, a person could get re-infected. He warned against C-19 recovered healthcare staff believing they were ‘safe” once back at work.

The most promising and advanced candidate vaccine so far was under development in the United Kingdom. This chimpanzee adenovirus vaccine trial embraced 200 volunteers after the data on primate studies showed that a single dose induced neutralising antibodies that protected against severe disease when challenged with infection. However, the UK’s challenge was finding enough volunteers to increase their sample size (in a rapidly plummeted infection curve). The good news was that clinical trial approval in South Africa for the same candidate vaccine were imminent, enabling rich sample size pickings and hopefully showing initial results before Christmas.

Steering a wayward C-19 ship – Prof Slim Karim

It’s easy to pick holes in a strategy which affects nearly 60 million lives – it’s entirely another thing to take full responsibility for your part in it and to own up when things don’t work.

In this exclusive story, the man leading the way on scientific coronavirus advice to Health Minister, Dr Zweli Mhkize, gives us unique insight into just how far his reach goes, what he can advise on, and what he has no control over. Like lockdown level 3 regulations enacted by other cabinet ministers who have their own scientific advisory teams – and for whose actions he often wrongly gets the flak. He gives us chapter and verse of one such change he has advised on – among 50 advisories from his task team that Dr Mkhize has accepted and acted on. It’s around coronavirus testing which was virtually imploding on itself as the national laboratory services got bogged down in an impossible volume of tests with turnaround times, negating the entire point of the exercise. Like turning around an oil supertanker at sea, it takes time. Prof Karim explains why.

Story: Karim on changing C-19 strategies, podcast interview; Chris Bateman (you can also listen to the full podcast below).

Karim changes coronavirus strategy – exclusive

Lengthy turn-around times for coronavirus tests are ‘disappointing,’ but the strategy of community health worker-led testing has been substituted with the promotion of self-compliance risk-reduction measures, thus lowering testing volumes and reducing the test results backlog.

This is according to Professor Salim Abdool Karim, the chair of the Health Minister’s scientific advisory task team, in an exclusive interview with Biznews. He added that bulk testing kit supplies had recently been secured with testing now prioritizing hospital workers and patients, vulnerable people and infection ‘hot spots.’  This is in line with protracted calls by the scientific community to make this adjustment, instead of dispersing testing so widely that the national health laboratory services, (NHLS), are overwhelmed, taking up to seven days to turn tests around. Infectious disease experts and epidemiologists such as Professor Shabir Madhi confirm that after seven days, a person is far less infectious and that test turnaround times longer than 12-24 hours put hospital workers and thus patients at unnecessary risk. Tests taking 5-7 days were ‘virtually useless,’ Prof Madhi told a Discovery Health webinar a fortnight ago.

Says Prof Karim; “I have to say, it’s been disappointing that it’s taken the NHLS so long to prioritize. This has been an issue because we know that in a clinical setting, we need test results quickly. Our advisory committee told the minister we need to reduce testing demand, increase the number of test kits and use them more efficiently. As the President announced in his televised address this week, we’ll be accessing test kits through the African-level platform, where some 15 million are being made available on a monthly basis, so this will increase the supply to some extent.”

Hospital staff and patient tests would now be prioritized while changing strategy for the tens of thousands of community healthcare workers to advise people in their homes to wear masks, wash hands and practice social distancing would take some time. Giving an example of the challenges in turning a ministerial recommendation into action on the ground, Prof Karim said his committee’s initial advice shortly after lockdown was to initiate a health care worker program of going house to house, looking for cases.

“We were seeing far too few cases and we wanted to get ahead of the pandemic and find them before they came to the hospital,” he explained.

However, this was easier said than done. It involved a ‘huge amt of work; massive planning and resources.

“You have to spend time getting community buy-in. So now we make a recommendation that, given the shortage of testing, we should change that program so that it doesn’t involve testing. The approach is that when a person in a community is found to have symptoms, we initiate quarantine – without a test. To implement that means going back to all stakeholders and getting new buy in. It’s a process that takes time. Those of us in academia expect things to always get done quickly, but in government that’s not easy because it’s a massive program. Changing things without consulting loses you credibility in the community,” he added.

Testing backlogs hugely reduced

Asked what he saw as the optimal test result turn-around time, Prof Karim said he expected a PCR test result within 48hours, “and 72 hours in some instances – we’re now quite close to that. The backlogs are pretty much done in most cases, though I’m not best placed to tell you. From what I’ve been told, there’s no backlog in the Western Cape and other provinces are now significantly lower, including KwaZulu Natal (where he is based). We expected quicker action, but it turned out that this doesn’t translate so easily in NHLS work procedures.”

Challenged on coronavirus infection projections having changed from initial actuarial calculations to actual data over time and the controversies that erupted, Prof Karim said the wider context was working in an environment of ‘imperfect data and evidence.”

“We’ve only known about the existence of this virus since January and we’re just scratching the surface. It’s like caring for patient who’ll die if you don’t act. You have to act, even if you make the wrong diagnosis, you then change course. I have a reasonable understanding of the current state of the pandemic and what the likely scenarios are in the next few weeks.  Again, converting a recommendation into action on the ground with government requires substantial work,” he added.

All previous epidemics South Africa faced gave scientists time to follow the traditional health paradigm of collecting evidence to understand how the disease spread, developing an intervention program, piloting it and then adjusting. This was followed by taking it to adopters, consulting and eventually diffusing it into the general population.

“That takes one or two years. We couldn’t do that here, so we locked down and explained to people that this is a deadly, highly infectious novel disease.  Now it’s no longer about enforcement.  Just the opposite. We’ve lifted the lockdown, telling people they must take radical responsibility to protect themselves, and supporting them to do so as much as possible,” he said.

 Asked how he thought the public was responding, Prof Karim said he’s seen both sides of the coin while out walking or shopping.

“On my morning walks, nearly everybody is wearing masks and the supermarkets have adjusted very well with distancing protocols, floor queuing markers and sanitizing measures. It’s quite impressive. We could never have got to this place in March. Then I go to other areas and I’m shocked at the lack of self-protection measures. We’re not a regimented society. Some will make decisions not in the overall or their own interests. We have to accept that that’s part of it. The extent to which we lose that battle will define how severe the epidemic will be. However, I see a silver lining informed by the HIV/Aids pandemic. As the C-19 pandemic progresses and people know someone who has the disease or who has died, they change their behavior,” he said.

Asked what his central take-home message would be for people, he responded; “the risk of the coronavirus to you, your families and communities is all in your hands.”

Virus ‘rock star’ becomes COVID-19 treatment guinea-pig

It’s not often ‘virus-slayers extraordinaire” like Professor Peter Piot fall victim to a historically unique version of a global virus – one which very nearly killed him.

In his own jocular words, ‘after I made the life of viruses miserable for several decades, a virus got me,’ (his team co-discovered the Ebola virus and developed a successful vaccine for it, plus he’s an AIDS research pioneer). Three months ago, Prof Piot developed splitting headaches and extreme exhaustion, ironically struggling to get an NHI C-19 test in London before securing it privately. He tested positive and was admitted to the University College London Hospital, the first patient to be diagnosed with C-19 and interstitial pneumonia, with a hyper-immune response. After discharge, he arrived home in tears of relief, and promptly developed atrial fibrillation and fibrosis on the lungs, conditions which he says now seem to be slowly clearing up, though he expects some lung-scarring.

The guest on a popular webinar last Thursday (June 4th), part of a series hosted by Discovery Health in conjunction with Medical Brief, the Desmond Tutu HIV Foundation, the SA Medical Association, the SA Private Practitioners Forum and the Unity Forum for Family Practitioners, Prof Piot had his audience of some 1 500, mostly clinicians, enthralled, not only for sharing his ‘inside out’ learning experience, but for his expertise and opinions on the virus, which has eluded all mitigation therapies and so far, a vaccine.

“I’m glad I had Corona and not Ebola, although I read a scientific study that concluded you have a 30% chance of dying if you end up in a British hospital with COVID-19. That’s about the same overall mortality rate as for Ebola in 2014 in West Africa. That makes you lose your scientific level-headedness at times, and you surrender to emotional reflections,” he confessed to webinar facilitator Professor Linda-Gail Bekker, the deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT.

C-19 can affect multiple organs

Prof Piot, described in the Financial Times as, ‘the Mick Jagger of Microbiology,” told his audience that, “Many people think COVID-19 kills 1% of patients, and the rest get away with some flu-like symptoms. But the story gets more complicated. Many people will be left with chronic kidney and heart problems. Even their neural system is disrupted. There will be hundreds of thousands of people worldwide, possibly more, who will need treatments such as renal dialysis for the rest of their lives. The more we learn about the coronavirus, the more questions arise. We’re learning while we’re sailing. That’s why I get so annoyed by the many commentators on the side-lines who, without much insight, criticise the scientists and policymakers trying hard to get the epidemic under control. That’s very unfair.”

He said that, coming from the HIV tradition, he’d seen how people living with HIV played a big role, especially in South Africa, something almost total absent with COVID-19 where public discussion centred on data and flattening the infection and mortality curves.  His experience of being infected and the publicity it generated completely changed his perspective as feedback from those with similar, until then rare symptoms, began pouring in.

Strongly backing the use of all-purpose oxygen versus ventilators for treatment, he said it was vital to address patients with symptoms similar to his, “who fall between those who have a bit of a flu which is over in 5 days or week and those in the 1% bracket who’ll die – plus there’s the belief that infected people over 70, (he’s 73), will die soon anyway. I want to show what’s in between, which has been hugely neglected, because we think this is a respiratory virus which mainly affects the lungs.’

Prof Piot described the virus as, “nasty – it goes into your whole body.”

He said it caught the world by surprise, with those countries most affected by the H1NI and SARS pandemics, (Hong Kong, Singapore and South Korea), faring best as their populations proved compliant with masks, hand hygiene and social distancing and response systems in place. In stark contrast, political C-19 denialism among political leaders, best exhibited in Brazil and to a lesser extent in the USA, was akin to the Mbeki AIDS denial years in South Africa.

Like practicing a fire drill as hospital burns

The analogy he used in describing global preparedness and most C-19 responses was one of a hospital practicing a fire drill as it burnt down. A firm advocate of investing billions in preparedness around health care infrastructure, and therapeutic and vaccine research protocols, Prof Piot said the biggest challenge was that it was not obvious what the return on investment was in the absence of a pandemic. Manufacturing ancillary products such as millions of glass vials, was also a challenge. He’s a firm advocate of solid, peer-reviewed clinical trials, and stresses that any therapy or vaccine with even a one percent serious side-effect would harm millions in a global pandemic such as the coronavirus.

Of the actual pandemic he said; “The same thing could happen again in 40 or 50 years-time. It’s a bit like San Francisco talking about the ‘Big One,” (an earthquake), destroying the city sometime in the future.”.

Stressing preparedness, he said that for C-19, finding an anti-viral therapy, (AVT), quickly and using it as a pre and post exposure prophylaxis was vital, while the use of both AVT and immune-suppressants early on would be hugely effective. However, if used too late these would have no impact. He said the development of two vaccines for Ebola was ‘great news,’ but for C-19, testing seemed to be extraordinarily difficult to organise, with it being rationed in the United Kingdom, something he had a direct, traumatic experience of.

“This is simply bad policy. Government institutions only test symptomatic people. Yes, we know how many uncertainties there are. Asymptomatic people can transmit the virus; it’s probably very contagious two days before symptoms show, and yet they deny access to testing and centralise it! Testing should be in pharmacies and at point-of-care. We also need a system with rigorous quality assurance and validation of those tests, which complicates life,” he added.

He said herd immunity was misunderstood. It only worked if a minimum level of individuals were rendered immune through vaccination. For example, with measles, this meant 90% of a population had to be vaccinated in order to protect the unvaccinated. Protecting the vulnerable while exposing the younger, less infection-prone to the virus seemed like a sensible strategy, yet Sweden’s herd-immunity policy left them with the biggest C-19 mortality in Europe.

“We’re no longer in the Middle Ages – we shouldn’t let the natural course of an infection go. There’s no way that by some miracle, one fine day it will disappear. As long as there are susceptible people in the world, the virus will look for people – a virus’s very reason for living is to find a host!” he added.

Groote Schuur Hospital – sharing early C-19 lessons

COVID-19 patients with diabetes and/or obesity are three times more likely to die than those who are HIV positive, whether the latter are on anti-retroviral drugs or not.

That’s the hands-on experience of the country’s advance guard of clinicians treating coronavirus patients at Groote Schuur Hospital where 180 Coronavirus-infected patients were under care by June 5th, with numbers expected to double over the next fortnight as the Western Cape’s two main tertiary hospitals (Tygerberg Hospital is the other), deal with a surge in the country’s worst-affected metropole and province. More than 1 500 clinicians and other healthcare workers from across the country listened intently during a June 11th webinar in which Groote Schuur’s medical team leader, Professor Graeme Meintjes, shared his freshly-acquired knowledge on all aspects of C-19 patient care, symptoms and co-morbidities.

Prof Meintjes, a health advisor to the Department of Science and Technology and the country’s research chair in poverty-related infections, is also Deputy Head of the Department of Medicine at UCT. The webinar was held last Thursday (June 11th), as part of a series hosted by Discovery Health in conjunction with Medical Brief, the Desmond Tutu HIV Foundation, the SA Medical Association, the SA Private Practitioners Forum and the Unity Forum for Family Practitioners. The session was facilitated by Professor Linda-Gail Bekker, the deputy director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT, and introduced by Dr Maurice Goodman, Chief Medical Officer at Discovery Health.

Prof Meintjes said that as of 11th June, there were 36 000 people in the Western Cape diagnosed with C-19 and 900 deaths. This represents well over half of the country’s C-19 burden, with tourism, the life-blood of the province’s economy, believed responsible for multiple seeding of the virus there by overseas visitors. Groote Schuur Hospital serves four of the heavy-burden sub-districts of the Cape Metropole. There was arguably a sigh of relief in the audience as Prof Meintjes said HIV-positive patients represented just over a two-fold higher C-19 infection risk than those without any other co-morbidities – a relatively low contributor to serious C-19 debilitation.

“There’s no difference between patients with suppressed viral load and those not on ART. It may be socio economic factors. HIV is associated with increased Covid risk, but what we’re seeing is probably lower than the cited figure of 2,7 times greater risk. While the obesity data are not available, we can see it’s a big contributor, especially when there’s accompanying high blood pressure. About half our C-19 deaths can be attributed to diabetes, but only 12% to HIV,” he revealed.

He said the first C-19 patient was admitted to GSH wards on March 18th and there’d been a gradual increase though March and April, escalating dramatically over the past few weeks.

“The first few weeks gave us an opportunity to prepare; psychologically, communications-wise, agree on a plan for the redeployment of staff, and to rapidly scale up. We now have isolation rooms and six wards set aside for those under investigation, including the maternity and psyche wards,” Prof Meintjes said.

Deaths strongly age-related

About 25% of deaths in the Western Cape were people in their 50’s and another 25% those in their 60’s, with the percentages climbing with age.

Serious co-morbidities nearly always contributed to the far lesser mortalities in younger age groups. C-19 affected males more severely than females with the biggest risk factors being uncontrolled diabetes, obesity, cardio-vascular, hypertension and pulmonary disease. About 5% of all their admissions required ICU treatment.

Asked how common pulmonary emoboli were, Prof Meintjes said about 25% of patients at the severe end of the C-19 spectrum were shown to have them and/or deep vein thrombosis, with an increased mortality risk of 22 to 33%.

He recommended treating patients without intubation, where possible. His team’s early experience was that high-flow nasal oxygen, (HFNO), had a 31% survival rate with 55% of serious patients intubated. Of those on failed HFNO that required ventilation, there had been no survivors – all had either died or were still on ventilators.

Answering a question on duration of HFNO, Prof Meintjes said the timing varied according to individual patients.

“Some we’ve been able to consider weaning after three days and some stay on for two weeks. For those on HFNO for 10 days or longer, we worry about pneumonia and so we do radiology and start them on steroids,” he added.

Prof Meintjes strongly promoted ‘awake-proning,’ (the turning of patients onto their stomachs for two hours or longer, if they can tolerate it), where gravity allows blood to settle in the anterior part of the lungs, providing better oxygenation in two thirds of patients, according to studies. He said oxygen saturation when doing this increased by up to 20%, dramatically increasing a patient’s chances of survival.  However, he warned against doing this for severely restless or disoriented patients as they could easily turn onto their backs.

Asked about the use of extracorporeal membrane oxygenation, (ECMO), he said this was in the domain of his critical care colleagues, however it would only be considered in very select patients, especially those with single organ failure (not multiple). ECMO provides temporary support for patients with cardiac or pulmonary failure.

Thanking Prof Meintjes on behalf of webinar participants, Prof Bekker said he cut his teeth on the HIV/AIDS epidemic, which probably helped him prepare for the COVID-19 pandemic. He and his courageous colleagues were at the coalface of the coronavirus pandemic daily, serving at both Khayelitsha and Groote Schuur hospitals, risking their wellbeing in service of others and paving the way for the rest of the country, still bracing itself for a surge of C-19 admissions.

Handling an enigmatic disease – and a flood of patients

Covid-19 is not a single-specialty disease; everyone has to collaborate, parceling out work where resources are most needed and finding the best way to handle individual cases.

This is according to Dr Nicky Longley, a one-time University of Cape Town-trained infectious diseases Fellow, currently working in a London hospital that has just emerged from a bruising encounter with a flood of Coronavirus patients in a city that saw most of the UK’s infections and deaths. She was the special guest at a webinar attended by 1 500 South African clinicians and healthcare workers anxious to gain knowledge and insights from her in advance of their own surge in hospital admissions that will inevitably accompany local lock-down relaxations and/or lifting.  The webinar, hosted by Discovery Health in conjunction with Medical Brief, was on Thursday, May 14th and Professor Linda-Gail Bekker, Deputy Director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT, and an erstwhile colleague of Dr Longley’s, facilitating. Dr Longley is an associate professor at the London School of Hygiene and Tropical Medicine and a consultant at London’s Hospital of Tropical Diseases.

She said South Africa had the advantage of foresight in having witnessed the pandemic sweep through countries like Italy and the UK and thus had the unique advantage of time to prepare and mobilize.

Risk stratification vital

“Nobody (no hospital) has enough isolation facilities or side-rooms to cope with this,” said Dr Longley, emphasizing how pivotal the risk stratification of patients was.

“You have to see who is most vulnerable in the population and work out how to shield them when they come into hospital,” she added.

Case definition swabs were vital but diagnoses not always as rapid as clinicians wanted. At the hospital entrance, patients were divided into those at high risk of transmitting the virus (put into the ‘dirty’ area), those unlikely to have Covid-19, but with underlying conditions which put them at a high risk of a poor outcome if they contracted it (e.g. the elderly, pregnant, or with malignancies) – put into a clean area, and then difficult cases that defied easy definition.

Dr Longley stressed the importance of a ‘buddy system’ when healthcare workers entered or exited ‘dirty’ areas such as ICU’s and high-dependency units.

“Somebody else watches you put on and take off personal protective equipment each time, because you’re stressed and tired and may also forget hand hygiene between each step when you take scrubs off and when you go home. Also, have a shower before you go home and leave your dirty crocks or shoes behind,’ she advised.

With 233 151 Covid-19 cases and 33 600 deaths in the United Kingdom at the time she spoke, Dr Longley said things were finally slowing down after a dramatically-effective but limited lockdown that allowed exercise, movement and shopping, with social distancing, hand hygiene and masks strongly encouraged. Her hospital went from being almost overflowing with operating theatres converted into ICU’s with extra beds, to being 25% full currently, which was lower than normal for this time of year.

Dr Longley said doctors had to realize that, ‘this is not a sprint, it’s a marathon – we have to be kind to our teams and ourselves.”

“As clinicians we won’t get it right all the time. We can step away. We’re used to being able to deal with, and know what we’re doing. Yet we’ve only been around this disease for some months – in some ways we feel helpless. It’s super important to realize that psychological impact. Our intensivists say this is not the normal thing they know. Your staff and patients are frightened. They’ve been told to stay away and self-isolate, and now they’re coming in. It’s reminiscent of the beginning of the AIDS epidemic. Nobody wanted to touch these people. There’s also fear from patients, ancillary staff and your own staff and their relatives when they’re read to go home,” she told her audience, which later peppered her with questions.

Dr Longley said people in isolation felt vulnerable being confronted with doctors and nurses suited up in intimidating personal protective equipment.

“They don’t see your smile. Instead they see your worried eyes. They’re without familiar things. We set up a library in the Covid ward, because they’re there for a long time,” she revealed.

Do I have it or not?

She said she and her colleagues felt guilt over being away from their families, scared they’d bring the virus home, fall ill and have to abandon their colleagues. A significant percentage of her colleagues were asymptomatic or quasi-symptomatic, or as she put it, “slightly under the weather.”

When stressed or tired they were never sure whether they had the virus or if they were suffering psychosomatic symptoms. An irony was that while healthcare workers were afraid of entering Covid wards, these were probably the least risky because everybody was on guard and took precautions. The danger came when working in so-called ‘clean’ zones where you least expected to become infected.

She said Covid presented with a host of unexpected non-pulmonary symptoms which made for a steep learning curve. A snapshot of 35 ICU patients showed that 60% had acute kidney injury while others had inflammation and direct invasion of the tubular system, needing continuous electrolyte replacement, having lost large amounts of phosphate, sodium and potassium. One third of scans showed pulmonary embolisms and some deep vein thrombosis. Those requiring high flow oxygen in ICU or on CPAP needed more anti-coagulants, though plasma-exchange studies were ongoing. Nervous system symptoms included a dramatic loss of smell, hypo-active delirium with deregulation of the autonomic nervous system, and strokes. Other unexpected variations included, (towards the end of the epidemic), a Kawasaki-like syndrome among a handful of children and young adults (treated with steroids and biologic therapy), myocarditis, diarrhoea and vomiting – associated with hepatitis, not respiratory symptoms.

Dr Longley’s advice was to treat conditions associated with Covid normally, as if they were presenting in isolation.

She emphasized that results were still pending in a 6 000-person London-based study comparing all the world’s highly debated drug therapies suspected to mitigate Covid-19. There was currently no significant evidence to say any worked. Biologicals were currently looking more promising than anti-viral treatments, but nothing had yet succeeded as a prophylactic.

She warned colleagues to be on the look-out for, (especially in elderly patients), straightforward presentations such as a urinary tract infection.

“Don’t forget to be a doctor – it’s not all Covid!” she said, citing two malaria deaths that occurred simply because the London-based former-travelers tragically self-isolated at home with fever-like or flu symptoms, thinking they had Covid-19.

Lessons from a London Covid-19 hospital flood

Clinicians and hospital staff facing the first flood of Covid-19 patients often feel helpless, scared and overwhelmed, reminiscent of the beginning of the HIV/AIDS epidemic, and need to cut themselves, their colleagues and their patients some slack.

This is one of the core messages from Dr Nicky Longley, a one-time University of Cape Town-trained infectious diseases Fellow, currently working at a London hospital emerging from the brunt of the initial Coronavirus patient onslaught in a city that faced most of the UK’s infections and deaths. She was the special guest at a webinar attended by 1 500 South African clinicians and healthcare workers eager to glean knowledge and insights from her in advance of their own surge in hospital admissions that will inevitably accompany local lock-down relaxations and/or lifting.  The webinar, hosted by Discovery Health in conjunction with Medical Brief, took place on Thursday, May 14th and was facilitated by Professor Linda-Gail Bekker, Deputy Director of the Desmond Tutu HIV Centre at the Institute of Infectious Diseases and Molecular Medicine at UCT, and an erstwhile colleague of Dr Longley’s. Dr Longley is an associate professor at the London School of Hygiene and Tropical Medicine and a consultant at London’s Hospital of Tropical Diseases. She worked for several years in infectious diseases in South Africa.

With 233 151 Covid-19 cases and 33 600 deaths in the United Kingdom at the time she spoke, Dr Longley said things were finally slowing down after a dramatically-effective but limited lockdown that allowed exercise, movement and shopping, with social distancing, hand hygiene and masks strongly encouraged. Her hospital went from being almost overflowing with operating theatres converted into ICU’s with extra beds, to being 25% full currently, which was lower than normal for this time of year.

Quoting her clinical chief at her hospital, Dr Longley said doctors had to realize that, ‘this is not a sprint, it’s a marathon – we have to be kind to our teams and ourselves.”

“As clinicians we won’t get it right all the time. We can step away. We’re used to being able to deal with, and know what we’re doing. Yet we’ve only been around this disease for some months – in some ways we feel helpless. It’s super important to realize that psychological impact. Our intensivists say this is not the normal thing they know. Your staff and patients are frightened. They’ve been told to stay away and self-isolate, and now they’re coming in. It’s reminiscent of the beginning of the AIDS epidemic. Nobody wanted to touch these people. There’s also fear from patients, ancillary staff and your own staff and their relatives when they’re read to go home,” she told her audience, which later peppered her with questions.

Dr Longley said people in isolation felt vulnerable being confronted with doctors and nurses suited up in intimidating personal protective equipment.

“They don’t see your smile. Instead they see your worried eyes. They’re without familiar things. We set up a library in the Covid ward, because they’re there for a long time,” she revealed.

She said her colleagues and herself felt guilt over being away from their families, scared they’d bring the virus home, fall ill and have to abandon their colleagues. A significant percentage of her colleagues were asymptomatic or quasi-symptomatic, or as she put it, “slightly under the weather.”

When stressed or tired they were never sure whether they had the virus or if they were suffering psychosomatic symptoms. An irony was that while healthcare workers were afraid of entering Covid wards, these were probably the least risky because everybody was on guard and took precautions. The danger came when working in so-called ‘clean’ zones where you least expected a threat.

She said Covid presented with a host of unexpected non-pulmonary symptoms which made for a steep learning curve. A snapshot of 35 ICU patients showed that 60% had acute kidney injury while others had inflammation and direct invasion of the tubular system, needing continuous electrolyte replacement, having lost large amounts of phosphate, sodium and potassium. One third of scans showed pulmonary embolisms and some deep vein thrombosis. Those requiring high flow oxygen in ICU or on CPAP needed more anti-coagulants, though plasma-exchange studies were ongoing. Nervous system symptoms included a dramatic loss of smell, hypo-active delirium with deregulation of the autonomic nervous system, and strokes. Other unexpected variations included, (towards the end of the epidemic), a Kawasaki-like syndrome among a handful of children and young adults (treated with steroids and biologic therapy), myocarditis, diarrhoea and vomiting – associated with hepatitis, not respiratory symptoms.

Dr Longley’s advice was to treat conditions associated with Covid normally, as if they were presenting in isolation.

She emphasized that results were still pending in a 6 000-person London-based study comparing all the world’s highly debated drug therapies suspected to mitigate Covid-19. There was currently no significant evidence to say any worked. Biologicals were currently looking more promising than anti-viral treatments, but nothing had yet succeeded as a prophylactic.

She said the good news was that their HIV positive patients that were virologically suppressed with good CD4 counts displayed no greater risk than the general population. She warned colleagues to be on the look-out for (especially in elderly patients), straightforward presentations like a urinary tract infection.

“Don’t forget to be a doctor – it’s not all Covid!” she said, citing two malaria deaths that occurred simply because the London-based former-travelers tragically self-isolated at home with fever-like or flu symptoms, thinking they had Covid-19.