Latest / The SHEA Podcast / COVID-19: South Africa Perspective On COVID & Variants, 3/11/21

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COVID-19: South Africa Perspective On COVID & Variants, 3/11/21 · The SHEA Podcast

• 0:08
  SPEAKER_02: Welcome to the Rapid Response Podcast brought to you by the Society for Healthcare Epidemiology of America, Shay, promoting the prevention of healthcare-associated infections and antibiotic resistance and seeking to advance the field of healthcare epidemiology and antibiotic storture.
• 0:23
  SPEAKER_02: I'm Dr.
• 0:24
  SPEAKER_02: Jennifer Hanarhan, infectious disease specialist at the University of Toledo, and I will serve as your moderator.
• 0:29
  SPEAKER_02: Discussion on the podcast does not reflect Shay's perspective, but facilitates communication of multiple perspectives and experiences as we go through this challenging time together.
• 0:39
  SPEAKER_02: Shea is excited to launch this episode of the podcast, COVID-19 updates, what we know now.
• 0:44
  SPEAKER_02: Today's discussion will focus on South Africa perspective on COVID-19 variants.
• 0:50
  SPEAKER_02: Our speaker today is Dr.
• 0:51
  SPEAKER_02: Wolfgang Preiser, Professor and Head of the Division of Medical Virology in the Department of Pathology and Faculty of Medicine and Health Sciences at Stellenbosch University and NHLS Tiger Bear.
• 1:04
  SPEAKER_02: Thank you for joining us today.
• 1:06
  SPEAKER_02: Before we start our discussion, I would like to turn it over to Dr.
• 1:09
  SPEAKER_02: Ishrat Kamal Ahmed to get us started with a brief news and guidance update for the week.
• 1:16
  SPEAKER_01: For our news update today, we'll start with a global update.
• 1:20
  SPEAKER_01: Globally, as of March 8, 2021, there have been 116 million confirmed cases of COVID-19, including 2.5 million deaths.
• 1:30
  SPEAKER_01: As for the US update, the Centers for Disease Control and Prevention said on Monday, March 8, 2021, that about 60 million people have received at least one dose of a COVID-19 vaccine, including about 31.3 million people who have been fully vaccinated.
• 1:46
  SPEAKER_01: If the country maintains its current pace of administering first doses, about half of the total population would be at least partially vaccinated around late May and nearly all around early September, assuming supply pledges are met and vaccines are eventually available to children.
• 2:04
  SPEAKER_01: As for the highly anticipated guideline, on March 8, 2021, the CDC issued its first set of recommendations on activities that people who fully vaccinated against COVID-19 can safely resume.
• 2:17
  SPEAKER_01: A person is considered fully vaccinated two weeks after receiving the last required dose of vaccine.
• 2:23
  SPEAKER_01: These recommendations apply to non-healthcare settings.
• 2:27
  SPEAKER_01: Now, fully vaccinated people can do these three things.
• 2:30
  SPEAKER_01: They can visit with other fully vaccinated people indoors without wearing masks or physical distancing.
• 2:36
  SPEAKER_01: They can visit unvaccinated people from a single household who are at low risk of severe COVID-19 disease indoors without wearing masks or physical distancing.
• 2:46
  SPEAKER_01: They can also refrain from quarantine and testing following a known exposure if asymptomatic.
• 2:52
  SPEAKER_01: CDC recommends that fully vaccinated people continue to take COVID-19 precautions when in public, when visiting with unvaccinated people from multiple other households, and when around unvaccinated people who are at high risk of getting severely ill from COVID-19, they should still wear a well-fitted mask, stay at least six feet from people they don't live with, avoid medium and large-sized in-person gatherings, get tested if experiencing COVID-19 symptoms, they should follow guidance issued by individual employers, and they should follow CDC and Health Department travel requirements and recommendations.
• 3:27
  SPEAKER_01: As for studies, our first article released early in MMWR on March 8th highlights a dose response relationship between higher body mass index or BMI and severe COVID-19 associated illness.
• 3:40
  SPEAKER_01: Multivariate logic models were used to estimate adjusted risk ratios between BMI categories and poor outcomes of interest, hospitalization, ICU admission, invasive medical ventilation, and death among hospitalized patients.
• 3:54
  SPEAKER_01: A nonlinear relationship was found between BMI and COVID-19 severity, with lowest risk at BMI near the threshold between healthy weight and overweight in most instances, then increasing with higher BMI.
• 4:07
  SPEAKER_01: Overweight and obesity were risk factors for invasive medical ventilation.
• 4:12
  SPEAKER_01: Obesity was a risk factor for hospitalization and death, particularly among adults aged 65 years and older.
• 4:18
  SPEAKER_01: These findings highlight clinical and public health implications of higher BMIs, including the need for intensive management of COVID-19 associated illness, continued vaccine priorization, and masking, and policies to support healthy behaviors.
• 4:32
  SPEAKER_01: The second article published on March 5th in MMWR examines the relationship between state-issued mask mandates and on-premise restaurant dining with county level COVID cases and death growth rates.
• 4:44
  SPEAKER_01: Two outcomes were examined: the daily percentage point growth rate of county-level COVID-19 cases and counter-level COVID-19 deaths.
• 4:52
  SPEAKER_01: The findings suggest that mask mandates are associated with reduction in COVID-19 cases and hospitalization growth rates, whereas reopening on-premises dining at restaurants is associated with increased COVID-19 cases and deaths, particularly in the absence of mask mandates.
• 5:08
  SPEAKER_01: The authors concluded that policies that require universal mask use and restrict any on-premises restaurant dining are important components of a comprehensive strategy to reduce exposure to and transmission of COVID-19.
• 5:22
  SPEAKER_01: Such efforts are increasingly important given the emergence of highly transmissible SARS-CoV-19 variants in the United States.
• 5:30
  SPEAKER_01: Our last study is from JAMA Open Network on March 2nd.
• 5:35
  SPEAKER_01: It's an assessment of a hodl-based COVID-19 isolation and quarantine strategy for persons experiencing homelessness.
• 5:42
  SPEAKER_01: The disrospective cohort study of a hodl-based isolation and quarantine care system for homeless and unstably housed individuals in San Francisco, California was conducted from March 19 through May 31, 2020.
• 5:56
  SPEAKER_01: Individuals unable to safely isolate or quarantine at home with mild to moderate COVID-19, persons under investigation or close contacts were referred from hospitals, outpatient settings, and public health surveillance to five IQ hotels.
• 6:12
  SPEAKER_01: A physician-supervised team of nurses and health workers provided around-the-clock support, including symptom monitoring, wellness checks, meals, harm reduction services, and medications for opioid use disorder.
• 6:25
  SPEAKER_01: Overall, direct transfers to IQ hotels from emergency and outpatient departments were associated with averting many hospital admissions.
• 6:34
  SPEAKER_01: The study suggests that during the COVID-19 pandemic, a hotel-based isolation and quarantine strategy that delivers integrate medical and behavioral health support to people experiencing homelessness can be done safely outside the hospital setting.
• 6:49
  SPEAKER_01: These are the updates for today, and thank you for joining.
• 6:52
  SPEAKER_02: Thank you, Dr.
• 6:53
  SPEAKER_02: Kamal Ahmed.
• 6:54
  SPEAKER_02: I now want to move into the discussion with our speaker.
• 6:57
  SPEAKER_02: Thank you again, Dr.
• 6:58
  SPEAKER_02: Prizer, for joining us today.
• 7:00
  SPEAKER_00: Hello, Dr.
• 7:00
  SPEAKER_00: Hanran.
• 7:01
  SPEAKER_00: It's a great pleasure, and I look forward to discussing with you.
• 7:05
  SPEAKER_02: Dr.
• 7:05
  SPEAKER_02: Prizer, you have published a great deal about COVID-19.
• 7:09
  SPEAKER_02: Can you tell us about some of the work that you've been doing?
• 7:12
  SPEAKER_00: Well, it started almost to the day a year ago when we realized that we would have to set up large-scale diagnostic testing for SARS-CoV-2.
• 7:20
  SPEAKER_00: Unfortunately, over the past 15 years, we've been through a similar exercise when our anti-jual rollout program started here in South Africa from very small beginnings to the biggest program in the world, and the labs had to keep pace.
• 7:34
  SPEAKER_00: And so we've been through this before, and I think that served us quite well.
• 7:38
  SPEAKER_00: And with that came, of course, the need to perform validations of diagnostic assays, but we wanted to go beyond.
• 7:45
  SPEAKER_00: So we made use of a unique or rare facility that we have here, and that is our biosafety level three laboratory.
• 7:52
  SPEAKER_00: And we managed to isolate the new virus in cell cultures, which is in the present climate, in the present weeks, actually more important even than previously, seeing that we've witnessed the emergence of the new variant.
• 8:06
  SPEAKER_00: And I think we're probably going to talk about that later still.
• 8:09
  SPEAKER_00: And that is something for which one needs cell culture, isolates of the virus in order to prepare standards and so on.
• 8:17
  SPEAKER_00: All those things are, of course, not exciting, cutting-edge signs in their own right, but they are important to support all sorts of other endeavors.
• 8:25
  SPEAKER_00: And another ability of our lab is sequencing and sequence analysis.
• 8:29
  SPEAKER_00: And as part of a national program, that, and I think that's something that South Africa can be proud of, that was implemented as early as May last year.
• 8:40
  SPEAKER_00: We have been sequencing a proportion of our positive cases ever since.
• 8:44
  SPEAKER_00: And that has served us very well, shedding light on the arrival of the virus here in our area.
• 8:51
  SPEAKER_00: That is Cape Town in the Western Cape.
• 8:53
  SPEAKER_00: It's the southwestern tip of the African continent.
• 8:57
  SPEAKER_00: We could show that the virus came here via Europe on several occasions.
• 9:02
  SPEAKER_00: It wasn't just one importation, it was several ones.
• 9:05
  SPEAKER_00: And we could also then show the subsequent spread of some of these variants in the local population, even during our very strict and early full lockdown, where really the activity was extremely curtailed and only a few so-called essential businesses were able to operate.
• 9:23
  SPEAKER_00: And yet that was enough for the virus to spread.
• 9:26
  SPEAKER_00: Subsequently, we've looked at some super spreading event that occurred last year, where again, of course, looking for viral variants and linking cases to one another is very valuable.
• 9:38
  SPEAKER_00: And then last but not least, we were able to witness almost real-time the emergence of the new 501YV2 variant of the virus.
• 9:48
  SPEAKER_00: And that coincided with our second wave, which fortunately we have now left behind us.
• 9:54
  SPEAKER_00: We were also involved in a number of clinical and other trials in a supportive function.
• 10:00
  SPEAKER_00: So it's really a mixture of different things that we are trying to do.
• 10:04
  SPEAKER_00: And last but not least, zero surveillance studies.
• 10:07
  SPEAKER_00: And again, it confirmed that even the strict lockdown was unable to prevent the spread in certain low-income areas.
• 10:15
  SPEAKER_00: And I think that's something that's been seen in many other countries, including the United States, that if your work does not allow you to work from home, if you have to commute to work, and here it is sadly in the absence of other forms of public transport, it's in those mini taxis where you have 12 to 15 people sitting in small vans very closely together, traveling an hour or longer to work and then in the evenings back from work.
• 10:42
  SPEAKER_00: That of course is very conducive to spread.
• 10:44
  SPEAKER_00: And if if such people then return to their homes that are normally very small dwellings with large families, often of several generations living together, that of course leads to a massive spread.
• 10:57
  SPEAKER_00: And this is exactly what we could confirm by doing seriosurveillance studies.
• 11:01
  SPEAKER_00: And we are currently doing another round doing convenience sampling of, i.e., testing residual diagnostic specimens sent for other purposes, knowing that this is, of course, not an accurate reflection of what's happening in the community at large, but it gives you an insight into certain population groups.
• 11:20
  SPEAKER_00: And we want to see what the massive second wave did to our serial prevalence.
• 11:25
  SPEAKER_00: And the early indications are it surged.
• 11:29
  SPEAKER_00: So in some areas, at least in the urban context, we have sero prevalence rates above 50%.
• 11:36
  SPEAKER_02: Wow, that is stunning.
• 11:38
  SPEAKER_02: But I have to follow up on you know some of what you've said.
• 11:41
  SPEAKER_02: It's amazing that you've had this big surge and that you have this high serial prevalence rate.
• 11:47
  SPEAKER_02: What do you think helped lead to the end of this surge?
• 11:52
  SPEAKER_00: That is actually a question which we are still trying to come to terms with.
• 11:57
  SPEAKER_00: We don't know.
• 11:58
  SPEAKER_00: The second wave happened, and I think I speak for the vast majority of colleagues here in epidemiology, virology, public health, and so on, it caught us by surprise.
• 12:09
  SPEAKER_00: We did expect that the Christmas period, which coincides, of course, with the Southern Hemisphere summer holiday, would spar travel.
• 12:17
  SPEAKER_00: It's traditionally the period when people travel, meet family, you know, all those things that are, of course, conducive to the spread of the virus.
• 12:25
  SPEAKER_00: But the sheer magnitude of it was overwhelming.
• 12:28
  SPEAKER_00: And I can say that even in our province here around Cape Town, that's the Western Cape, which came very well through the first wave in terms of health system capacity, you know, the general upkeep of essential services.
• 12:43
  SPEAKER_00: Even we were between Christmas and the new year, we were very much on the edge.
• 12:48
  SPEAKER_00: It was, it was really a near miss in terms of oxygen supply and so on.
• 12:52
  SPEAKER_00: And that is not because of poor preparation or implementation of policies.
• 12:58
  SPEAKER_00: That is really, it just reflected the sheer enormous size of the second wave.
• 13:03
  SPEAKER_00: But it almost came to an end almost as rapidly as it started.
• 13:07
  SPEAKER_00: And we probably have to consider two factors.
• 13:11
  SPEAKER_00: So, firstly, we may have reached in quite some areas, and we are looking into this now through these serial surveillance studies, we may have reached some degree of population immunity that simply made it more difficult for the virus to spread further.
• 13:25
  SPEAKER_00: But it was also a somewhat belated, I have to say, implementation of renewed, stricter lockdown measures.
• 13:33
  SPEAKER_00: And so if we look at across the country, the numbers started coming down almost simultaneously in the different provinces, but the wave had not run its course everywhere to the same degree.
• 13:43
  SPEAKER_00: So we do think that these measures made a difference.
• 13:47
  SPEAKER_00: And in certain areas, at least, the high zero province rate may also have sort of deprived the virus of fuel for for the time being.
• 13:56
  SPEAKER_00: But we don't know for sure.
• 13:57
  SPEAKER_00: So this work is ongoing still.
• 14:00
  SPEAKER_02: So, Dr.
• 14:01
  SPEAKER_02: Prizer, you touched on some of this already, but Africa has some unique challenges in that there have been other outbreaks happening at the same time as COVID-19.
• 14:09
  SPEAKER_02: For example, we're hearing now about another Ebola outbreak in Guinea.
• 14:14
  SPEAKER_02: What are some of the unique challenges that are being faced?
• 14:17
  SPEAKER_00: You know, Africa is very much in the epidemiological transition.
• 14:20
  SPEAKER_00: So we have on one hand, and I think South Africa, anybody who's been here and sort of gone beyond the normal touristic activities would have seen this.
• 14:30
  SPEAKER_00: South Africa is absolutely extreme in that it is really two countries rolled into one, you know, in the vicinity of one another.
• 14:37
  SPEAKER_00: I mean, you have areas that are affluent and middle class and where people live very nice lives.
• 14:43
  SPEAKER_00: And then, you know, two kilometers down the road, you have very impoverished areas.
• 14:47
  SPEAKER_00: So it's it's it's crazy.
• 14:49
  SPEAKER_00: You know in a way it sort of exemplifies maybe the modern world.
• 14:52
  SPEAKER_00: Uh, and we've never been able to really move beyond a scenario where there's a lot of infectious diseases.
• 14:58
  SPEAKER_00: And down here it's it's particularly TB.
• 15:01
  SPEAKER_00: I have to say that in the 15 years that I have been here since 2005, HIV has we have really made bad inroads into HIV with a very good penetration of the anti-retroviral rollout program.
• 15:15
  SPEAKER_00: Prevention of mother-to-child transmission of HIV is really taken that down from almost 20% in our area here to less than 1%.
• 15:24
  SPEAKER_00: So, you know, we I'm not I'm not saying that we haven't made progress, but TB is and remains a challenge.
• 15:30
  SPEAKER_00: There were big concerns about what would happen if COVID meets TB.
• 15:34
  SPEAKER_00: And it is obviously not helpful, but it's also not the biggest problem.
• 15:38
  SPEAKER_00: It's not the worst comorbidity to have if you contract a SARS-CoV-2 infection.
• 15:43
  SPEAKER_00: Other areas had, you know, had to contend with outbreaks, including South Africa, in the northern provinces, malaria, cholera occasionally.
• 15:51
  SPEAKER_00: And there was sort of the assumption almost that Africa is used to this, so Africa knows how to do this.
• 15:57
  SPEAKER_00: And I would contest that in that it's a question of the mode of spread and the recognition of you know the risks and so on.
• 16:06
  SPEAKER_00: And I would argue that that COVID was sufficiently different from those infectious diseases encountered previously, so as to not make it just, you know, just another one on the list.
• 16:16
  SPEAKER_00: And I think that's what we've seen.
• 16:18
  SPEAKER_00: There's also, you know, initially been much speculation about the allegedly hot African climate and weather conditions, which, you know, I'm not sure I would subscribe to.
• 16:29
  SPEAKER_00: I've never been colder in my life than on some occasions in Africa, but it's not not invariably just very hot and humid.
• 16:36
  SPEAKER_00: But the experience since, and and also, of course, Manaus in Amazonia, where it's also hot and tropical year-round, I think are ample warning that you know one can't rely on hot temperatures and the summer months to take the edge of the spread of this respiratory infection.
• 16:53
  SPEAKER_00: I have to say that I found it quite stunning that facing an endemic, catastrophic infectious disease such as TB, which you know, South Africa has done now for more than 100 years, we would still be quite unprepared for another, obviously more acute, but I might argue less dangerous respiratory tract infection to arrive.
• 17:17
  SPEAKER_00: So one would have hoped that infection control in hospitals would have been in a better state and that whatever was in place against TB would have protected also against COVID.
• 17:26
  SPEAKER_00: And I think what we have seen is that what is being done against TB, which is an ongoing threat, of course, and has been endemic for a long time, is simply not enough.
• 17:38
  SPEAKER_00: The difference being that it doesn't hit as quickly as COVID.
• 17:42
  SPEAKER_00: So, you know, people I think don't make the connection so easily because of the long incubation period and so on and so forth.
• 17:49
  SPEAKER_00: And in fact, we have seen many tragic cases over the years here of colleagues, medical students, and others contracting TB, including multi- and and extended drug-resistant TB strains here at Tiger Vic Hospital and, of course, also elsewhere, and suffering debilitating illness from that.
• 18:07
  SPEAKER_00: And my personal hope is that COVID will provide an impetus to tackle this issue, even you know, when maybe in a year or more from now we'll all be all or many of us will be vaccinated and it will have sort of it won't be as scary as it is now, that we will still keep up certain behaviors that will then also be provide better protection against tuberculosis.
• 18:32
  SPEAKER_02: Well, I think certainly it sounds extremely challenging.
• 18:35
  SPEAKER_02: I want to ask you, and you know, you alluded to this already, but I just want to make sure I'm understanding this correctly.
• 18:41
  SPEAKER_02: So, what has the impact of the South African variant been on the epidemic?
• 18:45
  SPEAKER_02: Are you saying that there were two surges because of the emergence of the variant?
• 18:50
  SPEAKER_00: I think it coincided.
• 18:52
  SPEAKER_00: And the big question is whether the variant happened to be there and to hitch a ride on the upcoming uh surge or whether it was actually the driver behind it.
• 19:05
  SPEAKER_00: To be honest, I was skeptical initially, seeing that for the first eight months or so of the pandemic, we we used the genetic differences between the different SARS-CoV-2 variants for epidemiological purposes, as I've briefly described earlier, but there wasn't much in terms of difference or evidence for difference in behavior, epidemiologically speaking.
• 19:29
  SPEAKER_00: So I was skeptical initially when I heard that the Eastern Cape, which is the province where our second wave started, that there was this new variant.
• 19:38
  SPEAKER_00: And fortunately, we had this network in place already, this national consortium.
• 19:42
  SPEAKER_00: So we were able to very quickly put the data together.
• 19:45
  SPEAKER_00: And I think the trick is firstly to sequence a certain proportion of positives, which of course many industrialized countries are doing.
• 19:53
  SPEAKER_00: But I think the second important aspect is that you know you need to put these data together.
• 19:58
  SPEAKER_00: And I think this is where the strength lies of our consortium, that this is compiled in a systematic fashion so that you can see patterns emerging over time and across areas.
• 20:10
  SPEAKER_00: And so this variant was noticed first in the Eastern Cape, that was at the time experiencing a very bad second wave, the first province in our country at the time.
• 20:20
  SPEAKER_00: And it could then be followed, spreading along the coast, both northwards towards KwaZulu Natal and westwards to into our province, the Western Cape province.
• 20:31
  SPEAKER_00: So, you know, it was a very strong pattern temporarily and geographically.
• 20:35
  SPEAKER_00: And we are still looking in, you know, we have still sequencing samples that we've all stored in our minus 80 freezers now.
• 20:43
  SPEAKER_00: But there's a clear picture emerging that this variant was virtually absent from our area here in Cape Town.
• 20:50
  SPEAKER_00: It arrived in early November, and by the end of November, it had become the majority variant found in infected patients.
• 20:57
  SPEAKER_00: And at the same time, the numbers of infections surged.
• 21:00
  SPEAKER_00: So, you know, and I was hesitant initially to ascribe any particular properties to the new variant, but I have been convinced that it is probably more easily transmitted than the wild type virus that we saw before.
• 21:14
  SPEAKER_00: So I think what happened is we were really very unlucky in that the emergence of this variant coincided with the impending second wave of the outbreak, and together it really blew it out of proportion.
• 21:27
  SPEAKER_02: So you mentioned a little bit about vaccinations.
• 21:30
  SPEAKER_02: I'm curious, first of all, how readily available are vaccines?
• 21:34
  SPEAKER_02: And has the fact that the variants in South Africa may be less likely to be covered by current vaccines influenced decisions for people to become vaccinated?
• 21:43
  SPEAKER_00: What a good question.
• 21:44
  SPEAKER_00: It's very difficult.
• 21:45
  SPEAKER_00: I mean, let me start with saying that we are in the fortunate situation in South Africa that we have quite a strong research network and tradition when it comes to testing vaccines.
• 21:57
  SPEAKER_00: A lot of it has been built up for working on.
• 22:00
  SPEAKER_00: On HIV vaccines, and we all know we are not there yet.
• 22:04
  SPEAKER_00: But also for other, you know, vaccine trials.
• 22:07
  SPEAKER_00: And that served us very well because from early on last year, there were different trial sites, clinical trial sites for different vaccines here in South Africa.
• 22:16
  SPEAKER_00: And that again is a huge asset.
• 22:18
  SPEAKER_00: This is it basically only this allows one to assess how a particular vaccine will do in the local context.
• 22:25
  SPEAKER_00: That said, of course, timing is also important, and particularly when it comes to a new variant, which, you know, in Cape Town area really took over during the course of November last year and then spread northwards.
• 22:37
  SPEAKER_00: So in densely populated province further up, north in Hao Teng, it was really during the course of December.
• 22:44
  SPEAKER_00: And so you need to have, and that is of course purely fortuitous.
• 22:47
  SPEAKER_00: I mean, you you can't plan these things.
• 22:49
  SPEAKER_00: You need to have your trials ready to run and being rolled out and starting as such a wave occurs and the variant hits.
• 22:57
  SPEAKER_00: And that happened for a couple of these vaccines.
• 23:00
  SPEAKER_00: And I think most worryingly, one of them, the AstraZeneca vaccine, did not seem to protect against mild to moderate disease in a phase two trial.
• 23:11
  SPEAKER_00: And I think that is the important detail that is often omitted.
• 23:15
  SPEAKER_00: This was not a phase three trial, which is about efficacy in sort of a real type of target population.
• 23:21
  SPEAKER_00: This was a phase two trial.
• 23:23
  SPEAKER_00: And even though this is very significant data, of course, because one would hope any vaccine to also reduce the risk of infection per C, you know, it it basically what it doesn't say is that this vaccine is not going to protect against severe disease and death.
• 23:36
  SPEAKER_00: And that is ultimately what we are all looking for.
• 23:39
  SPEAKER_00: And that has caused a huge confusion tragically in that the government, after what I think is fair to say, a sort of belated start in the in the vaccine, other than signing up for COVAX and then not doing anything beyond during the month of December.
• 23:55
  SPEAKER_00: Together with many colleagues, we sort of took up arms, so in that case, our keyboards, and you know, urged the government to get going in terms of vaccine procurement.
• 24:05
  SPEAKER_00: And what they did is they they got the AstraZeneca vaccine, a million doses, and a bit made in India, which arrived, was met at the airport by the president.
• 24:15
  SPEAKER_00: And then a week later, this bomb bursts and the data from the AstraZeneca trial come out that this vaccine is not going to protect against mild to moderate illness.
• 24:25
  SPEAKER_00: So here changes the plan yet again.
• 24:28
  SPEAKER_00: And that of course is difficult.
• 24:30
  SPEAKER_00: I mean, on one hand, it's a fantastic situation to be in.
• 24:33
  SPEAKER_00: I mean, I you know, I have to tell myself that little did I expect vaccines to be available in the in the millions and tens of millions of doses as soon as a year after this this whole pandemic kicked off.
• 24:44
  SPEAKER_00: I mean, this is absolutely fantastic and a huge achievement of science.
• 24:49
  SPEAKER_00: And I think you know that that helps me preserve my sanity when I remind myself of that.
• 24:55
  SPEAKER_00: But of course, there are many issues, and and one issue is, of course, capacity for administering the vaccine and of course for making enough of it.
• 25:02
  SPEAKER_00: So having a million doses here in the country sitting in in warehouse but not being used now, you can imagine that this gives uh rise to heated discussions as to whether it should be used or not.
• 25:14
  SPEAKER_00: And you know, there are arguments too uh for and against, and you know, I don't think anybody knows the absolute truth.
• 25:21
  SPEAKER_00: What's happened is that much fewer doses of the Johnson ⁇ Johnson vaccine, which I think is now also being FDA approved for the United States, were procured, and so they have started uh vaccinating healthcare workers, including here at our facility, Tiger Hospital.
• 25:37
  SPEAKER_00: But of course, this is a relatively slow start.
• 25:40
  SPEAKER_00: There's a long way to go just to cover the healthcare workers, and then there will be further population groups with vaccines still having to be, I think they are procured.
• 25:50
  SPEAKER_00: We don't know many details about it.
• 25:52
  SPEAKER_00: But these are all difficult issues.
• 25:55
  SPEAKER_00: As regards, I think, vaccine hesitancy is the current term best to be used.
• 26:00
  SPEAKER_00: Again, I think the weird, if I may say so, situation in South Africa is reflected in uptake.
• 26:06
  SPEAKER_00: So I think many of the working class population, and I count myself amongst them, that have seen the devastation of COVID in, you know, not only at work, like like we have, of course, here in the healthcare sector, but also, you know, amongst family and friends and neighbors and and and so on.
• 26:23
  SPEAKER_00: So I can't imagine that many can be completely oblivious to what it has done.
• 26:28
  SPEAKER_00: You know, I mean, for us, there is basically no question, of course.
• 26:31
  SPEAKER_00: You know, thank you.
• 26:32
  SPEAKER_00: Tell me when, and I will roll up my sleeve.
• 26:35
  SPEAKER_00: But there is, of course, also in the, and particularly in the social media, so that's people that have access to this and they use it and they also have time to do that.
• 26:44
  SPEAKER_00: There's a lot of vaccine denial and all sorts of, let me not qualify by using impolite words, but you know, all sorts of issues.
• 26:53
  SPEAKER_00: I think very much like what one also sees in industrialized countries.
• 26:57
  SPEAKER_00: In a way, I have to say I take some comfort in feeling and hoping that those that do not have good education, that have less of a choice in many things in life, simply they have to make do and they, you know, they don't have the luxury of procrastinating about certain decisions for too long.
• 27:16
  SPEAKER_00: I take some consolation in the fact that they will they are probably more likely to go for vaccination and then be protected and let those who should be in a position to get proper information and to form their own opinion on it and come to valid conclusions.
• 27:32
  SPEAKER_00: If they choose not to do so and go astray, then then by all means let them go.
• 27:38
  SPEAKER_00: It's a weird thing which we have seen in the past when we had measles outbreaks, where somewhat paradoxically, perhaps, children growing up in township areas in very poor areas had a higher chance of being immunized against measles through the state vaccine program than the children in the more affluent suburbs where parents sadly still had picked up on long debunked stories about autism and so on.
• 28:07
  SPEAKER_00: So it is a problem, the vaccine hesitancy, but I do hope that those at the forefront of the pandemic response have taken the right message with from the experiences.
• 28:19
  SPEAKER_00: And I'm quite confident that we will not see a worse uptake than we've seen in many other countries.
• 28:25
  SPEAKER_02: So, Dr.
• 28:25
  SPEAKER_02: Prizer, you have described the fact that different countries in Africa face different challenges in mitigating this pandemic.
• 28:32
  SPEAKER_02: Can you describe some of the differences that these different countries face?
• 28:36
  SPEAKER_00: Yeah, I think Africa generally went for very early and strict response.
• 28:41
  SPEAKER_00: So we we we locked down, and you know, many countries before they had seen any appreciable number of infections.
• 28:48
  SPEAKER_00: And on one hand, of course, one thinks well, this is great, let's be the next South Korea or Taiwan, and let's sort of not allow this thing to get a foothold here.
• 28:58
  SPEAKER_00: Of course, this is not how things work in Africa.
• 29:01
  SPEAKER_00: So the full response of those few countries that were really able to keep it away, and also often have very unique situations of you know being islands and so on.
• 29:11
  SPEAKER_00: They basically threw themselves on the case with an immense testing and so on effort, which is simply not doable in Africa.
• 29:18
  SPEAKER_00: And I think that ultimately proved the downfall of our attempts.
• 29:22
  SPEAKER_00: It looked good initially, but it didn't go far.
• 29:25
  SPEAKER_00: And I think another lesson that we've learned here in South Africa is that lockdown measures, and as I mentioned, they were very strict here.
• 29:33
  SPEAKER_00: They work in the amongst the more affluent parts of the population, but they cannot be successful amongst the really poor because not only do they not have any livelihood, they also live in very crowded circumstances with large families where distancing is basically not an option.
• 29:49
  SPEAKER_00: I mean, imagine where several households, which often live in mere shacks, share one standpipe somewhere where of course everybody meets when they fetch water and then they also share a toilet somewhere.
• 30:02
  SPEAKER_00: So that, you know, the circumstances of life are just very different.
• 30:05
  SPEAKER_00: There are a few countries in Africa that sadly adopted, or probably not the country, but the the governments adopted unscientific stances.
• 30:14
  SPEAKER_00: And again, that's not unique.
• 30:16
  SPEAKER_00: We've seen that previously with HIV from denial.
• 30:19
  SPEAKER_00: Tanzania, for example, I think is only now coming, officially coming to grips with sitting on a disaster here after several high-ranking politicians have now succumbed to COVID.
• 30:31
  SPEAKER_00: Others like Madagascar touted herbal remedies, you know, in an unscientific fashion.
• 30:37
  SPEAKER_00: I'm not saying that you wouldn't have some pharmaceutical benefit for symptom alleviation, for example, by traditional or herbal remedies.
• 30:45
  SPEAKER_00: But of course, we all realize this is not a it's not a cure and it's not a prophylactic that would do any good.
• 30:51
  SPEAKER_00: And it's it simply doesn't replace all the other measures.
• 30:54
  SPEAKER_00: And if it is propagated as such a miracle intervention, then you know it's it's going to do more harm than any good.
• 31:01
  SPEAKER_00: So there were vastly different responses.
• 31:04
  SPEAKER_00: Several countries seem to have done very well, but I think the problem is the long haul and the overall very limited capacity to survive.
• 31:14
  SPEAKER_00: I mean, in economically and socially survive prolonged areas of shutdown.
• 31:20
  SPEAKER_00: It is difficult as is even in affluent countries.
• 31:23
  SPEAKER_00: And I think in poor countries, you know, a large proportion of the population simply need to make ends meet in whatever way.
• 31:31
  SPEAKER_00: And, you know, thinking of the person's safety and staying out of touch is really the seen as a luxury because otherwise one doesn't eat.
• 31:39
  SPEAKER_00: South Africa has seen a major rollout of social grants and other things, which I think alleviated the problem.
• 31:46
  SPEAKER_00: But again, we're also beset with issues.
• 31:48
  SPEAKER_00: Again, I don't think this is unique to Africa, other countries have have seen it, but here it just hits harder because people have less reserve to stay on.
• 31:57
  SPEAKER_00: So it I think there is only a limited period of time that one can afford to shut down economic activity, and then as that resumes, so does the risk.
• 32:08
  SPEAKER_00: And I think that's what we've seen.
• 32:09
  SPEAKER_00: And I have to say that even though it feels like at the moment we are out of the woods, the numbers are way down.
• 32:16
  SPEAKER_00: And of course, it is nice that certain economic activities are returning after our lockdown level was now decreased to level one, which is the mildest form.
• 32:26
  SPEAKER_00: At the same time, I'm sure I'm not the only urologist and epidemiologist that sees that also with some trepidation, because we know that this is, of course, the situation under which the epidemic will increase again.
• 32:38
  SPEAKER_00: Maybe an added aspect, which I think is rare or has rarely been done elsewhere.
• 32:43
  SPEAKER_00: South Africa has a massive alcohol problem.
• 32:47
  SPEAKER_00: And part of our strict lockdowns was a limitation and for several weeks a total ban on the sale of alcohol.
• 32:56
  SPEAKER_00: And the purpose of that is less sort of avoidance of social situations where people drink and, you know, obviously also then get close to one another and may transmit the infection.
• 33:08
  SPEAKER_00: But it was largely, often together with a curfew, meant to reduce the trauma numbers.
• 33:14
  SPEAKER_00: And it is absolutely amazing to watch the effects.
• 33:18
  SPEAKER_00: Before Christmas, we were on the brink of failure here at Tigerberg Hospital, which is a large academic hospital serving half the Western Cape province due to the combined effects of a massive surge in COVID cases plus an enormous burden in trauma.
• 33:33
  SPEAKER_00: And that is both crime, criminal trauma and accidents, and largely linked to drunkenness.
• 33:40
  SPEAKER_00: And the day after the alcohol ban was reinstituted, the trauma unit had I think from 70 patients down to four or so.
• 33:49
  SPEAKER_00: It was a drastic reduction, which helped.
• 33:52
  SPEAKER_00: I mean, I I sighed a breath of uh relief that I, you know, like hardly ever before.
• 33:57
  SPEAKER_00: And we, I mean, I'm only in the lab, but we felt it because we didn't get these enormous numbers of patients that had to be screened on arrival urgently in order to be managed accordingly.
• 34:07
  SPEAKER_00: It made a massive difference.
• 34:09
  SPEAKER_00: And I very much wish that in some way, some of the good that has been done, so many deaths and and serious injuries have been avoided due to that.
• 34:19
  SPEAKER_00: So I really wish that there was a way in that some of the good consequences will be, you know, rescued into the future.
• 34:27
  SPEAKER_00: I'm not sure how to do that, but evidence is extremely strong.
• 34:31
  SPEAKER_02: Yeah, it's interesting.
• 34:32
  SPEAKER_02: Some of the problems that you talk about are really the same problems, you know, that people are describing all over the world.
• 34:37
  SPEAKER_02: I mean, these wish for some miracle cure is uh we've certainly seen our share of that in the United States as well.
• 34:45
  SPEAKER_02: I want to ask you, how accessible is testing for SARS-CoV-2 in South Africa?
• 34:50
  SPEAKER_02: And can you discuss any of the barriers that exist to testing?
• 34:53
  SPEAKER_00: It is very accessible.
• 34:55
  SPEAKER_00: I think we we did quite a good job in setting up testing on large scale.
• 34:59
  SPEAKER_00: I have to explain briefly the background.
• 35:02
  SPEAKER_00: About 20% of the South African population are in employment and usually have private healthcare insurance.
• 35:08
  SPEAKER_00: And they would make use of private healthcare providers, including private labs, of which there are several big ones with a presence more or less around the country.
• 35:18
  SPEAKER_00: And they scaled up their provision, and so did we, as part of the National Health Laboratory Service.
• 35:24
  SPEAKER_00: And that is a national peristatal organization that provides all the laboratory testing for the approximately 80% of South Africans that do not have private healthcare insurance.
• 35:33
  SPEAKER_00: And we realized something was coming.
• 35:36
  SPEAKER_00: We set up in-house assays, soon realized we would have to go beyond.
• 35:41
  SPEAKER_00: And then, of course, there were a number of manufacturers and increasing numbers providing solutions for SARS-CoV-2 testing.
• 35:49
  SPEAKER_00: I have to say that even though ultimately I think we did well, one of the big disappointments of the past year is linked to that, in that some of the big platforms, which have an enormous presence here, and that is really thanks to the TB and HIV treatment programs.
• 36:07
  SPEAKER_00: That basically meant that there are numerous labs that have these platforms, that for a long time it was not possible to procure sufficient supplies to run SARS-CoV-2 testing on those platforms.
• 36:21
  SPEAKER_00: And that would have made an enormous difference.
• 36:23
  SPEAKER_00: Labs like ours, that has an academic footprint, of course, is linked to an academic unit, are able to operate in-house assays or non-automated commercial assays very successfully.
• 36:36
  SPEAKER_00: Other laboratories cannot do this because they don't have the manpower, you know, they have staff expertise, staff numbers, and so on and so forth.
• 36:44
  SPEAKER_00: So for them, it would have been extremely valuable to have access to sufficient numbers of test kits for these big platforms, which are, you know, and then it doesn't really matter whether you test for SARS-CoV-2 or HIV Viraload or TV, because you know the machine basically does it.
• 37:00
  SPEAKER_00: I'm simplifying now, of course, it's never that easy.
• 37:03
  SPEAKER_00: But it's still it's a lot more uh accomplishable than these non-automated assays.
• 37:09
  SPEAKER_00: And that remained a big issue.
• 37:11
  SPEAKER_00: And another sad experience was that a particular platform that again has a wide footprint across South Africa for rapid molecular testing in a cartridge format, which basically means you can get away using staff with minimal training.
• 37:27
  SPEAKER_00: You don't need to know about PCR and all that.
• 37:29
  SPEAKER_00: So the machines are available, trained staff are available, but we simply could not get enough kits.
• 37:35
  SPEAKER_00: And that would have made an enormous difference in that it would have allowed also the more remote parts of the country to test their patients rapidly instead of shipping the specimens to the centralized laboratories and you know adding basically 24 hours or so right from the start.
• 37:50
  SPEAKER_00: That said, there were, of course, times when we were overwhelmed.
• 37:54
  SPEAKER_00: During the first wave, there came the time when our turnaround times rose inacceptably and so as to render the test results unuseful.
• 38:03
  SPEAKER_00: And I think that's another experience that other countries have had as well.
• 38:06
  SPEAKER_00: And during these periods, we limited the accessibility of testing.
• 38:11
  SPEAKER_00: And so if you were below 55 years of age and didn't have risk factors for severe disease, but had consistent symptoms, you didn't have a swap sample taken and tested, you were just told to consider yourself as having COVID and to isolate.
• 38:26
  SPEAKER_00: We know this is not ideal because people might not do it.
• 38:29
  SPEAKER_00: They might even not do it even if they got a positive test result.
• 38:33
  SPEAKER_00: But in the absence of such a test result, you know, they are even less likely to do that.
• 38:36
  SPEAKER_00: So it's it's it's not ideal, but it did protect the clinical services where, you know, the important decisions have to be made urgently.
• 38:45
  SPEAKER_00: We then reintroduced a similar restriction on who could get tested during the second wave, but I have to say that thanks to the much increased capacity, and so we used the period from July to October last year to really massively upscale our equipment, to train staff, to hire additional staff, and lab services really didn't go down with the second wave.
• 39:08
  SPEAKER_00: We were able to maintain our very rapid turnaround times, and I think that was a big advantage to allow clinical services to function efficiently.
• 39:17
  SPEAKER_00: We are not talking of raw testing.
• 39:19
  SPEAKER_00: There were attempts at doing community screen and test, whereby, you know, teams would go out into communities and screen people for symptoms and contact history and then test if they fulfilled certain criteria.
• 39:31
  SPEAKER_00: That never really worked well.
• 39:33
  SPEAKER_00: And the reason being that it coincided with the first wave, and you know, test results were simply too slow to arrive to in order to make a difference.
• 39:41
  SPEAKER_00: And this is something where we have now, and through the second wave already, used rapid antigen tests.
• 39:47
  SPEAKER_00: And I have to say it is a positive experience.
• 39:50
  SPEAKER_00: We use it in a different context from some industrialized countries where screening at schools and workplaces is being done or being contemplated.
• 39:58
  SPEAKER_00: And we all know that it can go wrong and that it is not 100% fail a safe thing to do.
• 40:04
  SPEAKER_00: And there have been some prominent examples of people relying on a negative antigen test and otherwise being reckless.
• 40:11
  SPEAKER_00: But we use it in the context of a clinical service.
• 40:15
  SPEAKER_00: And I must say that it probably identifies people currently infectious quite well, and it has helped us a great deal to have this as an additional instrument during the peak times.
• 40:27
  SPEAKER_02: So, Dr.
• 40:28
  SPEAKER_02: Pizar, you recently published an article about 16 different variants that emerged in South Africa.
• 40:33
  SPEAKER_02: This seems like a very large number over a relatively short period of time.
• 40:37
  SPEAKER_02: Would you expect to find the same number of variants in other areas of the world?
• 40:41
  SPEAKER_02: And was there any difference in clinical illness that anyone could detect with any of these strains?
• 40:46
  SPEAKER_00: Yeah, these strains that was prior to the emergence of our 501YV2 variant.
• 40:53
  SPEAKER_00: So these we really looked at in the context of molecular epidemiology.
• 40:57
  SPEAKER_00: So we we were trying to figure out what was happening in the country, how SARS-CoV-2 had arrived here, and then how it on various occasions into various parts of the country, and then how it spread.
• 41:09
  SPEAKER_00: So they were used as a tool, and there is no evidence that they behave differently in terms of transmissibility or clinical illness.
• 41:17
  SPEAKER_00: That said, even the new strain, which is very likely to be more easily transmitted than those variants, until very recently, we did not have any evidence that it would make any difference clinically.
• 41:30
  SPEAKER_00: So looking at risk factors and clinical courses during the first and the second wave did not reveal any marked differences.
• 41:38
  SPEAKER_00: But there is now some sort of some hint at maybe a higher pathogenicity, uh higher virulence of the new variant.
• 41:45
  SPEAKER_00: But these are all very early data, and of course, they are always difficult to figure out and to, you know, there are many confounding factors that need to be teased out.
• 41:54
  SPEAKER_00: So it's it's probably too early to say that.
• 41:56
  SPEAKER_00: But there is a bit like with the variant that first recognized in in the southeast of England, there may be some signal of also a higher clinical severity, but that cannot be said for those that we observed previously, where really doing the genomics was a molecular epidemiological tool rather than anything else.
• 42:16
  SPEAKER_00: And now we, of course, we we have the issue that we are not at the end.
• 42:19
  SPEAKER_00: I mean, we now have sadly we have this variant, and it's posing enormous problems in terms of, of course, diagnostic assays.
• 42:26
  SPEAKER_00: Luckily, there's no evidence that any of the currently used assays misses it, but you know, it's still something you need to watch.
• 42:33
  SPEAKER_00: Efficacy of vaccines is something that we are worried about, and I think rightly so.
• 42:38
  SPEAKER_00: In vitro data also show that the currently available vaccines protect less well against our new variant.
• 42:45
  SPEAKER_00: Fortunately, it doesn't work the other way around.
• 42:47
  SPEAKER_00: So if you have antibodies against the new variant, those antibodies are good at neutralizing other variants, including the preceding ones.
• 42:54
  SPEAKER_00: So that is good news, but of course, ultimately we'll need to have vaccines that use the new variants' antigens.
• 43:00
  SPEAKER_00: So that is, of course, an area that needs watching.
• 43:04
  SPEAKER_00: But it's not the end of the day.
• 43:05
  SPEAKER_00: I mean, we we still need to monitor the circulation of the virus and recognize any other variants that might still emerge.
• 43:12
  SPEAKER_00: And I think that's also one of the results of the much increased activity monitoring, genomic monitoring activity over the past two months.
• 43:21
  SPEAKER_00: That, you know, variants are being discovered all over now.
• 43:24
  SPEAKER_00: So if if one looks, one will find how relevant they are is then another question that needs investigation.
• 43:31
  SPEAKER_00: But I think we have been warned.
• 43:33
  SPEAKER_00: We did not see this issue coming.
• 43:35
  SPEAKER_00: I think that's also fair to say.
• 43:37
  SPEAKER_00: We've had a wake-up call, and I think we also realize that it is really time to get vaccines into arms, to get as many people immune as we can, as quickly as we can, in order to prevent the ongoing circulation and the emergence of future additional viral variation.
• 43:54
  SPEAKER_02: Dr.
• 43:55
  SPEAKER_02: Preiser, I want to thank you for being so generous with your time for our listeners.
• 43:59
  SPEAKER_02: Do you have any last words of wisdom about how we in the United States can effectively fight back against these variants?
• 44:06
  SPEAKER_00: Of course, my my first uh plea would be, you know, if when you get the chance to be vaccinated, you know, go for it and get vaccinated.
• 44:14
  SPEAKER_00: I think this is the best tool by far.
• 44:17
  SPEAKER_00: And being vaccinated, of course, does not mean that, you know, for the time being at least you can revert back to life as we knew it before 2020, you know, there is an interim period during which the masks need to stay up and the distancing needs to be maintained and so on.
• 44:32
  SPEAKER_00: But uh clearly getting vaccinated when the opportunity arises is a very important message.
• 44:37
  SPEAKER_00: And secondly, I think please spare a thought to how these variants emerge.
• 44:42
  SPEAKER_00: And it is really true that as long as this virus is allowed to spread in whatever part of the world, you know, for that time the virus will keep evolving, viral evolution will not stop.
• 44:55
  SPEAKER_00: And, you know, chances are this will include variants of concern and they can come back and spread.
• 45:02
  SPEAKER_00: We do want to open the global world again to everybody, so we will have intensified travel.
• 45:07
  SPEAKER_00: But I must say that even under the very limited travel options that are available currently, it's amazing how fast these variants have spread into other parts of the world.
• 45:17
  SPEAKER_00: So even though air traffic is a is but a fraction of what it used to be, even that very limited amount was able to spread the variant.
• 45:25
  SPEAKER_00: And just imagine what that would be like in a world where travel links have been restored and travel activity has resumed.
• 45:32
  SPEAKER_00: Many people will not be immune or will not be well immune against the new variants and then be traveling.
• 45:38
  SPEAKER_00: So, in other words, I think, you know, let's let's try and really get the world's population immune against this virus.
• 45:45
  SPEAKER_00: And I personally hope that the affluent countries have ordered so many doses of vaccine for their own populations.
• 45:52
  SPEAKER_00: I mean, often several times more than there are inhabitants in the country, because one didn't know which of the vaccines would work and how well they would work.
• 46:02
  SPEAKER_00: The surprise was a good one.
• 46:03
  SPEAKER_00: Most of them seem to work very well, which is fantastic news.
• 46:07
  SPEAKER_00: But it will also hopefully mean that you will find yourselves with tens or hundreds, possibly of millions of doses left over come 2022, and everyone else has been vaccinated.
• 46:17
  SPEAKER_00: And you know, please do ship those to the countries that have missed out so far.
• 46:22
  SPEAKER_00: And let's see whether we can't get this thing under control globally.
• 46:26
  SPEAKER_00: Thank you.
• 46:27
  SPEAKER_02: Thank you, Dr.
• 46:28
  SPEAKER_02: Prizer.
• 46:29
  SPEAKER_02: Thank you very much to our speaker for sharing your perspectives and experiences.
• 46:33
  SPEAKER_02: This podcast can be accessed on Shay's online education center, learning CE, under the Rapid Response Program.
• 46:40
  SPEAKER_02: You will also find resources such as the recorded webinars, healthcare facility, outbreak preparedness, and the SHA COVID-19 town halls.
• 46:48
  SPEAKER_02: New members can now receive 50% off 2021 SHA membership by using the coupon code WELCOME2021 until March 31st.
• 46:56
  SPEAKER_02: This concludes this episode of the Rapid Response Podcast.
• 46:59
  SPEAKER_02: Thank you for tuning in.