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COVID-19 International Perspectives: South Africa, 10/9 · The SHEA Podcast

• 0:09
  SPEAKER_00: Welcome to the Rapid Response Podcast, brought to you by the Society for Healthcare Epidemiology of America, Shea, promoting the prevention of healthcare associated infections and antibiotic resistance and seeking to advance the fields of healthcare epidemiology and antibiotic stewardship.
• 0:24
  SPEAKER_00: I am Dr.
• 0:25
  SPEAKER_00: David Bannock from the University of Connecticut, and I will serve as your moderator for today's podcast.
• 0:29
  SPEAKER_00: 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.
• 0:38
  SPEAKER_00: Shay is excited to launch this episode of the podcast, COVID-19 updates, What We Know Now.
• 0:44
  SPEAKER_00: Today's discussion will focus on an international perspective from South Africa.
• 0:48
  SPEAKER_00: Our speaker today is Dr.
• 0:50
  SPEAKER_00: Angela Dramowski, an associate professor from Stellenbosch University in Cape Town, South Africa.
• 0:56
  SPEAKER_00: Thank you for joining us today.
• 0:57
  SPEAKER_00: Before we start our discussion, I would like to turn it over to Dr.
• 1:00
  SPEAKER_00: Jennifer Hammerhan to get us started with a brief news and guidance update from the week.
• 1:05
  SPEAKER_02: Thank you, David.
• 1:06
  SPEAKER_02: As of October 6, 2020, there have been 35,537,491 confirmed cases of COVID-19, including 1,042,798 deaths reported to the World Health Organization.
• 1:23
  SPEAKER_02: On October 5th, the Centers for Disease Control posted a message stating that there were updated recommendations regarding possible airborne transmission of SARS-CoV-2.
• 1:33
  SPEAKER_02: On October 5th, the CDC issued updated guidance to its How COVID-19 spreads website, which includes information about the potential for airborne spread of the virus that causes COVID-19.
• 1:43
  SPEAKER_02: The guidance states that CDC continues to believe, based on current signs, that people are more likely to become infected the longer and closer they are to a person with COVID-19.
• 1:53
  SPEAKER_02: Monday's update acknowledges the existence of some published reports showing limited, uncommon circumstances where people with COVID-19 affected others who were more than six feet away or shortly after the COVID-19 positive person left an area.
• 2:06
  SPEAKER_02: In these instances, transmission occurred in poorly ventilated and closed spaces that often involved activities that caused heavier breathing, like singing or exercise.
• 2:15
  SPEAKER_02: Such environments and activities may contribute to the buildup of virus-carrying particles.
• 2:20
  SPEAKER_02: CDC's recommendations remain the same based on existing science and after a thorough technical review of the guidance.
• 2:26
  SPEAKER_02: People can protect themselves from the virus that causes COVID-19 by staying at least six feet away from others, wearing a mask that covers their nose and mouth, washing their hands frequently, cleaning touch surfaces often, and staying home when sick.
• 2:39
  SPEAKER_02: Much of the news during this last week was dominated by President Trump's illness and the White House coronavirus outbreak, which now includes 34 people, many of whom were guests at Amy Coney Barrett's nomination ceremony, where social distancing was not observed and masks were not worn.
• 2:55
  SPEAKER_02: The COVID-19 pandemic has caused a number of adverse effects, including now reports of increased adult alcohol use during the pandemic.
• 3:02
  SPEAKER_02: A study published in Jamma Network open on September 29th shows increases in both U.S.
• 3:08
  SPEAKER_02: in-store and online sales of alcohol in March and April compared with 2019.
• 3:13
  SPEAKER_02: Researchers examined two surveys performed April 29th through June 9, 2019, and May 28th through June 16, 2020 for adults ages 30 to 80.
• 3:23
  SPEAKER_02: The survey found that on average, alcohol was consumed one day more per month than three of four adults.
• 3:29
  SPEAKER_02: For women, there was also a significant increase of 0.18 days of heavy drinking from a baseline of 0.44 days in 2019 represents an increase of 41% over baseline.
• 3:40
  SPEAKER_02: This equates to an increase of one day for one in five women.
• 3:43
  SPEAKER_02: For women, there was an average increase in the short inventory problem scale, which is indicative of increased alcohol-related problems independent of consumption level for nearly one in ten women.
• 3:54
  SPEAKER_02: Finally, the FDA issued guidance on emergency use authorization for a vaccine to prevent COVID-19.
• 4:00
  SPEAKER_02: The guidance document is posted on the FDA website and includes stricter guidelines that would make vaccine approval unlikely in the next few weeks.
• 4:08
  SPEAKER_02: These guidelines include a recommendation for a two-month follow-up period, as well as having some severe cases in the placebo group, in order to determine efficacy in preventing severe illness.
• 4:19
  SPEAKER_02: And that's the news this week.
• 4:20
  SPEAKER_02: I turn over to the moderated discussion.
• 4:24
  SPEAKER_00: Thank you, Dr.
• 4:24
  SPEAKER_00: Hammerhin, for that update.
• 4:26
  SPEAKER_00: Sounds like a lot of activity and uh you know certainly a lot of important information there.
• 4:30
  SPEAKER_00: So we really appreciate it.
• 4:31
  SPEAKER_00: And I do want to welcome uh Dr.
• 4:32
  SPEAKER_00: Dramowski to the podcast.
• 4:35
  SPEAKER_00: Over the early periods of COVID pandemic, a lot of our discussions were with representation from the United States and hearing a lot on the uh experience that we've been having here in the United States.
• 4:44
  SPEAKER_00: But over the last few weeks, we've had speakers from other countries, including Singapore and Brazil, and it's been really eye-opening to hear some of their experiences, and there's a lot that we can learn from hearing the experience of others.
• 4:55
  SPEAKER_00: So thank you again, uh Dr.
• 4:56
  SPEAKER_00: Dramowski, for uh joining the podcast.
• 4:59
  SPEAKER_01: Thank you very much to Shay for the opportunity to share our experiences from South Africa.
• 5:05
  SPEAKER_00: Excellent.
• 5:06
  SPEAKER_00: I want to uh start the discussion, at least getting some information as to where things stand right now in South Africa, and then we'll go back to some of the earlier phases of the pandemic.
• 5:15
  SPEAKER_00: So, what's the current state of COVID-19 right now in South Africa?
• 5:19
  SPEAKER_01: So we have approximately 680,000 laboratory-confirmed infections and total deaths approximately 17,000.
• 5:31
  SPEAKER_01: On the John Hopkins worldometer, we've fortunately dropped from a high of fifth ranking worldwide to 10th place.
• 5:40
  SPEAKER_01: And we're encouraged by recent improvements and reductions in our case positivity rate from highs of around 30% down to about 7% of all tests conducted.
• 5:54
  SPEAKER_01: And so at the current seven-day rolling average, we've had about a thousand new infections per week, and we've managed to reduce the number of tests being performed per day, as the number of symptomatic individuals has also declined.
• 6:12
  SPEAKER_01: Our reproductive number is also encouragingly dropped below one, sitting about 0.85 currently.
• 6:19
  SPEAKER_01: And so things are moving in the right direction after many months.
• 6:24
  SPEAKER_01: And certainly looking aside from just infections and deaths, our numbers in terms of current hospital admissions, ICU admitted patients, and ventilated patients are showing similar downward trends.
• 6:38
  SPEAKER_01: It's not a homogenous picture nationwide.
• 6:41
  SPEAKER_01: So of our nine provincial areas, uh, three are continuing to see increases, although these are modest, and they are our three smallest provinces who started their pandemics later compared to the rest of the country.
• 6:58
  SPEAKER_01: So generally moving in the right direction, I would say.
• 7:19
  SPEAKER_00: That came up a lot last week when we looked at Brazil, and there were some quite significant differences within the country, and that really affected the response of the country.
• 7:29
  SPEAKER_00: So maybe we can take it back to the earlier days of COVID-19, thinking like around January, February, going into March.
• 7:36
  SPEAKER_00: Can you uh kind of think back to those earlier days and describe the experience in South Africa as to when COVID first started to appear and the initial response that the country had to seeing patients with COVID?
• 7:49
  SPEAKER_01: Sure.
• 7:50
  SPEAKER_01: I think we were in the fortunate position that our South African epidemic started a lot later than Europe and the US.
• 7:58
  SPEAKER_01: And so we had the welcome opportunity to prepare.
• 8:03
  SPEAKER_01: And we were anticipating for several weeks the arrival of our first cases.
• 8:08
  SPEAKER_01: Almost undoubtedly, we missed the initial transmissions that certainly were linked later by viral genomics to introductions from mainland Europe.
• 8:21
  SPEAKER_01: And we certainly it coincided with the peak of our tourist season, which runs January, February, March.
• 8:27
  SPEAKER_01: And certainly there were many introductions before the first cases were detected towards the end of February, beginning of March.
• 8:35
  SPEAKER_01: We went into a national lockdown around about the 27th of March.
• 8:40
  SPEAKER_01: And at that point, the cases were really increasing very slowly.
• 8:45
  SPEAKER_01: Darted in KwaZulu-Natal province on the East Coast through a cluster of travelers from Italy, a whole family with several members who were later confirmed to have infection.
• 8:57
  SPEAKER_01: And then I think from then it was really the main metros, so Cape Town, Durban, and Johannesburg that showed the most rapid increases.
• 9:07
  SPEAKER_01: And everyone was surprised that the epicenter later was confirmed to be Cape Town.
• 9:13
  SPEAKER_01: But I think it was no surprise to us because we have the highest volume of international travelers.
• 9:18
  SPEAKER_01: And we think that we had sort of seeding and early beginnings of community transmission in the Western Cape much earlier than our provincial capital in Pretoria and Johannesburg.
• 9:30
  SPEAKER_01: So Cape Town took an early lead.
• 9:32
  SPEAKER_01: I work at the second largest hospital in the country, Tigerberg Hospital, which was the designated COVID hospital for the Western Cape, although as has it emerged in the States and everywhere else, every hospital became a COVID hospital quite rapidly.
• 9:48
  SPEAKER_01: We had large numbers of patients admitted towards the end of March, April, May, and June, and then a slow tailing off from June onwards.
• 9:59
  SPEAKER_01: We started out at the highest lockdown level, which was five, which, similar to all countries, prevented international arrivals, prevented movement within our own country, and even restricted local movement with a curfew after dark and a very strict introduction of public health measures quite early on, including the use of universal masking, physical distancing, and encouraging staff to work from home very actively.
• 10:31
  SPEAKER_00: Thanks for sharing that extensive description of the approach.
• 10:34
  SPEAKER_00: You know, I'm interested in the lockdown period that it sounds like began at the end of March and how that was implemented and what the community response was like.
• 10:43
  SPEAKER_00: Last week we talked about when lockdowns are implemented, when there's maybe not necessarily a universal nationwide response, some of the challenges that accompany that.
• 10:53
  SPEAKER_00: Here in the United States, there was a lot of variability between different states in terms of how restrictions were initiated and how they've been subsequently lifted.
• 11:01
  SPEAKER_00: And I'm interested in hearing about the South Africa experience, both in terms of whether there were differences throughout the country with regard to what the lockdown and the subsequent lifting of restrictions looks like, and then also what the public response was like to some of these measures.
• 11:16
  SPEAKER_01: Sure.
• 11:17
  SPEAKER_01: So I think one of the strengths of the South African government's approach to COVID-19 and public health lockdowns and restrictions has been that they were universally implemented across all nine provinces.
• 11:32
  SPEAKER_01: And although each province has some autonomy and local government is the implementer of policy, the policy came from central government and from the Department of Health.
• 11:45
  SPEAKER_01: And the leadership came from the top, from our president, and a very active and vocal minister of health who was advised by a multidisciplinary team called the Ministerial Advisory Committee on COVID-19.
• 12:01
  SPEAKER_01: They chose leading scientists, public health experts, virologists, infection prevention practitioners, infectious diseases docs, and a wide variety of people, including later on social scientists, particularly to help understand how to implement behavioral modification measures at population level.
• 12:23
  SPEAKER_01: Very early on, I think even towards the end of March, as the lockdown loomed, the president was on national television and radio giving addresses, explaining the need for these measures and trying to encourage compliance with all the recommendations.
• 12:39
  SPEAKER_01: We certainly don't have a socialist state.
• 12:42
  SPEAKER_01: Things are very democratic, but I think there's a word in South Africa called Ubuntu, and it's an understanding that we are through each other.
• 12:51
  SPEAKER_01: And so there is a lot of community-mindedness, and people generally are willing to sacrifice some freedoms for the greater good or the good of the community.
• 13:01
  SPEAKER_01: And I think that sense really contributed to a feeling that everybody had something important to do to reduce community transmission.
• 13:11
  SPEAKER_01: Another effective intervention was a rapid communication in all of our, we have 11 official languages, so in every official language, in print, radio, media, etc., as well as the launching in March of an interactive WhatsApp-based information system where everyone could register with a cell phone or mobile phone and then literally type in a number for the information that they would like to receive, whether it was to do with contact tracing or infection prevention measures in the home or workplace recommendations.
• 13:44
  SPEAKER_01: Information was available on demand to all in South Africa.
• 13:48
  SPEAKER_01: Another strength of the South African approach was the involvement early on of community healthcare workers.
• 13:55
  SPEAKER_01: You may know we have a small army of community healthcare workers who do a lot of work around TB and HIV detection and prevention at community level, and they were rapidly retrained to do screening and education in communities regarding COVID-19 with referral of symptomatic persons to public health clinics and hospitals for testing.
• 14:20
  SPEAKER_01: So I think that was also a fairly effective approach that had greater reach beyond the big metros.
• 14:28
  SPEAKER_00: I think that's terrific.
• 14:29
  SPEAKER_00: I mean, so many aspects of what you just discussed are really things that a lot of countries can learn from.
• 14:34
  SPEAKER_00: The multidisciplinary approach, engagement with scientific leaders, including social scientists, is really so critical.
• 14:42
  SPEAKER_00: Communication and community engagement is a huge piece of inadequate balance.
• 14:46
  SPEAKER_00: And I really love how the country leveraged their existing community health workers to help in a response to COVID-19.
• 14:52
  SPEAKER_00: I think that all really uh shows how to implement a strong and effective response.
• 14:58
  SPEAKER_00: And there's a lot that other countries I think can learn from hearing about that experience.
• 15:02
  SPEAKER_00: Can you speak a little bit to the experience in hospitals?
• 15:05
  SPEAKER_00: You know, in in uh the United States, we've in medical settings have faced a lot of challenges.
• 15:11
  SPEAKER_00: We had a quite a rapid surge in a lot of areas of the country, which really tested the limits of our healthcare infrastructure.
• 15:18
  SPEAKER_00: And specific to COVID-19, we ran into challenges with testing and PPE in the United States.
• 15:24
  SPEAKER_00: So I'm interested if you can reflect a little bit about uh how COVID-19 impacted healthcare in South Africa, both in a general sense but also with specific attention to caring for patients with COVID-19.
• 15:37
  SPEAKER_01: Owing to our very early and complete lockdown, I think we really managed to flatten the curve and avoid largely a mass influx of symptomatic patients requiring hospitalization.
• 15:53
  SPEAKER_01: So there were very few hospitals that were overwhelmed.
• 15:57
  SPEAKER_01: On the flip side, the negative of a very effective lockdown is that a lot of patients who genuinely required care for other conditions did not access health care.
• 16:08
  SPEAKER_01: So, particularly, we saw our rate of TB diagnoses halved over the last six months, and the number of individuals newly started on antiretroviral regimens also significantly reduced.
• 16:21
  SPEAKER_01: So I do think there will be a price to pay.
• 16:24
  SPEAKER_01: Another example of that is unfortunately our routine immunization program.
• 16:29
  SPEAKER_01: There were many children who have missed out on vaccinations, partly because people were just too scared to access public health care and didn't want to be exposed.
• 16:39
  SPEAKER_01: And so we are very aware of all of these missed opportunities to access care in the last seven months.
• 16:46
  SPEAKER_01: And the government is now doing a lot to try to get those individuals who have missed out on TB, HIV care and routine immunizations to present to healthcare facilities now that the risk is reduced.
• 16:59
  SPEAKER_01: There were some innovations, particularly in the Western province where I work, to make things easier for patients.
• 17:04
  SPEAKER_01: So a lot of chronic medications were delivered to people's houses, even in informal settlements, to try to avoid unnecessary exposure in public health facilities.
• 17:15
  SPEAKER_01: On the testing front, we had many, many teething problems and it took a long time to scale up.
• 17:22
  SPEAKER_01: I think one of the advantages is that the private health sector did as much testing and scale up as the public sector.
• 17:31
  SPEAKER_01: You may know that South Africa is probably one of the most unequal countries in the world in terms of household income.
• 17:39
  SPEAKER_01: So we have a very separated public and private system.
• 17:43
  SPEAKER_01: But currently at full capacity, we were probably doing about 50 to 60,000 tests per day.
• 17:51
  SPEAKER_01: And that was roughly 50-50 split between the private and the public sector.
• 17:56
  SPEAKER_01: The turnaround times initially were very long in the public sector, up to seven days, which really made contact tracing almost impossible.
• 18:05
  SPEAKER_01: But that has now improved in almost all provinces to less than 24 to 48 hours as the capacity and experience in ramping up laboratory services has improved.
• 18:18
  SPEAKER_01: From the PPE perspective, I think again, one of the strengths very early on was the Department of Health at national level decided to coordinate purchasing and procurement of PPE centrally, so that we would not have a situation where different provinces were outbidding each other and buying PPE out from under the feet of another province.
• 18:40
  SPEAKER_01: And so everything was centrally procured and equitably distributed to where the need was greatest at the time.
• 18:47
  SPEAKER_01: And we certainly saw that the Western Cape had a large volume need for PPE early on.
• 18:52
  SPEAKER_01: And as that declined, Ghao Ting took over.
• 18:55
  SPEAKER_01: And so they were able to move PPE resources where it was most needed and developed a lot of PPE tracking tools.
• 19:03
  SPEAKER_01: Notwithstanding that we certainly had many challenges, particularly for acquiring N95 respirators.
• 19:10
  SPEAKER_01: We fortunately probably had a lot of buffer stock as the pandemic began because we use them extensively for prevention of TB infection amongst our staff.
• 19:20
  SPEAKER_01: But as with every country in the world, PPE shortages were experienced from time to time.
• 19:26
  SPEAKER_01: And we had multiple issues with imports, particularly of KN95s, for example, from China that were just not up to standard and failed fit tests and various other suppliers that supplied poor quality PPE.
• 19:40
  SPEAKER_01: So all of these were real issues for IPC practitioners on the ground to keep an eye on the quality of the PPE that was coming in, because from one week to the next, you you never knew who the supplier would be.
• 19:53
  SPEAKER_01: But far and away, most facilities had PPE available most of the time or all of the time.
• 20:01
  SPEAKER_00: Thank you.
• 20:01
  SPEAKER_00: So it sounds like a lot of the challenges that you faced in South Africa were quite similar to what we saw here in the United States, but with coordination and some of the centralization, particularly with the PPE, really helped with the response and meeting the uh the needs of the country.
• 20:17
  SPEAKER_00: So thank you for sharing that experience.
• 20:19
  SPEAKER_00: So before we finish up, and the last thing I'd like to hear your thoughts on are what the future might look like in South Africa.
• 20:24
  SPEAKER_00: Here in the United States, you know, we're approaching our flu season.
• 20:27
  SPEAKER_00: There's a lot of concerns about how to balance COVID and the influenza, and even thinking about vaccination, both for flu vaccine, which is currently underway, and the future with a SARS-CoV-2 vaccine.
• 20:40
  SPEAKER_00: So I'm interested to hear from your perspective, sort of what's on your mind as of today, thinking about the future, what you're anticipating, recognizing that we can anticipate exactly what's going to happen.
• 20:51
  SPEAKER_00: But you know, what are you thinking about and what do you have your eye on moving forward within South Africa?
• 20:57
  SPEAKER_01: Sure.
• 20:58
  SPEAKER_01: So first looking back, I think one of my biggest fears as our cases emerged in March this year was that we were going into the winter season then, and we we really anticipated that we would have a collision of our flu, annual flu season and COVID.
• 21:15
  SPEAKER_01: But amazingly, thanks to the lockdown and the limitation of importation of influenza from the northern hemisphere, flu did not materialize in South Africa this year.
• 21:25
  SPEAKER_01: We've had really, really few cases, and we have quite a good influenza detection surveillance system that runs each year.
• 21:33
  SPEAKER_01: So our numbers have been very small.
• 21:34
  SPEAKER_01: Having said that, I'm a pediatrician, and in the last couple of months, we've had a very bad RSV season.
• 21:41
  SPEAKER_01: And certainly, strangely enough, lockdown didn't, and all the additional hygiene measures, hand hygiene and social distancing, didn't really seem to impact on our usual peak of RSV admissions.
• 21:53
  SPEAKER_01: Fortunately for us, we are now heading into summer, and so we expect that the other respiratory viruses will give us a break for some time, and we don't really anticipate having uh huge issues.
• 22:03
  SPEAKER_01: Having said that, as we prepared PPE and trained staff in in March 2020, we did do a concerted effort to ensure that our available doses of flu vaccine were widely distributed to healthcare workers who were at high risk and certainly frontline workers.
• 22:21
  SPEAKER_01: Although the flu supply to healthcare workers in South Africa unfortunately is very limited.
• 22:28
  SPEAKER_01: And we currently prioritize pregnant women and children under the age of five and those with comorbidities.
• 22:34
  SPEAKER_01: So there's never enough for all the healthcare workers that should receive flu vaccine.
• 22:38
  SPEAKER_01: But this year we made a special effort to vaccinate as many healthcare workers as we could.
• 22:43
  SPEAKER_01: And having said that, we did do a lot of testing of healthcare workers who were SARS-CoV-2 negative and didn't find very much flu in them either.
• 22:54
  SPEAKER_00: Thank you for sharing that.
• 22:56
  SPEAKER_00: You know, we all have our uh challenges that we're looking towards in the future, but it sounds like based on your experiences in the last few months, South Africa seems to be well positioned thinking about the future.
• 23:06
  SPEAKER_00: Thank you for really sharing your experiences.
• 23:08
  SPEAKER_00: I think there's a lot that we can learn from what you've been through and uh some of the strengths and the successes that you've seen.
• 23:15
  SPEAKER_00: We really appreciate you uh coming on to the podcast.
• 23:18
  SPEAKER_00: So thank you again for joining us.
• 23:20
  SPEAKER_01: It's a great pleasure.
• 23:21
  SPEAKER_01: Thank you very much for the opportunity.
• 23:24
  SPEAKER_00: Thank you very much to our speaker, Dr.
• 23:26
  SPEAKER_00: Dramowski, for sharing her experiences and perspectives and a sincere thank you from Shay to all healthcare personnel for all that you are doing to respond to COVID-19.
• 23:36
  SPEAKER_00: This podcast can be accessed on Shay's online educational center, Learning CE, under the Rapid Response Program.
• 23:44
  SPEAKER_00: You will also find resources such as the recorded webinars, healthcare facility outbreak preparedness, and the SHAY COVID-19 town halls.
• 23:52
  SPEAKER_00: Additional resources available on Learning CE pertinent to this pandemic include the SHAY CDC Outbreak Response Training Program, ORTP, and the Prevention Course in HAI Knowledge and Control Prevention Check.
• 24:04
  SPEAKER_00: You can now receive 75% off-share membership for the remainder of 2020 using the coupon code podcast during checkout.
• 24:11
  SPEAKER_00: This concludes this episode of the Rapid Response Podcast.
• 24:15
  SPEAKER_00: Thank you for tuning in.