Decision-making at the early stages of the SARS-CoV-2 pandemic (the coronavirus causing COVID-19) was constrained by a paucity of medical evidence and epidemiological data. Knowledge gained over the past two months can therefore inform the next phase of the strategy.
In the context of the initial uncertainty, South Africa’s early lockdown was prudent. It allowed time to prepare the health care system, to ramp up wide-spread testing and to introduce other measures to reduce transmission rates. Extending the lockdown is no longer required. It is also no longer reducing transmission rates and has become unaffordable.
Current evidence indicates that:
It is impossible to eliminate the virus and the spread will continue. Only a few countries have been able to minimise the rate of spread but they remain highly susceptible to repeated outbreaks.
The majority, approximately 70%, of people infected with SARS-CoV-2 are asymptomatic, or have a moderate, self-limiting illness (approximately 25%). The 5% who develop severe COVID-19, with the risk of dying, are usually older than 65 years (greater than 80%) or have underlying comorbidities (such as hypertension, diabetes and obesity).
Children under 18 years are generally spared from developing severe COVID-19 and contribute less than 1% of all COVID-19 deaths (none among the more than 30,000 COVID-19 deaths in Italy).
It is not likely that a vaccine will become available in the near future. Without this, control of the infection would require about 60% of the population to develop immunity. This will take time and while there is considerable uncertainty over the number of deaths that may occur from COVID-19 over the next two years. Current evidence suggests that it may be less than originally estimated.
An extended lockdown comes with substantial health costs. These include costs brought about by undermining public health initiatives such as immunising children against threatening diseases and in the impaired provision of health services to those living with comorbidities such as diabetes, tuberculosis (TB), HIV and hypertension. Indeed, there is evidence that currently the gains made over recent years in reducing the rates of, and deaths from TB are being reversed.
SARS-CoV-2 is highly infectious, with a reproduction rate every four days of roughly 2.5 at the onset of the outbreak. The reproduction rate measures the number of people to whom an infected person will pass on the virus. When South Africa introduced the lockdown, the reproduction rate was low relative to other countries. However, South Africa’s reproduction rate has remained above 1, even under a highly restrictive lockdown. Indications are it will remain above 1 at least for the foreseeable future.
The hard, extended lockdown has come at significant economic cost. While there is debate about the cost to date, with estimates from 5%-16% of GDP, economists agree that this has been significant.
The lockdown has also imposed social costs. For example, children are missing out on schooling. This is detrimental for their cognitive development and for many other reasons. Children are at risk of becoming malnourished due to missing out on school feeding schemes, as well as from the increasing number of families that are being pushed into poverty.
South Africa needs to accept that it is not on a unique trajectory. The virus cannot be eliminated. The country’s strategy needs to move away from a hard lockdown. In our view, South Africa should focus on using interventions aimed at slowing the virus’ transmission rate.
The success of these interventions depends on the buy-in and cooperation of citizens. The message to South Africa must be clear: It is not going to be spared deaths from COVID-19. But it is possible to prevent some of these through our own actions and by promoting strategic public health interventions.
South Africa should plan to mitigate the effects of the pandemic using the above strategies for at least two years, or until a vaccine becomes available.
Areas of uncertainty
There are two important areas of additional uncertainty. The first is that it is too early to establish the effect of COVID-19 on people living with HIV. But emerging evidence appears to be reassuring. People living with HIV who are on antiretroviral treatment do not appear to be at an increased risk.
Secondly, South Africa is not achieving the testing levels or reporting speeds required to contain the spread through diagnosis and contact-tracing. This gets harder as infection rates rise. Without this, it is unlikely that the country will stay ahead of the epidemic.
South Africa’s strategic thinking should therefore be informed by the following:
The need to minimise infection in vulnerable, high-risk groups and, where possible, to minimise deaths from COVID-19. This requires clear communication on the actual threat of the virus, preventative strategies, and slowing the spread of the virus to levels that spare the healthcare system and the economy while preventing the economic effects themselves from causing death.
It is not possible to contain the spread through lockdowns, because of the economic cost and the fact that it is not possible to keep the reproduction rate at consistently low levels easing lockdown.
It is therefore vital that the country develops strategies to control the virus and simultaneously manage the health, social and economic implications without resorting to further lockdowns.
We suggest that South Africa move rapidly to stage 2 lockdown and that a risk-assessed framework be adapted. We propose that such a framework permit all economic activity, except where there is a clear and material threat to public health. The other exception are activities that pose a high risk of transmission over a short period of time, for example mass gatherings or transmission hotspots.
The framework should specify, by exception, economic activity not allowed on public health grounds. This would see the reopening of critical areas of the economy coupled with current behavioural and societal mechanisms to slow viral spread.
Within this framework, we also suggest that:
Health of workers should be a high priority. Precautions with respect to the protection of healthcare workers and protocols in healthcare settings require careful attention.
Regulations should specify employer responsibilities to ensure that the opening up of the economy does not result in flareups of infections.
Retail opening hours be extended to reduce density and exposure to the virus, with early pensioner-only hours.
The frequency of public transport services be increased to enable movement subject to the adoption of health protocols. These protocols can be enhanced as necessary.
The hours of work for accessing public services be extended to make it possible for the population to access services in ways consistent with health protocols.
For now, international travel for leisure should not be allowed.
The health risks associated with this economic strategy should be premised on effective strategies to mitigate the rapid rate of transmission of the virus. This is best achieved by:
Reinforcing physical distance measures in settings where people have no option but to gather, and paying attention to ventilation. In the case of busses and taxis, windows should be opened to prevent prolonged contact with potentially contaminated air.
Reinforcing evidence-based public health measures like hand washing. This should include providing sanitation to all communities.
The continued use of face masks for all outside of the home. Reusable masks must be made available to all communities free of charge.
This list is not exhaustive but sets parameters which can guide an adaptation to level 2.
The ability of the country to avert the possible full impact of the virus will only succeed if all citizens of South Africa cooperate willingly with measures aimed at slowing the rate of transmission. If that does not happen, the full might of this virus will manifest itself sooner rather than later, irrespective of the level of official lockdown.