End SA’s national state of disaster
- Francois Venter, Marc Mendelson, Jeremy Nel, Lucille Blumberg, Zameer Brey and Shabir A Madhi
Covid-19: On 15 March 2020, President Cyril Ramaphosa declared a national state of disaster in terms of the Disaster Management Act.
Almost two years on, we are entering a new phase of the pandemic. All over the world, including within the WHO, there is an assessment taking place of the measures that will be most suited to this phase. Top of the list is vaccination, good indoor ventilation, and close monitoring of the SARS-Cov-2 virus and other possible pandemic threats.
South Africa needs to do this too. As scientists, our current understanding of the science, the building of immunity protecting against severe Covid-19, and experience with policy renders most state of disaster measures still in place unfit for purpose and requires tailoring of others.
Being on permanent “Code Red” affords little protection against a hyper-transmissible SARS-CoV-2 variant such as Omicron and entails unacceptable societal costs.
SARS-CoV-2 has been a devastating virus, killing friends, family and colleagues, as well as leaving many people with symptoms of long Covid. We are not suggesting ignoring it, but the risk is changing for South Africa and our response needs titrating against the risk it poses.
We have no truck with Covid-denialists or anti-vaxxers.
But change is needed now. The focus on Covid-19 has set back many other health programmes and broader socioeconomic and educational programmes.
Finally, the continued lack of accountability and transparency the act affords to politicians for unscientific and irrational decision-making on issues of public health is long past justification.
Further evolution of SARS-CoV-2 may generate more variants, but the foundation of protection from severe disease, hospitalisation and death that is our immune response — whether by prior infection (now, very conservatively, an estimated three quarters of South African inhabitants) or by vaccination (for about a third) — has been consistently exhibited across the three waves caused by the Beta, Delta and now Omicron dominant variants.
The decoupling of infections and severe disease and death from Covid-19 has been most stark in the waning Omicron-dominant wave in South Africa, despite earlier theoretical concern about the spectrum of mutations identified in the variant.
Omicron, a variant that causes many millions of infections (possibly infecting half the South African population), did not result in significant stress on the country’s health system through hospitalisations and excess deaths (see here).
Consequently, despite formal case numbers probably equating to the combined total of both the first and second Covid-19 waves, immunity derived from prior infection and vaccination protecting against severe Covid-19 won the day.
We believe that this is likely to continue in future waves, barring the unlikelihood of mutations affecting all aspects of immune responses, which would be analogous to a completely “new” type of virus having evolved from an immunological perspective.
In such an unlikely scenario, as would be the case for the immediate emergence of another novel pandemic-causing virus, containment measures could be reconsidered. But we can’t proceed as if this is the likely scenario — it isn’t, and the costs of pretending it is too high.
The vast majority of South Africans now have immunity, meaning Covid-19 in 2022 is likely to have a similar death rate to seasonal influenza (10,000-11,000 deaths a year) in the pre-Covid era, as opposed to the 290,000 Covid- related excess deaths over the past 22 months of the pandemic, and much lower than the projected 58,000 annual TB-related deaths.
Hence, as the beginning ends, we believe the time is now to immediately end those measures that serve no purpose, some of which are detrimental, and progressively enable a return to normal.
End the state of disaster
We see no reason for the continued use of this legislation, nor for the National Coronavirus Command Council.
In terms of SARS-CoV-2 the government should be single-mindedly focused on the vaccine programme and protecting health facilities from the impact of large numbers of admissions.
Our suggestions below do not require continued centralised, secretive and unaccountable decision-making for this to occur. Arguments that the state of disaster is required to enforce interventions like masks or limits on social gatherings are unconvincing, as most restrictions need to be lifted anyway; improved communication, together with conventional legal and social persuasion mechanisms can be used to ensure that the very limited number of interventions required are executed.
We know the vital Covid Social Relief of Distress (SRD) grant is linked to the Disaster Management Act, and it is vital for millions of people’s livelihoods that this continues. The Department of Social Development Expert Panel on Basic Income Support has provided clear guidance regarding how this can be continued under the Social Assistance Act, which we support.
We are advocating that Covid be seen as another health priority, with rapid decision-making led by the Department of Health consulting other departments through inter-ministerial or other existing legislative structures. There is a multiplicity of examples of where health collaborates closely with other departments, and these can be employed.
Stop school restrictions
The impact on education has been severe, and we are now at the point where every resource should be focused on making 2022 a “back to normal” year.
Unfortunately, the Minister of Education has announced further rotational learning — a huge mistake.
Children experience only a very small chance of harm from infection with SARS-CoV-2, except for those under one year of age or in the presence of underlying medical conditions. Children suffer illnesses from influenza and a range of other viruses and infections too, and we sent them to school prior to this pandemic, understanding the massive benefits to child health and development.
Furthermore, keeping children out of schools inflicts harm to the social/financial fabric of the household when carers have to stay home to mind the kids (anyone doubtful about the huge consequences of these school disruptions should read this Unesco document capturing the harms in detail).
Schooling needs to happen again as normal. Vaccine mandates are appropriate for all educational staff, for their own health and to protect children by avoiding further disruptions to teaching. Teachers or other educational workers should be assisted with attention to ventilation and encouraged to wear masks indoors if they are in high-risk groups.
With the very high levels of asymptomatic transmission and community immunity present, there is no reason to continue restricting class sizes or children playing. Enforcing physical distancing measures in classrooms, such as requiring students to be 1.5 metres apart from each other, is impractical and not likely to substantially reduce transmission in the face of these new variants. Also, considering that for every one documented Covid-19 case in South Africa there are nine other undiagnosed cases due to limited testing, there is no place for school closures when cases of Covid-19 are identified.
Reform how Covid is handled in healthcare facilities
The ongoing restrictions on allowing family visitors in hospitals are unnecessary and cruel.
Testing asymptomatic patients for Covid indefinitely is a waste of money and resources — even in hospitals, in most instances. Testing of people with respiratory symptoms, especially when there is a resurgence, should continue into the immediate future as it could assist in management of the person.
As for educators, vaccine mandates for healthcare workers make sense, to protect them at an individual level, and the health system from sickness-related absenteeism.
Also, healthcare workers, being more susceptible to being infected because of the nature of their work, might require annual booster doses of vaccines to enhance protection even against mild disease. Also, booster doses to healthcare workers could reduce the risk of them transmitting the virus to vulnerable patients.
Finally, meaningful managerial support to facilities — ensuring the mundane, but crucial everyday issues such as staffing, compliance with general infection prevention measures, oxygen and drug supply, and ambulance services, which was found wanting despite plenty of warning, especially during the first three waves — should be a primary focus of the Department of Health.
End all restrictions on outdoor activities
With increasing vaccination coverage and a greater understanding of the predominant role of aerosols in transmission, it is time to open up our outdoor activities again.
Furthermore, masks should no longer be compulsory outdoors. Vulnerable people may elect to wear a mask outdoors in crowded circumstances, while understanding that vaccinations will provide the greatest protection to their health.
What about indoor restrictions?
We must eventually accept that indoor restrictions will have to end too. As an intermediate step, vulnerable people may be advised to avoid crowded indoor venues when the Covid caseload is high, and/or wear a mask for added protection.
As medical veterans of mask-wearing, we have no patience with arguments around discomfort, health or misguided infringements of freedoms. However, we can’t keep wearing masks in all indoor circumstances forever, and more so now that the risk of severe Covid-19 is greatly diminished compared with earlier stages of the pandemic when there was little immunity against severe Covid-19.
Masks, especially high-quality masks, work when fitted well, but we have to anticipate that — for all but the most vulnerable patients — our immune systems are going to be enough to protect us (vaccines!).
There may be places where masks stay mandated (on densely packed public transport), but overall, the indoor mask-wearing mandate should eventually fall away.
End routine sanitising (and taking of contact details)
We now know acquisition of SARS-CoV-2 from surfaces (and hands) is very rare (and here).
We think having routine foot-pump hand sanitisers at the entrance to bathrooms, food markets and crowded venues is good hygiene, and one of the few things we want left over from the pandemic — not for the prevention of Covid-19, but for all the other nasty bugs killed by handwashing.
However, the “hygiene theatre” at many workplaces, venues and restaurants, with the spraying of hands repeatedly with alcohol sprays combined with thermometry, both of uncertain quality, and recording of names and cell numbers with no intention of following up, is a waste of time and distracts from things that make a difference — opening windows and encouraging ventilation.
End routine thermometry and daily screenings
It is a useless waste of time and money. Always was. Many infections are asymptomatic, and even when they’re not, a fever is only present in a small minority of cases. Most of the readings of less than 35oC imply the person is dead or rapidly becoming so!
Also asking people to complete a questionnaire on whether they have any symptoms of Covid-19 is meaningless, since a large majority of infections would be asymptomatic. If individuals are symptomatic for respiratory illness (and not only due to Covid-19), they should always take precautions of not infecting others by limiting their social engagement and wearing a face mask when in public. This message needs reinforcing: it is a basic of public health and infection control.
Stop fogging — yesterday
Another waste of time and money, but this time it can be harmful. This holiday, several of us stayed in places proudly advertising that they “fogged” between guests. We also note that government departments, despite their own guidelines from early 2020, persist in shutting down police stations, grant offices and schools, at massive cost.
Fogging is potentially harmful to health, using damaging chemicals, and is only used in highly focused infection outbreaks in health facilities. Cut it out. There is no scientific basis for the fogging and closure of any venue, including police stations and other government buildings following the diagnosis of an infected case.
Stop all PCR and antigen testing at borders
There is no reason for insisting on this when the virus is circulating so widely. Requiring testing for a plane trip from Gaborone to Joburg, but not Cape Town to Joburg, or for people driving in a private vehicle from Mozambique, makes no sense. It does not stop variants and even if someone with the virus slipped over the border, the contribution to existing infection rates is negligible.
This testing requirement, pervasive across the world, has created a massive money and time-wasting international industry, with no health benefits.
South Africa, a victim (and previous proponent) of baseless travel bans, should take a public and widely communicated step that the ONLY requirement to enter the country is proof of vaccination (or medical reason for not having vaccination), mainly to protect our hospitals and ICUs.
Instead, redirect these resources towards vaccinating at borders for those leaving and those coming into South Africa, recognising many of our neighbouring countries continue to have constrained vaccine supply.
Stop routine testing mild and asymptomatic cases
There is nothing to offer people who are positive that you wouldn’t offer for any mild respiratory infection. Routine testing of asymptomatic patients should stop. Staff should be vaccinated and theatre staff should use high-quality masks. PCR testing protocols (with gaps between testing and actual surgery) are far from perfect, and asymptomatic infection probably adds minimal risk to surgery.
Hospitalised symptomatic people should be tested, as we have treatments, but for mild disease, testing really only makes sense for those at high risk (so we can watch them closely, and for possible future access to new drugs that seem to work well at keeping this group out of hospital).
You can make a case for testing yourself if visiting granny or someone vulnerable, but understand that the tests are not perfect (they can give a false negative result) and that unless the person you are visiting is living as a hermit, their risk of exposure to someone else who isn’t testing and infected is very high.
Again, vaccines are the best protector of the vulnerable, including the need for a third dose of vaccines which the government needs to make available with fewer restrictions.
End quarantine and contact tracing
On 23 December 2021, the Ministerial Advisory Committee on Covid-19 issued revised protocols on contact tracing, quarantine and isolation, eliminating the need to contact trace and quarantine the contacts of people who tested positive. Five days later, the Department of Health rescinded the advisory.
We have recently explained in an opinion piece, why contact tracing and quarantine has long been redundant in South Africa.
Put simply, only a tiny percentage (~10%) of people who are infected with the virus will have been tested and found to be positive. Very high rates of asymptomatic infection, high levels of protective immunity against severe disease, and the social barriers stopping most of the population from effectively quarantining, makes the practice redundant.
For similar reasons — plus a lack of feasibility to contact trace even the people who have been in contact with a known case of Covid-19 due to the extreme numbers (remember, Omicron may have infected almost half the country) — it would make contact tracing an entirely moot point.
Currently, confirmed Covid-19 cases are asked to isolate for 10 days from their test (if no symptoms), or from the beginning of symptoms. Ten days came from original data which suggested that peak infectiousness was from one to three days pre-symptoms until eight days post the onset of symptoms. Recently, a number of countries, including the US, have shortened the isolation period to five days from test or symptom onset.
We believe the US CDC’s more pragmatic approach of five days isolation, with a return to work and society using a mask for the next five days, is sound.
Even more pragmatic is to limit isolation only if a person is symptomatic.
Stop all curfews
The only reason for this was to protect health facilities from trauma-related hospital and ICU admissions. Our facilities coped with the last wave, so this reason no longer holds. The government would do much better to run high-profile education campaigns on alcohol harm and better policing and punishment of traffic and alcohol-related crime. Glad to see that all current curfews have been lifted.
Replace the current vaccination programme with something radically better
The fact that only a third of South Africans have received at least a single dose of Covid-19 vaccine after almost a year is woeful. Others have eloquently pointed to the many failings and reasons.
If we are called upon to suddenly boost the conservatively estimated 30% of the population that is vulnerable (the elderly and those with diabetes and obesity, the major readily identifiable risk factors for severe illness), at current rates it would take another year to get anywhere close — for Omicron, we perhaps had two weeks before the wave was firmly upon us.
The current system simply does not move quickly enough, and vaccine hesitancy is a convenient shroud to hide behind a system that is currently unable to deliver vaccines efficiently or conveniently.
Vaccines are our major protector — everything else is a mitigator — and we need a radical new strategy that makes getting vaccines as easy as buying milk and bread.
South Africa has already inadvertently reached 70% “immunity” due to the high force of infection and roll-out of vaccines. Besides which, the 70% target for vaccine coverage is outdated and now a totally arbitrary value because herd immunity (ie when the virus is unable to transmit in the community) is no longer an option.
The main focus of the vaccine drive should be to achieve >90% vaccine coverage in people older than 50, and to provide third doses to very high-risk groups.
In addition: Replace the cumbersome EVDS system’s registration requirements with a simplified guideline; allow the private sector to separately procure and distribute vaccines and start a proper seamless door-to-door campaign that aims to reach the millions of poor and undocumented (there are excellent Eastern Cape and other models); offer vaccines at routine medical queues and chronic medicine pick-up points, grants and pension queues, and central taxi vaccination distribution programmes.
For people needing certification so that they can cross borders, special sites can administer and provide digital certificates.
If we listen to individuals in communities (as done in the most recent Covid-19 Vaccine Survey), we will hear many people who are ready to be vaccinated asking for an easier, more convenient process. For example, 34% of the unvaccinated in the survey would get vaccinated as soon as possible, and of those, 70% would take the vaccine if offered at home or place of work.
Furthermore, messaging and administrative processes around EVDS leave much to be desired, with only a quarter understanding that pre-registration is no longer a requirement for vaccination.
We have never made electronic registration a requirement for any social or health programme, and introducing it in a pandemic is risky, even in well-resourced, high-income countries.
Arguments about duplication (“people getting more vaccines than they should”) are weak, with only a third of the country vaccinated.
Where data on specific demographics is available (perhaps captured retrospectively into the EVDS or similar system), it should be made public, so community-wide efforts to reach under-vaccinated populations can be made.
Some countries (like Greece and Austria) have made vaccines mandatory for vulnerable populations, with fines for noncompliance, reasoning that this is required to protect precious hospital and ICU resources.
Vaccination mandates have been implemented very effectively in many countries, including places with strong histories of individuality, such as France, and in many workplaces in South Africa.
We have no patience with the wilful misportrayal of vaccine side-effects by anti-vaxxers on social media, and the use of this argument against mandates.
The authors acknowledge the programmatic complexity and feasibility of vaccine mandates. The current vaccines work best in protecting against severe Covid-19 and are somewhat less predictable in preventing infections due to some antibody-evasive variants such as Beta and Omicron.
Nevertheless, Covid-19 vaccines still result in a quicker decrease in the viral load and lessen the duration of shedding, even due to Omicron, which would reduce the infectiousness of a person (see here).
In the context of safeguarding healthcare systems from avoidable hospitalisations, as well as using whichever tools are available to us to safeguard people in high-risk indoor environments, mandatory vaccination should be considered, particularly when people are involved in indoor gatherings.
Dropping all these restrictions: what if we are wrong?
The virus has caught us off-guard on several occasions, especially regarding the remarkable transmissibility of Delta and Omicron, and the antibody-evasiveness of Omicron, and it may happen again. But we feel there are two extremes in the debate — a “we must stay on Code Red until we are certain’’ extreme (which does not acknowledge that we have a wealth of knowledge and experience now), and a “let-it-rip’’ extreme (which is a spectrum from understandable exhaustion and frustration with a lack of seeming progress on relaxing restrictions, to a range of over-confident pundits).
So what are we recommending?
In summary, we are recommending a risk-adjusted approach where scarce resources are much more targeted and the negative consequences of increasingly irrelevant measures, best described as Covid theatre, are discarded.
We are advocating for a strong focus on those at risk of severe infection by increasing vaccination, masks being worn when indoors and maybe avoid indoors during a wave. In the long term, vaccination is by far the greatest priority over other measures (including boosters, as needed).
It is quite possible to responsibly open society rapidly while maintaining early monitoring systems — something South Africa is blessed with.
Remember that all the current vaccines, as well as immunity from past infections, maintained high protection against severe Covid and death against ALL the variants, across the globe, and probably will work against the next one.
A cautious approach would be to get rid of the above measures, while monitoring and sounding any early alarms such as ongoing sentinel wastewater surveillance to detect an increase in virus load in the community.
Once there is a suggestion of a new surge of infections, increasing attention to new vaccination requirements (by fast-tracking vulnerable people to boosters, if the science suggests this), while monitoring and ensuring health facilities are prepared, makes sense.
At the same time, communicating carefully and transparently regarding any escalating risk, especially to vulnerable populations, may allow them to take additional measures to protect themselves: they may temporarily want to pay more attention to distancing and masking indoors, as much as they are able.
Government support to vulnerable populations thus far has been poor, and unfocused, so attention to this group — delivery of medication at home, food security, home vaccinations and other assistance — should receive priority. Many of the innovations that healthcare workers have developed in this vein should remain part of the health system in perpetuity as they take us closer to patient-centric care.
Finally, there is as great a chance that we are at risk of another pandemic virus in the future, as of the evolution of this one. TB and seasonal influenza were major killers pre-Covid and will remain so, as we have not addressed social determinants of infection.
We call on the South African government to set up a permanent pandemic preparedness body, be it a Ministerial Advisory Committee on Emergency Preparedness or Strategic and Technical Advisory Group, to monitor global threats, ensure that the policies and procedures are in place to rapidly move the country into pandemic mode (if needed), and that supply chain requirements are met.
Finally, we all need to reflect on the fact that there are also several current pandemics that continue to kill tens of thousands of people every year in South Africa — TB, pneumonia, HIV, antibiotic-resistant infections — which never went away. Many are prevented by vaccines or treatment — and greater attention needs to be focused on those, too.
Francois Venter, Ezintsha, Faculty of Health Sciences, University of the Witwatersrand. Marc Mendelson, head of Infectious Diseases and HIV, University of Cape Town. Jeremy Nel, Head of Department, Infectious Diseases, University of the Witwatersrand. Lucille Blumberg, Right To Care and University of Stellenbosch. Zameer Brey, health systems adviser and Groote Schuur Hospital board member. Shabir A Madhi, Dean, Faculty of Health Sciences and Professor of Vaccinology, University of the Witwatersrand.