Health workers may be experiencing challenges as they fight Covid-19, but there are also positive developments happening in the field that need to be celebrated, writesMarc Mendelson.

The pandemic of novel coronavirus, SARS-CoV-2, which causes Covid-19, has now claimed over half a million lives and close to 11 million confirmed infections worldwide.1 At home, the seriousness of the situation has required a state of national disaster to be declared, with all the health, social, and economic consequences that it brings.

Lifting of the lockdown brings with it its own challenges for how we, as a society, embrace the new norm of how we live our daily lives and prevent the transmission of the virus to our family, friends and within our communities and at work. There is no getting away from the seriousness of the situation, nor can any broadening of the narrative belittle its gravity.

However, it is time that a modicum of balance is brought to the sense of helplessness and nihilism that is becoming entrenched in society. There are success stories out there, that need to be heard.

Scientific tools

We have remarkable scientific tools at our disposal, that have allowed us to isolate, diagnose, monitor and treat the virus, at a pace not seen with even modern epidemics of Ebola, HIV or previous coronaviruses.

From the start of this epidemic, we were faced with a rapidly evolving field. The last decade has seen quantum leaps in scientific advances that we are now benefitting from, especially in the field of emerging and re-emerging infectious diseases; the identification of SARS-CoV-2 only days after the announcement of atypical pneumonia cases in Wuhan occurred at unprecedented speed, closely followed by a diagnostic test for the virus that allowed outbreak investigations and accelerated understanding of the rapidly expanding global pandemic.

South African expertise in outbreak control, including listeria and drug resistant TB, along with public health expertise in HIV, have allowed for rapid in-depth analysis in a way that rivals many European countries and certainly the US.

In addition, new ways in which we perform clinical trials with "adaptive" designs means that medicines that may be of benefit in treating an emerging infection can be studied rapidly, and a "go-no go" given much earlier than previously possible.

Again, South Africa's rich research community, largely having cut its teeth on infectious diseases and vaccine research during the last 20 years, has swiftly pivoted and begun evaluating a large number of prevention and treatment options. In South Africa, and across the globe, our management of this pandemic has been greatly improved by these advances.

In just a few months, we have acquired enough knowledge to return most people to health, with increasing success in people with severe disease. The pandemic has transfixed society on macro-level numbers, chief among which are the number of cases and the number of deaths. Little attention is given to the number of persons who have recovered.

While about half of the people infected by SARS-CoV-2 will have no symptoms at all (asymptomatic), most of those that do develop symptoms (~80%) will have mild disease, which can be managed at home.

What about outcomes of those that have the most severe disease and require admission to hospital? The most recent DATCOV report from the National Institute for Communicable Diseases (NICD 28th June 2020) tells of 14 555 people admitted to 278 public and private hospitals, countrywide.2

Advances

Although 2 115 (15%) persons had died, 8 189 (56%) had been discharged alive or transferred out, and 4 250 (29%) were still in hospital. Every death is a tragedy, but every person who survives is equally a triumph.

Those successes have been aided by advances in our knowledge of how we treat the sickest patients who are admitted to hospital. Two main advances are the use of the steroid dexamethasone, and alternative ways of delivering more oxygen to patients, short of intubation and mechanically aiding their breathing in the intensive care unit.

Dexamethasone is a commonly used corticosteroid (steroid) available in South Africa and across the world. Recently, results of its use in hospitalised patients with severe Covid-19 were announced by investigators of the UK RECOVERY trial, that set out to study six different possible treatments for Covid-19 at the same time, an example of an adaptive clinical trial alluded to above3.

They found that people admitted to hospital, who needed oxygen support, had a reduction in death of one fifth, and for those on a ventilator in ICU, the reduction in death was one third if they took dexamethasone daily for 10 days. There was no effect for patients who did not require oxygen. This is a major advance as it is the first medicine to show an effect on death rate in severely ill patients with Covid-19.

Another medicine, remdesivir, has been shown in a trial in the US to reduce the duration of symptoms, but did not affect the mortality. Since the publication of these results, doctors in South African hospitals have rapidly started to use these approaches, treating patients with Covid-19 who require oxygen by giving dexamethasone or an equivalent steroid to benefit the patient.

Covid-19 is first and foremost an infection of the lungs, and we are also advancing the way in which we support the sickest patients by giving greater amounts of oxygen in an attempt to reduce the need for people to be ventilated on the ICU.

Like dexamethasone, treating critically ill patients with humidified high flow nasal oxygen (HFNO) is not new, but the global experience, and now ours in South Africa, has taught us that using HFNO in the general wards as well as in the ICU, can improve survival of some patients.

Added to this, the incredibly simple understanding that nursing patients with them lying on their front (proning) also improves oxygen supply to the body. This, too, has been previously used in ICUs, but is now being employed in the wards. Some patients will still need to be ventilated on the ICU.

Despite these sickest patients having the highest risk of dying, we are seeing some patients survive and come off the ventilators to be discharged. The public perception that going into hospital invariably results in death is not the case, despite the very high numbers that do sadly succumb.

This balance in narrative that healthcare workers can provide needs to be matched with the stories of survivors of Covid-19 in South Africa. We need to hear and learn from the experiences of patients, relatives, and staff in our health services, if we are to make further improvements and gain greater insight into how best to manage Covid-19, and its place in society.

Equally, it is absolutely critical that clinical trials of new medicines and vaccines can take place in our country, so that we can ensure that they work in our setting, which is unique in so many ways.

Physical distancing and masks

We welcome the vaccine trials that are under way4, and clinical trials, such as the international World Health Organisation SOLIDARITY trial5among others, that will start shortly in South Africa, looking at new treatment options for Covid-19.

Lastly, the positive benefits of reducing coronavirus transmission by following the simple public health measures of social distancing, universal masking, hand hygiene, regular decontaminating of often-used surfaces, and isolating if symptoms develop, cannot be stressed enough.

These are truly positive rather than negative narratives, in so much as they protect our most vulnerable older populations and those with comorbid medical conditions.

An understandably nihilistic viewpoint of Covid-19, especially for the sickest of our population, needs to be balanced with the positive developments that are happening in the field.

This, coupled with the outstanding ability and dedication of the South African health workforce, gives hope for the coming months, despite the incredible challenges that we face from Covid-19.

-Marc Mendelson isProfessor of Infectious Diseases, Head of Division of Infectious Diseases & HIV Medicine atGroote Schuur Hospital,University of Cape Town and a member of the Ministerial Advisory Committee on Covid-19.

References

1. Johns Hopkins University. Covid-19 Dashboard by the Centre for Systems Science and Engineering (CSSE). Available at https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html#/bda7594740fd40299423467b48e9ecf6 (Accessed on 3rd July 2020)

2. National Institute for Communicable Diseases. Covid-19 Surveillance Reports. Available at https://www.nicd.ac.za/diseases-a-z-index/covid-19/surveillance-reports/ (Accessed on 3rd July 2020)

Randomised Evaluation of Covid-19 Therapy (RECOVERY): Low-cost dexamethasone reduces death by up to one third in hospitalised patients with severe respiratory complications of Covid-19. Availablehttps://www.recoverytrial.net/files/recovery_dexamethasone_statement_160620_v2final.pdf (Accessed on 3rd July 2020)

3. University of Witwatersrand. The first Covid-19 vaccine trial is South Africa begins. Available at http://www.wits.ac.za/covid19vaccine/ (Accessed on 3rd July 2020)

4. World Health Organisation. "Solidarity" clinical trial for Covid-19 treatments. Available at https://www.who.int/emergencies/diseases/novel-coronavirus-2019/global-research-on-novel-coronavirus-2019-ncov/solidarity-clinical-trial-for-covid-19-treatments (Accessed on 3rd July 2020)

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OPINION | 100 days of lockdown: Success stories need to bring some balance to Covid-19 narrative - News24