Health minister Dr Zweli Mkhize has underlined some of the key statistics from South Africa’s ongoing fight against the coronavirus, as the country heads towards its peak.
Citing a new report published by the National Institute of Communicable Diseases (NICD) at the end of June, Dr Mkhize said that the data ‘brings things home’ and provides a better sense of the burden the country has faced and how the healthcare system has coped.
He noted that the data also marries these lessons to the projections that have been modelled of the coming surge.
The NICD reported 10,700 Covid-19 admissions from 269 facilities (71 public sector and 198 private sector) in all nine provinces of South Africa between 5 March and 21 June 2020.
These are the key findings:
- The median age of Covid-19 admissions is 50 years;
- 338 (3%) admissions in patients were under the age of 18 years and 1,386 (13%) patients were over the age of 70;
- 54% of patients (5,778) were female.
- Among 8,245 (77%) patients with data on co-morbid conditions, 2,810 (34%) had one co-morbid condition and 3,126 (37%) had two or more co-morbid conditions;
- Of the 5,836 patients who had a co-morbid condition, the most commonly reported were hypertension 3,419 (59%) and diabetes 2,813 (48%);
- There were 1,116 (19%) patients admitted with HIV, 240 (4%) with active tuberculosis (TB) and 579 (10%) patients with previous history of tuberculosis;
- Obesity, while not consistently recorded for all reported Covid-19 admissions, was noted by clinicians as a risk factor in 297 (3%) patients.
- Of the 10,700 admissions, 3,260 (31%) patients were in hospital at the time of the report, 5,925 (55%) patients were discharged alive or transferred out, and 1,515 (14%) patients had died;
- Of the 7,324 Covid-19 patients who had recorded in-hospital outcomes (died and discharged), 1,515 died, equating to an in-hospital case fatality ratio (CFR) of 21%;
- Some of the factors associated with in-hospital mortality were older age groups; male sex; and having co-morbid hypertension, diabetes, chronic cardiac disease, chronic renal disease, malignancy, HIV and obesity.
“As the numbers of admissions increase, so too must our clinical acumen. We are constantly learning more about the behaviour of the virus when it enters the body,” Mkhize said.
“Our ability to refine our clinical management will have a significant impact on the overall burden of the disease on our health care system.”
He noted that the virus was initially isolated from the bronchoalveolar lavage (a washout of the lung airways) of three patients who were admitted to a hospital in Wuhan.
“We have since learnt that the virus is shed through the airways and spreads by infected droplets passing from one individual to another.
“The virus has also been detected in saliva, lacrimal (tear) fluid, in stool, and in the semen of men with acute infection, as well as semen of some male patients who have recovered. Having said that, sexual transmission of the virus has not been recorded. ”
He noted that there is also variability with regard to Coronavirus persistence on various surfaces.
“A study found that SARS-CoV-2 remained detectable for up to 72 hours on some surfaces despite decreasing infectivity over time.
“Notably, the study reported that no viable Coronavirus was measured after 4 hours on copper or after 24 hours on cardboard. ”
Mkhize said that Covid-19 symptoms may develop between two days and two weeks following exposure to the virus.
“Clinical characteristics of Covid-19 include fever and symptoms typical of a viral respiratory tract infection: cough, sore throat, loss of taste and loss of smell, nasal congestion, and even conjunctivitis, have been reported.
“Further, gastrointestinal symptoms of nausea, vomiting, and diarrhoea are also common with Covid-19.”
Dr Mkhize said that the virus can progress to cause lower respiratory tract infection resulting in, pneumonia and its complications.
“Acute Respiratory Distress Syndrome (ARDS) is a serious complication of Covid-19. The lungs may become stiff and difficult to ventilate.
“It is for this reason that ARDS is associated with a high mortality rate. Added to this, some reports from Italy seem to suggest there is an atypical form of ARDS in patients with Covid-19, leading to much higher oxygen requirements.”
There have been two major advancements in the case management of severely ill patients who require ventilatory support.
First is the advent of dexamethasone which has shown that deaths can be reduced by a third for patients on ventilators and can also help patients who only need supplemental oxygen.
“Apart from dexamethasone, we are also learning a great deal about ventilating patients. Evidence increasingly supports the avoidance of invasive ventilation strategies as far as possible,” the minister said.
This is because when one is very ill, they generate a fight or flight response.
“These hormones drive your body to work harder to breath; your heart to beat faster to circulate oxygen and nutrients to a body that is demanding more; and for you to be able to pay attention to warning signs such as pain or heat,” Dr Mkhize said.
He said that when a patient is intubated, and ventilated artificially, this has to be facilitated by sedation and a limited period of muscle relaxation.
“These processes remove, or significantly dampen, the fight or flight response and therefore remove the ability for the patient to physiologically cooperate with the interventions you are making as a doctor.
“Therefore, it is always better to have a patient who can optimally mount these responses that lead to improved outcomes,” he said.
Mkhize said that he expects the president’s Ministerial Advisory Committee on Covid-19 to issue advisories on the use of high flow oxygen for patients who are very ill but can be managed without intubation and ventilation, soon.