Letter from South Africa—COVID‐19: The good, the bad and the ugly

Of the African countries, South Africa has been the hardest hit by the coronavirus disease 2019 (COVID‐19) pandemic. Fourteen months into the pandemic, South Africa has recorded over 1.6 million COVID‐19 cases, 56,506 deaths and a case fatality rate of 3.4% (as of 30 May 2021). After first detecting severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) in March 2020, South Africa had rising COVID‐19 cases peaking in July 2020, a second larger rise in infections with peak in early January 2021 and are currently facing a ‘third wave’ as infections rise again (Figure 1). The second wave of infections was characterized by a new more transmissible variant, 501Y.V2, which was associated with higher incidence and faster increases in cases and hospitalization compared to the first wave, but was not associated with increased in‐hospital mortality.¹ In addition, this new variant was one of the factors contributing to the local delay in vaccination programme initiation. Despite initial concerns of an overwhelming pandemic with high mortality in Southern Africa, South Africa's health system has managed in the main to cope with the increased pressure on the health system, the COVID‐19 contributable loss has been marked (96.2 per 100,000 population) but less than in many high resourced settings in Europe and the Americas. However, the indirect losses of life and livelihood from this pandemic have been devastating and are yet to be fully realized.

FIGURE 1.

South African coronavirus disease 2019 (COVID‐19) epidemic curve by day (7‐day moving average). Reproduced with permissiom from the National Institute for Communicable Diseases¹

The South African government's initial approach was an early introduction of very strict public health measures, including complete lockdown (27 March 2021), ban on tobacco and alcohol sales, prolonged closure of schools and public amenities, strict social distancing, sanitation and mask wearing. Mask wearing has been compulsory in all public spaces since May 2020. These measures have been the corner stone to preventing the spread of the virus and overwhelming the health system, and to that end have been relatively effective. The sero‐prevalence estimates after the second wave were 34.5% (based on data from three of nine provinces), an increase from 9% in November 2020 after the first wave of infections. This was possibly due to the increased transmissibility of the prevalent 501Y.V2 variant and the by then less strict social lockdown.¹ This also points to the likely vast under‐detection of cases, with many uncounted mild or asymptomatic infections. The national vaccine programme, which began in March 2021, has unfortunately been problematic and slow. As of 3 June 2021, 1,193,652 healthcare workers and people over 60 years have received one vaccine dose, 480,665 being fully vaccinated, a mere 0.82% of the population, with a >60% of population target set for April 2022. The challenges have included access to vaccines, new virus serotypes requiring change in vaccine strategy, temporary halting of vaccinations for safety review, infrastructure limitations and political factors.

South Africa entered this pandemic with the existing challenge of dual HIV and tuberculosis (TB) epidemics, as well as prevalent risk factors for infectious disease vulnerability, such as poverty and overcrowding. As with many Sub‐Saharan African countries, there was fear for our vulnerable populations. Emerging data on risks for those living with HIV or with current or previous TB, notably rifampicin‐resistant TB, have shown both to be independently associated with COVID‐19‐related death in adults, with HIV adjusted hazard ratio (aHR) of 2.14 (95% CI: 1.70–2.70) and current and previous TB aHR (95% CI) of 2.70 (1.81–4.04) and 1.51 (1.18–1.93), respectively.², ³ However, as has been seen globally, the stronger risk factors for severe disease and death have been increasing age, obesity and comorbidities including diabetes and hypertension. The impact of the COVID‐19 response on health system programmes has however impacted timely diagnosis and delivery of care for people living with HIV and TB. In one province, HIV testing halved and initiation of antiretroviral therapy treatment decreased during the initial lockdown,⁴ with improvements since but not to pre‐lockdown levels. There have been similar impacts on TB programmes, with COVID‐19‐related estimates of 400,000 excess TB‐related deaths globally in 2020.⁵ A stark reminder of the broader health gains lost in the wake of this crisis.

However, the biggest losers in this pandemic must be the children who have experienced multiple deprivations as a consequence of, or exaggerated by, the pandemic. South African children represented only a small proportion of COVID‐19 cases and even less deaths: 9.4% of laboratory‐confirmed COVID‐19 cases and 3.8% of all COVID‐19‐associated admissions in South Africa.¹ They have presented with mostly mild respiratory disease and modest burden of multisystem inflammatory syndrome post COVID‐19, yet they have suffered health losses that will impact their potential to thrive for years to come. These have included decreased access to preventive, acute and chronic health care as health resources were shifted to the COVID‐19 epidemic response; loss of household income driving food insecurity; loss of carers from sickness or death without the usual access to community supports, leaving many children in unsafe situations; social isolation with increased mental health issues; and prolonged interruption to education with no meaningful access to online alternatives in the children most at need. All these factors have worsened deep inequalities that are experienced here and globally. This is a picture hard to face beside the current inequities of the international COVID‐19 vaccine rollout. As South Africa heads into the next wave of COVID‐19 infections, they urgently need strategies that prioritize these health and social fall outs, whilst establishing an effective vaccine rollout amidst the local and global challenges.

This time last year, we were witness to a unique (for our times) worldwide camaraderie of common purpose, aided through digital connection. Countries reached out to each other across language and culture, science worked with industry, governments and regulatory bodies worked together to ensure that we produced, in record time, effective vaccines. New information was shared freely and graciously, collaborations were extended, peer review was expedited and access to information was open and encouraged, it was as if the world had realized that we needed each other to achieve the impossible. But just as this pandemic has shown what can be done when we work together for a common good, it has shone a searing spotlight on the gross inequalities that persist globally and the dismal failure of current global economic systems to address these, whether through design or execution. As we continue to tackle this global challenge, let us consider the African proverbial wisdom, ‘If you want to go fast, go alone; if you want to go far go together’.

Gray DM. Letter from South Africa—COVID‐19: The good, the bad and the ugly. Respirology. 2021;26:893–894. 10.1111/resp.14104