A third wave is coming and SA needs to be prepared, because a widespread vaccine rollout will not be complete by the time a new surge in infections hits around April or May.
This is the word from Medecins Sans Frontieres (Doctors Without Borders, MSF), which has been providing support to hospitals in the Eastern Cape, KwaZulu-Natal and Western Cape.
It warned on Wednesday that to avert more deaths and to ensure adequate care to thousands of Covid-19 patients, hospitals that were overwhelmed during the second wave must be better prepared.
According to MSF, between October 2020 and February 2021, 17% more people were infected than in the first eight months of the epidemic, and more people died — 26,000 in total.
“The rapid spread of the new dominant variant 501Y.V2, which differs from the original by up to 20 mutations and is twice as transmissible, caused a more severe second wave than was expected.
“Vaccines are now being rolled out to front-line health care workers in SA, but it is likely that a more widespread vaccine rollout will not have occurred before a new surge in infections in a third wave begins after April/May.”
Reflecting on the past year, MSF believes the medical fraternity must draw on lessons from the first and second wave to be better prepared.
It said its staff working in hard-hit provinces such as the Eastern Cape “witnessed the enormous toll that the first Covid-19 wave took on human resources working in public health facilities, in the form of burnout, absenteeism, illness and resignations. And how this hampered the ability of facilities to respond to the second wave.”
“Hardly had the flames of the first wave died down and we were back in it, weary and with only a third of the staff we’d had in June,” said Dr John Black, an infectious diseases physician at Livingstone Tertiary Hospital in Gqeberha.
It started to see a dramatic rise in Covid-19 patients in late October 2020, the first area in SA to experience a second surge.
According to MSF a state-of-the-art Covid-19 ward in the basement of Livingstone Hospital, the city’s main referral hospital for the virus, stood empty at the peak of the second wave because of insufficient doctors and nurses to staff it.
Hardly had the flames of the first wave died down and we were back in it, weary, and with only a third of the staff we had in June.
— Dr John Black, infectious diseases specialiist at Livingstone Tertiary Hospital in Gqeberha
“To cope, a rapid injection of human resources was needed, specifically doctors and nurses with Covid-19 experience.
“The addition of a 10-person MSF team in mid-November enabled the opening of the basement ward, including several beds equipped with high-flow nasal oxygen.”
Dr Emma Gardener, the hospital’s Covid-19 coordinator, said the additional capacity “meant that Covid-19 patients in the outpatient department could be put on oxygen faster, and the process of decongesting the overrun casualty ward could begin”.
The second wave hit KwaZulu-Natal in December 2020, at a time when South Africans traditionally travel between provinces in large numbers, and gather with family and friends.
“The health system was caught off guard, with many staff on leave, many exhausted from the first wave, and some now having to deal with a lot of festive season trauma cases.
“And of course it was the new variant, which meant people came in very quickly, one after the other,” said Dr Kwenzakwenkosi Shange, a physician based at Ngwelezana Tertiary Hospital, northern KwaZulu-Natal’s largest Covid-19 referral hospital.
To cope with the Covid-19 pressures, Ngwelezana requested additional human resources, and the health department reacted, adding eight community service doctors and a team of nurses.
“That made a huge difference, because we now had a stable team of doctors responding to Covid-19,” Shange said.
In certain facilities where MSF worked during the second wave, medical staff noticed that patients were dying for avoidable reasons.
“People died because their nasal prongs and masks had come loose and were not replaced. This particularly happened at night,” said Dr Gilles van Cutsem, Covid-19 medical activities manager and TB/HIV adviser with the Southern Africa Medical Unit.
“We also saw people dying of dehydration and acute kidney injury because of a lack of drinking water at the bedside, or because really sick patients received insufficient help with hydration.”
Dr Manny Thandrayen, who joined the MSF KwaZulu-Natal team in January 2021 as medical coordinator said: “Often in the hurly-burly of an emergency situation comorbidities are missed, or the rapidly deployed staff do not have the right experience. Rectifying this situation requires expert attention and lots of training, which MSF was well-placed to provide.
“The first thing that struck me when I joined the MSF team was that the health department had agreed to collaborate with a non-governmental partner on the Covid-19 response. I have worked in senior management positions in public hospitals for many years, and I can tell you this is rare.
“These public-private partnerships are much needed. Leaders in medical NGOs and their counterparts in government need to find ways to collaborate efficiently, and in a timely manner.
“When MSF arrived at Ngwelezana it was already the peak, which limited the potential effect. How do we ensure that the right partnerships are in place weeks before, to save the maximum number of lives? This is an important question.”
In Mitchells Plain Hospital of Hope in the Western Cape, where several MSF staff worked in January 2021, half the patients were diabetic, which data has shown is the single biggest risk factor for mortality.
“In all the places where staff were trained, it was particularly important to ensure there was extensive bedside training on the basics of managing diabetes, which is to ensure glucose levels are checked at the correct times pre-meal, and that insulin is given at the correct times,” said Dr Rosie Burton, an infectious diseases physician at MSF’s Southern Africa Medical Unit.
Burton added that with high rates of diabetes, glucometers are often in short supply in Covid-19 wards.
The first Covid-19 wave showed SA that several public hospitals lacked adequate oxygen supply, a situation that many facilities remedied by installing liquid oxygen tanks, making piped oxygen available in these wards.
“There is a perception that mechanical ventilators in ICU settings are the key to saving lives in patients with Covid-19, but in fact most lives are saved by ensuring the basics are done well, with basic oxygen delivery and proning,” said Burton.
