Over 90 new cases a day? Then lockdown drags on

South Africa’s lockdown will have to be extended if there were more than 90 new cases a day over the next few days, an epidemiologist warned on Monday.

Prof Salim Adbool Karim, who is a government advisor, added that the virus was only expected to peak in September. 

He said South Africa was in the midst of a “critical week”, warning that if more than 90 new cases were confirmed on average per day, between April 10 and 16, the country would “need to continue the lockdown”.

But it is not all bad news – SA does seem to be dealing with the pandemic very well compared to other nations, he said.

Karim was speaking shortly after health minister Zweli Mkhize announced there had been two new deaths, including a 57-year-old man from Gauteng who did not appear to have any underlying medical conditions. If this was the case, it would be the first such death for SA.

By Monday night, SA had 27 Covid-19 deaths and 2,272 confirmed cases. There had been 83,663 people tested, with 21,290 of those from the public sector.

Mkhize described South Africa’s path as a “long march”.

“It is a march that demands national unity. It is a march that requires us to focus and know that each and every person’s actions will count. You are protecting us as a nation through your actions, you are protecting yourself as well as an individual. We must know that we can only defeat Covid-19 collectively as a nation. We need to work together,” the minister said.

Virus could only peak in September

Karim, who made a presentation after Mkhize, warned there would be an “inevitable” spike in cases, irrespective of when the lockdown ended. The current estimate was that the virus would peak in September.

He said several factors needed to be considered to slow down the spread, including extending the lockdown beyond the end of April, regulating funerals and a “voluntary partial lockdown until end September” for people older than 60 and those with underlying conditions.

But what was immediately crucial, said Karim, was what happened between April 10 and 16.

“So this coming week is critical. We need to know what the average number of cases is going to be. Why? Because we want to know what the community transmission [local transmission] levels are, because we want to use that to guide us on what next steps we should follow and how we should manage the lockdown,” he said.

This week would show whether the pattern of between 45 and 90 cases a day – or 67 cases on average – was accurate.

“So by April 16, we will know if community transmission – and whether our interpretation that the community transmission has been kept low – is accurate ...

“If we look at just the passive cases, between April 10 and 16, and if we see 90 or more cases, on average, between April 10 and 16, then we need to continue the lockdown. And the reason, put very simply, is that the average number of cases per day is going up,” said Karim.

Also, if there is more than one positive test for 1,000 active screenings, “then we continue the lockdown”.

“If it’s below one in 1,000 then we can ease the lockdown. Similarly, if the absolute number of cases is 44 or lower then we can ease the lockdown,” he said.

He cautioned that the numbers needed to be analysed over a period in time.

“So that’s why we look at a whole week at a time and we compare weeks with weeks.

“We know that if we end the lockdown – and we end it rapidly – we may run the risk of undoing all of the effort and the benefit we’ve achieved. Because then we’ll be putting high risk and low risk people together, travelling in the same buses, taxis and trains. We have to do something about it. We have to avoid that situation.

“And so we need to think about and plan for a systematic easing of the lockdown starting with transport hubs, and then working our way down from the lowest risk to the highest risk,” said Karim.

Earlier in his hour-long presentation, Karim praised SA for how well it had responded to the coronavirus pandemic this far.

He said the country initially showed the same trajectory of Covid-19 cases as many places in the world. SA was “entering that exponential curve where the number of cases was increasing rapidly”. But that started changing on March 26.

“Instead of continuing a straight upward exponential curve, the epidemic took a turn. And what we began to see was a decline in the number of cases, and then we reach a stage of what we call a plateau, where we’re just seeing a similar number of cases every day. Now, March 26 is significant because that was the date of the lockdown,” said Karim.

“What you can see is that we were on a simple trajectory like every other country, increasing rapidly, day by day. And then suddenly on March 26 it turned and started going down again. And as it went down, it reached a point, somewhere around 60, 70 cases a day, and it sort of hovered around there.

“So why is SA not on the expected Covid epidemic trajectory? 

“Our epidemic trajectory is unique. No other country has reached that point, and has been able to reach a stage where you get that kind of plateau. So why is SA different? Why is it that our new cases declined and have reached a plateau?”

He said there were three scenarios:

• We are “testing less” and “just not doing enough tests”;
• We are doing a lot of tests but they’re in the private sector and not in the public sector – “and so we’re not getting a sense of what the epidemic is doing in our poorer communities”; and
• The reduction in cases was “genuine and that it’s due to the interventions that we have implemented”.

Early indications are that the third scenario was the most likely.

“It’s not something we can say definitively, but we can say that that’s the likely situation,” he said.

This did not mean SA would escape the spread of the novel coronavirus, or the Covid-19 respiratory illness it causes.

“Can SA escape the worst of this epidemic? Is the exponential spread avoidable? The answer is that it is very, very unlikely. Put simply: no, we cannot escape this epidemic,” he said.

He said that once the lockdown was ended – “and we are going to have to end it at some point”, he said – then new cases were likely.

“As soon as the opportunity arises for this virus to spread, we are likely to see the exponential curve again,” he said.

However, SA had “gained time” to get hospitals ready, actively track cases and, in the long term, have a vaccine.

“So why is the delay important; why is it that we should delay? ... Because if we allow it to grow unchecked we will see what you see in New York. You will see thousands of people trying to get into a hospital for care, and we simply do not have enough ICU beds or ventilators or medical care. Any of that. We simply cannot provide care to so many people at one time. And so that's the challenge we face,” he said.

What will Ramaphosa do?

Mkhize said all of this was being presented to President Cyril Ramaphosa, who had to wrap his head around the possibility of a further lockdown extension.

“A lot of modelling is taking place to advise the president and the cabinet on the impact of coronavirus and the interventions that we’re putting in place. Trade and industry and Treasury have been working on a number of scenarios as well as projections of what the impact will be on our economy and fiscus, and specific sectors of the economy and therefore all that is being taken into account.

“These also include the social impact of the outbreak as well as the interventions, such as the lockdown.

“We are looking at the fact that we have a community with a large amount of poverty and inequality, unemployment, and the economy has gone through a downgrade, as well as other challenges such as the supply of energy.

“When we talk about what we do, we have to consider the impact,” he said.

Praise from WHO

Dr Brian Williams, epidemiologist for the World Health Organisation in Geneva, was full of praise for SA’s efforts.

“Professor Karrim reminded us that our epidemic pattern is unique. The question is: why did we manage to stop the initial exponential rise so effectively when almost any other country anywhere in the world has achieved as much?

“All of this is dependent on this leadership and a very clear vision of the minister and people like Professor Karim, and the commitment and dedication of community health workers who are on the frontline.

“I would like to think what we have achieved would become the gold standard model for how we respond to future epidemics which will surely come,” he said.

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