Lessons from two waves of SARS-CoV-2 in South Africa


As of July 2021, at least four worrisome variants were circulating around the world in the SARS-CoV-2 pandemic which resulted in nearly 180 million documented viral infections and nearly 4 million Deaths from COVID-19 around the world since December 2019. Variants of concern are those lines that evolved from the ancestral RNA virus with enough mutations to cause substantial changes in viral characteristics, such as increased transmissibility or a detrimental change in the epidemiology of COVID -19; increased virulence or change in clinical presentation; or a decrease in the effectiveness of public health and social measures, diagnostics, vaccines or treatments available.
1
  • Abdool Karim SS
  • By Oliveira T
New variants of SARS-CoV-2 – clinical, public health and vaccine implications.

In The Lancet Global Health, Waasila Jassat and her colleagues
2
  • Jassat W
  • Moudara C
  • Ozougwu L
  • et al.
Difference in mortality among people admitted to hospital with COVID-19 in the first and second waves in South Africa: a cohort study.

describe the effect of a circulating variant first described in South Africa (501Y.V2 or B.1.351), now known as Beta, with increased transmissibility and immune evasion.

3
WHO
Monitoring of SARS-CoV-2 variants.

South Africa’s second wave of COVID-19 coincided with the onset of the beta variant, characterized by rapid spread and higher rates of infections, admissions and death than in the first wave – the authors thus drawing deductions on the differences in virulence of the ancestor. and beta variants. These include evidence of greater morbidity and mortality seen with the beta variant, although the authors suggest that the inference of greater virulence in the variant had several caveats: notably the difficulty in differentiating between true biological effects of the quality of care in a pressurized and overwhelmed state of health. system. This 13-month study of two waves driven by two different viral lineages is both interesting and informative. We can draw several important lessons from this South African case study on COVID-19.

The first is that overcrowding in hospitals at the height of a COVID-19 wave is a major cause of increased mortality. Therefore, a crucial public health measure is to find ways to alleviate overcrowding through rapid expansion of hospital facilities or through a strategy known as flattening the curve. Expansion of hospital facilities is feasible, especially if it includes field, general and intensive care beds rather than intensive care facilities, which require more limited and specialized clinical and technical expertise. Flattening the curve, on the other hand, can be more difficult. The effectiveness of non-pharmaceutical measures in this regard, including tightly regulated shutdowns, remains controversial. A combination of the aforementioned strategies may have reduced the effect of COVID-19 in South Africa’s first wave, where strict closures, including an alcohol ban, may have reduced demand and overcrowded hospitals, in particular. in emergency and intensive care departments, reducing the acuity of the flare-up, which could have given healthcare systems sufficient time to develop and prepare.
4
Timeline: a year of Covid-19 in South Africa.

The second lesson is that new variations are bad news and everything must be done to reduce the likelihood of them occurring. Not only do new variants lead to reinfection with escape of pre-existing immunity to a previous infection, but also new mutations promote viral survival with features such as increased transmissibility leading to faster spread, more acute flare-ups with an inherent congestion of hospitals, and increased mortality.
1
  • Abdool Karim SS
  • By Oliveira T
New variants of SARS-CoV-2 – clinical, public health and vaccine implications.

It is this effect which, according to Jassat and his colleagues, could have caused an increase in mortality during the second wave. After adjusting for age, sex, race, co-morbidities, health sector, province, and weekly admissions, there was still a residual increase in mortality (aOR 1.31, 95% CI 1 , 28-1.35), which they believe may be due to the virus itself.

Appropriate management of chronic diseases and comorbidities is essential during and between outbreaks of COVID-19. Chronic SARS-CoV-2 infection in patients with reduced immunity may be a key mechanism promoting the development of variants of concern.
5
  • Karim F
  • Moosa MYS
  • Gosnell BI
  • et al.
Persistent SARS-CoV-2 infection and intra-host course in association with advanced HIV infection.

Globally, we have seen a reduction in access and retention of care for patients with HIV, tuberculosis and noncommunicable diseases such as diabetes and cancer over the past 18 months. .

6
The Global Fund
The impact of COVID-19 on health services and systems related to HIV, tuberculosis and malaria: an overview of 502 health facilities in Africa and Asia.

Strengthening health systems to ensure continuity of care for chronic diseases will be crucial in limiting new variants of concern.

Finally (and perhaps the most important lesson), immunization and vaccine coverage in the COVID-19 pandemic are urgent. The speed at which COVID-19 vaccines have been developed, tested and reviewed for emergency use approval is both unprecedented and crucial as we consider potential ways to achieve control of the outbreak. Many vaccines are now available on the WHO list and show reasonable vaccine efficacy, even against viral strains that are alternatives to ancestral strains. Countries and cohort studies are starting to report real-world efficacy data that would indicate not only benefits for the most clinically vulnerable individuals, but also a reduction in transmission due to reduced disease. community viral load secondary to immunization coverage. South Africa, and Africa in general, has not yet had the same immunization coverage as most of the rest of the world. This is largely due to the vaccine supply, the global availability of vaccines and vaccine nationalism.
8
  • Katz IT
  • Weintraub R
  • Bekker LG
  • et al.
From vaccine nationalism to vaccine equity – finding a way forward.

The consequences of this could translate into uncontrolled transmission of SARS-CoV-2 in Africa with continued replication and the risk of new potentially problematic variants.

Thirty years ago, we faced similar inequalities in the distribution of life-saving antiretroviral agents for treating HIV.
9
The first decade of antiretroviral therapy in Africa.

The consequence then was the unnecessary loss of young lives simply because of cost, availability and neglect. Within months, we have seen worrying new variants of SARS-CoV-2 spread around the world. Inequitable distribution of COVID-19 vaccines will lead to much greater pandemic devastation globally. It is time to act with conviction and to vaccinate the whole world.

We do not declare any competing interests.

The references

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    • Abdool Karim SS
    • By Oliveira T

    New variants of SARS-CoV-2 – clinical, public health and vaccine implications.

    N Engl J Med. 2021; 384: 1866-1868

  2. 2.
    • Jassat W
    • Moudara C
    • Ozougwu L
    • et al.

    Difference in mortality among people admitted to hospital with COVID-19 in the first and second waves in South Africa: a cohort study.

    Lancet Glob Health. 2021; ()

  3. 3.

    Monitoring of SARS-CoV-2 variants.

  4. 4.

    Timeline: a year of Covid-19 in South Africa.

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    • Karim F
    • Moosa MYS
    • Gosnell BI
    • et al.

    Persistent SARS-CoV-2 infection and intra-host course in association with advanced HIV infection.

    medRxiv. 2021; ()

  6. 6.

    The impact of COVID-19 on health services and systems related to HIV, tuberculosis and malaria: an overview of 502 health facilities in Africa and Asia.

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    Vaccines against covid19.

  8. 8.
    • Katz IT
    • Weintraub R
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    • et al.

    From vaccine nationalism to vaccine equity – finding a way forward.

    N Engl J Med. 2021; 384: 1281-1283

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    The first decade of antiretroviral therapy in Africa.

    Global health. 2011; 7: 33

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