Experts unpack cabinet’s easing of restrictions
This week, South Africa’s COVID-19 regulations were amended to state that people who test positive for SARS-CoV-2 who do not have symptoms do not have to self-isolate. People who test positive and who have COVID-19 symptoms have to isolate for seven days unless a longer period is recommended by a medical practitioner. Prior to the change, people had to isolate for 10 days, irrespective of whether or not they had symptoms.
The changes come in the context of various calls to relax South Africa’s COVID-19 restrictions – such as this Daily Maverick article co-authored by a group of leading local health experts. We understand it is also in line with the latest recommendations from South Africa’s Vaccination Ministerial Advisory Committee (VMAC) – although the relevant advice has not yet been published on the SACoronavirus website.
The reasoning behind the changes
“There were several premises upon which we recommended eased restrictions to cabinet. One was the high level of asymptomatically infected people,” says Professor Barry Schoub, Chairperson of the VMAC. The more asymptomatic infections there are, the harder it is to effectively contain the spread of SARS-CoV-2.
Schoub also pointed out that a full 80% of the South African population is now protected against COVID-induced death or severe disease through prior infection and/or vaccination. The risk of people getting severe disease or dying is thus much lower now than it was earlier in the pandemic.
“We now also know that the virus is spread by aerosol (airborne droplets), so the criteria of 1.5 metres doesn’t necessarily hold. Another reason for easing restrictions is that the economic costs of quarantine and isolation become prohibitive,” Schoub added.
Speaking on Wednesday along with three other experts and leaders managing the pandemic, Schoub says the fourth wave is effectively over with just a couple of provinces yet to reach significant subsidence. With a national test positivity rate of 8.1%, Schoub says measurements show less than 30 Omicron cases per 100 000 population per week.
According to leading Wits virologist, Professor Shabir Madhi, the ideal test positivity rate is 5% or lower – with 10% and above, indicating substantial infectivity.
Madhi supported the isolation period for those with symptomatic COVID-19 being reduced from ten days to seven days but says he would have gone further.
“I’m surprised they didn’t adopt the National Department of Health’s December proposals and do away with quarantine and contact tracing altogether. The bottom line is that if you’re only diagnosing about five percent of all the infection among asymptomatic individuals, from a public health perspective, it doesn’t achieve much. The flip side is that 95% of those who’ve not been diagnosed, (but are positive), are still walking around. It puts unnecessary pressure on healthcare facilities (when staff have to isolate and cannot work). We’re no longer trying to protect against infection because of our high levels of protection against severe disease. In that context, it makes no sense to continue with isolation of asymptomatic cases.”
‘Open sports stadiums’
Two of the experts spoken to by Spotlight, Madhi, and Dr Saadiq Kariem, Health Operations Manager for the Western Cape, believe restrictions could be eased further. They called for the opening of sports stadia and outdoor gatherings, saying that halving of attendance would be “more than adequate”.
“By continuing closure to spectators, you’re just filling up pubs and homes where they defer to and watch the same game in enclosed spaces. It makes no sense,” says Madhi.
The outdoor restriction has been eased to a maximum of 1 000 people indoors and 2 000 people (at most) attending outdoor venues. Where the venue is too small to accommodate these numbers with appropriate social distancing, no more than 50 percent of the capacity of the venue may currently be used.
“There’s absolutely no reason for any sort of restriction on outdoor gatherings,” says Madhi. “The number of 2 000 makes no sense. You can pretty much open up your stadiums and outdoor spaces. The same goes for indoor spaces – but you need to reflect on what you’re trying to achieve indoors. You could make a case for increasing indoor numbers given the immunity against severe disease, but guard against poor ventilation.”
Schoub was more cautious, saying he knew of no studies showing just how many people gathered in pubs and homes to watch sport.
All three experts, however, agree that South Africa has all but exited the fourth wave. They do add that future variants are a distinct possibility.
Health Minister Dr Joe Phaahla during a press briefing on Friday said, “There are proposals on the table in terms of opening up sport and arts and culture with necessary safety measures. These proposals are being fine-tuned and the final decisions will be made in the next few weeks and announcements will be made accordingly.”
Fifth wave possible mid-year
“We had to make some prediction – our provincial cabinet wants a sense of what’s coming for the year and what funding to set aside,” says Kariem. “Our public health experts think a fifth wave will probably hit us about May or June. But having said that, I think we’re moving towards endemicity with Omicron itself being less virulent, (lethal), than the wild-type virus. The analogy is that it becomes like a flu season,” he says.
“My hope is that President Cyril Ramaphosa will make a definitive announcement on the State of Disaster regulations in his State of the Nation Address on 10 February. There are some good practices embedded in there, but we must find a way to bring these into our current regulatory framework and thus into our everyday lives. We need to move away from disaster regulation.”
None of the trio believe South Africa is exiting the COVID pandemic anytime soon.
“We shouldn’t accept any more than the number of people who die annually of TB (some 58 000) – I think in this space we’ll probably see COVID deaths coming down to be on par with seasonal flu within a year or two,” says Kariem. Around 10 000 to 11 000 people die of flu in South Africa every year. In 2021, there were around 200 000 excess natural deaths in South Africa, the vast majority thought to be COVID-19 deaths.
Madhi trashed suggestions from some quarters that the COVID-19 infection fatality rate was historically no worse than seasonal flu.
“In SA, about 20 million people, (one-third of the population), are infected with seasonal flu, which kills about 10 000 to 11 000 people annually resulting in an infection fatality risk of 0.055%. Now with COVID, when 70% of the population were infected with COVID-19, some 270 000 people had died before the onset of Omicron, the infection fatality risk is >10 fold higher at 0.64%. Both these sets of stats for flu and COVID attributable deaths are calculated the same way using an excess mortality approach. To consider COVID-19 to be a bad seasonal flu is absolute nonsense,” he said.
Changes at schools
National cabinet has agreed that schools can return to full-time onsite learning with the one-metre physical distancing rule scrapped. Spotlight asked the Western Cape’s Head of Education, Brent Walters, what indoor precautionary measures were being taken at schools in the province, particularly with two recent local heat waves prompting calls for fans and more air-conditioning.
Walters said he expected most of the schools in the province to be back to a five-day school week soon, with masks, hand washing, and sanitising remaining compulsory. However, “budgetary considerations” ruled out installing fans and air conditioning, in spite of COVID.
“We’re looking at how to balance the need for education with the comfort and safety of our children. We’re gathering information. Schools have three days to get all their latest reports on available space and the like to us. We should have a good idea by Monday (7 February),” he said.
Walters said that there had been major COVID-induced educational losses, especially in the lower grades.
“Each school can make a decision about the heat based on conditions on the ground and apply to us for closure, which has happened in the past. But we won’t be doing fans and aircon. Ventilation must be via open doors and windows – that’s going to be key. And we’ll hope for cool days,” he said.
Walters said that over the last two years of COVID, his department had been forced to ‘redirect’ their infrastructure budget to pay for sanitiser, cleaning materials, and masks.
Department of Health Director-General, Sandile Buthelezi, is on record as saying containment strategies are no longer appropriate. “Mitigation is the only viable strategy. People having to isolate without symptoms deprives them of income or children of school time,” he said.