EDITORIAL

 

What are we doing to the children of South Africa under the guise of COVID-19 lockdown?

 

 

In response to rising numbers of cases of COVID-19, which had been declared a pandemic by the World Health Organization, the President of South Africa imposed a nationwide lockdown on 23 March 2020, effective on 27 March 2020.^[1] While some other countries seemed to panic, flounder and in some cases even turn their backs on the rising threat of COVID-19, for South Africa this was almost a Dunkirk moment. The nation showed an extraordinary degree of unity as the President implemented severe measures that have proved effective at 'flattening the curve'.

What should be of major concern to South Africans, however, is that the background care of children has been tremendously compromised by lockdown. We the undersigned are extremely perturbed at the aggressive nature of some of the regulations and how they are being implemented. Some of these regulations directly affect children's access to healthcare and education, and maternal support for hospitalised children. The consequences of decisions made during the lockdown by politicians, healthcare workers and parents are giving rise to an increasing sense of disquiet.

Nearly half of the COVID-19 positive individuals have now recovered, and the majority of those infected have had a mild or asymptomatic illness.^[2] Between 5 March and 19 May, 16 433 South Africans became infected and 286 died (mortality rate 1.74%). But in anticipation of the reopening of schools, the South African Democratic Teachers Union stated that 'corpses can neither be taught nor can they teach', associating the opening of schools directly with COVID-19 and death. However, politicians have reassured us that their policies will be guided by science, and on those grounds alone our argument requires a dispassionate stance. We therefore carefully set out our concerns and avoid the speculation that is rife at this time.

Our first concern is the belief among South Africans, including the public, parents and healthcare workers, that SARS-CoV-2 infection is synonymous with severe disease and even death.

Mothers are no longer allowed into paediatric wards, doctors and nurses are refusing to see or care for children if their COVID-19 status is unknown, and the first reports have come through about clinics declining to provide essential services, such as immunisation. However, tuberculosis and influenza are estimated to kill 60 000 and 10 000 South Africans, respectively, every year.^[3,4] The care of children with these deadly diseases is currently being compromised by the extraordinary measures being taken to halt the spread of COVID-19. Empty consulting rooms and paediatric wards are frightening. Surely it is unlikely that there are no sick children out there? Have we driven disease underground? And more frightening still, have we perhaps allowed sick children to die at home without care?

A second major concern is the myth surrounding transmission of COVID-19. At some hospitals, asymptomatic doctors are required to test weekly for SARS-CoV-2, to be allowed access to the hospital. Teachers are being asked to fumigate and disinfect schools before re-opening, while SARS-CoV-2 does not survive for longer than 9 days on surfaces^[5] and the schools have been closed for 2 months.

Healthcare practitioners wearing appropriate personal protective equipment (PPE) have been asked to self-isolate if they come into contact with a SARS-CoV-2-positive patient, and even contacts of contacts have been asked to stay at home. However, data have shown that hand hygiene and health workers' use of PPE (N95 respirators for aerosol-generating procedures or surgical masks) offer adequate protection.^[6-8] PPE is our protection, and we are essential service providers. Who will look after sick children when all our healthcare workers are at home?

Lastly, we worry about the treatment of suspected or confirmed COVID-19 in children. Senior paediatricians are treating children with empirical antibiotics, hydroxychloroquine and azithromycin, even for mild disease, although these are not recommended in any guideline. Side-effects, antibiotic resistance and dysbiosis of our microbiome are still important reasons not to use unnecessary antibiotics. Hydroxychloroquine and azithromycin have no proven benefit in COVID-19, and if used should be reserved for severe cases and preferably as part of a clinical research triaU^[9]

Reasons why South Africans are so disproportionately afraid of COVID-19 remain elusive. The general population has come to know and fear viral diseases, and to associate them with mortality. Before the availability of antiretroviral therapy, being diagnosed with HIV was synonymous with ill health and often death.^[10] Not surprisingly this fear of viral disease is rife, not only in our citizens, but especially, and even more profoundly, among our nursing staff. Many webinars and training courses bypass these most important members of our team. Also, in a society where healthcare is easily criminalised, healthcare institutions may fear liability. We are aware that at least two individuals have been arrested and charged with attempted murder after they tested positive for SARS-CoV-2 and did not self-quarantine. Such acts of criminalisation further worsen the stigma around the disease.^[11]

Whatever the cause of the mass hysteria, when it comes to children, this fear is not in line with the latest paediatric data on COVID-19. Even though final information is still awaited, evidence is emerging that children are at less risk of being infected than adults, and are not likely to be the index case in the household. Children are predicted to be responsible for only ~10% of clusters of disease.^[12] Once infected, most children present with mild symptoms,^[13] if any, and although severe disease is possible, it is rare and mortality is negligible when compared with other childhood diseases in Africa.^[13]

Children are the victims of the measures taken to halt the spread of COVID-19. They have been denied basic rights of access to healthcare and education. Schools have been closed, and for many vulnerable pupils this has meant an experience of isolation, anxiety and hunger.^[14] These restrictions may be considered a form of abuse or neglect. Children with malnutrition are once more being admitted to paediatric wards in state hospitals. Soon there will be a return of measles, gastroenteritis and pneumonia as we lose our vaccination opportunities.

SARS-CoV-2 is a new infection spreading in a non-immune population and we have no clarity yet on its full impact, so prudence is definitely warranted. But this virus will probably remain in our society for some time until we have a safe and effective vaccine.

It may seem redundant, but is absolutely necessary, to point out that contagious diseases have emerged, or re-emerged, in naive populations. These include severe acute respiratory syndrome (SARS), Zika, Ebola, Middle East respiratory syndrome (MERS) and others.^[15] The fear and dread of these viruses was intense, but none of them shut down countries - and neither have vaccines emerged for them, despite decades of research. As mentioned above, influenza, tuberculosis, HIV/AIDS, malaria and malnutrition are more deadly to our population, and yet no draconian measures have been taken to curb them.

Local transmission is expected and needed for widespread immunity. If we continue to avoid every infection and every death by closing schools, clinics and hospitals, the children of this country will suffer deeply.

This is not a plea to unselectively remove lockdown regulations, it is a plea to be rational and realistic about the decisions we make. It is undisputable that we started with 'unknown unknowns' about this panic pandemic, but there are now sufficient 'known knowns' to review policies.^[15] We cannot lock down children who need our care, our love and our humanity. We cannot afford to sacrifice our children's health and wellbeing to avoid a presumably 'deadly' disease in adults.

'There can be no keener revelation of a society's soul than the way in which it treats its children.' (Nelson Mandela)

Lore van Bruwaene, Fatima Mustafa, Jeane Cloete

Department of Paediatrics and Child Health, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa

Ameena Goga

Department of Paediatrics and Child Health, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa; and Health Systems Research Unit and HIV Prevention Research Unit, South African Medical Research Council, Cape Town, South Africa

Robin J Green

Department of Paediatrics and Child Health, School of Medicine, Faculty of Health Sciences, University of Pretoria, South Africa robin.green@up.ac.za

 

References

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2. National Institute of Communicable Diseases. COVID-19. https://www.nicd.ac.za/diseases-a-z-index/covid-19/ (accessed 16 May 2020).         [ Links ]

3. Centers for Disease Control and Prevention. South African Regional Global Disease Detection Centre. Global Health - South Africa. https://www.cdc.gov/globalhealth/countries/southafrica/default.htm (accessed 16 May 2020).         [ Links ]

4. World Health Organization. Global tuberculosis report 2019. https://tbsouthafrica.org.za/sites/default/files/WHO%20Global% 20Tuberculosis%20Report%202019.pdf (accessed 16 May 2020).         [ Links ]

5. National Department of Health, South Africa. Covid-19 infection prevention and control guidelines for South Africa - draft V1. https://www.sapc.za.org/Media/Default/Documents/Final%20draft%20COVID %2019%20IPC%20Guidelines%2031%20MARCH.pdf (accessed 16 May 2020).         [ Links ]

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7. Bartoszko JJ, Farooqi MAM, Alhazzani W, Loeb M. Medical masks vs N95 respirators for preventing COVID-19 in health care workers: A systematic review and meta-analysis of randomized trials. Influenza Other Respir Viruses 2020 (epub 4 April 2020). https://doi.org/10.1111/irv.12745        [ Links ]

8. Lai THT, Tang EWH, Fung KSC, Li KKW. Reply to 'Does hand hygiene reduce SARS-CoV-2 transmission?' Graefes Arch Clin Exp Ophthalmol 2020;258(5):1135. https://doi.org/10.1007/s00417-020-04653-4        [ Links ]

9. Gautret P, Lagier JC, Parola P, et al. Hydroxychloroquine and azithromycin as a treatment of COVID-19: Results of an open-label non-randomized clinical trial. Int J Antimicrob Agents 2020 (epub 20 March 2020). https://doi.org/10.1016/j.ijantimicag.2020.105949        [ Links ]

10. Chigwedere P, Seage GR, Gruskin S, Lee TH, Essex M. Estimating the lost benefits of antiretroviral drug use in South Africa. J Acquir Immune Defic Syndr 2008;49(4):410-415. https://doi.org/10.1097/QAI.0b013e31818a6cd5        [ Links ]

11. Abdool Karim S. Criminalisation of transmission of SARS-CoV-2: A potential challenge to controlling the outbreak in South Africa. S Afr Med J (epub 22 April 2020). https://doi.org/10.7196/SAMJ.2020.v110i6.14753        [ Links ]

12. Munro APS, Faust SN. Children are not COVID-19 super spreaders: Time to go back to school. Arch Dis Child 2020 (epub 5 May 2020). https://doi.org/10.1136/archdischild-2020-319474        [ Links ]

13. Dong Y, Mo X, Hu Y, et al. Epidemiology of COVID-19 among children in China. Pediatrics 2020;145(6):e20200702. https://doi.org/10.1542/peds.2020-0702        [ Links ]

14. Mphahlele K. The kids are not all right. Spotlight, 17 April 2020. https://www.spotlightnsp.co.za/2020/04/17/covid-19-the-kids-are-not-all-right/ (accessed 16 May 2020).         [ Links ]

15. Gear J, McGorian I. Lockdown in South Africa can no longer be justified. Daily Maverick, 13 May 2020. https://www.dailymaverick.co.za/article/2020-05-13-lockdown-in-south-africa-can-no-longer-be-justifie (accessed 16 May 2020).         [ Links ]