15 December 2021
We should end Covid testing at public health facilities, stop quarantining after contact with a person infected with Covid, and reduce the time spent in isolation after testing positive for Covid to five days.
This is according to a proposal by Hassan Mahomed, David Pienaar, Mary-Ann Davies, Angela De Sa, Andrea Mendelsohn, Benjamin Botha, all academics in the medical field at the University of Cape Town or officials at the Western Cape Department of Health.
South African policy makers have implemented many restrictions in response to the Covid pandemic.
Some, like the ban on hot food, were abandoned quickly as there was no conceivable purpose to the measure. Others, like the alcohol ban which drastically reduced admissions to hospitals that were suffering under a mass of Covid patients, were fit-for-purpose but repealed once the wave of infections fell and after the public reached the limit of their temperance.
Mahomed and the other authors are firm in their conviction that we must vaccinate, make sure we have good ventilation, and continue wearing masks indoors. These measures are effective.
But, they suggest, other parts of our anti-pandemic arsenal do not work as we had hoped they might, and may be counterproductive for public health.
Covid is an astonishingly difficult disease to contain. A local study from the Beta variant-dominated second wave, referenced in the report, showed that more than 80% of confirmed Covid cases were asymptomatic.
The emergence of the Omicron variant, which appears to produce a larger proportion of milder Covid cases, and a significantly lower chance of death (whether from vaccination, past infection or some intrinsic quality of the mutant), offers an opportunity to reconsider the context of anti-Covid protocols. Covid, the report suggests, is becoming endemic, and cannot be controlled.
Our current testing strategy, which requires a costly medical referral and must be administered by a healthcare professional, fails to identify most Covid cases - as low as one in ten cases, according to sources cited in the report.
The paper estimates that a week in which about 13,000 tests are done at the primary healthcare level would cost the health service “over 50,000 patient-hours … assessing and testing very mild Covid-19 disease”. This time could be used to attend to patients with HIV, TB, non-communicable diseases, among other things.
The effect on curbing transmission? Effectively nil. “Testing has no impact on clinical management for the individual nor is it impacting community transmission, hospital admissions or deaths,” says the report. So, we should stop offering Covid testing at the primary healthcare level.
Our current quarantine protocol says that people who have been in close contact with a Covid patient for an extended period of time should remove themselves from public life and wait to see if they become ill. In the healthcare context this can lead to huge drops in health workers - the report refers to the two-week closure of the antenatal clinic at the New Somerset Hospital due to a lack of staff, after Covid infections were identified.
But the predominance of asymptomatic infections means that “the vast majority of high-risk contacts go undetected, since contact occurs in the context of a case that is never identified in the first place”. Since most contacts are not identified, ”quarantining contacts of these cases serves no demonstrable public health purpose,” and should be done away with.
The final proposed amendment is that people who do have symptomatic Covid infections should reduce the number of days that they spend in isolation.
At present, people with Covid should isolate themselves for ten days. In asymptomatic infection this is counted from test date; for mild illness, from symptom onset, and for severe cases, from when clinical stability is achieved.
The report argues that most often, by the time Covid cases are identified, most onward transmission has already occurred. The report further suggests that “viral load in vaccinated individuals drops more quickly than in unvaccinated individuals, presumably rendering them non-infectious even more rapidly”.
By keeping up the use of N95 masks in health facilities, staff with Covid infections should be able to return to work more quickly.
Isolation should be reduced to just five days, says the report, and asymptomatic cases “should not isolate at all, since it is not clear when they were infected.”
The report is unclear on some things. For instance, if, as proposed, primary-level healthcare Covid testing is abandoned, how could a person know whether to enter a five-day isolation? One possibility, which GroundUp has written about, is enabling home-use antigen tests.
The proposals are already generating much debate among public health experts. There is consensus that masks, ventilation and, most importantly, vaccination are effective. The near return to normality that the authors propose is indicative of a growing (but far from unanimous) view that Covid has entered a new stage where it has become a less deadly disease than it was a few months ago. It is here to stay and we have to learn to live it.