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A practical guide to the 5th Wave in South Africa

Nobody really wants to read about Covid anymore. Covid-19 was a 2020 and 2021 problem. Life needs to carry on and we all want to return to normal. Masks are last year's fashion item, fist pumps have been replaced with hugs and social distancing is out of vogue. Parties are happening, theatres have audiences, sports events have spectators and travel is once again a possibility.


The milder Omicron variant, population immunity from vaccines and past infections, and low case numbers following the fourth wave, as well as the “decoupling” of infections and mortality, have lulled us into complacency.


So what happens as South Africa enters the 5th wave, winter weather forces us indoors, infection numbers shoot up and hospitalisations are rising? How do we live our lives but avoid getting ill?


To try to rationalise what best practices should be and what risks one is prepared to take, we need to assess what the current situation is.


1. What is happening in South Africa?

● For the last two or three weeks, GPs have noticed large increases in patients presenting with respiratory symptoms (sore throats, coughs, headaches and congestion). Some of these test positive for Covid-19; some have Influenza, some have RSV (Respiratory Syncytial Virus) and some have other respiratory viruses or bacteria. Many people with respiratory symptoms don’t test at all as they don’t know (or don’t want to know) that their sore throat or sinus symptoms or cough could be COVID.

● Despite the limited testing, the NICD reports a large increase in case numbers over the last two weeks, and the test positivity has risen to above 20%.

● Genomic surveillance has shown that Omicron BA.4 and BA.5 variants are dominant in most provinces. These are more contagious than the earlier Omicron strains and have replaced them.


2. What are the symptoms of this strain?

● Common symptoms we are seeing are sore throats, coughs, wheezy chests, congestion and headaches.

● Fevers, body pain and loss of smell are also often present.

● GPs have seen some patients with worse chests than we experienced in December/

January with the 4th Omicron wave. We are also seeing more patients with elevated

inflammation and clotting markers.

● There have been more hospital admissions for Covid patients in the last two weeks.

● However, although hospital Covid admissions are going up a bit, it is still early in the

onset of this wave and too soon to comment on whether the strain that we are seeing is causing more serious symptoms.

● We also await updated data on outcomes in vaccinated versus unvaccinated patients.


3. What’s the point of testing?

● Testing is important as it impacts treatment, monitoring and behaviour.

● A positive test early on in symptoms means that the infected person can isolate and

prevent spreading it. This could save others from potentially getting very ill.

● Knowing it is Covid as opposed to other viruses or bacteria means that one should

monitor carefully (particularly oxygen levels), rest and treat symptoms appropriately eg There is no need to take an antibiotic for the sore throat as it’s likely a direct symptom of the virus and not a bacteria.

● Testing an index person in a family is probably sufficient - in other words, if mom has a cough and tests positive, you can assume that when dad and kids have a sore throat and a cough two days later, that is Covid too.


4. Can I get Omicron again?

● It’s still uncertain how much protection a previous infection gives, but the Sigal lab in KZN reported immune escape with new BA.4 and Tullio De Oliviera stated that “previous infections with Omicron BA.1 will not be sufficient to prevent a second infection with BA.4 and BA.5”.

● Anecdotally, I and other GPs have seen patients symptomatic and testing positive on antigen tests, who had documented covid as recently as February 2022.

● The Sigal study showed that immune escape with Omicron BA.4 and .5 is much more pronounced in unvaccinated people; in other words vaccine antibody immunity was superior to immunity from prior infection.


5. Do I need to get a booster?

● Vaccine immunity wanes with time, so it is highly recommended that if you are eligible for a booster and your last vaccine was more than 12 weeks ago, you get boosted.

● A reminder of vaccine schedules:

1st Pfizer - 21-day interval to 2nd Pfizer - 90-day interval to booster (either Pfizer or J&J) OR

1st J&J - 60-day interval to 1st booster (either J&J or Pfizer) - 90-day interval to 2nd booster (either J&J or Pfizer).

● A fourth “extra” dose is currently only registered for immunocompromised patients and can be given 28 days to 3 months after the second or third dose.

● Teenagers 12 to 17 years old are only eligible for two Pfizer doses, 21 days or more apart, and no booster.

● Children under 12 years are still not eligible for vaccines in South Africa, although vaccines in this age group have shown benefits in the UK, USA and Israel.


6. Should I have a flu vaccine?

● Yes!!

● Influenza is a different virus to SARS-CoV-2 and Covid vaccines offer protection only against Covid-19 and not against flu.

● Flu vaccines should be done annually. For the last two years, there have been very low levels of Influenza in the country, but this year we have started seeing Influenza again and could potentially have a significant outbreak.

● Influenza can cause significant symptoms of fevers, body pain and respiratory symptoms with potential complications. Having a flu vaccine greatly reduces the symptoms and risks of complications although it may not prevent one from getting infected entirely (similarly to Covid vaccines).


7. What treatment do I need if I get Covid?

● Treatment remains symptomatic.

● Rest is important.

● Most people just need panado, throat lozenges, decongestants and cough syrup to

relieve respiratory symptoms.

● Vitamins like Vitamin D, C and Zinc may be useful to boost the immune system.

● Many patients ask their GPs and pharmacists for medication like antibiotics, Ivermectin,

antivirals like Tamiflu and other medicines - these have not proven to be effective against

the SARS-COV-2 virus and should not be used.

● Cortisone should only be used when prescribed by a doctor. The doctor should only

prescribe cortisone if inflammatory markers are elevated and the patient is hypoxic

(oxygen saturation is low).

● Similarly, anticoagulants can be dangerous and should only be used if prescribed by a

doctor (usually only if a CT scan shows that there is clotting). A D Dimer blood test may be useful in high-risk patients to screen for clotting but is not conclusive as it can also be elevated from inflammation.

● Paxlovid (nirmatrelvir and ritonavir) is an antiviral that has been shown to be effective at preventing severe Covid when given to high-risk patients in the first five days of developing symptoms. It is unfortunately unavailable in South Africa. (There is a Johannesburg trial using Paxlovid but patients who have had any Covid vaccine in the previous 12 months are not eligible to participate - patients are blindly randomised so may receive either Paxlovid or placebo and won’t know which they are getting).


8. How do I monitor myself?

● Monitoring the symptoms of Covid is still important, particularly in patients who are elderly and those with underlying medical conditions.

● The following signs should alert you to contact a doctor or go to the hospital:

- Temperature staying above 39 degrees for more than five days

- Heartrate remaining more than 125 beats per minute

- Chest pain

- Coughing up blood

- Difficulty breathing, fast breathing, unable to speak in full sentences, difficulty walking

- Confusion

- Children who appear very ill


9. Do I still need to isolate?

● Current South African guidelines are that people infected with Covid who have mild symptoms should isolate for seven days from the onset of symptoms.

● Asymptomatic people who test positive (eg testing for travel or before a procedure), do not have to isolate themselves but should wear a good mask and avoid close contact, particularly with vulnerable people.

● Contacts of positive people do not need to isolate but should be cautious: wear a mask, avoid large gatherings and if symptoms develop, they should isolate for seven days.


10. Does isolation still mean staying in my room and having my food left outside my door?

● We have learnt a lot since early 2020 when shopping bags and shoes were sanitised. The virus is spread in the air, and while sanitising is important, I don’t believe that infected patients need to be locked in their rooms.

● Families need to be practical and do what works for them. If someone in the house has Covid, there’s a good chance the rest of the family have already been exposed. Anyone with symptoms needs to assume they also have Covid and ideally stay home, even if they don’t test or if they test negative.

● In the house, the affected person should keep their mask on and keep a distance. Anyone vulnerable in the house (elderly/ unvaccinated/ immunocompromised) should also keep their masks on and keep a distance. Rooms should be ventilated - leave windows and doors open, and the infected person should not eat with those who are uninfected (unless outside and at a large distance). Everyone in the house should wash and sanitise their hands regularly. If feasible, the infected person should sleep in a separate room.


11. What do we do to protect ourselves?

● Being fully vaccinated and boosted is the best defence against getting severe illness, hospitalisation and death from Covid-19.

● While numbers are racing up again, each person needs to evaluate their risk and do their best to minimise their risk in each situation. This can be done by paying attention to ventilation and spacing, wearing masks indoors and sanitising hands regularly.

● The quality of masks is important - an N95 mask for public travel and indoor gatherings is advantageous.

● Anyone who is sick with respiratory symptoms should ideally stay home and avoid putting others at risk.


12. Why not just get infected?

● It remains unpredictable who will be severely affected by the virus.

● While most people have a mild illness, occasionally even young healthy people suffer

serious complications.

● Long Covid is an unpleasant complication of even mild infections, and fatigue, heart and

lung complications and brain fog can persist for many months.


CONCLUSIONS

We have learned a great deal about the virus since March 2020 and now need to continue living our lives while remaining cautious. Mental health and socialising are vital to well-being, and while it is important to try to avoid being infected, vaccinations and immunity have lessened the threat that kept us cooped up in our homes for the last two years. However, while numbers increase and there remains some uncertainty about the severity and dangers of new strains, I would still advise caution. High-risk individuals, in particular, need to carefully evaluate their risks when considering whether to participate in group events and should they choose to take part, they should do so with an element of vigilance.


Article was written by Dr Sheri Fanaroff