The peak is still to come:
I still believe that we are all going to get it and that our peak has been effectively delayed by our prolonged lockdown. After having six positive patients in the practice in March, I have not seen one in April; a testament to the dedication of our patients to the cause. But am not sure how lockdown can be effectively sustained in large communities that are overcrowded with small rooms, whilst the autumn sun shines brightly outside. This will probably be our biggest challenge in containing the epidemic because discipline is so hard to encourage. Current testing in South Africa is probably not optimal and may be understating actual true numbers.
Lockdown and restrictions the right move:
The purpose of the lockdown was to prepare ICU-type facilities to meet the peak of the epidemic. Strategies have included consideration for small rural towns which have no ICU facilities, as well as freeing up hospital beds by denying alcohol, which causes a large percentage of admissions due to MVA’s (motor vehicle accidents), violence and immune weakness along with malnutrition. The lockdown has restricted cigarette usage, which has limited the number of people outside of their homes going to buy cigarettes, estimated to be about 200 000 at any time. Pollution, especially NO₂ from diesel emissions, is down, which has been implicated in higher death rates in polluted cities in France, Italy and Spain.
The virus is smart:
We are starting to understand a bit more about the virus and the clever way it hijacks some of our cell membrane to clothe and protect it from our immune system, which recognizes it as not-foreign. The immune mechanism is not clearly understood and the mutations may allow us to contract it again and again, much like the annual variety of flu.
What to expect when you get it:
Most of us will have it mildly, but a percentage will get a type of pneumonia, which is provoked by an inappropriate immune-response, thus making it worse. This will be when respirators may be required. Fortunately, there are some new medicines being tested that reduce the time that sick people will need to be on such respiratory support. A percentage of people will have damage to their haemoglobin and may benefit from Malaria type drugs. Diabetics will be more vulnerable here. In general, the most worrying early symptom is shortness of breath from the above scenarios and a pulse oximeter will detect early serious disease. Your doctor should have one of these.
How we treat it:
The mainstay of treatment will be confinement to home, bed-rest and Paracetamol for the headache and sore throat. Quarantine for your home will be mandatory and retesting is no longer required to proclaim you cured. Two weeks after your symptoms are over is long enough to say that you are no longer infected or infectious, and are now immune. Most young healthy people will deal with it as though it a common flu.
Mask usage has been controversial, but I believe that it will become the new social norm and people close by will be more comfortable if you wear one.
How we will win:
Killing the epidemic will ultimately rely on effective vaccine application and the first vaccines in England are being tested as from this week. We are still a long way from injecting potentially toxic viral particles into the general population. Another important consideration is how to measure if one is immune, especially if you contracted a mild version of the infection. A good standard test is required for this purpose, so that immune persons can go out into the world unencumbered by red tape and without making the uninfected fearful. This will be especially useful in healthcare workers who can treat Corona patients without protective equipment. Such tests are becoming available, but are not here yet.
Although the lockdown may be extended, I understand that there will be a step up or down approach to it in certain populations that are showing reduced infection rates. We need to immunize our herd and this will not happen unless we allow some people to contract it in a staggered manner, so I think that intermittent lockdowns are here to stay until spring.
Dr Mark Holliday. 22 April 2020