Being prepared for the 3rd wave of Covid-19 hitting us is crucial.
While getting a vaccine is a matter of national and international concern,
there are small, low-cost high-impact strategies that can be put in place in every hospital right now that will strengthen our healthcare system.
South Africa was widely praised for successfully flattening the curve of the first wave of Covid-19.
Early, strict lockdown measures, including a ban on alcohol, allowed the health system to prepare for a surge of cases.
When the first wave eventually hit, the number of cases was lower than expected.
Hospitals and clinics had set up screening and triage of patients, additional oxygen,
human resource and bed capacity had been created — even if sometimes wastefully—
guidelines were in place and emergency departments weren’t overloaded with victims of
alcohol-related violence and car accidents.
During the early days of the lockdown, the country’s overall death rate was even lower than it was the year before.
In addition to early prevention measures, the first wave was characterised by multiple
external introductions of SARS-CoV-2, the virus that causes Covid-19, into South Africa,
before local transmission started in earnest. People coming by air from Europe
transmitted the virus in the areas around South Africa’s major airports: Cape Town,
Johannesburg and Durban. Most air traffic to South Africa comes from Europe, so this was expected.
The epidemic then spread gradually from these early introductions to local transmission,
from the Western Cape to the Eastern Cape, then Gauteng, then KwaZulu-Natal, and later
the other provinces. This gradual spread also allowed for lessons learnt in one province to
be applied in others.
The South African response wasn’t perfect though. Hard enforcement of lockdown
measures by police and military was marred by reports of human rights violations,
including several deaths. The Western Cape government rounded up hundreds of
homeless people in the infamous Strandfontein camp, creating conditions conducive to
super-spreader events, and infringing on the basic rights of the most vulnerable in
Corruption scandals and wasteful expenditure amounting to billions of rands around the
procurement of personal protective equipment and the running of the ICU field hospital
project in Gauteng, some involving high-profile players, shocked the nation.
On 3 October 2020, the National Institute for Communicable Diseases reported 681,289
cases and 16,976 deaths since the beginning of the epidemic in South Africa. New cases
per day were dropping in every province. It was the end of the first wave. Lockdown
measures were lifted. People rejoiced and celebrated their newfound freedom.
Slowly and unnoticed
As the summer holidays were approaching, an extremely dangerous event was developing
unnoticed. The different strains of the virus responsible for the first wave were all rapidly
being replaced by one new dominant strain. So far the virus showed a relatively slow rate
of two new mutations per month and differed by about 10 mutations from the original
virus. The new variant, dubbed 501Y.V2, differs by up to 20 mutations.
Moreover, many of these mutations caused changes in the spike protein, one of the main
targets of our immune system, and of many vaccines. This new variant is twice as
transmissible as the previous strains. It might also escape our immune system better and
be more likely to cause reinfections.
With the increased mobility of people, a sharp drop in prevention measures and end-of-
year festivities taking place, the new variant quickly spread in the Eastern Cape through
local transmission, then the Western Cape, and a little later Gauteng, KwaZulu-Natal and
the rest of the country.
The number of cases and deaths in the second wave was much higher than in the first.
On 8 February 2021, the total number of reported cases was close to 1.5 million.
The total number of deaths was 43,768. During the months from October 2020 to February 2021,
there had been close to 800,000 new cases and an additional 26,000 reported deaths:
a 17% increase in cases and a 57% increase in deaths compared with the first eight months of the epidemic.
3rd wave of Covid-19
The higher transmissibility of the virus and the lower prevention measures of the
population created the perfect environment for massive transmission.
As many more people became infected, more people were severely ill, more people needed hospitalisation, and more died.
As hospitals were overwhelmed by large numbers of patients the in-hospital death rate increased.
While it can’t be completely ruled out that the new variant causes more severe disease,
preliminary data does not indicate that this is the case.
What is more likely is that patient numbers exceeded the capacity of the health system.
The numbers of doctors, nurses and oxygen points just weren’t enough.
Lack of basic care led to deaths
From my personal experience and that of my colleagues in several hospital support
interventions of Doctors without Borders in KwaZulu-Natal, hospital staff were so
overwhelmed during the peak of the second wave that many patients died because of lack
of the basics: oxygen, water, and basic patient monitoring and support.
It is in times of emergency that we rediscover the importance of small things.
People died because no one noticed that their oxygen mask wasn’t well positioned any
more or that their oxygen saturation was dropping. People died because they didn’t
receive enough water. People died because they disconnected from oxygen when trying to
go to the bathroom, because no one helped them with a bedpan. People died at night,
when exhausted staff was even less present and alert. People died because of
organisational chaos compounded by the rapid addition of inexperienced health staff.
In a normal environment, many of those basic tasks are partially taken over by the
patient’s family. In Covid wards however, family is not allowed to enter, to prevent further
transmission. All these tasks usually performed by family fall on to the nurses. Yet nurses
were understaffed to cope with the second wave and finding additional nurses is difficult,
3rd wave of Covid-19 is coming.
While many people have been infected, many more haven’t, and previous infection might
not even protect against reinfection with the new variant. Herd immunity from infection is
not an option – it’s neither ethical nor practical. We’ll need herd immunity through
vaccination to stop this epidemic.
Yet the news on vaccination is not good. While more data is needed it is most likely
that efficacy of at least some of the vaccines is reduced for the new variant. New vaccines
– adapted to this strain – will solve this, but this will take time. The rollout of the current
vaccine is facing delays due to various reasons.
We need to be prepared for the next wave. We’ve learnt a lot from the two first waves and
from the fight against other epidemics such as HIV and Ebola. We should not be caught
off guard. There are many things that can be done. While getting a vaccine that is
efficacious and affordable in time is a matter of national and international concern, there
are small things that can be done now in every hospital.
Small things are crucial
First there is oxygen. Without it patients with severe Covid can’t survive.
Now is the time to ensure every hospital has sufficient oxygen capacity to deal with the
oncoming waves of Covid. Piped oxygen is the best option, but not always
feasible. Oxygen concentrators, extracting oxygen from ambient air, are an excellent
solution where providing piped oxygen is not possible. The last option is oxygen bottles.
They are impractical as they run out quickly and are heavy to move.
In addition to oxygen, or in the absence thereof, proning of patients on their stomachs
can increase oxygen saturation by 10%. This can be life-saving.
The second essential is sufficient staff for basic patient care. This can be achieved by
task-shifting to entry-level health staff: enrolled nursing auxiliaries, nursing assistants,
caregivers, nurse aids or even volunteers. Identifying and hiring a sufficient number of
this essential cadre can decrease the burden on nurses and save lives.
If entry-level staff members are ensuring mask monitoring, oxygen saturation monitoring,
drinking, feeding, washing and bedpan support, this leaves time for nurses to focus on
more medical tasks. Volunteers can be hired to function as runners and porters, and to
communicate with families.
Emergency response requires a great deal of coordination. For a team of sometimes
inexperienced and/or new staff to work coherently it is critical to ensure adequate
management staff. In Ngwelezana Hospital in Empangeni, KwaZulu-Natal, the addition of
a nurse activity manager made an incredible difference to the organisation of the ward,
management, training and mentoring of nurses. The same is necessary for entry-level
Do not neglect the night shift. Most patients die at night. Ensuring increased attention to
and sufficient staff for patient monitoring and support can save lives. And make sure basic
items such as water bottles, cups, straws, pillows for proning and bedpans are available in
sufficient quantities. These items may be less sexy than ventilators, but they probably
save more lives.
The number of cases in the second wave declined everywhere after South Africa
implemented new prevention measures: a total alcohol ban, curfew at 9pm, prohibition of
gatherings. However, this was only put in place after hundreds of people had died.
The decline also suggests that the risk for new waves to emerge after prevention measures are eased is high.
The time is now: low-cost high-impact strategies
The time to prepare for a third wave is now.
More waves will continue to come as long as there is no access to an effective and
affordable vaccine. This is a priority for the national government and the international
community. There is no place for vaccine nationalism in a pandemic.
A relatively high level of prevention measures is likely to be needed to delay and/or decrease future waves.
Provincial governments and hospitals can reduce mortality by adequately planning
sufficient oxygen capacity, human resources and supplies.
Low-cost high-impact strategies include task-shifting basic patient support to enrolled
nursing auxiliaries, and other tasks to lay staff; being prepared to hire sufficient numbers
of these cadres;
and procuring basic supplies such as water bottles, cups, straws, finger
oxygen saturation monitors, pillows and bedpans.
Sometimes the small things are those that matter most.