In early May, Ronald Abvajee spoke with Professor Shabir Madhi, who is an esteemed sector expert in vaccinology. He holds a number of reputable positions including Professor of vaccinology at Wits, Director of the Medical Research Council Respiratory and Meningeal Pathogens Research Unit, South African Research Chair in Vaccine-Preventable Diseases, and Co-Director of the African Leadership Initiative for Vaccinology Expertise.
In the discussion, Professor Madhi spoke about the latest developments to date around COVID-19 in South Africa, and how it affects children and the re-opening of schools.
Pandemic in South Africa
Madhi noted that South Africa is still at a relatively early stage of the pandemic. While the increasing numbers already appear frightening, the peak is expected in July or August, with still a long road ahead thereafter. Further, the numbers currently reported are not accurate, and he surmises that we are probably only picking up 10-15% of infected cases.
This is due to not testing at scale and the result’s turnaround time (5-10 days) being too slow for quick action. Including isolating the testee, tracing their contacts, and isolating them. By the time someone knows their status, they are likely no longer infectious and it is too late to trace and isolate their contacts.
He also noted that there is no preventing people from eventually getting the virus. No respiratory virus has ever been eliminated with a vaccine. As such, he expected (assuming no vaccine) that within 2-3 years there will be multiple waves and at least two thirds (i.e. 60%) of the population are going to need to be infected for immunity to be developed. Making the virus less efficient in transmitting from one person to another. With this extended time in mind, he asserts that whatever decisions are made now will need to be followed for the next 2-3 years.
Madhi advised that international evidence is showing that not everyone who has the virus actually becomes ill – reportedly 50-80% of those infected have not shown symptoms. Therefore most people who have the virus will be completely well. The majority of those who do become symptomatic will only have mild symptoms, appearing like the seasonal flu.
In the minority, approximately 26 people out of 1000 will require hospitalisation, and in 2-3 years, an estimated 5 people out of 1000 will die from the virus. These estimates however are sensitive to age (e.g. above age 65 years) and comorbidities (e.g. hypertension and diabetes).
Non-therapeutic interventions such as wearing masks and social distancing are about protecting these high risk groups from hospitalisations and death, and protecting the healthcare system from overburden and collapse.
Figure 1. SARS-COV-2: What to expect in adult population over approx. 2 years
On the positive side, the Professor highlighted that out of the 3-4 million cases globally, only approximately 2500 children make up these cases. This is a very low proportion especially considering children make up 20% of the global population.
Yet, there are few children severely affected by the virus; there is no clear reason why. It is estimated that few if any children will die from COVID unless they have severe comorbidity. Madhi asserts that there is no escaping children getting infected, but they are not expected to contribute to hospitalisations and mortalities.
Figure 2. SARS-COV-2: Estimates for children under 18 years of age
Schools were initially closed in early March given learnings from other respiratory viruses such as seasonal flu, for which children are effective transmitters. However, this was before international evidence emerged indicating that children are not vectors in the transmission of the virus and they play a minor role in infecting adults.
As indicated in Figures 3 and 4, evidence from the Netherlands indicates that infected children infect almost no one. In sum, not only are children not severely affected by the virus, but they are also not effective transmitters.
Figure 3. Percentage of contacts that became infected, by age group of the patient
Figure 4. Distribution of COVID-19 by age-group: Relationship of infector (transmitter) and infected (secondary case)
When schools are opened, there are some precautions that should be taken, but the pragmatics must be considered:
- Children using public transport should wear a mask, and the driver should ensure that there is no talking in the vehicle (to prevent droplet spread).
- Children should wear a mask if practical (less practical for children under the age of 5).
- Hand sanitation products need to be available; not just waterless sanitiser, but water and soap to wash hands
- The gathering of children needs to be minimised. There should be no assemblies.
- Children’s movement should be minimised. They should be limited to a classroom to reduce traffic in between classes. Teachers should be moving from class to class.
- Given that teachers are more likely to be infected and infectors of others (especially other teachers more so than children), they should be taking strict precautions in terms of wearing masks, hand hygiene (frequent hand washing and using sanitiser when changing classes), and maintaining physical distance (at least 1.5m) from learners and staff (avoid gathering in the staffroom). Further, if teachers have any symptoms, they must not attend school.
In conclusion, Professor Madhi emphasised that children will indeed be infected; there is no escaping it. But they will not be infected severely and they are not effective transmitters. He asserts that the greatest risk to children in this time is thus not infection with COVID-19, but rather the harms associated with a lockdown. Including their families being pushed below the poverty line, poor food security, and fewer vaccinations.
He thus argues that keeping schools closed is not for the benefit of children. He expressed concern for children missing out on learning opportunities, especially young children whose cognitive development is at its prime, making it difficult for time out of school to be made up at a later stage. There are certainly trade-offs between keeping schools closed which serves more to protect the adult population, versus re-opening schools which safeguard the livelihoods of children.
To hear the full discussion with Professor Madhi, please visit MyHealth TV.
By Jenna Joffe
For more on COVID-19 and education, you can read Who Should Go Back To School First.