Missing piece in battle plans for the coming Covid-19 onslaught

Patients are being let into this clinic one at a time with the consequence that a tightly packed crowd has formed outside. (Photo:

By Lynne Wilkinson, Tom Boyles, Shabir Moosa, Madeleine Muller

16 Apr 2020

As Professor Salim Abdool Karim and colleagues clearly stated in a 13 April briefing document to Health Minister Zweli Mkhize, we cannot avoid the exponential spread of Covid-19 after lockdown. We need to use the remaining 14 days of lockdown well. A critical area not mentioned in the briefing is the need to prepare and leverage public health facilities.

Patients queuing outside a clinic without physical distancing, it is a common occurrence.
(Photo: Supplied by Authors)Nobody can predict the shape of the coronavirus epidemic once lockdown restrictions are eased or lifted, but it is unlikely Covid-19 cases in South Africa will be eliminated until an effective vaccine is found.

So, for many months to come, South Africans who rely on attendance at public healthcare facilities will face threats of exposure to Covid-19. Preventing infections in healthcare facilities is uniquely difficult — and important. Outpatients and healthcare staff are most likely to be infected, possibly without symptoms, and the consequences of infecting someone who is attending a healthcare facility can be serious as they may have an underlying condition.

It is vital that we do everything possible now, while the infection curve is relatively flat, to prepare facilities to reduce transmission of Covid-19 among patients and healthcare workers.

Currently, attendance at many public health facilities has been reduced and efforts are underway to ensure people don’t need to visit unless it is essential. However, in many places, long queues to enter clinics continue to snake around community blocks. People might feel the need to go to public-sector clinics for many reasons – they may be unwell with anything from a simple, treatable sexually transmitted infection to a more complex problem such as drug-resistant TB; they may require routine healthcare (ante-natal services, immunisations or chronic care, including HIV management and treatment); they may be concerned they have Covid-19, or may be accompanying or attending on behalf of a vulnerable person, such as a child or aged individual.

We have a duty to protect people at health facilities from Covid-19 infection, while continuing to provide essential health services. People continue to need non-Covid-19 healthcare and, if we fail to deliver it, people will get sick, experience disease-related complications and might die. Essential services must remain available and accessible throughout the many pandemic months.

Monay of those visiting public health facilities will present with Covid-19 symptoms, even more so as we enter the influenza season. It is vital to identify, separate or triage, test for Covid-19 and appropriately manage isolation and contact tracing.

Testing every person who arrives at a public health facility with Covid-19 symptoms utilises existing infrastructure, time and resources needed to set up parallel systems. Professional healthcare workers, existing laboratory networks and community health workers assigned to these facilities can be leveraged to expand testing, isolation and contact tracing quickly across the country.

Patients are being let into this clinic one at a time with the consequence that a tightly packed crowd has formed outside. (Photo: Supplied by Authors)

Effectively utilising public health facilities requires careful consideration, clear communication and standardised preparation. Facilities need to be supported to implement appropriate entry and exit pathways, queue management (people queuing at least 1.5 metres apart), hand sanitation and, critically, triaging people with Covid-19 symptoms to a separate, designated, outside area within the facility premises for comprehensive management and testing.

We have personally visited a number of public health facilities in South Africa since President Cyril Ramaphosa declared a National State of Disaster. While each facility has made commendable efforts, few have reached an appropriate level of preparedness and infection control.

We have seen well-intentioned but deleterious interventions, including people being locked outside the premises, resulting in large groups congregating while trying to enter. Many facilities allow everyone in after hand sanitation, but very few appropriately triage patients and ensure comprehensive management and testing within a designated Covid-19 symptom-positive area.

To prepare, it is essential to make it very clear what is expected at each facility, from primary care level through to tertiary hospitals, and to provide the equipment, resources and support necessary for set-up and testing. These resources include everything from the paint to mark the queue system to tents for management and testing.

Having worked in West Africa at the front line of the Ebola epidemic in 2014/15, our sole aim has been to use the lessons learned in South Africa should it face a similar threat. Covid-19 is that threat and, based on our experience and knowledge, we have developed a tool to prepare South African facilities that has been endorsed by the Infectious Disease Society of South Africa and the Rural Doctors Association of South Africa (Covid-19 PHC facility preparedness guide). Some facilities and districts are already attempting to implement this guide. Scaled implementation will be far easier if it becomes a recognised part of the national emergency plan.

We fully support the importance of widespread community testing.

However, finding community members with Covid-19 symptoms for testing by going door-to-door must be accompanied by identifying those already presenting at our public health facilities. Let us do both.

We need to focus on planning, preparing, setting up and utilising our public health facilities as South Africans will continue to use them. DM/MC

Lynne Wilkinson is a public health specialist at the International AIDS Society and the University of Cape Town; Tom Boyles is an infectious diseases specialist at Helen Joseph Hospital and the University of the Witwatersrand; Shabir Moosa is Associate Professor in the Department of Family Medicine at the University of the Witwatersrand; Madeleine Muller is a family medicine specialist at Nkqubela TB hospital in East London.

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