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The Covid-19 pandemic has affected millions around the world and damaged the mental well-being of many.

This damage may be hard to reverse without prompt action. Coupled with the social isolation linked to the prolonged lockdown, the pandemic is expected to lead to new episodes of mental illness for many South Africans and exacerbate pre-existing mental illness.

Thirty months after the SARS outbreak in 2003 (the first massive infectious disease outbreak of the 21st century), a third of survivors  met criteria for any psychiatric disorder; a quarter met criteria for post-traumatic stress disorder (PTSD); and approximately 16% had depressive disorders. These statistics underscore the importance of detecting and treating psychiatric illness in people with Covid-19, and in their contacts.

We cannot ignore the profound negative effects of stress, fear, profound loss and grief. If evidence from other countries is anything to go by, the physical and mental health, and social and economic impacts of the disease, will be inordinately borne by poor South Africans (more than 50% of South Africans live below the poverty line). Billions of people around the world have either been or currently are in full or partial lockdown. This may be a mammoth “experiment” but the consequent physical distancing has undoubtedly slowed the transmission chain.

Stressors during the pandemic

That said, the pandemic and the lockdown, independently and in combination, have unintended consequences by severing family ties and inhibiting  social norms, values and rituals, and will arguably exert a severe toll on the mental health of people  – not only in the immediate and short-term but for many years to come. 

Quarantines can lead to PTSD symptoms, depression, and alcohol abuse and dependence, with some evidence that quarantines of longer duration are associated with poorer mental health, specifically PTSD, over time. During previous infectious disease epidemics, common stressors endorsed during quarantine were a long period of quarantine, fears of being infected, frustration, boredom, shortage of supplies, inadequate information from public health authorities, financial loss, and stigma. These are all stressors that are being endorsed during the current pandemic.

Research on the mental health consequences of economic crises has taught us about the significant relationship between severe economic recession and population-level psychological distress, including the emergence, and worsening, of mood, anxiety and substance-related disorders and suicide. Physical isolation, economic worries, heightened anxiety and guilt (about exposing others to the virus or not doing enough to help others) are all risk factors for suicidal behaviours (this includes suicidal thoughts, attempts, and completed suicide). 

In a recent article, Danny Horesh and Adam Brown contend that like other mass traumatic events, the Covid-19 pandemic is expected to result in PTSD, with typical features of hypervigilance (centred on protective measures to avoid infection), intrusive thoughts (related to infection, health, fears of dying), avoidance, and negative mood and cognitions (around fears of the world changing and the future being bleak) that will be subjectively distressing and persistently impact on day-to-day functioning over time.  

Unique challenges

In the face of the restrictions and accompanying economic hardship, South Africa’s youth and  persons with pre-existing mental illness may be especially hard hit by the potentially severe and long-term mental health consequences of the Covid-19 crisis. The stress, fear and emotional pain induced by the rapid and aggressive spread of infection, as well as the scale of prolonged grief from the sudden and massive loss of life, will be felt for a long time, and by successive generations. Like other pandemics, this one is also characterised  by unpredictability, widespread community impact, mass fatalities, and persistence as American scholars Ginny Sprang and Miriam Silman have pointed out. 

The COVID-19 pandemic also poses unique challenges for the management of hospital inpatients and outpatients with psychiatric illnesses. Prior to the pandemic, psychiatric services in our public sector, especially at district and community levels, were already overstretched and under-resourced in terms of bed capacity and shortages of mental health personnel.

The deployment of these staff within hospitals to assist with the screening and management of suspected and confirmed Covid-19 cases in general medical settings, and the closure of psychiatric wards because of Covid-19 infection, further add to the challenge of providing adequate psychiatric care. Psychiatric units in public hospitals are typically characterised by bed shortages, overcrowding and sharing of dining, bathroom and daily activity spaces (e.g. for group activities such as occupational therapy and group psychotherapy). 

Given their compromised and disordered mental states, disorganised behaviour, impulsivity, sub-optimal self-care and impaired insight, patients with mental illness may not be in a position to adhere to infection prevention and control measures and protect themselves in the face of Covid-19. Those who cannot access outpatient care may be left to self-manage their mental and physical health, as Benjamin Druss from Emory University argued recently.

Mental health system needs urgent strengthening

Existing social isolation, loneliness, homelessness, poorer physical health in patients with serious mental illness (e.g. schizophrenia, bipolar illness), overweight/obesity, lack of exercise and other unhealthy lifestyle factors associated with psychiatric illness, and the side effects of psychotropic medication, are added risks. As a result of the high rates of co-occurring physical illness (e.g. diabetes, cardiovascular disease) – at least two-fold higher than the general population – patients with mental illness have a heightened vulnerability to developing Covid-19 pneumonia and other complications. 

Our mental health system needs urgent strengthening through multi-sectoral interventions targeting mental health, well-being and resilience, for both the general population and for vulnerable groups. This includes, but is not limited to, health care workers, women, youth, the elderly, and the mentally ill. These interventions should be embedded in the general medical Covid-19 pandemic care that is already being provided. 

More than ever, given the scale of the pandemic, we need sound research to learn more about the psychiatric and neurological manifestations and their impact in our general population and in vulnerable groups. There are already several research studies currently underway at Stellenbosch University, and a number of these are collaborative multi-country initiatives (e.g., www.coh-fit.com). As this is a novel, ravaging virus, it may be prudent to over-estimate the mental health sequelae and the resources that will be required. We can harness the interconnectedness and the tremendous co-ordinated response from the health sector that Covid-19 has necessitated to achieve this. 

*Prof Soraya Seedat is the Executive Head of the Department of Psychiatry at Stellenbosch University.

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Soraya Seedat

While coronavirus testing increased week-on-week since early in April, a decrease in testing has been observed in the week ending 17 May, according to a report from the National Institute for Communicable Diseases (NICD).

The week-on-week increase, the NICD said, was on the back of “a larger network of testing laboratories and the implementation of targeted community symptom screening, and referral for testing”.

However, according to the NICD, for the week ending 17 May, a decrease in testing volumes has been observed – likely due to a limited number of testing kits, and laboratory testing backlogs. 

In the report, laboratory delays are indicated by an increase in the number of days between the day the test is done and the specimen collected, and the reporting of the result. Currently, the turnaround time for the public sector increased from two days to more than six days (in the weeks leading up to week 20 – the week ending 17 May), while the turnaround in the private sector remained less than two days. 

A reduction in testing volumes was also observed over weekends and public holidays, according to the report from the NICD.

The delay between tests and results was seen in the public sectors of all five provinces where the largest number of tests were done, but a significant delay was reported in Gauteng.

In Gauteng, where it previously took an average of 2.3 days from test to result, it is now more than eight days. 

Test kits not interchangeable

Professor Glenda Davison, head of the biomedical sciences department at the Cape Peninsula University of Technology, told Health24 that test kit availability would definitely be a reason for a decrease in testing.

“I would say the decrease in test kits is one reason for the decrease in testing,” she said.

“The test kits are acquired from a number of international companies and are most often imported which could result in delays. The reason being that countries throughout the world are doing these tests and the supply just can’t keep up with the demand.”

Another problem, she explained is that laboratories are often locked into using a specific company’s test kits as they are specifically designed for the instrument that they have purchased. 

“For example, the National Health laboratory service has a number of GeneXpert machines which should be able to produce test results quickly and within 24 hours. However, these machines can only use test kits/cartridges from the machine manufacturer (Cepheid).

“Cepheid also cannot seem to meet the demand, and although there are a number of other companies (e.g. Roche) who also manufacture test kits, these kits cannot be used on the GeneXpert as they are designed for the machine they are specifically made for.

“In other words, the test kits are not interchangeable.”

So why the reliance on kits from international companies?

Professor Davison says although the method to develop our own test kits is available, and we certainly have the capability, this is a long process, and once again they would not be suitable to use on the large commercial automated machines.

“And at this point, we need to be able to process tests on an automated platform”.

Understanding how a test is done

Professor Davison tells us that another reason could be in the process of viral RNA extraction.

To understand this, she briefly explains how the test is done.

“The method currently used to diagnose Covid-19 or detect the SARS-CoV-2 virus is a molecular test known as RT-PCR (reverse transcript real-time polymerase chain reaction). Once the nasal or throat swab arrives in the laboratory, the first thing that is required is to extract the viral RNA from the sample.

“This is a long process and is often done manually. It is here that delays often occur as the technologists or laboratory scientist must ensure that the quality and amount of RNA are adequate.

“Ideally, this process should be automated so that the RNA is extracted quickly and the backlog of unprocessed specimens can be cleared. After this has been done, the RNA can be converted to DNA using reverse transcriptase and then using the relevant instrument and test kit, is amplified and detected using PCR.”

So, she says a delay could take place at the point where the viral RNA is extracted from the throat or nasal swab, especially if this is a manual method.

Rectifying the situation

With the expectation that things will get worse, before getting better, regarding Covid-19 infections, Professor Davison has expressed concerns about the backlogs.

“This could have huge repercussions. One of the first things I think of is the contact tracing process. If someone is suspected of having Covid-19, one would like to know as soon as possible so that all the contacts can be traced and tested in order to prevent spreading.

“By delaying the tests it makes this process very difficult. It also makes the daily data which is released to the public less accurate and up to date. This makes it difficult to predict how the numbers are going to increase and what action should be taken.”

Epidemiologists need up-to-date data to detect hotspots so that they can be contained and controlled. 

Also, worryingly, she tells us that, from a technical point of view, RNA degrades fairly quickly, and so if samples are left too long it could result in a false-negative result. 

“So, it is important that we rectify this situation,” she says.

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Marelize Wilké and Bevan lakay

Over the last few months, we’ve been inundated with news about research and vaccine development as various expert teams are rushing towards finding a successful vaccine against the new coronavirus.

While waiting for a vaccine or any other effective treatment, many parts of the world are relying on so-called “new norms” of physical distancing and lockdown measures.

Meanwhile, the first coronavirus vaccine to reach phase 1 clinical trial has been found to be safe, well-tolerated and able to generate an immune response against SARS-Cov-2 in humans, according to a news release.

This research was published in The Lancet.

Who developed this vaccine?

This new Ad5-NCov vaccine, an adenovirus type-5 vaccine which expresses the spike glycoprotein of the SARS-Cov-2 virus, was developed by the Beijing Institute of Biotechnology and CanSino Biologics in Tianjin, China.

The developers cloned a spike gene based on the SARS-CoV-2 virus.

Promising results

This trial was conducted among 108 healthy adults between the ages of 18 and 60 in an open-label way – this means that both the trial candidate and the research knew exactly what the candidate would be receiving. These adults showed promising results after 28 days, but the results need to be evaluated for a period of six months.

The researchers tested the blood of the candidates at regular intervals to see how the immune system was affected.

The vaccine was generally well-tolerated at all doses, with no serious adverse reactions reported.

The vaccine stimulated a rapid T-cell response in the majority of volunteers, which was greater in those given the higher and middle doses of vaccine, with levels peaking at 14 days after vaccination, according to the news release.

The researchers, however, did note that the antibody and T-cell response could be reduced by certain factors, such as pre-existing immunity to adenovirus type 5 (usually the vector or carrier of a common cold): “Our study found that pre-existing Ad5 immunity could slow down the rapid immune responses to SARS-CoV-2 and also lower the peaking level of the responses.

“Moreover, high pre-existing Ad5 immunity may also have a negative impact on the persistence of the vaccine-elicited immune responses,” stated Professor Feng-Cai Zhu from Jiangsu Provincial Center for Disease Control and Prevention in China who led the study.

Mild adverse reactions

According to the researchers, the most common adverse reactions were mild pain at the injection site, slight fatigue, headache and muscle pain. Only one participant who received the highest vaccine dose experienced severe fatigue, shortness of breath and muscle pain, but these symptoms cleared up in less than 48 hours.

Limitations and next steps

According to the news release, the phase 2 trial will be randomised, double-sided and placebo-controlled to see whether the results of phase 1 could be replicated. The next stage of the trial will include 500 healthy adults, of whom 125 will be given a placebo. This phase will now also include candidates older than 60, as this age group is a key target population.

The researchers did note that the phase 1 trial had limitations due to small sample size, short duration and lack of randomised control group to identify rarer side effects, but the initial response was promising.

Further research will be needed before the vaccine becomes available.

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Compiled by Marelize Wilke

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