The now-trendy keto diet is said to turn fat into fuel. But a new, small study says it may also change the vast array of microbes residing in your gut (the microbiome).
That could be a good thing, as those changes may ultimately strengthen the immune system by tamping down inflammation, researchers say.
The keto diet, which severely restricts carbohydrates and emphasises fats and protein, has been touted as a way to rein in epilepsy, diabetes and expanding waistlines. Yet despite rising popularity, it remains controversial, and much is unknown about its true impact on health.
The new finding follows a two-month study that tracked diet-related shifts in microbiome content among 17 overweight or obese men, with follow-up tests in mice.
Changes to gut microbes
“There has been a lot of work on ketogenic diets,” noted study author Peter Turnbaugh, an associate professor of microbiology and immunology at the University of California, San Francisco.
“But we didn’t know much about how these diets differ from other high-fat diets, how exactly they impact microbes, or whether or not these diet-induced changes to gut microbes matter,” he said.
To find out, Turnbaugh and his colleagues first placed half the men on a one-month “standard” Western diet composed of 50% carbs, 15% protein and 35% fat.
The other half started off on a keto diet made up of 5% carbs, 15% protein and 80% fat. After a month the two groups switched.
Stool sample analyses revealed that when participants switched over to a keto diet they experienced “significant shifts” in levels of 19 bacterial “families.”
The researchers then extracted microbial samples from the guts of the keto group and inserted them into the guts of mice. The result: a drop in levels of a critical infection-fighting cell that’s also known to promote inflammation in autoimmune diseases.
Levels that promote ketones
The mice were then exposed to low-fat, high-fat and low-carb keto diet options, with fat content respectively rising from 12% to 75% to 90%. And those results were surprising on several levels, Turnbaugh said.
For one, gut microbe levels driven up by a relatively high-fat diet were actually driven down by the low-carb keto diet, and vice versa.
This suggests the microbiome responds differently as dietary fat increases to levels that promote ketones when carbs are restricted.
And while mice on both the high-fat and keto diets gained more bodyweight than those on a low-fat diet, those on keto diets gained “significantly less” weight.
The other surprise, said Turnbaugh, was the role of so-called “ketone bodies”.
“Ketone bodies,” he explained, “are chemicals produced in our body when our cells do not have access to dietary carbohydrates,” such as when following a keto diet. That forces the body to use fat reserves for energy, instead of carbs. And scientists know that the by-product of that shift is a steady rise in ketone production.
But Turnbaugh and his colleagues discovered that in mice a gradual rise in ketone levels (sparked by a keto diet) was accompanied by a gradual shift in gut composition.
The tip of the iceberg
And that begged the question, could boosting ketone levels alone – independent of diet – also alter gut composition? More mouse research, said Turnbaugh, suggested that the answer is yes: “Ketone bodies can directly affect gut bacteria even in the absence of the full diet.”
Still, Turnbaugh cautioned that the current effort is “likely the tip of the iceberg” when it comes to better understanding the complex interaction between a keto diet, ketone bodies, the microbiome and disease risk. The study was small and more research is needed.
A similar note of caution was struck by Lona Sandon, who reviewed the findings. She is an assistant professor of clinical nutrition at the University of Texas Southwestern Medical Center at Dallas.
“I am surprised that the keto diet showed potential effects on the gut microbiome that would lead to reduced inflammation in mice,” Sandon said. She added that prior research actually “suggests high fat/high protein diets are detrimental to the microbiome and increase inflammation”.
Sandon stressed that a keto diet comes with downsides. For one, although popular because it “can help control appetite”, people should know that the “benefits seen initially typically wane over time”, she said. And, she warned, patients prescribed keto to tackle other medical issues “often end up overweight and with increased cardiovascular risk factors”.
The study was published in the 20 May issue of the journal Cell.
The world post Covid-19 could see more regional integration with countries working together, but there are also concerns of rising economic nationalism, which was already in the works before the crisis hit, deputy finance minister David Masondo has said.
Masondo was on Wednesday afternoon part of a panel discussion hosted by the University of Johannesburg’s Institute for Future Knowledge, where he shared views on what the world may look like in the wake of the coronavirus crisis.
Other panellists included Grant Harris, a former advisor on Africa to President Barack Obama, and Professor Dong Wang of Peking University’s Institute for Global Cooperation and Understanding.
The virtual panel discussion also broached issues such as opportunities for countries working together to fight the pandemic and the global risks of rising nationalism.
Nine Eastern Cape healthcare workers, including five nurses, have been suspended for allegedly refusing to attend a Covid-19 patient as they apparently did not have personal protective equipment.
This after Bhisho Hospital was closed after a senior nurse died and her three colleagues tested positive for Covid-19.
Eastern Cape health department spokesperson Sizwe Kupelo confirmed the suspension of the workers at Grey Hospital in King William’s Town.
He said Bhisho Hospital had been closed following the cases, saying this would allow for decontamination and deep cleaning.
While Gauteng Premier David Makhura says he believes his province is ready for Level 3 of the Covid-19 lockdown, that decision will still be made by President Cyril Ramaphosa’s National Coronavirus Command Council (NCCC).
On Wednesday, the premier and his executive visited manufacturing companies around the province to assess the level of compliance ahead of the relaxation of lockdown regulations at the end of May.
South Africa is currently under a lockdown, which has 5 alert levels, with Level 5 being a hard lockdown with reduced economic activity, while Level 1 would see sit-down restaurants and sporting facilities being reopened.
On Tuesday, Makhura told the Gauteng Legislature that the entire province would move to Level 3 in June. He said it couldn’t work for some parts of the country’s economic hub to be on Level 3, while others remained on Level 4 or some even shifted to Level 2 as regions and districts were all interconnected.
The “early flare-up” of Covid-19 infections in the Western Cape is an indication that a similar explosion can happen elsewhere, hence there will be a “focused intervention” in the Western Cape, Deputy Minister of Health Joe Phaahla told Parliament’s health committees.
This after several ANC MPs expressed their concern to the Department of Health at Wednesday’s meeting of the Portfolio Committee on Health and the Select Committee on Health and Social Services.
The committees were being briefed on the health department’s annual performance plan, budget and strategy for 2021 to 2025.
ANC MP Tshilidzi Munyai wanted the national government to intervene in the DA-governed Western Cape’s handling of the Covid-19 pandemic.
Western Cape Premier Alan Winde has advised schoolchildren and teachers with comorbidities to stay at home as the province rides out the coronavirus pandemic, even though schools are due to partially open on 1 June.
“If you are a learner and you do have one of those comorbidities, my advice would be that you would need to continue your lessons from home,” he said during a virtual press briefing on Wednesday.
Winde said the department would have to get the lessons to the pupil.
He added that the same applied to affected teachers – that they should stay home.
This was after Basic Education Minister Angie Motshekga announced on Tuesday that Grades 7 and 12 could return to school on 1 June.
According to the province’s head of the Department of Health, Dr Keith Cloete, the Western Cape is heading into its peak coronavirus period.
The global economy could be set back by a harrowing $82 trillion (the equivalent of R1.47 quadrillion, or one thousand four hundred and seventy trillion rand) in damages related to the coronavirus pandemic over the next five years, according to recent findings by a University of Cambridge department that examines systemic risks.
These cost projections are based on 2019 gross domestic product volumes which stood at $69.2 trillion for the world’s 19 leading economies. The contrast, in comparison, is visibly massive.
The Centre for Risk Studies at the University of Cambridge Judge Business School determined that the potential toll could range between what it called an “optimistic loss” of $3.3 trillion in case of rapid recovery, and $82 trillion in the event of an economic depression.
While lost value of $82 trillion is the worst case scenario, the centre’s consensus projection was a loss of some $26.8 trillion, or 5.3%, of global GDP in the coming five years.
Covid-19, the disease caused in humans by the SARS-CoV-2 virus, remains a mystery that needs a lot more unwrapping. At first, experts believed that the conditions caused by the novel coronavirus were just respiratory diseases.
But as the virus circled the globe, doctors saw a wider range of diseases in their patients, fatal in many cases.
These complications include heart failure, heart attacks and blood clots, which were all reported by emergency doctors in a new scientific paper.
The paper was published in the American Journal of Emergency Medicine.
A Canadian newborn is a “probable” case of infection with the new coronavirus while still in the womb, doctors report. Other such cases have been suspected and reported in prior studies.
But the mother’s active case of Covid-19, along with the fact that the baby boy was delivered via C-section, add weight to the notion that maternal-foetal transmission of the SARS-CoV-2 virus can occur, the Toronto doctors concluded.
There was good news, however: Although the baby was born preterm (about 36 weeks), he was a healthy 6.5 pounds (just under 3kg). And even though testing positive for coronavirus, he did not develop Covid-19.
Still, the case “represents a probable case of congenital SARS-CoV-2 infection in a liveborn neonate,” said researchers led by paediatrician Dr Prakesh Shah, of Toronto’s Mount Sinai Hospital. They published their report on 14 May in the Canadian Medical Association Journal.
The coronavirus pandemic could scuttle more than 28 million elective surgeries across the globe this year, according to a new study. British researchers gathered information from surgeons at 359 hospitals in 71 countries about elective surgery plans, and used that data in a statistical model to estimate numbers in 190 countries.
Based on a 12-week period of peak disruption to hospital services caused by the pandemic, 28.4 million elective surgeries worldwide could be cancelled or postponed in 2020, the study found.
Each additional week of hospital service disruption would cause 2.4 more million cancellations.
“Although essential, cancellations place a heavy burden on patients and society,” said study author Dr Aneel Bhangu, consultant surgeon and senior lecturer at the University of Birmingham.
• Maintain physical distancing – stay at least one metre away from somebody who is coughing or sneezing
• Practise frequent hand-washing, especially after direct contact with ill people or their environment
• Avoid touching your eyes, nose and mouth, as your hands touch many surfaces and could potentially transfer the virus
• Practise respiratory hygiene – cover your mouth with your bent elbow or tissue when you cough or sneeze. Remember to dispose the tissue immediately after use.
Dr Alison Bentley is a general practitioner who has consulted in sleep medicine and sleep disorders, in both adults and children of all ages, for almost 30 years. She also researches and publishes on a number of sleep-related topics both in formal research journals and lay publications including as editor of Sleep Matters, an educational newsletter on sleep disorders for doctors.
If you’ve ever wondered what your brain is doing while you sleep, a new study gives the first direct evidence that it’s busy “replaying” our waking experiences.
The finding comes from a research project called BrainGate, which is testing new technology for people who are paralysed or have lost a limb. Participants have “micro-electrodes” implanted in their brains, to allow them to exert mind control over assistive devices or prosthetic limbs.
The work also let researchers catch a glimpse of what happens in the brain during rest – specifically after participants had played a new game. It turned out that the same brain cells that were firing during the game kept firing as people drifted into light sleep.
In a nutshell, the brain seemed to be “replaying” the experience, said researcher Beata Jarosiewicz, a senior scientist at NeuroPace, Inc., a California-based company that makes implantable medical devices.
‘Replay’ during sleep
That’s not direct proof that sleep helps us consolidate memories or learn more efficiently, Jarosiewicz emphasised. But, she said, the findings add to the list of reasons to get enough rest.
“Sleep is important for many reasons, including your brain function,” she said.
The findings, published on 5 May in the journal Cell Reports, are not surprising.
Based on past research in animals and humans, researchers have believed that replay happens during sleep, according to Dr Phyllis Zee, a sleep researcher who was not involved in the study.
But past studies of humans have used non-invasive recordings of brain activity. And they’ve looked at broader patterns of “collective” brain-cell firing, said Zee, a professor of neurology at Northwestern University Feinberg School of Medicine, in Chicago.
Here, she said, researchers were able to zero in on which brain cells were firing. And the same ones that fired during the game fired during the rest period immediately after.
Replaying the experience
For the study, Jarosiewicz and her colleagues observed two patients who had had microelectrodes implanted in their brains. Both were paralysed – one due to a spinal cord injury, the other to amyotrophic lateral sclerosis (Lou Gehrig’s disease).
The researchers asked both to play a “sequence-copying” game, which they describe as similar to the 1980s game Simon: Four colour panels lit up in different sequences that the players had to repeat. But instead of using their hands to do it, they used their minds.
Before and after each game-playing session, participants had a rest period of about 30 minutes. During that time, they drifted off into early-stage sleep, Jarosiewicz said. Yet their brain cells continued to fire as they did during the game – as if the cells were replaying the experience.
The study did not dig into whether such replay improved participants’ learning or game performance. That’s for future research, according to Jarosiewicz. Another question, she said, is whether similar replay happens when we go to sleep at night – and not just during a catnap.
Helping your brain reset
What’s interesting, Zee said, is that the replay activity was present when participants were simply resting and grew stronger once they were dozing.
That raises the possibility that even short rest periods could be a learning aid, she said.
“Maybe if people took a break during the day – got a little downtime – it might help with memory consolidation,” Zee said.
That idea is in line with some advice she often gives patients.
“Just lie back and close your eyes for a while,” Zee said. “It calms you down and may help your brain reset.”
A new analysis suggests there may be a simple, noninvasive technique that could delay, or even eliminate, the need for ventilation in Covid-19 patients.
It’s called “proning”. And it appears to be remarkably effective at boosting “blood oxygen saturation” levels, often called sats, among Covid patients struggling with abnormally low levels (known as hypoxia).
“Proning is basically having patients turn over onto their stomach or onto their side while lying down,” explained study author Dr Nicholas Caputo. He’s the associate chief at New York City Health and Hospitals/Lincoln Medical and Mental Health Center’s department of emergency medicine.
How does it work? Gravity, says Caputo. “It makes sense anatomically,” he noted, “because when your body is parallel to the ground all the organs lay off of it like on a clothesline. So, by flipping over or to your side you open up the areas, like your lungs, that would otherwise be compressed when you’re on your back.”
Very high mortality rate
But when the coronavirus pandemic first struck, proning was not a go-to intervention, Caputo noted. Instead, US patients with severely low sats – sometimes coupled with abnormally rapid and shallow breathing and troubling lung X-rays – were often quickly put on ventilators.
Generally speaking, mechanical ventilators – though invasive – can be lifesavers for patients who can’t breathe on their own, Caputo said.
The problem? “ER physicians knew that if we just intubated everyone we would run out of ventilators in a few days,” he noted. “And then there was also the early data coming out of Europe that was showing that there was a very high mortality rate among ventilated Covid patients.”
In fact, that latter concern was backed by recent findings involving roughly 2 600 COVID patients at Northwell Health System in New York City. The study found that while the overall death rate was 21%, it shot up to 88% among those placed on ventilators.
The other twist was that many Covid patients come to the ER with very low blood sats, but are otherwise functional. They have none of the signs of respiratory distress that low sats are expected to generate. This raised additional questions about whether quick ventilation was the best way to handle these “happy hypoxemics”.
“We knew something wasn’t quite right,” said Caputo, “and we wanted to figure out what we could do to prevent patients from being ventilated in the first place.”
Dangerously low sat levels
So between 1 March and 1 April, Caputo and his team set out to test the effectiveness of proning as a means for elevating sat levels and halting a worsening of symptoms among 50 adult Covid-19 patients.
All had hypoxia, with sats below 90%. Sat levels can be registered by means of a finger-clip device called a pulse oximeter, with a normal reading falling between 95% and 100%.
More than three-quarters of the patients (80%) were also struggling with abnormally rapid and shallow breathing, and 44% were already taking supplemental oxygen before going to the ER.
Those who weren’t already taking supplemental oxygen were given some. Yet, while those patients did improve a bit, all 50 were still struggling with dangerously low sat levels ranging from 75% to 90%.
So Caputo and his team turned to proning. “We didn’t move them ourselves,” he noted. “We had patients self-prone by turning themselves.”
The result? After just five minutes of proning, sat levels rose to a near-normal mean of 94%. And in the end, about three-quarters of the patients never had to be put on a ventilator.
More research needed
Still, about a quarter of the patients ultimately failed to regain normal sats, and those 13 patients had to be intubated within 24 hours of hospital admission.
“Also, this was an observational study,” Caputo stressed, “not a controlled investigation with a comparison group.” That, he said, makes it premature to conclude that proning definitively staved off ventilation and boosted survival.
“We need more research,” he acknowledged. “But proning is such a low-risk procedure that I would definitely say that this is certainly worth considering going forward.”
The findings were published recently in the journal Accident Emergency Medicine.
Two experts not involved in the study cautiously agreed.
“A lot of the benefit of proning has been anecdotal,” cautioned Dr Armeen Poor, an attending physician in pulmonary critical care medicine at Metropolitan Hospital Center in New York City.
Risk ‘pretty minimal’
“And while oxygen saturation is an important number, it’s not the be-all of clinical status. Also, we don’t know what the consequences or trade-offs are. For example, a quarter of these patients still needed to be intubated. Did the delay in making that happen cause them harm?” Poor said.
“But I would say that the risk of proning is pretty minimal,” he added. “And we are seeing that some patients get remarkably better with proning, without being intubated. So, if someone is awake and they’re okay to do it, and it doesn’t make them more uncomfortable, then it’s not an unreasonable thing to try.”
Dr Albert Rizzo, chief medical officer of the American Lung Association, seconded the thought.
“This has been a learning process for all of us as to the exact physiology of what this virus does to the lungs,” he noted. “For example, we’re seeing that the lungs of Covid-19 patients are not as stiff as we typically see in other patients with pneumonia. And that means that proning could be a sufficient way to increase oxygen flow, without needing the pressure of a ventilator.
“And being able to hold off on using a ventilator does have a lot of plusses to it because, on a ventilator patients can’t communicate,” Rizzo said. “And even the process of putting it [the ventilator] in, exposes frontline health care workers to greater risk themselves. And yes, unfortunately, once Covid-19 patients go on a ventilator many of them never come off. So, if we can use gravity to help improve outcomes, all the better.”
In South Africa, we’ve seen the headlines about the deaths of nurses from Covid-19. As healthcare workers are exposed to SARS-Cov-2 on a daily basis, it makes sense that they are more at risk for Covid-19 infection.
But it still seems that some people are more at risk of illness than others. This led a group of researchers funded by the British Heart Foundation (BHF) to set up a clinical study of NHS healthcare workers in the United Kingdom to determine which frontline workers are most at risk.
According to a news release, this study will continue to collect samples from several frontline healthcare workers (doctors, nurses, administrators and others) who are not showing any symptoms of the virus
The researchers collected samples of blood, saliva and nasal swabs from workers in three London hospitals to determine who were most likely to be exposed early on in the pandemic. The researchers also wanted to determine whether anyone who was constantly exposed to the virus developed immunity, and if there were any exposure hotspots inside the hospitals.
Study extended to Cape Town and Sydney
Not only will the research determine which people are more likely to contract Covid-19, but the research can also help enhance ways of testing for the virus, and create a sample library that can be utilised for vaccines or drug development, according to the news report.
The study will also help determine whether BAME (black, Asian and minority ethnicities) healthcare workers are more at risk of severe Covid-19 than Caucasian healthcare workers.
The study has been extended from the UK to Cape Town and Sydney to help answer other questions more related to the Southern Hemisphere (such as climate conditions etc).
Dr Thomas Treibel, BHF Intermediate Research Fellow at Bart Health and University College Hospital London, stated: “Covid-19 is devastating families and severely disrupting our way of life right across the world. There is a lot we don’t know about how the virus works, and so we have acted with speed to set up this clinical study in response to the pandemic.
“Looking at samples from 1 000 frontline staff who are exposed to the virus will be crucial in understanding why some people become hospitalised with Covid-19, while others develop mild symptoms. By collaborating with the best minds and scientific labs in the UK and beyond, we will be able to get quick answers on how the virus works, including the role genetics plays and the immune response to Covid-19. Answering these questions will enable us to design much-needed treatments before a second wave occurs.”
As Covid-19 sweeps across the globe, and the number of cases in South Africa grows on a daily basis, we are eagerly awaiting the arrival of an effective vaccine.
Health24 recently published an article explaining why clinical trials are key to ensure the safety of any medication, and why it may still be a while before we have a Covid-19 vaccine.
Researchers at Baylor College of Medicine and Texas Children’s Hospitals are experiencing first hand the challenges surrounding the development of a new vaccine.
Vaccines, pathogens and the immune system
The National School of Tropical Medicine at Baylor and the Center for Vaccine Development at Texas Children’s Hospital are currently in the process of developing a coronavirus vaccine.
The key goal of a vaccine is to trigger an immune response that will fight off a virus, but still be safe enough not to make the person sick. This is true for all vaccines, but the end product is different for each pathogen.
According to Dr Maria Elena Bottazzi, vaccine development is a balancing act between design and the immune response.
“As we proceed with the designing and testing of vaccine candidates, we felt the need to collaborate with a clinical immunologist, who also is engaged in basic and translational research, so that together we can inform our vaccine development efforts and ensure we evaluate both the protective mechanisms and avoid inducing any undesirable immunological responses that have been associated with some respiratory viruses,” she stated in a news report.
Bottazzi and fellow researcher Dr Peter Hotex approached Baylor’s pulmonologist Dr David Corry – professor of immunology, allergy and rheumatology and Fulbright Endowed Chair in Pathology in the Department of Pathology and Immunology – to collaborate.
Their research outcomes are published in the journal Nature Reviews Immunology, where an analysis of the vaccine development strategy can be read.
How does a vaccine protect against Covid-19?
While there is still a lot to be researched about SARS-CoV-2, the virus responsible for Covid-19, researchers now know that our bodies are most likely protected from the virus by a robust antibody response with a neutralising capacity.
We also need an immune response where the release of cytokines is balanced, as to not cause illness.
Previous studies have shown that it might be possible to develop protective antibodies.
“We are encouraged by the evidence supporting the likelihood that immunising against the spike protein’s receptor-binding domain represents a realistic and viable vaccination strategy. However, many questions remain,” said Dr Hotez in a statement.
“Studying the immunological responses triggered in people infected by the virus is one way researchers can select what viral components or antigens are promising candidates to use when designing the vaccine,” Bottazzi said. “That, coupled with studies using laboratory models of disease, is how scientists attempt to predict what are the ideal mechanisms of protection triggered by vaccines,” he remarked.
What could go wrong?
As a vaccine’s main goal is to trigger an immune response without harming the body, the researchers have looked at the effects of their previous developments in two ways – how a vaccine influences the immune system and what it does to the cells.
According to the news release, experimental and pre-clinical observations in earlier vaccine attempts against respiratory viruses showed that some of the formulations may trigger negative responses by the immune system.
Pre-clinical testing also showed that there could be tissue damage caused by cellular infiltrates after an immune response.
“Some experimental animals developed an inflammatory response in the lung or liver characterised by significant infiltration of immune cells – lymphocytes, monocytes and eosinophils,” Corry said. “Our literature search suggests that this cellular infiltration can be associated with IL-6, a cytokine or immune protein that is strongly increased in patients with Covid-19 who experience a cytokine storm, an excessive production of cytokines that can be life-threatening.”
There might also be undesirable responses from antibodies. While this has happened with other viruses, Bottazzi and team haven’t observed it in their vaccines: “We have not found any evidence that our vaccine triggers antibody-dependent enhancement in laboratory pre-clinical experiments. Experimental evidence suggests that our vaccine against the receptor-binding domain leads to the neutralisation of the virus,” Bottazzi said.
“Pre-clinical studies, performed with our partners at the University of Texas Medical Branch, show that the receptor binding domain on alum is indeed a promising vaccine candidate. It can trigger an immune response that is protective and does not induce undesirable cellular immune responses. We are working to advance this approach into the clinic for phase 1 studies,” Bottazzi added.
Time needed to find the right vaccine
While vaccine development has always been challenging, scientists are collaborating like never before, according to the research team.
“We believe that we need to have many vaccine candidates, platforms and trials, so we can evaluate as many vaccine options as possible to select the ones that are the most appropriate and prove to be the most effective and safe,” said Hotez.
“We invested almost a decade of research to maximise immune protection and minimise or prevent immune enhancement. Ultimately our goal is that these vaccines are made for the global population, accessible and affordable to all.”
The general goal is to try and distance yourself as much as possible from the novel coronavirus. However, a controversial approach called 1 Day Sooner is aiming to purposely infect a large number of volunteers with the virus to speed up clinical trials.
When Health24 reported on this approach in late April 2020, 2 300 volunteers had already signed up for this grassroots effort. But that number has now grown to more than 16 000, according to the latest reports.
What is the goal of this approach?
Co-founder Josh Morrison wants to use this campaign to demonstrate that many people are keen to participate in helping to speed up clinical trials and the possible success of a vaccine.
Without a successful vaccine or treatment, the only reality is to live with the virus and practice measures of physical distancing. A vaccine is the only way to return to a normal world as we know it. Unfortunately, developing a vaccine takes a long time and comprises several stages – the four phases of clinical trials being crucial to establish safety and efficacy in a large, diverse group of people.
Morrison stated that the goal of 1 Day Sooner is to recruit as many people as possible to pre-qualify them as suitable to participate in human trials as they occur.
Controversial or selfless?
But what about the ethics and risks involved in voluntarily being infected with a virus? Dr Nir Eyal, director of the Center for Population-Level Bioethics at Rutgers University agrees that it’s not a standard approach, but that it may help.
“It’s not every day we give a healthy individual an exposure to a pathogen – the very same thing doctors are trying to protect people from, but it becomes increasingly clear that the only sustainable exit from the current health and societal crisis is a vaccine, and there are ways to conduct such a trial that are perfectly ethical,” he said in a statement.
What does the human challenge entail?
Initially, people who sign up for this challenge should be relatively young and healthy.
According to an article published in Nature, the risk of harm in volunteers is reduced significantly when they are between the ages of 20 and 45 and generally healthy.
The goal is not to make anyone significantly ill.
Volunteers are also kept safe by daily monitoring and access to medical care once they are infected, Morrison said.
Would authorities allow this?
While there are currently no plans for a public study in the US, several politicians and volunteers are pushing for this, and the World Health Organization (WHO) has released a document to set out criteria for an ethically acceptable plan.
The Food and Drug Administration (FDA) has never allowed a trial of this type for a disease this new, especially without a specific cure, but hasn’t ruled out the possibility completely. Right now, they are open to the idea, but advise caution.
“Human challenge studies are a way to expedite the development of a vaccine to prevent Covid-19,” the FDA stated in an article. “Because these studies involve exposing volunteers to the virus, the studies raise a variety of potential scientific, feasibility, and ethical issues. The FDA will work with those who are interested in conducting human challenge trials to help them evaluate these issues.”
Dr Matthew Memoli, director of clinical studies at the Laboratory of Infectious Diseases at the National Institutes of Health, also stated that a human challenge trial of this type might be pursued as the pandemic is rapidly changing our society.
The Covid-19 epidemic in South Africa is now in its exponential phase. Cases are rapidly increasing in many areas. This is most apparent in the Western Cape province, which could be due to higher rates of testing per capita, coupled with a more selective testing strategy than in other provinces.
The doubling time of mortality in the province’s Cape Town metro is now 8-9 days, indicating a rapid increase in the number of severe cases and deaths from Covid-19. Although the health system is better prepared as a result of the initial lockdown, major cracks are starting to show. This is causing a deterioration in clinical service which, if not stemmed, threatens the country’s response to the epidemic.
Globally, rates of testing for SARS-CoV-2 infection have varied between and within countries. For example, testing rates (per 1 000 people) range from 148 in Iceland to 0.76 in India. In South Africa, as of 3 May 2020, the testing rate was 4.5. The high demand globally for molecular assays (known as PCR) to identify infectious cases has led to a shortage of samples and kits required in laboratories.
In South Africa’s case, the rise in the number of cases in the Western Cape, and the pressure this is putting on laboratories charged with processing tests, is only the forerunner. Here, we explain what needs to be done, and why.
Turnaround time
Diagnosis of Covid-19 relies on a laboratory test that is simple, but laborious. The time taken from the sample being taken to communication of the result – the “turnaround time” – is influenced by a number of factors. These include the speed at which the sample reaches the lab, the lab’s capacity to run the test – access to reagents and test kits, number of analysis machines, availability of staff, errors leading to a need for re-testing – and the communication process.
Early reports by the National Health Laboratory Service indicated that it had the capacity to do 36 000 tests a day by the end of April 2020. But capability to do so has not materialised.
Currently, the number of tests received in laboratories exceeds their capacity to deliver results within 12-24 hours of sampling. In many parts of the country, turnaround time has increased from 24 hours to over 5-14 days. According to correspondence we have seen, some labs with the capacity to do 1 000 tests a day have a backlog of 10 000.
Why is “turnaround time” so critical?
South Africa’s ambitious community testing programme relies on identifying infected persons, isolating them, tracing their contacts, and isolating or quarantining them.
Identification of infectious cases – even if only a quarter of those who are infected are identified – coupled with adequate tracing of their contacts and ensuring isolation (of cases) and quarantine (for up to 14 days) of test-negative contacts, could assist in slowing the rate of community transmission of the virus.
This would mitigate the expected surge in severe Covid-19 cases occurring over a very short period of time. Healthcare facilities could be better equipped to deal with the expected surge of Covid-19 cases over the next 2-3 months.
But for such a strategy to be effective requires a clear line of sight in terms of efficiency of testing, isolation of cases as quickly as possible (within 12-24 hours of being tested), and effective and immediate tracing of their close contacts.
It is estimated that any single case will, on average, have 20 close contacts (probably higher in South Africa) who should be traced. These include any close contacts (someone who spends more than 15-30 minutes within 1.5 metres of the person) occurring from at least 2-3 days prior to symptom onset in the identified case, and up until the case has been isolated. Assuming that isolation occurs on the third day after symptoms appear, for each case there would be approximately 120 close contacts to be followed up.
For this strategy to assist with slowing the spread of the virus requires tracing (and physical contact for screening for symptoms) of approximately 80%. Although possibly achievable in the initial phase of the epidemic, it becomes an unrealistic goal to aspire to when identifying 400 “new cases” each day, as that would require tracking and physical tracing of approximately 5 200 contacts.
This is why the turnaround time matters. A delay means that the current “new” cases reported in South Africa reflect cases that were likely sampled approximately a week ago.
This points to the need to shift the focus of PCR testing to patients being admitted to the hospitals. This would inform the management of the patient and limit the likelihood of spread within hospitals.
But the turnaround time for this cannot be anything more than 12-24 hours if it is to achieve any of these goals of testing. When a person with Covid-19 is admitted to a hospital, it is critical that they do not infect others. We achieve this by triaging patients into those who are Covid-19 suspects (a “person under investigation”) and those who are not. We separate patients into different wards accordingly.
Slow turnaround time for tests means a delay in diagnosis. The longer the turnaround time, the worse it gets. As the epidemic accelerates in South Africa, the number of patients needing to be admitted to hospital as a “person under investigation” and subsequently Covid-19-confirmed cases rapidly rises, and the system becomes overwhelmed.
This is why we are arguing for a wholesale change to the current system.
How to fix the faults
We believe the following crucial steps need to be introduced as a matter of urgency.
Stop the testing and contact tracing components of the community surveillance programme, in favour of self-reporting of symptoms via an app-based programme on mobile phones. We believe there is sufficient mobile coverage and access to do this. This would allow monitoring of disease activity, and self-isolation of symptomatic people for 14 days on the probability of Covid-19 infection. If resources allow for testing to confirm negative status sooner than 14 days to accelerate early return to work, that should be considered, but not at the expense of undermining turnaround times in hospitalised patients.
Steps need to be taken to map the spread of SARS-CoV-2 in communities. This should be done by gathering evidence on the seroprevalence, which can be measured using rapid antibody blood tests to detect recent or past SARS-CoV-2 infection (but not whether currently infectious). Geospatial mapping of the epidemic could assist in a more measured and informed approach for developing district or regional strategies to reduce the rate of community transmission. It could also help inform anticipated demands on healthcare services.
Focus testing resources on specific groups of people for whom a rapid turnaround time result will effect significant change.
Allow rapid diagnosis of hospitalised people under investigation, which allows optimal case management of severe Covid-19, optimal infection prevention and control, and patient flow to enable hospitals to cope with the escalating numbers as we climb the exponential curve to the peak.
Rapidly isolate and quarantine symptomatic healthcare workers and their close contacts to limit hospital outbreaks.
Introduce high risk group surveillance and testing, including patients and staff at long-term care facilities.
Convene an intersectoral government task force to analyse the barriers to operational flow of the entire testing system and make recommendations for a new testing strategy.
Health Minister Zweli Mkhize confirmed that South Africa has 9 420 coronavirus cases, with the Western Cape being the biggest contributor to these numbers.
He warned those living in cities across the country that they may have to brace themselves for stricter restrictions for longer, as all metros were currently coronavirus hotspots.
There would be no “once-size-fits-all” approach to these lockdown restrictions. Instead, every area would be assessed in terms of their specific risk profiles, Mkhize said.
Asked why the Western Cape had significantly more Covid-19 infections than the rest of the country, Mkhize said one of the features of the pandemic in the province was the outbreak in “clusters” of infections. These were primarily in factories and busy retail areas.
South African smokers have turned to some gnarly, cheap locally made smokes to get their nicotine fix in the six weeks since the government banned the sale of cigarettes.
These weird and wonderful new brands are put on the market by what are called “value brand manufacturers”. There are literally dozens of value brands out there for the unsuspecting South African smoker to choose from, including Caesar, F1s, Golden Flake, Ossum, Kingdom, Pacific Blue, Gold Mount, Sahawi, Navara, and JFK.
“Technically speaking, all cigarettes being sold during lockdown, regardless of brand, are considered ‘illegal’. This renders the illicit trade in cigarettes under lockdown as 100% of the market,” says Johann van Loggerenberg, the author of the searing exposé Tobacco Wars, about the illegal cigarette trade in South Africa.
Beyond being illegal, these economy brands tend to taste pretty awful too, or have other serious drawbacks.
Krugersdorp resident Cheryl Taylor Lubbe normally smokes Dunhill Fine Cuts, which cost her approximately R48 a box. After the lockdown, she managed to score a carton of Richman Blue for R180, which were “still acceptable and didn’t taste horrible”, although they “made my house seem blue with the smoke and the smell was terrible”.
When she went back to her supplier, she learnt that the smokes were going at R450 a carton at illegal selling points, the same price as her Dunhills. So she switched to another knock-off brand called Voyager and discovered “why it’s called ‘Voyager’ – because those smokes fly. I easily smoked forty cigarettes a day because I felt I wasn’t getting my nicotine fix”.
On top of that, the Voyagers “made my tongue feel and taste like I’ve been eating sour jelly babies”.
So she switched to yet another shady brand called Cape Navy Cut.
“The box and the cigarettes look like the candy cigarettes you could buy in the 80s and 90s”.
Welcome to the world of fly-by-night cigarette brands, under the table sales, and “severe headaches and sinusitis”.
The ban on cigarette and alcohol sales during the lockdown has created an underground market of rampant deals all over Pietermaritzburg.
And it’s not only dodgy characters indulging in the goods offered. Those supporting it are normally law-abiding citizens and many professional people. A Weekend Witness investigation, conducted this week, revealed a “dial-a-fix” network on social media with door-to-door cigarette and alcohol deliveries.
Sources say phone calls and SMSes to place orders for cigarettes and alcohol have been going on since the lockdown was announced and that the availability and accessibility has made it easy for people to buy and get their buzz.
Some tuck-shop and pub owners, and their connections, have formed WhatsApp groups advertising what they have in stock. The connection puts in an order for the third party and the pickup for the booze or tobacco is arranged.
While at least 19 000 inmates inside South Africa’s prisons will be eligible for special parole to curb the spread of coronavirus, those sentenced for a range of serious crimes will not make the cut.
This as President Cyril Ramaphosa authorised the release on parole of low-risk inmates to ease overcrowding and curb the spread of Covid-19 in prisons.
On Friday, Ramaphosa announced and gazetted the decision in terms of Section 84(2)(1) of the Constitution together with SectionB2(1)(a) of the Correctional Services Act 1998.
In Proclamation 19 of 2020 gazetted on 8 May, Ramaphosa outlined only select inmates would be eligible and only released after processes have been followed.
On May 8, 1980, the World Health Assembly officially declared smallpox eradicated.
The disease had “plagued humanity for at least 3 000 years, and killed 300 million people in the 20th century alone,” the World Health Organisation director-general Tedros Adhanom Ghebreyesus said during a media briefing exactly 40 years later, on May 8, 2020.
“Humanity’s victory over smallpox is a reminder of what’s possible when nations come together to fight a common health threat,” he said.
Getting there involved many of the tactics used today against the novel coronavirus, including case finding, contact tracing, and mass communication campaigns. But one “crucial tool” is still missing: a vaccine, which WHO, among many organisations and researchers, is working to develop.
Even when an effective coronavirus vaccine is available and widely accessible, the eradication of Covid-19 is likely a ways off, if it happens at all. Smallpox remains the only human disease to be eradicated globally, and it took 184 years between the development of the first-ever vaccine in 1796 to its eradication in 1980.
The American government agency, the Food and Drug Administration, has issued recommendations for pet owners during the coronavirus pandemic, encouraging social distancing practices for cats and dogs.
An FDA fact sheet from April 30 indicates that pets should not interact with people or other animals outside the immediate household. Cats should be kept indoors when possible, and dogs should be kept on a leash that can maintain at least six feet distance from other humans and animals.
The agency also recommended dog owners avoid dog parks or other public places “where a large number of people and dogs gather.”
While the USDA oversees livestock, the FDA is responsible for monitoring pet food and medications.
• Maintain physical distancing – stay at least one metre away from somebody who is coughing or sneezing
• Practise frequent hand-washing, especially after direct contact with ill people or their environment
• Avoid touching your eyes, nose and mouth, as your hands touch many surfaces and could potentially transfer the virus
• Practise respiratory hygiene – cover your mouth with your bent elbow or tissue when you cough or sneeze. Remember to dispose the tissue immediately after use.
