COVID19 Mitigation Measures & Child Health - Mandy Wessels HCU Paediatrics, Queen Nandi Regional Hospital - PatchSA
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COVID19 Mitigation Measures & Child Health Mandy Wessels HCU Paediatrics, Queen Nandi Regional Hospital
Context - revision 2.
1.International
National
Education
Provincial
Environment
6.
Healthcare
3. Household system
5.
4. Violence
Social/family
Mitigation Measures
• “Measures put in place to slow the spread of infectious diseases” (1)
• Nationwide lockdown and social/physical distancing
• Compulsory mask-wearing
• Increased handwashing and use of Alcohol-based hand-rub
• Disclaimer:
1. Purpose of talk not to argue the necessity of these measures or
dispute them, rather to try to predict what the effects will be on
Child Health
2. Raw data used because data for this time period is largely
unpublished
Outline How will the nationwide lockdown and physical distancing impact on • Food security - Macro, Meso & Micro level economics? • Health care – access, utilisation, LTHC and acute care and the different experience within the system • Indicators • Violence and Child abuse • Education & Early Childhood Development • Not time for – mental health of our children
Economy and Food Security
• Macro – from our honourable finance minister’s address (2)
• Expected Global economy contraction of 5.2% (prior to pandemic, expected
3.3% increase)
• Worst contraction since 1870
• We know this will affect child health, mechanisms are complex
• Has anyone studied this?
The impact of economic shrinkage at macro level on
Child health
• Article published in 2017 by Maruthapu et al in the BMJ Global Health
studied the child health effects of economic downturns (3)
• Using the World Bank Development Indicators and Global Finance
Indicators, economic downturns were mapped between 1981 - 2010
• Every one of the 197 countries experienced one economic downturn during this time,
but on average 7.9 during this study period
• Child Health Indicators were poorer across all spheres – neonatal, perinatal
and U5 mortality rates, correlating to the period of recession
• Additional findings
• Children in low-income countries experienced a threefold downturn in U5MR during
recession as compared with wealthier countries
• Vulnerable groups of children experience the worst outcomes
Meso level – SA economic contraction • Meso – South Africa • SA economy expected to contract by 7.2% (worst in over 90 years) (2) • From our experience in previous recession • Budget cuts and moratorium on posts in Health Care sector • Job losses, retrenchments, reduced hours in other sectors • Food price increases • Food prices – impact even those who’s income has not been directly affected by income loss (price is set at meso level but felt at micro level)
Food Prices • Over the month of March 2020, The cost of a low-income household food basket increased by 7% (R220) (4) • Stats SA (5) published changes in prices of essential goods only during lockdown 5 (April) – showed overall deflation of 0.5% but some items such as eggs increased by 19.8% • Formula milk and baby cereal was decreased by 5 & 6% respectively • PMB Economic Justice and Dignity Group compared a food basket between March and May, the increase was 7.8% or R250 (6)
Micro level – acute loss of income • FOOD SECURITY • Children are dependent on adults • Loss of adult wages = reduced food security
Micro or household level
• Finance Minister Tito Mboweni announced an increase in
unemployment by 1 percentage point for the first quarter of 2020 vs 4th
quarter 2019 (2)
• Detailing this on Stats SA (7) – 15-34 yr age group were hardest hit.
• These are the parents of our children under 5.
• Of the 20.4 million people in this age group, 41.7% were neither in employment,
education nor training and 1.9 million had indicated that they were no longer
looking for work and had disengaged with the labour market
• Even those documented as employed are not necessarily in secure employment
and may lose income temporarily or after businesses have suffered economic
lossEmployment (4)
• 1/3 of our children in SA live in households where no adult is
employed
• 2/3 live in a household where there is income from adult labour
• 3 million of these are in household entirely dependent in the informal sector
• 1.5 million live in households with a combination of formal and informal
sector income
• Households relying on informal sector employment are likely to be
hardest hit during lockdown, though informal sector jobs had
increased most in Quarter 1 (prior to mitigation measures)Domestic Workers
• Approximately 1 million domestic workers according to Stats SA
Quarterly Labour Force Survey Results (7)
• A survey in April 2020 by Izwi Domestic Worker Alliance of 600 domestic
workers showed that 79% were not registered for UIF and 11% did not know if
they were (8)
• They would be unable to benefit from the UIF TERS funding
• They may not qualify for the R350 covid19 Relief Grant if foreign national without Home
Affairs registrationOther Factors impacting Nutrition • Access • Local shops in communities were unable to trade • Supply to smaller outlets was reduced • Transport to larger centres was difficult – permits, fewer taxi’s • Unable to shop around for good prices, further increasing food prices • Shop times – this affected those of us working during level 5 • Queues outside • Unable or reluctant to shop with children & no childcare • Percentage spent on cleaning agents vs food • Stocking up on non-perishables due to the above access issues and fewer perishable items – quality of food provided to our children
School Feeding Schemes
• Annual report of the National School Nutrition Programme (9)
• 9 131 836 learners benefit from school feeding scheme
• For many, this is the only nutritious or hot meal per day
• Schools have been closed from 16 March to date (mostly) – 4 months of
missing this daily meal
• 2.5 million 3-5 year olds attending ECD also benefited from meals served at
schoolsSevere Acute Malnutrition
• I was unable to access Provincial data on SAM separations or Case Fatality
Rates
• At QNRH & in KCD, there has not yet been an increase in absolute
numbers (separations)
• Some concerning patterns, anecdotally
• Age of the SAM babies – all have been under 6 months, formula-fed
• Older SAM children have only started being referred now, in June (we expect it will
take longer for these children to manifest features of SAM
• Severity and higher CFR
• Higher percentage of our admissions – these appear to still be coming despite low
admission numbersHave we started to see the effect of food insecurity?
SAM separations – King Cetshwayo District (10)
50
45
40
35
30
25
20
15
10
5
0
February March April May
QNRH 2019 QNRH 2020 KCD 2020Child Healthcare
Acute Care - Admissions
• There has been a decrease in utilisation of facilities across all levels
and in all areas
• The drop in admissions to paediatric wards has been attributed to
many things – all speculation
• Access & transport
• Fear of health facilities & avoidance of screening queues
• Closure of wards/some sections
• Some speculate that this is because children are not mixing at schools and
ECD centres thus not spreading usual respiratory and enteral pathogensAcute Care – DHIS Provincial Data
• Total admissions in April 2020 across the Province –DHIS (11)
• Paediatric admissions showed a 65% decline vs the average of the prior 11
months (6385 to 2225)
• By District, paediatric-specific data not available
• Ilembe admissions decreased by 63% and Ethekwini by 47%
• Unexpectedly, this decrease has been sustained as we have moved
from Level 5 – 4 – 3
• Type of child admitted has been interesting
• High percentage of epileptics with breakthrough seizures first
• Followed by a high number of cardiac patients
• Higher than usual injuries and poisonings (burns in District and surgical
service) as we experience in school holidays
• Severe, young SAM patietnsAcute Care
Regional Hospital Paediatric Ward Separations (12, 13)
282
269
263
253 257
249
239
231
194
150 145
136 133
122
110
EDENDALE KEH VIII QNRH
Jan Feb March April MayOutpatient Visits
• Provincial data shows a sharp decline in OPD visits but, again, these
are not paediatric specific
• In total, OPD headcount declined by 84% during the month of April
• While those attending OPD without being referred by a clinic, increased by
about 10% (patients appeared to be bypassing clinics to arrive directly at
hospital OPD)
• Paediatric data from the 3 Regional centres mentioned abovePaediatric OPD data from Regional Hospitals
Paediatric Outpatient Headcount in Regional Hospitals
1889
1733
1627
1342 1342
1258 1258
1200 1200
984
934
601 637 601 637
EDENDALE KEH VII QNRH
Jan-20 Feb-20 Mar-20 Apr-20 May-20PHC utilisation & preventative services • PHC utilisation under 5 yr rate • Calculated by PHC headcount under 5 years/population under 5 yrs • Declined from 3.5 monthly average to 1.2 – 62.5% drop • Healthcare utilization has decreased across all levels
Preventative services
• Vit A and Deworming
• Deworming coverage has dropped by over 80% with vast differences between
Districts
• Deworming coverage in Ilembe has dropped by 92% and in eThekwini 76.6%,
while it has decreased by just over 50% in Ugu, Umkhanyakude and
Umzinyathi
• Vit A shows a similar pattern, though the decline is greater than that of
DewormingImmunization Coverage
• This is a more complex issue than caregivers not presenting to facilities
• UNICEF has published statements regarding supply of all vaccines due to
decreased airfreight (14)
• Indicators available make it difficult to analyze acutely
• Immunization under 1 year coverage
• Meases second dose coverage – more acute
• Nationally, Immunization coverage in April 2020 dropped to 62% compared
with 81% for the same time last year (15)
• Second dose measles coverage is as low as 55% in April 2020 compared
with 77% in April 2019 (15)
• Will we repurpose beds for Child Health when the measles outbreaks hits?
• In KCD – raw data showed a 50% reduction in the rates of vaccine coverage but went immediately back to
baseline in May – this is encouraging and may suggest catch-up opportunitiesWhat about our neonates?
• For now, neonatal mortality rate remains constant
• But delivery in-facility rate declined sharply across the province – 55%
in Uthukela, 44% (Ilembe and eThekwini) while only 9.8% in Harry
Gwala district
• Delivery at home carries a higher perinatal morbidity and mortality
• We may not know the effect of this as many neonatal deaths occurring at
home are not registered since the births are not yet registered.What about our neonates still to come?
• Can we expect a “baby boom” following a period of lockdown and
difficulty accessing Family planning?
• Couple year protection rate (serves as a proxy for Contraception Prevalence
Rate) declined from an average of 56.8% in the 11 months prior to lockdown,
to 7.8% in April 2020
• This is a concern, particularly while schools and universities were closed,
making teen pregnancies particularly high risk
• Watch this space in 7-9 months’ timeTo assess after the pandemic • Numbers tell a small part of the story • Community deaths will need to be examined carefully • Mortuary data • General household surveys • Community death reporting (via CHIP platform) – WC province do this
Other Child Healthcare Issues related to the pandemic
• Visitation policies and challenges with boarder mothers
• Mental health of children who are admitted
• Repurposing of children’s wards for adult COVID suspects/positives
• ICU beds – as adult services scramble, paediatric beds may be taken
• Referrals – awaiting negative COVID results before allowed to move to
higher level of care; causes delay and deterioration
• Closure of wards due to outbreaksOther Child Healthcare Issues related to the pandemic
• Staff – ENA to Staff nurse and Staff nurse to P.N translation (13 nurses
in one neonatal unit)
• Staff reshuffle to staff field hospitals and busy adult services
• Staff sick or self-isolation (interns from other rotations)
• Education and training – difficult to train interns and students
comprehensively at this time, effect may be felt for a few years
• Meetings, paperwork, taking away from regular paediatric care
• Hands-off approach of examining ENT and resp cases – is the care of
the same quality?
• Burnout – covered nextNon-accidental Injury and Childhood Sexual
Abuse
• According to the United Nations (16)
• France showed an increase in domestic violence by 30%
• Argentina an increase in call centre volumes of 25%
• United Kingdom NGO “Refuge” reported a 700% increase in calls from victims
and 25% from men wanting to change their behaviour
• These figures made South Africa very nervous – we already have one
of the highest rates of Violence against women and children in the
world
• There were many fake news reports early on & some misquoted
figures – we appeared to be following the same patternWhat do the numbers tell us so far?
• Police minister, Bheki Cele, released comparative figures from March to May 2019 vs 2020 (17)
• Not specific to violence against children but domestic violence, even in the presence of children is
an exposure we need to monitor
• The decline is largely suspected due to the ban on alcohol
27 March to 21 May 27 March to 21 May 2020 Percentage Decline
2019
Rape 5350 919 -82%
Domestic 21 033 6651 -68,4%
Violence
• Was reporting possible? No safe spaces (teachers, religious communities, more distant relatives)
and access to police or hospitals to report
• Again – it will be important to monitor what happens afterwards? Will our Thuthuzela centres,
dedicated Child Abuse clinics etc become flooded afterwards?Child-specific call centre data
• Childline Gauteng published a 35-day report from 27 March to 30
April and compared data from 2019 with 2020 (18)
• Not all were for domestic violence, physical or sexual abuse
• E.g. 99.6% increase in health-related calls (Covid19 queries); 95.2%
increase in poverty-related calls and 85% increase in calls for
psychological health
• Calls relating to school performance and failure dropped by 6%
Number of Calls 27 March to 30 27 March to 30 Difference
April 2019 April 2020
Total 10 720 17 919 60% increaseChildline call Categories – Abuse (18)
In the table of calls
relating to family
problems,
relationship
problems between
parent and child
increased by 81%Education
• School are reopening at various rates around the country
• Education and schooling are crucial aspects of total Child Health
• The first 1000 days and Early Chidlhood Development (DSD) straddles the
health sector in many more ways than just feeding schemes
• UNESCO (19) published a long list of the potential social and economic
costs of prolonged school closures
• It highlights how these hit vulnerable and marginilized students the hardest
• In South Africa, this was one of the many fault lines exposed by the
virus – the vast and shocking inequalities in the education sectorEarly Childhood Development • Department of Social Development has been very quiet compard with Basic Education regarding opening up of ECD centres • Many mothers have no other childcare options • As almost sections of the economy open up, there will be increasing demands for child care • The fear is there will be many unsupervised young children, even more so as their older siblings return to school • The SA Childcare Association was due to present the case for ECD centres to open on 6 July in court on 23 June 2020. The case was postponed. To date, there is still no firm decision and many schools are interpreting this as they please • Knock-on effect is no accreditation of the sites
UNESCO’s list • Interrupted learning – disproportionately affects learners of different socio-economic backgrounds and types of schools. Foundation phase may feel this the most • Parents unprepared for distance learning • Working parents • Parents of lower educational grade • Technological challenges and data costs • Rapidly converting curricula to home-based • Enormous strain on human capital (educators) and technology • Parental work (economic factor) – parents may miss work to look after children, even healthcare workers • Childcare gap, particulary ECD centres – this is not yet resolved in SA • Young children, “supervision-related injuries” • Older children – peer pressure, substance abuse, gang behaviour and teen pregnancy • Inability to grade scholars and allow progression • Mental Health – school provides social interaction; anxiety may worsen when alone
Could there be a silver lining?
• There may some positive “spin-offs”
• Fault line exposure is the first necessary step to repair
• Some schools got water and sanitation in the haste to be ready for Covid19,
after needing this for years
• The domestic violence, crime and trauma statistics while there were no
alcohol sales was a very interesting social experiment. Could this affect
change in some way in the future?
• A wealth of research possibilities for Public Health and Child Health
Practitioners to study impact and social movement on disease
patternsReferences 1. Centers for Disease Control and Prevention. Framework for Implementation of COVID-19 Community Mitigation Measures for Lower-Resource Countries . 26 June 2020 2. Mboweni, T. Supplementary Budget Speech 2020. 24 June 2020. Found at https://www.gov.za/speeches/minister-tito-mboweni- 2020-supplementary-budget-speech-24-jun-2020-0000 3. Maruthappu M, Watson RA, Watkins J, Zeltner T, Raine R, Atun R. Effects of economic downturns on child mortality: a global economic analysis, 1981-2010. BMJ Glob Health. 2017 Apr 18;2(2):e000157. doi: 10.1136/bmjgh-2016-000157. PMID: 28589010; PMCID: PMC5435251. 4. Hall, K. Covid-19 info brief: Social grant increases are an immediate and feasible route to protecting children and their families. Children’s institutue, University of Cape Town. 1 April 2020 5. Department of Statistics, South Africa. COVID-19: Deflation of essential product prices during Level 5 lockdown. 15 May 2020. 6. Abrahams M, Smith J. Research Report: Food, hunger and Covid-19. Pietermaritzburg Economic Justice and Dignity. 26 May 2020. 7. Department of Statistics, South Africa. Quarterly Labour Fource Survey. 23 June 2020. 8. Izwi Domestic Worker’s Alliance. Domestic workers pay a heavy price for employers’ non-compliance with labour law. 29 April 2020. Found at https://www.izwi.org.za/post/domestic-workers-pay-a-heavy-price-for-employers-noncompliance-with-labour-law 9. Department of Basic Education, Republic of South Africa. National School Nutrition Programme (NSNP). 2013/14 Annual Report 10. Makhoba M. District Health Information System, King Cetshwayo District. 25 June 2020. 11. Lutge E, Department of Health, Republic of South Africa. Directorate: Epidemiology & Health & Research Management. Internal Memo: Description of Health Service Delivery and Utilisation during the first month of the Covid19 lockdown. 13 May 2020.
References 12. Ntombela, Z for Department of Health, Republic of South Africa. POPD Head Count Data and Child Health Problem Identification Data, Edendale Hospital. 29 June 2020. 13. Naidoo, KL. King Edward VIII Paediatric work data 2019-2020 14. UNICEF Supply Division. Emergency Alert: Impact of COVID-19 on vaccine supplies. 10 June 2020. Found at https://www.unicef.org/supply/stories/impact-covid-19-vaccine-supplies 15. Bamford L, acting Chief Director for Child, Youth and School Health, Department of Health, Republic of South Africa. In Spotlight: Dramatic drop in SA’s immunisation rates. 24 June 2020 16.Departmtent of Global Communications, United Nations. UN supporting ‘trapped’ domestic violence victims during COVID-19 pandemic. 12 June 2020. 17. Cele, B. Coronavirus Covid-19 regulations levels of compliance and adherence. 22 May 2020. Found at https://www.gov.za/speeches/minister-bheki-cele-coronavirus-covid-19-regulations-levels-compliance-and- adherence-22-may 18. Childline Gauteng. Covid-19 - report on help line data lockdown period 27th march 2020 – 30th april 2020. Found at https://childlinegauteng.co.za/wp-content/uploads/2020/05/2.-Lockdown-Level-5_CLGP_-Stats- Report_Final.pdf 19. . United Nations Education Scientific and Cultural Organisation (UNESCO). Adverse consequences of school closures. France, March 2020.
Personal Thanks • Prof Neil McKerrow, Provincial Department of Health • Dr Kimesh Naidoo, KEH VIII • Dr Zama Ntombela, Edendale Hospital • Mandlenkosi Makhoba, FIO QNRH • Nicole Govender, Dietician, QNRH
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