What is shielding? Protecting the vulnerable from COVID-19. June 2021

BETTER HEALTH PROGRAMME SOUTH AFRICA

CASE STUDIES

JUNE 2021

WHAT IS SHIELDING?

Protecting the vulnerable from COVID-19

Médicins sans Frontières pilot shielding programme, Eshowe, KwaZulu Natal.

How can we shield the most vulnerable people from COVID-19? In response to a request from the NCD cluster of the National Department of Health (NDoH), on April 21 BHPSA hosted a webinar to explore the many issues around shielding within the South African context. It was co-hosted by the NDoH and the World Health Organization who both participated in the conceptualisation of the event. The aim was to increase the awareness of shielding, particularly among provincial departments of health. This involves understanding different approaches to shielding and the different categories of people who need to be shielded. The webinar also shared key messages, guiding principles and resources for effective shielding interventions. The meeting was ably chaired by the WHO’s Dr Joseph Mwangi and opening remarks made by Itumeleng Setlhare from the NCD cluster of the NDoH. He emphasised that the NDoH is committed to reducing infections among the most vulnerable populations, particularly the aged and people living with NCDs.

NEVER WASTE A GOOD CRISIS!

Dr Yogan Pillay, head of the Clinton Health Access Initiative (CHAI) in South Africa, provided the background of the syndemic, or synergistic epidemics of COVID-19 and NCDs, and gave the rationale for shielding. He also showed that initial approaches to shielding in South Africa, such as quarantine and isolation, were unsuccessful as people were reluctant to leave their homes. Shielding may be possible he said, but interventions will only work if they meet local needs. Practical shielding interventions include providing information, non-pharmaceutical interventions such as wearing masks, distancing and hand washing, expanded COVID-19 testing and vaccination. Pillay’s take-home point was that the COVID-19 pandemic has highlighted the need for a new paradigm to respond to NCDs – one which is patientcentred and patient-led. If we learn lessons from COVID-19 and implement them, the crisis will not be wasted.

WHO ARE THE MOST VULNERABLE?

Prof Mary-Anne Davies from the Western Cape Department of Health, presented clinical and demographic data from South Africa and other countries that showed that age is the single most important risk factor for severe COVID-19 and death. The risk, of dying after 30 days of infection, increases steeply from the age of 55 years for both men and women. Other comorbidities, particularly diabetes, hypertension, obesity and uncontrolled HIV and TB, also signifi cantly increase the risk. These then are the groups who most need to be shielded from COVID-19 infection.

Figure 1: Probability of death by 30 days since COVID-19 diagnosis by age (adjusted for comorbidities)

SHIELDING ADVICE AND KEY MESSAGES

Prof Lara Fairall and Daniella Georgeu-Pepper from the Knowledge Translation Unit, University of Cape Town, presented their work on shielding. The three key messages for vulnerable people are: stay at home, if you do go out or spend time with others keep a physical distance, wear a mask and wash hands often.

Fairall noted that shielding recommendations so far have been informed by modelling, not evidence, and have had variable levels of success. Long-term shielding may also harm people’s physical and mental health through decreased physical activity, social isolation, reduced health care and loss of income. However, shielding has played an important role in protecting vulnerable people before vaccines were available. Some countries recommend that even after vaccination, vulnerable people should avoid high-risk settings and still wear masks when going out. Georgeu-Pepper shared the resources available from KTU, which consist of booklets, posters and videos. Clinical content is targeted at health care workers and communities and posters and informational booklets on keeping safe from COVID-19 are available from www.coronawise.org.za.

Probability of death

25%

20%

15%

10%

5%

0%

20-24

Females Males

25-29 30-34 35-39 40-44 45-49 50-54 55-59

Age

60-64 65-69 ≥70

SHIELDING IN PRACTICE

Dr Liesbet Ohler, from Medicins sans Frontieres (MSF), shared a community-based approach to shielding which they have piloted in one area of KwaZulu Natal. The pilot programme focuses on engaging key community members in the implementation of shielding and demonstrates how a shielding package can be integrated with the core services provided by community health workers (CHW) who are part of ward-based outreach teams (WBOTS). The process includes identifying hotspots for COVID19 transmission as well as vulnerable people in those communities. Two supervisors train community health workers to deliver a shielding package. A champion from the community is also appointed in the area. The shielding package includes education and materials, identifi cation of safe zones in the home to accommodate the vulnerable, and identifi cation of a trusted person to help with shopping and collection of medication and grants. The MSF pilot demonstrates that is it possible to incorporate shielding into the routine activities of WBOTs if they are properly trained.

DISCUSSION AND CONCLUSION

Participants were keen to discuss the practical implications of shielding in low- and middle-income countries. It was felt that there was a need to understand vulnerability as more than just risk of severe health outcomes and to widen it to include issues such as access to employment/income and social and health services as well as the possible negative impact on mental well-being. There was a strong feeling that shielding in its pure form (staying home etc.) is not sustainable over the long term as it presents health and socio-economic harms.

Some concluding points made by presenters were: ■ The pandemic has had lessons for the NCD community including the need for social mobilisation by an integrated group across all NCDs. ■ The diffi culties of implementing conventional shielding means we need to vaccinate the vulnerable as soon as possible. ■ There needs to be a shift in focus to move health from formal facilities to communities and households where people can take charge of their health and longer-term NCD prevention. ■ Shielding in resource-poor settings is feasible with trained community health workers.

The Better Health Programme, South Africa (BHPSA) is a health system strengthening programme funded by the UK government through the British High Commission in Pretoria and managed by Mott MacDonald.