As daily Covid-19 cases rise sharply, the question about the fourth wave is not if, but when

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  • South Africa is experiencing an uptick in Covid cases, particularly in Gauteng.
  • A potential fourth wave could begin in December, experts have warned.
  • Public health officials have urged people to act responsibly and get vaccinated ahead of the holiday season.

South Africa’s Covid-19 cases are ticking upward ahead of an expected fourth wave. 

New confirmed daily infections have risen exponentially, with 1 275 new cases reported on 24 November.

Data by the National Institute for Communicable Diseases (NICD) this week showed an increase in the seven-day moving average in new Covid cases in Gauteng.

7-day average

The increase in cases appears to be concentrated in Tshwane, in the age group 10 to 29, News24 reported. A cluster among the 20 to 44 age group at an institute of higher education in Tshwane has also been identified, the NICD said.

"We are monitoring these trends to see if these increases persist," the NICD's interim executive director, Professor Adrian Puren, said in a statement.

Puren added that "localised increases in case numbers (clusters) are not unexpected", but that it was hard to determine whether the increases indicate the start of a widespread resurgence.

The South African Medical Research Council (SAMRC) data also show that excess deaths have been rising in recent weeks.

Uncertainty about emergence of 4th wave

For the past several weeks, scientists have warned that South Africa is expected to experience a fourth wave of cases. However, the timing of this resurgence is less clear.

Spokesperson for the national Department of Health, Foster Mohale, told Health24:

"Nobody knows when we will officially be in the fourth wave. Gauteng is already showing signs of increased cases so this may be the start."

The emergence of a wave

Former chair of the Covid-19 ministerial advisory committee, Professor Salim Abdool Karim, told Bhekisisa in June that in order to determine whether a new wave has emerged, many countries collectively interpret three measures: the number of new cases, the test positivity rate, and hospitalisations.

If the new cases, the number of tests, and positivity rate increase steadily, it could signal a red flag, particularly when the test positivity rate exceeds 5%, Bhekisisa explained, which, according to the World Health Organisation (WHO), is a sign the pandemic is no longer under control.

South Africa’s test positivity rate was 3.6% on 24 November.

Could begin in December

Experts, including the South African Covid-19 Modelling Consortium team who are working with the government, have predicted that a fourth wave could begin as early as December. 

Dr Sheetal Silal, a statistical scientist who researches mathematical modelling of infectious diseases and is part of the team, said in a media briefing this month:

"There is considerable uncertainty in that nobody knows when this next wave is going to start."

The team stated that the resurgence is "projected to be considerably smaller than those of previous waves", thanks to the country's vaccination coverage, and due to 60-70% of South Africans already contracting the virus over the course of the past three waves, Health24 reported.

Hospitals not guaranteed to cope

Still, the team cautioned that whether Covid admissions will result in overwhelmed hospitals depends on how much bed capacity is made available.

“The available capacity to manage an increase in Covid admissions is different to what it was in the second and third waves. That means that even a lower peak than what we had observed in previous waves might be sufficient to breach capacity," Silal said.

The team urged hospital managers to assess these projections and plan ahead to ensure sufficient hospital bed capacity during the next wave.

How the waves could compare

Some experts have echoed the projections that the country’s next surge may not be as bad as the last one.

"My feeling is… that the fourth wave is not going to be as bad as the third wave … but not as good as the best possible experience, had we attained a high coverage for vaccination," Johnny Myers, Emeritus Professor in Public Health, University of Cape Town, said during a webinar hosted by Tshikululu on 8 November. 

Myers believed a less severe fourth wave could be possible due to South Africa having a "relatively high" vaccination coverage for the over-60s age group.

As of 24 November, close to 25 million doses had been administered across the country. Around 65% of people aged 60 years and older had received at least one dose of the two-dose Pfizer-BioNTech vaccine.

Importance of third dose, over 60s

However, another expert believes that two doses is not necessarily sufficient to ensure high protection in this high-risk group who are vulnerable to severe Covid-19.

Professor Shabir Madhi, Dean of the Faculty of Health Sciences and Professor of Vaccinology at the University of the Witwatersrand (Wits), previously told Health24 that a third dose should have been offered to the older age group several weeks before the fourth wave, based on data indicating that two doses do not provide this age group with adequate protection.

Madhi said: "The WHO itself has made the recommendation that people above the age of 65, as well as those with underlying medical conditions and with immunosuppressive conditions, require a third vaccine dose." 

Pfizer applies for approval of third dose

Pfizer has applied to the South African Health Products Regulatory Authority (Sahpra) for clearance of its third dose "booster" shot, AFP reported this week.

Sahpra said in a statement on Monday that it received the application last Wednesday and will start, "... assessment of data for the safety and efficacy of the third dose".

Fourth wave not necessarily insignificant

Despite South Africa having increasing vaccination coverage and many people immunity from natural infection, the fourth wave should not be underestimated, cautioned Madhi.

"It’s not going to be insignificant, especially if we don’t have 80–90% of people above the age of 60 vaccinated," he said.

Again, Madhi stressed that the big issue around the resurgence was the under-vaccination of people above the age of 60. 

"That goes to the issue of why we… need to vaccinate the 18–34 year age group," he said. He explained that despite young adults being at low risk for severe Covid, they need to be vaccinated as it is the socially responsible thing to do, so that they don’t become "vectors of transmission of the virus."

Vaccine uptake in this group has been worryingly low, Health Minister Joe Phaahla said earlier this month.

Madhi added: "Even in the above-60 age group who are fully vaccinated, and in those with immunosuppressive medical conditions, two doses of the vaccine is, unfortunately, not ideal because there’s clear evidence that they probably require a third dose of vaccine to get higher levels of effectiveness against severe disease." 

Speeding up vaccination levels

While it is difficult to predict the magnitude and timing of the potential fourth wave, Head of the Division of Public Health Surveillance and Response at the NICD, Dr Michelle Groome, said: 

"We implore the unvaccinated to get the Covid-19 vaccine, especially the elderly and those with comorbidities."

Taking precaution ahead of holiday season

With the holiday season ahead, officials and experts are calling for South Africans to celebrate responsibly.

Lisa Maragakis, Professor of Epidemiology at Johns Hopkins Medicine, explained that following Covid precautions, such as getting vaccinated, practicing physical distancing, and mask-wearing helps to keep viral transmission lower. 

Where fewer people are vaccinated and not wearing masks, and where more people are gathering indoors to socialise without physical distancing, cases tend to rise, she said.

Madhi told Health24: “The most important thing is to ensure adequate ventilation in indoor gatherings, and the wearing of masks when indoors, especially in crowded settings,” he said.

*For more Covid-19 research, science and news, click here. You can also sign up for our Daily Dose newsletter here.

READ | Experts explain why so many young adults in SA don’t want Covid-19 vaccine

READ | Covid-19 is surging in Europe: Why is this happening, and should we be worried in SA?

READ | Covid-19: Experts urging health workers to get J&J booster before 4th wave

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