South Africa’s Mass Screening Helps Stem the Coronavirus Tide
Use of community health workers to identify cases draws heavily on experience battling tuberculosis and HIV
A woman is tested for Covid-19 in Johannesburg’s Alexandra township © Kim Ludbrook/EPA/Shutterstock
Joseph Cotterill in Johannesburg
Financial Times
South Africa has used a combination of mass screening, targeted testing and a draconian lockdown to control the early stages of a coronavirus outbreak that threatened to overwhelm the country if left unchecked in its densely populated townships.
In the past month President Cyril Ramaphosa’s government has mobilised 28,000 health workers to screen over 7m people, more than one in 10 South Africans.
Known as active case finding, the use of community health workers to identify patients with symptoms draws heavily on South Africa’s experience battling tuberculosis and HIV. It differs from the approach of most European governments that have relied on citizens coming forward for tests and then tracing their contacts.
John Nkengasong, director of the Africa Centers for Disease Control and Prevention, has lauded South Africa’s aggressive strategy but has warned that Africa overall needs to test more.
South Africa has increased its level of testing to more than 10,000 tests a day. All the while the number of positive tests has remained consistent at about 3 per cent, a sign that while infections are growing they are not outpacing efforts to find them.
“Incredible, that much testing for that return,” Michael Ryan, head of the World Health Organization’s emergency operations, said last month.
Now the strategy faces a critical test. South Africa imposed one of the world’s strictest lockdowns before it had recorded a single death but began a phased lifting of the most severe restrictions last week.
The country has had more than 7,200 cases and 130 deaths, and in some townships testing is now picking up a faster spread of the virus. Tough measures, including a nightly curfew, remain in force, and public frustration is rising, particularly after allegations of police violence.
“We have not nearly reached the peak of infections in South Africa,” Mr Ramaphosa said on Monday. “All the scientific models show that the infection rate will continue to rise at a much faster rate in the next few months.”
The South African approach to date has relied heavily on an army of community health workers. Whereas other countries need to hire thousands of people to conduct screening and contract tracing — the US would require at least 100,000 contact tracers at a cost of $3.6bn, according to one estimate — South Africa already had teams in place, detecting tuberculosis, a national killer, and bringing drugs to the millions of South Africans living with HIV.
“We have been on the front lines for many years . . . we were there to fight HIV, we were there to educate communities about TB,” said Tshepo Matoko, secretary of the Gauteng Community Health Care Forum, a body representing workers.
So far about 3 per cent of tests referred from community screening have come back positive, similar to the proportion of positive results among patients tested at health centres. That suggests the government’s community health workers have successfully identified many cases that might have otherwise slipped through the net.
But although the screening programme has been extensive, wide variations exist in the approach and the number of tests administered in each of the nine provinces.
The Western Cape, which contains Cape Town, for example, has tested a higher percentage of its population than other parts of the country and overtaken Gauteng, the most populous region, as the province with the most active infections. About 6 per cent of tests have returned a positive result in Western Cape, compared with the 3 per cent average nationally. For the tests administered in the province on Monday that figure jumped to 13 per cent.
The province has detected an especially large rise in cases in the sprawling township of Khayelitsha, just outside Cape Town.
The findings are “based on our active case-finding approach, where we purposely follow the ‘bush fires’ — the pockets of infections within communities — to ensure that every person who has been infected by Covid-19 is identified as quickly as possible,” said Alan Winde, the Western Cape premier.
Community screening cannot identify asymptomatic cases. But it can point to emerging clusters, and help later contact tracing to find asymptomatic carriers, health experts said.
South Africa has also taken a different approach to contact tracing than many western countries, which are largely placing their faith in voluntary smartphone apps.
South African Covid-19 testing
Sector Total tested Latest daily tests
Private 123,580 3,161
Public 122,167 11,900
Total 245,747 15,061
Under lockdown regulations, subject to regular review by a former constitutional court judge, the state has the power to access data from mobile phone companies on the movements of possible coronavirus contacts.
“The major difference in South Africa is that it is not an opt-in app, as it is in Singapore and Australia,” said Livia Dyer, a partner at Bowmans, a South African law firm. “It is reflective of the way mobile phones are used in this country,” she said, since the poorest citizens do not have smartphones.
Mr Ramaphosa’s warning that South Africa is still early in its epidemic means it will have to keep up these screening, testing and tracing efforts for many months to come. His government has said that different forms of a lockdown could be in force for at least six months and public health experts have predicted a possible peak in the number of infections in September.
That will add to the pressure on the thousands of community health workers on the front line who have battled for years to be recognised as permanent government employees and are now central to the state’s response, said Mr Matoko.
“[The government] never saw the importance of these workers until . . . Covid-19,” he said.
A woman is tested for Covid-19 in Johannesburg’s Alexandra township © Kim Ludbrook/EPA/Shutterstock
Joseph Cotterill in Johannesburg
Financial Times
South Africa has used a combination of mass screening, targeted testing and a draconian lockdown to control the early stages of a coronavirus outbreak that threatened to overwhelm the country if left unchecked in its densely populated townships.
In the past month President Cyril Ramaphosa’s government has mobilised 28,000 health workers to screen over 7m people, more than one in 10 South Africans.
Known as active case finding, the use of community health workers to identify patients with symptoms draws heavily on South Africa’s experience battling tuberculosis and HIV. It differs from the approach of most European governments that have relied on citizens coming forward for tests and then tracing their contacts.
John Nkengasong, director of the Africa Centers for Disease Control and Prevention, has lauded South Africa’s aggressive strategy but has warned that Africa overall needs to test more.
South Africa has increased its level of testing to more than 10,000 tests a day. All the while the number of positive tests has remained consistent at about 3 per cent, a sign that while infections are growing they are not outpacing efforts to find them.
“Incredible, that much testing for that return,” Michael Ryan, head of the World Health Organization’s emergency operations, said last month.
Now the strategy faces a critical test. South Africa imposed one of the world’s strictest lockdowns before it had recorded a single death but began a phased lifting of the most severe restrictions last week.
The country has had more than 7,200 cases and 130 deaths, and in some townships testing is now picking up a faster spread of the virus. Tough measures, including a nightly curfew, remain in force, and public frustration is rising, particularly after allegations of police violence.
“We have not nearly reached the peak of infections in South Africa,” Mr Ramaphosa said on Monday. “All the scientific models show that the infection rate will continue to rise at a much faster rate in the next few months.”
The South African approach to date has relied heavily on an army of community health workers. Whereas other countries need to hire thousands of people to conduct screening and contract tracing — the US would require at least 100,000 contact tracers at a cost of $3.6bn, according to one estimate — South Africa already had teams in place, detecting tuberculosis, a national killer, and bringing drugs to the millions of South Africans living with HIV.
“We have been on the front lines for many years . . . we were there to fight HIV, we were there to educate communities about TB,” said Tshepo Matoko, secretary of the Gauteng Community Health Care Forum, a body representing workers.
So far about 3 per cent of tests referred from community screening have come back positive, similar to the proportion of positive results among patients tested at health centres. That suggests the government’s community health workers have successfully identified many cases that might have otherwise slipped through the net.
But although the screening programme has been extensive, wide variations exist in the approach and the number of tests administered in each of the nine provinces.
The Western Cape, which contains Cape Town, for example, has tested a higher percentage of its population than other parts of the country and overtaken Gauteng, the most populous region, as the province with the most active infections. About 6 per cent of tests have returned a positive result in Western Cape, compared with the 3 per cent average nationally. For the tests administered in the province on Monday that figure jumped to 13 per cent.
The province has detected an especially large rise in cases in the sprawling township of Khayelitsha, just outside Cape Town.
The findings are “based on our active case-finding approach, where we purposely follow the ‘bush fires’ — the pockets of infections within communities — to ensure that every person who has been infected by Covid-19 is identified as quickly as possible,” said Alan Winde, the Western Cape premier.
Community screening cannot identify asymptomatic cases. But it can point to emerging clusters, and help later contact tracing to find asymptomatic carriers, health experts said.
South Africa has also taken a different approach to contact tracing than many western countries, which are largely placing their faith in voluntary smartphone apps.
South African Covid-19 testing
Sector Total tested Latest daily tests
Private 123,580 3,161
Public 122,167 11,900
Total 245,747 15,061
Under lockdown regulations, subject to regular review by a former constitutional court judge, the state has the power to access data from mobile phone companies on the movements of possible coronavirus contacts.
“The major difference in South Africa is that it is not an opt-in app, as it is in Singapore and Australia,” said Livia Dyer, a partner at Bowmans, a South African law firm. “It is reflective of the way mobile phones are used in this country,” she said, since the poorest citizens do not have smartphones.
Mr Ramaphosa’s warning that South Africa is still early in its epidemic means it will have to keep up these screening, testing and tracing efforts for many months to come. His government has said that different forms of a lockdown could be in force for at least six months and public health experts have predicted a possible peak in the number of infections in September.
That will add to the pressure on the thousands of community health workers on the front line who have battled for years to be recognised as permanent government employees and are now central to the state’s response, said Mr Matoko.
“[The government] never saw the importance of these workers until . . . Covid-19,” he said.
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