Mandy Wessels

HCU Paediatrics, Queen Nandi Regional Hospital

COVID19 Mitigation Measures & Child Health

Context - revision 2.

Environment

3. Household

4. Social/family

1.International NationalProvincial

6. Healthcare

system

5. Violence

Education

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 Raw data used because data for this time period is largely unpublished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 loss

Employment (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 registration

Other 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 schools

Severe 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 numbers

Have we started to see the effect of food insecurity?

0

5

10

15

20

25

30

35

40

45

50

QNRH 2019 QNRH 2020 KCD 2020

SAM separations – King Cetshwayo District (10)

February March April May

Child 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 pathogens

Acute 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 patietns

Acute Care

194

239249253

231

263257

269282

122

136

150

110

133145

EDENDALE KEH VIII QNRH

Regional Hospital Paediatric Ward Separations (12, 13)

Jan Feb March April May

Outpatient 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 above

Paediatric OPD data from Regional Hospitals

1627

1342 1342

1733

1258 1258

1889

1200 1200

934

601 601

984

637 637

EDENDALE KEH VII QNRH

Paediatric Outpatient Headcount in Regional Hospitals

Jan-20 Feb-20 Mar-20 Apr-20 May-20

PHC 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 Deworming

Immunization 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 opportunities

What 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’ time

To 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 outbreaks

Other 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 next

Non-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 pattern

What 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

• 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?

27 March to 21 May 2019

27 March to 21 May 2020 Percentage Decline

Rape 5350 919 -82%

Domestic Violence

21 033 6651 -68,4%

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 April 2019

27 March to 30 April 2020

Difference

Total 10 720 17 919 60% increase

Childline 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 sector

Early 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 patterns

References

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