Transcript: Minister of Health, Dr. Aaron Motsoaledi on H1N1 influenza pandemic

13 August 2009

Facilitator: Themba Maseko, Government Spokesperson
Panellist: DR. AARON MOTSOALEDI, Minister of Health
Dr. Frew Benson, Cluster Manager, Communicable Disease, Department of Health
Prof Barry D Schoub, Executive Director, National Institute for Communicable Disease
Date: 13 August 2009
Venue: Union Buildings (with video-link to Cape Town)

Statement read by Minister Motsoaledi

As part of its regular Cabinet meetings, Cabinet met yesterday and among the issues discussed was the current H1N1 Influenza pandemic.  Cabinet decided to mount an enhanced national response to build on what has already been done so far by the Department, the Department Education, NICD and the World Health Organisation’s (WHO) Country Office.
As the lead Department, the Department of Health wishes to outline what it is doing in this regard.

But before coming to that, we wish to recap the present problem:

As we have previously communicated, the pandemic started in Mexico and the USA in April this year and rapidly spread to 166 countries globally with a cumulative number of 174 913 laboratory confirmed cases and 1 411 confirmed deaths.

In South Africa, to date we have 1 910 confirmed cases with 3 deaths.

On 6 July the WHO described the spread of the pandemic within affected countries and to new countries as inevitable and largely unstoppable. Fortunately though, while this may the case they noted that the virus is largely mild and not virulent at all. Hence they believe that countries should rather take steps to mitigate the impact on the communities.
The additional measures from the Department of Health are as follows:

  • Letters co-signed by the Ministers of Health, Basic Education and Higher Education will be send to all school principals, rectors/principals of institutions of higher learning. These letters will describe the challenges that we face and advise school principals on what action they need to take. This will further enhance the communiqué sent out so far.
  • The Minister of Health will also be sending personal letters to leaders of all major faith groups. In these letters the Minister will call upon religious leaders to share information on the virus with their congregations.
  • Similar letters will also be sent to organised labour and organised business.
  • We recognise the need to also better inform Members of Parliament, NCOP, Provincial Legislatures and Premiers and all councillors in municipalities. To this effect, letters from the Minister on their roles will also be send out in the new future. The same letters will be sent to all the traditional leaders, CDWs and social workers.   
  • In addition to letters described above, the Minister will also be recording advertorials this afternoon that will be broadcast on national TV and radio and community radio stations.
  • Finally, pamphlets and posters will be distributed in local communities in the local languages, at taxi ranks, shopping malls and other public places etc to further spread information on the virus, the symptoms and what we need to do to ensure mitigation of its impact.

At present we have a functional hotline for health workers who may have queries. This is operated by the National Institute of Communicable Diseases. In addition, we shall have a shared call number operational by Wednesday next week for members of the general public who have queries or concerns.

Let me remind you of the symptoms of H1N1 influenza. These can be divided into mild, moderate and severe.

Mild symptoms include: runny or blocked nose; fever; muscle aches and pain; general feeling of unwellness and cough.

The overwhelming majority of people have mild symptoms and will not need any specialised medical care and we believe nothing should happen to them. Such symptoms should be treated as is the case other influenza-like symptoms.

However, if mild symptoms develop in people with chronic heart or lung disease, pregnant women or people living with HIV and AIDS, these people are advised to seek medical care immediately.

Moderate symptoms include: mild symptoms plus shortness of breath; chest pain; persistent vomiting and diarrhoea and signs of dehydration.

Severe symptoms include mild and moderate symptoms plus signs of respiratory distress, blue lips and other parts of the body and severe drowsiness and loss of consciousness.

Anyone with moderate or severe symptoms should immediately seek medical attention.

Experience throughout the world has shown that closures of learning institutions, and other such places such as shopping malls has not been effective in stemming the spread of the disease instead it causes social disruptions. What should rather happen is that any learner or teacher with mild symptoms should stay at home. If there is large scale infection the two relevant Departments will meet and decide on what course of action should be embarked upon.

Questions and answers

Journalist: Minister, there does seem to be a bit of panic and fear amongst citizens. Do you think that this initiative will contribute to that fear or do you think it would stem it?

Journalist: I’d like to find out as a precautionary measure, would you think that perhaps people perhaps with diabetes and pre-diseases that you mentioned should perhaps wear facemasks? Is that something that people should contemplate doing?

Journalist: Minister, I believe in the past you’ve said that Africa will be hardest hit by the H1N1. What did you mean by that and again do we have as a country enough Tamiflu as a precautionary measure to get the disease?

Dr. Aaron Motsoaledi: Well, the issue of fear or panic has actually been debated widely. We believe if there is any fear or panic it will stem from ignorance from rather a lack of information. Let me put it that way, not ignorance. If people don’t have information about what’s going on, obviously they’ll be fearful and they’ll get very restless.
Now we believe while you are going to help us to inform the people we also need to go to them directly. Like these individual letters which we’ll write to principals, ministers of religion, traditional healers, social workers, CDW, you know all the people who on a daily basis have got conduct with mass base of people. We believe we must go to them directly and we believe when they have got enough information then that will be much better. The issue of people with diabetes wearing masks, we don’t really think that is practicable. All we are saying is that if you have got chronic chest diseases like asthma, bronchitis or you have got diabetes or you‘ve got cancer, or you are pregnant, once you encounter mild symptoms which people encounter every winter. I mean, all these people I’ve mentioned, every winter they do encounter mild symptoms of flu. But we are saying in this case when they encounter them they must look for help because normally they don’t usually do so, I mean they are used to having flu, seasonal influenza, but we say people in those categories even if it’s mild let them look for help. Now the second category of people which must look for help obviously are those with moderate illness, and obviously the ones we see here, illness. The issue of Africa being hardest hit, what I actually meant by this statement is that any communicable diseases that occurs, whether it is this H1N1 influenza, whether it’s HIV and AIDS, whether it’s TB, or there is the haemorrhagic fevers, whether it was SARS, you remember the severe respiratory influenza syndrome. We are saying whether its malaria, regardless of its origin, it is Africa which really suffers the most. The reason I said so is all the communicable diseases need massive resources to deal with, and you know Africa is a continent which is resource poor, and every time you have got these problems. And I give an example, you’re aware that HIV and AIDS did not originate in Africa, it originated in America. But who is suffering the most? (It’s) us here on the continent of Africa. So that’s what I meant. H1N1 did not originate in Africa, it originated in Mexico. But we are saying because of being resource poor, once it spread we believe it’s the continent of Africa that will have problems. For this reason… it is for this reason that the World Health Organisation, Africa region, despite the fact that there’ve been conferences all over the world, found it appropriate to hold a special Africa conference which is now taking place in Boksburg, because of the recognition of this problem I’ve just mentioned, that we are in a continent where once anything that is communicable translates into a very serious problem, and that’s why they then said South Africa, because you are a little bit better in terms of resources, that’s why they choose our continent. I mean, sorry, our country to hold such a conference. The issue of Tamiflu, whether we’ve got enough, when we have got 100,000 doses in store, and in the Western countries because again the issue of resources they have got stores for one percent of their population. In South Africa what we have got in store is for 0.2% of the population, so those are in stores and whenever there is a need to treat anybody with Tamiflu we’ll take from those stocks. Thank you.

Journalist: Good morning, Minister. You say people with moderate or severe symptoms should seek medical attention. Can you guarantee that there are stocks of Tamiflu in all day hospitals and clinics in townships? Because so far in Cape Town people have been going to check in those clinics and it seems that there are no stocks there, some people are even being sent away and told to mix up their own cough mixture and it seems that the Tamiflu is actually only available you know in the private sector which is for wealthier people.

Journalist: One, have you determined what sort of burden the H1N1 pandemic will place on especially public health facilities as it spreads much more rapidly, you know, among the population. And two, with our country having you had these incidents of HIV/AIDS and now with the combination of the H1N1, has the Department determined then how detrimental it’s going to be, you know, this whole combination of people who are HIV-positive, now also contracting or at the risk of contracting H1N1?

Journalist: Minister, I just want to know, there are media reports of these tests in the private sector costing up to R800, is Government considering drawing the sector in and seeing if those tests can’t be done at a cheaper level or a cheaper price? And is there a backlog… or how long do people have to wait for results from laboratories? Can laboratories keep up with the amount of people or tests that they have to do?
Dr. Aaron Motsoaledi: Well, I will ask Dr. Benson to respond to some of the questions. As already said, we have got 100,000 stocks of Tamiflu, not in private hospitals; I’m talking about the public sector. We have got 100,000 doses up to so far. And this Tamiflu has been sent to major centres. Obviously it won’t be in any health institution throughout the country. It’s in major centres, considering also that it’s not every small laboratory in the country which has got the capacity to test for this. But I will leave it to Dr. Benson to try and help. But the Tamiflu I’m talking about is not private. I don’t know what the stocks are in the private sector. I know about the public sector. On the issue of placing a strain in the public health facilities, so far we believe and hope there won’t be much strain considering that throughout the whole world an overwhelming majority of people who contract H1N1 have got mild symptoms, basically we believe quite a large number of people might even have contracted it without knowing, because they had very mild symptoms and they might not even have recognised it, so we are not really expecting such a high strain on the public health facilities. But if it occurs, we still have got the emergency teams which were helping us to deal with cholera etcetera, etcetera. The HIV/AIDS as a risk for contracting H1N1 we have said it many times, people with HIV/AIDS are always at risk of contracting any communicable diseases that come along, and they are always at risk. Because it simply means in short any person with a compromised immunity whenever there is a communicable disease they are ones who are at risk. So H1… I mean, HIV/AIDS patients have got compromised immunity. Any communicable disease, they are always at risk of getting that, that’s why we’re saying whenever they encounter mild symptoms, even if they are mild, they must also rush to the nearest health facility to get checked. It is true that the test in the private sector costs 800 rand per test. In the public sector it’s 400 rand. It is definitely expensive. Remember, this is not an ordinary blood test, it is what they call a PCR, where we take a blood swab and we need a very… we need an expert who must go and check the genetic material of the virus in ourselves. It’s a very highly specialised test. But we don’t believe there must be a mass testing, like any disease people don’t just… you know, doctors decide that this one can be sent for a test and all that. But we have got a belief that there is over-testing in the private sector. Remember that the over-testing in the private sector is not only happening with H1N1, it’s happening with many other diseases and it is worrying us. I’ve just got a report from Mr. Judi Kollapen of the Human Rights Commission, who attest to that the research they have done about access to health, they believe there is over-subscription to test in the private sector and it’s raising the cost high. In fact, they are saying there’s over-testing done by even rich people in England. And because I received that report two weeks ago, yes, that’s what they said. We suspect this is following a similar pattern and we believe it’s dangerous because the reports we get is that we are already about to run out of reagents. The reagents to test this do not exist anywhere in South Africa. We take them from the Centre of Disease Control in America. That’s the only place that supplies us with reagents, and if there is mass testing etcetera and we run out of reagents, that might not be a very good thing.

Dr. Frew Benson: Thank you. I am Dr. Frew Benson from the Department of Health. I’m going to ask Prof. Barry Schoub as well to assist with some of the questions related to lab costs because as you are aware the majority of tests in South Africa have been done at the National Institute of Communicable Diseases. In terms of Tamiflu, not all cases, as the Minister has indicated, the majority of cases will have a mild illness. Now in that particular case they do not need any specific treatment, and Tamiflu is not indicated for those particular cases. Those cases, all they really need to do is stay at home, take sufficient amount of fluids, and around about a seven day period of staying at home would be sufficient. If they need any assistance or care they need one person that can care for them, they need to practise cough etiquette by coughing into their elbow or into their sleeve or into a tissue that they can discard and wash their hands. The disease will be self limiting in those individuals and it will be over. Tamiflu and treatment is really indicated for the high risk group, for the moderate group and for the particular people with severe illnesses. Now those people with severe acute respiratory infections will probably present at a primary healthcare institution and may be referred to a community health centre or to a hospital for admission. The institutions that you refer to, the day hospitals are normally primary healthcare institutions. Now we’ve made Tamiflu available to all our provinces and they in turn made it available to their institutions. But having said that, it will only be used for those where it’s indicated, not for people that it’s not indicated. Then in terms of the burden of disease, Prof. Schoub will talk a bit more about HIV/AIDS and its interaction with H1N1. What we know is that the majority of countries where this infection have flourished like America and Mexico do not have the HIV/AIDS burden that we have in South Africa. So we don’t have all the answers of how it will interact. But what Prof. Schoub will tell you about is that there are some theories that in fact in some of these groups, because they don’t mount an immune response and the majority of people who die from this disease do develop a viral pneumonia that’s developed through an immune response. Now the majority of people with HIV/Aids will not mount such a response. And will not develop such severe symptoms. But having said that, that’s still theories we have. We don’t have the absolute facts about it. Professor Schoub, I don’t know if you can jus add.

Professor Schoub: Thanks very much Minister. Thanks very much Dr Benson. I’m not sure I can add a tremendous amount. It has been very articulately said by both the Minister and Dr Benson, but maybe just a few points. First of all, the issue about HIV – as Dr Benson said, at the moment we just don’t have enough data because most of what has been described, certainly in the scientific literature with regard to H1N1 has been in countries with low instance of HIV. And what has been reported of the interaction we just don’t know. We can try and understand what happens in H1N1 if we look at our regular seasonal flu and certainly for seasonal flu, its people whose immune systems are suppressed, who are at risk. But they’re not at risk from the influenza itself. What they are at risk of is the secondary complications. And because of that, for seasonal flu people living with HIV should be immunised with a seasonal flu vaccine. Now coming back to the H1N1 does present a little bit differently in the sense that for example, elderly people are not mainly involved with the pandemic H1N1 whereas they are with seasonal flu so there are some differences and we can’t totally learn from those. So we are monitoring the situation very, very closely to try and understand whether HIV and similar causes of immune suppression will aggravate H1N1. At this stage we don’t have the answers. As Dr Benson said, there may even be a situation where they may have less severe, because a part of the disease of H1N1 is a result of the immune system reacting to it. But at this stage that is purely theoretical. At this stage we really need to watch the situation and try and get enough information. With regard to both Tamiflu and testing I couldn’t agree more with what the minister said, that there’s overuse of testing and there’s also overuse of Tamiflu. Both of these really have to be used where they are indicated. With regard to the testing, particularly in the private sector, there’s a tremendous overuse. It really is totally unnecessary to test every case, even a suspected H1N1 in the laboratory. It is unfortunately an expensive test. It uses very expensive agents. It uses expensive equipment and there is no way that, that test can be made cheaper because these are the costs which go into the test itself. But the important point is that it is really not necessary to test all the cases. There are very, very few cases where one really needs a laboratory confirmation. In the initial stages of the pandemic we did test all cases because we really need the information – has the virus come into the country and is it spreading in the country? And for that reason we had to test, this was the first 100 cases – 100 was really the arbitrary figure to establish or to get that information. We now have that information that the virus is in the country and is spreading in the country. So we don’t now need to test every case. If a case presents with the symptoms as the minister has described, we can clinically diagnose it as influenza and then treat accordingly. And the vast majority of cases are mild. They don’t need any specific treatment. And they certainly don’t need Tamiflu. If it is more severe then they need Tamiflu but the laboratory is not going to help that. If they’ve got either seasonal flu or Tamiflu, if they are getting moderate or severe disease, they need Tamiflu. So we don’t need to test that. And worldwide, like particularly in the United Kingdom, there’s now many, many people, many scientists and authorities who are now cautioning against the trivial use of Tamiflu. It has got a place in high risk people and in severe cases. But certainly not for the vast majority of cases which are mild and I think what we are seeing in the country, particularly in the private sector is a gross overuse of Tamiflu, with regard to resistance as the one problem and we have seen resistance with the seasonal H1N1 which is a similar kind of virus. In fact a great majority of seasonal H1N1 is resistant. Fortunately the pandemic H1N1 is sensitive but this can change particularly if there’s overuse of Tamiflu. That is the danger, that it can lead to mass resistance and that’s why we need to be very cautious in using it. The other thing is that Tamiflu itself has got side effects. In the United Kingdom over 50% of children that went on to Tamiflu had some side effects and we don’t want to give children with a mild disease a drug which is going to cause side effects. That’s another problem. The other thing is that Tamiflu is not a magic word. It’s not penicillin. It can reduce the severity. It can reduce the duration of the illness but it is not that if you take Tamiflu you’re going to get instantly better. I think I’ll leave it at that. Thank you.

Themba Maseko: I think we’ve covered all the questions, unless there’s a burning question. I would like to close and thank the journalists for taking the time and the patience, and thank the Minister and the Deputy Minister for joining us this morning.

Fidel Hadebe (spokesperson for Health)
Cell: 079 5173333

Issued by: Government Communications (GCIS)