Western Cape Department of Health briefing

Meeting report

Western Cape Government: Health Presentation on Covid-19 response
Dr Keith Cloete, Head: Western Cape Department of Health explained the guiding principles of the response.
• A whole of government, whole of society approach
• Preparedness measures based on sound intelligence as far as is possible
• Nuanced approach, responsive to 4 transmission scenarios: no cases, sporadic cases, clusters of cases,
widespread community transmission.
• Context sensitive approach to public health measures
• Risk communication that is dynamic and honest.

Approach to Contact Tracing
- The ‘no cases’ transmission scenario:
Active case finding is required, this means vigilance for any case that enters the province or district and the focus is on messaging people returning to the country or entering the area, alerting them to symptoms and encouraging those with symptoms to test.
- The ‘sporadic cases’ transmission scenario:
The focus here is on stopping transmission. This requires timeous throughput of laboratory specimens and the contact of cases on the same day that the results become available. This is best done through telephoning cases, or if that fails, arranging for a home visit. In addition, effort to shutdown transmission requires attention to ascertaining and contacting close contacts of cases, to ensure quarantining.
- The ‘clusters of cases’ transmission scenario:
This scenario occurs when more than one case has been detected in for example a workplace or home setting. Focusing on testing close contacts of cases in these settings, with and without symptoms, is critical. Both symptomatic and asymptomatic cases should go into isolation, and their close contacts should quarantine. Case and contact tracing in this phase of the epidemic aims to contain the epidemic, to prevent widespread community transmission. Tracing and contacting close work contacts of each case is the responsibility of the workplace.
- The community transmission scenario:
The focus is protection of high-risk people and reserving test kits for high-risk people, health workers, and the sick. Nonetheless, the focus on contacting cases and high-risk contacts is important, and each person tested has the right to know their status to manage their health and to protect the health of their families and communities. Mild cases will not be tested but if COVID-19 is suspected, the person is asked to self-isolate.

PHC, Testing & Triage and Acute care
Existing Primary Health Care (PHC) facilities are all being prepared to be able to manage large numbers of the milder cases. These will largely require assessment and triaging for self-management at home. A key consideration will be to fast-track clinical assessments of high-risk individuals, who may require hospitalisation.

Testing & Triage: Temporary Structures have been designed for Triage & Testing at prioritised health facilities. These structures are designed in line with Infection Prevention and Control (IPC) strategies.

Acute Hospitalisation:
- Acute care beds for moderate cases – capacity created in existing public sector – 2 162 beds, of which 658 beds are additional beds, through expansion.
- Intermediate care beds (field hospitals) for mild cases – 2210 beds being planned:
CTICC = 862 beds
Brakengate R300 = 338 beds
Thusong Centre Khayelitsha = 60 beds
Cape Winelands - Sonstraal Hospital  = 150 beds
CTICC 2 = 800 beds

Critical care and Palliative care:
- Critical care (ICU / High Care) beds for severe cases - existing capacity in public sector - 135 beds
- Additional critical care to be created in public sector - 100 beds [requires additional resources]
- Public sector to purchase from private sector - 300 beds
- Oxygen supply – need to confirm supply at the peak   
                                                                       
Palliative Care:
- In-patient care and community service delivery model finalised
- 795 beds planned for peak, includes additional palliative care overflow of 75 stand-alone.                                            
National Department Support
Minister Mhkize has designated Dr Nicholas Crisp to assist the Western Cape health team with finalisation of plans to address the challenges. His primary task is to assist with the implementation of a hotspot containment strategy, hence his involvement with scaling up the Q&I capacity. He has been instrumental in bringing the negotiations with the private sector to conclusion, with the establishment of a national fee structure. The health team has identified the testing capacity challenges, the staffing challenges and the budget challenges for National support. A plan will be concluded this week, with an undertaking by National Health Minister to address the budget challenges with the National Finance Minister. 

Private Hospital groups progress
- A Call for Service was issued to licensed private Hospital Groups in the Western Cape to purchase bed capacity for palliative care, general, critical care HC & ICU. The main need is critical care beds and services
NDOH has negotiated the per diem tariffs. The Hospital groups have confirmed their commitment and each have nominated their chosen Admin Intermediary. The parties are busy concluding and signing the SLAs and addressing the operational requirements. There has been engagements with Specialist groups as well.
- The WC Health Department has: prepared the requisite clinical protocols and guidelines, set up a functioning Ethics Committee, established a Joint Operating Committee (JOC) constituted from both Public and Private individuals which will govern arrangements, and prepared an indemnity approval.

Health Worker Infections – 7 June 2020
Cumulative number of cases: 1832 (6% of total  cases in the Western Cape); 652 are currently active.
Number of deaths: 15 (0.9% of all known cases); HCW infections as percentage of total staff complement is approx. 4.5% (for Provincial WCG employees only).

General Remarks
- We remain seriously concerned about health worker safety during Covid pandemic.
- Very high levels of anxiety and fear amongst staff including for their families
- Interventions include: Multiple policies developed; Tools for implementation; Training; Occupational Health Expertise made available to support frontline medics; Engaging with organised labour – weekly at provincial level and being strengthened at facility level.

Hotspot Strategy
Reduce community transmission of Covid-19:
- Get people to stay at home unless necessary to leave home
- Maintain physical distance when outside the home
- Using a mask at all time outside of the house
- Maintaining hygiene – hand washing and cough etiquette
 
Reduce morbidity and mortality of vulnerable people
- Targeted screening of households and institutions with vulnerable people
- Targeted testing for vulnerable people
- Referral to designated quarantine and isolation facilities
- Active case management of vulnerable people

Western Cape Hotspots
- National Definition: All Districts with >5 active cases per 100 000 population
- These includes City of Cape Town, Cape Winelands, West Coast and Overberg
- Priority Hotspots:
- Prioritised Cape Metro hotspot areas: Tygerberg, Khayelitsha, Klipfontein, Mitchells Plain, Western – Du Noon plus other priority areas, Southern – Hout Bay plus other priority areas, Eastern, Northern
- Prioritised Rural hotspot areas:  Winelands, followed by West Coast, Overberg and Garden Route

Risk analysis
Risk 1 – Testing Strategy and Capacity
- Testing backlog has grown to 27 000 backlog across the NHLS laboratories by 29 May 2020 – test kits being redirected to WC – backlog reduced to 10 000 by Friday. [cleared 18 June]
- More GeneXpert kits and reagents are being re-directed to Western Cape
- Department to purchase testing capacity directly from private laboratories / universities to scale up capacity
- Rapid serology test kits have been approved by SAHPRA, should be made available to Western Cape within next few weeks
- Change testing policy to prioritise patients under investigation in hospitals, health care workers and symptomatic vulnerable persons
- We need consistent National and Provincial messaging around testing

Risk 2 – Recruiting and sourcing additional staff members
- Current intermediate care facilities require 1306 staff. CTICC 2 will require 836 staff.
- Additional critical care capacity will require 188 staff and additional acute care capacity 498 staff.
- Rate of infections amongst health care staff is increasing across all health facilities.
- With an expected 20% absenteeism rate at any given time, an additional 3 929 staff are required.
- We are able to supply 1 477 staff from existing available sources.
- We will require 5 272 additional staff from external sources. We specifically request assistance from other provinces and other medical services.

Risk 3 – Budget approval and available finances
- As at 26 May 2020, the WC Department of Health (Vote 6) had spent R251.259 million on COVID expenditure in this current financial year, and had made additional commitments of R542.4078 million.
- Department of Transport and Public Works (Vote 10) has spent R121.133 million and has made additional commitments of R54.253 million. Expenditures and commitments are now accelerating sharply.
- Health Department exceeded planned expenditure by R336 million in April 2020 alone.
- It is currently projected that a net R3.416 billion is required in current financial year to respond to COVID-19 by the Department of Health (R2.774 billion) and Transport and Public Works (R642 million) alone.
- This excludes additional costs for other government expenditure.

Conclusions
We on the steep slope of the curve and seeing an exponential increase in admissions and deaths. The next few weeks to months is going to be tough. Health care workers working on the frontline are increasingly anxious and fearful and need to be supported. We have to be mindful of focussing on impactful interventions and the opportunity costs of less value-adding activity. We have to re-calibrate to address non Covid-19 services. It is critical we are united in our response as a Whole of Government and Whole of Society.

Discussion
The Chairperson thanked Mr Cloete for the presentation and expressed support and gratitude for healthcare workers on the frontline as well as the efforts of the management teams.

Ms W Philander (DA) thanked the Department of Health for the extensive presentation. A summary of the infections, fatalities, recoveries; with and without co-morbidities in the Western Cape was sought. She asked what the impact would be of the testing policy that had been recently been implemented. With Tygerberg Hospital being referred to as the breeding ground for Covid-19 in the Western Cape, she asked for a breakdown of infected staff, in which area of the hospital, if clinical or non-clinical, and contingency measures put in place by the Department.

The Chairperson wanted to understand how the new testing regime would impact the management of the virus, as the province entered into its peak. She asked when the funding allocations assigned to the Western Cape by the President on Friday would be available. She asked for number of Covid-19 deaths which occurred at home versus at hospitals. She emphasized that more testing capacity was needed. How did National Government intend to resolve lack of testing capacity?

Ms R Windvogel (ANC) was concerned about the new testing criteria as it effectively showed a misrepresentation of the number of Covid-19 cases in the province and gave citizens a false sense of security. It meant that many individuals would be carriers of the virus and they passed it onto others due to not being allowed to be tested. She asked what circumstances led to the widespread infections in densely populated working-class communities and what mitigation measures were in place to deal with that. She asked if there was a reason the numbers for contact tracing had not been included.

Mr B Herron (GOOD) explained that he failed to understand why community screening was not given the same level of priority as the other health protocols. On his visit to George and Pacaltsdorp on Friday 5 June, community screening had already ended at 1pm; after being cancelled on the Thursday. It seemed that community screening had not been a priority.

Mr Herron said that the Head of Department for Transport and Public Works in the Western Cape, Ms J Gooch, had advised that for the higher trajectory model Western Cape would need 11 500 isolation beds and 53 000 quarantine beds. However, the presentation indicated WCDOH was looking to achieve 9 400 beds in total. He asked if WCDOH is following a lower trajectory model and what happened to the other needed beds?

Mr Herron asked how WCDOH and community healthcare workers were engaging with positive cases in dense areas such as the Cape Flats when people are required to isolate or quarantine but lack the facilities to do so.

Mr F Christians (ACDP) was extremely concerned about people walking around after having tested positive due to the lack of isolation and quarantine facilities. What was WCDOH doing about Macassar where people continued to work in factories after testing positive for Covid-19 leading to more people being infected.

He asked where the Cuban doctors would be deployed and noted that the President had said that nurses would be deployed to the Western Cape to avoid staff shortages. There was a shortfall of about R3 billion in the budget and the President had stated that the money would be made available. When would that be? Emphasizing that Health Minister Mkhize stated that the testing problem would be resolved very quickly, he asked what the progress had been so far.

Mr P Marais (FF+) asked if the Protection of Personal Information Act (POPI Act) had been observed in the contact tracing, as people are very sensitive about the protection of their personal information. He asked if this information was being protected from third parties which could lead to an invasion of people’s privacy.

The inability of people to maintain social distancing was a big concern. He asked if the 16 000 prisoners in the Western Cape that were released actually assist or aggravate the problem. They were released from a congested prison only to enter a congested community where social distancing cannot be maintained. He asked if the public was consulted at all when the decision was made to release the prisoners.

He remarked that Cuban Doctors could only work in the Western Cape under supervision. He asked if the Covid-19 patient influx to healthcare facilities would negatively affect the normal patients that utilized those clinics regularly for their chronic medication.

Response
Dr Cloete replied that the data on the dashboard served as evidence of the case management success rate. Out of approximately 34 000 cases, more than 20 000 had recovered; with the success rate standing at approximately 60-70%. New evidence had suggested that the isolation period of 14 days could be shortened, with patients posing no risk of exposure to others after 8-9 days.

It was made clear that the situation at Tygerberg Hospital was a result of the fractious relationship between the organized labour formation and hospital management, coupled with staff being exhausted. Tygerberg had a large number of staff and therefore was more susceptible to more staff being infected; however, the percentage was not out of the ordinary when comparing with staff numbers at other places. A lot of time was spent engaging with organized labour and staff of each individual unit. To say that Tygerberg Hospital was the breeding ground for Covid-19 was far from accurate. He promised that a breakdown of all staff members who had tested positive per unit and area would be supplied to the Committee. The National Guidelines were influenced by an occupation specialist person at Tygerberg Hospital and the contingency measures in every unit was to ensure that everything was appropriately cleaned. He explained that higher risk areas within the hospital such as the ICU unit was in fact not an area of high transmission as people there were very cognizant that they had to be on high alert. People dropped their guard when they entered communal areas. Some of the transmissions occurred as a result of community infections.

Dr Krish Vallabhjee, WCDOH Chief Director: Strategy and Health Support, replied that while the figures tended to have a lag time; the number of deaths occurring outside hospitals currently stood at 100 deaths.

Dr Cloete explained that for the last four to five weeks, the entire country had been severely strained, with test turnaround time exceeding 14 days. This created a big impediment for WCDOH work. The turnaround time was reported to the Health Minister and President as a challenge in the Western Cape. He was glad to inform the Committee that the backlog of 27 000 tests had been reduced to a backlog of 3 000 tests. He assured the Committee that the backlog would be completely wiped out within the next few days. Testing had been prioritized for high risk patients, patients admitted to hospital and health workers. However, nothing stopped WCDOH from making more tests freely available once the testing regimen had been stabilized and sufficient capacity had had been reintroduced. It would be pointless to reintroduce testing, only to end up with a backlog of thousands of tests again. He emphasized that the more cases there were, the more difficult it became to test every single case but WCDOH would obviously prefer having an excess of testing capacity so that they could test everyone. Large cases of community cluster transmissions emerged in the second week of April. That was when the Shoprite in Bothasig saw 60 out of 100 people being infected – all living in underprivileged areas on the Cape Flats. Once it was on the Cape Flats, it only began to spread. Prof Salim Karim and Minister Mkhize asserted the same stance when they were interviewed.

On the access to quarantine and isolation facilities, this was part of the emphasis at the beginning of the Covid-19 planning discussion. However, the issue is that people need to be able to make their own choice about isolation and quarantine.

In reply to Mr Herron, Dr Cloete explained that one had to follow the national eight-step Covid-19 strategy model for the eight stages. Community screening and testing preceded hotspot and cluster investigations. Community screening and testing came in while they already had clusters. The clusters had already been imminent and as such the two phases merged.

Dr Cloete explained that the presentation indicated the figures for the next 21 days, not for the full duration. The default regimen had been for a person to self-isolate. The Department had now flipped that switch the other way and assumed that the default would be that one could not self-isolate nor self-quarantine. WCDOH would offer patients to go to a quarantine place and take the conversation from there. A lot of conversations had been taking place and WCDOH was now actively convincing people rather to make use of the facilities provided than to self-isolate. With factories, WCDOH had been working with the Department of Economic Development and Tourism and where a workplace had not been compliant, they could be closed down. Complaints were submitted through the Department of Labour. Most of the Cuban doctors were family physicians and had extensive experience working in a community setting, including community hospitals. Most of the Cuban doctors would be working at the CTICC. They had also been orientated both in Karl Bremer and Tygerberg Hospitals. Irrespective of the Cuban doctors, there continued to be a significant shortfall of personnel. Staff would be deployed from other provinces, including deployment from the military. The aim was to assist the Western Cape now so that when other provinces experienced their peak, Western Cape staff could be deployed there to help.

On the invasion of privacy and contact tracing, Dr Cloete explained that nothing was done without the consent of the person. The exact details could not be supplied for the social distancing and prison questions. The decision was made by the National Joint Operations Centre (JOC). WCDOH had not been personally consulted. WCDOH was working with Correctional Services to advise them on how to deal with social distancing. Secondly, a clear system for inmates was put in place to guide Correctional Services about the contraction of the virus. He emphasized that everyone should be working together to convince all who were possibly infected to isolate themselves at a facility, especially if they lived in densely populated areas. He noted that within the last four weeks he had signed off on at least five court interdicts to restrict the movement of individuals who were putting the greater population at risk.

Further questions
The Chairperson asked how the Western Cape would know when it reached its peak, especially with the reduced testing capacity. Initially autoimmune diseases were considered a risk factor but now these did not seem to feature on the list of co-morbidities. Autoimmune diseases were inflammatory in nature. Since COVID-19 caused inflammation and blood clotting, it was strange that it did not feature on the high-risk list.

Ms Philander asked if there were any comorbidities of patients unknown to WCDOH, including if it had put measures in place to ensure those comorbidities were identified.

Ms Windvogel asked for the infection and mortality rate of children under 20 years of age. She asked how many agency personnel had been recruited and the costs associated with that. She referred to slide 34 and asked about the private sector beds.

Mr Herron asked if the 76 000 contacts mentioned was the total number of contacts identified or identified and traced. He found the ‘National Covid-19 epi-model’ slide very interesting as it showed how the modeling had been adapted for the Western Cape. He asked if the ‘R rate’ and 3.38 referred to the reproduction rate; along with what exactly it meant.

Mr Christians said that he had seen a clip that morning on Morning Live that indicated that 1 787 children under the age of 20 had confirmed positive after going back to school. While it had been said that younger children are not easily impacted by the disease, it continued to be a concern. He asked if the rumour was true that people who died during the pandemic were classified to have died of the virus when in fact some had just died of natural causes. He asked what WCDOH had been doing to assist healthcare workers and their families who were experiencing concern and anxiety. WCDOH needed to take a holistic approach to caring for those who served on the frontline.

Mr Marais complimented Mr Cloete on his very detailed, clear and concise answers to the questions, stating that it encouraged people to interact and attend meetings. While chronic patients needed their medication from clinics, many were afraid to leave their homes for fear of contract Covid-19. He asked what was being done to address this. He asked what was happening about the policeman who had tested positive and was forced to self-isolate in his small home which was not a viable solution.

Response
Mr Cloete appreciated the compliment. He replied that even with the best testing intentions in the world and if there were no restricted testing capacity, it would be extremely difficult to test every person that was potentially positive. Internationally, there had not been a single case where a country reached its peak with unlimited testing capability. A major problem with testing was that internationally it was known there was a vast number of people who were asymptomatic – and not only showed no signs of the virus but had virtually no risk of transmitting the virus. Evidence proved that asymptomatic patients rarely transmit the virus. This leads to further complications on how testing ought to be done.

Mr Cloete said how fortunate WCDOH was to have Prof Mary-Ann Davies, an epidemiologist, who had analyzed and updated the comorbidity profile. The risk factors she found were: The older one was, the more at risk one was of contracting the virus; Certain diseases place the individual at a far higher risk such as diabetes and renal disease; Diseases such as diabetes that are under control put one in a better position than those which are not. What was presumed to be autoimmune disease turned out to be hypertension. Diabetes and kidney disease were found to be a third more high risk than that of HIV/AIDS. Having a child was a higher risk than having TB.

Mr Cloete clarified that Covid-19 had been declared a natural cause of death. Any unnatural causes of death was automatically submitted for autopsy. The only thing they could do was to find if there was evidence on the databases in the public and private health sector that a person had some chronic disease, but that was as far as they could go. For an unexplained death, a sample would be taken after death, however, that was not a post-mortem but simply a sample to check if the sample was positive. Out of 34 000 cases in the Western Cape, 1 787 cases were children under the age of 20; with 20% of them being in the 7-8 years age group. The matter of private beds was still being discussed. They would be paying R16 160 per day for a private ICU bed, as the person would need to be managed as a public sector patient in the private sector ICU facilities. Palliative care was lower and had an all-inclusive hospital rate which included the specialist and everyone else associated.

Mr Cloete replied that the agency personnel costs were for CTICC for which nurses were being recruited. They directly appointed the nurses who were employed by them, in addition they were working with agencies as one of means of getting additional staff. The 76 000 referred to the contact entries.

The reproduction rate of 3.38 was correct. It was a model used in making assumptions based on the rate of hospitalization. The first model did not have sufficient data to show how it could be calibrated and therefore it only made assumptions.  Of the deaths of individuals under 20, strictly speaking only two of the five deaths were actually Covid-19 related. The virus had been present in the other three deaths but had not caused the deaths.

WCDOH had contracted with Metropolitan Health who were offering staff support services where staff could phone in to receive psychological help from a psychologist and psychiatrists. The service was provided free of charge and helped staff to address and overcome difficulty and turmoil with their families.

WCDOH introduced a system where they contracted with Uber services where for the past eight weeks, government chronic patients had their medication delivered by Uber accompanied by a community health worker who dropped the medication off at the door.

Mr Cloete agreed that a positive person that could not self-isolate ought to be given an option to self-isolate using the available government facilities. It had been very clearly articulated yesterday to policemen, prison wardens and even members of the community that when someone tests positive for the virus and cannot self-isolate, they should be given the option to make use of the facilities provided by government as they had sufficient capacity to provide that for people.

The Chairperson thanked WCDOH for the presentation and answering their questions. He noted a sincere thank you and appreciation, with fellow Members joining in to express their gratitude.

Committee Report and Minutes: adoption
The Chairperson noted the amended Committee Report on the themes covered during May 2020. The Committee went through the report from pages 1-19 and then formally adopted it.

The Committee adopted the minutes for the 27 May and 3 June 2020 meetings.

Committee Programme
The Chairperson informed the Committee that as part of the resolutions of the 3 June 2020 meeting, it had been agreed that a meeting would be held on the expiration of the 14 days of the court order. This meeting would take place on Thursday 18 June at 9am. The legal opinion would be forwarded to all Members. The WCPP Legal Department will be present to answer any possible questions that may arise.