Poorly prepared Gauteng is now epicentre of pandemic

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Last night, 8  July, Gauteng would become the new epicentre of the COVID-19 epidemic, Health Minister Dr Zweli Mkhize told the National Assembly in a briefing earlier in the day, reports MedicalBrief. It strikes a an ill-prepared province teetering on the brink.

Nationally, the Health Minister says bed capacity is expected to be overwhelmed. The “greatest challenge” was the irrational demand by everyone for full spectrum personal protective equipment.

“We have now reached the surge, Mkhize told Parliament. “The storm that we have consistently warned South Africans about is now arriving. As a nation we have every reason to be united in this fight against COVID-19. We dare not be divided.”

Mkhize said that while current projection still predict a mid-August peak, this will be at lower level than the previously projected optimistic curve. However, despite the consequently lower need of hospital and ICU beds, “bed capacity is still expected to be breached or overwhelmed in all provinces”.

Personal Protective Equipment (PPE) supply chains have become severely constrained both globally as well as in South Africa, a situation that is being aggravated by trade union over-caution and fears.

“The rational use of PPE’s is the greatest challenge facing us during this pandemic. Health care workers, labour unions, and professional associations, due to the concern for the safety of themselves and their members are expecting to be provided with the full spectrum of PPEs.

“In determining the PPE requirements for health care workers, we are guided by the advice from infection prevention and control experts. We want to assure frontline health care workers that the PPE requirements for health workers at different levels of risk are informed by evidence.”

“In selected hospitalised patients, a short course of the drug dexamethasone can reduce deaths from COVID-19. The injectable form of this medicine is available in the country and will immediately be used in selected patients. Another drug that can reduce hospital stay of COVID-19 patients called Remdesivir is being used in clinical trials.

“As much as we look forward to an effective and safe vaccine, and to more effective therapies for COVID-19, current clinical management relies mainly on supportive measures, including the provision of oxygen. South Africa has a well-developed medical oxygen supply system, but careful planning and management will be needed to ensure that every patient who needs oxygen is able to access it.

Mkhize said that as at the end of June, 4,821 health care workers had been infected with the virus across the country. “The leading number of infections are amongst nurses with 2,473 infections followed by other health professionals including community health workers reporting 1,971 and doctors recording 377 infections.”

Mkhize said that thus far there had been 215,855 cases nationwide, of which 48% of the confirmed cases have so far recovered, with 3,470 confirmed deaths. That’s a case fatality ratio of 1.6%. More than 20 million people have been screened and 302,713 suspected cases have been referred for testing.

As Gauteng became the new pandemic epicentre, media reports paint a picture of currently barely contained chaos. Daily Maverick reports that doctors are having to practise “bush medicine” as referral clinics teeter on the brink of collapse, and increasing numbers of healthcare staff are struck by the virus, forcing intermittent clinic closures.

“There are over 100 clinics in Johannesburg and on any day, a large number are closed. This adds considerable pressure on the system, and symptomatic patients often have nowhere to go.

It quotes Lynne Wilkinson of the University of Cape Town’s Centre for Infectious Disease, Epidemiology and Research, who is in touch with Johannesburg clinics: “The central data system (linking clinics to hospitals so patients can be referred for available beds) is inaccurate so doctors can’t use it. You’ve got clinicians calling for beds. And hospitals are not answering.”

Daily Maverick writes that while only a small number of Covid-19 patients require hospitalisation and oxygen, it’s usually urgent when they do need it. Francois Venter, deputy director of the Reproductive Health Unit at Wits University, questions whether the lockdown healthcare system planning in Gauteng has worked.

“The bottom line is we are not prepared,” says Venter. On top of the pressure on beds, oxygen has run low or run out at many facilities. At the Nasrec quarantine, isolation and field hospital facility, planning was done without oxygen beds – a basic requirement for patients with Covid-19 who need hospitalisation and oxygen for an average of one or two days.” Venter says that “testing is still a disaster” and this means that doctors wait between four to five days to get case results, meaning that they cannot transfer patients.

“The healthcare service is under huge stress,” says Dr Francesca Conradie, deputy director of the Clinical HIV Research Unit of Wits University.  “The steps put in place have been sound and the lockdown gave us time, but the system was still caught unawares,” she says, adding that “the situation is probably worse at lower level clinics”.

It quotes Conradie saying that understaffing and undertraining of nurses and other healthcare workers is eating away at the system, with over 1,000 staffers testing positive as of last week. And if oxygen stocks at clinics run any lower, “there is a risk of death at the primary healthcare level”, says Wilkinson.

Full Text of Mkhize’s parliamentary statement:

Honourable House Chairperson and Honourable members, we meet today being the 104th day since the His Excellency, President Ramaphosa announced that our country will be going on a national lockdown. At the time the President made the following remarks: “While this measure will have a considerable impact on people’s livelihoods, on the life of our society and our economy, the human cost of delaying this action would be far, far greater”.

Indeed Chairperson, as a country we did witness the intended benefits of the lockdown. The delay in the spread of infection allowed us achieve what we could not have achieved as a country, had we continued in the normal course.

For the period 01 March 2020 through to 6 July 2020, 1 907 532 laboratory tests for SARS-CoV-2 were conducted nationally. Four provinces including Western Cape, Eastern Cape, KwaZulu-Natal and Gauteng accounted for 82% of tests performed up to the 06 July 2020. The overall percentage testing positive was 11.8%.

As of the 07th of July 2020, South Africa has 10 144 new cases, bringing the cumulative confirmed cases since our first case to 215 855. To date 48% of the confirmed cases have recovered bringing the total to 103 934. Unfortunately, there have been 3 470 confirmed deaths. This brings the case fatality ratio of 1.6%. The Western Cape continues to have the highest number of confirmed cases at 72 156 followed by Gauteng on 71 488, the Eastern Cape on 40 401 cases and KwaZulu-Natal on 16 743 confirmed cases. We however expect Gauteng to have the highest number of confirmed cases, thus making it the epicentre.

We have used a differentiated approach in our response through a classification of districts as areas of ‘vigilance’ and ‘hotspots’. In all areas the focus continues to be on prevention of new infections, containment, mitigation and recovery. The overarching objective is to strengthen the national and provincial mechanisms for timely detection, management and containment of the spread of COVID-19 with nine overarching strategic priorities or pillars namely:

• Providing effective governance and leadership;
• Strengthening surveillance and strategic information;
• Augmenting health system readiness by assessing health system readiness against the epidemiological curve, identify gaps and planning to ensure health services availability according to need – focusing on the health workforce, beds, medicines, equipment and products;
• Enhancing community engagement by ensuring effective communication to the public;
• Improving laboratory capacity to test by strengthening the National Health Laboratory Service (NHLS) and private laboratory capacity for SARS-CoV-2 testing to meet the requirements of the COVID-19 response and improve coordination between the public and private sectors;
• Clarifying care pathways in respect of case detection, management and clinical pathways and to align the hierarchy of facilities established or reconfigured for the COVID 19 response;
• Scaling-up Infection Prevention and Control (IPC) Measures;
• Strengthening capacity at ports of entry by enhancing screening capacity at key ports of entry and augmenting environmental health; and
• Expediting research and the introduction of therapeutics, diagnostics and vaccines by institutionalizing mechanisms for COVID-19 related health products regulation and research coordination and building mechanisms for ongoing learning from research and experiences from other countries, to ensure that these inform the response at the frontline.

Between Level 4 and Level 3 (after June 1st), the number of COVID cases increased across the provinces. During level 4 of the lockdown the Western Cape, Gauteng, Eastern Cape and KwaZulu-Natal had hotspots using the less than 5 and greater than 5 number of active case definition, however after moving to level 3 of the lockdown, 2 additional provinces namely, North West and Free State registered hotspots.

Due to the increasing number of cases, the less than 5 and greater than 5 number of active case definition of a hotspot will need to be revised.
With regards to quarantine, as of the 7th of July we have activated 139 quarantine facilities across the country. It constitutes a total of 12 532 beds.
The Community Screening and Testing (CST) Programme initiated on 7th of April 2020 has ensured that more than 20 million people have been screened and 302 713 suspected cases have been referred for testing.
Screenings in identified hotspot areas and emerging hotspots show that the CST programme has assisted in active case finding amongst high transmission communities which has allowed our provinces to divert resources to the district or sub-district level.

As at 30 June 2020, 4 821 Health Care Workers (HCWs) were reported to have been infected with the Covid-19 virus across the country. This data represents cases of health workers in both the public and private sector. The Western Cape Province continues to account for the majority (68%) of infected Health Care Workers with 3 285 infections as at 29 June 2020. The leading number of infections are amongst nurses with 2 473 infections followed by other health professionals including community health workers reporting 1 971 and doctors recording 377 infections.

Several interventions have been put in place to address infections among health care workers. Guidelines to support all health workers across the continuum of care were developed.  A targeted training programme has been designed and implemented to enhance the understanding of the pandemic and facilitate application of these guidelines, which primarily include Infection Prevention and Control as well as case management. In-service training of all health care workers to ensure that workers can cope with the management of the pandemic relative to their scope of work has been initiated.

The occupational health and safety of workers, visitors and clients is an important aspect of our response to COVID-19 as we unlock the economy. The Department of Health worked closely with the Department of Employment and Labour and through NEDLAC drafted a consensus document on workplace interventions in responding to COVID-19 and to ensure the health and safety of workers.  We have also provided guidelines covering risk assessments in workplaces, symptom screening and testing of workers, psychosocial support interventions, disinfection of workplaces and return to work assessments.

Personal protective equipment (PPE) is specifically required to protect health care workers and other frontline workers from Covid-19 infection. Since the Covid-19 pandemic, PPE supply chains have become severely constrained both globally as well as in South Africa. Limited imports and shortages of raw materials adversely affected local production. Through the generosity of donations made by South Africans, the Solidarity Fund was able to commit a total R815 million towards procurement of urgently needed PPE’s for South Africa. The country also received generous donations of PPE from several countries, foundations, businesses and Churches. We are happy that the Solidarity Fund has indicated its willingness to support the immediate distribution of PPE in its possession to various province. This will greatly assist us in closing gaps in provinces where there are stockouts on some PPE items.

The rational use of PPE’s is the greatest challenge facing us during this pandemic. Health care workers, labour unions, and professional associations, due to the concern for the safety of themselves and their members are expecting to be provided with the full spectrum of PPEs. In determining the PPE requirements for health care workers, we are guided by the advice from infection prevention and control experts. We want to assure frontline health care workers that the PPE requirements for health workers at different levels of risk are informed by evidence.

Our assessment as of 7 July 2020 is that we have sufficient PPE stock available to meet the requirements of frontline health care workers. We endeavour to ensure that the appropriate PPE is made available to protect frontline health care workers from getting infected by the corona virus.
The National Department of Health (NDoH) and National Institute of Communicable Diseases (NICD) have provided clear guidance for local clinicians and have updated that advice as evidence has emerged.

In selected hospitalised patients, a short course of the drug dexamethasone can reduce deaths from COVID-19. The injectable form of this medicine is available in the country and will immediately be used in selected patients. Another drug that can reduce hospital stay of COVID-19 patients called Remdesivir is being used in clinical trials.

As much as we look forward to an effective and safe vaccine, and to more effective therapies for COVID-19, current clinical management relies mainly on supportive measures, including the provision of oxygen. South Africa has a well-developed medical oxygen supply system, but careful planning and management will be needed to ensure that every patient who needs oxygen is able to access it.

Since the last release of scientific model results in May 2020, the National COVID Epi Model has been updated to model COVID-19 at a district level, making use of South African hospitalisation data, updated estimates of the reproductive number, and a shift in testing priorities.  Model projections indicate that while the epidemic is predicted to peak nationally at a similar time to the previously projected optimistic curve (that is mid-August), it does so at a lower level. This means that fewer people were infected in May and June than was previously predicted even under the optimistic scenario.

While the model projects a lower need for hospital (non-ICU) and ICU beds at a national level, bed capacity is still expected to be breached or overwhelmed in all provinces. Currently planned hospital beds in the Eastern Cape and Gauteng are projected to be insufficient for combined non-ICU bed demand and the overflow from ICU once ICU capacity has been breached. Bed capacity (including all currently committed public and private sector beds) is expected to be breached in the next four weeks.
The Department of Health has developed and is implementing the Surge Strategy, in anticipation of the peak. This will ensure that the department increases capacity for COVID-19, while at the same time continuing to deliver other health services to the health care users. During this process, the Department repurposed a total of 27 467 beds for COVID-19, which has increased to 40 309 beds as the provinces started to experience a sudden increase in the number of cases.

The Department of Health is working with the Department of Trade and Industry and Competition to manufacture Continuous Positive Air Pressure devices called CPAP, for short. Through this arrangement, the Department of Trade, Industry and Competition has mandated the South African Radio Astronomy Observatory (SARAO) to manage the national effort required for the local design, development, production and procurement of these respiratory ventilators to support the government’s response. These are being procured in top of the 1000 ventilators generously donated by the US government.

The Department of Health has built several field hospitals, which will primarily be used for admission of mild cases. The Western Cape has completed constructing three field hospitals which are functional. Gauteng (NASREC), KwaZulu-Natal (Pietermaritzburg) and Eastern Cape (Port Elizabeth, VW) each have one field hospital which are also operational.
The Department is working with the National Treasury and partners to conduct an audit of the oxygen reticulation infrastructure in all our hospitals. These audits are being conducted with a priority focus on the Eastern Cape, KwaZulu-Natal and Gauteng. The outcome of these audits will give us a sense of the amount of work that needs to be done to address the gaps that undermine the expanded supply of oxygen to patients.

Honourable House Chairperson and Honourable members, by now its no longer a matter of announcing numbers of confirmed cases. We are now at a point where it’s our fathers, mothers, brothers, sisters, close friend and comrade that is infected. As a country and the world at large, we are now in this reality where we must live with knowing that some of us cannot even bury our loved ones because of restrictions or even because we ourselves have been exposed. This pandemic that is attacking us globally, will cause some of us lifetime scars. It steals from us, from some lives, others jobs, others businesses. It spares no race, no gender or social class.

Honourable House Chairperson and Honourable Members, we have now reached the surge. The storm that we have consistently warned south Africans about is now arriving. As a nation we have every reason to be united in this fight against COVID-19. We dare not be divided. As government, we have said, we cannot fight this COVID-19 enemy alone. We need all political parties, social partners and every citizen to come on board. As we continue this battle, we look beyond our differences and ensure that wherever we are, we and those around us, change our behaviour and observe all measures announced to contain the spread of this virus. We must do so with a conviction that we have a duty to not only protect ourselves but those around us. In the end, united, we will overcome.

Full Daily Maverick report

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