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SA's COVID-19 roundup – 30 April 2020: Eastern Cape spike as outbreak pattern changes

A spike in COVID-19 infections in the Eastern Cape is part of changing patterns in the outbreak, Health Minister Zweli Mkhize told a parliamentary committee.

Some provinces or even localised districts may stay in tighter lockdowns than other parts of the country as South Africa embarks on a risk-based approach to reopening the economy and allowing the limited movement of people. A Mail & Guardian report says this was revealed by Health Minister Zweli Mkhize during a briefing to Parliament’s joint committee on health and social services. Mkhize told them that models of the rate of infection and transmission patterns have changed since the first reported case in South Africa in early March.

“There’s a change in pattern. We are seeing cluster outbreaks in workplaces that were originally identified as essential services. So, to look at it, we need additional support for that province (Western Cape),” Mkhize said.

“It looks like some of the work that has been done is quite promising. The numbers (of cases) are increasing. But we have to ultimately concentrate on how we contain the spread,” Mkhize said. The government may also decide to enforce lockdown in one province or district while opening up in other parts where the risk of infection is lower. The report says this could particularly affect the Western Cape, Gauteng, KwaZulu-Natal and the Eastern Cape.

Officials are also reporting a spike in cases in the Eastern Cape, while the outbreak in KwaZulu-Natal remains a problem. “KZN has also been quite high, but we are also concerned that the Free State, that was once a concern, has now been overtaken by the Eastern Cape. In the Free State the pattern was based on one incident where there was a church gathering, where many people got infected. That has now been contained. The numbers have remained stable around 110. But the Eastern Cape has shot up.

The Western Cape's COVID-19 cluster outbreaks indicate what may happen when more sectors open up for business under level 4 lockdown regulations, starting next month, reports The Times. “I think the example of the Western Cape is what's going to happen. We must expect that there would be areas where we will say we can proceed with bringing up normal economic activities and open up various industries and transport routes and so on, but there will be areas where we might have to stop that and say we thought this was safe, it's no longer safe, let's go back,” Mkhize is quoted as saying.

“It's not going to ever be a straightforward issue. If in one instance we would have understood that the rate of transmission is still very high, we would actually reduce the numbers of industries that must be started and be put in operation immediately,” he said. “On the other hand, where we think things are getting well and the transmission rate is low, and the economic activities can be resumed, we will move into that, but as soon as we start picking (up that) the numbers are going up, we are forced to close down some of those sites,” he added.

Mkhize said food outlets and pharmaceutical companies that remained open for business because they were designated as essential services, were where the cluster outbreaks occurred, leading to several Shoprite stores and one GlaxoSmithKline factory closing in Cape Town as a large number of people were found to be positive.

Community screening is up – 5,832,572 across South Africa, with 41,707 people referred from this process for coronavirus testing, reports Daily Maverick. A total of 168,643 coronavirus tests have been conducted since the start of the pandemic, according to the Health Department briefing documents. And while the daily COVID-19 updates show testing ranges between 6,500 to 8,5000 a day – that’s hovering around the half-way mark of claimed public capacity – Mkhize has emphasised testing is increasingly done in the public sector.

“We are seeing increasing numbers (of testing) from the public sector. That is for us quite encouraging. However, we think there is still a long way to go,” he is quoted in the report as saying. “South Africa really has not done badly. What we are happy about is that we are targeting areas where we are having problems.”

According to the minister, the challenge was the supply of diagnostic kits.

Nationally, of the 288 planned quarantine sites, 81 actually are activated as of 25 April 2020. In terms of beds, that means 8,832 of the available 23,604 beds for quarantine have been activated, and are available. Mkhize said South Africa was well prepared: “If people are not sick we can actually go a long way without the pressure of overcrowding”.

Also, the report says mortality rates nationally average 1.9%, significantly lower than global trends, but important provincial trends emerge, signalling potentially dangerous health system deficiencies. In Limpopo, the mortality rate stood at 6.5% as of 25 April, the highest in South Africa, followed by the Free State at 4.5%. And while the Western Cape is now the coronavirus epicentre, the death rate stands at 2%. In comparison, the other significantly affected provinces Gauteng and KwaZulu-Natal have recorded mortality rates of 0.6% and 3.4% respectively.

Health acting director-general Anban Pillay, who had taken the parliamentarians through the presentation before Mkhize joined, told lawmakers: “Community-level spread is still at a very low level…”

The report says these testing, hospitalisation and overall epidemiological statistics are important as South Africa’s hard lockdown is set to ease somewhat from 1 May.

Pillay said that South African hospitals are currently not overwhelmed by the pandemic, News24. Pillay said at the moment there isn't a high demand for high care of COVID-19 patients. Mkhize said at the moment there also hasn't been a lot of ventilator usage.

Mkhize said people in quarantine are mostly those who can't self-isolate, and repatriated citizens. Due to the latter arriving at OR Tambo International Airport, most of the quarantine sites are in Gauteng.

South Africa’s government officials say a swift move to lockdown and widespread screening has been the key to fighting the virus. But an abundance of caution remains, says a BMJ report, which notes that South Africa is no stranger to the rampant spread of infectious diseases. Long before the country’s first COVID-19 case was announced on 5 March, there were fears of how it would impact the public health system, already coping with a high incidence of tuberculosis and HIV. And in a country where 13% of the population live in crowded informal settlements with poor access to running water and sanitation, there was a high risk of local transmission.
Salim Abdool Karim, the chair of South Africa’s COVID-19 ministerial committee points to the lockdown that started on 27 March, announced when South Africa had just 402 known COVID-19 infections and no deaths. By contrast, many countries in the global north applied lockdown measures only once cases were well into the thousands.

Critics have viewed with suspicion countries that seem to have low numbers of cases, often citing a lack of testing. But, the report says, Karim dismisses that theory. “Despite early restrictive testing, we aren’t seeing much evidence of clinical disease or respiratory distress that would indicate missed cases,” he is quoted as saying. He believes the low numbers show a “genuine effect,” the result of early interventions including travel restrictions.

Kerrin Begg, public health medicine specialist at Stellenbosch University, agreed. “The first wave didn’t transmit to communities. The enforced physical distancing and early lockdown managed to delay transmission,” the report quotes her as saying.

Tracey Naledi, chair of Tekano, an independent health equity organisation, told The BMJ that South Africa has avoided pressure on hospitals so far, but warned, “It’s when we increased community testing – and targeting poorer communities in particular – that we saw an increase in new cases. This suggests that we may have been testing where we did not have cases.”

The report says South Africa’s response sounds like a success. But the crisis is far from over, as the country expects another spike in cases once the lockdown lifts. A full easing of restrictions seems unlikely any time soon. “We’re seeing clusters in supermarkets, police stations, hospitals, and manufacturing plants,” said Begg, “This is to be expected, and we’re moving quickly to test all staff.”

She told The BMJ that a “high number” of asymptomatic cases have been detected, adding that the country is “now firmly in stage two of epidemic transmission, moving to stage three as cluster transmissions move to localised transmission in areas where essential workers live.”

Infection prevention and control measures are challenging in densely populated areas, but Begg says that health workers are moving swiftly to test, contact trace, and move people to isolation or quarantine centres.

The report says the country has a clear strategy for the months to come that involves ongoing sample testing surveillance in hotspots like mines and densely populated areas; building field hospitals for triage for milder cases; increasing the number of intensive care beds and ventilators; expanding burial capacity; and managing the psychological and social impact of covid-19.

There remains concern, however, for the estimated 2.5m South Africans who are HIV positive but not on antiretrovirals and especially those who have low CD4 counts, and those over 60 with underlying conditions – the demographic making up most COVID-19 deaths in the country.

“Until the end of September, we anticipate a partial lockdown for those over 60, plus those with diabetes and heart and respiratory disease,” said Karim.

Meanwhile, an earlier Mail & Guardian report noted that just over 200 Cubans, including doctors, were on their way to South Africa to assist in the battle against the spread of COVID-19. About 30 Cubans will be assigned to the South African National Defence Force (SANDF) and the rest will assist the department of health.

“These are doctors who have been to Europe and elsewhere, who understand the signs and symptoms of the virus and the clinical management of the COVID-19 and how to treat it,” said health department spokesperson Popo Maja. The report says the arrival of the Cubans in the country could assist with curbing the spread of the virus particularly in the provinces where the numbers are increasing rapidly.

[link url="https://mg.co.za/article/2020-04-27-shifting-patterns-in-covid-19-cases-leads-to-redrawing-of-battle-plans/"]Full Mail & Guardian report[/link]

[link url="https://www.timeslive.co.za/politics/2020-04-27-expect-more-cluster-outbreaks-under-level-4-zweli-mkhize/"]Full report in The Times[/link]

[link url="https://www.dailymaverick.co.za/article/2020-04-27-with-screening-and-testing-up-more-covid-19-positive-cases-but-average-1-9-mortality-rate-remains-zweli-mkhize/"]Full Daily Maverick report[/link]

[link url="https://www.news24.com/SouthAfrica/News/coronavirus-sas-hospitals-currently-not-overwhelmed-mps-hear-20200427"]Full News24 report[/link]

[link url="https://www.bmj.com/content/369/bmj.m1623"]BMJ report[/link]

[link url="https://blogs.bmj.com/bmj/2020/04/17/kwanele-asante-covid-19-in-south-africa-calm-before-a-heavy-and-devastating-storm/"]BMJ opinion[/link]

[link url="https://mg.co.za/article/2020-04-25-200-cuban-medics-to-help-sa-fight-covid-19/"]Full Mail & Guardian report[/link]

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