Listeriosis outbreak: Minister of Health briefing; Day Zero readiness: Western Cape Department of Health

Meeting report

The Chairperson welcomed everyone in attendance. She said the matters to be discussed were crucial as there were affecting communities in the current conjuncture.

Presentation on Listeriosis Outbreak in South Africa

Dr Aaron Motsoaledi, Minister of Health (NDOH), took the Committee through a presentation on the Department of Health’s strategies in addressing the listeriosis outbreak. Listeriosis is a serious but treatable and preventable disease caused by a bacterium called Listeria monocytogenes. This bacterium is widely distributed in nature and can be found in: soil; water; vegetation; and faeces of some animals. From the identified sources, food and food products can be contaminated. This would include animal products and fresh produce such as fruits and vegetables. Contamination can happen at any one of the following food production sites: at farm level; at food processing plants; at food packaging sites; at preparation sites, be it at home, restaurant, among others. Ingesting food contaminated from all these sites can lead to a person to get Listeriosis. Once infected, the following three conditions can occur in a person: flu-like illnesses, like fever, general body pains, joint pains, diarrhoea and vomiting, and general weakness; infection of the brain and the membranes covering the brain (meningoencephalitis); and infection of the blood which is called septicaemia.

Although anyone can get Listeriosis, there are people who are particularly vulnerable and at high risk of developing severe disease. These include: new-borns; pregnant women; the elderly; persons with weak immunity, such as people living with HIV, Diabetes, cancer, chronic liver or kidney diseases. In July 2017, doctors from neonatal units at the Chris Hani Baragwanath Hospital and Steve Biko Academic Hospital, alerted the National Institute for Communicable Diseases (NICD) about the unusually high numbers of babies with Listeriosis. The NICD then triggered a review of all cases diagnosed in both private and public hospitals, by contacting both private and public laboratories. For the past 41 years, Listeria did not qualify as a notifiable disease, and about 60 to 80 cases were detected and treated annually. The difference this time around is that it is behaving unusually and spreading rapidly, which it had not done before.

There had been significant action in various fronts since the NICD was informed. The tracing of laboratory infected cases dating from 1 January 2017 commenced. In October 2017, the Multi-sectorial National Outbreak Response Team (MNORT) which had been formed since the 2010 FIFA World Cup was reactivated and briefed on the situation in the country. On 29 November 2017 when a total of 557 cases were confirmed, the MNORT asked for a meeting with the Minister; which was then convened on 4 December 2017 wherein an outbreak was declared. A press conference was called for the 5 December 2017 to inform the Nation.

In an effort to combat the outbreak, the MNORT was involved in coordination; risk communication; clinical and molecular investigations; targeted environmental sampling; food safety records; processing plant inspections; and external collaboration. These activities were being undertaken in collaboration with relevant stakeholders. Technical assistance had also been requested from the World Health Organisation (WHO), which sent a Risk Communication Specialist, an Epidemiologist and Foodborne outbreak experts who were deployed for a week.

This present outbreak being experienced was caused by a strain called ST6, which had been identified in isolates from all nine provinces. This brought the Department to a current working hypothesis; this being that a single source of food contamination was causing the outbreak, i.e. a single widely-consumed food product, or multiple food products produced at a single facility.

Most importantly, while scientists were still conducting their laboratory search, and while MNORT members were also doing the search on food production sites and environment, the Nation should be taking precautions. These are in the form of five keys to safer food, which came from the WHO. These being:

• Keep clean – washing of hands with soap and clean running water before handling food or after visiting the bathroom
• Cook food thoroughly because Listeria is sensitive to heat, and will die in well-cooked
• Separate raw and cooked food - for the reasons above
• Keep food at safe temperatures – do not leave cooked food at room temperature for more than 2 hours, promptly refrigerate cooked food below 5 degrees
• Use safe water and raw materials – boil water if it is not from a clean safe source, and wash fruit and vegetables thoroughly before ingesting

From January 2017 to November 2017, a total of 557 laboratory-confirmed cases were reported in all nine provinces. However, most cases were reported in Gauteng (62%), Western Cape (13%) and KwaZulu-Natal (7%). He assured the Committee that the situation was under control.

Discussion

Mr Shaik-Emam (NFP) noted that the Listeriosis outbreak seemed to be under control. He asked what was being done to control food sold in open spaces. Access to clean water was paramount in the fight against the disease. Hence, how can water crises be mitigated? What could be done differently? He asked for statistics on the number of fatalities per province. Also, what efforts had been made to identify possible sources of the bacteria after it was traced?

Dr P Maesela (ANC) asked what was being done to identify the source of the listeria bacteria. There should be the narrowing of localities where the cases were identified.

Mr W Maphanga (ANC) emphasised the need for proactivity in dealing with the listeria outbreak. MNORT had to be strengthened by involving other stakeholders such as environmental health practitioners especially at municipal level. This would ensure that the remotest communities are aware of the disease and preventative measures.

Ms S Kopane (DA) asked if hospitals had the capacity to inform their patients and the public on the severity of the outbreak. There was need for properly coordinated national campaigns to ensure people are well aware and are taking necessary precautionary measures. Were there sufficient funds to deal with the crisis?

Ms N Ndaba (ANC) commented that local municipalities should work hand-in-hand with the national Department and all public health facilities in carrying out extensive awareness campaigns.

Dr Motsoaledi, in response, acknowledged that awareness campaigns on the outbreak were key. The ‘five commandments’ were general guidelines on the handling of food and the Department was trying its best to ensure the public was well aware of Listeria. Engaging environmental health practitioners was important. However, given that these practitioners were now under municipal purview instead of the National Department, their effectiveness had dwindled especially in rural areas. This was a weakness that had to be addressed through legislation. As to whether the source of the outbreak had been identified, there were practical challenges in identifying the source of the bacteria as its incubation period was anything between two and 70 days. Tracing the exact source of the bacteria in ordinary day life was thus difficult and scientists would need to navigate around a multiplicity of practical challenges. There was no reason to believe that there had been a change in the provincial spread of the bacteria since initial reporting of the outbreak. Also, he had received assurance from the Minister of Water and Sanitation that all hospitals and clinics will not be affected by Day Zero in the Western Cape. The source of listeria might not be found and might die a natural death. NICD had enough capacity and was world class. Veterinarians were taking samples in abattoirs around the country. He added that the reality was the outbreak of diseases should be expected more often due to the impact of antimicrobial drug resistance and climate change.

The Chairperson said the general populace should take heed of the identified interventions. Members had the responsibility that their constituencies were empowered about the interventions. It was not only the responsibility of government to educate communities.

Presentation by Western Cape Provincial Department of Health on Water Security Programme

Dr Laura du Toit, Chief Director: Infrastructure and Technical Management, Western Cape Department of Health, briefed the Committee on the Western Cape Provincial Department of Health’s readiness for Day Zero. The purpose of the Water Security Programme was mainly to mitigate the risk of service disruption due to lack of water at health facilities in the Western Cape. The overarching strategy was meant to: reduce water consumption at health care facilities; be prepared for the possibility of water rationing; and be prepared for the total loss of municipal water supply.

Elements of the Water Security Strategy included: reduction of water consumption and supply of potable water; augmenting availability of water, disaster response, and assessing health impacts of drought. These were to be implemented through a comprehensive governance structure and activation of the plan. Clinical service prioritisation was informed by risks such as potential increases in water borne diseases (e.g. dysentery, cholera, diarrhoea disease, typhoid, hepatitis A), civil unrest, among other, in an event that taps run dry.

Managing and monitoring of water utilisation was crucial. Therefore, the Provincial Department of Health identified the need for frequent, accurate water meter readings; reliable data results in improved monitoring and response, and maintaining user sensitisation (not only during time of crisis). Setting targets per facility and not per facility type; shortening maintenance and response time (e.g. leaks, pipe bursts); and feedback to and engagement with facilities managers with respect to excessive use was also essential.

Various measures to avert a crisis were underway. These included installation of smart meters at hospitals (enabling constant monitoring of water consumption), and continuous monitoring and reporting on utilisation at all levels. Consistent with these, a revised water utilisation indicator had been included in the 2018/19 Annual Performance Plan. In an effort to conserve water in health facilities, the Provincial Department was focusing on setting usage targets and minimum water requirements for each facility. Focused interventions would include: behaviour change; exploring more uptake of alternatives such as alcohol hand sanitizers, and bottled water for drinking; awareness campaign to reduce water consumption, and having only severely soiled linen sent to the laundries.

Dr Wayne Smith, Western Cape Department of Health, outlined the engineering interventions which were part of Water Security Programme. These included: maintenance reticulation and leak minimisation interventions (eliminate leaks); shutting off of basin taps (use of hand sanitizers); installation of low flow sanitary fixtures; installation of waterless urinals; installation of Water Efficient Equipment and Systems; and re-use of treated water.

Consistent with the identified interventions, Groote Schuur Hospital, in the past seven years, had halved its water consumption. The reduction in consumption had been the result of good maintenance rather than new technologies. This emphasised the need for good maintenance. As part of its focused interventions, the hospital was re-cycling autoclave water in the central sterile services department, resulting in a saving of five million litres of water per year. The hospital had recently installed heat pumps that cool water from the air conditioning system prior to the main chillers. This not only saved substantial electrical energy, but reduces the water required by the cooling towers. It was planned to use waste water from theatre autoclaves, reverse osmosis plants, and rain water harvesting for toilet flushing. At present the New Main Hospital Building uses 70 million litres of water per-year to flush toilets. With water recycling and rain water harvesting in place none of this need be potable water.

To augment availability of water, a number of interventions were being explored. These included: focused interventions for reducing the demand on municipal water; use of ground water for large facilities; use of ground water for large facilities; reinstatement of existing boreholes; drilling new boreholes; installation of storage tanks; engineering work for connection to water reticulation system; water treatment technologies, among other measures.

For all the demand and supply side interventions, Western Cape Government (WCG) Water Business Continuity Plan (BCP) focused on how and which service delivery requirements of the WCG could continue to be met when there was constrained or no municipal water in a geographic area. Collaborative efforts between the WCG Department of Health and Department of Transport and Public Works (including with DTPW and all 13 departments and 4 entities of the WCG) were also underway. The Water BCP had two focus areas, these being: demand management interventions to reduce water consumption at all WCG facilities in order to contribute to avoiding a “dry-taps” scenario in any areas of the province; and supply-side interventions to not only reduce municipal water consumption but also to ensure that there are essential supplies of drinking water, for hygiene as well as for fire safety purposes in key facilities to secure vital facilities.

The structure of the WCG Water Disaster Response was as follows:

• Phase 1: Preservation restrictions (rationing)
• Phase 2: Disaster restrictions ‘Day Zero’
• Phase 3: Full-scale disaster implementation

Phase 1 was characterised by reducing demand, water rationing through limiting supply and advanced pressure management which severely limits available water supply in the system per day. The purpose being to avoid escalation to Phase 2. Phase 2 is triggered at 13.5% surface water levels of the Western Cape Water Supply System’s six largest dams, and its purpose was to avoid escalation to Phase 3 (Full-scale disaster implementation). Phase 2 was characterised by water rationing aimed at maintaining human life and critical services.

Dr Smith assured the Committee that through strategic partnerships with City of Cape Town (CoCT), health facilities would be protected at Day Zero. An agreement had been reached with CoCT, such that water will not be shut off at Health Facilities (public and private) at Day Zero. Also, Part A of Groundwater Security Programme will be completed before Day Zero, and it will effectively reduce the water demand of nine Metro Hospitals (including the two central hospitals). CoCT Phase 3 will imply the shut off of water provision to healthcare facilities too. Such date cannot be established at this point. However, the City of Cape Town had confirmed that all private, public and military health facilities in the Metro area would remain with Municipal water supply at Phase 2. It was a comprehensive approach that had been put down and there was a lot of work and micro-level management underway. He urged the public to collectively conserve water as it is not known whether the next rainy season would fully replenish water sources.

Discussion

Dr Maesela felt the outlined plans were just a means of averting imminent Day Zero when they should actually be for the long term. Long-term strategies such as tapping into the aquifers in the Cape Flats and erection of desalination plants should be explored. Disaster and water security preparation strategies should be for the next 100 years.

Ms Kopane asked about the role of other departments in coming up with the Day Zero disaster mitigation strategies.

The Chairperson asked for details on how water-saving interventions in the laundry areas would work. The Provincial Department had to closely monitor such a programme to ensure that it would not pose health risks.

Ms Malebona Matsoso, Director-General: National Department of Health, commented on the National Department’s readiness for Day Zero. The Department’s interventions had been much more comprehensive because the water crises were a matter affecting all public health institutions. Dealing with both electricity and water shortages was urgent. Such comprehensive interventions would involve other departments and stakeholders such as South African Local Government Association (SALGA) from national down to municipal levels. The Department’s role was to ensure that municipalities were ready for Day Zero and consequently, national outreach response teams had been established. The issue of water was an emergency as it affects service delivery. The interventions and monitoring was not limited to the Western Cape but all other provinces with water challenges.

Ms du Toit replied that the outlined strategies were not only for crisis mitigation in the event of Day Zero but for the long-term as the forecasts were indicating that the Western Cape might receive low rainfall in this coming season as well. The preparations were surely for the long-term. The cost of the Programme was R150 million. Part of the planning involved coordination with the Provincial Department of Community Safety, Public Works and the broader safety family in preparation for Day Zero. Efforts were being made to strengthen those networks. Also, regional laundry services had been recently upgraded to save water and linen-saving measures would be monitored to ensure patients’ lives were not put at risk.

A Western Cape Department of Health official added that the preparations and measures being put in place were meant to sustain the province going forward. Climate change was a reality and this was an opportunity to strengthen networks and partnerships in water-saving. Gearing up not only for imminent Day Zero but for the future was paramount. He agreed that various aquifers had to be strategically harnessed to serve communities into the future.

The Chairperson thanked the Minister and the Western Cape Department of Health for the informative presentations and responses. She indicated that the Committee was not taking the Member of the Executive Council’s (MEC) absence kindly. When a province is called to appear before a Committee, it had to be accompanied by the political head. Hence, her continual absence was completely unacceptable and bordering on undermining Parliament. She asked the Provincial Department officials to convey the message on behalf of the Committee.

The meeting was adjourned.