Health indicators and health responses to COVID-19

Adhoc Committee on Covid-19 (WCPP)

15 July 2020
Chairperson: Ms M Wenger (DA)
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Meeting Summary

Video: AD HOC COMMITTEE ON COVID-19, 15 JULY 2020, 13:00

In a virtual meeting, the Committee met with the Western Cape Department of Health. The presentation updated the Committee with the latest health data/indicators, future predictions for death rates and peak projections, containment strategy, testing strategy, health platform response, hotspot strategy update and the “new normal” post the peak. The COVID-19 epidemic is at the advanced established community transmission stage in many sub-districts in the Cape Metro.

It has been noted that the Khayelitsha and Klipfontein sub-districts have the highest number of deaths due to COVID-19 in line with the fact that they have had amongst the highest number of cases. The number of deaths in recent weeks appear to be stabilising and possibly going down but it is too early to suggest that this is a trend.

Members asked about the status of the field hospitals outside of the mtro, contraction and fatalities of hospital staff, management issues, tracking and tracing and the charges associated with the Hospital of Hope at the Cape Town International Convention Centre (CTICC). Clarity was sought on the possible discrepancies in numbers and information and co-morbidities.

The Committee also probed the red dot project and if the service is being used to its full capacity and quarantine and isolation facilities.

Meeting report

The Chairperson welcomed the Head of the Western Cape Department of Health, Dr Keith Cloete, and his team.

Western Cape Department of Health: Health Strategy Update
Dr Cloete said the COVID-19 epidemic is at the advanced established community transmission stage in many sub-districts in the Cape Metro. The Khayelitsha and Klipfontein sub-districts have the highest number of deaths from COVID-19. This will be analyzed in greater detail over the coming days.

Conclusion on Preliminary Review
The Khayelitsha and Klipfontein subdistricts have the highest number of deaths per sub-district, in line with the fact it had amongst the highest number of cases.
In the Klipfontein sub-district, the suburb distribution is dominated by two areas, Guguletu and Nyanga.
The number of deaths in recent weeks appear to be stabilising, and possibly going down, but it is too early to suggest this is a trend.
Socio economic conditions also contribute to the risk of disease and subsequent mortality.

Impact of Alcohol on Trauma load and Health Services
As the country approaches the peak of the COVID-19 epidemic, the hospital Emergency Centres (EC) are inundated with severely ill COVID-19 patients requiring stabilisation, emergency management, and admission for further care. The lifting of the alcohol ban effectively resulted in:
62% increase in daily trauma cases
Approximately 40% of trauma cases require admission

It is depleting the ability to effectively manage and prevent the mortality from the double burden of COVID-19 and trauma deaths as the peak is approached. Recommendation: The alcohol ban be reinstated to minimise the impact on our health services in its ability to manage COVID-19 in the Western Cape.

Cape Metro-Quarantine and Isolation
All clients with severe symptoms, as well as clients at high risk for COVID morbidity and mortality, are assessed for the need for hospitalisation.
All symptomatic clients not requiring hospitalisation are currently offered assisted quarantine (with or without testing.) Once this facility is filled, the Department will move onto other contracted quarantine facilities.
All clients who test positive are currently offered isolation.

Critical Care Bed Shortages
The Department remains under pressure for critical care beds in the public sector.

This is essentially due to staff shortages: absenteeism from Covid infections and other causes

The Intensive Care Unit (ICU) beds in the private sector are already under pressure and experience high occupancies.

Strategies to impact on Covid-19 deaths
It was noted certain sub-districts (e.g. Khayelitsha and Klipfontein sub-districts in the Cape Metro) have higher number of deaths due to COVID-19.
The differential death rates across sub-districts will be analysed in greater detail.
Further earlier identification and active management of Covid patients with other co-morbidities will be pursued. 
The more active management of chronic diseases to achieve higher levels of control will be a medium to long-term strategy.

Behavior change and public health support in hotspot strategy

Covid 19 Behavior Change: what to do
Masks, masks, masks - Must be freely available in quantity everywhere.
Actionable specific advice is key:
- Focus on high risk contexts
- Wearing a mask when going shopping or riding in a taxi
- Washing hands when collecting grant
- Elbow bump only – no shaking hands
       -  Messaging must be consistent and harmonised

For the full presentation, see attached document.

Ms W Philander (DA) thanked the Department for its commitment and dedication. She is grateful to reside in the Western Cape, a comment with no reference to any political agenda.

She asked about the status of the field hospital outside the metro area and asked when occupation will take place.

Regarding the staff complement, she wanted to know about the contraction and fatality rate. She asked because of the concerns there will not be enough staff to man facilities.

Lastly, she wanted to know which interventions the Department took regarding other state departments, such as the police and correctional services.

Mr C Dugmore (ANC) thanked Dr Cloete and his team. He said Dr Cloete seemed slightly more relaxed than in the last meeting.

He asked for more detail on the status of health workers at both hospitals and clinics. Management issues led to some conflict situations over the last month. He wanted to get a sense as to what exactly caused the stir-up, and if Dr Cloete and his team believe the management issues with unions at Tygerberg Hospital and to some extent Groote Schuur are addressed. 

If possible, he asked for the number of infections and deaths to be expressed as a percentage of the total number of health workers within the Western Cape.

Regarding contact tracing, he asked if the Department felt it is on top of the issue. He asked for more information on its efforts. He asked if it is possible for the Department to give further information broken down into the different ward levels.

Mr B Herron (GOOD) asked for clarity regarding the charges associated with the Hospital of Hope at the Cape Town International Convention Centre (CTICC). The Committee was told the facility is provided rent free. Social media posts showed R24 million per month is spent. He wanted to know if this is fake news.  

He asked for clarity regarding why it appears the information provided by the Department seems to be at conflict with the information provided on hospitalisation and capacity. On the one hand the information given is that hospitals are not pressurised. On the other hand, the information is that the impact of trauma patients puts pressure on hospitals. He asked for clarity.

On contact tracing, between 2 and 9 July, there were around ten thousand new cases in a week. An estimate of 20 000 contacts were traced. The slides today showed 32% of the call centres are left unanswered. Firstly, it created an estimated number of contacts traced rather than an actual number. It reaches only around two contacts per positive case. Secondly, calls are left unanswered. It is a critical part of the health protocols.

He wanted Dr Cloete to explain why HIV is regarded as a co-morbidity in younger patients. He is of the understanding HIV patients are only at a heightened risk if not on treatment.

Mr P Marais (FF+) wanted to know if poor nutrition and poverty correlated not only to each other but also the survival rate of patients. He asked if patients who have diabetes or hypertension, who contract COVID-19, belong mainly to private medical aid or rely on government hospitals and clinics for chronic medication.

Dr Cloete said the Department’s management team has the specific role to work with other sectors. It must be the guide providing public health expertise and advice related to COVID-19.

Regarding sectors of field hospitals outside the metro, additional capacity is provided and patient admittance started. Additional capacity is created. Despite being much smaller, the capacity is essentially to help deal with the impact of COVID-19 on hospitalisations in those areas. It reorganised capacity in the coastal areas, and planned for a very high peak, with a high infection rate among staff members. It did the calculations itself. It came to the conclusion it will be short staffed.

However, firstly the peak is not as high as expected. Secondly, the infection rate amongst staff must be explained. The Department predicted the CTICC facilities becoming full. It is not in a position to be able to fill all staffing posts. This means staff employed will be under more pressure, but not overwhelmed. He assured the Committee the Department has sufficient staff and are able to cope at the moment.

Regarding fatalities, a facility at Tygerberg Hospital is prepared in the event of fatalities increasing. It started taking in bodies last week. However, the numbers, once again, are less than expected. 

Regarding screening and testing, the Department did community screening and testing at the same time as clusters became evident in the province. The Department responded by focusing, targeting, and investigating clusters in its screening approach. At the same time, it is very concerned about the vulnerable people in the metro. As such it focused its attention on not just clusters, but toward vulnerable people as well. This led to the testing regiment tightening.

As of last Friday, 33 medical workers died. This equated to 0.83% of all workers who tested positive. Of the 33 medical workers who died, 16 are nurses. A breakdown is available on the location of the deaths. Eighty percent of all health workers infected across the facilities are recovered by this point. There are 19 active cases of 780. Of these, 0.83% of the cases died, and 80% recovered.

Management challenges, which was also called ‘friction’, was reported across management facilities by organised labour. Weekly engagements occurred with organised labour and Members from the Chamber. The parties agreed the Department of Health (DOH) will go in as an external mediator between management and organised labour. The mediation is to help get to the bottom of key issues and to facilitate what everyone wants. There is a relationship between management and organised labour. While it seems strained in certain places, the Department is committed to assisting all parties work together. It is pleasantly surprised by the levels of commitment and co-operation from management to work with organised labour, to solve those problems.

The contact tracing system, Track and Trace, is a software system where someone can register if tested positive or negative. The person enrolls on the software system. It is a platform which gives the Department access to the person. It is an avenue to get to all positive cases and their contacts to get to the person without giving the person a call. It communicates with these individuals via a WhatsApp platform. The platform will only roll out to the rest of the Provinces in July. It will be a big advantage for the country.

Regarding call centres, the Department endeavours to get on top of things. It has a system which releases the ward data every Friday. The intention is to release it every Friday.

The original hire agreement for the Hospital of Hope at the CTICC is from 4 May to 17 September 2020. The original hire agreement is from 4 May to 17 September, for R36.443 million. This is on the agreement following its 100% discount on the venue rental. The agreement costs for the entire period include staffing costs for CTICC to keep the place running so the Department can run the hospital, waste management, cleaning and cleaning consumables, electricity, water, operating lifts, generators, pests, plumbing, safety CCTV, laundry costs to decontaminate the place afterwards, parking bays (50% discount), and catering for patients at R150 per day. The amount of R36.444 million was projected. The Department paid R36.212 million to date. This is to use the venue.

In addition to this, the Department also had to construct the hospital very quickly. It constructed it within three weeks. It had a separate contract with Scan Display which is for R10.197 million to build the hospital with the various installations. To date the Department paid R9.9 million of this. On top of this are the operating costs for running the hospital such as oxygen and beds. The hire agreement to use the facility is free. It is the operating costs which the Department is responsible for.

The health care system is acutely aware of the impact of alcohol. When the alcohol restriction was lifted, the impact in the first week of June 7 is, additional beds were occupied which were not occupied when the alcohol ban was in place. From the beginning of June until July, the Department observed a lightening of the COVID-19 needs. Its capacity increased as a result. It provides for capacity which does not necessarily realise as hospitalisation.

Alcohol restrictions impacts on health care provisions. However, it is not as if alcohol is pushing out COVID-19.

Regarding contact tracing, there are concerns regarding the numbers, which is a direct result of the percentage of people who are not answering phones. This is a system the Department wants to close.

Regarding co-morbidities in Khayelitsha, the first two biggest co-morbidities are not hypertension and diabetes. It is HIV for positive people. There is a disproportionate number of HIV positive as a co-morbidity with Covid. It does not say anything about the predisposition for being vulnerable for hospitalisation.

The Department did a comparison with what it called a social economic vulnerability index. If you overlay on a map where people live from a perspective of poverty and crowding and overlay it with another map of COVID-19 cases, the highest cases of COVID are in these pockets. It is assumed the socio-economic vulnerability and nutrition run together. Therefore nutrition and socio-economic vulnerability are a prerequisite vulnerability index for COVID-19. It is also a vulnerability for hypertension, for HIV, and TB. Majority of the people who have diabetes and hypertension are dependent on the public sector. In the metro, the Department delivers the medication to persons who cannot collect it.

Dr Beth Engelbrecht, Strategic Manager, Western Cape Department of Health ,said when the Department first received the data, it saw all sectors are impacted upon, early in the pandemic already. It realised it must focus on other sectors.

Traces of COVID-19 were first reported in prisons just before it had community transmissions. The Department worked alongside prison correctional services, and the Department of Community Safety to deal with the COVID-19 situation in prisons. The intention is also, post-COVID-19, the Department must have established relationships which will continue in future.

It visited a post-war hospital to get an understanding of what the risk assessments are, where offenders are, what the risks are, and measures put in place. The Department realises it has public health expertise and occupational expertise. This is a privilege it needs to make sure is available to other sectors. The guidelines it assisted local correctional services with, was taken nationally and seems to be informing the national process. It worked with training doctors in the management of COVID-19. The last figures received showed there are no new infections in correctional facilities. The Department is not only extremely proud of the relationship it established with correctional services, but also of how correctional services stepped into the space and provided good leadership.

Evidence now indicates a whole place will not have to be closed to clean a spot or area. It also engaged with the Provincial Commissioner through the Department of Community Safety and its colleagues. It appears the occupational health and safety capacity is more at a national level. It works very closely to assist with guidelines which are relevant and easy to follow.

Dr Engelbrecht said the Department is currently developing an electronic training program which will allow people to train themselves on COVID-19. The most important thing is for people to realise COVID-19 will be around for the next few years. Unless sectors improve its capacity, it will not be able to maintain a standard of safety for its employees.

Ms N Nkondlo (ANC) referred to the red dot project and given the HOD’s indications about the challenges related to people’s responses to the project being established. She wanted to know if the service is being used to full capacity.

Secondly, asked about the level of pressure placed on the infrastructure of clinics in hotspot areas, regarding hotspot strategy, she wanted to understand if the City of Cape Town, along with hotspot areas has local multi-stakeholder structures. Once again there is a government led response which shows communities were not getting on board when it comes to some of the behavioural issues.

Mr Herron said he was surprised at the answer regarding the CTICC’s hospital. He interpreted it as so many others would thinking ‘rent free’ included operating costs, waste, electricity and water. He assumed rent free literally meant without any costs involved. However, now it seems R9 million per month is paid to use those facilities. He asked what places were or are offering quarantine and isolation facilities. Lastly, he wanted to know what it meant when someone did not qualify medically to make use of those quarantine and isolation facilities.

Mr Marais said he found it interesting to see Dr Cloete touching his face throughout the entire presentation. He posed the question if it is not time citizens are informed to not only wash hands but also to wash faces. Many like Dr Cloete wash hands but will forget about could have been touched and then incidentally touch the face.

Dr Cloete thanked Mr Marais for pointing it out. He said he is very much aware of his habit of touching his face. It is part of the behavior change issue. Sometimes people, himself included, are not even aware of doing it as it becomes a habit, but really speaks to the importance of keeping good hygiene.

In November last year, at the Department’s management meeting, Dr Salim Abdool Karim raised a red flag, when COVID-19 took root in China, which happens to be one of the biggest producers of all the medication in the world. It is made by pharmaceutical companies that come out of China and India. Dr Karim raised the issue with the Department. The strategy right from the onset is to have a team of people working at trying to secure sustainable chronic medication sources, generic alternative sources and establishing a system in place from the get-go. The systems are in place and currently it is just a matter of getting the stock of medications from the distribution networks. The Department worked alongside Uber and health workers who deliver medication to people’s homes. A WhatsApp and email line are being created for people who need help with chronic medication.

While recognising people die from Covid-19, the majority had diabetes.  However, there is a small percentage of people who died, and despite being suspected of having diabetes, it was not detected.

Regarding the Hospital of Hope at the CTICC, he said the costs are not rental costs but operational costs. This is separated from what the rental costs would have been if the Department had to pay rent.

The International Classification of Diseases (ICD) guidelines and the National Guidance say quarantine and isolation is preferably a position individuals must do at the individual’s own home. If not at the means to do it, the Western Cape Department of Health (WCDoH) will offer a designated facility in a state facility.

As such, the Department will first find out if the individual is able to do it from home before deciding on the matter. What the Department regards as good criteria for isolation and quarantine is if there is a positive test and if the person is within the window of infecting other people.

Regarding capacity and infrastructure, there continues to be a lot of infrastructure challenges at Tygerberg. Part of the management issues at Tygerberg Hospital were linked to the really inappropriate infrastructure, with the East side claimed as a waste. The infrastructure project of rebuilding Tygerberg Hospital continues to be one of the things it works on very hard.

The evidence emerging around COVID-19 being an airborne disease has far reaching implications. The Department is looking at the technical indications, but the Ministerial Advisory Committee guides the WCDoH regarding what it looks at. It currently expects some guidelines from the Medical Advisory Committee on how to adjust its strategy.

There are 300 staff member vacancies associated with the field hospitals. While the CTICC Hospital of Hope has capacity for 860 beds, it comfortably manages 400 beds now while still having staff vacancies. Potentially it does not have to fill those vacancies as the 400 beds seem to be sufficient for what it is currently doing.

The Department is going to the Standing Committee on its budget adjustment in two weeks time. It gets very little money from National. It received R500 million external for the HIV Conditional Grant. This does not touch the R2.4 billion the Health Department said it needs. It may not need the full R2.4 billion but there is internal provincial re-prioritisation and a commitment from Provincial Treasury who will give the Health Department additional surety for additional resources.

The Chairperson reminded the Committee about the weekly report in which a number of questions were determined in April 2020. It was proposed the set of questions be amended with the Committee’s permission, given the Western Cape found itself at a different phase of the pandemic. It proposed questions on the following be included:

The availability of oxygen and oxygen supplies in the Western Cape.
Hospital admissions of COVID-19 patients
Hospital capacity

It proposed the following questions be removed:
The number of tests, as the statistics are provided through press statements.
Testing delays
The peak
The gene-expert machines

Ms D Baartman (DA) moved to support the resolution.

The Committee agreed.

The Chairperson alerted Members to the Draft Committee Report on its activities for the month of June which must be adopted. Members were asked to go through the Report.

Ms P Lekker (ANC) moved to adopt the Report.

Ms Philander seconded the adoption of the Report.

The Report was adopted.

The Chairperson thanked the Members and said the Report will be in the Announcements, Tablings, and Committee Reports (ATC).

She informed Members of the consideration and adoption of the Draft Committee Minutes for 18 June 2020, the meeting where the legal note was considered.

Members were asked to go through the Minutes.

Ms Baartman moved to adopt the Minutes.

Ms Philander seconded the adoption of the Minutes.

The Minutes were adopted.

The meeting was adjourned.



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