Western Cape Premier on Adjusted Level 3 Lockdown; COVID-19 Update & Vaccine roll-out

Meeting report

The Chairperson welcomed everyone to the second Covid-19 Committee meeting convened during recess.

Adjusted Level 3 Lockdown update
Premier Alan Winde noted he would not discuss each slide but would preserve time for more engagement with Members. He said all indications look as though the peak of the pandemic is being reached. He always gets worried when speaking of “the peak” since it appears to give people licence to relax. The peak means that hospitals are full, and that the pressure on the healthcare system is “really up there.” Therefore citizens should not relax their efforts because we need to flatten the curve.

Before 29 December 2020, in the lead-up to the Adjusted Level 3 lockdown, only the Garden Route in the province was deemed a hotspot. This was “well into” the peak of infection in the Garden Route. The province had engaged the Minister of Health, through the oversight committee and at Provincial Command Council (PCC) level, on how the health system could be protected. He had requested a further 14 days of lockdown which was part of the original (as opposed to the “adjusted”) Level 3 restrictions. He had requested a few restrictions which were acceded to, but he did not want the beaches, parks and other open areas closed. Due to the regulations which were implemented in the province, it was apparent that the spread was slowed down. The province was now moving out of the peak of the second wave. There is definite decline in infection numbers along the Garden Route which would be seen in the next presentation.

Upon moving from the “first round to the second round” on 29 December, the only real difference was the move of curfew from 5am to 6am and from 10pm to 9pm; everything else remained the same. Changes in regulations on the country’s borders did not affect the province, as it does the neighbouring provinces.

Dr Cloete continued with an update on liquor regulations and trauma units and the efficacy of regulations. The initial alcohol ban in late March was lifted on 1 June. On 12 July 2020 the alcohol ban was reinstated. It was lifted on 18 August 2020. On 21 September 2020 alcohol regulations were again relaxed, the curfew was extended to midnight and alcohol sales were permitted on Fridays. On 12 November 2020 the ban on alcohol sales over weekends was lifted. On 15 December 2020, restrictions were reintroduced for sales only from Mondays to Thursdays. On the 28 December 2020, the total ban was re-instituted. This caused the “significant reduction” in trauma cases during this period.

One week before the current alcohol ban there were more than 150 trauma patients (the median being 74 cases). Immediately after the alcohol ban, daily trauma presentations on average decreased by 47% to 66 cases (the median being 39 cases). If Boxing Day is compared with New Years Day, the maximum daily trauma presentations saw a decline to 58%. Compared to New Year's Day in 2020, we flattened the curve of trauma and saw trauma presentations to hospitals decrease by 65%, from 188 cases to 64 cases on New Year's Day in 2021. Similar trends were observed throughout the country.

Director-General of the Western Cape Government, Dr Harry Malila, spoke about the enforcement of regulations. In the weekly Premier's Coordinating Forum (PCF) meetings with all municipalities, health issues are dealt with in addition to enforcement and communication. Statistical information had now been requested from the South African Police Service (SAPS) to test the efficacy of existing information.

He said slides 10 to 13 deal with law enforcement. Slide 10 is information from SAPS. Slide 11 deals with awareness campaigns, particularly from a law enforcement perspective. This information is reported to the provincial Health Department on a weekly basis.

Slide 12 deals with law enforcement by the City of Cape Town. Given the size of the metro, the area is dealt with in detail. Most contraventions were violations of the curfew or not wearing masks.

Slide 13 deals with provincial traffic as part of law enforcement.

Slide 14 deals with the enforcement of liquor regulations, particularly through the Western Cape Liquor Authority (WCLA). 345 investigations have taken place since 27 March 2020 to date. Fifty-four licences were suspended; 23 applications dismissed; 14 applications referred back to the prosecutor; 1 application withdrawn; and 3 applications are pending.

Of the 54 licences suspended, 53 return hearings took place in which one licence was revoked after finalisation of a section 20 consideration; 49 suspensions were lifted by the Liquor Licencing Tribunal (LTT); one suspension was confirmed with the licence remaining suspended; and two suspensions were lifted (one in the High Court and one as part of an internal appeal).

Challenges faced by the WCLA include:
● Increased infections amongst liquor inspectors during this time period as well as exposure of some inspectors to Covid-19 positive cases;
● Currently two liquor inspectors have tested Covid-19 positive (one hospitalised) and one inspector was directly exposed to the virus and thus needed to self-isolate;
● With the country placed on an Adjusted Level 3 with all liquor sales prohibited, it was reported that most police stations had no matters of non-compliance recorded; and
● Those operations deferred due to Covid-19 infections and exposures during the December period are planned to commence in January 2021.

Dr Malila concluded that the prohibition on the sale of alcohol (on-site or off-site) had been effective in reducing trauma cases in five key hospitals, and by extension all facilities in the province. The Department of Health would provide information on cases, hospitalisations and deaths as an indicator of the efficacy of the regulations. Enforcement of the Disaster Management Act (DMA) regulations had been ongoing throughout the festive season, fines had been issued and arrests had been made.

Discussion
The Chairperson thanked the presenters and opened the first round of questions by Committee Members, at two minutes per party.

Mr R Mackenzie (DA) appreciated the concise update. He asked if representations had been made to relax some regulations along the Garden Route, given the present situation as outlined in today's briefing.

On the alcohol ban, he asked how the Western Cape government would regulate alcohol going forward, given its importance to the province and given that it cannot be banned “forever.”

Addressing the Director-General, he asked what sort of services the millions of people in the Western Cape can expect. He asked what the plans were for employees who were back from leave, given that the country was now on Adjusted Level 3 Lockdown.

He asked what the Covid-19 impact had been on staffing in the province (for instance, the number of absent employees, the number of employee deaths, and the like). He asked if plans were in place to provide counseling for the “tens of thousands of employees” who have returned to work.

Addressing the Premier, he asked if discussions had been had in the PCF meetings with the economic cluster about smaller municipalities affected by beach closures. He asked how these municipalities would be funded given the economic impact of these closures – such as the foreclosing of small businesses like restaurants which rely on the ocean economy and other income from tourists.

Mr M Sayed (ANC) asked the Premier what discussions there were about the reopening of schools during the peak of infections. Was there a possibility of delaying the reopening of schools and, if not, what measures are being put in place.

He recalled that the Premier had cautioned Health MEC Mbombo about a statement she had made about her holiday. He asked what practical steps the Premier had taken in response to the Health MEC's statement. 

Mr C Dugmore (ANC) asked the Premier about the communication and the advisability of referring to a ‘peak’ without qualifying that statement. This question was about the Premier's remarks about people relaxing when he spoke of passing the peak. Mr Dugmore suggested that the possibility of a third wave should be communicated to the public with due urgency.

Mr B Herron (GOOD) asked the Premier what happens after the second wave peak. He said “I feel like we have seen this movie before” referring to the relaxing of restrictions upon the reduction in case numbers after restrictions were instituted. He asked what the plan was once the province comes out of the second peak when people are expecting restrictions to relax. How did the province intended to avoid going into a third wave, and if that was even possible.

On enforcement and military assistance in the Western Cape, he asked if the Premier could provide details about what the military’s role was.

Mr F Christians (ACDP) queried the Western Cape Government’s plan for field hospitals for a possible third wave. He asked this particularly due to cost concerns. He noted a dispute about the closure of certain temporary field hospitals.

He echoed Mr Mackenzie’s question by asking what the province would do to support businesses dependent upon tourism and the beach economy.

He also echoed the question on what the province was going to do about the alcohol ban, given that it could not be banned forever and that it was an important industry in the Western Cape.

Mr P Marais (FF+), by way of metaphor, suggested that all actions taken by the government were superfluous if, as is the case, there is not an adequate supply of vaccines in the country. He got the impression that we are mopping up water caused by a broken pipe and that we are unable to turn off the taps. 

He asked why Ivermectin was not being used given its surging popularity and its recent endorsement by several “senior medical experts.” There are very few side effects and in countries where it was tested, it had “very great results.” He asked what the Western Cape was doing to put forward the case for the use of Ivermectin given the dire situation in hospitals.

Responses
Premier Winde commented that many of the questions would be covered in the second presentation by Dr Cloete. On the question of the Garden Route, Premier Winde said that he had argued that the Garden Route should - as the initial hotspot in the region - be looked at through a “differentiated approach”. The Eastern Cape premier had argued the same thing in that region. Although he attends the PCC meetings, final deliberations on this happens at a national cabinet level. He continues to believe that however long the virus is going to be with us, we must prepare for a “new normal.” Dr Cloete had been saying this for a while – that the virus will be with us for at least another 18 months. He believes in a differentiated approach going forward because the country and the economy cannot afford to have “big blanket lockdowns”. Shorter interventions were needed to mitigate the harm to the economy but which have as much impact as possible in slowing down the virus.

On the alcohol ban, he agreed “we cannot have these alcohol bans or even these lockdowns which last for a very long time". He had been arguing for much more for business support from government. That is, when government imposes a lockdown in which businesses are forced to close, there needs to be a support package for businesses to prevent ever-increasing business closure.

Premier Winde raised two points on the alcohol ban. The first was that during harvest time - which it presently is - the existing and unpackaged supplies of alcohol will have to be dumped to make way for the new harvest, which has financial implications for alcohol producers. The second point was that although there had been a decrease in the number of hospitalisations linked to alcohol consumption, yet the dumping of alcohol supplies would result in a drop in liquor prices due to oversupply, which may see an increase in trauma causes. This would reverse the trend of decreased hospitalisations which the regulations banning alcohol aimed to achieve in the first instance.

Once the festive season arrived, at the last cabinet meeting of 2020, he implemented a “festive season operation and management plan” where the PCF meets every Tuesday. The last PCF meeting of the festive season is next Tuesday 19 January 2021. All municipalities and municipal managers are involved. This would involve discussion on the beaches which he called “critical,” especially for businesses which rely on the “oceans economy". The industry is massive. This economy ranges from the ice-cream man on the beach to renting deck-chairs to fishermen to restaurants, the hospitality industry, and people who provide surfer and swimmer training. They have not had an income in the height of their season, where they would normally have had an income which would sustain them for the rest of the year. This income has “absolutely disappeared". He will keep pushing for business support programmes such as UIF and other business support initiatives.

On the opening of schools, there was a meeting that morning and that there was a further follow up with the provincial department, which would culminate in a President's Coordinating Council (PCC) meeting with the President called “On Education” to take place on 14 January 2021 where provinces would give their input. As things stand, the Western Cape Education Department (WCED) is prepared and ready for schools to open".

On the Western Cape Minister of Health’s supposed holiday trip to Limpopo which had been in question, he confirmed that “the Minister did not go to Limpopo. The Minister did not take a holiday. She has been in every single one of the meetings we have been holding right throughout this period. She was singing a song—she can talk about the words of the song where she talks about Limpopo". The question could be raised with her directly.

On Mr Dugmore’s question on the “peak” and when it was expected that there could be a third wave, Premier Winde replied that "when we talk about ‘the peak’ it concerns me because I do not want people to relax". He reiterated that a “new normal” has to be developed. It is developing now, more so after the first wave because everyone knows someone who has lost a loved one; everyone understands the full implications of this. “And of course the second thing that hit us was this second strain". In looking at what the second wave would mean for the Western Cape, it was determined that the implication for the province would be a wave “twice as high” and the much more infectious virus demands a readjustment of the model used. What we said in the beginning was ‘we are not going to run out of beds, we are not going to run out of oxygen'. Quite frankly if you think about the restrictions, the reason we have the extra layer of restrictions was actually not for beds or for oxygen, but really for our health workers". The question was how do we protect our front line?

Premier Winde “definitely” did not agree that the closure of the Cape Town International Convention Centre (CTICC) field hospital was a failure. In actual fact, go and visit the extra beds that have been put in at Mitchell’s Plain. It was a strategic decision which was based on “manpower". The consequence of that decision means that we have got more beds in this province—across the province and those beds are actually permanent beds; they have got oxygen laid on and after this wave they can be used for other needs. We always knew that even before Covid came along, our hospitals were always under pressure and now we have much more capability. He reiterated that when the indicators show that it looks like we could be reaching the peak, no one must relax.

Addressing Mr Herron’s question, Premier Winde replied we will continue with that messaging. According to the epidemiologists that he has spoke to, we have got to rely on the data and we are learning all the time. We cannot overlay the first wave with the second because there is a second strain. Maybe there will be a different strain again. He added that there are also certain immunities building up; there are certain areas where the curves are less steep which implies a certain amount of immunity build-up. This will help in mitigating the risks.

On the military rollout, Premier Winde replied that Dr Cloete and the Western Cape Government three weeks ago requested medical help due to the front line being under pressure. They asked for thousands of extra frontline workers and any other area. We were asking for medical help, military-medical help, and it was the Garden Route, in its peak that asked for military help. We got that help through the Joint Operations Command. We did not formally request the other help that has landed in the City, but it is 60 personnel on a shift – which in actual fact is a small number of military service members if compared to the number of police officers, which is just over 20 000, plus another 5 000 metro and traffic officers. 

The question on vaccines would be addressed as part of second presentation.

During the pandemic, staffing has always been under a lot of pressure, but it will be seen from the second presentation that the good news is that we are seeing fewer infections in staff, but we have also had a number of uptakes in our request for more staff and more contract staff.

There was an effective plan in place to supply extra beds which are not field hospitals, because obviously at some stage we have to break those beds down, whereas all of the beds we are building are fully-functional beds, much easier for staff because they are in existing health facilities, so it really does make a lot of sense.

Premier Winde replied that he had already spoken about the oceans economy and that the science indicated that the beaches need not have been closed. There was an economy around the beaches and thus many people are suffering. The province would continue to push for the beaches to be reopened.

On alcohol, he thinks there is an opportunity for learning; he had mentioned his worries about the wine industry. Now is the time that we can look at engaging with the industry itself; we have got to relook at our own regulatory environment. What can we do that helps us—with the economy on the one side—getting the balance right but also making sure that we have a new normal about trauma? And what else can we learn from what has happened now with some of these methods we have put in place?

On the mopping up metaphor by Mr Marais, he replied we have to get our new normal right, and quite frankly every time we have opened up and got new freedoms…we had to come in with more law enforcement because not everyone was able to use that freedom in a new normal way. We got so many people that were really not playing the game. And of course when that happens your numbers go up and we have to protect the front line, we have got to protect the beds, we have got to protect the oxygen, and of course we want to make sure that we do not lose our loved ones.

Premier Winde did not want to say too much about Ivermectin. There was lots of incoming information. We have a system called SAHRPA and there were many interesting articles written by doctors and professors. He wanted to use this system one was starting to see that people using the product in incorrect dosages is leading to harm. He implored citizens to understand that these products must go through a process where they get vetted. Effectiveness and safety of a product must not be based on a video clip or hearsay.

On staffing, Dr Malila replied that every department has the necessary protocols in place and have activated their occupational health and safety committees. He explained that there was a process in place if there is a positive Covid employee at work, where the Department of Transport and Public Works (DTPW) comes in to clean the space.

On communication, Dr Malila replied there was daily Covid messaging which goes both to staff and the public. There are also two messages per week which go to staff, such as the message issued on 12 January 2021 which dealt with return to the workplace. At the moment there was encouragement of staff to continue meeting virtually and to limit physical interaction with fellow colleagues.

In the line departments where staffers work with the community, staffers observe the necessary health protocols, particularly in large service delivery departments. There are institutional protocols in place for departments who do not have a direct service interface with the community.

On the Covid update, Dr Malila replied that a weekly Covid-19 report is generated and submitted to the Department of Public Service and Administration (DPSA) in Pretoria. For the nine Western Cape departments as at 8 January 2020, there was a total of 9 529 cases. There are only 1 108 active. About 8 200 have recovered. Total fatalities come to 174, most emanating from the Department of Education (92 cases) and Department of Health (76 cases). DPSA was working on the protocol circular for the Adjusted Level 3 Lockdown which will be issued shortly to all departments now that people were starting to return to work.

The second wave had a major impact on staff and the broader community. The Department has been engaging with organised labour and would reengage counselling services. Top managers had a role to play by talking to staff and trying to calm them down. His was a caring government and would institute the appropriate health measures to protect staff.

Further questions
The Chairperson thanked Dr Malila and asked the Premier and the Director-General if, when a vaccine is acquired in the Western Cape, if they have thought about messaging and if the anti-vaccine sentiment is something we should be concerned about in the province. She had read an article called The Greatest Story Never Told – millions of people get vaccinated without issue but one or two individuals will have an issue with the vaccine and then this is the story that people tell. She asked if there were ways the province was thinking about encouraging people to get vaccinated when the time comes. How do we get people who are hesitant about vaccines to have an informed view around vaccination?

Ms N Nkondlo (ANC) asked if the Premier was aware that nine SASSA service points have been closed since March 2020 in the City. Everyone in Helderberg must travel to Elsies River for their disability grant. This was causing queues of between 500 to 1 500 people, and some are even sleeping over. This makes them vulnerable to infection.

She asked if the hotspot strategy implemented in the first phase is still being implemented. If so, she wanted to know in which areas the strategy has proven successful.

Mr Herron asked if the third wave was inevitable or likely to be inevitable, or if there was something the province could do to mitigate the need for the kinds of restrictions put in place in the first and second waves.

Mr Christians said people on social media were joking about the vaccine, saying politicians ought to take them first. The fact that vaccines are safe, tried and tested is the message that should be going out to the public.

Mr Marais said that the report he received from the Department said that hospitalisations dropped by 26%. However, the same report said that deaths continue to increase. What was the correlation between the two? He asked if the people who had died, died at home because they were unable to be admitted to hospitals. The report indicated that hospital admissions between 5 and 12 January 2021 was 2 400 and discharges was 2 100. There must have been a balance brought forward. He asked for the figure before 5 January. 

Responses
Premier Winde replied that Dr Cloete’s presentation would address questions on leadership and the vaccine rollout, as well as the communication strategy. Despite the jokes about vaccines, politicians might have to take the vaccine first and he was prepared to do so if necessary. Mistrust about vaccines was due to the very short time to get them to market across the world. Boundaries had to be pushed to get the trials going. However, 30.5 million vaccines have already been administered across the world, and nearly 1 million have received the second dose.

He was fully aware of the SASSA debacle. It really was rocking him to the core. He raised the issue with the President on the preceding Sunday 10 January 2021. First to note was that the poorest of the poor were now being pushed aside again. Secondly, the resultant gathering was a major problem during this time due to increased risk of transmission. This had been discussed the previous day in the PCF meeting, as well as in an emergency meeting held with the National Minister both the previous day and that very morning. There was an issue between SASSA and some of the service points which were narrowed down during the first lockdown phase. If the province or City can help, they will do so.

On the hotspot strategy, he hopes the differentiated approach gets traction. Right now there are certain provinces that should not be in the lockdown level we are in, like Gauteng, KZN and Western Cape, because quite frankly we should be looking after those economies. He had the same opinion about the Garden Route which has had three weeks of decline. He would write to the national Minister of Health about his suggestion of a differentiated approach.

On the question about the third wave, Premier Winde replied that the province was liaising with its epidemiologists on this. Part of these discussions concerned what could be done to prevent a further economic lockdown, whilst still managing the health aspect. It was a matter of finding the right balance.

Western Cape Department of Health briefing
Dr Nomafrench Mbombo, Western Cape Minister of Health, made introductory remarks saying the committee invitation had asked the Ministry and the Department to focus on (1) latest statistics, (2) oxygen supplies, (3) management of hospital capacity, (4) fatalities, and (5) vaccine rollout.

After the stricter lockdown restrictions announced by the President on the 28 December, we still have to see the results of the two-week stricter lockdown. Western Cape had made a submission requesting two weeks to give a space for the healthcare workers to regroup and be able to reenergise. Therefore when you see the figures presented, it is just part of the process progress and it does not give much on exactly where we are. The Premier keeps on asking ‘are we in the peak or not’ – it depends. We do not know, especially now we hear about the numbers of people who are at super-spreader events such as the SASSA queues, we do not know what will happen.

On oxygen management, Members are aware that there is a contract between National Treasury and the National Department of Health to provide oxygen to the provinces during the Disaster Management Act (DMA) period. However, Afrox has most of its plants located inland so the Western Cape and Cape Town have insufficient capacity, partly due to demand also. Therefore, the Western Cape Health Department has to negotiate with the private sector which had similar challenges.

When Dr Cloete presents on hospital capacity, it is not only about bed numbers, but about operational beds that are inclusive of the staff. Going towards universal health coverage, strengthening the whole of the health system, even beyond Covid, we are not only talking about beds. Members keep on referring to the CTICC field hospital that was closed down. However, the team at the local level have come up with innovative approaches for extending the number of beds at hospitals such as converting old lecture halls, boiler rooms, store rooms—so that is part of the whole of the process.

Each hospital bed has its purpose – for example the level one district hospitals are not meant to have ICUs because they are level one. There is high level specialisation at level two and three. However, because the district hospital can offer high-flow nasal oxygen we find that some district hospitals are providing part of the critical care acute beds.

Dr Cloete would make a presentation on deaths happening in hospitals. On deaths happening outside the health system, this is being picked up by Home Affairs. This enables the identification of how many of these deaths have been hospitalised patients or at home. Graves are the responsibility of the municipality.

Although planning is being done on the vaccine rollout, it is ineffectual without the actual vaccine. This is dependent on the national government. It is unclear when or how many vaccines would be received. The province was working on 10% of the 1.5 million vaccines announced earlier in the month. The plan is therefore incomplete. Dr Cloete would answer in more detail other questions raised by Members in his presentation.

Dr Keith Cloete, Western Cape Health Department Head, said the strategy which would be used for all future waves comprised of:
● Community Prevention
● Surveillance and Response Update
● Scaling-up Health Platform Covid-19 Capacity
● Fatalities Management
● Vaccine Strategy

Community Prevention
This involves three elements:
● Disaster regulations: Adjusted Alert Level 3 remains and all Western Cape districts remain hotspots. The curfew on the movement of people is from 9pm to 5am, and establishments close at 8pm. There is mandatory face mask wearing, and restrictions on gatherings and public transport. Alcohol is prohibited for off-site, on-site and public consumption.
● Law enforcement: Provincial, City and District Disaster Management Centres are coordinating the systematic enforcement of regulations, along with SAPS. Multiple joint operations have occurred between the law enforcement agencies across a range of high-risk settings.
● Communication: The central messaging is on risk of transmission at especially indoor gatherings. Decentralised and sector-specific targeted messaging continues.

Surveillance and Response Update
Dr Cloete briefly overviewed the key indicators in slide 7 and their interpretation on slide 8.

According to the data, it is evident that we are entering another peak. By no means has there been a decline and that there remains a significant risk. In the last two weeks, there had been a decline in the test positivity rate. The data illustrates that increase in hospital admission is starting to decline, but that hospitals remain full. The green line on the graph indicating the level of admissions to hospitals shows that these facilities remain at or near capacity. The number of new people admitted are starting to even out.

In terms of critical care, in the last week or two, additional capacity had started to open up in the private sector, but not in the public sector.

On the mortality rate, the Department always looks at same day reporting. The grey line on the graph illustrates projected deaths based on historical evidence. The green dotted line shows excess deaths. The Department data is calibrated against MRC data. The reproduction number represents an international benchmark. It refers to the number of persons to which a single infected person transmits the virus.

When we were at our last peak, every single positive person, according to this reproduction number, was infecting about 1.2 to 1.3 persons on average. For instance, 10 cases would result in a further 13 cases which resulted in a growth in cases.

The reproduction number tends towards 1 when we come out of peak infections. All indications point to the fact that one infection is resulting in the infection of only one other, where the ratio is 1:1.

On characteristics of deceased patients by time period, these were divided into four separate phases: (1) early wave 1, (2) late wave 1, (3) between waves, and (4) wave 2. This information is limited to public sector where information on co-morbidities is complete.

He reported that there was no gender disparity in the data. There were no notable differences in age, sex or co-morbidities of deceased patients for different wave periods. These results are similar for admissions. The only minor difference was that HIV is less common in deaths in wave 2 due to areas worst hit in wave 1 having higher HIV prevalence.

Looking at the province, the case data continues to be affected by the festive season public holidays and the change in testing criteria. However, it is a good sign that cases are not increasing but have decreased by 1%. The proportion of positive cases on 7 January 2021 was 35.6%. This has dropped from a peak of over 50%. Further positive news is that total hospitalisations have dropped by 26%. The stabilisation of cases and more importantly the drop in the proportion of positive tests and admissions are very good signs that the second wave is stabilising. As always, we are hopeful but cautious and will continue to watch the data. Deaths have continued to increase. We will watch closely over the next few days to see if this changes.

Looking at the Metro, there is an 8% drop in cases. Even with the change in testing, this can be viewed as a positive sign. Across the Metro, most sub-districts show a decline in cases except for Northern and Eastern, which show very slight increases. These trends can be seen in the number of cases in Metro sub-districts:
Khayelitsha: 19% decrease
Klipfontein: 10% decrease
Mitchell’s Plain: 14% decrease
Tygerberg: 3% decrease
Southern: 13% decrease
Western: 17% decrease
Eastern: 1% increase
Northern: 1% increase

Looking at the rural overview, we can see that case numbers in rural areas as a whole continue to stabilise. There is a small increase of 1% for the entire region. The West Coast shows an increase in cases and this is indicative of the area being at an earlier stage of the second wave than the other districts. The Central Karoo shows a 24% increase in cases, but this is based on small case numbers. The Garden Route has passed the peak of the second wave and continues on a downward trajectory. These trends can be seen in the number of cases in the rural areas:
West Coast: 7% increase
Garden Route: 13% decrease
Overberg: 4% decrease
Cape Winelands: 1% increase
Central Karoo: 24% increase (large increase but the base number of cases is very small).

Scaling-up Health Platform Covid-19 capacity
Dr Cloete said that primary healthcare (PHC) facilities continue to do Covid testing and triage cases to get people who need oxygen into hospitals. On PHC capacity, these facilities have continued to see demand for Covid testing and triage confirmed cases. There has been active de-escalation of non-Covid PHC services.

On hospital capacity:7 693 total acute operational public sector beds (excluding specialised beds at psychiatric hospitals, TB hospitals, Red Cross hospital, Mowbray Maternity hospital), inclusive of general and critical care public sector beds for Covid patients. The operational bed number differs from day to day. There are 626 intermediate care beds provisioned in the Metro: 336 Brackengate, 90 Lentegeur, 200 Mitchells Plain Hospital Covid-19 field hospital — beds commissioned in an incremental fashion. We also have 64 intermediate care beds at Sonstraal Hospital (5 extra beds had been added) in Paarl. We have opened—of the potential additional 136 intermediate care beds.

On fatalities management, the mass fatality centre in the Metro with capacity for 336 bodies (additional 96 spaces added); currently holds 101 decedents and a cumulative total of 1006 bodies admitted. The mass fatality working group is coordinating capacity across the province.

On the acute service platform, currently there are 3 323 Covid patients in our acute hospitals (1 889 in public hospitals and 1 434 in private hospitals). This excludes patients under investigation (PUIs) and cases in specialised hospital settings. Covid hospitalisations have stabilised. Whilst we continue to experience psychiatric pressures; trauma has decreased significantly. The Metro hospitals have an average occupancy rate of 93%; George area hospitals at 61%; Paarl area hospitals at 74% and Worcester area hospitals at 73%. Occupancies in the Covid general beds reflect the ongoing Covid pressures with Metro hospitals at 91%; George area hospitals at 59%; Paarl area hospitals at 90%; Worcester area hospitals at 73%. Covid and PUI cases currently make up 35% of all available acute general hospital capacity in both Metro and Rural Regional Hospital areas. Covid intermediate care— Hospital of Hope (Brackengate) currently has 305 patients (2 606 cumulative admissions), Freesia and Ward 99 has 67 patients, Mitchell Plain Hospital of Hope has 92 patients and Sonstraal has 60 patients.

Temporary tents have been commissioned at the following hospitals: Khayelitsha, Wesfleur, Mitchell’s Plain, Eerste River, Helderberg, Karl Bremmer, Brackengate. These are used for discharges mainly to ensure a more rapid turn-around time of the operational beds. Brackengate has two tents used for admissions and discharges.

Emergency Medical Service (EMS) and DTPW Taxi service have implemented a streamlined transport system to assist with inter-facility transfers and rapid discharges to optimise capacity. The combined effect of this has been to significantly assist in decongesting the service platform.

Our data team has developed an integrated daily hospital bed available capacity and utilisation dashboard, which is linked to available staffing and oxygen capacity at each of the hospitals.

There has been a significant increase in testing in the public sector that has been maintained at double the testing numbers prior to the resurgence. The National Health Laboratory Service (NHLS) is successfully using antigen testing across the province including mobile antigen (Ag) testing, hospitals with on-site laboratories and now also at hospitals with no on-site lab.  We aim to expand Ag testing across the province.

The testing criteria have been updated based on available testing capacity, and testing restrictions have been implemented.

On oxygen utilisation, the combined oxygen utilisation in the Western Cape public and private hospital sectors is currently approximately 73 tons daily (slightly reduced from the average daily utilisation last week). Whilst public sector hospital consumption is 69% of the Western Cape production capacity, the additional 31% is used by the private sector—the combined utilisation is still above the maximal production capacity of the Afrox Western Cape plant (70 tons). Afrox have put contingency plans in place by bringing additional oxygen into the province daily to augment the provincial supplies. The Western Cape now has 5 bulk oxygen tankers allocated for the daily delivery of oxygen supplies to individual hospitals. We will monitor the utilisation of oxygen carefully over the coming weeks.

Fatalities Management
With the onset of pandemic in South Africa in March 2020, a working group was established to plan for and put measures in place, across the Western Cape to deal with mass fatalities should this be required. The working group initiated, developed and implemented comprehensive strategies for fatality management at provincial and district level. This included:
● Mass fatality plans and supporting strategies
● Communication protocols with provincial and national departments and the funeral industry
● Mass burial capabilities should this be required.

The actions completed to date include:
● Mass Fatality Plans: the city and all five districts have prepared Mass Fatality Plans and support plans.
● Support of Home Affairs including additional offices and extended hours to register deaths.
● Crematoria function overnight and over weekends to ensure that backlogs are cleared. 
● The working group is involved in ongoing monitoring of availability of storage space across the Province and to date have resolved all storage capacity problems.

Each district daily monitors the availability of spaces for fatality management in terms of mortuary and undertakers, each day. Each district has comprehensive strategies at every point in the fatalities value chain to ensure that we do not run out of space. On 6 January 2020, we had 2690 shelves, 1547 shelves occupied and 1143 shelves available. The commissioning of the Tygerberg Mass Fatality Centre has played a critical role in ensuring adequate shelves during both Covid-19 peaks in the Metro.

Vaccine Strategy
The vaccine is probably the most powerful global weapon to turn the tide against the Covid-19 pandemic.
The National Department is driving the procurement and we align with their efforts. The National Minister announced on 7 January 2021 the acquisition from the Serum Institute of India 1 million doses of the AstraZeneca vaccine by the end of January 2021 and a further 500 000 doses in February 2021. Further negotiations are being pursued with other vaccine suppliers for more stock in addition to the stock secured via the COVAX initiative. The Western Cape Department of Health is focusing on readiness to implement the vaccination programme.

The objectives of the strategy is to provide equitable and ethical access to Covid-19 vaccines in the Western Cape to reduce morbidity and mortality in vulnerable people, to reduce community transmission through herd immunity, and to protect the health system capability

The framework is guided by three elements: science, ethics and implementation.

There will be three phases to the strategy. The first phase is primarily to target healthcare workers for vaccinations, the second phase for essential workers, people over 60, those with co-morbidities (who are older than 18), and the third phase would be every other adult. The Department will further refine prioritisation based on expert advice.

On messaging and communication: honest and transparent communication to build trust is essential.

The following are the focus areas:
● Motivating people and all sectors of society—lets unite to vaccinate—mass social mobilisation
● Build vaccination confidence: address medical concerns (efficacy, new variant, and so on); address religious and cultural concerns; address misinformation
● Logistics around availability, accessibility and acceptability

Stakeholder engagement is a massive operation that requires a multi-sectoral approach and the support of public. Key stakeholders include organised labour; civil society; higher education institutions (HEIs); business; religious communities. We will use existing forums and structures, including statutory structures such as clinic committees and health facility boards, as feasible. Stakeholders will be mobilised both provincially and at district and local municipality levels. 

In tracking progress through the information system, data is a critical requirement to track coverage at individual and community level. The Provincial Department supports the National Department's proposed computer application system. Contingency plans will mitigate risk of any delays. Ideally, an opportunity to capture electronically at the point of administration should be utilised.

There is a great opportunity to:
● Build a movement for better health;
● Unite all sectors and parts of the community around a common objective Lets Unite to Vaccinate to turn the tide against COVID; and
● Lay a good foundation for collaboration between public, private and civil society for Universal Health Coverage (UHC).

Vaccination does not replace the need for non-pharmaceutical interventions (NPIs) like mask wearing, social distancing and hand washing, for the foreseeable future. We have to reprioritise our efforts and resources to act with urgency to vaccinate as many healthcare workers and people as soon as possible. We call on the public and all stakeholders to join us on this most critical collective intervention.

Dr Cloete concluded by stating that we have entered the peak of the second wave in the Western Cape, with early signs of stabilisation. Our local teams are still on high alert for surveillance and response to localised clusters that can be targeted for maximum impact, especially the vulnerable. Our biggest concern is the non-adherence to protective behaviours – hence the targeted law enforcement interventions, in line with the new regulations. The hospitalisation and mortality data continue to show an increase, with early signs of moving to a plateau. We have activated contingency plans per geographic area to scale up hospital Covid capacity as required, while alcohol-related trauma has decreased. Our key consideration is that our healthcare workers continue to face significant strain. We need to safeguard them and their families. It is essential to maintain a strong focus on behaviour change to ensure containment for the six months, while clarity on the vaccine emerges.

Discussion
Ms W Philander (DA) asked how sure is the province that the current oxygen provider would be able to continue to provide oxygen. She recognised the contingency plans Dr Cloete had mentioned but was concerned about what would happen in possible third or fourth waves. She asked if there were further contingency plans such as using other providers.

On the centralised procurement of the vaccine, she asked when the 100 000 healthcare workers in the province may be expected to be vaccinated.

On the SASSA debacle of long queues, she asked how concerned the Health Department was that these are super-spreader events, especially in districts which are now starting to stabilise. She asked what the Health Department was doing about this. 

Ms R Windvogel (ANC) asked about the number of infected persons between the ages of 15 and 19. She asked if there was any truth to the claim that persons between these ages were more vulnerable and, if so, what measures were put in place to respond to this.

On testing, she said that testing stations have been turning people away when their daily testing targets were reached. She asked therefore if the positive figures reported were not manipulated. She asked if there was data on how infection rates were likely to change in districts and sub-districts following the return of people from holiday destinations, along with the measures put in place to address this. Hospitals had been turning patients over 55 away, due to their increased risk of fatality. This had been her experience in Swellendam.

She asked how many additional staff had been employed between November 2020 and January 2021 in response to rising infections and mounting service pressure.

On the possibility of third and fourth waves, Mr Herron said that if we accept that stabilisation is not an opportunity for relaxation, then how do we move out of the second wave in a way that allows us to relax some of the restrictions and proceed in a way that we enter the third and fourth wave without having to re-impose those restrictions. Is that possible and what do we do as a provincial government to proceed from the second wave forward into the third and fourth waves and avoid returning to the economic and social movement restrictions?

On the presentation slide dealing with the reproduction number, he asked why the death and admission rates are recorded on the same slide. He asked what this tells us about the reproduction number.

On the differentiated infections in sub-metro regions, he asked why the province was seeing lower infection rates in Klipfontein, Mitchell’s Plain and Khayelitsha as compared to other sub-regions.

On the vaccination phases, he asked if Dr Cloete had a timeline for Phases 1, 2 and 3.

On the Afrox daily oxygen production and supply, Mr Christians noted that in the 29 December meeting the Health Department stated that 65 tons per day were produced, and that the company was looking at an additional daily production of 5 tons. The usage was currently at 75 tons per day. He asked - as had already been asked - what the backup plan would be if the oxygen supply reached capacity.

He asked if Dr Cloete was aware of cases where patients tested positive and subsequently died, were turned away from hospitals. If so, he asked where this occurred.

Mr Marais asked if it was wise to vaccinate healthcare workers first, since if the vaccine has unforeseen effects, the healthcare system would be compromised. He raised doubt whether healthcare workers should be treated as guinea pigs.

On co-morbidities, he said that diabetics are not tested in the same way HIV patients are. He asked how they were testing for diabetes, and how a programme previously convened under the Head of Department (HOD) was going. He also asked how many people were receiving their chronic medication.

He asked if the lack of doctors at clinics and hospitals was being addressed, and if public doctors were reexamining people who had expired disability grants who could not afford to go to private hospitals and providing them with certificates for disability grants.

Responses
On oxygen supply, Dr Cloete replied that there were extensive negotiations with Afrox, the National Department of Health and Air Liquide. Both Air Liquide and Afrox have big oxygen generating capacity in the Gauteng and Mpumalanga because of the industrial activities in those areas. It is only Afrox that has production capacity in Cape Town and in Port Elizabeth which is much smaller than the big capacity elsewhere. What is evident is that if Air Liquide had to be the backup for Afrox in this area, they would have to drive in 20 trucks of oxygen from Sasol to the province. This would take those two to three days to deliver oxygen. There was an agreement on the afternoon of 2 and 3 January 2021, additional trucks will be redirected into the Western Cape. We are using in excess of 73 tons a day, private and public. They are producing 70 tons per day in the province; we have spare oxygen of 120 tons. In all hospitals there are 180 tons.  So the supply is secure for what we have now.

On the question of plans for the third and fourth wave, Dr Cloete replied that this was part of contingency planning. What they had learnt was that planning has to be done for the country and not for individual provinces. The national team was working with the province.

On vaccines, he replied that the province expects a consignment from the National Department. The province is preparing for Phase 1 for healthcare workers for the first week of February 2021. Logistics are being shored up as if the province is going to receive some doses before the end of February 2021 so that we can start with Phase 1 in February. The province was using the current month to plan for Phase 2, but an understanding is needed of when additional doses will be available in the country. After this understanding, a timeline will be established. This will apply for Phases 2 and 3. The province was awaiting the date on when additional doses will be arriving.

On SASSA, he replied this is a concern, as are all other super-spreader events. There is a hotline which calls everyone who is positive. If positive cases are found to be linked to these queues, there will be an extensive case-finding exercise which will have to unfold. He gave examples of linked cases. The first was a case in Helderstroom prison; the second was a case connected with Sea Harvest; another was a case involving nursing students at a nursing college. When linked cases are observed, there is a departmental response.

On the number of infected persons between the ages of 15 and 19, he replied that Ms Windvogel was not being specific enough in terms of time frame. He would send her the data for whatever period of time. This age group was not more vulnerable to the virus, but is more vulnerable in how this group socialised in December. The risk lies in the gathering transmission, not in the virus.

On testing stations, he replied they operate with no quotas in mind. If this happens, he asked that Members provide specific information on where this was occurring. Some people do arrive after the closing time, this is when people are turned away and asked to come the next day.

On the question of the manipulation of figures, he replied that when the current stage is reached, not every single person who is positive will be tested, and that they rely on statistical extrapolation.

On people returning from holiday destinations, he replied that the Department is vigilant and mass returns will be picked up. Whether someone was living across the street or whether someone was coming back from Gauteng, the risk was the same.

On people being turned away over 55, he replied that when the clinical prognosis of someone is not looking favorable, it becomes an issue of prioritisation of resources in the system. As far as possible everyone is given access, but decisions have to be made about who is most likely to benefit from scarce resources.

The number of additional staff taken on since November 2020 would be provided in writing.

Mr Herron's question about the third and fourth wave was crucial. The Department has learnt a lot from the first wave. The concept of herd immunity and vaccine uptake will be introduced. That learning from the first wave will go a long way in determining how to deal with subsequent waves. He did not say when and to what extent a third and fourth wave was expected, but replied it was a sophisticated way of looking at things.

On the reproduction number, he replied that what is done for completeness—since it is a validation exercise—is that one takes cases (which eventually becomes unreliable) and extrapolate from deaths and hospitalisations.

On the lower numbers in certain sub-regions, he replied the working hypothesis is that there was a higher uptake of Covid in these areas in the first wave. There seems to have been a higher level of inherent immunity in those areas which provided protection and kept numbers low in the second wave. He conceded this was only a hypothesis.

On people being sent home from hospitals, he replied people are assessed in an emergency centre, they are given oxygen if required, and at a certain point family members are contacted and told that the hospital has done all it can. He is not aware of people being sent home to die.

On healthcare workers being used as vaccine guinea pigs, he replied that when regulators such as SAHPRA approve a vaccine, they will only do so (1) if it is safe, (2) if it has been tested on human beings and (3) where the clinical data is robust. By virtue of this, no one will be the guinea pig. Vaccines are life-saving. They will go to people who deserve them most regardless of background. Giving healthcare workers the vaccines first is an ethical decision since they work with Covid patients the most.

On co-morbidities such as diabetes, he replied the Health Department has learnt more about diabetes from Covid than before. And the approach to diabetes will have to be changed.

On disability grants, he replied it was disappointing that they expired on 31 December 2020 when the healthcare system was under pressure and healthcare workers are responsible for filling out forms for disability grants. This was the responsibility of SASSA. It was made clear to SASSA that our healthcare workers are busy saving lives, working in the system, and many of them are infected and it is not the right time to be filling in disability grant forms. There has been a request to ask for an extension of that expiry date.

On vaccines, Dr Mbombo replied it was crucial to realise that the reason the province was piggy-backing off the national government (in terms of centralisation) was because it is part of inter-governmental cooperation and also derives from the DMA. This is part of the understanding of the concurrent functions of the government. This is the case even for older and more established vaccines, such as with TB. The vaccine plan needed to be consistent with an equitable rollout.

On the third and fourth wave, she replied that it all starts with prevention measures. She referenced the SASSA termination of disability grants as well as the potential lifting of the recent lockdown restrictions. Also 88% of cases of the new Covid variant were in the Western Cape. Now with these vulnerable community members queuing for the SASSA grant renewal, it means that the health system will end up having to absorb them. That is why I am more vocal on this aspect because fingers will be pointing at us, yet it is not even our own issue. Every problem that is happening outside the health system, we ended up absorbing.  After repeating comments made by Dr Cloete, she concluded her remarks.

Further questions
The Chairperson said that there had been a number of rapid antibody testing stations popping up all over the place. She would like to understand if those private entities are obliged to share non-personal data with the Health Department. She asked what level of communication the Provincial Department is receiving from the National Health of Department to assist with provincial planning.

She also asked why the national government was the only entity that can procure vaccines nationally. She asked if this has a basis in law or if it is merely a convention.

Ms Windvogel asked if the province had stopped the use of ventilators, and which was more effective in managing Covid-19. Swellendam has three ventilators which are not in use. She asked if it was not better to send these unused ventilators to other hospitals that could make use of them.

She asked the Premier to clarify if the province would attempt to secure vaccines for Western Cape residents.

On protecting health workers in the third and fourth wave, Mr Herron asked if at the 15 February 2021 expiration date of the Adjusted Level Three restrictions and healthcare workers have not yet been vaccinated, would they not continue with the current level of restrictions until they are vaccinated.

Responses
On the question of rapid antibody testing stations, Dr Cloete replied that the Department had received some complaints about these. These stations had to get permission from the National Department of Health (NDOH). The Provincial Department has been in communication with the NDOH Director-General about what the prerequisites are to set up such stations in terms of standards, quality of processes and sharing of results. Such stations were meant to disclose the data to the Provincial Department; they had been reporting this through some complicated route. He has asked NDOH how they know if these entities are registered as the Provincial Department has no jurisdiction.

Dr Cloete replied that the cooperation of the Provincial Department with NDOH has been extremely good. Senior management team took a decision to have a check-in meeting every single day. 

On central procurement, international suppliers are working only with national entities and not sub-national entities; this is by preference. Moreover, all vaccines have to be approved by the national entity, SAHPRA.

National Treasury has to give whichever entities that want to enter into a procurement process special dispensation to be able to talk to providers. This is because of very strict procurement rules in South Africa. National Treasury granted permission to these entities to approach suppliers and to enter into procurement. Private sector entities which have special ventilators and specially trained staff where additional capacity needed to be brought in, there has been a special dispensation where some of these ventilators do exist, that the regional hospital has worked with some capacity in those places to say ‘do you guys have capacity, is somebody trained, can you do it’ and there has been ‘special dispensation’ for certain areas.

In addition to this, the province also has CPAP machines, high-flow nasal oxygen – these are both alternatives to being ventilated in an ICU or high-care setting.

On Mr Herron’s question, he replied the point is we need to endeavour to vaccinate healthcare workers. At this point the Department does not quite know what the projection is as to when waves three and four are expected. However, it is not likely to be before March or April 2021, nevertheless the plan is to vaccinate people in the month of February 2021.

Premier Winde replied that there was a national position of central procurement and below that sits both the government sector and private sector. So far we have the promise of the first 1.5 million vaccines and later in the year some more vaccines. As an elected representative of the Western Cape, his responsibility is to get the citizens of the province vaccinated as soon as possible to get the economy up and running again. He acknowledged that there is a national system of procurement. Although he is adhering to the central procurement plan laid out by the national government, he is still making calls himself to find extra vaccines for the province, but also for frontline healthcare workers around the country.

The Chairperson thanked the Department and the Premier for their presentation and responses. Any additional questions could be submitted by email to the procedural officer.

The minutes for the 24 November and 29 December 2020 were adopted.

The Chairperson proposed that the next meeting be 3 February 2021.

The Chairperson thanked all Members and adjourned the meeting.