COVID-19 indicators and situational analysis; Update on vaccine roll-out

Meeting report

The Chairperson welcomed the Committee and delegation to the meeting. The rules of engagement were explained, and apologies were tabled.

Western Cape Government: Health update on Covid-19

Dr Keith Cloete, Head of Department: Western Cape Department of Health, in his opening statements, mentioned that the number of daily new Covid-19 cases had increased further to an overage of 200 new diagnoses each day with a 25% week on week increase. Admissions and deaths continued to increase but the absolute numbers were still exceedingly small. On average there had been 30-35 admissions and 4 deaths each day. The average proportion of test positivity remained at just > 5%.

The resurgence monitor showed a sustained increase for 12 days in the number of new cases in the current week vs the previous week. The province remained in a resurgence state, although the week-on-week percentage increases have declined. The Western Cape has not yet met the criteria for being in a third wave but could enter a third wave in 2-3 weeks if the current trajectory continued.

Why do we need to reduce the size of a third wave?

• SA COVID-19 modelling consortium predicts a third wave that will be smaller than the second wave in the Western Cape but there is alot of uncertainty e.g. if different variants emerge.
• If we respond strongly and quickly to an increase in cases (darker blue bars) we can dramatically reduce the number of admissions and deaths.
• Increased hospital admissions are associated with increased mortality if the healthcare system overwhelmed (avoid preventable deaths).
• Limit needed for de-escalation of routine health services.
• Not interrupt the vaccine programme.

Variants first detected in India and UK: Update

• No identification of B.1.617 (India) in the Western Cape.
• No further identification of B.1.1.7 beyond the 8 that were reported in early May.
• They experienced some challenges with sequencing machines - so some specimens are still waiting to be sequenced.
• Given the spread of B.1.617 to more than a dozen countries, a travel ban has not been considered to be feasible (informal communication with MAC).
• Vigilance at airports should be maintained. 

Third Wave: Resurgence and Response

• We continue to see a very concerning increase in the number of cases and remain in resurgence.
• Behaviour change is key to mitigate the 3rd wave. We can delay the onset and/or reduce the size of the third wave (flatten the curve) until more people are vaccinated.
• Call on Western Cape community to flatten the curve by:
  • Ensuring consistent social distancing, mask wearing, hand hygiene.
  • Avoiding all non-essential gatherings
  • Essential gatherings to be outdoors if possible and reduce size of essential gatherings to <50 people indoors and <100 outdoors.
  • Work remotely if possible.
  • Avoid non-essential travel especially to provinces/areas with increasing case numbers.
• We will be engaging with religious leaders, sporting bodies, retail, restaurant/bar, entertainment and hospitality sectors to collectively ensure adherence to National Productivity Institute (NPIs). We are also engaging with the Joint Operations Committee (JOCs) to ensure enforcement of Level One regulations.

Acute Service Platform: Current Picture

• Currently 763 COVID patients in our acute hospitals (416 in public hospitals & 347 in private hospitals). This excludes Patients Under Investigation (PUIs) and cases in specialised hospital settings.
• The metro hospitals have an average occupancy rate of 90%; George drainage area hospitals at 65%; Paarl drainage area hospitals at 74% and Worcester drainage area hospitals at 72%.
• COVID and PUI cases currently make up 5% of all available acute general hospital capacity in both metro and rural regional hospital drainage areas.
• COVID inter-mediate care – the Brackengate Hospital of Hope currently has 17 patients (3 380 cumulative patients), Freesia and Ward 99 had zero patients, Mitchells Plain Hospital of Hope has 0 patients and Sonstraal currently has 0 patient. 
• The Metro mass fatality centre has capacity for 240 bodies; currently three decedents (cumulative total of 1415 bodies) admitted. The overall capacity has been successfully managed across the province.

Vaccine Update:

• 70% of the estimated target of health care workers were vaccinated via the Sisonke Programme.
• The balance of health care workers - Phase 1B - commenced on 17 May 2021. 
• 33 900 doses of the Pfizer vaccine to complete Phase 1 and commence with Phase 2, was received in the province on 13 May 2021.

J & J Sisonke Programme: 17 February to 15 May 2021

• The Western Cape received a total 95 880 doses of the J&J vaccine to vaccinate healthcare workers as part of the Sisonke Programme.
• The Sisonke Programme started on 17 February 2021 and concluded on 15 May 2021.
• A total of 93 153 health care workers have been vaccinated in the province (public and private sectors) through the Sisonke Programme.
• Phase 1B to mop up remaining healthcare workers has commenced on 17 May 2021 parallel to the launch of Phase 2. 

Launch of Phase 1B and 2

• The Western Cape officially launched Phase 1B and Phase 2 on 17 May 2021 at Brooklyn Chest Hospital.
• Religious leaders from different faiths, including Archbishop Desmond and Mrs Leah Tutu were amongst the first citizens aged 60 years and older to be vaccinated.

Vaccine Registration Dashboard

The dashboard aims to address:

• How many elderly citizens (60yrs+) are there across the Western Cape and where are the clusters of the elderly in communities?
• What is the distribution of the elderly population across the communities which have high levels of socio-economic vulnerability?
• What the estimated elderly population within a 1km to 5km radius of a vaccination site?
• Where should additional support be provided to improve registration numbers across communities?
• What are the surrounding footprints of social facilities (like WiFi sites) which may support vaccination efforts?

Concluding Remarks

• We are in a resurgence and urge everyone to adhere to protective behaviours, as a key drive to contain a third wave.
• We anticipate that the third wave will be lower than the second wave. However, this is dependent on the strength of our behaviour over the coming weeks.
• Preparations for the third wave are in full swing, with clearly identified trigger points for an appropriate health platform resource response. 
• We require a concerted whole of Government and whole of society response to flatten the 3rd wave.
• Phase 1B and Phase 2 vaccinations commenced on 17th May 2021 and will significantly scale up capacity to administer vaccines over the coming weeks, in a sequential manner in each geographic area.
• We need to mobilise and assist everyone >60 years to be registered on the Electronic Vaccination Data System (EVDS) for Phase 2, it is in everybody’s interest – “Let’s do This”.

Discussion

The Chairperson wanted to know as to who was coordinating the private sector with regards to the vaccine rollout. How does the electronic system decide who gets an appointment first and whether that person gets sent to a public or private facility, as well as how the vaccines are administered. Secondly, clarification was sought as to whether the number of registrations on the electronic vaccine system influenced how many vaccines the Western Cape received. Lastly, advice was sought as to what public representatives could do to help their constituencies flatten the curve.

Ms W Philander (DA) wanted to know what measures the Department of Health (DoH) has taken to respond to the anticipated third wave. She wanted to know what the third wave meant for healthcare workers who had not yet been vaccinated and whether the Department has made additional appointments for the possible absence of workers during the anticipated third wave. An update on the filling of critical vacant posts due to Covid-19 was asked about.

Ms R Windvogel (ANC) wanted to know as to how many healthcare workers were vaccinated during phase one and how many still needed to be vaccinated. She wanted to know whether farm workers were included as essential workers and how many vaccination sites were in farming communities. What is the number of registrations that have been received for the second phase and are there any facilities which have experienced any challenges thus far? She wanted to know what the strategy would be to deal with chronic medical cases and other health services during the third wave.

Ms P Lekker (ANC) suggested that perhaps those who collected their chronic medication on appointment could perhaps be given the vaccine, as a method of ensuring that everyone who needed to get the vaccine does receive it with the least inconvenience. The HOD was alerted to the fact that within Ms Lekker’s constituencies there have been those who had not registered but received the vaccine, while those who had registered were still waiting for it. She asked as to how the electronic system was being monitored to ensure that things ran smoothly.

Mr B Herron (GOOD) stated that his questions had to do with the interview by one of the news channels over the weekend on television with Dr Cloete. He wanted to know as to why the Department had ordered only 30 000 vaccines for the week for the Western Cape, when he believed that they could have ordered far more. He explained that he was trying to understand how the distribution of vaccines worked and how many they could administer in a given week. The increase of the vaccination pace from 60 thousand to 120 thousand still seemed fairly low to Mr Herron, with him wanting to know as to why no vaccinations took place over weekends. Lastly, he wanted to know as to why there were so many social media posts regarding vaccinations at private facilities in Gauteng, whilst the Western Cape’s contrast gave a different picture.

Mr P Marais (FF+) wanted to know as to how the budget cuts over the MTEF would affect the Departments plans going forward. Elaborating further that they have been cut by R20.7 billion over the three-year period. Advice was sought as to whether Committee oversight visits should be stopped during the third wave and current period as they possibly endangered other members of various communities.

He wanted to know as to why citizens could not choose the vaccine they wanted between Pfizer and J&J. Why would the government decide without knowing the medical history of patients was something Mr Marais found disturbing. Lastly, the view of the HOD was sought regarding ivermectin and the recent ruling by the North Gauteng High Court.

Response

Dr Cloete responded saying that the Department has been coordinating with the private sector ever since the planning started. They had a Committee, convened by Dr Karim (Chief Operations in the DoH) that met weekly with their private sector colleagues from all entities. They have put the plans together for the Western Cape. However, the coordination has been complicated by two things. Business for South Africa (B4SA) have been coordinating the private sector response centrally for the whole country with the National Department. The delays therefore related to the rates to be charged and the fees structures which needed to be gazetted and the mechanism for charging between the private and public sector around vaccinations.

The system was designed so that the person assigned, was assigned to the nearest sites within their residential geographic area – depending on if the site was open and accepting appointments. As such, private sector and public sector sites were likely to get patients from the other sector. It did not mean that someone with or without medical aid could not possibly be seen by the other sector. The system was set up to do allocations in terms of available slots for appointments at the various sites.

The National Health Minister proposed that the system of allocating doses across the provinces be influenced by the number of people which were registered on the system.

Public representatives must promote the six issues to their constituencies: working from home; not having unnecessary gatherings; encouraging people to meet outdoors and keeping it small; encouraging people to wear their masks and social distance; washing their hands and to not travel to areas which could introduce additional infections. It was really important that public representatives got that message to their constituencies and made sure that they obeyed it to the best of their ability.

They have appointed more than 2 000 healthcare workers, adding from the 1 400 previously mentioned. The budget has allowed them to allocate additional people for vaccinations and for Covid-19. There were still another 4 500 allocations which could be added if necessary. There were approximately 95 000 healthcare workers within the province who were vaccinated.

Regarding whether the farm workers constituted essential workers was not something he could answer, however, if the farm worker was over the age of 60, healthcare workers from the Department would be reaching out and getting them registered on the system in order to vaccinate them accordingly. The biggest challenge faced was people having access to the means to be registered. The targeted strategy was to assist people in poor communities to be able to register.

He emphasised that the Department had to find a way to flatten the curve which would allow it to also maintain its essential services so as not to neglect chronic patients. It was essentially a balancing act. The chronic medication system was intentionally designed to have medication delivered to them. The system was also designed so that a person who registers first and has been matched to the nearest site would likely receive their appointment first. However, what happens at times was that someone in another geographical area who had registered after someone else but had been matched to a site with less matches could get an earlier appointment. It was important to note that staff would not dismiss walk-ins despite it being discouraged and frowned upon.

He stated that the 33 000 vaccines ordered were a result of the registrations on the system. He stated that there were bigger orders which had been placed as the Department ramps up its bigger services with the opening of their bigger sites. Bigger sites would be open for seven days a week and should occur within the next two weeks.

He explained that the public sector received its stock from national and the same was meant to occur for the private sector. The Department has worked with the private sector, in providing it with stock where delays occurred, provided that its stock got returned. A system was in place to make sure that no private sector ran out of stock. Two Discovery sites would be opening – one in Claremont and near the Discovery headquarters in Century City. Other private sector sites included Clicks pharmacies, Dischem pharmacies and four Mediclinic hospitals. Their framework has been to focus on smaller sites which have a larger reach to communities which are less empowered, simultaneously registering them and vaccinating them at the same time.  

The budget cuts over the MTEF was a serious concern to the Department. Their three priorities for the current year was to vaccinate, to deal with the third wave and to maintain their normal services. Budget challenges in year three was a big concern with the Department being able to maintain its normal services and as such it was crucial that the vaccinations work. The Department also looking at working with the private sector in order to deal with the budget pressures which would be on the healthcare system. Advice to everyone and not just Committees, was that any visit deemed unnecessary was not worth the risk and should be avoided at all costs.

Regarding the two vaccines, there was no evidence to suggest that the one works better than the other. Both vaccines worked perfectly well for everyone and as such there was no choice because it made no difference.

The High Court ruling was that access must be provided to ivermectin under s25 conditions which meant that an individual clinician needed to initiate and apply to the South African Health Products Authority (SAHPRA) for that clinician to have access to ivermectin. Then there was a ruling settlement with AgriForum that compounding should be allowed for ivermectin which made it easier and eliminated the need to go through a s25 application. The stance by the Department was that the evidence was not rigorous enough to suggest that it works, with no country in the world accepting the use of ivermectin either. The evidence of ivermectin had not passed the muster of the expert committees which looked at it. The Department’s stance remained that more clinical trials were needed and once there was evidence to suggest its effectiveness, as they had done with dexamethasone last year, they would introduce the treatment.

Discussion

Mr A Van der Westhuizen (DA) asked what attirbuted to the major causes of the two percent loss in vaccinations, including what could be done to lower the number even further. He asked if it would be possible for a recipient of an sms to indicate that he or she would still liked to be vaccinated, however, the time or venue allocated was unsuitable for them. He wanted to know how the resident cap compared in identifying covid-19 cases with other provinces. He learnt that the average duration of hospitalisation was significantly reduced between the first and second wave. He asked if that meant that there was signficant improvements in the clinical treament of patients. Lastly, he wanted to know what the latest views were on people being reinfected.

Ms Philander asked what the Department’s measures were to support mitigation strategies pertaining to insurgence of Covid-19 infections at schools.

The Chairperson sought clarity as to whether the system of essential workers had been abandoned in favour of the age band.

Ms Windvogel wanted to know if there was reason for appointments being made on contract as opposed to permanent employment, especially given the staff shortages in hospitals. Regarding slide 11, more light was asked to be shed on the school cluster in the Cape Winelands. Reason was asked for as to why the vaccine roll-out budget decreased to R150 million.

Mr Herron expressed that he failed to understand Dr Cloete’s response to the question of the private sector’s delay. It seemed that the Western Cape had a delay in terms of activating private sites while other Provinces did not, as such his response to the question did not make sense as it could not be a National programme problem if only the Western Cape had the issue. Lastly, he sought the current status of the J&J vaccine and if the Department was aware of any progress regarding its roll-out.

Mr Marais asked for Dr Cloete to expand on the ‘1531 variant’ and what was meant by ‘most dangerous.’ If every variant responds different, he struggled to understand how the two different vaccines would have the same effect. He alerted the HOD to a case where people in Bishop Lavis informed him that that they were to get their vaccinations done in Nyanga. He wanted to know if there was a site in Bishop Lavis and whether the referral to Nyanga could have been an error possibly. He stated that he could not see how a person, most likely a pensioner staying in Bishop Lavis could be referred to Nyanga.

Department Response

Dr Cloete responded that it was not just about drawing up the dosage and injecting it into someone’s arm, but rather about considering the logistical factors involved which could lead to possible wastage. The international norm was that there was no more than 10 of the vaccines wasted. The Department set the target however of no more than 5%, with it achieving half of that thus far. Considering the programme and processes involved, he explained that a zero-percentage wastage was impossible.

Regarding SMS recipients and appointments, his advice was for people to try and stick to the allocated time and venue which had been allocated to them. However, if people could not make it, they could call the line available to discuss the matter. There were no guarantees, with the most likely outcome being that they would be added back into the queue and the system would issue them with another appointment.

Regarding hospitalisation time, he stated that the shorter time period was due to there being less pressure on more beds for people to be admitted. It had nothing to do with the clinical management of the hospitals. He stated that out of 190 thousand cases, there have been 3000 reinfection cases in the Western cape.

He explained that keeping the system regulated to an age band, allowed the system to be less vulnerable to fraud and abuse. Healthcare workers and over 60s fell part of phase. Phase two opened the bands up to essential workers, however, that opened the system up to abuse and the determination as to who fell part of essential workers. Limiting it to age bands seemed the most effective method currently. There has been a proposal to open it up next to the ages of 40 and above. There has also been a proposal to categorise it based on infection risks which would see police, teachers and social workers being part of that.

The Department has been working with the Department of Education since the first wave right through to the second and would continue working with them through the third wave. The DoH issued the DoE with strict guidelines and protocols on everything surrounding covid-19. Surges in schools were to follow a concise process.

The reason behind contract appointments was due to budget. The money which had been issued for covid-19 and vaccines was not money which would carry through for three years. It was an additional amount of money which would only last for a certain period of time. Permanent appointments made were done with the balance of the budget which the Department had for the three years. It was important to remember that all appointments made were being done against the backdrop of the wage negotiations and the current negotiations about the impact on salaries and wages.

Between the Budget Speech of the Finance Minister and the final allocation in the DoH, a decision had been taken between Treasury and the DoH, that only a percentage of the money which had been allocated for available vaccines would be put onto the books of the DoH. If the DoH needed access to additional money which was not put onto the books, it could request it from Treasury.

The J&J vaccine in the Aspen factory in the Eastern Cape had been ready for usage four weeks ago already, however, there was an international hold on all factories in order to sort out the quality assurance of J&J factories worldwide. The Aspen factory in Eastern Cape had perfect processes in place. The moment the hold was lifted, vaccines would be made available. The most likely period being around the start of June.

He clarified that what he meant was not ‘most dangerous’, but rather the ‘most predominant’. A variant being more predominant meant that it spread faster. The new variant which was the one first detected in India is one which everyone is monitoring as it could potentially be challenging in terms of how predominant it becomes in terms of spreading. Regarding the vaccines, an individual assessment could not determine whether one should have a J&J or Pfizer vaccine and clinical trials indicated that there were no differences between the two.

The Bishop Lavis site opened on Monday. He saw no reason as to why someone from Bishop Lavis going forward would be required to go to Nyanga. However, it depended on when the sites opened. The Nyanga site saw people from as far as Goodwood and Wynberg even.

Dr Nomafrench Mbombo, MEC: Western Cape Health, responded that the allocation of vaccines constantly changed based on the availability and demand as received on a weekly basis. It would become of no use if the National Department of Health simply gave provinces vaccines, where some would end up not being used. The electronic system needed to be sticked to as far as possible. Walk-ins were right that they were entitled to the vaccine, however, it was also being unfair and inhuman when one jumped the queue knowing that there were other vulnerable people who also needed to be vaccinated. 

Until now not all health workers had been vaccinated, with delays being caused as a result of pregnancies and some who merely just refused to take the vaccine. An example of a healthcare worker in Khayelitsha who refused to be vaccinated was told to the Committee. Workers could not be forced to take the vaccine. No deaths of vaccinated healthcare workers had occurred.

Mr Marais wanted to know whether Dr Mbombo and Dr Cloete felt that it would be necessary for the Committee to have presentations done on the budget implications which was now at the forefront of concern. Its implications on the ability to effectively manage covid-19 is something he felt may be necessary, however, sought the opinion by the DoH.

Dr Cloete responded that as the Accounting Officer, he and his team met weekly with the Heads of Provincial Treasury for the last three months. Discussions included: what the financial situation is; how they were spending; what they were doing; and jointly building a case for sustainable financing for the healthcare system for the next 10-20 years. The issue was something which needed to be put onto the table, as other provinces were far worse off than the Western Cape. Budget pressures required budget reprioritisation which was where the difficulty came in on whether to give more money to education, health or other purposes. The Department was currently working to get the most for its money in order to get the maximum impact. It was also looking at ways to influence society and getting them into healthier habits, in order to shift the main focus away from a ‘constantly ill’ society to a ‘well-being’ society.

Resolutions

Mr Marais proposed that the Committee pass a resolution expressing its gratitude and thanks to the Minister, HOD and the Department for the most efficient way in which they have been handling the Covid-19 crisis in the Western Cape.

The Chairperson stated that it was a very kind gesture and Committee agreed to the proposal by Mr Marais. A note would be written to the Department of Health to state that on resolution of the Adhoc Committee on Covid-19, the Committee thanked both the Department and Minister for the manner in which they have been managing the Covid-19 pandemic in the Western Cape.

The Chairperson stated that there were no minutes to adopt, and Members were thanked for their attendance and robust participation.

The meeting was adjourned.