“The days are getting wild” is a phrase Suhair Solomon has repeated many times during our conversations over the past two months. Solomon and Sheila McCloen are part of the Department of Health’s Covid-19 response team at Kess, the Khayelitsha Eastern Substructure office for Kuils River, Eerste River, Strand to Khayelitsha, Faure and Macassar.
Along with the rest of the Covid-19 response team, they have been working non-stop since the middle of February, responsible for coordinating case and contact management, isolation and quarantine, and community screening and testing (CST) services.
The team’s initial response included getting clinics and hospitals ready to provide medical care for Covid-19 patients, and preparing isolation and quarantine facilities. It has also been alleviating the burden on clinics by taking on non-essential services such as the collecting of chronic medicine, which community health workers now deliver to recipients.
Preparing for the pandemic included training staff in the proper use of personal protective equipment (PPE). It is at one of these training sessions that the Covid-19 response team received a call about its first close contact.
Management and tracing
Every day, the team receives a list of people who have either tested positive for Covid-19 or been in close contact with someone who has contracted the virus. The team contacts the person involved and assesses every positive case to determine how best to support them. A team member then determines if the person has comorbidities, if self-isolation is possible but food assistance is needed, or if the person needs to be moved to an isolation facility. If needed, the team will issue a letter to the person’s employer notifying them of the 14-day quarantine.
The team member will also determine who’s been in close contact with the person who has contracted the virus. Those contacts will then be notified and advised to self-isolate for 14 days. By isolating positive cases and their close contacts, the team hoped to slow the spread of the virus.
The first contact
On 13 March, Solomon received a call notifying them that someone in one of their communities in Eerste River had been in close contact with a person who had tested positive for Covid-19. After making contact, a few team members drove to the area in an unmarked vehicle to avoid drawing attention to themselves as they were mindful of the stigma around Covid-19 at the time.
They dropped a brown paper bag containing masks, gloves, a thermometer and Covid-19 pamphlets at an agreed spot, which was close to where the person lived. At the time, multiple members of the team were able to work on each close contact.
In March, all the testing in Kess’ area was being done at clinics and hospitals. Then, the criteria for screening included travel to a country that had been experiencing an outbreak or exposure to a known positive case. People would be tested if they sought a test and satisfied the screening criteria, or if they were picked up at a screening point when entering a hospital or clinic. The requests for contact management were coming to the team as a result of tracing the contacts of people who had tested positive in other geographical areas. In April, this would change to include results from screening and testing in communities.
First day of CST
CST involves setting up testing booths in the community, usually on a field or other area that has enough space, but just as easily in a community hall. Those who meet the criteria to be tested are able to do so without going to a hospital or clinic. The intention is to identify hotspots and prevent the unnecessary movement of people.
On 3 April, the Department of Health gave the go-ahead for CST in the Cape Town metro to begin the following week. McCloen and Solomon got their respective teams ready to do community screening the next day in Happy Valley in Eerste River and Ilitha Park in Khayelitsha, deciding to do testing as well. Working with the City of Cape Town Solid Waste Management Department, Doctors Without Borders, ward councillors, the Khayelitsha District Hospital, environmental health volunteers, community health workers, law enforcement and the South African Police Service, they carried out their duties successfully. It was the first CST in the metro.
“You plan today for tomorrow,” said McCloen. Outbreak response is part of her job, so the last-minute organising was nothing new for her. “Everyone was on board, and everyone was just willing to come in and see how we can try to contain it and prevent this thing from spreading.” However, their positive feelings at the success of the CST did not blind them to the reality of what lay ahead.
“We could do everything in our power to try and mitigate that by having good processes in place, but the reality of spatial injustice in a community like Khayelitsha essentially lends itself to an outbreak of disproportionate numbers,” said Solomon. “We knew it was going to mushroom much faster than in other places.”
In the following weeks, the Covid-19 response team embarked on a campaign to carry out CST in its areas on a per-ward basis. Owing to the size of the wards and its capacity to screen and test, it was impossible to cover many of the wards fully. The team took the approach of carrying out CST in close proximity to confirmed cases.
“Basically, every single one of our community screening and testing exercises yielded clusters of positive results,” said Solomon. The team members were finding hotspots, which suggested that community transmission was already happening.
A case they were requested on 8 April to manage gave them a glimpse of how the virus was being transmitted in certain living conditions. The person who had tested positive was living in a two-bedroom house with nine other people. A further eight people were living in the back yard. When they went to drop off thermometers and saw the circumstances under which the inhabitants of the house were living, McCloen and Solomon decided to test them all as it was clearly a high-risk household. At the time, only symptomatic people were being tested.
Ten of the 18 people making up the household tested positive for Covid-19. The results informed the decision to allow close contacts of infected persons access to testing, even if they were asymptomatic. The team’s testing strategy was becoming more comprehensive and suited to the communities, but the limitations of CST would soon become apparent.
Out with the old
In early May, debates began about whether using widespread CST was still an appropriate strategy for containing the spread of the virus. The National Health Laboratory Service (NHLS) was not able to process the 36 000 tests a day that it had projected. The lab was overwhelmed. On 10 May, CST was suspended temporarily across the metro to allow the NHLS to work through the backlog.
It was clear that it was no longer possible to slow the spread of the virus using a mass testing strategy because test results were not available soon enough to have the necessary impact.
The Covid-19 response team has since shifted its strategy from focusing on containing the spread of the virus to focusing on high-risk individuals, with the aim of reducing mortality. Under the new strategy, those deemed to be at the highest risk are people older than 55 with comorbidities such as hypertension, diabetes and respiratory conditions. The aim is to catch the infection in higher-risk people earlier so their symptoms can be treated sooner in the hope of saving their lives. The coming weeks will reveal the challenges this new strategy brings.
It has been weeks and weeks of non-stop hard work. The team is feeling overwhelmed and the number of coronavirus cases has yet to peak in the Western Cape. “I feel the threshold shifts every time, so I could have told you a month ago we were already feeling overwhelmed, but the threshold shifts every single day,” said Solomon.