On Wednesday, 26 February Spotlight and Daily Maverick sent a combined list of 22 questions about South Africa’s state of preparedness for Covid-19 (Coronavirus Disease 2019) to the Department of Health and the National Institute for Communicable Diseases (NICD). Our intention was to get beyond the sensational surface of the issue and gain a deeper insight into how government is preparing for a potentially very serious epidemic in South Africa.

We were particularly interested in the legal basis on which various measures might be taken and in what steps government will take to ensure a response that is proportional and in line with the protection of human rights.

We received the below answers to our 22 questions on the morning of Monday 2 March (five days after we sent them).

This relatively late response was partly because our questions were redirected from the NICD to the Health Minister (through whom it seems all government communications on Covid-19 are being channelled). This was also partly due to news that broke in this period regarding two South Africans who tested positive for the virus on a cruise ship in Japan and plans to repatriate South Africans from Wuhan in China.

The response was sent to us by Dr Lwazi Manzi, Health Minister Dr Zweli Mkhize’s spokesperson. Below we reproduce her responses as she sent them (only making minor stylistic changes that do not change the meaning). Below the questions and answers we also reproduce a media statement delivered by Minister Mkhize on 1 March 2020.

We realise some of these answers raise further questions and we will be interrogating those questions in our Covid-19 coverage going forward.

1. What should someone in South Africa do if he or she suspects they may have contracted Covid-19? Especially people who have travelled to Covid-19 affected countries or who have been in touch with someone who travelled to Covid-19 affected countries. What number should they call? What will happen after they call this number?

Dr Lwazi Manzi (LM): People who develop symptoms of respiratory illness including cough, fever and shortness of breath either or during and after travel to countries where coronavirus is known to be circulating must seek medical care early and share information about travel history with their healthcare providers. The General Public Hotline Number is 0800 029 999 and operates on weekdays, Monday to Friday, during 08h00 to 16h00. The operator will then guide the caller on the steps he or she should take.

2. What is your advice for the public in South Africa regarding the use of masks?

LM: There is no evidence that masks protect people who are not sick/infected. If you are healthy, you only need to wear a mask if you are taking care of a person with suspected 2019-nCoV infection. Wear a mask if you are coughing or sneezing. Masks are effective only when used in combination with frequent hand-cleaning with alcohol-based hand rub or soap and water. If you wear a mask, read the package insert that will guide you on the proper use and disposal of the mask.

3. Is a mass public education campaign planned to prevent panic and misinformation?

LM: Yes. There is extensive communication not only from ourselves but from WHO as well. I take this opportunity to reiterate that the Department of Health, WHO and NICD platforms or officials/ experts from these entities are reliable, credible sources of information. The public must guard against getting their information from general social media or so called “experts” outside of these entities.

4. Are there self-isolation guidelines for South Africa, such as those in the UK, and what steps have been taken to disseminate such guidelines to the public?

LM: The STANDARD OPERATING PROCEDURES FOR PREPAREDNESS, DETECTION AND RESPONSE TO A CORONAVIRUS (2019-NCOV) OUTBREAK IN SOUTH AFRICA is the document that outlines the standard operating procedures for detection and response to case(s) of suspected novel coronavirus disease (2019-nCoV) in South Africa. This document has been widely disseminated to all stakeholders across the country accompanied by the relevant training for all personnel rendering services related to the country’s response to coronavirus.

It is important to bear in mind that South Africa has not had a case of coronavirus. It’s either the person has been potentially exposed and must follow the SOP or not. The advice we are giving to the public is very simple at this stage- if any concerns simply call the hotline or visit your nearest health care worker.

In fact according to the WHO “Quarantine Considerations in the context of coronavirus disease (Covid-19)” document published on 22 February 2020 “Quarantine implies the use or creation of the appropriate facilities in which persons quarantined are separated  from the community while being attended to… Possible settings may include a or other holiday facilities, dormitories or military facilities amongst others. While home quarantine may sometimes be the only feasible option, it is usually considered as a last resort”.

5. In some places ships, hotels or entire towns have essentially been placed under quarantine. What government entity in South Africa will take decisions regarding whether or not to quarantine larger groups like this and according to what legal framework or set of guidelines will decisions in this regard be made in South Africa?

LM: As you are now aware it was a cabinet decision.

There is supporting legislation in the National Health Act, National Plague Control Guidelines and the WHO ‘quarantine considerations in the context of Covid-19’ guidelines published 22 February 2020.

6. Should people in South Africa be placed under quarantine, either in facilities, or in their homes or their communities, what support will the state provide such people given potential loss of income and reduced access to services and food.

LM: Quarantine would be in a facility.

All amenities and provisions would be provided.

The state is not obliged to compensate for loss of income.

7. What steps will be taken to ensure people’s human rights are not infringed upon in the response to Covid-19?

LM: The legislature is quite clear about the manner in which policy should respond to an outbreak and is in line with the Constitution

8. What government entity in South Africa will take decisions regarding travel restrictions inside the country and according to what legal framework or set of guidelines will decisions in this regard be made in South Africa?

LM: There are no restrictions on travel or trade. If such a decision would be made it would likely be a cabinet decision again.

9. What government entity in South Africa will take decisions regarding the cancelation of public events such as sports matches in order to contain the spread of Covid-19 and according to what legal framework or set of guidelines will decisions in this regard be made in South Africa?

LM: I cannot answer this question the scope is too broad- it would really depend on what the group activity is and which government institutions would be involved.

But there is no intention to cancel any group activities at this stage. For example, we just had a Chinese Hockey Team doing their pre- Olympics friendlies with South Africa.

10. What steps has government taken to protect healthcare workers from Covid-19?

LM: The SOP has clear guidelines on the safety measures health care workers must take when dealing with suspected coronavirus cases.

It is also for this reason that we have designated facilities for the management of Covid-19 as these facilities are best equipped for aseptic and isolation chain or care.

Personal Protective Equipment need was quantified and additional PPE’s were procured on an urgent basis to address any shortfall the country.

11.   What plans have been put in place should healthcare workers get sick with Covid-19 and be unable to do their jobs – potentially rendering some already understaffed facilities even more understaffed?

LM: The management of staff capacity when a colleague is unable to work due to illness will certainly not be a novel concept because of Covid-19. All facilities have their systems of dealing with staff capacity and managing staff shortage due to sick leave, annual leave, death or disability etc. 

12.   Do we have enough N95 masks for health workers and what is being done to encourage health workers to make use of these masks?

LM: There is a worldwide shortage of N95 masks and ordinary facemasks, however we have not had any reports of a mask shortage crisis in any of our facilities. N95 masks are very familiar to South African healthcare workers who have to protect themselves from TB and other infections that are spread by air droplets already. Healthcare workers in this country need very little prompting to use N95 masks when necessary – be that as it may, we constantly communicate with them on their own personal protection and the proper manner of using PPEs and disposing of them. 

13.   What is being done to ensure that health facilities with poor access to enough clean water is able to promote handwashing?

 LM: The MNORT (Multisector National Outbreak Response Team) includes the Department of Water and Sanitation which will be able to deal with any issues arising out of any such challenges. None of the designated hospitals fall into this category. 

14.   What is being done to protect and educate Community Health Workers on how to handle any suspected cases?

 LM: The SOP is a step by step manual that instructs HCW on correct procedure for the management of suspected or confirmed Covid-19 cases and how to protect themselves as well. Healthcare workers have been trained across the country and know how to collect the relevant specimens. PPE packs have been stocked up. The clinicians hotline runs 24 hours a day and is fielding a massive number of calls.

15.  Public sector DR-TB patients were quarantined by force in South Africa in 2007/2008 – a policy that was eventually dropped in favour of a decentralised care model. What lessons has government learned from that experience that can be drawn on in the Covid-19 response?

LM: We are guided by current guidelines from WHO and our current laws on the quarantine from Covid-19. We cannot really make comparisons between TB and Covid-19: although they are both spread by droplets the pathologies are quite different and we are still learning a lot about Covid-19 so it needs to be managed on its own merits.

16.   So far little is known about how Covid-19 will impact the health of people living with HIV and/or TB. What assumptions are being made in this regard and are any special precautions being put in place given that South Africa has large HIV and TB epidemics?

LM: What we know about Covid-19 is that fatalities and serious morbidity certainly seems to be prevalent amongst those who are immuno-compromised. That does not just mean HIV+ or TB patients. That can be the very old and very young, pre-existing chronic conditions like diabetes, asthma etc or being on medication that causes you to be immunocompromised. It’s very important to remember, in our context, that most of our people living with HIV are on ARVs and have very high CD 4 counts. This makes them as immunocompetent as anyone not living with HIV or AIDS.

South Africa is taking all the necessary precautions to ensure that ALL South Africans regardless of their immune status are protected from Covid-19.

17.   How many people are known to have travelled from China to South Africa since mid-December and how many of these people have been tested for Covid-19?

LM: The NICD has to date tested 156 patients of which 109 were persons under investigation. All tested negative.

The number of travellers from China- please ask either DIRCO or Home Affairs.

18.   Which airports in South Africa are checking for possible infections and are they checking every incoming flight?

LM: All

19.   In what ways, and through what forum, is the public and private sector planning and working together regarding Covid-19?

LM: Through MNORT

20.   Has Cabinet held a discussion on Covid-19?

LM: Yes

21.   Has an inter-ministerial task team been appointed to co-ordinate the response?

LM: Yes

22.   How many samples from other African countries have been tested in South Africa and what regional co-operation efforts/ plans are in place?

LM: Please ask NICD (Ed note: NICD have consistently been referring questions to the Minister’s office)

The WHO announcement of a PHEIC (public health emergency of international concern) set in motion the mechanisms by which countries, regions, multilateral organisations and private sector work together to co-ordinate efforts against Covid-19.

Sunday’s statement

Below we reproduce the full statement delivered by Minister of Health Dr Zweli Mkhize at a press conference on Sunday 1 March 2020. This statement was delivered four days after our list of 22 questions were sent and as such could not be taken into account in the formulation of the 22 questions.

Start of Minister Mkhize’s statement:

Background:

In December 2019 Chinese authorities announced the emergence of a novel coronavirus that was the causative agent for an outbreak of respiratory disease. It is believed the outbreak originated in a food market in Wuhan City, China. This virus has now come to be known as Covid-19. The symptoms are largely respiratory which can range from mild upper respiratory tract manifestations to respiratory failure, multi-organ failure and death. The mortality rate is around 3% and evidence shows that the vast majority of fatalities are patients who are immunocompromised either due to extremes of age or pre-existing conditions. Whilst there are ongoing studies, there is no proven cure and there is no vaccine.

On 30 January 2020, due to the emerging worldwide spread of the Virus, the World Health Organisation declared coronavirus a Public Health Emergency of International Concern. This set in motion pre-determined global policy implementation that enables the co-operation of governments, the private sector and multi-lateral organizations to optimize the response to the spread of the virus and ensure its early detection and containment in any territory around the world. This includes the ability to strengthen public health systems in territories that are under-resourced. I would like to take this opportunity to thank the World Health Organisation for the critical leadership provided.

We have been very fortunate that, to date, there has been no case of Covid-19 in South Africa.

However, as you have now heard, 2 South Africans who were crew members of the Princess Diamond ship tested positive for coronavirus.

We are in constant contact with our embassy in Japan and the Diamond Princess parked off the coast of Yokohama

Those citizens from the cruise liner are receiving direct contact with our team to monitor their progress. We have been assured that they are recovering. When they test negative they will be free to return except those going through quarantine. Thereafter they will return without restrictions

South Africa’s State of Readiness

The South African Government has worked hard to optimize our state of readiness with the resources and capability we have in the event that we should have a case of Covid-19.

–       The Multisector National Outbreak Response team (MNORT) is responsible for tracking and tracing outbreaks around the world, monitoring and analysis of developments, advising all relevant authorities on the country response to the outbreak and ensuring our state of preparedness.

–       The NICD had very early on picked up on the Covid-19 outbreak and MNORT had convened twice by the time the WHO announcement was made to ensure that there was a standard operating procedure in place for the early detection, containment and management of a possible outbreak in South Africa. This included up-capacitation of our ports of entry to be able to screen incoming passengers, especially those from China and other affected countries and preparing tertiary institutions to be referral centres for the isolation and management of Covid-19 patients as well as to take advantage of their research capabilities

–       On the eve of the WHO announcement I held a press briefing detailing these measures, which included the activation of the Emergency Operation Centre in the event of a WHO public health emergency announcement. When that announcement was made the EOC was immediately activated- many of the media had an opportunity to see the EOC and learn of its inner workings.

–       A 24 hour clinician hotline was set up as well as a working hours hotline set up for the public. The Public Hotline number is 0800 029 999 and operates from 8.00 to 16.00. If South Africa were to confirm a case of coronavirus the public hotline will convert to a 24 hour hotline. These hotlines have been extremely busy fielding calls from clinicians and the public and a second line has been linked to the clinicians hotline.

–       An Inter- Ministerial Committee was formed by the following Ministers:

•     Health
•     Defense
•     Home Affairs
•     International Relations and Co-operation
•     Justice
•     Social Development
•     Police

This ensures there is co-ordinated collaboration across different departments and each is able to directly respond to specific needs that may be required from it.

–       Since the outbreak our government has issued daily statements with situational updates for South Africa. As at 26 February 121 people have been tested for coronavirus and all the results were negative

On the first week of the outbreak the number of citizens wishing to return was negligibly low and contact was a challenge as many SA citizens do not report their whereabouts to the embassy or DIRCO

We must commend DIRCO and the embassy staff as well as Chinese authorities for assisting to locate our citizens in China

We gave a directive that every citizen must be frequently contacted directly personally and their concerns recorded This has enabled government to properly evaluate their needs hence the well informed decision  taken

Earlier government intervened to assist with advices and instances where there were special requirements for medical supplies and concerns of low food supplies

In all instances the Chinese authorities have been helpful and supportive hence we were happy with the condition of our citizens

Many reported challenges in personal resources and anxiety to return home and requests started to increase and government now has identities and precise location of our citizens

Government has prioritized the needs of our citizens

Accusations that the government prioritised diplomatic relations with China and accusations that government is sending mixed messages are ill informed, mischievous and are attempt to create sensation and controversy on a matter that requires single minded focus of all to ensure the safety of all South African citizens 

Decision to Evacuate Citizens From Wuhan/ Hubei

Following the President’s directive for the repatriation of asymptomatic South African citizens in Wuhan City, where the epicenter of the outbreak is, such contingency plans are now being effected as a matter of extreme urgency. We have noted that other areas of China do not represent a high risk for exposure to Covid-19 and so the citizens under lockdown in Wuhan have been prioritised.

We have been able to ascertain that there are approximately 199 South Africans living in Wuhan and, of those, 147 have indicated a wish to be repatriated. Amongst these are students who have completed studies and students whose studies were interrupted by the lockdown.

Citizens indicated they do not wish to return. There was also a South African citizen who elected to be repatriated with Indian citizens who were recently evacuated by the government of India.

In response to the plea by our citizens to return home, Cabinet instructed the inter ministerial committee to effect plans to evacuate and repatriate the citizens.

At this stage, through the DIRCO, we are making an effort to locate the remaining thirty-six (36) South Africans in Wuhan.  We are making a special appeal to the families who may have relatives in Wuhan to contact DIRCO at 012 351 1754 and 012 351 1756, [email protected] and [email protected].

The Repatriation Process is implemented in three phases namely Evacuation, Quarantine ad Re-unification. We are guided by the WHO guidelines and the relevant South African laws and policy framework.

I will now go into each phase in a bit more detail:

 Evacuation:

This will be an exercise undertaken by the Military in co-operation with DIRCO and Chinese authorities.

All South African citizens from Wuhan City that wish to be repatriated will be accommodated and brought back in a chartered aircraft under strict quarantine protocols that will be enforced. 

There will be a Multi-Disciplinary Medical Team on board the aircraft that will be responsible for pre and inflight screening and medical care. All nationals that do not meet the Medical Screening Requirements during pre-screening will be referred to the Chinese Health System. A Port of Entry has been prepared for the receipt of RSA Nationals, flight crew and medical team.

All support staff coming into direct contact with the repatriates will also fall into the quarantine protocol

 Quarantine:

The very nature of the quarantine exercise is to isolate a group of Covid negative people who have been exposed to a high risk environment, remove them from that high risk environment, and then allow the determined incubation period to lapse before being integrated into virgin society. Human contact and mixing of groups will be limited in the entire process.

–       A quarantine facility that meets all the requirements has been identified – There will be a perimeter line that will be guarded by the military. Within that perimeter the area will be declared a no entry zone and a no flight zone-   Those under quarantine will not be allowed to exit the perimeter but will be allowed to move freely within the perimeter

–       No-one will be allowed to enter the Zone. There will be a “no man’s land” strip to accommodate the collection of goods whereby there is zero contact between the deliverers and the collectors.

–       I must reiterate that no family members, friends or associates of those under quarantine may visit the Zone.

–       We plead with the media to respect the boundaries and not make attempts to enter the quarantine zone

–       Support staff in the facility will also be subject to quarantine protocols

–       The entire quarantine period will be 21 days duration to allow for arrival and phased exit.

–       Legal action will be taken against any individual that goes against the stipulated regulations in relation to quarantine

–       There will be a medical facility installed as per standard military procedures and the quarantine facility will be collaborating closely with the designated facilities for coronavirus in the country.

–       On arrival all quarantine members will be briefed and tested and there will be screening done at predetermined intervals.

–       Should someone develop symptoms they would be immediately isolated for further testing

–       Should the patient test positive for coronavirus they would immediately be transferred to a designated referral facility

–       Should there be multiple cases of coronavirus the project would be escalated to a multi-isolation system whereby quarantine members would then be confined to their rooms for the entire duration

–       For every incident of confirmed coronavirus, the quarantine period starts again at D- Day ( or day one).

 Reunification

Assuming the quarantine period is incident free:

–       The final day of quarantine is denoted by all members testing negative for coronavirus

–       The members would then be given the final counseling and then granted leave to depart

–       There will be continued contact with the citizens thereafter.

–       All affected equipment, venues, facilities etc will be subjected to decontamination protocols

 Reflection on the State of the coronavirus Outbreak Worldwide and what the future holds

Whilst it can never be possible to predict what will happen in South Africa if the virus were to be introduced to our territory, it is a useful exercise to survey the current global status and start to formulate projections that can help us guide public policy.

We continue to monitor the development in other countries and are in touch with our embassies

We are concerned that when we first reported this matter  there were 4500 cases reported largely in China. Today the coronavirus has spread to 50 countries worldwide with devastating consequences

We are in touch with and receive twice daily updates from our embassies and authorities in several countries where the infections are rising rapidly

South Korea has rapidly rising Covid-19 cases-  They have over 2000 cases and 13 deaths. The City of Daegu, 300km from Seoul, is the epicenter.

Iran is an area of concern seeing that they have 141 cases and high mortality of 19

We understand that both Algeria and Nigeria have infections that have no history of travel to China- they seem to have originated from Italy. 

Reports of a death in USA and infection on individuals that cannot record any contact with a known Covid-19 case mean that we are seeing Covid-19 as a disease prevailing in communities with no direct link with China

We have to get ready as there is no country that has a formula to prevent the coronavirus from infecting its people

In the long term we have to prepare for readiness for resident coronavirus that may arise in any part of the country — that is the advice from the WHO.

Research has to be done to ascertain how soon after the patient is tested negative of Covid-19 does it stop being infectious

Common experience suggests that once the test is negative there should be no possibility of transmitting the virus 

This point is important as we monitor those who return home after they have contracted and were treated and recovered from Covid-19

However there are positive developments.

The manner in which China has managed the outbreak has many lessons for the global community on what works and what mistakes to avoid, as they have treated around 80,000 patients with proven Covid-19. 

Approximately 32,000 have recovered and around 46,000 are still on treatment and there have been 2,.900 deaths. Relatively speaking this mortality is low at around 3%.

Furthermore in China the number of recoveries is exceeding the number of new infections day to day and the rate of infection is declining. This points to a very positive picture of a virus that can be managed at both clinical and public policy level.

 Conclusion

To conclude, it is important to bear in mind the highly dynamic nature of the global coronavirus phenomenon. There is no start or end to the work that must be done. There are more robust studies needed and medical precision needs to be sharpened. Our level of vigilance continues to be at the highest level in the wake of the WHO announcement of a Public Health Emergency of International Concern.

We will issue constant situational updates in the form of media statements. We wish to advise that there will be some measure of control as to what information the quarantine members can communicate to the media and on social media platforms as a matter of security and to that end we appeal for co-operation in this regard.

Ultimately we must remember that we are dealing with a group of healthy people who had built lives in Wuhan but found themselves disrupted by an extraordinary situation. As this operation unfolds it is most important to protect their safety and dignity and also public safety. Our citizens have been through a lot already in Wuhan, but they have conducted themselves with incredible stoicism and solidarity with the Chinese, co-operating with Chinese regulation and authority. Their dignified manner of partnering with China and also ourselves through the embassies should set an example and tone for the rest of us to follow as we engage in this process in the interest of public safety.

We have taken note of countries that have reported increased numbers of coronavirus cases. We therefore call on all travellers to immediately seek medical attention should you develop symptoms consistent with coronavirus. DM