COVID-19 SENTINEL HOSPITAL SURVEILLANCE UPDATE SOUTH AFRICA WEEK 30 2020 OVERVIEW This report summarises data of COVID-19 cases admitted to sentinel hospital surveillance sites in all provinces. The report is based on data collected from 5 March to 25 July 2020. HIGHLIGHTS 751, 34%) comorbid conditions. Diabetics ∙ As of 25 July, 33 401 COVID-19 admissions were with chronic renal disease (241/547, 44%) reported from 321 facilities (98 public-sector and obesity (146/292, 50%) had the highest and 223 private-sector) in all nine provinces CFRs. of South Africa. There was an increase of 5 ∙ 247 new admissions since the last report, ∙ Of the 12 771 patients admitted in the and 13 additional hospitals (10 public-sector public sector, most patients were admitted and 3 private-sector) reporting COVID-19 to district hospitals (4 653, 36%), national admissions. There were 12 761 (38%) and 20 central hospitals (4 071, 32%) and regional 640 (62%) admissions reported in public hospitals (2 407, 19%). CFR was highest in and private sector respectively. The majority regional (27%), provincial tertiary (27%), of COVID-19 admissions were reported national central (27%) and district hospitals from four provinces, 13 617 (41%) in Western (23%). Cape, 9 055 (27%) in Gauteng, 4 755 (14%) ∙ in KwaZulu-Natal and 2 153 (6%) in Eastern ∙ The median length of stay (time from Cape. Admissions in the Western Cape seem admission to outcome) for patients who to have plateaued in the past two weeks. were discharged was 5 days and for those ∙ who died was 6 days (p<0.001); was 5 days in ∙ Of the 3 3401 admissions, 6 886 (21%) patients public as compared to 6 days in the private were in hospital at the time of this report, 2 sector (p<0.001); and decreased with each 1502 (64%) patients were discharged alive or month of admission from 7 days in March transferred out and 5 013 (15%) patients had to 5 days in July (p<0.001). died. There were 1 202 additional deaths since the last report. Of the 2 6139 COVID-19 patients who had recorded in-hospital outcome (died and discharged), 5 013 died, equating to a case fatality ratio (CFR) of 19%. ∙ ∙ The CFR in patients who had diabetes only (420/1 872, 22%), increased in diabetics with two (927/3 126, 30%) and three or more (602/1 www.nicd.ac.za PAGE 1 METHODS DATCOV, sentinel hospital surveillance for COVID-19 admissions, was initiated on the 1 April 2020. Data are submitted by public and private hospitals that have agreed to report COVID-19 admissions through DATCOV surveillance in all nine provinces of South Africa. A COVID-19 case was defined as a person with a positive reverse transcriptase polymerase chain reaction (RT- PCR) assay for SARS-CoV-2 who was admitted to a DATCOV sentinel hospital. An individual was defined as having severe disease if treated in high care or intensive care unit (ICU), or ventilated or diagnosed with acute respiratory distress syndrome (ARDS). Case fatality ratio (CFR) was calculated for all closed cases, i.e. COVID-19 deaths divided by COVID-19 deaths plus COVID-19 discharges, excluding individuals who are still admitted in hospital. Data are received from all private hospitals nationally, from all public hospitals in the Western Cape (WC) Province and 37 public hospitals in the other eight provinces. As new hospitals join the surveillance system, they have retrospectively captured all admissions recorded. As of 25 July 2020, a total of 321 facilities, 98 from public sector and 223 from private sector, submitted data on hospitalised COVID-19 cases (Table 1). There were 13 additional hospitals (10 public-sector and 3 private-sector) reporting COVID-19 admissions since the last report. Table 1: Number of hospitals reporting data on COVID-19 admissions by province and sector, South Africa, 5 March-25 July 2020 Name of province Public Sector Private Sector Eastern Cape (EC) 19 13 Free State (FS) 11 18 Gauteng (GP) 6 82 KwaZulu-Natal (KZN) 7 41 Limpopo (LP) 1 6 North West (NW) 0 8 Northern Cape (NC) 2 12 Western Cape (WC) 1 6 Mpumalanga (MP) 51 37 South Africa 98 223 RESULTS Epidemiological and geographic trends in admissions From 5 March to 25 July, a total of 33 401 COVID-19 admissions (5 247 additional from last report) were reported from 321 facilities in all nine provinces of South Africa. Of these admissions, 12761 (38.2%) and 20 640 (61.8%) were reported in public and private sector, respectively. Initially, most admissions were reported in the private sector; from week 17 a higher proportion of total admissions was reported in the public sector; and since week 25 a higher proportion was reported in the private sector. The shift is most likely due to underreporting in the public sector in other provinces besides Western Cape in recent weeks. The decrease in reported admissions in the last epidemiological week is likely due to a delay in the submission of data (Figure 1). www.nicd.ac.za PAGE 2 5000 Public 4500 4000 Private 3500 19 Admissions - 3000 2500 2000 1500 Number Number of COVID 1000 500 0 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Epidemiological week of diagnosis Figure 1: Number of reported COVID-19 admissions by health sector and epidemiologic week of diagnosis, 5 March-25 July 2020, n=33401 The majority of admissions (29 580/3 3401, 88.6%) were recorded in four provinces, with the highest number reported in Western Cape (13 617/33 401, 40.8%), followed by Gauteng (9 055/33 401, 27.1%), KwaZulu-Natal (4 755/3 3401, 14.2%) and Eastern Cape (2 153/3 3401, 6.4%) provinces. Western Cape experienced an increase in admissions from week 19 which has in the past two weeks seemingly plateaued; the increase in Gauteng began in week 23 and in KwaZulu-Natal in week 26 (Figure 2). 16000 14000 Western Cape Gauteng KwaZulu-Natal 12000 Eastern Cape Free State North West 10000 19 admnissions 19 - 8000 Limpopo Mpumalanga Northern Cape 6000 4000 Number Number of COVID 2000 0 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 Epidemiological week Figure 2: Cumulative numbers of reported COVID-19 admissions, by province and epidemiological week of diagnosis, South Africa, 5 March-25 July 2020, n=3 3401 www.nicd.ac.za PAGE 3 DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF COVID-19 ADMISSIONS The median age of COVID-19 admissions was 51 years (interquartile range [IQR] 39 – 62). There were 1076 (3.2%) admissions in patients 18 years and younger and 4783 (14.3%) in patients older than 70 years. Among admitted individuals with COVID-19, 18171 (54.4%) were female. The sex ratio was equal in patients between 40 and 80 years; females were more common than males in patients between 10 and 40 years and males more common in patients younger than 10 years (Figure 3). 9000 100% Female Male % Male 8000 90% 7000 80% 70% 6000 19 admissions 60% - 19 admissions - 5000 50% 4000 40% 3000 30% 2000 20% Number Number of COVID 1000 10% Percentage male COVID 0 0% 0-9 >80 10-19 30-39 50-59 20-29 70-79 60-69 40-49 unknown Age group (years) Figure 3: Number of reported COVID-19 admissions by age, gender and percentage of males, South Africa, 5 March-25 July 2020, n=33401 www.nicd.ac.za PAGE 4 Of the 13666 (40.9%) patients for whom race was known, 9742 (71.3%) were Black African, 1583 (11.6%) were Coloured, 849 (6.2%) were Indian, 1461 (10.7%) were White and 31 (0.2%) were classified as Other race group. There were 806 (2.4%) health care workers (HCW) that were reported to be hospitalised. Among the 8360 admissions in females of child-bearing age 15-50 years, there were 908 (10.9%) females admitted who were pregnant or within 6 weeks post-partum. Among 27361 (81.9%) patients for whom comorbid conditions were known, 10729 (32.1%) had no comorbid condition reported, 7991 (23.9%) had one comorbid condition reported, 5706 (17.1%) had two comorbid conditions and 2935 (8.8%) had three or more comorbid conditions reported. Among the 16631 (49.8%) patients who had reported a comorbid condition, the most commonly reported were hypertension (10400/16631, 62.5%) and diabetes (8256/16631, 49.6%); there were 2893/16631 (17.4%) patients who were HIV-infected, 572/16631 (3.4%) patients with active tuberculosis (TB) and 1115/16631 (6.7%) patients with previous history of TB (Table 2). Obesity, defined by the subjective opinion of the attending HCW, while not consistently recorded for all reported COVID-19 admissions, was recorded as a risk factor in 997 (3.0%) of all patients hospitalised. Table 2: Reported comorbid conditions among COVID-19 admissions reporting at least one comorbid condition, South Africa, 5 March-25 July 2020, n=16631* Comorbid disease** n % Hypertension 10 400 62.5% Diabetes mellitus 8 256 49.6% Chronic cardiac disease 1 186 7.1% Chronic pulmonary disease/ Asthma 2 325 14.0% Chronic renal disease 1 119 6.7% Malignancy 331 2.0% HIV 2 893 17.4% Active TB 572 3.4% Previous history of TB 1 115 6.7% * Multiple comorbid conditions are counted more than once so the total number may be more than the total number of individuals reporting comorbid conditions.