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COVID-19 SENTINEL HOSPITAL SURVEILLANCE UPDATE

∙ As of 31 May, 4 718 COVID-19 admissions were reported from 218 facilities (57 public-sector and 161 private-sector) in all nine provinces of South Africa. There was an increase of 1 307 new admissions since the last report, and 11 additional hospitals (1 public-sector and 10 private-sector) reporting COVID-19 admissions. There were 2 267 (48%) and 2 451 (52%) admissions reported in private and public sector respectively. The majority of COVID-19 admissions were reported from four provinces, 3 078 (65%) in Western Cape, 497 (11%) in Gauteng, 452 (10%) in Eastern Cape and 439 (9%) in KwaZulu-Natal.

∙ The median age of COVID-19 admissions was 49 years; 194 (4%) admissions in patients <20 years and 704 (15%) in >70 years. Fifty four percent (2 563/4 718) were female.

∙ Among 3 737 (79%) patients with data on comorbid conditions; 1 127 (30%) had one comorbid condition, 1 295 (35%) had two or more comorbid conditions. Most commonly reported comorbid conditions were hypertension 1 353/2 422 (56%) and diabetes 1 167/2 422 (48%). There were 467 (19%) patients admitted with HIV, 97 (4%) with active tuberculosis and 276 (11%) patients with previous history of TB. There were 87

HIGHLIGHTS

(4%) patients who were reported to be obese.

∙ Of the 4 718 admissions, 1607 (34%) patients were in hospital at the time of this report, 2 503 (53%) patients were discharged alive or transferred out and 608 (13%) patients had died. There were 158 additional deaths since the last report. On multivariable analysis, factors associated with in-hospital mortality were older age groups, 40-64 years (316/2 293, case fatality ratio 14%; aOR 4.2; 95% CI 2.8-6.4) and ≥65 years (252/1004, 25%; aOR 7.4; 95% CI 4.8-11.4) as compared to <40 years (40/1421, 3%); male sex (311/2 155, 14%; aOR 1.5; 95% CI 1.2-1.8); admission in the public sector (390/2 451, 16%; aOR 1.5; 95% CI 1.1-1.9); and having comorbid hypertension (316/1 353, 23%; aOR 1.5; 95% CI 1.2-1.9), diabetes (286/1 167, 25%; aOR 1.6; 95% CI 1.3-2.0), chronic renal disease (85/213, 40%; aOR 2.5; 95% CI 1.8-3.5) and malignancy (8/30, 27%; aOR 3.5; 95% CI 1.8-8.4). Patients who died were less likely to be admitted in Gauteng Province (21/497, 4%; aOR 0.3; 95% CI 0.2-0.5) or North West province (1/114, 1%; aOR 0.1; 95% CI 0.01-0.6) as compared to the Eastern Cape Province.

OVERVIEWThis 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 31 May 2020.

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Table 1. Number of hospitals reporting data on COVID-19 admissions by province and sector, South Africa, 5 March-31 May 2020


METHODS

DATCOV19, 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 DATCOV19 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 DATCOV19 sentinel hospital. An individual was defined as having severe disease if treated in high care or ICU, or ventilated or diagnosed with acute respiratory distress syndrome (ARDS).

Data on hospitalised cases who were diagnosed with COVID-19 from 5 March to 31 May 2020 were collected. Data are received from all private hospitals nationally, and a subset of public hospitals in all nine provinces (data are received from all public hospitals in the Western Cape (WC) Province). As of 31 May 2020, a total of 218 facilities, 57 from public sector and 161 from private sector, submitted data on hospitalised COVID-19 cases (Table 1).

Name of province Public Sector Private Sector

Eastern Cape (EC) 5 11

Free State (FS) 3 6

Gauteng (GP) 3 61

KwaZulu-Natal (KZN) 4 32

Limpopo (LP) 1 4

North West (NW) 2 7

Northern Cape (NC) 1 5

Western Cape (WC) 38 31

Mpumalanga (MP) 0 4

South Africa 57 161

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Figure 1. Number of reported COVID-19 admissions by province and health-sector, South Africa, 5 March-31 May 2020, n=4 718


RESULTS

From 5 March to 31 May, a total of 4 718 COVID-19 admissions (1 307 additional from last report) were reported from 218 facilities (11 additional reporting sites since last report) in all nine provinces of South Africa. Of these admissions, 2 267 (48.1%) and 2 451 (51.9%) were reported in private and public sector, respectively (Figure 1). The majority of admissions (4 466/4 718, 94.7%) were recorded in four provinces, with the highest number (3 078/4 718, 65.2%) reported in Western Cape (WC), followed by (4 97/4 718; 10.5%) in Gauteng (GP), (4 52/4 718, 9.6%) in Eastern Cape (EC), and (4 39/4 718, 9.3%) in KwaZulu-Natal (KZN) provinces (Figure 1).

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Figure 2. Number of reported COVID-19 admissions by health sector and epidemiologic week of diagnosis, 5 March-31 May 2020, n=4 718


Initially, most reported admissions were in the private sector, however as from week 16 increasing proportion of total admissions was reported in the public sector (Figure 2).

DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF COVID-19 ADMISSIONS

The median age of COVID-19 admissions was 49 years (interquartile range [IQR] 37 – 61). There were 194 (4.1%) admissions in patients younger than 20 years and 704 (14.9%) in patients older than 70 years. Among admitted individuals with COVID-19, 2 563 (54.3%) were female. The sex ratio varied by age group with females more common than males in all age groups except in patients younger than 10 years (Figure 3).

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Figure 3. Number of reported COVID-19 admissions by age, gender and percentage of males, South Africa, 5 March-31 May 2020 (n=4 718)


Of the 2 288 (48.5%) patients for whom race was known, 1 458 (63.7%) were Black African, 436 (19.1%) were Coloured, 128 (5.6%) were Indian and 266 (11.6%) were White. There were 189 (4.0%) health care workers (HCW) that were reported to be hospitalised. Among the 2 563 female admissions, there were 210 (8.2%) females admitted who were pregnant or within 6 weeks post-partum.

Of the 3 737 (79.2%) patients for whom comorbid disease was known, 1 315/3 737 (35.2%) had no comorbid disease reported, 1 127/3 737 (30.2%) had one comorbid disease reported and 1 295/3 737 (34.7%) had two or more comorbid diseases reported. Among the 2 422 patients who had reported a comorbid condition, the most commonly reported comorbid conditions were hypertension (1 353/2 422, 55.9%) and diabetes (1 167/2 422, 48.2%). There were 4 67/2 422 (19.3%) patients who were HIV-infected, 97/2 422 (4.0%) patients with active tuberculosis (TB) and 276/2 422 (11.4%) patients with previous history of TB (Table 2). Obesity, while not consistently recorded for all reported COVID-19 admissions, was recorded as a risk factor in 87 patients.

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Table 2. Reported comorbid diseases among COVID-19 admissions reporting at least one comorbid disease, South Africa, 5 March-31 May 2020 (n=2 422)

Comorbid disease* n %

Hypertension 1 353 55.9%

Diabetes mellitus 1 167 48.2%

Chronic cardiac disease 67 2.8%

Chronic pulmonary disease/ Asthma 395 16.3%

Chronic renal disease 213 8.8%

Malignancy 30 1.2%

HIV 467 19.3%

Active TB 97 4.0%

Previous history of TB 276 11.4%

South Africa 57 161 * Multiple comorbid conditions would be counted more than once so the total number may be more than the total number of individuals reporting comorbid conditions


CLINICAL MANAGEMENT OF COVID-19 HOSPITALISED PATIENTS

Of the 1 607 COVID-19 patients currently in-hospital, 43 (2.7%) were being treated in isolation wards, 1254 (78.0%) in general wards, 101 (6.3%) in high care wards and 209 (13.0%) in Intensive Care Unit (ICU). There were 97 (6.0%) patients currently ventilated and 212 (13.2%) currently on supplementary oxygen.

SEVERITY

Of the 4718 COVID-19 admissions to date, 1 085 (23.0%) met the criteria for severe disease. The median age of patients who had severe disease was 53 (IQR 44 – 64) years; compared to 47 (IQR 35 – 60) years for those who did not have severe disease. The proportion of reported in-patients who were treated in ICU and ventilated in each epidemiological week has decreased in the past nine weeks (Figure 4).

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Figure 4. Proportion of COVID-19 in-patients treated in intensive care unit (ICU) and ventilated by epidemiological week, South Africa, 28 March-31 May 2020*

*Data on ventilation and ICU care was not reliable prior to epidemiological week 14


OUTCOMES

Of the 4718 admitted individuals, 1 607 (34.1%) were currently in hospital, 2 441 (51.7%) were discharged alive, 62 (1.3%) were transferred out to either higher level care or step-down facilities and 608 (12.9%) had died.

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Figure 5. Number of COVID-19 deaths reported per week by health sector and epidemiologic week, South Africa, 5 March-31 May 2020, n=608


MORTALITYOf the 4 718 COVID-19 patients admitted, 608 died, case fatality ratio (CFR) 12.9% (158 additional deaths from last report). In the first few weeks of the outbreaks most deaths were reported in the private sector but in recent weeks an increasing proportion of reported deaths was in the public sector (Figure 5).

The median age of patients who died was 61 (IQR 52 – 71) years, and for those who were still alive was 47 (IQR 35 – 58) years. On multivariable analysis, factors associated with in-hospital mortality were older age groups, 40-64 years (316/2 293, case fatality ratio 13.8%; aOR 4.2; 95% CI 2.8-6.4) and ≥65 years (252/1 004, 25.1%; aOR 7.4; 95% CI 4.8-11.4) as compared to <40 years (40/1 421, 2.8%); male sex (311/2 155, 14.4%; aOR 1.5; 95% CI 1.2-1.8); admitted in the public sector (390/2 451, 15.9%; aOR 1.5; 95% CI 1.1-1.9); and having comorbid hypertension (316/1 353, 23.4%; aOR 1.5; 95% CI 1.2-1.9), diabetes (286/1 167, 24.5%; aOR 1.6; 95% CI 1.3-2.0), chronic renal disease (85/213, 39.9%; aOR 2.5; 95% CI 1.8-3.5) and malignancy (8/30, 26.7%; aOR 3.5; 95% CI 1.8-8.4). Patients who died were less likely to be admitted in Gauteng Province (21/497, 4.2%; aOR 0.3; 95% CI 0.2-0.5) or North West Province (1/114, 0.9%; aOR 0.1; 95% CI 0.01-0.6) as compared to the Eastern Cape Province (Table 3).

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Table 3. Univariate and multivariable analysis of factors associated with mortality among 4718 admissions, South Africa, 5 March-31 May 2020

Characteristic Case-fatality ratio n/N (%)

Unadjusted OR (95% CI)

p-value Adjusted OR (95% CI)

p-value

Age group

<40 years 40/1 421 (2.8) Reference Reference

40-64 years 316/2 293 (13.8) 5.5 (3.9-7.7) <0.001 4.2 (2.8-6.4) <0.001

≥65 years 252/1 004 (25.1) 11.6 (8.2-16.3) <0.001 7.4 (4.8-11.4) <0.001

Sex

Female 297/2 563 (11.6) Reference Reference

Male 311/2 155 (14.4) 1.3 (1.1-1.5) 0.004 1.5 (1.2-1.8) <0.001

OccupationNot Healthcare worker 602/4 529 (13.3) Reference

Healthcare worker 6/189 (3.2) 0.2 (0.1-0.5) <0.001

Peri-partum NoYes

295/2 353 (12.5)2/210 (1.0)

Reference0.1 (0.0-0.3) <0.001

Comorbid condition

No co-morbidity 80/1 315 (6.1) Reference

1 co-morbid condition 149/1 127 (13.2) 2.4 (1.8-3.1) <0.001

≥2 comorbid conditionsUnknown

306/1 295 (23.6)73/981 (7.4)

4.8 (3.7-6.2)1.2 (0.9-1.7)

<0.0010.198

HypertensionNoYes

219/2 384 (9.2)316/1 353 (23.4

Reference3.0 (2.5-3.6) <0.001

Reference1.5 (1.2-1.9)* 0.001

Diabetes mellitusNoYes

249/2 570 (9.7)286/1 167 (24.5)

Reference3.0 (2.5-3.6) <0.001

Reference1.6 (1.3-2.0)* <0.001

Chronic cardiac diseaseNoYes

515/3 670 (14.0)20/67 (29.9)

Reference2.6 (1.5-4.4) <0.001

Reference1.4 (0.8-2.5)* 0.200

Chronic pulmonary disease/AsthmaNoYes

465/3342 (13.9)70/395 (17.7)

Reference1.3 (1.01-1.8) 0.042

Reference0.9 (0.7-1.3)* 0.701

Chronic renal diseaseNoYes

450/3524 (12.8)85/213 (39.9)

Reference4.5 (3.4-6.1) <0.001

Reference2.5 (1.8-3.5)* <0.001

MalignancyNoYes

527/3 707 (14.2)8/30 (26.7)

Reference2.2 (0.97-5.0) 0.059

Reference3.5 (1.4-8.4)* 0.006

HIVNoYes

472/3 270 (14.4)63/467 (13.5)

Reference0.9 (0.7-1.2) 0.586

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TuberculosisNoYes

520/3 640 (14.3)15/97 (15.5)

Reference1.1 (0.6-1.9 0.744

Past TuberculosisNoYes

485/3 461 (14.0)50/276 (18.1)

Reference1.4 (0.98-1.9) 0.062

Reference1.2 (0.8-1.7)* 0.355

Health sectorPrivate sector Public sector

218/2 267 (9.6)390/2 451 (15.9)

Reference1.8 (1.5-2.1) <0.001

Reference1.5 (1.1-1.9) 0.003

Province

Eastern Cape 67/452 (14.8) Reference Reference

Free State 7/95 (7.4) 0.5 (0.2-1.0) 0.059 0.6 (0.2-1.3) 0.195

Gauteng 21/497 (4.2) 0.3 (0.2-0.4) <0.001 0.3 (0.2-0.5) <0.001

KwaZulu-Natal 41/439 (9.3) 0.6 (0.4-0.9) 0.013 0.7 (0.4-1.0) 0.069

Limpopo 2/17 (11.8) 0.8 (0.2-3.4) 0.727 0.8 (0.2-3.9) 0.763

Mpumalanga 1/10 (10.0) 0.6 (0.1-5.1) 0.673 1 -

North West 1/114 (0.9) 0.1 (0.0-0.4) 0.003 0.1 (0.01-0.6) 0.012

Northern Cape 2/16 (12.5) 0.8 (0.2-3.7) 0.797 1.2 (0.3-5.9) 0.789

Western Cape 466/3 078 (15.1) 1.0 (0.8-1.4) 0.861 0.9 (0.6-1.2) 0.318

Severe**NoYes

352/3 633 (9.7)256/1 085 (23.6)

Reference2.9 (2.4-3.4) <0.001

Ever ICUNo Yes

404/4061 (10.1)204/657 (31.1

Reference4.1 (3.4-5.0) <0.001

Ever High CareNoYes

538/4 198 (12.8)70/520 (13.5)

Reference1.1 (0.8-1.4) 0.678

Ever ventilatedNo Yes

464/4 389 (10.6)144/329 (43.8)

Reference6.6 (5.2-8.4) <0.001

Ever on oxygenNoYes

427/3 759 (11.4)181/959 (18.9)

Reference1.8 (1.5-2.2) <0.001

* Multivariable model excluded all individuals without comorbid condition data

** Severe disease was defined as any individual who was treated in high care or intensive care unit (ICU), ventilated or diagnosed with acute respiratory distress syndrome (ARDS)

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ACKNOWLEDGEMENTS

Private hospital groups submitting data to DATCOV19: Netcare Life Healthcare Mediclinic Southern Africa National Hospital Network (NHN) Clinix Health Group Lenmed Joint Medical Holdings (JMH)

Western Cape province: all public sector hospitals submitting data to DATCOV19

Public hospitals using DATCOV19 surveillance online platform: Dora Nginza Hospital (EC) Frere Hospital (EC) Livingstone Hospital (EC) Madwaleni Hospital (EC) Uitenhage Hospital (EC) Pelonomi Hospital (FS) National District Hospital (FS) Universitas Hospital (FS) Tambo Memorial Hospital (GP) Steve Biko Academic Hospital (GP) Charlotte Maxeke Johannesburg Academic Hospital (GP) Greys Hospital (KZN) Ladysmith Hospital (KZN) Manguzi Hospital (KZN) Addington Hospital (KZN) Polokwane Hospital (LP) Robert Mangaliso Sobukwe Hospital (NC) Tshepong Hospital (NW) Job Shimankana Thabane Hospital (NW) Tygerberg Hospital (WC) Helderberg Hospital (WC)

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