Diabetics moved to front of Covid-19 test queue as deaths rocket

Diabetics are the new focus of the Western Cape’s evolving Covid-19 testing strategy.

Provincial head of health Dr Keith Cloete said on Thursday a new model of care had been developed after the deaths of one in five diabetics admitted to hospital with Covid-19.

“Over-50s and diabetics have a significant increase in risk. Those two together are the single biggest risk,” Cloete said during premier Alan Winde’s weekly Covid-19 news conference.

Of the first 5,136 diabetic Covid-19 patients in the Western Cape, 45.7% had been admitted to hospital, while in the non-diabetic population the admission rate was about 10%.

The mortality rate among those admitted with diabetes and Covid-19 was 45%, almost twice the average of 25%, said Cloete.

With the provincial Covid-19 testing backlog eliminated, he said, “we’ve decided to expand testing very selectively to all unexplained deaths and to vulnerable groups, especially diabetics”.

Cloete added: “As of today, everyone Covid-positive with obesity has to be tested for diabetes. If you’re a diabetic and negative, prevention is very important. We screen household members and have a very low threshold. If anyone in that household becomes symptomatic, we will ensure immediate separation [of the vulnerable person].”

Diabetics who tested positive for Covid-19 would be divided into three risk groups.

Those at low risk would receive a daily call from the provincial health call centre, asking if their condition had deteriorated. If it had, hospital admission would be considered.

People at moderate risk would be called daily by a specialised health-care professional, with experience of dealing with complex cases, and provided with a blood glucose monitoring device.

For this group there would be a “very low threshold” for admission to the temporary 860-bed Hospital of Hope at the Cape Town International Convention Centre.

Patients at high risk, including those over the age of 70 or with poorly controlled diabetes, would be admitted to hospital immediately.

“This is a very proactive management of diabetes that we’re implementing as of today,” said Cloete.

Winde said the latest “recalibration” of epidemiological models for the trajectory of Covid-19 in the Western Cape showed that the peak would be flatter, longer and later than previously forecast.

Cloete said the number of hospital beds expected to be required had come down to 5,400 from 7,500 as a result of the latest forecast, and the current number available was 5,915. The deficit for critical care beds had come down to 550.

However, agreements were now in place with private hospitals and the first three public-sector patients had been admitted to Netcare and Life health-care facilities to test the system.

The main constraint on expanding critical care and intensive care beds in the public sector was a shortage of staff, because of Covid-19 infections among health-care workers, and this was being addressed by offering nurses short courses, allowing them to upgrade their skills.

Cloete said the Hospital of Hope, which opened on June 8, had admitted 615 patients so far and discharged 338. It had recorded 28 deaths. Winde said work on an extension to the hospital had been put on hold in line with the new models.

Another field hospital, at Brackengate in Cape Town’s far northern suburbs, was handed over to the health department on Wednesday and will admit its first patient on July 10.

The R44m hospital has 338 beds and will be operated by 308 staff. Eight beds will be equipped to administer high-flow nasal oxygen, one of the treatments which has helped to reduce the number of hospital patients in ICU from 20% in the early stages of the pandemic to 10% or less.

Epidemiologist Prof Andrew Boulle said the flatter, longer, later peak did not mean the pandemic in the province was anything less than a crisis.

Though the mortality rate in the Western Cape had been lower than previously predicted, “we are still on an upward trajectory”, he said. As of Thursday, the province had reported 1,918 deaths, with a daily average of 46 in the past fortnight.

Boulle said Wednesday’s SA Medical Research Council (SAMRC) report on weekly deaths was sobering. “The dramatic increase in deaths year on year is unheralded. The last time we saw this in SA was at the height of the HIV/Aids epidemic, prior to the accessibility of treatment,” he said.

“What we are seeing only happens in epidemics and in times of war, and this pattern has been seen the world over.”

Even though the number of deaths per day was likely to be lower than under modellers’ earlier predictions, “they are now anticipating 2,000 additional deaths under this scenario than the previous one”, he said.

Boulle revealed that poverty-stricken parts of Cape Town had mortality rates exceeding the worst-hit areas of the world. The Klipfontein health subdistrict had a mortality rate of about 700 per million people and in Khayelitsha it was 500 per million.

In the UK, the Covid-19 mortality rate, by far the world’s worst, is 660 per million and in the US it is 390. In SA as a whole, it is just under 48 per million.

Boulle, who works at the University of Cape Town (UCT) Centre for Infectious Disease Epidemiology and Research, said: “If the Western Cape were a country and we compared it to other countries, at this point in time globally we might be one of the countries with the highest daily mortality rates.”

The eventual mortality rate could easily reached 1,500 per million, “which would take those communities into the realm of New York state, Madrid or Stockholm”, he said.

As of Thursday, Klipfontein, an area of 3.8 million people who live in neighbourhoods such as Delft, Gugulethu, Nyanga and Manenberg, had 6,316 confirmed Covid-19 cases.

The number of cases per 100,000 people was 1,662, the highest in Cape Town, meaning almost 17 people in every 1,000 have been infected. The subdistrict also has the highest per capita rate of active cases, which total about 400 per 100,000 people.

Boulle said one of the tragedies of Covid-19 in low- and middle-income countries around the world was that poorer areas were hardest hit.

“There are also substantial comorbidity burdens in those communities, such as diabetes, HIV and TB,” he said.

Explaining why modellers did not believe the Western Cape had reached its peak, Boulle said: “We are still seeing ongoing increases in mortality, even though the rate of change is slowing. We won’t call it a peak until we see mortality coming down robustly.”

Winde said the latest models from the Actuarial Society of SA and the National Covid-19 Modelling Consortium now suggested the Western Cape would see 10,000 Covid-19 deaths.

The peak was now likely to begin about the end of July and last four months, he said, adding that the “best and brightest” minds in the health department had not yet understood why the projections had changed.

“These top scientists are not yet clear on what has caused our curve to be flatter and pushed out. We are dealing with an unprecedented scenario and we are learning about this virus every day,” said Winde.

“One of the factors posited is that the virus is peaking in different places in the city at different times. Another scenario is that the virus does not infect everyone in the same way. Behaviour-change interventions, such as wearing a mask and keeping a distance, can also make a real difference.

“As more data becomes available and as we learn more about the pandemic in the Western Cape and SA, we will be able to be clearer on the reasons for these changes. I can also assure you that we are constantly analysing our data so that we make the best possible decisions.”