A descriptive study of a SARS-CoV-2 super spreader event: A funeral and a house-party in a district municipality of the Eastern Cape Province, South Africa, 2020

Phuti Sekwadi^1,&, Nomlindo Makubalo², Ntathu Mini², Lifukazi Ngcwangu², Mzimasi Neti¹, Ahmad Haeri Mazanderani^1,3, Nevashan Govender¹

 

¹National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg, 2131, South Africa, ²Nelson Mandela Bay Metropolitan, Eastern Cape Province, ³University of Limpopo, Limpopo Province, South Africa

 

 

^&Corresponding author
Phuti Sekwadi, National Institute for Communicable Diseases, Private Bag X4, Sandringham, Johannesburg, 2131, South Africa. pgsekwadi@gmail.com

 

 

 

 

Coronavirus Disease 2019 (COVID-19) is a respiratory illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 cases were first observed among dealers and vendors at a seafood, poultry, and live wildlife market in Wuhan, located within the Jianghan District of Hubei Province in China. The source of the virus is not yet known [1]. Some of the most common symptoms of this respiratory illness include fever, cough, and fatigue [2]. Recent studies have shown that loss of taste and loss of smell are characteristic symptoms of SARS-CoV-2 infection [3]. The median incubation period has been reported to be 5.1 days (95% CI, 4.5 to 5.8 days) [4]. While most people may never develop any symptoms, SARS-CoV-2 infection can lead to severe illness or death [5]. According to the World Health Organisation (WHO), there several modes of transmission for SARS-CoV-2 which include contact with an infected person, contact with droplets from an infected person and airborne transmission has also been reported [5]. The highest viral load has been reported among patients on the day of symptom onset and then a gradual decline in viral load noted thereafter; this correlates with the period when patients are most infectious [6, 7].

 

Prevention of new SARS-CoV-2 infection is a critical component of the response to the pandemic, which has rapidly spread across the world. The most important methods for curbing the spread of infection are isolation of the confirmed cases and quarantining of people who may have been exposed or in contact with a confirmed case [8-10]. Since asymptomatic cases can also spread the infection, physical distancing becomes critical for everyone in the community [11]. Physical distancing has been reported to reduce infection rates, as determined by a comparison of infection rates between countries that implemented and those that did not implement physical distancing measures [12].

 

In this study, we look at the role of social events that sparked a chain of transmission in one district in the Eastern Cape Province, namely Nelson Mandela Bay. The study focuses on a funeral service that was conducted in the early days of the pandemic in the province, and within one week of the first confirmed SARS-CoV-2 case in the district. This study aims to add to the growing body of knowledge on SARS-CoV-2 and how it is transmitted and to make recommendations for curbing the spread of this novel coronavirus.

 

 

Study design

 

This is a retrospective descriptive study of the COVID-19 super spreader events identified in the Nelson Mandela Bay district between 16 March and 30 April 2020. The events include two earliest clusters of COVID-19 cases in the district.

 

In this study, a COVID-19 case is defined as any person with a confirmed laboratory diagnosis of SARS-CoV-2 during the study period. A contact is defined as any person who had prolonged close contact (>15min duration within 1.5 metre distance in a closed environment) with a confirmed case, even though they may not be sick themselves.

 

A COVID-19 cluster in this study is defined as five or more cases of laboratory-confirmed COVID-19 that have an epidemiological link.

 

Study setting

 

This study focuses on the Nelson Mandela Bay district in the Eastern Cape Province, which comprises seven other district municipalities. According to the 2007 census, the district had an estimated population of 1,050,930 with a median age of 26 years and the average household size was reported to be four people per household. The district is divided into three sub-districts, namely Sub-District A, B, and C.

 

On 16 March 2020, the district recorded its first case of SARS-CoV-2, which was a patient with recent international travel history to countries that had reported SARS-CoV-2 transmission. Due to the ongoing increase in the number of COVID-19 cases worldwide and within South Africa, the South African president declared a national state of disaster on 15 March 2020, and subsequently introduced the national lockdown on 26 March 2020, putting in place regulations to curb the spread of infection. Among these regulations were limitations on the number of people allowed to attend social gatherings including funeral and religious events, which were restricted to 50 people [13].

 

However, on 21 March 2020, there was a funeral in one of the townships within the district. It was a burial of a healthcare worker, who worked as a nurse at one of the local clinics. The healthcare worker died from causes other than SARS-CoV-2. The funeral attracted more than a thousand attendees, which included family members, healthcare workers, and members of the community. As of the date of the funeral, only one case of confirmed SARS-CoV-2 had been reported within the district (on 16 March), which was travel related. This was the only case reported for the entire province as well.

 

Sample size

 

We included all the COVID-19 cases that were reported within the district between 16 March and 30 April 2020 because our focus is on the first clusters of cases identified in the district. The total number of people who attended the two events is unknown, as there were no attendance registers that were kept at these events. Only people who contracted COVID-19 after attendance of these events and had a positive COVID-19 test were included in this study. The sampling frame in both clusters was not available.

 

During the study period, SARS-CoV-2 testing criteria in South Africa was limited to hospitalized patients with severe acute respiratory illness and absence of an alternative diagnosis, and non-hospitalized patients with acute respiratory illness (defined as sudden onset of cough, sore throat, shortness of breath or fever) and a history of close contact with a COVID-19 case, travel outside of South Africa, or worked in or attended a health care facility where patients with SARS-CoV-2 infections were being treated 14 days prior to symptom onset. Asymptomatic contacts were not routinely tested at this stage.

 

Data collection

 

All the COVID-19 cases were diagnosed from both public and private laboratories that submit all the cases to a central database managed by the National Health Laboratory Service (NHLS). We obtained our data from the NHLS. A team of healthcare professionals followed up on the new cases within the district daily and conducted telephonic and/or face-to-face interviews with the cases. The interviews were done to gather possible exposures, risk factors, and demographics and more importantly to identify contacts to allow efficient contact tracing, testing, and facilitation of quarantine and isolation. A template of the questionnaire is available as an additional file (See additional file 1).

 

Data analysis

 

Data were captured and managed on google sheets (Google LLC. Data) and exported to Microsoft Excel. The analysis was done using Microsoft Excel to generate a Venn diagram showing different clusters identified and a histogram to display the epidemic curve. Age, gender, and outcome distributions were displayed using bar graphs generated through Microsoft Excel.

 

Availability of data and materials

 

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

 

Ethical considerations

 

The authors declare that all activities contributing to this work comply with the ethical standards of the relevant national and institutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. NICD outbreak investigations are approved by the research ethics committee at the University of the Witwatersrand, Johannesburg, South Africa (Clearance certificate number: M160667).

 

 

Descriptive epidemiology

 

As of 30 April 2020, 412 laboratory-confirmed cases of COVID-19 had been reported from the public and private laboratories within the district. Sub-District C accounted for most of the cases at 43% (177/412) followed by Sub-District A and B with 42% (171/412) and 14% (56/412), respectively Figure 1. The majority of these were female at 66% (272/412) and most cases were within age groups 25-29, 30-34, and 35-39 years with each accounting for 11% of the total cases Figure 2. The median age was 38 years with a range of 0 to 87 years. Age groups 75-79 years and ≥80 years accounted for the least number of cases at 1% (5/412) each followed by children aged 0-4 years at 2% (8/412). Where symptom information was recorded (56%; 231/412), most of the cases were symptomatic (74%; 172/231). As of 30 April 2020, the highest death rates were observed within older age groups which include 80 years & above (20%), 75-79 years (20%), and 65-69 years (17%) Figure 3.

 

Cluster description

 

There were two important clusters identified during the early stages of the pandemic in the district; these included a funeral gathering/service and a house party.

 

Funeral

 

A funeral took place on 21 March 2020 in Suburb A within Sub-District C. It was the funeral of a healthcare worker where there were reportedly over 1000 people in attendance.

 

There are different ways in which communities deal with grief across the globe. In South Africa, when death occurs in a family, the burial usually takes place a week after the passing on of the deceased. During this period people start gathering in that particular household to console family members and relatives who would be gathered in the household for the days leading to the day of the funeral. It is a norm that meals would be served to every visitor who comes to the house. Different visitors would be coming and going throughout this period.

 

African funerals are events usually rich with religious significance and practice. In every funeral, religion is practiced as a way of comforting the bereaved and conducting the funeral procession. This may include having a night vigil of singing and dancing as a way to comfort the bereaved, performing rituals by family members with the help of traditional healers, sharing meals, and many other practices, which involve close contact between people in mourning.

 

Houseparty

 

On 25 March 2020, (the eve of the national lockdown) a house-party was held in a household in Sub-District C. The attendees included individuals from other districts and other provinces, as the event occurred before the national lockdown, and the movement of people was not yet prohibited. Six of the attendees later tested positive for SARS-CoV-2 and one of these had close contact with an employee at Grocery store B. A chain of transmission among the employees of Grocery store B followed thereafter. This subsequently led to other clusters Figure 4.

 

A total of 116 (28%; 116/412) of the cases reported close contact with a known case before illness onset. Of the total cases, 204 (50%; 204/412) could be linked to a specific cluster. The first two clusters that were identified included one associated with the funeral and the other associated with the house party Figure 4. Of the first 100 cases, 42% (42/100) were linked to the funeral; these included people who attended the funeral and those who had contact with the funeral attendees.

 

 

Contrary to what has been reported in other countries, including the United States where most of the cases were older (median of 43 years) during the same period as our study, most of the cases in South Africa were youths with the median age of 38 years [14-17]. There were more females than there were males, as shown in other studies [18, 19]. Some of the reasons for this could be poor health-seeking behavior among males [20]; and females more likely to be caregivers to those that are sick, increasing their risk of exposure. Fatality rates were higher among older age groups, which is in keeping with what has been reported in other countries [21-23].

 

Most of the cases in the early stages of the outbreak were linked to the funeral, with over 40% of the first 100 cases linked to the funeral. This could be an underestimate as people started to refrain from disclosing that they attended the funeral for fear of victimization. From the data available, this particular funeral was a SARS-CoV-2 super spreader event, and likely triggered a rapid and sustained chain of transmission of the virus within the district.

 

The testing guidelines at the time contributed to the majority of laboratory confirmed cases being symptomatic, as asymptomatic contacts were not routinely tested. Asymptomatic contacts were tested when they were part of a specific cluster, or for any other reason the testing personnel saw fit to have them tested. Lack of routine testing asymptomatic contacts may have also facilitated further community transmission, especially at social gatherings such as funerals, as contacts may not have heeded quarantine regulations if they were not feeling ill. Routine testing for asymptomatic contacts could help with case finding, timely patient isolation, and reducing the risk of further transmission. However, a shortage of COVID-19 testing kits at the time, led to prioritization of at-risk-groups for testing. A study looking at transmission rates between symptomatic and asymptomatic COVID-19 cases reported that asymptomatic cases accounted for more than 50% of all transmissions[24]. Identification and isolation of asymptomatic cases are critical in reducing transmission rates [25, 26].

 

Social gatherings are high-risk events for SARS-CoV-2 transmission [27, 28]. Some of the COVID-19 super-spreader events realized earlier on in the South African context were funerals and religious gatherings [29, 30]. These continue to be high risk. One religious event in the Free State Province was linked to 45% (44/97) of the cases reported in that province on 13 April 2020. The Eastern Cape Province has been one of the provinces with a high number of cases linked to funeral gatherings, with the province later became a COVID-19 hotspot in the country [29, 31]. Studies from other countries have also shown the risk of SARS-CoV-2 transmission associated with religious/church gatherings [32-34]. If indeed one has to attend any gathering all precautions necessary to prevent SARS-CoV-2 infection, transmission should be taken, and adherence to COVID-19 prevention measures should be of utmost importance.

 

Adherence to the COVID-19 funeral guidelines as issued by the government can help reduce infection transmission rates at these events. The guidelines include restricting funeral attendance to a small number of people (50 people or less during the study period). Maintaining physical distancing and wearing a mask all the time when attending a funeral. Cultural and religious practices remain important parts of South Africans´ lives; however, practices that expose people to this virus should be avoided and other less risky methods should be implemented. Virtual platforms can be used for events such as memorial services and funeral services to allow more people to offer their support and condolence during times of grief without having to congregate in large numbers. Studies have reported on how virtual platforms can enable more people to offer their support to bereaved families [35, 36].

 

Community engagement in the form of mass public health educational campaigns, engagement of religious leaders in educating their constituents, and employing other community-based interventions can help improve adherence to existing COVID-19 prevention measures and guidelines by the public [37-39]. The acceptance and adherence to COVID-19 prevention guidelines by communities in events such as funerals, which cannot always be policed, are critical in the response to the pandemic.

 

Major limitations in this study included a lack of complete data on the risk factors associated with infection and comorbidities among those who were infected and those who demised. Hence, conducting an analytical study was not feasible. However, from the descriptive analysis, there are clear points that could be drawn regarding COVID-19 transmission and social gathering.

 

 

The transmission of COVID-19 within the district was inevitable, however, the funeral played an important role in the early transmission and spread of infection. Funerals continue to be an ongoing source of COVID-19 super-spreader events. While funerals cannot be avoided, adherence to COVID-19 guidelines on funerals can help reduce infection transmission rates. Exploring new methods, such as virtual funeral services and virtual memorial services can help reduce the risk of COVID-19 transmission associated with funerals.

 

 

The authors declare no competing interests.

 

 

PS analyzed and interpreted the data, created all the figures and tables and wrote the paper, NM data collection, collation and interpretation, NT data collection, collation and interpretation, LN data collection, collation and interpretation, MN data collection, collation and interpretation, AHM data interpretation, and epidemiological analysis support, NG data interpretation, and epidemiological analysis support.

 

 

We would like to acknowledge the following stakeholders for their outstanding work in their response to the COVID-19 pandemic in the province and district: Nelson Mandela Bay District Department of Health, Eastern Cape Provincial Department of Health, and the National Institute for Communicable Disease. Dr Juno Thomas and Dr Ntsieni Ramalwa of the Centre for Enteric Diseases at the National Institute for Communicable Diseases for their epidemiological analysis support.

 

 

Figure 1: Epidemic curve of SARS-CoV-2 cases in Nelson Mandela Bay district, March - April 2020

Figure 2: Age and gender distribution of SARS-CoV-2 cases in Nelson Mandela Bay district, March - April 2020

Figure 3: Age distribution and fatality rates of SARS-CoV-2 cases in Nelson Mandela Bay, March - April 2020

Figure 4: Clusters of SARS-CoV-2 cases in Nelson Mandela Bay district, March - April 2020

 

 

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