On March 9, a patient, who had recently been to Europe, visited a private hospital in Durban, South Africa , seeking treatment after showing symptoms of Covid-19, the disease caused by the pandemic coronavirus . Within weeks, 39 patients and 80 hospital staff had been infected and 15 were dead. The coronavirus spread rapidly, transmitted from ward to ward between patients, doctors and nurses in the early days of the country’s encounter with the disease. Now scientists at the University of KwaZulu-Natal have retraced the coronavirus’ deadly path through the hospital in a report that its authors say offers lessons not just for the medical facility but also for the public and private health system as a whole. Richard Lessells, an infectious diseases specialist at the university and one of the study’s authors, said the cluster was believed to have started in the emergency unit at St Augustine’s Hospital. On March 9, two patients came into close contact at the unit – one had suspected coronavirus and recently returned from Europe, and the other was being admitted after having a stroke. The virus found its way from one person to the other and from there it spread very rapidly throughout the hospital on various wards. “We could see evidence that it was transmitted from patient to patient and from patient to health care workers and back from health care workers to patients. There was quite a widespread transmission within the hospital,” Lessells said. The study, commissioned by the National Department of Health, revealed that patients were exposed to the virus in six main waves of transmission involving five hospital wards: neurology, intensive care units, surgical wards, and at a nearby nursing home and a dialysis centre. African countries ‘may be spared the worst of the pandemic’ In their investigation, the researchers reviewed both medical and staff files, laboratory records, and radiological images of confirmed cases. They also studied the inpatient electronic tracking system to determine the movement of cases within and between wards and to pinpoint the location of occupied beds. The spread through the hospital was helped by the frequent movement of patients between and within wards. From the main hospital, smaller outbreaks emerged at a nursing home, where four cases were recorded and at an outpatient dialysis unit on the hospital campus, where a further nine patients and eight staff were infected. The scientists were also able to generate the Covid-19 genome from 18 patient samples, with the identical viral strains in the samples pointing to a single source of the virus. “Overall, we estimate that up to 135 infections may have been … acquired [in the hospital] as a result of the single introduction of the virus to the hospital, accounting for about 14 per cent of all cases in KwaZulu‐Natal reported by April 30,” the scientists said. Fifteen of the 39 patients infected with Covid-19 in the main outbreak died, with a case fatality rate at 38.5 per cent. Most of the deaths were in elderly patients with underlying diseases such as diabetes, heart disease and high blood pressure, the researchers found. However, the study said the hospital missed earlier opportunities to control the spread of the disease, including overlooking coronavirus symptoms. “Earlier recognition of possible Covid-19 infection in the patients, leading to earlier isolation, tracing of potential sources of infection, and appropriate management of exposed contacts could potentially have averted infections and limited onwards transmission,” the study noted. The problem could have also been uncovered at an earlier stage if the first infected health care worker case had been investigated to identify potential sources of infection within the hospital. “This outbreak highlights how easily and rapidly Covid-19 can spread through a hospital, exposing weaknesses in respiratory virus infection prevention and control,” the report said. All eyes on China as Africa spurns G20 debt relief plan To reduce the risk of similar outbreaks, “we need to strengthen infection prevention and control systems and practices throughout our hospitals”. The report also advised hospitals to establish separate zones and entry points to isolate people who might have Covid-19 from those who probably did not have the disease. Craig Murphy, regional director of Netcare, the hospital group that owns St Augustine’s, described the cluster as “a sad and transformative experience”. He welcomed the report and said the recommendations and interventions made by the investigators had been implemented. “Many valuable lessons have been learned for our health care sector,” Murphy said. He said two of the greatest challenges associated with Covid-19 were that those infected did not always show or have any of the symptoms, and that the virus was highly infectious. The study was conducted when South Africa only had a handful of cases in early March. Its authors also included Mahomed Yunus Suleman Moosa, head of the department of infectious diseases at the University of KwaZulu‐Natal and Tulio de Oliveira, director of the KwaZulu‐Natal Research Innovation and Sequencing Platform, at the university. Lessells said the investigation was conducted “so that we can learn the lessons not just for St Augustine’s Hospital but for all the private and public hospital systems”. “We hope that by strengthening our systems we can limit the extent of the outbreaks and stop them from fuelling the transmission in the community. That’s our biggest worry at the moment that these clusters of infections in hospitals, workplaces and prisons are going to drive the transmissions in the community,” he said. Could Africa be the next major base for manufacturers after China? The report, which was released earlier this month but only made public over the weekend, came at a time when more than 3,400 health care workers in Africa have been infected by the coronavirus disease. The World Health Organisation has said that health authorities must prioritise the protection of health workers. South Africa, which has the highest number of infections on the continent, had recorded 23,615 cases and 481 deaths as of Monday. However, the country has also conducted half a million coronavirus tests – the most of any country in Africa.