Clinical Management and Mortality among COVID-19 Cases in Sub-Saharan Africa: A retrospective study from Burkina Faso and simulated case data analysis (preprint)

BackgroundAbsolute numbers of COVID-19 cases and deaths reported to date in the sub-Saharan Africa (SSA) region have been significantly lower than those across the Americas, Asia, and Europe. As a result, there has been limited information about the demographic and clinical characteristics of deceased cases in the region, as well as the impacts of different case management strategies. MethodsData from deceased cases reported across SSA through May 10, 2020 and from hospitalized cases in Burkina Faso through April 15, 2020 were analyzed. Demographic, epidemiological, and clinical information on deceased cases in SSA was derived through a line-list of publicly available information and, for cases in Burkina Faso, from aggregate records at the Center Hospitalier Universitaire de Tengandogo in Ouagadougou. A synthetic case population was derived probabilistically using distributions of age, sex, and underlying conditions from populations of West African countries to assess individual risk factors and treatment effect sizes. Logistic regression analysis was conducted to evaluate the adjusted odds of survival for patients receiving oxygen therapy or convalescent plasma, based on therapeutic effectiveness observed for other respiratory illnesses. ResultsAcross SSA, deceased cases for which demographic data are available have been predominantly male (63/103, 61.2%) and over 50 years of age (59/75, 78.7%). In Burkina Faso, specifically, the majority of deceased cases either did not seek care at all or were hospitalized for a single day (59.4%, 19/32); hypertension and diabetes were often reported as underlying conditions. After adjustment for sex, age, and underlying conditions in the synthetic case population, the odds of mortality for cases not receiving oxygen therapy was significantly higher than those receiving oxygen, such as due to disruptions to standard care (OR: 2.07; 95% CI: 1.56 - 2.75). Cases receiving convalescent plasma had 50% reduced odds of mortality than those who did not (95% CI: 0.24 - 0.93). ConclusionInvestment in sustainable production and maintenance of supplies for oxygen therapy, along with messaging around early and appropriate use for healthcare providers, caregivers, and patients could reduce COVID-19 deaths in SSA. Further investigation into convalescent plasma is warranted, as data on its effectiveness specifically in treating COVID-19 becomes available. The success of supportive or curative clinical interventions will depend on earlier treatment seeking, such that community engagement and risk communication will be critical components of the response.

Seeding COVID-19 across sub-Saharan Africa: an analysis of reported importation events across 40 countries (preprint)

BackgroundThe first case of COVID-19 in sub-Saharan Africa (SSA) was reported by Nigeria on February 27, 2020. While case counts in the entire region remain considerably less than those being reported by individual countries in Europe, Asia, and the Americas, SSA countries remain vulnerable to COVID morbidity and mortality due to systemic healthcare weaknesses, less financial resources and infrastructure to address the new crisis, and untreated comorbidities. Variation in preparedness and response capacity as well as in data availability has raised concerns about undetected transmission events. MethodsConfirmed cases reported by SSA countries were line-listed to capture epidemiological details related to early transmission events into and within countries. Data were retrieved from publicly available sources, including institutional websites, situation reports, press releases, and social media accounts, with supplementary details obtained from news articles. A data availability score was calculated for each imported case in terms of how many indicators (sex, age, travel history, date of arrival in country, reporting date of confirmation, and how detected) could be identified. We assessed the relationship between time to first importation and overall Global Health Security Index (GHSI) using Cox regression. K-means clustering grouped countries according to healthcare capacity and health and demographic risk factors. ResultsA total of 13,201 confirmed cases of COVID-19 were reported by 48 countries in SSA during the 54 days following the first known introduction to the region. Out of the 2516 cases for which travel history information was publicly available, 1129 (44.9%) were considered importation events. At the regional level, imported cases tended to be male (65.0%), were a median 41.0 years old (Range: 6 weeks - 88 years), and most frequently had recent travel history from Europe (53.1%). The median time to reporting an introduction was 19 days; a countrys time to report its first importation was not related to GHSI, after controlling for air traffic. Countries that had, on average, the highest case fatality rates, lowest healthcare capacity, and highest probability of premature death due to non-communicable diseases were among the last to report any cases. ConclusionsCountries with systemic, demographic, and pre-existing health vulnerabilities to severe COVID-related morbidity and mortality are less likely to report any cases or may be reporting with limited public availability of information. Reporting on COVID detection and response efforts, as well as on trends in non-COVID illness and care-seeking behavior, is critical to assessing direct and indirect consequences and capacity needs in resource-constrained settings. Such assessments aid in the ability to make data-driven decisions about interventions, country priorities, and risk assessment. Key MessagesO_LIWe line-listed epidemiological indicators for the initial cases reported by 48 countries in sub-Saharan Africa by reviewing and synthesizing information provided by official institutional outlets and news sources. C_LIO_LIOur findings suggest that countries with the largest proportions of untreated comorbidities, as measured by probability of premature death due to non-communicable diseases, and the fewest healthcare resources tended to not be reporting any cases at one-month post-introduction into the region. C_LIO_LIUsing data availability as a measure of gaps in detection and reporting and relating them to COVID-specific parameters for morbidity and mortality provides a measure of vulnerability. C_LIO_LIAccurate and available information on initial cases in seeding local outbreaks is key to projecting case counts and assessing the potential impact of intervention approaches, such that support for local data teams will be important as countries make decisions about control strategies. C_LI