Epidemiological and clinical characteristics of patients hospitalised with COVID-19 in Kenya: a multicentre cohort study.

OBJECTIVES: To assess outcomes of patients admitted to hospital with COVID-19 and to determine the predictors of mortality. SETTING: This study was conducted in six facilities, which included both government and privately run secondary and tertiary level facilities in the central and coastal regions of Kenya. PARTICIPANTS: We enrolled 787 reverse transcriptase-PCR-confirmed SARS-CoV2-infected persons. Patients whose records could not be accessed were excluded. PRIMARY AND SECONDARY OUTCOME MEASURES: The primary outcome was COVID-19-related death. We used Cox proportional hazards regressions to determine factors related to in-hospital mortality. RESULTS: Data from patients with 787 COVID-19 were available. The median age was 43 years (IQR 30-53), with 505 (64%) being men. At admission, 455 (58%) were symptomatic with an additional 63 (9%) developing clinical symptoms during hospitalisation. The most common symptoms were cough (337, 43%), loss of taste or smell (279, 35%) and fever (126, 16%). Comorbidities were reported in 340 (43%), with cardiovascular disease, diabetes and HIV documented in 130 (17%), 116 (15%), 53 (7%), respectively. 90 (11%) were admitted to the Intensive Care Unit (ICU) for a mean of 11 days, 52 (7%) were ventilated with a mean of 10 days, 107 (14%) died. The risk of death increased with age (HR 1.57 (95% CI 1.13 to 2.19)) for persons >60 years compared with those <60 years old; having comorbidities (HR 2.34 (1.68 to 3.25)) and among men (HR 1.76 (1.27 to 2.44)) compared with women. Elevated white cell count and aspartate aminotransferase were associated with higher risk of death. CONCLUSIONS: The risk of death from COVID-19 is high among older patients, those with comorbidities and among men. Clinical parameters including patient clinical signs, haematology and liver function tests were associated with risk of death and may guide stratification of high-risk patients.

Infectious disease modelling for SARS-CoV-2 in Africa to guide policy: A systematic review.

Applied epidemiological models have played a critical role in understanding the transmission and control of disease outbreaks. Their utility and accuracy in decision-making on appropriate responses during public health emergencies is however a factor of their calibration to local data, evidence informing model assumptions, speed of obtaining and communicating their results, ease of understanding and willingness by policymakers to use their insights. We conducted a systematic review of infectious disease models focused on SARS-CoV-2 in Africa to determine: a) spatial and temporal patterns of SARS-CoV-2 modelling in Africa, b) use of local data to calibrate the models and local expertise in modelling activities, and c) key modelling questions and policy insights. We searched PubMed, Embase, Web of Science and MedRxiv databases following the PRISMA guidelines to obtain all SARS-CoV-2 dynamic modelling papers for one or multiple African countries. We extracted data on countries studied, authors and their affiliations, modelling questions addressed, type of models used, use of local data to calibrate the models, and model insights for guiding policy decisions. A total of 74 papers met the inclusion criteria, with nearly two-thirds of these coming from 6% (3) of the African countries. Initial papers were published 2 months after the first cases were reported in Africa, with most papers published after the first wave. More than half of all papers (53, 78%) and (48, 65%) had a first and last author affiliated to an African institution respectively, and only 12% (9) used local data for model calibration. A total of 60% (46) of the papers modelled assessment of control interventions. The transmission rate parameter was found to drive the most uncertainty in the sensitivity analysis for majority of the models. The use of dynamic models to draw policy insights was crucial and therefore there is need to increase modelling capacity in the continent.

Rabies Elimination in Rural Kenya: Need for Improved Availability of Human Vaccines, Awareness and Knowledge on Rabies and Its Management Among Healthcare Workers.

Background: In Africa, rabies causes an estimated 24,000 human deaths annually. Mass dog vaccinations coupled with timely post-exposure prophylaxis (PEP) for dog-bite patients are the main interventions to eliminate human rabies deaths. A well-informed healthcare workforce and the availability and accessibility of rabies biologicals at health facilities are critical in reducing rabies deaths. We assessed awareness and knowledge regarding rabies and the management of rabies among healthcare workers, and PEP availability in rural eastern Kenya. Methodology: We interviewed 73 healthcare workers from 42 healthcare units in 13 wards in Makueni and Kibwezi West sub-counties, Makueni County, Kenya in November 2018. Data on demographics, years of work experience, knowledge of rabies, management of bite and rabies patients, and availability of rabies biologicals were collected and analyzed. Results: Rabies PEP vaccines were available in only 5 (12%) of 42 health facilities. None of the health facilities had rabies immunoglobulins in stock at the time of the study. PEP was primarily administered intramuscularly, with only 11% (n = 8) of the healthcare workers and 17% (7/42) healthcare facilities aware of the dose-sparing intradermal route. Less than a quarter of the healthcare workers were aware of the World Health Organization categorization of bite wounds that guides the use of PEP. Eighteen percent (n = 13) of healthcare workers reported they would administer PEP for category I exposures even though PEP is not recommended for this category of exposure. Only one of six respondents with acute encephalitis consultation considered rabies as a differential diagnosis highlighting the low index of suspicion for rabies. Conclusion: The availability and use of PEP for rabies was sub-optimal. We identified two urgent needs to support rabies elimination programmes: improving availability and access to PEP; and targeted training of the healthcare workers to improve awareness on bite wound management, judicious use of PEP including appropriate risk assessment following bites and the use of the dose-sparing intradermal route in facilities seeing multiple bite patients. Global and domestic funding plan that address these gaps in the human health sector is needed for efficient rabies elimination in Africa.

Examining unit costs for COVID-19 case management in Kenya.

INTRODUCTION: We estimated unit costs for COVID-19 case management for patients with asymptomatic, mild-to-moderate, severe and critical COVID-19 disease in Kenya. METHODS: We estimated per-day unit costs of COVID-19 case management for patients. We used a bottom-up approach to estimate full economic costs and adopted a health system perspective and patient episode of care as our time horizon. We obtained data on inputs and their quantities from data provided by three public COVID-19 treatment hospitals in Kenya and augmented this with guidelines. We obtained input prices from a recent costing survey of 20 hospitals in Kenya and from market prices for Kenya. RESULTS: Per-day, per-patient unit costs for asymptomatic patients and patients with mild-to-moderate COVID-19 disease under home-based care are 1993.01 Kenyan shilling (KES) (US$18.89) and 1995.17 KES (US$18.991), respectively. When these patients are managed in an isolation centre or hospital, the same unit costs for asymptomatic patients and patients with mild-to-moderate disease are 6717.74 KES (US$63.68) and 6719.90 KES (US$63.70), respectively. Per-day unit costs for patients with severe COVID-19 disease managed in general hospital wards and those with critical COVID-19 disease admitted in intensive care units are 13 137.07 KES (US$124.53) and 63 243.11 KES (US$599.51). CONCLUSION: COVID-19 case management costs are substantial, ranging between two and four times the average claims value reported by Kenya's public health insurer. Kenya will need to mobilise substantial resources and explore service delivery adaptations that will reduce unit costs.