Digital health in the era of COVID-19: Reshaping the next generation of healthcare

COVID-19 is one of the most deadly diseases to have stricken us in recent decades. In the fight against this disease, governments and stakeholders require all the assistance they can get from various systems, including digital health interventions. Digital health technologies are supporting the tracking of the COVID-19 outbreak, diagnosing patients, expediting the process of finding potential medicines and vaccines, and disinfecting the environment, The establishment of electronic medical and health records, computerized clinical decision support systems, telemedicine, and mobile health have shown the potential to strengthen the healthcare system. Recently, these technologies have aided the health sector in a variety of ways, including prevention, early diagnosis, treatment adherence, medication safety, care coordination, documentation, data management, outbreak tracking, and pandemic surveillance. On the other hand, implementation of such technologies has questions of cost, compatibility with existing systems, disruption in patient-provider interactions, and sustainability, calling for more evidence on clinical utility and economic evaluations to help shape the next generation of healthcare. This paper argues how digital health interventions assist in the fight against COVID-19 and their opportunities, implications, and limitations.

Digital health in the era of COVID-19: Reshaping the next generation of healthcare.

COVID-19 is one of the most deadly diseases to have stricken us in recent decades. In the fight against this disease, governments and stakeholders require all the assistance they can get from various systems, including digital health interventions. Digital health technologies are supporting the tracking of the COVID-19 outbreak, diagnosing patients, expediting the process of finding potential medicines and vaccines, and disinfecting the environment, The establishment of electronic medical and health records, computerized clinical decision support systems, telemedicine, and mobile health have shown the potential to strengthen the healthcare system. Recently, these technologies have aided the health sector in a variety of ways, including prevention, early diagnosis, treatment adherence, medication safety, care coordination, documentation, data management, outbreak tracking, and pandemic surveillance. On the other hand, implementation of such technologies has questions of cost, compatibility with existing systems, disruption in patient-provider interactions, and sustainability, calling for more evidence on clinical utility and economic evaluations to help shape the next generation of healthcare. This paper argues how digital health interventions assist in the fight against COVID-19 and their opportunities, implications, and limitations.

Limited value of neutrophil-to-lymphocyte ratio and serum creatinine as point-of-care biomarkers of disease severity and infection mortality in patients hospitalized with COVID-19.

INTRODUCTION: In hospitalized COVID-19, neutrophil-to-lymphocyte ratio (NLR) and serum creatinine is sometimes measured under assumption they predict disease severity and mortality. We determined the potential value of NLR and serum creatinine as predictors of disease severity and mortality in COVID-19. METHODS: Prospective cohort study of COVID-19 patients admitted to premier COVID-19 treatment hospitals in Ethiopia. Predictive capability of biomarkers in progression and prognosis of COVID-19 was analyzed using receiver operating characteristics. Survival of COVID-19 patients with different biomarker levels was computed. Logistic regression assessed associations between disease severity and mortality on NLR and serum creatinine adjusted for odds ratio (AOR). RESULTS: The study enrolled 126 adults with severe (n = 68) or mild/moderate (n = 58) COVID-19, with median age 50 [interquartile range (IQR 20-86)]; 57.1% males. The NLR value was significantly higher in severe cases [6.68 (IQR 3.03-12.21)] compared to the mild/moderate [3.23 (IQR 2.09-5.39)], with the NLR value markedly associated with disease severity (p<0.001). Mortality was higher in severe cases [13 (19.1%)] compared to mild/moderate cases [2 (3.4%)] (p = 0.007). The NLR value was significantly higher in non-survivors [15.17 (IQR 5.13-22.5)] compared to survivors [4.26 (IQR 2.40-7.90)] (p = 0.002). Serum creatinine was significantly elevated in severe cases [34 (50%)] compared with mild/moderate [11 (19%)] (p<0.001). Disease severity [AOR 6.58, 95%CI (1.29-33.56), p = 0.023] and NLR [AOR 1.07, 95%CI (1.02-1.12), p = 0.004)] might be associated with death. NLR had a sensitivity and specificity of 69.1% and 60.3% as predictor of disease severity (cut-off >4.08), and 86.7% and 55.9% as prognostic marker of mortality (cut-off >4.63). CONCLUSION: In COVID-19, NLR is a biomarker with only modest accuracy for predicting disease severity and mortality. Still, patients with NLR >4.63 are more likely to die. Monitoring of this biomarker at the earliest stage of the disease may predict outcome. Additionally, high creatinine seems related to disease severity and mortality.

Inflammatory mediators profile in patients hospitalized with COVID-19: A comparative study.

Abnormal inflammatory mediator concentrations during SARS-CoV-2 infection may represent disease severity. We aimed to assess plasma inflammatory mediator concentrations in patients with SARS-CoV-2 in Addis Ababa, Ethiopia. In this study, 260 adults: 126 hospitalized patients with confirmed COVID-19 sorted into severity groups: severe (n=68) and mild or moderate (n=58), and 134 healthy controls were enrolled. We quantified 39 plasma inflammatory mediators using multiplex ELISA. Spearman rank correlation and Mann-Whitney U test were used to identify mechanistically coupled inflammatory mediators and compare disease severity. Compared to healthy controls, patients with COVID-19 had significantly higher levels of interleukins 1α, 2, 6, 7, 8, 10 and 15, C-reactive protein (CRP), serum amyloid A (SAA), intercellular adhesion molecule 1 (ICAM-1), vascular cell adhesion protein 1 (VCAM-1), IFN-γ-inducible protein-10 (IP-10, CXCL10), macrophage inflammatory protein-1 alpha (MIP-1α, CCL3), eotaxin-3 (CCL26), interferon-gamma (IFN-γ), tumor necrosis factor-α (TNF-α), basic fibroblast growth factor (bFGF), placental growth factor (PlGF), and fms-like tyrosine kinase 1 (Flt-1). Patients with severe COVID-19 had higher IL-10 and lower macrophage-derived chemokine (MDC, CCL22) compared to the mild or moderate group (P<0.05). In the receiver operating characteristic curve, SAA, IL-6 and CRP showed strong sensitivity and specificity in predicting the severity and prognosis of COVID-19. Greater age and higher CRP had a significant association with disease severity (P<0.05). Our findings reveal that CRP, SAA, VCAM-1, CXCL10, CCL22 and IL-10 levels are promising biomarkers for COVID-19 disease severity, suggesting that plasma inflammatory mediators could be used as warning indicators of COVID-19 severity, aid in COVID-19 prognosis and treatment.

COVID-19 Burden on HIV Patients Attending Antiretroviral Therapy in Addis Ababa, Ethiopia: A Multicenter Cross-Sectional Study.

Background: There has been promising progress toward screening, testing, and retaining patients with HIV in care in Ethiopia. Concern exists that possible disruptions in HIV programs due to coronavirus disease 2019 (COVID-19) could result in a more HIV-related mortality and new HIV infections. This study aimed to investigate the real-time burden of COVID-19 on patients with HIV attending antiretroviral therapy. Methods: We conducted a facility-based, multicenter, and cross-sectional study among patients with HIV attending antiretroviral therapy in 10 healthcare facilities in Addis Ababa, Ethiopia, in the COVID-19 pandemic period. Data were collected using adapted, interviewer-based questionnaires, and entered into EpiInfo version 7 and exported to SPSS version 26 for analysis. Result: A total of 212 patients with HIV were included. The participants who missed visits for refill were 58 (27.4%). When the effects of other independent variables on appointments/visits for refill were controlled, the following characteristics were found to be the most important predictors of missed appointments (p< 0.05): age ≥ 55 [adjusted odds ratio (AOR) = 6.73, 95% CI (1.495-30.310)], fear of COVID-19 [AOR = 24.93, 95% CI (2.798-222.279)], transport disruption [AOR = 4.90, 95% CI (1.031-23.174)], reduced income for traveling to a health facility [AOR = 5.64, 95% CI (1.234-25.812)], limited access to masks [AOR = 7.67, 95% CI (1.303-45.174)], sanitizer [AOR = 0.07, 95% CI (0.007-0.729)], and non-medical support [AOR = 2.32, 95% CI (1.547-12.596)]. The participants were well aware of the COVID-19 preventive measures. The most costly COVID-19 preventive measures that cause financial burden to the patients were the costs for buying face masks (63.7%), disinfectants (55.2%), and soap for handwashing (22.2%). The participants who missed follow-up diagnostic tests were 56 (26.4%). Variables, which were found to be statistically significant, include the following: age ≥ 55 [AOR = 0.22, 95% CI (0.076-0.621)], partial lockdown [AOR = 0.10, 95% CI (0.011-0.833)], limited access to health services [AOR = 0.15, 95% CI (0.045-0.475)], reduced income for traveling to health facility [AOR = 0.18, 95% CI (0.039-0.784)], and unable to get masks [AOR = 0.12, 95% CI (0.026-0.543)]. The participants who missed counseling services were 55 (25.9%). In multivariate logistic regression, the following were statistically significant: age ≥ 55 [AOR = 0.21, 95% CI (0.078-0.570)], fear of COVID-19 [AOR = 0.11, 95% CI (0.013-0.912)], reduced income [AOR = 0.17, 95% CI (0.041-0.699)], unable to get face masks [AOR = 0.19, 95% CI (0.039-0.959)], and partial lockdown [AOR = 0.08, 95% CI (0.008-0.790)]. Conclusions: The COVID-19 had a significant burden on patients with HIV to attend their routine clinical care and treatment, which may lead to treatment failure and drug resistance. The impact was on their appointments for medication refills and clinical and laboratory follow-ups. Targeted initiatives are needed to sustain HIV clinical care and treatment services and improve the well-being of people living with HIV.

COVID-19 and Health Sector Development Plans in Africa: The Impact on Maternal and Child Health Outcomes in Uganda.

INTRODUCTION: Health Sector Development Plans (HSDPs) aim to accelerate movement towards achieving sustainable development goals for health, reducing inequalities, and ending poverty. Reproductive, maternal, newborn and child health (RMNCH) services are vulnerable to economic imbalances, including health insecurity, unmet need for healthcare, and low health expenditure. The same vulnerability influences the potential of a country to combat global outbreaks such as the COVID-19. We aimed to provide some important insights into the impacts of COVID-19 on RMNCH indicators and outcomes of the HSDP in Uganda. METHODS: We conducted a descriptive study of secondary data obtained from the Ugandan government-led portals, supplemented by analyses of relevant articles published up to 06 May 2021 and deposited in PubMed. RESULTS: Through synthesizing actionable and relevant evidence, we realized that RMNCH in Uganda is highly affected by the COVID-19 pandemic and the lockdown measures. The impact was across immunization, antenatal, sexual and reproductive health, emergency and obstetric, and postnatal care services. There was a decline sharply by 9.6% for under-five vitamin A coverage, 9% for DPT3HibHeb3 coverage, 6.8% for measles vaccination coverage, 6% for isoniazid preventive therapy coverage, and 3% for facility-based deliveries. Maternal and under-five deaths increased by 7.6% and 4%, respectively. Outreaches were rarely conducted in the lockdown period. CONCLUSION: The COVID-19 pandemic has created a multitude of questions regarding the optimal policies to mitigate the disease while minimizing the unintended detrimental consequences of RMNCH. The lockdown restrictions threatened to reverse the progress made on the national HSDP for RMNCH. In Uganda, where young women are vulnerable to early marriage, unintended pregnancies, and unsafe abortion, access to RMNCH services should continue regardless of the COVID-19 status in the country. We urge that Uganda and other African countries should build resilient and sustainable health systems that can withstand emerging diseases like the COVID-19.

Community Engagement in the Fight Against COVID-19: Knowledge, Attitude, and Prevention Practices Among Dire Dawa Residents, Eastern Ethiopia.

Background: There is a global concern that coronavirus disease 2019 (COVID-19) cannot be addressed without the integration and active engagement of communities. We aimed to investigate the knowledge, attitude, and practices (KAP) of the residents in Eastern Ethiopia toward COVID-19. Method: A community-based cross-sectional study was conducted on May 1-30, 2020 among the residents of Dire Dawa, Eastern Ethiopia. Data were collected using a structured questionnaire on the awareness, knowledge, attitudes, and preventive practices toward COVID-19. We used random sampling to select the participants. Data was entered into the statistics and data (STATA) version for data cleaning and analysis. Binary logistic regression models with 95% CI were used to conduct bivariable [crude odds ratio (COR)] and multivariable [adjusted odds ratio (AOR)] analyses. Result: A total of 415 community residents responded to the questionnaire. Of those participants, 52.5% (95% CI 47.7-57) had adequate knowledge, 31.6% (95% CI 27-36) had favorable attitudes, and 49% (95% CI 45-50) had good practice toward the precautionary measures of COVID-19. Adequate knowledge had a significant association with urban residence (AOR = 5, 95% CI 3.1-8.4) and literacy (AOR = 3.1, 95% CI 1.5-6.7). Good preventions practices had a significant association with place of residence (AOR = 4.1, 95% CI 2.3-7.2), literacy (AOR = 2.9, 95% CI: 1,2-7.4), adequate knowledge (AOR = 3.5, 95% CI 2.3-5.8), and favorable attitude (AOR = 2.3, 95% CI 1.4-3.8) about the disease. Conclusion: The overall COVID-19-related KAP was inadequate in the majority of the residents of Dire Dawa that occupy irregular migration flows. These call for robust community-centered behavioral communication strategies that could bridge the gaps and help prevent and control COVID-19 and other future pandemics in their community.

Real-Time Impact of COVID-19 on Clinical Care and Treatment of Patients with Tuberculosis: A Multicenter Cross-Sectional Study in Addis Ababa, Ethiopia.

Background: There were global concerns and predictions that Coronavirus disease 2019 (COVID-19) would severely affect tuberculosis (TB) care and treatment services in resource-constrained countries. This study aimed to assess the real-time impact of COVID-19 on clinical care and treatment of patients with TB in Addis Ababa, Ethiopia. Methods: This was a facility-based, multicenter, cross-sectional study conducted in 10 health centers with high TB clients in Addis Ababa, Ethiopia. Participants were patients with TB who have been attending TB clinical care and treatment in the COVID-19 pandemic period. Data were collected using adapted, interviewer-administered questionnaires to investigate the impact of COVID-19 in their routine care and treatment. Result: The study included a total of 212 consented participants. Study participants who missed appointments for medication refill were 40 (18.9%). The most important predictors of missed appointments were fear of COVID-19 [AOR = 4.25, 95% CI (1.710-25.446)], transport disruption [AOR = 8.88, 95% CI (1.618-48.761)], lockdown [AOR = 6.56, 95% CI (1.300-33.131)], traveling costs [AOR = 10.26, 95% CI (1.552-67.882)], and personal protective equipment costs [AOR = 11.15, 95% CI (2.164-57.437)]. The most costly COVID-19 preventive measures that caused financial burden to the patients were face mask [107 (50.5%)], disinfectant [106 (50%)], and sop [50 (23.6%)]. The participants were well aware of the recommended COVID-19 preventive measures. Their perceived most effective preventive measures were the use of face mask (90.1%), frequent hand washing with soap and use of disinfectant (83.0%), avoid touching eyes, nose and mouth with unwashed hands (77.8%), and stay at home (75.5%). Conclusions: COVID-19 significantly hampered the clinical care and treatment of patients with TB. The impact was primarily on their appointments for scheduled medication refills, clinical follow-ups, and laboratory follow-ups. Fear of getting infected with COVID-19, limited access to transportation, reduced income for traveling to health facilities, costs for personal protective equipment and traveling to healthcare facilities, and the lockdown were the major determinants. The impact could be mitigated by reducing the number of visits, rationing personal protective equipment as feasible, compensating travel expenses, providing health educations and community-based TB services, and maintaining TB services.

Containment of COVID-19 in Ethiopia and implications for tuberculosis care and research.

BACKGROUND: The coronavirus disease 2019 (COVID-19) has emerged as a global health and economic security threat with staggering cumulative incidence worldwide. Given the severity of projections, hospitals across the globe are creating additional critical care surge capacity and limiting patient routine access to care for other diseases like tuberculosis (TB). The outbreak fuels panic in sub-Saharan Africa where the healthcare system is fragile in withstanding the disease. Here, we looked over the COVID-19 containment measures in Ethiopia in context from reliable sources and put forth recommendations that leverage the health system response to COVID-19 and TB. MAIN TEXT: Ethiopia shares a major proportion of the global burden of infectious diseases, while the patterns of COVID-19 are still at an earlier stage of the epidemiology curve. The Ethiopian government exerted tremendous efforts to curb the disease. It limited public gatherings, ordered school closures, directed high-risk civil servants to work from home, and closed borders. It suspended flights to 120 countries and restricted mass transports. It declared a five-month national state of emergency and granted a pardon for 20 402 prisoners. It officially postponed parliamentary and presidential elections. It launched the 'PM Abiy-Jack Ma initiative', which supports African countries with COVID-19 diagnostics and infection prevention and control commodities. It expanded its COVID-19 testing capacity to 38 countrywide laboratories. Many institutions are made available to provide clinical care and quarantine. However, the outbreak still has the potential for greater loss of life in Ethiopia if the community is unable to shape the regular behavioral and sociocultural norms that would facilitate the spread of the disease. The government needs to keep cautious that irregular migrants would fuel the disease. A robust testing capacity is needed to figure out the actual status of the disease. The pandemic has reduced TB care and research activities significantly and these need due attention. CONCLUSIONS: Ethiopia took several steps to detect, manage, and control COVID-19. More efforts are needed to increase testing capacity and bring about behavioral changes in the community. The country needs to put in place alternative options to mitigate interruptions of essential healthcare services and scientific researches of significant impact.

Efficacy of remdesivir in patients with COVID-19: a protocol for systematic review and meta-analysis of randomised controlled trials.

BACKGROUND: Despite global containment measures to fight the coronavirus disease 2019 (COVID-19), the pandemic continued to rise, rapidly spread across the world, and resulting in 2.6 million confirmed cases and 185 061 deaths worldwide as of 23 April 2020. Yet, there are no approved vaccines or drugs to make the disease less deadly, while efforts are underway. Remdesivir, a nucleotide-analogue antiviral drug developed for Ebola, is determined to prevent and stop infections with COVID-19, while results are yet controversial. Here, we aim to conduct a systematic review and meta-analysis of randomised controlled trials (RCTs) to evaluate the efficacy of remdesivir in patients with COVID-19. METHOD AND ANALYSIS: We will search MEDLINE-PubMed, Embase, Cochrane Library, ClinicalTrials.gov and Google scholar databases for articles published as of 30 June 2020 and we will complete the study on 30 August 2020. We will follow the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) 2015 guidelines for the design and reporting of the results. We will include RCTs that assessed the efficacy of remdesivir versus placebo or standard of care. The primary endpoint will be time to clinical recovery. The secondary endpoints will be proportion of participants relieved from clinical symptoms defined at the time (in hours) from initiation of the study treatment, all-cause mortality, discharged date, frequency of respiratory progression and treatment-emergent adverse events. RevMan V.5.3 software will be used for statistical analysis. Random effects model will be carried out to calculate mean differences for continuous outcome data and risk ratio for dichotomous outcome data between remdesivir and placebo or standard of care. ETHICS AND DISSEMINATION: There are no ethical considerations associated with this study as we will use publicly available data from previously published studies. We plan to publish results in open-access peer-reviewed journals and present at international and national conferences. PROSPERO REGISTRATION NUMBER: CRD42020177953.