ABSTRACT
Patients with strong clinical features of COVID-19 with negative real time polymerase chain reaction (RT-PCR) SARS-CoV-2 testing are not currently included in official statistics. The scale, characteristics and clinical relevance of this group are thus unknown. We performed a retrospective cohort study in two large London hospitals to characterize the demographic, clinical, and hospitalization outcome characteristics of swab-negative clinical COVID-19 patients. We found 1 in 5 patients with a negative swab and clinical suspicion of COVID-19 received a clinical diagnosis of COVID-19 within clinical documentation, discharge summary or death certificate. We compared this group to a similar swab positive cohort and found similar demographic composition, symptomology and laboratory findings. Swab-negative clinical COVID-19 patients had better outcomes, with shorter length of hospital stay, reduced need for >60% supplementary oxygen and reduced mortality. Patients with strong clinical features of COVID-19 that are swab-negative are a common clinical challenge. Health systems must recognize and plan for the management of swab-negative patients in their COVID-19 clinical management, infection control policies and epidemiological assessments.
ABSTRACT
BackgroundCOVID-19 mitigation strategies have been challenging to implement in resource-limited settings such as Malawi due to the potential for widespread disruption to social and economic well-being. Here we estimate the clinical severity of COVID-19 in Malawi, quantifying the potential impact of intervention strategies and increases in health system capacity. MethodsThe infection fatality ratios (IFR) in Malawi were estimated by adjusting reported IFR for China accounting for demography, the current prevalence of comorbidities and health system capacity. These estimates were input into an age-structured deterministic model, which simulated the epidemic trajectory with non-pharmaceutical interventions. The impact of a novel therapeutic agent and increases in hospital capacity and oxygen availability were explored, given different assumptions on mortality rates. FindingsThe estimated age-specific IFR in Malawi are higher than those reported for China, however the younger average age of the population results in a slightly lower population-weighted IFR (0.48%, 95% uncertainty interval [UI] 0.30% - 0.72% compared with 0.60%, 95% CI 0.4% - 1.3% in China). The current interventions implemented, (i.e. social distancing, workplace closures and public transport restrictions) could potentially avert 3,100 deaths (95% UI 1,500 - 4,500) over the course of the epidemic. Enhanced shielding of people aged [≥] 60 years could avert a further 30,500 deaths (95% UI 17,500 - 45,600) and halve ICU admissions at the peak of the outbreak. Coverage of face coverings of 60% under the assumption of 50% efficacy could be sufficient to control the epidemic. A novel therapeutic agent, which reduces mortality by 0.65 and 0.8 for severe and critical cases respectively, in combination with increasing hospital capacity could reduce projected mortality to 2.55 deaths per 1,000 population (95% UI 1.58 - 3.84). ConclusionThe risks due to COVID-19 vary across settings and are influenced by age, underlying health and health system capacity. Summary BoxO_ST_ABSWhat is already known?C_ST_ABSO_LIAs COVID-19 spreads throughout Sub-Saharan Africa, countries are under increasing pressure to protect the most vulnerable by suppressing spread through, for example, stringent social distancing measures or shielding of those at highest risk away from the general population. C_LIO_LIThere are a number of studies estimating infection fatality ratio due to COVID-19 but none use data from African settings. The estimated IFR varies across settings ranging between 0.28-0.99%, with higher values estimated for Europe (0.77%, 95% CI 0.55 - 0.99%) compared with Asia (0.46%, 95% CI 0.38 - 0.55). C_LIO_LIThe IFR for African settings are still unknown, although several studies have highlighted the potential for increased mortality due to comorbidities such as HIV, TB and malaria. C_LIO_LIThere are a small number of studies looking at the impact of non-pharmaceutical interventions in Africa, particularly South Africa, but none to date have combined this with country-specific estimates of IFR adjusted for comorbidity prevalence and with consideration to the prevailing health system constraints and the impact of these constraints on mortality rates. C_LI What are the new findings?O_LIAfter accounting for the health system constraints and differing prevalences of underlying comorbidities, the estimated infection fatality ratio (IFR) for Malawi (0.48%, 95% uncertainty interval 0.30% - 0.72%) is within the ranges reported for the Americas, Asia and Europe (overall IFR 0.70, 95% CI 0.57 - 0.82, range 0.28 - 0.89). C_LIO_LIIntroducing enhanced shielding of people aged [≥] 60 years could avert up to 30,500 deaths (95% UI 17,500 - 45,600) and significantly reduce demand on ICU admissions. C_LIO_LIMaintaining coverage of face coverings at 60%, under the assumption of 50% efficacy, could be sufficient to control the epidemic. C_LIO_LICombining the introduction of a novel therapeutic agent with increases in hospital capacity could reduce projected mortality to 2.55 deaths per 1,000 population (95% UI 1.58 - 3.84). C_LI What do the new findings imply?O_LIAdjusting estimates of COVID-19 severity to account for underlying health is crucial for predicting health system demands. C_LIO_LIA multi-pronged approach to controlling transmission, including face coverings, increasing hospital capacity and using new therapeutic agents could significantly reduce deaths to COVID-19, but is not as effective as a theoretical long-lasting lockdown. C_LI
ABSTRACT
The numbers of deaths caused by HIV could increase substantially if the COVID-19 epidemic leads to interruptions in the availability of HIV services. We compare publicly available scenarios for COVID-19 mortality with predicted additional HIV-related mortality based on assumptions about possible interruptions in HIV programs. An interruption in the supply of ART for 40% of those on ART for 3 months could cause a number of deaths on the same order of magnitude as the number that are anticipated to be saved from COVID-19 through social distancing measures. In contrast, if the disruption can be managed such that the supply and usage of ART is maintained, the increase in AIDS deaths would be limited to 1% over five years, although this could still be accompanied by substantial increases in new HIV infections if there are reductions in VMMC, oral PrEP use, and condom availability.
