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Naidoo KL, Dorward J, Chinniah K, Lawler M, Nattar Y, Bottomley C, Archary M. Changes in the medical admissions and mortality amongst children in four South African hospitals following the COVID-19 pandemic: A five-year review. PLOS GLOBAL PUBLIC HEALTH 2024; 4:e0002829. [PMID: 39292683 PMCID: PMC11410242 DOI: 10.1371/journal.pgph.0002829] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 08/16/2024] [Indexed: 09/20/2024]
Abstract
Vulnerable children from poor communities with high HIV and Tuberculosis(TB) burdens were impacted by COVID-19 lockdowns. Concern was raised about the extent of this impact and anticipated post-pandemic surges in mortality. Interrupted time series segmented regression analyses were done using routinely collected facility-level data of children admitted for medical conditions at four South African referral hospitals. Monthly admission and mortality data over 60 months from 01 April 2018 to 31 January 2023 was analysed using models which included dummy lockdown level variables, a dummy post-COVID period variable, Fourier terms to account for seasonality, and excess mortality as a proxy for healthcare burden. Of the 45 015 admissions analysed, 1237(2·75%) demised with significant decreases in admissions during all the lockdown levels, with the most significant mean monthly decrease of 450(95%, CI = 657·3, -244·3) p<0·001 in level 5 (the most severe) lockdown. There was evidence of loss of seasonality on a six-month scale during the COVID periods for all admissions (p = 0·002), including under-one-year-olds (p = 0·034) and under-five-year-olds (p = 0·004). No decreases in mortality accompanied decreased admissions. Post-pandemic surges in admissions or mortality were not identified in children with acute gastroenteritis, acute pneumonia and severe acute malnutrition.During the COVID-19 pandemic, paediatric admissions in 4 hospitals serving communities with high levels of HIV, TB and poverty decreased, similar to global experiences; however, there was no change in in-hospital mortality. No post-pandemic surge in admissions or mortality was documented. Differences in the impact of pandemic control measures on the transmission of childhood infections and access to health care may account for differing outcomes seen in our setting compared to the global experiences. Further studies are needed to understand the impact of pandemic control measures on healthcare provision and transmission dynamics and to better inform future responses amongst vulnerable child populations.
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Affiliation(s)
- Kimesh Loganathan Naidoo
- Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Congella, Durban, South Africa
| | - Jienchi Dorward
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), Durban, South Africa
| | - Kogielambal Chinniah
- Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Mahatma Gandhi Memorial Hospital, Phoenix, Durban, South Africa
| | - Melissa Lawler
- Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- Prince Mshyeni Memorial Hospital, uMlazi, Durban, South Africa
| | - Yugendhree Nattar
- Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- RK Khan Memorial Hospital, Chatsworth, Durban, South Africa
| | | | - Moherndran Archary
- Department of Paediatrics and Child Health, School of Clinical Medicine, College of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
- King Edward VIII Hospital, Congella, Durban, South Africa
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Edoka I, Silal S, Jamieson L, Meyer-Rath G. A cost-effectiveness analysis of South Africa's COVID-19 vaccination programme. Vaccine 2024; 42:125988. [PMID: 38824084 DOI: 10.1016/j.vaccine.2024.05.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/15/2024] [Accepted: 05/16/2024] [Indexed: 06/03/2024]
Abstract
BACKGROUND COVID-19 vaccines were rolled out in South Africa beginning in February 2021. In this study we retrospectively assessed the cost-effectiveness of the vaccination programme in its first two years of implementation. METHOD We modelled the costs, expressed in 2021 US$, and health outcomes of the COVID-19 vaccination programme compared to a no vaccination programme scenario. The study was conducted from a public payer's perspective over two time-horizons - nine months (February to November 2021) and twenty-four months (February 2021 to January 2023). Health outcomes were estimated from a disease transmission model parameterised with data on COVID-19-related hospitalisations and deaths and were converted to disability adjusted life years (DALYs). Deterministic and probabilistic sensitivity analyses (DSA and PSA) were conducted to assess parameter uncertainty. RESULTS Incremental cost-effectiveness ratio (ICER) was estimated at US$1600 per DALY averted during the first study time horizon. The corresponding ICER for the second study period was estimated at US$1300 per DALY averted. When 85% of all excess deaths during these periods were included in the analysis, ICERs in the first and second study periods were estimated at US$1070 and US$660 per DALY averted, respectively. In the PSA, almost 100% of simulations fell below the estimated opportunity cost-based cost-effectiveness threshold for South Africa (US$2300 DALYs averted). COVID-19 vaccination programme cost per dose had the greatest impact on the ICERs. CONCLUSION Our findings suggest that South Africa's COVID-19 vaccination programme represented good value for money in the first two years of rollout.
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Affiliation(s)
- Ijeoma Edoka
- Health Economics and Epidemiology Research Office (HE(2)RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa.
| | - Sheetal Silal
- Modelling and Simulation Hub, Africa (MASHA), University of Cape Town, Cape Town, South Africa; Centre for Global Health, Nuffield Department of Medicine, Oxford University, Oxford, United Kingdom
| | - Lise Jamieson
- Health Economics and Epidemiology Research Office (HE(2)RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa
| | - Gesine Meyer-Rath
- Health Economics and Epidemiology Research Office (HE(2)RO), Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa; South African Centre for Epidemiological Modelling and Analysis (SACEMA), Stellenbosch University, Stellenbosch, South Africa; Department of Global Health, School of Public Health, Boston University, Boston, USA
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Garenne M, Stiegler N. Covid-19 demography in France and South Africa: A comparative study of morbidity and mortality in 2020-2022. PLoS One 2024; 19:e0294870. [PMID: 38315717 PMCID: PMC10843123 DOI: 10.1371/journal.pone.0294870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 11/09/2023] [Indexed: 02/07/2024] Open
Abstract
BACKGROUND Covid-19 epidemics raged around the world in years 2020-2022. The dynamics of the epidemics and their mortality varied by country depending on prevention, treatments, vaccination and health status of the population. OBJECTIVE The study compares Covid-19 morbidity and mortality in South-Africa and in France, two countries with similar population size and with reliable reporting systems, in order to better understand the dynamics and impacts of the epidemics and the effects of health policies and programs. DATA AND METHODS Data on cases, deaths, hospitalizations, vaccinations were drawn from national statistics. Published data on cases and deaths were corrected for undercount. RESULTS Results show a different epidemiology in the two countries in the first three years of the epidemic (2020-2022). Incidence was higher in South Africa, and some 44% more people were infected by December 2022 than in France. Mortality and case-fatality were also higher in South Africa despite a favourable age structure. The age pattern of mortality showed higher values in South Africa among the young adults. Young women appeared somewhat disadvantaged in South Africa. Lastly, vaccination appeared to have had no effect on incidence, but a large effect on case-fatality in France. CONCLUSIONS Despite about the same population size and the same crude death rate at baseline, South Africa exhibited more cases and more deaths from Covid-19 over the 2020-2022 period. Prevention strategies (lockdown and vaccination) appear to have had large impacts on morbidity and mortality.
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Affiliation(s)
- Michel Garenne
- Department of Statistics and Population Studies, University of the Western Cape, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit, School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Institut de Recherche pour le Développement (IRD), UMI Résiliences, Bondy, France
- Senior Fellow, FERDI, Université d’Auvergne, Clermont-Ferrand, France
| | - Nancy Stiegler
- Department of Statistics and Population Studies, University of the Western Cape, South Africa
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Groenewald P, Matzopoulos R, Afonso E, Bradshaw D. The importance of including manner of (injury) death on the death notification form. S Afr Med J 2023; 113:11-12. [PMID: 37882128 DOI: 10.7196/samj.2023.v113i9.915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Indexed: 10/27/2023] Open
Affiliation(s)
- P Groenewald
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.
| | - R Matzopoulos
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa; School of Public Health and Family Medicine, Faculty of Health Sciences, University of Cape Town, South Africa.
| | - E Afonso
- Division of Forensic Medicine, Department of Pathology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa.
| | - D Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Cape Town, South Africa.
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Sabet N, Omar T, Milovanovic M, Magajane T, Mosala M, Moloantoa T, Kato-Kalule N, Semedo LV, Swanepoel F, Wallis C, Abraham P, Lebina L, Variava E, Martinson N. Undiagnosed Pulmonary Tuberculosis (TB) and Coronavirus Disease 2019 (COVID-19) in Adults Dying at Home in a High-TB-Burden Setting, Before and During Pandemic COVID-19: An Autopsy Study. Clin Infect Dis 2023; 77:453-459. [PMID: 37041678 DOI: 10.1093/cid/ciad212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 03/29/2023] [Accepted: 04/06/2023] [Indexed: 04/13/2023] Open
Abstract
BACKGROUND Missing or undiagnosed patients with tuberculosis (TB) or coronavirus disease 2019 (COVID-19) are of concern. Identifying both infections in patients with no diagnosis prior to death contributes to understanding the burden of disease. To confirm reports of global reduction in TB incidence, a 2012 autopsy study of adults dying at home of natural causes in a high-TB-burden setting was repeated, including severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) assessments after the first COVID-19 surge in South Africa. METHODS Adult decedents who died at home with insufficient information to determine cause of death, no recent hospitalization, and no current antemortem TB or COVID-19 diagnosis were identified between March 2019 and October 2020 with a 4-month halt during lockdown. A standardized verbal autopsy followed by minimally invasive needle autopsy (MIA) was performed. Biopsies were taken for histopathology from liver, bilateral brain and lung; bronchoalveolar lavage fluid was collected for Xpert (MTB/RIF) and mycobacterial culture, and blood for human immunodeficiency virus (HIV) polymerase chain reaction (PCR) testing. After the start of the COVID-19 pandemic, a nasopharyngeal swab and lung tissue were subjected to SARS-CoV-2 PCR testing. RESULTS Sixty-six MIAs were completed in 25 men and 41 women (median age, 60 years); 68.2% had antemortem respiratory symptoms and 30.3% were people with HIV. Overall, TB was diagnosed in 11 of 66 (16.7%) decedents, and 14 of 41 (34.1%) in the COVID-19 pandemic were SARS-CoV-2 positive. CONCLUSIONS Undiagnosed TB in adults dying at home has decreased but remains unacceptably high. Forty percent of decedents had undiagnosed COVID-19, suggesting that estimates of excess deaths may underestimate the impact of SARS-CoV-2 on mortality.
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Affiliation(s)
- Nadia Sabet
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Tanvier Omar
- Department of Anatomical Pathology, National Health Laboratory Service and University of the Witwatersrand, Johannesburg, South Africa
| | - Minja Milovanovic
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Tebogo Magajane
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Modiehi Mosala
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Tumelo Moloantoa
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Nalukenge Kato-Kalule
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Imperial College Healthcare, National Health Service Trust, London, United Kingdom
| | - Lenise Varela Semedo
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Floris Swanepoel
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Carole Wallis
- Bio Analytical Research Corporation, Johannesburg, South Africa
| | - Pattamukkil Abraham
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Limakatso Lebina
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Africa Health Research Institute, Durban, South Africa
| | - Ebrahim Variava
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Department of Internal Medicine, Klerksdorp-Tshepong Hospital Complex, Klerksdorp, South Africa
| | - Neil Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, Johannesburg, South Africa
- Center for Tuberculosis Research, Johns Hopkins University, Baltimore, Maryland, USA
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Rapidly shifting immunologic landscape and severity of SARS-CoV-2 in the Omicron era in South Africa. Nat Commun 2023; 14:246. [PMID: 36646700 PMCID: PMC9842214 DOI: 10.1038/s41467-022-35652-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 12/16/2022] [Indexed: 01/18/2023] Open
Abstract
South Africa was among the first countries to detect the SARS-CoV-2 Omicron variant. However, the size of its Omicron BA.1 and BA.2 subvariants (BA.1/2) wave remains poorly understood. We analyzed sequential serum samples collected through a prospective cohort study before, during, and after the Omicron BA.1/2 wave to infer infection rates and monitor changes in the immune histories of participants over time. We found that the Omicron BA.1/2 wave infected more than half of the cohort population, with reinfections and vaccine breakthroughs accounting for > 60% of all infections in both rural and urban sites. After the Omicron BA.1/2 wave, we found few (< 6%) remained naïve to SARS-CoV-2 and the population immunologic landscape is fragmented with diverse infection/immunization histories. Prior infection with the ancestral strain, Beta, and Delta variants provided 13%, 34%, and 51% protection against Omicron BA.1/2 infection, respectively. Hybrid immunity and repeated prior infections reduced the risks of Omicron BA.1/2 infection by 60% and 85% respectively. Our study sheds light on a rapidly shifting landscape of population immunity in the Omicron era and provides context for anticipating the long-term circulation of SARS-CoV-2 in populations no longer naïve to the virus.
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Bradshaw D, Dorrington R, Moultrie T, Groenewald P, Moultrie H. Underestimated COVID-19 mortality in WHO African region. Lancet Glob Health 2022; 10:e1559. [PMID: 36240818 PMCID: PMC9553192 DOI: 10.1016/s2214-109x(22)00425-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2022] [Accepted: 09/22/2022] [Indexed: 11/17/2022]
Affiliation(s)
- Debbie Bradshaw
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg 7505, South Africa; Department of Family Medicine and Public Health, University of Cape Town, Rondebosch, South Africa.
| | - Robert Dorrington
- Centre for Actuarial Research, University of Cape Town, Rondebosch, South Africa
| | - Tom Moultrie
- Centre for Actuarial Research, University of Cape Town, Rondebosch, South Africa
| | - Pam Groenewald
- Burden of Disease Research Unit, South African Medical Research Council, Tygerberg 7505, South Africa
| | - Harry Moultrie
- Centre for Tuberculosis, National Institute for Communicable Diseases, Division of the National Health Laboratory Service, Johannesburg, South Africa; School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Underestimated COVID-19 mortality in WHO African region - Authors' reply. Lancet Glob Health 2022; 10:e1560. [PMID: 36240819 PMCID: PMC9553201 DOI: 10.1016/s2214-109x(22)00415-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2022] [Accepted: 09/16/2022] [Indexed: 11/07/2022]
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Sun K, Tempia S, Kleynhans J, von Gottberg A, McMorrow ML, Wolter N, Bhiman JN, Moyes J, Carrim M, Martinson NA, Kahn K, Lebina L, du Toit JD, Mkhencele T, Viboud C, Cohen C. Rapidly shifting immunologic landscape and severity of SARS-CoV-2 in the Omicron era in South Africa. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2022:2022.08.19.22278993. [PMID: 36032973 PMCID: PMC9413704 DOI: 10.1101/2022.08.19.22278993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
South Africa was among the first countries to detect the SARS-CoV-2 Omicron variant. Propelled by increased transmissibility and immune escape properties, Omicron displaced other globally circulating variants within 3 months of its emergence. Due to limited testing, Omicron's attenuated clinical severity, and an increased risk of reinfection, the size of the Omicron BA.1 and BA.2 subvariants (BA.1/2) wave remains poorly understood in South Africa and in many other countries. Using South African data from urban and rural cohorts closely monitored since the beginning of the pandemic, we analyzed sequential serum samples collected before, during, and after the Omicron BA.1/2 wave to infer infection rates and monitor changes in the immune histories of participants over time. Omicron BA.1/2 infection attack rates reached 65% (95% CI, 60% - 69%) in the rural cohort and 58% (95% CI, 61% - 74%) in the urban cohort, with repeat infections and vaccine breakthroughs accounting for >60% of all infections at both sites. Combined with previously collected data on pre-Omicron variant infections within the same cohorts, we identified 14 distinct categories of SARS-CoV-2 antigen exposure histories in the aftermath of the Omicron BA.1/2 wave, indicating a particularly fragmented immunologic landscape. Few individuals (<6%) remained naïve to SARS-CoV-2 and no exposure history category represented over 25% of the population at either cohort site. Further, cohort participants were more than twice as likely to get infected during the Omicron BA.1/2 wave, compared to the Delta wave. Prior infection with the ancestral strain (with D614G mutation), Beta, and Delta variants provided 13% (95% CI, -21% - 37%), 34% (95% CI, 17% - 48%), and 51% (95% CI, 39% - 60%) protection against Omicron BA.1/2 infection, respectively. Hybrid immunity (prior infection and vaccination) and repeated prior infections (without vaccination) reduced the risks of Omicron BA.1/2 infection by 60% (95% CI, 42% - 72%) and 85% (95% CI, 76% - 92%) respectively. Reinfections and vaccine breakthroughs had 41% (95% CI, 26% - 53%) lower risk of onward transmission than primary infections. Our study sheds light on a rapidly shifting landscape of population immunity, along with the changing characteristics of SARS-CoV-2, and how these factors interact to shape the success of emerging variants. Our findings are especially relevant to populations similar to South Africa with low SARS-CoV-2 vaccine coverage and a dominant contribution of immunity from prior infection. Looking forward, the study provides context for anticipating the long-term circulation of SARS-CoV-2 in populations no longer naïve to the virus.
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Affiliation(s)
- Kaiyuan Sun
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Stefano Tempia
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Influenza Division, Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
| | - Jackie Kleynhans
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Anne von Gottberg
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Meredith L McMorrow
- COVID-19 Response, Centers for Disease Control and Prevention, Atlanta, Georgia, United States
| | - Nicole Wolter
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Jinal N. Bhiman
- Centre for HIV and STIs, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- SAMRC Antibody Immunity Unit, University of the Witwatersrand, Johannesburg, South Africa
| | - Jocelyn Moyes
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Maimuna Carrim
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Pathology, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Neil A Martinson
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
- Johns Hopkins University Center for TB Research, Baltimore, Maryland, United States of America
| | - Kathleen Kahn
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Limakatso Lebina
- Perinatal HIV Research Unit, University of the Witwatersrand, South Africa
| | - Jacques D. du Toit
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Thulisa Mkhencele
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | - Cécile Viboud
- Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland, United States of America
| | - Cheryl Cohen
- Centre for Respiratory Diseases and Meningitis, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
- School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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