What Could Explain the Lower COVID-19 Burden in Africa despite Considerable Circulation of the SARS-CoV-2 Virus?

COVID-19 Risk Communication and Community Engagement (RCCE) in Malawi: Challenges and Response

The outbreak of COVID-19 created a global health crisis that has impacted our everyday lives. Risk communication and community engagement (RCCE) is one of the strategic pillars the World Health Organization (WHO) recommends when dealing with public health emergencies like COVID-19. In Malawi, the COVID-19 RCCE response was coordinated by the country's Ministry of Health and involved various organizations that distributed COVID-19 risk communication materials and engaged communities on important infection preventive practices. Furthermore, the Ministry of Information was involved in ensuring the messages were put across at national and subnational levels. Despite the efforts, most Malawians were reluctant to embrace set public health measures for COVID-19. Guided by a phenomenological approach, we used in-depth interviews with senior officials from 10 organizations, including the Ministry of Health, who were involved in RCCE response in Malawi, to understand the challenges that were faced in the implementation of RCCE activities in Malawi. We also reviewed project reports from three organizations, taken from the same implementing local organizations, to understand the experiences of implementing RCCE strategies in Malawi. We established that misconceptions, poor coordination, lack of political will, low-risk perceptions, and social norms undermined the response in Malawi. The results underscore the need for the authorities in Malawi to invest more in RCCE and strengthen the capacity to handle future epidemics. There is also a need to develop a national RCCE strategy with guidelines and protocols on methods of coordination, flow of communication, responsible ministry, tools for handling dis/misinformation and myths, and community engagement.

Seroprevalence of SARS-CoV-2 Antibodies and Associated Factors in Bamako, Mali: A Population-Based Cross-Sectional Study in September 2022

BACKGROUND

The sero-epidemiological characteristics of SARS-CoV-2 infections in Mali are not yet well understood. This study assessed SARS-CoV-2 antibody seroprevalence and factors associated with antibody responses in the general population of Bamako, the capital city and epicenter of COVID-19, to assess the magnitude of the pandemic and contribute to control strategy improvements in Mali.

METHODS

A cross-sectional survey was conducted in September 2022 to collect sociodemographic information, clinical characteristics, comorbid factors, and blood samples. ELISA was performed to determine anti-Spike (anti-S) and anti-RBD antibody levels. A total of 3601 participants were enrolled in REDCap. R-Studio was used for the statistical analysis. The chi-squared (χ2) test was used to compare the proportions across different groups. Logistic regression models were used to elucidate factors associated with antibody responses.

RESULT

The sex ratio for female-to-male was 3.6:1. The most representative groups were the 20-29-year-olds (28.9%, n = 1043) and the 30-39-year-olds (26.9%, n = 967). The COVID-19 vaccine coverage among the participants was 35.8%, with vaccines from Covishield AstraZeneca (13.4%), Johnson & Johnson (16.7%), Sinovac (3.9%), and BioNTech Pfizer (1.8%). Overall, S protein and RBD antibody seroprevalences were remarkably high in the study population (98% and 97%, respectively). Factors such as youth (1-9 years old) and male sex were associated with lower SARS-CoV-2 antibody responses, whereas COVID-19 vaccinations were associated with increased antibody responses.

CONCLUSION

This serosurvey demonstrated the high seroprevalence of SARS-CoV-2 antibodies and highlighted the factors influencing antibody responses, while clearly underlining an underestimation of the pandemic in Mali.

Increased difficulty accessing food and income change during the COVID-19 pandemic among youth living in the eThekwini district, South Africa

OBJECTIVE

To estimate the effect of income change on difficulty accessing food since the COVID-19 pandemic for South African youth and evaluate whether this effect was modified by receiving social grants.

DESIGN

A cross-sectional, online survey was conducted between December 2021 and May 2022. Primary outcome was increased difficulty accessing food since the COVID-19 pandemic. Income change was categorised as 'Decreased a lot', 'Decreased slightly' and 'Unchanged or increased'. Multivariable logistic regressions were used, with an interaction term between social grant receipt and income change.

SETTING

eThekwini district, South Africa.

PARTICIPANTS

Youth aged 16-24 years.

RESULTS

Among 1,620 participants, median age was 22 years (IQR 19-24); 861 (53 %) were women; 476 (29 %) reported increased difficulty accessing food; 297 (18 %) reported that income decreased a lot, of whom 149 (50 %) did not receive social grants. Experiencing a large income decrease was highly associated with increased difficulty accessing food during the COVID-19 pandemic (adjusted OR [aOR] 3·63, 95 % CI 2·70, 4·88). The aOR for the effect of a large income decrease on difficulty accessing food, compared to no income change, were 1·49 (95 % CI 0·98, 2·28) among participants receiving social grants, and 6·63 (95 % CI 4·39, 9·99) among participants not receiving social grants.

CONCLUSIONS

While social grant support made a great difference in lowering the effect of income decrease on difficulty accessing food, it was insufficient to fully protect youth from those difficulties. In post-pandemic recovery efforts, there is a critical need to support youth through economic empowerment programming and food schemes.

Narrative Review Explaining the Role of HLA-A, -B, and -C Molecules in COVID-19 Disease in and around Africa

The coronavirus disease 2019 (COVID-19) has left a devasting effect on various regions globally. Africa has exceptionally high rates of other infectious diseases, such as tuberculosis (TB), human immunodeficiency virus (HIV), and malaria, and was not impacted by COVID-19 to the extent of other continents Globally, COVID-19 has caused approximately 7 million deaths and 700 million infections thus far. COVID-19 disease severity and susceptibility vary among individuals and populations, which could be attributed to various factors, including the viral strain, host genetics, environment, lifespan, and co-existing conditions. Host genetics play a substantial part in COVID-19 disease severity among individuals. Human leukocyte antigen (HLA) was previously been shown to be very important across host immune responses against viruses. HLA has been a widely studied gene region for various disease associations that have been identified. HLA proteins present peptides to the cytotoxic lymphocytes, which causes an immune response to kill infected cells. The HLA molecule serves as the central region for infectious disease association; therefore, we expect HLA disease association with COVID-19. Therefore, in this narrative review, we look at the HLA gene region, particularly, HLA class I, to understand its role in COVID-19 disease.

Perceptions around COVID-19 among patients and community members in urban areas in Cameroon: A qualitative perspective

At the onset of the COVID-19 pandemic, the Cameroonian government, to abide by international regulations, prescribed preventive measures, which affected many aspects of social, political, economic, and cultural life. However, there needs to be more in-depth exploration of how communities in Cameroon perceived and were impacted by COVID-19. We explored perceptions and misconceptions concerning COVID-19's impact on urban communities' daily lives in Cameroon. We conducted semi-structured interviews and focus group discussions with a heterogeneous sample of 25 participants from five different social categories (health personnel, patients with a confirmed COVID-19 infection, close contacts of patients, community members, and community leaders) to assess their perceptions of the disease. Interviews and FGDs were recorded, fully transcribed, coded manually, and analyzed using a thematic analysis iterative coding process. Three main themes were identified: 1) Knowledge of COVID-19: antagonism between disease and invention, 2) Barrier measures imposed by the "dominant culture," and 3) Impact of COVID-19 on daily lives. Our study revealed perceptions around general knowledge of the COVID-19 pandemic, noting acceptance and observation of government-imposed protective measures while highlighting the significant changes endured in participants' daily lives. These findings draw attention to the need to develop flexible and appropriate response strategies for different communities. Although Cameroonian populations were not as intensely affected by the burden of the disease of COVID-19 as other regions, they were still compelled to follow static "cookie-cutter" measures that were internationally imposed, affecting their daily lives in ways that seemed disproportionate to their own experiences of the crisis. These findings have potential implications for the legitimacy of public health institutions and responses.

Coronavirus Disease 2019 Vaccination Coverage and Seropositivity amongst Nigerians 18 Years Old and Above

BACKGROUND

This was a cross-sectional community-based survey to study the prevalence of serum antibodies against the severe acute respiratory syndrome coronavirus 1 (SARS-COV-1) and determine possible source of antibodies as to whether from vaccination or from natural infection as well as attempt to compare antibody levels in response to the different four types of vaccines administered in Nigeria.

METHODS

A cross-sectional community-based study of the prevalence of serum antibodies against all four vaccine types used in Nigeria amongst a representative sample of people aged 18 years and above in the six geopolitical zones of the country using a multistage sampling technique covering 12 states of the country with two states being randomly selected from each geopolitical zone. High-throughput Roche electrochemiluminescence immunoassay system (Elecsys Anti-SARS-COV-1 Cobas) was used for qualitative and quantitative detection of antibodies to SARS-COV-1 in human plasma.

RESULTS

There was no statistically significant difference between the proportions with seropositivity for both the vaccinated and the unvaccinated (P = 0.95). The nucleocapsid antibody (anti-Nc) titres were similar in both the vaccinated and the unvaccinated, whereas the Spike protein antibody (anti-S) titres were significantly higher amongst the vaccinated than amongst the unvaccinated. Antibody levels in subjects who received different vaccines were compared to provide information for policy.

CONCLUSION

While only 45.9% of the subjects were reported to have been vaccinated, 98.7% of the subjects had had contact with the SARS-COV-1 as evidenced by the presence of nucleocapsid (NC) antibodies in their plasma. The 1.3% who had not been exposed to the virus, had spike protein antibodies which most likely resulted from vaccination in the absence of NC antibodies. Successive vaccination and booster doses either through heterogeneous or homologous vaccines increased antibody titres, and this stimulation of immune memory may offer greater protection against coronavirus disease 2019.

The HIV/AIDS responses pre and during the COVID-19 pandemic in sub-Saharan Africa: A basis for sustainable health system strengthening post-COVID-19

In May 2023, the World Health Organization announced that COVID-19 was no longer a global emergency. The impact of COVID-19 on the provision of HIV/AIDS services was not that severe due to the reprogramming of key resources. For health systems in sub-Saharan Africa to become resilient to future pandemics, lessons should be learned from the successful HIV/AIDS response in the region, and how the HIV/AIDS services were successfully adapted to the COVID-19 pandemic. In this article, we reviewed the 6 World Health Organization health system building blocks on how the best practices from the provision of HIV/AIDS services and the services' response to the COVID-19 pandemic can be used as a basis for restoring and strengthening health systems to offer universal access to quality essential health services. The success of the leadership and governance for universal access to anti-retroviral therapy can be a blueprint for the realization of universal health coverage. Significant efficiencies that resulted in the reduction in anti-retroviral therapy costs can be leveraged to ensure cheaper essential drugs while differentiated service delivery models can be used to improve health service accessibility. New technologies that have proven to be successful in HIV/AIDS care can also be used in the care of other diseases, including disease outbreaks. The strong health information systems developed for HIV programs can be used as a foundation for developing health information systems for the whole health sector while the healthcare professionals trained for the provision of HIV/AIDS services can be trained to provide services for a variety of other conditions.

Geoepidemiological perspective on COVID-19 pandemic review, an insight into the global impact

The COVID-19 pandemic showed major impacts, on societies worldwide, challenging healthcare systems, economies, and daily life of people. Geoepidemiology, an emerging field that combines geography and epidemiology, has played a vital role in understanding and combatting the spread of the virus. This interdisciplinary approach has provided insights into the spatial patterns, risk factors, and transmission dynamics of the COVID-19 pandemic at different scales, from local communities to global populations. Spatial patterns have revealed variations in incidence rates, with urban-rural divides and regional hotspots playing significant roles. Cross-border transmission has highlighted the importance of travel restrictions and coordinated public health responses. Risk factors such as age, underlying health conditions, socioeconomic factors, occupation, demographics, and behavior have influenced vulnerability and outcomes. Geoepidemiology has also provided insights into the transmissibility and spread of COVID-19, emphasizing the importance of asymptomatic and pre-symptomatic transmission, super-spreading events, and the impact of variants. Geoepidemiology should be vital in understanding and responding to evolving new viral challenges of this and future pandemics.

High SARS-CoV-2 seroprevalence in Lagos, Nigeria with robust antibody and cellular immune responses

Background

Early evidence suggested that the impact of the COVID-19 pandemic was less severe in Africa compared to other parts of the world. However, more recent studies indicate higher SARS-CoV-2 infection and COVID-19 mortality rates on the continent than previously documented. Research is needed to better understand SARS-CoV-2 infection and immunity in Africa.

Methods

In early 2021, we studied the immune responses in healthcare workers (HCWs) at Lagos University Teaching Hospital (n = 134) and Oxford-AstraZeneca COVID-19 vaccine recipients from the general population (n = 116) across five local government areas (LGAs) in Lagos State, Nigeria. Western blots were used to simultaneously detect SARS-CoV-2 spike and nucleocapsid (N) antibodies (n = 250), and stimulation of peripheral blood mononuclear cells with N followed by an IFN-γ ELISA was used to examine T cell responses (n = 114).

Results

Antibody data demonstrated high SARS-CoV-2 seroprevalence of 72·4% (97/134) in HCWs and 60·3% (70/116) in the general population. Antibodies directed to only SARS-CoV-2 N, suggesting pre-existing coronavirus immunity, were seen in 9·7% (13/134) of HCWs and 15·5% (18/116) of the general population. T cell responses against SARS-CoV-2 N (n = 114) were robust in detecting exposure to the virus, demonstrating 87·5% sensitivity and 92·9% specificity in a subset of control samples tested. T cell responses against SARS-CoV-2 N were also observed in 83.3% of individuals with N-only antibodies, further suggesting that prior non-SARS-CoV-2 coronavirus infection may provide cellular immunity to SARS-CoV-2.

Conclusions

These results have important implications for understanding the paradoxically high SARS-CoV-2 infection with low mortality rate in Africa and supports the need to better understand the implications of SARS-CoV-2 cellular immunity.

COVID-19 impacts on healthcare access in sub-Saharan Africa: an overview

This overview aimed to describe the situation of healthcare access in sub-Saharan Africa, excluding South Africa, during the COVID-19 pandemic. A PubMed^® search from March 31, 2020, to August 15, 2022, selected 116 articles. Healthcare access and consequences of COVID-19 were assessed based on comparisons with months before its onset or an identical season in previous years. A general reduction of healthcare delivery, associated with the decline of care quality, and closure of many specialty services were reported. The impact was heterogeneous in space and time, with an increase in urban areas at the beginning of the pandemic (March-June 2020). The return to normalcy was gradual from the 3^rd quarter of 2020 until the end of 2021. The impact of COVID-19 on the health system and its use was attributed to (a) conjunctural factors resulting from government actions to mitigate the spread of the epidemic (containment, transportation restrictions, closures of businesses, and places of entertainment or worship); (b) structural factors related to the disruption of public and private facilities and institutions, in particular, the health system; and (c) individual factors linked to the increase in costs, impoverishment of the population, and fear of contamination or stigmatization, which discouraged patients from going to health centers. They have caused considerable socio-economic damage. Several studies emphasized some adaptability of the healthcare offer and resilience of the healthcare system, despite its unpreparedness, which explained a return to normal activities as early as 2022 while the COVID-19 epidemic persisted. There appears to be a strong disproportion between the moderate incidence and severity of COVID-19 in sub-Saharan Africa, and the dramatic impact on healthcare access. Several articles make recommendations for lowering the socioeconomic consequences of future epidemics to ensure better management of health issues.

Incidence rate and predictors of COVID-19 in the two largest cities of Burkina Faso - prospective cohort study in 2021 (ANRS-COV13)

BACKGROUND

Early data on COVID-19 (based primarily on PCR testing) indicated a low burden in Sub-Saharan Africa. To better understand this, this study aimed to estimate the incidence rate and identify predictors of SARS-CoV-2 seroconversion in the two largest cities of Burkina Faso. This study is part of the EmulCOVID-19 project (ANRS-COV13).

METHODS

Our study utilized the WHO Unity protocol for cohort sero-epidemiological studies of COVID-19 in general population. We conducted random sampling stratified by age group and sex. Individuals aged 10 years and older in the cities of Ouagadougou and Bobo-Dioulasso, Burkina Faso were included and surveyed at 4 time points, each 21 days apart, from March 3 to May 15, 2021. WANTAI SARS-CoV-2 Ab ELISA serological tests were used to detect total antibodies (IgM, IgG) in serum. Predictors were investigated using Cox proportional hazards regression.

RESULTS

We analyzed the data from 1399 participants (1051 in Ouagadougou, 348 in Bobo-Dioulasso) who were SARS-CoV-2 seronegative at baseline and had at least one follow-up visit. The incidence rate of SARS-CoV-2 seroconversion was 14.3 cases [95%CI 13.3-15.4] per 100 person-weeks. The incidence rate was almost three times higher in Ouagadougou than in Bobo-Dioulasso (Incidence rate ratio: IRR = 2.7 [2.2-3.2], p < 0.001). The highest incidence rate was reported among women aged 19-59 years in Ouagadougou (22.8 cases [19.6-26.4] per 100 person-weeks) and the lowest among participants aged 60 years and over in Bobo-Dioulasso, 6.3 cases [4.6-8.6] per 100 person-weeks. Multivariable analysis showed that participants aged 19 years and older were almost twice as likely to seroconvert during the study period compared with those aged 10 to 18 years (Hazard ratio: HR = 1.7 [1.3-2.3], p < 0.001). Those aged 10-18 years exhibited more asymptomatic forms than those aged 19 years and older, among those who achieved seroconversion (72.9% vs. 40.4%, p < 0.001).

CONCLUSION

The spread of COVID-19 is more rapid in adults and in large cities. Strategies to control this pandemic in Burkina Faso, must take this into account. Adults living in large cities should be the priority targets for vaccination efforts against COVID-19.

COVID-19 surveillance in Democratic Republic of Congo, Nigeria, Senegal and Uganda: strengths, weaknesses and key Lessons

INTRODUCTION

As part of efforts to rapidly identify and care for individuals with COVID-19, trace and quarantine contacts, and monitor disease trends over time, most African countries implemented interventions to strengthen their existing disease surveillance systems. This research describes the strengths, weaknesses and lessons learnt from the COVID-19 surveillance strategies implemented in four African countries to inform the enhancement of surveillance systems for future epidemics on the continent.

METHODS

The four countries namely the Democratic Republic of Congo (DRC), Nigeria, Senegal, and Uganda, were selected based on their variability in COVID-19 response and representation of Francophone and Anglophone countries. A mixed-methods observational study was conducted including desk review and key informant interviews, to document best practices, gaps, and innovations in surveillance at the national, sub-national, health facilities, and community levels, and these learnings were synthesized across the countries.

RESULTS

Surveillance approaches across countries included - case investigation, contact tracing, community-based, laboratory-based sentinel, serological, telephone hotlines, and genomic sequencing surveillance. As the COVID-19 pandemic progressed, the health systems moved from aggressive testing and contact tracing to detect virus and triage individual contacts into quarantine and confirmed cases, isolation and clinical care. Surveillance, including case definitions, changed from contact tracing of all contacts of confirmed cases to only symptomatic contacts and travelers. All countries reported inadequate staffing, staff capacity gaps and lack of full integration of data sources. All four countries under study improved data management and surveillance capacity by training health workers and increasing resources for laboratories, but the disease burden was under-detected. Decentralizing surveillance to enable swifter implementation of targeted public health measures at the subnational level was a challenge. There were also gaps in genomic and postmortem surveillance including community level sero-prevalence studies, as well as digital technologies to provide more timely and accurate surveillance data.

CONCLUSION

All the four countries demonstrated a prompt public health surveillance response and adopted similar approaches to surveillance with some adaptations as the pandemic progresses. There is need for investments to enhance surveillance approaches and systems including decentralizing surveillance to the subnational and community levels, strengthening capabilities for genomic surveillance and use of digital technologies, among others. Investing in health worker capacity, ensuring data quality and availability and improving ability to transmit surveillance data between and across multiple levels of the health care system is also critical. Countries need to take immediate action in strengthening their surveillance systems to better prepare for the next major disease outbreak and pandemic.

Newly arrived migrants did not represent an additional COVID-19 burden for Italy: data from the italian information flow

BACKGROUND

During the COVID-19 pandemic, migrants arriving in host countries irregularly have not infrequently been perceived as increasing the COVID-19 burden. Italy is a transit and destination country for migrants who cross the Central Mediterranean route and, during the pandemic, all migrants who landed on Italian shores were COVID-19 tested and quarantined. Our study aimed to investigate the impact of the SARS-CoV-2 infection among migrants who landed on the Italian coasts by analyzing both incidence and health outcomes.

METHODS

A retrospective observational study has been designed. The population of interest was represented by 70,512 migrants (91% male, 99% <60 years old) who landed in Italy between January 2021 and 2022. SARS-CoV-2 incidence rate per 1,000 (with 95%CI) in migrants and the resident population in Italy of the corresponding age group was computed. The incidence rate ratio (IRR) was used to compare the incidence rates in migrants and the resident population.

RESULTS

2,861 migrants out of those landed in Italy during the observation period tested positive, with an incidence rate of 40.6 (39.1-42.1) cases per 1,000. During the same period, 177.6 (177.5-177.8) cases per 1,000 were reported in the resident population, with an IRR of 0.23 (0.22-0.24). 89.7% of cases were male and 54.6% belonged to the 20-29 age group. 99% of cases reported no symptoms, no relevant comorbidities were reported and no cases were hospitalized.

CONCLUSIONS

Our study found a low rate of SARS-CoV-2 infection in migrants reaching Italy by sea with an incidence rate that is roughly a quarter of that of the resident population. Thus, irregular migrants who arrived in Italy during the observation period did not increase the COVID-19 burden. Further studies are needed to investigate possible reasons for the low incidence observed in this population.

Consequences of COVID-19 Among Adult HIV Patients Versus Non-HIV Patients: Two-Year Data From the Primary Isolation Centre in Sudan

Background The COVID-19 pandemic remains to have a global impact despite the great efforts in prevention. Controversy persists regarding the outcomes of SARS-CoV-2 among HIV patients versus non-HIV individuals. Objective This study aimed to assess the impact of COVID-19 among adult patients with HIV versus non-HIV in the chief isolation centre in Khartoum state, Sudan. Methods This is an analytical cross-sectional, comparative single-centre study conducted at the Chief Sudanese Coronavirus Isolation Centre in Khartoum from March 2020 to July 2022. Data were analysed using SPSS V.26 (IBM Corp., Armonk, USA). Results This study included 99 participants. The overall age mean was 50±1 years old, with a male predominance of 66.7% (n=66). 9.1% (n=9) of the participants were HIV cases, 33.3% of whom were newly diagnosed. The majority, 77.8%, reported poor adherence to anti-retroviral therapy. The most common complications included acute respiratory failure (ARF) and multiple organ failure, 20.2% and 17.2%, respectively. The overall complications were higher among HIV cases than non-HIV cases; however, statistically insignificant (p>0.05 ), except for acute respiratory failure (p<0.05). 48.5% of participants were admitted to the intensive care unit (ICU), with slightly higher rates among HIV cases; however, this was statistically insignificant (p=0.656). Regarding the outcome, 36.4% (n=36) recovered and were discharged. Although a higher mortality rate was reported among HIV cases compared to non-HIV cases (55% vs 40%), it was statistically insignificant (p=0.238). Conclusion The mortality and morbidity percent proportion among HIV patients with superimposed COVID-19 infection was higher than in non-HIV patients but statistically insignificant aside from ARF. Consequently, this category of patients, to a large extent, should not be considered highly susceptible to adverse outcomes when infected with COVID-19; however, ARF should be closely monitored for.

Using telehealth to support community health workers in Uganda during COVID-19: a mixed-method study

Background

At the onset of the COVID-19 pandemic, a local consortium in Uganda set up a telehealth approach that aimed to educate 3,500 Community Health Workers (CHW) in rural areas about COVID-19, help them identify, refer and care for potential COVID-19 cases, and support them in continuing their regular community health work. The aim of this study was to assess the functioning of the telehealth approach that was set up to support CHWs during the COVID-19 pandemic.

Methods

For this mixed-method study, we combined analysis of routine consultation data from the call-center, 24 interviews with key-informants and two surveys of 150 CHWs. Data were analyzed using constant comparative method of analysis.

Results

Between March 2020 and June 2021, a total of 35,553 consultations took place via the call center. While the CHWs made extensive use of the call center, they rarely asked for support for potential Covid-19 cases. According to the CHWs, there were no signs that people in their communities were suffering from severe health problems due to COVID-19. People compared the lack of visible symptoms to diseases such as Ebola and were skeptical about the danger of COVID-19. At the same time, people in rural areas were afraid to report relevant symptoms and get tested for fear of being quarantined and stigmatized. The telehealth approach did prove useful for other purposes, such as supporting CHWs with their regular tasks and coordinating the supply of essential products. The health professionals at the call center supported CHWs in diagnosing, referring and treating patients and adhering to infection prevention and control practices. The CHWs felt more informed and less isolated, saying the support from the call center helped them to provide better care and improved the supply of medicine and other essential health products.

Conclusions

The telehealth approach, launched at the start of the COVID-19 pandemic, provided useful support to thousands of CHWs in rural communities in Uganda. The telehealth approach could be quickly set up and scaled up and offers a low cost strategy for providing useful and flexible support to CHWs in rural communities.

Antibiotic dispensing practices during COVID-19 and implications for antimicrobial resistance (AMR): parallel mystery client studies in Uganda and Tanzania

BACKGROUND

Over-the-counter antibiotic access is common in low-and-middle-income countries and this may accelerate antimicrobial resistance. Our study explores critical aspects of the drug seller-client interaction and antibiotic dispensing patterns for simulated COVID-19 symptoms during the pandemic in two study sites in Tanzania and Uganda, countries with different government responses to the pandemic.

METHODS

Research assistants posing as clients approached different types of drug sellers such as pharmacies (Pharms), drug shops (DSs), and accredited drug dispensing outlets (ADDOs) in Mwanza, Tanzania (nPharms =  415, nADDOs = 116) and Mbarara, Uganda (nPharms = 440, nDSs  = 67), from June 10 to July 30, 2021. The mystery clients held no prescription and sought advice for simulated COVID-19 symptoms from the drug sellers. They documented the quality of their interaction with sellers and the type of drugs dispensed.

RESULTS

Adherence to COVID-19 preventive measures and vigilance to COVID-19 symptoms was low in both sites but significantly higher in Uganda than in Tanzania. A higher percentage of drug sellers in Mbarara (Pharms = 36%, DSs = 35%, P-value = 0.947) compared to Mwanza (Pharms = 9%, ADDOs = 4%, P-value = 0.112) identified the client's symptoms as possibly COVID-19. More than three-quarters of drug sellers that sold prescription-only medicines in both Mbarara (Pharms = 86%, DSs = 89%) and Mwanza (Pharms = 93%, ADDOs = 97%) did not ask the MCs for a prescription. A relatively high percentage of drug sellers that sold prescription-only medicines in Mwanza (Pharms = 51%, ADDOs = 67%) compared to Mbarara (Pharms = 31%, DSs = 42%) sold a partial course without any hesitation. Of those who sold antibiotics, a higher proportion of drug sellers in Mbarara (Pharms = 73%, DSs = 78%, P-value = 0.580) compared to Mwanza (Pharms = 40% ADDOs = 46%, P-value = 0.537) sold antibiotics relevant for treating secondary bacterial infections in COVID-19 patients.

CONCLUSION

Our study highlights low vigilance towards COVID-19 symptoms, widespread propensity to dispense prescription-only antibiotics without a prescription, and to dispense partial doses of antibiotics. This implies that drug dispensing related to COVID-19 may further drive AMR. Our study also highlights the need for more efforts to improve antibiotic stewardship among drug sellers in response to COVID-19 and to prepare them for future health emergencies.

Leveraging Serosurveillance and Postmortem Surveillance to Quantify the Impact of Coronavirus Disease 2019 in Africa

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has had a devastating impact on global health, the magnitude of which appears to differ intercontinentally: For example, reports suggest that 271 900 per million people have been infected in Europe versus 8800 per million people in Africa. While Africa is the second-largest continent by population, its reported COVID-19 cases comprise <3% of global cases. Although social and environmental explanations have been proposed to clarify this discrepancy, systematic underascertainment of infections may be equally responsible.

METHODS

We sought to quantify magnitudes of underascertainment in COVID-19's cumulative incidence in Africa. Using serosurveillance and postmortem surveillance, we constructed multiplicative factors estimating ratios of true infections to reported cases in Africa since March 2020.

RESULTS

Multiplicative factors derived from serology data (subset of 12 nations) suggested a range of COVID-19 reporting rates, from 1 in 2 infections reported in Cape Verde (July 2020) to 1 in 3795 infections reported in Malawi (June 2020). A similar set of multiplicative factors for all nations derived from postmortem data points toward the same conclusion: Reported COVID-19 cases are unrepresentative of true infections, suggesting that a key reason for low case burden in many African nations is significant underdetection and underreporting.

CONCLUSIONS

While estimating the exact burden of COVID-19 is challenging, the multiplicative factors we present furnish incidence estimates reflecting likely-to-worst-case ranges of infection. Our results stress the need for expansive surveillance to allocate resources in areas experiencing discrepancies between reported cases, projected infections, and deaths.

Malaria and the incidence of COVID-19 in Africa: an ecological study

BACKGROUND

It has been shown that stimulation of innate immunity may provide temporary protection against a variety of infectious diseases. Malaria has been shown to induce a robust innate immune response. This study was conducted to test the hypothesis that if the cumulative number of cases diagnosed with COVID-19 per 100,000 population was correlated with the prevalence of malaria in African countries where both malaria and COVID-19 were prevalent.

METHODS

In this ecological study, the cumulative incidence of COVID-19 and the prevalence of malaria were compared in 53 African countries. A negative binomial regression analysis with the cumulative incidence of COVID-19 as the dependent variable, and the human development index (HDI) and the prevalence of malaria, as independent variables, were used.

RESULTS

The mean cumulative incidence of COVID-19 was 522 cases per 100,000. Each 0.1 unit increase in HDI was associated with 2.4-fold (95% confidence interval 1.8-3.1) increase in the cumulative incidence of COVID-19. Prevalence of malaria was also independently associated with the cumulative incidence; each 10% increase in the prevalence was associated with 28% (10-41%) decrease in the cumulative incidence of COVID-19.

CONCLUSIONS

Malaria might protect people against SARS-CoV-2 through the stimulation of innate immunity. Stimulation of the innate immune system could be the first line of defense in the pandemic preparedness arsenal.

[Impact of COVID-19 on public health in sub-Saharan Africa]

Objective

This work aimed to assess the impact of COVID-19 on healthcare supply in sub-Saharan Africa except South Africa.

Method

A search through PubMed® between April 2020 and August 2022 selected 135 articles. The impact of COVID-19 was assessed on comparisons with the months prior to the onset of COVID-19 or an identical season in previous years.

Results

The decline of health services, associated with a reduction in their quality, and the closure of specialized health units have been reported. Many control programs and public health interventions have been interrupted, with the risk of an increase of the corresponding diseases. Social disorganization has generated mental health issues among the population, including health personnel. The impact was heterogeneous in space and time. The main causes were attributed to containment measures (transport restrictions, trade closures) and the lack of human and material resources. The increase in costs, in addition to the impoverishment of the population, and the fear of being contaminated or stigmatized have discouraged patients from going to health centres. The studies mention the gradual return to normal after the first epidemic wave and the resilience of the healthcare system.

Conclusion

Several articles make recommendations aimed at reducing the impact of future epidemics: support for community workers, training of health workers and reorganization of services to improve the reception and care of patients, technological innovations (use of telephones, drones, etc.) and better information monitoring.

COVID-19 pandemic: what are the countries with low cases of COVID-19 doing right?

As of the 17th of September in 2021, the number of confirmed cases of COVID-19 over the world had reached 227.7 million, with around 8.2 million of those instances being reported in Africa and the island nations of the Atlantic and Pacific. The development of the COVID- 19 pandemic in Africa and other countries across the world has been significantly different from the first apocalyptic forecasts researchers in the scientific community provided. This is the case both in terms of the pandemic itself and its impact. This report investigates the factors – such as the political will to address COVID-19 through immediate and severe actions, collaborative leadership, and historical experience with infection disease outbreaks – that are responsible for the low reported cases of infections and deaths in two regions of the world: Africa and the island countries of the Atlantic and Pacific. In Africa, the political will to address COVID-19 through immediate and severe actions was high, and collaborative leadership was prevalent. Despite the fact that they have handled the pandemic in an effective way, vaccination continues to be a major worry because only a tiny fraction of the population in each of these locations has received at least one dose of vaccine. The healthcare systems in the countries located throughout these regions are in a poor shape, and an outbreak of a highly infectious coronavirus variety has the potential to overwhelm the already frail healthcare system and wreak havoc on these global regions. It is recommended that the leadership of these regions turn their attention inward and develop a collaborative strategy for the production of vaccines on a local level. Additionally, it is recommended that these regions make improvements to their healthcare systems so that they are adequately prepared to deal with the next major public health emergency.

Population-based assessment of the burden of COVID-19 infection in African countries: a first-year report card and public health implications

Background

The COVID-19 pandemic constitutes a global health threat and poses a major burden on the African continent. We assessed the real-world burden of COVID-19 infection in African Union (AU) member states to determine the distributional patterns of epidemiological measures during the first 1 year of the pandemic.

Methods

This retrospective cross-sectional study utilized COVID-19 data from publicly available data repositories of the African Center for Disease Control and Prevention and Our World in Data for the period February 2020 to January 2021. AU member states were classified into low, medium, and high burdens based on COVID-19 morbidity. We conducted descriptive and inferential analyses of COVID-19-reported cases, deaths, recoveries, active cases, COVID-19 tests, and epidemiological measures that included morbidity and mortality rates, case fatality rate (CFR), and case ratios.

Results

A total of 3.21 million cases were reported during the 1-year period, with 2.6 million recoveries, 536,784 cases remaining active, and 77,486 deaths. Most countries (49.1%, n = 26) in AU experienced a low burden of COVID-19 infection compared to 28.3% (n = 15) with medium burden and 22.6% (n = 12) with high burden. AU nations with a high burden of the disease were mainly in the northern and southern regions. South Africa recorded the highest number of cases (1.31 million), followed by Morocco with 457,625 and Tunisia with 175,065 cases. Correspondently, death tolls for these countries were 36,467, 7888, and 5528 deaths, respectively. Of the total COVID-19 tests performed (83.8 million) during the first 1 year, 62.43% were from high-burden countries. The least testing occurred in the medium-burden (18.42%) countries. The overall CFR of AU was 2.21%. A morbidity rate of 327.52/105 population and mortality rate of 5.96/105 population were recorded during the first 1-year period with significant variations (p < 0.0001) across burden levels. Continental morbidity and mortality rates of 17,359/105 and 315.933/105 populations were recorded with significant correlation (r = 0.863, p < 0.0001) between them and variations across selected epidemiological measures by COVID-19 burden levels.

Conclusion

Understanding the true burden of the disease in AU countries is important for establishing the impact of the pandemic in the African continent and for intervention planning, preparedness, and deployment of resources during COVID-19 surges and future pandemics.

The danger of the single storyline obfuscating the complexities of managing SARS-CoV-2/COVID-19

Chimamanda Ngozi Adichie showed how a single story is limited and thereby distorts the true nature of an issue. During this COVID-19 pandemic there have been, at least, three consecutive single stories-the 'lethal threat' story, followed by the 'economic threat' story, and finally the 'vaccine miracle' story. None of these single stories can convincingly and permanently capture the dynamics of the pandemic. This is because countries experienced different morbidity and mortality patterns, different socioeconomic disadvantage, age and vulnerability of population, timing and level of lockdown with economic variability, and, despite heavy promotion, vaccines were beset with a significant and variable degree of hesitancy. Lack of transparency, coherence and consistency of pandemic management-arising from holding on to single storylines-showed the global deficiency of public health policy and planning, an underfunding of (public) health and social services, and a growing distrust in governments' ability to manage crises effectively. Indeed, the global management has increased already large inequities, and little has been learnt to address the growing crises of more infectious and potentially more lethal virus mutations. Holding onto single stories prevents the necessary learnings to understand and manage the complexities of 'wicked' problems, whereas listening to the many stories provides insights and pathways to do so effectively as well as efficiently.

Segmentation of African Countries based on Infection and Death Rates of COVID-19 before Vaccination: A Rigid Population to Source for Workforce Amidst the Pandemic?

This study established segments among African countries to show the hierarchies of COVID-19 infection and death rates across the continent before the commencement of vaccination. Four clusters were extracted, each consisting of countries with a similar number of cumulative infections and deaths per 100 thousand population. When compared with the pre-vaccination figures from Europe, Americas, and Asia, it was observed that the African population exhibited a good level of rigidity and resilience to the pandemic, pre-vaccination. Majority of African countries - evaluating to 84% - were clustered into the segment with low infection and low death rates. Only 4% of the countries were clustered into the higher infection and highest death rates segment. This is an indication of the rigidity of a greater part of the African population to COVID-19 before vaccination. To forestall total business shutdown in the event of a similar pandemic in the future, multinational corporations could explore their workforce from the African population given the level of rigidity exhibited pre-vaccination.

Does poverty increase COVID-19 in Africa? A cross-country analysis

BACKGROUND

Most economies in African countries are informal. As such, households in these countries tend to face higher levels of informality coupled with a lack of social protection, and have no replacement income or savings in the event of unexpected external shocks, such as COVID-19. Thus, the COVID-19 shock and its negative economic effects triggered a cascade of income losses and bankruptcies that pushed a significant share of households in African countries into poverty. This research analyzes the effect of poverty on the spread of COVID-19 using a sample of 52 African countries.

METHODS

To achieve the objective of this research, this paper uses a multiple linear regression model and a sample of 52 African countries observed in 2020 to conduct a cross-country analysis. More importantly, two COVID-19 indicators (total number of officially reported cases and disease severity) and six poverty indicators (average poverty, poverty incidence, poverty depth, poverty severity, multidimensional poverty index, and extreme poverty) were used in this research.

RESULTS

The results show a positive and significant relationship between poverty and the spread of COVID-19.

CONCLUSIONS

These results suggest that more attention needs to be paid to poor populations in African countries during the pandemic. These populations are generally vulnerable, and there is a need for support programs targeting them to be put in place quickly. These programs may include food aid, distribution of supplies, health care support, fee waivers, and interest deferrals. In addition, sensitization of these disadvantaged groups on vaccination against COVID-19 to achieve herd immunity is strongly encouraged.

Tackling antimicrobial resistance across sub-Saharan Africa: current challenges and implications for the future

INTRODUCTION

Antimicrobial resistance (AMR) is a concern as this increases morbidity, mortality, and costs, with sub-Saharan Africa having the highest rates globally. Concerns with rising AMR have resulted in international, Pan-African, and country activities including the development of national action plans (NAPs). However, there is variable implementation across Africa with key challenges persisting.

AREAS COVERED

Consequently, there is an urgent need to document current NAP activities and challenges across sub-Saharan Africa to provide future guidance. This builds on a narrative review of the literature.

EXPERT OPINION

All surveyed sub-Saharan African countries have developed their NAPs; however, there is variable implementation. Countries including Botswana and Namibia are yet to officially launch their NAPs with Eswatini only recently launching its NAP. Cameroon is further ahead with its NAP than these countries; though there are concerns with implementation. South Africa appears to have made the greatest strides with implementing its NAP including regular monitoring of activities and instigation of antimicrobial stewardship programs. Key challenges remain across Africa. These include available personnel, expertise, capacity, and resources to undertake agreed NAP activities including active surveillance, lack of focal points to drive NAPs, and competing demands and priorities including among donors. These challenges are being addressed, with further co-ordinated efforts needed to reduce AMR.

[Health impact of COVID pandemic. SESPAS Report 2022]

Objetivo

Presentar, a los 22 meses de que la Organización Mundial de la Salud declarara como pandemia la infección global por SARS-CoV-2 el 11 de marzo de 2020, el impacto hasta el momento de la pandemia en términos de salud física y mental.

Método

Se han revisado resultados procedentes de metaanálisis y revisiones sistemáticas, citándose para algún aspecto específico de interés artículos individuales. La información nacional procede de la Red Nacional de Vigilancia Epidemiológica (RENAVE).

Resultados

Hasta finales de octubre se habían producido más de 250 millones de infecciones y 5 millones de muertes. En España se han notificado 4,7 millones de infecciones, aunque la cifra real es superior a los 7 millones. Se ha reducido la esperanza de vida, con efectos especialmente dramáticos en grupos de población con comorbilidad y de edad avanzada. Se constata un empeoramiento de la salud mental general. Es previsible que algunos colectivos, como los/las profesionales sanitarios/as, en su mayoría mujeres, y trabajadores/as de primera línea, tengan un mayor riesgo de desarrollar patologías de salud mental en el futuro. La pandemia y las medidas de control han tenido otras consecuencias indeseables, como la disminución de la actividad asistencial, el aumento del sedentarismo y el aumento de la violencia de género.

Conclusiones

Son necesarios estudios longitudinales para determinar la magnitud de las consecuencias de la propia infección y de las medidas de control y las actuaciones necesarias.

Increased airborne transmission of COVID-19 with new variants, implications for health policies

New COVID-19 variants, either of higher viral load such as delta or higher contagiousness like omicron, can lead to higher airborne transmission than historical strains. This paper highlights their implications for health policies, based on a clear analytical understanding and modeling of the airborne contamination paths, of the dose following exposure, and the importance of the counting unit for pathogens, itself linked to the dose-response law. Using the counting unit of Wells, i.e. the quantum of contagium, we develop the conservation equation of quanta which allows deriving the value of the quantum concentration at steady state for a well-mixed room. The link with the monitoring concentration of carbon dioxide is made and used for a risk analysis of a variety of situations for which we collected CO2 time-series observations. The main conclusions of these observations are that 1) the present norms of ventilation, are both insufficient and not respected, especially in a variety of public premises, leading to high risk of contamination and that 2) air can often be considered well-mixed. Finally, we insist that public health policy in the field of airborne transmission should be based on a multi parameter analysis such as the time of exposure, the quantum production rate, mask wearing and the infector proportion in the population in order to evaluate the risk, considering the whole complexity of dose evaluation. Recognizing airborne transmission requires thinking in terms of time of exposure rather than in terms of proximal distance.

Prospects on Repurposing a Live Attenuated Vaccine for the Control of Unrelated Infections

Live vaccines use attenuated microbes to acquire immunity against pathogens in a safe way. As live attenuated vaccines (LAVs) still maintain infectivity, the vaccination stimulates diverse immune responses by mimicking natural infection. Induction of pathogen-specific antibodies or cell-mediated cytotoxicity provides means of specific protection, but LAV can also elicit unintended off-target effects, termed non-specific effects. Such mechanisms as short-lived genetic interference and non-specific innate immune response or long-lasting trained immunity and heterologous immunity allow LAVs to develop resistance to subsequent microbial infections. Based on their safety and potential for interference, LAVs may be considered as an alternative for immediate mitigation and control of unexpected pandemic outbreaks before pathogen-specific therapeutic and prophylactic measures are deployed.

Empirical study and model simulation of global stock market dynamics during COVID-19

At the beginning of 2020, COVID-19 swept the world and changed various aspects of human society, such as economy and finance, life and health, migration and population. We first empirically study how the dynamic behaviors of stock markets are affected by COVID-19, and focus on the large volatility dynamics, variation-fluctuation correlation function and epidemic-fluctuation correlation function. Then we generalize the Heston model to simulate the global stock market dynamics, and an epidemic index computed from empirical data is directly taken as the external force in the modelling.

Predicting the transmission of SARS-CoV-2 in Africa: the case of Namibia

SARS-CoV-2 transmission models have been fairly inaccurate in their predictions for Africa. Here, based on an analysis of surveillance data from Namibia, we conclude that it is necessary to include spatial demography, and travel, in SARS-CoV-2 transmission models in order to make more accurate predictions for COVID-19 epidemics in Africa.

HIV and COVID-19 co-infection: A mathematical model and optimal control

A new mathematical model for COVID-19 and HIV/AIDS is considered to assess the impact of COVID-19 on HIV dynamics and vice-versa. Investigating the epidemiologic synergy between COVID-19 and HIV is important. The dynamics of the full model is driven by that of its sub-models; therefore, basic analysis of the two sub-models; HIV-only and COVID-19 only is carried out. The basic reproduction number is computed and used to prove local and global asymptotic stability of the sub-models' disease-free and endemic equilibria. Using the fmincon function in the Optimization Toolbox of MATLAB, the model is fitted to real COVID-19 data set from South Africa. The impact of intervention measures, namely, COVID-19 and HIV prevention interventions and COVID-19 treatment are incorporated into the model using time-dependent controls. It is observed that HIV prevention measures can significantly reduce the burden of co-infections with COVID-19, while effective treatment of COVID-19 could reduce co-infections with opportunistic infections such as HIV/AIDS. In particular, the COVID-19 only prevention strategy averted about 10,500 new co-infection cases, with similar number also averted by the HIV-only prevention control.

International examples of primary care COVID-19 preparedness and response: a comparison of four countries

We report the learnings gleaned from a four-country panel (Australia, South Africa, Egypt and Nigeria) sharing their countries' COVID-19 primary healthcare approaches and implementation of policy at the World Organization of Family Doctor's World virtual conference in November. The countries differ considerably with respect to size, national economies, average age, unemployment rates and proportion of people living rurally. South Africa has fared the worst with respect to waves of COVID-19 cases and deaths. All countries introduced strategies such as border closure, COVID-19 testing, physical distancing and face masks. Australia and Nigeria mobilised primary care, but the response was mostly public health and hospital-based in South Africa and Egypt. All countries rapidly adopted telehealth. All countries emphasised the critical importance of an integrated response between primary care and public health to conduct surveillance, diagnose cases through testing, provide community-based care unless hospitalisation is required and vaccinate the population to reduce infection spread.

The Prevalence and Impact of Coinfection and Superinfection on the Severity and Outcome of COVID-19 Infection: An Updated Literature Review

Patients with viral illness are at higher risk of secondary infections—whether bacterial, viral, or parasitic—that usually lead to a worse prognosis. In the setting of Corona Virus Disease 2019 (COVID-19), the Severe Acute Respiratory Syndrome Coronavirus-type 2 (SARS-CoV-2) infection may be preceded by a prior microbial infection or has a concurrent or superinfection. Previous reports documented a significantly higher risk of microbial coinfection in SARS-CoV-2-positive patients. Initial results from the United States (U.S.) and Europe found a significantly higher risk of mortality and severe illness among hospitalized patients with SARS-CoV-2 and bacterial coinfection. However, later studies found contradictory results concerning the impact of coinfection on the outcomes of COVID-19. Thus, we conducted the present literature review to provide updated evidence regarding the prevalence of coinfection and superinfection amongst patients with SARS-CoV-2, possible mechanisms underlying the higher risk of coinfection and superinfection in SARS-CoV-2 patients, and the impact of coinfection and superinfection on the outcomes of patients with COVID-19.

How has academia responded to the urgent needs created by COVID-19? A multi-level global, regional and national analysis

In the context of the COVID-19 pandemic, gaining insights into how academia has responded to this urgent challenge is of great significance. This article presents academic response patterns at a global, regional and national level from an analysis of publication volume versus reported cases of COVID-19, scientific collaboration and research focus. We also compare academic activity associated with this newly emerging infection to that related to long-standing infections. Our results show that the research community has responded quickly to COVID-19. The highly developed countries, which have the highest number of confirmed cases, are also the major academic contributors. National-level analysis reveals diverse response patterns from different countries. Specifically, academic research in the United Kingdom remained at a relatively constant level throughout the whole year (2020), while the global share of China’s research output was prone to shift as its domestic pandemic status changed. Strong alliances have formed among countries with academic capabilities in response to the COVID-19 pandemic. The distribution of disciplines is relatively decentralised, indicating that a diverse and broad knowledge base contributes to the COVID-19 literature. Most of the analysed countries show dynamic patterns of research focus that vary over time as the pandemic evolves, except India. As one of the world’s biggest suppliers of vaccines, India makes consistent efforts on vaccine research, especially those related to pharmaceutical preparations. Our findings may serve as resources for fostering strategies to respond to future threats of pandemics.

Cross-Reactive Antibodies to SARS-CoV-2 and MERS-CoV in Pre-COVID-19 Blood Samples from Sierra Leoneans

Many countries in sub-Saharan Africa have experienced lower COVID-19 caseloads and fewer deaths than countries in other regions worldwide. Under-reporting of cases and a younger population could partly account for these differences, but pre-existing immunity to coronaviruses is another potential factor. Blood samples from Sierra Leonean Lassa fever and Ebola survivors and their contacts collected before the first reported COVID-19 cases were assessed using enzyme-linked immunosorbent assays for the presence of antibodies binding to proteins of coronaviruses that infect humans. Results were compared to COVID-19 subjects and healthy blood donors from the United States. Prior to the pandemic, Sierra Leoneans had more frequent exposures than Americans to coronaviruses with epitopes that cross-react with severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), SARS-CoV, and Middle Eastern respiratory syndrome coronavirus (MERS-CoV). The percentage of Sierra Leoneans with antibodies reacting to seasonal coronaviruses was also higher than for American blood donors. Serological responses to coronaviruses by Sierra Leoneans did not differ by age or sex. Approximately a quarter of Sierra Leonian pre-pandemic blood samples had neutralizing antibodies against SARS-CoV-2 pseudovirus, while about a third neutralized MERS-CoV pseudovirus. Prior exposures to coronaviruses that induce cross-protective immunity may contribute to reduced COVID-19 cases and deaths in Sierra Leone.

High infectious disease burden as a basis for the observed high frequency of asymptomatic SARS-CoV-2 infections in sub-Saharan Africa

Following the coronavirus outbreaks described as severe acute respiratory syndrome (SARS) in 2003 and the Middle East respiratory syndrome (MERS) in 2012, the world has again been challenged by yet another corona virus, named severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). SARS-CoV-2 infections were first detected in a Chinese Province in December 2019 and then declared a pandemic by the World Health Organization in March 2020. An infection caused by SARS-CoV-2 may result in asymptomatic, uncomplicated or fatal coronavirus disease 2019 (COVID-19). Fatal disease has been linked with the uncontrolled "cytokine storm" manifesting with complications mostly in people with underlying cardiovascular and pulmonary disease conditions. The severity of COVID-19 disease and the associated mortality has been disproportionately lower in terms of number of cases and deaths in Africa and also Asia in comparison to Europe and North America. Also, persons of colour residing in Europe and North America have been identified as a highly susceptible population due to a combination of several socioeconomic factors and poor access to quality healthcare. Interestingly, this has not been the case in sub-Saharan Africa where majority of the population are even more deprived of the aforementioned factors. On the contrary, sub-Saharan Africa has recorded the lowest levels of mortality and morbidity associated with the disease, and an overwhelming proportion of infections are asymptomatic. Whilst it can be argued that these lower number of cases in Africa may be due to challenges associated with the diagnosis of the disease such as lack of trained personnel and infrastructure, the number of persons who get infected and develop symptoms is proportionally lower than those who are asymptomatic, including asymptomatic cases that are never diagnosed. This review discusses the most probable reasons for the significantly fewer cases of severe COVID-19 disease and deaths in sub-Saharan Africa.