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      Factors associated with COVID-19 infections and mortality in Africa: a cross-sectional study using publicly available data

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          Abstract

          Introduction

          The current COVID-19 pandemic is a global threat. This elicits questions on the level of preparedness and capacity of health systems to respond to emergencies relative to other parts of the world.

          Methods

          This cross-sectional study uses publicly available core health data for 53 African countries to determine risk factors for cumulative COVID-19 deaths and cases per million in all countries in the continent. Descriptive statistics were determined for the indicators, and a negative binomial regression was used for modelling the risk factors.

          Results

          In sub-Saharan Africa, an increase in the number of nursing and midwifery personnel decreased the risk of COVID-19 deaths (p=0.0178), while a unit increase in universal healthcare (UHC) index of service coverage and prevalence of insufficient physical activity among adults increased the risk of COVID-19 deaths (p=0.0432 and p=0.0127). An increase in the proportion of infants initiating breast feeding reduced the number of cases per million (p<0.0001), while an increase in higher healthy life expectancy at birth increased the number of cases per million (p=0.0340).

          Conclusion

          Despite its limited resources, Africa’s preparedness and response to the COVID-19 pandemic can be improved by identifying and addressing specific gaps in the funding of health services delivery. These gaps impact negatively on service delivery in Africa, which requires more nursing personnel and increased UHC coverage to mitigate the effects of COVID-19.

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          Most cited references17

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          Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

          Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p<0·0001), and d-dimer greater than 1 μg/mL (18·42, 2·64–128·55; p=0·0033) on admission. Median duration of viral shedding was 20·0 days (IQR 17·0–24·0) in survivors, but SARS-CoV-2 was detectable until death in non-survivors. The longest observed duration of viral shedding in survivors was 37 days. Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.
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            COVID-19 and Italy: what next?

            Summary The spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has already taken on pandemic proportions, affecting over 100 countries in a matter of weeks. A global response to prepare health systems worldwide is imperative. Although containment measures in China have reduced new cases by more than 90%, this reduction is not the case elsewhere, and Italy has been particularly affected. There is now grave concern regarding the Italian national health system's capacity to effectively respond to the needs of patients who are infected and require intensive care for SARS-CoV-2 pneumonia. The percentage of patients in intensive care reported daily in Italy between March 1 and March 11, 2020, has consistently been between 9% and 11% of patients who are actively infected. The number of patients infected since Feb 21 in Italy closely follows an exponential trend. If this trend continues for 1 more week, there will be 30 000 infected patients. Intensive care units will then be at maximum capacity; up to 4000 hospital beds will be needed by mid-April, 2020. Our analysis might help political leaders and health authorities to allocate enough resources, including personnel, beds, and intensive care facilities, to manage the situation in the next few days and weeks. If the Italian outbreak follows a similar trend as in Hubei province, China, the number of newly infected patients could start to decrease within 3–4 days, departing from the exponential trend. However, this cannot currently be predicted because of differences between social distancing measures and the capacity to quickly build dedicated facilities in China.
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              The COVID‐19 epidemic

              The current outbreak of the novel coronavirus SARS‐CoV‐2 (coronavirus disease 2019; previously 2019‐nCoV), epi‐centred in Hubei Province of the People’s Republic of China, has spread to many other countries. On 30. January 2020, the WHO Emergency Committee declared a global health emergency based on growing case notification rates at Chinese and international locations. The case detection rate is changing daily and can be tracked in almost real time on the website provided by Johns Hopkins University 1 and other forums. As of midst of February 2020, China bears the large burden of morbidity and mortality, whereas the incidence in other Asian countries, in Europe and North America remains low so far. Coronaviruses are enveloped, positive single‐stranded large RNA viruses that infect humans, but also a wide range of animals. Coronaviruses were first described in 1966 by Tyrell and Bynoe, who cultivated the viruses from patients with common colds 2. Based on their morphology as spherical virions with a core shell and surface projections resembling a solar corona, they were termed coronaviruses (Latin: corona = crown). Four subfamilies, namely alpha‐, beta‐, gamma‐ and delta‐coronaviruses exist. While alpha‐ and beta‐coronaviruses apparently originate from mammals, in particular from bats, gamma‐ and delta‐viruses originate from pigs and birds. The genome size varies between 26 kb and 32 kb. Among the seven subtypes of coronaviruses that can infect humans, the beta‐coronaviruses may cause severe disease and fatalities, whereas alpha‐coronaviruses cause asymptomatic or mildly symptomatic infections. SARS‐CoV‐2 belongs to the B lineage of the beta‐coronaviruses and is closely related to the SARS‐CoV virus 3, 4. The major four structural genes encode the nucleocapsid protein (N), the spike protein (S), a small membrane protein (SM) and the membrane glycoprotein (M) with an additional membrane glycoprotein (HE) occurring in the HCoV‐OC43 and HKU1 beta‐coronaviruses 5. SARS‐CoV‐2 is 96% identical at the whole‐genome level to a bat coronavirus 4. SARS‐CoV‐2 apparently succeeded in making its transition from animals to humans on the Huanan seafood market in Wuhan, China. However, endeavours to identify potential intermediate hosts seem to have been neglected in Wuhan and the exact route of transmission urgently needs to be clarified. The initial clinical sign of the SARS‐CoV‐2‐related disease COVID‐19 which allowed case detection was pneumonia. More recent reports also describe gastrointestinal symptoms and asymptomatic infections, especially among young children 6. Observations so far suggest a mean incubation period of five days 7 and a median incubation period of 3 days (range: 0–24 days) 8. The proportion of individuals infected by SARS‐CoV‐2 who remain asymptomatic throughout the course of infection has not yet been definitely assessed. In symptomatic patients, the clinical manifestations of the disease usually start after less than a week, consisting of fever, cough, nasal congestion, fatigue and other signs of upper respiratory tract infections. The infection can progress to severe disease with dyspnoea and severe chest symptoms corresponding to pneumonia in approximately 75% of patients, as seen by computed tomography on admission 8. Pneumonia mostly occurs in the second or third week of a symptomatic infection. Prominent signs of viral pneumonia include decreased oxygen saturation, blood gas deviations, changes visible through chest X‐rays and other imaging techniques, with ground glass abnormalities, patchy consolidation, alveolar exudates and interlobular involvement, eventually indicating deterioration. Lymphopenia appears to be common, and inflammatory markers (C‐reactive protein and proinflammatory cytokines) are elevated. Recent investigations of 425 confirmed cases demonstrate that the current epidemic may double in the number of affected individuals every seven days and that each patient spreads infection to 2.2 other individuals on average (R0) 6. Estimates from the SARS‐CoV outbreak in 2003 reported an R0 of 3 9. A recent data‐driven analysis from the early phase of the outbreak estimates a mean R0 range from 2.2 to 3.58 10. Dense communities are at particular risk and the most vulnerable region certainly is Africa, due to dense traffic between China and Africa. Very few African countries have sufficient and appropriate diagnostic capacities and obvious challenges exist to handle such outbreaks. Indeed, the virus might soon affect Africa. WHO has identified 13 top‐priority countries (Algeria, Angola, Cote d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Kenya, Mauritius, Nigeria, South Africa, Tanzania, Uganda, Zambia) which either maintain direct links to China or a high volume of travel to China. Recent studies indicate that patients ≥60 years of age are at higher risk than children who might be less likely to become infected or, if so, may show milder symptoms or even asymptomatic infection 7. As of 13. February 2020, the case fatality rate of COVID‐19 infections has been approximately 2.2% (1370/60363; 13. February 2020, 06:53 PM CET); it was 9.6% (774/8096) in the SARS‐CoV epidemic 11 and 34.4% (858/2494) in the MERS‐CoV outbreak since 2012 12. Like other viruses, SARS‐CoV‐2 infects lung alveolar epithelial cells using receptor‐mediated endocytosis via the angiotensin‐converting enzyme II (ACE2) as an entry receptor 4. Artificial intelligence predicts that drugs associated with AP2‐associated protein kinase 1 (AAK1) disrupting these proteins may inhibit viral entry into the target cells 13. Baricitinib, used in the treatment of rheumatoid arthritis, is an AAK1 and Janus kinase inhibitor and suggested for controlling viral replication 13. Moreover, one in vitro and a clinical study indicate that remdesivir, an adenosine analogue that acts as a viral protein inhibitor, has improved the condition in one patient 14, 15. Chloroquine, by increasing the endosomal pH required for virus‐cell fusion, has the potential of blocking viral infection 15 and was shown to affect activation of p38 mitogen‐activated protein kinase (MAPK), which is involved in replication of HCoV‐229E 16. A combination of the antiretroviral drugs lopinavir and ritonavir significantly improved the clinical condition of SARS‐CoV patients 17 and might be an option in COVID‐19 infections. Further possibilities include leronlimab, a humanised monoclonal antibody (CCR5 antagonist), and galidesivir, a nucleoside RNA polymerase inhibitor, both of which have shown survival benefits in several deadly virus infections and are being considered as potential treatment candidates 18. Repurposing these available drugs for immediate use in treatment in SARS‐CoV‐2 infections could improve the currently available clinical management. Clinical trials presently registered at ClinicalTrials.gov focus on the efficacy of remdesivir, immunoglobulins, arbidol hydrochloride combined with interferon atomisation, ASC09F+Oseltamivir, ritonavir plus oseltamivir, lopinavir plus ritonavir, mesenchymal stem cell treatment, darunavir plus cobicistat, hydroxychloroquine, methylprednisolone and washed microbiota transplantation 19. Given the fragile health systems in most sub‐Saharan African countries, new and re‐emerging disease outbreaks such as the current COVID‐19 epidemic can potentially paralyse health systems at the expense of primary healthcare requirements. The impact of the Ebola epidemic on the economy and healthcare structures is still felt five years later in those countries which were affected. Effective outbreak responses and preparedness during emergencies of such magnitude are challenging across African and other lower‐middle‐income countries. Such situations can partly only be mitigated by supporting existing regional and sub‐Saharan African health structures.
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                Author and article information

                Journal
                BMJ Open
                BMJ Open
                bmjopen
                bmjopen
                BMJ Open
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2044-6055
                2020
                11 November 2020
                : 10
                : 11
                : e042750
                Affiliations
                [1 ]departmentSchool of Economics and Finance , Faculty of Commerce, University of the Witwatersrand , Johannesburg, South Africa
                [2 ]departmentSchool of Public Health , Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
                [3 ]departmentPerinatal HIV Research Unit , Faculty of Health Sciences, University of the Witwatersrand , Johannesburg, South Africa
                Author notes
                [Correspondence to ] Dr Kennedy Otwombe; otwombeK@ 123456phru.co.za
                Author information
                http://orcid.org/0000-0002-7433-4383
                Article
                bmjopen-2020-042750
                10.1136/bmjopen-2020-042750
                7661348
                33177146
                b231c5c3-839d-4d06-972a-b5ca933996de
                © Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

                This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:  http://creativecommons.org/licenses/by-nc/4.0/.

                History
                : 18 July 2020
                : 07 October 2020
                : 12 October 2020
                Categories
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                Medicine
                covid-19,epidemiology,public health,statistics & research methods
                Medicine
                covid-19, epidemiology, public health, statistics & research methods

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