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

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          Abstract

          Background

          The coronavirus disease 2019 (COVID-19) has emerged as a global health and economic security threat with staggering cumulative incidence worldwide. Given the severity of projections, hospitals across the globe are creating additional critical care surge capacity and limiting patient routine access to care for other diseases like tuberculosis (TB). The outbreak fuels panic in sub-Saharan Africa where the healthcare system is fragile in withstanding the disease. Here, we looked over the COVID-19 containment measures in Ethiopia in context from reliable sources and put forth recommendations that leverage the health system response to COVID-19 and TB.

          Main text

          Ethiopia shares a major proportion of the global burden of infectious diseases, while the patterns of COVID-19 are still at an earlier stage of the epidemiology curve. The Ethiopian government exerted tremendous efforts to curb the disease. It limited public gatherings, ordered school closures, directed high-risk civil servants to work from home, and closed borders. It suspended flights to 120 countries and restricted mass transports. It declared a five-month national state of emergency and granted a pardon for 20 402 prisoners. It officially postponed parliamentary and presidential elections. It launched the ‘PM Abiy-Jack Ma initiative’, which supports African countries with COVID-19 diagnostics and infection prevention and control commodities. It expanded its COVID-19 testing capacity to 38 countrywide laboratories. Many institutions are made available to provide clinical care and quarantine. However, the outbreak still has the potential for greater loss of life in Ethiopia if the community is unable to shape the regular behavioral and sociocultural norms that would facilitate the spread of the disease. The government needs to keep cautious that irregular migrants would fuel the disease. A robust testing capacity is needed to figure out the actual status of the disease. The pandemic has reduced TB care and research activities significantly and these need due attention.

          Conclusions

          Ethiopia took several steps to detect, manage, and control COVID-19. More efforts are needed to increase testing capacity and bring about behavioral changes in the community. The country needs to put in place alternative options to mitigate interruptions of essential healthcare services and scientific researches of significant impact.

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          Most cited references12

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          Anticipating the impact of the COVID-19 pandemic on TB patients and TB control programmes

          The COVID-19 pandemic has currently overtaken every other health issue throughout the world. There are numerous ways in which this will impact existing public health issues. Here we reflect on the interactions between COVID-19 and tuberculosis (TB), which still ranks as the leading cause of death from a single infectious disease globally. There may be grave consequences for existing and undiagnosed TB patients globally, particularly in low and middle income countries (LMICs) where TB is endemic and health services poorly equipped. TB control programmes will be strained due to diversion of resources, and an inevitable loss of health system focus, such that some activities cannot or will not be prioritised. This is likely to lead to a reduction in quality of TB care and worse outcomes. Further, TB patients often have underlying co-morbidities and lung damage that may make them prone to more severe COVID-19. The symptoms of TB and COVID-19 can be similar, with for example cough and fever. Not only can this create diagnostic confusion, but it could worsen the stigmatization of TB patients especially in LMICs, given the fear of COVID-19. Children with TB are a vulnerable group especially likely to suffer as part of the “collateral damage”. There will be a confounding of symptoms and epidemiological data through co-infection, as happens already with TB–HIV, and this will require unpicking. Lessons for COVID-19 could be learned from the vast experience of running global TB control programmes, while the astonishingly rapid and relatively well co-ordinated response to COVID-19 demonstrates how existing programmes could be significantly improved.
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            What does the COVID-19 pandemic mean for HIV, tuberculosis, and malaria control?

            Despite its current relatively low global share of cases and deaths in Africa compared to other regions, coronavirus disease 2019 (COVID-19) has the potential to trigger other larger crises in the region. This is due to the vulnerability of health and economic systems, coupled with the high burden of human immunodeficiency virus (HIV), tuberculosis (TB), and malaria. Here we examine the potential implications of COVID-19 on the control of these major epidemic diseases in Africa. We use current evidence on disease burden of HIV, TB, and malaria, and epidemic dynamics of COVID-19 in Africa, retrieved from the literature. Our analysis shows that the current measures to control COVID-19 neglect important and complex context-specific epidemiological, social, and economic realities in Africa. There is a similarity of clinical features of TB and malaria, with those used to track COVID-19 cases. This coupled with institutional mistrust and misinformation might result in many patients with clinical features similar to those of COVID-19 being hesitant to voluntarily seek care in a formal health facility. Furthermore, most people in productive age in Africa work in the informal sector, and most of those in the formal sector are underemployed. With the current measures to control COVID-19, these populations might face unprecedented difficulties to access essential services, mainly due to reduced ability of patients to support direct and indirect medical costs, and unavailability of transportation means to reach health facilities. Therefore, if not accompanied with appropriate economic and epidemiological considerations, we anticipate that these measures might result in unprecedented difficulties among vulnerable segments of society to access essential services, including antiretroviral and prophylactic drugs among people living with HIV and Acquired Immune Deficiency Syndrome, anti-tuberculosis drugs, and curative and preventive treatments for malaria among pregnant women and children. This might increase the propensity of patients taking substandard doses and/or medicines, which has the potential to compromise drug efficacy, and worsen health inequalities in the region. COVID-19 responses at country level should include measures to protect vulnerable and under-served segments of society.
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              Estimation of exponential growth rate and basic reproduction number of the coronavirus disease 2019 (COVID-19) in Africa

              Background Since the first case of coronavirus disease 2019 (COVID-19) in Africa was detected on February 14, 2020, the cumulative confirmations reached 15 207 including 831 deaths by April 13, 2020. Africa has been described as one of the most vulnerable region with the COVID-19 infection during the initial phase of the outbreak, due to the fact that Africa is a great commercial partner of China and some other EU and American countries. Which result in large volume of travels by traders to the region more frequently and causing African countries face even bigger health threat during the COVID-19 pandemic. Furthermore, the fact that the control and management of COVID-19 pandemic rely heavily on a country’s health care system, and on average Africa has poor health care system which make it more vulnerable indicating a need for timely intervention to curtail the spread. In this paper, we estimate the exponential growth rate and basic reproduction number (R 0) of COVID-19 in Africa to show the potential of the virus to spread, and reveal the importance of sustaining stringent health measures to control the disease in Africa. Methods We analyzed the initial phase of the epidemic of COVID-19 in Africa between 1 March and 13 April 2020, by using the simple exponential growth model. We examined the publicly available materials published by the WHO situation report to show the potential of COVID-19 to spread without sustaining strict health measures. The Poisson likelihood framework is adopted for data fitting and parameter estimation. We modelled the distribution of COVID-19 generation interval (GI) as Gamma distributions with a mean of 4.7 days and standard deviation of 2.9 days estimated from previous work, and compute the basic reproduction number. Results We estimated the exponential growth rate as 0.22 per day (95% CI: 0.20–0.24), and the basic reproduction number, R 0, as 2.37 (95% CI: 2.22–2.51) based on the assumption that the exponential growth starting from 1 March 2020. With an R 0 at 2.37, we quantified the instantaneous transmissibility of the outbreak by the time-varying effective reproductive number to show the potential of COVID-19 to spread across African region. Conclusions The initial growth of COVID-19 cases in Africa was rapid and showed large variations across countries. Our estimates should be useful in preparedness planning against further spread of the COVID-19 epidemic in Africa.
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                Author and article information

                Contributors
                hus.aliya@gmail.com
                Journal
                Infect Dis Poverty
                Infect Dis Poverty
                Infectious Diseases of Poverty
                BioMed Central (London )
                2095-5162
                2049-9957
                16 September 2020
                16 September 2020
                2020
                : 9
                : 131
                Affiliations
                [1 ]GRID grid.7123.7, ISNI 0000 0001 1250 5688, Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), ; P.O Box 9086, Addis Ababa, Ethiopia
                [2 ]GRID grid.449080.1, ISNI 0000 0004 0455 6591, Department of Public Health, College of Medicine and Health Sciences, , Dire Dawa University, ; Dire Dawa, Ethiopia
                [3 ]GRID grid.192267.9, ISNI 0000 0001 0108 7468, School of Public Health, College of Health and Medical Sciences, Haramaya University, ; Harar, Ethiopia
                [4 ]GRID grid.192267.9, ISNI 0000 0001 0108 7468, School of Nursing and Midwifery, College of Health and Medical Sciences, Haramaya University, ; Harar, Ethiopia
                [5 ]Ohio State Global One Health Initiative, Office of International Affairs, The Ohio State University, Addis Ababa, Ethiopia
                [6 ]GRID grid.414601.6, ISNI 0000 0000 8853 076X, Global Health and Infection Department, , Brighton and Sussex Medical School, ; Brighton, UK
                Author information
                http://orcid.org/0000-0003-0625-627X
                http://orcid.org/0000-0002-8360-7574
                Article
                753
                10.1186/s40249-020-00753-9
                7492795
                31996251
                ec8ccf01-42d7-48f8-a24d-d62af5dc2ba0
                © The Author(s) 2020

                Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

                History
                : 18 May 2020
                : 8 September 2020
                Funding
                Funded by: FundRef http://dx.doi.org/10.13039/501100001713, European and Developing Countries Clinical Trials Partnership;
                Award ID: CSA2016S-1608
                Funded by: FundRef http://dx.doi.org/10.13039/100000061, Fogarty International Center;
                Award ID: D43TW009127
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                © The Author(s) 2020

                covid-19,coronavirus,public health,tuberculosis,containment,ethiopia

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