Covid-19 deaths in Africa: prospective systematic postmortem surveillance study
BMJ 2021; 372 doi: https://doi.org/10.1136/bmj.n334 (Published 17 February 2021) Cite this as: BMJ 2021;372:n334Linked Editorial
Covid-19 in Africa
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Dear Editor
It came as no surprise to us, when reading in the BMJ on 17 February that a Zambia post mortem detected on PCR testing that 16% of deaths were due to Covid-19; or that none of those dying in the community with pneumonia had been tested for Covid-19 prior to death.
Our Covid-19 and noncommunicable disease research project experience is from a large state in Nigeria of 4 million people with only two functional testing sites, and an entire country (Sierra Leone) with one Covid-19 PCR testing site. To date Nigeria has detected only around 2,000 Covid-19 deaths from its population of over 200 million. This is despite the expansion of testing capability to include 70 public and 36 private laboratories nationwide at the end of January 2021 [1]. While Sierra Leone has only reported 2,000 cases and 80 deaths [2].
The extremely low death rates attributable to Covid-19 in these countries are likely to represent a gross underestimation of the impact of Covid-19 due to low Covid-19 testing levels.
Why are so few people in Africa being tested or diagnosed with Covid-19? Our research (NIHR RUHF) suggests that people with coronavirus symptoms are not attending healthcare facilities, are being missed, not tested and assumed to be other causes. Despite good pre/post training results, there is limited use of our primary care Covid-19 guides in Sierra Leone and Nigeria. We have been understanding more about ‘why not’.
Post Ebola, and now Covid-19, patients feared to attend health facilities. Health workers lacked supplies of PPE. There are no guidelines for outpatient consultation of fever or upper respiratory infections in the context of Covid-19. We have prepared guides and training and made them available free for health workers online [3], however most health workers have still not had any guidelines or training.
Generally, from our experience, fever is assumed to be malaria, and people with coughs are given antibiotics. Covid-19 is not considered, few are referred for testing, and fewer still go to isolation and testing sites due to the fear, likely stigma and costs of travel. Added to this is widespread lack of social distancing, use of face masks and hand hygiene practice. Few tests have been done and so few cases reported, denial has set in. Yet, as in Zambia, there is likely to be mass community (and health worker) transmission of Covid-19. Possibly with the South African new variant, we do not know. Meanwhile myths on Covid-19 and vaccination are rampant in social media [4]. Vaccine supplies are presently on-going from the WHO COVAX initiative, but there are concerns about a low uptake of vaccination in Africa due to false conspiracy theories surrounding the vaccine.
Is it too late to invest resources into primary healthcare facility infection prevention and control (IPC), case finding and on-site Covid-19 testing and community education in Africa? We think this remains critical, also as a foundation for decision-making on future priorities in managing the Covid-19 epidemic and its successors.
Competing interests: No competing interests
Dear Editor
Rebuttal: Covid-19 deaths in Africa: prospective systematic postmortem surveillance study.
We refer to an article entitled, “Covid-19 deaths in Africa: prospective systematic postmortem surveillance study, that was published on 17th February 2021, in the British Medical Journal.1 We have made the following observations and wish to make a rebuttal to the said article for your consideration:
Firstly, the title of the article, “Covid-19 deaths in Africa: prospective systematic post-mortem surveillance study” is an over-statement because this was done in one country; one city; and one hospital with a limited catchment area; this study was not designed to be representative of the entire population of Lusaka, nor Zambia, let alone the Southern Africa region or the continent at large. The study site and study population is not well defined in this article; Lusaka city has another tertiary hospital, the Levy Mwanawasa University Teaching Hospital (LMUTH), which caters for a large part of the catchment area of the city. The LMUTH is the main COVID-19 Centre in Lusaka.2 Lusaka is divided into 6 sub-districts; each of these managing COVID-19 cases. In this case, the University Teaching Hospital (UTH) cannot be the hospital to represent the Lusaka population, let alone Zambia nor indeed Africa. On the other hand, this study can never be generalizable to Zambia and indeed to Africa, one cannot assume homogeneity for COVID-19 in Africa. To state as such is a misinterpretation of facts to fit a narrative that seems to be predetermined and with no due regard to implications.
Secondly, the authors have inaccurately stated that there is a widely held narrative asserting that COVID-19 has “largely skipped Africa and had little impact” or that “COVID-19 has spared Africa.” However, the cited articles have not categorically implied that COVID-19 skipped Africa but rather have clearly indicated and given possible explanations for the reasons Africa has been reporting fewer cases.3-5 This study does not prove otherwise. As opposed to COVID-19 skipping Africa, the issue has been that the continent has not observed as many deaths as was predicted by a number of models at the start of the pandemic.6,7 A lot of speculations and expert opinions have been put forward which need to be fully investigated 3-8. This paper, based on the data presented, does not address the impact of COVID-19 in Zambia nor Africa.
Thirdly, the authors state that “We postulate a more mundane explanation for the Africa paradox: insufficient data.” However, the efforts that Africa has made to strengthen disease surveillance through the World Health Organization (WHO) facilitated Integrated Disease Surveillance and Response (IDSR), the World Health Emergency Programme (WHE) and the Africa CDC must be acknowledged. It is undeniable that a lot has been done to improve surveillance systems across the continent.9-11 The authors should have acknowledged this fact and clearly stated so in the article.
Fourthly, all deaths occurring in the health facilities were being swabbed for SARS-CoV-2 as part of surveillance activities by Ministry of Health (MOH)/ Zambia National Public Health Institute (ZNPHI).2 The authorsseem not to have checked whether surveillance data was collected from the facilities; it must be noted that routine surveillance data is not entered on the medical charts but is rather entered separately. In this case to indicate that surveillance data was not collected is inaccurate. The authors ignored existing systems and context for the COVID-19 response in Zambia or did not undertake data collection as appropriate. The finding that none of the “community deaths” they swabbed from the UTH morgue were captured by the surveillance system for COVID-19 under MOH/ZNPHI is difficult to understand; this is so because during the time of this study all deaths that were occurring in the communities and brought to the health facilities as “brought-in-dead” (BIDs) bodies were being swabbed for SARS-CoV-2, in accordance with the MOH/ZNPHI guidelines.2,12
Lastly, the authors should have cited and referenced the assumption on the Malaria situation in Lusaka concerning it being eliminated. Our understanding is that malaria has not been eliminated in Lusaka.
We would like to state that this study does not provide evidence of increased severity of disease and deaths than what Zambia has been reporting within the acknowledged limitations. Severe disease and deaths are observed in all age groups across world regions, although treatment outcomes may be better in high income countries than in low income countries.13 Africa has acknowledged the impact of COVID-19 and through the Africa CDC and WHO has committed to mobilizing resources to ensure effective and affordable vaccines are made available to its citizens as outlined in the Communiqué from the Conference on Africa’s Leadership on COVID-19 Vaccine Development and Access held on 24th to 25th June 2020.14
We wish to fully support the observations made by Mucheleng'anga and Himwaze in their letter to the editor of the BMJ.12
During the dissemination to the Ministry of Health, all the issues raised in this rebuttal were brought to the attention of the CO-PI.
Key issues of concern that we have raised are that this study was biased and the sample size was not adequate to allow for the interpretation of the data as presented in the article that was published. This creates a lack of respect for science when it is needed to inform policy makers.
References
1. Mwananyanda L, Gill JC, Macleod W et al. Covid-19 deaths in Africa: prospective systematic post-mortem surveillance study. BMJ 2021;372: n334 http://dx.doi.org/10.1136/bmj.n334
2. Ministry of health, 2020. COVID-19 Pandemic: Zambia Response - https://echo.unm.edu/doc/covid/edited_Zambia_COVID-19_Response_AFRO.SF.pdf
3. Bamgboye EL, Omiye JA, Afolaranmi OJ, et al. COVID-19 Pandemic: Is Africa Different? J Natl Med Assoc 2020;S0027-9684(20)30345-X.
4. Lawal Y. Africa’s low COVID-19 mortality rate: A paradox?Int J Infect Dis 2021;102:118-22. doi:10.1016/j.ijid.2020.10.038
5. Twahirwa Rwema JO, Diouf D, Phaswana-Mafuya N, et al. COVID-19 Across Africa: Epidemiologic Heterogeneity and Necessity of Contextually Relevant Transmission Models and Intervention Strategies. Ann Intern Med 2020;173:752-3. doi:10.7326/M20-2628
6. Economic Commission for Africa. Addis Ababa, Ethiopia, author. Covid-19 in Africa: Protecting lives and economies. 2020. [April 20th, 2020]. from: http//:www.npr.org/sections/coronavirus.
7. Berhan Y. Will Africa be Devastated by Covid-19 as Many Predicted? Perspective and Prospective. Ethiop J Health Sci. 2020 May; 30(3): 459–467
8. Njenga MK, Dawa J, Nanyingi M et al. Why is There Low Morbidity and Mortality of COVID-19 in Africa? Am. J. Trop. Med. Hyg., 103(2), 2020, pp. 564–569 doi:10.4269/ajtmh.20-0474
9. Rosenthal JP, Breman GJ, Djimde AA et al. COVID-19: Shining the Light on Africa. Am. J. Trop. Med. Hyg., 102(6), 2020, pp. 1145–1148
10. Chersich FM, Gray G, Fairlie L et al. COVID-19 in Africa: care and protection for frontline healthcare workers. Globalization and Health (2020) 16:46 https://doi.org/10.1186/s12992-020-00574-3
11. Ihekweazu C and Agogo E. Africa’s response to COVID-19. BMC Medicine (2020) 18:151. https://doi.org/10.1186/s12916-020-01622-w
12. Mucheleng'anga AL and Himwaze MC. Rapid response to: Covid-19 deaths in Africa: prospective systematic postmortem surveillance study. BMJ 2021;372: n334; doi: https://doi.org/10.1136/bmj.n334
13. Chauvin JP, Fowler A and Herrera LN. The Younger Age Profile of COVID-19 Deaths in Developing Countries. Inter-American Development Bank, doi http://dx.doi.org/10.18235/000287
14. Africa CDC, Addis Ababa, Ethiopia. Available on https://africacdc.org/news-item/covid-19-vaccine-development-and-access-...
Competing interests: No competing interests
Dear Editor
Rapid response to “Covid-19 deaths in Africa: prospective systematic postmortem surveillance study”.
The British Medical Journal (BMJ), on 17th February 2021, published a paper titled “Covid-19 deaths in Africa: prospective systematic postmortem surveillance study,” which concluded that cases of covid-19 were under-reported because testing was rarely done and that if their data were generalizable, the impact of covid-19 in Africa had been vastly underestimated. These conclusions are highly questionable because all the study participants in the paper were enrolled within a period where all deaths were swabbed and tested at the University Teaching Hospital (UTH) mortuary [appendixes 1, 6-13].
As background, in April 2020, the Zambia National Public Health Institute initiated the Covid-19 Facility Active Screening and Mortality Surveillance in community deaths. This was first conducted at the UTH mortuary in Lusaka [appendix 1] and later scaled-up to include selected mortuaries around the country [appendix 2-4]. Data in the UTH mortuary show that between April 2020 and February 2021, 3562 deaths were tested for covid-19. Thus mortality and disease surveillance has remained an important component of the covid-19 fight in Zambia [1].
We observe that the paper title is misleading and inaccurate because the study subjects were drawn from Lusaka, Zambia, a country in sub-Saharan Africa. We are concerned as to why the authors conclude that a study sampling three hundred and seventy covid deaths in Lusaka would represent a general picture of all African cities. Sub-Saharan cities are different from North African ones, and their diversity is difficult to conceptualise [2]. This title is sensationalist and alarmist to the scientific community in general.
We submit in retrospect that the title should have read "Covid-19 deaths in Lusaka: prospective systematic postmortem surveillance study".
We observe that the introduction of the paper does not provide the reader with background information or a theoretical context on the fatal impact of covid-19 in an urban African population. The rationale of the study is challenging to deduce, and neither is the objective stated. We note that the main purpose of an introduction is to describe the study's importance by providing a rationale behind the design used to accomplish the stated objective [3].
The objective set out was to directly measure the fatal impact of coronavirus disease 2019 (Covid-19) in an urban African population. We observe that to achieve this objective, this study should have tabulated the number of deaths in the previous years before the covid-19 pandemic and the number of deaths during the pandemic. The authors further assume that not testing people in the community before they died was undoubtedly an important factor in underestimating the impact of Covid-19 in Lusaka. We argue that the fatal impact of covid-19 in Lusaka was not underestimated as community deaths were all tested by the surveillance team. So the policy-makers had a real picture of the burden of covid-19 at the time [4].
The methodology does not spell out how the study would measure the fatal impact of the covid-19, which is the object of the study. We categorically state that the authors have not measured the fatal impact of covid-19 in this study based on their methods as this study does not answer its objective. The authors, instead, enumerated deaths that had a positive test on PCR.
The authors got carried away writing about Zambia's economy. We are at pains to understand how this strengthens their objective. This piece of information may be irrelevant and misplaced to the study's title and object.
The authors mislead the scientific community by stating that health facilities may issue death certificates legally required to inter a body. To inter a body, one would require either a Medical Certification of the Cause of Death, Brought-in-Dead Certificate or a Coroners' Authority for Burial [appendix 14-17]. Issuance of a DC is the responsibility of the Registrar-General at the Ministry of Home Affairs [5, 6, 7]. We are concerned that this misrepresentation of the process may be cited as the correct process of obtaining a burial permit, given the journal's authoritative nature (The BMJ). We, therefore, urge the authors to correct this anomaly.
The authors state that the study enrolled community deaths, but we observe no violent deaths (homicides, suicides, accidents) in the results. We note that sampling natural deaths from the community is not representative of all community deaths, and hence positivity rate in this study is biased towards the natural causes.
The authors should have declared clearly that they are testing deaths that seemingly had a natural cause. Of note, the ZPRIME protocol is biased towards respiratory symptoms. The authors observed a high prevalence of mortality related to covid-19 because the study subjects were pooled from natural causes only. This in itself may denote a confirmation bias.
The authors used an abbreviated verbal autopsy tool to identify underlying risk factor comorbidities. We are concerned that this is mere hearsay with no scientific proof based on testing or examination. There was no effort to collaborate what was said by the informant and what was present in the deceased person. Were tuberculosis, hypertension, HIV/AIDS, alcohol misuse, and diabetes tested for postmortem? We do not observe this in the methodology.
The authors state that they were surprised to observe covid-19 deaths in children and further assume that it is a distinct feature of the presentation of covid-19 in Africa. There was no effort to validate the cause of deaths in these children. The study lost potential key information about the real mechanisms underlying deaths as verbal autopsies and PCR testing do not allow an extensive evaluation of the disease. This may even be overestimated given that the precise cause of death remains elusive [1, 8, 9].
The study has failed based on its methods to measure the fatal impact of covid-19 in Africa. We are confident that our concerns and observations will be taken into account by your highly revered editorial team.
Competing interests: No competing Interests
Reference
[1] Luchenga Mucheleng’anga, Cordilia Himwaze, The role of forensic pathology in the COVID-19 pandemic in Zambia, Forensic Science International: Reports, Volume 2,
2020, 100147, ISSN 2665-9107, https://doi.org/10.1016/j.fsir.2020.100147.
[2] Open edition journals, African Cities and the Development Conundrum
Actors and Agency in the Urban Grey Zone, https://journals.openedition.org/poldev/262. Retrieved on 25/02/2021 at 22:19 hours.
[3] Koehler, Steven A. Forensic Epidemiology (International Forensic Science and Investigation) (p. 249). Taylor and Francis CRC ebook account. Kindle Edition.
[4] Ministry of Health Zambia is at Ministry Of Health - Ndeke House,Lusaka, https://web.facebook.com/mohzambia. Retrieved on 25/02/2021 at 20:01 hours.
[5] The births and deaths registration act, chapter 51 of the laws of Zambia, http://www.parliament.gov.zm/sites/default/files/documents/acts/Births%2.... Retrieved on 27/02/2021 at 11:04 hours.
[6] Zambia-National-Strategic-Action-Plan-for-CRVS, http://www.crvs-dgb.org/wp-content/uploads/2015/11/Zambia-National-Strat.... Retrieved on 27/02/2021 at 11:10 hours.
[7] The inquests act chapter 36 of the laws of Zambia, http://www.parliament.gov.zm/sites/default/files/documents/acts/Inquests.... Retrieved on 27/02/2021 at 11:13 hours.
[8] Murray, C.J., Lopez, A.D., Black, R. et al. Population Health Metrics Research Consortium gold standard verbal autopsy validation study: design, implementation, and development of analysis datasets. Popul Health Metrics 9, 27 (2011) doi:10.1186/1478-7954-9-27
[9] Salerno M, Sessa F, Piscopo A et al (2020) No autopsies on COVID-19 deaths: a missed opportunity and the lockdown of science. J Clin Med 9. https://doi.org/10.3390/jcm9051472
APPENDICES (https://drive.google.com/drive/folders/1ENXRLJ8qR6t6HfRpm8RXBnU_CtCn1vCu...)
Competing interests: No competing interests
Dear Editor
While part of the world has already begun to vaccinate, Cuba waits for Soberana 01, Soberana 02, Mambisa or Abdala. The island's four vaccine candidates against COVID-19 are developed as subunit vaccines, one of the most economical approaches and the type for which Cuba has the greatest know-how and infrastructure. From protein S - the antigen or part of the SARS-CoV2 virus that all COVID vaccines target because it induces the strongest immune response in humans - Cuban candidates are based only on the part that is involved in contact with the cell's receptor: the RBD (receptor-binding domain) which is also the one that induces the greatest amount of neutralizing antibodies.
This strategy is not exclusive to Cuban vaccines. But Soberana 02 does distinguish itself from the rest of the world's candidates as the only “conjugate vaccine”. Currently in phase III clinical trials, it combines RBD with tetanus toxoid, which enhances the immune response. Apparently, with positive and early results, which have put it at the forefront of the Cuban race for the vaccine.
Cuba had already developed another vaccine with this principle. It is Cheimi-Hib, "the first of its kind to be approved in Latin America and the second in the world", against haemophilus influenzae type b, coccobacilli responsible for diseases such as meningitis, pneumonia and epiglottitis.
Competing interests: No competing interests
Health intervention began in Havana with vaccine candidate Abdala.
Dear Editor
Another 473 clinical sites in this capital join the health intervention in risk groups and territories with the vaccine candidate Abdala, the health intervention also began in ambulatory and psychiatric centers.
At the same time, the administration of the second dose of this immunogen, developed by the Center for Genetic Engineering and Biotechnology in East Havana, San Miguel del Padrón, Guanabacoa and Regla, continues, where 98 percent of the planned people were treated.
The objective is by the end of August to have vaccinated the entire population of the capital, except for those who do not meet the inclusion requirements.
The first dose in the case of the municipalities incorporated this Saturday must be administered within a period of between 10 and 12 days, and it is expected to immunize more than 378,000 people there.
Abdala is being applied to those over 19 years of age and with no age limit, and those with exclusion criteria are not vaccinated, associated with the presence of other chronic and decompensated diseases, allergic to thimerosal, pregnancy, oncological neoplastic diseases under treatment and infections requiring antibiotics, among other issues.
While this is happening, the pertinent authorities follow up on the evaluation and certification of the rest of the Havana municipalities where the vaccine candidate Soberana 02, from the Finlay Vaccine Institute, will be introduced, also in the form of a sanitary intervention.
Kind regards
Competing interests: No competing interests