The impact of the pandemic in Africa may be vastly underestimated, with 15-20% of deaths sampled in a Zambian post-mortem study linked to COVID-19 and the deaths across a wider age spectrum than reported elsewhere, including an unexpectedly high number of children.
Outside of South Africa, this is the first study to provide systematic surveillance data capturing the impact of COVID-19 in Africa.
Their findings, published in The BMJ, are based on polymerase chain reaction (PCR) test results for 364 deceased people of all ages at the University Teaching Hospital morgue in Lusaka, Zambia between June and September 2020, enrolled within 48 hours of death.
The findings show that COVID-19 deaths accounted for 15-20% of all sampled deaths – much more than official reports suggest and contradicting the widely held view that COVID-19 has largely skipped Africa and had little impact.
They also show that COVID-19 deaths occurred across a wider age spectrum than reported elsewhere and were concentrated among people aged under 65, including an unexpectedly high number of deaths in children.
The absence of data on COVID-19 in Africa has fostered a widely held view that the virus has largely skipped Africa and had little impact. However, this may be an example of the “absence of evidence” being widely misconstrued as “evidence of absence.”
To address this evidence gap, a team of international researchers set out to measure the fatal impact of COVID-19 in an urban African population.
Deaths were stratified by COVID-19 status, location, age, sex, and underlying risk factors. Overall, the virus was detected in 70 (19%) of people. The average age at death was 48 years and 70% were men.
Most deaths in people with covid-19 (73%) occurred in the community and none had been tested for the virus before death. Among the 19 people who died in hospital, six were tested before death.
Among the 52 people with data on symptoms, 44 had typical symptoms of COVID-19 (cough, fever, shortness of breath), of whom only five were tested before death.
COVID-19 was identified in seven children, only one of whom had been tested before death.
The proportion of deaths with covid-19 increased with age, but 76% of people who died were aged under 60 years.
The five most common underlying conditions (comorbidities) among people who died with COVID-19 were tuberculosis (31%), high blood pressure (27%), HIV/Aids (23%), alcohol misuse (17%), and diabetes (13%).
Understanding the true extent of COVID-19’s impact on Africa is critical, say the researchers. Not only is there a moral imperative that the world acknowledges suffering wherever it exists, if Africa is seen as posing little threat, this could put it at a lower priority for access to COVID-19 vaccines.
This is an observational study using data from one city, in one African country, over a short three-month span, and the researchers point to several limitations, such as relying on the accuracy of medical chart data and being unable to identify deaths indirectly due to COVID-19, such as from heart attacks or strokes.
However, this was a well-designed study, carried out by researchers with a high level of experience in post-mortem sampling and data collection, which minimised the potential for false positive results.
As such, the authors say that contrary to expectations, COVID-19 deaths were common in Lusaka, and the majority occurred in the community where testing capacity is lacking.
Yet few who died at health facilities were tested, despite presenting with typical symptoms of COVID-19. Therefore, COVID-19 cases were under reported because testing was rarely done, not because CV19 was rare, they explain.
If these data are generalisable, the impact of COVID-19 in Africa has been vastly underestimated, they conclude.
COVID-19 deaths in Africa: prospective systematic post-mortem surveillance study
Lawrence Mwananyanda, Christopher J Gill, William MacLeod, Geoffrey Kwenda, Rachel Pieciak, Zachariah Mupila, Rotem Lapidot, Francis Mupeta, Leah Forman, Luunga Ziko, Lauren Etter, Donald Thea
Published in BMJ on 17 February 2021
To directly measure the fatal impact of coronavirus disease 2019 (covid-19) in an urban African population.
Prospective systematic postmortem surveillance study.
Zambia’s largest tertiary care referral hospital.
Deceased people of all ages at the University Teaching Hospital morgue in Lusaka, Zambia, enrolled within 48 hours of death.
Main outcome measure
Postmortem nasopharyngeal swabs were tested via reverse transcriptase quantitative polymerase chain reaction (PCR) against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Deaths were stratified by covis-19 status, location, age, sex, and underlying risk factors.
372 participants were enrolled between June and September 2020; PCR results were available for 364 (97.8%). SARS-CoV-2 was detected in 58/364 (15.9%) according to the recommended cycle threshold value of <40 and in 70/364 (19.2%) when expanded to any level of PCR detection. The median age at death among people with a positive test for SARS-CoV-2 was 48 (interquartile range 36-72) years, and 69% (n=48) were male. Most deaths in people with covid-19 (51/70; 73%) occurred in the community; none had been tested for SARS-CoV-2 before death. Among the 19/70 people who died in hospital, six were tested before death. Among the 52/70 people with data on symptoms, 44/52 had typical symptoms of covid-19 (cough, fever, shortness of breath), of whom only five were tested before death. Covid-19 was identified in seven children, only one of whom had been tested before death. The proportion of deaths with covid-19 increased with age, but 76% (n=53) of people who died were aged under 60 years. The five most common comorbidities among people who died with covid-19 were tuberculosis (22; 31%), hypertension (19; 27%), HIV/AIDS (16; 23%), alcohol misuse (12; 17%), and diabetes (9; 13%).
Contrary to expectations, deaths with covid-19 were common in Lusaka. Most occurred in the community, where testing capacity is lacking. However, few people who died at facilities were tested, despite presenting with typical symptoms of covid-19. Therefore, cases of covid-19 were under-reported because testing was rarely done not because covid-19 was rare. If these data are generalizable, the impact of covid-19 in Africa has been vastly underestimated.
BMJ study (Open access)
BMJ editorial (Open access)
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