Authored by Sanghvi Reema*
Introduction
The COVID-19 pandemic has affected everyone across the world, either through the disease itself or with our response to the disease as healthcare professionals, for the better part of a year. In the matter of a few months, it managed to spread from its little corner of the world to a true pandemic. In response to this global pandemic many affluent nations have instituted lockdown procedures to protect their population, a practice that has been adopted by many low to low- middle income countries (LMICs) as well.
Unfortunately, this pandemic does not take place in a vacuum, and individuals can have more than one condition with resultant needs outside their homes. This becomes readily apparent when considering someone receiving medical treatment for a disease such as HIV or TB, who may struggle keeping their treatment appointments. It also can restrict patients who rely on public transportation to reach hospitals or clinics, for example, pregnant women attempting to see their obstetrician or when going into labor. A lockdown of this magnitude and duration, while bothersome in wealthy countries, can be catastrophic in LMICs. In addition to access to medical care, this lockdown can also have an effect on a family’s financial stability. Many work in the informal economy even a day without work could lead to an inability to place food on the table [1].
Many individuals in these countries live in overcrowded spaces, leading to local outbreaks within a community. Enforcement of the lockdown has also seen an increase in violence towards those violating the order. In this review we will examine the literature, with a few firsthand accounts as well, of how the pandemic is currently being handled. We will examine the multitude of effects these policies are having on the local populace, particularly in Sub-Saharan Africa, the socioeconomic impact it is having, and hopefully elicit agreed upon recommendations for how national health agencies could create an individualized approach to their own COVID-19 response. We will also highlight areas that would benefit from additional research in the coming months to years.
Background
As of August 2020, there had been over 19 million confirmed cases of COVID-19 and 716 thousand deaths worldwide. By the end of 2020 this jumped to 81.9 million cases and 1.8 million deaths [2]. Through 2020 a little less than half of these cases occurred in the Americas, the United States leading with 19.6 million cases and 341 thousand deaths [3]. By contrast, all of Africa has 1.9 million cases with 42 thousand deaths. This all translates to 86.6 deaths per 100,000 in the Americas and only 4.2 per 100,000 in Africa. It is also important to point out that, for example, in the country of Malawi the average age is 17 with only 6.6% of the population over the age of 60 [4]. In comparison, in the United States the median age is 38.5 with 16.9% greater than the age of 65, in the United Kingdom the median age is 40.6 with 18.5% greater than the age of 65, and in Japan the median age is 48.6 with 29.2% over the age of 65 [5]. This should be an important consideration seeing that advanced age is a significant risk factor for morbidity and mortality due to this disease. The response to this pandemic is constantly changing based on recommendations from the various international health organizations. As areas are hit harder by the disease, restrictions there may increase and vice versa. Nations have adopted their own policies in how to combat this pandemic from quarantining the sick to full on lockdown. It has been speculated and even shown that minimizing interactions within a population, along with better hygiene practices, can slow the spread of disease, the so-called flattening of the curve. This is of course a good thing for health care systems, and the more well-developed nations have benefited from this practice. The problem lies when considering how this could affect the developing world [6].
Many LMICs have also adopted these lockdown policies while their health care systems are significantly lacking compared to wealthier countries. There is evidence that non-COVID-19 deaths (such as cancer deaths, measles, women dying in labor) are increasing due to disruption in health services [6]. It has been postulated that lives lost to lockdown could potentially exceed those saved from COVID-19. In Africa patients rely on their national health services or non- government organizations (NGOs) for HIV and TB treatment programs which can face interruptions in access to treatment. Other potentially fatal unintended consequences of lockdown include hunger, food insecurity, and violence [4].
Some sources question the feasibility of the high-income country model in LMICs, stating that this blueprint could negatively affect the economy and food systems, access to education and routine clinical services, the burden of vaccine-preventable diseases, and could even be counterproductive with regards to COVID-19 spread due to lockdowns causing out-migration from cities [7]. In India, many informal workers live in outlying villages while working in large city centers [8]. When the lockdown was put into effect, public transportation shut down almost overnight and these individuals, deprived of their livelihood, were left with no other options but to walk for days, sometimes covering hundreds of miles, risking death just to escape the city and return home to their families.
COVID-19 Compared to other Pandemics
While not the focus of this review, it is still important to look back briefly at some other pandemics we have encountered. COVID-19 is unfortunately just the latest pandemic faced by humanity, with notable predecessors such as the H1N1 swine flu of 2009-2010, the related coronavirus SARS pandemic of 2002, the 1918 Spanish flu, and of course The Black Death of the 14th century [9]. The swine flu, while viral like SARS-CoV-2, has an interesting difference in that some of the older population had some immunity, likely due to infection from a similar strain decades before. This made 62-85% of swine flu fatalities in patients less than 65 [10]. COVID-19 is also more highly transmittable with a Ro of 1.6-2.6 [11] while the swine flu was 1.4- 1.6 [10]. The 2002 SARS pandemic was also caused by a coronavirus, SARS-CoV, also originating in China. These have a similar transmission and patient presentation with most fatalities in the elderly over 65, however COVID-19 does appear more infectious with more fatalities to date.
SARS was eventually eradicated through surveillance, isolation, and quarantine [12]. It is apparent with these few examples that these various pandemics share a lot of similarities and some notable differences. For example, The Black Death was caused by a bacterium while the others on this list are caused by viruses. However, one similarity shared between all these pandemics is the disproportional impact they have on vulnerable populations such as the old, the sick, and the poor. A lesson learned from these prior pandemics is the effectiveness of surveillance and quarantine. However, as the rest of this review will illustrate, it is important not to just quarantine an entire community. We must first consider the full effect it will have on the populace and ensure steps have been taken to address the aptly named lockdown effect.
Coexisting Conditions Requiring Regular Treatment
As mentioned earlier, COVID-19 does not exist in a vacuum. Individuals can and do have more than one condition affecting their overall health. In sub-Saharan Africa tuberculosis, malaria, and HIV/ AIDS had been a large focus of NGOs and national healthcare systems, and prior to the emergence of SARS-CoV-2 they had been working diligently to combat these diseases. They were accomplishing this by working to lower active and new infections now and in the coming years. These plans are now directly being jeopardized by the emergence of this new pandemic. Various reports are showing disruption of healthcare services, diversion of the workforce, and travel/supply chain disruption, all due to the COVID-19 response and various lockdowns [13]. The WHO notes that during the recent Ebola outbreak in west Africa there was an increase in other disease morbidity and mortality with the sudden increase in demand for health services [14]. The importance of ensuring continued access to care for these diseases, especially during the currently year-long COVID-19 pandemic, cannot be understated. It is also pertinent to note that while TB, malaria, and HIV/AIDS are well known in this region, other infection prevention campaigns are also affected. For example, according to a special report in Nature [15], measles rates have been declining for the past 40 years but due to concerns for COVID-19 over 20 countries have suspended vaccination campaigns and measles rates are projected to rise. This is especially concerning in a country like the Democratic Republic of the Congo as it has the greatest single nation outbreak of measles in decades, with an estimated 6,500 child deaths from 2019-20, and as of March 2020 projections are continuing to rise [15]. One highimpact scenario predicts 84 immunization preventable deaths in children in Africa for everyone excess COVID- 19 death attributed to infection acquired during routine vaccine clinic visits, which are shut down in the interest of quarantining [16]. However, in this review we will focus on tuberculosis, malaria, and HIV/AIDS as examples of the effect COVID-19 is having on combating other diseases.
Tuberculosis
Tuberculosis (TB) is a well-known bacterial infection seen worldwide with well documented treatment and prevention strategies. While seen across the world, around 20 countries, especially in Africa, south Asia, and south-east Asia, are collectively known as high-burden countries that make up 54% of the global TB burden [17]. The Stop TB Partnership performed a rapid assessment and modeling analysis of the impact COVID-19 and the associated lockdown are expected to have on TB in the coming months to years. Looking across 16 high-burden countries they noted at least 40% of TB facilities being utilized for COVID-19 responses [17]. In India they have noticed a decrease by 80% of daily TB notifications during the lockdown contributed to people avoiding or being unable to reach medical care, laboratory delays, and stoppage of case finding actives [17]. They note not only lack of access to testing but also lack of medicines with no time for hospitals to prepare in advance for curfews and lack of patient transportation [17]. The modeling report was focused on three countries in particular; India, Kenya, and Ukraine; with their results extrapolated to a global level. When looking at the estimated impact over the next 5 years the study showed upwards of 10.7% increase in cases and a 16% increase of deaths between 2020-2025 when considering a 3-month lockdown with 10-month recovery of services [18]. They also estimated for every month of lockdown they expect over 600,000 more cases and over 125,000 more deaths; with every month of recovery, they expect over 400,000 more cases and over 80,000 more deaths [18]. In summary they have determined a setback of 5-8 years in the fight against TB due to the increase in incidence and deaths due to the COVID-19 pandemic [18]. This illustrates the importance of ensuring continued access to care for patients with TB living and receiving treatment within locked down communities. TB requires months of antibiotic treatments, access and transportation to regular medical care, and timely recognition of new cases; all things directly impacted by a lockdown. While no one expected nor was prepared for such a lockdown steps need to be taken to ensure continued access to TB treatment throughout this pandemic.
Malaria
The case incidence rate of malaria has decreased by 30% from 2000 to 2018 while the case mortality has decreased by 60% over the same period, the majority of which has occurred in sub- Saharan Africa, the area of the world that accounts for 90% of global malaria cases [14]. The WHO had previously developed a modeling framework detailing the normalized malaria incidence per person year from 2016 to 2030, a model they used as the basis of their COVID-19 model. Prior to developing their model, they determined the primary disruptions in intervention secondary to the COVID-19 response to be distribution of insecticide treated nets, indoor residual spraying, seasonal malaria chemoprevention, and access to malaria diagnosis and treatment. They then looked at 9 different possible scenarios with differences in reduction of net campaigns, distribution, and available effective treatment. Examples of some of these scenarios include scenario 1 in which they assumed no net campaigns and continuous net distribution decreased by 25%. In scenario 4, only effective antimalarial treatment was assumed to be reduced by 25%. Finally, in scenario 9 they assumed no net campaigns and a 75% reduction in net distribution and effective treatment. The remaining six scenarios fell along a spectrum similar to these three. While considering possible effect, in scenario 9 they concluded that every country in sub-Saharan Africa would see at least 20% increase in malaria deaths in 2020 compared to 2018, with the highest being greater than 200% increase in malaria deaths specifically in Guinea Bissau and Uganda [14]. In addition, the WHO published recommendations for malaria intervention in the setting of COVID-19 with guidance for vector control, case management, chemoprevention, and other extraordinary interventions [19]. Malaria is a prime example of a disease that has seen great reductions in recent years and, prior to the emergence of COVID-19, continued improvement was expected. The WHO model looks at nine different scenarios that could play out in the coming months, all of which illustrate an increase in both malaria cases and mortality in the setting of COVID-19. Much like the other diseases analyzed in this paper, the importance of continued access to malaria care by healthcare systems needs to be maintained. Fortunately, in the case of malaria, the WHO has published comprehensive recommendations that can help guide healthcare systems in developing their COVID-19 response with regards to malaria, which can be found on the WHO website at https://www. who.int/publications/m/item/tailoring-malaria-interventions-inthe- covid-19-response.
HIV/AIDS
COVID-19 may be our current pandemic, but the HIV/AIDS pandemic was here long before COVID-19 and will continue to plague society after it is gone. There is not a corner of the world that has not experienced HIV/AIDS to some degree. It is the most wellknown pandemic prior to the one we currently find ourselves in, and it is also probably the best studied. Researchers have spent decades studying and developing therapies against HIV/AIDS while various national and international organizations have spent time and money combating this disease. As of 2018, there were 37.9 million people living with HIV, according to UNAIDS two-thirds of those live in sub- Saharan Africa [20]. The WHO and UNAIDS used 5 existing HIV models to determine the potential effect that disruptions of access to care due to the COVID-19 pandemic will have on prevention and treatment. The various models examined how disruptions in specific HIV related services would affect incidence and mortality over both and 1- and 5-year period. Some of the services they considered were condom availability, suspension of HIV testing, no new anti- retroviral therapy (ART) initiation, stoppage of viral load testing and adherence counseling services, ART interruption, and others [20]. Across the models they found a 1.87 – 2.80-fold increase in HIV related deaths after only a six-month interruption of antiretroviral drug supply [20]. For example, in Kenya there were an estimated 25,000 HIV-related deaths in 2018. The five models examined saw an increase of 32,000 – 58,000 excess HIV-related deaths over 1 year as compared to 2018 data [20], with similar trends in all other African nations. The total sub- Saharan Africa excess HIV deaths over 1 year after a 6-month interruption ranged from 471,000-673,000 based on the model examined [20]. During the current COVID-19 pandemic it is important to prioritize where the time and resources should go concerning HIV/AIDS. Based on the results in this study it appears that the most important service to ensure reduced interruptions is ART. Maintaining as many HIV/ AIDS related services as possible, such as prevention and testing, are also important yet ART interruption would have the largest effect. Therefore, it is important for healthcare systems and NGOs in sub-Saharan Africa to ensure continued access to anti-retroviral medications during this COVID-19 pandemic.
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