COVID-19 update: Africa, Italy and inequality.

As the world continues to respond to the evolving COVID-19 pandemic, four papers just released in leading journals assess key aspects of its past, present and possible future impact.

The first, published in the journal BMJ Global Health, predicts that without urgent action to contain the virus in Africa, 200 million people could be affected in the first year, resulting in 150,000 deaths. 

This estimate is low compared to regions like Europe and the US, but the authors say limited health resources would buckle under the strain and worsen the virus’s impact as other issues like HIV, tuberculosis, malaria and malnutrition fall in its shadow.

As of two weeks ago, 45 of the 47 African countries in the World Health Organisation – the report’s author – have reported cases of COVID-19 (SARS-CoV-2), including a significant number of health workers. 

Factoring social, developmental, environmental and population health factors into their modelling, the team estimates that while the pandemic will likely spread more slowly and less severely, it could linger for much longer. 

“COVID -19 could become a fixture in our lives for the next several years unless a proactive approach is taken by many governments in the region,” says WHO Africa head Matshidiso Moeti. “We need to test, trace, isolate and treat.” 

Mauritius, Seychelles and Equatorial Guinea would see the greatest proportion of people infected, while Nigeria could have the most infections overall, followed by Algeria and South Africa.

Over in northern Italy, the number of official deaths in Nembro, a hard-hit city in the Bergamo province of Lombardy, could have been under-estimated, report researchers from Germany’s Institute of Public Health, Berlin, and Italy’s Centro Medico Santagostino, Milan, in the journal BMJ.

They base this conclusion on comparisons of monthly all-cause mortality data between January 2012 and April 2020 with the number of confirmed deaths from COVID-19, and the weekly number of total deaths between January and April in recent years by age group and sex.

While monthly deaths from all causes fluctuated around 10 per 1000 person years since 2012, reaching a maximum of 21.5, it peaked at 154 in March this year, compared to 14 for the same month last year.

Increased deaths were mostly driven by older people aged 65 and over, especially men, but they note the observational study doesn’t establish a causal relationship.

Going global, researchers at the University of Birmingham, UK, predict that more than 28 million elective surgeries could be cancelled or postponed in 2020, deriving their estimates from a 12-week period of peak disruption to hospital services.

While cancer surgery would likely be prioritised, cancellations would be most common for orthopaedic surgery, which could worsen people’s existing conditions or injuries, increasing disability and inability to work. 

On top of this, waiting lists could blow out, compounding the problem and resulting in costly efforts to clear backlogs. 

The team collected detailed information from surgeons at 359 hospitals and 71 countries on plans to cancel elective surgery then modelled this to provide estimates across 190 countries, publishing their results in the British Journal of Surgery. 

They hope the findings will help communities with planning and resource prioritisation, balancing infection risks with extended treatment delays.

Another paper highlights the widening health inequalities in the UK as restricted access to non-urgent services impacts disadvantaged and marginalised communities disproportionately.

Meanwhile, public health doctors write in the Journal of the Royal Society of Medicine that visits to UK emergency departments – often used by vulnerable groups such as homeless people and migrants – dropped by nearly half in March.

Hospitals were told to stop anything non-urgent, leading a London teaching hospital, for instance, to drop services such as gynaecology, sexual health, paediatrics and diagnostic facilities by 80%.

And while clinics are trying to make appointments by phone or video consults, people who struggle with English or health literacy would be disadvantaged by this.

The authors propose some ways to address the problem. 

For instance, clean sites could be set up like those for cancer patients. Pregnant women from poorer neighbourhoods, who are more likely to smoke during pregnancy, should continue to be referred for remote counselling services.

Other areas of concern include people who work in high-risk hospital settings doing security, cleaning or catering, who tend to be migrants.

While some consequences of prioritising covid-19 services and restricting contact are unavoidable, the authors urge that the issue be acknowledged and addressed.

“Policymakers, managers and clinicians should take pause during this phase to protect the most vulnerable groups in our society from negative unintended consequences and avoid worsening health inequalities.”