By Maryam Nasir MBBS MSC; Zainab Mahmoud MD DTMH; and Khadija Rufai MD MHA
27TH APRIL 2020

Background:
The Coronavirus Disease (COVID-19) pandemic has created an unprecedented global health and economic crisis. Early into the spread of the COVID-19 pandemic, there were several reports that suggested the clinical course of COVID-19 in Nigeria and perhaps Africa was mild. We initiated a research project to investigate the clinical presentation of COVID-19 in Kano state. Our aim was to determine the severity of cases and outcomes. If indeed the cases were mild, then we could avoid stringent measures that have significant economic impact. However, prior to collecting our data, several media outlets as well as reports on social media purported an increased death rate in Kano metropolis. Undertakers interviewed at various cemeteries also reported increased frequency of burials. The events and facts around the cases remained unclear. Incidentally, at the same time, in the United States, autopsy reports revealed deaths that occurred in February under unclear circumstances were due to COVID-19. Given the current state of the global pandemic, we sought to investigate the circumstances around the Kano deaths and determine if these cases may be due to COVID-19.

Methods:
We utilized a similar method, verbal autopsy, used by the World Health Organization (WHO) during the Ebola outbreak. We disseminated a message via social media with our contact details encouraging people who have heard of deaths to report to us for investigation. We made phone calls to families of the deceased to obtain information regarding the death. We obtained verbal informed consent and notified families that information provided will be confidential. We gathered two sets of data. The first data set was obtained through direct family members (first degree relatives) of the deceased and the second data set was from indirect sources (friends, neighbors or relatives of the deceased). We gathered data for 48 hours. We obtained demographics, symptoms, exposure history and medical history of the deceased. Some family members volunteered further information around the deaths. We compiled and analyzed the data.

Results
Over the span of 48 hours, we received reports of 183 deaths in Kano metropolis that occurred between April 18 to April 25, 2020. We obtained direct information on 51 deaths summarized in Table 1 [ATTACHED].

Our findings indicate a trend of febrile and respiratory illness that progresses to
death within one to two weeks. These deaths occurred in various localities in Kano and are predominantly amongst elderly people with underlying medical conditions. This presentation mirrors severe COVID-19 cases reported around the world. Some family members volunteered further information around cases. One of the contacts, who had lost a father, stated that he became ill about 1 week after a wedding ceremony. He had fever, shortness of breath and diarrhea. Attempts to contact the Nigerian Centre for Disease Control (NCDC) were unsuccessful and he passed away 1 week later. Another contact stated that the deceased had fever and shortness of breath for a week. He was initially treated for pneumonia at a private hospital and subsequently required a ventilator. There were several reports of multiple people in a household or in a neighborhood dying from a similar illness. Of note, 40 out of 51 deaths had no recent travel history.

Limitations:
Our results cannot determine causality as none of these deaths were tested for COVID-19. Given that our data was collected over the phone, there was a significant limitation with lack of trust when we reached out to immediate family members who were grieving. Most families were understably hesitant to give out personal information to strangers over the phone. We therefore created two data sets to avoid including unreliable data and unconfirmed reports. Data from indirect sources were often incomplete as non-family members were unable to report exact symptoms and other medical history.

Conclusion:
Our findings indicate an uptake in deaths from a febrile illness in Kano. Given the COVID-19 pandemic, it is highly likely and plausible that these deaths reflect similar pattern occurring around the world. However regardless of etiology, it is imperative that local authorities, concerned groups and international organizations collaborate to create an emergent response in to the dire situation in Kano.

Recommendations:

  1. We recommend further and timely investigations into these deaths. A suggested approach is to track family members through cemeteries or hospitals.
  2. Our findings suggest community transmission in Kano metropolis. Therefore, we recommend enhancing testing capacity, community-based testing and setting up of mobile testing centers within Kano.
  3. Provision of personal protective equipment (PPE) to all staff with potential exposures especially at points of initial patient contact.
  4. Recognition of significant consequences of neglected non-COVID-19 medical care and consider diverting non-COVID-19 cases to private and other community hospitals.
  5. A strict guideline for burials should be issued.
  6. We suggest that restrictions around markets and essential businesses such as food stores and pharmacies be lifted. People must have access to food and medications during these unprecedented times. Other avenues such as mandatory face masks, restricting elderly or at-risk populations from market places should be explored. Failure to do this will cause a further spike in deaths from non-COVID-19 causes.

References

  1. https://africa.com/covid-19-in-africa-fewer-cases-so-far-and-more-preparation-needed/
  2. https://www.dw.com/en/coronavirus-special-podcast-3-are-african-youth-immune-to-covid-
    19/av-53053265
  3. http://saharareporters.com/2020/04/21/panic-kano-over-150-persons-die-‘mysteriously’-under-
    three-days-sparking-coronavirus
  4. https://www.reuters.com/article/uk-health-coronavirus-nigeria-kano-idUKKCN2252PL
  5. https://www.vanguardngr.com/2020/04/we-bury-more-corpse-now-than-before-says-kano-
    undertakers/
  6. https://www.sccgov.org/sites/covid19/Pages/press-release-04-21-20-early.aspx
  7. https://www.who.int/csr/resources/publications/ebola/Corrected%20CoverEboladoc1.pdf?ua=1
  8. Clinical course and mortality risk of severe COVID-19: Paul Weiss, David R Murdoch The Lancet,
    Volume 395, Issue 10229
  9. Clinical Characteristics of Coronavirus Disease 2019 in China: Wei-jie Guan, PhD et al NEJM, 2020


References

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