Regional vulnerability for COVID-19 in Cameroon

Abstract

Introduction: few studies have assessed risk for coronavirus disease 2019 (COVID-19) within African countries. Here we examine differences in vulnerability to COVID-19 among the ten administrative regions and two major cities of Cameroon based on epidemiological risk factors and access to healthcare resources.

Methods: regional epidemiological and healthcare access vulnerability indices were created and compared with cumulative COVID-19 cases, case fatality rates, co-morbidities, and healthcare resources in Cameroon.

Results: based on epidemiological risk factors, populations in the East Region, Douala (in the Littoral Region), West Region, and Yaoundé (in the Center Region) are at highest risk for COVID-19. Meanwhile, the North, Far North, East, and Adamawa Regions had the most healthcare access vulnerability. COVID-19 cases per population were highest in the Center, Littoral, and East Regions. Case fatality rates were greatest in the North Region. Potential co-morbidities with greater prevalence among COVID-19 patients included male sex, hypertension, and diabetes.

Conclusion: epidemiological risk factors for COVID-19 and access to healthcare varies between the regions of Cameroon. These discrepancies are potentially reflected in regional differences of COVID-19 cases and case fatality rates. In particular, the East Region has high epidemiological risk factors and low healthcare accessibility compared to other regions. Understanding the relationships between epidemiological risk factors, access to healthcare resources, and COVID-19 cases in Cameroon could aid decision-making among national policymakers and inform further research.

Introduction

As the pandemic of COVID-19 has spread across the globe, countries have faced diverse challenges. With additional countries facing increasing cases of COVID-19, it is important to realize that experiences and vulnerability may differ among and within countries. In particular, low- and middle-income countries (LMICs) may face particular problems given potential differences in resource availability, demographics, and co-morbidities. An initially lower than expected morbidity and mortality due to COVID-19 has been found in Africa, which some have attributed to a variety of reasons, including a younger population with different co-morbidities and previous exposure to viruses that are cross-reactive with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the virus that causes COVID-19 [1]. Exposure to other pathogens may have also influenced the immune systems of certain African populations, leading to less severity of COVID-19. Recent serological surveys in multiple African countries suggest that large populations may have already been exposed to SARS-CoV-2 or other cross-reactive viruses [2]. However, resource limitations and burden of diseases such as HIV/AIDS, tuberculosis, malnutrition, and malaria could also make certain African populations more vulnerable to COVID-19 [3]. Relatively few assessments of vulnerability for COVID-19 have been undertaken in Africa, and given heterogeneity among African countries, it is crucial to have contextually specific analyses [4]. Additionally, estimates of populations at risk for COVID-19 have been made on national levels in Africa but rarely on regional levels [5]. Limitations in reporting of cases along with co-morbidities may make it challenging to understand specific risk factors and vulnerability. However, existing and emerging epidemiological data may help in guiding these assessments. Vulnerability indices have been used to risk stratify populations based on demographic, health, socioeconomic, and epidemiological variables that could increase vulnerability for COVID-19 [6]. Similar assessments could aid in understanding vulnerability within and between African countries.

Current risk assessments and vulnerability indices for COVID-19 rely on the initial experiences and epidemiological data from primarily Asian, European, and North American countries. These initial epidemiological studies showed a higher proportion of older adults and males among Chinese, Italian, and United States cohorts [7-9]. Hypertension was the most common co-morbidity among the Italian cohort [7]. Diabetes was associated with progression to acute respiratory distress syndrome (ARDS) and death in a Chinese cohort, and it was the most common co-morbidity in a United States cohort [8,10]. Obesity was subsequently associated with increased rate of hospital and ICU admissions among patients in the United States [11]. Malignancy and chronic respiratory disease were also recognized as factors associated with increased risk for ARDS and death in China [10]. Similarly, smoking was also found to be associated with progression of COVID-19 [12]. In a recent cohort study from South Africa, diabetes and hypertension were more common among patients diagnosed with COVID-19 than non-cases, and mortality was associated with increased age, male sex, diabetes, hypertension, and chronic kidney disease [13]. Tuberculosis and HIV were also found to be associated with increased mortality in COVID-19 cases [13]. HIV has not been identified as a risk factor for COVID-19 in previous studies. In a United States cohort, there was no difference in adverse outcomes associated with HIV infection in hospitalized patients with COVID-19 [14]. In Spain, risk for COVID-19 was not higher among HIV positive patients than the general population [15]. Potential confounding variables and differing regional factors such as socioeconomic status, viral load suppression, and access to anti-retroviral therapy make these results difficult to interpret, so more research is necessary. Therefore, previously-identified and presumptive risk factors for COVID-19 could be used for assessing vulnerability in other populations until additional research is available.

While assessing decision-making and outbreak preparedness for emerging viruses in Cameroon, it was found that national policymakers preferred maps and analyses that were region-specific [16]. Cameroon has ten administrative regions and has faced challenges with progression of COVID-19 cases among the different regions [17]. The first cases were detected in the Center Region which contains the capitol, Yaoundé, and subsequently cases spread to the Littoral Region where Douala, the largest city, is located [17]. As of September 16^th 2020, 20,371 confirmed cases of COVID-19 had been reported in Cameroon, which ranked ninth among African countries in terms of total cases [18,19]. Cameroon is considered a level 3, high risk country for COVID-19 by the United States Centers for Disease Control and Prevention given ongoing concerns about transmission [20]. In discussions with national experts from Cameroon, it was determined that an assessment of vulnerability for COVID-19 by region in Cameroon could help guide further research. An assessment of differences in epidemiological risk factors for COVID-19 and access to healthcare in Cameroon could help identify particular regions at risk as well as potential mismatches between cases and resource availability. Therefore, we aimed to assess vulnerability for severity of COVID-19 and healthcare access by regions and major cities in Cameroon to identify whether any patterns or discrepancies may exist.

Acknowledgements

We would like to thank the healthcare workers, patients, public health experts, scientists, and institutions, especially the Ministry of Public Health, involved in the COVID-19 response in Cameroon. We also thank our colleagues at the University of Washington and University of California Los Angeles for their support and feedback.

The full article Regional vulnerability for COVID-19 in Cameroon is available at The Pan African Medical Journal in a special issue on COVID-19 in Africa.