Predicting the impact of COVID-19 and the potential impact of the public health response on disease burden in Uganda

The COVID-19 pandemic and public health “lockdown” responses in sub-Saharan Africa, including Uganda, are now widely reported. Although the impact of COVID-19 on African populations has been relatively light, it is feared that redirecting focus and prioritization of health systems to fight COVID-19 may have an impact on access to non–COVID-19 diseases. We applied age-based COVID-19 mortality data from China to the population structures of Uganda and non-African countries with previously established outbreaks, comparing theoretical mortality and disability-adjusted life years (DALYs) lost. We then predicted the impact of possible scenarios of the COVID-19 public health response on morbidity and mortality for HIV/AIDS, malaria, and maternal health in Uganda. Based on population age structure alone, Uganda is predicted to have a relatively low COVID-19 burden compared with an equivalent transmission in comparison countries, with 12% of the mortality and 19% of the lost DALYs predicted for an equivalent transmission in Italy. By contrast, scenarios of the impact of the public health response on malaria and HIV/AIDS predict additional disease burdens outweighing that predicted from extensive SARS-CoV-2 transmission. Emerging disease data from Uganda suggest that such deterioration may already be occurring. The results predict a relatively low COVID-19 impact on Uganda associated with its young population, with a high risk of negative impact on non–COVID-19 disease burden from a prolonged lockdown response. This may reverse hard-won gains in addressing fundamental vulnerabilities in women and children’s health, and underlines the importance of tailoring COVID-19 responses according to population structure and local disease vulnerabilities. Data collection was conducted in Uganda, which has a sporadic transmission of COVID-19 and conditions generalizable across several sub-Saharan countries.4 Information on the Ugandan population structure was obtained from the Uganda Bureau of Statistics census report, whereas data on comparison countries were obtained from UN data (Supplemental Table S1).13,24 Data on HIV and tuberculosis were obtained from the aggregated President’s Emergency Plan for Aids Relief (PEPFAR) weekly surge reports generated from data across 13 PEPFAR Uganda implementing partners,25 including the persons newly diagnosed with HIV as per the Uganda national HIV/AIDS treatment guidelines.26 Additional data on age-stratified HIV prevalence were obtained from the Uganda Population-based HIV Impact Assessment final report.27 Age-stratified malaria incidence for 2019–2020 was obtained from the Uganda Health Management Information System (HMIS) quarterly reporting.28 Maternal mortality data including deliveries from January 2019 to March 2020 inclusive were similarly obtained from the Uganda HMIS quarterly reporting.28 Calculations of DALYs lost followed broadly the methods outlined for the most recent WHO global burden of disease estimates.29 This involved defining life years lost by age as the difference between actual age of death and the life expectancy in a standard life table reflecting the highest life expectancy in the world today and a set of disability weights to reflect the relative severity of diseases. The unequal age-weighting function and discounting of future life years applied in earlier DALY versions were excluded.15 COVID-19 disease burden and excess HIV, malaria, and maternal mortality were calculated by multiplying the DALYs lost for a single health event by the population incidence and deaths by age-group. Disability-adjusted life years for COVID-19 are based on age-related mortality reported by Verity et al. from the China outbreak, applied to age structures of comparison countries with relatively high COVID-19 burden (the United States, China, Italy, and Spain) and Iceland,30 where testing rates have been relatively high.23 For the sake of comparison, a 20% total detectable infection rate was applied across all age-groups, this being assumed to be a worst case for comparison with deterioration in non-COVID disease burden. The details of assumptions involved in DALY calculations are provided in the supplementary file. Potential impact of reduced health service access in Uganda through the COVID-19 response was predicted for HIV/AIDS, malaria, and maternal mortality. HIV/AIDS predictions assumed an arbitrarily low (20%) loss to follow-up (no medication) for current infections extending for 6 months, with mortality returning to 1990 levels (essentially pre-ART). Reduced detection of new HIV infections and initiation of management is based on first quarter 2020 data.25 Excess malaria burden was estimated based on 6 months of incidence and mortality rate changes recently predicted by the WHO for three scenarios of minor, moderate, and major reductions in services (WHO scenario 1 [WS1]: no insecticide-treated net [ITN] campaigns, continuous ITN distributions reduced by 25%, WS4: no ITN campaigns, access to effective antimalarial treatment reduced by 25%, and WS9: no ITN campaigns, both continuous ITN distributions and access to effective antimalarial treatment reduced by 75%).31 Relative malaria mortality and incidence rates by age for Uganda were derived from the Institute of Health Metrics data,32 with the 2018 baseline mortality reported by the WHO.18 Maternal mortality was based on Uganda data from 2019 to 2020 and the data include only mortality, not persisting injury (see Results section). The study used publicly available secondary aggregate-level data. No individual person-identifying information was used.