Developing countries are likely to face extreme demand on health systems from COVID-19, despite having younger populations, according to researchers.

Writing in the journal Science, researchers from Imperial’s Covid-19 Response Team, Liverpool School of Tropical Medicine and University of Oxford, looked at the impact of coronavirus on low-middle income countries (LMICs).

The researchers write that LMICs tend to have a younger population than higher income countries – which means the risk of death from COVID-19 is lower for much of their population.

But the authors say that the strain on healthcare systems is likely to be more extreme in lower-income settings where healthcare capacity is typically more limited.

The researchers suggest that this strain on healthcare systems in LMICs is likely to nullify the protective benefits of having a younger population.

Limitations of healthcare systems

The researchers, from the WHO Collaborating Centre for Infectious Disease Modelling within the MRC Centre for Global Infectious Disease Analysis, Jameel Institute (J-IDEA), say that even optimal mitigative strategies will lead to substantial excess mortality and healthcare capacity will be exceeded.

Low-income countries also have lower percentage (1.47%) of hospital beds that are in intensive care units (ICU) compared with higher-income countries (3.30%).

The absence of mechanical ventilators is also likely to contribute to a much higher mortality rate in developing countries, with a range of 90-100%, for patients that would need it. This compares to a mortality rate of 51.6% in the UK for patients that require mechanical ventilation. 

Other factors: Size of households and early suppression

Low-middle income countries tend to have larger households where an older person, over the age of 65, is also resident, compared with higher-income countries.  

This not only increases the potential for spread generally but also specifically to this particularly vulnerable age-group.

LMICs have generally initiated suppression measures, such as lockdowns, earlier than higher-income countries. The authors suggest that when interventions are later released, transmission will rise again as there will be a low level of herd immunity at that point in LMICs. 

Recommendations: enhanced testing and medical supplies

The researchers say that in the short-term, the priority should be to increase the availability of oxygen support to mitigate the health impact alongside enhancing the capacity for surveillance and wide-scale testing to reduce the spread of infection and tailor appropriate measures.

In the longer-term, it should be a global priority to ensure that lower income countries have the same access to drugs and treatments to help combat the virus.

'Ensuring the world's poorest are not hit hardest'

Imperial's Professor Azra Ghani, said:“Our results demonstrate the real and continued threat that COVID-19 disease continues to pose to low- and middle-income countries where, despite the younger age of the populations, the more limited healthcare capacity mean that even small epidemics could give rise to significant mortality. Whilst many of these countries acted early to limit onward transmission, as interventions are gradually relaxed and normal life resumed it will be important to consider locally-adapted and sustainable strategies to limit spread so that healthcare services that are so vital for wider well-being are not overwhelmed.”

Professor David Lalloo, Director Liverpool School of Tropical Medicine, said: “This work highlights that compared to countries like the UK, COVID 19 poses considerable additional challenges for health systems in low and middle income countries”
“Without successful strategies to prevent transmission, COVID 19 could lead to many more deaths in LMICs because their health systems are so fragile”

Dr Patrick Walker, from Imperial, said: "Our research demonstrates that, in general, lower-income countries responded in a more effective and timely manner to the threat of Covid-19 than their high-income counterparts. However, the trade-offs in maintaining control are more severe where health systems and economies are more fragile. As death rates have fallen in higher-income countries, epicentres of the pandemic are emerging in lower- and middle-income countries including Brazil, India and South Africa. Identifying sustainable approaches to maintaining progress achieved in lower-income countries should be a global priority to ensure the world’s poorest are not hit hardest by the pandemic.”

Mr Charlie Whittaker, from Imperial, said: "Our work highlights the swift and decisive action many low- and middle-income countries have taken to contain transmission of the virus and prevent their epidemics reaching the tragic scale seen in North America and Western Europe to date. These gains are fragile though - and ultimately, until a vaccine is developed or sustainable control strategies can be implemented, relaxation of measures risks rapid resurgence, new epidemics and substantial loss of life." 

--

The Impact of COVID-19 and Strategies for Mitigation and Suppression in Low- and Middle-Income Countries, published in Science.