Associations between socioeconomic and public health indicators and the case-fatality rate of COVID-19 in sub-Saharan Africa

Aim: To investigate the influence of socioeconomic and public health indicators on the COVID-19 case-fatality rate (CFR) in sub-Saharan African countries. Methods: Ecological study using publicly available, aggregated COVID-19 data, between February 2020 to May 2021, from 46 sub-Saharan African countries. As the outcome of interest, country-specific CFRs were calculated for five 13-week periods. Spatial and temporal distributions of the variables were analysed, and negative binomial regressions with rate ratios (RR) were conducted to estimate the association between socioeconomic and public health indicators with CFR of COVID-19. Results: There were 1.7 million confirmed COVID-19 cases and 29,685 deaths in the 46 sub-Saharan African countries during the investigated time period. The median CFR was between 1% and 2%. A higher human development index (RR = 0.80; 95%CI: 0.63-1.02), higher political stability index (RR = 0.94; 95%CI: 0.90-1.00), higher number of hospital beds (RR = 0.84; 95%CI: 0.73-0.97), and higher population density (RR = 0.85; 95%CI: 0.71-1.01) resulted in a lower CFR. Elevated prevalence of diabetes mellitus (RR = 1.56; 95%CI: 0.99-2.45) and cardiovascular disease mortality (RR = 1.51; 95%CI: 1.04-2.20) were associated with higher CFR. Chronic respiratory disease and handwashing facilities presented little to no effects on COVID-19 CFR. Conclusion: The results draw attention to the vulnerabilities of the sub-Saharan African region which must be considered in the interpretation of our study. Nevertheless, the potential benefits of a lower proportion of pre-existing medical conditions and the young age structure seem to be contrasted by challenges due to socioeconomic and public health factors, which may present possible drivers of CFR on a population level.