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Innocent Maposa1,2, Richard Welch3,4, Lovelyn Ozougwu3,4
1Division of Epidemiology & Biostatistics, School of Public Health, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa. innocent.maposa@wits.ac.za.
Insights
Spatial analysis of COVID-19 in-hospital deaths in South Africa reveals significant variations. Certain districts show higher mortality, indicating potential health system challenges that require targeted interventions.
Area of Science:
- Epidemiology
- Spatial Analysis
- Public Health
Background:
- South Africa reported its first COVID-19 case in March 2020, with over 3.6 million cases and 100,000 deaths by March 2022.
- While general COVID-19 mortality shows spatial associations, in-hospital death patterns remain under-investigated.
- This study addresses this gap using national hospitalization data.
Purpose of the Study:
- To investigate the spatial effects on COVID-19 in-hospital deaths in South Africa.
- To adjust for known demographic and clinical mortality risk factors.
- To identify specific districts with significantly higher in-hospital mortality rates.
Main Methods:
- Utilized national COVID-19 hospitalization and death data from the National Institute for Communicable Diseases (NICD).
- Employed a generalized structured additive logistic regression model with Bayesian inference.
- Incorporated random walk priors for continuous covariates and Markov random field priors for spatial autocorrelation.
Main Results:
- In-hospital mortality risk increased with age, ICU admission, oxygen use, and mechanical ventilation.
- Public hospital admission was also significantly associated with higher mortality.
- Specific districts in Limpopo and Eastern Cape provinces showed significantly higher odds of COVID-19 hospital deaths after controlling for covariates.
Conclusions:
- Substantial spatial variation in COVID-19 in-hospital mortality exists across South African districts.
- Findings highlight potential health system challenges in specific districts, necessitating targeted interventions.
- Understanding spatial differences is crucial for strengthening health policies and improving public health outcomes.
Background:
The first case of COVID-19 in South Africa was reported in March 2020 and the country has since recorded over 3.6 million laboratory-confirmed cases and 100 000 deaths as of March 2022. Transmission and infection of SARS-CoV-2 virus and deaths in general due to COVID-19 have been shown to be spatially associated but spatial patterns in in-hospital deaths have not fully been investigated in South Africa. This study uses national COVID-19 hospitalization data to investigate the spatial effects on hospital deaths after adjusting for known mortality risk factors.
Methods:
COVID-19 hospitalization data and deaths were obtained from the National Institute for Communicable Diseases (NICD). Generalized structured additive logistic regression model was used to assess spatial effects on COVID-19 in-hospital deaths adjusting for demographic and clinical covariates. Continuous covariates were modelled by assuming second-order random walk priors, while spatial autocorrelation was specified with Markov random field prior and fixed effects with vague priors respectively. The inference was fully Bayesian.
Results:
The risk of COVID-19 in-hospital mortality increased with patient age, with admission to intensive care unit (ICU) (aOR = 4.16; 95% Credible Interval: 4.05-4.27), being on oxygen (aOR = 1.49; 95% Credible Interval: 1.46-1.51) and on invasive mechanical ventilation (aOR = 3.74; 95% Credible Interval: 3.61-3.87). Being admitted in a public hospital (aOR = 3.16; 95% Credible Interval: 3.10-3.21) was also significantly associated with mortality. Risk of in-hospital deaths increased in months following a surge in infections and dropped after months of successive low infections highlighting crest and troughs lagging the epidemic curve. After controlling for these factors, districts such as Vhembe, Capricorn and Mopani in Limpopo province, and Buffalo City, O.R. Tambo, Joe Gqabi and Chris Hani in Eastern Cape province remained with significantly higher odds of COVID-19 hospital deaths suggesting possible health systems challenges in those districts.
Conclusion:
The results show substantial COVID-19 in-hospital mortality variation across the 52 districts. Our analysis provides information that can be important for strengthening health policies and the public health system for the benefit of the whole South African population. Understanding differences in in-hospital COVID-19 mortality across space could guide interventions to achieve better health outcomes in affected districts.
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