![]() Contact patterns between age groups also differ by country (fig. 1B) compared with middle-income countries (MICs) and HICs, increasing the potential for spread generally but also specifically to this particularly vulnerable age group. The average size of households that have a resident over the age of 65 years is substantially higher in LICs ( Fig. Second, the household is a key setting for SARS-CoV-2 transmission ( 7). High-income countries (HICs) tend to have the oldest populations low-income countries (LICs), by contrast, have a much smaller proportion of the population who are above age 65 and therefore within the age interval currently observed to be at particularly high risk of mortality from COVID-19 disease ( 5). ![]() First, there is a strong correlation between the gross domestic product (GDP) of a country and its underlying demography ( Fig. On the basis of the observed doubling time in the incidence of deaths across Europe ( 6), we use a central estimate of the basic reproduction number ( R 0) of 3.0 (a 3.5-day doubling time) and investigate scenarios with R 0 between 2.3 (a 5-day doubling time) and 3.5 (a 3-day doubling time).įigure 1 summarizes two of the demographic and societal factors that are likely to determine the burden of COVID-19 disease across different income settings. ![]() To illustrate how these would determine the demand for health care over the course of an unmitigated epidemic, we applied age-specific estimates of the rates of hospitalization and of the proportion of these requiring critical care, and of the infection fatality ratio (IFR) ( 5) under an initial assumption of a consistent underlying role of comorbidities and the same level of medical care supplied during the epidemic in China (see materials and methods). We first include these within a simple SIR modeling framework ( 4) to estimate the theoretical final size of the outbreak (age-specific attack rate) in the absence of nonpharmaceutical interventions (NPIs). We collated data on global demographic projections of population size by age and country and available data on social mixing patterns by age and country-level income category. We sought to understand the factors that could result in a differential impact of the COVID-19 pandemic in low- and middle-income countries (LMICs), as well as to evaluate the potential strategies for suppression and mitigation in these settings given the current global state of the pandemic. This has potentially profound consequences for resource-poor settings, where the quality and availability of health care and related resources (such as oxygen) is typically poorer ( 3). The experience in countries to date has emphasized the intense pressure that a COVID-19 epidemic places on national health systems, with demand for intensive care beds and mechanical ventilators rapidly outstripping their availability, even in relatively highly resourced settings ( 2). The coronavirus disease 2019 (COVID-19) pandemic caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus is a major global health threat, with 5.4 million cases and 344,000 deaths confirmed worldwide as of ( 1). However, this will need to be maintained or triggered more frequently in these settings to keep below available health capacity, with associated detrimental consequences for the wider health, well-being, and economies of these countries. Of countries that have undertaken suppression to date, lower-income countries have acted earlier. Mitigation strategies that slow but do not interrupt transmission will still lead to COVID-19 epidemics rapidly overwhelming health systems, with substantial excess deaths in lower-income countries resulting from the poorer health care available. Younger populations in lower-income countries may reduce overall risk, but limited health system capacity coupled with closer intergenerational contact largely negates this benefit. We combine data on demography, contact patterns, disease severity, and health care capacity and quality to understand its impact and inform strategies for its control. The ongoing coronavirus disease 2019 (COVID-19) pandemic poses a severe threat to public health worldwide. Walters, Haowei Wang, Yuanrong Wang, Xiaoyue Xi, David G. Juliette Unwin, Robert Verity, Michaela Vollmer, Caroline E. Gaythorpe, Lily Geidelberg, Nicholas Grassly, David Haw, Sarah Hayes, Wes Hinsley, Natsuko Imai, David Jorgensen, Edward Knock, Daniel Laydon, Swapnil Mishra, Gemma Nedjati-Gilani, Lucy C. ![]() van Elsland, Rich FitzJohn, Han Fu, Katy A. Brazeau, Lorenzo Cattarino, Gina Cuomo-Dannenburg, Amy Dighe, Christl A. Ainslie, Sangeeta Bhatia, Samir Bhatt, Adhiratha Boonyasiri, Olivia Boyd, Nicholas F. Djafaara, … Show All …, Zulma Cucunubá, Daniela Olivera Mesa, Will Green, Hayley Thompson, Shevanthi Nayagam, Kylie E. Watson, Marc Baguelin, Peter Winskill, Arran Hamlet, Bimandra A.
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