The Pattern of COVID-19 in Horn of Africa countries, from March-December 2020

Background Coronavirus-19 (COVID-19) is a novel, highly infectious, and potentially fatal communicable pandemic disease. It has taken longer to reach Africa than the other continents. Objective To examine the pattern of COVID-19 in the Horn of Africa countries from March to December 2020. Methods A prospective cross-sectional study in which the total number of daily reported cases and deaths were collected from the official website of the World Health Organization (WHO) and Worldometer. Data were standardized based on the total population provided by World Population Prospects 2020 per million. Data sources of WHO reports and governmental reports from March to December 2020 were analyzed in this study. Data extraction was done using the microsoft excel spreadsheet tool, variables relating to the countries were computed in terms of frequencies and percentages. Results The findings revealed that as of 31st December 2020, 136,129 (7590 per million) cases were reported from the four countries in the Horn of Africa. The overall case fatality rate (CFR) in the Horn of Africa was 1.14%. The majority of the cases were reported from Djibouti (77.20%), followed by Ethiopia (14.07%), Eritrea (4.87%), and Somalia (3.86%). The highest case fatality rate (0.81%) was from Djibouti, and the lowest (0.01%) was from Eritrea. Conclusions The epidemiological pattern of COVID-19 among the Horn of African countries seems to have slow progress, given the prevalence of the new infections remains low, and the death toll seems stable throughout the study periods, except for Djibouti. Hence, the prevention control measures implemented in the countries should be further strengthened and supported. It is recommended that relevant stakeholders responsible for tackling the COVID-19 pandemic should put up measures to curb the spread of the virus in the region and set up a crisis management system to combat future pandemics.


Introduction
Coronaviruses (CoVs), a subfamily of Orthocoronavirinae in the family of Coronaviridae, Order Nidovirales 1 , has been causing different respiratory diseases such as Middle East Respiratory Syndrome (MERS), severe acute respiratory syndrome (SARS), and the novel coronavirus officially named as COVID-19 (SARS-Cov-2). Coronavirus is one of the major pathogens that primarily target the human respiratory system 2 . Previous outbreaks due to CoVs include the SARS-and the MERS-CoV, characterized as agents of tremendous public health threats 2 . Hereditary arrangement of the COVID-19 indicated over 80% similarity to SARS-CoV 3,4 and 50% to the MERS-CoV, both SARS-CoV and MERS-CoV begun in bats 5 .
Similarly, evidence from the phylogenetic analysis also demonstrates that the COVID-19 has a place with the genus betacoronavirus, which contains SARS-CoV, which infects people, bats, and wild creatures 2 .
COVID-19, which was first reported on 31 st December 2019 in Wuhan City of Hubei province of China, has spread to the whole world at an alarming rate 6,7 . In one month of its initial outbreak, on the 30 th of January 2020, the WHO declared that the 2019 novel coronavirus (2019-nCoV) outbreak constitutes a public health emergency of International concern. Since the declaration, many countries have implemented formal preventive measures, including travel restrictions to and from risky areas. The fast spread of the COVID-19 interfered with proper planning by health professionals to mitigate its effect. Adopting emergent measures meant an inadequate focus on health promotion, early detection of infection, disease prevention, and investment in equipping public health professionals with the necessary skills and knowledge to fight the virus. Misinformation and conspiracy theories towards the origin of the pandemic made the globe far away from collaborating on early prevention and mitigation factors. Subsequently, to these global developments, on 11 th March 2020, WHO declared COVID-19 as a pandemic 8 .
Although COVID-19 is believed to be a family of the previous outbreaks, the infectivity of COVID-19 is higher than SARS-CoV and MERS-CoV 9 . As a result, it is still considered a severe public health threat of this decade. The spill-over effects of the COVID-19 on a diverse aspect of life led the world to experience unimaginable economic, social, and psychological dilemmas. Although many published studies have tried to summarize its impact on different countries, the pandemic still hits on consecutive waves. Further, it aggravates the life of humankind on the globe 1,10-16 . Even though COVID-19 is tagged as "the most infectious disease in the last decades", no antidote has been found to eliminate this canker. The scientific community is still searching for a potent vaccine to safeguard the world from this ravaging pandemic. However, the emergence of new strains of the virus has hampered vaccine development. Presently, the fully embraced practices to break the transmission chain of the virus and ensure high-level community protection at all levels are individual and community-based approaches. At the initial stage of the COVID-19, many countries imposed local and international travel restrictions and various social distancing measures advocated by WHO. COVID-19 was expected to be more dreadful in low-income countries with a fragile economy, inadequate resources and infrastructure for mass screening, limited capacity on accommodation of cases, and lack of the desired therapeutic interventions [16][17][18] . Nonetheless, COVID-19 took longer to reach Africa's shores than other continents. However, even before the infection arrived at the locale, its extensive impacts were felt 19 . COVID-19 was reported in Africa initially in Egypt on 14 th February 2020 25 . The case fatality rate (CFR) of COVID-19 was 2.4% in Africa and 2.2 % globally.
This study is novel in the sense that it is one of the first to examine the pattern of COVID-19 infection in the Horn of Africa and advocate for a crisis-resistant system against future disasters/pandemics. Health officials, governmental agencies, policymakers, NGOs, and significant parties at the helm of authority will benefit from the knowledge of the trajectory of the COVID-19 in the Horn of Africa. Additionally, the study captures the effect of social distancing protocols amid the pandemic. The complexity of adhering to social distancing guidelines is linked to the multiplicity of factors associated with the COVID-19.
Due to contextual factors that fraught countries in the Horn of Africa, the burden of battling the daunting effect of the COVID-19 will be overwhelming if they hit on a similar magnitude to what has been experienced in the middle-and high-income countries. However, recent statistics demonstrate that the effect of the COVID-19 is not as high as professional analysts and the WHO anticipated. Hence, lessons on coverage of crucial prevention measures from countries in the Horn of Africa would aid in budget planning, the precise allocation of resources, and contextualized interventions needed most by these neighbouring countries besides the promoted general health guidelines. Hence, this study aims to summarize and compare the COVID-19 situation in the four Horn of African countries, namely Djibouti, Eritrea, Ethiopia, and Somalia.

Study design
A prospective cross-sectional study in which the total number of daily reported cases and deaths were collected from the official website of WHO and Worldometer. The study population were all clinically reported confirmed cases of the four Horn of Africa countries (Djibouti, Eritrea, Ethiopia, and Somalia) from March to December 2020. This study examines the patterns of COVID-19 incidences in the four countries of the Horn of Africa Sub-Saharan regions and the extent to which the community has adopted the COVID-19 precaution measures.

Study settings
The researchers analyzed data from the Horn of African countries. The Horn of Africa is a region of the eastern part of Africa, located closer to the Arabian Peninsula, connecting the Indian Ocean and the Red Sea. It consists of four countries: Djibouti, Eritrea, Ethiopia, and Somalia 26,27 . The people in these countries have interlinked and very close cultural, political and religious connections throughout their long history ( Figure I).

Data collection
These data were obtained from online reports 8,24 in which daily COVID-19 incidences were collected through an unstructured questionnaire by two independent investigators with core team members. The team met in a small group weekly virtually online via zoom and communicated for any discrepancy on a daily report of the respected country's official information. The researchers made observations from March 2020 to December 2020 on the national number of new cases, deaths, and recovery in each of the selected Horn of Africa region's countries.

Study population
All daily reported confirmed COVID-19 cases in the studied countries, from residents of the Horn of Africa region, were included in this study.

Data sources
Daily data recording of two or more trusted sources, mainly the national ministry of health report of each studied country, national media outlets, and WHO report of daily national and global cases, were used. Additionally, information on preventive measures from country sources was included 8, 24, 29-34 .

Statistical analysis
Two independent recorders performed data extraction using the Microsoft Excel Spreadsheet tool. The study's principal investigator carried out rigorous daily quality control monitoring. One of the researchers was assigned to compiling daily records and conducting checks randomly to ensure high-quality data. Descriptive statistics method of data analysis was used to show the distribution of the number of cases and deaths by country. Data were presented using the frequency and percentage of the variables. Standardization of data was based on each country's current total population as provided by the world population prospects 2020 35 per million.

Ethical Concerns
This study is exempt from ethical review as it has used publicly available data in which no participant's identification or socio-demographic information was exposed. Table 1 shows the number and percentage of confirmed cases segregated by the studied countries and the total in the Horn Africa region. As of 31 st December 2020, the cumulative number of COVID-19 cases detected in the Horn of Africa were 136,129 (7,590 per one million). Country wise distribution or share of these cases was: for Djibouti (77.20%), Eritrea (4.87%), Ethiopia (14.07%), and Somalia (3.86%). The overall case fatality rate (CFR) in the Horn of Africa was 1.14% during the study time.

Description of COVID-19 infection in the Horn of Africa
The highest infection and case fatality rates were recorded from Djibouti, which is 5831(5860 per million) and 61(61 per million), respectively. Somalia had the lowest infections, 4714 (293 per million), and Eritrea had the lowest death rate, only three deaths (1 per million) compared to the others. The recovery rate among COVID-19 cases was high in Djibouti (98.2%) and Ethiopia (90.2%), while in Eritrea and Somalia was 51.2% and 76.6%, respectively. The total number of deaths and recovered participants by country is presented in Table 1 below.    Figure III).   From Somalia, 50% (2/1M) and 12% (3/1M) out of 33 (4/1M) and 80 (25/1M) death cases were reported in April and May 2020, respectively (Table 3, Figure IV). More than 50% of deaths in the Horn of Africa were recorded from Ethiopia from August to December 2020 (  Figure IV). In August, the highest proportion of mortality reports was 71.4% (5/1M). Until November 2020, Eritrea was the only country in the Horn of Africa with no deaths related to COVID-19. However, in December 2020, the country reported three (1/1M) ( Table  3, Figure IV).   Djibouti's government received 5 million U.S dollars as an emergency fund approved from the World Bank on the 2 nd of April 2020 29 . Moreover, WHO provided personal protective equipment as a preventative measure to Djibouti. In contrast, Somalia assigned 5 million U.S. dollars to fight the pandemic 23 . An intensive campaign was given to the community using different mass media and community levels in Eritrea. The Ministry of Health announced quarantine for visitors to Eritrea from the epicentre countries beginning from 1 th March 2020 37 . Moreover, all schools were closed, social distancing in all religious places was also applied following the international standard protocols. Except for those with an approved license (permission), all public transport at regional levels and cities were suspended. Eritrean diaspora communities donated a huge amount of money to support the government in fighting the pandemic 38 and ensuring the well-being of nationals inside the country. Besides, many house owners' citizens living inside and abroad are offered at least two months to one-year free rental payment to their tenants.
In Djibouti, the government announced a national lockdown on 23 rd March and extended it to the 8 th of May 39 .
In line with this, all schools and worship places have been closed since 19 th and 22 nd March, respectively. Ethiopia's government has quickly taken various measures to prevent the spread and control the pandemic 34 . For instance, the authorities have closed all boundaries, shut down schools, universities, and colleges, requested the shuttering of nightclubs and amusement outlets, reported social distancing measures, called on retired healthcare professionals for support, and prepared clinical faculty for National Health Service. Moreover, all individuals entering Ethiopia from abroad were subjected to the mandatory 14-day isolation at assigned hotels at their own cost. On the 8 th of April 2020, Ethiopia banned inter-regional public transport and public gatherings except for the Djibouti border to transport commercial goods 40 .

Discussion
The emergent nature of the COVID-19 has stimulated huge community tensions in both developed and developing countries. Ever since the first case was detected, each government of the Horn of African countries immediately took various sweeping measures to reduce the impacts of the COVID-19. The measures included but are not limited to; schools' closure, travel restrictions, ban on public gathering, nationwide lockdown, mandatory quarantine; for any entering the country, those who had direct contact with a confirmed case, and communities or buildings where a case was detected 39,41 . Likewise, the other strategies were suspended public transport and imposed travel restrictions and task force formation responses to COVID-19 38  September to December in Ethiopia. In Somalia, the case fatality rate increased from July (1.1%) to December (6.9%) ( Figure IV). Djibouti's socio-economic situation forced the Djiboutian government's hand to lift implemented lockdown measures, resulting in the country's increased infection rate 47 . The high number of infections in Ethiopia could be due to the only partial and not complete lockdown measure implemented, the highly dense population in Addis Ababa, the capital 48 , and delayed suspension of incoming international flights 49  As cases worsen, a rapid response measure is essential to be put forward in halting the spread of the pandemic. Thus, subduing the COVID-19 was given a high priority for many countries. In response, Eritrea applied stricter measures that attained a substantial outcome in the rate of infection and death cases 61,62 . In addition, lockdown measures and early implementation were related to positive results 63 . Other reasons for the reduced cases and deaths in the Horn of Africa, particularly in Eritrea, were the demographics, low volume of global air traffic, and a moderately young population that played a positive part in slowing down the pandemic 62 . In general, as many studies have reported diseases associated with severe illness and death from COVID-19, regularly connected with older populations, such as for overweight, hypertension, cardiovascular diseases, chronic lung infection, malignancy, and diabetes, are less predominant in the region 52,62,64 .
Although burgeoning literature refers to Horn of Africa countries as economically fragile states [16][17][18] , they were adequately prepared for the pandemic as it took a long time to reach the region compared to other continents. This preparedness could be one reason for the low cases in the Horn of Africa. This observation is similar to what has been reported in West Africa 65 . To our knowledge, there was no delay concerning reporting, underreporting, or misdiagnosis in the Horn of Africa countries.

Conclusions
The Horn of Africa took several steps to detect, manage and control COVID-19. The epidemiological pattern of COVID-19 among the Horn of African countries seems to have slow progress, given the prevalence of the new infections remains low, and the death toll seems stable throughout the study periods, except for Djibouti. Hence, the pandemic needs timely consideration; and prevention and control measures to curb and mitigate the transmission of the infection and minimize death rate need to be further strengthened. In general, the Horn of Africa countries need to continue in harmony and collaboration to work together in solidarity to safeguard their population from the pandemic.
To the best of our knowledge, this is the first study to provide a trend on the COVID-19 using data from the four Horn of Africa countries. Nevertheless, this is not without a limitation. The limitation of our study is that the age and gender data of the Horn of Africa countries in the official website of the WHO and Worldometer were not available. Hence, the researchers could not compare based on age and gender. Also, since this study focused on the Horn of Africa countries, the situation in other parts of Africa wasn't reported. Comparisons were made regarding the previously mentioned countries in the Horn of Africa. Future researchers are encouraged to conduct a similar study that compares data based on demographic variables such as age and gender and captures statistical data on the pandemic situation in other African countries.