The rst 100 days of the COVID-19 epidemic in Mali: a descriptive analysis

Birama Apho Ly (  apholyca@hotmail.com ) Université des Sciences, des Techniques et des Technologies de Bamako Mohamed Ali Ag Ahmed Université de Sherbrooke Tamba Mina Millimouno National Rural Health Training and Research Centre of Maferinyah Yacouba Cissoko Université des Sciences, des Techniques et des Technologies de Bamako Christophe Laba Faye International Organization for Migration Fatoumata Bintou Traoré National Institute of Public Health, Bamako, Mali Niélé Hawa Diarra Université des Sciences, des Techniques et des Technologies de Bamako Ibrahima Berthé Ministry of Health and Social Affairs, Bamako, Mali Ahmadou Boly Ministry of Health and Social Affairs, Bamako, Mali Hamadoun Sangho Université des Sciences, des Techniques et des Technologies de Bamako Seydou Doumbia Université des Sciences, des Techniques et des Technologies de Bamako


Introduction
Effective public health intervention relies on the quality of health information (1)(2)(3).In the ght against epidemics, health information is even more important given the speed of transmission of these diseases, their health and non-health consequences, and the need for effective intervention (4)(5)(6)(7).As part of the ght against COVID-19, information is regularly provided by countries to inform national and international opinion on the evolution of the epidemic.In Mali, this information is communicated as a daily released of information and situation report by the National Institute of Public Health (INSP), the coordinating agency of the Ministry of Health and Social Affairs (MSAS) for COVID-19 control.These reports inform the national and international opinion on the evolution of COVID-19 situation and are considered to be among the most o cial communication tools on COVID-19 in Mali.This study aims to analyze the data shared through the daily released of information and situation reports provided by INSP during the rst 100 days of the epidemic.Analyses of the reports will provide valuable information for understanding the real magnitude and evolution of the epidemic.It will also contribute to improve the quality of the data related to COVID-19 by identifying the gaps in the information communicated for effectively guide intervention aiming to slow or stop the evolution of the epidemic.

Method
We focused on the indicators informed by the COVID-19 coordination Agency and published regularly through daily released of information and situation reports on Covid-19.Speci cally, we focused on the testing, con rmed cases, case-contacts, recovered patients and COVID-19 related deaths; and the geographic locations affected by the epidemic.The number of testing is the number of nasal swab specimen tested for SARS-CoV-2 using RT-PCR to detect the presence of viral RNA (8).Con rmed cases are individuals (asymptomatic or symptomatic) whom nasal swab specimens have been tested positive by RT-PCR.Asymptomatic cases are those with no clinical sign, while symptomatic cases are those presenting a single or multiple clinical signs (8).The well-known clinical signs attributable to COVID-19 are: fever, cough, myalgia, dyspnea, nasal congestion, headache, rhinorrhea, sore throat, vomiting, diarrhea, red eye, anosmia, ageusia and discomfort (9)(10)(11)(12).There are evidences that asymptomatic cases are the most common and may account for 50-80% of cases.A case-contact is a person who had been in contact with a con rmed case two days before and who begins to show signs up to 14 days after onset (8).Recovered patients are con rmed cases who remain negative after two consecutive RT-PCR tests.COVID-19 related deaths are COVID-19 con rmed cases who died before recovery, or found positive after a post-mortem testing (8).
Daily released of information on Covid-19 shared by the Coordination Agency for COVID-19 control during the rst 100 days of the COVID-19 epidemic were downloaded from the o cial website of MSAS.
Situation reports have been obtained from the Coordination Agency for COVID-19 control.It was possible to include more released of information and situation reports, but those of the rst 100 days were su cient to get an overview on the evolution of COVID-19 in Mali.Thus, from the released of information and situation reports of the rst 100 days, the data related to the above-mentioned indicators were extracted on an Excel le before being analyzed with SPSS 25 software.The analyses were essentially descriptive including Spearman correlation test and Chi 2 test for statistical signi cance (p≤0, 05).

Descriptive analyses
The number of testing during the rst 100 days of COVID-19 epidemic was 14,938.The daily mean of testing was 149.4; the median 126.5 and the mode zero (see Table 1).The total number of con rmed cases was 2,260.0, with a mean of 22.6 cases a day, a median of 19.0 and a mode of 19.00.The total number of recovered patients was 1502.00, the mean 14.02, the median 14.00 and the mode 0.00.The total number of COVID 19 related deaths was 117.00 with a mean of 1.2 deaths a day, a median of 1.00 and a mode of 0.00.The total number of case-contacts traced during the study period was 12,864.00.The mean was 128.6 contacts traced a day and the median 114.0.The trend curves of the number of testing, con rmed cases, case-contacts, recovered patients and COVID-19 related deaths all had a sawtooth pattern.Figure 1 shows the trend curve for con rmed cases.Examining the various distributions, only the number of con rmed cases and the number of COVID-19 related deaths had a normal distribution (see Figure 1).Descriptive analyses also showed that 5.17% of the con rmed cases dead during the rst 100 days of COVID-19.
The regions of Sikasso and Ségou were among the least affected regions.

Correlation analysis
Correlation analyses showed that the number of con rmed cases was positively correlated with the number of testing, case-contacts, recovered patients and COVID-19 related deaths (see Table 3).In other words, during the rst 100 years of COVID-19 the increase in the number of con rmed cases was correlated with the increase in the number of testing, case-contacts, recovered patients and COVID-19 related deaths.*.The correlation is significant at the 0.05 level (bilateral).

Discussions
The results showed during the 100 rst days of COVID-19 epidemic, Mali reported 2,260 con rmed cases.The saw-tooth distribution of these cases seems to re ect the variability in the number of testing meaning that the real distribution of COVID-19 cases needs to be known as the real distribution of the tested people needs to be known.The daily released of information and situation reports do not report the number of tested people.They only report the number of tested samples.Here, it is important to note that for diseases such as COVID-19, the number of tested samples is not the number of tested people as a person may provide more than one specimen for con rmation and monitoring purpose.Thus, the 14,726 tested samples do not correspond to 14726 people.Based on that, less than 1% of the Malian population estimated as 18 million was tested during the rst 100 days of the epidemic (13).With this information, it is di cult to say that the testing efforts undertaken in Mali during the rst 100 days provide an overview on the real magnitude of the epidemic.Without this overview, it is di cult to control that epidemic.
Evidence indicates that such overview is crucial to control epidemics such as COVID-19 (14).
Correlation analyses showed that there was a positive correlation between the number of con rmed cases and the number of testing.In other words, Mali could have more positive cases by testing more people.Thus, the 2,260 con rmed cases that have been reported may underestimate the real magnitude of the epidemic.This undermines any assumptions that African countries have few cases of COVID-19 or that Africans are more protected against the disease.If they were tested effectively and on a large scale, there would necessarily be more cases to support or refute the hypothesis of natural protective immunity in Malian population.There is evidence that the spread of diseases such as COVID-19 is more a matter of policy and epidemic management failures than biological factors (15).A large well-organized testing program, combined with extensive efforts to isolate infected people and trace and quarantine their contacts has been keys to the success in controlling the COVID-19 epidemic in South Korea (15).
In addition to underestimating the real magnitude of the epidemic, daily released of information and situation reports do not provide the proportion of asymptomatic or symptomatic patients with mild, moderate, severe or critical symptoms (5,16).The clinical characteristic of con rmed cases is important in terms of public health intervention and public risk communication as 3% to 6% of the cases may progress to the critical phase of the disease (17)(18)(19)(20).In Mali, the health authorities gave information on the con rmed cases without giving further details on the severity of the cases which could in uence the adoption of preventive measures against COVID-19.Another important gap in the information provided on COVID-19 situation is the inconsistency in the number of recovered cases and the lack of details about their trajectory.Tracking con rmed cases is very important as 12% to 19% of the cases of COVID-19 may go through hospitalization (17)(18)(19)(20).From the daily released of information and situation reports, it is di cult to determine the actual number of con rmed cases who recovered from hospitalization or at home.
It should be also noted that contact cases are not routinely tested in Mali.Because of a weak contacttracing policy, several cases of COVID-19 may have escaped the system, especially given the fact that many contaminated people remain asymptomatic for some time or forever (21)(22)(23)(24).It could thus favor pre-symptomatic or asymptomatic transmission, de ned as the transmission of the virus from an infected person showing no signs at the time of testing to an uninfected person (25).
Likewise, the number of COVID-19 related deaths is also underestimated.In order to better estimate the lethality, it is necessary to know the actual extend of the epidemic through a large-scale ante-mortem or post-mortem testing strategy.In Mali, a systematic post-mortem testing strategy was not adopted and could contribute to a better estimation of the lethality.
With regard to the geographic distribution of COVID-19, daily released of information and situation reports provided information only on the geographic location of con rmed cases.Also, several geographic locations close to Bamako seem to be less affected than some geographic locations quite far from Bamako (the epicenter of the epidemic).These geographic locations include Tombouctou, Mopti and Kidal which are located from 600 to 1500 Km from Bamako.This question is puzzling.Its Answer requires further investigation to better understand the dynamics of the spread of the virus through geographic locations.

Conclusion
This analysis of Mali COVID-19 reports shows that the country reported low numbers of COVID-19 cases during the rst 100 days of the epidemic.However, this is not necessarily indicative of low prevalence or successful control but insu cient virus testing and contact tracing.It suggests that Mali needs to do more COVID-19 viral testing by screening more people in ante-mortem and post-mortem, particularly among contact cases.It also highlights the need for improving the identi cation, location and follow-up of con rmed, contact, recovered and dead cases.Addressing these issues will help to understand the evolution of COVID-19 epidemic and to improve communication by adapting the content of daily released of information and situation reports to the needs of populations and health actors, contributing to reducing the spread of the epidemic and preserving populations' health.

COVID- 19 :
Coronavirus disease 2019 PCR: Polymerase chain reaction SPSS: Statistical Package for the Social Sciences SARS-Cov 2: Severe acute respiratory syndrome coronavirus 2 INSP: National Institute of Public Health MSAS: Ministry of Health and Social Affairs RNA: Ribonucleic acid RT-PCR: Reverse transcription polymerase chain reaction Sig.: signi cance Declarations Ethics approval and consent participate Not applicable, because the study focused only on data from the daily released of information and situation reports on COVID-19, which are publically shared by the Coordination Agency for COVID-19 control and available on the website of the Ministry of Health and Social Affairs and at the National Institute for Public Health.

Figure 1 Evolution
Figure 1

Table 1 :
Trend of testing; and confirmed cases, case-contacts, recovered patients and COVID-19 related deaths during the first 100 days of COVID-19 in Mali

Table 2 :
Distribution of confirmed cases, COVID-19 related deaths and lethality by geographic location

Table 3 :
Correlation between the number of tested samples; and confirmed, recovered, dead and contacts cases **.The correlation is significant at the 0.01 level (bilateral).