Thread by @InfectiousDz

It's been a tricky virus to track

In Somalia, where the average age is 18, life is lived more outdoors, there's less obesity, COVID hasnt made itself known

Testing in Somalia is expensive and primarily for those with a plane ticket to travel

Masking is also not common

https://twitter.com/ghn_news/status/1346497964357918723

Although case positivity is low, testing has not been aimed at those symptomatic, but often those who are tested are not those who are symptomatic. Many are tested for plane flights with ticket in hand.

Deaths from COVID have not stood out, but without testing and in a young population, severe cases may not be as apparent.

Age certainly influences the IFR world wide. Somalia is a young country.

Here is the age pyramid for Somalia. There are very few over the age of 50. This profoundly influences the severity of illnesses seen.

Compare Somalia age pyramid above to the US below. For COVID, the US is much more vulnerable, as a substantially larger number are over the age of 50.

Ventilation has been a crucial issue for COVID.
Summer in the US South is a time indoors with air conditioning, Winter in the US North (and European, Canadian) is also a time indoors in the heat. COVID took advantage.

More of life is lived with natural ventilation in Somalia

Here's a peek at some Somali windows, relying on natural ventilation (even if the sliding ones don't provide enough).

https://twitter.com/omar_degan/status/1063693606282764288?s=20

So although the health system is quite substantially in need of strengthening and cases are not being tracked, it's not that the epidemics seen in Europe and the US are just slipping through the tracks. It's been a different epidemic.

Without doubt, those who die, die undiagnosed in many parts of the world. Fever or malaria may be the only label.

There's also the issue of masks. They haven't been very popular. Those who wear them may be asked, do you have COVID? It can be visible and stigmatizing

There's also always competing issues. who.int/news-room/feat…

Can also tag on obesity, or lower rates thereof, to the landscape.

The result is a lack of urgency around COVID, after initial concern. It's sometimes said it's not in Somalia, it's not a Somali problem. If it ever is more of a problem, it will be that much harder to tackle.

Although a disease with 1% morality rate would not be notable in a resource limited country with lots of oxygen, most resource limited countries do not have lots of oxygen available. For every patient who died, there's often 7 others who need oxygen and may die without.