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Background: Population mortality is an important metric that sums information from different public health risk factors into a single indicator of health. However, the impact of COVID-19 on population mortality in low-income and crisis-affected countries like Sudan remains difficult to measure. Using a community-led approach, we estimated excess mortality during the COVID-19 epidemic in two Sudanese communities. Methods: Three sets of key informants in two study locations, identified by community-based research teams, were administered a standardised questionnaire to list all known decedents from January 2017 to February 2021. Based on key variables, we linked the records before analysing the data using a capture-recapture statistical technique that models the overlap among lists to estimate the true number of deaths. Results: We estimated that deaths per day were 5.5 times higher between March 2020 and February 2021 compared to the pre-pandemic period in East Gezira, while in El Obeid City, the rate was 1.6 times higher. Conclusion: This study suggests that using a community-led capture-recapture methodology to measure excess mortality is a feasible approach in Sudan and similar settings. Deploying similar community-led estimation methodologies should be considered wherever crises and weak health infrastructure prevent an accurate and timely real-time understanding of epidemics' mortality impact in real-time. [ABSTRACT FROM AUTHOR]

Background: Shielding of high-risk groups from coronavirus disease (COVID-19) has been suggested as a realistic alternative to severe movement restrictions during the COVID-19 epidemic in low-income countries. The intervention entails the establishment of 'green zones' for high-risk persons to live in, either within their homes or in communal structures, in a safe and dignified manner, for extended periods of time during the epidemic. To our knowledge, this concept has not been tested or evaluated in resource-poor settings. This study aimed to explore the acceptability and feasibility of strategies to shield persons at higher risk of severe COVID-19 outcomes, during the COVID-19 epidemic in six communities in Sudan.Methods: We purposively sampled participants from six communities, illustrative of urban, rural and forcibly-displaced settings. In-depth telephone interviews were held with 59 members of households with one or more members at higher risk of severe COVID-19 outcomes. Follow-up interviews were held with 30 community members after movement restrictions were eased across the country. All interviews were audio-recorded, transcribed verbatim, and analysed using a two-stage deductive and inductive thematic analysis.Results: Most participants were aware that some people are at higher risk of severe COVID-19 outcomes but were unaware of the concept of shielding. Most participants found shielding acceptable and consistent with cultural inclinations to respect elders and protect the vulnerable. However, extra-household shielding arrangements were mostly seen as socially unacceptable. Participants reported feasibility concerns related to the reduced socialisation of shielded persons and loss of income for shielding families. The acceptability and feasibility of shielding strategies were reduced after movement restrictions were eased, as participants reported lower perception of risk in their communities and increased pressure to comply with social commitments outside the house.Conclusion: Shielding is generally acceptable in the study communities. Acceptability is influenced by feasibility, and by contextual changes in the epidemic and associated policy response. The promotion of shielding should capitalise on the cultural and moral sense of duty towards elders and vulnerable groups. Communities and households should be provided with practical guidance to implement feasible shielding options. Households must be socially, psychologically and financially supported to adopt and sustain shielding effectively. [ABSTRACT FROM AUTHOR]

COVID-19 prevention strategies in resource limited settings, modelled on the earlier response in high income countries, have thus far focused on draconian containment strategies, which impose movement restrictions on a wide scale. These restrictions are unlikely to prevent cases from surging well beyond existing hospitalisation capacity; not withstanding their likely severe social and economic costs in the long term. We suggest that in low-income countries, time limited movement restrictions should be considered primarily as an opportunity to develop sustainable and resource appropriate mitigation strategies. These mitigation strategies, if focused on reducing COVID-19 transmission through a triad of prevention activities, have the potential to mitigate bed demand and mortality by a considerable extent. This triade is based on a combination of high-uptake of community led shielding of high-risk individuals, self-isolation of mild to moderately symptomatic cases, and moderate physical distancing in the community. We outline a set of principles for communities to consider how to support the protection of the most vulnerable, by shielding them from infection within and outside their homes. We further suggest three potential shielding options, with their likely applicability to different settings, for communities to consider and that would enable them to provide access to transmission-shielded arrangements for the highest risk community members. Importantly, any shielding strategy would need to be predicated on sound, locally informed behavioural science and monitored for effectiveness and evaluating its potential under realistic modelling assumptions. Perhaps, most importantly, it is essential that these strategies not be perceived as oppressive measures and be community led in their design and implementation. This is in order that they can be sustained for an extended period of time, until COVID-19 can be controlled or vaccine and treatment options become available. [ABSTRACT FROM AUTHOR]