The outcome of the analysis of COVID-19 data for the confirmed cases of infection and recorded deaths from the index case reporting to forty-five days study period indicates a clear cut division between the different countries being assessed. In particular, countries such as Nigeria and Ghana in sub-Saharan Africa were found to have consistently different pattern of confirmed cases of COVID-19 infection and recorded death cases compared to countries with more robust and well-resourced healthcare systems in Europe (Italy, Spain and UK) and USA. During the study period, the number of confirmed cases of infection and associated deaths in sub-Saharan Africa were found to be very low (confirmed cases – range from 318 to 408; Deaths - 6 to 10) compared to the exceeding high values (confirmed cases – range from 25150 to 189967; Death – 4064 to 12428) in the developed countries with better healthcare systems.

The wide variation in reported numbers of COVID-19 infection and deaths raises a lot of concern on what might be going on with respect to epidemiology, data collection and management of the disease in the countries assessed. According to Vaughan (2020), experts still do not know why so few cases of the new coronavirus have been reported in Africa, despite China – where the virus originated – being the continent’s top trading partner and the continent having a population of 1.3 billion people. The consensus within the scientific community based on views and opinion being expressed in many online platforms is that testing for COVID-19 among the sub-Saharan African countries is generally very low, and this would have a major influence on the number of reported confirmed cases of the infection in sub-Saharan Africa. According to available data accessed on the 17^th of April 2020, the volume of COVID-19 tests in sub-Saharan Africa ranges from 5000 (Nigeria) to 50719 (Ghana) compared to 3.4 million in USA, 1.1 million in Italy, 930230 in Spain and 417649 in UK (www.worldodometer.com). So it is quite possible that if more testing were carried out in these countries, the number of confirmed cases will most likely rise significantly. However, given the current level of awareness of COVID-19 on the African continent, the lack of coronavirus-linked death outbreaks of the scale in Ecuador, USA, Italy, Spain or UK suggest either there is a lag in the outbreak of the disease in Africa or other factors may be responsible for the low confirmed cases of the infection and death numbers in sub-Saharan Africa compared to the overwhelming high numbers in the European countries and USA evaluated in this study.

The outcome of the evaluation to determine possibility of mutational shift that could adversely contribute to the virulence or differential incubation period of the novel corona virus (SARS-CoV-2) based on geographical location, revealed that the recovery rate from the viral infection has no correlation with the mutational attributes of the virus. The sequenced strain from Nigeria had no significant difference from other geographical regions. Ahmed et. al. (2020) also reported that no mutation has been observed in these identified epitopes among the 120 available SARS-CoV-2 sequences (as of 21 February 2020) and suggested that immune targeting of these epitopes may potentially offer protection against this novel virus. Our observation therefore provides a bit of relief, as regarding the lesser mutation abilities of the virus, thereby reducing the probability of longer incubation period for the epitope in Nigeria.

Results from this study have shown that there is currently a higher infection rate of SARS- CoV-2 and mortality from COVID-19 in developed countries without a current universal BCG vaccination policy compared to African countries with a current universal vaccination policy. Miller et al. (2020) have also reported reduced morbidity and mortality in countries with a universal BCG vaccination policy compared to countries without a policy. They indicated that the earlier the country implemented a BCG vaccination policy, the lower the number of deaths per million inhabitants. The reduced infection rates of SARS-CoV-2 and death from COVID-19 currently reported in African countries may not be a direct impact of the implementation of a universal BCG vaccination policy alone. Other factors such as climatic conditions, lifestyle and incidence of other diseases such as malaria could be responsible for the reduced incidence of COVID-19 in these countries.

The evaluation of malaria endemicity with occurrence of COVID-19 revealed that countries with high malaria burden had surprisingly low COVID-19 incidence than those with low malaria burden. This result does not infer causation, but a possible explanation could be environmental. The countries most affected are in the temperate region and viral respiratory infections usually occur more frequently during winter and fall seasons; and the COVID-19 outbreak became more widespread during the flu season in Europe and USA (Wang et al., 2020). For the tropical countries, flu occurs more frequently during the more humid time of the year which is the rainy reason, predominantly between June and September-October and so may explain the low infection (Haines et al., 2006; Lin et al., 2006). As a result, several opinions have been expressed on different online platforms of a possible link to the use of Chloroquine for malaria treatment. However, in many African countries, Chloroquine use has long been changed to Artemisinin Combination Therapies (ACTs) as drug of choice for malaria treatment over a decade ago due to drug resistance. Therefore, the observation of occurrence of low confirmed cases of COVID-19 with high malaria burden associated with Chloroquine use cannot be fully substantiated. It is therefore highly possible that there are other existing factors which may be responsible for the observation of high malaria endemicity with low occurrence of COVID-19 cases in this study.

Although several factors have been reported to aid the dispersal and transmission of COVID- 19 across the globe, temperature remains a strong factor of the transmission efficiency (Chan et al., 2011; Yip et al., 2017). The outcome of our study suggests that COVID-19, like the flu disease category, thrive better in low temperatures. This result is consistent with Sajadi et al. (2020) who reported distribution of significant community outbreaks along restricted latitude, temperature and humidity which are consistent with the behavior of seasonal respiratory virus. Yao et al. (2020) however submit that there was no relationship between temperature (and radiation) and COVID-19 cases in the cities of China. There is therefore the need for more studies to determine how seasonal changes in temperature (summer vs. winter) will affect the transmission of COVID-19 especially as the boreal summer approaches and the southern temperate countries prepare for winter.

Current guidance from the World Health Organisation (WHO) is that there is no known cure for this virus with 100% certainty however, research for vaccinations and cure continues fervently. In the interim, official guidance from global public health authorities is to test, test and test as many individuals of the population, practise social distancing, washing of hands with soap, use of hand sanitizers and then to proceed with caution when adopting any of the speculative treatment options. This very loose guidance has led to differential healthcare approaches to management of COVID-19 in different countries across the world. The outcome of our findings has revealed that fundamental differences exist between the healthcare systems of sub-Saharan Africa and those of Europe and America. In Europe and America, the preferred treatment approach has been to test, voluntary isolation at home, hospitalise for observation and treat, however, in sub-Saharan Africa, the approach is basically test, mandatory isolation and treat (see Table 11). So while the developed countries are concentrating on testing, the sub-Saharan African countries seem to be concentrating more on treating the diseases with some of the speculative re-purposed drugs.

Although there seems to be no basis for comparison in terms of resources and organisation between the healthcare systems in Europe and USA with that of sub-Saharan Africa, the outcomes with regards to number of recorded deaths or recovery rate of COVID-19 patients is staggering and very baffling. While a more resourced healthcare system in Europe and America has an outcome of 4064 (USA), 1789 (UK), 8464 (Spain) and 12428 (Italy) deaths after 44 days of reporting the 1^st index case, a country like Nigeria recorded 10 deaths after 44 days (www.worldodometer.com). So it does appear that something must be amiss because the numbers simply do not follow basic logic. It therefore seems that there may be a need to review the current healthcare approaches or guidance the mentioned developed countries have adopted to managing the COVID-19 illness. The outcomes in terms of the substantial huge number of recorded deaths seem to indicate a weakness in the healthcare approach. It may just be time to learn a lesson or two from the approach which the less developed countries have adopted to manage the disease in this time of emergency.

In Europe and America, the healthcare system is largely centrally controlled; public sector based and with rampant initiation of professional consequences if a wrong call is made. Also, there is controlled access to many drugs. However, in sub-Saharan Africa countries like Nigeria, the healthcare system is predominantly private, with lesser occurrence of initiation of professional consequences. The inability or difficulty of the healthcare workers in the more developed countries to adapt rapidly and explore the use of speculative drugs during this emergency maybe attributable to the stringent medical guidance, professional consequences and exposure to lawsuits associated with medical care in the countries. However, the differential outcomes from the two approaches in the management of this pandemic between the selected countries is indicative that in the enactment of emergency legislations for disease outbreaks, the congress or legislative bodies need to consider inclusion of clauses which are aimed at shielding the healthcare professionals of potential litigations that may arise from some decisions taking in their attempts to save lives during this type of novel disease outbreaks.

Apart from healthcare approach to management of the disease, a curious look at the healthcare systems in the different countries points to major obvious differences. Aside from the substantial differences in funding and manpower availability, there is almost unfettered access to most types of prescription drugs. Therefore, it is very possible that a large number of COVID-19 positives in Africa would have reached out to the pharmacist for different treatment sessions before eventually going for COVID-19 test. So could this early treatment occasioned by easy access to prescription drugs be a factor in the lowering death numbers being recorded in countries like Nigeria and Ghana? There is little doubt that in an emergency situation like the COVID-19 pandemic, the somewhat informal nature of healthcare practice in sub-Saharan Africa probably gives the healthcare professionals more room to operate by prescribing without formal guidance, certain drugs which have been reported in several media as being effective for the treatment of COVID-19, without significant fear of professional consequences and litigations that are quite rampant in the health administration of the more developed countries. There is also little doubt that lessons learnt from the Ebola incident in sub-Saharan Africa may have also contributed to the low numbers of COVID-19 confirmed cases and deaths. Communities that experienced Ebola in West Africa in 2014-2016 seem to have learnt a painful lesson on how to cope with a deadly new infection with important information on strategies to address novel disease threats more generally (The World Bank, 2020). Nigeria for example, announced on Friday 28 January 2020 the first index case coronavirus disease COVID-19 in sub-Saharan Africa’s region and the confirmation led to the immediate activation of the country’s National Coronavirus Emergency Operation Centre riding on facilities put in place during the Ebola crisis (Nature Medicine, 2020). There is no doubt that when another epidemic arises again, the experiences of the COVID-19 pandemic will make a lot countries to act differently and possible swiftly, which might affect the overall disease burden.