Bayesian Spatio-Temporal Outbreak Detection for COVID-19 Mortality in South Africa: A Comparative Study of MCMC and Dynamic HMC Methods.

Background: Timely detection of localised COVID-19 surges is essential for targeting limited health resources, yet most routine surveillance algorithms ignore spatial dependence and many Bayesian spatio-temporal models are computationally demanding. Evidence on Hamiltonian Monte Carlo (HMC) performance for outbreak detection in low- and middle-income country (LMIC) settings remains limited. We applied a Bayesian spatio-temporal hidden Markov model (HMM) to South African COVID-19 hospital mortality, comparing data-augmented Markov chain Monte Carlo (MCMC) with dynamic HMC. Methods: We conducted a retrospective ecological time-series study of in-hospital COVID-19 deaths across 52 districts over 28 months (March 2020-June 2022), using national hospital surveillance linked to district-level health-system and population indicators. Death counts were modelled with a Poisson log-linear specification incorporating a smooth temporal trend, cyclic seasonality, spatial smoothing, and selected covariates, offset by expected deaths from admissions and a case-fatality ratio. Outbreaks were represented by a two-state HMM with latent indicators integrated out analytically and estimated via dynamic HMC in Stan. Eight candidate models were ranked using marginal likelihoods; the preferred model was re-fitted with both samplers to compare runtime, ESS, and convergence. Results: A spatial HMM with marginalised outbreak states was strongly favoured over non-outbreak and threshold-based alternatives. Posterior outbreak probabilities reproduced the four recognised national waves while revealing marked district-level heterogeneity, with early intense outbreaks in Western Cape and Gauteng districts and later peaks inland. Outbreaks were short-lived (mean around three months), and residual spatial risks indicated persistent excess mortality in the Eastern Cape and Free State. Dynamic HMC and MCMC yielded similar outbreak probability surfaces; however, HMC produced substantially larger ESS (approximately 5,000 versus 63) and near-ideal convergence, whereas MCMC showed poor mixing. ESS per second was similar, so HMC's extra computation yielded more informative samples. Conclusions: A Bayesian spatio-temporal HMM fitted with dynamic HMC delivers coherent, spatially resolved outbreak probabilities and captures short-lived district-level mortality surges within broader national waves. Despite greater computational intensity, dynamic HMC offers superior mixing and convergence and is preferable for routine surveillance when adequate computing resources are available. The framework is transferable to other routinely collected surveillance data in South Africa and similar LMIC settings.