Issue 5: Covid-19 in Africa: Scenarios and Signposts

Apr 29, 2020

By Alex Coutinho, MBChB / MPH / MSc / DTM&H

Ugandan physician and Chair of the Board of the International Partnership for Microbicides

The trajectory of COVID-19 in Africa is uncertain. While the continent has unique demographics and strengths in fighting infectious diseases, it will face major challenges as well.

The COVID-19 pandemic has been slow to get to Africa: As of 29th April 2020, there are over 32,000 estimated infections and fewer than 1,400 deaths due to COVID-19 – less than the number of daily deaths in the USA. The real figures are most likely higher due to insufficient testing globally and many COVID-19 deaths occurring without any confirmatory tests or outside of hospitals. The United Nations Economic Commission for Africa (ECA) has modelled a scenario of between 300,000 – 3,300,000 COVID-19 deaths in Africa, depending on how the continent responds. Is Africa therefore in greater danger compared to the rest of the globe? Or could the opposite be true?

It is important from the outset to recognize that Africa is diverse, and that individual countries like Egypt, Uganda and South Africa have very different contexts, demographies and health systems. The COVID-19 epidemic will likely play out differently, depending on local context, mitigation efforts and the advent of time and emerging knowledge, treatments and vaccines. Africa has the benefit of learning from emerging experiences of what works well and what does not work well in other regions of the world. Africa still has low numbers and if it utilizes the next few weeks well, it could emulate Singapore and South Korea in preventing widespread community transmission.

COVID-19 could wreak havoc in the many congested urban settings of Africa

Nonetheless, this virus has demonstrated that it is able to reach almost every country on the planet and it systematically exploits cracks, inequities and weaknesses in society. Given its infectiousness, early estimates project that 60 percent of the world’s population will be infected in the absence of a vaccine. This means that Africa can expect to be impacted in a manner similar to China, Europe or the USA, and that any differences will arise out of the underlying demographics, underlying medical conditions, mitigation measures countries are prepared to enforce, and the state of the health system. In particular, COVID-19 could wreak havoc in the many congested urban settings of Africa given its high Ro, no demonstrated existing immunity and transmission by asymptomatic infected individuals.

At this early stage of the pandemic, one can only speculate on the factors that could be protective against severe disease (there is no evidence yet that any population or ethnic group has protection against infection) and the factors that could put Africa at higher risk of severe clinical disease and widespread morbidity and death. In addition, as most African countries have instituted early and prolonged lockdowns, one cannot discount the collateral damage and death resulting from loss of livelihoods, insufficient food and medication and inability to access functioning health facilities for potentially life-threatening conditions like childbirth, severe malaria, surgical emergencies etc.

There are many particular strengths…

When one looks at sub-Saharan Africa specifically, there may be several characteristics that end up slowing infection rates and being protective of severe COVID-19 disease – in particular in the population aged 60 and below who are in the majority:

  • 95% of the population is below age 60 while only 2% is above age 70 
  • A much lower prevalence of obesity, particularly compared to the USA (5-15% vs 42%)
  • Lower reported prevalence of diabetes, hypertension or heart disease – though this may reflect poor health screening
  • Early lockdowns limiting infections mainly to imported cases and their contacts with minimal community spread so far as of 20th April 2020
  • Rural populations (58%) with low population density that slows transmission rates
  • Experience with proven public health approaches of case identification, isolation, contact tracing as a result of polio eradication efforts and Ebola
  • Community-based health volunteers than can contribute to case finding and notification

…and there are many particular dangers

Yet, at the same time there are several risk factors that potentially could lead to a very severe clinical COVID-19 emergency in several African countries:

  • Concomitant infectious diseases like HIV, TB and Malaria
  • Concomitant malnutrition and nutritional deficiencies
  • Dense cities and slums with unhygienic supplies of water, sub-optimal housing and poor air quality – 42% of Africa is now urbanized
  • Lack of PPE, soap and water even in health facilities
  • Poor and inexperienced health infrastructure to respond to severe respiratory disease
  • Insufficient capacity and test kits to carry out COVID-19 antigen and antibody tests
  • Shortages of key medicines and equipment that need to be imported during a lockdown
  • Inability to isolate the elderly who socially are dependent on and live with younger generations
  • High levels of chronic respiratory disease mainly due to indoor smoke inhalation, especially in rural populations who cook using firewood
  • The onset of winter in Southern Africa with its added seasonal influenza infections
  • Inability to sustain and enforce strict and prolonged lockdowns

Africa needs to start preparing yesterday for a severe and widespread clinical COVID-19 epidemic similar to that seen around the world. We probably are only 8 to 12 weeks behind the curve of China, Italy, and the USA. In particular, it is imperative that we quickly identify and isolate every case that tests positive regardless if asymptomatic or with mild disease – a key lesson from the China response.

In addition, we need to start domestic production of key PPE, like masks, face shields, gloves, waterproof gowns and hand sanitizer so our health care workers have the confidence to work in what will inevitably be stressful and risky conditions. And even though there is a dire shortage of respirators in Africa, there is an even bigger shortage of oxygen plants. Oxygen is a critical medication, so in this short window of opportunity we need to ramp up our ability to produce and deliver oxygen to needy patients.

Thinking about access from the outset

Ultimately though, there will only be two game changers for the world and for Africa:

  • an effective drug or product like monoclonal antibodies that can prevent COVID-19 infection prophylactically or prevent progression to severe disease and death
  • a COVID-19 vaccine that is universally effective

Sadly, given the global demand for these two products, Africa is in danger of being priced out (as with ARVs in the HIV epidemic prior to 2002) or insufficient production will prompt wealthier and more powerful countries to restrict exports until all their populations have access and there is a stockpile. This is the time to start the discussions and negotiations that will ensure universal access when, finally, we have a drug or a vaccine. The lessons from the global response to HIV will be very useful in that regard. Organizations like the WHO, the Africa Union, GAVI and the World Bank have a critical role to play to ensure equitable access to treatment and vaccines for Africa.

Finally, Africa must be part of the research effort to find the solutions to the COVID-19 pandemic. This includes genetic and other studies of both virus strains and human host to determine any correlation with infectivity and disease severity. Africa and its scientific institutions should also be prepared to carry out drug and vaccine trials to determine efficacy and safety of products in the African setting (see COVID-19 in Numbers below). This is both a scientific necessity and essential to ensuring simultaneous access. Institutions across the continent have decades of experience both conducting and overseeing complex clinical research. In addition to clinical trials, hopefully this pandemic will stimulate further investment in research to understand not just the COVID-19 virus but as well the human immunological reaction. This knowledge will have a broader benefit for other vaccine development including HIV, TB and Malaria.

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