Cape Town – As South Africa records over 930,000 COVID-19 cases and its scientists race to understand whether a new variant is driving the country’s second wave of infections, countries across the African continent are reporting an increase in cases.

But there is widespread anecdotal evidence that many African countries are massively  under-reporting their COVID-19 caseloads, primarily because not enough tests are being performed. The threat is that this is giving citizens a false sense of complacency.

According to the latest report from Africa Centers for Disease Control and Prevention (CDC), the countries with the highest caseloads on the continent are South Africa, Morocco, Egypt, Tunisia and Ethiopia, with Libya and Kenya not far behind. Nigeria, Zambia and the Democratic Republic of Congo are also reporting rising infections.

Since late October, the Africa CDC has been warning the continent to prepare for this scenario. And In the light of the new, potentially more infectious variant identified in South Africa, the CDC urged African countries “not to relent in their efforts to step up testing, contact tracing and early treatment of cases”.

Denial Across the Continent

But few countries have ramped up testing. In fact, many have even seen non-clinical prevention measures flaunted.

Large election rallies in Ghana, Tanzania and Uganda have seen large crowds of people in very close proximity without masks.

Tanzania is perhaps the most extreme example of COVID-denialism. President John Magafuli replaced 3 of the country’s top health officials in April and simply stopped reporting cases to the World Health Organisation (WHO) from 29 April.

In May, he said that imported coronavirus tests were faulty after claiming several non-human samples – including from goats and papayas – tested positive.

“We should not accept that every aid is meant to be good for this nation,” he said at the time.

The following month, he declared the country COVID-free thanks to the prayers of citizens, praising them for not wearing masks.

Since this declaration Tanzanian truck drivers, who are required to provide negative tests before entering neighbouring countries, have tested positive.

Health sources inside the country claim that it is impossible for anyone to receive a positive coronavirus test result as the government has taken control of testing at all private laboratories: only negative test results are being released to patients.

“Even travellers who need a test only get it back if it is negative, otherwise their test never comes back,” a source told Health Policy Watch.

In July, Kwanza TV was taken off air for 11 months for an “unpatriotic” post on Instagram: a message from the US embassy in Tanzania warning of “elevated risk” of community transmission in the country.

East Africa – Limited Capacities and Public Complacency

Meanwhile, in Kampala, Uganda, a doctor working in a busy hospital told Health Policy Watch that “all the hospitals are full and there are many respiratory-related cases” but that COVID-19 surveillance was low, in large part due to difficulties with the tests.

“The results come back late, and the patient might have already passed away, or the lab doesn’t send the results at all,” he said, adding that people were only able to get COVID-19 tests in Kampala or at major regional hospitals. “We are also under pressure not to put COVID-19 on the death certificate.”

Ghanaian President Nana Akufo-Addo has closed the country’s land and sea borders, and confirmed that beaches and pubs will remain closed during the festive period.

Last week, Zambia’s President Edgar Lunga raised concern about “a generalised spread of COVID-19” in North-Western, Muchinga, Copperbelt, Central, Lusaka and Southern provinces.

Zambian Ministry of Health Permanent Secretary Kennedy Malama has cautioned that the country is still at risk of a second wave. Cases in Zambia continue rising, especially in patients with HIV and other non-communicable diseases such as diabetes.  

But Zambia’s National Director for Infectious Diseases, Dr Lloyd Mulenga, said that his country has managed the pandemic  “pretty well” with the help of cooperating partners like the Africa CDC, which had helped to address shortages of health workers and in Personal Protection Equipment (PPE) for health workers.

Zambia closed four of its isolation centers in various parts of the country in October because not enough patients required the services.

However, a medical doctor at Levy Mwanawasa Teaching Hospital, one of the 12 isolation centers, warns of a likelihood of a spike in infections as people relax their adherence to safety measures.

He is also wary of the health ministry’s weekly COVID-19 statistics, claiming that these  under-represent the number of people infected with the virus and deaths due to COVID-19, which is making people complacent.

He believes that the recorded number of infections is small – 18,716 cases by 21 December – because the testing sample size is small. Usually, there are around 5,000 to 6,000 tests performed daily in Zambia.

“And yet in July, we were told the country could test up to 12,000 people a day. Why are we not doing it? We do not have sufficient test kits,” he said.

He worries that untested and unconfirmed infections could raise the rate of disease and fatalities in a susceptible population. That wards and health facilities have not been oversubscribed is not an indication that there are few COVID-19 infections, he says.

“Going by [government] statistics, there are 366 deaths recorded. Of those, 283 were brought in dead. This figure tells you that there are uncaptured infections in the community.” 

While there are several reasons people do not seek medical attention in health facilities, there is insufficient testing conducted in communities, he says. The government cannot reasonably say it is managing the crisis.

Another medical officer who worked in an isolation center and was part of the public testing campaign in the initial phase of the pandemic, told Health Policy Watch that  said the Ministry of Health was advised to stop random testing in communities because of a shortage of test kits. 

“Now we only test people coming to health posts presenting with one or more of COVID -19 symptoms, and those who are travelling abroad. This leaves out the huge segment of the population who do not, as a matter of course, seek medical attention when they are sick and are not going out of the country,” he said.

West Africa – Test Shortages and High Positivity Rates Among Youth

While Nigeria is the most populous country on the continent, it has the ninth highest number of cases of COVID-19 on the continent and has only conducted the sixth-highest number of COVID tests in Africa.

Nigeria’s daily new confirmed COVID-19 cases per million people have been rising steadily since 2 December but there are indications that there are more cases than are being reported. 

By 19 September, Oyo state had the third-highest number of confirmed cases of COVID-19 in Nigeria, but health officials attribute this to a community testing exercise. 

Kemi Ayoola, a medical scientist with the Oyo state ministry of health, said that during this time, she and her team were involved in community testing exercises in densely concentrated areas of the state.

“We would go to a community, announce that there was free testing and people would show up. During the period, we were seeing lots of cases. But when we stopped, the number of cases drastically dropped,” Ayoola told Health Policy Watch.

COVID-19 cases also emerged when young men were tested before being admitted to camps for the mandatory National Youth Service Corps (NYSC) service.

The Director of the Nigeria Center for Disease Control (NCDC), Dr Chikwe Ihekweazu, said that 138 out of a total of 34,785 corps members tested positive, representing a prevalence of 0.4%.

“It means one out of 200 people,” Ihekweazu said. For a population of 200 million, that could mean about 800,000 cases.

Officials at the NCDC told Health Policy Watch that testing with the recently approved antigen-based rapid diagnostic testing kit for SARS-CoV-2 would improve access to testing and is likely to further increase the number of confirmed cases.

The NCDC reported a “sharp increase” in cases between 30 November and 6 December, with almost three-quarters of those new infections found in Lagos, Kaduna and the Federal Capital Territory. Lagos has closed schools and banned large gatherings including concerts and carnivals over the festive season.

Boss Mustapha, chairperson of the Nigerian Presidential Task Force (PTF) on COVID-19, warned last Thursday that these indications seemed to spell a second wave.

“We are in a potentially difficult phase of the COVID-19 resurgence. Accessing the hope offered by the arrival of the vaccine is still some time ahead,” Mustapha said.​​​​​​​ 

Nigerian Health Minister Osagie Ehanire had earlier announced that the government would receive 20 million doses of a COVID-19 vaccine by January 2021.

PPE Shortages

After an 8-month stand-off with the government, the 7,000-strong Kenya Medical Practitioners, Pharmacists and Dentists Union (KMPDU) began striking from Monday in protest against pay problems and a shortage of PPE for health workers.

Health workers in Uganda have also reported chronic shortages of PPE in hospitals receiving COVID-19 patients – with doctors and nurses having to purchase their own masks and gloves. 

While teams undertaking the testing may be specially equipped with PPE, other doctors and health workers treating suspected COVID-19 patients often only have masks and gloves, and suspected COVID-19 patients remain in regular wards until their tests are confirmed.   

In Nigeria,  frontline health workers also embarked on a strike action to protest shortages in PPE, but this has been addressed by the local production of PPE.

In North Africa – Egypt To Be First Country Rolling Out Vaccines

Meanwhile, cases in Tunisia and Morocco peaked in November and are starting to reduce but Egypt’s caseload is rising again. However, Egypt has received a batch of doses of a Chinese COVID-19 vaccine, clinical trials for which were conducted in Egypt, and the country is now due to roll out vaccinations in early January, starting with health workers and people with chronic conditions.

Many other African countries are likely to have to wait a lot longer to get access to a vaccine and face increasing sickness and economic hardship as they do.

Image Credits: WHO, © WHO/Otto B..