This week, the Africa Center for Disease Control (Africa CDC) will be launching a continent-wide antibody study to measure the true extent of the COVID-19 pandemic in Africa, where reported coronavirus cases are much lower than initial dire predictions.

Africa CDC Director John Nkengasong announced the study at a regular Thursday press briefing. Just a week earlier, the number of confirmed cases of COVID-19 in Africa crossed one million, making Africa the last continent (apart from Oceania) to reach the sobering threshold. 

While the continent has a number of lessons for the rest of the world regarding handling COVID-19 and pandemics, its comparatively lower testing rate is raising concerns that  the official figures from the region do not accurately capture the true extent of pandemic. 

At the outset of the COVID-19 pandemic, Microsoft founder, Bill Gates predicted it could claim about 10 million lives in Africa. His wife and co-chair of the Gates Foundation, Melinda Gates, added that without drastic actions, COVID-19 could lead to dead bodies lining the streets of Africa.

But Africa has recorded fewer COVID-19 cases and deaths than other parts of the world. Despite the poor quality of health systems across the African continent, the case fatality rate (CFR) in Africa is among the longest globally, hovering around 2% against Europe’s 6.3%, South America’s 3.4%, North America (3.9%), and a global CFR of 3.7% as at August 7.

Dr Michel Yao, Emergency Operations Manager at WHO’s regional office for Africa, noted that earlier predictions (of doom) were based on the assumption that Africa would experience widespread community transmission, and weak health systems would be overwhelmed by the outbreak.

“That was a bit worrying for us – the idea that the system could be easily overwhelmed and the disease could spread faster. This was taken into consideration for the prediction,” Yao told a press conference on Thursday. 

“We are pleased to see that [the worst] did not happen,” Yao added. 

But other officials were more pessimistic. A WHO Africa technical officer warned that “the peak was yet to come,” in a statement to Al Jazeera.

Early Confinement Measures May Have Helped Slow Virus, But Reopening Led To New Cases

Yao noted that the decision of African countries to quickly implement lockdown measures may have helped slow  down the spread of the virus. 

“African countries had confinement measures earlier – closing schools as well as limitation of movements. All these reduced the spread,” Yao added.

However, widespread food insecurity and economic hardship forced many African countries to reopen their economies, resulting in an increase in cases. The case of South Africa, which now ranks among the top five countries with the highest coronavirus caseload, suggests that the country’s lockdown measures may have failed.

But Yao also  noted that African countries had given themselves time to build up treatment and laboratory capacities while under lockdown.

And even in South Africa, there is gradual decline in the daily number of new cases reported, noted Dr Matshidiso Moeti, WHO’s regional director for Africa.

“It is something that is starting but we need to observe for a little bit longer before we say firmly that this is a trend,” Moeti said last Thursday

Besides South Africa, Moeti noted a number of other countries that are seeing reduction in the number of cases to a similar degree – about 20% fewer cases were reported in the first week of August compared to the second week of July at the time of the press briefing. These countries include Nigeria, Côte d’Ivoire, Cameroun, Republic of Congo, Mauritania, The Democratic Republic of the Congo, the Central African Republic, Botswana, Liberia and Benin Republic. WHO also noted that while there has been a 13% increase in the number of COVID-19 cases in the African Region in the past week, it was lower than the 18% increase recorded during the previous reporting period.

“We still have countries [where] there was an initial increase in cases [after government relaxation of measures]. Now we are starting to see a decline. But the take home is we need to monitor this and just assure ourselves that the decline continues,” Moeti said.

Delays & Shortages in Testing Could Lead To Undercounting Cases

Several African countries have been facing a shortage of testing kits, raising concerns that the continent’s relatively low number of reported COVID-19 cases was due to lack of testing. 

For the first time, donor countries that often come to Africa’s aid are among the worst hit by the pandemic and are therefore prioritising their countries’ citizens, stockpiling PPEs and testing kits. Only 5 countries in Africa have carried out at least 500,000 COVID-19 tests and many have tested less than 1% of their population.

While 5.4% of tests conducted globally test positive for COVID-19, Africa has the second highest positivity rate of all seven continents at 11.6%. 

But the high positivity rate may be due to responders across the continent rationing tests to only those who showed symptoms of disease, who are much more likely to test positive. Moeti also said that the positivity rate has not changed in African countries that are expanding COVID-19 testing, indicating that current testing is capturing most cases in these countries.

“Some countries have increased their testing per capita while maintaining a low positivity rate. They include countries such as Mauritius, Rwanda, Cape Verde and Botswana,” Moeti added.

High Prevalence of SARS-CoV-2 Antibodies in Populations Indicates Higher Spread of Virus Than Testing Positivity Implies

Some countries are finding that many of their citizens are testing positive for antibodies for SARS-CoV-2, the virus that causes COVID-19. This may indicate that the virus has spread to more citizens than the testing positivity rate implies. For example, Mozambique has less than 3,000 confirmed cases of COVID-19 in the entire country, but serological surveys found SARS-CoV-2 antibodies in 5% of households in the city of Nampula and 2.5% of households in the city of Pemba alone. 

Addressing a press conference, Africa CDC director John Nkengasong said “What is important is far fewer people are coming down with the disease. How many people are infected and asymptomatic on our continent? We don’t know that.”

Still, the continent has a relatively lower COVID-19 death rate than expected, even in light of signs of wider spread of the virus. 

With the exception of South Africa, many countries are not observing excess deaths due to respiratory-related symptoms. While death and birth registration lags in Africa compared to other regions of the world, WHO AFRO officials noted that COVID-19 deaths remained low in African countries with efficient death reporting systems, implying that these African countries are seeing a true lower death rate than initially predicted.

Health experts have attributed the lower than expected case-fatality rate to Africa’s comparatively young population, which may withstand the virus better than populations with more older people. COVID-19 death rates are highest in people over the age of 65 years old. 

Collaboration &  Innovative Thinking Help African Countries Leverage Strengths

Another aspect of the African response has been the cooperation seen among various countries, and the coordination role being played by the African Centers for Disease Control (Africa CDC). 

Dr. Ahmed Ogwell Ouma, Africa CDC’s Deputy Director, told Health Policy Watch that the center is supporting African countries in centrally accessing testing kits and consumables including PPEs. It is also assisting in capacity development and risk communication.

With the COVID-19 not ending anytime soon, the WHO and Health Ministers of Rwanda and Niger republic noted that African countries are already taking localised actions that leverage on already existing infrastructure and capacity for the pandemic. 

Moeti mentioned that in Nigeria, advocacy by community leaders encouraged more people to go for testing. In Mauritania, university students are helping to ramp up surveillance while in Kenya, over 79,000 community health workers and 15,000 youth champions have been trained to help raise awareness among 17 million people through household visits and other activities.

Moreover in Zimbabwe, the integration of COVID-19 into polio eradication systems is providing real time information for decision making regarding both diseases. Cote d’Ivoire has also cascaded training to around 10,000 health workers in all of its 113 health districts.

Rwanda is one of the  countries in Africa that is actively deploying innovations to aid its COVID-19 response. Its decision to deploy robots to reduce contacts of health workers with persons that tested positive is already producing results, according to the country’s Health Minister Dr Daniel Ngamije. He revealed that less than ten healthcare workers in the East African country have contracted COVID-19. 

The country is also actively driving the adoption of cashless transactions to prevent possible transmission of the virus from one person to another through cash.

“We came to realise that financial cash transactions were also one of the sources of transmitting the disease. The government encouraged the use of mobile money’s cashless system by facilitating telecom companies to not charge those transactions, reducing the cost of transaction so that people can take advantage of not necessarily doing their transactions by exchanging money but they can do payment or transfer of money using technology,” the Minister said.

He added that the country also embraced digital tools for collecting data, which allow users to reduce the amount of materials and labor required to track down the virus. 

“While we were doing contact tracing, initially we were using some [paper] forms. But those also can be a vector for transmission of the disease, or just bring a lot of work. Then we went through a system of using iPad and mobile phone for collecting information especially when we are doing our contact tracing. We have an app which can be used on the devices. Even when there is no connection, later on the information can be analysed when a person is joining a place where there is connection. This was very helpful for investigation teams,” Ngamije explained.

Decentralisation Allows Countries To Cover More Ground

As the pandemic continues its spread and cases continue to rise, Rwanda and several other African countries are decentralising their pandemic response efforts. Over 30 countries have decentralised lab testing capacities, according to the WHO. This means that more testing facilities are emerging thus easing pressure on central facilities. In Nigeria, testing facilities increased from one to over 40. 

Beyond decentralising testing, African countries are also decentralizing case management and treatment. 

“We started with one national referral lab that is able to test COVID-19 in February, today we are with 10 sites in the country where COVID-19 can be tested,” Rwanda’s Health Minister said.

He added the country is already piloting home management of cases in order to decentralise case management. 

“We have started to test home-based management of COVID-19 and we are starting piloting model to see if this can be feasible in some settings in some households – treating COVID-19 at home without necessarily picking the person to isolation center because after 6 months of the pandemic, government is incurring a lot of expenditure and it is a lot of pressure to the health system. We should be anticipating ahead what might happen if there is generalised community transmission. We are already thinking how to manage the scenario,” Ngamije said.

This is a welcomed development for the WHO which has also heralded the introduction of pool testing in Ghana and elsewhere to maximise the limited testing kits and rapidly screening large populations to quickly identify positives.  

New Challenges Emerge As Airplanes Take Flight Over Africa Once More

With Africa’s airspace opening up and international travel resuming, it is becoming easier to move experts, utilities, PPEs, testing kits and additional around. The WHO is already sending experts to hotspot countries. But there are concerns that this could also lead to the resumption of  importation and exportation of positive cases. In Rwanda, the government said it is making efforts to ramp up testing of travelers. 

“Measures are in place to contain any arrival of imported cases. Even when people are traveling from Rwanda now (because we’ve opened our airspace), we have strict measures to test them before traveling. We are trying to avoid any new imported cases and also avoid exporting cases while we contain transmission of the disease within the country itself,” the country’s Health Minister said.

With major aspects of economies across Africa already reopened, there are concerns that this could make citizens suggest that the pandemic is over. Yao noted that this needs to be addressed and measures need to be enforced. But some cities are already mandating and enforcing the use of face masks and other measures. In Osun state, Nigeria, individuals caught not wearing face masks are being charged and sentenced. Yao noted that for Africa to continue to maintain its good outing with COVID-19 and to start flattening the curve will require encouraging its citizens to continue to abide by the various health advisories. 

“It is not over yet. It is why some of the preventive measures need to be enforced again.  We are noticing in some countries that people are no longer using masks, not observing physical distancing. Countries should continue working. Decentralising is critical, we must be anticipating to avoid a worse scenario,” Yao concluded.

Image Credits: WHO Africa, P Adepoju/HP-Watch, WHO Africa.