A young population and high disease burden makes predicting the continent’s outbreak tricky, say experts.
On 24 February a Turkish Airlines flight with 156 passengers on board touched down at Murtala Muhammed International Airport in Lagos. Among them was an Italian man who, three days later, became the first confirmed sub-Saharan African case of COVID-19, the respiratory illness which has infected tens of thousands worldwide and killed over 3 000.
The rapid diagnosis of the man, the specialised care he is receiving in one of Nigeria’s designated COVID-19 care facilities and the diligent tracing of the 58 people with whom he had contact in the country, are the fruits of weeks of Africa-wide preparation for the disease. At the start of February only two African countries — South Africa and Senegal — could test for COVID-19. A month later, more than 40 have that capability.
COVID-19, whose symptoms include fever, coughing and shortness of breath, emerged in China’s city of Wuhan late last year. Chinese scientists identified the culprit as SARS-CoV-2, a new coronavirus of the same family as the common cold. Although China locked down entire cities to stop the virus from spreading, and many airlines stopped flying to China, the virus has since reached more than 70 countries and caused deaths in over a dozen. On 30 January the World Health Organisation (WHO) declared the outbreak a global health emergency.
Despite the rapid ramping-up of testing and surveillance across Africa, only a handful of cases have been picked up on the continent. Before the Italian man in Nigeria, Covid-19 had been found in Algeria and Egypt. On 2 March, one more sub-Saharan case was confirmed in Senegal. All of these cases seem to have picked up the virus abroad.
The virus’s slow march into Africa compared with the rest of the world has puzzled health experts given the continent’s substantial links with China. Some believe actual cases to be higher than confirmed numbers. Based on Africa’s aviation links with China, disease modelers at the Bill and Melinda Gates Foundation estimated that there were up to four undetected outbreaks in Africa in mid-February.
“Now that there are other sources — Italy, Iran, South Korea, etc — the numbers of likely introductions have gone up again, but we have not done another round of estimates. Safe to say there are more,” says Scott Dowell, the foundation’s head of vaccine development and surveillance, who participated in the work.
The African context
In an interview with the Africa Portal, John Nkengasong, director of the Ethiopia-based Africa Centres for Disease Control and Prevention, which is coordinating the continent’s response to COVID-19, says many questions remain to be answered about Africa’s outbreak. He believes the low numbers so far could be a combination of spotty testing, environmental factors and plain luck. He says in the early days of the outbreak, when Africa had little diagnostic capacity, cases could have easily slipped through. But with the ramp up in alertness, it’s unlikely that clusters of symptomatic cases are going undetected. Still, there is a chance that people with mild or no symptoms are slipping through the net, as they have in other parts of the world, he admits, adding that what happens over the next few weeks will be critical to understanding how the virus behaves in Africa.
There are a few factors that set the continent apart. Africa’s population is the world’s youngest. While that might count in its favour — COVID-19 has so far proved deadliest in elderly, infirm patients — this benefit might be cancelled by the continent’s high burden of diseases like malaria, HIV and tuberculosis. “We just don’t know,” he says,adding that it is also possible that environmental factors like warm temperatures slow the spread of the virus in Africa. “We can’t exclude anything.”
For Nkengasong, stopping the virus from spreading within Africa remains the prime goal. Globally, 15-20% of those diagnosed with COVID-19 require hospitalisation. In countries with limited health infrastructure, like most in Africa, such numbers could rapidly overwhelm clinics and hospitals. Nkengasong says the thing that keeps him awake at night is the thought of an African country being hit by an outbreak similar to that in China.
He is not alone. “Our biggest concern continues to be the potential for Covid-19 to spread in countries with weaker health systems,” said WHO director-general Tedros Ghebreyesus in a statement in February.
“In countries with limited health infrastructure, like most in Africa, such numbers could rapidly overwhelm clinics and hospitals.”
To this end, the WHO has asked for global donors to contribute US$675 million to fund the global coronavirus response, with a special focus on the most vulnerable countries. In Africa, that may not be the countries with the highest risk of importing COVID-19. A study published in The Lancet on 19 February said that although South Africa, Egypt and Algeria had more air linkages with China than any other countries on the continent, they were also among those best prepared to cope with outbreaks. Instead, the paper suggested that support concentrate on countries with moderate risk of importing the virus that causes COVID-19, but whose health systems are more vulnerable — Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya.
Some of Africa’s most vulnerable countries have an ace up their sleeve. The Democratic Republic of the Congo has been able to adapt its surveillance system used to detect Ebola to also screen for COVID-19. Isolation wards created for Ebola patients are standing ready for COVID-19 patients, should they appear. “It is helpful that a lot of the infrastructure needed to diagnose, isolate and treat severe cases is already in place due to Ebola,” said Gervais Folefack Tengomo, the country’s WHO Incident Manager for COVID-19.
But the impact of the virus will not just be felt by Africa’s health systems. Markets are already smarting from a slowdown in Chinese demand for natural resources. China’s intake of oil from West Africa will drop by a third from February to March, Bloomberg reported. In Ghana, China-funded road-building projects have hit a standstill. And in South Africa, poor fishing communities are facing financial hardship after their Chinese export market collapsed rapidly.
A further concern is that the virus will stoke xenophopic tensions. Nkengasong says that misinformation spread online is already fuelling “stigmatisation and blame games” in many countries. South Africa’s National Institute for Communicable Diseases (NICD) has A reports of “growing antipathy” against people from areas affected by the outbreak, including Asia, Europe and the Middle East.
This constitutes the biggest challenge in South Africa’s COVID-19 response, as it might force symptomatic people underground, Sibongile Walaza, an epidemiologist with NICD, told the Africa Portal. “We have been working hard to deal with misinformation because the identification of suspected cases as well as diagnosing COVID-19 would require individuals of the community who display symptoms to seek medical care and undergo the relevant testing,” he said.
(Main image: A mother and child body temperatures are being tested at the gate of entry upon arrival at the Murtala International Airport in Lagos, on 2 March 2020. — Benson Ibeabuchi / AFP via Getty Images)
The opinions expressed in this article are those of the author(s) and do not necessarily reflect the views of SAIIA or CIGI.
