Africa Succeeded Against COVID-19’s First Wave, but the Second Wave Brings New Challenges | Global Health | JAMA | JAMA Network
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Medical News & Perspectives
January 6, 2021

Africa Succeeded Against COVID-19’s First Wave, but the Second Wave Brings New Challenges

JAMA. 2021;325(4):327-328. doi:10.1001/jama.2020.24288

Africa defied many dire predictions during the coronavirus disease 2019 (COVID-19) pandemic’s first wave. The continent’s success can be credited to a rapid, coordinated response among African leaders, experience with infectious diseases, an aggressive campaign to combat misinformation, and community engagement in the response.

Despite the early success, many challenges lie ahead as the continent faces a second surge that began last fall. Countries will need massive vaccination campaigns and other measures to prevent hospitals from becoming overwhelmed with patients. Leaders will also have to curb the unintended health and economic consequences of pandemic control measures.

John Nkengasong, MSc, PhD, director of the Africa Centres for Disease Control and Prevention (Africa CDC), cautioned during a recent Drugs for Neglected Diseases initiative (DNDi) webinar that the continent can’t let down its guard against the pandemic.

“We’ve fought a very good fight in the beginning, but the battle is not over,” he said.

Rapid Response

Health ministers from across Africa convened early in 2020 to establish a unified strategy for combating the pandemic. The plan focused on 3 pillars: preventing severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission, averting deaths, and avoiding social and economic harm, Nkengasong said.

“That strategy has been a cornerstone for our response,” said Nkengasong, who leads the Africa Task Force for Coronavirus (AFCOR), which began meeting weekly in February 2020. The plan led most African countries to ban travelers from countries with ongoing outbreaks by the end of March, according to a report in Nature Medicine by Nkengasong and other African leaders. Local restrictions on travel and gatherings followed throughout the spring.

Among the early challenges they faced were the need to roll out a massive testing campaign and difficulties securing necessary supplies like personal protective equipment (PPE), hand sanitizer, and ventilators. The African Union and Africa CDC launched the Partnership to Accelerate COVID-19 Testing (PACT) to help increase testing and to deploy 1 million community health workers to aid in contact tracing.

“Overall, testing across the continent has significantly increased,” Nkengasong said. “However, there are some countries that are still lagging behind.” To help make more community-based testing available, Africa CDC recently joined a collaboration with the World Health Organization (WHO) and several other organizations to make 120 million rapid diagnostic tests available.

The African Union, working in partnership with the United Nations Economic Commission for Africa, Afreximbank, and other collaborators also have created the Africa Medical Supplies Platform, a centralized resource for supplies. Many African countries have turned to local manufacturing for supplies. For example, Ghana manufactures hand sanitizer, PPE, and ventilators designed by local universities.

These efforts helped keep the death rate among Africa’s 1.4 billion inhabitants far lower than in Europe or the US, with about 62 000 deaths out of more than 2.6 million cases reported in late December on the Africa CDC COVID-19 dashboard. That’s in stark relief to 19 million cases and 334 000 deaths reported late last year among the 331 million people living in the US.

In addition to a low death rate, 80% of people with COVID-19 have had mild or no symptoms, according to Borna Nyaoke-Anoke, MBChB, MPH, senior clinical project manager at DNDi in Kenya. Demographics may play a role. Nyaoke-Anoke explained that the median age in Africa is about 19 years and that 91% of infections have occurred in people younger than 60 years. Additionally, most infections have been confined to urban areas with younger populations and international travel hubs.

Africa’s past experience with infectious disease outbreaks likely helped health experts to act more rapidly to control SARS-CoV-2 infections than officials in Europe or the US, according to Brian Godman, PhD, a senior researcher at the Karolinska Institute, in Stockholm, Sweden, who joined colleagues across Africa in reviewing the continent’s response but didn’t participate in the DNDi webinar.

“Africans are used to dealing with viruses, and they knew that it was real, and that you've got fragile economies out there and you just don't want them further compromised if you can avoid it,” Godman, who is also a visiting professor at the Sefako Makgatho Health Sciences University in Pretoria, South Africa, said in an interview.

An important lesson learned from successful efforts to combat Ebola virus outbreaks in West Africa and the Democratic Republic of Congo was the importance of community participation in control efforts, said Steve Ahuka, MD, PhD, incident manager for the current COVID-19 response in the Democratic Republic of Congo as well as for the 10th Ebola outbreak there in 2018. He explained that it’s important to engage political and other local leaders and community health workers. He and WHO Ebola experts emphasized the importance of integrating social science into the response.

“This can avoid any misinformation during the crisis,” said Ahuka, who is also senior researcher at the University of Kinshasa.

Additionally, some African countries, including Kenya and South Africa, also levy hefty fines against individuals or organizations who spread COVID-19 misinformation, Godman noted.

Challenges Ahead

As lockdowns and travel restrictions eased across Africa last fall, concern heightened about spread of the virus to more rural areas with older populations who have higher comorbidity rates, Nyaoke-Anoke said. Protecting this population and preventing health care facilities, which have limited capacity for critical care, from being inundated are among the challenges ahead.

Spikes in COVID-19 cases were reported in Kenya in mid-November 2020. Only half of Kenya’s roughly 64 000 hospital beds have access to oxygen, and across the country only 537 intensive care beds and 256 ventilators were available. News reports indicated that South Africa entered a second wave of COVID-19 case increases in early December 2020.

“We need to be able to have treatments in place that would prevent this progress of mild, moderate disease into severe disease to prevent this overwhelming of our health care facilities,” Nyaoke-Anoke said. Effective treatments are also essential for workers who rely on a daily wage for food, she noted. She and her DNDi colleagues are working to enroll more than 3000 patients in at least 13 African countries in the ANTICOV clinical trial. The phase 3 randomized trial is administering new or repurposed therapeutics to people with confirmed COVID-19 treated as outpatients to determine whether any of the treatments prevent progression to severe disease.

Vaccines will be essential to Africa’s response, said Helen Rees, MBBCh, MA, executive director of the Wits Reproductive Health and HIV Institute in Johannesburg, South Africa. “Unless we start to focus on getting a vaccine to complement the immunity that’s been generated through natural infection, we are not going to be able to stop this,” said Reese, who is also a member of the steering committee for DNDi’s COVID-19 Clinical Research Coalition.

Rees emphasized the importance of African participation in vaccine trials to ensure that approved vaccines will be safe and effective among the population, given the higher rates of malaria and HIV infection. Nkengasong noted that several trials are already underway.

To help secure access to COVID-19 vaccines, the Africa CDC has partnered with Gavi, the Vaccine Alliance, and the WHO in the COVAX pillar, which will supply enough vaccine for about 100 million people in Africa—about 8% of the population, Nkengasong said. He explained that to achieve herd immunity by vaccinating 60% of the population, the continent will need about 1.5 billion doses of vaccine at a cost of about $10 billion to $15 billion.

“We have to take our own destiny in our hands,” Nkengasong said. During a press briefing, Nkengasong celebrated news of the Pfizer and Moderna messenger RNA vaccine data showing efficacy rates in excess of 90%. But he noted the Pfizer vaccine’s requirement for ultracold storage might complicate large-scale distribution in Africa. He said he also expected data on protein-based vaccines soon.

“Let us be hopeful other candidate vaccines will lend themselves to ease of distribution across resource-limited settings like Africa,” he said.

Rapid access to vaccines or disease-limiting therapeutics could help to mitigate the pandemic’s health and financial effects, Godman said. He noted that it’s also important to address unintended effects of pandemic control measures on routine vaccinations and care for other infectious and chronic diseases, which are a growing concern on the continent.

“Anything you can do to get back to normal life as soon as possible would be welcome because it is difficult to know how long [workers who rely on daily wages] can go in a lockdown situation,” Godman said.

Until then, Rees noted the importance of continuing steps to control the virus, while taking the lightest touch possible with restrictions to minimize the suffering caused by lockdowns. Nkengasong urged African governments to continue to work together and with their communities to promote prevention strategies, expand testing, and purchase masks for low-income individuals.

“We are inevitably edging toward the second wave of the pandemic on the continent,” Nkengasong said during the press briefing. “We cannot relent; if we do, then all the sacrifices and investments we’ve put in the last 10 months will be wiped away.”

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    2 Comments for this article
    Adopting a Comprehensive Primary Health Care Approach in the Fight against COVID
    Kudzai Hlahla, BPharm and MPH | University of Zimbabwe Clinical Trials Research Center
    Thank you for the informative article.

    I agree 100% with the need for interventions that are Africa-centric as we, unlike high-middle income countries, do not have the capacity to sustain prolonged lockdowns due to various economic factors. We therefore have to take a comprehensive approach to fighting COVID-19 involving community engagement and empowerment as well as inter-sectoral collaboration across ministries, NGOs and the private sector. There is also a need to address social determinants of health that interfere with the implementation of COVID-19 prevention strategies in the African setting.

    Without these actions, we cannot guarantee sustainable
    preventive action in our communities or equitable access to resources such as vaccines once they become available
    Tailoring the response
    David Bell, MBBS, PhD | Independent consultant
    Africa has indeed been relatively lightly touched by COVID19, especially the 1.1B people between South Africa and the countries of the Mediterranean coast (whether due to the young population age, climate, low rate of relevant co-morbidities, or prior T-cell cross-immunity). As transmission in some areas (e.g., Kenyan cities) has been quite high based on serology, perhaps this mainly reflects a lack of susceptibility rather than 'success' in combating the virus. It is also noticeable that countries without strict lockdowns (e.g., Malawi, Tanzania) do not appear to have fared significantly worse. However, given the reduction in routine vaccination, predicted increases in malnutrition, malaria, TB, HIV/AIDS and other disease burden, perhaps assertions that a mass vaccination campaign is necessary (a huge further draw on health resources and finance) need to be rethought and based on a measured cost-benefit analysis. Relative DALYs lost from COVID vs these diseases that hit far younger people suggests that the equation may not necessarily resolve in the favor of mass vaccination.

    Very few people die from COVID in most countries in sub-Saharan Africa - good practice would suggest that resources concentrate on where the burden is greatest.