Steve K K Kenei – Data Analyst, International Center for Humanitarian Affairs, Kenya Red Cross Society
Julia Shen – Epidemiologist, Health Services Research and Policy Department, London School of Hygiene and Tropical Medicine
Halima Saado Abdillahi – Head of Research and Learning , International Center for Humanitarian Affairs, Kenya Red Cross Society
Cover photo: Victor Ogalle / Kenya Red Cross Society
Background: On 31st December 2019, a cluster of pneumonia cases of unknown aetiology was reported in Wuhan, Hubei Province, China. On 9th January 2020, China CDC reported a novel coronavirus as the causative agent of this outbreak, which is phylogenetically in the SARS-CoV clade and thus closely related to previously known human viruses such as those causing severe acute respiratory syndrome (SARS) and Middle Eastern Respiratory Syndrome (MERS). The disease associated with this new SARS-CoV-2019 virus is referred to as novel coronavirus disease 2019 (or “COVID-19”).
By mid January 2020, the disease had crossed international boundaries with first cases being reported in Asia. The epidemic quickly progressed into Europe and the Americas, eventually arriving in Africa with the first case confirmed in Egypt on 14 February 2020, rapidly followed by others in the WHO Africa region in Algeria, Senegal, Nigeria, South Africa, and subsequently Kenya on 13 March 2020. The rapid growth in reported cases around the world led to the Director General of the World Health Organization, Dr Tedros Adhanom Ghebreyesus, to declare COVID-19 a Public Health Emergency of International Concern on 30 January 2020, with one of the reasons being the alarmingly high number of Case Fatalities (CF). The WHO subsequently referred to COVID-19 as a “pandemic” in March 2020, reflecting its rapid global spread to the majority of the world’s human population.
Current situation in Africa
Victor Ogalle / Kenya Red Cross Society
At the moment (10/07/2020), Africa has recorded 520,198 cases of COVID-19, with 7,520 deaths. These figures compared to the rest of the continents seem low. For comparison, recorded cases in Europe stand at 2.5 million and close to 200,000 deaths, while the Americas has over 6 million cases with 280,190 deaths.
There have been various attempts to rationalise these low figures in Africa in news media, for example BBC Africa Coronavirus in Africa: Contained or unrecorded? and The Daily Nation Low number of the coronavirus cases in Africa baffles scientists.
These low figures could mean one of two things:
- We are doing very well and the disease is being contained with current measures.
- We are not testing the right people or doing enough testing to know the true picture on the ground.
A number of factors indicate the second scenario is more likely as discussed below.
COVID-19 spreads quickly and very silently
Victor Ogalle / Kenya Red Cross Society
Evidence suggest the average time between infections is only 4 to 5 days, the typical ill person infects between 2 to 3 other individuals, and it is currently believed that about up to 25% of transmission happens before an infected person shows any symptoms. Combined with the high transmissibility from its aerosol pathway, that makes COVID-19 very dangerous. In any given month of 30 days, and assuming no measures are taken, there can be up to 6 generations of infections traced to a single individual. Infections multiply exponentially: In the absence of careful public health measures, a single infected person can ultimately cause dozens or even hundreds of infections by the end of a month.
Most spread of COVID-19 is via close household contacts, i.e. family members or others who share the same living space with an affected individual. However, COVID-19 and similar viruses such as SARS are also known to proliferate through ‘super-spreading’ events in confined spaces such as cruise ships and prisons, and of particular concern, through medical settings and health care workers.
It is more than likely the first reported cases were not the first actual COVID cases on the continent
John Bundi / Kenya Red Cross Society
Given the dynamics of COVID disease spread and severity, particularly in a younger population like Africa’s, robust mathematical models actually suggest at the time of the first announced death directly attributed to COVID-19 in March and April, between 100-600 cases would have been active in the population approximately three weeks prior to the observed death in respective countries.
This is especially true for African countries identified in advance by epidemiological modelling as being at most risk to imported cases of COVID-19 based on volume of trade and commerce flows with China in December to January during the initial spread of the virus.
Role of demographics
IFRC / Corrie Butler
COVID-19 is known to be more severe in certain age groups and people living with certain underlying conditions.
The age population pyramid for the continent is bottom heavy with majority of the population being under the age of 35 while most of the urban working population is below the age of 50. It is very likely individuals have been sick and recovered from COVID-19 without detection, or even seeking formal medical care.
It is possible that African health system has been dealing with COVID-19 as cases of upper respiratory tract infection (URTI) or pneumonia. Admittedly, there is not enough research to confirm or refute this, but this could mean that such treatment has helped to curb the spread, while on the other, it also indicates weaknesses of surveillance system on the continent.
What does this mean for National Societies?
It is safe to assume that COVID-19 cases are more spread out in Africa than we currently know. Policy interventions are already in place, however, the efficacy of such measures are not yet known and impact on the growth curve is not clear given the number of tests and characteristics of individuals being tested. In fact, the trend indicates clearly that we have not yet reached a peak in the epidemic, though it is possible that we are flattening it from what it would otherwise be.
For National Societies on the continent, this means we need dramatic action to protect public health;
- Safeguard staff and communities: We must continue to implement risk management procedures across our day-to-day operations, with emergency business continuity procedures. This includes protecting the safety and wellbeing of staff and volunteers, especially those who are more aged and/or have pre-existing conditions, or who have household family members with such risk from COVID-19. Furthermore, a risk management exercise should be undertaken with the patients and communities we currently serve.
- Educate the public: Building on National Societies’ strong public trust and stakeholder networks, we can play a very positive role by educating the public about COVID-19 with facts and evidence-based analysis: alleviating panic by countering harmful misinformation and rumours while also prompting serious and appropriate action, such as compliance with social distancing, face masking and improved uptake of handwashing. As part of our sensitisation, we must include messaging about safety of key populations that the disease affects severely, that is the elderly and those with pre-existing chronic conditions that make infection severe, including HIV and TB.
- Ramp up psychosocial support systems: There is no escaping the severity of what is coming, as there will be a rise in case fatalities and hospitalisations from COVID-19 in Africa. The pandemic is already causing general feelings of panic and worry in the public and very disruptive changes to daily routines and economic security as a result of drastic public health interventions. Mental health care and promotion will require sustained and strengthened investment alongside the clinical treatment of ‘purely physical’ effects for COVID-19 patients, survivors, health care workers, families, and at-risk populations generally.
- Sustain humanitarian support and health programmes: National Societies play an important role in supporting the overall health systems capacity of the country. It is very important wherever feasible, that we continue our previous public health programming, in order to avoid spill over effects of COVID-19 in making other illnesses worse. In addition, where our work addresses other illnesses or social vulnerabilities that increase the COVID-19 risk in a given population, our continued efforts improves their resilience and likelihood of surviving and even thriving despite the epidemic.
- Mitigate the harm of COVID-19: In light of the high probability of generalised community transmission in Africa, we also need to explore shielding measures of these key populations, especially the elderly in rural areas. Such measures should be coordinated and planned carefully with the direction of the national Ministry of Health, local governments, and other government leaders. Humanitarian experts have identified a “shielding” strategy – with pivotal involvement and social coordination enabled by Red Cross/Red Crescent and similar community-level actors – as the most pragmatic intervention in low-income settings Such efforts should be coordinated with other important stakeholders, including other health agencies and research groups like KEMRI.
- Monitor, learn and prepare for the future: Given the rapidly changing situation and evidence around this new virus, constant research, modelling, and analysis will be vital to agile and appropriate response. Given experience from the last global pandemic that was this severe (1918 flu), there will be a second and perhaps further waves of this disease coming after the lifting of initial public health restrictions, and/or from viral mutation or loss of immunity. Once the strict socialization measures are lifted, we need to prepare for a subsequent epidemic, and for a potential worst-case scenario in which immunity from recovery or vaccines is not lasting. Even if we bring COVID-19 under control quickly, future pandemics – especially from animal-to-human origins – are very likely and the current situation must provide an enduring lesson about the importance of public health systems strengthening in all societies.
Lastly, the need for collaboration and shared learning cannot be over emphasised. The sharing of data between the Ministries of health and health experts, and transfer of innovations between societies and collaborative research will be critical in flattening the curve and successfully eradicating the virus from Africa.