Since the beginning of the coronavirus disease (Covid-19) Pandemic in
Wuhan (China), Sub-Saharan Africa (SSA) seems to be the least affected
region worldwide. As of April 21, 2020, the number of Covid-19 cases per
1 million persons in the three most populated countries, including
Nigeria, Ethiopia, and the Democratic Republic of Congo (DRC) was 3.8,
1.0, and 4.0, respectively.1,2These rates are neatly lower than
the average rate reported worldwide (329.9 cases per 1 million persons
on April 21, 2020).1
We proposed several hypotheses to explain this discrepancy with the
other parts of the world, such as Europe and the United States of
America (USA); (1) there is a low number of people tested for Covid-19
in SSA. For example, in the DRC, 806 tests were performed as of April
21, 2020, approximately less than two tests per 100 000 persons every
day, which underestimated the true number of cases. Conversely, South
Africa had the higher number of tests done in Africa (approximately
126,937) as well as the higher number of Covid-19 cases, with 3465 cases
equivalent to 58.4 per 1 million persons.2 (2) African
population may be more immune to Covid-19 compared to the Western or
American population. Recent evidence suggest that countries with
mandatory policies to vaccinate against tuberculosis, including Japan
and South Korea, reported fewer number of confirmed cases and deaths
from Covid-19.3 Although vaccination against
tuberculosis is mandatory in SSA, it remained unclear whether these
results can apply to the African population. (3) African population is
younger compared to the Western population. The median population age is
43.1 in Europe, 38.4 in China, but only 19.7 in Africa. Current
literature suggests that older people are at higher risk of Covid-19 and
related complications. (4) It might be a matter of time. SSA might be at
an early stage of the Covid-19 pandemic. The first case of Covid-19 in
SSA was reported in Nigeria on February 27th, 2020.
One month and a half later (i.e., April 21, 2020), this number increased
to over 24,000 confirmed cases of coronavirus across
Africa.2 (5) The seasonality might play an important
role in the occurrence of Covid-19 infections. Prediction research
suggested that regions with temperate warm and cold climates followed by
regions with arid climates would be the most affected, while regions
with tropical climates should be less affected by this
pandemic.4
Despite the low incidence of Covid-19, SSA has quickly
adopted important measures to slow down the spread of the pandemic. As
of March 30, 2020, 46 of sub-SSA’s 49 sovereign states have imposed
partial or full closures of their borders; 44 have closed schools,
banned public gatherings, or put in place other social distancing
measures; and 11 have declared a state of emergency. However, in many
countries, the number of confirmed cases has increased exponentially
even after the implementation of these measures, suggesting a community
transmission of the virus. For example, South African citizens returning
from high-risk countries have been tested and put on self-isolation or
quarantine upon their return to South Africa since March
17th, 2020. Regardless of these measures, the number
of Covid-19 cases have jumped from 1353 on March 31, 2020 to 3465 cases
on April 21, 2020. 2
The current situation in SSA calls for immediate action to slow down
transmission and avoid the collapse of the healthcare system. With five
intensive care beds per million people, few ventilators for millions of
people, two doctors and 11 nursing/midwifery personnel per 10,000
population, SSA will not be able to face this pandemic, if the
healthcare system gets overwhelmed.
In the absence of a vaccine, more rigorous strategies tailored to the
local context are urgently needed to flatten the Covid-19 curve in SSA.
(1) Many African countries should increase their capacity to test
Covid-19 and trace contact using cellphone location as in South Korea.
The widespread use of cellphones in urban cities (the most affected
areas in SSA) is an opportunity to contain the spread of Covid-19. SSA
should also test people at higher risk of contracting Covid-19
infections, including health care professionals, older adults as well as
people living with HIV and tuberculosis.
(2) complete lockdowns with social distancing measures, frequent
handwashing, and regularly disinfect high-touch surfaces are currently
the most effective strategy to control the spread of this virus
worldwide. Although it is difficult to achieve in SSA, those policies
are vital since many lives are at stake. For example, governments, in
collaboration with not-for-profit organizations, may create food banks
and ensure distribution to the African population with priority to the
poorer. SSA should also work closely with epidemiologists to assess
whether those measures are effective at flattening the curve. A study
conducted by the Imperial College Covid-19 response team predicted that
300.000 deaths would occur by the end of the year if people respected an
intense social distancing. Conversely, if no intervention was
implemented in Africa, this number would increase to 3.5 million deaths
by the end of the year.
(3) SSA should use its prior experience with Ebola outbreak to increase
awareness of African population about the Covid-19 and its fatal
complications. Each African government may also share with their fellow
citizens results from prediction models using their data to increase
awareness and save millions of lives.
(4) Physicians who prescribed chloroquine/hydroxychloroquine with
azithromycin for the treatment of Covid-19 should be aware of potential
side effects even during a short course of treatment. As we await
stronger evidence to support the role of chloroquine/hydroxychloroquine
with azithromycin in the treatment of Covid-19, many countries,
including those in SSA, have adopted these combinations for the
management of the disease. As such, clinicians prescribing
chloroquine/hydroxychloroquine should be cognizant of the following side
effects, including prolongation of QTc interval (especially in a patient
with pre-existing cardiac disease or when used in combination with
azithromycin), hypoglycemia, neuropsychiatric effect, drug-drug
interaction with beta-blocker (carvedilol) or opioids (codeine,
tramadol) and idiosyncratic hypersensitivity reactions (Stevens-Johnson
syndrome).5 Although the risk is low, a close
follow-up with patients to identify early signs of side effects should
be mandatory, and self-medication with the combinations of
chloroquine/hydroxychloroquine with azithromycin should be
contraindicated.
(5) SSA should maintain essential health services (routine vaccination;
reproductive health services including care during pregnancy and
childbirth; care of young infants and older adults; management of mental
health conditions as well as noncommunicable diseases and infectious
diseases like HIV, malaria, and tuberculosis …) during the
Covid-19 pandemic. Failure to do so would increase non-Covid-19
hospitalizations, which would have a detrimental effect on flattening
the curve.
(6) SSA should be part of current research on Covid-19 to ensure that
future treatment and vaccine are also effective in an African
population. Of the 745 studies reported on the website
clinicaltrials.gov, only three studies (0.4%) will be conducted in SSA.
However, some African governments encourage local initiative of research
on Covid-19 using improved traditional medicine (i.e Manacovid,
Covid-Organics, and Apivirine). To date, no randomized controlled trials
have been conducted to test their efficacy.
In conclusion, the Covid-19 rate is low but on the rise in SSA. In
collaboration with traditional partners and not-for-profit
organizations, a global response with rigorous strategies tailored to
the local context is urgently needed to flatten the Covid-19 curve and
save millions of lives in SSA.