Covid-19 in Africa: 6 questions to understand its evolution

Éric D’Ortenzio is a medical doctor and public health specialist. He is the scientific coordinator of the Reacting consortium. He returns for The Conversation on the evolution of the Covid-19 epidemic on the African continent.

In Africa, where is the situation of the epidemic?

The explosion of the Covid-19 epidemic that was feared a few weeks ago has not yet occurred. Official contamination figures are still relatively low: as of June 4, the CDC Africa recorded 162,673 cases and 4,601 deaths on the continent. But some states are more or less affected: talking about Africa in general does not make sense, it is a continent made up of 54 countries and populated by 1.2 billion inhabitants, whose realities are very different depending on the regions.

The Maghreb countries were the first to be affected, notably Egypt, which is one of the first countries to report imported cases, Algeria, Morocco. This age of the epidemic could explain why there are the most cases, reported to the population.

In sub-Saharan Africa, health systems are more or less fragile depending on the country. This would partly explain the disparities in the dynamics of the epidemic: some governments have been able to put in place a larger offer of tests, others have acquired over the years experience of epidemics which they use during the current crisis.

Countries that can better test their populations are likely to be better able to control the Covid-19 epidemic by isolating the sick and identifying contacts. We can clearly see that the situation differs from place to place: the number of Covid-19 cases, for example, has increased much more in Côte d’Ivoire and Senegal than in Burkina or Mali. What we see, however, represents only the tip of the iceberg, based on official figures in circulation.

Read also Covid-19: Africa, did you say mystery?

How to explain this weak growth of the epidemic, contrary to the fears expressed at the beginning of the crisis?

Several hypotheses are considered to explain it. The available test offer had to play: due to international tension on equipment and reagents, supply difficulties were significant. This would have resulted in insufficient access to tests, and therefore an underestimation of the number of cases. But this does not explain everything.

A second hypothesis is also advanced: the population is on average rather young on the continent, and the proportion of people over 65 is very low (it represents perhaps 5% of the population in sub-Saharan Africa). This could explain this impression that the epidemic is not flaring: the virus would circulate, but the little or asymptomatic forms, not detected, would be in the majority. We know that severe forms mainly concern the elderly or at risk, with comorbidities of the obesity type, diabetes, cardiovascular problems. However, even if in Africa we consider that there is an epidemiological transition (from infectious diseases to chronic diseases) and that more and more people develop diabetes, overweight, and cardiovascular pathologies, the prevalence remains lower than that from European or North American countries.

Another hypothesis: the first cases would have rather affected the socio-economic elite, that is to say people who can afford to travel abroad. When they got home, they imported the disease. These first cases, which belonged to the wealthy social classes, could perhaps have been better isolated and tested by the first days following their return. Furthermore, at that time, the governments, worried about the European situation, were starting to put in place containment measures. The conjunction of these two factors would partly explain why the disease has not spread massively in the general population.

Explanations are also to be sought on the side of lifestyles, which differ from those of Western countries. Due to often precarious living conditions, a large part of the population lives more outside. People spend less time in confined and confined spaces where the virus is known to be better transmitted. This also contributes to the dynamics of the epidemic.

Among the avenues to explore is also the immune response: there could be differences in certain populations subjected to numerous microbial exposures. We can hypothesize a cross immunity (the antibodies produced following a previous infection by other pathogenic microbes would also be active, at least partially, against the coronavirus Sars-CoV-2, Editor’s note).

Finally, it would also be necessary to study the question of climate, to determine for example if heat, humidity could play a role.

This bundle of hypotheses would explain why the epidemic does not seem to be igniting in Africa. However, to confirm these assumptions, studies aimed at better understanding what happened in each country, on the scale of a region, of a city, will be necessary. Only solid, well-analyzed data can explain what happened.

Read also Post-Covid-19: the tomorrows of economic challenges for Africa

In this regard, how does the Covid-19 pandemic affect other epidemics?

In the Democratic Republic of the Congo, there has been a resurgence of Ebola virus disease in North Kivu. We thought the epidemic was over, but a few sporadic cases still occur every week in this region where armed groups clash. These new cases show that the Ebola epidemic is not under control there. A new outbreak in Equateur province, near the town of Mbandaka, has also just been confirmed.

This situation puts the country in difficulty, especially in the face of other epidemics such as that of measles, very deadly since 2019, which also affects the neighboring Central African Republic. The concomitance of other epidemics such as Lassa fever or yellow fever in Nigeria, Rift Valley fever in Sudan, or cholera epidemics in many countries makes the management of these co-circulations of pathogens more complex. This type of situation concerns various other vulnerable areas elsewhere on the continent.

In addition, the issue of access to the diagnosis of Covid-19 disease in rural areas is often complicated. The offer is centralized in the capitals. Several centers take samples there, which are then sent to the reference laboratories where the analyzes are carried out. When a suspect case is identified in the region, its samples can be sent to the capital, but sometimes the patient moves there. If it is indeed positive, it risks spreading the virus.

Read also Covid-19: Africa more resilient than expected

Fearing an outbreak of the epidemic on the continent, the World Health Organization had called for international aid very early on. Has this been followed up?

Yes, the mobilization took place from the start of the epidemic, because everyone feared the explosion. The funding that was made available quickly made it possible, for example, to strengthen diagnostic capacities, which also undoubtedly influenced the dynamics of the epidemic. France participated via the French Development Agency, which launched the “Covid-19 – Joint Health” initiative, in response to the global health crisis. AFD has also funded projects from various institutes such as Inserm, IRD and the Institut Pasteur, as well as those of Fondation Mérieux and non-governmental organizations such as Alima and the ICRC.

This funding has notably enabled the APHRO-CoV capacity building project to see the light of day, in partnership with 5 countries: Mali, Senegal, Ivory Coast, Burkina and Gabon. Initiated under the aegis of the African Society of Infectious Pathologies, this project is multi-actor. It is managed by Inserm via REACTing, in collaboration with the PAC-CI program in Côte d’Ivoire as well as the University of Bordeaux, and draws on the expertise of the AP-HP. Concretely, it is deployed with four objectives:

– train, equip and strengthen the capacities of 5 hospital laboratories located near the infectious disease departments of the referral university hospitals (CHU), which are called upon to deal with suspected cases. The aim is to reduce the time taken to render the result, which currently calls on a national or regional reference laboratory;

– train, equip and strengthen the capacities of the infectious disease departments of these 5 teaching hospitals called to take care of cases (suspects and confirmed) in terms of hospital hygiene, adequate care and psychological support for people and personnel concerned;

– train and strengthen the capacities of the National Institutes of Public Health and their “Health Emergency Response Operations Centers” (Corus) in the field of early warning and information circuits for surveillance and follow-up of contact cases ;

– support response measures with an analysis of the fears and rumors that circulate, in order to better guide the responses of decision-makers, particularly in terms of communication.

We had to adapt to the health crisis. For example, following the restriction of travel between African countries and internationally imposed by governments, training has been modified and is now organized in the form of webinars.

The network of partners that we are building is intended not only to respond to the current challenges, which are glaring, but also to become sustainable. The capacity building carried out during the Covid-19 epidemic at the level of the CHU laboratories could subsequently make it possible to improve the diagnosis of other pathologies, in particular other respiratory viruses.

Read also “The Covid-19 will have had the psychological virtue of uninhibiting Africans”

How are the populations of the countries concerned by the project coping with the situation? Do we observe a certain distrust, as in a part of Western populations?

The experiences of ancient epidemics have shown that distrust of decision-makers and politicians is generally very strong. It is probably the same thing in the case of the Covid-19 epidemic, even if for the moment we can only assume it. In Senegal, we have been witnessing protests against the imposed curfew in recent days, so we can see that the reactions of the populations can be very violent when faced with political decisions. It is on this distrust that we must work. Communication is essential and decisive here.

Commitment is also important: if the population does not feel involved and an actor in the fight against the epidemic, it will not work. We worked a lot on community engagement during the Ebola epidemic in Guinea, which helped regain the confidence of the population both in the fight against the epidemic and in the implementation of clinical trials.

One of the problems is also to find methods of confinement compatible with the daily life of the populations. In many social classes, people are forced to go out every day to earn a living. Some countries have had to adapt the containment to take this into account.

Each government has made its own decisions, whether or not it has surrounded itself with a scientific council to obtain opinions … Côte d’Ivoire has partially lifted the confinement, Guinea has opted for relative confinement where we can get out at condition of wearing a mask, where the inhabitants of the capital cannot leave it except imperative reason, where school, bars and restaurant are closed…

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How will the next few months go?

The situation remains very fragile, and it is still too early to know how it will develop. The virus will likely still circulate for several months or even years. From an epidemic, the situation will become endemic.

Co-circulation with other infectious diseases (HIV, malaria, tuberculosis, respiratory infections, diarrhea, etc.) is sometimes compounded by increased vulnerability due to malnutrition. This could be problematic in the case of the Covid-19 epidemic. All the more so since it risks disrupting vaccination programs, making populations even more fragile in the face of vaccine-preventable diseases. Programs to fight other pandemics will also be affected.

Vigilance is therefore required. We must not relax, whether in terms of surveillance, testing offer, clinical management, knowledge of the disease in African contexts. The contribution of the human and social sciences is essential here to better understand and propose relevant prevention measures. The determining factor will be the health system. The countries where it is most fragile will be the most at risk, this is where we must strengthen. All the more, obviously, if the political or health situation is difficult: conflicts, population movements, other epidemics …

All this will play. The concern concerns many countries, in particular those with tens of millions of inhabitants, where the population is sometimes concentrated in overcrowded capitals like Lagos, Cairo, Kinshasa, Johannesburg, Nairobi … If the epidemic soared, it would be very problematic.

The attention paid to the circulation of the virus must remain permanent, to prevent this region of the world from suffering the catastrophe announced.

Read also Fred Eboko: “Africa has kept the memory of Ebola”

* Eric D’Ortenzio is an epidemiologist, scientific coordinator of REACTing, Inserm.

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