Coronavirus in Africa: what happens next?

By Kate Hodal and Samuel Okiror

Just seven weeks after Africa recorded its first case of Covid-19 – an Italian national in Algeria – the virus is creeping across the continent, infecting more than 10,000 people and causing 487 deaths. Three of the region’s 54 countries – São Tome and Principe, Comoros, and Lesotho – remain apparently virus-free.

“Case numbers are increasing exponentially in the African region,” said Dr Matshidiso Moeti, the World Health Organization (WHO) regional director for Africa. “It took 16 days from the first confirmed case in the region to reach 100 cases. It took a further 10 days to reach the first thousand. Three days after this, there were 2,000 cases, and two days later we were at 3,000.”

In the Democratic Republic of the Congo, coronavirus has spread beyond the capital, Kinshasa, to the easternmost regions of the country, which until recently were still in the grip of an Ebola outbreak, according to the WHO.

In South Africa, which has the highest viral incidence on the continent, all provinces are now fighting the outbreak of Covid-19. Confirmed cases in Cameroon, Senegal and Burkina Faso are also widespread.

While transmission rates are still low, the key fear is over what happens next.

“The issues with Africa – like many places but even more so – are that the lack of testing means we don’t have any secure understanding of the true amounts of infection,” said Dr William Hanage, professor of epidemiology at Harvard. “We would expect it to be in the early stages now, given that in general the major metropolitan centres are less connected than, say, New York.

“Without better understanding of the way the virus operates – such as the immunological or genetic factors that may protect some people – it is impossible to say how severe the impact of Covid-19 will be on the continent, said Prof Thumbi Ndung’u of the African Institute for Health Research.

“We don’t yet have a good answer as to why rates are lower in Africa than in Europe or China. One possibility is that that coronavirus hit during the European winter and the virus doesn’t spread perhaps as efficiently in warmer and more humid climates, which one study has shown. Another possibility is that Africa, in general, has a much younger population [than Europe or China].

“The last possibility is that it may just be a matter of time before it hits Africa as much as it’s hit other places. If that’s the case, and we get community transmission in sub-Saharan Africa at the rates that we’ve witnessed in Italy, we could be staring at a catastrophe,” Ndung’u said.

He added: “We don’t have the hospitals, the ICUs or the ventilators to deal with massive amounts of [infected] people, so if the spread is comparable to that seen in Europe or China, the outcome could be devastating.”

In South Africa, which has the highest prevalence of HIV in the world and among the highest for tuberculosis, people have already been hit by lockdowns and reduced access to health clinics, according to Dr Michelle Moorhouse, of Ezintsha, Wits Institute in Johannesburg.

“We are telling people to stay home and avoid the clinics so this will impact testing, starting treatment, and potentially could see people interrupting treatment, if they are afraid to venture out and collect their medication,” she said. “We have been urging, where possible, that clinics dispense more antiretrovirals (ARVs) at each visit to try to keep people living with HIV out of clinics and so reduce their exposure.

“We do not really have any clear idea what Covid-19 will do in a population where overcrowding, TB and HIV are highly prevalent.”

In Uganda, at least 1.4 million people are living with HIV. Milly Katana, a public health specialist, told the Guardian that the coronavirus lockdown is “unfortunately” not locking up HIV.

“I have information from Ankole districts [in western Uganda] where patients are in a desperate situation, walking for seven hours, sleeping at health facilities and going back the following day,” said Katana, warning that the situation could lead to drug resistance.

“Many of our friends are running out of ARVs. This is more worrying given that dolutegravir (DTG), the first-line drug of choice, has a very short ‘temper’. Miss a few doses and one gets a resistant strain of HIV. The next HIV epidemic will be resistant to not only DTG, but the drugs in the same class.”

For Helen Jenkins, epidemiologist at Boston University School of Public Health, the suspension of research into – and vaccination of – infectious diseases is likely to have a profound impact. “I am very concerned for when the pandemic truly hits a high-TB-burden country, of which there are many in Africa,” she said.

“There is likely to be greater severity of Covid-19 infection in people with TB, or damaged lungs from previous TB. In addition, research into all infectious diseases is stopping in many places, vaccination campaigns are stopping, so we are likely to see increases in vaccine-preventable diseases such as measles or polio.”

Malaria symptoms can also present similarly to coronavirus, leading to confusion.

“Anyone whose body temperature is higher than normal is suspected to be infected with coronavirus and put in isolation wards and in quarantine locations where people who have arrived from abroad are being observed,” said Chris Macoloo, director for the US development charity World Neighbors in east and west Africa.

“The possibility is that a person who has merely a raised temperature (maybe unrelated to the virus) is likely to be infected when brought closer to people under isolation. There is a likelihood that lower-order health facilities such as dispensaries are referring malaria patients to the Covid-19 health teams. So in the incubation stage, a lot of confusion is occurring.”

Dr Joyce Samoutou-Wong of the Congo-based charity New Sight Eye Care says her charity has distributed more than 12,000 leaflets and posters and recorded several broadcasts in Congo and abroad regarding the virus.

“We had to close our clinic on 31 March and we normally serve 200 patients per month. Cargo supplies are still running, for now, but we depend on visits from abroad to bring a lot of our supplies, which have obviously been suspended, plus we’ve had to postpone the construction of an eye hospital.”

Samoutou-Wong said a European-style lockdown would be totally impossible in Africa. “A lot of myths are out there. People think Congo bololo (a plant) or lemon and garlic can protect them from the virus.

“We are on the edge of the rainforest, so there is no panic buying because people don’t have the resources to stock up on supplies, and quarantine is impossible because people share clothes, beds, floor space, utensils. Water pumps are a hotspot for the virus, so the hardest measure to implement is simply hand washing.”

This article originally appeared on theguardian.com on April 8, 2020