A new analysis by WHO has concluded that the vast majority of cases of COVID-19 in Africa are not being detected. At time of the analysis, Oct 10, 2021, Africa had recorded around 8·4 million SARS-CoV-2 infections, and 217 000 deaths (the continent has since reported another 200 000 or so infections and 2000 deaths). WHO calculated that the true number of infections was seven times higher than the reported figure. The same analysis showed that two in three deaths from COVID-19 are not being registered in Africa. As The Lancet Respiratory Medicine went to press, 6% of Africans had been fully vaccinated against COVID-19. Although the supply of vaccines to the continent has accelerated over the past few months, it is still suboptimal and WHO has warned that 2022 could see a shortfall of syringes.
Ngozi Erondu is senior research fellow at the Chatham House Centre for Global Health Security (London, UK). She points out that there was always likely to be a sizeable number of missed cases of COVID-19 in Africa. “Many African countries have weak surveillance systems”, said Erondu. “There are challenges in detecting known diseases like meningitis; a new disease that has non-specific febrile symptoms is going to be even more difficult to pick up.” At the start of 2020, Africa contained two laboratories capable of undertaking RT-PCR testing. Capacity has since improved, but it is almost entirely restricted to the cities. More than half of sub-Saharan Africans live in rural settings.
Africa's demographics have worked in its favour during the pandemic. The median age is 19·5 years. Of the 1·3 billion people who live on the continent, only 6 million are older than 80 years. There is not a huge burden of diabetes or obesity. WHO reckons that 65–85% of SARS-CoV-2 infections in Africa do not produce any symptoms. “We are missing many cases, but we are not seeing a lot of people who are getting sick or severely ill, and we are not hearing of there being a high impact on hospitals or graveyards”, explained Thierno Balde, deputy incident manager for emergency response at the WHO Regional office for Africa (Brazzaville, Republic of the Congo). After the third wave peaked in July, 2021, there has been a steady decline in new cases of COVID-19 across Africa, though a handful of countries are seeing resurgences.
Nevertheless, the pandemic has taken its toll. There has been tremendous economic damage. Millions of Africans have lost their jobs. In 2020, 32 million people in sub-Saharan Africa fell into extreme poverty. School closures meant that over 50 million children were deprived of free meals. The alpha, beta, and delta variants have each been detected in more than 40 states on the continent. The longer SARS-CoV-2 continues in widespread circulation, the greater the chance that dangerous new variants will arise.
WHO projects that just five African nations will manage to fully vaccinate 40% of their populations by the end of 2021. Only one of these nations, Mauritania, is in sub-Saharan Africa. Moreover, the misleading impression given by the official figures on COVID-19 could lead to reduced vaccine take-up, if people assume that the virus is under control. Even if vaccines are made available, delivering them is not always straightforward. Several countries struggle to maintain cold chains. There have been issues with vaccine hesitancy, and reports of donated vaccines that are on the brink of expiration.
Africa has mostly limited testing to individuals who show symptoms. A new programme by WHO aims to kickstart active case-finding. The plan is to reach more than 7 million Africans across eight countries over the course of the next year. Households within a 100 m radius of an individual who has tested positive for SARS-CoV-2 will be offered rapid diagnostic tests. Those who have contracted COVID-19 will receive care either at home or at designated treatment centres, depending on the severity of the disease. Burundi, Democratic Republic of the Congo, and Senegal are among the participating countries. “We really need to bring testing into the community, and this programme is doing exactly that”, commented Erondu. “It uses a ring strategy, which has been very effective for other infectious diseases, and should help us pick up a lot of cases of COVID-19.” As high-income countries become aware of the true burden of disease in Africa, they might decide to step-up vaccine donations. The COVAX facility, which aims to ensure equitable global access to the COVID-19 vaccines, has thus far received less than one-third of the 1·3 billion doses of the vaccines that have been promised.
“African governments are starting to come together to establish the capacity for vaccine manufacturing on the continent; if this does not happen we will be in the same situation every time there is a new pandemic”, added Erondu. She hopes that proposals to waive intellectual property protections for the COVID-19 vaccines, which have been backed by countries including the USA, will be taken up by the World Trade Organisation. On Oct 26, 2021, BioNTech, which partnered with Pfizer to produce the first COVID-19 vaccine to receive regulatory approval in the UK and USA, announced plans to start work on a manufacturing centre for mRNA vaccines in Africa sometime next year.
© 2021 Daniel Buah/Science Photo Library