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Ethiopian Journal of Health Sciences logoLink to Ethiopian Journal of Health Sciences
. 2021 Nov;31(6):1075–1088. doi: 10.4314/ejhs.v31i6.2

COVID-19 in WHO African Region: Account and Correlation of Epidemiological Indices with Some Selected Health-related Metrics

Henshaw Uchechi Okoroiwu 1,2,, Christopher Ogar Ogar 2, Dennis Akongfe Abunimye 3, Ifeyinwa Maryann Okafor 2, Ikenna Kingsley Uchendu 3
PMCID: PMC8968369  PMID: 35392328

Abstract

Background

The coronavirus disease 2019 (COVID-19) is a highly contagious and pathogenic viral disease caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Since it was first reported in Wuhan, China, it has spread across the continents. The study is aimed at describing epidemiological indices of COVID-19 as reported by the World Health Organization and to examine correlations with some country specific measures of general health status.

Methods

Data from the WHO African region were extracted from World Health Organization, Global Health Security Index, Worldometer and World Bank databases, as at September 8, 2020. Other epidemiological indices were computed for the various countries. Epidemiological indices of COVID-19 were correlated with some selected health related metrics: Global Health Security index (GHSI) and current health expenditure (CHE). Pearson correlation was used to access the relationship between the health-related metrics and epidemiological indices.

Results

Forty-seven (47) countries belonging to the WHO African region were evaluated. A total of 1,086,499 confirmed cases and 23,213 deaths were recorded giving a fatality rate of 2.1%. South Africa recorded the highest cumulative confirmed cases as well as deaths (Cases: 639,362; Deaths: 15,004) while Seychelles (Cases:135) and Eritrea/Seychelles (Deaths:0) had the least cumulative cases and deaths (135;0 and 330;0), respectively. South Africa recorded the highest attack rate (1127.67/100,000) while Republic of Tanzania recorded the least attack rate (0.78/100,000). The highest case fatality rate/ratio was observed in Chad (7.60%) while the least value was observed in Seychelles (0.0%). France was the most common country involved in travel history of index cases. Sporadic transmission was recorded in 3 countries, 9 countries had cluster of cases while the rest had community transmission. The first WHO African region country to record COVID-19 case was Algeria, while Comoros was the last. Significant positive correlation was found between COVID-19 case number/deaths and Global Health Security Index.

Conclusion

The WHO African region has had its own share of the pandemic with all the countries being affected. The trio of cluster cases, sporadic and community transmission were recorded with majority being community transmission.

Keywords: COVID-19, SARS-Cov-2, COVID-19 in Africa, Coronavirus

Introduction

The Coronavirus disease 2019 (COVID-19) caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has metamorphosed into global pandemic with noxious morbidity and mortality (1,2). The COVID-19 pandemic is the most pressing health care issue globally (3). At the onset of the pandemic it was broadly designated as a severe respiratory illness presenting with fever, atypical pneumonia, cough and dyspnea (4,5). However, altered sense of smell and taste have long been found to be associated with the disease (5,6). More so, a review of 77 observational studies showed a good number of patients presenting with less typical symptoms. (5,7).

As of July 22, 2021, SARS-CoV-2 has been responsible for 191,773,590 infections and 4,127,963 confirmed deaths (fatality rate: 2.15%) globally with the United States accounting for 33,875,385 cases and 604,546 confirmed deaths (the highest disease burden). The stratification of the data showed that the region of the Americas are currently the epicenter of the pandemic accounting for 39.22% (75,220,757) of the confirmed cases followed by Europe that accounted for 30.54% (58,576,440) of confirmed COVID-19 cases. Then in subsequent order South East Asia, Eastern Mediterranean, Africa and West Pacific regions (of WHO Classification) accounted for 19.39% (37,191,075), 6.26% (12,000,909), 2.44% (4,688,762) and 2.13% (4,094,883), respectively of global COVID-19 cases (8). Consequently, the WHO African region is the 5th worst hit out of the six (6) WHO regions. This study is aimed at describing epidemiological indices of COVID-19 in WHO African region as reported by the World Health Organization and to examine correlations with some country specific measures of general health status.

Methods

Data collection: Epidemiological indices of COVID-19 up to September 8, 2020 were collected from the official dashboard of World Health Organization (WHO) (9). The cumulative confirmed cases, cumulative deaths and attack rate per 100,000 of the population, transmission pattern and percentage of all deaths were extracted while case fatality ratio was computed for each country. The population of the various countries was extracted from Worldometer (10). While the health expenditure (%GDP) was extracted from World Bank database (11), the 2019 global health security index (GHSI) was extracted from the Global Health Security index database (12). Information on index cases were extracted from center for disease control/infectious disease control centers/COVID-19 update/COVID-19 information Hub/Ministry of Health web page of the various studied countries and WHO African region web page. The following search clauses were used: “World health organization African region+country index case”; “Country COVID-19 index case+country ministry of health”; “Country CDC”; “Country COVID-19 update dashboard”. In some cases, Africa news web page (13) was used to complement the details.

Quality control on data extraction: Data used in this study were extracted by the authors. The authors were divided into two groups: A (HUO and COO) and B (DAA and IMO). The two groups independently extracted the required data based on the study design. IKU harmonized the two independent results. In few cases of disparity all the authors double checked to ratify the correct data.

The following operation definitions of terms/variables were used:

Global health security index: Global health security index (GHSI) is the first comprehensive assessment and benchmarking of health security and related capabilities across the 195 countries that make up the state parties to International Health Regulations 2005. The index was intended to spur measurable changes in national health security and improve international capability to address world risk such as infectious diseases outbreak that could lead to pandemics. The GHS index relies entirely on open source information (data that the country has reported on its own or has been reported by an international entity). The index prioritizes both countries' capacities as well as existence of functional, tested, proven capabilities for stopping outbreaks source (12).

Current health expenditure (%GDP): This refers to the level of current health expenditure expressed as a percentage of gross domestic product (GDP). Current health expenditure as a share of GDP provides an indication on the level of resources channeled to health relative to other uses. It shows the importance of health sector in the whole economy and indicates the societal priority which health is given measured in monetary terms. It is measured as percentage of GDP (%GDP) (14). It includes health care goods consumed each year and does not include capital health expenditure such as buildings, machinery (15).

Confirmed cases/cumulative confirmed cases: This refers to the total number of confirmed COVID-19 infection cases within the period of study. It is represented as frequency.

Deaths/cumulative deaths: This refers to the total number of deaths that resulted owing to COVID-19 infection within the study period. It is represented as frequency.

Percentage of deaths: This refers to the number of COVID-19 deaths recorded in a country in relation to the cumulative COVID-19 related deaths recorded in all the countries assessed within the study period. It is represented in percentage.

Attack rate / Attack rate per 100,000 of population: The index refers to the number of persons infected with COVID-19 per 100,000 of the country's population. It is represented as frequency per 100,000 of population.

Case fatality rate/ratio: It refers to the proportion of people who died from COVID-19 infection among all individuals diagnosed with COVID-19 over the studied period.

Statistical analysis: Retrieved data were analyzed with SPSS for windows, version 22 (IBM Corp Armonk, NY). Epidemiological and health related metrics were described using frequencies and proportions (percentages). Pearson correlation was used in determining association of some COVID-19 epidemiological indices with some health related cum financial metrics. The alpha value was benched at 0.05.

Results

Forty-seven (47) countries belonging to the WHO African region were assessed. A total number of 1,086,499 cases and 23,213 deaths were recorded in the WHO African region giving a case fatality rate of 2.1% as of September 8, 2020. South Africa (639,362), Ethiopia (59,648) and Nigeria (55,160) were the leading countries in terms of cumulative confirmed cases, while Seychelles (135), Eritrea (330) and Mauritius (356) had the least cumulative confirmed cases. In terms of COVID-19 related deaths, South Africa (15,004), Algeria (1,562) and Nigeria (1,061) had the highest values while Seychelles (0), Eritrea (0) and Burundi (1) had the least cumulative deaths. South Africa (1,127.67), Cape Verde (788.99) and Equatorial Guinea (515.11) recorded the highest attack rates per 100,000 of the population, while Republic of Tanzania (0.79), Niger (3.24) and Burundi (3.54) had the least attack rates per 100,000 of population. The highest case fatality rates were observed in Chad (7.60%), Liberia (6.25%) and Niger (5.86%) while Seychelles (0), Eritrea (0) and Burundi (0.21) had the least case fatality rates. Eight (8) countries: Burkina Faso, Cameroon, Lesotho, Congo, South Africa, Mauritius, Togo and Rwanda were involved in transmission history of the index cases while sixteen non-African countries: Italy, Portugal, France, UK, United Arab Emirate (Dubai), Spain, Norway, USA, Japan, Turkey, Belgium, Switzerland, Saudi Arabia, India, Netherlands and Germany were involved in the transmission history of index cases (Table 1)

Table 1.

Account and epidemiological indices of COVID-19 and some health-related metrics among the WHO African region countries up to September 8, 2020

Country Confirmed
cases
Deaths % of all
death
Attack
rate
Case
Fatality rate
Date of
index case
Transmission
pattern
Route of index case Population GHS-I Health exp.
(%GDP)
Algeria 46653 1562 6.73 108.46 3.35 Feb. 25 CT Italy 43851044 23.6 6.37
Angola 2981 120 0.52 10.19 4.03 March 21 Clusters Portugal 32866272 25.2 2.79
Benin 2213 40 0.17 17.72 1.81 March, 16 CT Burkina Faso 12123200 28.8 3.72
Burkina Faso 1452 55 0.24 7.03 3.79 March, 9 CT France 20903273 30.1 6.92
Botswana 2126 9 0.04 86.79 0.42 March 30 Clusters UK, Thailand. 2351627 31.1 6.13
Burundi 466 1 0.00 3.54 0.21 March 31 Clusters Rwanda, Dubai. 11890784 22.8 7.52
Cameroon 19848 415 1.79 71.18 2.09 March, 6 CT France 26545863 34.4 4.67
Cape Verde 4358 42 0.18 788.99 0.96 March, 20 Clusters UK 555987 29.3 5.17
Chad 1040 79 0.34 4.61 7.60 March, 19 CT Cameroon 16425864 28.8 4.49
CAR 4729 62 0.27 22.81 1.31 March, 14 CT Italy 4829767 27.3 5.82
Congo 4891 114 0.49 82.20 2.33 March, 14 CT France 5518087 23.6 2.93
Comoros 448 7 0.03 50.73 1.56 April 30 CT France 869601 27.2 7.38
Cote d'Ivoire 18701 119 0.51 73.05 0.64 March, 11 CT Italy 26378274 35.5 4.45
DRC 10233 260 1.12 10.88 2.54 March, 10 CT France 89561403 26.5 3.98
Equatorial
Guinea
4985 83 0.36 515.11 1.66 March, 14 CT Spain 1402985 16.2 3.11
Eritrea 330 0 0.00 5.56 0.00 March, 21 Sporadic Norway 3546421 22.4 2.87
Eswatini 4884 94 0.40 359.36 1.92 March, 14 CT USA, Lesotho 1160164 31.1 6.93
Ethiopia 59648 933 4.02 52.86 1.56 March, 13 CT Japan 114963588 40.6 3.50
Gabon 8608 53 0.23 449.31 0.62 March, 12 CT France 2225734 20.0 2.78
Gambia 3196 99 0.43 136.83 3.10 March, 17 CT UK 2416668 25.2 3.28
Ghana 44777 283 1.22 146.63 0.63 March, 12 CT Norway, Turkey 31072940 35.5 3.26
Guinea 9816 62 0.27 68.39 0.63 March, 13 CT Belgium 13132796 32.7 4.12
Guinea Bissau 2245 38 0.16 105.97 1.69 March, 25 CT Congo, India 1968001 20.0 7.24
Kenya 35205 599 2.58 67.29 1.70 March, 13 CT USA 53771296 47.1 4.80
Liberia 1311 82 0.35 25.73 6.25 March, 16 CT Switzerland 5057681 35.1 8.16
Lesotho 1164 31 0.13 51.71 2.66 May, 13 Clusters South Africa, Saudi
Arabia
2142249 30.2 8.76
Madagascar 15352 202 0.87 55.23 1.32 March, 20 CT France, Mauritius, 27691018 40.1 5.50
Mali 2870 127 0.55 13.98 4.43 March, 25 CT France 20250833 29.0 3.79
Mauritania 7164 160 0.69 157.58 2.23 March, 13 CT Europe 4649658 27.5 4.40
Mauritius 356 10 0.04 27.57 2.81 March, 18 Sporadic Belgium 1271768 34.9 5.72
Malawi 5621 176 0.76 28.11 3.13 April, 2 CT India 19129952 28.0 9.65
Mozambique 4557 27 0.12 14.24 0.59 March, 22 CT UK 31255435 28.1 4.94
Niger 1178 69 0.29 3.24 5.86 March, 19 Clusters Togo 24206644 32.2 7.74
Nigeria 55160 1061 4.57 26.62 1.92 Feb. 27 CT Italy 207151803 37.8 3.76
Namibia 8810 91 0.39 321.09 1.03 March, 14 CT Spain 2540905 35.6 8.55
Rwanda 4409 19 0.08 33.61 0.43 March, 14 Clusters India 12952218 34.2 6.57
Sao Tome &
Principe
898 15 0.06 426.37 1.67 April, 6 Clusters 219157 17.7 6.23
Senegal 13987 290 1.23 80.14 2.07 March, 2 CT France 16743927 37.9 4.13
Seychelles 135 0 0.00 136.52 0.00 March, 14 Sporadic Italy 98347 31.9 5.01
Sierra Leone 2055 71 0.31 28.86 3.45 March 31 CT France 7976983 38.2 13.42
South Africa 639,362 15004 64.64 1127.67 2.35 March, 5 CT Italy 59308690 54.8 8.11
South Sudan 2552 49 0.21 17.2 1.92 April, 5 CT Netherlands 11193725 21.7 9.76
Togo 1488 32 0.14 18.01 2.15 March, 6 CT France, Benin Germany Turkey 8278724 32.5 6.20
Uganda 3776 44 0.19 7.7 1.17 March, 22 Clusters Dubai 45741007 44.3 6.19
United Rep. of
Tanzania
509 21 0.09 0.79 4.13 March, 16 CT Belgium 59734218 36.4 3.65
Zambia 12836 295 1.27 67.85 2.3 March, 18 CT France 18,383955 28.7 4.47
Zimbabwe 7116 208 0.89 40.78 2.92 March, 21 CT UK 14862924 38.2 6.64

Afri: African, UK: United Kingdom, CT: Community transmission, CAR: Central African Republic, DRC: Democratic Republic of Congo, Rep: Republic; GDP: Gross domestic product, GHS-I: Global health security index, †: Country not disclosed. All dates refer to 2021

The detailed description of the index cases of the various WHO African Region countries studied is shown in Table 2.

Table 2.

Description of the index cases of the various countries studied

Country Description of index case Country Description of index case Country Description of index case
Algeria An Italian who arrived the country on February
17, 2020 from Italy.
Eswatini A 33 year-old female with travel history from
USA at the end of February, 2020, then to
Lesotho.
Niger A 36 year-old Nigerian man. He had travelled to
Lome, Accra, Abidjan and Ougadougou.
Angola Two persons returning from Portugal on March
17–18, 2020. The 1st case was a Sonangol
employee who flew from Lisbon to Luanda.
The 2nd case had flown in from Porto.
Ethiopia Japanese who travelled from Japan to Burkina
Faso and arrived in Ethiopia.
Nigeria An Italian man who flew from Milan Italy to
Nigeria on February 25, 2020.
Benin A 49 year- old Burkinabe citizen who entered
Benin on March 12, 2020 from Belgium and
Burkina Faso.
Gabon A 27 year old Gabonese man who had recently
entered Gabon from France 4 days prior to
confirmation.
Namibia The two cases were a Romanian couple who
arrived in Windhoek from Spain via Doha, Qatar,
on 11 March, 2020.
Burkina
Faso
Husband and wife, had recently returned to
Burkina Faso from a trip to France.
Gambia A woman in her thirties who had travelled to
the Gambia from the United Kingdom on 15th
March, 2020.
Rwanda An Indian citizen who arrived from Mumbai,
India on March 8th, 2020.
Botswana 2 males and 1 female who travelled to UK and
Thailand.
Ghana The two patients who tested positive for the
virus had arrived from Norway and Turkey to
Ghana.
Sao Tome &
Principe
4 cases reported at once without disclosure of
travel history
Burundi A Burundian returning from Rwanda: A
Burundian returning from Dubai via Rwanda.
Guinea An employee of EU delegation to Guinea who
travelled from Brussels in Belgium to
Conakry, Guinea.
Senegal A French national and a resident of Senegal who
returned to Dakar from France on 26th February,
2020.
Cameroon A 58 year-old French national who arrived in 2020.
Cameroon on February 24, 2020.
Guinea
Bissau
The first two confirmed cases were: a
Congolese U. N. employee and an Indian
citizen.
Seychelles The two cases were Seychellois who returned
from Italy.
Cape Verde A 62 year-old British national who arrived on
the island of Boa Vista on March 9 and started
to show symptoms of fever and cough on
March, 16.
Kenya A 27 year old Kenyan woman who returned from the
USA via London, UK on the 5th March, 2020.
Sierra
Leone
A 37 year-old man who travelled from
France to Sierra Leone on 16th March,
2020.
Chad A Moroccan national who had travelled to
Chad from Cameroon.
Liberia Liberian government official who returned from
Switzerland to Liberia.
South
Africa
A South African national who returned
from Italy.
Central Afri.
Rep
A 74 year-old Italian man who returned to
Central African Republic from Milan, Italy.
Lesotho A positive result from Lesotho citizen travelers among
the 81 citizens/ travelers from South Africa and Saudi
Arabia
South
Sudan
A 29 year-old United Nations staff
(woman) who returned from
Netherlands via Addis Ababa on
February 28th, Sierra Leone and resided
there for five weeks.
Congo A 50 year-old Franco-Congolese national who
arrived in Congo on 1st March, 2020 from Paris
after a brief stay in Amsterdam, Holland.
Madagascar 3 cases: A 41 year-old Malagasy citizen returning from
France via Air France on March 17, 2020; A 19 year-old
Malagasy citizen returning from Mauritius via Air
Mauritius on 18th March, 2020; A 45 year-old Malagasy
citizen returning from France via Air Madagascar on
March 19th, 2020. All were women.
Togo A 42 year-old female Togolese who
recently travelled to France, Benin,
Germany and Turkey but returned to
Lome through Benin by road.
Comoros A 50 year-old Franco-Comorian who has since
been admitted since April 23, 2020. The patient
came into contact with a national with recent
travel history to France.
Mali 2 Malian nationals that returned from France on 12th and
16th March, 2020: A 9 year old woman and a 62 year old
male.
Uganda A 36 year-old Ugandan male who
travelled to Dubai on 17th March, 2020
and returned on 21st March, 2020.
Cote d'Ivoire A 45 year-old Ivorian man who went to the
hospital with complaints of fever and a runny
nose after returning from Italy.
Mauritania The case is an expatriate from a yet to be disclosed
country in Europe who arrived in the Mauritanian capital
of Nouakchott on March 9, 2020.
United Rep.
of Tanzania
A 46 year-old female Tanzanian who
departed the country on 3rd March 2020
to Belgium and had visited Denmark
and Sweden between the dates 5 and 13
March 2020. On the 15th March 2020,
she flew back to Tanzania from
Belgium.
Democratic
Rep. of
Congo
The patient is a Congolese citizen who returned
from France.
Mauritius 3 cases: A 52 year-old man who had dual Belgian and
Mauritian nationality that returned to Mauritius from
Belgium on 21st Feb. 2020; A 52 year old man with both
British and Mauritius nationality who returned to
Mauritius on March 7, 2020; A 21 year old male cruise
ship male worker that entered Mauritius on March 14,
2020.
Zambia The two cases were a couple that had
travelled to France on holiday.
Equatorial
Guinea
A 43 year-old woman in Malabo, who returned
to Equatorial Guinea from Madrid Spain.
Malawi The 3 cases include a Malawian of Asian origin who
travelled back from India, her relative and their
housemaid.
Zimbabwe A 43 year-old tourist who travelled back
the UK through South Africa to
Zimbabwe.
Eritrea An Eritrean national arriving Asmara in Eritrea
from Norway.
Mozambique A 75 year-old man who had recently returned from
Britain midway through March, 2020.

Distribution of COVID-19 cases based on range in map of Africa indicating the WHO African regions are shown in Figure 1.

Figure 1.

Figure 1

Diagrammatic representation of COVID-19 case distribution in the studied area.

South Africa (639,362), Ethiopia (59,648) and Nigeria (55,160), were at the top of the list of countries with the top 10 confirmed COVID-19 cases while South Africa (15,004), Algeria (1,562), Nigeria (1,061), were at the top of the list of countries with top 10 COVID-19- related mortality. Analysis of the top 10 attack rates per 100,000 of the population showed South Africa (1,127.67), Cape Verde (788.99) and Equatorial Guinea (515.11) on top of the table. On the other hand, Chad (7.60%), Liberia (6.25%) and Niger (5.86%) were on the top of the list of the top 10 case fatality rates in the WHO African Region (Table 3).

Table 3.

Summary of top 10 countries in the various COVID-19 epidemiological indices

COVID-19 epidemiological indices

Rank Confirmed cases Deaths (% of all deaths) Case fatality rate Attack rate
1st South Africa 639,362 South Africa 15,004(64.64) Chad 7.60 South
Africa
1,127.67
2nd Ethiopia 59,648 Algeria 1,562 (6.73) Liberia 6.25 Cape
Verde
788.99
3rd Nigeria 55,160 Nigeria 1,061 (4.57) Niger 5.86 Equatorial
Guinea
515.11
4th Algeria 46,653 Ethiopia 933 (4.02) Mali 4.43 Gabon 449.31
5th Ghana 44,777 Kenya 599 (2.58) United Rep.
of Tanzania
4.13 Sao Tome
& Principe
426.37
6th Kenya 35,205 Cameroon 415 (1.79) Angola 4.03 Eswatini 359.36
7th Cameroon 19,848 Zambia 295 (1.27) Burkina
Faso
3.79 Namibia 321.09
8th Madagascar 15,352 Senegal 290 (1.23) Sierra Leone 3.45 Ghana 146.63
9th Senegal 13,987 Ghana 283 (1.22) Algeria 3.35 Gambia 136.83
10th Zambia 12,836 Dem. Rep.
Congo
260(1.12) Malawi 3.13 Seychelles 136.52

France was the most common country involved in the history of the transmission of the index cases in the studied countries involving 11 countries: Burkina Faso, Cameroon, Congo, Comoros, Democratic Republic of Congo, Gabon, Madagascar, Mali, Senegal, Zambia and Togo. On the other hand, Italy was involved in the history of the index case of 6 countries (Algeria, Cote d'Ivoire, South Africa, Seychelles, Central African Republic and Nigeria), while United Kingdom (UK) were involved in the transmission history of index cases of 5 countries (Botswana, Cape Verde, Gambia, Zimbabwe and Mozambique). Other countries noted were involved in less than 4 country index case history (Table 4).

Table 4.

Stratification of various African countries and the corresponding country of origin of index case

Country of origin of
index case
No. of countries
involved
Countries affected Route
classification
Italy 6 Algeria, Cote d'Ivoire, South Africa,
Seychelles,
Central African Republic, Nigeria.
Intercontinental
Portugal 1 Angola Intercontinental
Burkina Faso 1 Benin Intracontinental
France 11 Burkina Faso, Cameroon, Congo,
Comoros,
Democratic Republic of Congo,
Gabon,
Madagascar, Mali, Senegal, Zambia,
Togo*
Intercontinental
UK 5 Botswana, Cape Verde, Gambia, Zimbabwe, Mozambique Intercontinental
Dubai 2 Burundi, Uganda Intercontinental
Cameroon 1 Chad Intracontinental
Spain 2 Equatorial Guinea, Namibia Intercontinental
Norway 2 Eritrea, Ghana Intercontinental
USA 2 Eswatini*, Kenya Intercontinental
Lesotho 1 Eswatini* Intracontinental
Japan 1 Ethiopia Intercontinental
Turkey 1 Togo* Intercontinental
Belgium 3 Guinea, Mauritius, United Republic of
Tanzania
Intercontinental
Congo 1 Guinea Bissau Intracontinental
Switzerland 1 Liberia Intercontinental
South Africa 1 Lesotho* Intracontinental
Saudi Arabia 1 Lesotho* Intercontinental
Mauritius 1 Madagascar Intracontinental
India 2 Malawi, Rwanda Intercontinental
Togo 1 Niger Intracontinental
Netherlands 1 South Sudan Intercontinental
Germany 1 Togo Intercontinental
Rwanda 1 Burundi Intracontinental
*

More than 1 travel history

Sporadic transmission was recorded in Eritrea, Mauritius and Seychelles while cluster of cases were observed in Angola, Botswana, Burundi, Cape Verde, Lesotho, Niger, Rwanda, Sao Tome and Principe, and Uganda. The remaining countries had community transmission on-going (Table 1).

The first two African countries to record COVID-19 cases were Algeria (February 25, 2020) and Nigeria (February 27, 2020). These were followed by Senegal, South Africa, Cameroon, Togo, Burkina Faso, Democratic Republic of Congo, Cote d'Ivoire, Ghana, Gabon, Ethiopia, Guinea, Kenya, Mauritania, Central Africa Republic, Congo, Equatorial Guinea, Eswatini, Namibia, Rwanda, Seychelles, Benin, Liberia, United Republic of Tanzania, Gambia, Zambia, Mauritius, Niger, Chad, Cape Verde, Madagascar, Zimbabwe, Eritrea, Angola, Mozambique, Uganda, Guinea Bissau, Mali, Botswana, Sierra Leone and Burundi that recorded their index cases between March 2nd and March 31st, 2020. The last 3 countries to record their index cases were South Sudan, Sao Tome and Principe and Comoros that had their index cases on 5th, 6th and 30th April, 2020, respectively (Figure 2).

Figure 2.

Figure 2

Chronological order of COVID-19 index case record of the various countries in WHO African region.

Significant positive correlation (P<0.05) was observed between Global Health Security Index and cumulative confirmed COVID-19 cases, as well as cumulative COVID-19 related deaths and Global Health Security Index. Although non-significant correlation was recorded in cumulative confirmed COVID-19 cases vs Health expenditure; Cumulative deaths vs Health expenditure; Cumulative fatality rate vs Global Health Security Index; Cumulative fatality rate vs Health expenditure; Attack rate vs Global Health Security Index; Attack rate vs Health expenditure, their Pearson correlation coefficient are 0.120, 0.142, 0.035, 0.113, 0.177 and 0.024 (Table 5).

Table 5.

Correlation results of some epidemiological indices and health service indicators

Correlated variables Pearson correlation coefficient P-value
Cumulative confirmed cases Vs GHSI 0.519 <0.01
Confirmed cases Vs Health Expenditure 0.120 0.422
Cumulative deaths Vs GHSI 0.495 <0.01
Cumulative deaths Vs Health Expenditure 0.142 0.342
Cumulative fatality rate Vs GHSI 0.035 0.816
Cumulative fatality rate Vs Health Expenditure 0.113 0.450
Attack rate Vs GHSI 0.177 0.239
Attack rate Vs Health Expenditure 0.024 0.873

Note: GHSI: Global health security index, Vs: versus

Discussion

A total of 1,086,499 and 23,213 deaths were recorded in the WHO African region studied, giving rise to case fatality ratio of 2.1%. This placed the WHO African region 5/6 of the other WHO regions in terms of COVID-19 cases. The case fatality ratio observed in this study is below the global average (3.4%) (16) and that of the region of the Americas, Europe and South East Asia. In contrast to the Ebola Virus disease (EVD), the CFR is far below that of EVD which had global average of 50% (even up to 90% in some places) (17) and ranged from 39.6% to 84.3% in the West African Sub-region (20). However, COVID-19 has been found to be more contagious with an average Ro value of 3, consequently cause for higher cumulative number of deaths observed (19). Since the report of the first case in the region in Algeria on February 25, 2020, seven months later the epidemic curve in the region remained flatter in comparison with region of Americas, Europe and Asia as against earlier insinuations. Before now, African has been predicted to be most vulnerable continent in terms of COVID-19 infection and was predicted as region where COVID-19 will have major impact. This prediction was based on the continent's weak health care system cum large immunocompromised population (20,21,22). However, the prediction proved otherwise. There have been varying hypothesis in attempt to explain the reason to the relatively low COVID-19 cases in African region as against expectations. Some experts attributed this to low numbers of SARS-CoV-2 introduced (seeding) into Africa possibly due to low volume of air travel to the region (23). More so, the mitigative measures (partial and complete lock down and travel restrictions) (2) may have played role. Some researchers have proposed that the greater youthful population of the African region with median age < 20 years as against Europe and the USA with medium age > 38 years (24,25) is a contributing factor. Also, some authors have attributed the low incidence to favorable climate. Sajadi and colleagues have recorded association between temperature / humidity and COVID-19 spread (26) which is in line with previously reported factors for survival in earlier epidemic: SARS-CoV and influenza (27,28,29). Africa experiences warmer and drier weather within December and April season with average temperature of the day > 20 degree Celsius (30). In a different perspective, some authors have posited that a population across Africa have some level of SARS-CoV-2 immunity as a result of prior exposure to other coronaviruses (30). Lastly, there are postulations of prospective effect of Bacilli Calmette-Guerin (BCG) vaccination against COVID-19 infection (31). However, the reports were not from clinical trials (but experimental studies) which prompted WHO to recommend disregarding the results until the clinical trials are complete (32). Alternatively, there is possibility of low report of COVID-19 cases in African region owing to lack of material resources as available in the Americas and Europe continents that are more economically buoyant. Although some of the postulations have conflicting versions, future studies would help unravel the explicit contributing factors to the relatively low COVID-19 event in African region.

In this study, we found South Africa to be the epicenter of COVID-19 pandemic in the WHO African region. As of September 8, 2020, South Africa had 639,362 confirmed COVID-19 cases, accounting for more than half (58.8%) of the pandemic in the region. Comparatively to the global data, South Africa ranked 12th in the global burden of COVID-19 pandemic below USA, India, Brazil, Russia, Argentina, Colombia, Spain, Peru, Mexico, France and UK. Though we could not “pin – point” the exact reason for such large burden, however, some authors have argued that South Africa carries a significant burden of tuberculosis, HIV, and HIV/TB coinfection, with millions of the population on immunosuppressant drugs as well as others who are HIV-positive but not on retroviral therapy (33). South Africa still has the largest global burden of HIV (approximately 19%) (34,35). There are reports that those with comorbidities are more susceptible to developing severe COVID-19 (36). On the flip side, some authors have attributed the “sky rocketing” of the pandemic in South Africa to arrival of winter in South Africa at the start of the epidemic considering the fact that all respiratory viruses spread more effectively in winter (20).

Adjusting the COVID-19 cases per 100,000 of the population (attack rate per 100,000 of population) still showed South Africa, then Cape Verde and Equatorial Guinea at the top. South Africa alone clocked attack rate above 1000 cases per 100,000 of the population. Although Cape Verde and Equatorial Guinea do not rank among the top 10 in terms of cumulative confirmed cases, cases per 100,000 of the population were observed to be high.

South Africa accounted for majority (64.64%) of all deaths in the region followed by Algeria and Nigeria. These three were among the first four countries in the region recording COVID-19 cases on March 5, February 25 and 27, respectively. As of the time of this report, Eritrea and Seychelles were the only countries in the region without record of COVID-19 related mortality.

Chad (7.60%), Liberia (6.25%) and Niger (5.86%) had the highest case fatality ratios. These values are quite far from the average CFR of the entire region and only comparable to values seen in countries in region of America and Europe such as Mexico (10.1%) and Italy (8.2%) (37). Although merely passed 1000 case profile, the case fatality rate of Chad is high and is among the highest values globally. Before the pandemic, Chad has been ravaged by malaria, Chikunguya and measles. The high incidence of measles have been attributed to insufficient vaccination (only 22% of children aged 12 to 23 months are vaccinated) (38). Inter-country comparison of CFR is an important indicator of disease characteristics and is important for both national and international priority settings as well as recognizing health system performance. However, it is pertinent to note that there are varying factors that can confound the value: undetected cases / low case detection, and delayed case reporting (39).

France was the most involved country in travel history of index cases in the region, followed by Italy and UK. A striking feature about countries that had index case with France travel history is that all except Democratic Republic of Congo and Zambia were all former French colonies. France still maintains very strong ties and less travel/visa bureaucracy with its former colonies more than their British (UK) counterpart (40).

In this study we found strong positive correlation between cumulative confirmed cases / cumulative deaths and Global Health Security Index. This observation is quite ironic in the sense that cases and deaths were supposed to be low in countries that have high GHSI and vice versa (negative correlation). This trend is also observed in global data of COVID-19 where countries with high GHSI such as USA and UK have high cumulative confirmed cases and deaths. Though we were not able to “pin point” the exact reason for this reverse trend, however, it can be inferred that countries with low human development index are less inclined to report or to put effort to get proper measures of COVID-19 cases and deaths. Nevertheless, future research and events would possibly substantiate this.

The findings of this study are potentially prone to varying limitations. First, the study took results in retrospect and the inherent limitations such as selection bias may not be ruled out. Secondly, the outcome at the time of going to press is not conclusive as the pandemic is still ongoing. Also, metric such as Global health security index (GHSI) relies on open-source information, it might be prone to bias.

In conclusion, the WHO African region has had its own share of the pandemic with all the countries being affected. The trio of cluster cases, sporadic and community transmission were recorded with majority being community transmission. Global health security index was found to be positively correlated with cumulative confirmed cases and cumulative deaths.

References


Articles from Ethiopian Journal of Health Sciences are provided here courtesy of College of Public Health and Medical Sciences of Jimma University

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