key: cord-0793768-aefuykm7
authors: Alhassan, Robert Kaba; Nutor, Jerry John; Abuosi, Aaron Asibi; Afaya, Agani; Mohammed, Solomon Salia; Dalaba, Maxwel Ayindenaba; Immurana, Mustapha; Manyeh, Alfred Kwesi; Klu, Desmond; Aberese-Ako, Matilda; Doegah, Phidelia Theresa; Acquah, Evelyn; Nketiah-Amponsah, Edward; Tampouri, John; Akoriyea, Samuel Kaba; Amuna, Paul; Ansah, Evelyn Kokor; Gyapong, Margaret; Owusu-Agyei, Seth; Gyapong, John Owusu
title: Urban health nexus with coronavirus disease 2019 (COVID-19) preparedness and response in Africa: Rapid scoping review of the early evidence
date: 2021-02-11
journal: SAGE Open Med
DOI: 10.1177/2050312121994360
sha: ec5375dd02b90c246cacbca6ff9bcb730d1bdb8a
doc_id: 793768
cord_uid: aefuykm7

INTRODUCTION: Severe acute respiratory syndrome coronavirus 2 also called coronavirus disease 2019 was first reported in the African continent on 14 February 2020 in Egypt. As at 18 December 2020, the continent reported 2,449,754 confirmed cases, 57,817 deaths and 2,073,214 recoveries. Urban cities in Africa have particularly suffered the brunt of coronavirus disease 2019 coupled with criticisms that the response strategies have largely been a ‘one-size-fits-all’ approach. This article reviewed early evidence on urban health nexus with coronavirus disease 2019 preparedness and response in Africa. METHODS: A rapid scoping review of empirical and grey literature was done using data sources such as ScienceDirect, GoogleScholar, PubMed, HINARI and official websites of World Health Organization and Africa Centres for Disease Control and Prevention. A total of 26 full articles (empirical studies, reviews and commentaries) were synthesised and analysed qualitatively based on predefined inclusion criteria on publication relevance and quality. RESULTS: Over 70% of the 26 articles reported on coronavirus disease 2019 response strategies across Africa; 27% of the articles reported on preparedness towards coronavirus disease 2019, while 38% reported on urbanisation nexus with coronavirus disease 2019; 40% of the publications were full-text empirical studies, while the remaining 60% were either commentaries, reviews or editorials. It was found that urban cities remain epicentres of coronavirus disease 2019 in Africa. Even though some successes have been recorded in Africa regarding coronavirus disease 2019 fight, the continent’s response strategies were largely found to be a ‘one-size-fits-all’ approach. Consequently, adoption of ‘Western elitist’ mitigating measures for coronavirus disease 2019 containment resulted in excesses and spillover effects on individuals, families and economies in Africa. CONCLUSION: Africa needs to increase commitment to health systems strengthening through context-specific interventions and prioritisation of pandemic preparedness over response. Likewise, improved economic resilience and proper urban planning will help African countries to respond better to future public health emergencies, as coronavirus disease 2019 cases continue to surge on the continent.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) also called coronavirus disease 2019 (COVID- 19) was first reported in China in the latter part of 2019 and has so far infected over 73 million people, killed over 1.6 million victims globally as at 17 December 2020 1 and rapidly overwhelmed health systems globally. COVID-19 was first reported in the African continent on 14 February 2020 in Egypt. 1 As at 18 December 2020, Africa reported 2,449,754 confirmed cases, 57,817 deaths and 2,073,214 recoveries. 2 Southern Africa region remains the worst affected with over 1 million cases followed by North Africa with over 848,500 recorded cases; Eastern Africa with 304,400 cases and West Africa with approximately 224,000 recorded cases. The least affected region being central Africa with approximately 69,900 recorded cases. 2 Figures 1-3 show details of the COVID-19 pandemic situation in Africa, at the time of writing this article. Urban cities in this era of globalisation face a triple health burden of non-communicable and communicable diseases, including COVID-19. 3, 4 Evidence suggests that most emerging infectious diseases either originate in urban settings (e.g. the emergence of COVID-19 in Wuhan, China) or they rapidly propagate because of urbanisation. 5, 6 Urban cities easily become epicentres of global pandemics due to several factors, key of them being overcrowding, poor housing and urban sanitation. In the early COVID-19 literature, poor housing has been a major cause of COVID-19 spread due to poor ventilation and communal living. 7 Strict adherence to personal hygiene practices and social distancing among urban dwellers is also low because of insufficient social amenities. 8, 9 It is estimated that barely 56% of urban populations in Africa have access to pipe water, 10, 11 making routine handwashing practically impossible especially among the urban poor.

Similarly, population density in urban cities impedes strict adherence to social distancing in the wake of COVID-19. [7] [8] [9] 12 The situation is aggravated by the inability of health authorities to effectively trace the routes and circulation of infected people in urban settlements because of poor street naming and address systems even in national capitals. Consequently, contact tracing under these circumstances has largely been unsuccessful, thus resulting in early and unabated community spread of COVID-19. 12 Alegbeleye 8 intimated that observing social distancing in many urban communities in Africa is virtually not feasible. This challenge according to Alegbeleye 8 is due to high urban population densities coupled with contrary African societal and cultural norms, which are inherently communal and do not respect social distancing protocols.

Furthermore, in many African countries, urban poverty, illiteracy, ignorance, misconceptions and cultural belief systems have negatively affected the fight against global pandemics, including COVID- 19 . In most cases, these conditions promoted the easy spread of these pandemics. Spiritual dimensions to global pandemics have also reversed gains made by African countries on COVID-19 and during Ebola outbreak in Liberia, 13, 14 Sierra Leone 15, 16 and Guinea, 17, 18 where index cases and families preferred seeking care from faith healers and spiritualists instead of mainstream healthcare systems.

In addition, rural-urban labour mobility historically promotes the rapid spread of pandemics in urban settings. 19 In the case of COVID-19, partial lockdown in the two biggest cities in Ghana witnessed huge labour migrants escaping these cities to rural areas on the eve of the lockdown. This migrant mobility raised concerns on the effectiveness of the lockdown measure since carriers of the virus probably escaped with it into other parts of the country. 20, 21 Similarly, unabated rural-urban migration for better health, social and economic opportunities in urban cities has resulted in overstretching existing health infrastructure in many African countries. It was predicted in the early days of COVID-19 that, in the United States, at least 200,000 intensive care unit (ICU) beds were needed in the case of a moderate outbreak of the pandemic. 22 Uganda, on the contrary, had 55 ICU beds in 12 operational units 23 with 80% of these ICU beds were located in the capital Kampala. 24 Likewise, in Ghana, the number of isolation and quarantine centres remain inadequate, given the COVID-19 case counts 25 and the fact that the country is only second to Nigeria in terms of case count in the West-African subregion. 2 Similarly, in an international survey by Tabah et al., 26 on personal protective equipment (PPE) and ICU workers' safety, it was found that out of the 2711 respondents, 52% of them indicated at least one piece of standard PPE was unavailable for use, while 30% reported reusing single-use PPE. In addition, Tabah et al. 26 found that over 50% reported at least one PPE item missing or out of stock, while 80% reported adverse effects of PPE. These empirical studies, among others, elucidate the existing challenge of limited health infrastructure in fragile health systems in Africa as the continent continues the battle against COVID-19. See Table 1 on index COVID-19 cases in selected African countries.

This scoping review synthesised and analysed available evidence on urban health nexus with COVID-19 preparedness and response by African countries. This rapid review is expected to contribute to early scientific evidence on the COVID-19 pandemic and further inform public health policy dialogues on post-COVID-19 interventions to improve health systems resilience against future public health emergencies in Africa and across the globe.

Coronavirus disease 2019, pandemic preparedness, response strategies, Africa, urban health Date received: 31 August 2020; accepted: 20 January 2021

This is a rapid scoping review aimed at understanding the scope and existing body of evidence on urbanisation nexus with COVID-19 preparedness and response in Africa. This review will therefore adduce broad evidence on urbanisation nexus with COVID-19 preparedness and response in Africa. Consequently, this evidence will help inform the formulation and implementation of effective policies that are specific to the African region as a whole.

In line with Joanna Briggs Institute (JBI) guideline for comprehensive systematic reviews (see Supplementary File 1), the review questions and components were based on population, concept and context (PCC) principles since it is a systematic scoping review of the available evidence. The population in the milieu of this review is the various countries in Africa and their health systems while the concept is the COVID-19 preparedness and response strategies; the context milieu is Africa. Population, Intervention, Comparator and Outcome (PICO) was not applied in this article since the review does not seek to answer questions on effectiveness. Moreover, the review is not an umbrella review, which makes PICO inappropriate under the circumstance.

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow chart (2009) was used to determine the eligibility criteria for literature inclusion and exclusion (see Figure 4 ). 

Records of search output aŌer removal of duplicates and irrelevant publicaƟons (n=255)

Records screened by Ɵtle and abstract (n=90) (n = )

Records excluded (n = 21)

Full-text publicaƟons assessed for eligibility (n=69)

Full-text not on Africa (n=17) Full-text not on COVID-19 (n=12) Grey literature/reports (n=6) Full-text grey/non-academic (n=8)

Studies included in qualitaƟve synthesis (n = 26)

Empirical studies (n=11) Commentaries/reviews (n=15) language, not published on COVID-19 and not focused on Africa or urbanisation nexus with COVID-19. Screening and literature quality JBI Critical Appraisal Checklist for Systematic Reviews and Research Syntheses was used to promote quality in the review process. Publications that did not meet at least 70% of the criteria were dropped from the final synthesis and analysis. In the case of empirical peer-reviewed publications, the critical appraisal quality checks per the JBI Critical Appraisal Checklist for non-experimental studies included publications having explicitly stated research questions/ objectives/aims, inclusion/exclusion criteria, literature search sources, study setting and study subjects. Other quality checks were methodology employed, outcome measures and confounders, and appropriateness of statistical analysis.

The remaining quality checks were as follows: recognised limitations and mitigating measures, ethical considerations and interpretation of findings. In addition, published literature should have been peer-reviewed (or undergoing review in preprint). Commentaries, perspectives and reviews were included because of the paucity of publications on COVID-19 at the time of writing this scoping review.

Data extraction from the accessed literature was done using an extraction form developed by the authors based on JBI guidelines for scoping reviews. For objectivity and reduction of chance effect bias, literature search, screening and data extraction were concurrently done by two independent reviewers who later reconciled the extracted information for convergence. Synthesis and analysis were guided by the recurrent themes from the reviewed literature. Where applicable, data extraction categories included authors, year of publication, study location/context, outcome measures, study type and participants/subjects. Main thematic areas that emerged from the review on COVID-19 were preparedness, response strategies and the COVID-19 nexus with urban health. Key findings/ conclusions and thrusts of each publication were also captured in the extraction form as shown in Table 3 .

Out of nearly 200,000 initial search output from the various databases, 26 full-text publications (see Table 3 ) were retained, synthesised and analysed. Retained articles were arrived at after removing repetitive and irrelevant publications based on the predefined inclusion and exclusion criteria explained earlier. These articles included empirical studies, systematic reviews and commentary publications. The 26 publications were synthesised and analysed based on relevance to the African context and quality; all publications were published in 2020. Eleven out of 26 publications were empirical studies, which were mostly cross-sectional descriptive studies, with one being a case study and three publications based on secondary data. The largest sample size for the publications based on primary data was 2711 and lowest was 10.

In terms of context distributions of reviewed articles, most of the publications focused on Africa as a continent (n = 5) followed by Sub-Saharan Africa (SSA; n = 4). Eight publications focused on global context with interest on Africa and other low-and middle-income countries (LMICs). A few others specifically focused on Ghana (n = 2), South Africa (n = 2), Ethiopia (n = 1), Nigeria (n = 1), Kenya (n = 1), Democratic Republic of Congo (DRC; n = 1) and Liberia (n = 1).

Concerning the type of study participants investigated, majority of the publications focused broadly on health systems (n = 7) and community participants such as slum/urban dwellers, women, children and people living with HIV (PLWHIV; n = 7). Other articles focused on healthcare workers (HCWs) such as community health workers (n = 5), while dentists (n = 1) and critically ill COVID-19 patients had one article each. Two publications concentrated on public transport vehicles and motorcycle riders, while two others broadly investigated COVID-19 impact on economies of countries in Africa as shown in Table 2 .

Synthesis by themes revealed that majority of the publications (77%) predominantly examined COVID-19 response strategies in Africa with a few others looking at the combine spectra of preparedness, response and urbanisation. Ten out of 26 synthesised publications primarily focused on COVID-19 nexus with urbanisation, while 27% primarily focused on health system preparedness for COVID-19 in Africa.

Furthermore, the review revealed that most recurrent themes were on impact of COVID-19 on health service provision (mental health, maternal and child health services, mortality outcomes among the critically ill), health logistics and supplies, including HIV/AIDS medications. Another most recurrent theme was health systems resilience in Africa towards COVID-19 and future pandemics. Other recurrent theme was spillover effects of COVID-19 response strategies on economies and livelihoods. Literature on Africa's approach to COVID-19 was also apt in many of the publications.

Additional recurrent themes were health sector human resources to fight the pandemic and lack of compliance with COVID-19 prevention and safety protocols. One publication emphasised leveraging Africa's past experiences with Ebola and HIV/AIDS in the prevention and control of COVID-19. Finally, another publication examined the nexus between urbanisation and COVID-19 in Africa's urban slums and informal settlements, while one other prospective cohort study examined the association between limited critical care resources and COVID-19-related mortalities (see Table 3 and Figure 5 ).

Globally, it has been established that sufficient preparedness for pandemics by countries is a crucial investment since the cost is comparatively smaller than an unmitigated impact of health emergencies like COVID-19. For instance, the global financing gap for health emergency preparedness, estimated at US$4.5 billion per year, is minuscule compared with the estimated pandemic costs of US$570 billion per year. 27 Health emergency preparedness activities in Africa with more fragile health systems are particularly crucial 48, 49 because of increasing urban populations and the attendant negative public health implications. 50 Thus, opportunities in urban environments thus need to be leveraged to enhance the preparedness of urban settings for health emergencies like COVID-19. Table 2 presents the challenges and opportunities for urban settings in raising preparedness for public health emergencies in Africa.

In many parts of Europe and the Americas, strict COVID-19 prevention and control measures have been enforced, including total lockdowns. Unfortunately, many African countries spontaneously adopted same lockdown measures without requisite knowledge of the COVID-19 infection rate and the context-specific relevance of these measures. 30, 33, 34, 41, 43, 45, 46 Ghana, for instance, observed three weeks partial lockdown in the two most urbanised regions as part of the early control measures without sufficient evidence. Unlike other continents, Africa was fortunate to record COVID-19 cases months after other continents recorded cases. The continent thus had the benefit of time and hindsight to prepare and respond differently to the pandemic based on lessons learnt. However, reviewed literature predominantly suggests that Africa's response strategies were largely not context-specific but can best be described as a carbon copy of interventions adopted in China, other Asian countries, Europe and the Americas, albeit the circumstances and epidemiology of the virus are different. [5] [6] [7] [8] Consequently, a 'one-size-fits-all' approach was spontaneously adopted by many countries in Africa. Indeed, some of the COVID-19 response measures were needless and turned out to be ineffective. 51 Restrictions in social gatherings have also been imposed to control the spread of the virus particularly church activities, funerals, weddings and closure of schools. 52 Compulsory wearing of face masks and use of hand sanitisers are other pervasive COVID-19 preventive measures in Africa even though strict compliance remains problematic due to ignorance, poverty, resource constraints and unfavourable belief systems. 28, 36, [53] [54] [55] Although some successes have been achieved in respect of these response strategies, critics have described them as 'one-size-fit-all' and 'Western elitist' approach because of their relevance to Africa's local settings vis-à-vis trends in other parts of the world.

For example, in many African countries, hand sanitisers have been misconceived as a replacement for regular hand hygiene mainly due to ignorance and lack of education. Likewise, enforcement of social distancing in crowded urban communities is proving to be impracticable just like self-isolation in congested households. These measures have largely been ineffective partly due to poor living standard particularly in urban slums. Also, the 'work from home' mantra immediately embraced by already fragile economies in Africa is equally, arguably, an ineffective response strategy relative to more resilient economies outside Africa. For instance, over 70% of Africa's workforce is in the informal sector and predominantly engaged in manual labour. In view of the huge informal sector in Africa, the 'work from home' policy at the initial phase of the pandemic rather worsened the plight of many citizens already in the lower wealth quintiles. 44, [56] [57] [58] Other COVID-19 mitigating measures questioned and heavily criticised in Africa are mass closure of schools without established e-learning systems and infrastructure, enforcement of handwashing protocols when over 50% of households in Africa do not have access to portable water, 51 temperature checks of travellers at borders and airports without accounting for asymptomatic carriers of the virus and mass testing capacities coupled with ability to pay for COVID-19 testing upon arrival at airports.

Moreover, many countries in Africa are still battling fearbased messaging and misinformation on COVID-19 59 similar to Ebola and HIV/AIDS. 13 Available literature maintains that misinformation and fear-based communication cause anxiety and possibly deaths 39 of which COVID-19 is not an exception. Over the years, in pandemics response, fear has rarely been a good motivator for people's adherence to safety precautions. Indeed, people generally respond better to calm and fact-based messages/information. 39 Unfortunately, many countries in Africa have not performed optimally well in respect of COVID-19, Ebola and HIV/AIDS, and stigma management. In effect, misinformation and fear-based messaging associated with COVID-19 continue to break stigma, discouraging infected persons to declare their status and seek early treatment. Similarly, fear of disclosure potentially promotes community spread of the virus.

Notwithstanding these challenges, Africa is praised for some positives in the COVID-19 fight. For instance, countries with more recent experience with Ebola appear to be leveraging this expertise in response to COVID-19. Liberia, Sierra Leone, DRC and Guinea are currently re-purposing existing structures used during Ebola as COVID-19 isolation and treatment centres. 30, 34 In DRC, single-patient-transparent cubes originally designed for isolation of Ebola cases are re-purposed for COVID-19 isolation and treatment centres. 41 Likewise, inter-sectoral collaboration with government institutions, non-governmental organisations (NGOs), religious bodies, industry players and national security agencies have been effectively leveraged in many countries in Africa towards COVID-19 fight. 12, 33, 43, 45, 46, 51, 52 The role of the media and civil society in propagating health education and communication on COVID-19 prevention and control has equally been phenomenal in Africa. 51 In addition, the ingenuity of many African countries in developing locally manufactured handwashing devices and PPE is especially commended in the bit to promote self-reliance and sustainability in the wake of COVID-19. 53 Pre-print article.

The "X" is used to denote applicable key perspectives in columns 7, 8 and 9. Finally, lessons learnt from Ebola in West Africa show that balancing urgent clinical care with the general wellbeing of the community is the best prescription for containing pandemic outbreaks, particularly in urban settings which have so far suffered most from the pandemic. In light of this, some African countries have incorporated community engagement approach in the prevention and control of COVID-19. 30, 42, 60, 61 Some reports suggest that lockdown impositions in Africa were executed with human considerations and social support for the less privileged through community mobilisation. These community-centred response strategies have contributed to high compliance with the COVID-19 preventive measures in some countries 62 and must be encouraged and sustained.

Irrespective of these important achievements chalked in Africa, the reviewed literature also reports instances of spillover effects from the COVID-19 mitigation measures especially in urban settings. First, urban dwellers working in the informal sector (and are predominantly labour migrants) are so far the worst affected by COVID-19 in Africa since approximately 85% of workers in Africa are not on regular wages and do not have the option to work from home. 63 For instance, during the lockdowns, these underprivilege majority did not earn a wage throughout the period. The story of the Kenyan widow of many children boiling stones for her children during the lockdown elucidates this point. 64 Furthermore, many countries in Africa recorded an interruption in food supply chain especially in urban cities, which often relied on rural communities for food supplies. Countries like Ghana witnessed an escalation in food prices by nearly 30% during the partial lockdowns 65,66 due to panic buying and disruptions in food supply chain. Even though lockdowns might have helped curb the virus transmission, these measures also pushed millions of people into extreme poverty to the extent that hunger, rather than COVID-19, had a greater chance of killing already impoverished individuals during the lockdowns. [63] [64] [65] [66] [67] The review also found that human rights abuse during lockdowns 54, 67 were excesses that emanated from the COVID-19 response measures in many parts of Africa.

Other spillover effect of the COVID-19 response measures in Africa was the effect on already fragile health systems. Neglect of the public health needs of populations in the wake of COVID-19 has already been reported with unprecedented reduction in health service utilisation, including HIV/AIDS services. 68 Utilisation of mental health, 37, 38, 40, 69 maternal/child health and related outpatient department (OPD) services 29, 40, 47, [70] [71] [72] have equally been adversely affected in Africa. There are equally fears of imminent post-COVID 19 negative impact on African economies with a possible gross domestic product (GDP) growth rate dropping to record low of single digits. 23, 36, 44, 46 Finally, evidence adduced by Biccard et al. 31 on a relatively higher case mortality in critically ill COVID-19 African patients than any other regions in the world suggests the urgent need to resource healthcare facilities in Africa to improve on the quality of healthcare for COVID-19 victims. Biccard et al., 31 for instance, found that there is an excess mortality of 18 and 29 deaths per 100 COVID-19 African patients compared to other parts of the world with an even worrying evidence of a positive correlation between COVID-19-related mortalities and limited critical care resources. Since the impact of COVID-19 has so far been most severe in urban settings which do not also have the requisite healthcare facilities to promote strict adherence to the COVID-19 safety protocols in many parts of Africa including Ghana, 32 there is the need for greater commitment to health systems strengthening to avert possible humanitarian catastrophe as the pandemic continues to strike harder on Africa.

This review included commentaries, editorials, perspectives and some grey literature because of the novel nature of COVID-19 and the fact that not many empirical publications are yet available, especially on Africa. Africa therefore needs a rigorous research agenda on COVID-19 to inform evidence-based policies during and after the pandemic to help address this existing limitation.

Evidence from the reviewed literature suggests that countries, particularly in Africa, need to improve health infrastructure, human resources and medical technology using local resources to enable the continent respond adequately to public health emergencies. COVID-19 has taught the world, including Africa, that pandemic preparedness should be prioritised over response. A relatively less expensive yet effective investment should be community-level preparedness and response strategies long before pandemics strike.

Improving health sector human resource capacity at the primary healthcare level such as community health workers has particularly proven to be an effective approach to early containment of global pandemics and must be prioritised as Africa's trump-card in pandemics response. Trillions of dollars have already been committed in just a little over a year for the COVID-19 response globally. Meanwhile, a COVID-19 vaccine or treatment might take months if not years to become commercially available and accessible to resourcepoor settings mostly in Africa.

Moreover, a readily available and accessible COVID-19 vaccine today does not guarantee acceptance and adoption in many African countries where there are shortages of health sector human resources to effectively deliver COVID-19 vaccines. A comparative US$2 billion annual investment in African health systems to bolster CHWs for primary care is minuscule compared to the current global cost of health systems response to the current pandemic. These practical nuances elucidate the need for prioritisation of efficient and effective community-level interventions particularly for the urban poor in resource-constrained countries in Africa which are often the worst affected victims of global pandemics.

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The authors appreciate and acknowledge important institutional repositories such as the Ghana Health Service (GHS) COVID-19 (coronavirus disease 2019) update platform and likewise the Africa Centres for Disease Control and Prevention (CDC) and the official website of the World Health Organization (WHO).