key: cord-0803620-g96pz7t1
authors: Sokhna, Cheikh; Brah, Souleymane; Djimde, Abdoulaye; Mouffok, Nadjet; Zahraoui, Majida; Boukhary, Ali Ould Mohamed Salem; Bitam, Idir; Cisse, Badara; Thera, Mahamadou Ali; Lekana-Douki, Jean-Bernard; Adehossi, Eric; Seydi, Moussa; Akiana, Jean; Heikel, Jaafar; Lagier, Jean-Christophe; Mboup, Souleymane; Mouyembe-Tamfum, Jean-Jacques; Parola, Philippe
title: COVID-19 in africa: what else?
date: 2022-05-09
journal: New Microbes New Infect
DOI: 10.1016/j.nmni.2022.100982
sha: d8f15bf39fc1b5c1ad2b93be28f1a46ec87006ee
doc_id: 803620
cord_uid: g96pz7t1

nan

In Spring 2020, both WHO and the UN Economic Commission for Africa predicted that COVID-19 would take a heavy toll in Africa. However, 10 months after the first cases in Africa were detected, mortality, probably the most significant way to measure the burden of COVID-19, was still low. It has remained at a low level by April 2022 (Table 1 ).

One could say that mortality tends to be higher in older populations, as the median age of Africa is 19.7 (compared to 42.5 in Europe and 38.6 in northern America). However, high mortality has also been reported in South Africa (median age 27). Also, while South Africa was one of the countries with the best laboratory facilities to confirm deaths related to COVID-19, laboratory facilities have rapidly increased in our other countries [1] .

Factors which may explain the dampened course of COVID-19 in Africa have been discussed, ranging from genetic characteristics to immunological factors and even microbiota.

However, after the first Chinese publications about the antiviral effects of chloroquine (CQ) and its derivatives against SARS-COV2 and a preliminary trial in France [2] , many African countries adopted CQ or hydroxychloroquine (HCQ) with or without azithromycin (AZ) to treat presumptive or confirmed COVID-19 cases. This, despite the WHO position and other published or retracted studies claiming that this regimen would not be effective or toxic.

More evidence came with the demonstration of a synergistic effect in vitro of the HCQ-AZ combination on SARS-CoV-2 and from observational studies with thousands of cases. Both HCQ and AZ are immunomodulators, which may prevent the "cytokine storm" of COVID-19.

The HCQ antithrombotic effects might also be useful in the context of Covid-associated pulmonary embolism and coagulopathy. Finally, HCQ-AZ has been associated with a reduction in viral shedding, with potential public health effects by reducing the duration of contagiousness [2] .

By the end of 2020, while in several African countries a pragmatic, safe use of CQ or HCQ with or without AZ had prevailed, Western countries were still awaiting the results of J o u r n a l P r e -p r o o f clinical trials to define their strategy, worrying about hypothetical side effects of HCQ-AZ, which has been used for decades, or were promoting other treatments (with no demonstrated efficacy) or standard care only, which may be limited when people are asked to remain at home by health authorities.

The dogma about the need randomized controlled trials (RCTs) to support therapeutic choice and public health decision is an issue. However, a Cochrane Library publication stated that observational studies and randomized controlled trials (RCTs) give the same results [3] . By [4] . Interestingly, the supplementary material must be sometimes carefully reviewed to learn that HCQ was one of the most active drugs, as this had been omitted in the text and the summary.

Other factors, such as blood type, climate, and prevalence of obesity among the population, have to be assessed in order to provide more insights on COVID-19 epidemiological patterns in Africa. SARS-CoV-2 variant emergence may also be an issue [5] . The age structure of the population of our countries may also help explain differences in fatality rates across countries better than the mean age.

The use of HCQ-AZ for COVID-19 treatment and has resulted in political issues, academic discord, as well as passionate debates in the media and scientific journals about the efficacy or possible toxicity of CQ or HCQ. This, seen from an African perspective, where billions of doses have been dispensed in the past century, speaks volumes about the real safety of these drugs.

To date, most of the countries with the highest mortality from COVID-19 include the countries where the most negative media noise about CQ, HCQ or HCQ-AZ has been made, and this despite current higher percentage of population fully vaccinated (Table 1) J o u r n a l P r e -p r o o f

What could explain the late emergence of COVID-19 in Africa? New Microbes New Infect

Natural history of COVID-19 and therapeutic options

Healthcare outcomes assessed with observational study designs compared with those assessed in randomized trials. Cochrane Database Syst Rev

Early combination therapy with hydroxychloroquine and azithromycin reduces mortality in 10,429 COVID-19 outpatients

The emergence, dynamics and significance of SARS-CoV-2 variants. New Microbes New Infect

COVID-19 in Africa: What else? NMNI-D

This manuscript has been edited by a native English speaker.

Each author made substantial contributions to the conception, design, writing and review of this article

The authors have no financial or non-financial actual or potential conflicts of interest.J o u r n a l P r e -p r o o f

All authors made substantial contributions to the conception, design, writing, validation and review of this article. Philippe Parola Supervised the work.J o u r n a l P r e -p r o o f