key: cord-0961488-lzy4cc8s
authors: Dzinamarira, Tafadzwa; Dzobo, Mathias; Chitungo, Itai
title: Covid‐19: A Perspective on Africa's Capacity and Response
date: 2020-06-11
journal: J Med Virol
DOI: 10.1002/jmv.26159
sha: 986dc85c77027b284455bdd61f0b1ca5815d3d1d
doc_id: 961488
cord_uid: lzy4cc8s

Global powerhouses with tried and tested health systems have struggled to contain the COVID‐19 pandemic. One is left to wonder what will be left of Africa, the second most populous continent after Asia, which is torn by civil wars, hunger, and diseases like AIDS and TB and, in recent years, the Ebola Virus Disease (EVD). The majority of countries’ health systems, already dependent on donor aid, are ill‐equipped and under‐resourced to deal with the raging pandemic. There is a lack of isolation and intensive care infrastructure, ventilators, and financial resources to bankroll the fight against COVID‐19 pandemic. However, there is some cause for optimism, for example, in West Africa where infrastructure like diagnostic testing facilities, intensive care units, surveillance, and systems for reporting emergencies used during the EVD outbreak of 2013‐2016 can be leveraged to fight the COVID‐19 pandemic. Further, a number of African countries have responded swiftly by activating the necessary political and financial tools to combat the pandemic. Technical support from continental bodies like the Africa Centres for Disease Control and global development partners has improved the capacity of the continent to handle the pandemic. In this article, the authors unpack, review, and share a perspective on Africa's capacity to contain and control the COVID‐19 pandemic and review the current response. This article is protected by copyright. All rights reserved.

COVID-19 has had an impact on all of life's aspects. China, the source country of the disease, appears to have brought the pandemic under control, and the once worst affected areas have begun to open up. For the rest of the world, the situation is a stark contrast. Since the first case was reported, it took over two months for the number of confirmed cases to reach 100,000, two weeks to 250,000, just six days to reach 500,000, and another five days to 862,547 confirmed cases by 1 April 2020 and over 5,8 million by 29 May 2020 1 . This indicates a growing pandemic, the infection rate of which continues to increase despite concerted efforts. Factors attributed to its rapid spread include inadequate test kits 6 , inadequate protective gear 7 , lack of a known cure, and difficulties enforcing protective measures 8 .

One of the priorities for every country is to improve testing as an essential tool to control the spread of the disease. Medical scientists have been busy trying to develop a vaccine against the novel virus. Human testing is underway, but it might be a year at the earliest until a mass market vaccine is rolled out 9 . According to the Centers for Disease Control and Prevention (CDC), people critically affected by the disease are those with underlying medical conditions as well as older people whose immune systems are generally weak 10 . Currently, there is no specific treatment approved for COVID-19 and no known cure for infection. Younger healthier people have shown a relatively high recovery rate in comparison to people above the age of 65 10 . With every passing day, doctors and scientists are learning new things about the virus concerning its symptoms, spread, mutation, and aid recovery among other elements of the disease. The pandemic This article is protected by copyright. All rights reserved.

of 29 May 2020. Of the cases reported within the first week since the confirmation of the first case on African soil, nearly all of them were people who had returned from China or European countries. Local transmission then later followed thereby increasing the number of infections. The WHO has warned that potentially 190,000 deaths could occur in Africa if measures to control the pandemic fail. As the disease has spread to almost all African states, the predominant risk factors for the spread have been international exposure, poor health systems, and the dense population found in urban centers.

Africa's response to the pandemic was by and large quick and decisive. Africa implemented airport screening and adopted mitigation efforts such as hand washing, social distancing, and stay-at-home lockdown measures 16 However, for some countries, there was generally a slow response to the pandemic due to several reasons. As the COVID-19 pandemic spread rapidly across some European countries, there was a general belief that this virus could be restricted to colder climates 18

and to areas outside of Africa. As a result, people were slow to take the necessary precautions such as travel restrictions, closure of borders, and containment measures. Some believed, as was the case with SARS 1 virus, that COVID-19 would be contained in Asia and Europe and therefore adopted a laissez-faire approach to the pandemic.

A new threat is also emerging for the spread of the virus, as truck drivers who were allowed to traverse borders to keep the supply chain active have become carriers of infection from one country to another. Controversial political decisions 19 , mistrust, and limited epidemiological data complicate the response to the Covid-19 pandemic in east Africa 20 .

According to medical experts, the number of reported cases is an acute underestimation, and a high number of cases remain undetected 21 . This is attributed to African health systems not being robust enough, poor monitoring, and the lack of sufficient test kits.

Poor testing capacity has hampered case identification, quarantine, and contact tracing efforts. The WHO advocates for effective community surveillance through increasing testing. Most African countries have inadequate surveillance and laboratory capacity 22 to perform testing coupled with limited fiscal support to acquire testing or build the diagnostic capacity necessary to decentralize testing 23 . Majority of the countries rely on donor aid to supplement public health budget, and some countries were only able to start COVID-19 testing after receiving donated testing kits from the Jack Ma Foundation. It is also worth noting that testing has not been universally accepted, with Tanzanian This article is protected by copyright. All rights reserved.

authorities dismissing the validity of WHO recommended testing platforms and test kits 19 .

The challenge of under-funded health systems extends beyond the fragile health systems to include the economies. The economic conditions of nearly all African countries will have a huge impact on just how far and quickly the disease spreads. About 85% of Africans survive on less than 5.50 USD per day, which allows for little or no savings, according to a World Bank report 24 . Hygiene and sanitation levels remain astonishingly low, offering a breeding ground for the disease. All these factors coupled with the weak health systems can cause the disease to have impacts far beyond those experienced by the worst affected countries. The challenge herein is that those countries that could offer help to Africa are struggling to put the pandemic under control in their own backyard.

Africa's vulnerability is obvious given the fragile health systems that have struggled to contain other communicable diseases such as cholera and malaria in the past. Accessibility to hospitals is equally a major challenge. South Africa, a country with one of the best health systems in Africa, has less than 1000 Intensive Care Unit (ICU) beds for the country's 56 million people, while Kenya, a country of nearly 50 million people, has about 200 ICU beds 25 . Table 1 Protective gear for health workers is in short supply but has in recent days benefitted from donations from philanthropists such as Jack Ma 30 . Even then, the novel virus is not allowing time for health systems to build their capacities. Even the delayed arrival of the disease in Africa has done little to allow governments to strengthen their emergency coordination and surveillance or to ramp up hospital equipment. Nigeria, Africa's largest economy, by its own admission, does not have a suitable capacity, according to Chikwe Ihekweazu, the head of Nigeria's Center for Disease Control (NCDC) 31 : "Our health system is not as strong as we'd like it to be. It is because we are a bit worried about our capacity to deal with a large outbreak that we are focused so intensively on prevention and early detection". However, as of May 2020, the NCDC has mobilized a National Emergency COVID-19 (LF) multi-partner, the multi-sectoral This article is protected by copyright. All rights reserved.

Operations Centre (EOC), to coordinate response activities across Nigerian states. The agency has also accredited and activated twenty-six (26) testing laboratories across Nigeria and conducted training for health workers in multiple states.

Beyond the accessibility, medical equipment, and health capacities, Africa's drug manufacturing capacities are very low. Most African countries import more than of 70% of their total drugs 32 . These drugs are imported mainly from India, Europe, and a smaller percentage from the US. With countries moving toward export bans for drugs, the continent may face a shortage of basic and essential medication, hampering COVID-19 control efforts.

Medical scientists are currently conducting extensive research to understand how the virus mutates and how it affects persons with different medical conditions. Research is ongoing in testing methodologies 33 and strategies 34 and even vaccine development 35 .

Even if there is ongoing research, doubts exist as to whether it is at the same level as in other countries such as India, which is equally a developing nation like the rest of Africa.

By not having a clear understanding of the disease, the health systems can only do so much and hope that what has worked in other countries will also work for Africa and its people. Though progress is evident, it will be years until all the African countries develop sound research institutions that can be relied upon to find urgent solutions in times of crisis. As COVID-19 continues to spread, this critical aspect of effective health systems is unsurprisingly lacking.

According 41 . That outbreak seems all but over, but now the DRC faces both a major measles outbreak that has claimed almost 6000 lives in the past year and the new COVID-19 pandemic. Countries with ongoing outbreaks and those that are still recovering from recent ones will find it hard to manage the new COVID-19 pandemic due to lack of manpower, infrastructure, and financial resources.

Several African countries have put in place measures to prevent importation of the virus by closing airports and closing borders. To limit local transmission, governments have increased surveillance, identification of infected people and those at risk, rapid diagnosis, and contact tracing. Countrywide lockdowns have been initiated with periods spanning from 14 to 21 days. Experts say this move may not yield the desired results in povertystricken countries where people are informally employed and some governments have not This article is protected by copyright. All rights reserved.

come up with food aid to support citizens during the lockdown. Lockdown and restrictive measures have proved successful in arresting the spread of COVID-19 in China's Wuhan province 42 . The economic situation of most of Africa is, however, likely to work against such a measure. Although a difficult decision, it is one that needs to be taken. It is time for governments to enforce shelter-in-place orders especially within these vulnerable communities. Enforced social distancing will ultimately prove to be the most effective means of reducing the spread of COVID-19 amongst communities. Coupled with regular hand washing, contact tracing, and isolation, these are the only ways to compensate for the weak health systems. However, governments must do more than just enforce orders.

They have to channel resources from other non-critical departments towards providing necessities to these communities. The decision must, however, be based upon reliable estimates. Adhering to the 14-day quarantine period after possible exposure even if one does not show any symptoms can cripple the spread of the virus within communities 43 .

While food security remains a challenge and with perennial drought being the norm, several African countries, among them Kenya, Uganda, and Tanzania, have strategic food reserves adequate to feed the most vulnerable for such a duration of time. The obvious disregard for voluntarily social distancing makes total lock-down even more plausible.

Africa is not new to epidemics. Other epidemics such as HIV remain important public health concerns 39 These resources bolstered Nigeria's response to COVID-19 46 .

The world today is a global village and itis time for Africa to prioritize partnerships. COVID-19 is a global challenge that requires collaborative efforts to overcome. Even without the technical capacity, African medical scientists have an input in this, but they cannot do it on their own. Government coordination is the first step. For example, scientists at the Pasteur Institute of Dakar in Senegal are currently working with a United-Kingdom-based biotech laboratory to develop rapid diagnostic test for COVID-This article is protected by copyright. All rights reserved.

19 that will reduce the diagnosis time from 4 hours to 10 minutes 47 . By the end of April, trials had already begun for the kits 48 . If successful, this single collaboration will be a huge step forward towards mass testing. This highlights just how much can be achieved by working together for the benefit of not just African countries but of the whole world. 

The spread of the SARS-CoV-2 virus is already worrying, but the situation is not out of hand yet. There will be numerous challenges along the way given the scarcity of This article is protected by copyright. All rights reserved. 

and understandable, it is such people that need to be informed that by being out there, they endanger the lives of the very people they are striving to feed. The economy can be rebuilt, but the loss of life is irreversible. Appealing to people's inner being has had its successes, and now is the time to try every workable way to stop the spread of the virus.

Mobile phone access in Africa has grown rapidly over the last decade and can be relied upon to relay educative messages. Lack of sufficient information has proven costly in past epidemics.

Data from affected other countries, among them Italy, Spain, and China, show that people above the age of 65 are more vulnerable. The median age in Africa is 19.7 years in comparison to China's 38 50 . Although Africa's youth may be considered a significant protective factor in the pandemic, how the virus will evolve and manifest itself on the continent remains unknown. Africa's greater youthfulness may act to its advantage in terms of lower death rates. However, African countries must not expect a mild version of the disease or lower infection rates. Rather, planning must be centered on containing the spread of the virus as one way of cushioning the fragile health systems and reducing the overall impact of the virus. Capitalizing on the youthfulness of the African population should be through leveraging predictive modeling to develop Africa-specific responses both medically and economically. Responding to the virus through economic policies is equally important as it affects the people's everyday way of life, and long after the virus is gone, the economic effects are likely to persist.

There is a need to strengthen testing strategies for screening to improve quarantine and contact tracing. Further, governments can draw lessons from Germany and set up strategies for ending lockdowns through the attainment of herd immunity. Mobile phone applications for people to self-report on signs and symptoms, thereby using an algorithm to identify hotspots and target mass testing and resources mobilization, could also be explored.

Known comorbidities for severe cases of COVID-19, such as cardiovascular disease, diabetes, chronic respiratory disease, hypertension, and cancer 51 , are also ongoing public health problems for Africa 52 . For example, it is estimated that diabetes' prevalence in some sub-Saharan African countries has reached almost 22% in the adult population and as high as 30% in men and women aged 55-65 years. Currently, only half of those with diabetes are diagnosed, and of those, only 1 in 10 are receiving treatment 53 . Therefore, patients with co-morbidities require more rigorous prevention mechanisms 54 , through ensuring social distancing, restricted travel, and avoiding large gatherings.

Containment measures need to consider strengthening diagnosis, care, and treatment services for infectious diseases as well to avoid a knock-on effect. For example, access to HIV testing can be maintained through the scale up of home-based HIV testing such as HIV self-testing 55 . Access to antiretroviral therapy during lockdowns should be maintained. Multi-month dispensing and community antiretroviral distribution models could benefit African health systems. 56-58 .

Given the medical equipment and supplies export bans discussed above, African countries ought to support endogenous personal and protective equipment (PPE) This article is protected by copyright. All rights reserved.

manufacturers. Tackling COVID-19 requires increasing domestic production 59 . Where necessary, governments should explore the need to provide financial aid as part of a cooperative domestic response.

As a long-term goal, strengthening health systems through redirecting resources can be beneficial. This will allow for improved primary healthcare and referral systems. This may be achieved by encouraging public and private partnerships. As of 2018, only three African countries had reached the Abuja declaration to commit 15% of public expenditure on health 60 . This is concerning and shows a gap still exists on governments commitment to health.

COVID-19 continues to spread across the world, with increasing morbidity and mortality. Africa currently is the least affected of all the continents; however, it has to maintain its preparedness and strengthen surveillance. Developed nations with sound health systems adopted different response strategies with various outcomes. Africa does not have the luxury to experiment and needs to adopt those strategies that are efficacious.

Granted, Africa does not have the same resources as first world countries, but it can modify those strategies within individual countries' capacities to best mitigate the effects of the pandemic. Beyond this pandemic, Africa needs to strengthen its healthcare system and pursue universal coverage as a means to mitigate against future epidemics.

None declared

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