The world is slowly grappling with the biggest health crisis of the 21st century so far. Yet, precise studies about the number of African cases remain rare as African countries have been reporting fragmented data, undermining the number of cases, leading to dangerous outbreaks. The African population tops at 1.216 Billion, or 16.7% of the total world population, which is higher than the US and Europe population combined. Yet precise epidemiology to inform humanitarian and economic policy is lagging. Alcimed explores in this article how African innovation could provide better data and solutions for the pandemic response on the continent.
African countries have much lower COVID-19 cases, why?
The first listed case of COVID 19 in Africa occurred in Egypt, on 14 February. Since then, 508k cases and around 12k deaths have been reported in the 54 African countries . Those numbers represent an underwhelming fraction of the world’s total number of cases (4.3%) and deaths (2.2%) and questions must be raised to understand why 16.7% of the world population only represents 4.3% of reported cases. To explain such a difference, we used public data paired with a literature review to extrapolate a trend line (see our interactive chart below).
This exercise showed surprising results, with an African trend line above the Asian one while being also higher than European and Oceanian countries. This suggests that African cases might have been underestimated and that more testing would have shown way higher number of cases. Overall, we challenged those results and found that they could be explained thanks to two main factors:
Factor 1 : Low test availability
As pointed out by John Nkengasong, Africa CDC Head, “the collapse of global cooperation and a failure of international solidarity has shoved Africa out of the Diagnostic market” even if they are “used to widespread testing for pathogens such as HIV” . Therefore, African CDC has been developing guidelines for targeted testing concentrating on highly suspicious patients, that could partly explain why some countries like Nigeria have a high percentage of a positive test (18%) while having very low number of tests performed per thousand habitants (0.72/1000 vs. world average of 58/1000), bringing artificially the official number of cases down. Nevertheless, it is interesting to note that some countries, like Rwanda, still have a very low positive test percentage (less than 1%), suggesting that COVID-19 has a lower penetration in those countries.
In all cases, this factor highlights three limitations of our representation:
– The first limitation is that several African countries have not communicated up-to-date data and are therefore not included in our representation.
– The second limitation is the establishment of a “positive bias” due to the selection of patients with high suspicion of COVID-19 in those African countries because of the low-test supply. This tends to higher the trend slope, which could be lower than what it appears.
– The third limit is the choice of not to weight these results by the size of these countries, in order to be able to assess the real state of each state, even if it implies reducing the precision of the trend lines.
Having those limitations in mind, this trend lines are still providing solid clues on the real COVID-19 situation in Africa and what a higher testing number would have shown, which is a potential number of COVID-19 African cases between European and North-American levels.
Factor 2 : A better response from the African consortium
The lower reported number can also be explained thanks to African history and experience. African population has been more reactive towards COVID-19, as pointed out by Tedros Adhanom Ghebreyesus, Director of the World Health Organization. He said that “African countries garnered a great deal of experience from tackling infectious diseases like polio, measles, Ebola, yellow fever, influenza and many more” . Therefore, the African Union, under the Chairmanship of President Ramaphosa of South Africa, has been quick to put effective control measures. Moreover, multiple African countries had formidable individual responses against COVID-19. For instance, Morocco has gone from lacking surgical mask supply to being able to export up to 50% of its production, while providing to its population masks with a price tag as low as €7cts per unit (~$8cts) .
The Moroccan national industry answer, under the government initiative, has set new world standards to be taken as an example by other countries. Eventually, those governmental solutions proved effective, also explaining why the African trend line is lower than its Middle-East or American counterpart.
What could be done to improve the African COVID-19 report’s accuracy?
Based on the collected data, we would suggest a combined approach of three methods:
1. Improve the analytical method
By using projection and the trend line from the reported cases (see our interactive chart above) and consolidating them with the excess mortality, defined by Checchi, F., & Roberts, as “the number of deaths which occurred in a given crisis above and beyond what we would have expected to see under ‘normal’ conditions” . Indeed, we could assume that most of the excess mortality in those countries is due to the COVID-19 pandemic. As defined, this method could help to lower uncertainty when projecting the real number of African people infected, and the real number of deaths that occurred in those countries. This would help to tailor the direction government and industries should be taking.
2. Ramp up the testing
Accelerating the number of tests should be achieved by lowering the price and enhancing the supply of testing kits. An initiative like the one done by the researchers at DiaTropix, an infectious disease laboratory run by the Pasteur Institute in Dakar-Senegal, is lowering the price to 1$ each (vs. 50€ or 57$ in France for instance) and should be promoted. This project, done hand in hand with a UK-based company Mologic, has recently been certified with CE mark the 3rd June thanks to a sensitivity of 96% and a specificity of 98.8% . This triple antibody test, looking for the presence of IgA, IgM and IgG COVID-19 antibodies within 10 minutes, proves how Africa’s experience with infectious diseases, like Ebola, is a real asset for finding cheap and effective solutions.
3. Encourage the work of the African coalitions
The coalitions should be encouraged, like the one made by the Africa CDC which launched an initiative called “Partnership to Accelerate COVID-19 Testing” (PACT). To date, their goal is to reach 10 million tests in four months, but the continent is still far from its objective, with only 1.8m people tested as of May 26 . Helping such initiative should be a priority and should be done through international collaboration and knowledge sharing to accelerate such a process. In the meantime, this coalition has been launching several initiatives, like “TEST, TRACE, and TREAT”, aiming to facilitate African countries’ work and create partnerships and protocols to enhance the continent’s answer.
Overall, it is important to note that African COVID-19 cases have undoubtedly been underestimated and are leading to new clusters that could jeopardize the efforts made. Any plan should then ensure that the answer will be up to the challenge and take into account those “not reported” cases. Eventually, other questions will be raised, and the long-term economic impact will have to be tackled more thoroughly to ensure African’s stability and prosperity.
The world may have much to learn from African countries’ response to COVID-19, as the continent’s experience has proved to be useful during this crisis, creating solutions within a short period and for a much lower price than what is available elsewhere. African countries have shown great ingenuity with the tools available. Other regions of the world could then build on that knowledge and collaborate more closely with African countries to make sure that no new COVID-19 spikes are seen, ensure a fast recovery, and anticipate any other future epidemic crisis.
About the author
Hichame, Consultant in Alcimed’s Healthcare team in the US
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