Keeping COVID-19 at bay in Africa.

On Feb 15, 2020, Egypt recorded Africa's first case of coronavirus disease 2019 (COVID-19) 12 days later, Nigeria recorded the first sub-Saharan Africa incident. 2 months later, the Comoro Islands and eSwatini are the only two countries of 54 in Africa that are unaffected by the global pandemic, stretching health systems and nearly paralysing economies.

The African Centre for Disease Control (Africa CDC), an African Union body partnering with the WHO Regional Office for Africa, is leading broad measures to control COVID-19. The disease has since accelerated in Africa, reaching 27 427 cases, 1298 deaths, and 7474 recoveries as of April 24. Compared with the rest of the world, Africa's infection rates are relatively low, but there is a growing sense of urgency given the acute absence of health-care infrastructure on the continent.

Weeks of fighting the pandemic saw African governments following measures backed by scientific advice, such as quarantine of people exposed to confirmed cases. One Cochrane review found that quarantine might avert high proportions of infection and deaths compared with no measures.

“It's important to emphasise that we anticipated that this would happen and have been planning for response”, says John Nkengasong, Director of the Africa CDC, in one of his weekly media briefings. Thanks to Africa CDC, 43 laboratories from 43 African countries are now able to test for COVID-19.

The response of Africa CDC includes testing and contact tracing. Nkengasong says there is a possibility that 15 million tests will be required in Africa over the next 3 months. A UN Economic Commission for Africa report says about 300 000 Africans could die of COVID-19. Estimates show that the death toll could rise to 3·3 million Africans due to the pandemic spread.

African governments have instituted lockdowns, restricted travel, redirected research funding, and asked for donations from local and international funders to buy medicines, testing kits, ventilators, and protective clothing for health workers in anticipation for the worst-case scenario.

When COVID-19 infections jumped 6 times in just 8 days from 61 to 402 cases, on March 23, Cyril Ramaphosa, South Africa's President, announced a national lockdown for 21 days, further extending it for 2 weeks to April 30, gradually easing the lockdown thereafter, to reopen the economy while limiting the spread.

“There are so many unknowns about this virus”, Glenda Davison, Head of the Biomedical Sciences Department at Cape Peninsula University of Technology (Cape Town, South Africa) told The Lancet Respiratory Medicine. “However, I do believe that South Africa has taken the right decision to lockdown early in the pandemic.” This early action means that the rate of infection has slowed, giving the country the time, and hopefully the capacity, to treat those that require intensive care unit. She adds, “an increase in cases will continue, but at a slower rate if observance of social distancing continues”. South Africa's townships are overcrowded with people living in informal housing, born out of central business districts, hostels, rural shacks, and periurban settlements (South Africa has a total population of 58 million). “The concern is that the virus has now moved into communities, which are often overcrowded and under-resourced”, says Davison.

A high prevalence of tuberculosis and HIV in South Africa means a high proportion of the population has compromised immunity, which could change the pattern of the pandemic for South Africa. South Africa is targeting crowded hotspots countrywide with high infection rate potential, deploying 28 000 health-care workers to test everyone, said Salim Abdool Karim, chair of a ministerial advisory group on COVID-19, on April 13.

In Nigeria, a private sector-led group, Coalition Against COVID-19, ordered 250 000 tests and 150 000 extraction kits to fast-track molecular testing for COVID-19, and set up isolation centres in the states of Lagos, Kano, Rivers, Borno, and Enugu. The coalition is also renovating hospitals and boosting medical supplies in other states and earmarked food parcels to 1·7 million vulnerable households. In April, Osagie Ehanire, Nigeria's Health Minister, unveiled 12 COVID-19 testing laboratories that can test 1500 samples daily. Ehanire says increased testing capacity would mean the number of cases identified would increase and would include testing contacts of confirmed COVID-19 cases.

Among Africa's urban population, social distancing is a privilege few can afford. The majority of people live in crowded settlements. For instance, in Zimbabwe, during a 3-week lockdown in April, the shortage of mielie-meal, a basic commodity, saw crowds swarming to shops selling it, completely disregarding social distancing measures. On April 19, Emmerson Mnangagwa, Zimbabwe's President, extended the lockdown for 2 weeks; however mines are still allowed to resume operations, as one of the main income sources for the country through exports, but all workers must be tested.

“We have continued to see a rise in new cases over the past few weeks”, says Fortune Nyasha Nyamande, spokesperson for the Zimbabwe Association of Doctors for Human Rights. “However, the true extent of the pandemic is difficult to assess because of the limited number of tests that have been conducted to date.” Zimbabwe has fewer than 10 intensive care unit beds in public COVID-19 facilities and fewer than 1000 beds hospitalisation capacity.

“It was sensible for countries to apply strong social distancing measures, to begin with, to try to buy a bit of time”, says Kevin Marsh, Senior Advisor for the African Academy of Science. In the long term, it will not be possible to maintain lockdowns measures as seen in many European countries, he says. “The risk of economic collapse, shortages of food, and social unrest carry greater risks to health in the long term than direct deaths from COVID-19”, Marsh told The Lancet Respiratory Medicine.

As Africa fights to control COVID-19, health systems are severely strained, threatening to reverse progress made with other diseases such as malaria or polio. “We saw with the Ebola virus disease outbreak in West Africa that we lost more people to malaria, for instance, than we lost to the Ebola outbreak. Let us not repeat that with COVID-19”, says Matshidiso Moeti, WHO Regional Director for Africa. The COVID-19 response has already disrupted measles vaccination efforts in Chad, Ethiopia, Nigeria, and South Sudan, leaving approximately 21 million children unprotected. The lives of about 400 000 children and adolescents in Africa who need tuberculosis treatment each year could be drastically affected if resources are diverted fight COVID-19, says The International Union Against Tuberculosis and Lung Disease (The Union). “BCG and other routine vaccinations for infants and children must continue during any COVID-19 response”, said Grania Brigden, Director of Tuberculosis Department at The Union. “We have to ensure that these children do not become collateral damage of the COVID-19 response”, she said. “The fight against the dual epidemic of tuberculosis and HIV has been going on for decades, in both adults and children in sub-Saharan Africa; and these communities face an unprecedented resurgence in both diseases, which could greatly compound the devastation likely to be caused by the coronavirus”, Dongo says.