SARS-CoV-2 epidemic in African countries-are we losing perspective?

In their Correspondence, Chad Wells and colleagues wrote about COVID-19 in the African continent, proposing more rigorous measures of prevention and lockdown and predicting a total death toll of greater than 300 000 for DR Congo alone. We question the appropriateness of the mathematical model used by the authors and of the conclusions drawn. A more accurate prediction must go beyond this model and encompass long-term health strategies of the country, as well as death tolls attributable to the prevention measures themselves.

We know little about the dynamics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in African countries, including its infectiousness and the proportion of infected people who develop symptoms. Confined exposure of 2010 people on an aircraft carrier resulted in an infection rate of just 50%, and only 50% of infected people developed symptoms. Under less confined conditions, and similar to other circulating viruses that cause acute respiratory infections, SARS-CoV-2 might cause infection rates well below 30%, thus unable to provoke herd immunity but most probably causing recurring annual infections.

Estimated infection fatality rates of around 0·3% draw a much less dramatic picture of COVID-19-related deaths than predicted by Wells and colleagues, who presumed 95% of all Congolese will be infected, with an infection fatality rate of over 4%. In DR Congo, we might thus estimate fewer than 40 000 attributable deaths compared with 800 000 Congolese people dying each year in the country. Such estimates put the prioritisation of this disease over other health threats on the continent immediately into question.

Country-specific age structures and infrastructure in Africa differ greatly from higher-income settings. In DR Congo and Malawi, for instance, 63% and 67% of the population, respectively, are younger than 25 years, and in both countries only 2·69% of the population is older than 65 years. Although densely populated, except for in major cities, neither DR Congo nor Malawi has the infrastructure or population clustering to drive an epidemic in the country as projected by Wells and colleagues.

The lockdown measures proposed by Wells and colleagues do not appear applicable to the African continent and might cause more harm than SARS-CoV-2 itself. We have already seen the cumulative effects of psychosocial, economic, and health damage, including hunger, altered health-seeking behaviour, and postponed treatment. Other interventions proposed by the authors, such as price controls, waving of taxes, and cash transfers, are not effective in countries where prices depend on dealers and intermediate traders, only a minority of the population pays taxes, and cash transfers can be an open invitation to fraud.

Africa, a collection of 54 independent states with different population and economic parameters, requires a differentiated look. Between the two seemingly unachievable polarities—herd immunity and eradication—it seems likely that we must accept living with the virus, as we have done with many viruses before. At the very least, we need to define a goal for control policies, assess side-effects of those, and incorporate various sociocultural aspects. We must balance COVID-19-directed control measures with other challenges following a well established public health principle: equal attention to equal health threats.