Leveraging Africa's preparedness towards the next phase of the COVID-19 pandemic
Authors: Madikay Senghore, Merveille K Savi, Bénédicte Gnangnon, William P Hanage, Iruka N Okeke
Journal: The Lancet Global Health (2020)

The coronavirus disease 2019 (COVID-19) response in many African countries has been swift, progressive, and adaptable, despite resource limitations.1Kapata N Ihekweazu C Ntoumi F et al.Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future.Int J Infect Dis. 2020; 93: 233-236Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar As the novel coronavirus infection spread through Wuhan (China) in January, 2020, African countries rapidly acquired de novo severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) testing capacity so that by March, most could confirm COVID-19. Airport screening began early and efforts to mitigate the spread of COVID-19 have typically emphasised case identification, contact tracing and isolation, handwashing and hand hygiene, and several social distancing and stay-at-home measures with, in some cases, lockdowns of exceedingly high risk areas (appendix). These strategies are likely to remain integral to disease mitigation until an effective vaccine is deployed or population immunity is sufficient to slow transmission. However, the application of COVID-19 mitigation strategies in sub-Saharan Africa needs careful and continued deliberation because of the unique socioeconomic dynamics in this region. In this Comment, we discuss some of these challenges and suggest potential, non-resource-intensive solutions. Rapid urbanisation has led to an informal sector surge and consequent increase in people living in informal settlements and slums within African cities.2Medina L Jonelis AW Cangul M The informal economy in sub-Saharan Africa: size and determinants.https://www.imf.org/en/Publications/WP/Issues/2017/07/10/The-Informal-Economy-in-Sub-Saharan-Africa-Size-and-Determinants-45017Date: 2017Date accessed: April 17, 2020Google Scholar These communities are particularly susceptible to economic shock resulting from stay-at-home orders and lockdowns, which need to be tempered with food and basic necessity provisions.2Medina L Jonelis AW Cangul M The informal economy in sub-Saharan Africa: size and determinants.https://www.imf.org/en/Publications/WP/Issues/2017/07/10/The-Informal-Economy-in-Sub-Saharan-Africa-Size-and-Determinants-45017Date: 2017Date accessed: April 17, 2020Google Scholar, 3Corburn J Vlahov D Mberu B et al.Slum health: arresting COVID-19 and improving well-being in urban informal settlements. Yale School of Medicine, 2020https://medicine.yale.edu/news-article/23734/Date accessed: April 17, 2020Google Scholar Water tanks can be set up for handwashing and sanitation in these susceptible communities, as well as public toilets which could potentially serve as sentinel COVID-19 surveillance sites through periodic faecal matter sampling and testing.4Wu F Xiao A Zhang J et al.SARS-CoV-2 titers in wastewater are higher than expected from clinically confirmed cases.medRxiv. 2020; (published online April 7.) (preprint)DOI: 10.1101/2020.04.05.20051540Google Scholar An added layer of complexity is the multigenerational structure and large size of typical African households.5UNHousehold size and composition around the world 2017.https://www.un.org/en/development/desa/population/publications/pdf/ageing/household_size_and_composition_around_the_world_2017_data_booklet.pdfDate: 2017Date accessed: April 17, 2020Google Scholar Household transmission is a substantial driver of SARS-CoV-2 spread in the community and multigenerational households might be prone to higher fatality.6Korea Centers for Disease Control and PreventionCoronavirus disease-19: summary of 2,370 contact investigations of the first 30 cases in the Republic of Korea.Osong Public Health Res Perspect. 2020; 11: 81-84Crossref PubMed Scopus (52) Google Scholar Interrupting COVID-19 transmission is challenging because a substantial proportion of transmission occurs in the presymptomatic stage.7Ferretti L Wymant C Kendall M et al.Quantifying SARS-CoV-2 transmission suggests epidemic control with digital contact tracing.Science. 2020; (published online March 31.)DOI:10.1126/science.abb6936Crossref Scopus (1535) Google Scholar Effective contact tracing, testing in the community, and targeted door-to-door surveillance in high-risk areas can help to identify preclinical COVID-19 patients early and isolate them to prevent onward transmission.8Salathé M Althaus CL Neher R et al.COVID-19 epidemic in Switzerland: on the importance of testing, contact tracing and isolation.Swiss Med Wkly. 2020; 150w20225PubMed Google Scholar Mandatory involuntary quarantine could be deemed an impingement of civil liberties. However, voluntary isolation at financially compensated (ie, pre-paid for by government) designated facilities for those who cannot self-isolate at home, and for frontline health-care workers who risk exposing their families to COVID-19, could be instrumental to curbing transmission. Sustained containment of COVID-19 will ideally prevent uncontrolled spread in the community and overwhelming of health-care capacity. Most African countries have a narrow margin for error because of weak health systems operating at near capacity outside of a pandemic and the need to maintain control of other infectious diseases.1Kapata N Ihekweazu C Ntoumi F et al.Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future.Int J Infect Dis. 2020; 93: 233-236Summary Full Text Full Text PDF PubMed Scopus (125) Google Scholar Staggered periods of relaxed social distancing could avoid a large resurgence of cases while providing respite for economic activity. However, monitoring the effectiveness of non-pharmaceutical interventions and exercising flexibility in their implementation needs to be guided by continued surveillance through community testing. To meet this demand, testing capacity and implementation need to be scaled up substantially. Pooling of samples for quantitative PCR (qPCR) detection will be the most cost-effective approach, with one study showing that a SARS-CoV-2-positive sample could be detected by qPCR in a pool of up to 31 samples.9Yelin I Aharony N Shaer-Tamar E et al.Evaluation of COVID-19 RT-qPCR test in multi-sample pools.medRxiv. 2020; (published online March 27.) (preprint).DOI: https://doi.org/10.1101/2020.03.26.20039438Google Scholar Scientists from Harvard (MA, USA) and the Broad Institute (MA, USA) are developing a low-technology framework to guide sample pooling strategies on the basis of the number of samples collected and testing capacity. Technological advances in COVID-19 testing can also be leveraged to scale up testing. The newly approved Xpert Xpress SARS-CoV-2 (Cepheid, Sunnyvale, CA, USA) cartridge can provide a result within 45 min.10Sheridan C Fast, portable tests come online to curb coronavirus pandemic. Nature Biotechnology.https://www.nature.com/articles/d41587-020-00010-2Date: March 23, 2020Date accessed: April 17, 2020Google Scholar Because most control programmes for tuberculosis and HIV in Africa have GeneXpert modules and trained laboratory scientists, this technology can be easily deployed. However, in areas with high disease burden, existing GeneXpert modules are already overwhelmed. Additional modules must be procured to prevent existing control programmes being derailed. Evaluation and field testing of other portable rapid diagnostic tools needs to start urgently to make COVID-19 testing accessible in places without qPCR capacity. The high burden of endemic infectious disease in sub-Saharan Africa, and ongoing Lassa fever and Ebola outbreaks in Nigeria and DR Congo, mean that the COVID-19 response has an unusual and precarious context. This context emphasises the need to use cross-beneficial mitigating strategies and to maintain broad-based disease surveillance and vaccination programmes through the pandemic. Beyond COVID-19, Africa needs to continue to harness scientific advances to enhance health and productivity and equitably towards meeting the Sustainable Development Goals. We declare no competing interests. Download .pdf (.18 MB) Help with pdf files Supplementary appendix