COVID-19 Across Africa: Epidemiologic Heterogeneity and Necessity of Contextually Relevant Transmission Models and Intervention Strategies
Authors: Jean Olivier Twahirwa Rwema, Daouda Diouf, Nancy Phaswana-Mafuya, Jean Christophe Rusatira, Alain Manouan, Emelyne Uwizeye, Fatou M. Drame, Ubald Tamoufe, Stefan David Baral
Journal: Annals of Internal Medicine (2020)

Ideas and Opinions18 June 2020COVID-19 Across Africa: Epidemiologic Heterogeneity and Necessity of Contextually Relevant Transmission Models and Intervention StrategiesFREEJean Olivier Twahirwa Rwema, MD, MPH, Daouda Diouf, MSc, Nancy Phaswana-Mafuya, PhD, Jean Christophe Rusatira, MD, MPH, Alain Manouan, MSc, Emelyne Uwizeye, BSc, Fatou M. Drame, PhD, Ubald Tamoufe, MPH, MSc, and Stefan David Baral, MD, MPHJean Olivier Twahirwa Rwema, MD, MPHJohns Hopkins School of Public Health, Baltimore, Maryland (J.O.T., S.D.B.)Search for more papers by this author, Daouda Diouf, MScEnda Santé, Dakar, Senegal (D.D.)Search for more papers by this author, Nancy Phaswana-Mafuya, PhDNorth West University, Potchefstroom, South Africa (N.P.)Search for more papers by this author, Jean Christophe Rusatira, MD, MPHBill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, Maryland (J.C.R.)Search for more papers by this author, Alain Manouan, MScInternational Treatment Preparedness Coalition (ITPC) (A.M.)Search for more papers by this author, Emelyne Uwizeye, BScUniversity of Maryland Baltimore County, Baltimore, Maryland (E.U.)Search for more papers by this author, Fatou M. Drame, PhDGaston Berger University, Saint-Louis, Senegal (F.M.D.)Search for more papers by this author, Ubald Tamoufe, MPH, MScJohns Hopkins Cameroon Program, Yaoundé, Cameroon (U.T.)Search for more papers by this author, and Stefan David Baral, MD, MPHJohns Hopkins School of Public Health, Baltimore, Maryland (J.O.T., S.D.B.)Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M20-2628 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Coronavirus disease 2019 (COVID-19) has rapidly emerged as a global public health threat with epicenters in regions of China, parts of Europe, and larger urban centers across North America (1). By comparison, population-level COVID-19 diagnostic rates and associated morbidity and mortality have been limited to date in much of the African continent. Initially, multiple mathematical models projected substantial increases in COVID-19 incidence and related deaths across Africa, with one estimating 300 000 to 3 million people dying, although newer models have estimated lower mortality (2, 3). These models have assumed homogeneity in the transmission dynamics of respiratory pathogens between the African continent and other regions of the world as well as across the African continent. In addition, there has been limited integration of the diverse range of country-led mitigation strategies. Furthermore, these models have not included evaluation of competing health risks to COVID-19 associated with disruptions to the health and social systems in countries across the continent. Finally, they overlook the contextually specific heterogeneities in environmental, social, and structural factors that may potentiate or reduce COVID-19 risks in countries across Africa.To date, the burden and outcomes associated with COVID-19 have varied substantially across the African continent. Specifically, 8 of the 54 African countries—South Africa, Egypt, Nigeria, Algeria, Ghana, Morocco, Cameroon, and Sudan—account for two thirds of all known COVID-19 cases (1). Furthermore, Egypt, Algeria, and South Africa alone account for more than one half of all deaths. And even within these countries, the epidemiology of COVID-19 appears to be, similar to other infectious diseases, not evenly distributed, with concentration of risks in urban epicenters, among lower socioeconomic status communities, with certain occupations, and within congregate living settings.The transmission and mortality models have been parameterized primarily with European and Chinese data, with the primary adjustment being for different age distributions across Africa (3, 4). Moreover, the assumptions have further included higher morbidity and mortality among youth because of preexisting comorbidities, including malnutrition, HIV, tuberculosis, and diagnosed or undiagnosed noncommunicable diseases (4). However, there has been limited consideration of factors driving the diversity in the transmission dynamics of respiratory pathogens across the continent. These include temperature, humidity, and population structure and density, which affect transmission of COVID-19 as well as other respiratory viral pathogens, including influenza (5). Influenza surveillance remains limited in much of Africa, but substantial diversity in influenza seasonality and strains has been observed even between neighboring countries (6). Moreover, there is evidence of substantial phenotypic and genetic diversity in Middle East respiratory syndrome coronavirus in West and North Africa compared with serotypes observed in the Arabian Peninsula (7). Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is immunologically new to humans but is a lipid-enveloped respiratory pathogen, and the integration of historical transmission dynamics of other respiratory pathogens is critical in estimating the potential morbidity and mortality of this virus. Assumptions of homogeneity in transmission dynamics challenging estimations with COVID-19 similarly affected model estimations of Ebola across West and Central Africa in 2014–2016 (8).In early March, governments across sub-Saharan Africa implemented interventions to mitigate COVID-19 along a continuum of specificity that included interruption of international and domestic travel; banning large gatherings, including worship and sporting events; and closure of schools and nonessential businesses. Some countries, including South Africa and Algeria, implemented versions of a complete lockdown, whereas others, including Botswana and Mozambique, implemented less stringent measures (9). Although the differential impact of these interventions is yet to be empirically measured, there have been disconnects between COVID-19 incidence and breadth of public health interventions, including in South Africa; this reinforces the need to characterize other determinants of COVID-19 heterogeneity across the continent. Testing for COVID-19 is still challenging in Africa and worldwide owing to limited availability, variable sensitivity of polymerase chain reaction–based tests, as well as variable accuracy of available serologic tests. Thus, the actual case numbers and deaths are probably higher than the reported numbers, but the trends within countries are critical, as testing and surveillance have only increased over the past several weeks. Outside of North Africa, more than 6 months into the COVID-19 pandemic, there has been no evidence of exhaustion of existing health system resources. And a critical lesson heeded in many countries from the Ebola outbreak was balancing the management of the outbreak and disruptions to health systems.Competing health risks to COVID-19 across the African continent include both endemic communicable and noncommunicable diseases. And the level of health disruption is probably associated with the breadth of the social distancing mandates potentially affecting the provision of malaria, HIV, tuberculosis, vaccination, and maternal and child health programs; sexual and reproductive health and rights; and non-communicable disease services across the continent (10). Telemedicine programs are not scalable across most countries, and there may be substantial morbidity, mortality, and years of life lost in the coming months from these interventions. Similar to other countries worldwide, countries across Africa may experience increases in all-cause mortality that significantly exceed official COVID-19–related mortality, but it is vital to assess what proportion is uncounted direct mortality due to the SARS-CoV-2 virus and what proportion represents indirect mortality from the COVID-19 response. Furthermore, several countries across Sub-Saharan Africa are particularly sensitive to the downstream economic consequences of COVID-19 that will probably disrupt expansion of social and health services. Specifically, it has been estimated that economic growth will slow at a rate of 1.8% to 2.6%, potentially resulting in 27 million new individuals across Africa becoming extremely poor, with associated food insecurity and even starvation (2).Coronavirus disease 2019 represents a public health emergency for countries across Africa. However, African public health institutions, such as the Africa Centres for Disease Control and Prevention, have a long history of effective measures to mitigate infectious diseases, such as Ebola, Zika, malaria, and dengue, among others, suggesting cautious optimism being warranted now. To increase utility, forecasting models that are being used to guide implementation strategies should effectively integrate historical trends for the high level of continental and intercontinental heterogeneity in respiratory pathogens, because the transmission dynamics of COVID-19 appear to be equally heterogenous. It is likely that SARS-CoV-2 will remain in circulation across Africa for the foreseeable future; thus, adaptation of mitigation strategies to sustainable approaches with evolving epidemic trajectories is similarly critical. Ultimately, as African data are rarely used to parameterize models of transmission or inform implementation strategies for Europe or Asia, so too should the international community be hesitant in developing forecasts and prevention strategies in the absence of integration of African data and leadership by African institutions.References1. World Health Organization. Coronavirus disease (COVID-19): situation report, 140. World Health Organization; 2020. Accessed at https://apps.who.int/iris/handle/10665/332389?show=full/ on 8 June 2020. Google Scholar2. United Nations Economic Commission for Africa. COVID-19 in Africa: Protecting Lives and Economies. United Nations Economic Commission for Africa; 2020. Accessed at www.uneca.org/publications/covid-19-africa-protecting-lives-and-economies/ on 25 April 2020. Google Scholar3. Achoki T, Alam U, Were L, et al. COVID-19 pandemic in the African continent: Forecasts of cumulative cases, new infections, and mortality. medRxiv. Preprint posted online 28 April 2020. doi:10.1101/2020.04.09.20059154 Google Scholar4. Van Zandvoort K, Jarvis CI, Pearson C, et al. Response strategies for COVID-19 epidemics in African settings: a mathematical modelling study. medRxiv. Preprint posted online 3 May 2020. doi:10.1101/2020.04.27.20081711 Google Scholar5. Carleton T, Meng KC. Causal empirical estimates suggest COVID-19 transmission rates are highly seasonal. medRxiv. Preprint posted online 30 March 2020. doi:10.1101/2020.03.26.20044420 Google Scholar6. Radin JM, Katz MA, Tempia S, et al. Influenza surveillance in 15 countries in Africa, 2006-2010. J Infect Dis. 2012;206 Suppl 1:S14-21. [PMID: 23169960] doi:10.1093/infdis/jis606 CrossrefMedlineGoogle Scholar7. Chu DKW, Hui KPY, Perera RAPM, et al. MERS coronaviruses from camels in Africa exhibit region-dependent genetic diversity. Proc Natl Acad Sci U S A. 2018;115:3144-3149. [PMID: 29507189] doi:10.1073/pnas.1718769115 CrossrefMedlineGoogle Scholar8. Aylward B, Barboza P, Bawo L, et al. WHO Ebola Response Team. Ebola virus disease in West Africa—the first 9 months of the epidemic and forward projections. N Engl J Med. 2014;371:1481-95. [PMID: 25244186] doi:10.1056/NEJMoa1411100 CrossrefMedlineGoogle Scholar9. Blavatnik School of Government, Oxford University. COVID-19 government response tracker. 2020. Accessed at www.bsg.ox.ac.uk/research/research-projects/coronavirus-government-response-tracker/ on 7 June 2020. Google Scholar10. Jewell BL, Smith JA, Hallett TB. The potential impact of interruptions to HIV services: a modelling case study for South Africa. medRxiv. Preprint posted online 27 April 2020. doi:10.1101/2020.04.22.20075861 Google Scholar Comments 0 Comments Sign In to Submit A Comment Jose D. Debes 1,2, Nasreen S. Quadri 1, Amir Sultan 3, Abdelmajeed Mahmoud Moussa 4, Mirghani Yousif 51) University of Minnesota 2) Hennepin Healthcare 3) Addis Ababa University, Ethiopia 4) Aswan University Hospital, Egypt 5) University of Gezira, Wad Madani, Sudan29 June 2020 COVID-19 in Africa: the importance of supporting the healthcare workforce Twahirwa Rwema and colleagues provide an eloquent description of the strengths of African public health institutions as an important resource to minimize the devastating effects of the SARS-CoV-2 pandemic in the continent(1). These institutions and their implemented actions will likely mitigate the impact of the virus in the general population. Attention, however, should also be placed on the impact of the pandemic on healthcare workers (HCWs) across Africa. Providers in the region are painfully exposed to a general lack of support from local institutions. As physicians and nurses in other regions are praised as heroes, many of those in Africa are confronted with social marginalization (due to fears of transmission), lack of personal protective equipment (PPE) and economic insecurity. Indeed, preliminary analysis from a survey related to COVID-19 effects conducted by us in over a dozen African countries evidenced that over 50% of interviewed HCWs suffered some form of salary reduction, less than 15% perceived adequate access to PPE and a staggering 36% have been confronted with social stigma, either by being asked to leave home, not share public transportation, or been not allowed into local markets (personal communications). Lack of care for those providing medical care to others can have serious and prolonged effects on the medical system that extend beyond the current pandemic. An already exhausted population of HCWs that is not protected from social, physical and economical hardship risks a path to a demoralized workforce with insufficient strength to help those suffering from disease during and after the pandemic. While the continent is being praised, as it should, for its public health interventions against SARS-CoV-2, countries across Africa should also contemplate empowering and protecting HCWs since the physical and mental strength of this workforce will be critical for the prolonged and unremitting fight against the pandemic. References 1. Twahirwa Rwema JO, Diouf D, Phaswana-Mafuya N, Rusatira JC, Manouan A, Uwizeye E, et al. COVID-19 Across Africa: Epidemiologic Heterogeneity and Necessity of Contextually Relevant Transmission Models and Intervention Strategies. Ann Intern Med. 2020. Disclosures: Financial support: Funded by the Robert Wood Johnson Foundation, Mitialto Foundation, and University of Minnesota Center for Global Health and Social Responsibility Global Health Seed Award Author, Article, and Disclosure InformationAuthors: Jean Olivier Twahirwa Rwema, MD, MPH; Daouda Diouf, MSc; Nancy Phaswana-Mafuya, PhD; Jean Christophe Rusatira, MD, MPH; Alain Manouan, MSc; Emelyne Uwizeye, BSc; Fatou M. Drame, PhD; Ubald Tamoufe, MPH, MSc; Stefan David Baral, MD, MPHAffiliations: Johns Hopkins School of Public Health, Baltimore, Maryland (J.O.T., S.D.B.)Enda Santé, Dakar, Senegal (D.D.)North West University, Potchefstroom, South Africa (N.P.)Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins School of Public Health, Baltimore, Maryland (J.C.R.)International Treatment Preparedness Coalition (ITPC) (A.M.)University of Maryland Baltimore County, Baltimore, Maryland (E.U.)Gaston Berger University, Saint-Louis, Senegal (F.M.D.)Johns Hopkins Cameroon Program, Yaoundé, Cameroon (U.T.)Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M20-2628.Corresponding Author: Jean Olivier Twahirwa Rwema, MD, MPH, Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E 7133, Baltimore, MD 21205; e-mail, jtwahir1@jhu.edu.Current Author Addresses: Dr. Twahirwa Rwema: Key Populations Program, Center for Public Health and Human Rights, Johns Hopkins Bloomberg School of Public Health, 615 North Wolfe Street, E 7133, Baltimore, MD 21205.Mr. Diouf: Enda Santé, 56 Cité Comico VDN, BP: 3370 Dakar, Senegal.Dr. Phaswana-Mafuya: North West University, 26a Postma Street, The Dam Area, Potchefstroom 2531 South Africa.Dr. Rusatira: Bill & Melinda Gates Institute for Population and Reproductive Health, Johns Hopkins School of Public Health, 615 North Wolfe Street, W 4041, Baltimore, MD 21205.Mr. Manouan: International Treatment Preparedness Coalition (ITPC), Cocody Angre 7è Tranche vallée, Abidjan, Côte d'Ivoire.Ms. Uwizeye: University of Maryland Baltimore County, 1000 Hilltop Circle, Baltimore, MD 21250.Dr. Drame: Gaston Berger University, Sanar, Saint-Louis 32002, Senegal.Mr. Tamoufe: BP 7039, Carrefour Intendance, Yaoundé, Cameroon.Dr. Baral: Johns Hopkins School of Public Health, 615 North Wolfe Street, E 7146, Baltimore, MD 21205.Author Contributions: Conception and design: J.O. Twahirwa Rwema, D. Diouf, N. Phaswana-Mafuya, J.C. Rusatira, S. Baral.Analysis and interpretation of the data: D. Diouf, J.C. Rusatira, F.M. Drame.Drafting of the article: J.O. Twahirwa Rwema, D. Diouf, J.C. Rusatira, E. Uwizeye, F.M. Drame, S. Baral.Critical revision for important intellectual content: J.O. Twahirwa Rwema, D. Diouf, N. Phaswana-Mafuya, J.C. Rusatira, E. Uwizeye, S. Baral.Final approval of the article: J.O. Twahirwa Rwema, D. Diouf, N. Phaswana-Mafuya, J.C. Rusatira, A. Manouan, E. Uwizeye, F.M. Drame, U. Tamoufe, S. Baral.Administrative, technical, or logistic support: U. Tamoufe.Collection and assembly of data: D. Diouf.This article was published at Annals.org on 18 June 2020. 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