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The Under-estimated Toll of the COVID-19 Pandemic on the African Continent Dr Matshidiso Moeti, Regional Director, WHO Regional Office for Africa - Regional Expert
Africa has recorded an official toll of 8.7 million cases of COVID-19, but if that accounts for only one in every seven infections, then countries should actually be working seven times harder – and with seven times more resources – to curb the spread of the virus.
Amidst widespread scientific debate around whether Africa’s youthful population and aggressive lockdowns could be credited for relatively low COVID-19 rates on the continent, WHO assessments instead revealed the serious underestimation in the toll the pandemic was taking.
The assessment, grounded in population-based studies and utilising the COVID-19 calculator, were conducted over the past year. Analysing registered cases and death rates, it revealed that as few as 14.2% – or only about one in seven – COVID-19 infections are being detected in Africa. As of 10 October 2021, the cumulative number of COVID-19 infections on the continent was instead estimated to stand at 59 million.
To back up the findings, WHO also conducted seroprevalence studies in 11 countries in the Region to determine the level of antibodies and conferred immunities. Based on those studies, estimates were that up to about 68% of the population had some conferred immunity (as of September 2021).
A further triangulation of Regional data analytics also revealed serious underestimates in death rates. COVID-19 mortality in the 18 months up to September 2021 was set at 618 000 – about three times more than the 223 000 being reported two months later, at the end of November this year.
The serious underestimation of the toll of the pandemic in Africa is likely to have resulted from differences and limitations in strategies and capacities implemented by African countries. For instance, the number of COVID-19 cases detected on the continent is a reflection of the number of people with symptoms reporting to health facilities, in addition to the arriving or departing passengers being tested for travel. Given the higher percentage of asymptomatic cases on the continent, the large-scale under-reporting becomes less surprising.
Taking account of the commonly held view that between 65% and 85% of COVID-19 infections in Africa generate few or no symptoms, it follows that most Africans infected with the virus would not seek treatment at local health facilities, where most testing occurs. Yet, asymptomatic people play a key role in facilitating transmission to those who are more vulnerable, raising the risk for severe disease or death.
The application of different case definitions and testing strategies are also potential alternative factors that could be influencing the underestimation, along with variable ways of counting cases. For example, testing and counting may not be applied to mild cases. Inconsistent handling of time lags, dissimilar quality of care or interventions being introduced at conflicting stages of illness; and the varying profiles of patients (age, genders, ethnicity and underlying comorbidities variations between countries) are other possibilities.
Lack of reporting on the disruption of essential services could also have a role to play. WHO utilized a pulse survey to track the impact of the pandemic on the continuity of the essential services, by measuring health service interruptions in the first quarter of 2021. Preliminary analysis of data from 47 countries saw more than half report disruptions in the availability and quality of primary care services. About one in three countries said they had experienced disruptions to life-saving emergency, and critical and operative care, while 41% reported disruptions to rehabilitative, palliative and longterm care.
In the WHO African Region, 61% of countries have reported disruptions to HIV testing, 53% said tuberculosis (TB) diagnosis and treatment was impacted, while 40% reported disruptions in respect of Hepatitis B and C diagnosis and treatment. Almost half the countries in the Region reported disruptions to routine outreach immunisation services, while 43% said routine facility-based immunisation services had been interrupted.
For Non-Communicable Diseases, more than 40% of countries reported disruptions to hypertension management, diabetes management, cancer screening and cancer treatment services.
Disruptions results from a combination of supply and demand factors, with health workforce-related issues mostly responsible for supply disruptions.
Unavailability/stockouts of essential medicines and cancellation of elective procedures were also reported. On the demand side, community fear/ mistrust, financial difficulties during the pandemic, and decreases in outpatient volume due to absent patients were identified as the biggest contributors to disruptions.
One of the biggest concerns associated with underreporting of cases is the concomitant low vaccination rates, with only about 7.2% of people in Africa now fully vaccinated. This represents only 4.5% of COVID-19 doses administered globally. Meanwhile, only 27 African countries have administered at least one dose to 10% of their total populations, with 20 fully vaccinated one in ten of their citizens.
WHO set the target of all countries fully vaccinating 40% of their populations by the end of the year, but so far only five countries have got there – with no more predicted to follow suit at current rates of vaccine supply and uptake.
In the absence of good vaccine coverage, and with the threat of the emergence of new variants such as the latest Omicron, reduction of transmission in Africa is reliant on proactive community testing strategies.
WHO is working with countries to ramp up testing to enhance surveillance efforts to provide a more realistic picture of the COVID-19 burden, and to conduct seroprevalence surveys to determine the number of people with COVID-19 antibodies.
Focused initially on eight countries, the innovative community-based surveillance project uses cost-effective, easy-to-use diagnostics to augment the detection and management of COVID-19 cases in communities, while also improving testing and tracing capacities. In addition, 109 serosurveillance studies are planned for 35 countries, 65 of which has already begun in 25 countries.
While it’s not a quick-fix to address the under-estimated toll of the COVID-19 pandemic on African countries, it is an important start to the process to secure reliable data, that can in turn inform effective pandemic response in the Region.