The entire continent of Africa is really terrible

COVID-19 in Africa: Africa seems safer than Europe

The African states are getting through the pandemic much better than feared at the beginning. Despite the presumably high number of unreported infections, mortality is low. Scientists are looking for explanations that could tell them more about how to deal with pandemics.

Enlightenment with Grafitis: Creative pictures, like here in Nairobi, Kenya, reach many people where they are on the go every day. The Grafitis often provide information on how to wear the mask correctly or show the slogan "Corona is real". Photo: picture alliance / ASSOCIATED PRESS / Brian Inganga

Uncontrollable chains of infection, millions of deaths and a collapse of health systems: The World Health Organization's (WHO) initial forecasts for Africa were devastating. But none of that has happened so far. The 55 countries seem to be getting through the pandemic even better than many countries on other continents. Around 60,000 new infections are currently reported across Africa each week, a third less than on the European continent in a single day. But the comparison is unclear, because Africa tests significantly less. Official figures from 18 African countries, compiled by the OurWorldInData.org website, show between 0.01 and 0.6 tests per 1,000 inhabitants every day. In Europe, the number of tests fluctuates more significantly: from 0.6 tests per 1,000 residents in Ukraine to Denmark with 6.6 tests per 1,000 residents. Like many Central European countries, Germany moves around two tests per 1,000 people.

"Nobody knows exact numbers"

Everyone in Africa expects a high number of unreported infections, explains Dr. med. Yenew Kebede Tebeja, Head of Laboratory Systems and Networks Department at the African Center for Disease Control (Africa CDC). “Nobody knows the exact numbers,” he said at a digital expert meeting at the end of September. Because at the beginning of the pandemic, only two laboratories across the continent could have tested for SARS-CoV-2. There are now more than 42 laboratories and every African country can have smears analyzed there. Africa is receiving a lot of international support for this, including from the Robert Koch Institute (RKI) in Germany, which provides PCR test kits. Tebeja expects a further increase in PCR capacities. The top priority remains to test as much as possible, even if the required reagents are currently very expensive on the world market and there is a lack of qualified laboratory staff in some places. For the future, the Afrika CDC is therefore focusing on antigen tests and the development of new, cheaper test methods in parallel. But even then, laboratory-confirmed infections would be able to depict “only a small part of all cases”, believes the experienced microbiologist from Ethiopia.

The under-reporting explains the low number of new infections, but not the different mortality rates of the continents. Because if there was a large increase in unexplained deaths in Africa, one would notice, say experts from the University of Nairobi. According to data from the Africa CDC, among the 1.2 billion inhabitants of Africa there have been around 1.6 million infected and around 38,000 dead since the pandemic began. In comparison with a population of around 600 million, the European continent has so far had just under four million infected people and around 200,000 deaths, according to the European Center for Disease Control.

The combination of the apparent under-reporting of infections on the one hand and the low reported mortality on the other raises the question of what is going differently in Africa (see also DÄ 35–36 / 2020). According to the Regional Director for Africa at the World Health Organization (WHO), Dr. h.c. Matshidiso Moeti, attributed to "a multitude of socio-ecological factors as well as early and strong government action". On the one hand, Africa is a young continent - the average age is around 19 years. Only around three percent of Africans are older than 65 years. Nine out of ten SARS-CoV-2 evidence occurred in Africans under 60 years of age. That could be one reason for the low mortality, so Moeti. In addition, 80 percent of the young infected people showed no symptoms and therefore often did not allow themselves to be tested.

Lockdown before the first fall

On the other hand, the tropical climate as well as the population distribution and restricted mobility in many rural areas would counteract the spread of the virus, says the WHO regional director. The spread of SARS-CoV-2 is also significantly more uneven in Africa than in Europe. A third of the 1.6 million reported infected came from South Africa. Together with Morocco, Egypt and Ethiopia, four countries account for more than two thirds of the cases. In Europe the picture is a little more homogeneous. The four most affected countries Spain, France, Great Britain and Italy contribute around half of the total of four million infected. Germany is not far behind. African states had "implemented measures such as travel restrictions, curfews and school closings compared to other continents, often before a country had discovered a case," wrote one
international team of scientists in an article in
Science (1).

The immune system hypothesis

Affluent diseases such as cardiovascular diseases, obesity and type 2 diabetes would also be rarer in Africa than in Europe or America, the researchers argue. Infectious diseases, such as HIV, malaria, tuberculosis and other respiratory infections, would have a higher prevalence. The adaptive, specific immune system could therefore also play a role. So far this is only a hypothesis. However, there are studies that show "significant differences" in the activation as well as the cytokine and memory profiles of the immune cells. “Not only among Africans versus Europeans, but also among Africans with high and low exposure to microorganisms and parasites,” the scientists wrote. This could make the COVID-19-associated cytokine storm weaker.

Due to the high level of infection made possible in young asymptomatic Africans, herd immunity may develop more quickly, the authors suspect. But it is also possible that the pandemic will only hit Africa with a delay. Moeti therefore urges caution despite the currently low numbers: "Other regions of the world have experienced similar trends and have found that the number of cases is rising again with the relaxation of social and health policy measures." The current slow spread of the virus also means "That the pandemic will continue to smolder for some time and will occasionally flare up again," said Moeti.

In many parts of Africa, so-called “Community Health Workers” (CHW) play a key role in combating this. As trained confidants in their communities or villages, they take over the follow-up of contacts or advise their community on locally feasible protection concepts, explains Dr. med. Anna Kühne in conversation with Deutsches Ärzteblatt. She is an epidemiological advisor for Doctors Without Borders and has worked in Africa several times, including to fight the Ebola epidemic. The communities there had had many experiences during outbreaks that would help them now. Dealing with contact persons or isolating risk groups are, for example, already practiced procedures of the CHWs. "But you can also identify sick people and then work with the communities to find solutions to get them medical care," says Kühne.

The CHWs do not have any medical training for this. However, they are usually trained and prepared for their tasks by health institutions.

The epidemiologist believes that just by educating their own communities and villages about health issues and refuting rumors or false reports, they would make a major contribution to containing the virus. In addition, however, they made sure that “there are actually sufficient options for hand hygiene in the relevant places, for example, and that there is soap and water,” explains Kühne. In theory, every African country can now carry out tests, but the distances for patients to a test station are sometimes "incredibly long," she says. The CHW would therefore close a crucial gap in the often weak health systems. Jonathan Fischer-Fels

On the subject of COVID-19 in Africa:
www.aerzteblatt.de/201616

Yazdanbakhsh M et al .: COVID-19 in Africa: Dampening the storm? Science Aug 2020; 6504: 624-6. CrossRefMEDLINE