The African time bomb
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The African time bomb

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Until now, official figures seemed to indicate that sub-Saharan Africa, with a population of more than 1 billion, had been lucky. The interactive map of reported cases of COVID-19, managed by Johns Hopkins University, shows large red spots almost everywhere - except in sub-Saharan Africa. But today, the first cases are being reported in different countries, raising fears of a silent spread that obscures the reality of the numbers. « My concern is that we have a ticking time bomb« says Bruce Bassett, an expert from the University of Cape Town who has been tracking COVID-19 data since January.

Although Africa's handling of the pandemic has received little global attention to date, experts fear that the virus could ravage countries with weak health systems and a population already disproportionately affected by HIV, tuberculosis and other infectious diseases. Social distancing" will be difficult to achieve in the continent's overcrowded cities and slums.

Real-time map of COVID-19 propagation around the world (Johns Hopkins University)

We really have no idea how COVID-19 will behave in Africa.« fears Glenda Gray, a paediatrician and HIV researcher and Chair of the South African Medical Research Council. Last month, the Director-General of the World Health Organization, Tedros Adhanom Ghebreyesus, who is 70 % of our countries are not readyEthiopian, said his "greatest concern" was the spread of COVID-19 in countries with weak health systems. Vera Songwe, executive secretary of the U.N. Economic Commission for Africa (UNECA), said the "greatest concern" is the spread of COVID-19 to countries with weak health systems, alert : " 70 % of our countries are not ready ".

Sub-Saharan Africa only detected its first case on 27 February, in an Italian man who had travelled to Nigeria. Since then, most of the other cases have been imported from Europe, but fewer have come from the Americas and Asia. Until today, there have been no examples of community-wide spread.

Passenger screening

It's not just due to a lack of tests. More than 40 African countries now have the opportunity to test for COVID-19, compared to only two at the beginning of the epidemic in China. But surveillance of COVID-19 in Africa has focused on countries' entry points, and testing has targeted people who have recently travelled to epidemic-affected areas abroad. However, testing for fever among passengers has been revealed It is largely ineffective because it does not detect individuals still in the incubation phase, which is 14 days for COVID-19. Nor does it detect cases that occur in African communities. « I think the cases are falling through the cracks. There's an urgent need to investigate and address this point« says Francine Ntoumi, a parasitologist and public health expert at the Université Marien Ngouabi in the Republic of Congo.

NIGERIA-HEALTH-VIRUS
Control at Lagos airport in Nigeria. Photo BENSON IBEABUCHI/AFP

One way to find out if the disease is spreading in the community is to examine patients with influenza-like illnesses in clinics and hospitals. The number of such patients is not yet increasing in Durban, which is located in KwaZuluNatal, the province with the highest rate of HIV infection in South Africa, says Salim Abdool Karim, director of the Centre for the AIDS Research Programme in South Africa. Doctors are also not seeing an increase in the number of elderly patients suffering from acute respiratory distress. « On this basis, I am reasonably convinced that we do not have a widespread Community spread that goes undetected.« said Abdool Karim.

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But he believes it is only a matter of time before imported cases of COVID-19 - most of which would be relatively wealthy people who can afford to travel - spread to the country's most vulnerable communities. Patients from Europe are likely to have had contact with South Africans before their diagnosis, including household helpers, who often take crowded minibuses to travel home to low-income areas - perfect conditions for COVID-19 to spread. « I think it's inevitable that we're going to have a major epidemic...« says Abdool Karim.

Another way to verify the reality of reported VIDOC-19 cases is to look for unusual spikes in surveillance systems that track influenza-like illness. The global influenza surveillance and response system shows high levels for some African countries, says John Nkengasong, director of the African Centers for Disease Control and Prevention (CDC Africa), which is based in Addis Ababa, Ethiopia. But this could be due to reasons other than COVID-19, he says, such as improving the quality of surveillance data. Nor is it clear how sensitive these detection methods are. In the United States, where the number of reported cases is much higher than in Africa, scientists see potential signals in the data sets that track Alzheimer's disease in older age groups, which are disproportionately affected by COVID-19, says Dan Weinberger, an epidemiologist at Yale University.

I'm afraid it's going to be chaos

Sub-Saharan Africa has a major advantage with respect to COVID-19: its average age is the lowest in the world. (The median age is less than 20 years.) Children rarely get sick from COVID-19, and most young adults appear to suffer mild symptoms; older people have a significantly higher risk of serious illness and death. However, only 3 % of the population in sub-Saharan Africa are over 65 years of age, compared to about 12 % in China.

Some scientists also believe that high temperatures in many African countries could make life more difficult for the coronavirus that causes COVID-19. But the question of whether COVID-19 will be a seasonal disease remains a question of debate. wide open to the specialists.

The Alexandra township in the suburbs of Johannesburg. Photo Valérie Hirsch/Le Soir

However, many other factors could aggravate the pandemic in Africa. It will be difficult to implement the societal and police interventions that have brought the virus to very low levels in China and helped South Korea to more or less contain the epidemic. Several countries have already introduced rules to thwart the spread; Rwanda has announced that it will close places of worship, schools and universities after its first case. But social distancing is certainly impossible in overcrowded townships, and it is not clear how containment would work in African households where several generations live together, says Ntoumi. How do you protect the elderly, how do you tell village populations to wash their hands when there is no water, or to use a gel to disinfect their hands when they don't have enough money for food? « I'm afraid it's going to be chaos« she says.

Care capacity and comorbidity

And many African countries simply do not have the health care capacity to manage critically ill VIDOC-19 patients. According to a 2015 document, Kenya, a country of 50 million people that reported its first case a few days ago, has only 130 intensive care unit beds and about 200 intensive care nurses, according to a 2015 document. Many other countries face similar constraints, says Ifedayo Adetifa, clinical epidemiologist with the KEMRI-Wellcome Trust research programme: "We have a lot of people who have to work in the ICU, but we have a lot of people who have to work in the ICU," says Ifedayo Adetifa. Large or small population pyramid, without universal health care and health insurance, we simply cannot afford to have many cases of VIDOC-19 because we cannot manage the most severe cases."

High rates of other diseases could complicate matters further. « The most important thing for us is to describe the natural history of COVID-19 in South Africa to see if TB and HIV are making it worse.« ...explains Mr. Gray. Chances are, based on experience with other respiratory infections, this is likely to be the case. Last week, the South African Academy of Sciences warned that people living with HIV are eight times more likely to be hospitalized for pneumonia caused by the flu virus than the general population, and three times more likely to die from it.

If the number of cases continues to increase in South Africa, its scientists are ready to study the testing of potential therapies. The country has a great deal of expertise and infrastructure to conduct randomized, placebo-controlled trials (RCTs), for example on drugs and vaccines for HIV and tuberculosis. « What we're doing is trying to quickly identify sites so that, if this activity takes off, large hospitals that have the capacity to conduct clinical trials will be ready to participate in treatment research.« says Helen Rees, Executive Director of the Institute of Reproductive Health and HIV at the University of the Witwatersrand.

Source : Science

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