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Infectious Diseases

Updated 31 March 2020

'Anticipatory anxiety': Africa on the cusp of coronavirus pandemic

As many African countries opt for lockdown, there is uncertainty over whether this will be enough to prevent the spread of the new coronavirus or whether authorities will be able to implement this in overcrowded urban areas. Kerry Cullinan reports.

There is a sense that Africans are on the shore watching the sea draw back before the tsunami of new coronavirus infections hits, overwhelming the continent’s health facilities and killing thousands of people.

In late February, a handful of African countries had recorded a few coronavirus cases. Egypt, Algeria and South Africa, with a high volume of air traffic from affected regions, were hit first. 

By Sunday, 29 March, 4 282 cases of the virus had been recorded in 46 of the 54 African countries, according to Africa Centres for Disease Control and Prevention (CDC). 

World Health organization Director-General, Dr Tedros Adhanom Ghebreyesus recently warned the continent to "prepare for the worst".

African countries have been struggling to reconcile measures to arrest the virus, such as travel bans, social distancing and restricting public gatherings, with the need to protect their weak economies. 

Drastic measures

Amid growing consensus that China’s reversal of its pandemic started from lockdown and this is the most effective way to reverse the pandemic, key African countries have opted for drastic measures to contain the virus in the past few days. 

Rwandans are in a 14-day lockdown which started on 22 March. Kenya has a night-time curfew and restrictions on gatherings. South Africa went into a 21-day total lockdown on Friday.

"Those countries that have acted swiftly and dramatically have been far more effective in controlling the spread of the disease," said South African President Cyril Ramaphosa.

"While this measure will have a considerable impact on people's livelihoods, on the life of our society and on our economy, the human cost of delaying this action would be far, far greater."

The Democratic Republic of Congo implemented a four-day lockdown on Saturday, although it has been delayed for a few days after the prices of essential goods spiked.

Yesterday’s Nigerian president Muhammadu Buhari announced a 14-day lockdown for Lagos and Ogun state which will come into effect at 11pm today, 30 March. 

Ghanians living in Accra and Kumasi face a two-week lockdown from today. Zimbabweans also face a 21-day lockdown from today, and Lesotho citizens face a 25-day lockdown. Congo-Brazzaville goes into lockdown from tomorrow, Tuesday, 31 March, and eight towns in Burkina Faso will be shut down from Friday for 14 days.

However, implementing the lockdowns has proven challenging.

Protect health workers

South Africans may only leave their homes to buy basic groceries or medical supplies and there is a ban on the sale of alcohol. The South African National Defence Force has been brought in to support the police. Police used rubber bullets and water cannons to disperse shoppers in Johannesburg who were refusing to stand an arm’s length apart.

Two Rwandans were reported to have been shot dead over the weekend, although that government subsequently denied that the shootings were related to the lockdown.

Meanwhile, epidemics experts are urging African governments to do whatever they can to protect the continent’s thin line of health workers.

They urgently need personal protective equipment (PPE) such as masks, gloves and hand sanitiser.

"But other measures are very important such as ventilation, spacing, early triage and separation of potential cases and increased access to water and supplies," said Amanda McClelland, senior vice-president of Prevent Epidemics, part of Vital Strategies' Resolve to Save Lives programme. 

Dr Gilles van Cutsem, an infectious disease doctor and epidemiologist with Médicins sans Frontières (MSF), stressed that "there needs to be planning and preparation for screening and triage at health facilities to avoid overcrowding and saturation of hospitals, and ensure that hospitals do not become foci of transmission".

"In Italy and China triage tents were set up outside hospitals to receive and separate patients," added van Cutsem.

Major challenges

Meanwhile, HIV clinician Dr Francois Venter urged those who are "mildly symptomatic" to stay away from health facilities to make sure that there is space for the very sick. Speaking after 14 days in quarantine, Venter said he had "anticipatory anxiety" as he waited for the deluge of patients.

"I was almost disappointed that my [Covid-19] test was negative. For the first time in my life, I understand emotionally the relief that some of my gay clients expressed when they finally tested positive for HIV," said Venter.

While the WHO has reportedly sent large consignments of PPE to various African countries, shortages are being reported all over the continent.

There were only 60 masks between 280 health workers at China-Uganda Friendship Hospital near Kampala, a designated treatment facility for Covid-19 patients, according to a well-placed source.

They had only received gloves after threatening to go on strike. McClelland recently returned from Ethiopia, Africa’s second most populous African country, and has few illusions about the massive tasks that lie ahead: "There is still much more to do in Ethiopia to test and detect cases. The extent of transmission in this country with 105 million people is not really known."

There are two major challenges: preparing and training health workers – Ethiopia only has 19 000 – and engaging communities to change their personal behaviour to limit the spread.

Sobering new data from Imperial College predicts that 250 critical care beds will be needed per 100 000 people if none of the non-pharmaceutical interventions, such as social distancing and restricting gatherings, are successful.

A recent report from Nigeria estimates that the country may only have around 500 ventilators for a population of over 200-million. 

Lessons learnt from Ebola

While Covid-19 is a different kind of infection and its effect is likely eclipse Ebola, the continent has learnt important lessons about epidemics from Ebola.

While trying to contain Ebola, Guinea introduced a form of community quarantine called "micro-cerclage" (micro-encirclement) to limit the movement of people in Ebola-affected areas.

Those showing symptoms of Ebola were placed in isolation while those close to them were asked to limit their movements.

Limited essential movement – such as attending to crops - was allowed and was often monitored by people's mobile phones.

Community leaders' support for the policy was key, as were local response teams who enforced the monitoring. Affected households were also provided with food and basic toiletries.

"Microcerclage is one approach that will potentially add real value to addressing Covid-19, but this will depend on the scale of community transmission," says McClelland, who came face-to-face with Ebola while working in the Emergency Health Unit of the International Federation of Red Cross and Red Crescent Societies. 

"If clusters can be detected early and isolated then this approach could help communities to not be negatively impacted and to continue to have access to key services and resources including food and water."

Engagement and trust

But a huge challenge is how to quarantine city dwellers. Over 20 million people live in crowded conditions in Lagos, five million live in Johannesburg and three million in Addis Ababa.

"Self-isolation and restriction of population movement on a much larger scale in some cities would stretch the resources to be able to provide food, water and services on a citywide scale," warned McClelland.

Ebola also has negative lessons.

"Without community engagement and trust, the outcomes can be devastating," warned McClelland.

"In the Ebola response, this tragically included violence against first responders. We must do everything we can to avoid this in the response to Covid-19."

In 2019 in the DRC alone, MSF recorded more than 300 attacks on Ebola health workers, during which six people were killed and 70 wounded. 

Stigmatising foreigners assumed to be infected with Covid-19 is already happening.

On 18 March, the US embassy in Ethiopia issued a security alert warning of "a rise in anti-foreigner sentiment revolving around the announcement of Covid-19".

"Incidents of harassment and assault directly related to Covid-19 have been reported by other foreigners living within Addis Ababa and other cities throughout the country. Reports indicate that foreigners have been attacked with stones, denied transportation services, being spat on, chased on foot, and been accused of being infected with Covid-19," according to the Embassy.

Poor lab capacity

Laboratory capacity has also been improved in many Ebola-affected countries, and Nigeria in particular has made substantial improvements in combating epidemics in the last few years. 

But Van Cutsem warned that the laboratory capacity of most African countries, aside from South Africa is "extremely poor".

"Countries have to find ways to improve the capacity of their laboratories to process tests, and we need the introduction of rapid tests," said Van Cutsem. 

While some African leaders have speculated that the virus may not survive in high temperatures, McClelland simply says: "The short answer is we do not know yet. The science is still not clear. There is some evidence that, in a laboratory, the virus may be affected by warmer temperatures.

"But we also have transmission occurring in warm climates like Australia, the Middle East and South East Asia. Influenza transmits all year round in much of Africa and can actually be worse in dusty conditions. It is too early to assume Africa is protected due to heat and they must prepare with the same sense of urgency as other countries."

Hopes that the pandemic may be short-lived are not shared by experts who quietly talk about the current conditions continuing for many more months. “Settle down to this. Social isolation might be the new normal for the rest of the year. Look after your mental health, check in with people and be kind,” advises Venter.

Cullinan is the health editor for openDemocracy 50.50, and based in South Africa.

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