Possible Reasons Why Sub-Saharan Africa Experienced a Less Severe COVID-19 Pandemic in 2020
Received 30 July 2021
Accepted for publication 9 November 2021
Published 25 November 2021 Volume 2021:14 Pages 3267—3271
Checked for plagiarism Yes
Review by Single anonymous peer review
Peer reviewer comments 4
Editor who approved publication: Dr Scott Fraser
Obinna O Oleribe,1 Ahmed AA Suliman,2,3 Simon D Taylor-Robinson,4 Tumani Corrah5
1Office of the Director General, Nigerian Institute of Medical Research, Yabba, Lagos, Nigeria; 2Department of Medicine, Faculty of Medicine, University of Khartoum, Khartoum, Sudan; 3Department of Cardiology, Shab Teaching Hospital, Khartoum, Sudan; 4Department of Surgery and Cancer, Imperial College London, St Mary’s Hospital Campus, London, UK; 5Africa Research Excellence Fund, c/o MRC the Gambia Unit @ LSHTM, Fajara, The Gambia
Correspondence: Simon D Taylor-Robinson Email [email protected]
Abstract: Both scientific authorities and governments of nations worldwide were found lacking in their COVID-19 response and management, resulting in significant distrust by the general public in 2020. Scientific and medical bodies often failed to give the right counsel on the appropriate course of action on COVID-19, because proven steps were not known, while many governments around the world took ineffective, late or inappropriate COVID-19 control and containment strategies. If the 2020 COVID-19 incidence rates are to be believed, much of sub-Saharan Africa had a lower disease prevalence than expected. We put forward six factors peculiar to much of sub-Saharan Africa that may have accounted for the pandemic landscape there in 2020. We also discuss why the situation has become more serious in 2021.
Keywords: COVID-19, Africa, public health, multidisciplinary care, pandemic
The COVID-19 pandemic response across much of sub-Saharan Africa has been uncoordinated - some governments have denied the infectivity and seriousness of the problem (eg, Tanzania),1,2 and others have refused to implement global prevention strategies, but rather have promoted local cures and home remedies, while conducting business as usual (for example, Zambia and Madagascar).3–5 Tanzania even refused COVID-19 vaccines, as the health minister announced that the country “has no plans in place to accept COVID-19 vaccines” following President John Magufuli expressing doubt about vaccines sourced abroad, without offering evidence.6
Despite the various missteps and the fact that Africa, as a whole, accounts for 25% of the global burden of diseases, the epidemic seems to have spared many sub-Saharan African countries to some degree in 2020, if the WHO case reporting is to be believed. At the time of writing, the African continent has had a lower COVID-19 prevalence, compared to the Americas and Europe.7 Although the situation is more serious in 2021 in Africa, as of July 6, 2021, of the 183,934,913 confirmed cases of COVID worldwide, only 4,224,102 (2.3%) have been reported in the continent; and of the 3,985,022 documented COVID-19 related deaths, only 98,718 (2.5%) have been reported in Africa7 – despite it being the second most populous continent after Asia, and despite having been negatively impacted by civil wars, hunger, diseases such as HIV-AIDS, tuberculosis and, in recent years, Ebola virus disease (EVD).7,8 This low COVID-19 prevalence across much of the continent is despite the fact that mathematical models projected large COVID-19 epidemics as many African countries ostensibly had fewer means to suppress transmission and manage cases.8
It is of note that some African nations developed or swiftly reactivated some basic infrastructure like diagnostic testing facilities, intensive care units, surveillance, and systems for reporting emergencies to fight the COVID-19 pandemic; activated political and financial tools to combat the pandemic; and enjoyed a level of technical support from the Africa Centers for Disease Control and global development partners. However, the overall response was poorly coordinated and funded.8 In reality, the relative low reported impact of COVID-19 in the African continent in 2020 was not actually a result of an excellent, coordinated or thought-out response on behalf of governments or medical authorities in the African continent.3,9,10 Although the situation is changing rapidly in 2021, the WHO recorded low case rates across the continent in 2020; we would hypothesise that the low reported COVID-19 rates in a swathe of sub-Saharan African countries in 2020 could be linked to:
- Sub-Saharan African Disease Patterns: Although a majority of sub-Saharan African nations are battling with the triple burden of diseases – communicable, non-communicable and trauma/injuries, seasonal influenza is not common in across much of the continent.11–15 Colds and catarrhal ailments may be seen during the dry seasons, but these do not normally translate into an epidemic in most sub-Saharan African nations, unlike in Europe and the Americas where influenza results in deaths of thousands of people annually.16,17 Several environmental factors, such as the climate and the population distribution may negate the establishment and spread of influenza viruses. Such factors may have helped mitigate the extent of the COVID-19 pandemic in sub-Saharan Africa in 2020. Although there is increasing prevalence of COVID-19 in four different waves, the African continent still has the lowest number of documented cases at the time of writing.7
- Sub-Saharan African Herd Immunity: Communicable diseases, including malaria, typhoid, and viral haemorrhagic fevers are still very common across the continent. In addition, a lack of adequate sanitation, a growing population of vectors, such as flies and mosquitoes, and a scarcity of drinkable water may expose the immune system of the average African to viral, bacterial, fungal, helminthic and protozoal agents that may stimulate the immune system without necessarily producing overt clinical disease.18 Repeated exposure over the years may help Africans to build active defences against common protozoal, bacterial and viral diseases, resulting in herd immunity and cross-immunity that may have protected a large proportion of the population from emerging and reemerging disease agents such as SARS-CoV-2.18 It has been argued that because people with malaria develop anti-GPI antibodies that may recognise SARS-CoV-2 glycoproteins, repeated malarial exposure may be protective against COVID-19 or bring about a milder disease pattern.19
Furthermore, with nearly 13% of the world population living in extreme poverty, the continent has the largest share of poor people worldwide.20 Accompanying this level of poverty in sub-Saharan Africa, people frequently live in slums, shared space with multiple families in a single-family house, and many living in a classical congregate setting in proximity (although it could be argued that the same applies to parts of India). Beyond sharing space, people also share food, water, amenities, utensils and their diseases, resulting in diverse cross-immunity. The culture of shared space makes social distancing difficult, if not impossible. Close interaction, which was feared to have worsened the epidemic in America and Europe, rather that worsening the pandemic in sub-Saharan Africa, may have brought about low-level contemporaneous exposure to a number of infectious agents including SARS-CoV-2, resulting in cross-immunity against several infections, including against COVID-19.20 It is, therefore, possible that space sharing, congregate living conditions and economic poverty may have contributed to a better pandemic outcome for sub-Saharan Africans with high-level herd immunity against multiple infections, which may have contributed significantly to the lower documented cases of COVID-19, as well as deaths associated with COVID-19 across much of the African continent in 2020.7
While death rates are now rising in 2021 across the African continent to levels not seen in 2020, this may be related to the emergence of new viral variants which have reduced the natural resistance of communities across the continent, such as the delta variant and/or to the lack of COVID-19 vaccination throughout Africa.7
We should be mindful that the COVID-19 pandemic has completely changed the way the world functions, how businesses are managed (with remote working), patients are cared for (with tele-health) and meetings are held (through video-conferencing). However, we will not reach an equilibrium until COVID-19 vaccination is widespread around the world. The potential for new viral variants to occur in unvaccinated populations is too great and currently, sub-Saharan Africa being a source of concern in this regard.34 In sub-Saharan Africa, vaccination is going to become the next hurdle as vaccines are not widely available. As of July 12 2021, 3.44 billion doses have been delivered worldwide, but less than 0.5% of the total has been in the continent.35 Where COVID-19 vaccines are available, such as in the Republic of South Africa, uptake is poor owing to vaccine hesitancy, skepticism, mistrust of the system, and poor/ineffective public health dissemination policies.36 Public healthcare policies need to be directed towards education of the general public with respect to improving vaccine uptake and reducing vaccine skepticism.37–40
While there is not a one-size-fits-all policy for the continent and this is apparent when focusing on countries such as the Republic of South Africa, which was harder hit by the pandemic,41 we believe that it will be good to review the current COVID pandemic comprehensively to document the mistakes made, the lessons learned, and to develop a global pandemic response protocol that will prepare governments, scientists and healthcare professionals for appropriate action in any future pandemics. Such lessons need to be reviewed in a multidisciplinary way (and not just from a medical perspective), as factors such as atmospheric stability, wind speed and environmental pollution all have had an impact on COVID-19 transmission and given that weather patterns are frequently predictable, such data should be added into public health models of disease transmission to more accurately forecast future trends across the continent, both in the current pandemic and in future potential disease outbreaks.42
SDT-R is grateful to the British National Institute for Healthcare Research Biomedical Facility at Imperial College London for infrastructure support. SDT-R was funded by Wellcome ISSF at Imperial College London. We thank Professor Marsha Morgan for philosophical, linguistic and syntactical comments on the manuscript.
The authors report no conflicts of interest in this work.
1. Buguzi S. COVID-19: counting the cost of denial in Tanzania. BMJ. 2021;373:n1052.
2. Nakkazi E. Obstacles to COVID-19 control in East Africa. Lancet Infect Dis. 2020;20:660. doi:10.1016/S1473-3099(20)30382-0
3. Umviligihozo G, Mupfumi L, Sonela N, et al. Sub-Saharan Africa preparedness and response to the COVID-19 pandemic: a perspective of early career African scientists. Wellcome Open Res. 2020;5:163.
4. Atabong AB. How Pan-African media helped Madagascar advance its claim of a COVID-19 ‘miracle cure’ as a form of medical diplomacy. africaportal.org; 2020. Available from: https://www.africaportal.org/publications/how-pan-african-media-helped-madagascar-advance-its-claim-covid-19-miracle-cure-form-medical-diplomacy/.
5. Orisakwe OE, Orish CN, Nwanaforo EO. Coronavirus disease (COVID-19) and Africa: acclaimed home remedies. Sci Afr. 2020;e00620. doi:10.1016/j.sciaf.2020.e00620
6. Makoni M. Tanzania refuses COVID-19 vaccines. Lancet. 2021;397:566. doi:10.1016/S0140-6736(21)00362-7
8. Dzinamarira T, Dzobo M, Chitungo I. COVID‐19: a perspective on Africa’s capacity and response. J Med Virol. 2020;92:2465–2472. doi:10.1002/jmv.26159
9. Van Zandvoort K, Jarvis CI, Pearson CA, et al. Response strategies for COVID-19 epidemics in African settings: a mathematical modelling study. BMC Med. 2020;18:1–19. doi:10.1186/s12916-020-01789-2
10. Haider N, Osman AY, Gadzekpo A, et al. Lockdown measures in response to COVID-19 in nine sub-Saharan African countries. BMJ Global Health. 2020;5:e003319. doi:10.1136/bmjgh-2020-003319
11. Cooper RS, Osotimehin B, Kaufman JS, Forrester T. Disease burden in sub-Saharan Africa: what should we conclude in the absence of data? Lancet. 1998;351:208–210. doi:10.1016/S0140-6736(97)06512-4
12. Boum Y, Mburu Y. Burden of disease in Francophone Africa 1990–2017: the triple penalty? Lancet Global Health. 2020;8:e306–e307. doi:10.1016/S2214-109X(20)30040-1
13. Labadarios D, Steyn NP. Nutritional disorders in Africa: the triple burden. Nutrition. 2005;21:2. doi:10.1016/j.nut.2004.09.002
14. Norman R, Matzopoulos R, Groenewald P, Bradshaw D. The high burden of injuries in South Africa. Bull World Health Organ. 2007;85:695–702. doi:10.2471/BLT.06.037184
15. Agyei-Mensah S, Aikins ADG. Epidemiological transition and the double burden of disease in Accra, Ghana. J Urban Health. 2010;87:879–897. doi:10.1007/s11524-010-9492-y
16. Beveridge WI. The chronicle of influenza epidemics. Hist Philos Life Sci. 1991;13(2):223-234.
17. Bloom-Feshbach K, Alonso WJ, Charu V, et al. Latitudinal variations in seasonal activity of influenza and respiratory syncytial virus (RSV): a global comparative review. PLoS One. 2013;8:e54445. doi:10.1371/journal.pone.0054445
18. Sotgiu S, Angius A, Embry A, Rosati G, Musumeci S. Hygiene hypothesis: innate immunity, malaria and multiple sclerosis. Med Hypotheses. 2008;70::819–825. doi:10.1016/j.mehy.2006.10.069
19. Hussein MIH, Albashir AAD, Elawad OAMA, et al. Malaria and COVID-19: unmasking their ties. Malar J. 2020;19:457. doi:10.1186/s12936-020-03541-w
20. Statista. African Countries with the Highest Share of Global Population Living Below the Extreme Poverty Line in 2021; 2021.
22. Zinkina J, Korotayev A. Explosive Population Growth in Tropical Africa: crucial Omission in Development Forecasts (Emerging Risks and Way Out). World Futures. 2014;70/2:120–139. doi:10.1080/02604027.2014.894868
24. Neuzil KM, Hohlbein C, Zhu Y. Illness among schoolchildren during influenza season: effect on school absenteeism, parental absenteeism from work, and secondary illness in families. Arch Pedi Adolesc Med. 2002;156:986–991. doi:10.1001/archpedi.156.10.986
25. Smith S, Morbey R, Pebody RG, et al. Retrospective observational study of atypical winter respiratory illness season using real-time syndromic surveillance, England, 2014–15. Emerg Infect Dis. 2017;23:1834. doi:10.3201/eid2311.161632
26. Mulu A, Bekele A, Abdissa A, et al. The challenges of COVID-19 testing in Africa: the Ethiopian experience. Pan Afr Med J. 2021;38. doi:10.11604/pamj.2021.38.6.26902
27. Kobia F, Gitaka J. COVID-19: Are Africa’s diagnostic challenges blunting response effectiveness? AAS Open Res. 2020;3:4.
28. Oleribe OO, Oskouipour P, Nwanyanwu O, Taylor-Robinson SD. The COVID-19 era: the view from Nigeria. QJM. 2021;114:13–15. doi:10.1093/qjmed/hcaa297
29. Oleribe OO, Osita-Oleribe P, Salako BL, Ishola TA, Fertleman M, Taylor-Robinson SD. COVID-19 experience: taking the right steps at the right time to prevent avoidable morbidity and mortality in Nigeria and other nations of the world. Int J Gen Med. 2020;13:491. doi:10.2147/IJGM.S261256
30. Oleribe O, Ezechi O, Osita-Oleribe P, et al. Public perception of COVID-19 management and response in Nigeria: a cross-sectional survey. BMJ Open. 2020;10:e041936. doi:10.1136/bmjopen-2020-041936
32. Oni T, Micklesfield LK, Wadende P, et al. Implications of COVID-19 control measures for diet and physical activity, and lessons for addressing other pandemics facing rapidly urbanising countries. Glob Health Action. 2020;13:1810415. doi:10.1080/16549716.2020.1810415
33. Spalletta G, Porcari DE, Banaj N, Ciullo V, Palmer K. Effects of COVID-19 infection control measures on appointment cancelation in an Italian outpatient memory clinic. Front Psychiatry. 2020;11:1335. doi:10.3389/fpsyt.2020.599844
34. Conti P, Caraffa A, Gallenga CE, et al. The British variant of the new coronavirus-19 (SARS-Cov-2) should not create a vaccine problem. J Biol Regul Homeost Agents. 2021;35:1–4.
36. Zhu J, Yan W, Zhu L, Liu J. COVID-19 pandemic in BRICS countries and its association with socio-economic and demographic characteristics, health vulnerability, resources, and policy response. Infect Dis Poverty. 2021;10:97. PMID: 34238368; PMCID: PMC8264992. doi:10.1186/s40249-021-00881-w
37. Echoru I, Ajambo PD, Keirania E, Bukenya EEM. Sociodemographic factors associated with acceptance of COVID-19 vaccine and clinical trials in Uganda: a cross-sectional study in western Uganda. BMC Publ Health. 2021;21:1106. PMID: 34112143; PMCID: PMC8190743. doi:10.1186/s12889-021-11197-7
38. Coccia M. Preparedness of countries to face COVID-19 pandemic crisis: strategic positioning and underlying structural factors to support strategies of prevention of pandemic threats. Environ Res. 2021;203:111678. PMID: 34280421; PMCID: PMC8284056. doi:10.1016/j.envres.2021.111678
39. Frederiksen L, Zhang Y, Foged C, Thakur A. The long road toward COVID-19 herd immunity: vaccine platform technologies and mass immunization strategies. Front Immunol. 2020;11:1817. PMID: 32793245; PMCID: PMC7385234. doi:10.3389/fimmu.2020.01817
40. Kanyike AM, Olum R, Kajjimu J, et al. Acceptance of the coronavirus disease-2019 vaccine among medical students in Uganda. Trop Med Health. 2021;49(1):37. doi:10.1186/s41182-021-00331-1
41. Broadbent A, Combrink H, Smart B. COVID-19 in South Africa. Global Epidemiol. 2020;2020:100034. doi:10.1016/j.gloepi.2020.100034
42. Coccia M. The effects of atmospheric stability with low wind speed and of air pollution on the accelerated transmission dynamics of COVID-19. Int J Environ Stud. 2021;78(1):1–27. doi:10.1080/00207233.2020.1802937
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