By Sharon Atieno

Africa’s Second wave of COVID-19 was more severe than the first, a new study published in The Lancet journal reveals.

The first-ever continent-wide analysis observes that during the first peak in mid-July 2020, there was a mean number of 18,273 new cases reported each day. However, by the end of December, 2020, when approximately 65% of countries (36) had experienced, or were currently experiencing, a second wave of infections, the mean number of new daily cases had risen by 30% to 23,790.

The authors say African countries’ rapid, coordinated initial responses to the pandemic likely limited severity of the first wave. Subsequent loosening of public health measures and a drop in adherence to public health and social measures (PHSMs) after the first wave (probably due to adherence fatigue and economic necessity) are thought to have contributed to the greater impacts observed during the second wave.

Among the 50 countries for which PHSM data were available, nearly 72% (36 countries), implemented their first strict control measures approximately 15 days before reporting their first COVID-19 case. By the 15th April 2020, almost all countries (48 countries), had at least five strict PHSMs in place.

However, during the second wave of cases later in the year, many countries did not enforce PHSMs as strongly as they had done during the early stages of the pandemic. Of the 38 countries that had previously experienced, or were experiencing, a second wave, and recorded PHSMs, almost half (45%, 17 countries) had fewer – typically two less – than during the first wave.

The analysis reveals that though Africa did not report as many coronavirus cases and deaths as the rest of the world, at country-level some nations were worst affected than others with nine AU Member States accounting for 83% of the cases.

In addition, while every nation except the Seychelles reported COVID-19 deaths, more than three quarters of these (78%) occurred in five countries: South Africa, Egypt, Morocco, Tunisia, and Algeria. The highest incidences of cases per 100,000 population were recorded in Cabo Verde, South Africa , Libya, Morocco, and Tunisia, respectively with over 1100 cases.

Of the 53 countries that reported more than 100 COVID-19 cases, one third (18/53) had case fatality ratios (CFRs) – the proportion of deaths compared to total cases – higher than the global average of 2.2%.

Due to the high case and death rates in some countries, major differences were detected at the regional level, with the Southern region accounting for close to half of Africa’s cases (43%) and deaths (46%). The Northern region was also heavily affected, with more than one third of all cases (34%) and deaths (37%) occurring there. The Eastern region accounted for 12% of cases and 9% of deaths, with 9% of cases and 5% of deaths in the Western region, and 3% of cases and 2% of deaths in the Central region.

By the end of March 2020, most countries (49/55) had the ability to run COVID-19 PCR tests, and, by July 2020, all were able to do so. As of 31st December 2020, more than 26 million COVID-19 tests had been carried out in the 55 AU Member States. However, the analysis indicates that many countries were unable to meet demand for tests (based on a WHO recommendation of ‘test per case’ ratios greater than 10) during peak outbreak periods.

While more than two thirds of countries (28/40) that recorded the relevant data had enough testing capacity when the first wave began, only one quarter (14/53) could meet the demand for tests at the peak of the first wave. At the peak of the second wave, just one third of countries (4/11) could meet demand for tests.

The study further alludes that the emergence of COVID-19 variants, some of which are more transmissible than the original strain, is also partly to blame.

“Our findings indicate that several factors likely led to Africa’s larger second wave of COVID-19 cases. Alongside reports that adherence to public health measures – such as mask wearing and physical distancing – has decreased, they highlight the importance of continued monitoring and analysis, particularly in light of the emergence of new, more transmissible variants,” said Dr John Nkengasong, Africa Centres for Disease Control and Prevention (Africa CDC)-Ethiopia in a statement.

“These insights also reveal a need to improve testing capacity and reinvigorate public health campaigns, to re-emphasise the importance of abiding by measures that aim to strike a fine balance between controlling the spread of COVID-19 and sustaining economies and people’s livelihoods.”

With further waves of COVID-19 infections expected in Africa, the authors call for continued monitoring of COVID-19 data, improvements to testing capacity, and renewed efforts to adhere to public health measures.

Writing in a linked Comment, Professor Yap Boum, Dr Lisa M Bebell, and Professor Anne-Cécile Zoung-Kanyi Bisseck (who were not involved in the study), from Médecins Sans Frontières, Harvard Medical School, and the Ministry of Public Health of Cameroon, echo the authors’ call for country-specific solutions to tackle the pandemic: “As African countries continue to face the COVID-19 pandemic, innovative and homegrown solutions, including local production of vaccine and rapid diagnostic tests, stronger involvement of community workers in disease surveillance, and telemedicine, have never been more important. Local solutions should ensure COVID-19 is not only a challenge that is met, but also an opportunity to strengthen health systems before the next pandemic.”

Dr Justin Maeda, Africa CDC-Ethiopia, said: “This first comprehensive analysis of the pandemic in Africa provides greater insights into the impacts of COVID-19 on the continent as a whole, and within its diverse regions and Member States. Better understanding of the challenges posed at national, regional, and continental levels are essential for informing ongoing efforts to tackle current outbreaks and future waves of infections.”

The Executive Director for Africa Science Media Centre (AfriSMC), Daniel Otunge noted that the Lancet study should be an eye-opener for African governments, especially those that have relaxed Covid-19 control measures against the advice of experts, to reintroduce tougher containment measures and expand information, education, and behavior change communication campaigns.

“I say this because already countries are experiencing the third wave of Covid-19 infections that are more deadly than the first and the second waves. The country’s hospital intensive care units (ICUs) are full to capacity and patients being delicately transported across the country in search of ICU beds. Unfortunately, a number of them die in the process,” he said.

“Therefore, the time to reintroduce the lockdowns and to expand educational activities is now if the continent is to have a chance of containing the spread of Covid-19 that experts say is driven by an even more deadly variant of the virus. The WHO, Africa-CDC and African governments working together with the international community should do everything possible to ensure universal access to Covid-19 vaccines in Africa to avoid an impending disaster of unimaginable proportions.”

One of the limitations of the study, the authors acknowledge, is that the analysis was concluded on 31st December 2020 and thus, not possible to assess the effects of new COVID-19 variants, including the South African variant B.1.351.

Also, the scarcity of case-specific data such as age, gender, occupation, or underlying conditions limited the authors’ ability to gain insights into any impacts of these variables, highlighting a need for improved data collection systems. Not all countries reported cases and testing data on a daily basis, and a variety of testing approaches were used, which may have affected the analysis.