Africa: Four Pillars - An African Response Strategy for COVID-19

Solidarity flight from the hub in Addis Ababa to Brazzaville delivering supplies for the flight against COVID-19.
10 May 2020
guest column

Fear and anxiety in African nations is understandable as COVID-19 engulfs the world. While African leaders scramble to craft an appropriate response, with health care systems ill-prepared, there are four critical interventions every sub-Saharan African country should implement quickly to modify the final outcome of the pandemic in the region.

Because of confusing models predicting a catastrophe, countries all across Africa are introducing severe travel restrictions that could cripple fragile economies. So far, the lag time has given Africa time to realize the magnitude of the pandemic and prepare for the worse.

Considering the possible devastation, experts have been advocating severe measures to prevent the emergence of sustained community transmission. The high transmissibility and logarithmic spread of COVID-19 makes the natural trajectory highly predictable.

What is promising is, by implementing certain  interventions, it is possible to modify the trajectory of the pandemic.  Countries may have different trajectories as a result of the adopted measures and the degree to which they have implemented them. This was seen in Hong Kong, Taiwan, and Vietnam, three countries that have reported a low burden of COVID-19 cases.

Interventions can modify the trajectory of the pandemic.

Modeling the disease trajectory has been challenging. Models continue to be revised in real time as data is collected and the effects of interventions are quantified.

Unfortunately, Africa has limited capacity to produce a detailed model that takes into consideration the standard of living, rural and urban population distribution, and the age distribution of the population.  So far, most models being used are country based, with no stratification for differences in population densities. Consideration is not given to the nature of the epidemics, as outbreaks are propagated city by city, rather than country wide at one time.

All this has forced African countries to introduce measures from airport closures to social distancing, which likely have modified and slowed the trajectory of the epidemic. In some African countries, propagation of cases has been slow and non-exponential, which is likely explained by the intense societal interventions that have been implemented. To better quantify the impact of each implemented measure, Sub-Saharan Africa needs a model that is locally responsive that quantifies measures that could be implemented.

Improving hospital capacity to accommodate the potential surge of patient population is another priority countries must tackle. Unfortunately, the financial demands to upgrade hospitals and train additional health-care workers in such a short period of time is beyond the reach of most countries in sub-Saharan Africa.

For most African nations, community based interventions are the only viable solutions to mitigate COVID-19 epidemics.  Community health interventions, as implemented by health extension workers, have been utilized to address health issues throughout the continent. Deploying community-health extension workers who can reach deep into cities, and rural communities will allow nations to implement key public health interventions – including the strategies of contact tracing, isolation, quarantine, and mass screening.

Against this background, four critical interventions are recommended to quickly modify the final outcomes in the region.

International Travel Restrictions

African countries must heavily restrict international travel. Most countries have a single international point of entry for air travel. Unfortunately, many have porous land crossings. Restricting flights, screening arriving travelers at the airport, and quarantining all entrants, including those crossing international land borders, for the incubation period of two weeks will decrease the initial case load that could fuel the epidemics. Decreasing the initial number of infected cases arriving in each country will directly impact the transmission of COVID-19 to close contacts, significantly reducing the final number of cases a country will see.

COVID-19 Testing: Countries must test widely

This has been the weakest link in the four-pillared strategy that sub-Saharan African countries should follow. Expensive testing equipment and the scarcity of testing kits has been a challenge for poor African nations, which have been forced to compete for supplies in the free market with Europe and the United States. The World Health Organization, International Monetary Fund, World Bank and bilateral donors must quickly enable scaled-up testing capacity in Africa to fully reveal the magnitude of the problem in each nation. Only with increasing testing will all other interventions be successfully implemented. Epidemic modeling projections require good baseline data to forecast reliable estimates of morbidity and mortality from COVID-19.

Contact Tracing and Isolation (CTI)

CTI must be scaled up rapidly, anticipating the need with short notice. Health extension workers should be trained and ready to respond in a moment's notice both in cities and rural communities. Countries should aim for at least 30 contact tracers for every 100,000 people. By isolating potential cases and arresting forward transmission of disease, CTI will dampen the trajectory of the epidemic curve in a measurable way.

Face Masks

The final piece of this four-pillar strategy is universal face masking. COVID-19 is transmitted by droplets that are spread by coughing, sneezing, talking, or singing. Though researchers are still debating the magnitude of the impact, one thing is clear: any type of cover is better than leaving the mouth and nose unprotected. Face masks could block droplets and aerosols containing COVID-19 from reaching susceptible uninfected individuals, thus preventing or reducing wider dissemination of the virus.

Simple cloth masks that are being advocated for the public have not been well-studied, leading to concern and hesitancy from decision makers to implement their widespread use. But for African countries, with limited resources and few measures to contain the disease, this is an intervention that has to be taken very seriously. Leaders should fully endorse the wearing of cloth face masks covering the nose and mouth while in public. In countries that have introduced universal face masking as part of their strategy, it has played a critical role complementing social distancing.

African nations should adopt these four measures as pillars of their COVID-19 intervention strategy while continuing to promote hand washing and social distancing practices. Non-essential travels and large gatherings should remain restricted as part of the strategy.

Prepare for a worst case. Work towards the best case.

If all these measures are implemented, then severe country wide lockdowns that curtail all essential actives may not be a rational approach, unless a country documents a sustained community transmission. Considering the economic fallout from a prolonged lockdown, sub-Saharan nations who have limited resources to weather such draconian measures can mitigate the economic impact of the pandemic by relying on the four-pillar strategy. Hand in hand, countries should design a strategy and line up the necessary resources to lockdown cities or neighborhoods in a moment's notice, when sustained transmission is detected. Uniform, country-wide measures that do not take the actual local trajectory of the epidemic into account may prove less effective and economically devastating.

Countries that have locked down their cities should start to widen the circle of "essential activities" and return some normalcy to daily life until definitive, sustained community transmission is documented in the country. At the same time, they should prepare citizens for the possibility of future lockdowns that may need to be implemented with short notice. Wuhan, China closed its borders after evidence of sustained transmission with cases approaching 500.

It is difficult to predict how the pandemic will unfold on the African continent. So far, most African countries seem to have averted sustained community transmission. By implementing the four-pillar strategy described above, African nations have the power to move the trajectory in their favor, although that is not guaranteed. Without such interventions, it takes just a few cases for a devastating epidemic to cascade in any country.

Let us be cautious, get ready for what could be the worst scenario, but hope for the best!

Dawd Siraj is a professor of Medicine at the University of Wisconsin-Madison's Division of Infectious Diseases. He is a physician with advanced degrees in public health and tropical medicine and a Fellow of the Infectious Diseases Society of America. He is an advisor to the Ethiopian Health Minister on COVID-19 and a member of the Ethiopian Diaspora High-Level Advisory Council on COVID-19.

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