Africa’s Perfect Storm

Africa now faces a perfect storm. Daily confirmed cases have increased by nearly 200 per cent in the past month. Daily new tests have increased by 14 per cent in the past week, yet the positivity rate remains high, with most countries recording a positivity rate significantly higher than the World Health Organisation recommended rate of 5 per cent.

Seventeen countries experienced an increase in mortality rates in the past fortnight, with 13 of those increasing by more than 20 per cent. And just 1 per cent of the continent’s population is fully vaccinated, compared to 11 per cent of people globally and more than 46 per cent of people in the US and the UK.

The speed and scale of the third wave of Covid-19 is unprecedented in Africa, and it risks overwhelming health systems across the continent, with extremely serious consequences for lives and livelihoods.

There is much that Africa’s leaders can do to prevent transmission and save lives, including prioritising mass testing with antigen rapid diagnostic tests to control viral spread. This will free up PCR tests to be used for genomic sequencing to identify emerging variants, the front line in Africa’s Covid-19 defence.

When it comes to vaccines, the challenge comprises three elements, all of which must be addressed if Africa is to benefit from the protection they provide.

There is now an absolutely urgent, vital necessity for the world to step up vaccine supply to Africa. We know all the reasons why vaccines promised have not been delivered. But the longer this unacceptable situation continues, not only Africa but the whole world is at risk.

The Delta variant is, unfortunately, a game-changer and the international community needs to respond by stepping up the pace of deliveries to Africa. Meanwhile, African governments should explore every avenue to secure supplies for themselves beyond the COVAX programme. The export of vaccines from any manufacturing sites (including fill-and-finish sites) on the continent to countries with surplus vaccine supplies agreed should be reconsidered.

Vaccine absorption is clearly an issue in some countries. Getting vaccines from ports into arms is a significant operational and logistical task, which governments and donors should address. Every vaccine wasted is a travesty, and governments need to do all they can to prepare for when vaccines do arrive.

Similarly, vaccine hesitancy, where it exists, threatens the success of vaccine rollout. Campaigns by Africa’s governments to inform their populations about vaccines must be accompanied by greater clarity and coordination from vaccine-rich countries, whose confusing messages about the risks from approved vaccines and a lack of concerted regulatory responses have fanned the flames of hesitancy worldwide. But let us be clear: data show that at least 80 per cent of African populations are not hesitant or resistant to the vaccines, so let us not use the minority hesitancy as an excuse for not addressing supply.

By addressing all three issues – with African governments, the West and the wider international community working in lockstep – the damage to Africa’s health systems can be minimised, and Africa can benefit from the protection that we know vaccines can provide.

Tony Blair

Executive Chairman

The third wave of Covid-19 currently surging across Africa is the continent’s most severe yet, driven by the highly contagious Delta variant.

According to the World Health Organisation (WHO), cases are currently doubling every three weeks, compared to every four weeks at the start of the second wave. At the same time, vaccination rates are stalling amid dwindling supply. After more than doubling in mid-June, vaccination rates fell in the past fortnight as the number of vaccines received decreased by 83 per cent. In total, just 1 per cent of Africa’s population is fully vaccinated, compared to 11 per cent of people globally and more than 46 per cent of people in the US and the UK.

Surging transmission coupled with low vaccination rates indicate that Africa is confronting a perfect storm of pandemic-related risks that threatens to collapse health systems. The consequences will be considerable and far-reaching if governments do not take immediate action.

The end of June marked the seventh consecutive week of case growth across Africa. In just the last week, daily confirmed cases have increased by 31 per cent on average and by nearly 200 per cent in the past month. Some countries have experienced even sharper month-on-month growth, with cases in Uganda, for example, increasing by as much as 2,000 per cent. At this rate, the third wave peak will soon surpass that of the second wave and is expected to continue climbing.

Of 27 countries experiencing growth over the past two weeks, 20 countries have seen an increase of more than 20 per cent, including Mozambique (172 per cent), Rwanda (138 per cent), Malawi (110 per cent), Nigeria (86 per cent), Ghana (51 per cent) and South Africa (38 per cent). Infections among health-care workers are on the rise in numerous countries, especially in Ethiopia, Namibia, Kenya and the Seychelles.

Mortality is also climbing. In the past week, deaths have increased by 23 per cent; they have increased by over 80 per cent in the past month. Seventeen countries experienced an increase in mortality rates in the past fortnight. In 13 of those countries, mortality rates increased by more than 20 per cent, including I Liberia (380 per cent), Rwanda (217 per cent), Kenya (202 per cent), Mozambique (186 per cent), Côte d’Ivoire (100 per cent), and Malawi (56 per cent).

Although 5.4 million cumulative cases and 141,000 cumulative deaths place Africa as the second-least-affected region globally (after Oceania), the continent’s comparatively more fragile health systems, including limited intensive-care resources and medical personnel, have caused Africa to have the highest mortality rate globally for critically ill Covid-19 patients. Compared to the global average of 31.5 per cent, in Africa 48.2 per cent of critically ill hospitalised patients died within 30 days of being admitted. This points to the elevated risk that increased transmission and resultant increased hospitalisations pose for the population.

Numerous countries are reporting that their hospitals are already over capacity. As cases continue to climb in Liberia, the minister of health confirmed in mid-June that public hospitals were full and forced to turn Covid-19 patients away. The government of Namibia is working to increase isolation bed capacity by setting up two new field hospitals and repurposing existing hospital space. Of the original 1,700 total public and private isolation beds countrywide, just 143 were intended for intensive-care units. Namibia is currently experiencing an average of 40 deaths per day, a national record since the pandemic began.

In South Africa, hospital admissions increased by about 60 per cent in the first weeks of June. Weekly admissions are nearly where they were at the peak of the first wave, yet the third wave is expected to be twice as high. While the country struggles to expand bed capacity, experts say even with more space, there are not enough medical staff to meet demand.

As hospitalisations escalated rapidly in Uganda, hospitals reported not having enough time to adequately prepare and stockpile supplies. In the first wave, it took almost four months to reach the current number of critically ill patients, but in the latest wave it took less than two weeks. According to the Ministry of Health, younger groups have been hit the hardest in this wave; 30- to 39-year-olds have been the worst affected and 20- to 29-year-olds account for the second-highest number of positive cases. The impact on younger populations is attributed to a likely reduction in adherence to public-health and social measures by that age group, as well as the Delta variant, which early studies suggest affects younger people more than the other variants of concern. In addition to hospital-capacity challenges, Uganda is experiencing a critical shortage of medical personnel and oxygen.

Adequate oxygen supply for medical procedures was a critical challenge for African health systems before the onset of the pandemic. With Covid-19 and the increased demand for oxygen, especially in this third wave, the dearth of supply is a growing crisis across the continent. Compared to the rest of the world, Africa has fewer industrial plants that create oxygen. For example, Sierra Leone has just two plants that service the entire country. Not only is oxygen scarce but so are the cylinders that hold it, obliging plants to ship empty cylinders back to be refilled, which is time consuming.

The WHO estimates that oxygen demand in Africa is now 50 per cent greater than it was for the first-wave peak. Mozambique, Rwanda, Sierra Leone, South Africa, Zimbabwe and Uganda are just some of the many countries that have seen demand soar. Zambia’s change in demand is among the most drastic. The country shifted from needing close to zero cubic metres of oxygen per day on 1 June to more than 120,000 per day by the end of the month. The intensified oxygen shortage is not only causing preventable deaths from Covid-19 but also likely having an impact on routine health services.

The Delta variant is largely accelerating this third wave. Though Alpha is currently the dominant variant in Africa, having been identified in 35 countries, Delta is spreading rapidly. The number of countries with the variant has more than doubled in the past month from eight to 17. Of the countries that have confirmed the presence of Delta, 70 per cent are reporting growth in daily cases and 58 per cent are reporting growth in daily deaths over the past two weeks.

With 40 to 60 per cent higher transmissibility than the other variants of SARS-CoV-2 (and possibly higher severity), Delta is the most dangerous variant of concern identified to date. A more transmissible virus spreads faster among the population, making it more difficult to control, increasing the number of infected individuals at any given time and escalating exposure risk to those most vulnerable. This leads to increased hospitalisations, health-system strain and, ultimately, mortality.

Given it is more transmissible, Delta is expected to overtake the other variants and become the dominant form of the virus within the next few months. This has already happened in Uganda, where Delta has been detected in 97 per cent of sequenced samples, and the Democratic Republic of the Congo, where Delta makes up 79 per cent of samples.

Low testing and surveillance and limited genomic-sequencing capacity on the continent affect the speed and scale of variant detection. Global health authorities advise sequencing at least 5 per cent of cases. In Africa, only 0.6 per cent of cases have been sequenced to date, 40 per cent of which come from a single country, South Africa. This means variant circulation is still significantly underreported on the continent. Notably, most countries around the world do not yet meet the 5 per cent target, signalling a global shortfall in variant detection.

Much like the first and second waves, this third wave of Covid-19 – where cases appear to be rising beyond rates previously observed – has forced African governments to impose new public-health measures on movement and gatherings. The measures range from international to national and local restrictions.

Local Restrictions

In the past few weeks, more stringent nationwide restrictions have been imposed, for example in Namibia and South Africa, as well as lighter temporary restrictions in Kenya and Zambia.

Namibia is locking down the whole country and banning interregional travel from 1 July. Similarly, South Africa tightened restrictions for 14 days, including prohibiting all gatherings, banning the sale of alcohol, enforcing a curfew from 9pm to 4am and the temporarily closure of schools.

Kenya is extending the night curfew by 60 days while pledging to ramp up vaccination against Covid-19 amid surges in western parts of the country. Zambia has announced the closure of nightclubs, casinos and other establishments where alcohol is served following continued flouting of Covid-19 preventive guidelines.

Zimbabwe, where restrictions have been in place in Covid hotspots, plans to make Covid-19 vaccination mandatory in selected public markets. However, no policy is in place yet, as only 4 per cent of the population has received full doses.

International Restrictions

Countries have also imposed restrictions on international travellers. Nigeria, for example, has banned travellers coming from some African countries due to concerns about the spread of Covid-19 from those countries – no one will be accepted from South Africa, Zambia, Rwanda, Namibia and Uganda. Abuja has also extended the travel ban for travellers from Turkey, Brazil and India for four weeks. These are promising examples of evidence-based public-health measures. Imposing such restrictions requires efficient testing to assess the national and regional risk.

Overall, Covid-19 testing is increasing in Africa. There has been a 14 per cent increase in daily new tests conducted in the past week. However, positivity rates remain high, with most countries recording a positivity rate significantly higher than the WHO recommended rate of 5 per cent. This can be attributed to the fact that most countries’ testing strategies are focused on testing symptomatic patients and key groups while public/mass testing is limited. These rates indicate that the actual number of Covid-19 cases may be much higher than reported.

While public-health measures are essential to fight the spread of the virus, vaccination remains a key long-term preventive solution. Vaccination efforts in Africa have been severely hindered by current challenges related to vaccine access and administration. With most countries relying on the COVAX AMC facility for their procurement, the suspension on exports from the Serum Institute of India (SII), the largest manufacturer of the AstraZeneca vaccine, has adversely affected Africa’s main vaccine source. It can be observed in Figure 3, below, that the amount of vaccines being imported into the continent is in decline, as is the number of vaccines being administered. Close to 76 per cent of supply received has been administered, leaving about 15 million doses of Covid-19 vaccines in stock. While there is some variation among countries, the underlying problem is clear: Africa is running out of vaccines.

The challenge Africa is facing is not only one of supply, but also of absorption. Although Africa makes up over 17 per cent of the global population, it has administered only 1.7 per cent of global jabs. So far only 2.9 per cent of the population has received one dose and 1 per cent of the population has received two doses and is fully vaccinated (~15 million people). The low absorption rate, the rate at which available vaccines are administered, is attributed to a number of challenges that countries are facing, including lack of capacity and infrastructure to administer vaccines as well as vaccine hesitancy among some of the population. After an increase in daily vaccination doses administered in early June, with 990,000 doses administered per day, Africa’s cumulative daily vaccination rate is now less than half of that – the lowest regional rate globally.

Figure 3

Number of vaccines received versus administered in Africa

Source: TBI analysis from various sources

The adverse impacts of low absorptive capacity were witnessed in April as countries were destroying or returning available vaccines because they were unable to distribute them before the expiry dates. Overall 20,000 vaccine doses have been destroyed in Malawi, 72,000 were returned to COVAX from South Sudan and 1.3 million were returned to COVAX from the Democratic Republic of the Congo. This shows the need to both build capacity for speedy vaccine rollout and increase efforts to curb vaccine hesitancy.

The speed and scale of the third wave of Covid-19 is unprecedented in Africa. In the absence of sufficient vaccine supply, governments need to continue to rely on non-pharmaceutical public-health and social measures to protect their populations. To avert a perfect storm, governments must take immediate and strategic action to contain the spread of Delta and alleviate strain on health systems.

Enhance risk-communication strategies. Communication with the public regarding the risks the virus poses, particularly the Delta variant, should be strengthened. The purpose of risk-communication strategies is to ensure those at risk – the public – can make informed decisions to mitigate the impact of the threat and take protective and preventive measures. Key principles of a communication strategy include: transparency and speed in messaging, acknowledging and communicating even in uncertainty, engaging and involving the community, trust and an integrated approach. Improving risk-communication will increase compliance with public-health and social measures, such as mask-wearing and social distancing, which may in turn preclude governments from having to implement more severe lockdown policies. It also plays a pivotal role in increasing vaccine uptake and reducing hesitancy.

Implement evidence-based, locally tailored and targeted public-health and social measures. Although restrictions on movement such as curfews and closures of spaces where people can gather, work or learn are effective in stemming transmission, they carry a high economic and social cost. For these reasons, such restrictions, when necessary, should be applied locally rather than nationally, utilising data to define targeted areas. Restrictive interventions must be implemented based on evidence and lessons learned over the past year in terms of what is most effective in local contexts.

Conduct testing on a mass scale. To do this, antigen rapid diagnostic tests (Ag-RDTs) should be deployed together with PCR testing. Ag-RDTs are accurate, affordable, fast and portable and can alleviate pressure on more resource-intensive PCR tests, which are also needed for genome sequencing to identify emerging variants and routine essential health services. Systematic implementation of Ag-RDTs will control viral spread and allow for safe economic activity. Testing must be reprioritised as an essential first line of defence against the virus.

Elevate (or re-elevate) the Covid-19 Taskforce to the presidential level. It is essential that the highest office has access to appropriate information regarding the status of the pandemic in the country. This information should be regular, up to date and data-driven, and the Taskforce should be flexible in its briefings based on the developing situation. Presidents need to take a hands-on role in driving their countries’ emergency responses. Signalling to the public that the top of government is focused on ending the pandemic will also support the country’s risk-communication strategy.

Increase supply of vaccines and effective rollout. The decreasing vaccine stocks show the imminent need for increased supply of vaccines. Governments need to go beyond the COVAX scheme and ramp up bilateral deals to increase vaccine supply, by leveraging diplomatic relationships with embassies as well as vaccine manufacturers. Similarly, the international community, both vaccine manufacturers and governments, need to increase support to African countries both in terms of vaccine supply and rollout by recognising that the battle against Covid-19 requires a global effort and that the increasing vaccine inequality we are witnessing today is a danger not only to Africa but for the global community. In addition to vaccine supply, governments need to ensure effective rollout by increased collaboration across government, with proactive communications strategies that are tailored to the context of the communities being served, and the acceleration of digital record-keeping and new technology infrastructure.

Increase effective contact tracing, isolation and monitoring. Parallel to mass testing, contact tracing is key to identifying local surges of cases, and isolating and monitoring them. Governments need to enforce contact-tracing schemes to maintain spread and use the data for enforcing localised and tailored public-health measures.

Increase local manufacturing of medical equipment. For the longer term, governments need to support the scaling up of local manufacturing capabilities of ventilators and other medical supplies, and ensure timely and affordable availability of these items, so that health systems do not collapse due to shortages of essential items amid high levels of import dependence.

These interventions should be put into effect as soon as possible. Controlling transmission – not only to protect health systems but also to prevent new, even more dangerous variants from emerging – should be a top priority for governments right now.

The perfect storm that Africa is facing is a wake-up call to African governments – and to the international community – to act now so the impact on Africa is minimised.

Lead Image: Getty Images

Charts created with Highcharts unless otherwise credited.