Covid-19: Africa’s low death toll explained

Covid-19 death rates have been low and share of recoveries high in Africa despite earlier warnings from experts that the virus would overrun weak health systems in most countries and kill millions.

Fears of a catastrophe in Africa were further fuelled by the fact that the novel coronavirus infected people with weak immune systems are at higher risk of severe sickness and death. This prediction did not augur well for the continent with the highest number of people living with HIV, which compromises the immune system. 

But about six months after Africa recorded its first case in Egypt, on February 14, the continent has so far escaped the dire predictions.
The continent has the second-lowest number of coronavirus infected people dying from Covid-19 of six world’s regions, according to data from Johns Hopkins University. Oceania leads with a confirmed case-death rate of 1.6 per cent, followed by Africa and Asia (two percent each), South America (three per cent each), North America (four per cent) while Europe has the highest rate (six per cent).

With 17 per cent of the world population, Africa has about five per cent of confirmed cases and three per cent of deaths. With population considered, the continent also has the second-lowest rate of death of 19 deaths per one million people, which is about 34 times lower than North America’s, the region with the highest rate. 

Even South Africa, which is fifth globally and leads Africa in number and rate of infections and deaths, has maintained a low case-fatality rate of two per cent. Among the 10 worst-hit countries globally, the country, Russia that is a position above it and India, the third-worst affected, have the lowest case-death rate of two percent. 

But many experts are wary of the statistics from African countries observing that low testing rates and poor data reporting and death registration mask the extent of the disease in Africa.

Virus free

It is true that most African countries are not conducting mass testing without which it is not easy to determine the spread of the disease in communities.  Due to inadequate capacity, countries like Kenya have opted for testing symptomatic and high risk groups including essential workers such as health workers and truck drivers. Others like Tanzania have thrown in the towel and declared their countries “virus free”. 

Acting Health Director-General Dr Patrick Amoth says because of community spread of the virus targeted testing is the most effective option for a developing country like Kenya. 

When population is factored in, just six African countries feature in the top 100 out of 215 countries and self –governing territories in testing rate, indicate figures from Johns Hopkins University.  They include Mauritius with 161,384 tests per million people, the highest rate in Africa as at August 15, and South Africa. Mauritius is ranked 28th globally in rate of testing while South Africa is at position 80 with 56,418 tests per million people. Kenya lags behind at position 160 with 7,074 tests per million people. African countries do not compare well with top performers such as Luxembourg which has achieved the best testing rate in the world (1,072,615 per million people). 

But while the number of people tested is low, so is the test positivity rate. A positive rate of less than five per cent is an indicator that the epidemic is under control in a country or region, according to criteria published by the World Health Organisation (WHO) in May. The positivity rate helps our understanding of the spread of the virus. Rising positivity rate suggests that the virus is spreading faster than the growth seen in confirmed cases.  Kenya case positivity rate is seven per cent which is relatively low while South Africa’s is more than double the rate (17 per cent), which is high but not as extreme as parts of Northern and Latin America.

Findings of antibodies studies have raised more questions about the real situation in Africa.  A recent sero-surveillance of blood donors in Kenya, for instance, seems to give credence to the concerns that the virus is more widespread in many countries than what is reported. 

The Kenya Medical Research Institute (Kemri) study claims that one in 20 Kenyans age 15-64 (1.6 million) has the novel coronavirus antibodies. People who have been infected with the virus produce antibodies.  The number was way above the 2,093 Covid-19 cases and 71 deaths that had been confirmed midday into the study. 

The finding differed with the higher numbers of cases and deaths reported in parts of Europe, Asia and North America when seropositivity rate was similar.  For instance, at the end of the epidemic wave in Spain, seropositivity was the same as Kenya but the European country is the 10 worst-hit country with 358,843 cases and 28,617 deaths by August 15.  

So why is it that there are no increased acute health emergencies and unusual high numbers of deaths being observed in Africa? What explains the huge gap between antibody test findings and the confirmed infection and death numbers?

Senior science advisor to the director of Africa Centers of Disease Control and Prevention Dr Nicaise Ndembi, says the Kemri study cannot be compared to the ones done in Europe because the study populations and testing methods were different.  “The Spanish study randomly sampled the general population while the Kemri study tested residual blood donor samples,” says Dr Ndemi. The studies also used different tests and platforms that do not have the same sensitivity and accuracy. He recommends more standardised antibody studies to help fill out the picture.

But a recent South African Medical Research Council weekly excess deaths reports suggests that the country’s real death toll is much higher than what has been officially confirmed. The report showed that excess natural deaths rose by more than half from 6 May to 14 July compared to past years. Even though the excess deaths could be a result of both underreported Covid-19 deaths and other diseases as people shy away from seeking health services during the pandemic, experts say there are indications that coronavirus is the biggest factor in the unexplained deaths. 

Dr Ndembi says that as experts try to unravel the puzzle of the unexpected low death toll, the fact that Africa is now more prepared for public health crises because of Ebola and HIV pandemics experiences is being overlooked. For example, he says, many Africa countries are carrying out coronavirus tests on platforms built during the Ebola and HIV/Aids crises. “Because of the lessons learnt during the Ebola crisis, Africa countries together with Africa CDC and the World Health Organization are carrying out a coordinated response with the heads of state meeting regularly to strategise,” he says. 
Dr Ndembi adds that at the start of the pandemic the entire continent had only 30 laboratories that could test for the virus but due to the corporation, just Nigeria has that number.  Government- private sector partnerships have worked even as philanthropists within and without the continent have stepped up to complement government responses. “Half of the 30 laboratories in Nigeria are government-private sector partnerships,” he says.  One of the isolation centres in Kericho is at the Unilever Central Hospital, a private facility. “The centre has been set aside to cater for healthworkers who contract the virus. It has so far attended to 10 health services providers,” said Cabinet Secretary for Health Mutahi Kagwe during a visit to the county.

Younger people

Most of the people who have contracted the virus in Africa are young compared to other regions. Younger people are more likely to be asymptotic or suffer mild symptoms that are likely to be undetected. By the end of July, for instance, over 82 per cent of those who had been confirmed to have been infected by the virus in Kenya were aged below 50. Just one in 23 infected people experienced symptoms.
Patients older than 80 were at least 20 times more likely to die from Covid-19 than those in their 50s, and hundreds of times more likely to die than those below the age of 40, found a study of more than 17 million people in England that was published in the in the journal Nature.

In May, a World Health Organization prediction model forecasted a continuation of a slower rate of transmission in Africa compared to other regions and attributed it to social and environmental factors slowing the transmission, and a younger population that has benefitted from the control of communicable diseases such as HIV and tuberculosis to reduce possible vulnerabilities and the lower prevalence of chronic diseases such as cancer and diabetes.
In Eastern and Southern Africa new HIV infection reduced by nearly 40 percent in 2019 and the regions are closing in on the 90–90–90 testing and treatment targets (90 per cent of people living with HIV know their HIV status, of whom 90 per cent are on antiretroviral treatment and of whom 90 per cent are virally supressed), according to UNAIDs. 
Seven countries have reached those targets (Botswana, Eswatini, Namibia, Rwanda, Uganda, Zambia and Zimbabwe), and three others are very close to doing so (Kenya, Malawi and the United Republic of Tanzania). 
Dr Ndembi says early testing and contact tracing and lockdowns contributed to the slow spread, even if containment measures are not fully respected due to socioeconomic reasons including the reality that poverty levels are also high. Most workers earning below living wages in the informal sector with no safety nets that would enable them survive a lockdown without working.
So far, almost three-quarters of people infected with the coronavirus have recovered in Africa.

Ndembi warns that Africa is not out of the woods yet and what will happen as countries continue to reopen is unknown.  “The picture might change when schools reopen and the 25 countries who have not yet opened their airspace do so,” warns Ndembi.