The Clash of the Titans: Where Epidemics Meet

As the COVID-19 pandemic sweeps across the globe causing severe disease and death in vulnerable populations in Asia, Europe and North America, we look to the African continent with concern. While highly resourced European health systems are battling the wave of COVID-19 cases, fragile health systems in Africa prepare for the deadly spread of the disease.

While highly resourced European health systems are battling the wave of COVID-19 cases, fragile health systems in Africa prepare for the deadly spread of the disease

COVID-19 disease severity thus far has been associated with older age and underlying conditions such as diabetes and chronic lung disease. In the European Union, about 20% of population is over 65; in China it is about 11%; whereas in Sub-Saharan Africa this figure is closer to 4%. But younger people in Africa may be at greater risk for severe disease from COVID-19 than what we have observed in Europe and North America.

In Sub-Saharan Africa, highly prevalent conditions such as tuberculosis (TB), HIV and malnutrition represent underlying conditions which are likely to make younger adults and children more vulnerable to severe COVID-19 disease. Data on COVID-19 infections in adults and children suffering from TB, HIV or malnutrition are limited.

Over ten million cases of tuberculosis occurred worldwide in 2019, of which one million were in children. In addition to being the number one killer in the world, tuberculosis can lead to long-lasting lung dysfunction, even after treatment. Thus, survivors of pulmonary TB may be at increased risk for COVID-19.

In Sub-Saharan Africa, highly prevalent conditions such as tuberculosis, HIV and malnutrition represent underlying conditions which are likely to make younger adults and children more vulnerable to severe COVID-19 disease

HIV, another major underlying condition, affects nearly 25% of the population of some southern African regions, causes severe immunosuppression and can lead to a high prevalence of lung impairment. Lifelong antiretroviral treatment for HIV does not cure the infection, but restores most of a person’s immune defenses. However, UNAIDS estimates that only 50-60% of the 25 million people living with HIV in sub-Saharan Africa receive treatment. Thus, millions of people living with HIV may be moderately or severely immunosuppressed, putting them at risk for COVID-19 disease. And finally, malnutrition associated with poor sanitation, food insecurity and childhood infectious diseases is present in close to one-third of children under age five in Sub-Saharan Africa and could increase the risk of severe COVID-19 disease in children.

The strategy of testing and isolation of cases of COVID-19, successfully implemented in some places such as South Korea, has been difficult to implement as fully in Europe and North America, and is unlikely to be implemented on a widespread basis in Africa. In addition, densely populated urban areas, multiple families in single-dwellings, overcrowded settlements and refugee camps with minimal infrastructure make social distancing and confinement nearly impossible. Additionally, as we have witnessed in Italy and Spain, many health workers have fallen ill and have needed to self-isolate. Such a situation in Africa would deplete the already limited number of doctors and nurses needed at the front lines.

But necessity is the mother of invention, and over the past two decades, African countries have had to innovate and restructure their health systems in response to deadly infectious diseases such as HIV, tuberculosis, Ebola and malaria. This has led to the decentralization of many health services in the form of task-shifting to community health workers as well as community-based service delivery models, mobile clinics, use of smartphone technology, mass drug administration and even door-to-door interventions. Extensive experience has shown that community health workers can serve as a bridge to sustainable health care. This is especially true in Sub-Saharan Africa, which according to World Bank data from 2015 had an average of 0,2 physicians per 1,000 inhabitants as compared to 3,6 per 1,000 in the European Union.

Extensive experience has shown that community health workers can serve as a bridge to sustainable health care

Out-of-clinic models of care across the continent could play a pivotal role in the fight against COVID-19. For example, if a drug such as of chloroquine, remdesivir or another antiviral were to be shown to be effective for prevention or control of COVID-19, its distribution could be piggybacked onto existing work streams for community distribution and/or mass drug administration. Such interventions could alleviate hospitals, keep crowds away from the clinics, and thus preserve the scarce hospital resources for the most severe cases. Approaches that have evolved in Sub-Saharan Africa to diagnose and care for people living with HIV and tuberculosis could contribute to saving thousands of lives during the COVID-19 pandemic.

China, the first country to grapple with the COVID-19 outbreak, did not have any information on how the SARS-CoV-2 would progress. The pandemic has since spread across Asia, Europe, Australia and North America. As it hits Africa, the precious experience and data gained from other countries must be used for predictions to aid in the organisation of a realistic response. An approach adjusted to the limited resources available and maximizing lessons learnt from HIV, tuberculosis, Ebola and malaria.

As it hits Africa, the precious experience and data gained from other countries must be used for predictions to aid in the organisation of a realistic response

Mass testing is not likely to be available and ventilators and other types of life support equipment are scarce in already strained African health systems. Thus, non-medical interventions will be key. This may mean protecting the vulnerable and leveraging the community programs that are already in place. Social distancing may not be widely feasible, but we can keep the vulnerable away from crowded health facilities and maintain access to antiretroviral medicines, tuberculosis treatment and child nutritional support throughout the COVID-19 crisis. Researchers are scrambling to develop and mass-produce rapid diagnostic tests and antiviral drugs as well as a vaccine. While they work to find medium- long-term solutions, we need to use what we know to save lives.