Hidden Risks in Africa’s Low COVID Cases, Fourth Wave?
Model insights into emerging scenarios with variants of concern
§ It has become a global urgency to calibrate COVID-19 containment policies in informed ways that can avoid long-term economic recession from over-protection or eventually explosive health risks due to over-relaxation and pandemic fatigue.
§ To avoid falling below or exceeding the optimal standards needed to strike a healthy balance between protecting health and promoting the economy, the calibration of country COVID-19 containment measures must be informed by transparent and reliable data as well as scientifically sound decision models.
§ Based on the reported cumulative cases, Europe has become the region with the lowest probability of developing severe cases of COVID-19 (0.01%) followed by North America (0.03%) and Oceania (0.04%). As of July 5, 2021, Africa was above the global average (0.04%), with a probability of 0.08%, only second South America (0.09%) but above Asia (0.05%) and Kenya (0.06%).
§ Examined against her share of global COVID-19 cases (3%), Africa has been unique. The metrics as of July 5, 2021 show that the continent’s share of global COVID-19 deaths (3.7%) and of global severe cases (serious or critical — 5.9%) have been disproportionately higher. Africa’s case fatality rate of 2.6% has also been the second highest in the world, after South America’s (3.1%).
§ In Africa, the country metrics on population-normalised testing rate have generally remained low. Cameroon, Egypt, and Ivory Coast have posted a more remarkable improvement on this metric between September 18, 2020 and July 15, 2021 at a time most African countries have stagnated on this measure, or even declined as has been the case in Mauritius.
§ The recent resurgence in COVID-19 cases in Kenya, which started on June 9, 2021 as the country was already experiencing her third wave, has persisted enough to justify the pronouncement of an emerging fourth wave in the second half of July.
As of July 16, 2021, the global tally of reported COVID-19 cases had exceeded 190 million with stabilised metrics reflected in a case fatality rate of 2.2% and recovery rate of 91%. Until recently, confirmed COVID-19 cases in Africa have painted the portrait of a continent largely spared the worst hit by the wily and wavy pandemic ravaging the globe. Not anymore! The entry of more contagious variants of concern named after the Greek alphabet is changing the story if the blow the Delta variant has dealt African countries is anything to go by. The emerging trend of a daily increase in confirmed cases in Mozambique, Zambia, Namibia, Senegal, Kenya, Rwanda, Uganda, among others, is already telling of a determinedly new wave across Africa of late. As this unfolds, some countries are ahead in the vaccination race with booster doses, a graphic illustration of vaccine inequity.
As of July 5, Africa has been posting a lower share of the global COVID-19 cases, about 3%, despite hosting 17% of the global population. Testing and tracing capacity constraints must be a key part of the explanation. As of July 16, the recent surge of cases in Africa has seen her cases top 6.1 million. The case fatality rate was 2.5% with a recovery rate of 87% by this date.
Turning COVID-19 tests and the resultant data into decisions is critical. Reliable data and models are the bedrock of sound decisions on containing COVID-19 as new variants emerge. Such decisions should help check the containment measures, to avoid falling below or exceeding the optimal standards needed to strike a healthy balance between protecting health and promoting the economy.
Testing Capacity and Disparities
As shown in the radar plot below for selected country representatives from September 18, 2020, to July 15, 2021, the pace of testing in Africa has been low and slow in progress, unlike the other continents. South Africa, Morocco, Mauritius, and Rwanda have been among the highest scorers in population-normalised average testing rates — measured in tests per million people per day. Cameroon, Egypt, and Ivory Coast have posted a more remarkable improvement on this metric over a period that has seen most African countries stagnating on this metric, or even declining as has been the case in Mauritius.
Outside Africa, the leading scores on this population-normalised testing metric have been recorded in the UK, the USA, Israel, Italy, France, Canada, among others. As shown in the radar plot, the UK, Italy, France, and Israel have “stretched the web” more remarkably over the last ten months — a sign of a significant increase in their daily tests.
Chaari and Golubnitschaja (2020) confirmed from their research in Tunisia that reliable “real-time” monitoring based on randomised laboratory tests is the optimal predictive strategy for evidence-based preventive measures. This approach should aid in calibrating policy decisions to avoid long-term economic recession from over-protection or eventually explosive health risks that can arise from over-relaxation of containment measures and pandemic fatigue.
Shares of Global Cases by Region and Probability of Severe Cases
Examined against her share of global COVID-19 cases (3%), Africa has been unique. The metrics as of July 5, 2021, show that show the continent’s share of global COVID-19 deaths (3.7%) and of global severe cases (serious or critical — 5.9%) have been disproportionately higher. Africa’s case fatality rate of 2.6% has also been the second-highest in the world, after South America’s (3.1%).
Based on the reported cumulative cases, Europe has become the region with the lowest probability of developing severe cases of COVID-19 (0.01%) followed by North America (0.03%) and Oceania (0.04%). As of July 5, 2021, Africa with a severity probability of 0.08%, was above the global average (0.04%), only second South America (0.09%) but above Asia (0.05%) and Kenya (0.06%).
As of July 16, 2021, the probability of developing severe cases in Africa had increased from 0.055% in mid-June to 0.071%. This was at a time the global equivalent over the same period had reduced from 0.050% to 0.042%. In Kenya, the same period saw the probability practically steady at 0.060% — 0.065%.
Mining the Full Story from the Low COVID-19 Cases in Africa
Among the continents, Africa has one of the highest case fatality rates. Relative to her share of the total reported global COVID-19 cases, Africa has a disproportionately high share of global COVID-19 deaths and severe COVID-19 cases. The African countries which in this modelling series had by April 2020 shown early signs of fast-rising curves have all moved up the battered league table in Africa to claim the top-twenty positions. The countries include South Africa, Egypt, Kenya, and Cameroon.
The key message is that Africa’s low reported COVID-19 cases do not communicate the full story without going deeper into the proportionate performance indicators and other normalised measures relative to other regions. The undersupply of vaccines to Africa tends to aggravate the African situation and retard the pace towards herd immunity. This is happening at a time some countries are already administering booster doses to their vulnerable citizens. The implication for African governments and citizens is not to relax containment measures. The emergence of variants of concern, the Delta variant being key, reaffirms this advice.
Kenya as Africa’s Exemplar of Ravaging Effects of Variants of Concern
The surge of new cases in Kenya from June 9, 2021, is evident in the simulation model below, initially following the simulated upper trajectory but eventually surpassing it. On a rather long streak by any measure, the daily positivity rates have stayed above 5% since June 9, and even shot beyond 13% on July 13. The upper trajectory had predicted that registering a mean of new daily cases exceeding 437 between June 16 and July 4, reaching more than 184,500 cases on July 4, 2021 would signal a significant surge towards a more viscous fourth wave in Kenya. This figure was surpassed earlier, on July 1, with 184,537 cases. The actual reported cases on July 8 of 187,977 was already 0.6% above the simulated upper trajectory of 186,866.
The simulated peak on the upper trajectory comes to 192,244 cases on August 8, 2021. Again, the trend of testing and reported cases in Kenya as depicted by the behaviour-over-time graphs (BOT) in this research series has established that this simulated peak of 192,244 cases should be surpassed three weeks earlier, on either July 17 or 18, 2021. The tests in Kenya have typically been lower over the weekends. In April 2020, a key finding in this series showed that the COVID-19 curves of the leading country cases in Africa were taking an average of 16 days to begin their fast-rising phases (Adero, 2021). This was long before the Delta variant appeared. Based on this finding, the country needs to prepare adequately for timely containment of more serious surges due to the more contagious Delta variant and the solid evidence that these model projections have been getting exceeded three weeks earlier.
In western Kenya, where the Delta variant was first confirmed in the country, the variant has ravaged the region and painted its map red. For example, in the city of Kisumu, where the cases of Delta were confirmed, the share of the national COVID-19 case tally rose from 2% in mid-April to 3.3% in mid-July, 2021. Over the same period, the case fatality rate in Kenya increased from 1.7% to 2.0%. From the recent reports by the Ministry of Health, the recovery rate seems to have suddenly jumped from 68% to 94%, leading to lower than 4% of active cases over the last several weeks. As of July 16, the cases had reached 191,712 but the population-normalised testing rate had only increased marginally in a month, from 74 to 75 tests/per million people/day.
Conclusion and Recommendation
The recent resurgence in COVID-19 cases in Kenya, which started on June 9, 2021, when the country was already experiencing her third wave, has grown to a level that justifies the pronouncement of a fourth wave picking up the pace in this second half of July.
Given the high public health and policy importance of reliable country COVID-19 statistics and the reality of supply chain constraints in testing materials, the implication for African countries is to innovate sampling and testing procedures that can enhance outcomes to match the WHO recommendation of minimum daily tests, for a more accurate picture of the spread of the novel coronavirus as more variants of concern arise.
The higher probabilities of developing severe COVID-19 cases and COVID-19 deaths in Africa relative to the continent’s share of global COVID-19 cases is a warning sign that calls for stricter compliance with, and enforcement of, adequate containment measures as a preventive strategy. Up to now, any declaration that the worst COVID-19 scenarios are behind us needs to be regarded more as a statement of hope and cautious optimism, rather than an established fact go by.
Predictive data-driven models are key to sound advice on the level of strictness necessary to avoid both extremes: over-protection that suppresses the economy or under-protection that exposes people to the ravaging effects of the emerging variants of concern.
Adero, N. (2021). Lessons from Modelling COVID-19 Scenarios in Kenya and Implications for Policy and Planning. Academia Letters, Article 1862. https://doi.org/10.20935/AL1862.
Chaari, L., & Golubnitschaja, O. (2020). Covid-19 pandemic by the “real-time” monitoring: the Tunisian case and lessons for global epidemics in the context of 3PM strategies. EPMA J. 25;11(2):1–6. doi: 10.1007/s13167–020–00207–0.
Republic of Kenya — Ministry of Health (2021). Daily COVID-19 updates. https://www.health.go.ke/.
A geospatial and systems modelling expert, lecturer, youth mentor and trained policy analyst, who applies system dynamics to model complex adaptive systems. NASHON J. ADERO FOLLOWS
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