The Lancet: First continent-wide analysis confirms Africa’s second COVID-19 wave was more severe than its first
**Country-level data available in the article**
- Almost 3 million COVID-19 cases and more than 65,000 deaths were reported in Africa between 14th February and 31st December 2020.
- Although case numbers and deaths in Africa as a whole were low compared to many other parts of the world, country-level analysis reveals particularly high incidence rates in some nations (including Cabo Verde, South Africa, Libya, and Morocco), which are similar to other countries across the world.
- Despite daily infections being 30% higher during the rise of the continent’s second wave compared with the peak of the first wave, most countries implemented fewer public health measures
- With further waves of COVID-19 infections expected in Africa, the authors call for continued monitoring of COVID-19 data, improvements to testing capacity, and renewed efforts to adhere to public health measures.
Africa’s second wave of COVID-19 was more severe than the first, according to an observational study published in The Lancet journal. In the first-ever continent-wide analysis, authors found that daily infections were approximately 30% higher during the rise of Africa’s second wave as compared to the peak of the first wave.
The authors say African countries’ rapid, coordinated initial responses to the pandemic likely limited severity of the first wave. Subsequent loosening of public health measures and a drop in adherence to public health and social measures (PHSMs) after the first wave (probably due to adherence fatigue and economic necessity) are thought to have contributed to the greater impacts observed during the second wave.
The surge of cases during the second wave is also likely to have been partly driven by the emergence of COVID-19 variants, some of which are more transmissible than the original strain, though it was not possible to assess their affects in the analysis.
With African countries expected to face further COVID-19 infection waves, findings from the study highlight the need for ongoing monitoring and analysis of COVID-19 data to help nations balance controlling transmission with supporting economies and livelihoods.
Previous research suggests that COVID-19 spread more slowly across Africa than other parts of the world. However, to date, no in-depth assessment has been made of the nature of the pandemic across all of the continent’s regions and the 55 African Union (AU) Member States, which are home to more than 1.3 billion people.
Dr Justin Maeda, Africa Centres for Disease Control and Prevention (Africa CDC), Ethiopia, said: “This first comprehensive analysis of the pandemic in Africa provides greater insights into the impacts of COVID-19 on the continent as a whole, and within its diverse regions and Member States. Better understanding of the challenges posed at national, regional, and continental levels are essential for informing ongoing efforts to tackle current outbreaks and future waves of infections.” 
The authors analysed COVID-19 cases, deaths, recoveries, and tests carried out across all 55 AU Member States between 14th February and 31st December 2020, using data collected by the Africa CDC. Analysis of PHSMs (such as school closures and travel restrictions), in place during the same period, was conducted using publicly available data on the Partnership for Evidence-Based Response to COVID-19 dashboard and Oxford COVID-19 Government Response Tracker.
As of 31st December 2020, Africa had reported 2,763,421 COVID-19 cases – around 3% of the global total – and 65,602 deaths. A mean number of 18,273 new cases were reported each day during the first peak in mid-July 2020. However, by the end of December 2020, when approximately 65% of countries (36) had experienced, or were currently experiencing, a second wave of infections, the mean number of new daily cases had risen by 30% to 23,790.
Analysis of public health measures in place at the same time confirms that countries initially acted quickly to implement PHSMs, which appeared to slow progress of the pandemic in Africa. Among the 50 countries for which PHSM data were available, nearly 72% (36 countries), implemented their first strict control measures approximately 15 days before reporting their first COVID-19 case. By the 15th April 2020, almost all countries (96%, 48 countries), had at least five strict PHSMs in place.
However, when faced with a second wave of cases later in the year, many countries did not enforce PHSMs as strongly as they had done during the early stages of the pandemic. Of the 38 countries that had previously experienced, or were experiencing, a second wave, and recorded PHSMs, almost half (45%, 17 countries) had fewer – typically two less – in place during the second wave.
While the analysis indicates that Africa, as a whole, did not report as many COVID-19 cases and deaths as many other parts of the world, it reveals considerable variations across the continent. At the country-level, some nations were worse affected than others, with nine AU Member States accounting for most cases (83%, 2,283,613/2,763,421). In addition, while every nation except the Seychelles reported COVID-19 deaths, more than three quarters of these (78%, 50,974/65,602) occurred in five countries: South Africa, Egypt, Morocco, Tunisia, and Algeria. The highest incidences of cases per 100,000 population were recorded in Cabo Verde (1973.3), South Africa (1819.6), Libya (1526.4), Morocco (1200.0), and Tunisia (1191.2). Full country-level data is presented in Table 2.
Of the 53 countries that reported more than 100 COVID-19 cases, one third (34%, 18/53) had case fatality ratios (CFRs) – the proportion of deaths compared to total cases – higher than the global average of 2.2%.
Due to the high case and death rates in some countries, major differences were detected at the regional level, with the Southern region accounting for close to half of Africa’s cases (43%, 1,185,617/2,763,421) and deaths (46%, 30,453/65,602). The Northern region was also heavily affected, with more than one third of all cases (34%, 932,564/2,763,421) and deaths (37%, 24,323/65,602) occurring there. The Eastern region accounted for 12% of cases (325,472/2,763,421) and 9% of deaths (6,082/65,602), with 9% of cases (244,602/2,763,421) and 5% of deaths (3,261/65,602) in the Western region, and 3% of cases (75,166/2,763,421) and 2% of deaths (1,483/65,602) in the Central region.
By the end of March 2020, most countries (89%, 49/55) had the ability to run COVID-19 PCR tests, and, by July 2020, all were able to do so. As of 31st December 2020, more than 26 million COVID-19 tests had been carried out in the 55 AU Member States. However, the analysis indicates that many countries were unable to meet demand for tests (based on a WHO recommendation of ‘test per case’ ratios greater than 10) during peak outbreak periods. While more than two thirds of countries (70%, 28/40) that recorded the relevant data had enough testing capacity when the first wave began, only one quarter (26%, 14/53) could meet the demand for tests at the peak of the first wave. At the peak of the second wave, just one third of countries (36%, 4/11) could meet demand for tests.
Dr John Nkengasong, from the Africa Centres for Disease Control and Prevention (Africa CDC), Ethiopia, said: “Our findings indicate that several factors likely led to Africa’s larger second wave of COVID-19 cases. Alongside reports that adherence to public health measures – such as mask wearing and physical distancing – has decreased, they highlight the importance of continued monitoring and analysis, particularly in light of the emergence of new, more transmissible variants.
“These insights also reveal a need to improve testing capacity and reinvigorate public health campaigns, to re-emphasise the importance of abiding by measures that aim to strike a fine balance between controlling the spread of COVID-19 and sustaining economies and people’s livelihoods.” 
The authors acknowledge some limitations to their study. As the analysis concluded on 31st December 2020, it was not possible to assess the effects of new COVID-19 variants, including the South African variant B.1.351. A scarcity of case-specific data such as age, gender, occupation, or underlying conditions limited the authors’ ability to gain insights into any impacts of these variables, highlighting a need for improved data collection systems. Not all countries reported cases and testing data on a daily basis, and a variety of testing approaches were used, which may have affected the analysis.
Writing in a linked Comment, Professor Yap Boum, Dr Lisa M Bebell, and Professor Anne-Cécile Zoung-Kanyi Bisseck (who were not involved in the study), from Médecins Sans Frontières, Harvard Medical School, and the Ministry of Public Health of Cameroon, echo the authors’ call for country-specific solutions to tackle the pandemic: “As African countries continue to face the COVID-19 pandemic, innovative and homegrown solutions, including local production of vaccine and rapid diagnostic tests, stronger involvement of community workers in disease surveillance, and telemedicine, have never been more important. Local solutions should ensure COVID-19 is not only a challenge that is met, but also an opportunity to strengthen health systems before the next pandemic.”
NOTES TO EDITORS
This study received no designated funding. It was conducted by researchers from Africa Centres for Disease
Control and Prevention (Africa CDC), Ethiopia; US Centers for Disease Control and Prevention (US CDC), USA; Ministry of Health, Morocco; Nigeria Centre for Disease Control; National Institute for Communicable Diseases, South Africa; and Ethiopian Public Health Institute.
Country-specific data on COVID-19 cases, deaths, recoveries, and tests as of 31st December 2020 are in Table 1.
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