African countries may suffer in the global rush for vaccines because they are unable to gather statistics that reveal the true extent of the spread of Covid among their populations, epidemiologists and other experts fear.
According to data from Johns Hopkins university, there have been 3.7m confirmed cases in Africa, and the landmark figure of 100,000 confirmed deaths is likely to be reached within days.
A series of studies has raised fears that the official figures are a significant underestimate, raising the possibility that Africa may not be seen as a priority for scarce global vaccine supplies despite the urgent need.
Many African countries are unable to afford mass testing and lack capacity to collect reliable data on cases and deaths, especially in remote areas. Stigma attached to the disease, a lack of information and victims’ inability to either reach or pay for health facilities may also reduce reporting.
The World Health Organization has said the “unique socio-ecological make-up in a number of African countries means a slower rate of transmission, and fewer severe cases as compared to the hardest hit countries”.
Mortality rates have been relatively low across Africa compared with other regions, though they are rising.
Dr Oliver Watson, an infectious disease expert at Imperial College London, said the shortcomings in data collection on the continent could undermine efforts to secure equitable access to vaccines.
“Some might argue the need for vaccines is much less urgent … so the vaccines will go to countries with stronger reporting systems and so further entrench inequity,” he said.
A study by scientists from ICL’s Covid-19 response team in Sudan found that only about 2% of Covid deaths had been reported in the capital, Khartoum, through most of last year. As a result, the team estimated that as many as 16,090 deaths may have been unaccounted for as of 20 November. Sudan has officially recorded fewer than 30,000 cases and 1,849 deaths.
According to UK Sudan’s Doctors’ Association, 40 doctors are thought to have died of Covid in the country between March and January. As of 6 February, 1,107 health staff had been tested for Covid with 76% returning a positive result.
Dr Ibrahim Fahal, the president of the UK-based Sudan Medical Care Foundation, said frontline medical staff faced acute shortages of PPE, limited safety measures and very large numbers of patients. “They are very exposed,” he said. “A way to get them vaccines has to be found and as soon as possible.”
A study by the Boston University School of Public Health in Zambia concluded that Africa’s relatively low numbers of Covid cases might simply be “a matter of lack of testing, with the coronavirus actually taking a terrible but invisible toll across the continent”.
The study, which is expected to be published in the British Medical Journal in the coming days, found that more than 15% of recently-deceased people arriving at the main morgue in the capital, Lusaka, over the summer tested positive for Covid. Despite most having had symptoms, few were tested before death.
“Our findings cast doubt on the assumption that Covid-19 somehow skipped Africa or has not impacted the continent as heavily,” said co-author Lawrence Mwananyanda. “This study shows that with proper diagnostics and testing, we can begin to identify the scale of Covid-19 in African countries such as Zambia.”
The most recent excess mortality figures in South Africa reveal 137,000 extra deaths since May last year, of which a high proportion can be attributed to Covid-19, experts say. The official Covid death toll stands at 47,382.
Only a handful of serological studies have been conducted in Africa compared with Europe, the Americas or South Asia, but these also point to a much wider spread than official figures suggest.
One in Kenya showed that by the end of July 2020, when the country had reported only 341 deaths and 20,000 cases, around one in 25 blood donors in several locations had been infected.
The low number of deaths was explained by demographics in Kenya, where less than 4% of the population is 65 or older, a factor which may also help explain the relatively low death rates across the continent.
Official figures do not include Tanzania, a country of nearly 60m, which has not reported official statistics since April, when it logged 509 cases. Its president, John Magufuli, has disparaged vaccines and said Christian faith will protect the country.
The US embassy in Dar es Saleem said in a statement on Thursday that it was aware of a “significant increase in the number of Covid-19 cases since January”.
Anecdotal evidence also suggests much higher numbers than reflected in official statistics in neighbouring Zimbabwe, which has officially recorded 35,000 cases and 1,364 cases.
Grave diggers and undertakers in Harare’s Warren Hills cemetery, however, describe an unprecedented number of deaths.
Ewing Ishemunyoro said he had been digging six graves a day since January, three times the previous average. “It is clear the authorities do not want people to know that there are more Covid burials, but it is happening and we see that every day,” he said.
Only a handful of African countries believe they will be able to immunise their frontline health workers over coming months, and the vaccination of general populations may not be completed for several years, leaving hundreds of millions of people vulnerable.
African health facilities have struggled to cope with a second wave of infections across much of the continent, fuelled by new variants of the virus. Two-thirds of the 21 countries the WHO surveyed reported inadequate critical care capacity and more reported a shortage of oxygen in recent months.
The WHO’s regional director for Africa, Dr Matshidiso Moeti, said last week: “The increasing deaths from Covid-19 we are seeing are tragic, but are also disturbing warning signs that health workers and health systems in Africa are dangerously overstretched.”
The WHO said it had repeatedly made clear that their statistics for the continent showed reported cases and that only sero-prevalence studies could reveal the actual burden.
“It is important that we do not allow pre-conceived biases about Africa to cloud our understanding of what is happening in the region.
“Transmission and mortality are lower than what we see in other hard-hit countries, but the fragility of health systems necessitates a strong response. We have no evidence to the contrary.”
Additional reporting by Nyasha Chingono in Harare