Lack of Covid-19 testing undermines Africa's 'success'

The relatively low number of coronavirus cases in Africa so far "have raised hopes that African countries may be spared the worst of the pandemic", in the words of the UN. But at the same time it urges caution.

There is a general consensus among those in charge of health policy on the continent that testing rates are woefully low, and this could be distorting our understanding of how far the virus has spread.

As countries move beyond the lockdown phase only testing and surveillance will allow governments to really know what is going on.

Of course, there are wide variations in testing policy across the more than 50 countries but cases could be going undetected, epidemiologists say.

The early apparent successes in combatting the spread of the virus were notable, and the number of cases has not risen as quickly as elsewhere.

Many countries acted swiftly where, to varying degrees, lockdowns, partial lockdowns, bans on large gatherings, curfews and border closures were introduced.

South Africa, Cameroon, Mauritania and parts of Nigeria launched massive community door-to-door campaigns to screen people and identify potential cases for testing.

Some island nations and countries with smaller populations on the continental mainland have kept the numbers low.

The Seychelles last reported a case in early April and the 11 confirmed coronavirus cases have all recovered. Namibia had not had a case for more than a month until two women who were in quarantine, after arriving from neighbouring South Africa, tested positive on 21 May.

In Mauritius two people who had been repatriated from India and placed in quarantine tested positive on Sunday - the first new cases for more than a month.

The South African authorities imposed a very strict lockdown which appeared, in its initial phase, to slow the spread of the virus. But President Cyril Ramaphosa, while announcing an easing of the lockdown, said the country should expect infection numbers to "rise even further and even faster".

"The coronavirus pandemic in South Africa is going to get much worse before it gets better," he added.

Nonetheless, South Africa may be in a better position than many other countries on the continent and it has is administered around 10 tests per 1,000 people. The country's testing capacity is also growing.

But continent wide there is a mixed picture.

The director of the Africa Centres for Disease Control and Prevention (Africa CDC), Dr John Nkengasong, said that in mid-May, only 1.3 million tests had been conducted across the continent.

That translates to a continental average of one test per 1,000 people. There are however huge discrepancies between countries.

Smaller and wealthier nations, like Mauritius, have some of the highest rates, even by global standards.

On 12 May, the government there said it had carried out more than 73,500 tests, which is the equivalent of 61 tests for every 1,000 people - a higher figure than either Germany or the UK at that point.

Less affluent countries and those experiencing ongoing internal conflict have tested the least.

According to figures compiled by the International Rescue Committee, Chad has done 0.1 tests per 1,000 people and Mali 0.17 per 1,000.

But Nigeria, the continent's most-populous country - and one of the richest, has carried out 0.23 tests per 1,000.

In response to this low figure, the Nigerian government says it is focused on clusters of outbreaks rather than mass testing of the population.

Chikwe Ihekweazu, director general for the Nigeria Centre for Disease Control, said in late April: "I would rather go a little bit slower and get it right than speed into a situation that we will end up regretting."

There are also big gaps in the data, such as in Tanzania, which stopped testing. President John Magufuli declared a thanksgiving period to celebrate a decline in the number of people with coronavirus - despite significant numbers of positive cases continuing to be detected along its borders with Kenya and Zambia.

Neighbours have announced border closures fearing an upsurge in imported cases.

In countries that are testing but at low rates, there are fears that cases could be going undetected.

However, Dr Nkengasong does not think a large number of cases are being missed as the continent is not seeing a spike in unexplained deaths in the community, in other words where the cause of death is not known.

"We're [also] not seeing hospitals being flooded with individuals that are Covid-19 infected and looking for hospitalisation," he added.

But it is not unusual for health systems to miss cases of disease. With inadequate infrastructure and relatively low number of medical staff, not everyone has access to a clinic or hospital. As a result cases are not being picked up.

A global shortage of diagnostic kits has affected the continent and limited countries' ability to ramp up testing.

"The West has commandeered most of the materials for the testing… and we're further back in the queue asking for them," Professor Robin Wood of the Desmond Tutu HIV Centre in South Africa told the BBC in April.

With the rest of the world consumed with their own internal battles against the disease, Africa has been left exposed.

External support - to which much of the continent has grown unsurprisingly accustomed especially with regard to its health programmes - has been reduced to a trickle.

The Jack Ma Foundation - created by the Chinese internet entrepreneur - has donated protective equipment and diagnostic kits, included tens of thousands of testing kits and swabs, to every African country.

But Professor Wood said that rather than relying on outside help, Africa's best way forward is to innovate.

There are efforts to develop alternatives in Africa. For example, the Institut Pasteur in Senegal has been working on a rapid test that is expected to cost about $1 (£0.82) each.

"Global solidarity is needed to address shortages of test kits across the region and ensure equitable access," Dr Matshidiso Moeti, the WHO's Africa head, told global leaders during the World Health Assembly.

The Africa CDC has been leading a continental effort to raise funds and procure supplies.

Under an initiative called the Partnership to Accelerate Covid-19 Testing (Pact) it is supporting countries with the aim of carrying out between 10 million and 15 million tests across the continent - covering about 1% of the population.

It is expected that with more testing, the number of cases will increase significantly - especially in countries that still have evidence of active transmission of infection.

Kenya projects that, with current curfew and testing measures in place, the number of new cases could peak around August or September.

Africa's proactive response to the arrival of Covid 19 on the continent may have slowed the spread of the pandemic, but governments' actions in the coming months are what will determine the trajectory of infection and how it will impact communities.