Emma Ross
Good morning, and thank you for joining us for this week’s Chatham House COVID-19 briefing with Chatham House Distinguished Fellow, David Heymann, who, as many of you know, is a renowned expert on outbreak control, who spearheaded the global response to the SARS outbreak in 2003. He now Chairs the Strategic and Technical Advisory Group on Infectious Hazards, which is advising the WHO Emergencies Department on the response to this pandemic. The theme this week is on experiences and responses in Africa. So, today we have with us Dr John Nkengasong, an eminent Virologist with 30 years in public health under his belt, who’s currently the Director of the Africa Center for Disease Control and Prevention, which is at the heart of the response across Africa. So, welcome, John. John, I was hoping we could start with an overview from you. Could you start us off by sharing your assessment of the COVID-19 situation in Africa?
Dr John Nkengasong
Yes, thank you. Let me, first of all, ask my team is projecting my screen, and thank you for the opportunity to share this conversation with you, and greetings from Addis Ababa, from the Africa Centers for Disease Control and Prevention, at the heart of the African Union, and I’d also like to thank David for reaching out to inviting us to be part of this very exciting conversation, and I hope it will be. Let me say that, as my slides are projected, there are three key messages that I wanted to leave with you, and that is starting with the end in mind. One is that the pandemic in Africa has been a delayed pandemic. Second message is that it is expanding, and thirdly, is that it required a strong co-ordination within the continent and a strong expression of solidarity across the world to be – for Africa, to enable Africa to cope with this. So, I have a few slides just to use that to at least substantiate the three elements that I just mentioned.
What you see in front of you here, and I would like to start with that, because it shows a military aircraft behind, with respondents from the Democratic Republic of Congo, that are heading – and that military craft is donated by the government of Cameroon to Africa CDC to go and lift up responders from the Democratic Republic of Congo and deposit them in Mali, Burkina Faso and Niger, and Cameroon. So, these are really – and the colleagues you see in green there are from DRC, they have been fighting Ebola with us for the past close to three years, and because of the Ebola outbreak in North Kivu was coming down and coming to an end, we – the expertise was needed in other countries then.
Unfortunately, as you are all aware, there’s now a new outbreak in Équateur in Mbdanka, so that – I use that to show the extraordinary co-ordination that is going on within the continent, and the only reason that we will be able to use a military aircraft to transport people across multiple countries is because the Peace and Security Council of the AU is wholly behind the efforts of the Africa CDC. They recognise this as a serious economic threat, a serious health threat, and a serious security threat for the continent, and then to be able to unlock the airspaces across multiple countries for this to happen, was an extraordinary event or project. So, I’d like to – I wanted to start with that to emphasise the importance of co-ordination that the continent is championing.
Next slide. Just to start with, I mean, we know this, and this that we – over six million people infected globally with about 370,000 deaths. Next slide. Then, if we look inside the continent carefully, as we speak today, the continent of Africa has reported 157,000 cases of COVID-19 with about 4,500 deaths, and 67,000 have recovered. The graph shows here the – by colour, the different regions, and by how much increase that we see per week, and, for example, if we look at the block arrows there, they indicate the number of increases, and over last week from West Africa, then Southern Africa, North and to Central Africa.
Next slide. So, this slide maybe shows you a little bit more content of what I just provided and is really emphasised – and the take home point is that the new cases are increasing quickly, over the days and weeks. We are seeing, next slide, an increase of about 3,000 to 4,000 new cases a day. One of the greatest challenge we see on the continent is testing. As a continent, as of yesterday, we have conducted about 2.4 million tests. That comes down to about 1,652 tests per million population, with a positivity rate of 6.4%. So, there are two messages here, that our testing rates, if you look at it over the last couple of months, is – well, is low, but it’s increasing, as you can see in the curve there, so all is not that dark. But we have a long way to go to get to at least 1% of testing, that is a population of 1.2 billion people, if we have to test 1% of the population, we really need to be testing about 12 million – conducting 12 million tests on the continent.
Next slide. So, this slide shows you a snapshot of some of the countries that are really driving this and the pandemic on the continent, so it’s not a homogenous pandemic, it’s very heterogenous. The top five countries that are driving that are shown on this slide are South Africa with 35,000 cases, followed by Egypt with 27,000 cases, Nigeria 10,000, Algeria 9,600, and Ghana 8,600.
Next slide. I would like to make a point that our pandemic is very heterogenous, even within each region, so I would like to just very quickly go through five slides. Slide you’re seeing here is the Central Africa region, and has about ten countries, and you can see there, there are three countries that are really driving this – the pandemic in Central Africa, that is Cameroon, DRC and Gabon. At the bottom part of that you see a cluster of countries, that they are – is rising, but I can say that it’s really not taking off significantly, and I will come back to that in a while, but the three countries out of ten driving that are those indicated there.
Next slide. Then you look at East Africa and top in East Africa is Sudan, followed by Djibouti and Somalia, and Kenya is catching up, just below the Somalia red line there. Then you have, again, like in Central Africa, a cluster of countries right down, which are just seen as slow progression, but also – but steadily, slowly and sluggishly increasing. Next slide. Then in North Africa, of course Egypt is really still seeing a very rapid increase in the rate of new infections, followed by Algeria and Morocco. The rest of the countries at the bottom part of the curve shows you a cluster of countries that are seeing rather a more stable progression of that – of COVID-19.
Next slide. In Southern Africa, it’s a very unusual epidemiologic situation we are seeing. South Africa is right up there with, as I said, more than 30,000 cases and the rest of the countries are really down on the lower part of the curve there. Next slide. And, lastly, in West Africa, you see Nigeria and Ghana, and very distinct, and then, in the middle of the curve, you see Guinea, Cote d’Ivoire and Senegal, and then a set of countries are right below there, and the West Africa is a region of about 15 countries, and you see the rest of the countries clustering below there.
Next slide. And this slide just shows you the progression by region, and each colour represents a specific region. There you can see that the West Africa region is really raising up, and followed by the Southern Africa and – which is again biased here because it’s essentially driven by the numbers in South Africa, and the Central Africa region in green is at the bottom, in terms of the progression. Next slide.
And next slide, I’ll skip this one. And then there – just to – as I move to my conclusion, the continental strategy. Very early on, on February 22nd, under the leadership of the Chairperson of the African Union, Excellence Moussa Faki, convened a meeting of all Ministers of Health and we agreed and developed a joint continental strategy that had three pillars. One is to prevent transmission, the second is to prevent deaths, and the third pillar is to prevent social and economic harm. And that has been driving our response strategy, which is really underpinned by ability to cope with, co-ordinate, collaborate and communicate, through a taskforce that functions and comes together as a continent every Tuesday at 4:00pm East African Time to co-ordinate our strategy from a clinical standpoint and keep adjusting it. So, it’s called the AFTCOR, the African Coronavirus Taskforce, there at the bottom of this slide.
Next slide. And again, because of the testing number, we again compare here, this slide just shows you the top panel in orange and is the testing per million, and looking at Iceland, Italy, United States, Singapore, the UK and South Korea, and then you compare that – underneath that are countries in Southern Africa, and you see South Africa is around 12,000 tests per million, and the rest of the countries, we can see where they are really still struggling with that, with an average continental per testing and million number of about 1,600.
Next slide. So, because of this, we have launched an initiative called Partnership to Accelerate COVID Testing in Africa, which is initiated and launched by the African Union to really help us both respond, but also help us ease the lockdown process. The Partnership to Accelerate COVID Testing, abbreviated PACT, has four goals. One, to increase our testing to over 20 million in the next 100 days, second is to deploy one million community health workers to support the tracing component of that, and then to train over 100,000 healthcare workers to support the treatment component, and lastly, to launch a continental platform that will help us in the procurement of laboratories and medical supplies, which are so critical for us to be – to mount an effective response, as part of the continental strategy.
Next slide. So, I think that is the – I mean, the end. I wanted to end on that because actually, tomorrow we shall be rolling this strategy out at the AU and by the Chairperson of the African Union Commission, and we’re looking for extended partnership to achieve those goals as stated there. Thank you.
Emma Ross
Thank you, John, there were some great slides there, brilliant information. David, I’m wanting to know what your reflections were on what John’s just recounted.
Professor David Heymann CBE
Well, thanks, Emma, and thanks, John, for a very clear presentation, and I think number one that comes to my mind is the way that the Africa CDC has taken charge, and is not only providing technical support to countries, and I know they’ve done that through training on testing and provision of testing kits, but also, just on having the excess manpower that countries need, coming from within Africa. Because it’s only people who can really understand the context in which they’re working, who can be effective in responding to any outbreak, whether it’s Ebola or whether it’s this, so I think the Africa CDC has really accomplished unifying African public health in a way that many parts of Europe and other parts of the world have not done so well. So, I think it’s really important that the Africa CDC be supported, along with the regional office and WHO, which provides the standards and the norms that are followed by the Africa CDC. So, that’s one reflection, that Africa is really taking charge of this itself.
The second is that there have been many people from the North, from other countries, who are saying why Africa isn’t having outbreaks, this and that, when really, we understand clearly what’s going on now in Africa. We understand that there is a limit in the testing that can be done, and that certainly reflects on how many cases are being reported, but more than that, we also can see that there is actually an effort to understand this outbreak, and we know that people are dying. I think what’s encouraging to date is that there are clusters of deaths being reported from African countries, as there have been for many European and other countries, which suggests that, as John said, Africa is still early in the epidemic. It’s still early in the epidemic curve because it didn’t arrive there as rapidly as it arrived in other countries.
It’s also very important that, and I know John has been working with this, making sure that the Chinese collaborations and the North American and European collaborations are collaborations, which aren’t bringing in the disease from those countries, but that are working in conjunction with the collaboration mechanisms in Africa. So, I would just say that the reason we know now what’s going on in Africa is because of the great effort and the great co-ordination being done in Africa by the Africa CDC, and I would just say it’s really a pleasure for me, having worked in Africa 30 or 40 years ago, to see how Africa’s really taking charge of this on its own. So, Emma, back to you, and, again, thanks to John for having come and met with us today.
Emma Ross
Thank you, David. John, I did have a follow-up question on the graphs. The curves that are diverging and showing a variety that’s based on cases reported, I just wondered the relativity between the countries, to what extent is that down to the differences in the testing capacity, or at least case finding, rather than real differences? Is there a big variety in the case finding capacity between those countries that may be showing up in the way those lines are showing up on the graph?
Dr John Nkengasong
Very good question, and that’s why I said, in my presentation, that I wanted to draw your attention to that and then that would at least lead to this kind of a reflection or questions. I think there are two things that – and two ways of looking at that. First, is that countries that you see them deviating upward are those that are doing more testing, and as I’ve always maintained, if you test, you’ll find. And then secondly, is that countries that are not – that are doing – the other countries that are on the bottom part of each of these slide are those that are doing less testing there. I think we don’t have evidence for that, I mean, we actually, of course, know that South Africa is doing a lot of testing. We also know that countries like Botswana, Namibia, Zimbabwe, are doing a lot of testing, and, I mean, as well.
So, I think it’s a mixture of that. I think it’s – it could be a combination of that countries are testing more now. Nigeria, for example, you saw that they’re testing per million, okay, their number of testing is increasing, but is not – it’s nowhere near to where it should be for a country of about 200 million. So, the – my short answer to that would be that it’s a combination of two things, either we are seeing testing playing a role, or that the – we are just see some of these countries doing the best at testing, isolating and doing the contact tracing there. So that, again, by doing this kind of analysis, it begins to allow you ask the next set of questions, as to what are they doing that is keeping their curves a little bit slow – evolving slowly versus those that are very prominent there.
Emma Ross
Yes. One thing on – one more thing on that, if it is down to differences in testing, obviously, the more you test, the more cases you find, the worse your epidemic looks relative to others who aren’t. Are the countries okay, comfortable, with being shown to have high numbers or – relative to others? Is there any sense or any reticence to show high numbers? Because I would imagine it’s something to be applauded and supported that they test, rather than look better by not having as many reported cases.
Dr John Nkengasong
So, with rare exception, I can say that we’re – the continent as a whole is reporting and reporting accurately, as best as – again, with rare exceptions. You can imagine that your knowledge of Africa is as good as mine, that we are dealing with 55 member states and the behaviours, at times, who tend to differ. But again, overall, their behaviour in patterns of reporting of the cases have been characterised and that’s a very good response. We still, of course, have a few countries that we have challenge with, but I would not think that those countries, even if you were one or two countries, or two or three countries, that that will change the overall pattern here of the behaviour of reporting. So, this has been a good co-operation, which all the countries signed on, they signed on the 22nd of February that we’ll co-operate, we’ll collaborate, we’ll co-ordinate and we’ll communicate.
Emma Ross
Thank you. On the delayed epidemic, high numbers of deaths were expected in Africa because of fragile health systems and inadequate access to preventive measures, etc., but the continent appears to have so far been relatively spared the scale of the outbreak that we’ve seen in other places, if you go by the number of – obviously, we’ve discussed the testing situation, but surely that can’t explain everything. Do you have any thoughts as to why that is? There seem to be many hypotheses floating around, but what’s your view as to what’s – what might be going on there?
Dr John Nkengasong
So – and again, I’m happy you share my views because there is no evidence that – or scientific evidence yet to back any of the things that I will say, and it can only by a hypotheses that would definitely lend themselves to good studies that would analyse this. I think we are early on. We’re – this is, what, four or five months into the pandemic in Africa, and as we used to say in HIV, you have to know your epidemic to respond appropriately. In this case, we have to know our pandemic on the continent, and we will be doing studies across – and of course, as a network of countries, to understand some of the reasons is, but a couple of thoughts.
I mean, one is that – and a couple of views here, and one is that, because of the young population we have, that might be playing a role, a favourably role for – that works in our favour for mortality. I was on a seminar with a Kenyan, about two weeks ago, and I was – it was interesting to hear the officials there stated very strongly that they have so many young people or people that are running around with – are COVID infected, but they are not sick. They are not – and so – and they said, and quote, “Large number of our people are running around, and they are not sick. They are positive, but they are” – so I think that could be one hypothesis to investigate, I think, but again, good studies would need to be done to really understand this and be – and to make statements that are backed by evidence.
Second hypothesis or view is that we may not be seeing recording all the deaths that are happening in the community, that is all possible. But if that was the case, I think mortality in – of course, surveillance in Africa is not as strong, but deaths are taken seriously on the continent. You will hear if there were a large number of deaths occurring, like what we understand has been going on in some parts of Nigeria, you hear that, okay, I’m in Ethiopia and I’ve not – and with the media or social media or others based on – event-based surveillance is not telling us that large number of people are dying in the community and that we are not aware of, and that is true across Africa. And so, I think those are the only two possibilities that I can think of, but really good data, and good studies, that will allow us to substantiate this in a more definitive manner.
Emma Ross
Thank you. David, do you have a favourite theory on this?
Professor David Heymann CBE
Well, no, but I think John has expressed two of the major ones is the age of the population, and also, I think the median age, John, is 19 years on the African continent, if I’m not mistaken, which is quite young. And I think the second thing is that we’re just – they’re just not able to identify clusters of death, which has been the indicator, in many countries, and it’s what derailed many of the good epidemiological approaches in countries in Europe to go immediately to a mitigation strategy and abandon this test, trace and treat strategy, which Africa is putting in place. And so, I think that we can see that Africa is observing what’s going on, is learning from Asia and from countries in Europe like Germany, which continued contact tracing and testing throughout the efforts to decrease the burden on hospitals, and it’s been effective in those countries that continued it. So, I think Africa is showing that it has seen, and, John, you might correct if I’m wrong, but did you see that this disease is not like influenza, this disease can be stopped and outbreaks – discrete outbreaks can be contained, if you do the proper contact tracing and isolation procedures, and you can interrupt a whole new series of chains or transmission, which might occur. But, again, John, you can correct that if you feel differently on that. Over.
Dr John Nkengasong
No, David, and I refute strongly about that, and that’s why we put up this strategy and which we really want to applaud the leadership of the continent, not just the technical leader, the political leadership of the continent has been very, very strong, under President Ramaphosa. The President of South Africa has been leading, in his capacity as the President of the African Union, has actually moved this strategy to the Bureau of the Head of States and they endorsed it. So, this has been endorsed at the highest level of the continent, based on the advice that the task force has given them. I think this is unprecedented, that the Head of States that have had the chance to brief – briefing them about four times, have endorsed this strategy. Is – we call it the winning strategy because we don’t have the vaccine for this, I think we will – if we are lucky, we’ll have the vaccine after one year or so, we don’t have treatment, so we are really left with the ability to test, expand our testing, trace, isolate, do the basic public health functions that – I mean, we all know called a standard leather – shoe-leather epidemiology, that is our winning formula. And that’s why we are calling on one million community health workers to really be deployed across the continent, and we, as Africa CDC, we’re start – and not start, are beginning to increase that as much as possible, and as we launch or roll out this strategy tomorrow, it will truly be – and we hope can be a gamechanger, so that when they test they can actually trace and isolate and do the work is required.
Emma Ross
And I wanted to ask you about previous efforts to build – strengthen public health capacity and health emergency preparedness in Africa. This has been pledged and committed to several times, and most recently after the West Africa Ebola epidemic a few years ago, all the review panels and the commitments to strengthen capacities in Africa. How much of that was actually done and did those efforts help better equip the response to this pandemic? Are you seeing any of that stuff coming through and playing out in your ability to tackle the pandemic this time?
Dr John Nkengasong
So, the answer to that, in my view, is yes and no. The yes part is that if you look at, excuse me, Liberia, Sierra Leone and Guinea, after the Ebola outbreak, we had the strength in the national public health institutes and they know how to do, in community engagement, because all of what we just discussed earlier will – the battle for COVID in Africa will be won at the community level. I mean, period, I think we need that co-operation, we need that collaboration with the community, and those countries in West Africa there with Ebola, really understand how to engage with the community, and I think we are seeing that in Liberia, Sierra Leone and Guinea.
You’re also seeing that in DRC ‘cause DRC has been battling Ebola. I mean, as we speak, you’re all aware, we have two outbreaks going on there, and that community engagement approach has – would yield a lot of benefits there. So, I think that much Africa has been – can use that expertise and also the expertise in – and their experiences in battling HIV. The way South Africa could – and the reason they were able to move very quickly, and there’s been a large number of people and employed in the community, I think they currently have about 28,000 to 29,000 community workers supporting their efforts, is their HIV experience, they have vast HIV experience there. So, it’s something that the continent has been primed and can use.
The no part of that is that we are still really lagging behind, with respect to the number of the public health workforce that is required, and we did Ebola in West Africa in 2014. It was – everybody knew that the number one gap that we have on the continent is the number of phone line Epidemiologists or the Epidemiologists, as the number states, I mean, we are a continent of 1.2 billion, we need about 6,000 Epidemiologists. Let me just restrict that, not even looking at the entire spectrum of healthcare workers like the lab, the nurses, and all – just Epidemiologists, 6,000 are needed. We currently – the numbers that I’m aware of is that we are around 1,500.
Okay, but I’ve not seen a big move that happens since the Ebola outbreak in West Africa, that says let’s train a large number of frontline Epidemiologists in the way that you train an army when you are reconstructing Afghanistan or Iraq. I mean, we just didn’t go to Iraq and Afghanistan and started training ten cohorts of ten, there were – we went in there massively and trained a large army. That’s what we should be doing in this health security space, where we really say this is serious and this is devastating.
I keep telling the AU that this virus is dangerous, dangerous, vicious, straight for the continent. It took us 40 years for HIV to infect 75 million people. It’s taken us five months for the world to be – for this virus to infect close to six million people, five months. So, I mean, if it spreads this way, then I think we really – we need an army of people on the continent to – of probably health work, but that is the gap right there, which I don’t think that previous pandemics or outbreaks have helped us to bridge that gap at all.
Emma Ross
David…
Professor David Heymann CBE
Emma, I…
Emma Ross
…is there anything you wanted to add?
Professor David Heymann CBE
Yeah. Yeah, I might just add a little bit. You know, there’s a Global Preparedness Monitoring Board, which has been setup under the leadership of Gro Harlem Brundtland, who used to be the Director General of WHO, and Prime Minister of Norway, and with a group from Oxford, Chatham House and Oxford developed a background paper for them in their first report on monitoring preparedness. And what our conclusions were is that the governments in the North are still trying to spend money on developing capacity in their own countries to respond to outbreaks elsewhere and setting up global mechanisms, whereas what they need to do is exactly what John has said, strengthen the capacity in countries, so they can detect and respond when and where infections occur, not wait for an outbreak to occur and then for a team from the North or from somewhere else to come in and try to stop the outbreak with them.
They need to have that capacity, and we need to begin to change our thinking from we will do it for you to we will help you strengthen the capacity to do it yourself. It’s a very difficult mentality to change in many countries in the Northern Hemisphere, where their idea of global health security is defend ourselves by setting up mechanisms that can stop diseases from coming in, rather than strengthening the capacity where and when diseases occur.
So, I think there is a shift going on, and I think the Global Preparedness Monitoring Board has emphasised that needs to happen, and I think groups like the African Union and Africa CDC can make sure that that happens by making sure that the international development community understands that it’s no longer you come in and do this job for us, you come in and train us to do the job and we’ll do it for you and keep these diseases from spreading, wherever they might spread. So, that was what I had to add onto what John has said, and I think it’s a very important message that countries begin to understand that it’s no longer we do it for you, you do it for yourselves and here’s the way we will help you strengthen that capacity.
Emma Ross
Thank you. I’m going to move onto questions now, starting with one from Mark Malik Brown. “How is the CDC common Pan-African procurement of PPE, etc., going? And second, “What is the division of work with WHO Africa?”
Dr John Nkengasong
No, sure, I just wanted to be sure the format, you wanted us to do question-by-question or take a pool of questions.
Emma Ross
Oh, no, I think we’ll do it question-by-question, and then I might do two the next one.
Dr John Nkengasong
Okay, well, whatever formula. So, I think the whole procurement mechanism is going extremely well. As we speak, in the next one hour, we – the Chairperson of the African Union Commission, that is again one of the strong co-ordination component of this pandemic respondent, must be highlighted, will be hosting a meeting in exactly one hour’s time where all Ministers of Finance and Ministers of Health are coming together, with the special Envoys that the Chairperson of the AU, President Ramaphosa, appointed the Ngozis, the Donald Kaberuka and others, to present the platform that we just developed, okay, with the support of the private sector, which will be like alibaba.com or amazon.com, where you can go in there and pull things and put into your basket and pay. That will ease – begin to unlock the process of supply chain management that has been a big, big problem for us.
I think that is really – and I’m excited with that and it will be presented today, again, in the next one hour that will be done. I will give them an overview of the – the joint Ministers of Finance and Health. The Ministers of Finance because of the debt relief, the debt stand still, and other mechanisms that the World Bank, IMF has made available to the countries. The money is there, but we need to bring them together so that the Ministers of Finance and Health shake hands and agree that they will buy this and they can release the monies to buy these commodities that are so important, if they have to unlock the economy, you have to first of all stop the virus. I think that is – so we are very excited with that. We will see how it goes. There are about five countries already that are primed up to start using the platform already, and it will be officially launched by the Bureau of the Head of States, headed by President Ramaphosa, and of course the Chairperson, Moussa Faki, next week. So, I think that is that.
With respect to the division of labour with WHO, we are in very close contact with the WHO, in the two regions, with the afro and myself and Dr Moeti and a friend for many, many years, we talk very frequently, and just as of yesterday, we were also talking about the Ebola outbreak in DRC, the new outbreak, and we will be jointly issuing guidelines for the serology testing and on the continent and many other aspects that are there. Again, the task force that I presented is a continental taskforce, and those are the highest level of the continent, so we are all part of that continental structure, which was launched on February 22nd with the presence of Dr Moeti and Dr Tedros calling from Geneva for the first hour of that meeting, so we are co-ordinating and linking up as much as possible.
Emma Ross
This is a question, a most upvoted question, from Louise Hart. “Is there any evidence so far that the trajectory of the outbreak in countries in Africa is differing from the way it has developed elsewhere in the world?” And I think you can both probably have something to say about that, so…
Professor David Heymann CBE
Maybe I’ll start.
Emma Ross
David…
Professor David Heymann CBE
Yeah, maybe I’ll start, John.
Emma Ross
Yeah.
Professor David Heymann CBE
I think that, as John said, this is a new – it’s relatively new in Africa, the outbreaks. They didn’t come in, as they came in to Europe early in January and February, and so now it’s coming in and they’re beginning to understand, and interestingly, in South Africa, they’ve shown that it’s come in from Europe and not from Asia. So, I think it’s beginning to enter into Africa from many different places, and Africa is now setting up the mechanisms to really deal with it. So, you know, that’s the first thing that I wanted to say about this, is that it really is young, and Africa’s beginning to respond the way it is, and it’s coming from many different directions at the same time.
What’s the next part of the question, Emma? The…
Emma Ross
It’s whether the trajectory of…
Professor David Heymann CBE
Hmmm hmm.
Emma Ross
…the disease in Africa is behaving – is it going the same way as it has anywhere else or any evidence that it’s different from the way…
Professor David Heymann CBE
Well, I’ll just speak…
Emma Ross
…it’s behaved elsewhere?
Professor David Heymann CBE
Yeah. I’ll just speak from what I know about discussions at WHO with various countries. The trajectory in South Africa could have been just like in European countries. It began ‘cause they rapidly went out to their health facilities, and as John said, the local response is what’s really effective, in many places including Africa. They went out and they strengthened the capacity in their primary healthcare facilities, and then they saw the outbreaks shift from a European population that had brought it in, and the populations in the major cities, to areas in rural South Africa ‘cause they were able to contain those outbreaks as they were occurring. So the trajectory, at least in South Africa, was the same, and I think that’s why – John can speak better, but that’s why I think this test, trace, treat strategy is going on now, in order to prevent this, the same way that South Africa’s prevented it from taking off in that part of the world. So, back to John, I guess, for the – his observations.
Dr John Nkengasong
No, I mean, David, you’re absolutely right, and this is again not an area of speculation, but backed with data, because when countries went into lockdown very early on in March, it was interesting that when we left Addis Ababa and agreed to develop a joint continental strategy on February 22nd, only Egypt had reported a case. And when they left and by the end of the month, exactly I think 29 or 28 of February, and Nigeria started – and reported cases, and then subsequently, the first week of March, I would say – I use this word deliberately, the continent chip, because so many countries reported cases from Europe are coming in there.
But then they did something extraordinary. The countries were locking down where they had two cases or three cases, and some countries went to states of emergency where they had no case – cases, and so that helped to blunt that. We have data that shows that South Africa, for example, was seeing a daily increase in number of cases, about 30 to 40%, and with the lockdown, after two weeks or three weeks there, it was – it had decreased to about 5% increase on daily basis. So, we have enough data to support that that help to blunt that – the outbreak, otherwise it would have been a – we would be in a very, very different situation.
Now, the challenge we have is, as countries are unlocking themselves, we have to provide guidance, and which we’ve just developed guidance for unlocking the economies, and which is really a balance between saving lives and saving livelihoods. And we will see, of course, in the next coming weeks, what that will look like, because, as we unlock a system, it will be – it’s clear that we will see an increase in number of cases, but the key question will be, are we doing the test, trace and treat strategy in an enhanced way? And also, have we used the time that – the Ebola time that we had to increase our healthcare facilities to receive more patients, are we – have we learnt some new lessons that we can apply there? So, I think it’s – I don’t know if many of those answers – as David said, we are dealing with a new virus, we are learning every day, and we are trying to understand a pandemic as much as possible.
Emma Ross
This is another one for you, John, I think, from William Crawley at the BBC. Is the disproportionate risk of infection reported among BAME communities in UK and USA specific to those countries, or is it reflected in the African statistics as well?
Dr John Nkengasong
To be quite honest with you, we have not done a continent world analysis, and, again, as I said at the start of this, the continent itself is so diverse, and that’s why I took time off to go region-by-region, and we see that it’s very misleading to down numbers on the continent. It will give you a very different picture. So, that analysis is beginning to happen. It couldn’t have happened earlier because the number – the confirmed death number rates was low, excuse me, and as we move with this large number, countries are beginning to do their own analysis, like South Africa, to understand what are their own – their groups that are most vulnerable and what are their underlying factors that – who are driving mortality, and again it’s too early. But some of the initial trend shows that people with dia – existing diabetes, hypertension, have seen higher mortality amongst them, as well as the HIV. I think that, as we would have expected, that is. But, again, it’s very early, we still have to pool this data together, work through it as a task force, continental task force, to analyse and understand this data a little bit more.
Emma Ross
Thank you. Here’s a question that we’ve kind of covered, this is about – from Yaser Abdul, it’s an upvoted questions. “What would you say Africa is doing well that European countries and others could learn from and vice versa?” We’ve discussed the regional approach seems to be quite – this unifying approach, but, David, why don’t we start with you, of what you’ve observed Africa doing that European countries could learn from?
Professor David Heymann CBE
Well, I think that…
Emma Ross
And vice versa.
Professor David Heymann CBE
…you know, everybo – thanks, Emma. I think everybody is striving to equalise the risk and equalise the response capacity, so that international travel and trade can begin again. In other words, countries with the same risk and with the same capacity to respond will be those countries that can be fairly well-assured that if they open their travel and trade, they will have the ability to not see a – they will not see an increase in cases in their countries. That requires a good disease detection system, and that’s where Africa may have difficulty at present, but they’re strengthening this capacity, to detect this, and in – certainly in capital cities, they’ll be able to detect where there are cases that are occurring, so they can rapidly respond.
Where Africa has in place a system to respond is much better than in some European and other countries, this track, test, trace and treat mechanism, which is vital to being sure that there is a response capacity, so that, when risks are equal, the response can be occurring if necessary. And so, I think Africa will have – will be possibly ahead of many countries in having this ability. They already have it from outbreaks of Ebola, outbreaks of meningitis, whatever they have to deal with, they already know how to do this, contact tracing, trace – test, trace and treat. So, they’re way ahead in that. They may not be ahead in disease detection systems, but I know that they are working, under the African Union under WHO, to make sure that those systems are in place and can be reporting, when there are diseases that might be COVID, for example. So, that would be my views, Emma, and I turn it over to John now for his views on this.
Dr John Nkengasong
I think, David, there are two components to this. There – we had the great fortune of seeing what was going on in China, Europe and the United States, and used that to argue for a strong, co-ordinated, continental approach, I think which again is – was exceptional, that within a week of the first case being reported in Egypt, the continent came together and that continental mechanism still exists. Every week, on Mondays, we – Ministers from the different regions all come together, about 15 or 20 of them, and we discuss this together, for about two hours. I think that is a very good thing, and I have said that the – you also have Ministers of Finance co-ordinating and transport, and that all feeds into the Bureau of the Head of States, Chaired by President Ramaphosa, and with the strong co-ordination of Chairperson Moussa Faki, so I think that is good.
There’s a difference between knowing what to do and having the ability to do or to implement what you know what to do. I think that is clear. We – if our pandemic goes out of hand, it’s not because we don’t know what to do, it’s just that we are limited with capacity to do, to implement what we know to do, and I must say very personally that that to me is very – it stresses me more than anything else. I think that – I mean, that – if you see the challenge we have in getting diagnostics, okay, in, say, supporting Chikwe or supporting [inaudible – 46:44] or supporting Victor Mukokna in Zambia to get access to tests. I mean, he called and said, “John, we have five swabs, okay, to do the testing.” This was very early on, and then what do you do? So, I’m scratching my head, looking across the whole world to find additional swabs to send to Zambia.
So, you ask yourself the question, if we have those who knew what to do, and if we had those commodities to respond, where we will be? Okay, so, I think that is something we must factor into the discussion, when we think, we do an after action review of how our response was, I mean, it – that – I really will hope that should be central stage in the discussion and how do we fix those gaps, what are called the non – do nothing gaps on the continent. Some of that is on the continent itself. We have to evolve from the continent that says we must manufacture certain things, like diagnostics, we have to have platforms that can di – manufacture diagnostics on the continent, so that we – you don’t rely completely from external supplies for diagnostics that you could – I mean, I’m happy that the Senegal Group is developing that, Morocco is developing something. I believe South Africa and Kenya are doing that, and we at the centre, as Africa CDC, helping to co-ordinate that manufacturing process and evaluation processes there. So, yeah, I would say that – I mean, there’s – those gaps that existed, which are – I mean, there’s a lesson for Africa to learn early on and hopefully that the continent – the world is learning something from Africa.
Emma Ross
Following on from that actually, and I think you’ve partially answered this, two questions from John McDermott from The Economist, and the first one was “What needs to be done to get tests to Africa? What are the precise bottlenecks? You’ve discussed manufacturing capacity and the reliance on importing, but is there anything else that are specific and precise bottleneck in testing capacity?” And the second question is “Are you – is the CDC doing anything to try to measure excess mortality rates, which are viewed as the gold standard way of measuring the impact of COVID-19? Many countries don’t have cause of death data, but is it possible to do samples in hotspots?” So, if you want to answer the bottleneck in testing first maybe.
Dr John Nkengasong
Yeah, the bottlenecks in testing, as I indicated, when the – in my presentation, it was – and it continues to be a challenge, but it’s something that we should look at, the trajectory we are heading to. Just about a few weeks ago, really weeks, I mean, the continent was testing about – oh, had tested less than 400,000 tests, and now today, we are about 2.4 million tests and the curve is in the right direction, and I think when we fix and we address issues, we don’t expect that the solutions will address those overnight. So, I think we are very encouraged to see the direction we are heading with the testing. And built to that is the ability to trace, I think the testing alone – this is not a malware test or an HIV test, it’s testing for a virus that is spreading quickly. It’s testing for COVID that we know that we have to have the resource in a timely manner and then do all the need for, I think that is key. We are unlocking that as we go and learning from it as much as possible.
So, the second question on excess mortality is that, I mean, we – and as CDC, we have to rely on member states to do that, and we are encouraging that, that those surveillance systems should be put in place to – for countries to generate such data, because that would be extremely valuable for us to know our pandemic, as we – as I said earlier, it’s an effective response will only be guided by good science and good data.
Emma Ross
Thank you. Did we do – yes. So, let’s take two questions together. First one for David from Caroline Johns on vaccines, this is most upvoted at the moment. “Please could you comment on the recent reports that people who’ve had the BCG vaccination may be protected somewhat against COVID-19?” And Judith McGregor, is there any information about which groups and population in different countries are proving most vulnerable to contracting the virus and most likely to succumb to it?” Are the patterns emerging similar in Africa and in other parts of the world?
Dr John Nkengasong
The BCG vaccine, please, I will say very briefly that we don’t have any data on that. I mean, we don’t have any evidence, but as we are learning, it’s a new virus, we’re learning, and I’m sure that, with time, the data that will emerge will help us address that, but we just don’t have anything to stand on to make any conclusions on that. With respect, excuse me, with respect to the different patterns, I said – as I indicated earlier, we’re doing an analysis and we are seeing that, of course, the – early on – I mean, in this, we are very early on, that we’re beginning to see some of the risks for mortality being very similar to what we saw in Europe, and North America and Asia, which is diseases, underlying diseases like diabetes, hypertension, and some of the very early data is beginning to emerge on HIV, and will be factors that will accelerate. But in terms of vulnerable populations as a whole, we expect that this virus, when it seeds itself into very vulnerable populations, like the slums around big cities, there it can be devastating, and I think we have to be extremely worried, collectively, about such a possibility. Refugee camps, for example, are also a risk that – and the [inaudible – 53:04] populations are those that we should all be worried about.
Emma Ross
David, do you have any thoughts or anything you’re hearing from the WHO level on the BCG? This has…
Professor David Heymann CBE
Well…
Emma Ross
…come up a few times.
Professor David Heymann CBE
Yeah, John has already answered the question. I would say that BCG has been considered as being useful perhaps because it stimulates the immune system, and it’s used, as many people know, to treat cancers, for example, cancer of the bladder is treated with BCG, because the BCG stimulates the immune system to get rid of the cancer cells in the bladder. So there are some examples of where BCG vaccine does stimulate the immune system, but the BCG vaccine is – has been touted as possibly the reason that Africa hasn’t seen outbreaks, but I think John’s arguments are much more convincing, that it’s just early in the stage of the entry of the virus into the African continent, and there will, of course, be a look to see whether or not BCG, which is given to all children in Africa and very young and at birth many times, which is given to children, to see if it has any protective effect. But it’s probably unlikely at present that it will show any effect, although, you know, it’s a good hypothesis, and, as John says, what we need to do is collect evidence, and when we have the evidence, then we can say yes or no. So, it’s – the jury is still out on BCG, but I think most experts think that it may not be an effective way of preventing infections.
Emma Ross
I wanted to pick up on the comment John made on refugees, there’s actually a question on that from John Tasker from CBC. “Cabo Delgado in Mozambique is a hotspot for COVID-19 and the population is on the move to escape from terrorist attacks. It appears movement of refugees may be spreading the virus into towns and cities. How much of a risk does CDC consider this is?”
Dr John Nkengasong
So, there’s a whole department within the Commission, of the African Union Commission, called the Department of Social Affairs, that deals with issues like immigration, refugees, and they work very closely with the Peace and Security Council of the African Union to address those issues. But we, as the CDC, have not taken a lead on that yet, just because of the limited capacity to help, but we are advising countries very strongly that those populations should be really taken very seriously. And several meetings have been held and I’ve addressed several countries, and with respect to what approach they should be taking in that – in those populations, which is essentially, a community-led effort, which the solutions, in terms of prevention, have to come from the community, which means we have to build trust with those communities. We have to make – create community leaders that will own that process and actually know exactly how to interact with their various communities.
Emma Ross
Thank you. We’re running – oh my God, we’re running out of time. I’ll do two more questions. One is – this is the most upvoted question at the moment from Andrew Zacala, “What measures have been put in place to ensure that the funds the governments are putting into place are used for the intended purpose?” And another one from Osmond R, “Ghana has pioneered pooled testing of samples and explains why they have relatively high testing statistics. What is the ACDC position on this, because if done well, it has the potential to significantly ramp up testing capacity across the continent?”
Dr John Nkengasong
So, if you don’t mind just repeat the first question. I just…
Emma Ross
The first question is, “What measures have been put in place to ensure that the funds that the governments are putting in place for the response are used for the intended purpose?” I guess, yeah, the financing, corruption controls, and that’s the first question, and the second question was about pooled testing of samples.
Dr John Nkengasong
So, yeah, so, with respect to the first question, we – the African Union has actually put together an African Union COVID Response Fund, with a very strong vote that includes the private sector and the public sector, they’re really a group of well-respected Africans that are managing the funds. So, countries are pledging, that is also another aspect that the continent has done very, very well. Pledges have come in and we really are excited with that innovation. At the country level, as you know, this is a pandemic that is very different from Ebola. During the Ebola outbreak, we were able, as African Union, to have a common fund for everybody, but as we know, many countries that have developed a fund for the – locally, which enables the private sector within the countries to contribute.
As to the transparency and governance of that – those funds, we can only expect that everyone knows that this is a serious health threat. Everyone knows that this is a serious economic threat, and actually, a security threat for our continent, and that those funds will be directed to address the most appropriate needs. I always say that the – my analogy, the crude analogy of the COVID-19, is that the kitchen tap is – sink is leaking and the tap is flowing and water is on the floor. In order to get a dry kitchen, you have to lock that tap off, I mean, and all efforts should be done to use monies that are raised to close that tap, so that we can at least now clean the floor and bring the kitchen back to normal. I think, again, I expect that it will be good transparency and to use the funds that are generated appropriately.
With respect to pooled testing in Ghana, it’s a known…
Emma Ross
A quick one. Yes or no. Sorry, a quick one ‘cause we’ve run out of time and David is chairing another webinar right now, but generally, good idea, bad idea, pooled testing?
Dr John Nkengasong
A good idea.
Emma Ross
Great. Thank you. I’m sorry I had to rush you at the end of that, but thank you both for joining us, and a great discussion, and for everybody else, a recording of this, in case you came in late, is on the website, and next week, David and I will be talking with WHO Disease Detective, Oliver Morgan, all about contract tracing. So, thank you all again, and I’m sorry we ran over, and brilliant to have you. Thank you.
Professor David Heymann CBE
Thanks very much, John, and thank you, Emma.
Dr John Nkengasong
Thanks. Thank you so much for inviting Africa CDC to be part of this.
