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      Limiting the spread of COVID-19 in Africa: one size mitigation strategies do not fit all countries

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          Abstract

          On March 11, 2020, when coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), was declared a pandemic by WHO, there were comparatively few cases reported from Africa. 1 Our Comment draws on early imported COVID-19 cases in South Africa, Senegal, Democratic Republic of the Congo, and Egypt as case studies to discuss important mitigation strategies of COVID-19 in Africa. Early COVID-19 cases in Africa were mostly imported from Europe, due to the higher volume of business and tourism airline traffic between African countries and Europe, and less from China. 2 The first confirmed case was reported in Egypt on Feb 14, 2020, (an adult male whose 17 contacts tested negative) and prompted African preparedness efforts.3, 4 In South Africa, on Feb 29, 2020, a group of nine adult travellers returned from a skiing holiday in Italy, where the COVID-19 epidemic was rampant. After developing a flu-like illness, one traveller tested positive for COVID-19, which was confirmed by RT-PCR on March 5, 2020; his wife was asymptomatic but tested positive on March 8, 2020. Overall, seven of the nine travellers were positive for COVID-19, five of whom were asymptomatic. In Senegal, the first COVID-19 case was reported on March 7, 2020, in a traveller returning from Italy. Contact tracing identified a cluster of transmission of 20 cases within his immediate household. Democratic Republic of the Congo confirmed its first case of COVID-19 on March 10, 2020: an adult male who tested positive in the capital city of Kinshasa after developing a cough and fever, 2 days after returning from France. These early index cases show the imported nature of the epidemic in Africa among young affluent adult travellers from Europe. However, the majority of COVID-19 cases currently being identified and reported from African countries are due to local transmission. Early estimates of case fatality rates (CFRs) also seem to vary substantially. As of April 24, 2020, South Africa had reported 3635 cases with 65 deaths (CFR 1·8%) and Senegal had reported 442 cases with 6 deaths (CFR 1·3%). These CFRs seem lower than in most European countries (eg, Italy had reported 187 327 cases with 25 085 deaths; CFR 13·4%). Since mortality rates are generally higher in older people, it could be assumed that a younger African population distribution will lessen the death rate of COVID-19 on the continent. 4 However, it is too early to predict the death rate as Africa is at the ascending phase of the epidemic curve. Furthermore, the high prevalence of HIV, tuberculosis, hypertension, and diabetes, coupled with weak health-care systems in Africa, might lead to high mortality rates among comorbid populations. Indeed, Egypt (3659 cases with 276 deaths; CFR 7·5%) and Democratic Republic of the Congo (359 cases with 25 deaths; CFR 6·9%) have reported much higher CFRs than South Africa and Senegal. Since the emergence of COVID-19 on the continent, African governments have had to decide whether, in addition to following WHO recommendations to test widely, contact trace, and quarantine, 5 they would adopt draconian measures such as total lockdowns, stay at home to save lives campaigns, and travel and movement restrictions as has been done in European and Asian countries. 5 Physical distancing and handwashing, globally adopted interventions to combat the spread of COVID-19, remain a major challenge in the context of overcrowding, poverty, and weak health-care systems. 6 A combination model of country-specific economic estimates of the benefits of disease avoidance and epidemiological projections of the spread of COVID-19 raises several possible issues. 7 First, the benefits of physical distancing could be substantially smaller in low-income countries due to the smaller proportions of older people and because, although physical distancing and lockdowns flatten the epidemic curve and reduce pressure on health systems, this effect is less apparent in countries with already overwhelmed and weak health-care systems. Second, the economic value in terms of lives saved by physical distancing policies is likely to be much higher in high-income countries than countries in which these policies have more detrimental effects on incomes. Although physical distancing slows the transmission of the virus, it exacts a heavy toll on the informal economic and casual labour sector. In search of income for the day-to-day livelihood of extended families, many Africans could be forced to ignore concerns about contracting COVID-19 and fend for their survival. Furthermore, the effect of ongoing lockdowns (eg, partial in Senegal and Democratic Republic of the Congo vs total in South Africa) and case-finding mitigation strategies will depend on each country's political leadership, socioeconomic realities, and epidemic stage. Early evidence of flattening the epidemic curve through a proactive, 30-day total lockdown and physical distancing is being documented in South Africa. However, before physical distancing measures can be eased, it is crucial to have in place a robust and functioning public health infrastructure to scale up case finding through testing, isolation, and contact tracing to ultimately interrupt coronavirus transmission. To reduce the rate of infections, the South African National Health Laboratory Service is planning to administer 36 000 RT-PCR-based tests per day by the end of April and more than 28 000 trained community health-workers will be sent house-to-house in susceptible communities for screening, testing, and contact tracing using mobile phone technology assisted by Médecins Sans Frontières. 8 Notably, point-of-care RT-PCR-based Xpert Xpress SARS-CoV-2 testing with a fast turnaround (45 min) using small GeneXpert machines (Cepheid, Sunnyvale, CA, USA), ideal for mass community testing, will be available in South Africa by the end of April, 2020. 9 As COVID-19 spreads across Africa, causing disruption of already fragile health systems, it is becoming clear that responses require action beyond the health sector and must be tailored to the local situation. Lacking governmental financial support, as is being provided for populations and businesses in Europe and USA, most of Africa's poorest citizens will ignore quarantine directives and continue to engage in communal activities to earn incomes for their families. Some countries must also provide for other vulnerable populations such as migrants, stateless people, and forcibly displaced refugees. As larger datasets are generated by increasing case numbers in Africa and while vaccines are awaited, factors which underlie asymptomatic or milder clinical presentations and any differences of mortality or severe disease between geographical regions of Africa need to be investigated further to find local solutions. 10 Possible factors include innate immune mechanisms, HLA types, effects of the BCG vaccination, cross-protective immunity due to repeated infections with other coronavirus species that cause mild upper respiratory tract infections or locally prevalent parasitic infections. These factors could ultimately provide clues to the development of preventive and therapeutic interventions for COVID-19 relevant to Africa and beyond. In conclusion, while African leaders ponder COVID-19 mitigation strategies to reduce risks of transmission versus the deprivation and hunger that will result from prolonged economic disruption, the quest for solutions must continue. Some countries are investing in low-cost preventive measures to improve physical distancing, such as stopping international travel, reducing the number of people at religious and social gatherings, and universal masking using non-medical cloth masks for the community. Other measures could focus on protecting older people, allowing individuals restricted working hours for income generation, information campaigns for personal hygiene, physical distancing, and handwashing. As lockdowns and physical distancing measures are eased, proactive surveillance, case detection, and contact tracing with isolation will be required to prevent a dramatic resurgence of COVID-19 cases.

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          Scientific and ethical basis for social-distancing interventions against COVID-19

          On Dec 31, 2019, the WHO China Country Office received notice of a cluster of pneumonia cases of unknown aetiology in the Chinese city of Wuhan, Hubei province. 1 The incidence of coronavirus disease 2019 (COVID-19; caused by severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2]) has since risen exponentially, now affecting all WHO regions. The number of cases reported to date is likely to represent an underestimation of the true burden as a result of shortcomings in surveillance and diagnostic capacity affecting case ascertainment in both high-resource and low-resource settings. 2 By all scientifically meaningful criteria, the world is undergoing a COVID-19 pandemic. In the absence of any pharmaceutical intervention, the only strategy against COVID-19 is to reduce mixing of susceptible and infectious people through early ascertainment of cases or reduction of contact. In The Lancet Infectious Diseases, Joel Koo and colleagues 3 assessed the potential effect of such social distancing interventions on SARS-CoV-2 spread and COVID-19 burden in Singapore. The context is worthy of study, since Singapore was among the first settings to report imported cases, and has so far succeeded in preventing community spread. During the 2003 severe acute respiratory syndrome coronavirus (SARS-CoV) outbreak in Singapore, numerous non-pharmaceutical interventions were implemented successfully, including effective triage and infection control measures in health-care settings, isolation and quarantine of patients with SARS and their contacts, and mass screening of school-aged children for febrile illness. 4 Each of these measures represented an escalation of typical public health action. However, the scale and disruptive impact of these interventions were small compared with the measures that have been implemented in China in response to COVID-19, including closure of schools, workplaces, roads, and transit systems; cancellation of public gatherings; mandatory quarantine of uninfected people without known exposure to SARS-CoV-2; and large-scale electronic surveillance.5, 6 Although these actions have been praised by WHO, 5 the possibility of imposing similar measures in other countries raises important questions. Populations for whom social-distancing interventions have been implemented require and deserve assurance that the decision to enact these measures is informed by the best attainable evidence. For a novel pathogen such as SARS-CoV-2, mathematical modelling of transmission under differing scenarios is the only viable and timely method to generate such evidence. Koo and colleagues 3 adapted an existing influenza epidemic simulation model 7 using granular data on the composition and behaviour of the population of Singapore to assess the potential consequences of specific social-distancing interventions on the transmission dynamics of SARS-CoV-2. The authors considered three infectivity scenarios (basic reproduction number [R 0] of 1·5, 2·0, or 2·5) and assumed between 7·5% and 50·0% of infections were asymptomatic. The interventions were quarantine with or without school closure and workplace distancing (whereby 50% of workers telecommute). Although the complexity of the model makes it difficult to understand the impact of each parameter, the primary conclusions were robust to sensitivity analyses. The combined intervention, in which quarantine, school closure, and workplace distancing were implemented, was the most effective: compared with the baseline scenario of no interventions, the combined intervention reduced the estimated median number of infections by 99·3% (IQR 92·6–99·9) when R 0 was 1·5, by 93·0% (81·5–99·7) when R 0 was 2·0, and by 78·2% (59·0–94·4) when R 0 was 2·5. The observation that the greatest reduction in COVID-19 cases was achieved under the combined intervention is not surprising. However, the assessment of the additional benefit of each intervention, when implemented in combination, offers valuable insight. Since each approach individually will result in considerable societal disruption, it is important to understand the extent of intervention needed to reduce transmission and disease burden. New findings emerge daily about transmission routes and the clinical profile of SARS-CoV-2, including the substantially underestimated rate of infection among children. 8 The implications of such findings with regard to the authors' conclusions about school closure remain unclear. Additionally, reproductive number estimates for Singapore are not yet available. The authors estimated that 7·5% of infections are clinically asymptomatic, although data on the proportion of infections that are asymptomatic are scarce; as shown by Koo and colleagues in sensitivity analyses with higher asymptomatic proportions, this value will influence the effectiveness of social-distancing interventions. Additionally, the analysis assumes high compliance of the general population, which is not guaranteed. Although the scientific basis for these interventions might be robust, ethical considerations are multifaceted. 9 Importantly, political leaders must enact quarantine and social-distancing policies that do not bias against any population group. The legacies of social and economic injustices perpetrated in the name of public health have lasting repercussions. 10 Interventions might pose risks of reduced income and even job loss, disproportionately affecting the most disadvantaged populations: policies to lessen such risks are urgently needed. Special attention should be given to protections for vulnerable populations, such as homeless, incarcerated, older, or disabled individuals, and undocumented migrants. Similarly, exceptions might be necessary for certain groups, including people who are reliant on ongoing medical treatment. The effectiveness and societal impact of quarantine and social distancing will depend on the credibility of public health authorities, political leaders, and institutions. It is important that policy makers maintain the public's trust through use of evidence-based interventions and fully transparent, fact-based communication. © 2020 Caia Image/Science Photo Library 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.
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            Looming threat of COVID-19 infection in Africa: act collectively, and fast

            Because of the high volume of air traffic and trade between China and Africa, 1 Africa is at a high risk for the introduction and spread of the novel coronavirus disease 2019 (COVID-19); although only Egypt has reported the first case, from a non-national. 2 The greatest concern for public health experts is whether COVID-19 will become a pandemic, with sustained year-round transmission, similar to influenza, as is now being observed in several countries. 3 What might happen to Africa—where most countries have weak health-care systems, including inadequate surveillance and laboratory capacity, scarcity of public health human resources, and limited financial means—if a pandemic occurs? With neither treatment nor vaccines, and without pre-existing immunity, the effect might be devastating because of the multiple health challenges the continent already faces: rapid population growth and increased movement of people; existing endemic diseases, such as human immunodeficiency virus, tuberculosis, and malaria; remerging and emerging infectious pathogens such as Ebola virus disease, Lassa haemorrhagic fever, and others; and increasing incidence of non-communicable diseases. Models that enable the continent to better allocate scarce resources to better prepare and respond to the COVID-19 epidemic are crucial. The modelling study by Marius Gilbert and colleagues in The Lancet 4 identifies each African country's risk of importation of COVID-19 from China, using data on the volume of air travel from three airports in provinces in China to African countries. Gilbert and colleagues use two indicators to determine the capacity of countries to detect and respond to cases: preparedness, using the WHO International Health Regulations Monitoring and Evaluation Framework; and vulnerability, using the Infectious Disease Vulnerability Index. Based on their analysis, Egypt, Algeria, and South Africa had the highest importation risk, and a moderate to high capacity to respond to outbreaks. Nigeria, Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya had moderate risk with variable capacity and high vulnerability. In the model, the risk mainly originates from Guangdong, Fujian, and Beijing. The study provides a valuable tool that can help countries in Africa prioritise and allocate resources as they prepare to respond to the potential introduction and spread of COVID-19. The study should also be interpreted in light of the fast-evolving nature of the COVID-19 outbreak. First, with the exception of Ethiopian airlines, all African airlines have suspended flights to China. Although these measures might delay, but not stop, 5 the importation risk of COVID-19 into Africa, their implementation is still worthwhile. Second, although Beijing, Shanghai, and Fujian do not report the highest number of cases of COVID-19 in China, the volume of travel from these cities to Africa is high, which might increase the risk of exporting cases to Africa. Lastly, almost half of the flights from Africa to China are operated by Ethiopian Airlines, so it is possible that cases might pass through Ethiopia and affect destination countries. The report by Gilbert and colleagues 4 provides an important tool to map out the continental risk for the spread of COVID-19 in Africa, which should be used to inform a framework of action to prepare the continent for any potential importation and spread of COVID-19. First, collectively, Africa needs a unified continent-wide strategy for preparedness and response. The strategy must be comprehensive, and member states, donors, and partners should immediately commit to releasing financial resources to support country-customised implementation plans derived from the strategy. To help develop a common strategy that will allow for effective coordination, collaboration, and communication, the African Union Commission, Africa Centres for Disease Control and Prevention (Africa CDC), and WHO, in partnership with African countries, have established the Africa Taskforce for Coronavirus Preparedness and Response (AFTCOR). The partnership has six work streams: laboratory diagnosis and subtyping; surveillance, including screening at points of entry and cross-border activities; infection prevention and control in health-care facilities; clinical management of people with severe COVID-19; risk communication; and supply-chain management and stockpiles. Because mitigating the potential spread of COVID-19 in Africa will require rapid detection and containment, the laboratory work streams of AFTCOR, Africa CDC, and WHO are working closely to expeditiously scale up diagnostic testing capacity linked to enhanced surveillance and monitoring—eg, at the beginning of February, only two countries in Africa had the diagnostic capacity to test for COVID-19. However, as of Feb 25, 2020, more than 40 countries would have been capacitated to accurately diagnose COVID-19 infection, thanks to the coordination efforts of AFTCOR. 6 As testing becomes more available, it is possible that more cases might be detected. Second, any effective preparedness and response strategy for COVID-19 requires a committed political will; as such, the African Union Commission, Africa CDC, and WHO convened, on Feb 22, 2020, in Addis Ababa, Ethiopia, an emergency meeting of all ministers of health of 55 member states to commit to acting fast and collectively to develop and implement a coordinated continent-wide strategy. AFTCOR taskforce was formed, and a continent-wide strategy was endorsed at the end of the emergency meeting, with a call for strong coordination of efforts. To prevent the occurrence of a social, health security, and economic tragedy, actions agreed at the emergency ministerial meeting will need to be acted on quickly, before any additional COVID-19 cases are introduced to the continent, and result in sustained human-to-human transmission. The potential social, economic, and security devastation that COVID-19 could cause in Africa should be enough of an incentive for African governments to invest immediately in preparedness for the worst-case scenario. Third, commitment and release of financial resources from partners and donors before a crisis hits Africa will help anticipate demand and address supply chain management, mapping, and stockpiling of COVID-19 response needs, such as large quantities of personal protective equipment, gloves, surgical masks, coveralls, and hoods, and medical countermeasures like antiviral agents. Supplies of these items will be limited in Africa because of reduced manufacturing capacity. © 2020 Luke Dray/Stringer/Getty Images 2020 Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active. Fourth, national, regional, and international organisations need to cooperate and collaborate to optimise limited supplies, using a whole of government approach. Fifth, all member states will need to urgently develop and put in place proper quarantine and infection control protocols, including procedures for implementing social distancing (mass gathering and potential closure of public facilities). Lastly, the capacity-building training efforts that Africa CDC and WHO are conducting must be implemented and cascaded immediately down the health system pyramid in each country. Medical staff at major hospitals must be trained in the proper protocols of quarantining individuals who are at-risk of COVID-19 infection, as well as isolation and safe treatment of patients who test positive. As the Director General of WHO has stated several times, the window of opportunity to act is narrowing. Africa needs to be supported to act now, and needs to act fast.
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              Is Africa prepared for tackling the COVID-19 (SARS-CoV-2) epidemic. Lessons from past outbreaks, ongoing pan-African public health efforts, and implications for the future

              Soon after the novel coronavirus, SARS-CoV-2 (2019-nCoV), was first identified in a cluster of patients with pneumonia (Li et al., 2020), in the Chinese city of Wuhan on 31 December 2019, rapid human to human transmission was anticipated (Hui et al., 2020). The fast pace of transmission is wreaking havoc and stirring media hype and public health concern (Ippolito et al., 2020) globally. When the World Health Organization (WHO) declared the disease, (now officially named COVID-19) a Public Health Emergency of International Concern (PHEIC) on 31st January 2020 (WHO, 2020a), the Director General Dr Tedros Ghebreyesus justified the decision by stating that WHOs greatest concern was the potential for the virus to spread to countries with weaker health systems. Repeated outbreaks of other preventable emerging and re-emerging infectious diseases with epidemic potential have taken their toll on the health systems of many African countries. The devastating 2014–2016 Ebola Virus Epidemic (WHO, 2020b) in West Africa, demonstrated how ill-prepared the affected countries were to rapidly identify the infection and halt transmission (WHO, 2020d, Largent, 2016, Hoffman and Silverberg, 2018, Omoleke et al., 2016). Similarly, the smoldering remnants of the 2018–19 Ebola Virus outbreak in the Democratic Republic of Congo, have demonstrated even for health services with considerable experience of dealing with a certain emerging pathogen, geography and sociopolitical instability, can hamper the response (Aruna et al., 2019). A recent analysis of the spatial and temporal distribution of infectious disease epidemics, disasters and other potential public health emergencies in the WHO Africa Region highlighted that 41 African countries (87% of the continent) had at least one epidemic, and 21 countries (45%) had at least one epidemic annually (Talisuna et al., 2020). The top five causes of epidemics were Cholera, Measles, Viral haemorrhagic diseases, malaria and meningitis. Seven countries which experienced over 10 events, all had limited International Health Regulations (IHR) capacities which are now being developed. Most sub-Saharan African countries are operating at maximum capacity with the huge existing workload in hospitals and clinics. The WHO’s Joint External Evaluation reports, conducted since 2016, suggest that the ability to respond to an International Health Regulation hazard, such as the importation of an infectious disease like COVID-19, requires almost universal improvement across sub-Saharan Africa (WHO, 2020c).Thus, it is essential for African countries to take the lead, become proactive and prepare surveillance systems for the rapid detection of any imported cases of COVID-19, to prevent rapid spread as seen in China. The question arises, ‘Is Africa prepared and equipped to deal with yet another outbreak of a highly infectious disease – COVID-19? The answer to the question is, it is better prepared than ever before. Substantial progress has been made since the 2014–16 Ebola outbreak (WHO, 2020d), with lessons learned from previous and ongoing outbreaks, followed by significant investments into surveillance and preparedness (WHO, 2020d, Largent, 2016, Hoffman and Silverberg, 2018, Omoleke et al., 2016). Africa is now better prepared than ever before. Thus, African countries have been on heightened alert to detect and isolated any imported cases of COVID-19. There has been rapid response to the COVID-19 epidemic from Africa’s public health systems, well before any cases of COVID-19 had been reported from Africa. This response has been made possible with the re-organization of the WHO including the creation of the World Health Emergencies Programme; the establishment of the Africa Centers for Disease Control and Prevention (Africa CDC, 2020) and creation and funding of consortia such as the ONE-HUMAN-ANIMAL-HEALTH Africa-Europe research, training and capacity development network (PANDORA-ID-NET)(Pandora-ID-NET, 2020) for tackling emerging and re-emerging infections with epidemic potential. This ONE-HEALTH network works effectively and equitably together across all Africa regions, fully engaging with national disease control authorities and public health institutes, in close liaison with the Nigeria CDC, Africa CDC and other African and global public health agencies. Importantly, this consortium has allowed strengthening of communication and establishment of trust and ‘unity of purpose’ between African governments, Africa CDC, Nigeria CDC (Nigeria CDC, 2020), local communities and the PANDORA-ID-NET consortium local African and European public health workers and scientists. An estimated 2 million Chinese nationals live and work in Africa, and there is increasing travel in the opposite direction, with people going to China for education, business and leisure. Prior to the travel restrictions imposed after the COVID-19 outbreak, there were an average of eight flights a day operated between China and African cities (Haider et al., 2020a, Haider et al., 2020b). There are ongoing efforts in Africa to prepare to deal with imported cases or subsequent local outbreaks of COVID-19, led by the Africa CDC, Nigeria CDC, African Union, PANDORA-ID-NET and other research and capacity development and training consortia. Many African countries have already introduced screening of arrivals for COVID-19 at airports, and at some seaports. ‘First public health emergency responders’ from African countries met in Senegal in early February 2020 to equip themselves with the latest advances on COVID-19 diagnostics (Corman et al., 2020), prevention and healthcare knowledge. Over 20 African nations are now able to test for COVID-19. Several African countries have identified isolation and quarantine centers and Nigeria, Kenya, Ethiopia, Ivory Coast, Ghana, Uganda and Botswana have rapidly dealt with suspected cases carrying out laboratory tests, and in some cases, placing them in quarantine while laboratory tests were performed. Nigeria was one of the first countries to recognize the risk and start planning the response for COVID-19. In a massive effort of national coordination, a multi-sectoral National Coronavirus Preparedness Group was established by Nigeria CDC on January 7, 2020, one week after China first reported the cases and three weeks before WHO declared the disease to be of international concern. The country has also established diagnostic capacity for COVID-19 in three laboratories within the country in one month. Nigeria CDC has established a national team that meets daily to assess the risk coronavirus poses to the nation and review its response to it. Uganda quarantined more than 100 people who arrived at Entebbe International Airport, some at hospitals in Entebbe and Kampala, and others were confined in their homes. Zambia has dedicated two medical facilities in the capital, Lusaka, to quarantine people suspected of having the disease. They include designating a new 800-bed capacity hospital in Lusaka, funded and built by China development aid to Zambia. Thermal body scanners have also been set up at all ports of entry to detect travelers showing symptoms of the virus. Kenya has introduced mandatory screening at all ports of entry, and established isolation facilities and a rapid response team to handle suspected cases. South Africa has set up national and provincial response teams, designated 300 health officials to ports of entry and begun screening all travelers from China. The Africa CDC has trained numerous participants from across Africa, including Egypt, on enhancing detection of COVID-19 at points-of-entry in collaboration with US-CDC, WHO, and the International Civil Aviation Authority (WHO, 2020e). Two airlines, Kenya Airways and South African Airlines, were also represented in the training. Additional training and resources have been provided to Egypt and other at-risk countries for infection prevention and control in healthcare facilities, medical management of COVID-19, and risk communication and community engagement. The Africa Union, West African Health Organization (WAHO) and external donors have been quick to provide support to the Africa CDC. In response to emergency grant calls for COVID-19, there have been several consortia fielding grant applications for research and capacity development. The long anticipated and inevitable and detection of the introduction of SARS-CoV-2 into Africa was announced on 14 February 2020, by the Minister of Health and Population of Egypt, Dr Hala Zayed, who confirmed the first case of the novel coronavirus disease COVID-19 in Egypt. The patient was a 33 year old male of foreign origin whose 17 contacts tested negative but were under home quarantine for 14 days. This has ignited a reflection on the readiness of the continent to take on the challenge and showcase its new potential. Following detection of this first case in Africa, the Africa CDC, Nigeria CDC and other national public health institutes in liaison with the WHO are scaling up preparedness efforts in the African region, supporting countries to implement recommendations outlined by the WHO International Health Regulations Emergency Committee. The Emergency Committee recommended that all countries should be prepared for containment, including active surveillance, early detection, isolation and case management, contact tracing and prevention of onward spread of SARS-CoV-2. Thirteen nations with close links with China, including Nigeria, South Africa, Kenya and the Democratic Republic of the Congo, have been identified as especially high-risk priority zones for proactive surveillance, detection and containing the spread of COVID-19. The WHO has sent diagnostic kits to 29 laboratories in Africa, and reagents and positive controls are being shipped worldwide by PANDORA-ID-NET partner in Germany, Charité-Universitätsmedizin Berlin Institute of Virology, to ensure the capacity to screen and test. Some countries in Africa, including DRC, are also leveraging the capacity they have built up to test for Ebola, to test for COVID-19. Thus, early detection of cases with implementation of infection control procedures will remain a priority to control the spread of COVID-19 in Africa. On 22nd February, 2020 an Emergency Ministerial meeting on COVID-19 was organized by the African Union and the Africa Centres for Disease Control and Prevention following which the WHO DG announced several additional measures and plans for supporting the Africa response to COVID-19 (WHO, 2020g). He appointed Dr John Nkengasong, Director of the Africa CDC, and Professor Samba Sow, Director-General of the Center for Vaccine Development in Mali, as special envoys on COVID-19, to provide strategic advice and high-level political advocacy and engagement in Africa. A WHO Strategic Preparedness and Response Plan has been developed, with a call for US$675 million to support those African countries which are most vulnerable. WHO have also shipped over 30,000 sets of personal protective equipment to several countries in Africa, and 60,000 more sets are to be shipped to the 19 vulnerable countries in the coming weeks. During the past month about 11,000 African health workers have been trained using WHO’s online courses on COVID-19, which are available free of charge in English, French and other languages at OpenWHO.org. As of 5th March, 2020, worldwide there were 93,090 laboratory confirmed cases of COVID-19 reported to the WHO. Of these 80,422 cases (with 2,984 deaths) were from China, and 12,668 cases (with 214 deaths) were from 76 countries outside China. From Africa there have been 5 cases from Algeria, 1 from Nigeria, 1 from Senegal and 2 from Egypt (WHO, 2020f). Given the extent of the outbreak in China, and with a high degree of awareness of COVID-19 in Africa, and proactive screening on the rise, more COVID-19 cases are anticipated in Africa. Several lessons have been learnt from the SARS-CoV-2 epidemic, which is the third lethal human zoonotic coronavirus with epidemic potential to emerge past 2 decades, the first being SARS-CoV identified in 2002 and second MERS-CoV in 2012 (Hui et al., 2014, McCloskey et al., 2014). Whilst the news and social media hype has evoked public and political anxieties, it is important to note that COVID-19 appears to have less than 3% mortality rates and is not more serious than outbreaks of viral respiratory tract infections such as influenza (Ippolito et al., 2020). It is crucial that other communicable diseases which impact a higher toll and burden on health services in Africa are not neglected or sidelined by the current hype and scaremongering of the COVID-19 epidemic. An important need remains for ensuring long-term sustainability of what is being built. Africa needs to continue its upward trajectory of activities so as to align public health resources, scientific expertise and experience, and political commitment so that any future infectious disease outbreaks can be stopped before they become an epidemic in Africa. Africa needs more investments into ONE-HEALTH collaborative activities across the continent in order to meet the challenges of current and future public health threats (Kock et al., 2020, Petersen et al., 2019, Talisuna et al., 2020, Hui et al., 2020, Zumla et al., 2016). A whole new young generation of enthusiastic, committed and dedicated African public health workers, epidemiologists, researchers, healthcare workers and laboratory personnel have emerged over the past 5 years, and they need to be supported by security of funding to build their careers and sustain their capabilities to take forward their research and training portfolios. The future of Africa’s public health security relies on them. Increased governmental and donor investments are required to advance locally led, world-class public health work with surveillance, data and analytics capabilities and further expanding state-of-the-art laboratory capacities with more trained personnel to sustain capacity to rapidly respond to outbreaks at their source. A well-planned long-term strategy from the Africa Union will add major value for consolidating African leadership of public health capacity building, training and research. Conflicts of interest All author declare no other conflicts of interest Author contributions Sir Prof Alimuddin Zumla, Dr Nathan Kapata, Dr Chikwe Ihekweazu, Prof Giuseppe Ippolito and Prof Francine Ntoumi conceptualized the editorial and developed the first draft. All authors contributed to writing and finalizing the manuscript.
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                Author and article information

                Contributors
                Journal
                Lancet Glob Health
                Lancet Glob Health
                The Lancet. Global Health
                The Author(s). Published by Elsevier Ltd.
                2214-109X
                28 April 2020
                28 April 2020
                Affiliations
                [a ]Division of Medical Virology, Department of Pathology, Stellenbosch University, Cape Town, South Africa
                [b ]Department of Medicine and Centre for Infectious Diseases, Stellenbosch University, Cape Town, South Africa
                [c ]Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
                [d ]Infection Control Africa Network, Cape Town, South Africa
                [e ]National Health Laboratory Service Tygerberg, Cape Town, South Africa
                [f ]Service de Maladies Infectieuses et Tropicales, Centre Hospitalo-Universitaire de Fann, Université Cheik Anta-Diop, Dakar, Senegal
                [g ]Centre des opérations d'urgences sanitaires du Sénégal, Dakar, Senegal
                [h ]National Institute of Biomedical Research, Kinshasa, Democratic Republic of the Congo
                [i ]Erasme Hospital, Université libre de Bruxelles, Brussels, Belgium
                [j ]Division of Infection and Immunity, Centre for Clinical Microbiology, and National Institute for Health Research Biomedical Research Centre, University College London Hospitals University College London, London, UK
                [k ]Department of Epidemiology and International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
                [l ]Department of Epidemiology and Center for Global Health, University of Pittsburgh, Graduate School of Public, Pittsburgh, PA 15261, USA
                Article
                S2214-109X(20)30212-6
                10.1016/S2214-109X(20)30212-6
                7195296
                © 2020 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC-BY 4.0 license

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