Coronavirus: North Africa must develop its own strategy to ease lockdown
While the numbers of infections and deaths continue to rise across the African continent, North African countries have begun a gradual lifting of restrictions, but will that leave the region vulnerable to the pandemic?
The latest count by The Africa Report and Jeune Afrique reports over 1,200 deaths linked to the COVID-19 epidemic on the continent. In the Maghreb and Egypt, containment measures, coupled with more or less strict curfews, were deployed as soon as the first cases appeared.
But the economic cost of such decisions is now leading states to prepare for a forthcoming easing of travel restrictions, as was the case on 4 May in Tunisia for example.
Youssef Oulhote, professor of general and environmental epidemiology and researcher at the University of Massachusetts (UMASS) in Boston, USA, analyses for Jeune Afrique the latest statistics, the effectiveness of public policies and the risks of premature opening of lockdown and curfews.
Jeune Afrique: How would you describe the evolution of the epidemic curve in the Maghreb?
Youssef Oulhote: If we look at the number of cases at a given time, the evolution of the curve is not worrying. But these figures can mislead us, because they depend on the screening capacity of the states and the screening strategy (which is considered a probable case). It is inappropriate to use this parameter to model the epidemic because it is biased.
This is not something that concerns the Maghreb only but the whole world: here in the United States, the number of cases is underestimated by 5 to 10 times or more in some regions! In North Africa, it would be more useful to publish the number of hospitalizations, which is a much better indicator of the situation.
For my part, I am interested in models that measure the gap between the number of cases detected and the number of actual cases. It would seem that Tunisia is doing well (7% to 40% of actual cases are detected), as is Morocco (6% to 25%). On the other hand, Egypt and Algeria appear to be lagging behind in case detection.
But is the epidemic under control? Will the Maghreb be more spared than Europe?
It is too early to say. All we can say at the moment is that Tunisia and Morocco are doing better in detecting the virus. In the long term, in order to keep the pandemic under control, this testing capacity will have to be further increased. Once again, let us not forget that no one knows the real number of cases, because not everyone is tested.
In the absence of a vaccine, we must radically review our lifestyles.
For example, here in Massachusetts, in a community called “Chelsea”, where you have a high population density with a large diaspora from South America and North Africa, officially, less than 3% of the population has COVID-19.
But an experiment has been carried out, with a random selection of passers-by on the street. More than a third tested positive. That’s a quota ten times higher than the officially reported percentage.
The bias here is that many people do not necessarily have their papers in order, and are therefore afraid to report themselves to the authorities. That is why I would call for caution with regard to the figures. At this stage, many projections based solely on published figures are speculative.
One of the consolidated data, the number of deaths, is low in the Maghreb. Can this be explained by the young age population?
Yes, the age pyramid helps lower the lethality rate. But we must also look at the capacity to care for the sick. Where hospitals have been overwhelmed, the number of deaths has exploded, as in Italy for example. In Europe, the population is older, too. Finally, the weather is one of the factors that scientists are looking at. This could explain the slowdown in the Maghreb, but could not by itself explain any halt to the epidemic.
However, as far as the case-fatality rate you mentioned is concerned, it is calculated by dividing the total number of deaths due to a disease by the total number of people diagnosed with that disease. It would appear that the current case-fatality rate is overestimated because of statistical bias in the denominator – the discrepancy between official and real cases.
Today, the case-fatality rate of this virus is estimated to be between 3% and 10% depending on the country. We are confident that once we have tested it on a large scale this ratio will drop to between 0.4% and 1.2%.
Apart from age, and possibly climate, should this epidemiological slowdown be put to the credit of the governments of North Africa?
Yes, governments intervened early and took preventive measures, a little before Europe, and despite the economic cost. This saved time. But it is too early to say that the Maghreb is safe from the virus. What will happen once these measures are lifted? I believe there is a great risk of a second wave of contamination.
That is why, when the number of cases is at its lowest, the states must deploy more detailed surveillance to find people who have been in contact with a patient and isolate them before they affect others.
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There will be no return to the way things were before until a vaccine has been found. I think one of the fastest vaccines to be developed in history is the mumps vaccine, which took almost four years to be finalized. I’m optimistic that scientists will be able to do much better with COVID-19, as 41 vaccines are currently in early pre-clinical development and six are in clinical trials.
What about the possibility of developing herd immunity?
Before even mentioning it, we need a clear picture of the reality of the situation and to know precisely the number of people carrying the virus. If the actual number of cases is much higher than the official figures, this means that infected people, who today do not overwhelm hospitals, will be put back into transport, offices, collective living places to participate in the economy and work. However, this will require much more reliable serological tests than what is currently on the market.
It is likely that the virus will strike again next fall, and that we will learn to live with it over the next few years.
One of the uncertainties about herd immunity is also how long you are immune once you are infected. A few months, a year? Ten years? Twenty years? If your antibodies don’t protect you for long, then the virus is here to stay and you’re going to need a good vaccine.
Is it still possible to come out of containment and still avoid a second wave?
In my view, the most dangerous thing that North African countries can do is to emulate the de-containment model of their European or American neighbours. The contexts are completely different.
One of the pillars of de-confinement strategies is the ability to test: Test as many people as possible, and as many times as possible as well. I’m not sure that this capacity for large-scale testing exists in North Africa. And, given the international competition on testing – all countries need it at the same time – the Maghreb has no choice but to learn how to produce it itself and to establish intelligent monitoring procedures.
Is this the only way to monitor the transmission of the virus?
In the absence of individual screening, it is possible to monitor the transmission of the virus at the collective level by being ingenious and designing ad hoc tools.
A new study has concluded that traces of Sars Cov-2 can be found in excrement that ends up in sewage. If you monitor these facilities, you can assess the amount of virus in circulation and take preventative measures to ensure that the epidemic does not flare up again.
It is also possible to network doctors. Each one can quickly report to the community the number of patients they receive each week for influenza-like illness, which already exists in most countries, and see whether the number of suspected cases is increasing or not.
In Morocco, the state of health emergency runs until 20 May. And the wearing of masks is compulsory in public areas. How to go further?
In the absence of a vaccine, we must radically review our lifestyles. On a daily basis, the wearing of masks will be indispensable.
Those who can work online from home will have to do so for some time. And at school, you will no longer be able to have overcrowded classrooms. Also, de-confinement will have to give priority to those who have no choice but to leave home to work.
The reopening of borders must be one of the last remaining flexibilities. At the same time, an enormous challenge awaits governments: to ensure, in their war against COVID-19, that no other virus emerges.
The other vaccinations must therefore continue to prevent new epidemics. No one wants to save one child from COVID-19 by having 40 others get mumps or some other more lethal virus. These are some of the cornerstones of public health.
So will we have to live for a long time with rules and restrictions on movement and social distancing?
Three factors are responsible for the spread of the virus. Firstly, the number of people who are susceptible to it, which was the case for everyone at the beginning, because no one was immune. Second[ly], the ability to transmit the virus, which depends in particular, on its viability under certain conditions. How likely is it that people I come into contact with will catch my virus? And finally, the last parameter, the number of people I come into contact with.
Physical distancing and movement restrictions are the things we can do and which could affect the last parameter by reducing the rate of contact.
So, yes, the less people assemble, the more you avoid a fast transmission of the virus. That’s why we need to focus on what we can control, which is social distancing, identification of infected people, and isolation. This has been a proven solution since its discovery in the 14th century.