Big African cities with international travel links worst hit by Covid-19

African countries expected to be the “least vulnerable to an epidemic” were the hardest hit by Covid-19, with SA the worst affected by deaths in the first and second waves, a new study in the journal Nature Medicine shows.

Those with the biggest urban populations and international travel hubs were the hardest hit by Covid-19 deaths, the researchers from the University of Edinburgh and the World Health Organisation (WHO) Africa region found.

The island nation of Mauritius recorded no deaths during its second wave into this year.

The director of the university’s NIHR Global Health Research Unit Tackling Infections to Benefit Africa (Tiba), Prof Mark Woolhouse, who co-led the study, said: “That seemingly well-prepared, resilient countries have fared worst during the pandemic is not only true in Africa; the result is consistent with a global trend that more developed countries have often been particularly hard hit by Covid-19.

“Our results show that we should not equate high levels of preparedness and resilience with low vulnerability.”

SA had the highest reported mortality rate during the May and August 2020 first wave of Covid-19, at 33.3 deaths recorded per 100,000 people of the 44 countries that made data available to the WHO Africa region.

Next was Cape Verde with 17,5 deaths per 100,000, followed by Eswatini at 8.6 deaths per 100,000. Uganda recorded the lowest mortality at 0.26 deaths per 100,000.

Besides those with large urban populations and robust international travel links, high rates of HIV in a country were likely to push up mortality rates. The researchers suggested that people with HIV could have other health conditions, making them more vulnerable to Covid-19.

In the second wave, SA also reported the highest mortality rate from December 2020 to February 2021, at 55.4 deaths per 100,000.

Eswatini was next worse off, jumping up nearly five times from the first wave to recorded rates of 39.8 deaths per 100,000, while another SA neighbour, Botswana, came in at third place with 17.7 deaths per 100,000.

Tiba and WHO AFRO analysed factors driving fatality rates during the first two waves of Covid-19 in Africa and the timing of the first reported cases.

WHO regional director for Africa and co-author Dr Matshidiso Moeti said: “The early models which predicted how Covid-19 would lead to a massive number of cases in Africa were largely the work of institutions not from our continent.”

Seemingly well-prepared, resilient countries have fared worst during the pandemic.

This collaboration between researchers in Africa and Europe underlines the importance of anchoring analysis on Africa’s epidemics firmly here.

“We can no longer focus our understanding of disease transmission purely on the characteristics of a virus — Covid-19 operates within a social context which has a major impact on its spread.”

Finding a “consistent impact pattern” between the mortality rate and government-imposed restrictions proved difficult for the team.

But they reported: “Restrictions during peaks of infection are well documented to have interrupted transmission in the region.”

The countries thought to be at the highest risk from coronavirus had the lowest levels of restrictions, such as lockdowns and travel bans.

The first recorded cases of Covid-19 were in countries where most people live in cities with thriving international travel links and greater testing capacity.

The first reported case of Covid-19 in Africa was on February 25 2020 in Algeria.

“Most countries had recorded cases by late March 2020, with Lesotho the last to report one, on May 14 2020,” the report stated.

During the second wave, infections peaked at a higher number and more deaths were reported compared with the first wave - with 675 deaths reported across the continent at the peak of January 18 2021 compared with 323 deaths during the first wave peak on August 5 2020.

The Africa Centres for Disease Control and Prevention (CDC) reports that the average case fatality rate during the continent’s third wave, from June to the end of August, has been higher than during the first two waves.

The latest study, published on September 15, challenges assumptions about epidemic preparedness and resilience in Africa, said Dr Sarah Puddicombe, NIHR’s assistant director for Global Health Research.