The back door of the morgue at University Teaching Hospital in Lusaka, Zambia.

coronavirus

COVID-19 in Africa Is Severely Underestimated, Zambia Deaths Show

Almost one in five recently-deceased people arriving at Lusaka’s main morgue over the summer tested positive for the coronavirus, indicating that low reported numbers across the continent are due to lack of testing.

The global community has assumed that Africa somehow “dodged” the COVID-19 pandemic, generating various theories to explain low reported numbers of infections and deaths.

But a new School of Public Health study in Lusaka, Zambia’s capital, indicates that Africa’s low numbers may simply be a matter of lack of testing, with the coronavirus actually taking a terrible but invisible toll across the continent.

Published in The BMJ, the study finds that over 15 percent—and potentially as many as 19 percent—of recently-deceased people arriving at Lusaka’s main morgue over the summer tested positive for the coronavirus, peaking at 31 percent in July. Despite most having had COVID symptoms, few were tested before death.

“Our findings cast doubt on the assumption that COVID-19 somehow skipped Africa or has not impacted the continent as heavily,” says study co-author Lawrence Mwananyanda, an adjunct research assistant professor of global health at SPH based in Lusaka.

“This study shows that with proper diagnostics and testing, we can begin to identify the scale of COVID-19 in African countries such as Zambia,” he says. “I hope this study will encourage African governments to look closer at the rollout of COVID-19 testing, as well as empower Africans to take proactive steps—such as wearing masks, physically distancing, and skipping handshakes—to protect themselves from COVID-19.”

The findings also have important implications for global health decision makers, says study corresponding author Christopher Gill, associate professor of global health. “We will only end the COVID-19 pandemic if we ensure equitable access to a vaccine. Without the full data picture of the spread of COVID-19 in Africa, it will be impossible to ensure COVID-19 vaccines can get to the people and places that need it most,” he says.

“If we think that Africa has been ‘spared,’ then Africa will not be a priority in terms of who gets access to the coming COVID-19 vaccines, and that would be a tragedy.”

An estimated 80 percent of people who die in Lusaka pass through the University Teaching Hospital morgue. From June to September, polymerase chain reaction (PCR) tests on 364 recently-deceased people found the coronavirus in 70 of them.

While the majority of COVID-19 deaths in the United States and Europe have been in older adults, most of the deceased people who tested positive in this study were under 60 years old, including seven children. The researchers say that such a high proportion of pediatric deaths was particularly surprising given how rare COVID-19 deaths in children have been reported elsewhere. 

Of the 70 people who tested positive, the researchers had next-of-kin and/or hospital data on 51, finding that 44 had typical COVID symptoms. But only 6 (all of whom died in the hospital) had been tested before death.

However, detecting the coronavirus in any country is no easy feat, much less in countries with limited resources. The researchers say Zambia’s Ministry of Health has been very proactive and supportive of this and other COVID studies. “They’re really grateful that we can provide them this data, and they can make informed decisions moving forward with this epidemic,” Mwananyanda says.

The researchers were well-positioned to track COVID in Zambia. With funding from the Bill & Melinda Gates Foundation, they have been conducting the Zambia Pertussis/RSV Infant Mortality Estimation Study (ZPRIME) at the University Teaching Hospital morgue in Lusaka since 2017. In that ongoing study, nurses and physicians’ assistants approach families who have lost a child between the ages of four days and six months for consent to conduct a nasal swab of the infant, and to offer grief counseling.

“Building studies such as this from scratch can take time and resources that can be difficult in the time needed to tackle the COVID-19 pandemic,” says study co-author Rachel Pieciak (SPH’16), a research fellow in the Department of Global Health. “We invested a lot of time and money and human resources to building infrastructure that allowed for that extensive surveillance. So, what we’ve done was repurpose ZPRIME study capacity to focus on enrolling all deaths across all ages and testing for COVID-19.”

Other research teams in similar situations might also be able to pivot in this way, Pieciak says. While many governments don’t have the resources to effectively track COVID rates, “there’s a lot of research money in places where we’re not seeing really great COVID data,” she says. “I would encourage other groups like us to think creatively about the resources that they have available, and to contribute to this effort.”

For their part, the research team’s findings will help inform COVID-19 efforts not just in Zambia, but many other countries.

“What this study tells us is that when we looked for COVID-19 in Zambia, we found it—and there are a whole lot of other countries where there’s similar lack of testing,” says study co-author William MacLeod, research associate professor of global health.

The study’s senior author is Donald Thea, professor of global health. At SPH, the study was also co-authored by Lauren Etter, a research fellow in the Department of Global Health; and Leah Forman, a statistical programmer in the Biostatistics & Epidemiology Data Analytics Center (BEDAC). The other co-authors are: Geoffrey Kwenda, senior lecturer in medical microbiology and molecular biology in the Department of Biomedical Sciences at the University of Zambia; Zachariah Mupila of the Department of Biomedical Sciences at the University of Zambia; Francis Mupeta, head of the Infectious Disease Unit at University Teaching Hospital in Lusaka; Luunga Ziko, who was registrar of infectious diseases at University Teaching Hospital during the study; and Mwaka Monze, medical officer/virologist at University Teaching Hospital.