An in-depth statistical analysis of the COVID-19 pandemic's initial spread in the WHO African region

ABSTRACT

During the first wave of the COVID-19 pandemic, sub-Saharan African countries experienced comparatively lower rates of SARS-CoV-2 infections and related deaths than in other parts of the world, the reasons for which remain unclear. Yet, there was also considerable variation between countries. Here, we explored potential drivers of this variation among 46 of the 47 World Health Organization African region member states in a cross-sectional study. We described five indicators of early COVID-19 spread and severity for each country as of 29 November 2020 delay in detection of the first case, length of the early epidemic growth period, cumulative and peak attack rates, and crude case fatality ratio (CFR). We tested the influence of 13 pre-pandemic and pandemic response predictor variables on the country-level variation in the spread and severity indicators using multivariate statistics and regression analysis. We found that wealthier African countries, with larger tourism industries and older populations, had higher peak (p < 0.001) and cumulative (p < 0.001) attack rates, and lower CFRs (p = 0.021). More urbanized countries also had higher attack rates (p < 0.001 for both indicators). Countries applying more stringent early control policies experienced greater delay in detection of the first case (p < 0.001), but the initial propagation of the virus was slower in relatively wealthy, touristic African countries (p = 0.023). Careful and early implementation of strict government policies were likely pivotal to delaying the initial phase of the pandemic, but did not have much impact on other indicators of spread and severity. An over-reliance on disruptive containment measures in more resource-limited contexts is neither effective nor sustainable. We thus urge decision-makers to prioritize the reduction of resource-based health disparities, and surveillance and response capacities in particular, to ensure global resilience against future threats to public health and economic stability. Summary BoxO_ST_ABSWhat is already known on this topic?C_ST_ABSO_LICOVID-19 trajectories varied widely across the world, and within the African continent. C_LIO_LIThere is significant heterogeneity in the surveillance and response capacities among WHO African region member states. C_LI What are the new findings?O_LICumulative and peak attack rates during the first wave of COVID-19 were higher in WHO African region member states with higher per-capita GDP, larger tourism industries, older and more urbanized populations, and higher pandemic preparedness scores. C_LIO_LIAlthough better-resourced African countries documented higher attack rates, they succeeded in limiting rapid early spread and mortalities due to COVID-19 infection. C_LIO_LIAfrican countries that had more stringent early COVID-19 response policies managed to delay the onset of the outbreak at the national level. However, this phenomenon is partially explained by a lack of detection capacity, captured in low pandemic preparedness scores, and subsequent initial epidemic growth rates were slower in relatively well-resourced countries. C_LI What do the new findings imply?Careful implementation of strict government policies can aid in delaying an epidemic, but investments in public health infrastructure and pandemic preparedness are needed to better mitigate its impact on the population as a whole.