In Africa, the “hidden” burden of excess mortality due to Covid-19

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The grave of a man who died of Covid-19 at the Saint-Lazare cemetery in Dakar, August 4, 2021.

It’s time for reckoning. If throughout the world, the Covid-19 pandemic has caused, directly and indirectly, almost three times as many deaths as the official death toll, as reported on May 5 by the World Health Organization (WHO ), Africa is no exception. Between 1er January 2020 and December 31, 2021, the number of Africans who died of Covid-19 would amount to 1.24 million, five and a half times more than the 229,197 deaths officially listed on January 4, 2022 by the African Centers office. Disease Control and Prevention (CDC) of the African Union.

Despite this, the countries of the continent, like those with low and middle incomes in the rest of the world, carry “only” 19% of this “hidden” burden, with the greatest observed excess mortality concentrated in Southeast Asia, Eastern Europe, North America and Latin America. Worldwide, SARS-CoV-2 and its multiple variants are responsible for the death of 13.3 to 16.6 million people. Much more than the 5.5 million deaths officially recorded over the same period, according to the WHO, whose figures confirm the spectacular reassessments announced in a study published in early March in the scientific journal The Lancet.

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To carry out these models, the UN agency compared the number of deaths that occurred in each country with those of previous years. Figures that must however be spoken with caution, explained the WHO during the presentation of the results. “The African estimates were presented without us having been able to have all the necessary data, recognized William Msemburi, an analyst at the WHO. Only five countries were able to provide consolidated data, 42 do not have enough and a few none at all. We are therefore faced with a real difficulty in modeling”, which could raise fears of a greater number of these “hidden” deaths.

“The shortcomings revealed by the Covid-19 pandemic indicate that one of the crucial challenges of the years to come will be to strengthen health information systems, everywhere in the world, in order to be able to better protect and prevent”, added Dr. Samira Asma, in charge of the file at the WHO.

Southern Africa pays the heaviest price

To explain the difference between the number of deaths announced daily by the Africa CDC and these complex mathematical models, it must first be remembered that excess mortality not only counts deaths directly attributable to SARS-CoV-2 – curve on which public opinion world has had its eyes glued since the start of the crisis – but also those indirectly associated with it, all causes combined, “resulting from the impact of the pandemic on health systems and society”explains the WHO.

On the continent, and generally for developing countries, the figures suggest that Africans have died as much from Covid-19 itself as from its consequences. Because the pandemic has led to a major economic and social crisis: already fragile health systems shaken, renunciation of care, delays and resistance to anti-Covid vaccination, distancing of populations from health centers whose financial resources and personnel have been massively reassigned to the response, interrupted vaccination routine for other “big killer” diseases (AIDS, tuberculosis, malaria, measles), restricted access to certain treatments and drugs, sudden impoverishment of households. According to the United Nations, the number of people living on less than $1.90 a day – the extreme poverty line – in sub-Saharan Africa has increased by 37 million in 2021.

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In terms of excess mortality, large disparities are observed across the continent, the average of which is 61 “excess” deaths per 100,000 inhabitants, according to WHO models, while the world average is 82. Southern Africa pays the highest price, with rates of 200 for South Africa, 164 for Eswatini, 156 for Bostwana, 151 for Namibia, 93 for Lesotho, 67 for Mozambique, 63 for Zimbabwe and 62 for Zambia. In the Maghreb, Tunisia (160) and Egypt (122) together experienced higher excess mortality than Morocco (47), Algeria (79) and Libya (57) combined.

“In southern Africa, where the seasons are much more marked, we have seen hospital saturation phenomena during winter waves”, deciphers Professor Arnaud Fontanet, epidemiologist at the Institut Pasteur in Paris, specialist in Covid-19 : “This was less the case in intertropical Africa, where the virus circulated more constantly. » Excess mortality was both less visible and less significant. From Senegal to Ethiopia, via Côte d’Ivoire or Nigeria, practically all the countries of the sub-Saharan band have figures lower than the continental average, with the exception of Cameroon (66), the Central African (64), Somalia (110) and the Democratic Republic of Congo (65).

A majority of deaths at home

In this equation, however, it is difficult to determine precisely for each country the additional deaths directly attributable to the new coronavirus: a certain number of fatal cases of Covid-19 have been “missed”as the study points out, for lack of having tested the people ante Where post mortem or because national statistical systems are not robust enough.

A study made public at the end of March and carried out in Zambia on 1,118 people tested post mortem had revealed the presence of the virus in 90% of cases during the epidemic peak, which does not mean, however, that these people all died of SARS-CoV-2. “Thanks to the many seroprevalence studies carried out on the continent, we know that the virus has circulated there as much as elsewhere, recalls Arnaud Fontanet. But the case of Zambia is interesting because it also showed that 80% of Covid-19 deaths died at home. This is the missing piece of the puzzle to explain a large part of these hidden cases, even if there have still been few studies of this type in Africa. »

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Another meta-analysis study, led by Andrew Levin and presented in 2021 in the British Medical Journal, had shown that the risk of dying (fatality rate) was twice as high in developing countries as in high-income countries, in particular because of difficulties in accessing healthcare. An effect compensated, even counterbalanced, by the youth of the population in Africa. Out of 1.3 billion inhabitants, only 3.5% are over 65 years old.

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