Can we do more to scale COVID-19 testing in Africa?
We revisit an analysis from two months ago to see how COVID-19 testing capacity has changed in Africa.
A few weeks ago, we wrote an analysis on COVID-19 testing capacity in sub-Saharan Africa. At the time, testing was extremely limited and not accelerating at a sufficient pace. Today we revisit that analysis to see how the situation in Africa has changed since then.
At the time of our first post two months ago, there was considerable optimistic coverage in the media regarding Africa’s success with COVID-19 . We also saw doubt from politicians, think tanks, and economists as to the extent to which COVID-19 would cause death and disruption to the health system — often citing Africa’s young age, hot and arid climate and limited importation risk. Today’s coverage of the continent’s future outlook for coronavirus is more grim. Recent media coverage has focused on the rising case and death counts, excess and unseen deaths, threats to political stability, influence on corruption, and impact on economic recovery in Africa.
Indeed, the burden of disease and pace of new cases and deaths have increased tremendously. Using Our World in Data, we find that at the end of May there were nearly 100,000 cases and over 2,000 deaths, with an average of 3,500 new cases and 80 new deaths per day in sub-Saharan Africa. By the end of July these figures increased to 750,000 cases and almost 13,000 deaths, with an average of 15,000 new cases and more than 300 new deaths per day. This means that in the two-month period not only did the total burden increase 6- to 7-times, but the speed of increasing cases and deaths increased by 4- to 5-times. We note that even these concerning figures there are almost certainly underestimates (as highlighted in recent post on Counting the Dead in Africa).
The good news: Testing capacity and data availability are on the rise
The availability of testing data has increased significantly. Previously, between Our World in Data and ministry of health websites, Twitter feeds, Facebook, and media posts we could find testing data for only 25 countries representing about 750 million people. As of August 1st, we have obtained publicly available COVID-19 testing data from 42 countries in Africa representing over a billion people (about 92% of sub-Saharan Africa’s population). Furthermore, while previously we could only establish sufficient trend data for 8 countries, today we have daily testing trend data for 31 nations.
Tests per capita have also increased substantially. By early June, we found that only 2.5 tests per 1,000 people had been done in sub-Saharan Africa — about 15- to 30-fold less than the U.S or U.K. at that time. Today this figure more than doubled, with 6.0 tests per 1,000 persons totaling over 6 million tests for reporting countries.
At the national-level, Djibouti, South Africa, and Gabon have the highest testing rates at 58.7, 47.7, and 33.8 tests per 1,000 people, respectively (Figure 1). At the low end, Chad, Niger, and Democratic Republic of Congo are testing 0.25, 0.30, and 0.43 per 1,000 people, respectively.
Figure 1: COVID-19 Tests per Capita for Reporting Countries in Africa
The bad news: Testing capacity is insufficient and not accelerating fast enough
Currently, there are two important benchmark recommendations from WHO on determining whether testing capacity is sufficient or not. First, the WHO recommends that COVID-19 test positivity rates are at least 5% or lower for 14 days, such as to allow adequate capacity for test and trace (in theory). As of August 1st, only 12 countries meet that criteria with the continent-wide positivity rate greatly exceeding the recommended threshold at over 12% (Figure 2). This indicates that most countries do not currently have the required testing capacity to effectively test, trace, and isolate — a critical public health response measure for COVID-19.
Figure 2: WHO Testing Recommendation Status by Country, July 2020
A further WHO recommendation is that countries test on average 1 per 1,000 people per week. For the 31 countries with daily testing data for analysis, the average number of new tests added per day in July is 0.98 — nearly at the recommended value. However, only 8 of the 31 countries have surpassed the threshold of 1 per 1,000 per week (Rwanda, South Africa, Djibouti, Botswana, eSwatini, Gabon, Namibia, and Cape Verde). Only two countries — Rwanda and Botswana — have met both testing recommendations.
While it is true that testing capacity is low and insufficient in most countries, a key question is whether testing is increasing at a sufficient pace to catch up with need? We evaluated daily new tests figures from May through the end of July. In May, the average daily increase in new tests (in absolute terms) was 12, while it was 16 in June, and 22 in July — indicating the rate of increase is on the rise slightly.
On the relative scale, the rate of new test increase has almost doubled — but in absolute terms it means only an increase of 22 new tests per day in July — far short of reaching the testing levels required for gaining epidemic control. Unfortunately, even this modest acceleration disguises the fact that nearly a third of country-months actually saw decreases in the pace of daily new tests (Figure 3), indicating new tests are decelerating in many places. If we exclude the top and bottom 3 performing nations in July, the average falls from 22 to 11 — representing essentially no increase in pace of new tests. While some of these negative trends could be due to reporting issues, the overall pattern is less than promising.
Figure 3: Trend in New COVID-19 Tests in July 2020 for African Countries with Available Data
Africa continues to innovate but there is still more to be done
In review, total COVID-19 burden as well as the pace of increase in cases and deaths has increased several-fold in the past two months in sub-Saharan Africa. Data on test volume have become more available and the per capita testing rate has increased nearly three times but has not gained ground relative to the highest testing nations. Only a few countries have meet either WHO testing criteria, and only two countries meet both criteria of less than 5% test positivity and more than 1 test per 1,000 population per week. Finally, and most importantly, the rate of acceleration in the past two months is positive but is still extremely slow — adding an average of only 22 additional new tests per day.
Still, there are good signs on the horizon. Africa continues to innovate and adapt, with rapid tests being scaled up across the continent, as well as novel rapid tests being developed. Senegal, Ghana, and South Africa have made advancements in cheap, high quality, and novel test modalities. Furthermore, Rwanda has leveraged drones for health communication and distribution of tests. At the global level, continued investments to increase test supply productions and a leveling of scale-up in much of the world means that at least the constraint of global supply drastically outstripping demand may make acceleration of testing in Africa even more possible. Nonetheless, global health and donor communities must redouble their focus on COVID-19 testing to ensure adequate capacity is available to facilitate a sufficient public health response.
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