Experts Eye Japan For Clues On COVID-19 Trends; In Africa, Egypt, Algeria & South Africa At Highest Risk, Says Lancet Study
Ports of entry in the Democratic Republic of the Congo are now using temperature screening systems, created for detecting Ebola to screen travelers for COVID-19.

Experts were closely watching the development of Japan’s COVID-19 outbreak for signs of whether the virus might escape further out of control, moving closer to the tipping point of a pandemic – the worldwide spread of a new disease.

Meanwhile, a new study in The Lancet  found that in Africa, Egypt, Algeria and South Africa are at highest risk of new coronavirus cases. However, these countries also have the most prepared health systems and therefore  less vulnerable.

Countries at moderate risk, include Africa’s most populous nation, Nigeria, as well as Ethiopia, Sudan, Angola, Tanzania, Ghana, and Kenya. Significantly, they are also less prepared and more vulnerable, and require further support to help them detect and handle imported cases of novel coronavirus disease 2019 (COVID-19).

Algeria, Ethiopia, South Africa, and Nigeria were also among 13 top priority at-risk countries identified by the World Health Organization (WHO), based on their direct links and volume of travel to China. The first case of COVID-19 in Africa was confirmed in Egypt last Friday, on 14 February 2020.

China is Africa’s leading commercial partner with over 200,000 Chinese workers in Africa, and high volumes of travel, through which the novel coronavirus could reach the continent.

Global distribution of COVID-19 cases, as recorded by Chinese national authorities 19 February at 3 p.m. CET.

In Asia, Japan Most Immediate Focus; Korea and Singapore Close Behind

Currently, however, Japan and Singapore remained the most immediate hotspots of concern, with 84 cases each of the novel coronavirus, the most outside of China itself. China had recorded 74,284 cases as of late Wednesday afternoon Central European Time, 1,756 more than the day before, while deaths now reached 2009. Globally, there were 1,017 confirmed cases, a worrisome rise of 220 more over the day before.

Japan has faced a gradual influx of cases brought about by considerable tourism and employment related travel to and from China. But it has also been forced to grapple with the cases of the 621 infected people identified aboard the Diamond Princess cruise ship that was under a strict quarantine in Yokahama harbour until Wednesday, when the first 600 passengers who had been given a clean bill of health, were finally allowed to disembark.  Others of the original 3700 passengers and crew remained aboard because their COVID-19 tests had been positive, though not serious enough for hospitalization. A number of countries, including Canada, Australia and Korea have announced mass evacuations of their stranded citizens, following on the US evacuation of 300 nationals earlier this week.

Rather than containing infection, the quarantined ship may have proved to be an incubator for the spread of the virus, many experts now fear.  A prominent Japanese specialist, Kentaro Iwata, who boarded the ship on Tuesday slammed the infection control measures on board the ship as “completely inadquate.”  In a video posted on You Tube, but later removed, Iwata was quoted describing the ship environment “chaotic” with no distinction between infected and uninfected zones, and no infection control officials in charge, National Public Radio reported.

Former FDA commissioner Scott Gottlieb told CNBC that Japan seems to be “on the cusp of a large outbreak,” while Syra Madad, another public health expert, was quoted, saying “We’re really closing in on the tipping of this being declared a pandemic.”

Meanwhile Korea, which had 51 reported cases as of Wednesday afternoon, the third highest outside of China, announced a host of stringent infection control measures, for schools, businesses and public places following a meeting of top health officials, which was presided by the prime minister.

Those include: mass distribution of masks; as well as stepped up COVID-19 testing in hospitals. It has issued travel warnings against visiting China’s high-burden COVID-19 provinces, and instituted a mandated screening of all inbound travellers, including installation of a self-diagnosis and locational app on their cell phones.

Chinese employees returning from China following the Lunar New Year, will be required to spend two weeks in self-isolation, prior to returning to work as will a group of Koreans evacuated from the Diamond Princess, the announcement by the Korean Ministry of Health and Welfare also noted.

In Cambodia, meanwhile, Cambodian health officials, supported by WHO and the US Centres for Disease Control (CDC), were now scrambling to put in place a series of measures to contain transmission risks, after another cruise ship, the Westerdam, was allowed to dock in Sihanoukville last week and release its 1,455 passengers and 802 crew with far less scrutiny than the Diamond Princess.  However, shortly after disembarking, one 83 year old passenger was found to be infected with the virus upon her arrival in Malaysia.

In a press release late Wednesday evening, WHO said that in response to the confirmed case, the Cambodian Ministry of Health had convened an emergency working group, which decided to undertake COVID-19 laboratory screens for all former passengers still in Cambodia, and “health screening” of passengers still in Phnom Penh or Sihanoukville.   WHO also called on all of the 1455 former cruise passengers, who have now scattered widely, to practice “self-monitoring” and report any possible symptoms to their local health authority along with their travel history.

The WHO announcement reflected a wave of growing concern among global public health experts about the way in which the Westerdam’s passengers disembarked and scattered so quickly, without a rigorous screening for the virus, measures diametrically opposed to the tactics used on the quarantined Diamond Princess, however controversial.

“WHO’s strategy is still to contain the outbreak in China and try to make sure there is no sustained transmisison in other countries,” Eyal Leshem, head of the Center for Travel and Tropical Medicine at Sheba Medical Center in Israel, and a former medical epidemiologist with US CDC, told Health Policy Watch.  “The strategy mandates contact tracing and quarantine of contacts. Based on traditional public health principles, contact tracing and isolation, if you take 1400 people that have been potentially exposed, and you discharge them without creating a full quarantine, you potentially spread this disease to everywhere they go.”

African preparedness still creates huge risks for continent

In terms of Africa, another major at-risk region, only one case has so far been confirmed in Egypt.  However, weak health systems, combined with the sheer volumes of traffic between the continent and China, leave the continent extremely vulnerable should the virus make a beachhead, the Lancet study notes.

According to the China Africa Research Initiative (CARI), there were 202,689 Chinese workers in Africa by end of 2017, concentrated primarily in Angola, Algeria, Nigeria, Ethiopia and Zambia. Most of the Chinese investments in Africa go to Nigeria and Angola, according to Brooklings.

The Lancet study estimated the risk of African countries importing a COVID-19 case from China using data on the volume of air travel from infected Chinese provinces to Africa and the proportion of COVID-19 cases in the Chinese provinces as of 11 February 2020. Hubei province was not included, given the travel ban introduced by Chinese authorities on travel to and from the province on 23 January.

Maps showing (left) importation risk by country, (top right) country capacity to respond to risk, and (bottom right) Infectious Disease Vulnerability Index

The study notes that some measures to prevent the importation of COVID-19 cases from China, and contain transmission when and if infected people arrive, have already been implemented in many African countries.

However, more technical and operational expertise is required to carry out a full suite of measures that would be  required, including: heightened surveillance, rapid identification of suspected cases, patient transfer and isolation, rapid diagnosis, contact tracing, and follow-up of potential contacts.

“African countries have recently strengthened their preparedness to manage importations of COVID-19 cases, including airport surveillance, temperature screening at ports of entry, recommendations to avoid travel to China, and improved health information provided to health professionals and the general public. However, some countries remain ill-equipped,” said study author Dr Vittoria Colizza, of Inserm, Sorbonne Université, France in a press release.

But, “while almost three-quarters of all African countries have an influenza pandemic preparedness plan, most are outdated and considered inadequate to deal with a global pandemic. In addition, despite efforts to improve diagnostic capacity from WHO, some countries do not have the resources to test for the virus rapidly, meaning that tests would need to be done in other countries,” she added, noting:

“It is essential to train, equip, and strengthen the diagnostic capacities of hospital laboratories close to infectious disease and emergency departments to reduce the time to deliver results, manage confirmed cases and contacts more rapidly, and preserve strict infection control measures. Equally, increasing the number of available beds and supplies in resource-limited countries is crucial in preparation for possible local transmission following importation.”

More Countries Screen but Few Limit Travel Outright

As a result of the risks, pressure has been mounting in some African states to enact stricter limitations on travel to China, as well as on arrivals coming from the Asian nation.

While some countries have indeed issued travel advisories, and some major African airlines have suspended flights to mainland China, most countries have left the doors open.

On Jan. 31, Nigeria – Africa’s most populous nation, sent a powerful signal when Alhaji Lai Mohammed, the Minister for Information and Culture told journalists that Nigeria would not impose travel restrictions.

“We know it’s difficult to ban people from travelling,” Mohammed was quoted in The Guardian, a local Nigerian Daily as saying. “Another thing is that this is not stigmatise people who come from there.”

Despite the inherent risks, open doors policies have been generally supported by Dr Tedros Adhanom Ghebreyesus, World Health Organization (WHO) Director General, who has spoken out repeatedly against travel restrictions, both to the media as well as at the outset of the WHO Executive Board meeting in Geneva in early February, saying “there is no reason for measures that unnecessarily interfere with travel or trade.”

His advice clearly echoed among African health policymakers as well, among them Chikwe Ihekweazu, director general of Nigeria’s Centre for Disease Control, who tweeted, “I completely agree with the decision of the #Nigerian Govt. not to ban travel to China. As @DrTedros said, travel restrictions cause more harm than good by hindering info-sharing for public heatlh action, medical supply chains etc & have no obvious benefit.”

Observers have said that with such intertwined economic ties, most African countries simply cannot afford to be more restrictive about travel, regardless of the diverse public health and ethical issues involved.

“What is going on in China clearly shows that it is beyond a health issue. It is an economic threat to china and the world, it’s a security threat to China and the world, and it’s a social threat to China and the world,” said John Nkengasong,  director of the African Centre for Disease Control and Prevention in Addis Ababa, in an African Union news briefing in late January.

Instead of closing borders and limiting travel, countries have focused on ramping up early detection and screening measures at ports of entry, said Michael Yao, head of emergencies for the WHO Africa region, in a press briefing last week.

“What we are emphasizing to all countries is that at least they have early detection because we know how fragile the health system in the African continent is. and these systems are already overwhelmed by many ongoing disease outbreaks,” he said.

It is “critical” for cases to be detected early to “prevent spread within communities” which can trigger an influx of cases that would “easily overwhelm the treatment capacity,” added Yao. Severe cases of the new disease must be treated in intensive care units with respiratory equipment, facilities which are extremely limited in African clinics and hospitals.

 

Image Credits: Twitter: @MoetiTshidi, Preparedness and vulnerability of African countries against importations of COVID-19: a modelling study.