Marie Roseline Darnycka Bélizaire
Daogo Sosthène ZOMBRE
This paper is a contribution to the upcoming Vol. XI of the UNESCO book series on the General History of Africa, temporarily entitled Global Africa Today.
Note: The French version can be read at the end of the English version
This chapter discusses three key aspects of the problem of epidemics in Africa. Their trail in relation to international trade, their recurrence and key prevention strategies undertaken by the countries, their early detection and effective response.
An epidemic is defined as the rapid and sudden spread of an infectious disease proliferating to a large number of people in an area. A pandemic, meanwhile, is the spread of an epidemic to a whole continent or to the whole world. Outbreaks can be bacterial or viral. They are, in most cases, highly contagious with a very high rate of propagation. Epidemics have always represented a great challenge for humanity. Communities are often considerably marked by loss of life, economic depression and social mayhem. Often of unexpected origin and of unidentified past trail, they have been known to decimate between 20-30% of the population of affected communities. In 430 BCE for example, a smallpox epidemic shrunk the population of Athens in Greece by 20% (Retief, Cilliers, 1999).
This contribution provides a brief update on major epidemics in Africa in the early 21st century with a focus on Sub-Saharan Africa, and on response measures outlined by the countries, with the help of partners, to minimize their impact.
Exchange and spread of epidemics to Africa
The Justinian Plague, which began in 541, lasted nearly 200 years and killed about 50 million people in the Middle East, Asia and the Mediterranean basin, and by the year 567 spread to North Africa brought along by travellers. Europeans travelling in this part of the continent described a series of raging infectious diseases in the 18th-19th century. Most of them probably introduced by immigrants from Europe or the Middle East. The third plague pandemic began in the late 19th century (1894) in Yunnan in China. It struck Madagascar in 1896[i].
A number of diseases, becoming endemic in Africa, have also been introduced from other continents. Such as cholera. First encountered in the Indian subcontinent (Sarkar, Kanungo, Nair, 2012), the disease spread worldwide, in the 19th century along the trade routes. The six pandemics after cholera have killed millions of people on every continent. The current pandemic, the seventh, started in South Asia in 1961 and reached Africa in 1971, where cholera is now prevalent. Smallpox has also been imported into Africa in the 16th century by European settlers (Collins, Burns, 2014). This disease was introduced in 1755 in Cape Town, South Africa, by infected Europeans from east India. In 1864-1865, a major epidemic struck Namibia and Angola; it practically led to the annihilation of trade due to the depopulation of central Angola. In the 20th century, the influenza pandemic, commonly known as “Spanish flu”, which Chinese origin is still uncertain, and which resulted in the loss of 20-50 million victims worldwide, pursued its rampage in North and South Africa in the last months of 1918 (Philips, 2014).
More recently, in the early 21st century (in 2000), a Meningococcal NmW135 cerebrospinal meningitis epidemic spread from Saudi Arabia. It travelled across the African continent, including Burkina Faso, Niger, Central Africa, Senegal and Chad. In 2002, this strain resulted in more than 1447 deaths in Burkina Faso (Nicolas, 2012). Severe Acute Respiratory Syndrome (SARS), first reported in China in 2002, affected South Africa in April 2003[ii].
The extraordinary expansion in connections, especially by air, has shortened distances, brought people closer and transformed our world into a very tightly connected “village”. The latest report of the International Civil Aviation Organization (ICAO), dated 02 January 2017, indicates that the total number of passengers travelling on scheduled services reached 3,700 million in 2016 worldwide.
Africa has witnessed 3% of the world market for international passenger air traffic expressed as revenue passenger kilometres (RPK); the African international air traffic market rose from 2.3% in 2015 to 5.7% in 2016[iii]. The exchanges have had a positive impact on African economies, but have also increased the risk of spreading infectious diseases not only within the continent but also from Africa to other continents and vice versa. The first two decades of the 21st century have henceforth witnessed an increase in the number of outbreaks compared to the last decades of the 20th century.
Africa, permanently exposed to risks of epidemics
With its environmental, economic, social and cultural characteristics, Africa was and still is in the 21st century a continent where communicable diseases spread easily and rapidly. They are frequently deadly.
The continent has undeniable environmental assets: steady climate and rich biosphere, mainly in tropical and equatorial regions. However, this situation is also conducive to the proliferation of disease vectors (mosquitoes) and of microorganisms responsible for various diseases affecting a large number of its inhabitants.
According to scientists, yellow fever has evolved in Africa since 3000 years before our
era. It was exported to the American continent on ships carrying captives from West Africa, at the turn of 17th century[iv]. Typhus and tuberculosis appeared during the 17th century in Africa. The spread of epidemics on the continent is due to economic and sanitary conditions: a capped slice of Gross Domestic Product (GDP) dedicated to health, inadequate health care systems and poverty limit people’s access to them. Rituals and beliefs based on myths and legends, form the basis of much behaviour detrimental to health. The great majority of Africans officially proclaim to be Christians or Muslims but don’t actually let go of their local religions or customs[v]. For example funeral practices, with washing and dressing the corpse, lengthy vigils, prayers for the dead and the burials to which relatives and friends attend in large numbers. In Guinea, 60% of the EVD epidemic is a result of partaking in the washing and dressing of a relative[vi]. Other practices likely to promote the spread of epidemics include eating off the same plate, using only the hands in places with very poor hygiene conditions or sleeping on the same large mats, or frequently visiting the sick.
Figure 1: Epidemics frequency between 2000 and 2006
Moreover, despite the recommendations laid out by the Conference of Ministers of Education of the African Union in 2005[vii], the education rate remains low on the continent: In 2016, 26% of illiterate adults in the world lived in Sub-saharan Africa[viii]. All these socio-cultural factors contribute to the spread of outbreaks.
In accordance with the requirements of the International Health Regulations, dating from 1969 and revised in 2005, commonly known as the IHR, countries must notify to WHO epidemics affecting them and posing a threat to the international community. As a reminder, the IHR impose on the Member States to put in place the minimum requirements to detect, notify and respond, in a timely and adequate manner, to public health emergencies. It is organized around 19 technical areas.
Figure 2: Geographic distribution of epidemics in Africa
The WHO region of Malawi[ix] has recorded 602 infectious incidents (including poliomyelitis) from November 2000 to December 2006 (fig. 2). For this period, the Democratic Republic of Congo reported 12.29% (74/602) of the epidemics, an average of 14 infectious incidents per year (full period 2001- 2006), at least one epidemic per month; it is followed by Nigeria: 10.13% (61/602). Uganda and Kenya were also very affected, with more than 30 reports. However, there may be a discrepancy between these figures and the exact estimate of disease burden because many of the cases are not diagnosed due to weaknesses in surveillance systems and fears from countries of negative impacts on the population, trade and tourism.
The most common diseases are the cholera, yellow fever, meningococcal meningitis, measles, wild-type poliomyelitis, typhoid fever and shigellosis. There were in total 164 cholera epidemics from 2001 to 2006. In 2003, 18 cases of Severe Acute Respiratory Syndrome (SARS) were reported.
From 2011 to 2017[x], a total of 447 outbreaks were reported in Africa. The polio epidemics are excluded, a critical illness which is the subject of a very special reporting process throughout the above mentioned period. The most common infections are of zoonotic viral origin. However, pathogens of bacterial and parasitic origin also play an important role in the multiplication of epidemics on the continent. The most affected countries have common characteristics: vast territories, a high number of inhabitants, a low Human Development Index (HDI) between 0.353-0.527 (14). They have benefited from the programme to strengthen the epidemiological surveillance system for part of the studied period (fig. 2).
The analysis of outbreaks per year during the second decade of the 20th century, shows a curve with peaks of over 70 incidents in 2012 and 2016. The situation was fairly stable between 2013 and 2015 with rates ranging between 61-63 epidemics. It should be remembered that the years 2014-2016 were particularly marked by the deadly EVD epidemic. However, outbreaks are on the rise since the beginning of 2017. In 39 countries, a total 134 outbreaks occurred during the year 2017; the most common are due to viral haemorrhagic fever (28%), cholera (10%) and measles (8%).
Fight against epidemics and prospects
Measures to combat epidemics are of a logistics, operational and financial nature. To protect people, the African countries are getting organised: opening of quarantine wards in hospitals, building of medical centres and clinics, raising public awareness and implementing prevention policies by vaccinations (routine immunization and mass campaigns). With the multiplication of vaccines and antibiotics, some diseases, previously devastating – such as smallpox, meningitis, measles, cholera, tetanus or diphtheria – saw a significant reduction of their impact on mortality in Africa[xi].
In 1998, the WHO African Region Member States have developed an Integrated Disease Surveillance and Response (IDSR) strategy across the continent. The first edition of the IDSR Technical Guide has been widely adopted and adapted throughout the African region at the beginning of the 21st century (2001) (18). This surveillance integrates and empowers communities to actively involve them in prevention strategies (community-based surveillance). This makes it possible to set up early warning systems and quickly organize the response. The social mobilization of populations is therefore essential for the implementation of this strategy (18).
If, between 2014-2016, the Ebola outbreak was a potential threat to regional and global health security, it nevertheless allowed to draw attention again to the implementation of the IHR 2005 and the need for countries to have strong health systems to respond to sanitary incidents. Aware of this situation, the governments have adapted to the different global and regional strategies, in terms of readiness and response to public health emergencies. Between 2016 and early 2018 on the African continent, 35 countries conducted an assessment on their readiness and response to public health emergencies. A joint external audit assigning scores to the IHR 48 core capacity indicators was carried out, while identifying priority measures for each country according to its capacities at the time of the assessment. These priority measures must be used to develop a national action plan for health safety to which all affected partners must align.
These strategies go beyond the tackling of epidemics only. Indeed, the Countries are intensifying their capacities to be ready and respond to all hazards (biological, chemical, radioactive, natural disasters) capable of causing a public health problem of international scope. The initiatives were put in place in collaboration with various partners (Global Fund[xii], GAVI[xiii], IHP+[xiv], HHA[xv] and others) who are active in health programmes on the continent. Key agreements were drawn up with Pasteur Institutes for the identification of certain types of infectious agents causing epidemics and for quality control in laboratories diagnostics. The same with the Centre for Disease Control and Prevention in the USA (CDC Atlanta) in terms of quality control and the enhancement of laboratories capacities, epidemiological surveillance, training in field epidemiology. Operations development partners (multi-lateral or bilateral cooperation, international NGOs) have been active in the support of access to care initiatives for populations and have thus contributed to the bolstering of global health security. The United Nations System (SNU) supports governments in all aspects of epidemic management and other health emergencies. In 2005, the sectoral responsibility approach was adopted by the UN to improve the effectiveness of humanitarian action. The WHO, on the other hand, as a leader in the health sector, encourages and continuously advocates active leadership and a more substantial commitment from governments in identifying their needs and management of aid. It provides support in development support and availability of manuals and guides; it promotes wide-range training in all countries of the continent. It assists countries in adopting key strategies for managing epidemics.
On an operational scale, the Countries have put in place coordination mechanisms, at both national and multinational level, in collaboration with partners, non-governmental organizations (NGOs) and the communities themselves. Many countries have established health emergency operations centres. There is an endeavour to consolidate national programmes for prevention and control of infections, the treatment of cases, the empowerment of national laboratories, epidemiological surveillance and logistics emergency development which includes setting up of emergency services in locations identified during periodic risk assessments.
The tackling of the EVD epidemic has highlighted the importance of getting people involved in risk management. This has optimized the chances of obtaining convincing results. By being more aware of life’s hazards, and their anticipation, populations can better protect themselves through the acquisition of knowledge and a change of behaviour drawn from memory, life experience as well as family education. Community involvement is essential to counteract outbreaks. Although much of the response and prevention strategies must be implemented and coordinated by the State, to be effective, the fight must include a set of actions undertaken by communities that integrate them into their cultural practices. On the other hand, these actions must also lead to a remedy in funerary rites to guarantee the safe and dignified burial of the deceased as asserted by the communities. The lessons learned from the tackling of the EVD were highlighted in the recent handling of the plague epidemic in Madagascar in 2017, where steps have been taken to ensure that burials respect local customs while also respecting health rules.
Governments need to foster close cooperation with the communities through health campaigns so that the remedies in cultural behaviour happen naturally by integrating health concepts into the daily lives of people. Communities need to be actively involved in public health for them to benefit and to gain more from services and get better results in terms of impacts on the lives of individuals. The Countries must work with the communities to obtain their collective and individual commitment to fight epidemics. It is now imperative to involve the community in public health actions outside epidemics to ensure that the conduct is consistent during periods of epidemics.
Mass vaccination programmes at multinational level were held across Africa in the fight against polio, measles and meningococcal meningitis. In 2010, the meningitis belt countries launched a massive vaccination programme against meningococcal meningitis A, using a revolutionary vaccine that provided immunity for more than ten years. More than one hundred million people were vaccinated between 2010 and 2015 and more than 116 million in 2017.
In 2006, “the Yellow Fever Initiative” was launched to ensure the global supply of yellow fever vaccine and boost immunity in populations. From 2007 to 2016, thanks to this initiative, 14 countries conducted preventive vaccination programmes against yellow fever, more than 105 million people were vaccinated.
After the epidemic, the WHO member states (193 countries) adopted a new programme designed to address all risks that may endanger public health, in an adaptable manner, swiftly and with the principle of “no regrets”. This programme helped to meet the immediate needs of populations’ health affected by crises and at the same time lowered their vulnerability[xvi].
On the financial side, most countries have formulated their own plans for the speedy provision of resources. The regional economic communities, the Arab Maghreb Union, the Common Market for Eastern and Southern Africa, the Community of Sahelo-Saharan States, the Economic Community of Central African States, the East African Community, the Economic Community of West African States (ECOWAS), the Intergovernmental Authority on Development and the South Africa Development Community (SADC) ensured coordination at the sub-regional level. In 2012, the African Public Health Emergency Fund was created. It is funded by contributions from all 47 members of the WHO African region which purpose is to help countries in difficulty. It is actually a solidarity fund for epidemics. Countries also have the opportunity to appeal to the Central Emergency Response Fund (CERF) established by the United Nations System. Other logistics partners and donors also have fast financing mechanisms for emergencies available to countries in difficulty; the aid is either paid directly to governments or through international NGOs[xvii]. Via the Regional Disease Surveillance Systems Enhancement (REDISSE), the World Bank has supported the countries of West Africa in enhancing animal and human health systems to fight against infectious diseases
This project with a budget of US $ 114.06 million covers the period 2017-2023 and comprises five main components.: i) surveillance and information systems, ii) laboratory capacity enhancement, iii) emergency readiness and response iv) human resource management for effective disease surveillance and preparedness for epidemics, and v) strengthening of institutional capacity of Project Management and Coordination.
Thus, epidemics remain a major public health issue in Africa. The continent is the epicentre of health challenges of the 21st century. Significant grappling efforts are being made by countries and the international community, with encouraging results and sustained enthusiasm. However, whilst some diseases are becoming scarce, “new micro-organisms” are emerging, resistant to antimicrobials and threaten to destabilize not only health systems but also African economies, making the fight against epidemics a significant component of development. It is also important to note the presence of other humanitarian crises (armed conflicts, massive displacements of populations, terrorism) which increase the risks of epidemics and hinders their tackling. Nevertheless, African States should use the fight against epidemics as an opportunity to enhance their health systems as a whole and to advance towards the establishment of a universal health system, for a population deprived of basic health care cannot ensure its economic and social development.
Collins RO, Burns JM., 2014, A History of Sub-Saharan Africa, Second Edition, chapter 12, “Diseases and crops, old and new” p.190-199, Cambridge University Press.
Nicolas P., 2012, Épidémies de méningite à méningocoques dans la ceinture de la méningite (1995-2011) et introduction du vaccin méningococcique A conjugué, Med Sante Trop, 22 , p 246-258.
Retief FP, Cilliers L., 1998, “The epidemic of Athens, 430-426 BC” S Afr J Med., Jan, 88 (1), p 50-53.
Phillips H., 2014, “Influenza Pandemic (Africa)”, International Encyclopedia of the First World War 1914-1918, online 2014, online access on 22 July 2017. Available at: https://encyclopedia.1914-1918-online.net/article/influenza_pandemic_africa
Sarkar BL, Kanungo S, Nair GB, 2012, “How endemic is cholera in India?” The Indian Journal of Medical Research, 2012, 135 (2), p 246-248.
[i]Geneawiki, « Nos ancêtres et la peste », online access on 22 July 2017, available at: https://fr.geneawiki.com/index.php/Nos_anc%C3%AAtres_et_la_peste.
[ii] World Health Organization (WHO). Preparedness and response. Cumulative Number of Reported Probable Cases of SARS. 11 July 2003, online access on 22 July 2017, available at: http://www.who.int/csr/sars/country/2003_07_11/en/
[iii] International Civil Aviation Organization (ICAO). In 2016, increase in airline traffic and profitability were important elements of air transport, online access on 5 July 2017, available at: https://www.icao.int/Newsroom/Pages/ES/traffic-growth-and-airline-profitability-were-highlights-of-air-transport-in-2016.aspx
[iv] Center for Disease Control and Prevention (CDC). Office of Surveillance, Epidemiology and Laboratory services. Scientific Education and Professional Development Programme. History Timeline Transcript of Yellow fever. Online access on 1 July 2017, available at: https://www.cdc.gov/travel-training/local/HistoryEpidemiologyandVaccination/HistoryTimelineTranscript.pdf
[v] United Nations Educational, Scientific and Cultural Organization (UNESCO), Histoire générale de l’Afrique, volume VIII, L’Afrique depuis 1935, chapter 17, p 533-553, Online access on 22 July 2017, available at: http://unesdoc.unesco.org/images/0018/001843/184344f.pdf
[vi] World Health Organisation (WHO), Alerte au niveau mondial. Obstacles à un endiguement rapide de la flambée de maladie à virus Ebola, 11 August 2014, online access on 22 July 2017, available at: http://www.who.int/csr/disease/ebola/overview-august-2014/fr/
[vii] African Union (AU), Document of UNESCO, « Education and culture in Africa’s quest for development », Conference of Ministers of Education of the African Union (COMEDAF II), 1st Ordinary Session 8-11 April 2005 Algeria, online access on 22 July 2017, available at: http://ocpa.irmo.hr/resources/docs/COMEDAFII_Unesco_EdCultRole-en.pdf
[viii] UNESCO Institute of Statistics, Information Bulletin of the UIS, September 2016, 38, online access on 28 juin 2017, available at: http://uis.unesco.org/sites/default/files/documents/fs38-50th-anniversary-of-international-literacy-day-literacy-rates-are-on-the-rise-but-millions-remain-illiterate-2016-fr.pdf
[ix] The WHO African region comprises 47 countries in sub-Saharan Africa, plus Algeria for North Africa.
[x] The analysis was conducted in March 2017 by the Infectious Risk Management Programme of the WHO new Health Emergencies Programme. The data was collected until February 2017 and yet incomplete for 2016.
[xi] World Health Organisation (WHO), Statistiques sanitaires mondiales 2014, online access on 23 July 2017, available at: http://apps.who.int/iris/bitstream/10665/131954/1/9789240692688_fre.pdf?ua=1; World Health Organisation (WHO), La santé des populations: les mesures efficaces. Le rapport sur la santé dans la Région africaine 2014, online access on 22 July 2017, available at: http://www.aho.afro.who.int/sites/default/files/publications/2446/ARHR-2014-fr.pdf?ua=1; World Health Organisation (WHO), Activités de l’OMS dans la région africaine. Rapport biennal 2014-2015 de la Directrice régionale, online access on 22 July 2017, available at: http://www.sante-tchad.td/attachments/article/36/Rapport%20Biennal%20de%20la%20%20%20DG.pdf
[xii] Established in 2002, the Global Fund is an international public-private financing mechanism and not an executive agency. The Global Fund, however, works in partnership with countries and executive agencies to improve health prospects.
[xiii] GAVI (Global Alliance for Vaccines and Immunisation): Established in 2001, the GAVI Alliance is a global public-private partnership that brings together developing countries, private and public partners, international organizations and the vaccine industry in industrialized and developing countries to increase access to vaccination in the most deprived countries.
[xiv] IHP+ (International Health Partnership): created in 2007, it aims to improve MDG prospects and ensure universal access to health services.
[xv] HHA (Harmonization for Health in Africa): regional mechanism established in 2006, includes the regional directors of the United Nations institutions and development agencies active in the health sector.
[xvi] World Health Organisation (WHO), Statistiques sanitaires mondiales 2014., online access on 23 July 2017, available at: http://apps.who.int/iris/bitstream/10665/131954/1/9789240692688_fre.pdf?ua=1; World Health Organisation (WHO), La santé des populations: les mesures efficaces. Le rapport sur la santé dans la Région africaine 2014, online access on 22 July 2017, Available at: http://www.aho.afro.who.int/sites/default/files/publications/2446/ARHR-2014-fr.pdf?ua=1; World Health Organisation (WHO), Activités de l’OMS dans la région africaine. Rapport biennal 2014-2015 de la Directrice régionale, online access on 22 July 2017, available at: http://www.sante-tchad.td/attachments/article/36/Rapport%20Biennal%20de%20la%20%20%20DG.pdf
[xvii] World Health Organisation (WHO). Integrated Disease Surveillance and Response (IDSR) 2010.