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Africa may have reached the pandemic's holy grail npr.org/sections/goatsandsoda/2022/01/28/1072591923/africa-may-have-reached-the-pandemics-holy-grail

Goats and Sod a STORIES OF LIFE IN A CHANGING WORLD January 28, 20225:01 AM ET Nurith Aizenman 4-Minute Listen Download

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A studen t washes her hands be fore enterin g a classroom at a school in Blantyr e, Malawi, in March 2021. Top scientists say that man y African c ountries, incl uding Malawi, ap pear to have already arrived at a substanti ally less threaten ing stage of the coronavirus pan demic. Joseph Mizer e/Xinhua News Agency/Getty Images When the results of his stu dy came in, Kondwani Jambo was stunn ed. He's an immunologist in Malawi. And last year he had set out to de termine just how many people in his countr y had been infe cted with the coronavirus since the pandemic b egan. Jambo, who works for the Malawi-Liverpool-Wellcome Trust Clinical Researc h Programme, knew the total number of cases was going to be higher than the official numbers. But his study revealed that the scale of spread w as beyond anything he had anticipated — with a huge majority of Malawians infe cted long be fore the omicron variant emerged. "I was very shocked," he says. Most importan t, he says, the findin g suggests that it has now been months sin ce Malawi entered something akin to w hat many countries still strugglin g with massive omicron waves consider the holy grail: the endemic stage of the pandemic, in which the c oronavirus becomes a more predictable seasona l bug like the flu or c ommon cold. In fac t, top scientists in Africa say M alawi is just on e of many cou ntries on the c ontinent that appear to have already re ached — if not quite endemi city — at least a substantially less threatenin g stage, as evidence d by both studies of the populati on's prior exposu re to the coronavirus and its exper ience with the omicron variant. The Malawi mystery To unde rstand how these sc ientists have come to hold this view, it helps to first con sider what the p andemic has looked like in a cou ntry such as Malaw i. Before the omicron wave, Malawi didn't seem to have been hit to o hard by COVID-19. Even by July of last year, when Malawi had alre ady gone through se veral waves of the coronavirus, Jambo says it app eared that only a tiny share of M alawians had been infected. "Probably less than 10% [of the population], if we look at the number of in dividuals that have tested positive ," says Jambo. The numb er of peopl e turning up in hospitals w as also quite l ow — even dur ing the peak of each suc cessive COVID-19 w ave in Malawi. Jambo knew this likely masked what had really been going on in Mal awi. The coun try's population is very young — it has a median a ge of around 18, he notes. This sugge sts most infec tions prior to omic ron's arrival were probably asymptomatic ones unlikely to show up in

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official tallies. People wouldn't have f elt sick enou gh to go to the hosp ital. And coron avi rus tests were in short suppl y in the coun try and therefo re were ge nerally used on ly for peop le with severe symptoms or who nee ded tests for tra ve l.

Goats and Soda Opinion: 5 steps we must   take to vaccinate the world's vulnerable—and end the pandemic So to fill in the tru e picture, Jamb o and his collabor ators turned to another potential source of information: a repository of blood sample s that had been co llected fr om Malawians month after month by the national blood bank. And the y checked how man y of those samples had antibodies f or the coronaviru s. Their finding: By the start of Malawi's third COVID- 19 wave with the delta variant last su mme r, as much as 80% of the popul ation had already be en infec ted with some strain of the coronaviru s. "There was absolutely no way we woul d have guessed that this thing had spread that much," says Jambo.

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Similar studi es have been done in other Afr ican countrie s, including Kenya, Madagascar and South Afr ica, adds Jambo. "And practically in every place they've done this, the r esults are exactly the same" — very high prevalence of infection detected we ll before t he arrival of the omicron vari ant. Jambo thinks the findings from the blood samples in Malawi expl ain a key featu re of the recent omicron wave the re: The number of deaths this time has been a frac tion of the al ready low nu mber during p revious waves. Less than 5% of Malawians have been full y vaccinated. So Jambo says their apparent resistance to severe disease w as likely built up as a resul t of all the prior exposu re to earlier variants. "Now we have had the beta vari ant — we have had the delta variant and the original," notes Jambo. "It see ms like a combination of those three has been able to neutralize this omicron variant in terms of severe d ise ase." A promising pattern

Beachgoers play soccer in Durban, Sout h Africa, durin g the omicron su rge in Dec ember 2021. Rajesh Jantilal/AFP via Getty Images And now that the omicron wave has peaked acr oss Africa, cou ntry after co untry there see ms to have ex perienced the same pattern: a huge rise in infections that has not been matched by a commensu rate spike in hospi talizations and death.

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Shabir Madhi is a prominent vacc inologist at the Un iversity of the Witw atersrand in Sout h Africa. "I think we should draw c omfort from the fact that this has be en the least sever e wave in the country," he says. The most like ly reason, he says, is that — like Malawi — South Afric a gained immunity through prior infection s, he says. One dif ference is that in South Afr ica's case, this immunity came at a high pr ice. South Africa's p opulation is su bstantially older than Malawi's, and du ring the delta wave last summer, hospital s in the coun try were swampe d. Still, the upshot, says Mahdi, is that "w e've come to a p oint where at least three-qu arters — and now after omicron, probably 80% — of South African s have developed immu nity and at least protection against se ve re disease and de ath." Will the protection last? Of course, whether Af rica is truly now in a less dangerous position depends on a "ke y question," says Emory University biologist Rustom Ant ia. "How long doe s the immunity that protects us from gettin g ill last?" An tia has been studyin g what would n eed to happen for the coronavirus to become end emic. But Mahdi says there's reason to be optimistic on this front. Research su ggests this type of protection could l ast at least a year. So Mahdi says in Afri can countrie s — and likely in many other low- and middle-income countries with similar ex periences of COVID-19 — t he takeaway is already clear: "I think we've reac he d a turning point in this pan demic. What we need to do is learn to live with the viru s and get back to as much of a n ormal society as possible."

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What does that look like? For on e thing, says Mahdi, "we should stop chasing just getting an increase in the number of doses of vacc ines that are admin istered." Vaccination efforts should be more tightly targe ted on the vuln erable: "We n eed to ensure that at least 90% of people above the age of 50 are vaccin ated." Similarly, whe n the next vari ant comes along, Mahdi says, it will be important not to immediately panic over the me re rise in in fections. This rise will be in evitable, and any p olicy that's intended to stop it with economically di sr uptive restrict ions, such as harsh COVID- 19 lockdowns, isn't just unnec essarily damaging — "it's fanciful thinking." Instead, of ficials should keep an eye out for the far mo re unlikely sc enario of a r ise in severe il lness and death.

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If you examine the sero surveys in African countries you find:

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Well over 80% of people have been exposed to the virus will

only 5-10% have been exposed to the vaccine

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“Means the chance of severe disease have been severly”

reduced because of that infection exposure

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It’s sad, we didn’t do a good job on the theraputics

T

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March 23, 2022

Trying to Solve a Covid Mystery: Africa’s Low Death Rates

nytimes.com/202 2/03/23 /health/covid-africa-deaths.html

Advertisemen t Continue reading the main story KAMAKWIE, Sierra Leone — There are no Covid fears he re. The district’s Covid-19 response center has r egistered just 11 cases since the st art of the pandemic, and no deaths. At the regional hospi tal, the wards are packed — with malaria patients. The door to the Covid isolation ward is bolted shut and o ve rgrown with we eds. People cram together f or weddings, socc er matches, conc erts, with no masks in si ght. Sierra Leon e, a nation of eight million on the coast of W estern Afric a, feels like a land inexpl icably spared as a plague passed overhead. What has happe ned — or hasn’t happened — here and in much of sub-Saharan Afr ica is a great myste ry of the pand emic. The low rate of cor onavirus infectio ns, hospitalizations and de aths in West and C entral Afric a is the focus of a debate that has divided scien tists on the contin ent and beyond. Have the sick or dead simp ly not been counted? If Covid has in fact done less damage he re, why is that? If it has been just as vicious, how have we missed it?

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The answers “are relevant not just to us, but have implicat ions for the gre ater public good,” said Austin Demby, Sierra Leon e’s health minister, in an interview in Freetown, t he capital. Advertisemen t Continue reading the main story The assertion that Covid isn’t as big a threat in Af rica has sparked debate about whethe r the African Union’s push to vac cinate 70 per cent of Af ricans against the vi rus this year is the best use of health care re sources, given that the devastation from ot her pathogens, suc h as malaria, app ears to be muc h higher. In the first months of the pandemic, there was fear that C ovid might eviscerate A frica, tearing through countries with heal th systems as weak as Sierra Leone’s, where t he re are just three doctors f or every 100,000 peopl e, according to the World Heal th Organization. The high prevalence of malaria, H.I.V., tuberculosis and malnutrition w as seen as kindling for disaster. That has not happened. The f irst iteration of the virus that rac ed around the world had comparativel y minimal impact he re. The Beta varian t ravaged South Af rica, as did Del ta and Omicron, ye t much of the rest of the c ontinent did not record similar death tolls. Into Year Three of the pandemic, new research shows the re is no longe r any question of whether Covi d has spread widel y in Africa. It has. Advertisemen t Continue reading the main story Studies that tested blood sample s for antibodies to SARS-CoV-2, the offi cial name for the virus that c auses Covid, show that abou t two-thirds of the population in most sub-Saharan countr ies do indeed have those antibodies. Since only 14 perce nt of the po pulation has received any kind of Covid vac cination, the an tibodies are overwhelmingly from inf ection.

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A busy morning at the fish marke t at Man of War Bay in Free to wn, Sierra Leone’s capital.Credit...Finbarr O’Reilly for The Ne w York Times

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Fudia Kamara, 25, sat with her son Kabba Kargbo, 3, in the hospital in K am akwie, Sierra Leone. Like nearly all the children in the pediatric ward, he had malaria.Credit... Finbarr O’Reilly f or The New York Times A new W.H.O.-led analysis , not yet p eer-reviewed, syn thesized surveys from ac ross the contine nt and found that 65 perc ent of Afric ans had been in fected by the third quarter of 2021, higher than the rate in many parts of the w orld. Just 4 per cent of Af ricans had been vaccinated when these data were gathered. So the virus is in Africa. Is it killing f ewer peopl e? Some speculation has focused on the relative youth of Africans. T heir median age is 19 years, compared with 43 in Eu rope and 38 in the United States. N early two-thirds of the popul ation in sub-Saharan Africa is under 25, and only 3 perc ent is 65 or o lder. That means f ar fewer people, comparatively, have l ived long enou gh to develop the health issues (cardi ovasc ular disease, diabete s, chronic resp iratory disease and c ancer) that can sharply incre ase the risk of severe disease and death from Covid. Young peop le infecte d by the coronaviru s are often asymptomatic, whic h could acc ount for the low number of reported cases. Plenty of other hypotheses have be en floated. Hig h temperatures an d the fact that much of life is spent outdoors c ould be pr eventing spread. Or the low pop ulation density in many areas, or l imited public transportation in frastructure. Perhaps exposure to other pathogen s, inclu ding coronaviruses and deadly infe ctions such as Lassa f ever and Ebola , has somehow offere d protection.

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Since Covid tore through Sou th and Southeast Asia l ast year, it has bec ome harder to acc ept these theori es. After all, the population of India is you ng, too (with a med ian age of 28), an d temperatu res in the cou ntry are also r elatively high. But researchers have f ound that the Delta var iant caused mill ions of deaths in India, far more than the 400,000 offici ally reported. And rates of infection w ith malaria and other coronaviruses are high in place s, inclu ding India, that have also seen high Covid f atality rates. So are Covid deaths in Afric a simply not cou nted? Most global Covid trackers re gister no cases in Sierra Leone because testing for the virus her e is effe ctively nonexiste nt. With no testin g, there are no cases to repor t. A research p roject at Njala Unive rsity in Sierra Leo ne has found that 78 percent of people have antibodies for this coronavirus. Yet Sierra Leone has reported on ly 125 Covid deaths sinc e the start of the pandemic . Advertisemen t Continue reading the main story Most peop le die in the ir homes, not in hosp itals, either becau se they can’t r each a medical facility or because the ir families take the m home to die. Many deaths are never registered with civil authorities. This pattern is common across su b-Saharan Afric a. A recent survey by the United Nations Economic Commission for Af rica found that official re gistration systems captu red only one in three deaths.

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Nurses at a hospital in Neave, Sou th Africa, moved a patient who died of Covid to a t emporary morgue in November 2020. South Af ric a is the only cou ntry in sub-Saharan A frica to record high Covid infection and death rates.Cr edit...Samantha Reinders for The New York Times

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Preparing a Covid vaccine in the town of Kathan tha Yimbo in Sierra Leon e. The lack of re ported Covid cases in the country is raising question s about whether re so urces should be direc ted at more urgent problems.Credit...Finbarr O’ Re illy for The New York Times The one sub-Saharan coun try where almost e very death is coun ted is South Afr ica. And it’s clear from the data that Covid has killed a gr eat many people in that count ry, far more than the rep orted virus deaths. Ex cess mortality data show that between May 2020 and September 2021, some 250,000 more people died fro m natural cau se s than was predic ted for that time period, based on the pattern in p revious years. Surge s in death rates matc h those in Covid cases, su ggesting the virus was the culpr it. Dr. Lawre nce Mwananyan da, a Boston University e pidemiologist and sp ecial adviser to t he president of Zambia, said he had no doubt that the impact in Zambia had been just as se ve re as in South Africa, but t ha t Zambian deaths simply had not been ca ptured by a mu ch weaker registration system. Zambia, a countr y of more than 18 million peopl e, has reported 4,000 Covid-19 deaths. The Coronavirus Pandemic: Latest Updates

Updated March 26, 2022, 8:07 p.m. ETMarch 26, 2022 March 26, 2022 Lin-Manu el Miranda wi ll miss the Oscars af ter his wife tests positive for the coronavirus.

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These youn g New Yorkers have a message to share abou t getting vacc inated against Covid. The war in Ukraine threate ns to spread Covid and undo decad es of progress a gainst other inf ectious diseases. “If that is happening in South Africa, w hy should it be di fferent here?” he said. In fac t, he added, South Africa has a muc h stronger health syst em, which ought to mean a lower death rate, rathe r than a higher on e. Advertisemen t Continue reading the main story A research team he led found that dur ing Zambia’s Delta wave, 87 percen t of bodies in hospital morgues were infected with Co vid. “The morgue wa s full. Nothing else is diffe rent — what is dif ferent is that we just have very poor data.” The Economist, which has been tracking excess deaths throu ghout the pande mi c, shows similar rates of death across A frica. Sondre Sol stad, who runs the Africa model, sai d that there had been between one million and 2.9 million e xcess deaths on the continent du ring the pande mic. “It wou ld be beautif ul if Afr icans were spar ed, but they are n’t,” he said. But many scientists tracking t he pandemic on the ground disagr ee. It’s not possibl e that hundreds of thousands or even millions of C ovid deaths could have gone unnotic ed, they say. “We have not seen massive burial s in Africa. If that had happen ed, we’d have seen it,” said Dr. Thierno Baldé, who r uns the W.H.O.’s Covid eme rgency response in Africa. “A death in Africa neve r goes unrec orded, as much as we are poor at record-keep ing,” said Dr. Abdhal ah Ziraba, an epide miologist at the Af rican Populatio n and Health Researc h Center in Nairobi, Kenya. “There is a fu neral, an ann ouncement: A burial is never done within a week because it is a big event. For someone sitting in New York hypot he sizing that they were unrecorde d — well, we may not have the ac curate numbe rs, but the per ception is palpabl e. In the media, in your social c ircle, you kn ow if there ar e deaths.” Dr. Demby, the Sierra Leone health minister, who is an epidemiolo gist by training, agr eed. “We haven’t had overflowing hosp itals. We haven’t,” he said. “There is no evidence that excess d eaths are occur ring.” Which cou ld be keepin g the death rate lower?

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Abu Kamara tended to his mother, Ramatu Sesay, in the hospital at Kamakwie, Sierra Le one. The hospital wards contain cancer an d malaria patients, bu t none with Covid.Credit... Finbarr O’Reilly for The New York Times Advertisemen t Continue re ading the main story

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A path leading to the commun ity graveyard in Mabin . Many Sierra Leone ans who die are laid to rest in small village burial grounds and not inc luded in official records.Cre dit ...Finbarr O’Reilly for The New York Times While heal th surveillance is weak, he acknowledged, Sierra Le oneans have the rec ent, terrible experience of Eb ola, which killed 4,000 people here in 2014-16. Since then, he said, citize ns have been on alert for an infectiou s agent that cou ld be killing people in their communities. They wou ld not continu e to pack in to events if that w ere the case, he said. Dr. Salim Abdool Karim, who is on the Afric an Centers for Disease Control and Prevention Covid task force and who was part of the r esearch team trac kin g excess deaths in South Africa, believes the death toll contine ntwide is probabl y consistent with that of his countr y. There is simply no reason that Gambians or Ethiopian s would be l ess vulnerable to Covid than South A fricans, he said. But he a lso said it was cl ear that large numbers of pe ople were not turning up in the hospital with resp iratory distress. The you ng population is clearly a key factor, he said, while some older p eople who die of strokes and othe r Covid-induce d causes are n ot being identif ied as coronavirus deaths. Many are not making it to the ho sp ital at all, an d their deaths are not registere d. But others are not falling ill at rates see n elsewhere, and that’s a mystery that needs u nraveling. “It’s hugely relevant to t hi ngs as basic as vaccin e development and treatment,” said Dr. Prabhat Jha, who he ads the Centre for Global Heal th Research in Toro nto and is leadin g work to an alyze causes of death in Sierra Le one.

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Researchers working with Dr. Jha are using no ve l methods — such as looking for any increase in revenue from obituaries at radio stations in Sie rra Leonean tow ns over the past two years — to try to see if deaths coul d have risen unn oticed, but he said it was clear there had been no tide of de sp erately sick pe ople. Some organizati ons working on the Covid vaccination effort say the l ower rates of illness and death should be driving a re thinking of policy. John Johnson, vaccin ation adviser for Doctors Without Bor ders, said that vaccinat ing 70 percen t of Afric ans made sense a year ago when it seemed like vaccines might p rovide long-term immunity and make it possible to end Covid- 19 transmission. But n ow that it’s cle ar that protecti on wanes, coll ective immunity no longer looks achievable. And so an immun ization strategy that f ocuses on pro tecting just t he most vulnerable would arg uably be a bette r use of re sources in a p lace such as Si erra Leone. Advertisemen t Continue reading the main story “Is this the most important thing to try to carry ou t in countr ies where there are much bigge r problems with malaria, with p olio, with measles, wi th cholera, with me ningitis, with malnutrit ion? Is this what we want to spend our resourc es on in those c ountries?” he asked. “Because at this point, it’s n ot for those pe ople: It’s to tr y to prevent ne w variants.” And ne w variants of Covid pose the greatest risk in places with older pop ulations and high levels of comorbidities suc h as obesity, he said. Other ex perts cautione d that the virus re mained an unpr edictable foe and that scaling back efforts to vaccinate sub- Saharan African s could yet l ead to tragedy. “We can ’t get complac ent and assume A frica can’t go the way of I ndia,” Dr. Jha said. A new variant as infec tious as Omicron bu t more lethal than Delta cou ld yet emerge , he warned, leaving African s vulnerable u nless vaccination rates increased significantly. “We should really avoid the hubris that all A frica is safe,” he said.