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Towards a strengthened active surveillance partnership between European and African airports for controlling the COVID-19 pandemic

With COVID-19 cases slowly but steadily rising in Africa, the need for a real surveillance partnership between European and African airport authorities becomes urgent.

Unless you have lived on another planet lately, you probably know by now that the coronavirus disease (COVID-19) outbreak started in China in November-December 2019 and was declared a Public Health Emergency of International Concern (PHEIC) by the Director General of the World Health Organization on January 31, 2020. Last week, the WHO Director General officially declared the COVID-19 epidemic “a pandemic” in view of the rapid spread of cases worldwide with more than 150,000 cases in over 114 countries (at the time). Dr. Tedros also announced, “We expect to see the number of cases, the number of deaths, and the number of affected countries climb even higher“.

From China, the epidemic has gradually spread worldwide, although some countries have clearly been hit harder than others so far. Currently, the epicentre of the pandemic is in Europe.

How about  Africa? According to the WHO-AFRO  Covid-19  dashboard, as of 16 March, 27 countries on the African continent were affected, with 23 of them situated in the WHO African region (with 345 (Africa) and 170 cases (WHO Afro) respectively). Till recently, Africa was relatively ‘spared’ by the pandemic. Various hypotheses have been offered for this relative lack of cases so far (among others, early on, lack of detection, later on also climate/humidity aspects, a possible seasonal cycle  or also Africa’s demography), but there’s no hard evidence yet on these various hypotheses. And from the start on, global and African public health leaders have been very, very worried in case Covid-19 were to reach Africa.

Which is clearly the case now, unfortunately. On Sunday evening, for example, the South African president declared that Covid-19 had become a  “national disaster”. Is Africa, at last, also heading for very dire scenarios? Only time will tell.

Earlier in the outbreak, everyone expected African cases to arrive from China or other Asian countries with a modelling study in the Lancet predicting the countries and cities at most risk due to their air travel links with China. To the world’s (and Africa’s) great surprise, the cases detected in several African countries (Nigeria, Algeria, Morocco, Senegal, Togo, Burkina Faso, DRC, Ivory Coast, Ghana and Guinea, Liberia,… ) mostly came from Europe (Italy and France, predominantly), however, after the COVID-19 pandemic epicenter shifted to Europe.

As Dr Tedros has said repeatedly, the spread of the COVID-19 epidemic in Africa poses great risks since  health systems in many LMICs on the continent are quite fragile, public spending on healthcare in Africa is among the lowest worldwide, national budgets are low and support from donor countries has been inconsistent. As you recall, this was one of the main reasons why a PHEIC was announced end of January. Fortunately, unlike in some European countries (or Iran), most African countries still face the second or third of the four transmission scenarios listed by WHO. ‘Sporadic cases’ (countries with 1 or more cases, imported or locally detected; or ‘clusters of cases’ (countries experiencing cases clusters in time, geographic location and/or common exposure). Hopefully, ‘community transmission’ (the fourth scenario) can be prevented, as that would be a disaster for health systems in most African countries. But that will be easier said than done.

With regards to the current situation (i.e. most cases are apparently still ‘imported’ from European countries), questions to be asked are: (1) what are the reasons for the spread of the disease from Europe to Africa; (2) what can be done to reduce this spread from Europe to Africa?

It’s clear that air travel has been a key factor. By reviewing the Handbook for the Management of Public Health Events in Air Transport   published in 2015 and the provisional guidelines for the care of sick travelers at points of entry in the context of the COVID-19 outbreak published on February 16, 2020, a few explanatory hypotheses are possible. A first explanation could be the ineffectiveness of the monitoring mechanisms already in place, i.e. a lack of rigor in screening travelers departing from the European airports to identify individuals at risk based on the search for certain information. Indeed, the strengthening of such a mechanism, which involves airlines, would reduce the travel of people at risk to Africa and would therefore reduce the risk of contamination during air flights. Having said that, it becomes increasingly clear that even ‘effective’ airport checks could be futile for containing Covid-19. 

The second explanation would be the absence of (good) systems for detecting people at risk from epidemiological and clinical information at African airports. In a way, the same is true, in Africa, though, as on European airports: this is a particularly difficult virus which makes detection by airport screening based on thermal cameras not as effective as for other viruses in the past – due to asymptomatic transmission.

Nevertheless, a (2019) review on exit and entry screening practices for infectious Diseases among Travelers at Points of Entry shows that screening at the airport, although perhaps relatively futile in reducing disease spread (certainly also for Covid-19, it seems), has advantages that are difficult to measure, among others, “…discouraging travel of ill persons, raising awareness, and educating the traveling public and maintaining operation of flights from/to the affected areas”. Exit screening measures “should be combined with other measures such as patient information, epidemiological screening, contact tracing, quarantine to achieve a comprehensive outbreak management response”, and perhaps an algorithm could also be developed to facilitate decision making for entry/exit screening, the review argued.

Arguably, since the Ebola crisis in 2014 – 2015 in West Africa, a lot of health system capacity building has been done  in the region, with the support of international organizations (WHO, US CDC, GIZ) and African regional organizations (African Centers for Disease Control and Prevention, the West African Health Organisation and others), obviously in collaboration with national public health institutes. Among others, laboratory capacities, human resources and coordination were strengthened. In addition, focusing on entry points, training and simulation exercises have been conducted for the benefit of all actors and several member states. Since the appearance of the first COVID-19 cases, most African countries have also reinforced their capacities at entry points through the establishment of isolation and treatment centers for suspect cases, provision of equipment and essential consumables for an appropriate response, dissemination of messages to promote usual protection measures and the promotion of infection prevention and control strategies. 

The risk at African airports could no doubt also be further minimized by strengthening health collaboration between the two regions involving airport authorities, airlines and other specialized agencies which would allow a smooth exchange of information between both sides. In addition to the (very different) restrictions African airlines and airports have used so far (with especially Ethiopian airlines as a notable outlier, with respect to travel to and from China), which probably need to be streamlined and harmonized for the whole continent, African countries should also work on strengthening active surveillance systems at their international airports with appropriate information from the airlines so that arriving passengers are not surprised.

But the COVID-19 pandemic is evolving rapidly now, and cases are now also fast rising in some African countries. So it’s perhaps no surprise that several African governments on Sunday 15th March closed borders, canceled flights and imposed strict entry and quarantine requirements to contain the spread of the new coronavirus. In line with global trends, this seems to be the major orientation now in many countries…

In spite of this rapidly changing picture, however, we feel our case for strengthening an ‘active surveillance’ partnership between European and African airports (and authorities) still holds. In addition to general surveillance, early detection and response measures following international recommendations.

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