The impact of covid-19 in Africa has been vastly underestimated, warn researchers in a study published by The BMJ recently.

Outside of South Africa, this is the first study to provide systematic surveillance data capturing the impact of covid-19 in Africa.

Their findings are based on polymerase chain reaction (PCR) test results for 364 deceased people of all ages at the University Teaching Hospital morgue in Lusaka, Zambia between June and September 2020, enrolled within 48 hours of death.

The findings show that covid-19 deaths accounted for 15-20% of all sampled deaths - many more than official reports suggest and contradicting the widely held view that covid-19 has largely skipped Africa and had little impact.

They also show that covid-19 deaths occurred across a wider age spectrum than reported elsewhere and were concentrated among people aged under 65, including an unexpectedly high number of deaths in children.

The absence of data on covid-19 in Africa has fostered a widely held view that the virus has largely skipped Africa and had little impact. However, this may be an example of the “absence of evidence” being widely misconstrued as “evidence of absence.”

To address this evidence gap, a team of international researchers set out to measure the fatal impact of covid-19 in an urban African population.

Deaths were stratified by covid-19 status, location, age, sex, and underlying risk factors.

Overall, the virus was detected in 70 (19%) of people. The average age at death was 48 years and 70% were men.

Most deaths in people with covid-19 (73%) occurred in the community and none had been tested for the virus before death. Among the 19 people who died in hospital, six were tested before death. Among the 52 people with data on symptoms, 44 had typical symptoms of covid-19 (cough, fever, shortness of breath), of whom only five were tested before death.

Covid-19 was identified in seven children, only one of whom had been tested before death.

The proportion of deaths with covid-19 increased with age, but 76% of people who died were aged under 60 years.

The five most common underlying conditions (comorbidities) among people who died with covid-19 were tuberculosis (31%), high blood pressure (27%), HIV/AIDS (23%), alcohol misuse (17%), and diabetes (13%).

Understanding the true extent of covid-19’s impact on Africa is critical, say the researchers. Not only is there a moral imperative that the world acknowledges suffering wherever it exists, if Africa is seen as posing little threat, this could put it at a lower priority for access to covid-19 vaccines.

This is an observational study using data from one city, in one African country, over a short three month span, and the researchers point to several limitations, such as relying on the accuracy of medical chart data and being unable to identify deaths indirectly due to covid-19, such as from heart attacks or strokes.

However, this was a well-designed study, carried out by researchers with a high level of experience in postmortem sampling and data collection, which minimised the potential for false positive results.

As such, the authors say that contrary to expectations, covid-19 deaths were common in Lusaka, and the majority occurred in the community where testing capacity is lacking.

Yet few who died at health facilities were tested, despite presenting with typical symptoms of covid-19. Therefore, covid-19 cases were under reported because testing was rarely done, not because CV19 was rare, they explain.

If these data are generalizable, the impact of covid-19 in Africa has been vastly underestimated, they conclude.