As India, the second-most populous country in the world, grapples with a devastating second wave of COVID-19 infections that has pushed its health system to the brink of collapse, officials in Africa, the world's second-largest continent, are on high alert.
"What’s happening in India must not happen here," Dr. Matshidiso Moeti, the World Health Organization's regional director for Africa, said at a virtual press briefing last Thursday. "If we prepare now, we will not pay the price later."
The more than 414,000 newly confirmed cases of COVID-19 recorded in India last Thursday was the highest single-day count by any nation during the pandemic. But the alarming spike is a relatively new phenomenon there. Until late February, India was considered a success story, with experts surmising that declining infections might be due to the South Asian country's warm climate, young inhabitants and high population density. Now, India is the epicenter of the pandemic.
Africa, which has a comparable population size to India, has reported more than 4.6 million confirmed cases of COVID-19 and over 124,000 deaths from the disease so far, representing just under 3% of the world's cases and less than 4% of the fatalities, according to data collected by Johns Hopkins University and the Africa Centers for Disease Control and Prevention.
Overall, cases and deaths have been trending downward in Africa since peaking in mid-January. But countries across the continent continue to report sustained transmission and increases in some areas as new, more contagious variants of the virus make inroads, according to the WHO. Meanwhile, African countries are slipping behind the rest of the world in vaccine rollouts, with immunization campaigns heavily dependent on a global vaccine-sharing alliance known as COVAX, whose main supplier is the Serum Institute of India, the world's largest vaccine manufacturer.
The Serum Institute of India, which makes the Oxford/AstraZeneca vaccine, paused exports in March to battle India's worsening outbreak at home. Some 140 million Africa-bound doses that were supposed to be delivered through COVAX this spring have been delayed for the foreseeable future. Africa CDC data shows that under 2% of the continent's population has received the first or second dose of a COVID-19 vaccine so far -- that’s only about 1% of doses administered worldwide, according to the WHO.
ABC News spoke with experts about three African countries that have had different approaches to COVID-19 and face distinct challenges with their response efforts and vaccination campaigns. All agreed that India's crisis could be a harbinger of what could befall Africa, where many nations have fragile health systems and depend on aid.
"There is major concern that what is going on in India could easily happen in Africa," said Dr. Bertha Serwa Ayi, a consultant in infectious diseases at Essentia Health West in Fargo, North Dakota, who is also a member of the case management technical group of the Africa CDC's task force on COVID-19. While Ayi acknowledged that "Africa has been a leader" in "COVID-19 management, oversight and control," she said things could take a turn.
"It's like a bus at the edge of a cliff," she added. "Everybody's doing what they can to really hold the fort and make sure Africa doesn't become a situation like what's going on in India. But I think the potential is not lost on anyone."
South Africa: The continent's hardest-hit country trying to fend off a 3rd wave
South Africa doesn't have to look to India as a cautionary tale. The 59-million-strong nation arguably went through an India-like second wave of COVID-19 infections earlier this year. At its January peak, South Africa was reporting more cases per million people on average than India is currently reporting, according to data collected by Our World in Data.
South Africa is also the hardest-hit country in Africa by far, with more than 1.5 million confirmed cases and over 54,000 deaths, accounting for almost 35% of the continent’s infections and nearly 44% of the fatalities, according to Africa CDC data.
"We had a devastating second wave," said Dr. Richard Lessells, an infectious disease expert at Kwazulu-Natal Research Innovation and Sequencing Platform (KRISP) in Durban, where he researches the virus variant first identified in South Africa.
Although daily new infections in South Africa have fallen from nearly 22,000 in mid-January to around 2,000, the country -- as well as the greater southern Africa region -- is bracing for a third and potentially more severe wave with the start of winter season in June.
"We are concerned about the South African winter coming in," Moeti told reporters during the WHO press briefing last Thursday.
Lessells said he was less worried about winter and more concerned about complacency among South Africans with regard to public health measures, such as mask wearing and social distancing.
"We get lulled into this strange false sense of security,” he told ABC News. “We go through these devastating waves and then, partly because people don't understand the dynamics of an epidemic and why these waves contract, they think we're through the worst of it."
But while South Africa's second wave rivaled India's in terms of official infections per capita and mortality, India's health system is collapsing to an extent that South Africa's did not. Experts also said the real number of infections and deaths in India are likely far higher than the official reported numbers.
"Of course, eyes are on South Africa," Ayi told ABC News, "but they also have the hospital capacity and laboratory infrastructure to be able to hold things together."
While Lessells described South Africa's health system as "severely strained" during its second wave, pandemic preparedness and planning enabled the country to largely avoid the oxygen shortages India faces.
But health care quality and access isn't equal across South Africa. In addition to disparities between public and private hospitals, urban cities are better equipped to handle outbreaks than rural communities, and a third wave could potentially overwhelm outlying areas with weaker health infrastructure. Solely looking at metropolitan regions might give the impression South Africa is doing well, explained Dr. Jeffrey Mphahlele, a virologist and vice president for research at the South African Medical Research Council in Cape Town.
On the outskirts and in rural areas, "you see a different world of South Africa," Mphahlele said.
While many countries rich enough to buy or develop and manufacture vaccines have embarked on robust immunization campaigns to stem infection rates, South Africa's has barely begun, despite being well-positioned to do so financially and in terms of manufacturing.
In early February, South Africa halted its Oxford/AstraZeneca rollout over concerns the shot was less effective against the B.1.351 variant, the dominant virus strain there, and the government ultimately sold those doses to the Africa Union. Then in late April, the country's rollout of the Johnson & Johnson vaccine was temporarily suspended while the United States investigated a link to rare blood clots.
Eschewing the Oxford/AstraZeneca shot means South Africa isn't affected by India’s ban on vaccine exports, but switching immunization plans severely delayed its rollout. Less than 1% of people in South Africa have received at least one dose of a COVID-19 vaccine, according to Africa CDC data.
For months, South African President Cyril Ramaphosa has called on wealthy countries to share their excess doses with countries that need them. He doubled down on that perspective in his weekly newsletter to the nation on Monday, calling vaccines a global public good that should be available for all, not just the highest bidder.
"A situation in which the populations of advanced, rich countries are safely inoculated while millions in poorer countries die in the queue would be tantamount to vaccine apartheid," Ramaphosa wrote.
Ghana: After early COVID-19 success, vigilance wanes
Ghana was heralded as a success story in Africa and around the world early in the pandemic. It was the first country on the continent to announce a lockdown last year and has since been praised for its aggressive testing, contact tracing and strong leadership. To date, the West African nation of 30 million people has conducted more than 1.1 million COVID-19 tests and has confirmed over 93,000 cases and at least 783 deaths, according to Africa CDC data.
In late February, Ghana became the first country in the world to receive COVID-19 vaccine doses from COVAX. The rollout was launched a week later, with the Ghanaian President President Nana Akufo-Addo receiving the first shot.
In an interview with CNN last week, Akufo-Addo said his country aims to vaccinate 20 million people -- effectively the entire adult population -- by the end of 2021, but he acknowledged that delays in receiving doses from COVAX "have been a little troublesome."
"The need for us to look to ourselves to find the ways of resolving our problems has been heightened, has been intensified by what has happened in this last year," Akufo-Addo told CNN. "We cannot depend on charity, we cannot depend on the generosity of foreigners."
Experts told ABC News that Ghana is now looking into other sources to acquire more doses, given the hold-up in India, and is also hoping to start manufacturing them.
"What they've done well right from the beginning is leadership engagement," said Ayi, who is also an adjunct professor at the University of Health and Allied Sciences and the University of Development Studies’ School of Medicine and Health Sciences as well as a senior lecturer at Accra College of Medicine, all located in Ghana. “The [vaccine] rollout I think was excellent and superb.”
But others argued that the country’s COVID-19 response has been inconsistent. The Ghanian government allowed political rallies to be held during the December general election, in which Akufo-Addo was re-elected for a second term, and Johns Hopkins' data shows the country saw a surge in cases in the weeks after the vote. By the end of January, Ghana reported a record of more than 1,500 confirmed cases in a single day. In February, the Ghanaian parliament was forced to shut down for several weeks due to an outbreak among lawmakers and staff.
"We have been through a mini version of what India’s going through," said Nana Kofi Quakyi, a Ghana-based research fellow in the Department of Health Policy and Management at New York University's School of Global Public Health, where he is also a doctoral candidate.
Although the Ghanaian government has eased restrictions in recent months, including fully reopening schools, some establishments and venues remain closed and there are still restrictions on social gatherings. People are also required to wear face masks in public.
Quakyi, who has been living in Ghana’s capital for the past year but plans to return to New York City soon, said the enforcement and compliance of those measures is questionable as life has largely returned to normal from his viewpoint.
"We haven’t really seen much in the form of additional policy that would actually prevent the spread," he told ABC News. "If you were in Accra right now, you would not believe that there was COVID-19 here. There’s very low mask wearing, there is very little social distancing."
Ayi agreed that the vigilance surrounding mask wearing and social distancing "is gone."
"That needs to come back," she said.
Democratic Republic of the Congo: A surge in infections would be 'catastrophic'
With a population of 87 million in central Africa, the Democratic Republic of the Congo has among the lowest COVID-19 infection and death rates on the continent but has conducted fewer than 200,000 tests. So far, the country has reported more than 30,000 confirmed cases and at least 775 deaths, according to Africa CDC data. Experts told ABC News that while the true numbers are likely higher than what's being reported, there's currently no indication of a significant outbreak.
The pandemic hit as Congolese health workers were still in the throes of the country's 10th outbreak of Ebola virus disease, one of the deadliest on record anywhere and the first to occur in an active conflict zone. Although the Democratic Republic of the Congo is now Ebola-free and has a wealth of experience combating infectious diseases, experts said the country's COVID-19 response is insufficiently funded and lacks community engagement.
"The Ebola response got a lot of money. Unfortunately, COVID-19 has not got enough money," said Dr. Deogratious Wonya'rossi, a Congolese public health physician and tropical diseases researcher who has been part of the Ebola response. "On the other hand, the country has a good number of experts who are capable to organize and implement the responses as they are still doing now."
Like many other African nations, the Democratic Republic of the Congo was quick to respond to the pandemic, with the government announcing a state of emergency in March of last year and closing borders, schools, restaurants and places of worship. Those measures helped prevent COVID-19 from spreading, experts said, but overall the poor health care infrastructure makes the country unprepared to deal with a potential surge as the government struggles to scale up medical services.
"If we have a major outbreak coming, it's going to be extremely difficult to handle," said Jean Metenier, senior coordinator for the eastern Democratic Republic of the Congo at the United Nations International Children's Emergency Fund (UNICEF).
Moreover, the country’s COVID-19 vaccine rollout hasn't gone smoothly. First, the Congolese government delayed rolling out 1.7 million doses of the Oxford/AstraZeneca vaccine it received from COVAX in early March, after several European nations suspended use of the shots due to a link to rare blood clots. Then, after vaccinations began in late April, the government announced that it would redeploy 1.3 million of those doses to other African countries, including Ghana, which had already used up its initial supply. The government said it wouldn't be able to administer the doses before they expired on June 24 and that some people were simply refusing to get the shot.
"We have seen a surge in terms of vaccine hesitancy, particularly in urban areas where there's high penetration of social media," Dr. Richard Mihigo, immunization and vaccine development program coordinator at the WHO's regional office for Africa, told reporters during the press briefing last Thursday. "We are watching the situation in DRC quite very carefully."
Experts told ABC News that vaccine hesitancy is nothing new in the Democratic Republic of the Congo but has been exacerbated by the bad press surrounding the Oxford/AstraZeneca shot. A recent online survey of more than 4,100 people in the Democratic Republic of the Congo found that 24% of respondents were convinced COVID-19 did not exist, with just over 55% indicating they were willing to be vaccinated.
"This is where risk communication at the community level is important," said Tolbert Nyenswah, a senior research associate at the Johns Hopkins Bloomberg School of Public Health who was Liberia's deputy minister of health for disease surveillance and epidemic control from 2015 to 2017 during the Ebola outbreak across West Africa.
The Oxford/AstraZeneca shot, which is cheaper than others and can be stored at normal fridge temperatures as opposed to requiring ultra-cold storage, is currently the only COVID-19 vaccine available in the Democratic Republic of the Congo.
Last month, the AU announced the launch of a partnership to manufacture vaccines at five research centers to be built across the continent within the next 15 years, with a goal of locally producing 60% of all vaccines used in Africa within 20 years -- compared with 1% today. Congolese President Felix Tshisekedi, who is the current AU chair, said the initiative "will not just fight against COVID-19 but see the establishment of vaccine production for known illnesses and prepare for future epidemics and pandemics."
Meanwhile, a new virus variant first identified in India has since been detected in at least three African nations, including Uganda, which shares a border with the Democratic Republic of the Congo. On Monday, the WHO upped its classification of the B.1.617 strain from a "variant of interest" to a "variant of concern," noting that preliminary studies indicate it may be more transmissible than other variants.
"I am very, very worried with the fact that the Indian variant may be at the door of the DRC," Metenier told ABC News.
Nyenswah said it would be "catastrophic" if the Democratic Republic of the Congo saw a surge in COVID-19 infections.
"Amidst the many Ebola outbreaks, internal conflicts and health system challenges," he added, "the authorities there need to think beyond twice before giving up life-saving shots."