COVID-19 in Zambia
The first case(s) of COVID-19 in Zambia was confirmed on 17 March 2020 in a family returning from holiday in France. The family had quarantined as required on arrival and reported a febrile illness to the Ministry of Health who confirmed the infection in both parents but no children. The next documented case was in a local businessman who had travelled to Pakistan. Initially, most cases were tied to international travel or household contacts of such travellers. Subsequently, infections among overland travellers, particularly among truck drivers commuting through the Tanzanian border, became of concern. Per the Ministry of Health (MoH) Facebook page, as of 21 Sept 2020 there were 14,174 cases, 13,629 recoveries and 327 deaths.
Public health communications to the public regarding the pandemic have occurred largely through Facebook and local radio, making the Ministry’s messages widely available. Unlike other countries in the region, while measures were put into place to slow the spread of the virus, a full-scale lockdown was not instituted. As a land-locked country relying on imported supplies for fuel, some food and most medications, it was determined that the negative impact of a total shut down would outweigh any benefits. Nonetheless, schools were closed, limits were placed on public gatherings, many businesses including government offices changed work hours and/or allowed people to work from home to promote social distancing and limit the spread. In anticipation of the arrival of COVID-19, many HIV clinics provided patients with 6+ months of treatment during their visits in February and early March and made plans for people living with HIV to access further medications outside of major urban clinics in local HIV clinics closer to their homes. On 16 April 2020, the MoH mandated the wearing of masks in public spaces.
Great efforts have been made to decentralize testing, but challenges in maintaining the supplies and reagents needed have resulted in much of the testing still being conducted centrally in Lusaka. On average, ~300 tests per day are reported. The formal numbers for infections and deaths are almost certainly underestimating disease. In Lusaka, Levy Mwanawasa Hospital was the designated facility for COVID care but inevitably many cases are diagnosed at other government and private hospitals and COVID-19 patients are often hospitalized at these other facilities for some days before the diagnosis is confirmed and a transfer facilitated. Mandated transfer and hospitalization may be one contributor to the substantial stigma associated with having the condition—a stigma that is likely making case ascertainment even more challenging. Zambian research groups who pioneered stigma reduction in HIV over the past 2 decades are now beginning to tackle the stigma of COVID-19.
In June and July, the number of “BIDs” (‘brought in dead’) for certification began to markedly increase followed by increases in the number of adult inpatients with respiratory conditions requiring admissions. This was consistent with the expectations from models crafted by infectious diseases experts in-country. Many healthcare workers in Zambia’s public sector, especially junior doctors and nurses, have been providing heroic care to large numbers of COVID-19 patients while rotating through busy inpatient services that require quarantine periods away from their homes and families. During the same period, decreased number of patients have been presenting for other conditions, presumably due to COVID fears. This has been especially notable among pediatric cases. It may be some time before we understand the collateral deaths that have occurred due to delayed care-seeking to say nothing of the problems that we may see going forward due to delayed vaccinations services and lapses in malaria prevention programs. Informal reports shared by colleagues at a number of urban facilities indicate that the numbers of patients have stabilized and are possibly modestly decreasing which would also be consistent with the models previously developed.
Seroprevalence studies in the Zambian population conducted in June and only recently released in local newspapers indicate that among 4.2 million Zambians tested, 1.8 million had active SARS-CoV-2 infection via PCR or antibodies indicating past infection—a number staggeringly higher than the formal case numbers of 6,000 at that time. This suggests that widespread community transmission is likely to present in most urban settings in Zambia today. Despite these numbers, the images repeated in Italy, New York, Brazil and India of field morgues erected to deal with the large numbers of COVID-19 fatalities has not occurred in Zambia. Perhaps the very young demographics of the country, where 50% of the population are children, are moderating the outcomes here. Regardless, the seroprevalence data offers some encouragement to us that Zambia is well on its way to achieving herd immunity, if indeed repeat infections are unlikely.