Editorial
Mitigating lockdown challenges in response to COVID-19 in Sub-Saharan Africa
The coronavirus disease 2019 (COVID-19) which was first reportedinWuhan,Chinaattheendof2019(Luoetal.,2020)has spreadacrosstheworldwithremarkablespeed,withtheWorld Health Organization (WHO) officially declaring a pandemic in March,2020.Mostcountriesinsub-SaharanAfrica(SSA)arenow reporting an increasing number of cases, both imported and acquired locally. As of April 14th, 2020, a cumulative total of approximately,10,757confirmedCOVID-19caseswith520deaths havebeenreportedwithintheWHOAfricanRegion,withSouth Africa, Algeria and Cameroonrecording the highest number of cases(WHO,2020a).Arecentanalysishasindicatedthattheriskof transmissionofCOVID-19inAfricatoberelativelylowerthanin othercontinents(Haideretal.,2020).However,thescaleofCOVID- 19infectioninthecontinentanditsimpactonpopulationhealthis stillunclear. Routine information systemsin manyparts ofthe region are inadequate, and the current data are likely to underestimate the true extent of the epidemic. Furthermore, because it is unclear as to how COVID-19 will interact with conditions such as malnutrition, HIV/AIDS, tuberculosis, and malaria, one cannot be certain that infection fatality rates in Africawillbesimilartothosethathavebeenestimatedelsewhere.
AfricawillhavetocontendwiththesamefeaturesofCOVID-19 thathavemadethisanextremelydifficultpandemictodealwith elsewhere. This includes the high degreeof transmissibility of COVID-19 and the fact that the virus can be transmitted by individualswhoareasymptomaticorpre-symptomatic(Luoetal., 2020).ThesefeaturesofCOVID-19meanthatstandardcommuni- cabledisease(CD)controlmeasuresmayoftenbeinsufficientto bringaCOVID-19outbreakundercontrol.While casedetection, contact tracing, physical distancing, hand hygiene, masks, and selectiveisolationandquarantinemayreducetransmission,many countrieshave resorted toso-called ‘lockdown’ measures.This amounts to varying degrees of restriction on movement and gatheringsofcitizenstoreducetransmissionrisksandtoreduce thereproductiverateofanepidemicbelow1.
LockdowninthecontextofCOVID-19wasfirstimplementedin WuhanonJanuary23rd,2020,andthenextendedtothewholeof Hubei province, helping to bring the epidemic in China under controlquiterapidly(WHO,2020b).Sincethen,alockdownhas beendeemednecessarytopreventhealthsystemsinmanyhigh- incomecountriesfrombeingoverwhelmedbyCOVID-19.Where this lockdown was early in the importation cycle through the
closureofairtravel,thediseasewasalsoquicklybroughtunder control,withveryfew deathsrecorded,anexamplebeingNew Zealand. However, many questions remainabout the extent to which‘lockdown’isfeasible,sustainable,andtolerableinthelong term,andwhetheritsdisruptionofnormalsocialandeconomiclife mayproducemoreharmthanthevirusitself.Thehighpre-existing burden of diseaseand poverty in SSA, coupledwithits under- resourcedandfragmentedhealthsystems,alsomeanthatAfrican countriesfaceadditionalchallengesincontrollingCOVID-19and implementinglockdownmeasures.
Thispaperexaminesanddiscussesthefeasibility,effectiveness, andappropriatenessofimplementinglockdowninSSA.Tobegin with, itdefinesand describeswhatis meantby‘lockdown’and howitrelatestootherCDcontrolmeasures.Itthendiscusseshow lockdown might work toeither mitigateor suppressCOVID-19 transmission, and the opportunities and challenges entailedin doingso.Lastly,thepaperdiscussessometentativeconclusions andrecommendations.
Overthepastthreemonths,theterm‘lockdown’hasbecome commonparlanceacrosstheworldandhasbeenassimilatedinto multiplelanguages.However,itisnotpreciselydefined.Infact,as recentlyasMarch25th,2020,theWHOwasusingthephrase‘so- calledlockdownmeasures’(WHO,2020c).Acursoryexamination oftheacademicliteraturealsoindicatesnoclearoruniversally- accepteddefinitionoftheterm.Wecanalsoobservethatneither WHO’s 2018 guidelines for a national pandemic influenza preparedness(WHO,2018),norits2017GuidelinesforPandemic InfluenzaRiskManagement(WHO,2017)includesanymentionof lockdownatall.Thislackofdefinitionand clarityis surprising, especiallygiventhewidespreadreferencetovaryingdegreesof lockdown,suchas‘totallockdown’and‘partiallockdown,’or‘tight lockdown’ and ‘loose lockdown.’ It is also notable that the relationshipbetweenlockdown and otherCD controlmeasures isunclear.
Wehavethereforeconstructedadefinitionoflockdown,and relatedthistootherCDcontrolmeasures.Wedefineitasasetof measurestoreducecommunitytransmissionofCOVID-19thatare compulsoryandwhichareappliedindiscriminatelytothegeneral population.Thisdefinitionexcludesmeasuresthatarecompulsory but which are targeted at individuals or segments of the populationthataredeemedathighrisk. Bythis definition,one can isolate three lockdown measures that are relevant to
https://doi.org/10.1016/j.ijid.2020.05.018
1201-9712/©2020TheAuthor(s).PublishedbyElsevierLtdonbehalfofInternationalSocietyforInfectiousDiseases.ThisisanopenaccessarticleundertheCCBY-NC-ND license(http://creativecommons.org/licenses/by-nc-nd/4.0/).
InternationalJournalofInfectiousDiseases96(2020)308–310
ContentslistsavailableatScienceDirect
International Journal of Infectious Diseases
j o u r n a lh o m e p a g e : w w w . e l s e v i e r . c o m / l o c a t e / i j i d
COVID-19:(i)geographicalcontainment;(ii)homeconfinement;
and(iii)theclosureofsocial,educationalandeconomicactivities, andprohibitionofmassgatherings.Althoughseparate,thereisa degreetowhichthesemeasuresoverlapandoperateinsynergy witheachother.However,eachofthesemeasuresexistsacrossa spectrum ranging from being draconian at one end, to being lenientattheother.
The term lockdown is perhaps most associated with the decisionoftheChineseauthoritiestostopthemovementofpeople inandoutofWuhanCity.Thisgeographicalcontainment(cordon sanitaire)ofacityfromtherestofthecountrywaslaterextended totheentireprovinceofHubei(WHO,2020c).Theaimofsuch containmentistopreventepidemichotspotsfromspreadingthe virus to other parts of a country or region. The degree of enforcementanduseofsanctionstodeterorpunishtransgressors areimportantdetailsofthepolicyandmaydependontheextentto which the policy is socially acceptable as well as on the government’scapacity tomonitorandpolice compliance.There maybelessornorestrictionforpeopletravelingintoanareathat hasbeen puton lockdown, and exemptions madefor workers providingcriticalservicessuchasmaintainingtheflowoffoodand otheressentialcommoditiesintothelockdownarea.
The containment of a defined geographical area is often accompaniedbyarequirementforhomeconfinement.Thispolicy may also span across the draconian-lenient spectrum, with exemptions allowed for key workers and their children, and allowancesforpeopletoleavetheirhomesforcertainprescribed activities.Theterm‘curfew’hassometimesbeenusedtodescribe measuresaimedatconfiningpeopletotheirhomesorotherindoor facilities.Thethirdmeasureistheclosureofschools,universities, sportingevents,shops,restaurants,cinemasandtheatres,andthe prohibition of mass gatherings. The extent to which these measuresareenforced,aswellasthedegreetowhichexemptions fromthesemeasuresarepermitted,canvary.Insomecountries, only mass gatheringsabove a specific size are prohibited;and certaintypesofbusinessesareallowedtocontinueopening.
Thereisalotofvariationinhowlockdownisimplemented.In additiontowheretheyarepositionedonthedraconian-lenient spectrumforeachmeasure,countriesmayvaryinhowtheychoose tocombinethethreemeasuresasa singleintegratedlockdown strategy.Also,lockdownwillvaryaccordingtowhatmeasuresare putin placetomitigate theharms of lockdown.These include directpsychosocialandphysicalinjuriesassociatedwithcontain- ment,confinement,lossofimportantsocio-culturalactivities,and economichardship(Brooksetal.,2020).Thesedirectinjuriesare aggravated by indirect ones associated with the impacts of lockdownonsociety,whichincludeeconomicrecession,reduced accessto foodand otherbasic needs, theaggravation of social tensions,disruptiontoeducation,andtheerosionofcivilliberties.
Measurestomitigate theseunwantedeffects of lockdown may include enabling children to continue their schooling online, providing welfare support topoorer households that havelost income, and introducing fiscal measures to keep the economy going and ensure essential healthcare. Such measures are a criticallyimportantaspectoflockdown,althoughtheytendtobe neglected.
Total lockdown is unlikely to be accepted voluntarily by a majorityofthepopulationinSSA,owingtoitshighlydisruptive nature.Thisismadeworsebythefactthatsomeofthecountries which have implemented lockdown,have not put forwardany clearstrategytosupporttheirpopulations,particularlythe(most) vulnerable segments. As the epidemic progresses and many unknowns around its potential impact are resolved, context- specific measures should assume a more influential role in mitigation toavoid the unintended consequences of lockdown andotherexternalities.Withthisscenarioinmind,itisessential
thatnationalgovernmentsinSSAcarefullyevaluatethecostsand benefitsofstringentmeasures, withconstant monitoringofthe situation.
AsanincreasingnumberofSSAcountriescontemplatestricter containment strategies, it is critical to reflect on some salient featuresoftheCOVID-19pandemicinthelightoftheexperiences andcircumstancesinthesecountries.Thereareafewcriticalfacts thatdecision-makersinSSAmusttakeintoconsiderationasthe optionsareweighed.Country-specificriskassessmentsneedtobe undertaken toprovideevidencefordecision-making. Thisis an importanttakeawayfromthedifferenttrajectoriesoftheoutbreak in several European and other countries, which evolved in responsetocountry-specificmeasures.Inthisregard,avitalissue for publichealth expertsis helpingpolicymakersdecideonthe mainobjectivesofmitigation,forinstanceminimizingmorbidity and associated mortality, or avoiding an epidemic peak that overwhelms healthcare services, or keeping the effects on the economy within manageable levels,or flattening the epidemic curve(Andersonetal.,2020).So,thechoiceisbetweenaccepting spread andallowingherdimmunitytodevelopand acceptinga certainlossorattemptingsuppression.
In anycase,settingtheprioritiesshould drivethechoicesof mitigationstrategies(Hollingsworthetal.,2011).Thus,itisamatter of SSA countries predicting whether the relatively youthful populationisresilientenoughtowithstandthediseaseandperhaps institutingprotectivemeasuresonlyforthemorevulnerablecohort of agedpeople. Thelattercouldbeappealing inmanylow-and- middle-income countries, but it is difficult to justify without knowingitspotentialimpactontheoutcomes.Drasticmeasures couldbenefitfromaninformedriskassessmentthatidentifiesand isolatethemostvulnerablepopulationsegments.IntheSSAcontext, wheneverthescaleoftheCOVID-19crisisbecomesapparentand reaches the stage when a countrywide lockdown might be inevitable,theadoptionofarisk-basedstrategycouldfavorpartial lockdown by identifying ‘zones,’ while keeping up economic activitiesinotherareasorsectorsofthecountry.
TocontrolthespreadofCOVID-19inthelongrun,continued compliancewithphysicaldistancingcoupledwithotherpersonal behavioralmeasureswillbeessential.Moreover,forcommunities to comply with directives for self-quarantine, self-isolation, physicaldistancing,andlimitedtravelovera possiblyindefinite future, SSA governments must fulfill their reciprocal duties to make compliancesafeand feasible.Effective surveillancecoun- trywide anda trusted andtransparentsourceof information is criticaltoregularlyconveyaccurateinformationonthecountry’s pandemicsituation,theknownandunknownrisksaswellaswhat isbeingdonetolearnmoreandwhatarethemeasuresinplaceto controlthespreadofCOVID-19.
Authors’contributions
LeonardMboera,DavidMcCoy,andGeorgeAkipedeconceptu- alized the editorial and developed the first draft. All authors contributedtowritingandfinalizingthemanuscript.
Conflictsofinterest
Allauthorsdeclarenootherconflictsofinterest.
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LeonardE.G.Mboera*
SACIDSFoundationforOneHealth,SokoineUniversityofAgriculture, Morogoro,Tanzania GeorgeO.Akipedea,b
aCollegeofMedicine,AmbroseAlliUniversity,Ekpoma,Nigeria
bInstituteofLassaFeverResearchandControl,IrruaSpecialist TeachingHospital,Irrua,Nigeria AmitavaBanerjee InstituteofHealthInformatics,UniversityCollegeLondon,London, UnitedKingdom LuisE.Cuevas LiverpoolSchoolofTropicalMedicine,Liverpool,UnitedKingdom ThomasCzypionkaa,b
aInstituteforAdvancedStudies,Vienna,Austria
bLondonSchoolofEconomicsandPoliticalScience,London,United Kingdom MishalKhan LondonSchoolofHygiene&TropicalMedicine,London,United Kingdom RichardKock RoyalVeterinaryCollege,London,UnitedKingdom
DavidMcCoy InstituteofPopulationHealthSciences,BartsandLondonMedicaland DentalSchool,QueenMaryUniversityLondon,UnitedKingdom BlandinaT.Mmbaga KilimanjaroChristianMedicalUniversityCollegeandKilimanjaro ClinicalResearchInstitute,Moshi,Tanzania GeraldMisinzoa,b
aSACIDSFoundationforOneHealth,SokoineUniversityofAgriculture, Morogoro,Tanzania
bSokoineUniversityofAgriculture,Morogoro,Tanzania ElizabethH.Shayo NationalInstituteforMedicalResearch,DaresSalaam,Tanzania MeruSheel NationalCentreforEpidemiologyandPopulation,ANUCollegeof HealthandMedicine,AustraliaNationalUniversity,Canberra, Australia CalvinSindatoa,b
aSACIDSFoundationforOneHealth,SokoineUniversityofAgriculture, Morogoro,Tanzania
bNationalInstituteforMedicalResearch,Tabora,Tanzania MarkUrassa NationalInstituteforMedicalResearch,Mwanza,Tanzania
* Correspondingauthorat:SACIDSFoundationforOneHealth, SokoineUniversityofAgriculture,P.O.Box3297,ChuoKikuu, Morogoro,Tanzania.
E-mailaddresses:lmboera@gmail.com(L.Mboera), georgeakpede@yahoo.co.uk(G.Akipede), ami.banerjee@ucl.ac.uk(A.Banerjee), Luis.Cuevas@lstmed.ac.uk(L.Cuevas), czypionk@ihs.ac.at(T.Czypionka), Mishal.Khan@lshtm.ac.uk(M.Khan), rkock@rvc.ac.uk(R.Kock), d.mccoy@qmul.ac.uk(D.McCoy), blaymt@yahoo.com(B.Mmbaga), gmisinzo@gmail.com(G.Misinzo), bshayo@yahoo.com(E.Shayo), meru.sheel@anu.edu.au(M.Sheel), csindato@gmail.com(C.Sindato), urassamark@yahoo.co.uk(M.Urassa).
Received2May2020 310 L.E.G.Mboeraetal./InternationalJournalofInfectiousDiseases96(2020)308–310
