Preparing Africa for COVID-19: Learning lessons from the Ebola outbreak

Lessons learnt from the Ebola outbreak in Sierra Leone suggest that investing in laboratory capacity will be of critical importance to help Africa cope as the virus spreads across the continent.

“We have a simple message for all countries” declared Dr Tedros Adhanom Ghebreyesus, Director-General of the World Health Organization. “Test, test, test.”

Yet, if the past two months of this pandemic has taught us anything – it is that following Tedros’ mandate is hardly straightforward, despite the economic and public health rationale of mass testing being irrefutable.

Accurate diagnosis is essential to mitigating the increasingly disastrous impact of the COVID-19 outbreak. Policymakers fly blind if they don’t know who amongst the general population is sick or has previously been infected. They face unpredictable surges in cases, health workforce shortages and an interminable cycle of lockdowns and forced closures.

However, rapidly developing tests from scratch and deploying them widely demands clinical, commercial and regulatory coordination and, above all, a sufficiently-prepared and well-integrated laboratory system.

As the outbreak moves into the African continent, the question of diagnostic capacity looms large.

Lessons learnt from the Ebola outbreak in Sierra Leone

The inability to quickly diagnose and isolate cases was an important factor in the scale of the 2014-2016 Ebola outbreak.

In response, a range of novel Ebola diagnostic tools were trialled with unprecedented speed. This included automated PCR machines designed for laboratory benchtops and rapid test kits for point of care. Although these tools helped to bring the outbreak to an end, increasing the availability of tests was only the first step.

System-wide support was also needed to safely transport samples, source reagents, dispose of hazardous materials, and correctly interpret and feed-back diagnostic data into clinical and public health decision-making.

So has this helped prepare Africa well for the COVID-19 outbreak?

Despite a national legacy cohort of laboratory workers with experience in PCR testing and some GeneXpert PCR machines that can be repurposed for SARS-COV-2 testing, it remains uncertain whether previous laboratory strengthening efforts have prepared West African countries.

Prioritising Ebola-specific tests means weak supply chains. It also means waste management systems remain vulnerable across the region.

Need to fully engage national experts and institutions

When it comes to the ready deployment of global health innovations in Africa, regulatory capacity is often neglected. In an effort to accelerate research and development for Ebola diagnostics, the World Health Organization (WHO) developed the Emergency Use Listing (EUL) for the evaluation of new tools during the Ebola outbreak.

The aim was to alleviate the regulatory burden on National Regulatory Agencies (NRAs). Yet without local input or support, national agencies struggled to register the influx of new tests.

Regulatory authorities can be advocates for new medical products, but need they manpower and expertise:

• to evaluate device performance, guide deployment and procurement
• to provide the quality assurance and post-market surveillance essential for safeguarding patients and health staff

Thanks to the coordinating diagnostic capacity of Africa CDC leadership, national experts are now more likely to be heard when responding to the COVID-19 outbreak.

However, for regulatory alignment to be feasible, enhanced resources, training and investment must accompany a modified EUL procedure for COVID-19 places, with increased emphasis on the role of NRAs.

The diagnostic future of Africa

Africa is the next frontier for the pandemic. At the time of writing, the number of confirmed cases is near 10,000. What epidemiological realities lie behind that number is unclear, as diagnostic capacities across the continent differ widely.

Currently, there are more than 100 rapid point-of-care devices for COVID-19 in the pipeline, and the global health organisation, FIND is assisting African governments to evaluate COVID-19 tests coming onto the market.

While important, an emphasis on novel tests distracts from interventions that are just as critical for a successful response while also build capacity for the future.

The Sierra Leonean experience shows us that investment in new tests is just the starting point. If the COVID-19 outbreak is going to be contained, substantial investments must be made in national laboratory networks. This includes the supply chains, waste management systems, and health information infrastructures that support them.

This is the key to building strong laboratory systems for the next epidemic.

Images included in this essay feature laboratory workers and cleaners working at health facilities in and around Freetown and were taken by Olivia Acland for the DiaDev research project.

Research for this article was undertaken as part of the ‘Investigating Diagnostic Devices in Global Health’ research project (www.diadev.eu) and was supported by the European Research Council (ERC) under the European Union’s Horizon 2020 research and innovation programme grant agreement No 715450.