Coronavirus (1194) Lancet: The first and second waves of the COVID-19 pandemic in Africa

25 March, 2021

The second wave of the COVID-19 pandemic in Africa has been more severe than the first, due partly to more transmissible variants. Many countries have relaxed initially robust public health and social measures, contributing to the second wave and raising concerns for the future.

CITATION: The first and second waves of the COVID-19 pandemic in Africa: a cross-sectional study

Stephanie J Salyer et al. The Lancet

Published: March 24, 2021DOI:


Background: Although the first wave of the COVID-19 pandemic progressed more slowly in Africa than the rest of the world, by December, 2020, the second wave appeared to be much more aggressive with many more cases. To date, the pandemic situation in all 55 African Union (AU) Member States has not been comprehensively reviewed. We aimed to evaluate reported COVID-19 epidemiology data to better understand the pandemic's progression in Africa.

Methods: We did a cross-sectional analysis between Feb 14 and Dec 31, 2020, using COVID-19 epidemiological, testing, and mitigation strategy data reported by AU Member States to assess trends and identify the response and mitigation efforts at the country, regional, and continent levels. We did descriptive analyses on the variables of interest including cumulative and weekly incidence rates, case fatality ratios (CFRs), tests per case ratios, growth rates, and public health and social measures in place.

Findings: As of Dec 31, 2020, African countries had reported 2 763 421 COVID-19 cases and 65 602 deaths, accounting for 3·4% of the 82 312 150 cases and 3·6% of the 1 798 994 deaths reported globally. Nine of the 55 countries accounted for more than 82·6% (2 283 613) of reported cases. 18 countries reported CFRs greater than the global CFR (2·2%). 17 countries reported test per case ratios less than the recommended ten to 30 tests per case ratio range. At the peak of the first wave in Africa in July, 2020, the mean daily number of new cases was 18 273. As of Dec 31, 2020, 40 (73%) countries had experienced or were experiencing their second wave of cases with the continent reporting a mean of 23 790 daily new cases for epidemiological week 53. 48 (96%) of 50 Member States had five or more stringent public health and social measures in place by April 15, 2020, but this number had decreased to 36 (72%) as of Dec 31, 2020, despite an increase in cases in the preceding month.

Interpretation: Our analysis showed that the African continent had a more severe second wave of the COVID-19 pandemic than the first, and highlights the importance of examining multiple epidemiological variables down to the regional and country levels over time. These country-specific and regional results informed the implementation of continent-wide initiatives and supported equitable distribution of supplies and technical assistance. Monitoring and analysis of these data over time are essential for continued situational awareness, especially as Member States attempt to balance controlling COVID-19 transmission with ensuring stable economies and livelihoods.


'Early PHSM [public health and social measures] implementation is assumed to have slowed the pandemic in Africa; however, this analysis suggests that it is necessary to review multiple indicators down to the country level to fully understand the situation. Despite facing a second wave of cases and new, more transmissible variants of the virus, many countries had not implemented the same degree of PHSMs as they had early on in the pandemic. Additionally, for some countries where cases continue to increase despite maintaining most of their stringent PHSMs, other factors like changes in population behaviour are likely to be present. Increasing reports of PHSM adherence fatigue, leaves the continent's population at risk and highlights the need to reinvigorate and update existing communication strategies. These data indicate that Member States not only need to remain vigilant in collecting and analysing COVID-19 data to inform PHSM adjustments in place, but they also need to monitor PHSM adherence and ensure public health and case management capacities are sustained as cases rise.'

COMMENT (NPW): The paper does not explore the contribution of misinformation (in all its forms), but this is likely a major driver of the pandemic in Africa as it has been in other regions. And, as in other regions, the situation has been made worse by politically-motivated decisions to ignore or undermine public health evidence.

Best wishes, Neil

Coordinator, HIFA project on COVID-19, supported by University of Edinburgh

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HIFA profile: Neil Pakenham-Walsh is coordinator of the HIFA global health movement (Healthcare Information For All - ), a global community with more than 20,000 members in 180 countries, interacting on six global forums in four languages in collaboration with WHO. Twitter: @hifa_org FB: