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« COVID-19 on the African Continent » : Modeling the Epidemic in DRC

On May 6, 2020, The Lancet Infectious Diseases is publishing a projection of the grave toll that the COVID-19 pandemic could exact in the Democratic Republic of the Congo. The study, « COVID-19 on the African continent », of which Congo Research Group (CRG) director Jason Stearns is a co-author with epidemiologists from Yale University and the University of Kinshasa, suggests that if no interventions are made, the epidemic could infect millions and potentially kill hundreds of thousands in the DR Congo, most of whom will be elderly. These findings constitute a worst case scenario.

There is little testing and currently relatively few official cases of COVID-19 in the DR Congo. On May 6, the country had reported 863 cases and 36 deaths, mostly concentrated in the capital Kinshasa. The Congolese government took early and aggressive action against the disease, locking down part of the capital Kinshasa, suspending travel, and shutting down schools and public gatherings. However, some of these measures have now been loosened, and the realities of the Congolese economy, and those of other low-income countries, make prolonged lockdowns difficult to sustain. Over 80 percent of urban dwellers work in the informal sector, and a majority of the rural population lives off subsistence agriculture, making it almost impossible for them to stay at home for long periods of time. 

While there is much that is unknown about COVID-19, there is no reason to believe that the epidemic will spare the DR Congo. The model used in the study predicts that, in the absence of public health measures, the virus could spread to most of the Congolese population and 320,000 people could die. In comparison, around 46,000 people die due to malaria, the largest single cause of death in the country each year. 

The demographics of the Congolese population suggests that youths will be the primary vector of the disease, while the elderly suffer the most. Fifty-six percent of infections are projected to be in the 0-20 age group, while 55% of the deaths are among those 65 and older. This high proportion of youths will attenuate the impact of COVID-19, but will also make it more difficult to control its spread. Youths have far more social contacts per day than the elderly––an average of 24 compared with two––and tend to be more mobile. 

There are many unknowns that will affect the course the pandemic will take in the DR Congo. The virus is known to disproportionately affect patients with pre-existing conditions. For example, the DR Congo has a much lower incidence (4.3%) of diabetes than the United States (10.5%), but dramatically higher levels of malnutrition, with 43% of children suffering from chronic malnutrition. It is not clear how the high prevalence of tuberculosis could impact the spread of the disease, although the World Health Organization suggests it will exacerbate its impact. 

It is also unclear how the lack of testing and public health resources will affect the epidemic. There is currently only one laboratory, at the Institut National de Recherche Biomédicale (INRB), processing tests for the whole country. By mid-April, it was assessing around 200 tests per day. There are only a handful of ventilators for the country, and 8 hospital beds per 10,000 people.

The spread of the disease will also have important indirect consequences on Congolese. Other studies have suggested that the COVID-19 pandemic could exacerbate the impact of HIV, tuberculosis, and malaria in poor countries. The United Nations has warned that COVID-19 could disrupt vital humanitarian projects, and that immunization levels could drop, leading to the risk of measles and polio outbreaks. 

The model makes notable assumptions. Because of the uncertain impact that government policies will have, and the difficulty assessing their effectiveness at this early stage, this projection does not take them into account. It is also not a geospatial model; it is reasonable to assume that, due to differences in population density and social interaction patterns, the disease will spread at different speeds in urban and rural areas. Fifty-six percent of DR Congo’s population is rural. 

As with all epidemic modeling, the primary relevance of this study is to provide broad projections so as to help inform public health policy, rather than to produce precise predictions about the number of deaths or the duration of a disease. The message is clear: the government should treat the spread of the disease as inevitable and take urgent steps to protect the most vulnerable––the elderly and those with pre-existing conditions.