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Covid-19 deaths in Africa: prospective systematic postmortem surveillance study

BMJ 2021; 372 doi: (Published 17 February 2021) Cite this as: BMJ 2021;372:n334

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Re: Covid-19 deaths in Africa: prospective systematic postmortem surveillance study

Dear Editor

Rebuttal: Covid-19 deaths in Africa: prospective systematic postmortem surveillance study.

We refer to an article entitled, “Covid-19 deaths in Africa: prospective systematic postmortem surveillance study, that was published on 17th February 2021, in the British Medical Journal.1 We have made the following observations and wish to make a rebuttal to the said article for your consideration:

Firstly, the title of the article, “Covid-19 deaths in Africa: prospective systematic post-mortem surveillance study” is an over-statement because this was done in one country; one city; and one hospital with a limited catchment area; this study was not designed to be representative of the entire population of Lusaka, nor Zambia, let alone the Southern Africa region or the continent at large. The study site and study population is not well defined in this article; Lusaka city has another tertiary hospital, the Levy Mwanawasa University Teaching Hospital (LMUTH), which caters for a large part of the catchment area of the city. The LMUTH is the main COVID-19 Centre in Lusaka.2 Lusaka is divided into 6 sub-districts; each of these managing COVID-19 cases. In this case, the University Teaching Hospital (UTH) cannot be the hospital to represent the Lusaka population, let alone Zambia nor indeed Africa. On the other hand, this study can never be generalizable to Zambia and indeed to Africa, one cannot assume homogeneity for COVID-19 in Africa. To state as such is a misinterpretation of facts to fit a narrative that seems to be predetermined and with no due regard to implications.

Secondly, the authors have inaccurately stated that there is a widely held narrative asserting that COVID-19 has “largely skipped Africa and had little impact” or that “COVID-19 has spared Africa.” However, the cited articles have not categorically implied that COVID-19 skipped Africa but rather have clearly indicated and given possible explanations for the reasons Africa has been reporting fewer cases.3-5 This study does not prove otherwise. As opposed to COVID-19 skipping Africa, the issue has been that the continent has not observed as many deaths as was predicted by a number of models at the start of the pandemic.6,7 A lot of speculations and expert opinions have been put forward which need to be fully investigated 3-8. This paper, based on the data presented, does not address the impact of COVID-19 in Zambia nor Africa.

Thirdly, the authors state that “We postulate a more mundane explanation for the Africa paradox: insufficient data.” However, the efforts that Africa has made to strengthen disease surveillance through the World Health Organization (WHO) facilitated Integrated Disease Surveillance and Response (IDSR), the World Health Emergency Programme (WHE) and the Africa CDC must be acknowledged. It is undeniable that a lot has been done to improve surveillance systems across the continent.9-11 The authors should have acknowledged this fact and clearly stated so in the article.

Fourthly, all deaths occurring in the health facilities were being swabbed for SARS-CoV-2 as part of surveillance activities by Ministry of Health (MOH)/ Zambia National Public Health Institute (ZNPHI).2 The authorsseem not to have checked whether surveillance data was collected from the facilities; it must be noted that routine surveillance data is not entered on the medical charts but is rather entered separately. In this case to indicate that surveillance data was not collected is inaccurate. The authors ignored existing systems and context for the COVID-19 response in Zambia or did not undertake data collection as appropriate. The finding that none of the “community deaths” they swabbed from the UTH morgue were captured by the surveillance system for COVID-19 under MOH/ZNPHI is difficult to understand; this is so because during the time of this study all deaths that were occurring in the communities and brought to the health facilities as “brought-in-dead” (BIDs) bodies were being swabbed for SARS-CoV-2, in accordance with the MOH/ZNPHI guidelines.2,12

Lastly, the authors should have cited and referenced the assumption on the Malaria situation in Lusaka concerning it being eliminated. Our understanding is that malaria has not been eliminated in Lusaka.

We would like to state that this study does not provide evidence of increased severity of disease and deaths than what Zambia has been reporting within the acknowledged limitations. Severe disease and deaths are observed in all age groups across world regions, although treatment outcomes may be better in high income countries than in low income countries.13 Africa has acknowledged the impact of COVID-19 and through the Africa CDC and WHO has committed to mobilizing resources to ensure effective and affordable vaccines are made available to its citizens as outlined in the Communiqué from the Conference on Africa’s Leadership on COVID-19 Vaccine Development and Access held on 24th to 25th June 2020.14

We wish to fully support the observations made by Mucheleng'anga and Himwaze in their letter to the editor of the BMJ.12

During the dissemination to the Ministry of Health, all the issues raised in this rebuttal were brought to the attention of the CO-PI.

Key issues of concern that we have raised are that this study was biased and the sample size was not adequate to allow for the interpretation of the data as presented in the article that was published. This creates a lack of respect for science when it is needed to inform policy makers.

1. Mwananyanda L, Gill JC, Macleod W et al. Covid-19 deaths in Africa: prospective systematic post-mortem surveillance study. BMJ 2021;372: n334
2. Ministry of health, 2020. COVID-19 Pandemic: Zambia Response -
3. Bamgboye EL, Omiye JA, Afolaranmi OJ, et al. COVID-19 Pandemic: Is Africa Different? J Natl Med Assoc 2020;S0027-9684(20)30345-X.
4. Lawal Y. Africa’s low COVID-19 mortality rate: A paradox?Int J Infect Dis 2021;102:118-22. doi:10.1016/j.ijid.2020.10.038
5. Twahirwa Rwema JO, Diouf D, Phaswana-Mafuya N, et al. COVID-19 Across Africa: Epidemiologic Heterogeneity and Necessity of Contextually Relevant Transmission Models and Intervention Strategies. Ann Intern Med 2020;173:752-3. doi:10.7326/M20-2628
6. Economic Commission for Africa. Addis Ababa, Ethiopia, author. Covid-19 in Africa: Protecting lives and economies. 2020. [April 20th, 2020]. from: http//
7. Berhan Y. Will Africa be Devastated by Covid-19 as Many Predicted? Perspective and Prospective. Ethiop J Health Sci. 2020 May; 30(3): 459–467
8. Njenga MK, Dawa J, Nanyingi M et al. Why is There Low Morbidity and Mortality of COVID-19 in Africa? Am. J. Trop. Med. Hyg., 103(2), 2020, pp. 564–569 doi:10.4269/ajtmh.20-0474
9. Rosenthal JP, Breman GJ, Djimde AA et al. COVID-19: Shining the Light on Africa. Am. J. Trop. Med. Hyg., 102(6), 2020, pp. 1145–1148
10. Chersich FM, Gray G, Fairlie L et al. COVID-19 in Africa: care and protection for frontline healthcare workers. Globalization and Health (2020) 16:46
11. Ihekweazu C and Agogo E. Africa’s response to COVID-19. BMC Medicine (2020) 18:151.
12. Mucheleng'anga AL and Himwaze MC. Rapid response to: Covid-19 deaths in Africa: prospective systematic postmortem surveillance study. BMJ 2021;372: n334; doi:
13. Chauvin JP, Fowler A and Herrera LN. The Younger Age Profile of COVID-19 Deaths in Developing Countries. Inter-American Development Bank, doi
14. Africa CDC, Addis Ababa, Ethiopia. Available on

Competing interests: No competing interests

15 March 2021
Nathan Kapata
Head – Emergency Preparedness and Response
Prof. Victor Mukonka Director - ZNPHI Lusaka Zambia, Dr Nyambe Siyange FETP Coordinator and Epidemiologist ZNPHI Lusaka Zambia, Dr. Muzala Kapin’a Head – Surveillance and Disease Intelligence ZNPHI Lusaka Zambia, Ms. Albertina Morales Ngomah Knowledge Translation Officer ZNPHI Lusaka Zambia, Dr Raymond Hamoonga One Health Coordinator ZNPHI Lusaka Zambia, Ms Mazyanga Mazuba Liwewe Head- Communication Information and Research ZNPHI, Dr Aron Shibemba National Coordinator – Pathology and Laboratory Services Ministry of Health Lusaka Zambia, Dr. Alex Makupe Director – Clinical Care and Diagnostic Services Ministry of Health Lusaka Zambia, Prof. Lloyd Mulenga Director Infectious Diseases Ministry of Health Lusaka Zambia, Dr Kennedy Malama Permanent Secretary Ministry of Health Lusaka Zambia
Zambia National Public Health Institute (ZNPHI)/ Ministry of Health
Lusaka, Zambia