Pandemic Preparedness in Cameroon: Lessons from COVID-19
Overview
This policy briefing synthesizes key insights from the Cameroon Townhall for Healthcare Professionals meeting held on May 21, 2022, focusing on the theme "Pandemic Preparedness: Experiences and Lessons Learnt", with presentations by Dr. Bryan Tegomoh and Dr. Karl Gwei Njuwa Fai of Epicentre.
Context
The session took place as Omicron subvariants spread and monkeypox appeared in countries outside Africa. Cameroon had built new capacity during COVID-19 (an Emergency Operations Center, 45 PCR laboratories and four sequencing platforms), yet its 2021 IHR self-assessment remained below regional and global averages on most capacities, and only about 1.8 million vaccine doses had been given.
Key issues
- Hidden spread. Seroprevalence surveys showed infection far above reported cases across Africa, including 18.3 to 20.5 percent in Cameroon by mid-2021, so case counts alone misled decisions.
- Data not reaching decision makers. Much of the response's data and experience in Cameroon had not been published or shared, limiting its use by policymakers and partners.
- Genomic and laboratory dependence. Sequencing early in the pandemic relied on other countries, and laboratories depended on imported assays and reagents.
- Vaccine hesitancy and targeting. Acceptance was 37 percent nationally, with the belief that vaccines are dangerous the main reason for refusal. The problem had shifted from supply to uptake and cold chain.
- Gaps in IHR capacities. Policy and legal instruments, infection prevention and control, food safety and simulation exercises were weak points.
Discussion highlights
- Cameroon's Emergency Operations Center, built during Ebola preparedness, is now used for cholera, yellow fever and monkeypox.
- Screening with multiplex PCR before sequencing can cut sequencing costs by up to about 70 percent.
- Serosurvey results differ by platform, so methods need to be harmonised for comparison.
- Participants favoured vaccination targeted at older people and those with chronic disease, delivered through community engagement.
Recommendations
- Build preparedness into the Health Sector Strategy. MINSANTE should integrate IHR capacity gaps from the SPAR and Joint External Evaluation into the current Health Sector Strategy 2016 to 2027, with costed actions on legal instruments, infection prevention and control and food safety. A first step is a review workshop with the Emergency Operations Center.
- Institutionalise genomic surveillance. The National Public Health Laboratory and partners should run a routine Cameroon genomic surveillance dashboard with Africa CDC, using multiplex PCR screening to target sequencing, and link genomic data to epidemiological line lists.
- Publish and share response data. MINSANTE and Epicentre should publish seroprevalence, mortality and vaccine acceptance findings, and continue scientific writing workshops. Diaspora professionals should volunteer as writing coaches through the town hall.
- Target vaccination by risk. The Expanded Programme on Immunization and regional delegations should focus COVID-19 vaccination and boosters on older adults and people with hypertension or diabetes, using door-to-door community strategies, and plan repeat serosurveys to guide decisions.
- Train applied epidemiologists and test plans. MINSANTE should expand field epidemiology training and run regular simulation exercises for outbreaks such as monkeypox and cholera, starting with one tabletop exercise per region.
- Develop local assay and vaccine capacity. Research institutions should develop and validate in-house assays and use African technology transfer for vaccines against malaria, diarrhoeal disease and other local priorities.
Next steps
A Ministry of Health scientific writing workshop was scheduled for the following week, with diaspora coaching. Speakers offered laboratory and genomic collaboration to teams in Cameroon.
Conclusion
COVID-19 left Cameroon with real assets: an Emergency Operations Center, laboratory and sequencing capacity, and trained staff. Using them for the next threat will require linking data to decisions, publishing what was learned, targeting interventions to local risk and keeping the diaspora engaged.
Meeting minutes
Agenda
- Welcome and opening remarks by the lead moderator
- COVID-19 and monkeypox update by the Chair, Dr. Munoh Kenne Foma
- Presentation by Dr. Bryan Tegomoh: surveillance, genomic epidemiology and lessons from the US and Africa CDC
- Presentation by Dr. Karl Gwei Njuwa Fai: lessons from Epicentre's SARS-CoV-2 seroprevalence and mortality surveys
- Review of Cameroon's IHR capacity scores by the moderator
- Discussion and Q&A
- Closing and parking lot
Opening remarks
- The lead moderator opened the session in the middle of 2022 and said the town hall could not tire of discussing COVID-19, before introducing two speakers with first-hand experience of surveillance during the pandemic.
- The Chair thanked the moderators for their fortnightly volunteer work.
- In his update the Chair said new Omicron subvariants (BA.2.12.1 in the US, and BA.4 and BA.5) were circulating, that about one million people had died of COVID-19 in the US and about 6.2 million worldwide, and that around 12 billion vaccine doses had been given, against about 1.8 million doses in Cameroon. He said Africa was almost free of active disease at the time but should keep its guard up.
- He reviewed treatments: steroids (with dose equivalents), tocilizumab (costly and scarce in Africa), a JAK inhibitor available for rheumatology, nirmatrelvir/ritonavir (Paxlovid, which he said reduced mortality by almost 90 percent in trials), molnupiravir, remdesivir and tixagevimab/cilgavimab (Evusheld) for immunocompromised patients. Ivermectin, convalescent plasma, hydroxychloroquine, HIV drugs and vitamins C and D had not worked. He singled out the UK RECOVERY trial as a model.
- He reported 142 monkeypox cases in 12 countries outside the usual endemic zone. Asked whether monkeypox and SARS-CoV-2 could combine, he explained that this is not possible, since one is a large DNA virus and the other an RNA virus.
Presentation
1. Monkeypox and genomic diversity
Dr. Tegomoh said he had that morning been invited to co-write a review of past monkeypox outbreaks for an Infectious Diseases Society of America journal. Monkeypox is a double-stranded DNA virus with proofreading, so it mutates slowly, and the 2022 European genomes were very close to the 2018 West African sequences. He cautioned that a phylogenetic tree cannot show who infected whom without epidemiological context. Key unknowns included the role of transmission without rash, and he proposed a detailed line list of the 142 cases.
2. One Health and drivers of emergence
He showed global hotspots of zoonotic emergence and linked them to population growth, urbanisation, travel, trade, rising demand for animal protein, agricultural intensification, wildlife exploitation, land use change and climate change. Pandemic preparedness, he said, cannot be separated from the human, animal and environment interface.
3. The role of applied epidemiology
He described epidemiology as finding the right numerator and denominator, and applied epidemiology as acting on them and communicating results. Individuals mask, distance and test; epidemiologists run case investigation and contact tracing; data must inform directed health measures with policymakers. He led the investigation of the first Omicron cluster identified in the United States, where early cases showed less loss of taste and smell than with Delta, and said tools such as R and Python now allow line lists and transmission maps in real time. Communication, sociologists and anthropologists proved essential.
4. Genomic surveillance with Africa CDC
Early in the pandemic he worked with Africa CDC on continental genomic surveillance, pooling sequences from member states to detect variants before they became a problem. With a colleague at the Africa CDC Pathogen Genomics Initiative he maintains Nextstrain builds that pull sequences weekly from public health laboratories across Africa and flag mutations of concern. Turnaround from sample to published sequence had shortened markedly. He hoped to set up a similar system for Cameroon with colleagues at Epicentre.
5. Diagnostics and antibody studies in Cameroon
Dr. Fai said Cameroon was one of the first African countries with a working Public Health Emergency Operations Center. Epicentre first evaluated antigen and antibody rapid tests in symptomatic and asymptomatic patients, since PCR is costly and scarce, and found antibody detection improved after about 14 days. A study published in Scientific African showed IgM and IgG from natural infection declining over time.
6. Seroprevalence surveys across Africa
Surveys found far more infection than surveillance reported. Among blood donors in Koutiala, Mali, 23.7 percent were positive by rapid test and 65.3 percent by laboratory test. Among health staff in Maradi, Niger, 42.3 percent were positive by rapid test and 84.5 percent by laboratory test, against 7.6 percent by PCR. In Abidjan (1,861 participants), 35.6 percent were positive by rapid test and 79.4 percent by laboratory test. In Lubumbashi, more than half of households refused to take part amid vaccine rumours, a lesson in community communication. The Cameroon nationwide survey (July to August 2021, 5,739 participants) found 18.3 percent by rapid test and 20.5 percent by ELISA.
7. Mortality and vaccine acceptance
Retrospective mortality surveys in Lubumbashi showed crude mortality rising from 0.10 to 0.28 per 10,000 per day in the second wave, including among people under 20. In Cameroon (6,155 households, 22,314 people, 238 deaths from January 2020 to August 2021), mortality in those aged 50 and over rose from 0.26 to 0.76 per 10,000 per day, though this was not statistically significant. A national survey of 6,343 people found 37 percent vaccine acceptance, higher in the Adamawa, North and Far North regions and among the less educated; the main reason for refusal was the belief that the vaccine is dangerous (30.3 percent).
8. Cameroon's waves and the conclusion
Cameroon's first wave ran from April to August 2020. The Delta-driven wave was the most severe and the Omicron wave the mildest, and genomic surveillance began in the second wave with some samples sequenced in Nigeria. The country had notified no new cases for weeks. Dr. Fai concluded that no one-size-fits-all approach works in a continent as diverse as Africa, and that COVID-19 should be used to strengthen health systems before the next pandemic.
Discussion and Q&A
- The moderator presented Cameroon's 2021 State Party Self-Assessment Annual Reporting (SPAR) scores under the International Health Regulations and asked each participant to reflect on their own role. She also asked whether pandemic preparedness could be built into the Health Sector Strategy 2016 to 2027 while funding opportunities remain. She noted that Cameroon scored below regional and global averages on most capacities, including policy and legal instruments, infection prevention and control, and food safety, with better results for coordination and laboratory capacity. The strategy question was left as a point for reflection.
- The Chair asked why rapid test and laboratory results differed widely in some countries but were close in Cameroon. Dr. Fai said the reasons were still under study: different ELISA and immunofluorescence platforms were used in each country, and Cameroon's samples were dried blood spots sent to Yaoundé. Dr. Kenji said cross-reactivity with the nucleocapsid protein is common, and that pre-pandemic samples from Cameroon tested positive but did not neutralise the virus. He advised using the same test across sites and multiple targets (S1, RBD and nucleocapsid) to separate vaccine from natural immunity, and offered to collaborate.
- The Chair asked how prepared the CDC, WHO and Cameroon are for the next pandemic, and whether WHO had learned lessons for monkeypox. Dr. Tegomoh said the global response had not been the best. He called for platform trials like RECOVERY, a WHO applied epidemiology corps modelled on CDC's Epidemic Intelligence Service (citing Bill Gates' new book on preventing the next pandemic), better communication between agencies, and real-time data systems. Dr. Kenji said laboratories must stay ahead: design and validate assays with synthetic DNA before cases arrive, build local assay capacity instead of relying on Western suppliers, and screen samples with a multiplex PCR so that only unknowns are sequenced, which had cut his laboratory's sequencing costs by almost 70 percent.
- Dr. Fai answered for Cameroon. He described four elements: commitment (the Emergency Operations Center, now also leading the cholera response), action (health financing and laboratories, which grew from about two to many during the pandemic), collaboration (with Africa CDC and regional partners) and learning. Community vaccination, using health workers who go door to door as in national campaigns, had raised coverage from about 500,000 to 600,000 people six months earlier to about 1.8 million.
- Prof. Yap Boum II responded to a comment in the chat that there is no action. He said Cameroon went from one laboratory able to run COVID-19 PCR to 45, and now has four next-generation sequencing platforms using the same screening approach Dr. Kenji described. The Emergency Operations Center building, built with CDC Atlanta support during Ebola preparedness, and its incident management system are now used for cholera, yellow fever and monkeypox. What is missing is publication: the Ministry of Health was holding a scientific writing workshop the following week, with Dr. Tegomoh as a coach, and he invited others to coach. He argued vaccination should target those at highest risk (older people and those with hypertension or diabetes) through community engagement.
- A participant working with WHO described its support for preparedness. She said WHO supports coordination, national health security plans, laboratories, case management (including equipped intensive care units in the North West and South West), logistics and staff. Weak points remain local research, vaccine and therapeutic capacity, and too few simulation exercises; Cameroon had carried out an intra-action review of its COVID-19 response.
- The Chair asked whether Africans trust each other enough to buy vaccines made in Africa, noting that South Africa's vaccine had found no buyers. a participant asked about the use of genomic surveillance in Cameroon, and another asked how to overcome vaccine hesitancy. Dr. Tegomoh showed Africa CDC's regional and country Nextstrain builds, including Cameroon's shift from Delta to Omicron, stressed that genomic data need epidemiological context, and described wastewater surveillance as a promising approach where sewage systems exist. Dr. Fai said Africa CDC had told countries that further doses would wait because stocks were expiring, so the issue was hesitancy and cold chain rather than supply. Prof. Boum said technology transfer should be used for malaria and diarrhoeal disease vaccines, and that vaccination at the Africa Cup of Nations reached about 200,000 people.
- A participant asked how the town hall could contribute to the training of health professionals in Cameroon. Prof. Boum invited members to coach teams at home on scientific writing. The Chair said the platform is for two-way learning between those at home and in the diaspora, citing projects that grew from it: a repository of Cameroonian COVID-19 publications, planned oncology teaching sessions with residents in Cameroon, work with a surgeon in Cameroon, and earlier volunteer support to COVID-19 critical care in the North West and South West.
Calls to action and closing
- The moderators thanked the speakers and their teams at Africa CDC, US public health agencies and Epicentre.
- Participants were invited to the parking lot, an informal and unrecorded networking session.
Submitted by the Co-Moderators, Cameroon Town Hall for Healthcare Professionals.
