CAMEROON COVID-19 outbreak

Anticipated crisis impact

• Cameroon has 54 confirmed cases of COVID-19 in Central Region, Littoral Region and West Region as of 23 March 2020. (US Embassy) The first positive case was confirmed on 6 March 2020.

• Cameroon’s Ministry of Public Health has developed a preparedness plan for COVID-19, including active surveillance at points of entry, in-country diagnostic capacity at the national reference laboratory, and designated isolation and treatment centres. WHO and the U.S. Centres for Disease Control and Prevention (D) are providing technical support and are closely monitoring the situation in Cameroon. (US Embassy)

• The Cameroonian Prime Minister has announced that from 18 March all land, sea, and air borders are closed until further notice due to COVID-19. (US Embassy) (Journal de Cameroon, 18/03/2020)

• Isolation and treatment centres have been set up for confirmed cases of COVID-19 at: - Yaoundé Central Hospital, for Central Region, - Laquintinie Hospital in Douala, for Littoral Region, - Garoua Regional Hospital, for North Region, - Kribi District Hospital, for South Region (US Embassy)

• No data is available regarding a preparedness plan in the Far North Region, where more than 100,000 Nigerian refugees who fled the Boko Haram insurgency are living in Minawao refugee camp or in host communities throughout the region. (UNHCR, January 2020) People over 60 represent 3% of the displaced population overall across the country. (HNO 2019)

Key figures across the country

350,000 displaced people face limited access to basic services and living in overcrowded conditions

Food Insecurity and malnutrition The Far North region is most affected by food insecurity. SAM exceeds the alert threshold of 1%.

Vulnerable groups immunocompromised people, displaced population, malnourished children, pregnant women and elders.

National response capacity Cameroon’s Ministry of Public Health is leading the preparedness plan for COVID-19 across the country

International response capacity WHO and the U.S. Centres for Disease Control and Prevention (CDC) are providing technical support and closely monitoring the situation, together with UN and several INGOs

Anticipated scope and scale

Densely overcrowded areas, lacking access to clean water or basic sanitation, such as displacement camps, pose increased risk of COVID-19 transmission. There is a risk of diversion of healthcare resources from prevention and treatment of other people in the region, including malaria, cholera and measles, to tackle the COVID-19 outbreak. (New Scientists, 10/03/2020)

Lessons learned

A key lesson learned during the 2014 Ebola response in West Africa was the importance of community involvement. Tailored messages and effective communication channels are crucial, both in preparedness and during the intervention, to limit the impact of the virus. (ACAPS, February 2016)

Humanitarian constraints

Access has deteriorated across the country, particularly in the Northwest and Southwest Regions, where hostilities between anglophone separatists and the government have heightened insecurity. The setting up of checkpoints by both the separatists and the Rapid Intervention Battalion (BIR) is expected to hamper humanitarian logistical arrangements. (ACAPS, Short Note Cameroon, 21/01/2020); (Logistic Cluster Cameroon, 12/11/2018)

Aggravating factors and sectors at potential risk across the country

WASH

• WASH system is poor across the entire country. The supply of drinking water, in quantity and in quality, remains precarious. The latrines do not meet the standard and are unsecured. Reports show poor respect for good personal and community hygiene practices. (HNO 2019) Good hygiene practices are a critical factor in preventing the spread of COVID- 19. • Only 40.5% of the population has access to an improved water source in the Far North region compared to the average of 72.9% nationally. This is linked to insufficient investment in the water sector, poor infrastructure management capacity and increased demand for service following an influx of displaced populations. (HNO 2019)

• People living in the Gado, Ngam, Borgop, Lolo, Mbile, and Minawao refugee camps tend to have the most crucial needs for drinking water, hygiene, and sanitation services. (HNO 2019)

• The Ebola outbreak in West Africa showed that a lack of maintenance and the disruption of development programmes can become a major issue for the WASH sector.

• Inadequate community involvement in the response may lead to resistance to humanitarian actors trying to promote better hygiene and sanitation practices in order to limit the contagion. (ACAPS, February 2016)

Health

• The major problem of the health system in Cameroun is its shortage of healthy and productive human capital. This has several consequences: insufficient health awareness campaigns causing low adoption of healthy behaviours by the populations and therefore high prevalence and incidence of risk factors for preventable diseases; unsatisfactory case management both in health facilities and at community level; high morbidity and mortality that could be avoidable. (WATHI, September 2018)

Food and livelihoods

• In departments with high concentrations of internally displaced persons (IDPs) or refugees (Ouest and Adamaoua Regions) and in the districts of the Extrême-Nord affected by flooding and Boko Haram looting, deteriorating food access and income will push poor households to adopt Stressed (IPC Phase 2) coping strategies between February and May. (Fewsnet West Africa) Chronic malnutrition remains an urgent multisectoral problem in the country. (HNO 2019)

• A slowdown in the economy due to the COVID-19 outbreak is likely to exacerbate existing food insecurity. It limits people’s ability to access nutritious food in different ways, including through reduced income or increased job insecurity. (WFP, 16/03/2020)

• During a severe pandemic, all sectors of the economy—agriculture, manufacturing, services—face disruption, potentially leading to shortages, rapid price increases for staple goods, and economic stresses for households, private firms, and governments. (NCBI)

• Overall food production may decrease if families and agricultural labour workers fear exposure. Hunger, starvation and increased malnutrition can become the secondary impacts of the potential large-scale outbreak. (ACAPS, February 2016)

• In the Far North, Northwest and Southwest Regions, insecurity has reduced access to basic health services for around 523,000 people. Many health facilities are no longer functional due to destruction by armed groups or abandonment of health facilities by health staff while population movement, the massive influx of wounded following the various armed conflicts, armed attacks and recent epidemics, such as cholera continue to add additional pressure on health services that are already fragile. (HNO 2019)

• The majority of IDPs across the country are suffering from chronic health conditions (HIV / AIDS, tuberculosis, etc.). (HNO 2019) It is know that some of these pre-existing chronic illness worsen the outcome of COVID-19. (Health.com, 17 March 2020)

Major risks of a potential outbreak in refugees camps

There is no evidence that Cameroon has a general national public health emergency response plan for an epidemic in place, though some disease-specific response plans exist. According to the 2017 Joint External Evaluation of Cameroon, planning for public health emergencies is covered in the general ‘National contingency plan’ (2011), which is a disaster risk reduction plan; a sectoral contingency plans for diseases such as Ebola, polio and cholera. (GHS Index, Cameroon 2019)

The health system in the country is fragmented and the facilities are not equally distributed geographically. The same is true for medical equipment. (GHS Index, Cameroon 2019)

According to the 2017 Joint External Evaluation of Cameroon, carried out by WHO, the country has a functioning Public Health Emergency Operations Centre (PHEOC), but has yet to pass the regulation formally creating it and establishing its structure and functions. It is temporarily based within the Department for Combatting Epidemics and Pandemics, under the health ministry. The country also has regional public health alert cells, but there is no evidence of a risk communication plan specifically intended for use during a public health emergency. (GHS Index, Cameroon 2019) The management of a possible COVID-19 outbreak is likely to be critical in rural areas, where access is compromised by instability and insecurity, and where the health system is fragilized by the pression of the increased amount of displaced people.

There are more than 350,000 refugees in Cameroon. In the Far North Region, crossborder attacks perpetrated by Boko Haram cause regular arrival of Nigerian refugees seeking security. The regions of Adamaoua, East and North of Cameroon continue to receive new refugees, following the renewed insecurity in the Central African Republic (CAR). The number of Central African refugees in these regions increased from 217,000 in 2017 to 245,000 in 2018. According to the REVA vulnerability index nearly 87% of Central African refugees are very vulnerable to food security. (HRP 2019) The overcrowded and unhygienic conditions, which are common in the refugees camps in those regions increase the potential for the rapid spread of COVID-19. Given the poor health status of the population, the limited access to health care and the use of communal hygiene facilities, the potential mortality and morbidity risk associated with COVID-19 is likely to surpass global averages.

The overcrowded living conditions and movement restrictions to areas outside the camps prevent the refugees from social distancing or isolating themselves from others. In addition, the population density of the refugee camps, poor hygiene, and insufficient health facilities, increase the risk of infection within the camps. The population in refugee camps has to rely on public hygiene infrastructure, potentially exposing people to contagion due to physical proximity and lack of hygiene.

Fig. 1 Map of refugees inflow, January 2019

Source: HNO 2019

Fig.2 Refugees locations, UNHCR 2018

Source: UNHCR, Avril