Central Africa and the COVID-19 paradox: lessons from a silent spread

Initially perceived as a high-risk region at the onset of the COVID-19 pandemic, Central Africa raised major concerns due to its fragile health systems. Four years after the emergence of SARS-CoV-2, this review provides a critical analysis of seroprevalence data, epidemiological trends, diagnostic capabilities, and the technologies implemented in the regional response. An organized narrative review was conducted for the period 2020-2023. In total, 42 documents were included, comprising 27 peerreviewed articles and 15 institutional reports. The analysis covered a country-by-country description and a cross-cutting assessment of testing strategies, genomic surveillance, vaccination rollout, and health governance. The region exhibited significant disparities in its response, notably in testing capacity, vaccination coverage (often<15%), and fragmented genomic surveillance. Molecular testing by reverse transcription quantitative polymerase chain reaction (RT-qPCR) remained highly centralized, while antigen tests were inconsistently deployed in peripheral areas. Only a few countries could locally identify variants. Seroprevalence levels appear to be much higher than reported case numbers. Initial catastrophic forecasts did not materialize, likely due to underestimated demographic, community-based, and probably immunological factors. The pandemic highlighted both the structural weaknesses and the adaptive capacities of Central African health systems. Nevertheless, it has offered a strategic opportunity to invest in sustainable epidemiological surveillance and health sovereignty. Understanding the gap between early projections and actual outcomes underscores the need for context-sensitive, resilient public health models in the region.