Lessons from a year of COVID-19 in Zambia: reported attendance and mask wearing at large gatherings in rural communities

Zambia instituted prevention behavior guidelines for social gatherings before the first case of COVID-19 was confirmed on March 18, 2020. Guidelines included nonpharmaceutical interventions (NPIs) including mask wearing, social distancing, and reducing sizes of gatherings. Within a larger cluster randomized trial of community-based parenting groups in four rural districts (three in Southern Province, one in Eastern Province), we collected 5,711 questionnaires from intervention participants between August 2020 and September 2021, during which the country saw two COVID-19 waves. Questionnaires asked about participation and behaviors at community gatherings. Generally, perception of risk of contracting COVID-19 was low for respondents in districts in Southern Province but higher for those in Eastern Province. The highest compliance to mask wearing was reported at clinics (84%) and church services (81%), which were the most frequently attended gatherings. Many funerals were attended by 200 to 300 people, but individuals were 30% less likely to report wearing masks (odds ratio [OR] = 0.71, 95% confidence ratio [CI]: 0.6-0.8) than those attending a clinic visit. After controlling for other variables, the odds of self-reported mask wearing at events were higher in January to March 2021 (adjusted OR = 1.5, 95% CI: 1.3, 1.7) and July and September of 2021 (adjusted OR = 3.0, 95% CI: 2.5-3.5), timepoints that broadly overlay with two COVID-19 peaks observed in Zambia. Results suggest guideline dissemination penetrated the rural areas. However, there is need to optimize the messaging to increase compliance to NPIs at high-risk gatherings, including funerals. The findings from this analysis should be considered as the COVID-19 pandemic continues to evolve

COVID-19 knowledge and prevention behaviors in rural Zambia: a qualitative application of the information-motivation-behavioral skills model

In early 2020, the Zambian Ministry of Health instituted prevention guidelines to limit spread of COVID-19. We assessed community knowledge, motivations, behavioral skills, and perceived community adherence to prevention behaviors (i.e., hand hygiene, mask wearing, social distancing, and limiting gatherings). Within a cluster-randomized controlled trial in four rural districts, in November 2020 and May 2021, we conducted in-depth interviews with health center staff (N = 19) and community-based volunteers (N = 34) and focus group discussions with community members (N = 281). A content analysis was conducted in Nvivo v12. Data were interpreted using the Information-Motivation-Behavioral Skills Model. Generally, respondents showed good knowledge of COVID-19 symptoms, spread, and high-risk activities, with some gaps. Prevention behavior performance was driven by personal and social factors. Respondents described institutional settings (e.g., clinics and church) having higher levels of perceived adherence due to stronger enforcement measures and clear leadership. Conversely, informal community settings (e.g., weddings, funerals, football matches) lacked similar social and leadership expectations for adherence and had lower perceived levels of adherence. These settings often involved higher emotions (excitement or grief), and many involved alcohol use, resulting in community members "forgetting" guidelines. Doubt about disease existence or need for precautions persisted among some community members and drove non-adherence more generally. Although COVID-19 information successfully penetrated these very remote rural communities, more targeted messaging may address persistent COVID-19 doubt and misinformation. Engaging local leaders in religious, civic, and traditional leadership positions could improve community behaviors without adding additional monitoring duties on an already overburdened, resource-limited health system

A Randomized Controlled Trial of Artemotil (Β-Arteether) in Zambian Children With Cerebral Malaria

The efficacy and safety of intramuscular artemotil (ARTECEF®) was compared to intravenous quinine in African children with cerebral malaria. This prospective block randomized open-label study was conducted at two centers in Zambia. Subjects were children aged 0 to 10 years of age with cerebral malaria and a Blantyre Coma Score of 2 or less. Ninety two children were studied; 48 received artemotil and 44 quinine. No significant differences in survival, coma resolution time, neurologic sequelae, parasite clearance time, and fever resolution time were seen between the two regimens. Rates for negative malaria smears one month after therapy were similar in both groups. Artemotil was a well-tolerated drug in the 48 patients in this study. It appears to be at least therapeutically equivalent to quinine for the treatment of pediatric cerebral malaria. It has the advantage of being able to be given intramuscularly once daily for only five days

Assessment of the Effect of the Oral Iron Chelator Deferiprone on Asymptomatic Plasmodium Falciparum Parasitemia in Humans

While the parenteral iron-chelating agent desferrioxamine B has anti- malarial activity in humans, the usefulness of an orally active chelator for this indication has not been investigated previously in vivo. We conducted a prospective, double-blind, placebo-controlled, cross-over trial of deferiprone (L1; CP20; 1,2-dimethyl-3-hydroxypyridin-4-one) in 25 adult Zambians with asymptomatic Plasmodium falciparum parasitemia. Deferiprone was administered daily for three or four days in divided doses of 75 or 100 mg/kg of body weight, dosages that are effective for treating iron overload. No reduction in asexual intra-erythrocytic parasites was observed during or after deferiprone treatment. The mean peak plasma concentration of deferiprone (108.9 ± 24.9 μmol/L) achieved was within the range demonstrated to inhibit the growth of P. falciparum in vitro, but the systemic exposure as determined by the 24-hr plasma concentration-time curve would not be predicted inhibit growth in vivo. No evidence of deferiprone- associated hematological toxicity was noted in this short-term study of these subjects, all of whom had clinical evidence of normal body iron stores. Because of the risk of neutropenia and other adverse effects with higher doses or prolonged use of the chelator, additional trials of deferiprone as a sole anti-malarial agent would not seem to be justified. In contrast, further efforts are needed to develop other orally active iron-chelating agents specifically for their antimalarial action

Effect of Iron Chelation Therapy on Recovery From Deep Coma in Children With Cerebral Malaria

Cerebral malaria is a severe complication of Plasmodium falciparum infection in children, with a mortality rate of 15 to 50 percent despite antimalarial therapy. To determine whether combining iron chelation with quinine therapy speeds the recovery of consciousness, we conducted a randomized, double-blind, placebo-controlled trial of the iron chelator deferoxamine in 83 Zambian children with cerebral malaria. To be enrolled, patients had to be less than six years old, have P. falciparum parasitemia, have normal cerebrospinal fluid without evidence of bacterial infection, and be in a coma from which they could not be aroused. Deferoxamine (100 mg per kilogram of body weight per day, infused intravenously for 72 hours) or placebo was added to standard therapy with quinine and sulfadoxine—pyrimethamine. The time to the recovery of full consciousness, time to parasite clearance, and mortality were examined with Cox proportional-hazards regression analysis. The rate of recovery of full consciousness among the 42 patients given deferoxamine was 1.3 times that among the 41 given placebo (95 percent confidence interval, 0.7 to 2.3); the median time to recovery was 20.2 hours in the deferoxamine group and 43.1 hours in the placebo group (P = 0.38). Among 50 patients with deep coma, the rate of recovery of full consciousness was increased 2.2-fold with deferoxamine (95 percent confidence interval, 1.1 to 4.7), decreasing the median recovery time from 68.2 to 24.1 hours (P = 0.03). Among 69 patients for whom data on parasite clearance were available, the rate of clearance with deferoxamine was 2.0 times that with placebo (95 percent confidence interval, 1.2 to 3.6). Among all 83 patients, mortality was 17 percent in the deferoxamine group and 22 percent in the placebo group (P = 0.52). Iron chelation therapy may hasten the clearance of parasitemia and enhance recovery from deep coma in cerebral malaria. (N Engl J Med 1992; 327:1473–7.), CEREBRAL malaria, one of the most severe complications of infection with Plasmodium falciparum, is especially common among young children. Despite therapy with parenteral antimalarial agents and attentive management of complications, the mortality rate is 15 to 50 percent and gross neurologic sequelae persist in about 10 percent of the children who survive.1 2 3 It is estimated that in sub-Saharan Africa alone, over 1 million children die from severe forms of malaria annually.4 , 5 Cerebral malaria is diagnosed when asexual forms of P. falciparum are found in the blood of a patient with signs of an acute, diffuse symmetric encephalopathy not attributable to

Evaluating implementation effectiveness and sustainability of a maternity waiting homes intervention to improve access to safe delivery in rural Zambia: A mixed-methods protocol

Background: In low-income countries such as Zambia, where maternal mortality rates are persistently high, maternity waiting homes (MWHs) represent one potential strategy to improve access to safe delivery, especially for women living in remote areas. The Maternity Homes Access in Zambia project (MAHMAZ) is evaluating the impact of a MWH model on women’s access to safe delivery in rural Zambia. There is a growing need to understand not only the effectiveness of interventions but also the effectiveness of their implementation in order to appropriately interpret outcomes. There is little evidence to guide effective implementation of MWH for both immediate uptake and to promote sustainability in this context. This protocol describes a study that aims to investigate the effectiveness of the implementation of MAHMAZ by not only documenting fidelity but also identifying factors that influence implementation success and affect longer-term sustainability. Methods: This study will use mixed methods to evaluate the implementation effectiveness and sustainability of the MAHMAZ intervention. In our study, “implementation effectiveness” means to expand beyond measuring fidelity to the MWH model and includes assessing both the adoption and uptake of the model and identifying those factors that facilitate or inhibit uptake. Sustainability is defined as the routine implementation of an intervention after external support has ended. Quantitative methods include extracting data from existing records at the MWHs and health facilities to analyze patterns of utilization, and conducting a routine health facility assessment to determine facility-level factors that may influence MWH implementation and woman-level outcomes. We will also conduct an experience survey with MWH users and apply a checklist to assess fidelity to the MWH model. Qualitative methods include in-depth interviews and focus group discussions with MWH users, community members and other stakeholders. Qualitative data will be analyzed using an integrated framework drawing constructs from the Consolidated Framework for Implementation Research and the Conceptual Framework for Sustainability. Discussion: The findings from this evaluation will be shared with policymakers formulating policy affecting the implementation of MWH and may be used as evidence for programmatic decisions by the government and supporting agencies in deciding to take this model to scale

We are also dying like any other people, we are also people: perceptions of the impact of HIV/AIDs on health workers in two distrcits in Zambia

Item does not contain fulltextIn countries with a high AIDS prevalence, the health workforce is affected by AIDS in several ways. In Zambia, which has a prevalence rate of 16.5%, a study was carried out in 2004 with the aim to: explore the impact of HIV/AIDS on health workers, describe their coping mechanisms and recommend supportive measures. The qualitative study was complemented by a survey using self-administered questionnaires in four selected health facilities in two rural districts in Zambia, Mpika and Mazabuka. It is one of the few studies to have explored the impact of HIV/AIDS from the perspective of health workers and managers in the region. Thirty-four in-depth interviews and five group discussions were conducted with health workers, managers and volunteers, and 82 self-administered questionnaires were filled out by health workers. In addition, burnout among 42 health workers was measured using the Maslach Burnout Inventory (MBI). The MBI measures three components that contribute to burnout: emotional exhaustion, depersonalization and personal accomplishment. The results show that in both districts, HIV/AIDS has had a negative impact on workload and has considerably changed or added tasks to already overburdened health workers. In Mpika, 76% of respondents (29/38), and in Mazabuka, 79% (34/44) of respondents, expressed fear of infection at the workplace. HIV-positive health workers remained 'in hiding', did not talk about their illness and suffered in silence. Despite the fact that health workers were still relatively motivated, emotional exhaustion occurred among 62% of the respondents (26/42). The interviews revealed that counsellors and nurses were especially at risk for emotional exhaustion. In each of the selected facilities, organizational support for health workers to deal with HIV/AIDS was either haphazardly in place or not in place at all. AIDS complicates the already difficult work environment. In addition to health workers, management also needs support in dealing with AIDS at the workplace

Neopterin and procalcitonin are suitable biomarkers for exclusion of severe Plasmodium falciparum disease at the initial clinical assessment of travellers with imported malaria

Background. Most clinicians in developed, non-malaria endemic countries have limited or no experience in making clinical assessments of malaria disease severity and subsequent decisions regarding the need for parenteral therapy or high-level monitoring in febrile patients with imported malaria. In the present study, the diagnostic accuracy of plasma soluble Triggering Receptor Expressed on Myeloid cells 1 (TREM-1), neopterin and procalcitonin levels as biomarkers for severe Plasmodium falciparum disease was evaluated in 104 travellers with imported malaria (26 patients with non-P. falciparum malaria, 64 patients with uncomplicated P. falciparum malaria and 14 patients with severe P. falciparum malaria). Methods. TREM-1, neopterin and procalcitonin were determined in serum using commercially available ELISA or EIA tests. The diagnostic performance of these biomarkers for severe disease was compared with plasma lactate, a well-validated parameter for disease severity in patients with malaria, as reference. Severe malaria was defined according to the modified WHO criteria. Results. No significant differences in TREM-1 levels were detected between the different patient groups. Patients with severe P. falciparum malaria had significantly higher neopterin and procalcitonin levels on admission when compared to patients with uncomplicated P. falciparum malaria or non-P. falciparum malaria. Receiver Operating Characteristic (ROC) curve analysis showed that neopterin had the highest Area-Under-the-ROC curve (AUROC 0.85) compared with plasma lactate (AUROC 0.80) and procalcitonin (AUROC 0.78). At a cut-off point of 10.0 ng/ml, neopterin had a positive and negative predictive value of 0.38 and 0.98 whereas procalcitonin, at a cut-off point of 0.9 ng/ml, had a positive and negative predictive value of 0.30 and 1.00. Conclusion. Although the diagnostic value of neopterin and procalcitonin is limited, the high negative predictive value of both neopterin and procalcitonin may be helpful for a rapid exclusion of severe malaria disease on admission. This may be a valuable tool for physicians only occasionally dealing with ill-returned travellers from malaria-endemic regions and who need to decide on subsequent oral anti-malarial treatment or timely referral to a specialized centre for high-level monitoring and intensified parenteral treatment

Markers of Inflammation in Children With Severe Malarial Anaemia

OBJECTIVE. To investigate if severe malarial anaemia is associated with a specific immune response pattern, we determined serum levels of neopterin (a marker of activation of macrophages by interferon-γ) and of the anti- inflammatory cytokines, interleukins 4 and 10. METHODS. Zambian children \u3c 6 years of age presenting to a rural hospital with cerebral malaria were studied. Twenty-one children with admission haemoglobin concentrations ≤ 5 g/dl were classified as having severe anaemia and 40 with haemoglobin concentrations ≥ 7 g/dl served as a control group. RESULTS. Logistic regression modelling indicated that a 10-fold rise in serum neopterin concentrations was associated with a 50-fold increase in the estimated odds of having severe anaemia (P = 0.015), while a 10-fold rise in serum interleukin 4 concentrations was associated with a 10-fold decrease in the estimated odds of having severe anaemia (P = 0.023). Increasing serum interleukin 10 concentrations, measured in less than half of the subjects, were associated with a nonsignificant reduction in the odds of having severe anaemia (P = 0.095). CONCLUSION. Development of severe malarial anaemia may be directly associated with serum neopterin concentrations and inversely correlated with serum interleukin 4 levels