Community-informed research on malaria in pregnancy in Monrovia, Liberia: a grounded theory study

Background: Liberia is a West African country that needs substantial investment to strengthen its National Malaria Control Programme (NMCP), which was disrupted during the 2014–2016 Ebola epidemic. As elsewhere, Liberian pregnant women are especially vulnerable to malaria. Understanding prevention and treatment-seeking behaviours among the population is crucial to strategize context-specifc and women-centred actions, including locally-led malaria research, to improve women’s demand, access and use of NMCP strategies against malaria in pregnancy. Methods: In 2016, after the Ebola crisis, a qualitative inquiry was conducted in Monrovia to explore populations’ insights on the aetiology, prevention and therapeutics of malaria, as well as the community and health workers’ perceptions on the utility of malaria research for pregnant women. In-depth interviews and focus group discussions were conducted among pregnant women, traditional community representatives and hospital staf (n=38), using a feminist interpretation of grounded theory. Results: The narratives indicate that some Liberians believed in elements other than mosquito bites as causes of malaria; many had a low malaria risk perception and disliked current efective prevention methods, such as insecticide-treated nets; and some would resort to traditional medicine and spiritual care to cure malaria. Access to clinic-based malaria care for pregnant women was reportedly hindered by lack of fnancial means, by unofcial user fees requested by healthcare workers, and by male partners’ preference for traditional medicine. The participants suggested that malaria research in Liberia could help to design evidence-based education to change current malaria prevention, diagnostic and treatment-seeking attitudes, and to develop more acceptable prevention technologies. Conclusion: Poverty, insufcient education on malaria, corruption, and poor trust in healthcare establishment are structural factors that may play a greater role than local traditional beliefs in deterring Liberians from seeking, access‑ ing and using government-endorsed malaria control strategies. To increase access to and uptake of preventive and biomedical care by pregnant women, future malaria research must be informed by people’s expressed needs and constructed meanings and values on health, ill health and healthcare

Training through malaria research: building capacity in good clinical and laboratory practice in Liberia

Background: Limited health research capacities (HRC) undermine a country’s ability to identify and adequately respond to local health needs. Although numerous interventions to strengthen HRC have been conducted in Africa, there is a need to share the lessons learnt by funding organizations, institutes and researchers. The aim of this report is to identify best practices in HRC strengthening by describing a training programme conducted between 2016 and 2017 at the Saint Joseph’s Catholic Hospital (SJCH) in Monrovia (Liberia). Methods: A call for trainees was launched at the SJCH, the Liberia Medicines and Health Products Regulatory Author‑ ity (LMHRA), the Ministry of Health and Social Welfare, the Mother Pattern College of Health Sciences (MPCHS) and community members. Selected trainees participated in four workshops on Good Clinical Laboratory Practice (GCLP), standard operating procedures (SOP) and scientifc communication, as well as in a 5-months eLearning mentoring programme. After the training, a collectively-designed research project on malaria was conducted. Results: Twenty-one of the 28 trainees (14 from the SJCH, 3 from LMHRA, one from MPCHS, and 10 community representatives) completed the programme satisfactorily. Pre- and post-training questionnaires completed by 9 of the trainees showed a 14% increase in the percentage of correct answers. Trainees participated in a mixed-methods crosssectional study of Plasmodium falciparum infection among pregnant women at the SJCH. Selected trainees dissemi‑ nated activities and research outcomes in three international meetings and three scientifc publications. Conclusion: This training-through-research programme successfully involved SJCH staf and community members in a practical research exercise on malaria during pregnancy. The challenge is to ensure that the SJCH remains active in research. Harmonization of efectiveness indicators for HRC initiatives would strengthen the case for investing in such eforts

Quantifying the value of viral genomics when inferring who infected whom in the 2014–16 Ebola virus outbreak in Guinea

Transmission trees can be established through detailed contact histories, statistical or phylogenetic inference, or a combination of methods. Each approach has its limitations, and the extent to which they succeed in revealing a 'true' transmission history remains unclear. In this study, we compared the transmission trees obtained through contact tracing investigations and various inference methods to identify the contribution and value of each approach. We studied eighty-six sequenced cases reported in Guinea between March and November 2015. Contact tracing investigations classified these cases into eight independent transmission chains. We inferred the transmission history from the genetic sequences of the cases (phylogenetic approach), their onset date (epidemiological approach), and a combination of both (combined approach). The inferred transmission trees were then compared to those from the contact tracing investigations. Inference methods using individual data sources (i.e. the phylogenetic analysis and the epidemiological approach) were insufficiently informative to accurately reconstruct the transmission trees and the direction of transmission. The combined approach was able to identify a reduced pool of infectors for each case and highlight likely connections among chains classified as independent by the contact tracing investigations. Overall, the transmissions identified by the contact tracing investigations agreed with the evolutionary history of the viral genomes, even though some cases appeared to be misclassified. Therefore, collecting genetic sequences during outbreak is key to supplement the information contained in contact tracing investigations. Although none of the methods we used could identify one unique infector per case, the combined approach highlighted the added value of mixing epidemiological and genetic information to reconstruct who infected whom

Prevalence of Plasmodium falciparum infection among pregnant women at first antenatal visit in post-Ebola Monrovia, Liberia

Background: Disruption of malaria control strategies during the West African 2014–2016 Ebola epidemic led to an increase in malaria-attributable mortality. However, recent data on malaria infection in vulnerable groups, such as pregnant women, are lacking in this post-Ebola scenario. This cross-sectional study aimed to assess the prevalence of Plasmodium falciparum infection and of molecular markers of drug resistance among pregnant women attending antenatal care in Monrovia, capital of Liberia. Methods: From October 2016 to June 2017, all pregnant women attending their frst antenatal care visit at the Saint Joseph’s Catholic Hospital, Monrovia, were invited to participate in the study. In addition to their routine antenatal care tests, capillary blood spotted onto flter papers were collected from all consenting participants to determine presence of P. falciparum by real-time quantitative PCR. Molecular markers of anti-malarial drug resistance were assessed through Sanger sequencing and quantitative PCR in specimens positive for P. falciparum analysis. Results: Of the 195 women participants, 24 (12.3%) were P. falciparum-positive by qPCR. Infected women tended to be more commonly primigravidae and younger than uninfected ones. Parasite densities were higher in primigravidae. Fever was more frequently detected among the infected women. No statistically signifcant association between P. falciparum infection and haemoglobin levels or insecticide-treated net use was found. While high prevalence of genetic polymorphisms associated with chloroquine and amodiaquine resistance were detected, no molecular markers of artemisinin resistance were observed. Conclusion: Plasmodium falciparum infections are expected to occur in at least one in every eight women attending frst ANC at private clinics in Monrovia and outside the peak of the rainy season. Young primigravidae are at increased risk of P. falciparum infection. Molecular analyses did not provide evidence of resistance to artemisinins among the P. falciparum isolates tested. Further epidemiological studies involving pregnant women are necessary to describe the risk of malaria in this highly susceptible group outside Monrovia, as well as to closely monitor the emergence of resist‑ ance to anti-malarials, as recommended by the Liberian National Malaria Control Programme

'Researchers have love for life': opportunities and barriers to engage pregnant women in malaria research in post-Ebola Liberia

BACKGROUND: Adoption of prevention and therapeutic innovations to ensure that National Malaria Control Programmes meet their incidence reduction targets is highly dependent on the conduct of rigorous clinical trials. In Liberia, malaria control virtually halted during the recent Ebola epidemic, and could enormously benefit from innovations to protect its most vulnerable populations, including pregnant women, against malaria. Health policy-planners could feel more inclined to adopt novel interventions with demonstrated safety and efficacy when trialled among their women population. However, pregnant women are especially vulnerable when targeted as research participants. Whilst some studies in the region attempted to understand the ethical issues around the conduct of clinical research, there is need of such information from Liberia to inform future malaria research. METHODS: This is a grounded theory study that aims to understand the barriers and opportunities for pregnant women to consent to participate in malaria research in Liberia. The study was conducted between November 2016 and May 2017 at the St Joseph's Catholic Hospital, Monrovia. In-depth interviews and focus group discussions were held with hospital staff, traditional community representatives, and pregnant women. RESULTS: According to the participants, useful strategies to motivate pregnant women to consent to participate in malaria research could be providing evidence-based education on malaria and research to the general population and encouraging engagement of traditional leaders in research design and community mobilization. Fears and suspicions towards research and researchers, which were amplified during the conduct of Ebola vaccine and drug clinical trials, may influence women's acceptance and willingness to engage in malaria research. Population's mistrust in the public healthcare system might hinder their acceptance of research, undermining the probability of their benefiting from any improved malaria control intervention. CONCLUSION: Benchmarking for acceptable practices from previous public health interventions; building community discussion and dissemination platforms; and mapping communication and information errors from how previous research interventions were explained to the Liberian population, are strategies that might help ensure a safe and fully informed participation of pregnant women in malaria research. Inequity issues impeding access and use of biomedical care for women must be tackled urgently

Determinants of Transmission Risk During the Late Stage of the West African Ebola Epidemic.

Understanding risk factors for Ebola transmission is key for effective prediction and design of interventions. We used data on 860 cases in 129 chains of transmission from the latter half of the 2013-2016 Ebola epidemic in Guinea. Using negative binomial regression, we determined characteristics associated with the number of secondary cases resulting from each infected individual. We found that attending an Ebola treatment unit was associated with a 38% decrease in secondary cases (incidence rate ratio (IRR) = 0.62, 95% confidence interval (CI): 0.38, 0.99) among individuals that did not survive. Unsafe burial was associated with a higher number of secondary cases (IRR = 1.82, 95% CI: 1.10, 3.02). The average number of secondary cases was higher for the first generation of a transmission chain (mean = 1.77) compared with subsequent generations (mean = 0.70). Children were least likely to transmit (IRR = 0.35, 95% CI: 0.21, 0.57) compared with adults, whereas older adults were associated with higher numbers of secondary cases. Men were less likely to transmit than women (IRR = 0.71, 95% CI: 0.55, 0.93). This detailed surveillance data set provided an invaluable insight into transmission routes and risks. Our analysis highlights the key role that age, receiving treatment, and safe burial played in the spread of EVD

Communicating risk during early phases of COVID-19: Comparing governing structures for emergency risk communication across four contexts

BackgroundEmergency risk communication (ERC) is key to achieving compliance with public health measures during pandemics. Yet, the factors that facilitated ERC during COVID-19 have not been analyzed. We compare ERC in the early stages of the pandemic across four socio-economic settings to identify how risk communication can be improved in public health emergencies (PHE).MethodsTo map and assess the content, process, actors, and context of ERC in Germany, Guinea, Nigeria, and Singapore, we performed a qualitative document review, and thematically analyzed semi-structured key informant interviews with 155 stakeholders involved in ERC at national and sub-national levels. We applied Walt and Gilson's health policy triangle as a framework to structure the results.ResultsWe identified distinct ERC strategies in each of the four countries. Various actors, including governmental leads, experts, and organizations with close contact to the public, collaborated closely to implement ERC strategies. Early integration of ERC into preparedness and response plans, lessons from previous experiences, existing structures and networks, and clear leadership were identified as crucial for ensuring message clarity, consistency, relevance, and an efficient use of resources. Areas of improvement primarily included two-way communication, community engagement, and monitoring and evaluation. Countries with recurrent experiences of pandemics appeared to be more prepared and equipped to implement ERC strategies.ConclusionWe found that considerable potential exists for countries to improve communication during public health emergencies, particularly in the areas of bilateral communication and community engagement as well as monitoring and evaluation. Building adaptive structures and maintaining long-term relationships with at-risk communities reportedly facilitated suitable communication. The findings suggest considerable potential and transferable learning opportunities exist between countries in the global north and countries in the global south with experience of managing outbreaks

Community-informed research on malaria in pregnancy in Monrovia, Liberia: a grounded theory study

Abstract Background Liberia is a West African country that needs substantial investment to strengthen its National Malaria Control Programme (NMCP), which was disrupted during the 2014–2016 Ebola epidemic. As elsewhere, Liberian pregnant women are especially vulnerable to malaria. Understanding prevention and treatment-seeking behaviours among the population is crucial to strategize context-specific and women-centred actions, including locally-led malaria research, to improve women’s demand, access and use of NMCP strategies against malaria in pregnancy. Methods In 2016, after the Ebola crisis, a qualitative inquiry was conducted in Monrovia to explore populations’ insights on the aetiology, prevention and therapeutics of malaria, as well as the community and health workers’ perceptions on the utility of malaria research for pregnant women. In-depth interviews and focus group discussions were conducted among pregnant women, traditional community representatives and hospital staff (n = 38), using a feminist interpretation of grounded theory. Results The narratives indicate that some Liberians believed in elements other than mosquito bites as causes of malaria; many had a low malaria risk perception and disliked current effective prevention methods, such as insecticide-treated nets; and some would resort to traditional medicine and spiritual care to cure malaria. Access to clinic-based malaria care for pregnant women was reportedly hindered by lack of financial means, by unofficial user fees requested by healthcare workers, and by male partners’ preference for traditional medicine. The participants suggested that malaria research in Liberia could help to design evidence-based education to change current malaria prevention, diagnostic and treatment-seeking attitudes, and to develop more acceptable prevention technologies. Conclusion Poverty, insufficient education on malaria, corruption, and poor trust in healthcare establishment are structural factors that may play a greater role than local traditional beliefs in deterring Liberians from seeking, accessing and using government-endorsed malaria control strategies. To increase access to and uptake of preventive and biomedical care by pregnant women, future malaria research must be informed by people’s expressed needs and constructed meanings and values on health, ill health and healthcare

'Researchers have love for life': opportunities and barriers to engage pregnant women in malaria research in post-Ebola Liberia

BACKGROUND: Adoption of prevention and therapeutic innovations to ensure that National Malaria Control Programmes meet their incidence reduction targets is highly dependent on the conduct of rigorous clinical trials. In Liberia, malaria control virtually halted during the recent Ebola epidemic, and could enormously benefit from innovations to protect its most vulnerable populations, including pregnant women, against malaria. Health policy-planners could feel more inclined to adopt novel interventions with demonstrated safety and efficacy when trialled among their women population. However, pregnant women are especially vulnerable when targeted as research participants. Whilst some studies in the region attempted to understand the ethical issues around the conduct of clinical research, there is need of such information from Liberia to inform future malaria research. METHODS: This is a grounded theory study that aims to understand the barriers and opportunities for pregnant women to consent to participate in malaria research in Liberia. The study was conducted between November 2016 and May 2017 at the St Joseph's Catholic Hospital, Monrovia. In-depth interviews and focus group discussions were held with hospital staff, traditional community representatives, and pregnant women. RESULTS: According to the participants, useful strategies to motivate pregnant women to consent to participate in malaria research could be providing evidence-based education on malaria and research to the general population and encouraging engagement of traditional leaders in research design and community mobilization. Fears and suspicions towards research and researchers, which were amplified during the conduct of Ebola vaccine and drug clinical trials, may influence women's acceptance and willingness to engage in malaria research. Population's mistrust in the public healthcare system might hinder their acceptance of research, undermining the probability of their benefiting from any improved malaria control intervention. CONCLUSION: Benchmarking for acceptable practices from previous public health interventions; building community discussion and dissemination platforms; and mapping communication and information errors from how previous research interventions were explained to the Liberian population, are strategies that might help ensure a safe and fully informed participation of pregnant women in malaria research. Inequity issues impeding access and use of biomedical care for women must be tackled urgently

Séroprévalence de la co-infection VIH /virus de l’hépatite B à l’Hôpital de l’Amitié sino-guinéenne (HASIGUI) Kipé/Conakry (Guinée)

Objectif: L’objectif de cette étude était de déterminer la séroprévalence de la co-infection Virus de l’immunodéficience humaine et Virus de l’hépatite B (VIH/VHB) et les facteurs associés chez les patients reçus au laboratoire biomédical de l’Hôpital de l’Amitié Sino-guinéenne (HASIGUI).Méthodologie et Résultats: Il s’agit d’une étude prospective qui a été menée du 18 juillet 2016 au 18 Avril 2017 sur 525 patients reçus au laboratoire biomédical de HASIGUI pour des examens biologiques. La détection du VIH et le typage ont été faits par immuno-chromatographie à l’aide des Kits spécifiques. La recherche de l’hépatite B a été réalisée par la détection de l’AgHBs par immuno-chromatographie à l’aide de kits spécifiques et par méthode ELISA. Les résultats obtenus ont montré que la prévalence de la coinfection VIH/VHB était de 2,3%. L’âge moyen des patients était de 37 ans avec des extrêmes de 1 et 83 ans. Le sexe masculin était le plus représenté (71,2%) avec une sex-ratio (H/F) égal 2,47. La tranche d’âge la plus représentée était celle des 25 à 34 ans (37,7%). Les prévalences du VIH et de l’hépatite B étaient respectivement de 10,5 et 17,9%. La prévalence du VIH était plus élevée chez le sexe féminins (P=0,05). Tous les cas de VIH détectés étaient du type 1 (VIH1).Conclusion et application: Il ressort de cette étude que la séroprévalence du VIH et du virus de l’hépatite B sont élevées à Conakry. En revanche, celle de la co-infection VIH/VHB est relativement faible par rapport à la plupart des données rapportées dans d’autres pays d’Afrique Sub-saharienne. Cependant, la coinfection VIH/VHB pourrait être considérée comme un problème de santé publique non négligeable en Guinée, nécessitant ainsi son diagnostic précoce en organisant des campagnes de sensibilisation et de  dépistage dans la population, permettant ainsi une meilleure prise en charge des patients co-infectés (VIH/VHB) par un double traitement antirétrovirales et anti-hépatites B.Mots clés: Co-infection, VIH, AgHBs (VHB), HASIGUI, Kipé/ConakryEnglish Title:  Seroprevalence of Hepatitis B Virus and Human Immunodeficiency Virus Coinfection at the Chinese and Guinean Friendships Hospital (HASIGUI) of Kipé Conakry/ GuineaEnglish AbstractObjective: The aim of this study was to determine the seroprevalence of Hepatitis B virus (HBV) and Human Immunodeficiency virus (HIV) coinfection at the Chinese and Guinean friendships hospital of Kipé/Conakry.Methodology and Results: This prospective study was carried out on 525 patients attending to the biomedical laboratory of Kipé/Conakry (HASIGUI) from July 18th, 2016 to April 18th, 2017. HIV and HBV detection assays were done in the sera of all patients by immunochromatographic methods and ELISA. HIV detection and serotyping were processed in sera by immunochromatographic methods. Hepatitis B virus surface Antigen (HBsAg) was detected by immune-chromatographic methods and confirmed by ELISA. The seroprevalence of HIV/HBV coinfection was 2.3%. The mean age was 37 years, ranging from 1 to 83 years. Males were more represented than females and the sex-ratio (M/F) was 2.47%. HIV seroprevalence was 10,5%, while HBV seroprevalence was 17,9%. The HIV prevalence was high in females than males (P=0.05). HIV1 was the only type screened.Conclusion and application of results: This study findings showed that the seroprevalence of HIV/HBV coinfection rate was lower than that reported in other sub-Saharan Africa countries. HBV and HIV infections were similar to some reported prevalence in other sub-Saharan African countries. Then HIV/HBV coinfection must be considered as an important health problems in Guinea. Then, early diagnosis of HIV/HBV co-infected patients must be done to reduce its evolution and to improve its management practices by organizing awarenes and screening campaigns and treatment for both infections, using molecules against HBV and HIV infections.Keywords: HIV, HBV/HBsAg, Co-infection; HASIGUI; Kipé/Conakr