Case Management &coronavirus &COVID-19 &Research &water Bill Brieger | 31 Mar 2020
COVID19 Challenges for African Researchers
Not surprisingly COVID-19 related travel restrictions and bans now occur throughout the world, and for African researchers, this means inability to travel for research related collaborations, planning meetings and conferences. Thus, it becomes necessary to ask, “What can we do here at home,” especially considering increasing restrictions on local movement and gatherings.
In the very short time since COVID-19 was finally and officially recognized in China, many research articles have been published. Although these obviously focus on China, they raise possible research questions that need to be addressed in Africa, especially those countries still at the early stages of the epidemic.
Obviously, studies on the clinical management are needed, and one group of Chinese researchers are examining “biological products have broadly applied in the prevention and treatment of severe epidemic diseases, they are promising in blocking novel coronavirus infection,” especially based on reports from previous coronavirus experiences like SARS and MERS.[1] Other studies have examined the role of managing blood glucose levels[2], anticoagulant treatment[3] and the potential of antiviral treatment,[4] among others. What aspects of clinical management will become important to African patients’ survival?
In the process of requesting adequate diagnostic, monitoring and treatment supplies and equipment generally for the country, the tertiary and research hospitals need to ensure they have made requests for the equipment and supplies that are needed not just to provide life-saving treatment, but also to test appropriate approaches in the local setting. Each setting is different and must be studied because already there are anecdotal reports of younger age groups being affected by severe disease in the USA compared to earlier reports from China.
Taking a lesson from the Ebola epidemic in West Africa, there is need to study how COVID-19 will affect the delivery of health care, especially malaria services. Patrick Walker and colleagues[5] modeled the effects of health systems disruption on malaria including challenges in receiving based treatment when clinics were overwhelmed, seen as possible sources of disease and finally shut down as health workers themselves died. Outreach services like insecticide-treated net distribution were also stopped, and the efforts of community health workers were curtailed. To what extent is that happening with COVID-19?
Until there are proven drugs and vaccines, it is extremely important to learn about local epidemiology[6] in order to develop appropriate strategies to prevent the spread of COVID-19. This effort should involve researchers from many disciplines such as public health specialists, anthropologists, sociologists, educationists, and psychologists.
While the medical research mentioned above is carried out in hospitals and clinics, people conducting social and epidemiological studies ideally should be in the community where we can observe people washing their hands or not, gathering in groups or not, and finding out why they do these things. We need formative research to help develop health education, and at the same time ensure social and educational scientists can gather information to evaluate whether the health education as appropriate and worked.
Likewise, research is needed on health systems[7] and must involve political scientists, economists, public administrators, and of course public health specialists, also. A great danger exists for people who cannot keep a social distance from themselves such as those incarcerated in prison and living in camps for refugees and internally displaced people,[8] a common problem throughout the continent. They too need to get into the organizations and systems that provide care and learn what the policy makers and decision makers are thinking.
As Bronwyn Bruton has observed,[9] “Some 40 percent of Africans live in water-stressed environments in which obtaining access to clean water—let alone soap—is an insurmountable daily hurdle, and for those populations, even simple measures to prevent the spread of the virus, such as frequent handwashing, will be out of reach.” In addition he asks difficult questions about what happens to children who are home and cannot go to school, the vast numbers of people in the informal economy who cannot rely on a salary, if they stay home, and the many people in conflict zones. These are questions that urgently need to be studied in Africa.
Answers to our COVID-19 research questions are needed urgently, probably much sooner than funding can be found to support such research. The question for our African research colleagues is what can be done now with resources at hand in an environment where movement is restricted? We will definitely need speedy responses from our Institutional Ethics Review Boards and be creative in our use of research methods.
Roxana Elliott[10] reports that data collection in the diverse African region “is difficult, especially when measuring statistics such as mobile penetration, which require face-to-face data collection in order to include those who cannot be reached via mobile. Language barriers, lack of infrastructure, and the sheer number of people throughout Sub-Saharan Africa make collecting face-to-face data nearly impossible due to cost and time constraints, especially in rural areas.” She, therefore, suggests that mobile-based surveying methodologies can alleviate these issues. She also recommends a country-by-country approach, and hence we see that in 2017 an estimate of 32% of the population had a smartphone 48% a basic phone, and 20% no phone.
How can social and health researchers design studies using this mobile resource to answer vital COVID-19 questions in the nearest future? If our students are now at home, can they, for example, be contacted to observe, at a safe distance, the human health related actions in their communities? Can they interview family members to learn why people practice prevention or not? Can they relate family experiences seeking health services for suspected respiratory illness? Can they report on the water supply situation in the rural and urban areas where they are staying?
There are the questions which African colleagues can debate at a proper social distance (via phone, zoom, Skype, WhatsApp, and others), and come up with creative ways to find answers to prevent a worsening epidemic in Africa.
References
[1] Yan CX, Li J, Shen X, Luo L, Li Y, Li MY. [Biological Product Development Strategies for Prevention and Treatment of Coronavirus Disease 2019. Article in Chinese] Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):139-145. doi: 10.12182/20200360506. (English abstract in PubMed).
[2] Ma WX, Ran XW. [The Management of Blood Glucose Should be Emphasized in the Treatment of COVID-19. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):146-150. doi: 10.12182/20200360606.
[3] Tang N, Bai H, Chen X, Gong J, Li D, Sun Z.Anticoagulant treatment is associated with decreased mortality in severe coronavirus disease 2019 patients with coagulopathy. J Thromb Haemost. 2020 Mar 27. doi: 10.1111/jth.14817. [Epub ahead of print]
[4] Wu J, Li W, Shi X, Chen Z, Jiang B, Liu J, Wang D, Liu C, Meng Y, Cui L, Yu J, Cao H, Li L. Early antiviral treatment contributes to alleviate the severity and improve the prognosis of patients with novel coronavirus disease (COVID-19).J Intern Med. 2020 Mar 27. doi: 10.1111/joim.13063. [Epub ahead of print]
[5] Patrick G T Walker, Michael T White, Jamie T Griffin, Alison Reynolds, Neil M Ferguson, Azra C Ghani. Malaria morbidity and mortality in Ebola-affected countries caused by decreased health-care capacity, and the potential effect of mitigation strategies: a modelling analysis. www.thelancet.com/infection Published online April 24, 2015 http://dx.doi.org/10.1016/S1473-3099(15)70124-6
[6] Luan RS, Wang X, Sun X, Chen XS, Zhou T, Liu QH, Lü X, Wu XP, Gu DQ, Tang MS, Cui HJ, Shan XF, Ouyang J, Zhang B, Zhang W, Sichuan University Covid-ERG.[Epidemiology, Treatment, and Epidemic Prevention and Control of the Coronavirus Disease 2019: a Review. Article in Chinese]. Sichuan Da Xue Xue Bao Yi Xue Ban. 2020 Mar;51(2):131-138. doi: 10.12182/20200360505.
[7] Philip Obaji, Kim Hjelmgaard and Chris Erasmus Coronavirus infections in Africa are rapidly rising. Its weak health systems may buckle. USA Today. Updated 27 March 2020, Accessed 29 March 2020. https://www.usatoday.com/story/news/world/2020/03/27/coronavirus-africa-preparedness-rising-covid-19-infections/5076620002/
[8] Nick Turse. In West African Coronavirus Hotspot, War Has Left 700,000 Homeless and Exposed. The Intercept. March 26 2020, 5:33 p.m. https://theintercept.com/2020/03/26/burkina-faso-africa-coronavirus/
[9] Bronwyn Bruton. What does the coronavirus mean for Africa?. Atlantic Council. Tue, Mar 24, 2020. https://atlanticcouncil.org/blogs/africasource/what-does-the-coronavirus-mean-for-africa/
[10] Roxana Elliott. Mobile Phone Penetration Throughout Sub-Saharan Africa. GeoPoll (In Market Research, Tech & Innovation). Posted July 8, 2019 https://www.geopoll.com/blog/mobile-phone-penetration-africa/
Polio Bill Brieger | 10 Mar 2020
Leading the Final Push to Polio Eradication
Sophia Shea and Sophia Winchester have shared their thoughts about what may hopefully be the final stages of the polio eradication effort. Their original blog appears on the website for Social and Behavioral Foundations of Primary Health care.
Polio eradication has been on the world’s agenda for decades, and we are finally at the last push to eradicating the disease. However, Afghanistan and Pakistan remain on the frontlines of battling polio with added political tensions and suspicion against vaccination efforts.
Both Afghanistan and Pakistan have experienced political strife surrounding the involvement of the Taliban. While the Taliban supports polio eradication, they continue to battle with the WHO on how best to vaccinate the respective populations. In the past, Osama bin Landen was captured using spies in a door-to-door vaccine effort, which contributed to distrust among the community. The Taliban is strongly against door-to-door vaccination given this distrust; however, the WHO considers door-to-door to be bet practice and most effective.
There are religious leaders who also say that vaccination goes against Muslim law. Due to the increased religious pressure against vaccination, the Council of Islamic Ideology (CII) has released religious fatwas in support of vaccination and hopefully will promote vaccination in mosques.
Despite issues in governance between the Afghanistan/Pakistan governments and the Taliban, organizations involved in the Global Polio Eradication Initiative, such as UNICEF, Rotary International, and the Bill and Melinda Gates Foundation have been actively campaigning for mass vaccination efforts. In order to adequately support this initiative, it is critical that there be clear leadership and fully supported funding streams to direct this final push for eradication. Strict leadership by a governmentally neutral organization like the WHO will allow actors involved in this initiative to focus on their respective operations. Finally, polio eradication is estimated to cost nearly $4 billion over the next few years, and the financial requirements of this effort should not create a barrier to achieving the overall goal of eradicating polio.
Call to Action:
We are very close to eradicating polio from the world – Pakistan and Afghanistan two of the last few countries to have polio. Turmoil among the governments and the Taliban’s presence make it challenging to vaccinate children in these areas. In order to succeed in eradicating polio, we need to increase funding available for the Global Polio Eradication Initiative and its member organizations to increase their vaccination capacity. Your donation can make a difference. The end is near! We need to make sure there is not donor fatigue and that current efforts are supported.
Ebola Bill Brieger | 10 Mar 2020
Lessons Learned from Ebola Management in Sierra Leone
Figure #1: Image of a Village Health Worker in Sierra Leone Preparing Chlorinated Water
Lessons can still be learned from the Ebola experience in West Africa. Daniel Ehrenpreis and Masahiro Katahira as members of the class, Social and Behavioral Foundations of Primary Health Care, have posted a blog on the importance of financing at the local government level to ensure better disease control efforts. Their thoughts are posted below.
In 2015, Sierra Leone experienced the height of the Ebola epidemic, where there were over 13,000 confirmed cases; 29% of which were fatal. The prolific nature of this disease made controlling the spread difficult to manage. The government of Sierra Leone initially coordinated the Ebola mitigation efforts by allocating funding to centralized approaches . This method quickly became ineffective as the virus rapidly proliferated and mortality skyrocketed. Different Ebola response efforts were needed to curb the spread of this infectious disease.
While many international organizations were funneling funding into national response measures, localized infection control interventions were being undermined. This created uncoordinated Ebola control measures that exacerbated the virus’ mortality rate. Furthermore, localized non-governmental organizations (NGOs) were disproportionately underfunded and thus did not have the resources to implement effective Ebola mitigation techniques.
The National Ebola Response Center (NERC) consisted of the army of Sierra Leone and England, including international agencies such as, UNMEER, WHO, and CDC. All 14 districts of Sierra Leone had a District Ebola Response Center (DERC). (See Figure #2)
The DERC had localized roles, such as surveillance, alerts, burials, community mobilization & education, and quarantine. Low capacity of district health infrastructure and insufficient funding challenged DERCs and local NGOs. With a lack of medical resources including protective clothes due to their poor logistics system, reduced communication between staff in the NERC due to no electricity, distrust from community members, and an inadequate number of staff, there were many barriers preventing the success of localized Ebola response. Also, since every DERC had to meet the needs of different communities, the DERCs did not always act in alignment with the NERC’s plan. It was clear that more funding and resources were needed in the DERCs.
To respond effectively to future Ebola epidemics, national governments should consider allocating funding from both internal finance and international donors to decentralized health management approaches. The 2015 Ebola epidemic in Sierra Leone exemplified the need to strengthen local health sectors, and it is the responsibility of national policymakers to bolster the capacity of our localized health systems for effective control and response.