Feasibility of digital contact tracing in low-income settings - pilot trial for a location-based DCT app.

BACKGROUND: Data about the effectiveness of digital contact tracing are based on studies conducted in countries with predominantly high- or middle-income settings. Up to now, little research is done to identify specific problems for the implementation of such technique in low-income countries. METHODS: A Bluetooth-assisted GPS location-based digital contact tracing (DCT) app was tested by 141 participants during 14 days in a hospital in Monrovia, Liberia in February 2020. The DCT app was compared to a paper-based reference system. Hits between participants and 10 designated infected participants were recorded simultaneously by both methods. Additional data about GPS and Bluetooth adherence were gathered and surveys to estimate battery consumption and app adherence were conducted. DCT apps accuracy was evaluated in different settings. RESULTS: GPS coordinates from 101/141 (71.6%) participants were received. The number of hours recorded by the participants during the study period, true Hours Recorded (tHR), was 496.3 h (1.1% of maximum Hours recordable) during the study period. With the paper-based method 1075 hits and with the DCT app five hits of designated infected participants with other participants have been listed. Differences between true and maximum recording times were due to failed permission settings (45%), data transmission issues (11.3%), of the participants 10.1% switched off GPS and 32.5% experienced other technical or compliance problems. In buildings, use of Bluetooth increased the accuracy of the DCT app (GPS + BT 22.9 m ± 21.6 SD vs. GPS 60.9 m ± 34.7 SD; p = 0.004). GPS accuracy in public transportation was 10.3 m ± 10.05 SD with a significant (p = 0.007) correlation between precision and phone brand. GPS resolution outdoors was 10.4 m ± 4.2 SD. CONCLUSION: In our study several limitations of the DCT together with the impairment of GPS accuracy in urban settings impede the solely use of a DCT app. It could be feasible as a supplement to traditional manual contact tracing. DKRS, DRKS00029327 . Registered 20 June 2020 - Retrospectively registered.

Clinical sequelae among individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease in Liberia: a longitudinal cohort study.

BACKGROUND: Whether or not individuals with pauci-symptomatic or asymptomatic Ebola virus infection and unrecognised Ebola virus disease develop clinical sequelae is unknown. We assessed current symptoms and physical examination findings among individuals with pauci-symptomatic or asymptomatic infection and unrecognised Ebola virus disease compared with Ebola virus disease survivors and uninfected contacts. METHODS: Between June 17, 2015, and June 30, 2017, we studied a cohort of Ebola virus disease survivors and their contacts in Liberia. Surveys, current symptoms and physical examination findings, and serology were used to characterise disease status of reported Ebola virus disease, unrecognised Ebola virus disease, pauci-symptomatic or asymptomatic Ebola virus infection, or no infection. We pre-specified findings known to be differentially prevalent among Ebola virus disease survivors versus their contacts (urinary frequency, headache, fatigue, muscle pain, memory loss, joint pain, neurological findings, chest findings, muscle findings, joint findings, abdominal findings, and uveitis). We estimated the prevalence and incidence of selected clinical findings by disease status. FINDINGS: Our analytical cohort included 991 reported Ebola virus disease survivors and 2688 close contacts. The median time from acute Ebola virus disease onset to baseline was 317 days (IQR 271-366). Of 222 seropositive contacts, 115 had pauci-symptomatic or asymptomatic Ebola virus infection and 107 had unrecognised Ebola virus disease. At baseline, prevalent findings of joint pain, memory loss, muscle pain, and fatigue were lowest among those with pauci-symptomatic or asymptomatic infection or no infection, higher among contacts with unrecognised Ebola virus disease, and highest in reported survivors of Ebola virus disease. Joint pain was the most prevalent finding, and was reported in 434 (18%) of 2466 individuals with no infection, 14 (12%) of 115 with pauci-symptomatic or asymptomatic infection, 31 (29%) of 107 with unrecognised Ebola virus disease, and 476 (48%) of 991 with reported Ebola virus disease. In adjusted analyses, this pattern remained for joint pain and memory loss. Survivors had an increased odds of joint pain compared with unrecognised Ebola virus disease contacts (adjusted odds ratio [OR] 2·13, 95% CI 1·34-3·39); unrecognised Ebola virus disease contacts had an increased odds of joint pain compared with those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 1·89, 95% CI 1·21-2·97). The adjusted odds of memory loss was more than four-times higher among survivors than among unrecognised Ebola virus disease contacts (adjusted OR 4·47, 95% CI 2·41-8·30) and two-times higher among unrecognised Ebola virus disease contacts than in those with pauci-symptomatic or asymptomatic infection and uninfected contacts (adjusted OR 2·05, 95% CI 1·10-3·84). By 12 months, prevalent findings had decreased in the three infected groups. INTERPRETATION: Our findings provide evidence of post-Ebola virus disease clinical sequelae among contacts with unrecognised Ebola virus disease but not in people with pauci-symptomatic or asymptomatic Ebola virus infection. FUNDING: National Cancer Institute and National Institute of Allergy and Infectious Diseases of the National Institutes of Health.

Alternatives

The inequitable distribution of COVID-19 vaccines that we see today must be situated within the historical context of colonialism, global capitalism, and the othering of the Global South. The effects of these structural factors have resulted in an exclusive preoccupation with profitmaking through vaccine manufacturing at the expense of humanitarian concern. The deliberate neglect in the vaccination of those in the Global South will enable the virus to survive and mutate in marginalized parts of the world. Notably, in our globally-connected world, this neglect will provide opportunities for new variants to flourish and spread, thus contributing to the likely emergence of new pandemic threats in the future. This paper is part of the SPE Theme on the Political Economy of COVID-19.

Coordinated support for local action: Modeling strategies to facilitate behavior adoption in urban-poor communities of Liberia for sustained COVID-19 suppression.

BACKGROUND: Long-term suppression of SARS-CoV-2 transmission will involve strategies that recognize the heterogeneous capacity of communities to undertake public health recommendations. We highlight the epidemiological impact of barriers to adoption and the potential role of community-led coordination of support for cases and high-risk contacts in urban slums. METHODS: A compartmental model representing transmission of SARS-CoV-2 in urban poor versus less socioeconomically vulnerable subpopulations was developed for Montserrado County, Liberia. Adoption of home-isolation behavior was assumed to be related to the proportion of each subpopulation residing in housing units with multiple rooms and with access to sanitation, water, and food. We evaluated the potential impact of increasing the maximum attainable proportion of adoption among urban poor following the scheduled lifting of the state of emergency. RESULTS: Without intervention, the model estimated higher overall infection burden but fewer severe cases among urban poor versus the less socioeconomically vulnerable population. With self-isolation by mildly symptomatic individuals, median reductions in cumulative infections, severe cases, and maximum daily incidence were 7.6% (IQR: 2.2%-20.9%), 7.0% (2.0%-18.5%), and 9.9% (2.5%-31.4%), respectively, in the urban poor subpopulation and 16.8% (5.5%-29.3%), 15.0% (5.0%-26.4%), and 28.1% (9.3%-47.8%) in the less socioeconomically vulnerable population. An increase in the maximum attainable percentage of behavior adoption by the urban slum subpopulation was associated with median reductions of 19.2% (10.1%-34.0%), 21.1% (13.3%-34.2%), and 26.0% (11.5%-48.9%) relative to the status quo scenario. CONCLUSIONS: Post-lockdown recommendations that prioritize home-isolation by confirmed cases are limited by resource constraints. Investing in community-based initiatives that coordinate support for self-identified cases and their contacts could more effectively suppress COVID-19 in settings with socioeconomic vulnerabilities.

Mobilizing the social infrastructure of informal settlements in infectious disease response – The case of Ebola Virus Disease in West Africa

The growth of social precarity - particularly in the Global South - has meant that those living in informal settlements typically face a wide range of threats on a day-to-day basis due to the lack of basic welfare, social services and infrastructure, normally provided by the state. In the relative absence of formal infrastructures, people informally forge their own connections, capacities and opportunities so that they are able to access the social support they requirewhen needed. Recognizing this trend, this paper argues that there is a greater need for epidemic program planners to recognize and leverage the potential social infrastructure of informal communities and self-governance mechanisms during a disease epidemic. This need highlights the importance of tapping into already existing networks of social capital that can be readily mobilized during an epidemic to achieve a more rapid response. The empirical basis of our arguments draws primarily on qualitative research in informal settlements of Freetown, Sierra Leone and Monrovia, Liberia, following the 2014–16 Ebola Virus Disease (EVD) outbreaks. Our research reveals that distrust in government and inadequacies in the official response were identified as primary factors accounting for the severity of the EVD outbreaks in informal settlements. Overall, the research stresses the importance of adopting community-based approaches to infectious disease response that explicitly builds on context-specific knowledge pertaining to locally-based informal social arrangements, governance mechanisms and the local political history in which the informal settlement is embedded.

Equitable and Feasible Distribution of SARS-CoV-2 Vaccines for All in Africa.

As the fight against the coronavirus disease 2019 (COVID-19) pandemic continues, the necessity for wide-scale, global vaccine rollout to reduce the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and slow its mutation rate remains unassailable. The COVID-19 Vaccines Global Access (COVAX) initiative's campaign involves a proportional framework to finance and distribute SARS-CoV-2 vaccines in low- and middle-income countries. However, the COVAX framework has critical limitations, including limited funding and the failure to account for the special epidemic risks and needs of its participating nations, as recommended by the World Health Organization's Strategic Advisory Group of Experts on Immunization framework. These drawbacks disproportionately impact Africa, where many nations rely on COVAX as their main source of vaccines. The current plan to vaccinate only up to 20% of participating nations' populations is short-sighted from both epidemiologic and moral perspectives. COVAX must commit to vaccinating all of Africa and its initiative must be modified to account for the health and economic infrastructures in these countries. Lessons learned from successful vaccination campaigns, including the West African Ebola outbreak, have shown that vaccinating all of Africa is possible and feasible, and that infrastructure and human resources can support mass vaccination. To halt this global pandemic, global responsibility must be accepted to finance and equitably distribute SARS-CoV-2 vaccines to African nations. We urge COVAX to act swiftly to prevent Africa from becoming the new face of a persisting pandemic.