Experiences, coping strategies and perspectives of people in Malaysia during the COVID-19 pandemic.

BACKGROUND: A nationwide Movement Control Order (MCO) was enforced in Malaysia on 18 March 2020 in view of the global COVID-19 pandemic. Malaysia implemented various public health measures and later raced against time to administer COVID-19 vaccines when they became available. As a result of various public health measures to curb the spread of the virus, people in Malaysia faced unprecedented circumstances and new challenges. This study addressed the knowledge gap in our understanding the experiences, coping strategies and perspectives of the people in Malaysia about infection countermeasures by investigating their experiences during the COVID-19 pandemic. METHODS: A sequential mixed method approach was used to conduct an online survey and in-depth interviews among residents in Malaysia. A total of 827 respondents participated in the online survey from 1st May to 30th June 2020. Nineteen in-depth interviews were conducted online and by phone with key informants and members of the public, who were selected through maximum variation purposive sampling between 2nd May 2020 to 20th December 2021. The semi-structured interviews employed a phenomenological approach and transcripts were analysed using thematic analysis. The survey data were analysed using descriptive statistics in Stata 15.0. RESULTS: The survey reflected significant economic impacts of the pandemic, the maximum number of days that people could cope during the MCO, and their coping strategies, which generally entailed changes in lifestyle. The internet and social media were vital platforms to mitigate against the impact of public health measures. Thematic analysis of the interview data revealed participant experiences and perceptions of COVID-19 and public health measures in four main themes: (1) work and business; (2) emotional impact (3) coping with change and (4) the COVID-19 vaccine. CONCLUSIONS: This study provides insights into the experiences, coping strategies and perspectives of people in Malaysia living through the first-ever MCO during the COVID-19 pandemic. Such insights into COVID-19-related public health measures are pertinent for successfully planning and implementing future responses to pandemics.

Evaluation of augmented reality technology in global urologic surgery.

BACKGROUND: The COVID-19 pandemic drastically reduced opportunities for surgical skill sharing between high-income and low to middle-income countries. Augmented reality (AR) technology allows mentors in one country to virtually train a mentee in another country during surgical cases without international travel. We hypothesize that AR technology is an effective live surgical training and mentorship modality. METHODS: Three senior urologic surgeons in the US and UK worked with four urologic surgeon trainees across the continent of Africa using AR systems. Trainers and trainees individually completed post-operative questionnaires evaluating their experience. RESULTS: Trainees rated the quality of virtual training as equivalent to in-person training in 83% of cases (N = 5 of 6 responses). Trainers reported the technology's visual quality as "acceptable" in 67% of cases (N = 12 of 18 responses). The audiovisual capabilities of the technology had a "high" impact in the majority of the cases. CONCLUSION: AR technology can effectively facilitate surgical training when in-person training is limited or unavailable.

Toward a Continuum of Measures to Mitigate Primary and Secondary Impacts of COVID-19 and Other Public Health Emergencies.

The global COVID-19 response focused heavily on nonpharmaceutical interventions (NPIs) until vaccines became available. Even where vaccination coverage is low, over time governments have become increasingly reluctant to use NPIs. Inequities in vaccine and treatment accessibility and coverage, differences in vaccine effectiveness, waning immunity, and immune-escape variants of concern of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) reinforce the long-term need for mitigation. Initially, the concept of NPIs, and mitigation more broadly, was focused on prevention of SARS-CoV-2 transmission; however, mitigation can and has done more than prevent transmission. It has been used to address the clinical dimensions of the pandemic as well. The authors propose an expanded conceptualization of mitigation that encompasses a continuum of community and clinical mitigation measures that can help reduce infection, illness, and death from COVID-19. It can further help governments balance these efforts and address the disruptions in essential health services, increased violence, adverse mental health outcomes, and orphanhood precipitated by the pandemic and by NPIs themselves. The COVID-19 pandemic response revealed the benefits of a holistic and layered mitigation approach to public health emergencies from the outset. Lessons learned can inform the next phases of the current pandemic response and planning for future public health emergencies.

The Use of Adaptive Sampling to Reach Disadvantaged Populations for Immunization Programs and Assessments: A Systematic Review.

Vaccines prevent 4-5 million deaths every year, but inequities in vaccine coverage persist among key disadvantaged subpopulations. Under-immunized subpopulations (e.g., migrants, slum residents) may be consistently missed with conventional methods for estimating immunization coverage and assessing vaccination barriers. Adaptive sampling, such as respondent-driven sampling, may offer useful strategies for identifying and collecting data from these subpopulations that are often "hidden" or hard-to-reach. However, use of these adaptive sampling approaches in the field of global immunization has not been systematically documented. We searched PubMed, Scopus, and Embase databases to identify eligible studies published through November 2020 that used an adaptive sampling method to collect immunization-related data. From the eligible studies, we extracted relevant data on their objectives, setting and target population, and sampling methods. We categorized sampling methods and assessed their frequencies. Twenty-three studies met the inclusion criteria out of the 3069 articles screened for eligibility. Peer-driven sampling was the most frequently used adaptive sampling method (57%), followed by geospatial sampling (30%), venue-based sampling (17%), ethnographic mapping (9%), and compact segment sampling (9%). Sixty-one percent of studies were conducted in upper-middle-income or high-income countries. Data on immunization uptake were collected in 65% of studies, and data on knowledge and attitudes about immunizations were collected in 57% of studies. We found limited use of adaptive sampling methods in measuring immunization coverage and understanding determinants of vaccination uptake. The current under-utilization of adaptive sampling approaches leaves much room for improvement in how immunization programs calibrate their strategies to reach "hidden" subpopulations.

The role of community pharmacies in early detection of suspected COVID-19 cases in 2020: lessons from Dar es Salaam, Tanzania.

Tanzania reported its first COVID-19 case on 16 March 2020. We conducted event-based surveillance of COVID-19 suspect cases among pharmacy clients presenting with respiratory symptoms and influenza-like illness to increase early and rapid detection of COVID-19 cases and mitigate transmission. We conveniently sampled 103 pharmacies from Dar es Salaam, the epicentre for the COVID-19 pandemic in Tanzania at the time. Between 23 April 2020 and 18 May 2020, 67% of the pharmacies (69/103) reported an observed increase in the number of clients presenting with respiratory symptoms and influenza-like illness compared with the 1 month before the COVID-19 outbreak. In the 1-month surveillance period, the participating pharmacies recorded 75 alerts of COVID-19 suspect cases and referred all suspected COVID-19 cases to rapid response teams for additional symptomatic screening and SARS-CoV-2 testing. A key implementation challenge was that some clients identified as COVID-19 suspected cases were hesitant to provide follow-up information for linkage to rapid response teams. Addressing concerns among drug dispensers in the participating pharmacies and informing them of the benefits of the surveillance activity were important implementation components. Our approach demonstrates the overall feasibility of rapidly implementing an event-based surveillance system for an emerging health threat through an existing network of pharmacies within the community. The approach and tools used in this surveillance activity could be adapted in similar settings to detect and generate alerts of disease outbreaks in the community that other surveillance systems may otherwise miss.

Dysregulation of glutamine/glutamate metabolism in COVID-19 patients: A metabolism study in African population and mini meta-analysis.

Coronavirus disease 2019 (COVID-19) remains a serious global threat. The metabolic analysis had been successfully applied in the efforts to uncover the pathological mechanisms and biomarkers of disease severity. Here we performed a quasi-targeted metabolomic analysis on 56 COVID-19 patients from Sierra Leone in western Africa, revealing the metabolomic profiles and the association with disease severity, which was confirmed by the targeted metabolomic analysis of 19 pairs of COVID-19 patients. A meta-analysis was performed on published metabolic data of COVID-19 to verify our findings. Of the 596 identified metabolites, 58 showed significant differences between severe and nonsevere groups. The pathway enrichment of these differential metabolites revealed glutamine and glutamate metabolism as the most significant metabolic pathway (Impact = 0.5; -log10P = 1.959). Further targeted metabolic analysis revealed six metabolites with significant intergroup differences, with glutamine/glutamate ratio significantly associated with severe disease, negatively correlated with 10 clinical parameters and positively correlated with SPO2 (rs = 0.442, p = 0.005). Mini meta-analysis indicated elevated glutamate was related to increased risk of COVID-19 infection (pooled odd ratio [OR] = 2.02; 95% confidence interval [CI]: 1.17-3.50) and severe COVID-19 (pooled OR = 2.28; 95% CI: 1.14-4.56). In contrast, elevated glutamine related to decreased risk of infection and severe COVID-19, the pooled OR were 0.30 (95% CI: 0.20-0.44), and 0.44 (95% CI: 0.19-0.98), respectively. Glutamine and glutamate metabolism are associated with COVID-19 severity in multiple populations, which might confer potential therapeutic target of COVID-19, especially for severe patients.

Drivers of COVID-19 policy stringency in 175 countries and territories: COVID-19 cases and deaths, gross domestic products per capita, and health expenditures.

Background: New data on COVID-19 may influence the stringency of containment policies, but these potential effect are not understood. We aimed to understand the associations of new COVID-19 cases and deaths with policy stringency globally and regionally. Methods: We modelled the marginal effects of new COVID-19 cases and deaths on policy stringency (scored 0-100) in 175 countries and territories, adjusting for gross domestic product (GDP) per capita and health expenditure (% of GDP), and public expenditure on health. The time periods examined were March to August 2020, September 2020 to February 2021, and March to August 2021. Results: Policy response to new cases and deaths was faster and more stringent early in the COVID-19 pandemic (March to August 2020) compared to subsequent periods. New deaths were more strongly associated with stringent policies than new cases. In an average week, one new death per 100 000 people was associated with a stringency increase of 2.1 units in the March to August 2020 period, 1.3 units in the September 2020 to February 2021 period, and 0.7 units in the March to August 2021 period. New deaths in Africa and the Western Pacific were associated with more stringency than in other regions. Higher health expenditure as a percentage of GDP was associated with less stringent policies. Similarly, higher public expenditure on health by governments was mostly associated with less stringency across all three periods. GDP per capita did not have consistent patterns of associations with stringency. Conclusions: The stringency of COVID-19 policies was more strongly associated with new deaths than new cases. Our findings demonstrate the need for enhanced mortality surveillance to ensure policy alignment during health emergencies. Countries that invest less in health or have a lower public expenditure on health may be inclined to enact more stringent policies. This new empirical understanding of COVID-19 policy drivers can help public health officials anticipate and shape policy responses in future health emergencies.

Risk Factors for Severity and Mortality in Adult Patients Confirmed with COVID-19 in Sierra Leone: A Retrospective Study

Background: The coronavirus disease 2019 (COVID-19) is a highly infectious respiratory disease. There is no recommended antiviral treatment approved for COVID-19 in Sierra Leone, and supportive care and protection of vital organ function are performed for the patients. This study summarized the clinical characteristics, drug treatments, and risk factors for the severity and prognosis of COVID-19 in Sierra Leone to provide evidence for the treatment of COVID-19. Methods: Data of 180 adult COVID-19 patients from the 34th Military Hospital in Freetown Sierra Leone between March 31, 2020 and August 11, 2020 were retrospectively collected. Patients with severe and critically ill are classified in the severe group, while patients that presented asymptomatic, mild, and moderate disease were grouped in the non-severe group. The clinical and laboratory information was retrospectively collected to assess the risk factors and treatment strategies for severe COVID-19. Demographic information, travel history, clinical symptoms and signs, laboratory detection results, chest examination findings, therapeutics, and clinical outcomes were collected from each case file. Multivariate logistic analysis was adopted to identify the risk factors for deaths. Additionally, the clinical efficacy of dexamethasone treatment was investigated. Results: Seventy-six (42.22%) cases were confirmed with severe COVID-19, while 104 patients (57.78%) were divided into the non-severe group. Fever (56.67%, 102/180) and cough (50.00%, 90/180) were the common symptoms of COVID-19. The death rate was 18.89% (34/180), and severe pneumonia (44.12%, 15/34) and septic shock (23.53%, 8/34) represented the leading reasons for deaths. The older age population, a combination of hypertension and diabetes, the presence of pneumonia, and high levels of inflammatory markers were significantly associated with severity of COVID-19 development (P < 0.05 for all). Altered level of consciousness [odds ratio (OR) = 56.574, 95% confidence interval (CI) 5.645–566.940, P = 0.001], high levels of neutrophils (OR = 1.341, 95%CI 1.109–1.621, P = 0.002) and C-reactive protein (CRP) (OR = 1.014, 95%CI 1.003–1.025, P = 0.016) might be indicators for COVID-19 deaths. Dexamethasone treatment could reduce mortality [30.36% (17/56) vs. 50.00% (10/20)] among severe COVID-19 cases, but the results were not statistically significant (P > 0.05). Conclusions: The development and prognosis of COVID-19 may be significantly correlated with consciousness status, and the levels of neutrophils and CRP.

Behaviors Associated With Household Transmission of SARS-CoV-2 in California and Colorado, January 2021-April 2021.

Introduction: Mitigation behaviors are key to preventing SARS-CoV-2 transmission. We identified the behaviors associated with secondary transmission from confirmed SARS-CoV-2 primary cases to household contacts and described the characteristics associated with reporting these behaviors. Methods: Households with confirmed SARS-CoV-2 infections were recruited in California and Colorado from January to April 2021. Self-reported behaviors and demographics were collected through interviews. We investigated behaviors associated with transmission and individual and household characteristics associated with behaviors using univariable and multivariable logistic regression with generalized estimating equations to account for household clustering. Results: Among household contacts of primary cases, 43.3% (133 of 307) became infected with SARS-CoV-2. When an adjusted analysis was conducted, household contacts who slept in the same bedroom with the primary case (AOR=2.19; 95% CI=1.25, 3.84) and ate food prepared by the primary case (AOR=1.98; 95% CI=1.02, 3.87) had increased odds of SARS-CoV-2 infection. Household contacts in homes ≤2,000 square feet had increased odds of sleeping in the same bedroom as the primary case compared with those in homes >2,000 square feet (AOR=3.97; 95% CI=1.73, 9.10). Parents, siblings, and other relationships (extended family, friends, or roommates) of the primary case had decreased odds of eating food prepared by the primary case compared with partners. Conclusions: Sleeping in the same bedroom as the primary case and eating food prepared by the primary case were associated with secondary transmission. Household dimension and relationship to the primary case were associated with these behaviors. Our findings encourage innovative means to promote adherence to mitigation measures that reduce household transmission.

An Intra-COVID-19 Assessment of Hand Hygiene Facility, Policy and Staff Compliance in Two Hospitals in Sierra Leone: Is There a Difference between Regional and Capital City Hospitals?

Although hand hygiene (HH) is the most effective intervention to reduce the spread of infections, there are limited data on HH facilities, policy, and compliance in sub-Saharan Africa. This cross-sectional study is aimed at assessing HH using the WHO HH self-assessment framework, HH technical reference manual, and a modified infection control self-assessment tool in two hospitals in Sierra Leone. Only 10% and 9% of regional and capital city hospitals had running tap water, respectively. Veronica buckets were the resources for HH in 89% of units in the regional hospital and 92% of units in capital city hospital. Constant supply of soap and alcohol-based hand rub was available in 82% and 68%; and 74% and 79% of units in the capital city and regional hospitals, respectively. Only 10% of the units in both hospitals had hand-drying facilities and functional sinks. Overall HH compliance for the two hospitals was 18.6% and was higher in the regional (20.8%) than the capital city (17.0%) hospitals. The HH levels for the capital city and regional hospitals were 277.5 and 262.5 respectively. Despite the COVID-19 pandemic, there are still challenges with HH compliance in Sierra Leone. It is, therefore, necessary to strengthen the HH multi-modal strategy.

Debunking highly prevalent health misinformation using audio dramas delivered by WhatsApp: evidence from a randomised controlled trial in Sierra Leone.

INTRODUCTION: Infectious disease misinformation is widespread and poses challenges to disease control. There is limited evidence on how to effectively counter health misinformation in a community setting, particularly in low-income regions, and unsettled scientific debate about whether misinformation should be directly discussed and debunked, or implicitly countered by providing scientifically correct information. METHODS: The Contagious Misinformation Trial developed and tested interventions designed to counter highly prevalent infectious disease misinformation in Sierra Leone, namely the beliefs that (1) mosquitoes cause typhoid and (2) typhoid co-occurs with malaria. The information intervention for group A (n=246) explicitly discussed misinformation and explained why it was incorrect and then provided the scientifically correct information. The intervention for group B (n=245) only focused on providing correct information, without directly discussing related misinformation. Both interventions were delivered via audio dramas on WhatsApp that incorporated local cultural understandings of typhoid. Participants were randomised 1:1:1 to the intervention groups or the control group (n=245), who received two episodes about breast feeding. RESULTS: At baseline 51% believed that typhoid is caused by mosquitoes and 59% believed that typhoid and malaria always co-occur. The endline survey was completed by 91% of participants. Results from the intention-to-treat, per-protocol and as-treated analyses show that both interventions substantially reduced belief in misinformation compared with the control group. Estimates from these analyses, as well as an exploratory dose-response analysis, suggest that direct debunking may be more effective at countering misinformation. Both interventions improved people's knowledge and self-reported behaviour around typhoid risk reduction, and yielded self-reported increases in an important preventive method, drinking treated water. CONCLUSION: These results from a field experiment in a community setting show that highly prevalent health misinformation can be countered, and that direct, detailed debunking may be most effective. TRIAL REGISTRATION NUMBER: NCT04112680.

Using immunisation caregiver journey interviews to understand and optimise vaccination uptake: lessons from Sierra Leone.

Quantitative and qualitative assessments have revealed diverse factors that influence the uptake of childhood immunisation services and shed light on reasons for vaccination delays and refusals. UNICEF and partner organisations developed the Immunisation Caregiver Journey Framework as a novel way to understand caregiver experiences in accessing and receiving immunisation services for children. This framework aims to help immunisation programmes identify vaccination barriers and opportunities to improve vaccination uptake by enhancing the overall caregiver journey in a systems-focused manner, using human-centred design principles. In this paper, we adapt the framework into a flexible qualitative inquiry approach with theoretical guidance from interpretative phenomenology. We draw from the implementation experiences in Sierra Leone to inform methodological guidance on how to design and implement the Immunisation Caregiver Journey Interviews (ICJI) to understand the lived experiences of caregivers as they navigate immunisation services for their children. Practical guidance is provided on sampling techniques, conducting interviews, data management, data analysis and the use of data to inform programmatic actions. When properly implemented, the ICJI approach generates a rich qualitative understanding of how caregivers navigate household and community dynamics, as well as primary healthcare delivery systems. We argue that understanding and improving the caregiver journey will enhance essential immunisation outcomes, such as the completion of the recommended vaccination schedule, timeliness of vaccination visits and reduction in dropouts between vaccine doses.

Homecare for sick family members while waiting for medical help during the 2014-2015 Ebola outbreak in Sierra Leone: a mixed methods study.

INTRODUCTION: Caring for an Ebola patient is a known risk factor for disease transmission. In Sierra Leone during the outbreak in 2014/2015, isolation of patients in specialised facilities was not always immediately available and caring for a relative at home was sometimes the only alternative. This study sought to assess population-level protective caregiving intentions, to understand how families cared for their sick and to explore perceived barriers and facilitators influencing caregiving behaviours. METHODS: Data from a nationwide household survey conducted in December 2014 were used to assess intended protective behaviours if caring for a family member with suspected Ebola. Their association with socio-demographic variables, Ebola-specific knowledge and risk perception was analysed using multilevel logistic regression. To put the results into context, semi-structured interviews with caregivers were conducted in Freetown. RESULTS: Ebola-specific knowledge was positively associated with the intention to avoid touching a sick person and their bodily fluids (adjusted OR (AOR) 1.29; 95% CI 1.01 to 1.54) and the intention to take multiple protective measures (AOR 1.38; 95% CI 1.16 to 1.63). Compared with residing in the mostly urban Western Area, respondents from the initial epicentre of the outbreak (Eastern Province) had increased odds to avoid touching a sick person or their body fluids (AOR 4.74; 95% CI 2.55 to 8.81) and to take more than one protective measure (AOR 2.94; 95% CI 1.37 to 6.34). However, interviews revealed that caregivers, who were mostly aware of the risk of transmission and general protective measures, felt constrained by different contextual factors. Withholding care was not seen as an option and there was a perceived lack of practical advice. CONCLUSIONS: Ebola outbreak responses need to take the sociocultural reality of caregiving and the availability of resources into account, offering adapted and acceptable practical advice. The necessity to care for a loved one when no alternatives exist should not be underestimated.

A review and agenda for integrated disease models including social and behavioural factors.

Social and behavioural factors are critical to the emergence, spread and containment of human disease, and are key determinants of the course, duration and outcomes of disease outbreaks. Recent epidemics of Ebola in West Africa and coronavirus disease 2019 (COVID-19) globally have reinforced the importance of developing infectious disease models that better integrate social and behavioural dynamics and theories. Meanwhile, the growth in capacity, coordination and prioritization of social science research and of risk communication and community engagement (RCCE) practice within the current pandemic response provides an opportunity for collaboration among epidemiological modellers, social scientists and RCCE practitioners towards a mutually beneficial research and practice agenda. Here, we provide a review of the current modelling methodologies and describe the challenges and opportunities for integrating them with social science research and RCCE practice. Finally, we set out an agenda for advancing transdisciplinary collaboration for integrated disease modelling and for more robust policy and practice for reducing disease transmission.

Trends in classifying vaccine hesitancy reasons reported in the WHO/UNICEF Joint Reporting Form, 2014-2017: Use and comparability of the Vaccine Hesitancy Matrix.

Since 2014, the World Health Organization (WHO) member states have been annually reporting vaccine hesitancy reasons, using the WHO/UNICEF Joint Reporting Form (JRF). The Vaccine Hesitancy Matrix (VHM), developed by a WHO strategic advisory group of experts, can serve as an important tool to categorize vaccine hesitancy reasons reported in the JRF. We aimed to describe the reasons for vaccine hesitancy reported globally from 2014 to 2017 to ascertain trends over time and understand the comparability of using the VHM to classify hesitancy reasons from 2014 to 2016 based on previously published literature. We conducted a quantitative content analysis to code and categorize vaccine hesitancy reasons reported in the JRF from 2014 to 2017. Vaccine hesitancy trends were consistent from 2014 to 2017, where vaccine hesitancy reasons were mainly related to "individual and group level influences" (59%) followed by "contextual influences" (25%), and "vaccine- or vaccination-specific issues" (16%). Comparability of our approach to categorize vaccine hesitancy to the previously published JRF data showed that results were mostly but not entirely consistent. Major differences in categorizing vaccine hesitancy were noted between two specific reasons - "experience with past vaccination" (under "individual and group influences") and "risk/benefit- scientific evidence" (under "vaccine and vaccination-specific issues"); this was usually due to lack of clear definitions in some sub-categories and generic responses reported in the JRF. The JRF hesitancy module may benefit from modifications to improve the data quality. Understanding global vaccine hesitancy is crucial and JRF can serve as an important tool, especially with the potential introduction of a COVID-19 vaccine.

Behaviour adoption approaches during public health emergencies: implications for the COVID-19 pandemic and beyond.

Human behaviour will continue to play an important role as the world grapples with public health threats. In this paper, we draw from the emerging evidence on behaviour adoption during diverse public health emergencies to develop a framework that contextualises behaviour adoption vis-à-vis a combination of top-down, intermediary and bottom-up approaches. Using the COVID-19 pandemic as a case study, we operationalise the contextual framework to demonstrate how these three approaches differ in terms of their implementation, underlying drivers of action, enforcement, reach and uptake. We illustrate how blended strategies that include all three approaches can help accelerate and sustain protective behaviours that will remain important even when safe and effective vaccines become more widely available. As the world grapples with the COVID-19 pandemic and prepares to respond to (re)emerging public health threats, our contextual framework can inform the design, implementation, tracking and evaluation of comprehensive public health and social measures during health emergencies.