Spatio-temporal dynamic of the COVID-19 epidemic and the impact of imported cases in Rwanda.

INTRODUCTION: Africa was threatened by the coronavirus disease 2019 (COVID-19) due to the limited health care infrastructure. Rwanda has consistently used non-pharmaceutical strategies, such as lockdown, curfew, and enforcement of prevention measures to control the spread of COVID-19. Despite the mitigation measures taken, the country has faced a series of outbreaks in 2020 and 2021. In this paper, we investigate the nature of epidemic phenomena in Rwanda and the impact of imported cases on the spread of COVID-19 using endemic-epidemic spatio-temporal models. Our study provides a framework for understanding the dynamics of the epidemic in Rwanda and monitoring its phenomena to inform public health decision-makers for timely and targeted interventions. RESULTS: The findings provide insights into the effects of lockdown and imported infections in Rwanda's COVID-19 outbreaks. The findings showed that imported infections are dominated by locally transmitted cases. The high incidence was predominant in urban areas and at the borders of Rwanda with its neighboring countries. The inter-district spread of COVID-19 was very limited due to mitigation measures taken in Rwanda. CONCLUSION: The study recommends using evidence-based decisions in the management of epidemics and integrating statistical models in the analytics component of the health information system.

SMS-based digital health intervention in Rwanda's home-based care program for remote management of COVID-19 cases and contacts: A qualitative study of sustainability and scalability.

Background: COVID-19 pandemic resulted in unprecedented global health challenges. Rwanda identified its first COVID-19 case on March 14, 2020 and subsequently introduced Home-Base Care (HBC) Program in August 2020 following community transmission of the virus and to alleviate logistical and financial strain on the healthcare system. Cases and contacts eligible for HBC were remotely supported by WelTel, an SMS-based mHealth intervention that was successfully implemented before for HIV epidemic in Rwanda. Enrolled cases and contacts were supported and monitored daily via their cell and/or mobile phones until they complete isolation/quarantine period. This study explored the rationale, perspectives, and experiences of key informants (KIs) during the implementation WelTel's mHealth tool for HBC in Rwanda. Methods: Semi-structured one-on-one virtual interviews were conducted with KIs in this qualitative study. The KIs were classified into 2 major categories: (A) Senior staff including policymakers, directors, and senior managers; (B) Technical teams including case managers, and other staff supporting the implementation of WelTel (e.g., IT staff). Interviews were audio-recorded, transcribed, and analyzed in NVivo. Thematic analysis was conducted using a hybrid approach. A topic guide was developed using the Modified Consolidated Framework for Implementation Research and feedback from local stakeholders. Results: 7 KIs were interviewed. Five themes emerged following thematic analysis including: SMS-Based mHealth for Home-Isolation; Facilitators for Intervention Adoption; Barriers for Intervention Adoption; Infection prevention and control for Home-Isolation; and SMS-Based mHealth for Future Pandemics and Epidemics. Based on interviews, strong political commitment and advanced digital infrastructure were major facilitators for adopting WelTel for HBC. A major barrier to adopting WelTel was identified as technical-based issues. This was followed by local communication culture. All participates agreed on the significance of using WelTel to improve access and adherence to infection prevention and control measures, understand transmission dynamics, and inform public health decision-making regarding HBC. Conclusions: Rwanda successfully adopted WelTel for supporting and monitoring COVID-19 cases and contacts in home-isolation and the implementation was instrumental to the country's effort to manage the pandemic. Experiences and perspectives of cases and contacts enrolled into WelTel must be explored to understand the appropriateness and effectiveness of the intervention.

SMS-based digital health intervention in Rwanda's home-based care program for remote management of COVID-19 cases and contacts: A qualitative study of sustainability and scalability

Background COVID-19 pandemic resulted in unprecedented global health challenges. Rwanda identified its first COVID-19 case on March 14, 2020 and subsequently introduced Home-Base Care (HBC) Program in August 2020 following community transmission of the virus and to alleviate logistical and financial strain on the healthcare system. Cases and contacts eligible for HBC were remotely supported by WelTel, an SMS-based mHealth intervention that was successfully implemented before for HIV epidemic in Rwanda. Enrolled cases and contacts were supported and monitored daily via their cell and/or mobile phones until they complete isolation/quarantine period. This study explored the rationale, perspectives, and experiences of key informants (KIs) during the implementation WelTel's mHealth tool for HBC in Rwanda. Methods Semi-structured one-on-one virtual interviews were conducted with KIs in this qualitative study. The KIs were classified into 2 major categories: (A) Senior staff including policymakers, directors, and senior managers;(B) Technical teams including case managers, and other staff supporting the implementation of WelTel (e.g., IT staff). Interviews were audio-recorded, transcribed, and analyzed in NVivo. Thematic analysis was conducted using a hybrid approach. A topic guide was developed using the Modified Consolidated Framework for Implementation Research and feedback from local stakeholders. Results 7 KIs were interviewed. Five themes emerged following thematic analysis including: SMS-Based mHealth for Home-Isolation;Facilitators for Intervention Adoption;Barriers for Intervention Adoption;Infection prevention and control for Home-Isolation;and SMS-Based mHealth for Future Pandemics and Epidemics. Based on interviews, strong political commitment and advanced digital infrastructure were major facilitators for adopting WelTel for HBC. A major barrier to adopting WelTel was identified as technical-based issues. This was followed by local communication culture. All participates agreed on the significance of using WelTel to improve access and adherence to infection prevention and control measures, understand transmission dynamics, and inform public health decision-making regarding HBC. Conclusions Rwanda successfully adopted WelTel for supporting and monitoring COVID-19 cases and contacts in home-isolation and the implementation was instrumental to the country's effort to manage the pandemic. Experiences and perspectives of cases and contacts enrolled into WelTel must be explored to understand the appropriateness and effectiveness of the intervention.

Use of trained scent dogs for detection of COVID-19 and evidence of cost-saving.

Background: One of the lessons learned from the coronavirus disease 2019 (COVID-19) pandemic is the importance of early, flexible, and rapidly deployable disease detection methods. Currently, diagnosis of COVID-19 requires the collection of oro/nasopharyngal swabs, nasal turbinate, anterior nares and saliva but as the pandemic continues, disease detection methods that can identify infected individuals earlier and more quickly will be crucial for slowing the spread of the virus. Previous studies have indicated that dogs can be trained to identify volatile organic compounds (VOCs) produced during respiratory infections. We sought to determine whether this approach could be applied for detection of COVID-19 in Rwanda and measured its cost-saving. Methods: Over a period of 5 months, four dogs were trained to detect VOCs in sweat samples collected from human subjects confirmed positive or negative for COVID-19 by reverse transcription polymerase chain reaction (RT-PCR) testing. Dogs were trained using a detection dog training system (DDTS) and in vivo diagnosis. Samples were collected from 5,253 participants using a cotton pad swiped in the underarm to collect sweat samples. Statistical analysis was conducted using R statistical software. Findings: From August to September 2021 during the Delta wave, the sensitivity of the dogs' COVID-19 detection ranged from 75.0 to 89.9% for the lowest- and highest-performing dogs, respectively. Specificity ranged from 96.1 to 98.4%, respectively. In the second phase coinciding with the Omicron wave (January-March 2022), the sensitivity decreased substantially from 36.6 to 41.5%, while specificity remained above 95% for all four dogs. The sensitivity and specificity by any positive sample detected by at least one dog was 83.9, 95% CI: 75.8-90.2 and 94.9%; 95% CI: 93.9-95.8, respectively. The use of scent detection dogs was also found to be cost-saving compared to antigen rapid diagnostic tests, based on a marginal cost of approximately $14,000 USD for testing of the 5,253 samples which makes 2.67 USD per sample. Testing turnaround time was also faster with the scent detection dogs, at 3 h compared to 11 h with routine diagnostic testing. Conclusion: The findings from this study indicate that trained dogs can accurately identify respiratory secretion samples from asymptomatic and symptomatic COVID-19 patients timely and cost-effectively. Our findings recommend further uptake of this approach for COVID-19 detection.

Advancing detection and response capacities for emerging and re-emerging pathogens in Africa.

Recurrent disease outbreaks caused by a range of emerging and resurging pathogens over the past decade reveal major gaps in public health preparedness, detection, and response systems in Africa. Underlying causes of recurrent disease outbreaks include inadequacies in the detection of new infectious disease outbreaks in the community, in rapid pathogen identification, and in proactive surveillance systems. In sub-Saharan Africa, where 70% of zoonotic outbreaks occur, there remains the perennial risk of outbreaks of new or re-emerging pathogens for which no vaccines or treatments are available. As the Ebola virus disease, COVID-19, and mpox (formerly known as monkeypox) outbreaks highlight, a major paradigm shift is required to establish an effective infrastructure and common frameworks for preparedness and to prompt national and regional public health responses to mitigate the effects of future pandemics in Africa.

Digital mHealth and Virtual Care Use During COVID-19 in 4 Countries: Rapid Landscape Review.

BACKGROUND: As a result of the COVID-19 pandemic, providing health care while maintaining social distancing has resulted in the need to provide care remotely, support quarantined or isolated individuals, monitor infected individuals and their close contacts, as well as disseminate accurate information regarding COVID-19 to the public. This has led to an unprecedented rapid expansion of digital tools to provide digitized virtual care globally, especially mobile phone-facilitated health interventions, called mHealth. To help keep abreast of different mHealth and virtual care technologies being used internationally to facilitate patient care and public health during the COVID-19 pandemic, we carried out a rapid investigation of solutions being deployed and considered in 4 countries. OBJECTIVE: The aim of this paper was to describe mHealth and the digital and contact tracing technologies being used in the health care management of the COVID-19 pandemic among 2 high-income and 2 low-middle income countries. METHODS: We compared virtual care interventions used for COVID-19 management among 2 high-income countries (the United Kingdom and Canada) and 2 low-middle income (Kenya and Rwanda) countries. We focused on interventions used to facilitate patient care and public health. Information regarding specific virtual care technologies was procured from a variety of resources including gray literature, government and health organization websites, and coauthors' personal experiences as implementers of COVID-19 virtual care strategies. Search engine queries were performed to find health information that would be easily accessible to the general public, with keywords including "COVID-19," "contact-tracing," "tool-kit," "telehealth," and "virtual care," in conjunction with corresponding national health authorities. RESULTS: We identified a variety of technologies in Canada, the United Kingdom, Rwanda, and Kenya being used for patient care and public health. These countries are using both video and text message-based platforms to facilitate communication with health care providers (eg, WelTel and Zoom). Nationally developed contact tracing apps are provided free to the public, with most of them using Bluetooth-based technology. We identified that often multiple complimentary technologies are being utilized for different aspects of patient care and public health with the common purpose to disseminate information safely. There was a negligible difference among the types of technologies used in both high-income and low-middle income countries, although the latter implemented virtual care interventions earlier during the pandemic's first wave, which may account for their effective response. CONCLUSIONS: Virtual care and mHealth technologies have evolved rapidly as a tool for health care support for both patient care and public health. It is evident that, on an international level, a variety of mHealth and virtual care interventions, often in combination, are required to be able to address patient care and public health concerns during the COVID-19 pandemic, independent of a country's economic standing.

Toward a New Paradigm of North-South and South-South Partnerships for Pandemic Preparedness: Lessons Learned from COVID-19 and Other Outbreaks.

COVID-19 underscores the need to reimagine North-South partnerships and redefine best practices for building public health and research capacity to address emergent health threats and pandemic preparedness in low- and-middle income countries (LMICs). Historically, outbreak and emergency responses have failed to ensure that the Global South has the autonomy and capacity to respond to public health threats in a timely and equitable manner. The COVID-19 response, however, has demonstrated that innovations and solutions in the Global South can not only fill resource and capacity gaps in LMICs but can also provide solutions to challenges globally. These innovations offer valuable lessons about strengthening local manufacturing capacity to produce essential diagnostic, treatment, and prevention tools; implementing high-quality research studies; expanding laboratory and research capacity; and promoting effective cooperation and governance. We discuss specific examples of capacity-building from Rwanda, South Africa, and Senegal. To fulfill promises made to the Global South during the COVID-19 pandemic, restore and resume health service delivery, and effectively prevent and respond to the next health threat, we need to prioritize equitable access to local manufacturing of basic health tools while building health systems capacities in the Global South.

A multinational Delphi consensus to end the COVID-19 public health threat.

Despite notable scientific and medical advances, broader political, socioeconomic and behavioural factors continue to undercut the response to the COVID-19 pandemic^1,2. Here we convened, as part of this Delphi study, a diverse, multidisciplinary panel of 386 academic, health, non-governmental organization, government and other experts in COVID-19 response from 112 countries and territories to recommend specific actions to end this persistent global threat to public health. The panel developed a set of 41 consensus statements and 57 recommendations to governments, health systems, industry and other key stakeholders across six domains: communication; health systems; vaccination; prevention; treatment and care; and inequities. In the wake of nearly three years of fragmented global and national responses, it is instructive to note that three of the highest-ranked recommendations call for the adoption of whole-of-society and whole-of-government approaches¹, while maintaining proven prevention measures using a vaccines-plus approach² that employs a range of public health and financial support measures to complement vaccination. Other recommendations with at least 99% combined agreement advise governments and other stakeholders to improve communication, rebuild public trust and engage communities³ in the management of pandemic responses. The findings of the study, which have been further endorsed by 184 organizations globally, include points of unanimous agreement, as well as six recommendations with >5% disagreement, that provide health and social policy actions to address inadequacies in the pandemic response and help to bring this public health threat to an end.

Leveraging artificial intelligence and data science techniques in harmonizing, sharing, accessing and analyzing SARS-COV-2/COVID-19 data in Rwanda (LAISDAR Project): study design and rationale.

BACKGROUND: Since the outbreak of COVID-19 pandemic in Rwanda, a vast amount of SARS-COV-2/COVID-19-related data have been collected including COVID-19 testing and hospital routine care data. Unfortunately, those data are fragmented in silos with different data structures or formats and cannot be used to improve understanding of the disease, monitor its progress, and generate evidence to guide prevention measures. The objective of this project is to leverage the artificial intelligence (AI) and data science techniques in harmonizing datasets to support Rwandan government needs in monitoring and predicting the COVID-19 burden, including the hospital admissions and overall infection rates. METHODS: The project will gather the existing data including hospital electronic health records (EHRs), the COVID-19 testing data and will link with longitudinal data from community surveys. The open-source tools from Observational Health Data Sciences and Informatics (OHDSI) will be used to harmonize hospital EHRs through the Observational Medical Outcomes Partnership (OMOP) Common Data Model (CDM). The project will also leverage other OHDSI tools for data analytics and network integration, as well as R Studio and Python. The network will include up to 15 health facilities in Rwanda, whose EHR data will be harmonized to OMOP CDM. EXPECTED RESULTS: This study will yield a technical infrastructure where the 15 participating hospitals and health centres will have EHR data in OMOP CDM format on a local Mac Mini ("data node"), together with a set of OHDSI open-source tools. A central server, or portal, will contain a data catalogue of participating sites, as well as the OHDSI tools that are used to define and manage distributed studies. The central server will also integrate the information from the national Covid-19 registry, as well as the results of the community surveys. The ultimate project outcome is the dynamic prediction modelling for COVID-19 pandemic in Rwanda. DISCUSSION: The project is the first on the African continent leveraging AI and implementation of an OMOP CDM based federated data network for data harmonization. Such infrastructure is scalable for other pandemics monitoring, outcomes predictions, and tailored response planning.

Long-term effect of chronic hepatitis B on mortality in HIV-infected persons in a differential HBV transmission setting.

BACKGROUND: There remain gaps in quantifying mortality risk among individuals co-infected with chronic hepatitis B (HBV) and human immunodeficiency virus (HIV) in sub-Saharan African contexts. Among a cohort of HIV-positive individuals in Rwanda, we estimate the difference in time-to mortality between HBV-positive (HIV/HBV co-infected) and HBV-negative (HIV mono-infected) individuals. METHODS: Using a dataset of HIV-infected adults screened for hepatitis B surface antigen (HBsAg) from January to June 2016 in Rwanda, we performed time-to-event analysis from the date of HBsAg results until death or end of study (31 December 2019). We used the Kaplan-Meier method to estimate probability of survival over time and Cox proportional hazard models to adjust for other factors associated with mortality. RESULTS: Of 21,105 available entries, 18,459 (87.5%) met the inclusion criteria. Mean age was 42.3 years (SD = 11.4) and 394 (2.1%) died during follow-up (mortality rate = 45.7 per 100,000 person-months, 95% confidence interval (CI) 41.4-50.4) Mortality rate ratio for co-infection was 1.7, 95% CI 1.1-2.6, however, Cox regression analysis did not show any association with mortality between compared groups. The adjusted analysis of covariates stratified by co-infection status showed that males, residing outside of the capital Kigali, drinking alcohol, WHO-HIV-clinical stage 3 and 4 were associated with increased mortality in this HIV cohort. CONCLUSIONS: HBV infection does not significantly influence mortality among HIV-infected individuals in Rwanda. The current cohort is likely to have survived a period of high-risk exposure to HBV and HIV mortality and limited health care until their diagnosis.

Effect of unmanned aerial vehicle (drone) delivery on blood product delivery time and wastage in Rwanda: a retrospective, cross-sectional study and time series analysis.

BACKGROUND: The accessibility of blood and blood products remains challenging in many countries because of the complex supply chain of short lifetime products, timely access, and demand fluctuation at the hospital level. In an effort to improve availability and delivery times, Rwanda launched the use of drones to deliver blood products to remote health facilities. We evaluated the effect of this intervention on blood product delivery times and wastage. METHODS: We studied data from 20 health facilities between Jan 1, 2015, and Dec 31, 2019, in Rwanda. First, we did a cross-sectional comparison of data on emergency delivery times from the drone operator collected between March 17, 2017, and Dec 31, 2019, with two sources of estimated driving times (Regional Centre for Blood Transfusion estimates and Google Maps). Second, we used interrupted time series analysis and monthly administrative data to assess changes in blood product expirations after the commencement of drone deliveries. FINDINGS: Between March 17, 2017, and Dec 31, 2019, 12 733 blood product orders were delivered by drones. 5517 (43%) of 12 733 were emergency orders. The mean drone delivery time was 49·6 min (95% CI 49·1 to 50·2), which was 79 min faster than existing road delivery methods based on estimated driving times (p<0·0001) and 98 min faster based on Google Maps estimates (p<0·0001). The decrease in mean delivery time ranged from 3 min to 211 min depending on the distance to the facility and road quality. We also found a decrease of 7·1 blood unit expirations per month after the start of drone delivery (95% CI -11·8 to -2·4), which translated to a 67% reduction at 12 months. INTERPRETATION: We found that drone delivery led to faster delivery times and less blood component wastage in health facilities. Future studies should investigate if these improvements are cost-effective, and whether drone delivery might be effective for other pharmaceutical and health supplies that cannot be easily stored at remote facilities. FUNDING: Canadian Institutes for Health Research.

Qualitative evaluation of enabling factors and barriers to the success and sustainability of national public health institutes in Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia.

OBJECTIVES: The success of National Public Health Institutes (NPHIs) in low-income and middle-income countries (LMICs) is critical to countries' ability to deliver public health services to their populations and effectively respond to public health emergencies. However, empirical data are limited on factors that promote or are barriers to the sustainability of NPHIs. This evaluation explored stakeholders' perceptions about enabling factors and barriers to the success and sustainability of NPHIs in seven countries where the U.S. Centers for Disease Control and Prevention (CDC) has supported NPHI development and strengthening. DESIGN: Qualitative study. SETTING: Cambodia, Colombia, Liberia, Mozambique, Nigeria, Rwanda and Zambia. PARTICIPANTS: NPHI staff, non-NPHI government staff, and non-governmental and international organisation staff. METHODS: We conducted semistructured, in-person interviews at a location chosen by the participants in the seven countries. We analysed data using a directed content analysis approach. RESULTS: We interviewed 43 NPHI staff, 29 non-NPHI government staff and 24 staff from non-governmental and international organisations. Participants identified five enabling factors critical to the success and sustainability of NPHIs: (1) strong leadership, (2) financial autonomy, (3) political commitment and country ownership, (4) strengthening capacity of NPHI staff and (5) forming strategic partnerships. Three themes emerged related to major barriers or threats to the sustainability of NPHIs: (1) reliance on partner funding to maintain key activities, (2) changes in NPHI leadership and (3) staff attrition and turnover. CONCLUSIONS: Our findings contribute to the scant literature on sustainability of NPHIs in LMICs by identifying essential components of sustainability and types of support needed from various stakeholders. Integrating these components into each step of NPHI development and ensuring sufficient support will be critical to strengthening public health systems and safeguarding their continuity. Our findings offer potential approaches for country leadership to direct efforts to strengthen and sustain NPHIs.

Experience of Rwanda on COVID-19 Case Management: From Uncertainties to the Era of Neutralizing Monoclonal Antibodies.

The management of COVID-19 in Rwanda has been dynamic, and the use of COVID-19 therapeutics has gradually been updated based on scientific discoveries. The treatment for COVID-19 remained patient-centered and entirely state-sponsored during the first and second waves. From the time of identification of the index case in March 2020 up to August 2021, three versions of the clinical management guidelines were developed, with the aim of ensuring that the COVID-19 patients treated in Rwanda were receiving care based on the most recent therapeutic discoveries. As the case load increased and imposed imminent heavy burdens on the healthcare system, a smooth transition was made to enable that the asymptomatic and mild COVID-19 cases could continue to be closely observed and managed while they remained in their homes. The care provided to patients requiring facility-based interventions mainly focused on the provision of anti-inflammatory drugs, anticoagulation, broad-spectrum antibiotic therapy, management of hyperglycemia and the provision of therapeutics with a direct antiviral effect such as favipiravir and neutralizing monoclonal antibodies. The time to viral clearance was observed to be shortest among eligible patients treated with neutralizing monoclonal antibodies (bamlanivimab). Moving forward, as we strive to continue detecting COVID-19 cases as early as possible, and promptly initiate supportive interventions, the use of neutralizing monoclonal antibodies constitutes an attractive and cost-effective therapeutic approach. If this approach is used strategically along with other measures in place (i.e., COVID-19 vaccine roll out, etc.), it will enable us to bring this global battle against the COVID-19 pandemic under full control and with a low case fatality rate.

Genomic sequencing of SARS-CoV-2 in Rwanda reveals the importance of incoming travelers on lineage diversity.

COVID-19 transmission rates are often linked to locally circulating strains of SARS-CoV-2. Here we describe 203 SARS-CoV-2 whole genome sequences analyzed from strains circulating in Rwanda from May 2020 to February 2021. In particular, we report a shift in variant distribution towards the emerging sub-lineage A.23.1 that is currently dominating. Furthermore, we report the detection of the first Rwandan cases of the B.1.1.7 and B.1.351 variants of concern among incoming travelers tested at Kigali International Airport. To assess the importance of viral introductions from neighboring countries and local transmission, we exploit available individual travel history metadata to inform spatio-temporal phylogeographic inference, enabling us to take into account infections from unsampled locations. We uncover an important role of neighboring countries in seeding introductions into Rwanda, including those from which no genomic sequences were available. Our results highlight the importance of systematic genomic surveillance and regional collaborations for a durable response towards combating COVID-19.

African National Public Health Institutes Responses to COVID-19: Innovations, Systems Changes, and Challenges.

National public health institutes (NPHIs)-science-based governmental agencies typically part of, or closely aligned with, ministries of health-have played a critical part in many countries' responses to the COVID-19 pandemic. Through listening sessions with NPHI leadership, we captured the experiences of NPHIs in Africa. Our research was further supplemented by a review of the literature. To address issues related to COVID-19, NPHIs in Africa developed a variety of innovative approaches, such as working with the private sector to procure and manage vital supplies and address key information needs. Creative uses of technology, including virtual training and messaging from drones, contributed to sharing information and battling misinformation. Positive impacts of the pandemic response include increased laboratory capacity in many countries, modernized surveillance systems, and strengthened public-private partnerships; much of this enhanced capacity is expected to persist beyond the pandemic. However, several challenges remain, including the lack of staff trained in areas like bioinformatics (essential for genomic analysis) and the need for sustained relationships and data sharing between NPHIs and agencies not traditionally considered public health (eg, those related to border crossings), as well as the impact of the pandemic on prevention and control of non-COVID-19 conditions-both infectious and noncommunicable. Participants in the listening sessions also highlighted concerns about inequities in access to, and quality of, the public health services and clinical care with resultant disproportionate impact of the pandemic on certain populations. COVID-19 responses and challenges highlight the need for continued investment to strengthen NPHIs and public health infrastructure to address longstanding deficiencies and ensure preparedness for the next public health crisis.

The Need for a Practical Approach to Evaluate the Effectiveness of COVID-19 Vaccines for Low- and Middle-Income Countries.

The global demand for coronavirus disease 2019 (COVID-19) vaccines currently far outweighs the available global supply and manufacturing capacity. As a result, securing doses of vaccines for low- and middle-income countries has been challenging, particularly for African countries. Clinical trial investigation for COVID-19 vaccines has been rare in Africa, with the only randomized clinical trials (RCTs) for COVID-19 vaccines having been conducted in South Africa. In addition to addressing the current inequities in the vaccine roll-out for low- and middle-income countries, there is a need to monitor the real-world effectiveness of COVID-19 vaccines in these regions. Although RCTs are the superior method for evaluating vaccine efficacy, the feasibility of conducting RCTs to monitor COVID-19 vaccine effectiveness during mass vaccine campaigns will likely be low. There is still a need to evaluate the effectiveness of mass COVID-19 vaccine distribution in a practical manner. We discuss how target trial emulation, the application of trial design principles from RCTs to the analysis of observational data, can be used as a practical, cost-effective way to evaluate real-world effectiveness for COVID-19 vaccines. There are several study design considerations that need to be made in the analyses of observational data, such as uncontrolled confounders and selection biases. Target trial emulation accounts for these considerations to improve the analyses of observational data. The framework of target trial emulation provides a practical way to monitor the effectiveness of mass vaccine campaigns for COVID-19 using observational data.

Contact Tracing and the COVID-19 Response in Africa: Best Practices, Key Challenges, and Lessons Learned from Nigeria, Rwanda, South Africa, and Uganda.

Most African countries have recorded relatively lower COVID-19 burdens than Western countries. This has been attributed to early and strong political commitment and robust implementation of public health measures, such as nationwide lockdowns, travel restrictions, face mask wearing, testing, contact tracing, and isolation, along with community education and engagement. Other factors include the younger population age strata and hypothesized but yet-to-be confirmed partially protective cross-immunity from parasitic diseases and/or other circulating coronaviruses. However, the true burden may also be underestimated due to operational and resource issues for COVID-19 case identification and reporting. In this perspective article, we discuss selected best practices and challenges with COVID-19 contact tracing in Nigeria, Rwanda, South Africa, and Uganda. Best practices from these country case studies include sustained, multi-platform public communications; leveraging of technology innovations; applied public health expertise; deployment of community health workers; and robust community engagement. Challenges include an overwhelming workload of contact tracing and case detection for healthcare workers, misinformation and stigma, and poorly sustained adherence to isolation and quarantine. Important lessons learned include the need for decentralization of contact tracing to the lowest geographic levels of surveillance, rigorous use of data and technology to improve decision-making, and sustainment of both community sensitization and political commitment. Further research is needed to understand the role and importance of contact tracing in controlling community transmission dynamics in African countries, including among children. Also, implementation science will be critically needed to evaluate innovative, accessible, and cost-effective digital solutions to accommodate the contact tracing workload.