A Lifeline During the Pandemic

Background

Malawi faced a tough situation when the COVID-19 pandemic hit. The virus was causing a lot of problems, especially for people living with HIV (PLHIV), whose risk of other infections and complications would increase without adequate access to antiretroviral therapy (ART). The pandemic met health systems largely unprepared, especially those in low-income countries. COVID-19 presented far greater consequences for an overstretched health system, including the disruption of essential health services and potential reversal of progress in the fight against HIV/AIDS. The rapidly evolving nature of the pandemic meant that Malawi needed to act fast to reduce spread and associated hospitalizations, channel scarce health resources to the most vulnerable areas, and maintain population health gains. However, for these efforts to be well-coordinated within the COVID-19 context, the country needed effective surveillance systems to monitor the spread and understand the disease pattern.

Quick Thinking in a Pandemic

The Telephone-Based Syndromic Surveillance Survey of COVID-19 (COVID-19 SS) approach

Although it was important to respond quickly to COVID-19, the question that health stakeholders needed to answer was how? Part of answering this question was the Government-led development of the National COVID-19 Preparedness and Response Plan. This response plan provided opportunities for innovations such as the Telephone-Based Syndromic Surveillance Survey of COVID-19 (COVID-19 SS) to support government-led response. Dr Thulani Maphosa – a Principal Investigator (PI) on the COVID-19 SS project, explains its objectives, “Nobody knew what the effect of COVID-19 will be in Malawi. So, we wanted to ensure that we understood the transmission patterns, including Malawi’s most affected areas… We needed to look for people with signs and symptoms or any illnesses related to COVID-19 and the patterns around the numbers of people dying due to COVID-related signs and symptoms.”

To achieve these, the team needed to develop a cheap, easy-to-use, and innovative system to reach a large population during the pandemic. COVID-19 prevention measures such as social distancing and lockdowns made movement difficult. Again, cost concerns around implementing country-wide active surveillance and risk of COVID-19 spread between researchers and communities ruled out traditional data collection methods. These factors underlined the design of the COVID-19 SS model, which allowed the team to interact with telephone users across Malawi regularly, obtain COVID-19-related data, and share the same with relevant partners, including the Ministry of Health and Public Health Institute of Malawi (PHIM) for timely pandemic response. However, the team had to address several issues at the design phase to implement the COVID-19 SS effectively. Dr Thulani notes, “We had to develop a plan and get multi-level approvals within a short time, think of ethical ways to access people’s phone numbers, ensure confidentiality, and avoid harm to participants.” The COVID-19 SS was implemented from July 2020 – April 2022.

“We had to develop a plan and get multi-level approvals within a short time, think of ethical ways to access people’s phone numbers, ensure confidentiality, and avoid harm to participants.” Dr Thulani Maphosa

Key Survey Highlights

The project team put several elements in place to bring the COVID-19 SS to life. With support from the Regional Data Manager at Elizabeth Glaser Pediatric AIDS Foundation (EGPAF), the team set up a system that automatically generated Airtel and TNM phone numbers using tablets. Next, drawing inspiration from the “Chipatala Cha pa Foni” model – which means health centre by phone, the team set up a call centre for telephone interviews. EGPAF’s informatics department designed a real-time dashboard showing the data collection process and results. Experienced research assistants (RAs) including nurses and doctors with good research background were recruited ensure quality in the telephone-based surveillance process for the general population (GP) and PLHIV. For PLHIV, to ensure an extra layer of confidentiality, the team engaged “expert clients” including nurses with experience working with PLHIV to make the phone calls. Dr Thulani reports, “Despite our RAs having good research experience, we did a lot of training and demonstrations for them on how to approach the telephone-based surveillance, increase response rates by relating appropriately with participants and helping them to understand the need for the survey, and that they understood their roles.”

To ensure anonymity, participant-identifiable information was not collected, and phone numbers were not linked to questionnaires. GP data provided country-wide insight into the proportion of suspected COVID-19 cases, most affected areas, and healthcare access. While data from PLHIV in EGPAF-supported areas provided similar insight, it further helped the team understand health care access challenges this group faced during the pandemic. Of the 356,525 active numbers dialed for the GP, 138,751 were answered, and 100,160 surveys were completed. Among the GP reached, the data revealed – 7,298 suspected cases, 9,738 COVID-19 tests done, and 2,089 household reported deaths. For the PLHIV group, of the 202,278 active numbers, 81,117 were answered, and 35,204 surveys were completed. Among PLHIV reached, 2,173 suspected cases, 1,791 COVID-19 tests were done, and 452 household-reported deaths were recorded. Overall, participants mentioned unavailability of medications, high transportation costs, fear of getting COVID-19, treatment delays, and COVID-19 restrictions as reasons for not accessing health care.

Working Together for Progress

The success of the COVID-19 SS project highlighted the power of partnerships. Dr. Thulani acknowledges, “This was a collaboration led by several people… For example, The COVID-19 SS had three lead PIs – myself from EGPAF, Thoko Kalua the Deputy Director – Ministry of Health, Department of HIV and AIDS, and Annie Mwale the Epidemiologist – Ministry of Health/PHIM.” Close working with CDC and EGPAF leadership further highlighted the project’s reliance on team effort. Additionally, district representatives and other key partners supporting the COVID response through PHIMS participated.

Regarding the contributions of the different partners, CDC played a significant role in funding the project. EGPAF was charged with day-to-day secretariat services to ensure the project implementation according to plan. Other partners supported protocol design, logistics, and overall project coordination. The PIs established a Project Implementation Team comprising all partners which had biweekly meetings (or less in emergency cases) to harmonize partnership, evaluate progress, and improve implementation.

Lessons and Thoughts for the Future

The COVID-19 SS model has been praised as one of the greatest innovations developed in Malawi as part of pandemic response efforts despite prevailing limitations. Dr. Thulani highlights, “We were reaching out to a bigger proportion of people at an average of 2000+ a week for the general population, and about 1000+ for PLHIV. This provided us with real-time information, which is normally different from other survey designs.” The model allowed the team to identify suspected COVID-19 cases in real-time, track affected areas, and share information with relevant authorities. For instance, the COVID-19 SS model was able to pick up the peak infection phases of the pandemic and to some extent, identified additional cases that routine surveillance systems could have missed.

The COVID-19 SS model has been praised as one of the greatest innovations developed in Malawi as part of pandemic response efforts despite prevailing limitations.

Similarly, Precious Gumbo – an RA on the survey, notes, “The project was helpful… beyond collecting the data via the telephone, we were able to educate people about COVID-19, clear vaccine misconceptions, and encourage people to take the vaccines.” Nevertheless, the model had to navigate several implementation challenges, including calling some individuals many times to arrange an interview, amending survey design to accommodate changes and improve the survey, and obtaining additional approvals. The project team acknowledged that regular population sensitization using text messages, radio, and social media platforms such as Facebook greatly increased project acceptance. As regards the way forward, Dr. Thulani suggests, “I call it the future as the model is cost-effective, can be implemented in resource-poor settings, and is an advanced way of using existing technology in our countries.” The COVID-19 SS model holds much promise for future epidemic response as the design can be adapted for different diseases and settings.