Using new approaches to gain a better understanding of COVID-19 in Malawi
Published: 27 September 2022
A cooperative approach to developing methods to understand new diseases and securing community support to study them.
The COVID-19 crisis has had a profound impact on the WHO’s progress toward global health goals, disproportionately affecting vulnerable communities and highlighting the urgent need to develop innovative responses to disease outbreaks. Generating safe and culturally sensitive ways to study infectious diseases in low resource settings is key to tackling the challenge of emerging health threats for the world’s most vulnerable populations. At the Queen Elizabeth Central Hospital in Blantyre, Malawi, an interdisciplinary team of healthcare professionals, scientists and ethicists learned firsthand how vital a cooperative approach is when developing methods to understand new diseases and securing community support to study them.
Dr Christopher Moxon from the University of Glasgow collaborated with an international and inter-disciplinary team including Malawian pathologists, immunologists, lab technicians and field workers to investigate lung pathology and the immunological basis of disease in fatal Covid-19 cases in Malawi. The team wanted to study the impact of the virus on the lung tissue of patients who had died of the disease. The results of these studies are providing new insights in our understanding of COVID-19 and may guide scientists to develop novel approaches to the treatment of the illness.
Fear of the unknown
The team began their work at the Queen Elizabeth Central Hospital early in the pandemic, when little was known about the disease and an environment of fear permeated interactions between hospital staff and patients, including their families and communities.
Dr Moxon explains the complexities of the environment in which the team were working:
"People became frightened, because there were deaths from Covid-19 and so little information was available about what this condition was. The rationale behind protective measures such as screening patients in tents to ensure safe triage was not obvious to people. All these unknowns generated speculation, false rumors and fear about what was going on. And then some people stopped coming to hospital for anything at all. There was a period when hospital, wards, which had always packed suddenly became empty. People were terrified. There was a false perception that if they came to hospital they were going to die."
The team had to develop a new method of studying the illness and adjusting hospital staff, patients and their families to the realities of Covid-19. The approach required a group effort, building on the expertise of many people. The first task was to engage over 150 staff who would be involved in the project working in the acute medical ward to improve their understanding of the study and address their many concerns about what working on this research would mean not just for themselves, but for their families and communities as well. This included everyone who worked in the ward or who came into contact with the ward - doctors, nurses, lab techs, guards, cleaners, managers, drivers and mortuary attendants.
Social scientists and bioethicists Dr Deborah Nyirenda and Leticia Suwedi worked with the team to sensitize the community involved with the project. This process involved explaining the study details, generating discussion, and facilitating the hospital staff to express their concerns and give feedback. This input from health workers and the community enabled the team to work effectively to develop culturally and ethically acceptable strategies of addressing issues of consent. Open communication allowed the team to directly respond to issues, identify potential challenges and adjust the design of the study.
The team employed a detailed sensitization strategy:
- Local language was used to ensure effective communication
- Presentations were made by study team members to clearly explain the methodology
- Information leaflets were created, covering questions that could arise
- Timelines were developed detailing different actions of the study
- A decision-making tree was created to guide what action would be appropriate and at what time
- Posters were designed for healthcare workers
- Guidance was developed regarding the specific words to be spoken by health care workers to the guardians about the study
- Discussions were had about which health care worker would be permitted to talk about the study to the guardian and at what time
- Regular communication with key hospital staff at the beginning of the study also helped to address emerging challenges during implementation.
In Malawi, consent to perform an autopsy involves many members of the deceased person’s family. Building trust with the study team was therefore crucial. With misinformation about COVID-19 present in the community and concerns around the contagious nature of COVID-19, the team carefully considered the safest, most culturally sensitive and ethical way of informing the next of kin about the study after the death of their family member.
Feedback from the hospital engagement meetings helped the study team set up a dedicated partitioned area in the mortuary to perform autopsies on deceased Covid-19 patients. In addition to global supply chain issues in sourcing medical supplies, the team needed to develop a way to study lung tissue that would mitigate the risk of Covid-19 infection. Use of traditional open autopsy methods posed a theoretical risk of aerosolising the virus, creating a danger to the researchers. The team chose to instead use bore needles to take biopsies of the tissue, thus removing the need to open the body at all, therefore reducing the risk of infection.
The preliminary work of the team shows that in the case of Covid-19, the blood does not tell us very much about the effect on the lungs. The results suggest that scrapings of cells and/or fluid obtained from the nose are a better way of understanding the critical lung pathology of Covid-19. If true, this finding is important, as most of the work on Covid-19 aims to understand the effect the disease has on cells and factors in the blood. Nasal fluid and cell scrapings can readily be taken from live patients. The team hope that their results help focus future efforts on obtaining and analyzing nasal samples as a better surrogate sample for lung disease.
- Covid-19 causes several changes to the lung tissue that are similar in this Malawian population to those described in studies conducted in European, Asian or Hispanic populations.
- If critical cellular processes are also similar this would increase confidence that treatment for Covid-19 shown to be effective in other countries would be effective in Malawi. Thus reduce the need for clinical trials to be repeated in an African setting.
- We require alternative ways of treating Covid-19. Our preliminary results suggest that investigating the detailed cellular processes occurring in the lung is a powerful method to helping us discover targets for these treatments.
- The ethical and sensitization process developed as part of this research has been accepted for publication in a WHO case book on ethical and challenges in research in a pandemic.
The team developed this method as a platform for investigating many diverse types of diseases that go deep into organ tissue and cannot be looked at in living patients, such as malaria, pneumonia and meningitis in children. The study results suggest that autopsy is a viable and powerful way to understand disease and identify novel treatment targets, but one that needs careful consideration of the local context to be accepted and effective.
First published: 27 September 2022