12 January, 2023
‘Beyond the Pandemic: The Impact of COVID-19 Research Response in Low- and Middle-Income Countries’
Daniela Toale, Chantel Jones and Lucy Lawrenson
On 13 December 2022, UKCDR’s COVID CIRCLE Researcher Community (CCRC) hosted a virtual conference that brought together those researching COVID-19 across the globe, funders that have supported COVID-19 research, and other global health and research for development stakeholders to discuss the impacts of the COVID-19 research response in low- and middle-income countries (LMICs).
The conference featured live presentations and poster presentations from researchers working across multiple disciplines, showcasing their research and its impact, as well as considering lessons learnt and next steps. In addition, a session with UK-based funders reflected on and discussed how the COVID-19 pandemic has influenced decisions about future funding for emergency response research, particularly in LMIC settings.
Below is a summary of learnings from event.
Session One: Hearing from the Researchers (Pt 1.)
Watch all presentations from this session here
SARS-CoV-2 in an African birth cohort – a prospective study through four waves of the pandemic
The research presentations were kicked off by Professor Heather Zar. Her study aimed to investigate illness and serological responses in children and mothers in a birth cohort, the Drakenstein Child Health study, through four waves of the pandemic.
Key findings included:
- Protection against COVID-19 in children was not due to cross-reactive antibodies to seasonal human coronaviruses (sHCoVs);
- There was little disease but a very high incidence of infection – very high seroprevalence in mothers & children increasing over time;
- Higher S-original levels of antibody thresholds were needed for protection from variants of COVID-19, and the highest levels were needed for the Omicron variant;
- Hybrid immunity (natural infection + single vaccination) provided the highest levels of protection against the Omicron variant;
In future work, Professor Zar will investigate mechanisms of protection, the duration of protection, and T-cell immunity. She will also compare the results of this study with those of a hospitalised cohort of children with COVID and non-COVID pneumonia, looking as well at long-term outcomes, to help us understand the virus.
This project was funded by UKRI MRC and NIHR and is part of the Global Effort on COVID-19 (GECO) Health Research Call.
Professor Heather Zar
Heather Zar is Professor and Chair of the Department of Paediatrics and Child Health at Red Cross Children’s Hospital and Director of the SA-MRC Unit on Child & Adolescent Health University of Cape Town UCT. A global expert in childhood respiratory diseases, her work has focused on pneumonia, tuberculosis, asthma, and HIV-associated lung diseases. She has established an African birth cohort study, the Drakenstein Child Health study, to investigate the early life determinants of health. An NRF-A1–rated scientist, she’s published more than 550 peer–reviewed publications and currently mentors or has mentored 50 PhD or Master’s students. She is President of the Forum of International Respiratory Societies, the immediate past President of the Pan African Thoracic Society, and serves as an advisor to WHO, UNICEF and the Gates Foundation. She received the World Lung Health award from the American Thoracic Society in 2014. In 2018 she was awarded the L’Or’al-UNESCO for Women in Science Laureate for Africa and Arabia and in 2020 the SA-MRC Platinum medal for contributions over a lifetime.
POETIC: Provision of Essential Treatment in Critical Illness in COVID-19
For this presentation, we heard from Dr Tim Baker, Dr Karima Khalid and Dr Carl Otto Schell.
Essential Emergency and Critical Care (EECC) is the basic, low-cost care required by critically ill patients, such as oxygen and iv-fluids, and the system-wide requirements for their provision. This project aimed to generate knowledge and guide COVID-19 responses towards scalable strategies for increased survival in critical illness.
The study found:
- At a hospital level in Tanzania and Kenya, most resources for EECC were available; however, in the wards, 44% of EECC resources were missing;
- EECC costs $17-21USD per day and is very cost-effective at $23-28 USD per DALY (disability-adjusted life year) averted. This is similar to malaria treatment or emergency obstetric care;
- COVID-19 responses were not coordinated, system-wide or sustainable; thus, the system remains vulnerable to the next emergency; training and procurement of equipment are necessary but not sufficient as an overall solution.
Regarding impact, initial modelling suggests that EECC could avert one million deaths a year. Following the sharing of findings with decision-makers, stakeholders and clinicians, a national strategic plan for EECC is being set up in Tanzania and Zanzibar. The project plans to have effective coverage of EECC across 200 hospitals in Africa. Future research plans include running bottleneck studies, developing context-appropriate modular interventions, and running a cluster step-wedge RCT.
This project was funded by the Wellcome Trust.
Dr Tim Baker, Dr Karima Khalid and Dr Carl Otto Schell
Tim Baker is an Anesthesiologist/Critical Care Physician and Researcher at Muhimbili University of Health & Allied Sciences at the Ifakara Health Institute in Tanzania. Tim is also Associate Professor at LSHTM and at Karolinska Institutet, is a non-resident fellow at the Center for Global Development and has consultancies with WHO, UNICEF, USAID and the World Bank. Tim’s work focuses on evaluating and improving the provision of care to critically ill patients. Karima Khalid is an Anaesthesia and Critical Care Specialist and Researcher at Muhimbili Orthopaedic Institute, Muhimbili University of Health & Allied Sciences and Ifakara Health Institute in Tanzania. Her interests include capacity building in anaesthesia and critical care both in Tanzania and globally. Carl Otto Schell is a Specialist Physician in Internal Medicine and Cardiology in Nyköping, Sweden, and a researcher at Karolinska Institutet. His interests are in health systems and care of critical illness in resource-constrained settings, specifically how to best use the potential of basic, feasible, low-cost actions in healthcare that are often overlooked in policy, research, and practice.
Tracking COVID-19 in the Philippines: Developing and Implementing Genomic Surveillance Across the Country’s Public Health Network
Our third presentation came from Dr Timothy Dizon.
Only 8% of over 13 million COVID-19 sequences shared globally are from LMICs. Genomic surveillance (GS) was a powerful component of the pandemic response as it enabled the characterisation of circulating viruses and helped identify sources of introductions as well as global and local transmission patterns. This project set up GS and response capacity in the Philippines to help inform infection control at local and regional levels. Before the project, there was a lack of equipment and expertise for whole-genome sequencing in the Philippines, sequence capacity was limited, and there were no GS and referral systems in place. This project was impactful as it changed these norms.
The team will continue and extend SARS-CoV-2 routine sequencing in future work. Dr Dizon also seeks to:
- Expand SARS-CoV2 GS to other pathogens;
- Expand the genomic consortium to include other institutions within and outside the Philippines’ Department of Health;
- Continue the dialogue with stakeholders and policymakers.
Find out more about the study here.
This project was funded by UKRI MRC and NIHR and is part of the Global Effort on COVID-19 (GECO) Health Research Call.
Dr Timothy Dizon
Timothy Dizon is a clinical research professional, educator, and physician with substantial experience conducting research. Currently working for the Research Institute for Tropical Medicine, he is often involved in designing research protocols and managing ongoing projects in collaboration with local and foreign partners. https://ritm.gov.ph/
Session Two: Hearing from the Researchers (Pt 2.)
Watch all presentations from this session here
DialCOVID: Remote mitigation through telephone symptom surveillance in refugee settlements in Uganda
Session Two kicked off with a presentation from Dr Kelli O’Laughlin and Dr Timothy Muwonge.
This study set up a free telephone hotline in refugee settlements in Uganda that uses interactive voice response (IVR) technology to rapidly collect and disseminate information in a humanitarian setting. The hotline was provided in ten languages.
The study collected COVID-19 testing data and characteristic information, as well as data on knowledge and risk perceptions, ability to adhere to preventative measures, and barriers/facilitators to prevention and control measure adoption for refugees.
The study found:
- Participants adopted prevention strategies but risk perception and adoption of risk mitigation strategies decreased over time;
- Participants were generally favourable of COVID-19 vaccines;
- Barriers to adoption of control measures were unique to the refugee settlement context (inc. resource scarcity, high house density, and necessity to leave the home to attend to survival needs), which prevented isolation and quarantining;
- COVID-19 negatively impacted income generation, food security, social interactions, and contribution to incidents of child marriage and teenage pregnancies.
An IVR platform can be used to rapidly collect and disseminate information in many languages and difficult-to-reach places with the Dial-COVID tool being adapted for other applications such as routine surveillance and/or during future outbreaks of other transmissible diseases.
Dr Kelli O’Laughlin and Dr Timothy Muwonge
Kelli O’Laughlin is an Assistant Professor in the Departments of Emergency Medicine and Global Health at the University of Washington. Dr O’Laughlin attended the Oregon Health & Science University School of Medicine and completed her emergency medicine residency at the University of California, Los Angeles/Olive-View UCLA Emergency Medicine Residency Program. She earned her MPH at the Harvard T.H. Chan School of Public Health. She is a global health research scientist focused on assessing the health needs of refugee populations and on designing and evaluating refugee-specific interventions to improve care. She is assessing the health behaviour and ecologic context influences on HIV care among refugee populations in Uganda and implementing and evaluating an intervention to improve HIV care engagement in this setting (PI; K23 MH108440). Dr O’Laughlin is also investigating an interactive voice response (IVR) telephone-based COVID-19 symptom and exposure surveillance tool among refugees in Uganda. She aims to validate a prediction model with COVID-19 testing, assess knowledge and perceptions of risk and explore barriers and facilitators to risk mitigation strategy adoption among this population (PI; Elrha/R2HC, Funders: RCDO, Wellcome, NIHR). She is also working to investigate assisted partner notification for HIV among refugees in West Nile Uganda using an implementation science approach (PI; UW/FH Center for AIDS Research). Dr O’Laughlin is Affiliated Faculty at the Harvard Humanitarian Initiative. Timothy R Muwonge, MBChB, MPH, is an Infectious disease and Public Health Specialist and the Head of Programs for HIV prevention Research at the Makerere University Infectious Diseases Institute-Kasangati Uganda. He is a member of the Uganda National HIV Prevention technical working group at the Ministry of Health. He has previously supported the development of M&E tools and healthcare worker training material for the PrEP rollout in Uganda and Nigeria. He completed his degree in medicine and surgery from the Mbarara University of Science and Technology and his MPH from the School of Public Health, Makerere University. Over the past 12 years, Dr Muwonge has worked closely with a team of researchers at the International Clinical Research Centre at the University of Washington and Harvard Medical School on a number of HIV prevention trials and has co-authored over 30 papers in peer-reviewed journals. He is a co-author for over three versions of the CONSOLIDATED GUIDELINES FOR THE PREVENTION AND TREATMENT OF HIV AND AIDS IN UGANDA and co-author for the Uganda Technical guidelines on Pre-Exposure Prophylaxis. He is currently working on HIV care and prevention studies among key and vulnerable populations including refugees and has included telehealth innovations that were piloted for COVID-19 among vulnerable populations to disseminate public health messaging and surveys with the use of interactive voice response (IVR) technology (DIAL-COVID Project).
MAP at Home: Online mental health and psychosocial support through the arts in Rwanda
The conference’s fifth presentation was delivered by Dr Ananda Breed and Dr Chaste Uwihoreye.
This project aimed to research the prevention of, response to, and awareness of mental health and promotion of psychosocial well-being among youth, families and community members through an innovative arts-based, culturally informed approach, responsive to the needs of participants (both practitioners and users).
Activities and impact of this project include:
- A co-produced psychosocial module and online curriculum;
- The integration of MAP at Home into health centres and district hospitals;
- Additional training delivered to mental health workers, rehabilitation centres, health institutions, and prisons;
- The ‘Continuing Professional Development (CPD) Programme’ developed and launched in partnership with the University of Rwanda to embed MAP into their School of Medicine.
MAP at Home has set up memorandums of understandings with the Rwandan Ministry of Health, Ministry of Education, Hospitals and Schools to integrate the methodology into existing systems and activities. They have also secured additional funding through a Wellcome Trust Discovery project called Healing Through Evaluation, Arts and Learning (HEAL).
This project was funded by the UKRI GCRF/Newton Fund Agile COVID-19 Rapid Response Award.
Professor Ananda Breed and Dr Chaste Uwihoreye
Professor Ananda Breed is the author of Performing the Nation: Genocide, Justice, Reconciliation (Seagull Books, 2014), co-editor of Performance and Civic Engagement (Palgrave Macmillan, 2017), co-editor of The Routledge Companion to Applied Performance: Volume One – Mainland Europe, North and Latin America, South Africa, and Australia and New Zealand (Routledge, 2020), co-editor of The Routledge Companion to Applied Performance: Volume Two – Brazil, West Africa, South Asia, South East Asia, United Kingdom and Arab World (Routledge, 2020), and co-editor of Creating Culture in (Post) Socialist Central Asia (Palgrave, 2020) in addition to several publications that address transitional systems of governance and the arts. She has worked as a consultant for IREX and UNICEF in Kyrgyzstan on issues concerning conflict prevention and conducted applied arts workshops in the Democratic Republic of Congo (DRC), Indonesia, Japan, Kyrgyzstan, Nepal, Palestine, Rwanda and Turkey. Prof Breed was the founder of the Centre for Performing Arts Development (CPAD) at the University of East London and a former research fellow at the International Research Centre Interweaving Performance Cultures at Freie University 2013-2014). She is currently a Principal Investigator of the Arts and Humanities (AHRC) Global Challenges Research Fund (GCRF) project Mobile Arts for Peace (MAP): Informing the National Curriculum and Youth Policy for Peacebuilding in Kyrgyzstan, Rwanda, Indonesia and Nepal (2020-2024) and former Co-Investigator of AHRC GCRF project Changing the Story (2018-2022) and former Principal Investigator of UKRI GCRF Newton Fund project MAP at Home: online psychosocial support through the arts in Rwanda (2020-2022). https://staff.lincoln.ac.uk/abreed
Access to medicines and care during COVID-19: findings from the medicines retail sector in Uganda
Dr Eleanor Hutchinson and Dr Freddy Kitutu provided the final researcher presentation.
Their research focused on how the COVID-19 public health response shaped the supply of, and access to, treatment in the medicines retail sector (MRS) in Uganda. It also looked at how policy can be adapted to ensure continuity of safe access to essential medicines during this and future outbreaks. This is particularly important given that up to 80% of Ugandans seek care for fever in the MRS.
The study seeks to create policy change at the national and district level and ensure that the MRS are included in discussions at this level. Alongside data collection activities, the project held workshops with a diverse range of stakeholders and undertook multiple dissemination activities.
The project will host a final workshop to focus on how to create a better framework/structure to include MRS during pandemics. A PHIND grant has been secured to develop a complex intervention trial with drug shop vendors. The collaboration between Dr Hutchinson and Dr Kitutu will continue as Dr Kitutu is a visiting fellow at the Department for Global Health and Development, LSHTM.
Dr Eleanor Hutchinson and Dr Freddy Kitutu
Eleanor Hutchinson is an Associate Professor in Anthropology and Public Health at the London School of Hygiene and Tropical Medicine. Her work focuses on the structures of informality in health systems and seeks to find pragmatic ways to improve service provision that takes social, economic, and political contexts into account. She works in two settings: first, in the medicines retail sector where she has traced how ways of distributing medicines in these highly informal spaces are shaped by social and political networks, policy changes, public health interventions and social relations. Second, in the formal health system, where she has looked at how health workers incorporate change into daily practice and caregiving and how corruption shapes the delivery of care and is shaped by social networks and political systems within and beyond the health system. https://orcid.org/0000-0002-9718-2407 Freddy Kitutu is a Senior Lecturer of Health Systems Pharmacy and Researcher at Makerere University in Uganda. His doctoral studies evaluated a complex intervention to improve pediatric fever management in drug shops and understand how the medicines retail sector (MRS) in Uganda functions. Current research focuses on MRS and antibiotic stewardship, its critical position in the health system and potential vulnerabilities including those occasioned by COVID-19. Dr Kitutu has previously served as the Dean of Makerere University School of Health Sciences and as a member of the Epidemiology Advisory Committee of the Presidential Scientific Initiative on Epidemics (PRESIDE), chaired by the Senior Presidential Advisor on Epidemics. His research interests include antimicrobial consumption and use as a driver of antimicrobial resistance, interventions to promote antimicrobial stewardship and patient safety (including diagnostics, and patient record systems), adequate access to medicines, medical oxygen and vaccines, and implementation research at the interface of formal health structure, health markets and community health systems. He is part of a global and multidisciplinary research team investigating how to create and co-formulate Sustainable Pharmaceutical Systems in low- and middle-income countries. He volunteers his free time to serve on national and global technical task forces. https://orcid.org/0000-0003-2277-9572
Funder Perspectives & Next Steps Workshop
The conference’s workshop included a panel discussion, with representation from Wellcome, Elrha, UKRI Medical Research Council (MRC), and UK Department of Health and Social Care (DHSC). The session was Chaired by Dr Alice Norton, COVID CIRCLE Research Lead.
Each representative provided a high-level summary of their funders’ vision for the future of COVID-19 research and, more widely, pandemic and emergency research. The discussion was framed around three questions:
- What do the research community and funders think are and/or will be the lasting legacies of COVID-19 research funding?
- What elements of the COVID-19 pandemic funding landscape should be saved or continued without the COVID-19 focus?
- What should researchers and funders keep in mind if the need for rapid research arises again due to a new emergency?
It was acknowledged that funders were able to rapidly pivot their work to set up efforts to respond to COVID-19 at the start of the pandemic.
Several key insights were highlighted:
- There needs to be flexible mechanisms in place that allow funders and research to pivot quickly, as was required during COVID-19. Having more flexibility built into projects will mean that objectives can be adapted and components added;
- Existing strong and established partnerships were key to the rapid COVID-19 response. Pre-positioned partnerships were best placed to respond, i.e., teams who are positioned to do the work and engage the stakeholders through their existing connections;
- There is a need to strengthen research capacity in LMICs and the UK, to continue to fund high-quality, policy-relevant, and impactful research.
- Alignment of the research portfolio to previously agreed global research agendas (e.g. World Health Organisation (WHO) Research Roadmap and UN Research Roadmap for the COVID-19 Recovery) and locally identified priorities were key.
- Some research questions became more relevant than others, due to shifts in the pandemic landscape (e.g., vaccine development occurred as the pandemic progressed). However, funding to study diseases and for research into the knock-on impacts is equally important, e.g., food insecurity, as well as more preventative projects.
- There is a need to move from response to prevention, by generating predictive and preventative knowledge to act on;
- Research use was sometimes limited because it had limited generalisability and applicability. Impact was not a given just because the research was rapid. More support for research impact is needed to ensure there is the capacity for uptake;
- There were positive shifts in power dynamics in research teams during the pandemic, with researchers having more authority to act. Principles such as community engagement and involvement and equitable partnerships should continue to be promoted in research;
- Data must be used better;
- There were sometimes delays during studies, such as data collection taking a long time, projects taking longer than expected, and research populations having different priorities from those of the research studies they were involved in.
The Q&A section of the workshop raised questions regarding pre-existing inequalities and whether these had been exacerbated by research during the COVID-19 pandemic. Research funders acknowledge the disproportionate impact of negative events and circumstances on less privileged populations, and emphasised that it is crucial that bodies such as the WHO set up frameworks that funders can ensure are being responded to by the research that they fund. The purpose of the event was to showcase research that had taken place in LMICs, giving a voice to less advantaged populations through the research process.
Maggy Heintz, UKCDR Executive Director, highlighted UKCDR and ESSENCE on Health’s Four Approaches to Supporting Equitable Research Partnerships Report published in September 2022.
The workshop discussion also raised the the question of how funders can take the principle of flexibility forward. MRC and UKRI saw very positive impacts of flexibility and related support to grant-holders, especially given the nature of rapid research pivoting at the start of the pandemic. The GECO scheme was highlighted as an example of a very flexible and broad funding scheme. MRC’s regular conversations with grant holders and Principal Investigators were also identified as having been impactful and will be key to future work.
Further insights can be found here:
- Funding and undertaking research during the first year of the COVID-19 pandemic – UKCDR and GloPID-R
- Funding and undertaking research during the first two years of the COVID-19 pandemic – UKCDR and GloPID-R
- Five factors that make for successful research in a pandemic – Elrha
Opening and Closing Sessions
Ten poster presentations were exhibited at the conference, each highlighting outputs, research impact and lessons from the experience of conducting research during and for a pandemic, with a view to informing future research and emergency preparedness in global health and beyond.
Some posters also have accompanying videos. Posters and videos can be viewed below:
- Western Kenya integrated COVID-19 response and access to essential maternal and child health services during the acute phase of the pandemic – Dr Neema Kaseje
- COVID-19 impacts on women as transport users and transport workers in Africa – Professor Gina Porter et al.
- Are remote consultations in low-middle-income countries feasible, safe and trustworthy? A stepped wedge RCT of REaCH – Dr Jackie Stuart et al.
- Are remote consultations in low-middle-income countries feasible, safe and trustworthy? A process evalution alongside the stepped wedge RCT of REaCH – Dr Chinwe Onuegbu
- Watch Dr Onuegbu’s video here
- Perceived Challenges of managing diabetes type 2 during COVID-19 in Tanzania and Kenya – Dr Sally Mtenga
- Targeted messaging for COVID-19 Vaccine Acceptance (TM-COVAC) in Nigeria – Targetted messaging for COVID-19 Vaccine Acceptance (TM-COVAC) in Nigeria – Dr Nwamaka Ezeanya
- Watch Dr Ezeanya’s video here
- Pathways to impact in the pandemic: A Rapid Review of Covid-19-Related Research Engagement Strategies in Low- and Middle-Income Country Settings – The Institute of Development Studies
- Preparing for the next outbreak: lessons learned from collaborative academic-humanitarian research on COVID-19 among Syrian refugees in Lebanon – Dr Sawsan Abdulrahim
- Whose Crisis? COVID-19 explored through arts and cultural practices of African communities – Professor Mia Perry et al.
- Watch Professor Perry’s video here
- How do UK funders react in a global crisis? The COVID-19 case study – COVID CIRCLE
- Watch COVID CIRCLE’s video here
A huge thanks to everyone who attended our event, all presenters, Chairs, and the COVID CIRCLE Researcher Community funders.
Join us for our final COVID CIRCLE event, ‘Virtual dialogue: Utilising the lessons learnt from the COVID-19 pandemic, what are the future directions for epidemic- and pandemic-related research?’
Thursday, 19 of January, 12:00 – 13:30 [GMT].
Image credit: Mufid Majnun via Unsplash