Zambia’s COVID-19 Case Manager Leads Country’s Successful Test-and-Treat Roll Out

October 11, 2023
By Nellie Bristol

Zambia was facing a 5th COVID-19 wave in December 2022, when it gained a new tool to fight the disease: its first ever shipments of oral antivirals. Infectious disease physician Nyuma Mbewe, fresh from completing her medical residency and elevated to National COVID-19 Case Management Specialist within the Zambia Ministry of Health, was charged with ensuring the life-saving drugs reached those in need. With the help of colleagues, including critical support from Zambia’s Director of Infectious Diseases Lloyd Mulenga, she and her team quickly created the distribution and tracking systems, training materials, and public communications required. Aided by Mbewe’s leadership, Zambia made nirmatrelvir/ritonavir available within days of its arrival and administered more than 400 courses over a two-month period. The quick action provided protection for those most vulnerable to severe outcomes from the disease, preventing hospitalizations and even deaths, while alleviating strain on the recovering health system.

As case numbers currently are decreasing, Mbewe and colleagues are working to embed COVID-19 test-and-treat capacities into Zambia’s health system to mitigate future waves and strengthen the country’s primary health care system. “I hope COVID can become integrated into routine health services that same way you can walk into any hospital, any health center, any health post to get an HIV test,” she said.

Mbewe’s efforts are backed by the COVID Treatment QuickStart Consortium, which has partnered with eight low- and middle-income countries (LMICs) to offer 100,000 courses of nirmatrelvir/ritonavir, support test-and-treat implementation, and undertake operational research to generate insights on new product introduction, integration, and sustainable scale-up. The goal of the program is to create policy and regulatory pathways and primary care delivery capacities that can make testing and therapeutics available quickly for future COVID waves and other health emergencies as well as for routine care. The consortium comprises Duke University, the Clinton Health Access Initiative, Americares, and the COVID Collaborative as implementing partners with funding from the Conrad N. Hilton Foundation, Open Society Foundations, and Pfizer. In addition to Zambia, participating countries include Ghana, Kenya, Laos, Malawi, Nigeria, Rwanda, and Uganda.

Zambia was the first country to receive antivirals through the program and the timing was critical. The country had been hit hard by the pandemic, suffering more than 4,000 deaths in four waves of the disease. But after the Omicron wave ended in early 2022, cases numbers decreased drastically and “people got really relaxed because even the cases we did have were not as severe,” Mbewe said. Ministry officials were concerned that if they received the drug, stock would expire before they could be used. But with the onset of the 5th wave and haunted by the pandemic’s earlier devastation, the program became a welcome addition to the country’s COVID-19 toolbox.

As it did in many places, COVID-19 overran Zambian health services in the first two years of the pandemic. The worst period, Mbewe said, was June and July 2021 when the country saw more than 4,000 cases a day, most requiring hospital admission. The surge quickly depleted available ICU beds and isolation spaces and surgical wards were commandeered to fill the gap. Several hospitals that were under renovation but not yet completed had to be put to use. Hotel rooms were used to attend to patients with less severe infections who still needed oxygen. Some patients were turned away and available beds were rapidly turned over. “Immediately when somebody died, really quickly they just wiped the bed and put someone else in,” Mbewe said. “So crazy both for the patients and the clinical staff.”

Other shortages included doctors–who had to rotate through different hospitals–ambulances, and oxygen, which fell into a competitive black market. Cylinders went for up to $1,000 a piece with those able to pay often surviving the disease while others did not, Mbewe said.

Also, as in many LMICs, vaccinations came late and at first were not widely accepted. The first doses were available in April 2021 but were accompanied by “myths and misconceptions, even among health care workers,” Mbewe said. “People were scared it was an experiment or a money-making venture,” she said.

As a result of that experience, the Ministry of Health knew messaging around nirmatrelvir/ritonavir availability would be critical. The drug was officially launched in the Minister of Health’s annual address at the end of 2022. “That got us a lot of traction,” Mbewe said. She then participated in high level virtual meetings every other week to update provincial officials on the availability of strategies and trainings. To engage the public, she worked with traditional and social media outlets to ensure people knew about the drug and that it was offered free of charge. “That’s the most exciting thing. It actually is free because most of us wouldn’t have afforded it if not,” she said.

The communication strategies were successful. In fact, when nirmatrelvir/ritonavir first became available, one major issue was “overexcitement,” Mbewe said, requiring the program to ensure the drug was reserved for those most at risk of severe disease—older individuals and those with underlying health conditions. Focused prescribing was critical to preserving lives, Mbewe said, as Zambia has high rates of hypertension and diabetes. Conducting further trainings and establishing a monitoring and evaluation program helped ensure nirmatrelvir/ritonavir was reaching those who needed it most.

As the program expands, the Ministry and QuickStart partners are working on other improvements as well, Mbewe said. Among them is enhancing surveillance and improving forecasting to better determine where the antivirals will be needed. Additional training is also required as the program has struggled to ensure consistent and updated instruction is reaching all participating clinicians. As an example, after some trainings, Mbewe said, supervisors would return to facilities to find that those who had been trained and developed successful systems had been transferred so there was no one with the proper knowledge to continue the program. The Ministry of Health added quarterly technical support visits to each hospital and instituted facility assessment tools to make sure everything was done according to guidelines. They also involved doctors from other facilities to conduct peer reviews instead of sending in officials from the national level. “The biggest burden [in program implementation] has been trying to get everybody on the same page,” she said.

With 33 hospitals now using nirmatrelvir/ritonavir, Mbewe considers QuickStart a success. She hopes COVID-19 test-and-treat will become an integral part of the Zambian health system, especially as lower cost generic antivirals become available, and be expanded to lower-level facilities in the future. She cites in particular the program’s integration with TB clinics to ensure sustainability. “It means we don’t have to employ new staff with staff already working in the hospital and it’s just building capacity beyond what they can do with TB,” she said.

Mbewe also sees the program as a gateway for improving care for non-communicable diseases (NCDs). Currently, she says, Zambia has few resources to track and treat those with chronic illnesses and “patients tend to fall through the cracks.” Because COVID-19 test-and-treat requires patient reviews at 10- and 30-day intervals post treatment initiation, health workers are better able to identify and track patients with hypertension and other conditions. “Some of the hospitals have already used the post-COVID clinic as an opportunity to set up NCD clinics,” Mbewe said. In addition, supported with World Bank funding, Zambia is planning pilot studies using the first hospitals involved in QuickStart to study how many patients testing positive for COVID also had an NCD.

Developing sustained test-and-treat capacities, as it is doing through the QuickStart program, will enhance Zambia’s preparedness for future health emergencies and prevent unnecessary deaths. As the country uses test-and-treat staff and systems to address health issues beyond COVID-19, Mbewe’s portfolio is growing as well. She is using experience gained through the program with the Ministry of Health, procurement and regulatory authorities, and pharmaceutical companies to help lead the country’s epidemic disease program which now includes cholera, mumps, and measles. Despite her turn toward disease management leadership, Mbewe says “my primary work is still COVID and just trying to see how we can integrate it with other health systems and just make it a normal part of life.” With QuickStart’s support, that goal is well within reach.