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Kostandova N, Mutembo S, Prosperi C, Mwansa FD, Nakazwe C, Namukoko H, Nachinga B, Chongwe G, Chilumba I, Matakala KH, Musukwa G, Hamahuwa M, Mufwambi W, Matoba J, Situtu K, Mutale I, Kong AC, Simulundu E, Ndubani P, Hasan AZ, Truelove SA, Winter AK, Carcelen AC, Lau B, Moss WJ, Wesolowski A. Who is missed in a community-based survey: Assessment and implications of biases due to incomplete sampling frame in a community-based serosurvey, Choma and Ndola Districts, Zambia, 2022. PLOS Glob Public Health 2024; 4:e0003072. [PMID: 38683820 PMCID: PMC11057754 DOI: 10.1371/journal.pgph.0003072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2023] [Accepted: 03/10/2024] [Indexed: 05/02/2024]
Abstract
Community-based serological studies are increasingly relied upon to measure disease burden, identify population immunity gaps, and guide control and elimination strategies; however, there is little understanding of the potential for and impact of sampling biases on outcomes of interest. As part of efforts to quantify measles immunity gaps in Zambia, a community-based serological survey using stratified multi-stage cluster sampling approach was conducted in Ndola and Choma districts in May-June 2022, enrolling 1245 individuals. We carried out a follow-up study among individuals missed from the sampling frame of the serosurvey in July-August 2022, enrolling 672 individuals. We assessed the potential for and impact of biases in the community-based serosurvey by i) estimating differences in characteristics of households and individuals included and excluded (77% vs 23% of households) from the sampling frame of the serosurvey and ii) evaluating the magnitude these differences make on healthcare-seeking behavior, vaccination coverage, and measles seroprevalence. We found that missed households were 20% smaller and 25% less likely to have children. Missed individuals resided in less wealthy households, had different distributions of sex and occupation, and were more likely to seek care at health facilities. Despite these differences, simulating a survey in which missed households were included in the sampling frame resulted in less than a 5% estimated bias in these outcomes. Although community-based studies are upheld as the gold standard study design in assessing immunity gaps and underlying community health characteristics, these findings underscore the fact that sampling biases can impact the results of even well-conducted community-based surveys. Results from these studies should be interpreted in the context of the study methodology and challenges faced during implementation, which include shortcomings in establishing accurate and up-to-date sampling frames. Failure to account for these shortcomings may result in biased estimates and detrimental effects on decision-making.
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Affiliation(s)
- Natalya Kostandova
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Simon Mutembo
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Christine Prosperi
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Francis Dien Mwansa
- Department of Immunizations, Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Chola Nakazwe
- Information, Research and Dissemination, Zambia Statistics Agency, Lusaka, Zambia
| | - Harriet Namukoko
- Population and Social Statistics, Zambia Statistics Agency, Lusaka, Zambia
| | - Bertha Nachinga
- Information, Research and Dissemination, Zambia Statistics Agency, Lusaka, Zambia
| | | | - Innocent Chilumba
- Biomedial Sciences Department, Tropical Diseases Research Centre, Ndola, Zambia
| | | | | | - Mutinta Hamahuwa
- Clinical Research Laboratory Department, Macha Research Trust, Macha, Zambia
| | - Webster Mufwambi
- Administration, Tropical Diseases Research Centre, Ndola, Zambia
| | - Japhet Matoba
- Molecular Biology Department, Macha Research Trust, Macha, Zambia
| | - Kenny Situtu
- Tropical Diseases Research Centre, Ndola, Zambia
| | - Irene Mutale
- Tropical Diseases Research Centre, Ndola, Zambia
| | - Alex C. Kong
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | | | | | - Alvira Z. Hasan
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Shaun A. Truelove
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Amy K. Winter
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, United States of America
| | - Andrea C. Carcelen
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Bryan Lau
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - William J. Moss
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
- Department of International Health, International Vaccine Access Center, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Amy Wesolowski
- Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, United States of America
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Mutembo S, Yang Y, Carcelen A, Winter AK, Mwansa FD, Chilumba I, Mutale I, Chongwe G, Monze M, Mulundu G, Nkamba H, Mulenga L, Hayford K, Moss WJ. Measles immunity gaps among children and adolescents with HIV in Zambia despite high measles vaccination and antiretroviral therapy coverage. AIDS 2023; 37:2021-2029. [PMID: 37418463 PMCID: PMC10664789 DOI: 10.1097/qad.0000000000003634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 05/15/2023] [Accepted: 05/19/2023] [Indexed: 07/09/2023]
Abstract
OBJECTIVE The study objective was to identify measles and rubella immunity gaps among people with HIV (PWH) in Zambia despite high measles vaccine coverage and widespread access to antiretroviral therapy. DESIGN Nationally representative cross-sectional serosurvey using biorepository specimens. METHODS Blood specimens collected in the Zambia Population HIV Impact Assessment survey (ZAMPHIA) of 2016 were tested for measles and rubella immunoglobulin G (IgG) antibodies by enzyme immunoassay. Hierarchical generalized additive models were fit to characterize age-specific measles and rubella seroprevalence profiles by HIV infection status. Log-binomial regression was performed to identify factors associated with seronegativity. RESULTS Of the 25 383 specimens, a subsample of 11 500 were selected and 9852 (85%) were successfully tested. Measles seroprevalence was lower among PWH compared with HIV-uninfected individuals until approximately 30 years of age. Among children younger than the age of 10 years, measles seroprevalence was 47.2% [95% confidence interval (CI): 32.7, 61.7] in PWH and 76.4% (95% CI: 74.9, 78.0) in HIV-uninfected children in same age category. In contrast, rubella seroprevalence was higher among PWH than HIV-uninfected individuals, particularly for children younger than 10 years (68.6% vs. 44.3%, P < 0.001). Having a detectable viral load was associated with being measles seronegative (adjusted prevalence ratio 0.15, 95% CI: 0.06, 0.38). CONCLUSIONS These results from a nationally representative serosurvey demonstrate persistence of measles immunity gaps among PWH younger than 30 years of age. There is need to implement the World Health Organization's recommendation to revaccinate children living with HIV against measles following immune reconstitution with antiretroviral therapy to protect these children and prevent measles outbreaks.
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Affiliation(s)
- Simon Mutembo
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - Yangyupei Yang
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Andrea Carcelen
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Amy Kaye Winter
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, Georgia, USA
| | | | | | | | | | - Mwaka Monze
- Department of Pathology and Microbiology, University Teaching Hospital
| | - Gina Mulundu
- Department of Pathology and Microbiology, University Teaching Hospital
| | - Hope Nkamba
- Department of Pathology and Microbiology, University Teaching Hospital
| | - Lloyd Mulenga
- Ministry of Health, Directorate of Clinical Care and Diagnostic Service, Government of the Republic of Zambia, Lusaka, Zambia
| | - Kyla Hayford
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - William John Moss
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
- Department of Epidemiology
- W Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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Carcelen AC, Prosperi C, Mutembo S, Chongwe G, Mwansa FD, Ndubani P, Simulundu E, Chilumba I, Musukwa G, Thuma P, Kapungu K, Hamahuwa M, Mutale I, Winter A, Moss WJ, Truelove SA. COVID-19 vaccine hesitancy in Zambia: a glimpse at the possible challenges ahead for COVID-19 vaccination rollout in sub-Saharan Africa. Hum Vaccin Immunother 2021; 18:1-6. [PMID: 34227914 PMCID: PMC8920139 DOI: 10.1080/21645515.2021.1948784] [Citation(s) in RCA: 44] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
With unprecedented speed, multiple vaccines against SARS-CoV-2 are available 1 year after the COVID-19 pandemic was first identified. As we push to achieve global control through these new vaccines, old challenges present themselves, including cold-chain storage, the logistics of mass vaccination, and vaccine hesitancy. Understanding how much hesitancy toward COVID-19 vaccines might occur and what factors may be driving these concerns can improve the ability of public health workers and communicators to maximize vaccine uptake. We nested a survey within a measles-rubella mass vaccination campaign in Zambia in November 2020 and asked about sentiments and beliefs toward COVID-19 and COVID-19 vaccines. Among parents bringing their children to receive a measles-rubella vaccine, we found high acceptability of COVID-19 vaccination of their children, but substantial uncertainty and hesitancy about receiving the vaccine themselves. COVID-19 vaccination hesitancy was correlated with beliefs around COVID-19 severity and risk, as well as vaccine safety and effectiveness.
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Affiliation(s)
- Andrea C Carcelen
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Christine Prosperi
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Simon Mutembo
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Laboratory Science, Macha Research Trust, Choma, Zambia
| | - Gershom Chongwe
- Department of Immunology, Tropical Diseases Research Center, Ndola, Zambia
| | - Francis D Mwansa
- Ministry of the Health, Government of the Republic of Zambia, Lusaka, Zambia
| | | | | | - Innocent Chilumba
- Department of Immunology, Tropical Diseases Research Center, Ndola, Zambia
| | | | - Phil Thuma
- Laboratory Science, Macha Research Trust, Choma, Zambia
| | - Kelvin Kapungu
- Department of Immunology, Tropical Diseases Research Center, Ndola, Zambia
| | | | - Irene Mutale
- Department of Immunology, Tropical Diseases Research Center, Ndola, Zambia
| | - Amy Winter
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - William J Moss
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,W Harry Feinstone Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Shaun A Truelove
- Department of International Health, International Vaccine Access Center, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
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Carcelen AC, Mutembo S, Matakala KH, Chilumba I, Mulundu G, Monze M, Mwansa FD, Moss WJ, Hayford K. Impact of a Measles and Rubella Vaccination Campaign on Seroprevalence in Southern Province, Zambia. Am J Trop Med Hyg 2021; 104:2229-2232. [PMID: 33939639 PMCID: PMC8176503 DOI: 10.4269/ajtmh.20-1669] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 03/05/2021] [Indexed: 11/07/2022] Open
Abstract
Zambia conducted a measles and rubella (MR) vaccination campaign targeting children 9 months to younger than 15 years of age in 2016. This campaign was the first introduction of a rubella-containing vaccine in Zambia. To evaluate the impact of the campaign, we compared the MR seroprevalence estimates from serosurveys conducted before and after the campaign in Southern Province, Zambia. The measles seroprevalence increased from 77.8% (95% confidence interval [CI], 73.2-81.9) to 96.4% (95% CI, 91.7-98.5) among children younger than 15 years. The rubella seroprevalence increased from 51.3% (95% CI, 45.6-57.0) to 98.3% (95% CI, 95.5-99.4). After the campaign, slightly lower seroprevalence remained for young adults 15 to 19 years old, who were not included in the campaign because of their age. These serosurveys highlighted the significant impact of the vaccination campaign and identified immunity gaps for those beyond the targeted vaccination age. Continued monitoring of population immunity can signal the need for future targeted vaccination strategies.
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Affiliation(s)
- Andrea C Carcelen
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Simon Mutembo
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,2Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | | | | | - Gina Mulundu
- 5University of Zambia School of Medicine, Lusaka, Zambia.,6University Teaching Hospital, Lusaka, Zambia
| | - Mwaka Monze
- 5University of Zambia School of Medicine, Lusaka, Zambia
| | - Francis D Mwansa
- 2Ministry of Health, Government of the Republic of Zambia, Lusaka, Zambia
| | - William J Moss
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.,7Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kyla Hayford
- 1Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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