Perceptions of prevalence and management of [PASC] among healthcare workers in Kweneng District, Botswana, 2024, Mamalelala+

[SNT Gatchaman]

Perceptions of prevalence and management of post-acute sequelae of SARS-CoV-2 PASC infection among healthcare workers in Kweneng District, Botswana: Report of a district-wide survey
Tebogo T. Mamalelala; Savannah Karmen-Tuohy; Lettie Chimbwete; Ditebogo J. Mokone; Roger Shapiro; Claire Young; Sara Schwanke Khilji

Over 9.5 million confirmed cases of COVID-19 infection have been recorded in Africa. The syndrome of post-acute sequelae of SARS-CoV-2 infection (PASC) affects an estimated 32% to 87% of COVID patients globally. Data regarding prevalence and impact of PASC in Botswana are limited.

This study used a cross-sectional survey design to query healthcare workers in Kweneng District, Botswana about perceived PASC prevalence, duration, symptoms, impact, and management strategies. The survey was disseminated to participants via pre-existing WhatsApp groups and paper copy. Descriptive statistics were used to analyse quantitative data, including demographic data.

72 respondents consented and completed the survey, from an estimated 650 staff meeting eligibility criteria; 63% were female and 36% were male. The majority (90%) were nurses, with doctors and “other” accounting for 6% and 4% of respondents, respectively; no administrators responded. Over half (72%) worked at primary care facilities and 28% worked in hospitals. Nearly all (93%) indicated seeing patients with PASC on a weekly basis, though the majority (61%) identified these patients as comprising <10% of total patients. The most frequently reported PASC symptom was persistent cough (64%), followed by shortness of breath (54%) and fatigue (49%). A substantial minority of respondents were unsure how to manage common PASC symptoms, with 29% and 36% indicating uncertainty regarding management of persistent cough and fatigue, respectively.

Findings indicate that PASC symptoms are frequently encountered in clinical practice in Botswana with significant overlap with acute COVID-19, influenza-like illnesses, and tuberculosis, likely placing increased burden on existing health system processes. Providers reported uncertainty in managing presumed PASC, and current practice patterns may contribute to unintended adverse effects. Clear clinical algorithms for PASC screening, diagnosis, and management should be developed and disseminated in Botswana to mitigate the effects of PASC symptoms and improve the quality of life of COVID-19 survivors.

Link | PDF (PLOS Global Public Health) [Open Access]

 

[Hutan]

A second, qualitative component utilising key informant interviews to obtain more nuanced data relevant to secondary objectives two and three was completed following the survey; these results will be published separately. The anticipated outcome from the results of these combined studies is the planned development of clinical practice guidelines for the management of common PASC symptoms within the context of government-sponsored health facilities in Kweneng District, Botswana.

The final section of the survey invited participants to complete free-text short answers to indicate typical management of the following common PASC symptoms: persistent cough, persistent shortness of breath, chronic headache, intermittent chest pain, and fatigue. The large majority (89%) of respondents indicated that they routinely treat persistent shortness of breath with corticosteroids (route, i.e. inhaled vs oral, not specified). Similarly, the large majority reported prescribing over-the-counter analgesics for chronic headache (88%). Nearly half of respondents reported prescribing antibiotics for treatment of persistent cough attributed to PASC (Table 4). A substantial proportion of respondents were unsure how to respond to questions regarding managing common PASC symptoms, with 29% and 36% of participants indicating uncertainty regarding management of persistent cough and fatigue, respectively.

The survey concluded with questions assessing participants’ interest in receiving support for PASC management. Almost all participants (92%; n = 66) said they would attend a workplace-based training/informative session focusing on treatment for PASC symptoms, while an additional three respondents were unsure but indicated they might consider this. Additionally, 90% (n = 65) stated they would refer patients with COVID-19-related complications to multidisciplinary services, including physiotherapy, occupational therapy, and mental health services, if available; an additional three also expressed uncertainty about utilizing such services but indicated they might consider this possibility.

 

[Hutan]

Official reports may underestimate the real PASC burden in Southern Africa; Mendelsohn et al. found that only 24% of South African patients self-reporting symptoms consulted a clinician for long COVID, and only 7% received care for PASC in the public sector [18].

The need for targeted studies of the prevalence and impact of PASC in Botswana is further underscored by typical risk factors for PASC observed in similar populations. Factors associated with increased risk for development of PASC include older age, female sex, multiple comorbidities, and severe acute COVID-19 infection [23,24]. Notably, PASC burden in the region appears to vary according to baseline health. For instance, a regression analysis of observational data from Ghana found that patients with hypertension and diabetes mellitus had four times the odds of developing long COVID compared to those without comorbidities [25]. Karuna and colleagues conducted a multi-country observational cohort study of post-COVID conditions, finding that patients with a history of lung disease reported 45–58% longer duration of general, neurologic and respiratory symptoms [26]. These findings are highly relevant to the context in Kweneng District and Botswana as a whole, where combined death and disability due to diabetes increased over 40% from 2009 to 2019 (now ranking in the top ten causes of combined death and disability in the country), while hypertension rose to the fourth leading risk factor driving death and disability over the same time period [27]. Additionally, many people living in Kweneng District suffer from chronic lung disease related to high rates of background pneumoconioses, often linked to occupational exposures (particularly mining) [28] and complicated by high tuberculosis incidence, estimated at 235 per 100K population in 2021

Responses to this survey provide insight into typical patterns of PASC presentation in Botswana from the perspective of front-line HCWs in the public sector. The most frequently reported presenting PASC symptoms in Kweneng District—persistent cough, shortness of breath, fatigue, headache, and muscle or body aches—are similar to those reported in studies in the Southern African subregion, as well as globally. Findings from our study overlapped considerably with those reported by Pretorius et al [30], conducted in South Africa; this study found that the most commonly reported PASC symptoms locally were fatigue, brain fog, loss of concentration and forgetfulness, shortness of breath, joint and muscle pains. Fatigue was shown to be the most prevalent symptom and the primary cause for patients to seek medical attention across Africa [31,32].

Among respondents who completed free text responses detailing current practices for managing common PASC symptoms, most reported using management strategies more appropriate in the context of treating acute COVID-19 infection with potential bacterial superinfection, such as prescribing corticosteroids and antibiotics. These practice patterns raise concern related to the potential adverse effects of these treatments, which may directly contribute to endocrinologic complications, increased vulnerability to future infections, and antimicrobial resistance [36]. The potential negative impacts of unnecessary corticosteroid use on immune function are particularly relevant in Botswana where HIV is widespread, with an estimated 21% prevalence rate [37].

Equally concerning is the fact that these approaches appear to be utilised in place of appropriate evaluation and multidisciplinary management for PASC symptoms. For instance, no respondent indicated evaluating patients with chronic shortness of breath for either cardiac sequellae of COVID-19 infection or for potential pulmonary complications such as fibrosis or pulmonary embolism. In the absence of a clear case definition for PASC currently in use in Botswana, there is also a risk that HCWs might inadvertently attribute symptoms to PASC that are in fact related to other common pathologies. For instance, in a high-TB setting, chronic cough due to this infection could be misattributed to prior COVID-19 infection, placing patients and their communities at risk. Furthermore, survey respondents themselves indicated a clear desire for clinical decision-making support in diagnosing and managing PASC.

 

[Hutan]

Given the lack of existing national guidelines for PASC evaluation and management, it is unsurprising that primary HCWs report managing potential PASC-related symptoms according to established practices for undifferentiated headache, shortness of breath, persistent cough, and fatigue. To the best of our knowledge, one training was conducted on long-COVID during 2022, sponsored by the Botswana Ministry of Health in conjunction with the University of Botswana and disseminated to interested HCWs across the country as a live, synchronous online event. Beyond this, the authors (as HCWs who worked in Kweneng District during the period the survey was conducted) are unaware of other trainings or campaigns specific to PASC that may have influenced participant responses.

The results of this survey demonstrate the clinical imperative to develop centres for multidisciplinary PASC care, which could also function as educational hubs for training and dissemination of management algorithms. In the absence of such guidance and facilities, HCWs across Botswana must rely on clinical reasoning, often in isolated contexts.

 

[Hutan]

An interesting paper, thanks for posting it @SNT Gatchaman.