Zambia’s Response to the COVID-19 Pandemic: Exploring Lessons, Challenges and Implications for Future Policies and Strategies

The coronavirus disease 2019 (COVID-19) pandemic is a global public health problem that has affected the globe in different ways. There is little information published on the challenges and lessons learnt in responding to the COVID-19 epidemic in Zambia. Objective: To establish Zambia’s response, lessons and the challenges experienced in the fight against COVID-19. Re-sults: Since the emergence of COVID-19, Zambia has experienced three waves, with the third wave being the most severe. The Zambian government responded positively and effectively to all three pandemics with the help of cooperating partners. Zambia adopted the World Health Organization (WHO) recommended prevention methods such as hand hygiene, masking up in public, physical distancing, avoiding crowded areas and staying at home to prevent the further spread of the disease. Additionally, surveillance of COVID-19 was strengthened, which led to the early detection of cases. the COVID-19 of vaccinations.


Background
Like many other African countries, Zambia, a developing country in the southern part of Africa, is plagued by infectious diseases such as HIV/AIDs, tuberculosis, malaria, and diarrhoeal diseases [1]- [7]. The infectious disease burden has continued to negatively affect the healthcare system of Zambia. Besides, Zambia faces a burden of non-communicable diseases such as cancer, diabetes, and hypertension [8] [9] [10].
Disease outbreaks are a major concern for public health globally because they cause devastating effects on humans [11]. Previous respiratory tract infections that were declared pandemics include the Middle East Respiratory Syndrome (MERS) of 2003 and the influenza A H1N1 of 2009 [12] [13]. MERS was caused by a coronavirus that was transmitted via inhalation of respiratory droplets from a sick person [12] [13]. Similarly, influenza is transmitted mainly via inhalation of respiratory droplets from infected individuals [14] [15]. The previous pandemics caused increased morbidity and mortality globally.  [17]. It was declared a global pandemic by the World Health Organisation (WHO) on 11 th March 2020 after it had affected several countries [18] [19] [20] [21]. SARS-CoV-2 is transmitted mainly via inhalation of droplets or aerosols produced by infected persons after they cough or sneeze [22]. It presents with many clinical features, including headaches, fever, cough, sore throat, sneezing, body weakness, general malaise, diarrhoea, nausea, vomiting, and loss of taste [23] [24] [25]. Similarly to previous pandemics caused by respiratory tract infections, COVID-19 has caused increased morbidity and mortality. As of 29 th November 2021, there have been 210,150 confirmed cases and 3667 deaths in Zambia. Despite recording fewer cases and deaths than other countries, this still shows the burden that COVID-19 has inflicted on the Zambian healthcare system and public health. This paper was written to provide a perspective that with different COVID-19 waves, a modification in response mechanisms may be required to account for the different presentations of each wave to the following [26]. Many lessons have been learnt through the challenges experienced during the first, second and third waves of COVID-19 in Zambia. This paper may be used in the preparation and response to future COVID-19 waves and related pandemics.

Outbreak and Response to the First Wave of COVID-19 in Zambia
Zambia reported its first case of COVID-19 on 18 th March 2020, which marked the beginning of the first wave of COVID-19 in Zambia [18] [27]. Following the first two cases that were reported, an increase in community transmission was recorded. Due to the fear of the pandemic worsening, the government of the Republic of Zambia enforced a partial lockdown that led to the closure of schools, colleges, and universities on 20 th March 2020 [28]. This was instituted as a way to contain the pandemic. Similar measures were reported in other countries [29] [30] [31] [32] [33]. The closure of schools, colleges, and universities meant that learners had to learn via online platforms [34]. However, the majority of learners could not afford ICT devices such as smartphones, laptops, and tablets [34]. Furthermore, limited access to the internet and power outages made online learning difficult for many students, particularly in rural areas.
Lockdown involves a set of measures aimed at reducing the transmission of COVID-19 that are mandatory, applied indiscriminately to a general population, and involve restrictions on the established pattern of social and economic life [35]. Lockdowns are beneficial in preventing the spread of diseases because the risk of exposure to pathogens is reduced [36]. Lockdowns are one of the key methods used to reduce the transmission of SARS-CoV-2 by cutting person-to-  [45]. This also suggests that lockdowns are an effective measure to stop both the increase in the number of new cases and the number of deaths [45]. People significantly adjust their behaviour in response to partial or regional lockdowns, which are as effective as stricter measures [46] [47]. In Zambia, a lockdown was well implemented and helped in the response to the first wave of the pandemic [48]. Therefore, the move by the government of the Republic of Zambia to institute a partial lockdown was necessary and effective in containing the epidemic.
Further strategies by the government of the Republic of Zambia included the implementation of wearing of face masks in public, physical distancing, washing of hands adequately, hand sanitising, wearing of personal protective equipment, mass testing, self-isolation for those who experienced symptoms, and quarantine for those that tested positive for the disease. Following the global increase in cases of COVID-19, Zambia took a proactive stance by implementing measures thought to prevent the spread of the disease, even before a single case was reported in the country. In their press briefing held on the 17 th of March 2020, the Zambian Ministry of Health encouraged enhanced hygiene practices in public places with high human traffic (such as in the transport sector, shopping malls, schools, and places of worship), as well as social distancing [49].
On the 25 th of March 2020, the Zambian Republican President, His Excellency, Dr Edgar Chagwa Lungu, announced additional prevention measures against COVID-19. These included the restriction of gatherings such as weddings, funerals, and conferences to a maximum of 50 people, the quarantine of travellers entering the country for a period of 2 weeks, whether they exhibited symptoms or not, and the suspension of non-essential foreign travel to countries that had reported cases of COVID-19. By the 9 th of April 2020, COVID-19 cases stood at 39, with only one death and no new cases recorded in the previous week. Despite the recorded success, the Republican President announced further COVID-19 prevention measures, which included wearing face masks at all times, particularly in crowded places [50].
Mass testing had proved to be effective in a small town in Italy where the number of people with COVID-19 symptoms fell by more than 90% in 10 days and was further eliminated [51]. The Zambian government consequently implemented mass testing to stop the spread of the virus, with thousands of tests conducted among high-risk individuals in Lusaka, Kafue and Chirundu by the 21 st of May 2020 [52]. Moving forward, we recommend continuous mass testing in Zambia as a way of detecting COVID-19 cases and initiating treatment as early as possible [53]. Besides, mass testing must be decentralized so that many people are tested for SARS-CoV-2 and decisions are made based on the results.
Truck drivers carrying essential goods were subjected to mandatory health screening, had their trucks disinfected, and were escorted by security personnel to their final destination. Further, environmental cleaning and fumigation at all points of entry and the provision of personal protective equipment (PPE) were other measures implemented to prevent the spread of the virus [52]. Disinfection or fumigation of high-risk areas such as universities, colleges, markets, government offices, healthcare facilities, and churches has been very helpful in controlling the epidemic. The implementation of the preventive measures led to a reduction in the number of COVID-19 infections in Zambia and hence containment of the first wave of the epidemic. Despite the implementation of these preventive measures, non-adherence remains a key problem in the fight against COVID-19. However, it is important to note that approximately 20,462 cases and 386 deaths were recorded during the first wave of the pandemic. Besides, a prevalence of 9.3% among healthcare workers [54] and 10.6% among the general population [55] was reported in Zambia during the first wave.

Collaborations in Response to the COVID-19 Pandemic
To contain the pandemic, the Zambian government did not work in isolation.
The COVID-19 pandemic has been described as a disease without borders, and as such, it requires national and international coordination and collaboration to fight it [56]. Collaboration between public and private sectors, as well as international entities, entails collaborating to deliver products and services based on risk, resource, cost, and benefit-sharing [57] [58]. The Zambian government has leveraged both local and international support in combatting the COVID-19 pandemic. A great contribution in the form of personal protective equipment  [59]. Additionally, collaboration has been seen in the education and sensitisation of Zambian citizens about the pandemic and how to protect themselves through messages and adverts distributed via telephone companies, radio and TV stations. This has helped in mitigating disease transmission, as it has elsewhere [60]. Therefore, a multisectoral and collaborative approach was very important in the containment of the first wave by July 2020. Zambia has also seen great international collaboration and support in fighting the pandemic. International cooperation and collaboration are evident not only in assistance in the form of emergency medical supply assistance but also in medical technical assistance. For instance, the WHO's website has provided detailed documents and evidence-based recommendations for governments, hospitals, health workers, members of the public, and others to follow in fighting the pandemic [64].
Indeed, there is clear evidence that without both local and international collaboration and support, the Zambian government would have been overwhelmed by the pandemic. Zambia has continued collaborating with other countries and organisations to contain COVID-19 [65]. Therefore, there is a need to continue strengthening international relations as well as encouraging local organisations to continue supporting government efforts to strengthen the health sector in its response to the COVID-19 pandemic and future disease outbreaks.

Surveillance of COVID-19 and Other Respiratory Tract Infections
Surveillance of COVID-19 and flu-like infections has been strengthened in Zambia. Surveillance is essential when monitoring and evaluating disease outbreaks [66]. and how to report them to healthcare officials. This, in a way, will add to the surveillance system and early management of detected or diagnosed cases.

Outbreak and Response to the Second Wave of COVID-19 in Zambia
After the containment of the first wave, there was a relaxation in the adherence to the COVID-19 preventive measures. Besides, evidence has shown that a relaxation in the lockdown measures led to the second wave of COVID-19 [68].

Outbreak and Response to the Third Wave of COVID-19 in Zambia
The third wave of the COVID-19 pandemic in Zambia was declared in June 2021 [70]. In contrast to the previous two waves, the third wave started slowly with low morbidity and mortality but quickly progressed with comparably higher positivity rates, hospitalisations and deaths. This coincided with reports of the emergence of a more deleterious Delta variant, which had been attributed to higher infections and deaths in other countries [71].  [65]. These strategies will help to identify COVID-19 cases at an early stage and provide treatment before the disease worsens. Further, the resources and services required in the response to COVID-19 will be planned for and allocated accordingly. Furthermore, increasing vaccinations against COVID-19 will help many people develop immunity against COVID-19 [76]. However, the burden of dis-

COVID-19 Vaccination Programmes in Zambia
The COVID-19 vaccines are an important part of the strategy to contain the pandemic [77] [78]. Vaccines are substances that stimulate the immune system and aid in the fight against infectious agents [79]. There is evidence that indicates that vaccines are very effective in containing disease outbreaks [80]. Similarly, studies have shown that COVID-19 vaccines are very effective and safe in containing the pandemic [81]. In Zambia, five vaccines have been approved for emergency use in humans, including AstraZeneca's COVISHIELD, which is manufactured in India, AstraZeneca's COVID-19 vaccine produced in South Korea, Sinopharm, Janssen (Johnson & Johnson), and the Pfizer-BioNTech vaccine [70]. As of 30 th September 2021, approximately 731,450 doses of COVID-19 have been administered in Zambia, representing about 2% of vaccinated adult Zambians [75]. As of 29 th November 2021, the number of vaccinated Zambian adults rose to 1,074,368 due to the governments' emphasis on having many Zambians vaccinated. The number of adult Zambians vaccinated against COVID-19 is still very low because it is still below the 10% recommended by the WHO. This is according to a list of 15 African countries with more than 10% of their population fully vaccinated against COVID-19 as published by the WHO [82]. The 15 countries that have reached the target population fully vaccinated against COVID-19 include Seychelles, Mauritius, Morocco, Tunisia, Comoros, Cape Verde, Eswatini, Lesotho, Botswana, Zimbabwe, South Africa, Mauritania, Equatorial Guinea, Rwanda, and Sao Tome & Principe [82]. As of 31 st December 2021, the prevalence of COVID-19 vaccinations in Zambia was at 3.55% [83]. There is a need for further COVID-19 vaccination campaigns that will make people aware of the benefits of vaccination against COVID-19. When the majority of individuals receive the vaccine, the transmission of SARS-CoV-2 and the severity of future COVID-19 infections will be minimised [76]. This may help to prevent the severity of COVID-19 in exposed individuals. Besides, this will prevent the increased morbidity and mortality that the country experienced during the third wave of the pandemic. Hence, improving COVID-19 vaccine accep-  instances, international social media has been controversial due to misinformation and conspiracy theories. Wilson and Wiysonge found that using social media to organise offline action was highly predictive of the belief that vaccinations are unsafe [96]. Social media platforms are internet-based applications that enable communities of users to interact, create, and share content types in realtime with others. There is an urgent need to explore how social media may be used to improve health literacy and build public trust in vaccination as it has a broader influence on the population globally [97].

Number of people Vaccinated
Vaccinations Strategies for addressing vaccine hesitancy and increasing uptake are still poorly understood. The challenge is that most interventions identified operate from an assumption-based rather than an evidence-based approach due to a lack of appropriate evaluation [98]. The World Health Organisation (WHO) contends that vaccine hesitancy is a complex issue, and no single strategy will be able to address it single-handedly [99]. In a systematic review, the WHO SAGE working group dealing with vaccine hesitancy identified reminder-recall interventions, non-financial incentives, and dialogue-based interventions as the main strategies for addressing vaccine hesitancy and improving uptake of vaccination programmes [100] [101]. These strategies proposed by the WHO SAGE working group have proven to be effective in many countries. Hence, Zambia can adopt or adapt these strategies to suit the Zambian setup.
Dialogue-based interventions address misconceptions and community distrust regarding vaccines [102]. This strategy attempts to address these barriers using a

Negative Impacts of COVID-19 on Self-Medication, Economy and Mental Health
The COVID-19 pandemic has caused many challenges in different sectors [103].
In Zambia, the Ministry of Health warned individuals about the dangers of selfmedication [104]. This is because pandemics may predispose people to practice Based on the above information, there are a lot of challenges that Zambia and many countries have been experiencing during the COVID-19 pandemic. Zambia experienced increased morbidity and mortality rates due to and associated with COVID-19 as evidenced from the statistics reported during the first to the third wave of the epidemic. Besides, restrictions on movement and conducting businesses negatively affected all nations. Therefore, countries must always have a functional emergency preparedness and response plan and mitigation measures to contain pandemics. The Zambian government must also set aside adequate resources meant for responding to epidemics. Further, there is a need to increase awareness, acceptability, and uptake of COVID-19 vaccines to prevent the severity of future waves of the epidemic in Zambia.

Conclusion
The three waves of the COVID-19 epidemic presented differently in Zambia, with varying degrees of morbidity and mortality. The Zambian government responded effectively to the COVID-19 pandemic despite the initial lack of the needed resources to curb the epidemic. However, the number of confirmed COVID-19 cases and deaths increased in the third wave of the pandemic. There is a need to strengthen the surveillance of COVID-19 and other respiratory infections and to ensure continuous adherence to the COVID-19 preventive meas-ures. Besides, individuals must be encouraged to get vaccinated so that the pandemic and its devastating effects are controlled. Besides, vaccinations can prevent the severity of COVID-19 future waves.

Authors' Contributions
SM conceptualized the study. SM, MC, MM, CNH, MB, MK, KM, DCB, WM and VD participated in the literature search and commentary write up. All authors participated in the initial draft of the manuscript. All authors approved the final version of the manuscript.