Background Malaria is a leading cause of morbidity and mortality in refugee children in high-transmission parts of Africa. Characterizing the clinical features of malaria in refugees can inform approaches to reduce its burden. Methods The study was conducted in a high-transmission region of northern Zambia hosting Congolese refugees. We analyzed surveillance data and hospital records of children with severe malaria from refugee and local sites using multivariable regression models and geospatial visualization. Findings Malaria prevalence in the refugee settlement was similar to the highest burden areas in the district, consistent with the local ecology and leading to frequent rapid diagnostic test (RDT) stockouts. We identified 2,197 children hospitalized for severe malaria during the refugee crisis in 2017 and 2018. Refugee children referred from a refugee transit center (n = 63) experienced similar in-hospital mortality to local children and presented with less advanced infection. However, refugee children from a permanent refugee settlement (n = 110) had more than double the mortality of local children (p < 0.001), had lower referral rates, and presented more frequently with advanced infection and malnutrition. Distance from the hospital was an important mediator of the association between refugee status and mortality, but did not account for all of the increased risk. Interpretation Malaria outcomes were more favorable in refugee children referred from a highly outfitted refugee transit center than those referred later from a permanent refugee settlement. Refugee children experienced higher in-hospital malaria mortality due in part to delayed presentation and higher rates of malnutrition. Interventions tailored to the refugee context are required to ensure capacity for rapid diagnosis and referral to reduce malaria mortality.

Background Despite the availability of COVID-19 vaccines, vaccination uptake remains low in Liberia. Social norms, and in particular an individual’s family preferences can have a strong normative influence on health behavior. However, few studies across the globe have explored how behavioral intent about COVID-19 vaccination among household members affects individual vaccination acceptance, particularly in rural, resource-limited settings. We respond to this gap in knowledge by analyzing data from a household survey of women in rural Liberia with the goal of understanding how household COVID-19 beliefs and vaccine behavioral intent correlated with those of individual household members. Methods Data was analyzed from a household survey of 2,620 women aged 15-49 in 2,201 households in rural Grand Bassa County, Liberia, from March to April 2021. The survey included a COVID-19 module on protective health behaviors and intention to accept a COVID-19 vaccine when available. Each household was defined as being concordantly vaccine-hesitant, concordantly vaccine-accepting, or discordant. A multivariable logistic regression model was fitted to identify correlates of concordant acceptance, adjusting for potential confounders. Results The survey found that only approximately one in three households in rural Liberia were fully COVID-19 vaccine accepting. About 42% of households had discordant views on the vaccine, while 33% had concordantly accepting views, and 25% had concordantly hesitant views. The demographic characteristics of households with different vaccine beliefs were similar. Having a household member who accepted the COVID-19 vaccine was associated with an 18.1 percentage point greater likelihood of an individual accepting the vaccine (95% confidence interval, CI=7.3-28.9%, P=0.001). Conclusions Social norms around vaccine acceptance within households are strongly associated with individual acceptance. Interventions that target hesitant households and individuals could have a significant impact on vaccine acceptance rates.