COVID-19 and Vaccination: Knowledge, Attitudes and Practices of People Working on Illegal Gold Mining Sites in French Guiana

Introduction: French Guiana is a French territory bordering Brazil and Suriname where the COVID-19 pandemic has severely strained the French Guianese health system. The people working on illegal gold mining sites in French Guiana, also known as garimpeiros, are mainly of Brazilian origin. Their health conditions are precarious, they live under the radar of the surveillance system and therefore, assessment of their health is quite challenging.. The objective of this study was to describe their knowledge, attitudes and practices regarding COVID-19 and vaccination against this infection. Methods: We conducted an international multicenter cross-sectional survey between 1 March 2022 and 30 April 2022 in French Guiana and Suriname, using a structured questionnaire. Results: Eighty persons were included, 95.0% of whom were Brazilian. Most had good general knowledge of COVID-19. Antibiotic prophylaxis had been practiced by 10.0% of participants. Forty-three people thought they had been infected with COVID-19 (53.8%). Self-medication was frequent, often with antibiotics (32.6%, mostlychloroquine, ivermectin or azithromycin) and most had not consulted a physician for symptoms of COVID-19. A majority (62.5%) had received at least one dose of vaccine. Those who were ever tested for COVID-19 were the most likely to be vaccinated (PR = 1.98, p = 0.009). Conclusions: Garimpeiros have a good level of knowledge about COVID-19 but the high consumption of antibiotics raises concerns about the selection of resistant bacteria. The vaccination rate was higher than that of the Guianese population. The most vaccinated individuals were those who had already taken a COVID test suggesting that these individuals had more exposure to the disease, were more health conscious, or had easier access to health centers.


Introduction
Located in the Amazon forest, bordering Suriname and Brazil, French Guiana (FG) is the only French territory in South America. It is a territory with a high gold content and gold mining is regulated [1]. However, many clandestine small-scale gold miners, also called "garimpeiros", mainly of Brazilian origin, are installed in isolated camps in the forest. This mobile and poorly known population is estimated to be around 10,000 in FG [2,3]. The police repression of illegal gold mining aims to neutralize the logistical flows. In the midst of this struggle, the complexity of access to gold mining sites makes it difficult to provide medical care and prevention to the people who live there, and to study their health. In this context, studies have alerted to the health risk posed by illegal gold mining sites, due to their significant health precariousness, difficulties in accessing care, and the absence of appropriate care [4,5]. These risks are mainly infectious (malaria, leptospirosis, leishmaniasis, STIs, etc.) but also chronic illnesses such as high blood pressure, or musculoskeletal disorders [5][6][7][8]. Self-medication, misuse of antimicrobials and the risk of resistance have also been highlighted [5].
On the Maroni River, which marks the border with Suriname, the multicultural town of Maripasoula, relatively isolated from the rest of FG (access only by plane or boat), has a health center that is accessible free of charge to all people in the region. Many of the illegal gold mining sites in western FG have logistical rear bases in the villages just across from Maripasoula, on the Surinamese side of the Maroni River. These rear bases are small settlements (Antonio do Brinco and Ronaldo) composed of shops, restaurants and hotels that constitute logistical nodes where the garimpeiros come to spend time to buy goods, rest, spend their gold, associate, or sometimes get closer to health care structures [3]. This proximity allows some garimpeiros, while staying on these rear bases, to cross the river to come and consult for free at the health center of Maripasoula [9].
When the Sars-CoV2 (COVID-19) pandemic occurred in early 2020, FG initially appeared spared [10], but next experienced several important epidemic waves, against the backdrop of a tense sanitary situation, requiring prolonged restraint measures [11,12]. The management of the COVID-19 epidemic was not the same in FG and its neighboring country Brazil. Indeed, Brazil was particularly troubled by a strong politicization of science and medicine [13]. Brazilian health institutions encouraged and protocolized the prescription of drugs such as hydroxychloroquine, ivermectin and nitazoxanide (called "COVID Kit") to ambulatory patients with COVID-19 without scientific justification [13][14][15]. The DETECTOCov-19 study carried out between August and October 2020 in Brazil showed that, among those diagnosed with COVID-19, 56.0% had taken drugs to treat the disease, usually combining different drugs from the "COVID Kit" [16]. In May 2021 in Brazil, one in four people reported taking drugs from the COVID Kit for prophylaxis or treatment of COVID-19, including self-medication [17].
Understanding knowledge, attitudes, and practices about COVID-19 and COVID-19 vaccination is very important to improve health messages and thus improve prevention and management. Throughout the world, the literature on this topic is very extensive and depends on culture and context [18][19][20]. Therefore, it is difficult to extrapolate results from one study to other specific populations. To date, no such study has been conducted on COVID-19 in illegal mine workers in FG. However, understanding the knowledge andpractices of the disease in this vulnerable population virtually deprived from access to regular health care, is valuable for health care decision makers.
In the context of a difficult social situation and a rapidly evolving and hard-to-predict evolution of the epidemic, this study aimed to describe the knowledge, attitudes, and practices about COVID-19 and the anti-COVID vaccination of people who have worked on illegal gold mines in FG since the beginning of the pandemic.

Plan of the Study
This study was a cross-sectional, descriptive, transborder, multicenter KAP (Knowledge, Attitudes and Practices) study, with inclusions in French Guiana and Suriname. Data collection was prospective using standardized structured questionnaires (Supplementary Material).

Study Population
The study population consisted of adults who had worked for at least one month in one or more illegal gold mining sites in FG since March 2020, the date of the declaration of the pandemic in COVID-19 by the WHO. Exclusion criteria were minors, individuals who did not wish to participate in the study, and individuals with cognitive impairment who could not give informed consent.
Subjects were randomly recruited. A target of 80 to 100 participants was set for this study.

Inclusion Process
Inclusions took place from 1 March 2022 to 30 April 2022. Due to administrative and security aspects as well as logistical limitations, it was not possible to conduct the inclusions directly at the illegal gold mining sites. The 3 inclusion sites were: the health center of Maripasoula (FG), and the rear bases of Antonio Do Brinco (Suriname), and Ronaldo (Suriname). The questionnaires were filled out by a medical resident, assisted by a Portuguese-speaking translator.

Questionnaire
The study was conducted using a standardized, anonimizedquestionnaire (no directly identifying data). It lasted between 30 and 45 min and included a maximum of 81 questions divided into 5 categories: • These were mainly closed-ended single or multiple choice questions based on the literature [21,22]. Anti-infectious agents such as chloroquine, ivermectin and azithromycin were grouped under the term "antibiotics" and their prophylactic use under the term "antibiotic prophylaxis".

Ethical and Regulatory Aspects
Individual oral and written information was delivered face-to-face, in the participant's own language, and non-opposition was collected.
The project was registered with the Health Data Hub (N • F20220217195238) and the Commission Nationale de l'Informatique et des Libertés. The research protocol was approved by the ethical committee of Suriname (CMWO (Commissie voor Mensgebonden Wetenschappelijk Onderzoek) N • CMWO 16/23).

Statistical Analysis
Categorical, nominal, or ordinal categorical variables were presented as counts, percentages, and confidence intervals of percentages. Quantitative variables were presented as median and interquartile range. Bivariate analyses were performed using a Chi-square test 2 and Poisson regression to identify/study the relationship between being vaccinated against COVID-19 and the sociodemographic and behavioral characteristics of the respondents using prevalence ratio (PR). Statistical analyses were performed using Excel and Stata12.0 (StataCorp, College Station, TX, USA). The alpha risk was 5%.

Results
Between 1 March 2022, and 30 April 2022, 80 individuals were included. The refusal rate was negligible.

Socio-Demographic Characteristics
The socio-demographic characteristics of the participants are presented in Table 1. Almost all participants were Brazilian (95.0%), mostly from the state of Maranhão (57.9%). Most of the participants were men with a M/F sex ratio of 1.67. The median age was 44 years (IIQ = 36-51). Most participants had worked at two to four different mining sites since the beginning of the pandemic. Of all the people interviewed, 78.8% reported no medical history but five people reported HIV infection (6.3%, 95% CI = [0.9-11.6]).

Knowledge about COVID-19
Regarding knowledge about COVID-19, 75.0% of the participants had first heard about it on television ( Table 2). A small proportion of the participants (3.8%, 3/80) did not think that COVID-19 existed, and 92.2% (71/77) of the remaining 77 participants thought that the country of first appearance of the virus was China. Furthermore, 62.3% did not know the biological origin of the virus and 20.8% thought that the virus had accidentally escaped from a laboratory.
Most of the respondents (62.5%) reported that little had changed in their activities since the start of the pandemic, while 26.3% had stopped working at the gold mining site, and 8.8% had started working there since the start of the pandemic (Table 2).
Eight respondents (10.0%) had taken antimicrobialdrugs as prophylaxis against COVID-19: seven had taken azithromycin, five ivermectin and two chloroquine. These drugs had been obtained in Suriname (50.0%), French Guiana (25.0%) or Brazil (25.0%) and had been used both on the gold mining sites (50.0%) and on the resting sites (50.0%). There was no predominant dosage or duration of treatment for any of these treatments. Several participants also mentioned drinking tea as a prophylactic treatment.
Among the 43 people who reported being infected with COVID-19, the symptoms experienced were: fever (81.4%), rhinitis (81.4%) and myalgia (81.4%) followed by diarrhea (74.4%) and dysgeusia (74.4%). Among them, the majority said they had voluntarily isolated themselves (69.8%). A quarter had been infected a second time (27.9%), including five second infections confirmed by nasal test. A significant proportion reported suffering from sequelae (18.6%): asthenia, cough, myalgia, and pharyngeal pain. Twenty-three did not seek medical attention at the time of infection. Antibiotic treatment for curative purposes was reported in 43.5% of the 23 persons who did not consult a doctor and in 20.0% of the 20 who had received a medical consultation.

Anti-COVID Vaccination
Almost all participants (96.3%) trusted the French health authorities completely or somewhat, compared to 60.0% for the Brazilian authorities and 32.5% for the Surinamese authorities. Regarding vaccination, almost all (91.3%) trusted the information provided by the public authorities and 86.3% of participants were "very favorable" to vaccination in general. Regarding the properties of the vaccines against COVID, 76.3% thought that the vaccines against COVID were effective and 75.0% thought that they were safe. A quarter (26.0%) had received at least one dose of BNT162b mRNA (Pfizer ® -BioNTech ® , Mainz, Germany), 8.0% had received at least one dose of VAXZEVRIA (Astrazeneca ® , Cambridge, UK), and 6.0% had received at least one dose of Coronavac (Sinovac Biotech ® , Beijing, China). More than half (62.0%) did not know which vaccine they had received.
The 30 people (37.5%) who had not been vaccinated against COVID-19 explained it by the lack of safety of the vaccines (23.3%), difficulties to get vaccinated in their place of living (20.0%), difficulties to access vaccination centers (20.0%), not needing it (16.7%), and fearing the shots (10.0%). Only 6.7% did not think the COVID vaccines worked, and 6.7% mentioned lack of information about COVID vaccines.

Bivariate Analysis
After bivariate analysis (Table 3), women seemed to be more vaccinated than men without statistically significant difference (PR = 1.2, p = 0.283) and there was no difference in vaccination coverage between age categories. Those who considered themselves to be in poor health appeared to be more often vaccinated, as did those with chronic diseases (PR = 1.3, p = 0.18). People who have already taken a COVID test are the most likely to be vaccinated against COVID-19 (PR = 1.98, p = 0.009).

Discussion
This is the first study to describe KAP among COVID-19 in people working on illegal gold mining sites in FG. We found that this population is fairly familiar with the symptoms and prevention method, has often been exposed personally or by their entourage to COVID, consumes a lot of antimicrobial agents as prophylaxis or treatment for COVID-19, and has an estimated vaccination coverage at the time of the study of 62.5%.

Impact of the Pandemic on Gold Miners
The population of garimpeiros was strongly affected by the pandemic. More than half (53.8%) reported having been infected at least once, and the number of participants with relatives who died of the disease was high (51/80, 63.8%). These mortality results should be interpreted with caution because in our study, information on the location of relatives was not collected.This high mortality may be related to the health vulnerability of this population, which has already been highlighted in other studies [4,5] but also with the high mortality rate due to COVID-19 observed in Brazil, one of the countries with the highest number of deaths related to this disease since the beginning of the pandemic [23].
The profile of the participants included was similar to that of the gold miners before the pandemic [2,3,5]. They were mainly Brazilians from poor and rural states of Brazil (Maranhao state) with low levels of education [3,5,9]. The pandemic did not change the mining activity for 62.5% of the respondents while 26.3% had stopped working at the gold mining site. Similar results were found in another study among gold miners in Suriname [24]. Yet many factors could have disrupted their activity, such as the closure of borders or the fear of coming in places of higher density and therefore with more circulation of COVID-19. Indeed the border between French Guiana and Brazil was reopened on 20 December 2021 after 22 months of closure, a few weeks before the start of this study [25].
Although this study did not investigate the impact of COVID-19 on the well-being of this population, COVID-19 showed negative psychological distress in different regions of the world [26].

A Population with a Good Level of Knowledge about the COVID-19
In this study, the gold miners had good general knowledge about COVID-19 and seemed to understand the seriousness of this disease. However, their information network was limited and mainly consisted of television. This almost exclusively Portuguesespeaking population, was informed by the Brazilian media television channels, which corresponds to the observations made on the gold mining sites [3]. The knowledge of the participants on the country of occurrence of the virus, the modes of transmission, the protective measures, the risk factors and the symptoms was good. The biological mode of occurrence of the virus was less well known. Fake news did not seem to have a serious impact on the participants' answers in this survey. The comparison with literature data is complicated due to great disparity of KAP between different populations and its great evolution over time. Furthermore, behaviour is not always linked to knowledge: adequate knowledge does not necessarily lead to an adequate attitude [19].

Attitudes and Practices Similar to Those Observed in the Brazilian Population
It is interesting to see that the gold miners, mainly from Brazil, have attitudes and practices more comparable to those of the population of Brazil than to those of French Guiana, where they live. Thus, the practice of anti-COVID antibiotic prophylaxis was comparable to that was observed in Brazilian studies. In the Datafolha study, 12.0% had taken medication for prevention, including antibiotics and other medications [17]. In the Detectcov study, 24.6% had taken preventive self-medication including 35.8% paracetamol, 35.8% ivermectin, 21.5% azithromycin, and only 1.3% hydroxychloroquine [16]. In our study, almost one third (32.6%) of the people had taken antimicrobial medication (including ivermectin) for curative purposes. Before antibiotics, the most frequently found drugs were vitamins and paracetamol, which corresponds to the most commonly used drugs for self-medication among gold miners [9]. Access to antibiotics is easy for gold miners as they are freely available on Suriname's resting sites, in the informal sector called "Brazilian pharmacies" and from "Chinese" traders. These antibiotics, purchased and consumed in this way, can be poorly preserved or misused and are at risk of drug interactions, adverse effects and microbial resistance.
Preventive measures are little used: half of the garimpeiros declared respecting social distancing (51.3%) and hand disinfection (55.0%), even if they considered them "very effective". These figures do not reflect the reality observed in the field and are probably influenced by the fact that the interviewer had a medical background. They can also be explained by the lifestyle of the garimpeiros, who lived and worked essentially in an open environment where the risk of contamination is lower. In addition, it is not always easy for them to consult health centers or even to isolate themselves when they have symptoms. The self-medication, including antibiotics, observed in the Brazilian population, appears therefore, in the eyes of the garimpeiros, as a quick and easy solution and is generally considered as effective. Numerous studies have shown that KAP toward COVID-19 changed throughout the pandemic, depending on changes in medical knowledge, incidence rate, mortality rate, or perception of the policy response [28,29]. In this study, COVID-19 was considered severe and dangerous but the concern was moderate, probably related to the rather favorable epidemic situation at the time of our inclusions and the lower case fatality. Only repeated studies would allow to evaluate the trends of this perception and its relation to incidence.

Vaccination Rate Higher than that of the French Guianese Population
Nearly two out of three (62.5%) people in this study, had received at least one dose of COVID vaccine. This vaccination coverage appeared suprisingly high for a vulnerable and remote population. It was better than that of the general French Guianese population (45.0% of the eligible Guianese population) and closer to the Brazilian vaccination coverage (80.0%) at the time of the study [27,30]. This difference with the overall French Guianese population is all the more striking because western FG, where the commune of Maripasoula is located, had poorer vaccination coverage (7.0%) in in August 2021 [31].
In our study, the main reason for not getting vaccinated was difficult access to the vaccine, followed by lack of vaccine safety. Indeed, illegal gold mines are located in remote areas of the forest, which can be up to 5 days by boat or walk from health centers. This is very different from the French Guianese population who was very suspicious about the safety of the vaccine and did not trust the health authorities and massively refused the vaccine [22,32]. Several studies have shown that vaccination seemed to be correlated with the level of concern and the level of education [22,32]. We found similar results, as participants with at least one previous COVID test were more likely to be vaccinated. These may be people with more exposure to the disease, with greater concern for their health, or with better knowledge of and access to health care facilities. A large majority of those vaccinated had received at least one dose in French Guiana. This might reflect a good level of trust in the French authorities, despite their illegal status, which would be interesting to study.

Strengths and Limitations
The strong point of this first study to focus on COVID-19 among gold miners was that it allowed for a multicentric collection of data, both in a health care facility and on the resting sites of the gold miners, and that it was carried out, in part, with a Portuguese-speaking Brazilian mediator who was familiar with the target population.
The main bias of our study was recruitment bias. Indeed, our inclusions were mainly on the resting sites of the gold miners, which are places of passage, with a probable overrepresentation of people who move around the most, who may have the most means, or who are the least afraid of moving around and mingling with the crowds of the resting sites. Since poor access to the vaccine is the main cause of non-vaccination, vaccination coverage in our study may be overestimated since we included more people moving around. In addition, those most concerned about their health may have participated more. Thus our snow-ball based sample may not be representative of the whole gold miningpopulation. The interviewer being from the medical field, the participants may have given the expected answers rather than their real knowledge and practices. The small sample size reduces the power of the study and therefore the possibility of highlighting differences in behavior or knowledge. These biases limit the representativeness of our study and thus its external validity.

Conclusions
Despite their remoteness and vulnerability, people working in FG's illegal gold mines appear to have good knowledge of COVID-19 and are fairly well vaccinated. Given that these individuals are under the radar of the surveillance system, it was important to document KAP and vaccination coverage in this specific population. These data are of interest to healthcare institutions to better target this population and improve their health status. Improving health messages (especially limiting self-medication with antibiotics) and vaccination coverage could be done in partnership with Suriname, where the logistical rear bases of the gold mines are located, and through health mediators who are very important in empowering this community. Funding: This study received logistical support from the Centre Hospitalier de Cayenne (Centre d'investigation Clinique Antilles Guyane, CIC Inserm 1424). This research did not benefit from any specific grant from public, commercial, or non-profit funding agencies.

Institutional Review Board Statement:
The study complies with the MR004 reference methodology of the Jardé Law (France). An ethical opinion was therefore not required. Participants were informed in accordance with Article 13 of the GDPR of their right not to participate and to request access to their responses. A research protocol was submitted and validated by the ethical committee of Paramaribo (Suriname).

Informed Consent Statement:
Informed consent was obtained from all individuals involved in this study. Data Availability Statement: All data relevant to our analyses are fully described in the article and can be made available upon request. All data used for the analysis are available upon request from the corresponding author.