Monthly Archives: January 2017

PRIORITISING HEALTH PROMOTION, DISEASE PREVENTION AND CONTROL – A TRANSFORMATIONAL AGENDA FOR THE ZAMBIAN HEALTH SECTOR

The World Health Organisation describes health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity [1]. Most Ministries of Health focus on treatment of infirmities and yet there are various factors including those of social and economic influence that play a part in one’s complete well-being. Aspects of health as described by the WHO must be embraced for a healthy population and that the team in-charge of ensuring good health recognizes the link between all factors that have an influence on the total health of any being. The Ministry of Health in Zambia has taken recognizance of the fact that all determinants of health must be taken into account when dealing with disease prevention and control. Since 1995 the government of Zambia has developed national policies in specific aspects of health provision [2, 3]. The Ministry of Health as part of its transformational agenda has undergone yet another reform in its bid to improve health at all levels. A new directorate called the Directorate of Health Promotion, Environment and Social Determinants of Health has been included in the Ministry of Health Structure to ensure a holistic approach is utilised when managing the health of the Zambian population. The Health Press – Zambia had an opportunity to meet with the Director of the new Directorate Dr Kennedy Malama who shares his views in the following excerpt:


Zambia’s Health sector has undergone a number of reforms including the Strategies and Plans of 1991/1992 followed by the 1995 reforms anchored on the National Health Services Act which led to formation of Boards [4]. However, the reorganisation of the Health Sector in 2016/2017 is unique as it has been premised on a transformational agenda of prioritising Promotion of Good Health, Preventing and Controlling Disease. This shift has been necessitated by the fact that our disease burden has generally continued to rise despite the massive investment from Government and its Cooperating Partners in the Health Sector especially in the treatment platform. It is very clear that our health budget shall continue to increase if we continued at this trajectory. This scenario has called for rethinking in terms of where we want to go as a country.
Service delivery is made up of Health Promotion, Disease Prevention & Control, Treatment and Rehabilitation. As a country, our top priority should be on ensuring that people don’t fall sick and those that slip through the cracks are treated and rehabilitated accordingly. We need to take those high impact community interventions to the Households.
It is evident that the majority of determinants of health lie outside the health sector and ignoring this fact is at the peril of the Zambian people’s health. This mandate to navigate the determinates of Health makes the new directorate better placed to spearhead the prevention, and controlling of diseases; of course working closely with other directorates particular Public Health and Clinical Care & Diagnostic Services.
It is from the above background that Ministry of Health made a bold decision to amplify its emphasis on promoting health and preventing and controlling diseases. To ensure that this declaration does not remain rhetoric, a Directorate of Health Promotion, Environment and Social Determinants of Health has been created at the Ministry Headquarters.
The new directorate’s mandate include: promoting good health, preventing and controlling disease, coordinating environmental health, occupational health and food safety, fostering intersectoral collaboration within the framework of Whole Government and Whole Society, buying into the Principles of Health in All Policies (HiAP). In addition the new directorate shall spearhead legislation and policy formulation and review, setting of standards and guidelines, resource mobilisation and health Communication. Other roles include; provision of supervision, technical support, mentorship and monitoring & evaluation at all levels.
Zambia continues to be besieged by emerging and re-emerging infectious diseases. From 2016 through to 2017 Zambia has experienced two outbreaks of cutaneous anthrax associated with eating meat from anthrax infected hippopotamus and buffalo in Chama district of Muchinga province and beef in Limulunga, Nalolo, Kalabo, Shangombo districts of Western Province. The outbreaks have reoccurred in both provinces within 5 years despite varied interventions such as health education and vaccination of domestic animals. We also note persistent diarrhoeal disease in our communities despite various interventions. There is need to revise and input appropriate and effective health promotion and disease prevention and control interventions. A holistic approach to health promotion, prevention and control of disease remains a priority. Evidence from the anthrax and diarrhoeal diseases suggests engaging all stakeholders in preventing and controlling these and other diseases is the way to go. The community needs to be engaged at all levels in order to mitigate the high burden of many preventable diseases. Borrowing from the late President J.F Kennedy of the USA, “Let’s not ask what government can do for us but what we can do for human kind”
With this unprecedented prioritisation of health promotion, prevention and control of disease, the strength of this paradigm shift will greatly enhance Primary Health Care and expedite Zambia’s attainment of a healthy and productive population contributing to the socio-economic development of the country. This new focus shall be catalytic in Zambia’s attainment of the Universal Health Coverage. It’s expected that all these interventions targeting the community particularly the households shall significantly contribute to reduced incidence and prevalence of communicable and non –communicable diseases including maternal, New-born, child and adolescent morbidity and mortality.

We need to rush to that tap and close it rather than mopping the floor expecting the floor to become dry!

Dr. Kennedy Malama, Director Health Promotion, Environment & Social Determinants. Ministry of Health Headquarters Lusaka, Zambia.

References

1. Preamble to the Constitution of the World Health Organization as adopted by the International Health Conference, New York, 19-22 June, 1946; signed on 22 July 1946 by the representatives of 61 States (Official Records of the World Health Organization, no. 2, p. 100) and entered into force on 7 April 1948. URL: http://www.who.int/about/definition/en/print.html
2. Ministry of Health [Zambia]. National Health Policy: a nation of healthy and productive people. Lusaka: Ministry of Health; 2012. URL: http://www.moh.gov.zm/docs/healthpolicy.pdf
3. Ministry of Health [Zambia]. National Health Strategic Plan 2011 – 2015: towards attainment of health related Millennium Development Goals and other national health priorities in a clean, caring and competent environment. Lusaka: Ministry of Health. URL: http://www.moh.gov.zm/docs/nhsp.pdf
4. Bossert, Thomas, Mukosha Bona Chitah, Maryse Simonet, Ladslous Mwansa, Maureen Daura, Musa Mabandhala, Diana Bowser, Joseph Sevilla, Joel Beauvais, Gloria Silondwa, and Munalinga Simatele. Decentralization of the Health System in Zambia. Major Applied Research 6, Technical Paper No. 2. Bethesda, MD: Partnerships for Health Reform Project, Abt Associates Inc. December 2000.

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ANTIMICROBIAL RESISTANCE (AMR) – A GROWING GLOBAL HEALTH THREAT

Antimicrobial resistance (AMR) is the ability of a microorganism to withstand treatment with an antimicrobial drug. The rapid emergence of AMR has for several decades been a growing threat to the effective treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. The magnitude of the problem, the impact of AMR on human health, the costs for the health-care sector and the wider societal impact are potentially immense.

Globally, it is estimated that AMR will be responsible for upto 10 million deaths annually by 2050 if nothing is done to contain and prevent its spread [1]. Therefore, AMR is currently a major emerging international public health concern with potential to slow down human development (SDG-3).

In Zambia, like in many other countries, there is emerging evidence of antimicrobial resistance (AMR) in several pathogens. The University Teaching Hospital, the highest-level hospital in Zambia has been detecting multi-drug resistant pathogens, resistant to the first, second and third line antimicrobial agents which has left very limited options for antimicrobial therapy for infectious diseases. Superbugs, which are difficult to treat have been detected, these include pathogens such as Methicillin Resistant Staphylococci (MRSA), Extended Spectrum Beta-lactamase producing Klebsiella pneumoniae, and other multidrug resistant enterobacteria. High resistance to most antibiotics used to treat serious conditions such as blood stream infections have been reported. Resistance as high as 80% ciprofloxacin, ceftriaxone 90%, and Gentamicin 70%, has been reported in some blood stream strains with very limited expensive options for therapy [2]

Because antimicrobial resistant organisms have the potential to move between food producing animals and humans by direct exposure or through the food chain or the environment, AMR is therefore, a multi-sectoral problem encompassing the interface between humans, animals and the environment [3]. The fact that human and veterinary health, food and feed production systems and agro-ecological environments all contribute to and are affected by AMR, indicates the need for multi-sectoral and multi-dimensional “One Health” approach to curb its occurrence. The FAO/OIE/WHO tripartite, together with public and private organizations, share responsibilities for addressing global activities regarding AMR at the animal-human-ecosystem interfaces.
Zambia has adopted this “One Health” approach and, over the past one year, there has been activities being undertaken to develop a multisectoral National Action Plan (NAP) to combat and stop the spread of AMR. The NAP is intended to institute strategic interventions in all key sectors relevant to this fight, that is, the human, animal, plant, and environment sectors. Currently, a nationwide situation analysis study is underway to establish the baseline in all sectors in terms of antimicrobial use and assess capacity to carrying out effectively AMR related control and mitigation measures.
It is expected that the findings from the situation analysis will be utilized in finalizing the NAP, which is due to be presented to the World Health Assembly (WHA) in May 2017, by the Minister of Health.

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Anthrax— A worldwide, regional, and national disease of public health of importance

 

We are pleased and honoured to launch the inaugural issue of our monthly online open access publication of The Health Press – Zambia (THP-Z) this January 2017. A quarterly print version is planned for April 2017 onwards.

The Health Press – Zambia is a publication of the Zambia National Public Health Institute, which was established in February 2015. Even though every public health threat can be reduced if its scope and cause are not only known, but shared with policy makers and the public, much information gathered about public health concerns in Zambia is buried in reports that are not well used for decision making. The Health Press – Zambia has been established in recognition of the need to communicate reliable health information to policy makers, public health practitioners, and the general public. The contents of the publication are selected by the Editor in Chief; the publisher is the Zambia National Public Health Institute. The financial obligations including staff salaries and publication costs are provided by the Zambian government and Bloomberg Philanthropies though the CDC Foundation.

The Health Press – Zambia aspires to be a leading publication that informs policy makers, public health practitioners, and the general public by effectively and expeditiously disseminating influential scientific information and recommendations that will improve public health in southern Africa and beyond, especially for underserved and poor populations. The long-term goal is to provide a platform for public health professionals in this region and beyond to publish their work as a means to advance the science of public health. The Health Press Zambia aims to publish a variety of articles of public health significance including analyses of surveillance data, outbreak reports, reviews of public health problems and policies, and other reports with information of use to persons concerned about public health.

The Health Press – Zambia online issue will be accessible worldwide cost-free via the internet. There are no processing fees for publishing in the bulletin. No subscription fees will be charged, but readers are expected to subscribe to the publication to enjoy continuous access.  Our editorial policy is guided by a commitment to high standards, ensuring quality and integrity, and is managed by a team of Associate Editors with diverse expertise. All policies guiding authorship, editorial processing, and copyright matters are spelled out on the website. This being our inaugural issue, we will be getting back to you with a survey to get feedback on the bulletin. We encourage you to subscribe to The Health Press – Zambia on http://znphi.co.zm/thehealthpress/ and ‘like us’ on our Facebook page, The Health Press – Zambia and follow us on LinkedIn and Twitter.

This inaugural issue of The Health Press – Zambia focuses on anthrax in Zambia, with a review of anthrax outbreaks in Zambia, a report on the 2015 anthrax outbreak in Chama district, a report on an anthrax outbreak in Western province, and a report on the anthrax policy in Zambia. Other reports include an article on laboratory-confirmed urinary tract infections, a communication on the antimicrobial resistance program in Zambia, a case study from a forensic pathologist, and a report on trends in population health. 

 Anthrax— A worldwide, regional, and national disease of public health of importance

Anthrax has a long history in public health from ancient times to the present. It is a zoonotic disease caused by the gram-positive spore-forming bacterium Bacillus anthracis primarily affecting domestic and wild herbivores including cattle, sheep, goats, bison, deer, antelope and hippos among others [1]. Although primarily an animal disease, it is transmissible to human beings. Human to human transmission is very rare. A literature review on the history of major anthrax outbreaks globally indicates serious losses among animals including one that is believed to have killed 40,000 horses and 100,000 cattle herded by the Huns as they trekked across Eurasia, another in the 14th century in Germany, and one in the 17th century that killed over 60,000 cattle in Europe [2]. Although controlled in some regions such as the United States of America and Canada, anthrax is distributed globally and more commonly enzootic in sub-Saharan Africa, Asia and Central and South America [3]. Although a rare infection among humans, anthrax continues to be a disease of public health concern despite a vaccine being available.

In 2016, multiple outbreaks were documented: an outbreak among reindeer occurred in Siberia affecting dozens of persons, several outbreaks in Kenya affected animals and humans including an outbreak in Nakura associated with contact with infected buffalos [4]; another affecting over 70 persons in Maragua and Sanbura counties associated with anthrax-infected cattle, sheep and zebra. Human fatalities were recorded including a 73-year-old in Maragua and 7-year-old in Sanbura who tested positive for anthrax. Several animals that were ill or died tested positive for anthrax infection [5]. Other outbreaks in 2016 were reported in Shirajganj, Bangladesh affecting up to 125 persons associated with eating meat from anthrax-infected animals [6]. Up to six human fatalities linked with eating anthrax-infected beef in the Niger Republic were reported in October 2016 [7]. In France, anthrax outbreaks were found among sheep and cattle while in northeastern Bulgaria, only were affected with four fatalities among the animals. The outbreak in north-eastern Bulgaria could be linked to the 2015 outbreak that affected both humans and animals [8]. Zambia experienced two outbreaks in 2016 affecting over 80 persons and 20 animals in Chama district in Muchinga province and dozens of people and animals in four districts, namely Shang’ombo, Nalolo, Limulunga and Kalabo of Western province. In both outbreaks, infections among humans was associated with infections in hippos and buffalos in the former and dozens of cattle in Western province [9]. The outbreak in Western Province is still ongoing in 2017 but under control with animals being vaccinated and patients being given medical treatment. A cumulative total of 67 persons (with one fatality) and dozens of animals are affected [10]. All outbreaks among humans have been associated with contact with or consumption of anthrax-infected meat.

The natural transmission of anthrax to humans from the natural hosts, wild and domestic animals, is through direct or indirect contact with carcasses of animals that died from anthrax; consumption of meat from infected animals; or inhalation of spores aerosolized during work with contaminated materials such as animal hides and wool. However, infection has also resulted from inhalation through acts of bioterrorism [11]. Quite recently, an emerging form of anthrax infection is injection anthrax among injection drug users [12]. Since 2009, cases of injection anthrax have been reported from Denmark, France, Germany and the United Kingdom. Berger et al. [13], who reviewed reporting systems until through December 2013, reported 70 confirmed cases with 26 fatalities (case fatality rate = 37%).
Natural anthrax infections occur in three forms including lung (pneumonia), skin (cutaneous) and intestinal anthrax. Cutaneous anthrax is the most common (>95%) form of naturally occurring anthrax among humans [14]. The common characteristic of cutaneous anthrax is a black eschar on the skin of an infected person, hence the name anthrax derived from the Greek word anthrakos meaning coal [15]. In 2001, several media offices and two United States senators were exposed to anthrax spores sent through the post leading to 17 infections and five deaths [16]. Lung anthrax most often occurs as a result of a bioterrorism act, when anthrax spores are inhaled. In 1979, the largest outbreak of human inhalation anthrax ever documented occurred in Sverdlovsk near a Soviet military microbiology facility [17]. Intestinal anthrax occurs after ingestion of undercooked anthrax-infected meat [1].
Although control and awareness programs are being implemented in most countries, there is a need for a “one health” approach to prevent and control further outbreaks. There is a need for authorities to address the connections between anthrax outbreaks, environmental concerns, and food insecurity.

References

1.Communicable Disease Prevention and Control. San Francisco department of Public Health. Anthrax (Bacillus anthracis). URL http://www.sfcdcp.org/anthrax.html.
2.Knights EM. Anthrax. URL http://www.historymagazine.com/anthrax.html.
3.World Organization for Animal Health, World Health Organization, Food and Agriculture Organization of the United Nations. Anthrax in humans and animals. 4th edition. World Health Organization, 2008. URL: http://www.who.int/csr/resources/publications/anthrax_web.pdf.
4.Zwizwai R. Infectious disease surveillance update. Lancet Infect Dis. 2016;16:901.
5.ProMED. PRO/AH/EDR> Anthrax, human, livestock, wildlife – Kenya (Maragua, Samburu). Archive Number:
20060104.0026. Published 4 January 2006. URL: http://www.promedmail.org/post/20060104.0026
6.Herriman R. Bangladesh: 125 anthrax cases reported in Sirajganj. URL: http://outbreaknewstoday.com/bangladesh-125-anthraxcases-reported-in-sirajganj-74475/.
7.Herriman R. Anthrax in animals prompts warning in Nigeria, Zambia. URL:
http://outbreaknewstoday.com/anthrax-in-animalsprompts-warning-in-nigeria-zambia-85670/.
8.Herriman R. Anthrax kills four animals in north-eastern Bulgaria. http://outbreaknewstoday.com/anthrax-killsfour-animals-in-northeastern-bulgaria-99973/.
9.Herriman R. Anthrax outbreak linked to tainted hippo meat more than doubles in Zambia. URL:
http://outbreaknewstoday.com/anthrax-outbreak-linkedto-tainted-hippo-meat-more-than-doubles-in-zambia26869/.
10.Mwambi P. Anthrax outbreak in Muchinga. Unpublished report submitted to the World Health Organization: Lusaka, Zambia, 25 October 2016.
11.Shadomy SV, Traxler RM, Marston CK. Anthrax. URL: https://wwwnc.cdc.gov/travel/yellowbook/2016/infectiou s-diseases-related-to-travel/anthrax.
12.Centers for Disease Control and Prevention. Injection anthrax. URL: https://www.cdc.gov/anthrax/basics/types/injection.html
13.Berger T, Kassirer M, Aran AA. Injectional anthrax – new presentation of an old disease. Euro Surveill.2014;19.pii=20877.
14.Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. 11th ed. Washington DC: Public Health Foundation, 2009.
15.Turnbull PC. Introduction: anthrax history, disease and ecology. Curr Top Microbiol Immunol. 2002;271:1-19. 16.Jernigan DB, Raghunathan PL, Bell BP, Brechnert R, Bresnitz EA, Butler JC, et al. Investigation of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Emerg Infect Dis. 2002;8:1019-28.
17.Stembach G. The history of anthrax. J Emerg Med. 2003;24:463–7.

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