Monthly Archives: March 2019

Delayed referral for diagnostic endoscopy is a contributing factor to late gastric cancer diagnosis in Zambia

By: V Kayamba ^{1, 2}, P Kelly ^{1,2, 3}

1. Tropical Gastroenterology & Nutrition group, Department of Internal Medicine, PO Box 50398, Nationalist Road, Lusaka, Zambia.

2. University of Zambia School of Medicine, Department of Internal Medicine, PO Box 50110, Nationalist Road, Lusaka, Zambia.

3. Blizard Institute, Barts & The London School of Medicine and Dentistry, Queen Mary University of London, 4 Newark Street, London E1 2AT, UK.

Correspondence: Dr Violet Kayamba (viojole@yahoo.com)

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Citation Style For This Article: Kayamba V, Kelly P. Delayed referral for diagnostic endoscopy is a contributing factor to late gastric cancer diagnosis in Zambia. Health Press Zambia Bull. 2019;3(2); Pp 14-19

There is evidence that 15 % of gastric cancer patients in Zambia survive more than one-year after diagnosis. The major contributing factor to these poor outcomes is late case detection. We set out to investigate the time course of gastric cancer diagnosis in Zambia. The study was conducted at the University Teaching Hospital, in Lusaka. Consenting patients presenting to the endoscopy unit were enrolled and their endoscopic findings recorded. An interviewer-administered questionnaire was used to collect information on basic characteristics, presenting symptoms and duration. We enrolled 388 patients, 92 (24%) of whom had gastric cancer. About two-thirds of the gastric cancers were located in the distal part of the stomach. The median time to endoscopic gastric cancer diagnosis was 12 weeks, IQR 4-32 weeks after the first health care consultation. This was despite gastric cancer patients seeking healthcare attention within a median of 2 weeks, IQR 0-4 weeks of noticing the symptoms. Patients presenting with persistent vomiting or evidence of blood loss had significantly shorter delays than those with abdominal pain (p<0.05 and p<0.001 respectively). Delayed referral for diagnostic endoscopy is a contributing factor to late gastric cancer diagnosis in Zambia. The delay is highest in patients presenting with abdominal pain.

INTRODUCTION

Gastric cancer is a malignant tumour that can arise from any part of the stomach, including the cardia, fundus, body and antrum. It is the fifth most common cancer globally and the third leading cause of cancer related deaths. [1] Gastric cancer is commoner among men than women and the highest recorded incidence rates are from Korea, Mongolia and Japan. In Africa, data on gastric cancer are scarce mainly due to fragmented diagnostic facilities in these low resource countries. [2] There are very few African countries with reliable population-based registries region. [3] The Global Cancer Incidence, Mortality and Prevalence estimates the incidence of gastric cancer in Africa to be between 5.2 per 100,000 in some countries such as Angola to more than 20.2 per 100,000 in Mali. [1] In Zambia, gastric cancer is estimated to be the tenth among common cancers but this is similarly limited by challenges of case detection. Gastric cancer is the third most commonly diagnosed gastrointestinal cancer after oesophageal and liver cancers in the gastrointestinal unit at the University Teaching Hospital (UTH), unpublished observation.

The outcome of gastric cancer patients in Zambia is poor. We previously reported evidence that less than 15% of these patients live beyond one year after the initial diagnosis. [4] The advanced stage at which gastric cancer is diagnosed is one of the major contributors to the poor outcomes. Zambia has a referral system, in which patient’s first contact with healthcare is at primary care centres located in all districts of the country. Depending on the condition, the health care provider can then elect to refer them for secondary care offered at larger district and provincial hospitals. If specialist opinion is required, patients are then sent to tertiary institutions such as the UTH. Gastric cancer diagnosis can only be confirmed by examining a tissue sample obtained either endoscopically or during surgery, services that are not available in primary and most of the secondary care facilities. For a gastric cancer patient to be seen in a tertiary centre for confirmatory diagnosis, healthcare providers at the primary and secondary care levels have to promptly identify that such a patient needs urgent referral. This also depends on how quickly the patients present themselves at the health centres.

With the poor outcomes and delayed gastric cancer diagnoses observed at UTH, we endeavoured to analyse the time frames from the onset of symptoms to clinical diagnosis in order to establish the contributors to late diagnosis. The University of Zambia Biomedical Research Ethics committee, reference number 000-03-16, approved this study.

METHODS

Patient enrolment

The study was carried out between July 2016 and April 2018 at the University Teaching Hospital (UTH) gastroenterology unit. All consenting patients above the age 18 years coming in for upper gastrointestinal endoscopy were considered for enrolment. Excluded were those with history of ingesting a caustic substance or an obvious oesophageal or other extra gastric malignancy. Informed and written consent was obtained from all participating patients.

Study procedures

Upper gastrointestinal endoscopy was carried out on all patients following standard guidelines. Any lesions seen were recorded. After the procedure, an interviewer-administered questionnaire was used to collect information on the onset of symptoms and first healthcare consultation. In addition the data on basic characteristic were also collected.

Data analysis

Categorical and continuous variables were summarised using proportions, medians and interquartile ranges. Binary variables were compared using Fisher’s exact test and Kruskal-Wallis test was used to compare continuous variables. In all instances, a two-sided P value of <0.05 was considered statistically significant. Statistical analysis was done in STATA 15 (College Station, TX, USA).

RESULTS

Basic characteristics of patients stratified by endoscopic diagnosis

Table 1: Time from onset of symptoms to first consultation and endoscopic evaluation in patients stratified by endoscopic findings

	Endoscopic findings
	Normal (n=186)	Cancer (n=92)	Other diagnoses* (n=110)	P
	Median (IQR)	Median (IQR)	Median (IQR)
Time to first consultation	0 (0-13) weeks	2 (0-4) weeks	1 (0-8) weeks	1.000
Time to endoscopic diagnosis	16 (4-104)	12 (4-32)	8 (3-52)	0.120

Figure 1: Anatomical location of gastric cancer as seen during upper gastrointestinal endoscopy

Figure 2 Presenting symptoms of patients with or without gastric tumours. Significance testing done with the Fisher’s exact test.

Figure 3: Time in weeks from onset of symptoms to diagnosis. Each horizontal line represents a gastric cancer patient. The x-axis shows time in weeks

Figure 4: Time to endoscopic diagnosis stratified by presenting symptoms. Significance tested using the Kruskal-Wallis test,* p-value<0.05, ***p-value<0.001

We enrolled 388 patients, 207 (53%) of whom were female with median age of 51 years (IQR 41-65 years). Gastric cancer was seen endoscopically in 92 (24%) patients. Of those without gastric cancer 110/296 (37%) had benign mucosal lesions including gastric or duodenal ulcers, gastric erosions, varices, polyps and other oesophageal lesions.

Anatomical location and clinical presentation of gastric cancer.

During the endoscopic procedures, the location of gastric cancer was recorded, and we found that 30% and 35% of the cancers were located in the antrum and body respectively. These are known as distal gastric cancers. The remaining 35 % were proximal cancers (Figure 1). The major presenting symptoms for of each the patients was then compared between gastric cancer patients and those without cancer. Gastric cancer patients were more likely to present with vomiting [OR 3.3, 95% CI 1.6-6.6; p=0.0005] or dysphagia [OR 9.9, 95% CI 2.8-43; p<0.0001] while those without cancer were more likely to present with abdominal pain [OR 0.5; 95% CI 0.3-0.9; p=0.01] (Figure 2).

Time in weeks from onset of symptoms to first consultation, then endoscopy for gastric cancer patients

Enrolled patients were asked about the time when their symptoms were first noticed and their first health care consultation. The median time from onset of symptoms to the first health care consultation was 2 weeks, IQR 0-4 weeks. It then took another median of 12 weeks, IQR 4-34 weeks for these patients to be sent for endoscopic diagnosis. The difference between these two time frames was statistically significant (p<0.0001). In Figure 3, the time to first consultation for each of the gastric cancer patients is shown in green, while the time to endoscopic diagnosis is shown in orange (Figure 3).

Time in weeks from onset of symptoms to first consultation, then endoscopy for all enrolled patients

The median time in weeks from onset of symptoms to first health care consultation was less than three weeks for all the patient groups. The time to endoscopic diagnosis was much longer with the highest median being 16 weeks for patients without mucosal lesions. The time to endoscopic diagnosis was highest in patients presenting with abdominal pain or anaemia and lowest among those with persistent vomiting or evidence of blood loss (Figure 4).

DISCUSSION

In this study, we present evidence that delayed gastric cancer diagnosis in Zambia is not just due to late patient presentation. Gastric cancer patients enrolled in this study did seek medical attention soon after noticing their symptoms but were not sent for diagnostic gastrointestinal endoscopy promptly.

The referral system in Zambia is designed to reduce patient burden in tertiary institutions by making primary and secondary health facilities available in centres close to the communities. It is therefore, incumbent upon the healthcare providers in these centres to identify patients in need of referral for specialised care. Similar to other African countries such as South Africa, Rwanda and Malawi, [5, 6, 7] gastric cancer patients in Zambia present with very advanced disease and can therefore only be offered palliate care. Another example is Nigeria where it was reported that only 30% of gastric cancer patients presented within a year of the symptom development. [8]

Late diagnosis is one of the major contributors to poor outcomes. Until now, reasons for late gastric cancer diagnosis in Zambia have just been speculative, mainly focussing on late patient presentation. Our data show that the median time from onset of symptoms to first contact with health care providers was not as long as the time it took for patients to be given the final diagnosis. This difference was statistically significant. Our data do not allow us to determine if healthcare providers fail to identify the need for endoscopy. Another contributing factor could have been the non-specific nature of gastric cancer symptoms. Gastric cancer is one of those cancers without very distinct symptoms. In very early stages of disease, it is virtually asymptomatic making detection difficult. When symptoms are present, they are non-specific: poor appetite, unintentional weight loss, abdominal pain with fullness or swelling, reflux symptoms, nausea, vomiting (with or without blood), melaena or anaemia. [9] A patient might have just one or two of these symptoms which could also be a manifestation of other diseases that do not necessarily require endoscopic evaluation. In addition, many of these symptoms become obvious in advanced disease. In a breast cancer study done in Zambia, authors concluded that one of the reasons for late diagnosis was ignorance about the existence of the disease. [10] This might also be true for gastric cancer as well.

We then endeavoured to identify which symptoms most likely to be associated with delayed presentation. The least delay was in patients with blood loss or persistent vomiting, suggesting that health care providers did identify these symptoms as suspicious for conditions requiring endoscopy. It should be noted that overt bleeding and persistent vomiting which could be a sign of luminal occlusion are late symptoms of gastric cancer. [11] The longest delay to diagnosis was in patients with abdominal pain. This is not surprising as abdominal pain is a very common symptom and is usually not indicative of gastric cancer. It can be due to many other diseases some of which are outside the gastrointestinal tract.

Such delays in diagnoses could contribute towards patients by-passing the set out referral system in preference for direct consultation at tertiary centres. A study by Atkinson et al., showed that some patients in Zambia deliberately by-pass primary care centres and go directly to tertiary institutions. [12] There is some evidence that setting up screening camps for cancer diagnosis close to the communities could reduce diagnostic delays, [13] but the cost effectiveness for gastric cancer in Zambia has not be established. We recently published data in support of a non-invasive strategy that might be useful for early identification of patients with gastric cancer, but this is yet to be validated. [14]

This study has brought out information on gastric cancer diagnosis in Zambia that might be relevant to other cancers and medical conditions as well. Awareness of gastric cancer among health care workers needs to be increased. There is also need to conduct conduct more studies that will investigate particular reasons for each source of delay from onset of symptoms to final diagnosis and treatment.

CONCLUSION

Gastric cancer is diagnosed late in Zambia and this is not only due to late patient presentation. Patients presenting with abdominal pain have the longest delay.

ACKNOWLEDGEMENTS

We would like to acknowledge the three endoscopy nurses; Themba Banda, Rose Soko and Joyce Sibwani for their assistance rendered during all the endoscopic procedures.

FUNDING

Research reported in this publication was supported by the Fogarty International Center of the United States National Institutes of Health under Award number D43 TW009744. The content is solely the responsibility of the authors and does not necessarily represent the views of the National Institutes of Health.

List of References

1. Bray F, Ferlay J, Soerjomataram I, Siegel RL, Torre LA, Jemal A. Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA Cancer J Clin, 2018. 68(6): 394-424.

2. McFarlane G, Forman D, Sitas F, Lachlan G. A minimum estimate for the incidence of gastric cancer in Eastern Kenya. Br J Cancer. 2001. 85(9): 1322-5.

3. Laryea DO, Awuah B, Amoako YA, Osei-Bonsu E, Dogbe J, Larsen-Reindorf R, Ansong D, Yeboah-Awudzi K, Oppong JK, Konney TO, Boadu KO, Nguah SB, Titiloye NA, Frimpong NO, Awittor FK, Martin IK. Cancer incidence in Ghana, 2012: evidence from a population-based cancer registry. BMC Cancer. 2014.14: 362.

4. Asombang AW, Kayamba V, Turner-Moss E, Banda L, Trinkaus K, Colditz G, Mudenda V, Zulu R, Sinkala E, Kelly P. Gastric malignancy survival in Zambia, Southern Africa: A two year follow up study, Medical Journal of Zambia, 2014; 41, No. 1

5. Benamro F, Sartorius B, Clarke DL, Anderson F, Loots E, Olinger L. The spectrum of gastric cancer as seen in a large quaternary hospital in KwaZulu-Natal, South Africa. S Afr Med J. 2017 Jan 30;107(2):130-133.

6. Martin AN, Silverstein A, Ssebuufu R, Lule J, Mugenzi P, Fehr A, Mpunga T, Shulman LN, Park PH, Costas-Chavarri A. Impact of delayed care on surgical management of patients with gastric cancer in a low-resource setting. J Surg Oncol. 2018 Dec;118(8):1237-1242.

7. Kendig CE, Samuel JC, Tyson AF, Khoury AL, Boschini LP, Mabedi C, Cairns BA, Varela C, Shores CG, Charles AG. Cancer Treatment in Malawi: A Disease of Palliation. World J Oncol. 2013 Jun;4(3):142-146.

8. Osime OC, Momoh MI, Irowa OO, Obumse A. Gastric carcinoma–a big challenge in a poor economy. J Gastrointest Cancer. 2010 Jun;41(2):101-6.

9. American Cancer Society, signs and symptoms of gastric cancer. https://www.cancer.org/cancer/stomach-cancer/detection-diagnosis-staging/signs-symptoms.html, accessed on 10th January 2019.

10. McKenzie F, Zietsman A, Galukande M, Anele A, Adisa C, Parham G, Pinder L, Cubasch H, Joffe M, Kidaaga F, Lukande R, Offiah AU, Egejuru RO, Shibemba A, Schuz J, Anderson BO, Dos Santos Silva I, McCormack V. Drivers of advanced stage at breast cancer diagnosis in the multicountry African breast cancer – disparities in outcomes (ABC-DO) study. Int J Cancer. 2018 Apr 15;142(8):1568-1579.

11. National Cancer Institutes, Gastric cancer treatment. https://www.cancer.gov/types/stomach/patient/stomach-treatment-pdq, accessed on 11th January 2019.

12. Atkinson S, Ngwengwe A, Macwan’gi M, Ngulube TJ, Harpham T, O’Connell A. The referral process and urban health care in sub-Saharan Africa: the case of Lusaka, Zambia. Soc Sci Med. 1999 Jul;49(1):27-38.

13. Pinder LF, Nzayisenga JB, Shibemba A, Kusweje V, Chiboola H, Amuyunzu-Nyamongo M, Kapambwe S, Mwaba C, Lermontov P, Mumba C, Henry-Tillman R, Parham GP. Demonstration of an algorithm to overcome health system-related barriers to timely diagnosis of breast diseases in rural Zambia. PLoS One. 2018 May 10;13(5):e0196985.

14. Kayamba V, Zyambo K, Kelly P. Presence of blood in gastric juice: A sensitive marker for gastric cancer screening in a poor resource setting. PLoS One. 2018 Oct 15; 13(10):e0205185.

Anthrax Update (2018-2019)

By: B Gianetti¹, BM Katemba¹, A Moraes¹, C Groeneveld¹, KM Kanyanga¹, R Hamoonga¹, ML Mazaba¹

1. Information Systems Unit, Zambia National Public Health Institute.

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Citation Style For This Article: B Gianetti, BM Katemba, A Moraes, et.al. Anthrax Update (2018-2019). Health Press Zambia Bull. 2019 3(2); pp 8-13.

Anthrax is a zoonotic disease caused by the spore-forming bacteria Bacillus anthracis. Anthrax spores are resistant to extreme environmental pressures and are able to persist in the soil. Humans generally acquire anthrax by ingesting infected meat or handling infected animal carcasses and products. People can develop three forms of anthrax infection dependent on the inoculation route: cutaneous, gastrointestinal, and pulmonary [1]. Cutaneous anthrax occurs when spores enter the body through a wound or opening in the skin and has a 20% mortality rate if left untreated. Gastrointestinal anthrax infection occurs when persons ingest contaminated food and has a mortality rate between 25 to 60%. Pulmonary anthrax infection occurs when an individual inhales spores from the environment and has a mortality rate of greater than 80% [1].

Although several nations have made efforts to eliminate anthrax, infection still occurs in most sub-Saharan African countries. Anthrax is endemic in Zambia’s Luangwa valley and Zambezi floodplain [2–4]. Multiple anthrax outbreaks have been recorded in Zambia since 1990 due to the ingestion of contaminated beef and game meat, with case fatality rates (CFR) ranging from 4-20% [5–7].

In accordance with the Zambia Public Health Act (Chapter 295, Section 9), anthrax is a notifiable disease, and as such any suspected case requires a rapid Integrated Disease Surveillance and Response (IDSR) field investigation. Although reported anthrax cases have consistently decreased over the past 10 years, a recent outbreak of eight suspected cases in the Sesheke district of Western province prompted a review of reported anthrax cases in Western province from 2016-2019. This report presents an overview of the frequency and spatial distribution of suspected anthrax cases from January 2016 to January 2019.

Methods

We conducted a retrospective analysis of anthrax data collected using the IDSR system between January 2016 and January 2019 in order to identify trends in suspected anthrax cases in Zambia. Data was extracted from the weekly 2018 and 2019 IDSR reports as well as 2016 and 2017 outbreak investigation reports and analyzed using Microsoft Excel and Tableau.

The IDSR definition for a suspected cutaneous anthrax case is any person with an epidemiological link to confirmed or suspected animal cases or products who presents with a skin lesion that evolves over 1-6 days from a popular lesion to a vesicular lesion and ultimately to a black eschar accompanied by oedema. A suspected gastrointestinal anthrax case is any person with an epidemiological link to confirmed or suspected animal cases or products who presents with abdominal distress, characterised by nasusea, vomiting, anorexia, and fever. The suspected case definition for pulmonary anthrax is any person with an epidemiological link to confirmed or suspected animal cases or products who presents with symptoms resembling acute viral respiratory illness, followed by rapid onset of hypoxia, dyspnea, high temperature, and X-ray evidence of meditational widening.

Results

The majority of suspected anthrax cases occurred between July and December (Table 1). One hundred and twenty-seven suspected

Table 1. Suspected Anthrax cases 2016- 2019

anthrax cases were reported across Muchinga and Western provinces in 2016. Ninety cases were reported in Western province in 2017, and only four suspected anthrax cases were reported in Western province in 2018. Samples for laboratory testing were collected from about 17% of reported suspected anthrax cases (Table 1).

An anthrax outbreak occurred in Muchinga district in September 2016 that consisted of 79 cases. The majority of suspected cases presented with cutaneous infection, were under 20 years of age, and reported having consumed hippopotamus meat (96%) [7]. Of the twelve samples collected from suspected anthrax cases, three samples tested positive for B. anthracis (Table 1, [7]).

Except for the 2016 outbreak in Muchinga province, all reported outbreaks between 2016 and 2019 occurred in Western province (Table 1). Within Western province, four anthrax outbreaks were reported in 2016 and six in 2017. Between November 2016 and February 2017 anthrax outbreaks resulted in 87 cases and 6 deaths in Shangombo, Nalolo, Kalabo, and Limulanga districts. In July 2017 a small outbreak consisting of two suspected anthrax cases occurred in Kalabo district, and from September to November 2017 anthrax outbreaks resulted in 49 suspected cases and two deaths in Nalolo, Sioma, Senanga, and Shangombo districts (Table 1, Figure 1).

The 2016/2017 outbreaks in Western province comprised 138 suspected anthrax cases and 8 deaths (CFR 5.8%). Slightly more than 50% of all suspected cases were male, and almost half of all cases were between the ages of 5 and 19 years of age (44.9%) (Table 2). The majority of cases were reported in Kalabo and Shangombo districts (62.3%) (Table 2, Figure 1). One hundred and seventeen cases presented with cutaneous anthrax infection (84.8%), eleven cases had gastrointestinal anthrax (8.0%), and six cases presented with pulmonary anthrax (4.3%) (Table 2). Nearly all suspected anthrax cases received treatment (97.8%), most commonly at an outpatient health facility (88.4%). However, about three quarters (76.8%) of all suspected anthrax cases did not have a specimen collected for laboratory testing. Of the 28 specimens that were tested for B. anthracis, only 15 (53.6%) tested positive for anthrax infection (Table 2).

Figure 1. Map of suspected anthrax cases in Western province 2016 – 2019

Table 2. Characteristics of suspected anthrax cases in Western province 2016-2017

Table 3. Characteristics of anthrax deaths in Western province 2016-2017

Although the majority of cases reported during the 2016/2017 anthrax outbreaks in Western province were cutaneous infections, deaths due to anthrax occurred primarily amongst cases with gastrointestinal anthrax infections (62.5%) (Table 3). Deaths were reported in Kalabo, Nalolo, Shangombo, and Sioma districts. Three of eight (37.5%) reported anthrax fatalities did not receive treatment, and of those who sought care, 62.5% were treated at an inpatient health facility (Table 3).

Four isolated suspected cases of anthrax occurred in Limulunga, Shangombo, and Senanga districts in Western province in 2018. Furthermore, a recent outbreak in Sesheke district in Western province in January 2019 amassed eight suspected anthrax cases (Table 1, Figure 1). Laboratory samples were not tested from any suspected case in 2018 and 2019 (Table 1).

Discussion

Between January 2016 and January of 2019 nine outbreaks and 265 suspected cases of anthrax were reported. During this period, one outbreak occurred in Chama district of Muchinga province and all other outbreaks occurred in Western province. In Western province, suspected anthrax cases were reported from Kalabo, Nalolo, Shangombo, Sioma, Senanga, Limulunga, and Sesheke districts. The highest numbers of suspected cases were reported in Shangombo and Kalabo districts, and the majority of anthrax cases occurred between the months of July and December. Over 80% of cases reported in Western province in 2016 and 2017 were cutaneous infections; however, 62.5% of anthrax fatalities were cases with gastrointestinal infections.

Traditionally, the majority of anthrax outbreaks in Zambia have occurred in Western province. A large outbreak occurred in Western province in 1990, during which 220 cases were documented. Between 1991 and 1998 a total of 248 cases and 19 deaths were reported across eight districts in Western and North-western provinces. Most cases consisted of gastrointestinal anthrax, although 33 cases presented with cutaneous anthrax infection [2]. Between 1999 and 2007 a total of 1,790 anthrax cases and 83 anthrax deaths were reported in the Kalabo, Lukulu, Mongu, Kaoma, Senanga, and Sesheke districts in Western province, and a small outbreak consisting of 3 cases of cutaneous anthrax was investigated in five villages in Sesheke district in 2010 [4,8].

Most outbreaks in Western province are associated with suboptimal vaccination of cattle and transmission to humans due to contact with infected animals and consumption of found animal carcasses [5,6]. As such, farming families and persons classified as food insecure have a high risk of contracting anthrax [9]. Historically, an increase of anthrax outbreaks in Zambia bas been observed between June and December, when the dry climate promotes increased human and livestock occupancy of the floodplain [4].

Alternatively, anthrax outbreaks in Muchinga province have been associated with the consumption of contaminated hippopotamus meat. The majority of anthrax cases reported during the 2016 Chama outbreak responded that they had eaten hippo meat. Moreover, an anthrax outbreak investigated in Chama district of Muchinga province in 2011 also found an association between anthrax infection and contact with and consumption of contaminated hippopotamus meat. Similar to the 2016 outbreak, a vast majority (95%) of cases presented with cutaneous anthrax [3].

Regardless of the location of an anthrax outbreak or the type of anthrax infection, less than 20% of suspected anthrax cases had specimens collected for laboratory diagnosis. Of the samples that were tested from cases during the 2016 and 2017 Western province anthrax outbreaks, 46.4% tested negative for a Bacillus anthracis infection. However, nearly all suspected cases received treatment for anthrax. Collection of samples from suspected animal and human infections is required to improve anthrax surveillance and help monitor the potential development of antimicrobial resistance in endemic Bacillus anthracis strains[10].

Conclusions and recommendations

Previous efforts to control anthrax outbreaks in endemic regions include mass vaccination of livestock, quarantine of infected animals, burning or burying of animal carcasses, and sensitization of the community [5]. Despite these measures, the close proximity of people and animals and food insecurity in the region continue to drive anthrax transmission [8,11,12]. While most people are aware of the threat of anthrax, entrenched behaviors and cultural practices are difficult to change. Continued outbreaks in Western province highlight the importance of increasing community sensitization and health education campaigns in the area. Moving forward, a well-coordinated One Health approach is required to prevent animal and human anthrax infections in endemic regions of Zambia.

List of References

1. Types of Anthrax | Anthrax | CDC [Internet]. 2019 [cited 2019 Feb 26];Available from: https://www.cdc.gov/anthrax/basics/types/index.html

2. Siamudaala VM, Bwalya JM, Munang’andu HM, Munag’andu HM, Sinyangwe PG, Banda F, et al. Ecology and epidemiology of anthrax in cattle and humans in Zambia. Jpn. J. Vet. Res. 2006;54:15–23.

3. Hang’ombe MB, Mwansa JCL, Muwowo S, Mulenga P, Kapina M, Musenga E, et al. Human-animal anthrax outbreak in the Luangwa valley of Zambia in 2011. Trop. Doct. 2012;42:136–9.

4. Munang’andu HM, Banda F, Siamudaala VM, Munyeme M, Kasanga CJ, Hamududu B. The effect of seasonal variation on anthrax epidemiology in the upper Zambezi floodplain of western Zambia. J. Vet. Sci. 2012;13:293–8.

5. Moraes A. Recovering from an Anthrax epidemic: What are the control strategy challenges and policy options? Health Press Zamb. Bull 2017;1:63–6.

6. N Kasese-Chanda, Mulubwe B, Mwale F. Outbreak of Anthrax among humans and cattle in Western province of Zambia, November 2016 to January 2017. Health Press Zamb. Bull 2017;1:50–5.

7. Mwambi P, Mufunda J, Mwaba P, Kasese-Chanda N, Mumba C, Kalumbi T, et al. Cutaneous Anthrax outbreak in Chama District, Muchinga province, Zambia, 2016 as history repeats itself. Health Press Zamb. Bull 2017;1:38–49.

8. Munang’andu HM, Banda F, Chikampa W, Mutoloki S, Syakalima M, Munyeme M. Risk analysis of an anthrax outbreak in cattle and humans of Sesheke district of Western Zambia. Acta Trop. 2012;124:162–5.

9. Sitali DC, Mumba C, Skjerve E, Mweemba O, Kabonesa C, Mwinyi MO, et al. Awareness and attitudes towards anthrax and meat consumption practices among affected communities in Zambia: A mixed methods approach. PLoS Negl. Trop. Dis. 2017;11:e0005580.

10. Ågren J, Finn M, Bengtsson B, Segerman B. Microevolution during an Anthrax outbreak leading to clonal heterogeneity and penicillin resistance. PloS One 2014;9:e89112.

11. Lehman MW, Craig AS, Malama C, Kapina-Kany’anga M, Malenga P, Munsaka F, et al. Role of Food Insecurity in Outbreak of Anthrax Infections among Humans and Hippopotamuses Living in a Game Reserve Area, Rural Zambia. Emerg. Infect. Dis. 2017;23:1471–7.

12. Sitali DC, Twambo MC, Chisoni M, Bwalya MJ, Munyeme M. Lay perceptions, beliefs and practices linked to the persistence of anthrax outbreaks in cattle in the Western Province of Zambia. Onderstepoort J. Vet. Res. 2018;85:e1–8.

THE COMMEMORATION OF WORLD CANCER DAY

By: Hon. Dr Chitalu Chilufya, MP

Ministry of Health, Ndeke house, Lusaka, Zambia

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Citation Style For This Article: Hon Dr Chilufya C. The Commemoration of World Cancer Day. Health Press Zambia Bull. 2019 3(2); pp 6-7.

Today is an important day Zambia joins the rest of the World to commemorate Cancer day under the global theme: ‘I am and I will’. This day is significant because it unites the world’s population in the fight against cancer.

This year’s commemoration marks the launch of the 3-year ‘I am and I will’ campaign. ‘I am and I will’ is the empowering call-to-action urging for personal commitments and represent the power of the individual action taken now to impact the future. The local theme for this years is ‘I am concerned. I will fight cancer.’

The theme emphasizes the need for individuals to harness and mobilize the solutions and catalyze positive change in cancer prevention, control and treatment. It is in line with the Ministry of Health transformative agenda which integrates provision of promotive, preventive and screening, early diagnosis and treatment, rehabilitative and palliative health care services in the fight against cancer.

Cancer is one of the leading causes of deaths globally, with approximately 14 million new cases recorded each year.

From the WHO statistics based on data from the Zambia National Cancer Registry, the estimated total number of new cases in 2018 were over 12,000 whereas the total number of deaths were 7,380 representing approximately 60% of all new cancer cases.

Distinguished Ladies and Gentlemen,

The most frequent cancers in Zambia were cervical cancer with 3,000 new cases in 2018, followed by karposis Sarcoma at 1,700, Prostate cancer at 1,230 by breast cancer at 900. In children, the common cancers include Leukemia (cancer of the blood), Kaposi’s sarcoma (cancer of the skin), Nephroblastoma (cancer of the kidney) and Retinoblastoma (cancer of the eye).

The Patriotic Front Government under the leadership of His Excellency, Mr. Edgar Chagwa Lungu, President of the Republic of Zambia, has prioritized cancer prevention and control in its quest to attain Universal Health Coverage.

Some of the milestones scored under the cancer prevention and control program include setting up of 84 cervical cancer screening sites across the country and early treatment for pre-cancer abnormalities on the cervix.

In collaboration with traditional Leaders, the Ministry of Health has initiated village based cervical cancer screening programs with over 10,000 women accessing screening services in the their respective chiefdoms.

Following the approval of the National Human Papilloma Virus (HPV) vaccination application by Gavi, HPV vaccination will be part of the routine immunization for young girls aged nationwide starting this year.

In addition, Government through the Ministry of Health in partnership with Merck Foundation, has trained three medical officers in the super-specialties of surgical oncology, paediatric medical oncology and gynaecologic oncology, offered at Tata Memorial Centre/Hospital, a Center of Excellence in cancer care in India and the region around.

Distinguished ladies and gentlemen,

Our country now has a Zambian paediatric medical oncologist, surgical oncologist and gynaecologic oncologist for the first time. With continued partnership from Merck Foundation six doctors will be sent to India and Egypt to specialize in various fields of oncology.

Further, two more doctors are training as gynaecologic oncologists under the University of North Carolina collaboration in collaboration with Women and Newborn Hospital.

Government has partnered with St. Jude Children’s Hospital, USA to help improve treatment outcomes in children with cancer.

The Government has also advanced plans to decentralize cancer to the rest of the country with two new cancer treatment centres planned for construction on the Copperbelt and Southern provinces. These centers when established, will significantly improve cancer services in Zambia.

We have trained over 400 health workers in cervical cancer screening since inception with more than 80,000 women screened for cervical cancer in 2018.

Government is committed to expanding cancer prevention and control programs country-wide whilst ensuring financial stability, sustainability, and quality services for all our citizens.

Distinguished Guests, Let me take this opportunity to inform you that are here in Northwestern Province, two cervical cancer screening centres have been opened at Solwezi Urban Health Centre and Kalumbila Rural Health in Solwezi and Kalumbila districts, respectively. The cancer screening clinics are aimed at providing cancer preventive services as close to the people as possible.

It is important to note that approximately 30-50% of cancers can be prevented by avoiding or controlling lifestyle that are known to cause cancer. Understanding the modifiable risk factors that increase the likelihood of developing cancers such as: tobacco use, insufficient physical activity, harmful use of alcohol, unhealthy diets, cancer associated infections and environmental factors are cardinal steps in cancer prevention.

We can also reduce our risk from many cancers by maintaining a healthy weight and being physically active. Being overweight or obese increases the risk of 10 cancers namely bowel, breast, uterine, ovarian, pancreatic, esophagus, kidney, liver, prostate and gallbladder cancers. We need to make specific changes to our diets like limiting the intake of red meat and avoiding processed meat. Alcohol is also strongly linked with and increases risk of several cancers. Reducing alcohol consumption decrease the risk of cancers of the mouth, esophagus, bowel, liver and breast (Tobacco use also increases the risk of many cancers including that of the lung, head and neck cancers, cervix and bowel) More than a third of common cancers could be prevented by a healthy diet, being physically active and maintaining a healthy body weight. Everyone can make healthy lifestyles choices to reduce their risk of cancer.

Distinguished Guests, Ladies and gentlemen

As we live healthier lifestyle and periodically screen for cancers let us remember that early detection improves outcomes for most cancers. Early detection could be the difference between successful and unsuccessful treatment. Early detection saves lives. For a number of cancers, increasing awareness of how cancer presents and the importance of timely treatment has been shown to improve survival. This is because finding cancer early almost always makes it easier to treat or even cure. Public awareness campaigns and workplace health and wellbeing initiatives are important communication platforms to raise awareness of cancer and encourage people to seek help promptly. With the right information, individuals can be encouraged to know what is normal for their body and to recognize any unusual or persistent changes.

Maintaining social support networks and talking about cancer are important strategies for coping with the social and emotional impact of cancer, both in the short and long term.

This is true for both the person living with cancer and their care givers. Support can come from many sources; partners, friends, family, colleagues, healthcare professionals and counsellors with some people choosing to join self-help or support groups. The support can provide caring and supportive environment for people living with cancer to express their feelings and reduce anxiety and fear.

Distinguished Guests, The Government of Zambia with various partners and stakeholders has worked tirelessly to ensure that cancer prevention and treatment is prioritized. We have made tremendous progress in cancer prevention and control as a country. I would like to take this opportunity to acknowledge the strong collaboration between my ministry and various cooperating partners for the support and strengthening community systems and structures for cancer control services.

It is important to note that the fight against cancer faces numerous challenges such as inadequately skilled manpower, low awareness levels and the general misconceptions that members of the public hold, which leads to late detection of the disease.

However, the theme “I am and I will “highlight the ability of every individual to fight the cancer battle and challenges each and every one of us to take action. It is time to make a personal commitment to fight cancer. Challenges are however not insurmountable. The theme for this year reminds us that as a collective and as individuals we can help reduce the burden of cancer. “I am concerned and I will fight cancer “. In conclusion, the call to action in preventing cancer is asking you to stop smoking, reduce alcohol intake, increase physical activities and eat healthy diets with lots of fresh fruits and vegetables.

I thank you all and God bless!

CANCER – AN EMERGING HEALTH PROBLEM: THE ZAMBIAN PERSPECTIVE

By: L Banda¹, T Nyirongo¹, M Muntanga¹

1. Cancer Diseases Hospital, Lusaka, Zambia

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Citation Style For This Article: Banda L, Nyirongo T, Muntanga M. Cancer – An Emerging Health Problem:The Zambian Perspective. Health Press Zambia Bull. 2019;3(2); Pp 2-4.

The word “Cancer” has in the recent past become as common in people’s vocabulary as many other diseases. Whereas HIV and AIDS, diabetes, cardiovascular diseases and other communicable diseases such as malaria were the most spoken of diseases, non-communicable diseases such as cancer have now taken centre stage as some of the major causes of morbidity and mortality in the world and in Zambia in particular. According to the chief of the clinical radiation oncology branch at National Cancer Institute, Dr. Bhadrasain Vikram, the more common traditional health concerns of the developing world are infectious disease and malnutrition. Yet over the past two decades, the incidence, disease burden and risk for cancer-related mortality in low- and middle-income countries has increased dramatically [1]. Previously seen as a disease of the rich, cancer and its ravaging effects are now more common place and conspicuous in our communities. According to the Economist Magazine in an article titled “Cancer in the developing world”, Cancer has become more common than TB, Malaria, HIV and AIDS combined.

The National Cancer Institute of America defines Cancer as a name given to a collection of related diseases. It is not one disease, prognosis and response to treatment depend on the nature of the cancer. To understand what cancer is, we have to understand that throughout our lives, healthy cells in our bodies divide and replace themselves in a controlled fashion. Cancer starts when a cell is somehow altered so that it multiplies out of control. A tumour is a mass composed of a cluster of such abnormal cells [2]. Most cancers form tumours, but not all tumours are cancerous. Benign, or noncancerous, tumours do not spread to other parts of the body, and do not create new tumours. Malignant, or cancerous, tumours crowd out healthy cells, interfere with body functions, and draw nutrients from body tissues. Cancers continue to grow and spread by direct extension or through a process called metastasis, whereby the malignant cells travel through the lymphatic or blood vessels, eventually forming new tumours in other parts of the body.

In all types of cancer, some of the body’s cells begin to divide without stopping and spread into surrounding tissues. Cancer can start almost anywhere in the human body. Normally, human cells grow and divide to form cells as the body needs them. When cells grow old or become damaged, they die and new cells take their place. However, when cancer develops, this orderly process breaks down. As cells become more and more abnormal, old or damaged cells survive when they should die, and new cells form when they are not needed. These extra cells can divide without stopping and may form growths called tumours. The cancer is named according to the tissue or organ of origin such as cervical cancer is from the cervix and prostate cancer being cancer that affects the prostate gland.

Factors contributing to the high cancer burden are many and include among others, increased contact with infectious agents such as HPV (which causes cervical cancer), environmental factors such as exposure to chemical and toxins, social factors such as tobacco use, alcohol abuse, sedentary lifestyle, poor diet and others.

Global situation

In 2016, The World Health Organisation (WHO) estimated that of the 56.9 Million deaths recorded in that year globally, 40.5 Million (71%) of the deaths were due to Non Communicable Diseases [3] of which cancer accounted for 9.0 million deaths (22% of all NCDs). The burden of these diseases is rising disproportionately among lower income countries and populations. In 2016, over three quarters of NCD deaths (31.5 million) occurred in low-income and middle-income countries with about 46% of deaths occurring before the age of 70 in these countries. The International Agency for Research on Cancer (IARC) estimates that about 4.42 million women of ages 15 and above are at risk of developing cervical cancer in Zambia. Current estimates indicate that every year 2,994 women are diagnosed with cervical cancer and 1,839 die from the disease [4].

Zambian situation and mortality

In Zambia, the onset of NCDs is often insidious. Patients often present in middle age and when the disease is advanced. Over 80% of mortality from NCDs is also caused by the above mentioned NCDs which are a major cause of disability and premature death and contribute substantially to the escalating costs of health care. Among the four NCDs in Zambia, cancer has had significant morbidity and mortality, especially cancers that affect women namely Cervical and Breast Cancers. Other cancers of prominent incidence include Prostate, Kaposi’s sarcoma. The Zambia National Cancer Registry estimates that in 2018 there were over 12,000 new cancer cases countrywide with 7,380 deaths approximately 60% of all new cases. The most frequently cancers in Zambia in 2018 were cervical cancer with 3,000 new cases, followed by Kaposi’s sarcoma at 1,700, Prostate cancer with 1230 and breast cancer with 900 cases. Children’s cancers commonly diagnosed include Leukaemia (cancer of the blood), Kaposi’s sarcoma, Nephroblastoma and Retinoblastoma [5].

Cancer Diseases Hospital has to date seen over 21,000 cancer patients since inception in 2006. In 2018, the cancer diseases hospital saw 2,734 new cancer patients with cervical cancer leading followed by breast cancer, prostate, lymphomas and Kaposi’s sarcoma in that order. Total admission for the hospital in 2017 was 3967 of which 570 mortalities were recorded. In 2018, there was a reduction in mortality to 424 against total admission of 3718 [6].

Late presentation

As previously mentioned, most of the cases recorded on cervical cancer, as with most other cancers are late presentations. This means diagnosis is made late. The disease is detected late and at the time of diagnosis the diseases may have advanced and spread to other parts of the body. Late presentations are one of the highest reasons for mortality. Patients present late because of a number of reasons. These include among others: lack of diagnostic and treatment facilities close to their homes, centralised treatment facilities only available in Lusaka, Socio-economic, cultural, and other reasons that all lead to patients inability to access services [7].

Poor health seeking behaviour

Poor health seeking behaviour due to lack of information about cancer or fear of the unknown is another reason people present late. In some cases the lack of information by health providers. Socio-economic factors also have a role to play in whether or not a person will seek medical attention immediately they show symptoms of cancer. Issues of long distances to the nearest health facility, poor diagnostic capabilities of health centres in their localities and sometimes unfriendly health personnel who may not have enough information on cancer will in most cases deter a person from seeking medical attention resulting in disease progression and late presentation.

There are unfortunately a lot of social and cultural factors that hinder quick medical diagnosis of cancer. Though some are primarily because of lack of information about the causes, risk factors and treatment of cancer, others are because of beliefs and cultural norms such as seeking the attention of a traditional healer, beliefs that cancer is caused by witchcraft. These myths and misconceptions deter people from identifying the disease for what it is and seeking medical attention for it [8].

In Zambia, cancer is managed using various modalities such as surgery, radiotherapy and chemotherapy, nuclear medicine, and palliative care among others. Management is not without its challenges. Infrastructure, machinery, human capital, supplies and logistics required for effective management of the disease comes at a high cost. Cancer Diseases Hospital provides out-patient, in-patient, radiotherapy, chemotherapy, Paediatric oncology, surgical and gynaecological oncology, nuclear medicine, diagnostic services (radiology and laboratory), nutrition and palliative services. This is the only comprehensive cancer management centre in the country. With plans to decentralise cancer management services to all provinces of the country, which begins in 2019 by construction of the Ndola and Kitwe cancer treatment centres, challenges of distance to treatment facilities will be a thing of the past. This will eventually interpret into better accessibility and subsequent better treatment outcomes.

Some of the interventions that have been embarked on in the effort to reduce the disease burden include among others: Health promotion to raise awareness about cancer, the importance of prevention and screening, early diagnosis and treatment, and palliative care for those that come with advanced and metastatic diseases. As a country, we have prioritised four cancers that include cervical, prostate, breast and retinoblastoma. Beginning this year, vaccinations against HPV will commence for girls aged 9 to 14 years. Together with the cervical screening programme that is in progress, vaccinations will significantly reduce the number of cases the country is recording. It is important to know that cancer is preventable and curable if diagnosed at an early stage. There is need for people to avoid exposure to risk factors of cancer.

cervical, prostate, breast and retinoblastoma. Beginning this year, vaccinations against HPV will commence for girls aged 9 to 14 years. Together with the cervical screening programme which is in progress, vaccinations will significantly reduce the number of cases the country is recording.

It is important to know that cancer is preventable and highly curable if diagnosed at an early stage. There is need for people to avoid exposure to risk factors of cancer.

List of References

1. Vikram B. Cancer: the new challenge for health care in the developing world. URL: https://www.healio.com/hematology-oncology/practice-management/news/print/hemonc-today/%7B1e62b7a5-8940-4fda-8934-51fdbc394b03%7D/cancer-the-new-challenge-for-health-care-in-the-developing-world.

2. National Cancer Institute. Understanding cancer. What is cancer? URL: https://www.cancer.gov/about-cancer/understanding/what-is-cancer

3. NCD Countdown 2030 collaborators. NCD Countdown 2030: worldwide trends in non-communicable disease mortality and progress towards Sustainable Development Goal target 3.4. Lancet 2018;392(10152):1072-88; WHO. Global Health Observatory (GHO) data: NCD mortality and morbidity. URL: https://www.who.int/gho/ncd/mortality_morbidity/en/.

4. World Health organization. Global Health Observatory (GHO) data. NCD mortality and morbidity. URL: https://www.who.int/gho/ncd/mortality_morbidity/en/.

5. Ministry of Health [Zambia]. Zambia National Cancer Registry Report 2018. Ministry of Health: Lusaka, Zambia

6. Ministry of Health [Zambia]. Cancer Diseases Hospital Annual Report 2018. Ministry of Health: Lusaka, Zambia

7. Ministry of Health [Zambia]. National Cancer Control Strategic Plan 2016 -2021. Ministry of Health: Lusaka, Zambia

8. World Health Organization. Beyond World Cancer Day: Raising Awareness, Dispelling Myths About Cancer. URL: https://afro.who.int/news/beyond-world-cancer-day-raising-awareness-dispelling-myths-about-cancer.

I AM, I Will

By: ML Mazaba

Zambia National Public Health Institute.

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Citation Style For This Article: Mazaba ML. I AM, I Will. Health Press Zambia Bull. 2019 3(2); pp 1.

The Health Press Zambia (THP-Z) welcomes you to its second issue of 2019. We join the rest of the world in celebrating WORLD CANCER DAY (WCD) which fell on 4th February 2019. The 2019 World Cancer Day theme “I Am, I Will” is translated by the organizers in many words; “Whoever you are, you have the power to reduce the impact of cancer for yourself, the people you love and for the world. It’s time to make a personal commitment”.

The Zambian team tweaks the theme to read “I Am Concerned, I Will Fight Cancer”

The themes are aimed at empowering call-to-action urging for personal commitment and represents the power of individual action taken now to impact the future.

I believe this should be so not just for cancer but for all health issues as a matter of fact. There is need for any human being to take charge of their health issues.

To celebrate WCD we publish a number of articles on cancer including the guest editorial entitled ‘Cancer – An Emerging Health Problem: The Zambian Perspective ‘, a ministerial speech addressed by the Honourable Minister of health under the perspective section, an original research on late gastric cancer diagnosis “Delayed referral for diagnostic endoscopy is a contributing factor of late gastric cancer diagnosis in Zambia’

Early diagnosis and treatment has been known to allow for better outcomes in cancer and in order to not fall easy prey to the devastating condition of cancer, we encourage you our readers to take responsibility of your own health, get concerned and fight for your own health.

This issue has in addition an outbreak report on Anthrax in the Western Province of Zambia and a review of anthrax in the entire country, between 2016 and 2018 from the IDSR data.

Enjoy the read as you await yet another issue