Monthly Archives: October 2019

INFLUENZA SENTINEL SURVEILLANCE REPORT

National Influenza Center – Pathology and Microbiology Department,
University Teaching Hospital, Virology Laboratory

Methodology for Establishment of Epidemic Thresholds
Thresholds are calculated using Moving Epidemic Methods (MEM), a sequential analysis using R language available from: http//CRAN.R-project.org/web/package =mem) designed to calculate the duration, start and end of the annual influenza epidemic. MEM uses the 40th, 90th and 97.5th percentile established from available years of historical data to calculate threshold activities. Threshold activity for influenza is categorized as: below epidemic threshold, low, moderate, high or very high. Transmissibility of influenza can be inferred from ILI data while SARI data gives an indication of severity.

Summary

There was increased influenza activity in the second half of 2019 between epi-weeks 31 and 35. Rates of Influenza-Like Illness (ILI) and Severe Acute Respiratory Infection (SARI) attributable to influenza virus infection were within the moderate-high threshold and remained within the low seasonal threshold. This second cycle of activity was of high transmissibility and low severity. Children below five years of age were most affected.

ILI Surveillance:
Specimens from 719 outpatients were received from two ILI surveillance sites. 587 (82%) were adequately sampled and tested. Influenza virus was detected in 82 (14%) of these samples of which, 54 were identified as Influenza B, 3 Influenza A H3N2, 3 Influenza A H1N1 (pandemic), 18 influenza A Untyped and 4 as Influenza A unsubtypeable.
SARI Surveillance:
During this same period, specimens were received from 1242 patients admitted to four SARI surveillance sites. 801 (64%) were adequately sampled and tested. Influenza was detected in 93 (12%) specimens; 68 of which were identified as Influenza B, 1 as Influenza A H3N2, 5 as Influenza A H1N1 (pandemic), 16 influenza A Untyped and 3 as Influenza A unsubtypeable.

Influenza Transmissibility
Fig 1: Percentage of Influenza Positive ILI Cases1 (Out-Patient Visit Surveillance) per Epi-Week Against Epidemic Thresholds Set Using 2013 – 2018 Data

1ILI Case / Total ILI Sampled *100
In August 2019, ILI outpatient visits attributable to influenza virus infection were above the moderate epidemic threshold between weeks 31 and 34.

30th June 2019: Influenza Severity (Impact)
Fig 2: Hospital Admission Surveillance1 – (SARI Surveillance) for Influenza Detection and Epidemic Thresholds *

SARI Case / Total Admission Sampled *100
*Threshold based on 2013 – 2018
In August 2019, a SARI admission attributable to influenza virus infection rose to moderate threshold in week 31 but has remained in low epidemic threshold from week 34 to week 35.

Fig 3: Positives samples* by influenza types and detection rate by weeks in 2019.

*Influenza viruses circulating in the first half of 2019 were predominantly influenza B. There was also random detection of influenza A. Among the influenza A viruses that have been subtyped, H1N1 (Pandemic) and H3N2 were seen. Most viruses were detected between weeks 5 and 16

Fig 4: Number of Influenza Positive Cases by Age Group

The virus circulation was greater at either end of the age spectrum but the most affected age groups were the under-fives

Fig: 5: Cumulative number of influenza types and subtypes and total number of samples tested by sentinel sites.

The total number of samples collected as at 31st August 2019, is 1961; 1671(85%) were tested. 173 (10.4%), were positive for influenza virus and 1498 (89.6%) were negative.

INTEGRATED DISEASE SURVEILLANCE AND RESPONSE (IDSR)Week 35 – Epidemiology Bulletin – 22 August to 1 September 2019

C. Groeneveld, M. Banda, N. Kayeyi, ML. Mazaba, M. Kapina

Surveillance and Disease Intelligence Unit

Zambia National Public Health Institute

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Weekly Summary

Current outbreaks
Cholera: Seven (7) cases were reported from 27 to 30 August from Nsama district, NorthernProvince. Of these six 6 were culture confirmed positive for V Cholerae Inaba 0139
Rabies: Four (4) cases were reported with one (1) fatality from Mumbwa District from a suspected rabid dog. Three(3) cases are being treated with post-exposure prophylaxis for rabies
Ebola Virus Disease: Zero cases were reported
Immediately notifiable
Acute Flaccid Paralysis (AFP): Ten (10) cases were reported from Copperbelt (3), Northern (2), Luapula (2), Western (2) and Lusaka (1) provinces. Simples are under investigation for poliovirus
Measles: A total of six (6) cases were reported this week from Lusaka (3), Eastern (1), NorthWestern (1) and Luapula (1) provinces. Four specimens were investigated for measles & rubella
Maternal Deaths: Thirteen (13) maternal deaths were registered from Lusaka (5), Northern (3),
Eastern (1) Central (1), Muchinga(1), Western (1) and Luapula (1) provinces
Other diseases
Trypanosomiasis: Two (2) suspected cases were recorded from Nyimba district, Eastern Province with one fatality. One (1) confirmed case with T b rhodesiense is under treatment. dysenteriae

Regional Public Health Events

Source: WHO Weekly Bulletin on Outbreaks & Other Emergencies, Health & Emergencies Program
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PAPER AND ELECTRONIC HEALTH FACILITY REPORTING COMPLETENESS WEEK 34 TO 35

OUTBREAKS

Cholera Outbreak

 Seven (7) cases of suspected cholera were reported in Nsama district in week 35.

 The cumulative number of cases reported in Nsama by 1 September is 13 with nine (9) culture positives.

 Nationwide, 448 suspected cases of cholera (CFR = 2.5%) have been recorded from Lusaka and Northern provinces (Lusaka , Nsama , Mbala, and Mpulungu) since week 1.

HIGH PRIORITY DISEASES

Maternal Deaths

Thirteen maternal deaths were registered from Lusaka (5), Northern (3), Eastern (1) Central (1),Muchinga(1), Western (1) and Luapula (1) provinces.

Obstetric hemorrhages continue to be the leading cause of death.

Lusaka province has cumulatively recorded the highest number of deaths since week 1.

VACCINE PREVENTABLE DISEASES

SUMMARY REPORT PRIORITY DISEASES, CONDITIONS AND EVENTS (WEEK 35)

HIGH BURDEN DISEASES

HIGH BURDEN DISEASES

33,301 cases were tested in the week under review, with a positivity rate of 6.0.

Lusaka and Central provinces have cumulatively reported high numbers of new cases from week 1.

EARLY WARNING DISEASES
Ebola Virus, DRC and Uganda , 2018-2019

PUBLIC HEALTH ACTIONS

General Recommendations

Response pillars at ZNPHI to continue working with partners to strengthen surveillance, laboratory and epidemic preparedness for EVD, Cholera, Measles and other public health threats

Provincial health with veterinary municipalities should quickly respond to suspected of cases rabies, promote vaccination of dogs and sensitize communities on rabies prevention /treatment

Provinces to oversee that epidemic preparedness consumables (including vaccines ) are available for timely distribution to districts experiencing outbreaks or at high risk of outbreaks

Provinces should ensure that epidemic preparedness committees (provincial and districts) are functional, represented by all key multisector stakeholders & hold regular meetings to routinely discuss response activities

Ebola Virus Disease Preparedness

All provinces to strengthen EVD surveillance among all health care providers and raise community awareness of EVD prevention

Provide weekly reports in IDSR reports of active searches including zero reporting in at riskdistricts, including ports of entry

Ensure epidemic preparedness measures for detecting cases, sample testing / transportation and managing cases are effected

All border districts to strengthen the point of entry EVD screening including facilitation of cross-border monitoring and reporting of suspected EVD cases

Vaccine-Preventable Disease Surveillance in Silent Districts

Provinces to ensure silent districts not reporting AFP/measles cases are supported for active surveillance

DHMTs are encouraged to sensitize health workers for improved detection, reporting and investigation of suspected measles cases.

Provincial health offices to ensure sub regional attainment of the Non-Polio AFP and non Febrile Rash rate of 2 cases per 100,000

Prioritize sample referral of suspected cases to the national reference laboratory

Active Surveillance in Cholera Hotspots

Nsama and neighbouring districts to continue to support the ongoing outbreak through heightened active surveillance, management of cholera cases and timely reporting of epidemiological changes

Health education to sensitize communities and health workers on cholera preventative measures

WASH continue water monitoring and distribution of chlorine in identified at risk populations

Provincial epidemic preparedness committee’s to engage all relevant government stakeholders and multisector partners required to prevent cholera outbreaks

Reported by: Surveillance and Disease Intelligence Unit

Writers: Chanda Groeneveld, Muzala Kapin’a, Moses Banda, Nkomba Kayeyi, Mazyanga M Liwewe, VictorMukonka and Zambia National Public Health Institute (ZNPHI

ZAMBIA FIELD EPIDEMIOLOGY TRAINING PROGRAM UPDATES— JULY THROUGH SEPTEMBER 2019

Zambia National Public Health Institute

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During August 5-9, 2019, Zambia Field Epidemiology Training Program (ZFETP) conducted a third and last workshop for the fourth cohort of frontline Field Epidemiology Training Program (FETP) comprised of 21 residents; all the 21 residents graduated successfully (Figures 1 and 2).

Figure 1: Director ZNPHI, resident advisor and facilitators in a group photo with frontline cohort 4 graduates

Figure 2: Director ZNPHI hands over a certificate of completion to a Frontline FETP graduate

Participation in International Conferences
Three recent graduates from Zambia Advanced FETP have been selected to participate in the 10th TEPHINET global conference that will be held in Atlanta during 28 October through 1 November 2019. Two of the residents will make poster presentations while one will give an oral presentation.
Cohort Three Advanced FETP
Current cohort three of Advanced FETP completed the six months classroom work at the University of Zambia and have all reported in their field sites. Prior to reporting in their field sites, the field supervisors and residents were called in one central place for an orientation meeting on the expected deliverables in the field including roles of mentors and supervisors (Figures 3 and 4). During the meeting memorandums of understanding for field placements were signed.

Figure 4: Program Director making a presentation during the orientation meeting

Field Placements for Current Advanced Residents
Two residents have been assigned to National Malaria Elimination Centre; two at Zambia National Public Health Institute under surveillance, and epidemic preparedness and response; two at Ministry of Health department of public health; one and a tropical disease research centre; and three at provincial health offices. All the 10 residents have settled well and on course with their deliverables (Figure 5).

Figure 5: One of the residents at the field sites; office space and furniture provided.

New Resident Advisor for Zambia
Dr Jonas Hines arrived in Zambia to take over from Dr Ellen Yard; both were present during the orientation for current residents with the supervisors; this was strategic to allow for continuity of the support to Zambia FETP.

“RHD WEEK” HIGHLIGHTS EFFORTS TO ELIMINATE RHEUMATIC HEART DISEASE IN ZAMBIA

Perspective

J Musuku1, S Schwannger2

Children’s Hospital, University Teaching Hospital
Global Health, Novartis Institute of Biomedical Research, Cambridge, MA, USA

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Rheumatic heart disease (RHD) is the most common heart problem in young people in Zambia. It causes fatigue, breathlessness, swollen limbs, and frequently requires surgery. Left untreated, it can lead to premature death. Rheumatic heart disease has traditionally received little attention in Zambia but that is now changing. University Teaching Hospital (UTH) in Lusaka has launched a new multi-faceted initiative called “BeatRHD Zambia” with the aim of eventually eliminating RHD. The group, along with the Zambia Paediatric Association, spearheads the commemoration of World Rheumatic Heart Disease during the week of August 3-7, 2019 to increase public education and awareness about the disease and on the 29th September for the World Heart Day every year.
The BeatRHD Zambia team is led by Dr. John Musuku, a paediatric cardiologist at UTH, and is a joint effort with the Ministry of Health; Ministry of Education; Ministry of Community Development, Mother and Child Health; University of Zambia; University of Cape Town; and Novartis. BeatRHD Zambia is an extension of a broader initiative led by the Pan-African Society of Cardiology since 2006 to combat RHD throughout Africa. As part of these activities, WHO and the African Union Commission have recently endorsed RHD policy roadmaps.
“We are partnering with government clinics and schools in Lusaka district to educate families about how a sore throat can lead to a broken heart,” said Dr Musuku. “A bacterium called Strep is a frequent culprit that causes sore throat in children. Left untreated, Strep throat can lead to a condition called rheumatic fever and then to rheumatic heart disease. It is entirely preventable. All we must do is
ensuring that our children with sore throats receive prompt medical attention.”
Symptoms of Strep throat include pain, redness, or white patches in the throat. Also, the neck glands may be swollen and children may complain of stomach pain. The treatment is an antibiotic. The most commonly used antibiotic for Strep throat is penicillin. A single injection is all that is needed to treat Strep throat and prevent the risk of RHD.
Dr. Musuku spearheaded a large research study to measure the prevalence of rheumatic heart disease in Zambia in 2016. This was the first time in 25 years that such an investigation had been conducted. In the study, teams of doctors, nurses, and ultrasound technicians screened several thousand children in 50 Lusaka schools using state-of-the-art handheld echocardiography. The results are helping to advocate for health services that can prevent RHD. Children who are identified to have RHD receive treatment in a local health clinic and long-term medical care at UTH.
The BeatRHD Zambia team is also working directly with Lusaka health clinics to improve the diagnosis and treatment of Strep throat. The BeatRHD Zambia team hopes to be able to work with health clinics across the country over the next years.
RHD Week is held annually in Zambia in order to raise public awareness about the disease. RHD Week activities include a speech by the Minister of Health; display of educational posters and distribution of educational materials at shopping malls and a March Pass
“In the effort to eliminate RHD, we all have essential roles to play,” said Dr. Musuku, “it is up to parents and guardians to seek medical attention for their children when they complain of a sore throat. If all children with Strep sore throat are treated promptly with a single injection of penicillin, Zambia can stop RHD in our lifetime.”

Photo caption: “Dr. John Musuku from University Teaching Hospital demonstrates to Lusaka district schoolteachers the state-of-the-art handheld echocardiography device that is being used in a large research study to detect children with rheumatic heart disease.”

“The van used by the BeatRHD Zambia team helps to spread the educational message that untreated Strep sore throats can lead to rheumatic heart disease.”

BREASTMILK AND BREASTFEEDING – AN ASSURANCE OF GOOD HEALTH FOR ALL

Editorial

ML Mazaba
Zambia National Public Health Institute

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All things being equal every human being postpartum has the privilege of having a fully balanced nutritional liquid meal –BREASTMILK- containing essential nutrients, antibodies and other factors important for growth and development [1].

Breastmilk, a uniquely superior infant feed contains 88% water; no wonder a baby is easily calmed. Other important nutrients include: Proteins; Fats; Carbohydrates; Minerals; Vitamins; and trace elements. Another important component of breastmilk is Immunoglobulins A (IgA), G (IgG) and M (IgM) which are essential to the immunological link that occurs during the transfer of passive immunity from mother to infant [2].
Breast milk proteins are key in infection-protection from infectious agents such as yeast, bacteria, viruses and coliforms, while fats are useful in brain, retina and nervous systems development, absorption of fat-soluble vitamins,
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and are a source of primary calories. Carbohydrates, mostly consisting of lactose help to fight disease and promote the growth of healthy bacteria in the stomach with vitamins being essential to the infant’s health [3].
There is overwhelming evidence that Breast feeding should start immediately after birth, with exclusive breastfeeding for six months. The benefits to breastfeeding are overwhelming. World Bank – Human Development President Annette Dixon blogs “Breastfeeding can help avoid over 800,000 child deaths and 20,000 maternal deaths globally per year, from several causes including breast cancer and other forms of cancers, diabetes and other illnesses. In addition, breastfeeding is also one of the most sustainable elements of the food system, with zero carbon emissions and no food waste” [4].
The Health Press encourages breastfeeding and support the idea of longer maternity leave as well as establishment of breast feeding friendly corners. Some studies have indicated that to encourage and increase the rate of continued breastfeeding, there is a need for dedicated breastfeeding comfortable and clean rooms. We endorse the call by many that breast feeding is best for babies and must all play a part in making it a priority for all.
Please feel free to go beyond the editorial and look at the perspective on Rheumatic Heart Disease in Zambia and catch up on the status of some notifiable diseases in Zambia published in the Influenza and IDSR bulletin.

LIST OF REFERENCES

Infant Nutrition Council. www.infantnutritioncouncil.com/resources/breastmilk-information/
Hurley WL, Theil PK. Perspectives on immunoglobulins in colostrum and milk. Nutrients. 2011;3(4):442–474
American Pregnancy Society. https://americanpregnancy.org/first-year-of-life/whats-in-breastmilk/
Annette Dixon. Breastfeeding: A Foundational Investment in Human Capital. https://blogs.worldbank.org/health/breast feeding-foundational-investment-human-capital
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