By : BM Katemba, CMwango, JM. Nkaama, C Chunga, D Mwansa, D Mushinge, K M Banda National Health Research Authority

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Citation Style For This Article: Katemba BM, Mwango C, Nkaama JM, Chunga C, Mwansa D, Mushinge D, Banda KM. Reduce salt intake, Save a heart! Reduced Morbidity and Mortality Due to Hypertension. Health Press Zambia Bull 2020; 04(2); pp 6-10.

Key Messages

• Circulatory diseases are the third leading cause of death in Zambia

• Hypertension is a silent killer; most people do not know they have it

• Hypertension is non-curable but can be controlled

• In Zambia, hypertension accounts for the highest proportion of deaths due to cardiovascular diseases

• On average, 670 people die every year due to hypertension in Zambia

• Reduced sodium intake can increase someone’s life expectancy by 5-6 years

• The consumption of sodium among Zambians is twice as high (9.5 grams) as the World Health Organization (WHO) recommended (5 grams) per day

Problem Statement

Hypertension, also known as high or raised blood pressure, is a global public health issue. The condition rarely causes symptoms in the early stages and a lot of people go undiagnosed. Those who are diagnosed may not have access to treatment and may not be able to successfully control their illness overtime[ “Global_ brief_hypertension.Pdf.”]. It is currently estimated that 34.8% of the adult population (18-69 years) in Zambia are living with hypertension[ “Zambia-NCDSTEPS-Survey-Report-2017 (1).Pdf.”].

In 2016, hypertension accounted for 3.3% of all deaths in Zambia[ “2016 VITAL Statstics Report.Pdf.”]. Risk factors include unhealthy diet, harmful use of alcohol, lack of physical activity, excess weight, and stress[ Franco OH, Peeters A, Bonneux L, de Laet C: Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women. Hypertension 2005, 46:280.]. Diet has been identified as one of the major contributing factors to hypertension in Zambia[ “ZMB_B3_NCDs Strategic Plan. Pdf.”]. Research has shown that excess consumption of sodium is associated with an increased risk of hypertension and cardiovascular diseases. The 2017 Steps survey shows that Zambians consume an average of 9.5 grams of sodium/salt per day. This is nearly double the WHO recommended limit of 5 grams per day[ “Zambia-NCD-STEPS-Survey-Report-2017 (1). Pdf.”].

Reducing sodium intake has been identified as one of the most cost-effective measures countries can take to reduce hypertension incidence and improve health outcomes in hypertensive patients[ “Policybrief34.Pdf.”] yet Zambia is one of the countries that has no strategy on regulating sodium intake[ Trieu, K., Neal, B., Hawkes, C., Dunford, E., Campbell, N. C., RodriguezFernandez, R., Legetic, B., McLaren, L., Barberio, A. & Webster, J. (2015). Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target. PloS One, 10(7), e0130247. doi: 10.1371/journal. pone.0130247].

According to different studies done by WHO, the main source of consumed sodium is processed foods and ready-made meals[ “Global_brief_hypertension.Pdf.”]. With a great availability of processed foods in Zambia, regulating the amount of sodium in processed foods can prevent 2,716 deaths annually.

1.Maintain status quo The current status in Zambia is that there is no strategy to reduce sodium intake despite overwhelming evidence showing the benefit of sodium reduction on reducing hypertension. Sodium consumption in Zambia is currently double WHO’s recommended daily intake. With the current status, 34.8% of the adult population in Zambia are living with hypertension[ “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”]. As of 2016, a total of 36,400 premature deaths[ “Zmb_ en.Pdf.”] were recorded as a result of NCD and 3.3% were as a result of hypertension[ “2016 VITAL Statstics Report.Pdf.”]. 2.Mandatory regulation of the amount of sodium in processed foods and labelling What: Pass legislation on regulating the amount of sodium in processed foods. Manufacturers and importers are compelled by law to adhere to set standards. Sodium levels in food will be checked to make sure that companies are complying with the standards.

Why: The main source of food in most countries is ‘processed food’ and ready-made meals[ “Policybrief34.Pdf.”]. 70% of the consumed foods in Zambia is purchased[ Global Panel on Agriculture and Food Systems for Nutrition. (2016). Food systems and diets: Facing the challenges of the 21st Century. London: Global Panel] and studies have further shown that 70% of the consumed sodium/salt comes from processed foods[ https://www.cdc.gov/ salt/pdfs/sodium_role_processed.pdf]. Zambians consume 9.5 grams of sodium/ salt per day[ “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”] and currently, 34.8% of the people in Zambia are living with hypertension[]. Sodium reduction at 2.0 to 2.3 grams per day significantly decreases the risk of cardiovascular diseases by 20%[ Ha S. K. (2014). Dietary salt intake and hypertension. Electrolyte & blood pressure: E & BP, 12(1), 7–18. doi:10.5049/EBP.2014.12.1.7]. According to literature, 15% reduction in the sodium/salt intake translates to 3/1.4mm Hg drop in the average blood pressure in the adult population between a period of 8 years[ Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S, et al. National Diet & Nutrition Survey— Assessment of dietary sodium in adults (aged 19 to 64 years) in England, 2011. Department of Health; 2011 [cited 2014 29 October]. Available: https://www.gov.uk/government/ uploads/system/ uploads/attachment_ data/file/213420/Sodium-Survey-England-2011_Text_to-DH_FINAL1.pdf.] [ He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open. 2014 April 1, 2014; 4(4).]. Mandatory reduction of sodium/ salt addition in manufactured foods will reduce 70% of the daily consumed sodium/salt.

Feasibility: High. This policy option builds on government efforts to fight NCDs in the country. It will require a legal framework, sensitization of food manufacturers and enforcement officers to ensure that manufacturers adhere to the set standards.

3.Voluntary collaboration with food manufactures to regulate the amount of sodium in processed foods What: Engage food associations and food manufacturers to reduce the sodium content in their product portfolio. Manufactures will voluntarily participate in the programme and will sign an agreement with the responsible ministry to commit to gradual and progressive reduction of sodium content in manufactured foods. In the event of noncompliance, the responsible line ministry will issue a written notice in order to demand regularization. There will be no penalties for not conforming to the agreement.

Why: As established, 70% of the consumed sodium comes from processed and commercially prepared food. With this approach, it is expected that 62% of the manufacturers will comply[ https://ajph. aphapublications.org/doi/abs/10.2105/ AJPH.2016.303397] to set sodium reduction standards and 2,039 deaths will be averted annually.

Feasibility: High. To increase the feasibility of this policy option, there is need to engage food manufacturers from the initial stage of developing sodium reduction guidelines.

4.Health promotion and increased awareness of sodium intake via mass media and health care providers

What: Conduct Mass media awareness campaigns to raise consumer awareness and education on the dangers of unregulated sodium/salt intake.

Why: On average, 39% of households in Zambia have access to information through television or radio[ 2018 National Survey on Access and Usage of Information and Communication Technologies by Households and Individuals]. Through this strategy, 53%[ https://www.indexmundi. com/zambia/demographics_profile.html] (3,564,894) of people living in Zambia will be reached with campaign messages and it is expected that 59%[ https:// www.lusakatimes.com/2016/05/11/ local-manufacturers-told-improve-quality-products/] (2,103,288) will adhere to sodium/salt reduction messages although only 2 g/day reduction in sodium/salt is expected to be achieved by compliant volunteers[ Hyseni, L., Elliot Green, A., Lloyd-Williams, F., O’Flaherty, M., Kypridemos, C., McGill, R., Capewell, S. (2016). P48 Systematic review of dietary salt reduction policies: evidence for an “effectiveness hierarchy”? Journal of Epidemiology and Community Health, 70(Suppl 1), A74.2–A75.doi:10.1136/jech- 2016-208064.147].

Feasibility: High. This policy option builds on the already existing health promotion strategy that the ministry has adopted in tackling non-communicable diseases. This action will require behavior change and adherence of sodium/salt reduction messages by end users.

Policy Recommendations

Based on these findings, we can conclude that the mandatory regulation of sodium/salt uptake in processed foods is the most cost-effective method of curtailing hypertension in Zambia. The findings indicate that this intervention would yield the highest number of lives saved (2,716) over a 10-year period. Furthermore, the intervention yields the lowest cost to save an additional life and has the lowest annual implementation cost per death averted relative to the status quo. The relatively greater health benefit from mandatory reduction of sodium/salt in manufactured foods compared to voluntary interventions is consistent with previous works[ Cobiac LJ, Vos T, Veerman JL (2010) Cost-effectiveness of interventions to reduce dietary salt intake. Heart 96: 1920–1925. doi: 10.1136/hrt.2010.199240 PMID: 21041840] [ Collins M, Mason H, O’Flaherty M, Guzman-Castillo M, Critchley J, Capewell S. (2014) An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. Value Health 17: 517–524. doi: 10.1016/j.jval.2014.03.1722 PMID: 25128044] [ Collins, M., Mason, H., O’Flaherty, M., Guzman-Castillo, M., Critchley, J., & Capewell, S. (2014). An Economic Evaluation of Salt Reduction Policies to Reduce Coronary Heart Disease in England: A Policy Modeling Study. Value in Health, 17(5), 517–524. doi:10.1016/j.jval.2014.03.1722]and is not surprising given the strong scientific basis for the effectiveness of public health laws in general[ Moulton AD, Mercer SL, Popovic T, Briss PA, Goodman RA, Thombley ML, et al. (2009) The scientific basis for law as a public health tool. Am J Public Health 99: 17–24. doi: 10.2105/ AJPH.2007.130278 PMID: 19008510] [ Goodman RA, Moulton A, Matthews G, Shaw F, Kocher P, Mensah G, et al. (2006) Law and public health at CDC. MMWR Morb Mortal Wkly Rep 55 Suppl 2: 29–33. PMID: 17183242].

What needs to be done?

• Firstly: Identification of all key stakeholders to ensure that the developed guidelines incorporate all stakeholders concerns

• Secondly: MoH to work with (National Food and Drugs, ZABS, Manufacturer Association of Zambia) and other stakeholders to develop the first draft of the regulations

• Thirdly: Engage Zambia Law Development Commission to develop the final draft of the regulations which will be submitted to Ministry of Justice for adoption

• Fourthly: Launch and enforcement of the regulations

LIST OF REFERENCES

1. “Global_brief_hypertension.Pdf.”

2. “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”

3. “2016 VITAL Statstics Report.Pdf.”

4. Franco OH, Peeters A, Bonneux L, de Laet C: Blood pressure in adulthood and life expectancy with cardiovascular disease in men and women. Hypertension 2005, 46:280.

5. “ZMB_B3_NCDs Strategic Plan.Pdf.” 6. “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”

7. “Policybrief34.Pdf.”

8. Trieu, K., Neal, B., Hawkes, C., Dunford, E., Campbell, N. C., RodriguezFernandez, R., Legetic, B., McLaren, L., Barberio, A. & Webster, J. (2015). Salt Reduction Initiatives around the World – A Systematic Review of Progress towards the Global Target. PloS One, 10(7), e0130247. doi: 10.1371/journal.pone.0130247

9. “Global_brief_hypertension.Pdf.”

10. “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”

11. “Zmb_en.Pdf.” 12. “2016 VITAL Statstics Report.Pdf.” 13. “Policybrief34.Pdf.” 14. Global Panel on Agriculture and Food Systems for Nutrition. (2016). Food systems and diets: Facing the challenges of the 21st Century. London: Global Panel 15. https://www.cdc.gov/salt/pdfs/sodium_role_processed.pdf

16. “Zambia-NCD-STEPS-Survey-Report-2017 (1).Pdf.”

17.

18. Ha S. K. (2014). Dietary salt intake and hypertension. Electrolyte & blood pressure: E & BP, 12(1), 7–18. doi:10.5049/ EBP.2014.12.1.7

19. Sadler K, Nicholson S, Steer T, Gill V, Bates B, Tipping S, et al. National Diet & Nutrition Survey— Assessment of dietary sodium in adults (aged 19 to 64 years) in England, 2011. Department of Health; 2011 [cited 2014 29 October]. Available: https:// www.gov.uk/government/uploads/system/ uploads/attachment_data/file/213420/Sodium-Survey-England-2011_Text_toDH_FINAL1.pdf.

20. He FJ, Pombo-Rodrigues S, MacGregor GA. Salt reduction in England from 2003 to 2011: its relationship to blood pressure, stroke and ischaemic heart disease mortality. BMJ Open. 2014 April 1, 2014; 4(4).

21.https://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2016.303397

22. 2018 National Survey on Access and Usage of Information and Communication Technologies by Households and Individuals

23.https://www.indexmundi.com/zambia/demographics_profile.html

24. https://www.lusakatimes.com/2016/05/11/local-manufacturers-told-improve-quality-products/

25. Hyseni, L., Elliot Green, A., Lloyd-Williams, F., O’Flaherty, M., Kypridemos, C., McGill, R., Capewell, S. (2016). P48 Systematic review of dietary salt reduction policies: evidence for an “effectiveness hierarchy”? Journal of Epidemiology and Community Health, 70(Suppl 1), A74.2–A75.doi:10.1136/jech-2016-208064.147

26. Cobiac LJ, Vos T, Veerman JL (2010) Cost-effectiveness of interventions to reduce dietary salt intake. Heart 96: 1920–1925. doi: 10.1136/hrt.2010.199240 PMID: 21041840

27. Collins M, Mason H, O’Flaherty M, Guzman-Castillo M, Critchley J, Capewell S. (2014) An economic evaluation of salt reduction policies to reduce coronary heart disease in England: a policy modeling study. Value Health 17: 517–524. doi: 10.1016/j. jval.2014.03.1722 PMID: 25128044

28. Collins, M., Mason, H., O’Flaherty, M., Guzman-Castillo, M., Critchley, J., & Capewell, S. (2014). An Economic Evaluation of Salt Reduction Policies to Reduce Coronary Heart Disease in England: A Policy Modeling Study. Value in Health, 17(5), 517– 524.doi:10.1016/j.jval.2014.03.1722

29. Moulton AD, Mercer SL, Popovic T, Briss PA, Goodman RA, Thombley ML, et al. (2009) The scientific basis for law as a public health tool. Am J Public Health 99: 17–24. doi: 10.2105/AJPH.2007.130278 PMID: 19008510

30. Goodman RA, Moulton A, Matthews G, Shaw F, Kocher P, Mensah G, et al. (2006) Law and public health at CDC. MMWR Morb Mortal Wkly Rep 55 Suppl 2: 29–33. PMID: 17183242

By : NL Mulambya, A Moraes, M Washington National Health Research Authority

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Citation Style For This Article: Mulambya NL, Moraes A, Washington M . What the HEP is going on?!! Protecting future generations: Addressing hepatitis B among pregnant women and newborns in Zambia. Health Press Zambia Bull 2020; 04(2); pp 3-5.

Key Messages

• Hepatitis B virus (HBV) mother to child transmission (MTCT) accounts for onethird of the global hepatitis HBV burden

• Pregnant HBV infected woman have a 70- 90% increased risk of transmitting HBV to their newborn

• 90% of infected newborns develop chronic hepatitis B

• A birth HBV immunisation introduced in Zambia is estimated to reduce HBV MTCT infection by 80%

Problem Statement

Hepatitis B is a viral disease caused by the hepatitis B virus (HBV). Common modes of transmission include: mother to child transmission (MTCT), contact with infected blood and body fluids, and sexual transmission. According to the 2016 Zambia Population HIV Impact Assessment, 3.5% of the population is infected with HBV[1]. An estimated 208,000 children aged 0-9 years are HBV infected. Approximately 56,000 pregnant women are living with HBV[2] (about 6.5% of pregnant women), although most do not know there HBV status due irregular screening. Perinatal transmission from mother to infant at birth is very high with 70-90% of infants becoming infected in the absence of post exposure prophylaxis]3]. Furthermore, infections acquired in infancy through perinatal or early childhood exposure are 90% more likely to become chronic than infections acquired later in life as seen in Figure 12.

Zambia also performs irregular HBV screening, thus Zambian women who are HBV infected and unaware of their status are at an increased of HBV MTCT[4]. However, studies have shown that treatment of HBV positive women with tenofovir, used in ART treatment, reduces MTCT to less than 2%6,[5]. As an unintended positive consequence, women who are coinfected with HIV/HBV and on ART are at a lesser risk of HBV MTCT8.

The country has been aware of the dangers associated with HBV infection for decades, hence the introduction of HBV vaccination as part of routine childhood immunisation program in 2005. Despite these efforts, the risk for HBV MTCT is still high as vaccine is given beginning at 6 weeks, leaving infants younger than 6 weeks at an increased risk for HBV seroconversion. Studies have shown that an HBV immunization given within 24 hours of birth reduces HBV infection by 85%[2].

Policy Rational

1.In Zambia, one reason for the higher risk of chronic HBV is due to irregular testing and treatment of HBV infected pregnant women and the lack of the HBV birth dose immunization [7].

Considering the research showing the reduction of HBV MTCT from pre-birth prophylaxis of tenofovir to the infected mother and HBV immunisation of newborns, we are proposing four policy options: (2) introduce HBV screening and HBV treatment for HBV infected pregnant women; (3) introduce a birth HBV vaccination to newborns; and (4) the combination of HBV screening and HBV treatment for HBV infected mothers and birth HBV vaccination for newborns. This analysis is done assuming a healthcare facility that sees 36,000 births per year.

Policy Options

1.Currently, there is no vaccination at birth, no screening for HBV infected women, and no treatment for HBV infected pregnant women. Studies conducted in Malawi and South Africa showed a 10% infection rate among infants born from HIV/HBV co-infected mothers, which our model coming close to what we would expectin Zambia at 9.1%. This estimate is close to another Zambian estimate[8]. 2. Introduce HBV screening and treatment for HBV positive pregnant women (Treat Only) WHAT: HBV screening and treatment for HBV positive women WHY: In addition to the current routine ANC screening for HIV and syphilis, add HBV screening and giving tenofovir to HBV positive pregnant women from 28- 32 weeks of pregnancy to reduce HBV viral load and reduce the risk of transmission by up to 40%. If implement in Zambia, this could reduce the percentage of children infected to 7.7% at a cost of $4,222 per HBV infected child adverted.

FEASIBILITY: Low to medium. This option builds on the Ministry of Health (MOH) strategic plan to eliminate MTCT of HIV and HBV infection in the population by 2030. Implementation will require training of staff and community sensitization on HBV screening during antenatal visits. 3.Introduce a birth HBV vaccination to newborns (Vaccinate only)

WHAT: HBV vaccination for the newborn regardless of the mothers HBV status

WHY: Currently, HBV vaccination starts at 6 weeks meaning that babies remain at high risk for HBV infection during the first 6 weeks of life. If an HBV vaccine is given at birth, we estimate that this would reduce the percentage of HBV positive children down to 1.8% at a cost of $236 per HBV infected child adverted.

FEASIBILITY: Medium to high. This option also builds on the MOH strategic plan as stated above. Implementation will require training of staff and community sensitization in order to achieve maximum coverage as for other vaccines such as BCG and OPV. It will also require an additional budget of about $0.6 million for one health facility.

4.Combination of HBV screening and HBV treatment for HBV infected mothers and birth HBV vaccination for newborns Introduce HBV screening, treatment for HBV infected pregnant women, and HBV birth vaccination for the newborn (Option 2 and 3 combined)

WHAT: In addition to routine ANC screening for HIV and syphilis, add HBV screening and giving tenofovir treatment to HBV positive pregnant women from 28-32 weeks of pregnancy to reduce HBV viral load, combined with HBV vaccination for the newborn.

WHY: Most pregnant women are unaware of their HBV status. Furthermore, only the HIV/HBV co-infected pregnant women benefit from tenofovir, which leaves women who are HIV negative but HBV positive at risk of spreading infection to the newborn and possibly to their partners. Screening will identify these women and treatment can be provided.

Vaccination will add additional protecting to the newborn. We estimate that this policy option would reduce the percentage of HBV infected children to 1.5%, at a cost of $923 per infected child averted.

FEASIBILITY: Medium to high. This option builds on the MOH strategic plan to eliminate HBV infection in the population, but it is estimated to cost and additional $2.5 million for one health facility.

Recommendations and next steps

Option 3 offers the highest health benefit given the additional money spent to implement the strategy. Additionally, Option 4 can be considered for the benefit it offers to reduce transmission to the newborn and potentially to sexual partners, and possible curing the mother. These analyses do not take into consideration the long-term benefit: reducing expensive health cost and major health issues in the future year due to liver cancer, jaundice, and death. For example, treating someone today for liver cancer is $30,000. Costs are likely to be higher in the future. Implementation of these options will entail an estimated first-year spending the following at national level: Option 2: $38,607,364; option 3; $11,057,047; Option 4: $44,839,286. The following are also needed:

• Raised communication awareness about HBV

• Training of health workers on HBV screening and treatment guidelines.

• Introduction of mono-dose at birth vaccine into the current immunisation schedule

• Ensure logistics can accommodate the additional ART and vaccine requirement.

Without the introduction of these options, we can expect to see up to as many as 9% of newborns infected with HBV and the government would have to pay for the negative health outcomes in the future.

LIST OF REFERENCES

1. Oshitani H, Kasolo F, Tembo C, Mpabalwani M, Mizuta K, Luo N, et al. Hepatitis B virus infection among pregnant women in Zambia. East Afr Med J. 1995 ;72(12):813–5.

2. Pinkbook | Hepatitis B | Epidemiology of Vaccine Preventable Diseases | CDC [Internet]. 2018 [cited 2018 08 23]. Available from: https://www.cdc.gov/vaccines/pubs/pinkbook/hepb.html

3. Chronic Hepatitis B Virus Infection in Zambia – Full Text View – ClinicalTrials.gov [Internet]. [cited 2018 08 23]. Available from: https://clinicaltrials.gov/ct2/show/NCT03158818

4. Greenup A-J, Tan PK, Nguyen V, Glass A, Davison S, Chatterjee U, et al. Efficacy and safety of tenofovir disoproxil fumarate in pregnancy to prevent perinatal transmission of hepatitis B virus. J Hepatol. 2014 ;61(3):502–7.

5. Kapembwa KC, Goldman JD, Lakhi S, Banda Y, Bowa K, Vermund SH, et al. HIV, Hepatitis B, and Hepatitis C in Zambia. J Glob Infect Dis. 2011;3(3):269–74.

6. Zambia Consolidated HIV Guidelines | Children & AIDS [Internet]. [cited 2018-23]. Available from: https://www.childrenandaids.org/Zambia_Consolidated-HIV-Guidelines_2016

7. Spearman CW, Afihene M, Ally R, Apica B, Awuku Y, Cunha L, et al. Hepatitis B in sub-Saharan Africa: strategies to achieve the 2030 elimination targets. Lancet Gastroenterol Hepatol. 2017 ;2(12):900–9.

8. Phiti C. Sero-prevalence and risk factors of Hepatitis B and C viral infection in HIV positive children seen at the Paediatric Centre of Excellence, University Teaching Hospital, Lusaka, Zambia. Retrieved from UNZA Repository Home, Theses and Dissertations, Medicine (2015)

By : ML. Mazaba Zambia National Public Health Institute

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Citation Style For This Article: Mazaba ML. Water Contamination – A Public Health Concern. Health Press Zambia Bull. 2020; 4(2); pp 1-2.

a mainstay in safeguarding public health and national well-being. Poor water and sanitation propagate waterborne infectious diseases and other ailments that are caused by unsafe water. Waterborne diseases caused by bacteria, parasites and virus add substantially to worldwide morbidity and mortality. Various diseases including but not limited to diarrhoea, cholera, dysentery, typhoid, and polio have been attributed to consumption of feacal contaminated water. It is estimated that over 485,000 deaths each year are caused by diarrhoea associated with consumption of water or food contaminated with infectious agents, which often come from human and animal waste. Other diseases such as malaria, dengue, yellow fever, trachoma, and schistosomiasis are associated with contamination of water with vectors including mosquitoes and helminths also contribute to increased morbidity and mortality globally [1-3]. Other than microbial contamination, chemicals such as pesticides, hydrocarbons, persistent organic pollutants, or heavy metals contribute to morbidity and mortality. Noted are the increased number of persons affected with cancers, hormonal problems, damaged nervous systems, liver and kidney damage, slower growth and even death associated with consumption of chemically contaminated water [4]. In many parts of the world the quality and safety of drinking water continues to be an important public health issue despite an agenda to ensure equitable access to safe water and adequate sanitation; Target 7c of the Millennium Development Goals (MDG 7c) aimed to halve the population that had no sustainable access to water and basic sanitation before 2015 but this was not achieved and carried on to the Sustainable Development Goals – SDG Target 6.1 which calls for universal and equitable access to safe and affordable drinking water. Despite these strategies, it is anticipated that by 2025, half of the world’s population will still be living in water-stressed areas [5,6]. Conclusion Despite the fact that in 2010, the UN General Assembly explicitly recognized the human right to water and sanitation, emphasising that everyone has the right to sufficient, continuous, safe, acceptable, physically accessible, and affordable water for personal and domestic use, many individuals, families and communities do not have access to such a supply. And where there is an abundance of fresh water, these areas still face other challenges of pollution, activities such as industry and waste, inadequate or ineffective sanitation and other negative forces. Inadequate or inappropriately managed water and sanitation services expose individuals to preventable health risks. Water Sanitation and Hygiene (WASH) remain important determinants of health, therefore, key intervention strategies for reducing preventable morbidity, mortality and health care costs must be considered. Adequate safe and readily available water remains essential for individual and public health, as well as being a social determinant of health. It is important therefore that countries ensure improved water supply and sanitation, and better management of water resources. An improved status will in turn boost countries’ economic growth and can contribute greatly to poverty reduction. We must all play a role in ensuring Universal access to WASH for all!

LIST OF REFERENCES

1. The Water Project. URL: https://thewaterproject.org/water-scarcity/cholera-dengue-fever-malaria-water

2. Science Direct. Waterborne Diseases. URL: https://www.sciencedirect.com/topics/earth-and-planetary-sciences/waterborne-disease

3. Jagai JS, Rosenbaum BJ, Pierson SM, Messer LC, Rappazzo K, Naumova EN, et al. Putting regulatory data to work at the service of public health: utilizing data collected under the Clean Water Act. Water Quality, Exposure and Health. 2013. 1-9.

4. Science Direct. Water Pollutant. URL: https://www.sciencedirect.com/topics/earth-and-planetary-sciences/water-pollutant

5. World Health Organisation. URL: https://www.who.int/news-room/fact-sheets/detail/drinking-water

6. Itchon GS, Gensch R. Water Sanitation and Health. URL: https://sswm.info/arctic-wash/module-3-health-risk-assessment/ further-resources-indigenous-health-social-determinants/water%2C-sanitation-and-health.

Surveillance and Disease Intelligence Unit Zambia National Public Health Institute

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Citation Style For This Article: Surveillance and Disease Intelligence Unit. Intergrated Disease Surveillance and Response. Health Press Zambia Bull. 2019; 4(01); pp 10-19.

Weekly Summary

Current outbreaks and public health threats

 cVDPV Outbreak: No new confirmed cases were reported.

 Measles Outbreak: 22 cases were reported in Kasama district, Northern province with 2 testing positive for Measles IgM.

 Poliomyelitis: One sample tested positive for PV2 in Zambezi district of N/Western province and was sent for sequencing.

 Suspected Cholera Outbreak: 3 cases were reported from Mambwe district, Eastern Province during the week.

 Coronavirus: Covid-19 surveillance is ongoing, especially at points of entry.

Immediately notifiable diseases

 Acute Flaccid Paralysis (AFP): 6 cases were reported this week in Luapula (3), Northern (1), Southern (1) and Copperbelt (1) provinces.

 Maternal Deaths: 15 maternal deaths were recorded in Lusaka (3), Southern (3), Eastern (2), Northwestern (2) Copperbelt (2), Central (1), Northern (1) and Western (1) provinces.

 Measles: 8 cases of suspected measles were reported in Northern (4), Luapula (2) and Southern (2) provinces and two samples were sent for laboratory investigation.

Other diseases/events

 Typhoid: Eleven suspected cases were reported from North-western (8), Lusaka (2) and Eastern (1) provinces. One case sent for laboratory investigation tested positive.

 Anthrax: Four suspected cases were reported from Western Province in Kalabo (1), Sikongo (1) and

Paper and Electronic Timeliness and Completeness, Health Facility Level

Provincial Report Timeliness

Week 4

Cumulative Number of Maternal Deaths by Province

 Fifteen maternal deaths were registered this week.

 Obstetric hemorrhages and Indirect causes are the leading causes of maternal deaths.

 Lusaka & Southern provinces have cumulatively recorded the highest number of deaths since week 1.

 In total 47 maternal deaths have been recorded since week1.

Vaccine Preventable Diseases

AFP Surveillance

Districts with reported AFP Cases Week 1-4 2020

Week 4

 6 AFP cases were recorded in 6 districts: Mansa, Chembe & Mwansabombwe districts in Luapula; Kitwe in Copperbelt; Mungwi in Northern & Choma in Southern provinces.

 Cumulatively, 9 AFP cases have been reported since week 1.

 All results for AFP cases are pending.

 As a result of the outbreak, non-AFP target rates is 4/100, 000 of the population below 15 years.

 One sample from Zambezi district (North-western province) tested positive for PV2 and has been sent for sequencing .

 The total number of districts that have isolated type two poliovirus during this outbreak now stand at four: Lusaka, Chiengi, Senga Hill and Chavuma districts.

 The risk of cVDPV2 transmission in Zambia is high, especially in districts that are: 1) Silent, 2) Not attaining Non-Polio AFP Rates of 4/100,000 or 80% stool adequacy, 3) Neighboring to countries with active outbreaks and 4) Having low IPV vaccination coverages.

Poliovirus Environmental Surveillance (ES)

 Results for two ES samples collected in Week 48, 2019 tested positive for Polio Virus type 3 Sabin Like (PV3 SL).

 The two samples were from Ngwerere and Chelstone treatment plants in Lusaka district.

 Scheduled collections from sites on the Copperbelt province were conducted.

Measles Outbreak

 Kasama District has reported cases of a suspected measles outbreak.

 Cumulatively, twenty two cases have been reported from 3 health facilities.

 Six cases tested positive for Measles IgM

Measles & Rubella surveillance

 Eight suspected measles cases were reported this week.  Two cases were laboratory investigated and results are pending.

Non-Bloody Diarrhoea

 Cumulatively, 54,957 cases of non-bloody diarrhea were reported from week 1 to week 4 2020.

 The highest number of cases were reported in Lusaka province, representing 17% (9490) of the total cases. Muchinga province recorded the lowest with a cumulative total of 594 (1%).

Regional Public Health Events (Cases/Case Fatality Rate)

bola	Measles	Cholera	Poliovirus (c VDPD)	Plague
DRC : 3,416 CFR 66.0%	DRC: 311,471 CFR	DRC: 29,087 CFR 1.70%	Angola: 71 CFR 0.0% DRC: 51 CFR 5.70%	DRC: 84 CFR 0.0%

Early Warning Diseases

Ebola Virus, DRC 2018-2020

 Five new confirmed EVD cases and three deaths were recorded from DRC outbreak in the week under review.

 Cumulatively, 3,416 suspected cases, 3,298 confirmed cases and 2,239 deaths (CFR is 66.4%) have occurred since the outbreak in the 29 health zones of DRC.

 A total of 172 health workers have been affected with EVD representing 5%.

 Though number of new cases seem to be reducing, the regional risk of spread remains high.

Measles, DRC 2019-2020

 In week 1 (week ending 5 January 2020), 4,983 measles cases including 57 deaths (CFR 1.1%) were reported.

 There was an increased number of new cases reported in week 1 of 2020 compared to week 52 of 2019.

 Cumulative number of cases and deaths stands at 316,550 and 6,101, respectively.

 The number of measles laboratory confirmed cases stands at 2,717.

***For more information look up the WHO Weekly Bulletin on Outbreaks and Other Emergencies***

Public Health Actions Circulating Vaccine Derived Poliovirus Outbreak

 The national annualized Non Polio AFP detection rate has increased to 4 cases /100,000 of children detected under 15 years for provinces.

 Note all AFP cases are immediately notifiable and require immediate investigation with new case investigation forms.

 All districts are expected to conduct health facilities integrated supervisory active searches at priority sites as per recommended schedule.

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

 Provinces are to ensure health workers are sensitized for improved detection, reporting and investigation of suspected measles and AFP cases.

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 risk districts, including ports of entry.

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

 All border districts to strengthen point of entry EVD screening including facilitation of cross boarder monitoring and reporting of suspected EVD cases.

Heightened Surveillance in Cholera Hotspots

 With the increased rainfall patterns and imminent flooding that raises risks for diarrheal diseases, cholera hotspots are encouraged to continue and intensify surveillance and review of epidemiological trends to quickly detect and respond to changes.

 All provinces and districts are further advised to have sufficient stockpiles of chlorine (granular & soluble).

 Continue to provide 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 committees to engage all relevant government stakeholders and multisector partners required to prevent cholera outbreaks.

Global Alert of the Coronavirus & Preparedness

 The orientation of staff at points of entry on coronavirus in all provinces is advised

 Screening at all points of entry to be strengthened especially at international points of entry.

 Circulation of awareness materials to the public and health personnel to be done as soon as possible

 Report all suspected patients to the central level immediately .

 Strengthen surveillance for all Influenza Like Illness (ILI) and Severe Acute Respiratory Illness (SARI)

 Case definitions to be made available and other IEC materials in health facilities and public places.

 A call centre has been established at ZNPHI and all queries should be channeled to the following numbers: +260 96 4638726/+260 974493553/+260 95 3898941.

Reported by Surveillance and Disease Intelligence Unit: Muzala Kapin’a, Nkomba Kayeyi, Moses Banda, Mazyanga M Liwewe, Victor Mukonka and Zambia National Public Health Institute (ZNPHI)

By: M Chasaya, ML Phiri, MA Ngomah Zambia National Public Health Institute

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Citation Style For This Article: Chasaya M, Phiri ML, Ngomah MA,. An Update on Malaria trends in Zambia (2019 to 2020); A descriptive study.Health Press Zambia Bull. 2020; 4(01); pp 13-18

Abstract

”Malaria continues to be a major global health concern, killing hundreds of thousands annually, especially in sub-Saharan Africa such as Zambia. Using data from Zambia’s Integrated Disease Surveillance and Response reports analyzed using MiMicrosoft excel, this study aimed at studying and reporting on the malaria trends in a 10 month period (August 2019 to June 2020). It is also aimed at checking for possible associations between tested cases and confirmed cases. The study showed that malaria cases diagnosed as positive in Zambia are high, about 3700892 in a space of 10 months with a mean score of 370089.2 confirmed cases. The findings also identified an increase in testing rates especially from March 2020 onwards. Similarly, an increase was also noticed in the number of confirmed Malaria cases within the same period. A strong positive and significant relationship through regression analysis confirmed the association between tested cases and confirmed cases. The study also suspects the possible effect of the COVID-19 pandemic on Zambia’s healthcare system including the efforts in curbing malaria. The study further recommends continued disease surveillance at the national level and the need to prioritize malarial preventive and treatment interventions to avoid potential malarial outbreaks and morbidity. Keywords: Malaria; Zambia; Cases; IDSR

Introduction

It is easy to assume that the severity and incidence of Malaria is under-control in Zambia as well as other African nations. Unfortunately, research has consistently demonstrated that Malaria is one of the greatest killer diseases in Sub-Sahara African countries [1, 2, 3]. This also means that Malaria and its effects have negatively impacted the public health sector not only in Zambia but Africa wide as well. Considering the persistence of Malaria in Zambia, it is important for national health organizations and ministries to consistently do retrospective reviews of trends and patterns in order to enhance response strategies and models of intervention development which may in turn, improve the effectiveness and responsiveness of health systems [3]. Different intervention measures have been implemented by several Sub-Saharan African nations to fight malaria among other diseases. Among them is the International Disease Surveillance and Response system (IDSR). The goal of IDSR is to strengthen the overall national system for public health surveillance and response. Many countries embarked on the strategy of keeping national disease surveillance and response systems about a decade ago because researchers had recommended and observed that disease investigation and surveillance systems were effective measures for monitoring and controlling and responding to the prevalence of diseases such as malaria [4]. Some malaria interventions have focused on methods such as the epidemiological triangle model and the web of causation and social determinants of health. These interventions have tried to fight Malaria by concentrating on the relationship between the agent (mosquito), the host (human being and the environment [2, 3].

Others have concentrated on measures such as treatment, insecticide spraying and distribution of mosquito nets to communities. Most recent research evidence has predicted potential influence of COVID-19 on Malaria intervention. This prediction has been in line with the amount of stress COVID-19 has placed on African health care systems and its workers [5, 6]. The researchers have used COVID-19 and malaria transmission models to estimate the impact of disruption of malaria prevention activities and other core health services under four different COVID-19 epidemic scenarios. Their findings conclude that if activities are halted, the malaria burden in 2020 could be more than double that of 2019. They establish that in Nigeria alone, reducing case management for 6months and delaying prevention measures such as long-lasting insecticidal nets (LLINs) campaigns could result in 81,000 (44,000–119,000) additional deaths. Therefore, researchers have suggested that some of the ways of mitigating impacts of COVID-19 is by scaling up preventive interventions such as long lasting Insecticide nets and increased access to antimalarial treatments to prevent substantial malaria epidemics [5, 6, 7]. Zambia is among the countries that have been committed to the fight of Malaria for some time now. In 2010, 2012 and 2015, Zambia reported odds ratio of malaria for various malaria interventions measures. Those who slept under an insecticide-treated net (ITN) had odds at 0.90, indoor residual spraying (IRS) at 0.66, urban residence at 0.23 and standard house at 0.40. The country also reported that IRS reduced malaria prevalence by0.3% and ITNs by 0.2% [1].The national malaria incidence reduced from 386 per 1000 persons in 2013 to 409 per 1000 persons in 2014, and 335 per 1000 persons in 2015, with North-western Province recording the highest overall incidences and Luapula Province recording the highest incidence rates in pregnant individuals [8]. The 2018 Malaria Indicator Survey (MIS) reported that 79% of households owned at least one ITN with 45% of these households having all members sleeping under an ITN and a 9% drop in the national malaria parasite prevalence among children under age five [9]. Luangwa and Nyimba

district reported an increase in the use of ITNs in households where 398 mosquitoes were captured from light-trap collections, including 49 anophelines and 349 culicines [10]. Additionally, adherence to Mass Drug Administration (MDA) of antimalarial treatment Dihydroartemisinin–piperaquine (DHAp) in Zambia was recorded at 84.4% of households completing the full course of DHAp [11]. As the nation matches towards Malaria eradication, it is very essential to monitor diagnosis and complexity of the disease. Between January 2015 and July 2017, Choma-Southern Province reported parasite prevalence identification of 0.7% by RDT and 1.8% by quantitative Polymerase Chain Reaction (qPCR) with 8.5% of households having at least one resident with parasitaemia detected by qPCR or RDT [12]. Zambia has also recently recorded a reduction in the average complexity of infection and a consequential increase in the proportion of infections that harbored a single parasite genome [13]. 69.5% of patients have been reported as febrile of which 37.0% have had a malaria test conducted with a number of patients receiving diagnosis without parasitological confirmation and many continuing onto antimalarial treatment [14]. The current study is aimed at studying the trends in incidence of malaria cases in the period between August 2019 and June, 2020. Secondly the study aims at investigating the relationship that exists between the tested cases and the confirmed cases in Zambia during the same period. It is expected that this close study of the IDSR data may contribute to providing useful information for intervention direction and case management as far as fighting against malaria is concerned.

Methods

The current retrospective study extracted data from the Zambian Integrated Disease Surveillance and Response (IDSR) system for the period of August 2019 to June 2020. The study population included the Zambian population of those cases that were reported at the health facilities such as those suspected, those tested, and those confirmed. The data was analyzed using Microsoft Excel. Malaria cases were presented using graphs and tables generated from Microsoft Excel as well as descriptive statistical data. The study also used linear regression to check the relationship between tested cases and confirmed cases using Microsoft excel. Results.

The goal of IDSR is to strengthen the overall national system for public health surveillance and response. Based on data from the IDSR a total of 6480715 suspected Malaria cases between August 2019 and June 2020 (Table 1) with August 2019 recording the lowest number of suspected cases at 92668 and June 2020 recording the highest at 1105759 (Figure 1). Table 1 further illustrates that cumulatively 6335010 tests were conducted within the review period with a mean of 633501 tests across the months. The month of June 2020 recorded the highest number of tests conducted at 1088917 (Figure 2). Moreover, a total of 3700892 confirmed malaria cases occurred between August 2019 and June 2020 in Zambia (Table 1). The highest number of cases occurred during the month of May 2020 which recorded 866502 cases countrywide (Figure 3).

A linear regression analysis of the relationship between a number of tests conducted and the number of confirmed cases showed a strong relationship between the two variables. Firstly, an R Square of 0.83, f(38.0), p> 0.000269 indicated that 83% of the variation in confirmed cases can be explained by the number of tests conducted. Furthermore, tests conducted (β= 1.26) was a predictor of confirmed cases with a strong correlation of 0.9 (Table 2).

Table 1: Descriptive statistics for Malaria cases in Zambia from August 2019 to June 2020 by case type.

Table 2: Linear regression analysis between tested and confirmed cases

Discussion The study revealed that Zambia is committed to malaria testing with a steady increase from March, 2020 to June, 2020. Within the review period, the Zambian Ministry of health in the 10 months has conducted a total of 6335010 tests with the lowest number of tests being 89360 tests and the highest being 1088917 tests.

The increase in Malaria testing is a good sign on the part of the healthcare system. However, it is not certain as to whether the increase in testing is as a result of the strength in the capacity of the healthcare system or it is because of the increase in malaria related cases that prompt the testing. Interestingly, the increase in malaria testing seems to coincide with the outbreak of the COVID-19 pandemic in Zambia. However this is another research area that may need attention.

Interestingly, the findings also revealed an alarming rise in confirmed malaria cases between August, 2019 and June, 2020. The number of cases seemed to rise sharply from March 2020 to June 2020. Very recent literature has demonstrated concern on the potential of Covid-19 in halting the progress interventions fighting and preventing malaria [5, 6, 7]. Therefore the rise in cases may be facilitated by a COVID-19 strained healthcare system. This may imply that the current rise in cases may be facilitated by the COVID-19 pandemic of which the increased number of confirmed cases may also be due to the increase in malaria testing. Furthermore, linear regression as well revealed a statistically significant and strong positive relationship between the number of tested cases and the number of confirmed cases. This shows that the number of cases tested strongly predictive influence on the number of confirmed cases.

Therefore, this means that increasing the testing of malaria is most likely to reveal the increased incidence of malaria in the Zambian community. Increasing the testing could be useful in treatment focussed interventions.

Lastly, the results showed that the number of confirmed Malaria positive cases have been on the rise within the 10 months captured in the study. The number of confirmed cases in August 2019 was 27057 and the highest was 866502 cases. This rise in cases calls for concern from stakeholders because this means that Malaria as a pandemic may need more attention and re-evaluation of current preventive measures by stakeholders. The findings of increased confirmed cases may be owing to and highlight a potential reduction in the good adherence rates to available Malaria intervention measures alluded by previous studies [1, 8, 9, 10, 11]. The complexity of diseases as well as mode of diagnosis, as explained by previous research, would be very helpful considerations for shaping future targeted intervention measures [12, 13, 14].

Conclusion

In conclusion, it is certain from these findings that cases of malaria are raising. In the period of 10 months as covered in the study, the period beginning March onwards shows a sharp rise in tested and confirmed cases. This is indicative that despite the possibly Covid-19 induced strain on Zambia’s healthcare system, the ministry of health and other stake holders should prioritize prevention measures targeting Malaria aside covid-19 intervention to reduce the possibility of any malarial epidemic.

LIST OF REFERENCES

1. Nawa M, Hangoma P, Morse AP. et al. Investigating the upsurge of malaria prevalence in Zambia between 2010 and 2015: a decomposition of determinants. Malaria Journal. 2019

2. Chanda E, Hemingway J, Kleinschmidt I, et al. Insecticide resistance and the future of malaria control in Zambia. PLoS One. 2011; 6(9):e24336

3. Abdullahi AA, & Abubakar AD. Why It Is Difficult to Eradicate Malaria in Sub-Sahara Africa. Perspectives on Global Development and Technology. 2019; 18(3), 269-285

4. Ye Y, Wamukoya M, Ezeh A, Emina JB, & Sankoh O. Health and demographic surveillance systems: a step towards full civil registration and vital statistics system in sub-Sahara Africa?. BMC public health. 2012; 12(1), 741

5. Sherrard-Smith E, Hogan AB, Hamlet A. et al. The potential public health consequences of COVID-19 on malaria in Africa. Nat Med. 2020; 26, 1411–1416

6. Hogan AB, Jewell BL, Sherrard-Smith E, Vesga JF, Watson OJ, Whittaker C, Hamlet A, Smith JA, Winskill P, Verity R, Baguelin M. Potential impact of the COVID-19 pandemic on HIV, tuberculosis, and malaria in low-income and middle-income countries: a modelling study. The Lancet Global Health. 2020 Sep 1;8(9):e1132-41.

7. Nghochuzie NN, Olwal CO, Udoakang AJ, Amenga-Etego LNK, & Amambua-Ngwa A. Pausing the Fight Against Malaria to Combat the COVID-19 Pandemic in Africa: Is the Future of Malaria Bleak?. Frontiers in microbiology. 2020; 11, 1476.

8. Inambao AB, Kumar R, Hamainza B, Makasa M, Nielsen CF. Malaria Incidence in Zambia, 2013 to 2015: Observations from the Health Management Information System. Health Press Zambia Bull. 2017

9. Zambia National Malaria Elimination Centre, Lusaka, Zambia. Zambia’s 2018 Malaria Indicator Survey. Health Press Zambia Bull. 2019

10. Jumbam DT, Stevenson JC, Matoba J. et al. Knowledge, attitudes and practices assessment of malaria interventions in rural Zambia. BMC Public Health. 2020

11. Finn TP, Porter TR, Moonga H, Silumbe K, Daniels RF, Volkman SK. et al. Adherence to Mass Drug Administration with Dihydroartemisinin–Piperaquine and Plasmodium falciparum Clearance in Southern Province, Zambia. The American Journal of Tropical Medicine and Hygiene. 2020

12. Bhondoekhan FRP, Searle KM, Hamapumbu H. et al. Improving the efficiency of reactive case detection for malaria elimination in southern Zambia: a cross-sectional study. Malaria Journal. 2020; 19(175)

13. Daniels RF, Schaffner SF, Bennett A, et al. Evidence for Reduced Malaria Parasite Population after Application of Population-Level Antimalarial Drug Strategies in Southern Province, Zambia. Am J Trop Med Hyg. 2020;103(2_Suppl):66-73

14. Worges M, Celone M, Finn T, et al. Malaria case management in Zambia: A cross-sectional health facility survey. Acta Trop. 2019; 195:83-89.

By : A. Bhebhe, C. Leonard, M. Ng’uni, S Hachizovu

National Health Research Authority

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Citation Style For This Article: Bhebhe A, Leonard C, Ng’uni M, Hachizovu S . The Sweet Solution: Mandatory Folic Acid Fortification of Sugar to Prevent Neural Tube Defects in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 9-12

Key Messages

• A Neural tube defect (NTD) is a birth defect of the brain and spinal cord, which results from the failure of the neural tube closing in the first month of pregnancy1

• NTDs result in stillbirths, infant and under-five mortality, and disability for life1

• NTDs are preventable2,3

• We estimate that 1,418 infants are born with an NTD each year in Zambia

• Over half of all NTD cases can be prevented through folic acid fortification of sugar in Zambia

Problem Statement

Neural tube defects include various birth defects resulting from the failure of the brain and spinal cord to close during the first month of pregnancy. These birth defects range from anencephaly to acceptlocales to spina bifida, which all result in a variety of disabilities1. Globally, it is estimated that approximately 300,000 babies are born each year with a neural tube defect4, resulting in approximately 88,000 deaths and 8.6 million disability-adjusted life-years (DALYs)5. In low income countries, NTDs may account for 29% of neonatal deaths due to observable birth defects1. Sub-Saharan Africa has an overall NTD birth prevalence of 1.5/1,000 live births6. It is estimated that Zambia has an overall NTD birth prevalence of 2/1,000 live births. This means that in 2018, approximately 1,418 infants were born with an NTD in Zambia, or about 4 infants per day. However, there is large underreporting as only 200 new patients were treated for an NTD at the University Teaching Hospital, the largest referring hospital in Zambia, last year7.

There are five countries in the SADC region with mandatory maize and / or wheat flour fortification programs (Malawi, Mozambique, South Africa, TanTanzania, and Zimbabwe). Currently, Zambia has a Folic Acid Supplementation Program, which provides folic acid pills to pregnant women who attend antenatal care visits in Zambia. However, this program misses a key population: women who are yet to become pregnant and most pregnant women who are in their first month of pregnancy. Folic acid is needed before pregnancy and during the first month of pregnancy to prevent NTDs10. Therefore, this program is not sufficient to stop all NTDs. A more comprehensive prevention initiative spearheaded by the Ministry of Health could prevent the death and disability caused by NTDs in Zambia. Folic acid has been proven to prevent NTDs2,3. A 1991 study published in The Lancet found that folic acid had a 72% protective effect against NTDs and recommended that public health measures are taken to ensure that all women of child-bearing age (WCBA) have an adequate amount of folic acid2. Currently, there is no legislation mandating the fortification of any food with folic acid in Zambia.

Policy Options

In order to prevent deaths and lifelong disability from NTDs, we need to prevent NTDs from occurring among infants in the first place. We identified three policy options: maintain the status quo, fortifying sugar with folic acid, and a public health campaign to increase awareness of the importance of folic acid in preventing NTDs.

1.Maintain status quo Continue the current practice of treating patients with NTDs. There is no NTD prevention strategy or programme, and thus, it is estimated that over 1,400 infants are born with an NTD each year in Zambia. This causes approximately 315 stillbirths and 1,064 under-five deaths each year. However, there is no register to capture the number of infants born with an NTD across the country. Hence, the severity of the problem is likely underestimated. Those who survive are left with disabilities for life. Most are paralyzed from the waist down and have cognitive disabilityties9. There are only two neurosurgeons in Zambia and 12 neurosurgery registrars (all in Lusaka) that perform the necessary life-saving surgeries. Therefore, most of the patients are referred to Lusaka for treatment and consequently, many patients living in rural areas are unable to receive proper care on time. There is also an added cost to the Ministry of Health (MoH) because patients outside of Lusaka are taken via MoH ambulances to get treatment in Lusaka. In addition, all patients operated at UTH have to come back to attend neurosurgery clinics at UTH.

2.Folic Acid Fortification of Sugar What: The Zambian government would mandate that all Zambian-produced and imported sugar is fortified with folic acid. This option will also include a public awareness campaign during which MoH will inform the public about the new fortification initiative and the benefits of folic acid for all, especially WCBA. Why: NTDs develop within the first 28 days of pregnancy1 when many women do not even know that they are pregnant yet. Folic acid taken around the time of conception can prevent 60- 70% of NTDs5. Therefore, it is necessary that women have adequate folic acid levels at all times and before they become pregnant. This option will ensure that all women have adequate levels of folic acid before they become pregnant and during pregnancy. In addition, over 95% of all NTDs are a first occurrence12, meaning we cannot solely target women who have had a child with an NTD before for folic acid supplementation. Not only is folic acid benefits for women, but it is also beneficial for men and children/adolescents. Folic acid can help treat anemia11. Also, folic acid supplementation is effective to preventing stroke in those with cardiovascular disease13.

Over 80 countries have implemented a folic acid fortification program with great success14. In 2003, South Africa embarked on folic acid fortification of staple foods. They experienced a significant decline in the prevalence of NTDs by 33%15. We predict this policy option will more than half all cases of NTDs, reduce NTD-related stillbirths and neonatal and under-five morbidity and mortality. This option will also reduce government spending.

Feasibility: Medium. Mandatory fortification of folic acid has proven to be feasible and economical in the countries that have implemented it, including the United States, Canada, Costa Rica, South Africa, Guatemala, Vietnam, and others16. Although the upfront cost of implementing this policy option will be expensive, the cost-savings over the long-term will be high.

3.Public Health Campaign What: The Zambian government would implement a campaign to encourage women of child-bearing age to take folic acid supplements and increase their intake of folic acid-rich foods. The campaign would consist of an advocacy media campaign and supporting the Ministry of Health’s Folic Acid Supplementation program by distributing folic acid pills to health facilities that offer family planning services. The media campaign would include: televised commercials, radio adverts, and printed adverts to encourage WCBA to take folic acid pills and encourage everyone to eat local foods with high levels of folate (legumes, eggs, leafy greens (rape, chibwabwa), citrus fruits, beef liver17. This option would also include community sensitization meetings to explain the benefits of folic acid taken before conception for all WCBA and to encourage planned pregnancy. Furthermore, MoH would hold workshops with healthcare providers, including doctors, nurses, and pharmacists to encourage them to talk to their patients about taking folic acid pills if they are thinking about becoming pregnant or currently pregnant. Why: As previously mentioned, folic acid is beneficial because when taken around the time of conception, it can prevent 60- 70% of NTDs5. Folic acid supplements are generally safe and side effects are rare. Less than 1 in 1,000 patients may experience nausea, loss of appetite, or an allergic reaction18. A limitation of this option is compliance with folic acid supplementation as seen in various studies around the world, only 20- 30% of women take folic acid supplements before pregnancy even after awareness campaigns19,20. Feasibility: Medium.

This strategy will require community sensitization and engagement with health workers. It will require funds, the majority of which will be for procuring more folic acid supplements to accommodate the increased demand from the public health campaign. Additional costs will include advertising, transport, and human resources. This option is highly costly and will result in net spending of 154,360,535 kwacha by the government over a five-year period. As well, this option is continuous and will be rolled out over a five-year period.

Recommendations and next steps There is a need to urgently prevent NTDs. The fortification of sugar with folic acid is the only viable choice if we want to substantially prevent NTDs in Zambia. This policy option has the highest public health impact and is politically feasible. Actions have already been taken engaging external stakeholders who have experience supporting folic acid supplementation initiatives in other countries, including the Global Alliance for Improved Nutrition (GAIN), Food Fortification Initiative (FFI), Nutrition International, Smarter Futures, and the International Federation Spina Bifida and Hydrocephalus (IFSBH). In addition, the 5-year cost savings is around 6.6 Million USD, while on the other hand, the public health campaign has an added cost of 11.8 Million USD.

A statutory instrument should be adopteded to make folic acid fortification of sugar mandatory in Zambia. In addition, all sugar manufacture and/or imported into Zambia should be fortified with folic acid. The Zambian government must mandate the Zambian Bureau of Standards (ZABS) to adopt fortified sugar as a standard and monitor the process of fortification. In addition to the legal framework, this policy option will require:

•Baseline/ endline and ongoing evaluations of folic acid levels and uptake of sugar to inform needed improvements and effects of the initiative

•The sugar manufacturing companies to implement fortification of sugar additionally with folic acid and rebrand their products to display that the sugar is fortified with folic acid

•Laboratory capacity to enable the testing of sugar to monitor the fortification program locally or outsourced •ZABS to monitor the fortification of all sugar (locally produced and imported) with folic acid

•ZRA to waiver tax on the importation of premix fortificant and fortification equipment Ministry of Health to engage the public to make them aware of the new fortification initiative

LIST OF REFERENCES

1. Zambia National Cancer Registry Report. 2013

2. Parham GP, et al. Population-Level Scale-Up of Cervical Cancer Prevention Services in a Low-Resource Setting: Development, Implementation, and Evaluation of the Cervical Cancer Prevention Program in Zambia. 2015. PLoS ONE 10(4): e0122169. doi: 10.1371/journal.pone.0122169

3. Ferlay J, et al. GLOBOCAN 2012 v1.1, Cancer Incidence and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2014.

4. Bruni L, et al. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Zambia. 2017.

5. Central Statistical Office. Zambia Demographic Health Survey. 2014

6. Ullrich A, et al. Long-term care of AIDS and non-communicable diseases. Lancet 2011; 377: 639–640. doi: 10.1016/S0140- 6736(11)60233-X PMID: 21334535

7. Parham GP, et al. Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia. Gynecol Oncol 2006; 103: 1017–1022. PMID: 16875716

8. Cogliano, V, et al. Carcinogenicity of human papillomaviruses. 2005. [Congresses]. Lancet Oncol, 6(4), 204.

9. Strickler HD, et al. Natural history possible reactivation of human papillomavirus in human immunodeficiency virus-positive women, J Natl Cancer Inst , 2005, vol. 97 (pg. 577-86)

10. Salvatore V, et al. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. 2013. https://doi.org/10.1016/j.ejca.2013.04.024

11. Ministry of Health. Zambia STEPS survey. 2017

12. Ferrand R, et al. The effectiveness of Routine Opt-Out HIV testing for children in Harare, Zimbabwe, Acquired Immune Deficiency Syndrome, 2016

13. Baisley K, et al. Uptake of voluntary counseling and testing among young people participating in an HIV prevention trial: comparison of the opt-out and Opt-in strategies, Plos One, 2012

14. McQuillan G, et al. Prevalence of HPV in adults aged 18–69: the United States, 2011–2014. NCHS data brief, no 280. Hyattsville, MD: National Center for Health Statistics. 2017

By: KM. Banda, D Mwansa, K Rice National Health Research Authority Citation Style For This Article: Banda KM, Mwansa D, Rice K, Save a Cervix, Save a Life! “Reinforcing test and treat for HIV positive women in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 4-8

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Citation Style For This Article: Banda KM , Mwansa D, Rice K,. Save a Cervix, Save a Life! “Reinforcing test and treat for HIV positive women in Zambia. Health Press Zambia Bull. 2020; 4(01); pp 4-8

Key Messages

• Cervical cancer (CaCx) is the highest cause of all cancer deaths in Zambia.1

• About seven women are diagnosed with CaCx and about four women die from CaCx every day in Zambia.2

• More than half (53%) of all women with CaCx are HIV positive.2

• Only about 20% of HIV positive women have been screened for CaCx.2 • Opt-out testing, at 90% screened, decreases the number of estimated HIV positive women at risk of developing late-stage CaCx by about 168,828 Problem Statement Zambia’s double burden of CaCx and HIV Table 1: World Ranking of Cervical Cancer Incidence (2012)

• Opt-out testing, at 90% screened, decreases the number of estimated HIV positive women at risk of developing late-stage CaCx by about 168,828

Problem Statement

Zambia’s double burden of CaCx and HIV

Table 1: World Ranking of Cervical Cancer Incidence (2012)

• Zambia ranks 4th highest in the overall incidence of CaCx and highest in age-specific incidence of CaCx compared to the rest of the world. (See Table 13 and Figure 14) • Zambia has a high prevalence of HIV (about 15%) in the adult women population.5 • The significant intersection of HIV prevalence and CaCx risk has contributed greatly to the increase of CaCx and worsening of its prognosis.6-9

Figure 1: Estimated CaCx Age-specific Incidence Rates

Increasing Screening Reduces the Cost of CaCx and Saves Lives Unlike many other cancers, there is incredible evidence that screening for cervical cancer is one of the most efficient preventive measures with effective results. For instance, there was a dramatic fall in cervical cancer mortality as screening became widespread in North America and Western Europe between the 1950s and 1970s, and meta-analysis of CaCx trends of countries in five continents showed that in countries where effective screening had been in place for a long time the consequences of underlying increases in cohort-specific risk were largely avoided 10. However, in Zambia, only about 21% of all women aged 25-49 had screened for cervical cancer11 and only an estimated 20% of the HIV positive women had screened for CaCx.2 CaCx screening is particularly important for women living with HIV/ AIDS as their risk of infection is higher compared to the general population.2,7

What are we saying?

Figure 2: Estimated Cases of CaCx Prevented and Diagnosed among HIV Positive Women Screened

Policy Option

“Opt-Out” strategy for reinforcing CaCx test and treatment for HIV positive women in Zambia” Developing an “Opt-Out” strategy in an effort to reinforce existing guidelines for Treatment and Prevention of HIV will promote testing and treatment of CaCx at early stages. “Opt-out” strategy essentially means HIV positive women are told that CaCx screening will be conducted in the standard tests (that is to say, the screening will be given to all HIV positive women) unless they decline.

WHAT: Routinely CaCx screening for all HIV positive women with adequate information is provided to them as described in the HIV Treatment and Prevention guidelines during the health facility visits for ART.

WHY: According to the 2017 Zambia Population-based HIV Impact Assessment report, 86% of people living with HIV are on ART, which means that they would visit a health facility at some point for treatment. Currently, estimations show that only about 5% of the HIV positive have screened for CaCx at some point. Routine testing during treatment visits increases the number of women screened and the number of times a woman is screened for CaCx. The literature on a similar strategy employed in increasing HIV testing from Zimbabwe12 and Tanzania13 shows that this strategy has increased HIV testing up to 90%. In our model, applying the opt-out strategy for CaCx screening in one year at 45% and 90% screening, would increase the number of women screened and treated by about 37% and 80% respectively. FEASIBILITY: MEDIUM to HIGH.

This strategy builds on the government’s decision to ‘test and treat’ women for CaCx. It will require increasing the number of facilities providing CaCx screening, clinician’s adherence to the guidelines, trained counselors, and an increase in ‘test and treat’ supplies and equipment.

Policy Option Scenarios

Table 2 provides a comparison of costs and effects under two scenarios proposed to increase screening. We compare the existing status quo to an “Opt-Out” strategy to increase screening, targeting 45% or 90% of HIV positive women.

We estimated the number of women remaining under each scenario at risk of developing late-stage CaCx if left unscreened. We based the estimated numbers on high-risk HPV prevalence in HIV positive women (20-40%) using proxy data on US women from the National Center for Health Statistics14. Opt-out testing at 90% screening can potentially decrease the number of estimated HIV positive women at risk of developing late-stage CaCx of approximately 200,000 women (the maximum at risk if only 5% are screen (229,123) minus the maximum at risk if 90% are screened (24,118)).

Figure 3 shows the total number of women screened and estimated total costs for each of the scenarios proposed in Table 1. The figure shows the combined total costs of delivering a screen and treat program and costs of cancer treatment and care for women diagnosed with CaCx at each opt-out level over one year, compared to the status quo.

We include all financial costs from the Ministry of Health perspective, which include the overhead cost of operating medical facilities for cervical cancer screening and treatment, costs for VIA test kits and supplies, costs for medical equipment and supplies for cold coagulation and LEEP procedures, medication, cancer treatment costs, and all personnel labor (physicians and/or nurses).

Recommendations and Next Steps

An opt-out strategy for reinforcing HIV treatment guidelines is a feasible option to increase CaCx ‘Test and Treat’ among HIV positive women in this analysis. This strategy has been adopted for HIV testing in countries like Zimbabwe and Tanzania and henceforth could provide similar effective results for CaCx in Zambia. The opt-out strategy reduces the potential future burden of CaCx on the country and saves women’s lives in the long term. Successfully implementing this strategy will require

• Expanding CaCx screening to more facilities in all the provinces.

• Ensuring clinicians’ adherence to the guidelines.

• Increasing close collaboration between the CaCx screening and HIV/ ART programs at the Ministry of Health in developing operational strategies.

• Collaborating between partners working in CaCx and HIV/ART. Opt-Out strategy for increasing ‘Test and Treat’ will have a high public health impact in addressing the growing incidence of cervical cancer in Zambia!

LIST OF REFERENCES

1. Zambia National Cancer Registry Report. 2013

2. Parham GP, et al. Population-Level Scale-Up of Cervical Cancer Prevention Services in a Low-Resource Setting: Development, Implementation, and Evaluation of the Cervical Cancer Prevention Program in Zambia. 2015. PLoS ONE 10(4): e0122169. DOI: 10.1371/journal.pone.0122169

3. Ferlay J, et al. GLOBOCAN 2012 v1.1, Cancer Incidence, and Mortality Worldwide: IARC CancerBase No. 11 [Internet]. Lyon, France: International Agency for Research on Cancer; 2014.

4. Bruni L, et al. ICO Information Centre on HPV and Cancer (HPV Information Centre). Human Papillomavirus and Related Diseases in Zambia. 2017.

5. Central Statistical Office. Zambia Demographic Health Survey. 2014

6. Ullrich A, et al. Long-term care of AIDS and non-communicable diseases. Lancet 2011; 377: 639–640. DOI: 10.1016/S0140- 6736(11)60233-X PMID: 21334535

7. Parham GP, et al. Prevalence and predictors of squamous intraepithelial lesions of the cervix in HIV-infected women in Lusaka, Zambia. Gynecol Oncol 2006; 103: 1017–1022. PMID: 16875716

8. Cogliano, V, et al. Carcinogenicity of human papillomaviruses. 2005. [Congresses]. Lancet Oncol, 6(4), 204.

9. Strickler HD, et al. Natural history possible reactivation of human papillomavirus in human immunodeficiency virus-positive women, J Natl Cancer Inst, 2005, vol. 97 (pg. 577-86)

10. Salvatore V, et al. Worldwide trends in cervical cancer incidence: Impact of screening against changes in disease risk factors. 2013. https://doi.org/10.1016/j.ejca.2013.04.024

11. Ministry of Health. Zambia STEPS survey. 2017

12. Ferrand R, et al. The effectiveness of Routine Opt-Out HIV testing for children in Harare, Zimbabwe, Acquired Immune Deficiency Syndrome, 2016

13. Baisley K, et al. Uptake of voluntary counseling and testing among young people participating in an HIV prevention trial: comparison of the opt-out and Opt-in strategies, Plos One, 2012

14. McQuillan G, et al. Prevalence of HPV in adults aged 18–69: the United States, 2011–2014. NCHS data brief, no 280. Hyattsville, MD: National Center for Health Statistics. 2017

By: S. Siziya

Michael Chilufya Sata School of Medicine, Copperbelt University, Ndola, Zambia

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Citation Style For This Article: Siziya S. Impact of COVID-19 epidemic on malaria: limitations to achieving malaria elimination. Health Press Zambia Bull. 2020; 4(01); pp 1-3

Malaria remains a major public health problem in Zambia despite the sustained reduction in the number of cases. Highest prevalence rates for malaria have been reported in northern (Luapula, Northern, North-western and Muchinga provinces) regions of the country (20% or higher), followed by middle (Eastern, Central, Copper-belt and northern parts of Western provinces) regions of the country (10- 20%) and least southern (Lusaka, Southern and the southern parts of Western provinces) regions of the country (<10%) [1]. While the impact of malaria interventions might have a greater impact in high malaria prevalence regions, elimination of malaria is easier attained in regions of low prevalence rates. Given that the goal of malaria control is to reduce the number of cases to a very low level, then malaria control in Zambia should be targeted to the northern and central regions of the country. Meanwhile, malaria elimination efforts should be targeted to southern regions of the country. In its National malaria elimination strategic plan of 2017-2021, Zambia opted to eliminate local malaria infection and disease in Zambia by 2021 with the following elimination interventions: Vector control (Indoor residual spraying (IRS), Long Lasting Insecticide-treated mosquito nets (LLINs) and Larval source management); Case management (Diagnosis, Treatment and Integrated community case management); Malaria in pregnancy (Intermittent preventive treatment during pregnancy (IPTp)); Parasite clearance (Mass drug administration (MDA), Reactive case investigation and Focal drug administration); Health promotion (Advocacy with key policy and decision-makers on malaria elimination, Community engagement and SBCC for mobile and migrant populations including cross-border collaboration); Enhanced surveillance, monitoring, evaluation, and research for informed decision-making (Quality and timely facility/ community reporting); Incorporation of emerging tools as they become available and are epidemiologically relevant; Health systems capacity (Staffing and Decentralisation); and Financing (Domestic, Donor and Non-traditional/innovative sources (such as private, religious and community) [2]. Clearly, the elimination goal for the entire country will not be attained by the end of next year, 2021. Although Zambia has made progress in increasing the intervention coverages (Figures 1and 2), these have been below 80% coverage and not ensuring head immunity. Subsequently, malaria parasitemia rate among children aged below 5 years has not significantly (F=1.41, p=0.301) changed between 2006 and 2018 (Figure 3)

Source: Zambia Ministry of Health, 2018. Zambia National Malaria Indicator Survey 2018 [3]. Figure 1: Percent of households with at least one insecticide-treated net (ITN) and received insecticide residual spray (IRS).

Source: Zambia Ministry of Health, 2018. Zambia National Malaria Indicator Survey 2018 [3]. Figure 2: Percent of pregnant women who slept under an insecticide-treated net (ITN) and received 2+ doses of intermittent preventive treatment in pregnancy (IPTp).

Source: Zambia Ministry of Health, 2018. Zambia National Malaria Indicator Survey 2018 [3]. Figure 3: Percent of under 5 children who slept under an insecticide-treated net (ITN) and those who had parasitemia

Figure 3: Percent of Under 5 children who slept under an insecticide-treated net (ITN) and had malaria parasitemia. Health coverages of routine health services are affected by outbreaks of epidemics. The model on the Ebola outbreak of 2014-2016 to predict the Ebola epidemic impact on malaria morbidity reported that a 50% reduction in treatment coverage during the Ebola outbreak led to increased malaria-attributable mortality rates by 48.0% in Guinea, 53.6% in Liberia and 50.0% in Sierra Leone [4]. Concerning malaria control, the delivery of ITN and IRS require movement of community health workers, and their health facility supervisors to travel to communities. Inactive case finding at the community level, CHW tests everyone living within a 140 m radius of the sick person and observes the patient taking the malarial drug [5]. World Health Organization [6] has guided to ensure the safety of both the health worker and client/patient from COVID-19 in health facilities and communities in their interaction to deliver malaria interventions. The reductions in malaria burden have been variable over time in Zambia due to unstable financing and flows of critical antimalarial commodities, such as LLINs, IRS chemicals, antimalarial medicines, and RDT [7]. The major focus has been on containing the COVID-19 epidemic and as result, the malaria elimination program may be negatively affected. However, the Zambia End Malaria Council recommitted to keep malaria-funding high on the political agenda during the COVID-19 fight. As we strive to control and possibly eliminate COVID-19, we should not lose sight of controlling and possibly eliminating malaria.

LIST OF REFERENCES

1. Ministry of Health [Zambia], Central Statistics Office, PATH Malaria Control and Evaluation Partnership in Africa, the United States President’s Malaria Initiative (PMI), the World Bank, UNICEF, the World Health Organization. Malaria Indicator Survey. 2015. Lusaka, Zambia: Ministry of Health, 2015.

2. Ministry of Health [Zambia]. National malaria elimination strategic plan 2017-2021: Moving from accelerated burden reduction to malaria elimination in Zambia. Ministry of Health, National Malaria Elimination Centre. Lusaka, Zambia: Ministry of Health, 2017.

3. Ministry of Health [Zambia]. Zambia National Malaria Indicator Survey 2018. Lusaka, Zambia: Ministry of Health, 2018.

4. Parpia AS, Ndeffo-Mbah ML, Wenzel NS, Galvan AP. Effects of response to 2014–2015 Ebola outbreak on deaths from malaria, HIV/AIDS and tuberculosis, West Africa. Emerg Infect Dis 2061;22(3):433-41.

5. Anonymous. Zambia’s drive to eliminate malaria faces challenges. Bull World Health Organ 2018;96:302–3.

6. World Health Organization. Tailoring malaria interventions in the COVID-19 response. Geneva: World Health Organization; 2020. License: CC BY-NC-SA 3.0 IGO.

7. Ministry of Health [Zambia]. National malaria elimination strategic plan 2017-202 1: Moving from accelerated burden reduction to malaria elimination in Zambia. Lusaka, Zambia: Ministry of Health, 2017.