Surveillance and Disease Intelligence Unit Zambia National Public Health Institute
Citation Style For This Article: Surveillance and Disease Intelligence Unit. Intergrated Disease Surveillance and Response. Health Press Zambia Bull 2020; 04(2); pp 21-25.
Surveillance and Disease Intelligence Unit Zambia National Public Health Institute
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
Immediately notifiable diseases
Other diseases/events
Surveillance and Disease Intelligence Unit Zambia National Public Health Institute
Citation Style For This Article: Surveillance and Disease Intelligence Unit. Intergrated Disease Surveillance and Response. Health Press Zambia Bull. 2020; 4(3); pp 3-6
Weekly Summary
Current outbreaks and public health threats
COVID-19 (Coronavirus): 96 confirmed cases were reported in the week under review. Cumulatively as of the 31st of May, a total of 1,089 confirmed cases,7 deaths and 912 recoveries have been recorded.
cVDPV Outbreak: No new confirmed cases were recorded this week.
Measles Outbreak: No new suspected cases were reported in the week under review from the resurgence of the outbreak in Lunte district of Northern Province.
Immediately notifiable diseases
COVID-19 (Coronavirus): The country has recorded a cumulative total of 1089 confirmed cases from Muchinga (557), Lusaka (384), Copperbelt (77),Central (36), Eastern (6), Northern (6), Northwestern (6) Southern (5) and Luapula (5) provinces.
Acute Flaccid Paralysis (AFP): Two cases were reported in the week under review in Central (1) and Northern (1) provinces.
Maternal Deaths: Fifteen maternal deaths were recorded in Northern (4), Lusaka (2), Central (2), Western (2), Luapula (2) Southern (2) and Copperbelt (1) provinces.
Other diseases/events
Rabies: One suspected rabies death was recorded in the week under review from Serenje district of Central province.
Mumps: 140 suspected cases were reported in the week under review from Southern (35), Central (27), Eastern (27), Copperbelt (26), North western (14), Western (7) and Lusaka (4) provinces.
Paper and Electronic Timeliness and Completeness, Health Facility Level
Provincial Report Timeliness
Summary Report Priority Diseases, Conditions and Events (Week 22)
Maternal Deaths
Week 22
Cumulative Number of Maternal Deaths by Province
Fifteen maternal deaths were registered in the week under review.
Obstetric hemorrhages and Indirect causes continue to be the leading causes of maternal deaths.
Lusaka province (66) has cumulatively recorded the highest number of maternal deaths.
In total, 278 maternal deaths have been recorded from Epi week 1 to Epi week 22 of the year 2020.
Vaccine Preventable Diseases
AFP Surveillance
Districts with reported AFP Cases Week 1-22 2020
Week 22
Two cases of AFP were reported in the week under review from Mumbwa (1) district in Central province and Senga (1) district in Northern province.
All samples have been collected and sent for laboratory investigation
Cumulatively, 81 AFP cases have been recorded from 42 districts country wide.
As a result of the cVDPV outbreak, non-AFP target rate has been increased to 4/100, 000 population below 15.
All results received from specimens submitted to the regional lab came out negative for cVDPV
The risk of cVDPV2 transmission in Zambia is high in districts that are: 1) Silent, 2) Not attaining NonPolio 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)
Measles Outbreak
The 2nd episode of the outbreak in Lunte district of Northern province was confirmed in the previous epidemiological reporting week.
No new suspected cases were reported in the week under review,
The cumulative number of cases recorded since the resurgence of the outbreak, now stands at six suspected cases and One IgM confirmed.
The affected health facility in the district is Mulenga Mapesa.
Measles & Rubella surveillance
No new suspected measles cases were reported in the week under review.
Measles suspected cases are sent for laboratory investigations.
Cumulatively, 103 suspected measles cases , 15 measles Igm confirmed cases and 6 confirmed measles rubella cases have been recorded.
COVID-19
96 confirmed cases and 0 death of COVID–19 were reported in the week under review from Lusaka (35), Muchinga (27), Copperbelt (21), Southern (5), Eastern (6) and Luapula (2) provinces. Cumulatively, 1,089 confirmed cases have been recorded, 7 deaths and 912 recoveries.
The confirmed cases are distributed across Muchinga (557), Lusaka (384), Copperbelt (77), Central (36), Northwestern (6),Eastern (6), Southern (5), Luapula (5), and Northern (5) provinces.
The University Teaching Hospital Virology Lab (UTHVL), the School of Veterinary Medicine (UNZAVET) and Tropical Diseases Research Centre (TDRC) are conducting tests for suspected cases.
Week 22
Non-Bloody Diarrhoea
Cumulatively, 274,598 cases of non-bloody diarrhea were reported (week 1 to week 22).
The highest number of cases reported are from Central province representing 14.97% (42,297).
The highest cumulative incidence reported is from Central province at 2,438 per 100,000 of the population at risk.
A downwards trend in the cumulated number of non-bloody diarrhea cases reported has been
Global/Regional/Public Health Events (Cases/Case Fatality Rate)
| Ebola | Measles | Cholera | Poliovirus (c VDPD) | CoronaVirus (COVID 19) |
| DRC : 3,463 CFR 65.80% | DRC: 369,520 CFR 1.80% | DRC: 9,630 CFR 1.20% Moz: 2,305 CFR 0.80% | Angola: 121 CFR 0.0% DRC: 113 CFR 0.0% | Global:6,255,533CFR5.99% Africa: 102,133 CFR 2.6% |
COVID-19 WHO African Region
The coronavirus disease 2019 (COVID-19) pandemic continues to evolve rapidly in the WHO African Region since Countries in the WHO African Region, with all 47 Member States reporting confirmed cases
23,133 new confirmed cases and 515 deaths of COVID-19 were reported across all affected countries in the current reporting week.
Cumulatively, a total of 102,133 confirmed cases and 2,614 deaths have been reported in the African region.
Of the 102,133 confirmed COVID-19 cases reported, 45,925 (45%) cases have been documented as recovered. A total of 2,380(2.33%) health care workers have been infected by the pandemic.
Ebola Virus, DRC 2018-2020
There has been no new confirmed EVD cases in the week under review. This is the 27th successive day with zero reported confirmed EVD cases since the resurgence of the outbreak on 10 April 2020.
Cumulatively, 3,463 suspected cases, 3,317confirmed cases, 145 probable cases and 2,280 deaths (CFR is 66%) have occurred since the outbreak started earlier in 2018.
The total number of health workers affected remains at 171, representing 5% of confirmed and probable cases. ***For more information look up the WHO Weekly Bulletin on Outbreaks and Other Emergencies and for Global updates on the coronavirus COVID 19 look up John Hopkinsdashboard on
Public Health Actions
Circulating Vaccine Derived Poliovirus Outbreak
All provinces are further encouraged to strengthen AFP surveillance using available technological tools and geo code all cases detected.
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.
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 COVID– 19 High Risk Districts
Surveillance (including Event Based Surveillance) is being actively conducted at POEs, health facilities, and sentinel sites.
Screening facilities have been set up at POEs; additionally, screening is being done at the dry port in Makeni for all buses coming in from outside the country.
Additional thermal scanners to be procured and placed at the POEs to avoid over-crowding and enhance social distancing; set up/identification of designated quarantine facilities to enforce guidelines on quarantine.
Isolation facilities have also been set up in all high risk districts across the ten provinces;
Provincial epidemic preparedness committees to engage all relevant government stakeholders and multisector partners required to prevent, control and stop transmission of COVID– 19.
Global Alert of the Coronavirus & Preparedness
Orientation of staff at points of entry on COVID-19 in all provinces is being conducted in cascade
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 is being done.
Report all suspected patients to higher authority immediately.
Daily monitoring & 14 day quarantine of all travelers from high risk countries is mandatory. 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: 909/+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)
Surveillance and Disease Intelligence Unit Zambia National Public Health Institute
Citation Style For This Article: Surveillance and Disease Intelligence Unit. Intergrated Disease Surveillance and Response week 17 (20-26 April 2020 ). Health Press Zambia Bull. 2020; 4(3); pp 3-6
Weekly Summary
Current outbreaks and public health threats
COVID-19 (Coronavirus): 27 confirmed cases, 0 deaths and 9 recoveries were reported in the week under review. Cumulatively as of the 26th of April, a total of 88 confirmed cases,3 deaths and 42 recoveries have been recorded.
cVDPV Outbreak: No new confirmed cases were recorded this week.
Immediately notifiable diseases
COVID-19 (Coronavirus): The country has recorded a cumulative total of 88 confirmed cases from Lusaka (82), Copperbelt (5) and Central(1) provinces.
Acute Flaccid Paralysis (AFP): Three cases were reported in the week under review in the Copperbelt (2) and Northern (1) provinces.
Maternal Deaths: Seventeen maternal deaths were recorded in Central (4), Western (3), Lusaka (3) Northwestern (2), Southern (2), Northern (1), Copperbelt (1) and Eastern (1) provinces.
Measles: Two suspected cases were reported in Northern (1) and Muchinga (1) provinces.
Other diseases/events
Anthrax: Two suspected cases were reported from Luampa (1) and Kalabo (1) district of Western province.
Neonatal Tetanus: Two suspected cases were reported in the week under review Northern province.
Typhoid: Eight suspected cases were reported in the week under review in Luapula (4), Central (3) and Lusaka (1) provinces. Four samples were collected and sent for Laboratory investigation.
Paper and Electronic Timeliness and Completeness, Health Facility Level
Provincial Report Timeliness
Maternal Deaths
Week 17
Cumulative Number of Maternal Deaths by Province
17 maternal deaths were registered in the week under review.
Obstetric hemorrhages and Indirect causes continue to be the leading causes of maternal deaths.
Lusaka province (53) has cumulatively recorded the highest number of maternal deaths.
In total 222 maternal deaths have been recorded in the year 2020.
Vaccine Preventable Diseases
AFP Surveillance
Districts with reported AFP Cases Week 1-17 2020
Week 17
Three cases of AFP were reported in the week under review from Kitwe(2) districts of Copperbelt province and Kaputa (1) district of Northern province.
All samples habe been collected and sent for laboratory investigation
Cumulatively, 64 AFP cases have been recorded from 34 districts.
As a result of the cVDPV outbreak, non-AFP target rate has been increased to 4/100, 000 population below 15.
All results received from specimens submitted to the regional lab came out negative for cVDPV
The risk of cVDPV2 transmission in Zambia is high 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)
Measles Outbreak
No new cases were recorded from the ongoing Measles outbreak in Northern Province affecting Lunte district.
Cumulatively, 27 suspected cases have been reported since the outbreak was declared.
One Igm positive case was reported in the affected district.
The affected health facilities in the district are Mulenga Mapesa and Mukupa Kaoma. The outbreak appears to have come under control.
Measles & Rubella surveillance
Two suspected measles cases were reported in the week under review.
Suspected measles specimens are collected and sent for laboratory investigations.
Cumulatively, 95 suspected measles cases , 12 measles Igm confirmed cases and 5 confirmed measles rubella cases have been recorded.
COVID-19
27 confirmed cases, 0 death and 9 recoveries of COVID–19 were reported in the week under review from Lusaka (24) and Copperbelt (3) provinces. Cumulatively, 88 confirmed cases have been recorded, 3 deaths and 42 recoveries.
The confirmed cases are distributed across Lusaka (82), Copperbelt (5) and Central (1) provinces.
The confirmed cases are in quarantine at designated health facilities in strategic districts and are receiving medical care.
A total of 10,322 high risk persons are under observation, this includes travelers from high risk countries as well as persons that may have come in contact with the confirmed cases.
The University Teaching Hospital Virology Lab (UTHVL), the School of Veterinary Medicine (UNZA-VET) and Tropical Diseases Research Centre (TDRC) are conducting tests for suspected cases and has to date received 5,932 samples, 5,284 have been processed with 88 confirmed positive for COVID-19.
Epi-curve COVID-19 Confirmed cases N=88, Deaths=3(CFR 3.41%), Recoveries = 42
Non-Bloody Diarrhoea
Cumulatively, 227,866 cases of non-bloody diarrhea were reported from week 1 to week 17.
The highest number of cases reported are from Central province representing 16% (36,167).
The highest cumulative incidence reported is from Central province at 2,085 per 100,000 of the population at risk.
Global/Regional/Public Health Events (Cases/Case Fatality Rate)
| Ebola | Measles | Cholera | Poliovirus (c VDPD) | CoronaVirus (COVID |
| DRC : 3,461 CFR 66.00% | DRC: 361,935 CFR 1.80% | DRC: 7,207 CFR 1.10% Moz: 1,506 CFR 1.0% | Angola: 131 CFR 0.0% DRC: 110 CFR 0.0% | Global:2,989,175 CFR7.03% Africa: 20,652 CFR 4.2% |
COVID-19 WHO African Region
Countries in the WHO African Region have been affected by the current coronavirus disease 2019 (COVID- 19) global pandemic, with 45 of the 47 countries in region reporting confirmed cases.
6,245 new confirmed cases and 203 deaths of COVID-19 were reported across all affected countries in epi week 17.
Cumulatively, a total of 20,652 confirmed cases and 861 deaths have been reported in the WHO African region.
Of the 20,652 confirmed COVID-19 cases reported, 7,155 (35%) cases have been documented as recovered. A total of 325 (1.57%) health care workers have been infected by the pandemic.
Ebola Virus, DRC 2018-2020
There has been no new confirmed EVD cases in the week under review since the resurgence of the outbreak.
Cumulatively, 3,461 suspected cases, 3,316 confirmed cases, 147 probable cases and 2,277 deaths (CFR is 66%) have occurred since the outbreak started earlier in 2018.
The total number of health workers affected remains at 171, representing 5% of confirmed and probable cases.
***For more information look up the WHO Weekly Bulletin on Outbreaks and Other Emergencies and for Global updates on the coronavirus COVID 19 look up John Hopkinsdashboard on
https://gisanddata.maps.arcgis.com/apps/opsdashboard/index.html?***
Public Health Actions Circulating Vaccine Derived Poliovirus Outbreak
All provinces are further encouraged to strengthen AFP surveillance using available technological tools and geo code all cases detected.
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.
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 COVID– 19 High Risk Districts
Surveillance (including Event Based Surveillance) is being actively conducted at POEs, health facilities, and sentinel sites.
Screening facilities have been set up at POEs; additionally, screening is being done at the dry port in Makeni for all buses coming in from outside the country.
Additional thermal scanners to be procured and placed at the POEs to avoid over-crowding and enhance social distancing; set up/identification of designated quarantine facilities to enforce guidelines on quarantine. Isolation facilities have also been set up in all high risk districts across the ten provinces;
Provincial epidemic preparedness committees to engage all relevant government stakeholders and multisector partners required to prevent, control and stop transmission of COVID– 19.
Global Alert of the Coronavirus & Preparedness
Orientation of staff at points of entry on COVID-19 in all provinces is being conducted in cascade
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 is being done. Report all suspected patients to higher authority immediately. Daily monitoring & 14 day quarantine of all travelers from high risk countries is mandatory.
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: 909/+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 : ML Phiri, M Chasaya, MA Ngomah
Zambia National Public Health Institute
Citation Style For This Article: Phiri ML, Chasaya M, Ngomah MA . A Retrospective Analysis of Maternal Deaths in Zambia (2019-2020) . Health Press Zambia Bull. 2020; 4(3); pp 10-15
Abstract
Maternal mortality is still a public health concern in Zambia and globally. It is an important measure of the strength of a health care system. The current study was anchored on exploring the prevalence of maternal mortality in Zambia and report on the factors contributing to maternal mortality in order to identify areas of need in terms of intervention development and improvement of health care in Zambia. Using descriptive analysis of results in Excel and Tableau, the findings showed that overall, about 528 maternal deaths were recorded in a period of 10 months. Obstetric Hemorrhage and Hypertension were still the major causes of Maternal mortality. Geographical location and sociodemographic aspects seemed to have a role to play in the occurrence of maternal deaths in Zambia with Lusaka leading the number of cases. Another interesting finding was that the time factor by month did not show so much variation except in one month of November 2019 where the mortality deaths escalated to about 130 while the rest remained within the mean of 50 cases. The study identified consistent trends of associated causes with other previous studies indicating that there is need for increased attention in mortality rates as response to strengthening the health system of Zambia. So far, maternal mortality deaths are still high and this calls for attention even in the midst of an outbreak such as COVID-19.
Introduction
Maternal mortality continues to be a major public health concern both locally and globally. Many countries worldwide are working tirelessly to reduce these numbers. It is estimated that 303,000 women die during pregnancy and childbirth every year in the world and that most deaths occur in developing economies. Maternal mortality in Zambia is estimated at 183 deaths per 100,000 live births [1]. Reducing preventable maternal deaths has been a major concern even to the United Nations community as reflected in the sustainable development goals 3.1 which aims at reducing the global maternal mortality ratio to less than 70 per 100 000 live births by 2030 [1].
Many researchers from within Africa and outside have embarked on identifying factors associated with maternal mortality in order to aid possible intervention. Zambia is not an exception in the fight against maternal deaths and the ministry of health has been investing significant amount of resources to try and reduce these rates. There are unverified assumptions that the era of the COVID-19 pandemic may have an impact on maternal mortality.
Part of African research from Malawi has assessed how delay factors are associated with maternal mortality. These delay factors include reaching the health facility and receiving care. Using the three delays framework, data were analyzed for women who had; 1) died at a healthcare facility, 2) died at home but had previously accessed care and 3) died at home and had not accessed care. The findings suggest 62.2% (94/151) of maternal deaths occurred in a healthcare facility and a further 21.2% (32/151) of mothers died at home after they had accessed care at a healthcare facility. More than half of all women who died at a healthcare facility (52.1%) had experienced more than one type of delay. The researchers showed that improving quality of care at healthcare facility level was central to reducing maternal mortality [2].
Most recent research on Zambia shows correlates of maternal mortality in Zambia in the last three years dating from 2018 based on data in the Maternal Perinatal Death Surveillance of 2018 [1]. The primary correlates of maternal deaths have been found to be obstetric hemorrhage and indirect causes. Obstetric hemorrhage was the most common cause of death among women aged 30-49 and women who had experienced more than one pregnancy, while indirect causes attributed to the most deaths among pregnant women aged 10-29 and first-time pregnant women [1].
Researchers have described maternal death as an important measure of the strength of a health system [3, 4]. Due to this factor, other countries have introduced maternal death surveillance and response systems which involve the identification and reporting pathways for maternal deaths, review of deaths, aggregation of data, interpretation of findings, and formulation and implementation of recommendations for action. Kenya is among the countries that have implemented the maternal death surveillance system. However, several challenges have been encountered including underreporting of data, difficulties with reviewing the data, and suboptimal aggregation of data on cause of death. Experts have recommended that to ensure progress toward a full national enquiry of all maternal deaths, improving the notification of maternal deaths, ensuring regular audits and feedback at referral hospitals can lead to continuous quality improvement, and strengthening community linkages with health facilities to expedite maternal death reporting [3].
Most recent studies have reported the existence of COVID-19 related maternal mortality which already calls for concern to public health and the fight to reducing maternal mortality. Data from Brazil shows that the number of COVID-19 related mortality is on the rise [7]. This increase has been associated inadequate preventive preparedness for the pandemic by healthcare systems. Researchers predict a rise in maternal mortality if Covid-19 does not take a step backwards [7]. Part of existing literature has concentrated on factors associated with maternal mortality. A number of studies both within Africa and globally have found obstetric hemorrhage to be a huge contributing factor to maternal mortality [8, 9, 10]. Another common factor associated with high mortality rate is hypertension [9]. Some public health researchers have found that the impact of hypertension and obstetric hemorrhage on maternal mortality is most profound in low- and middle-income countries due to sub-standard maternal healthcare and sub-optimal use of evidence-based strategies to prevent and treat morbidity [8]. Moreover, a section of literature on management of obstetric hemorrhage has suggested that giving Tranexamic Acid to women who are hemorrhaging within 3 hours after delivery reduced the risk of death resulting from bleeding with no increase in thromboembolic complications [11, 12]. Further African studies have pointed out that one of the major challenges facing maternal death surveillance and response systems in Africa is politicization. Health workers and bureaucrats struggle to balance conflicting demands among the specific challenges such that when implementing the MDSR system, they are required to meet conflicting demands such as report all deaths; to deliver perceived success in maternal mortality reduction by reporting as few deaths as possible; and to avoid personalized accountability for deaths. Fear of personal and political accountability for maternal deaths strongly influences not only reporting practices, but also the care given in the health centers. Health workers report maternal deaths in ways that minimize their number and deflect responsibility for adverse outcomes. They attribute deaths to community and infrastructural factors, which are often beyond their control [4]. Despite having huge maternal deaths in developing countries, research from more developed nations with stronger health systems have not been spared from maternal mortality. For instance, a US literature revealed that despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington D.C. increased from 2000–2014, while the international trend was in the opposite direction. The authors expressed the need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year [5]. Some countries have recorded success stories in the provision of maternal health services and reduction of maternal mortality. For instance, China between 1997 and 2014 reduced maternal mortality by about 8.9% leading to the satisfaction of the 2015 millennium development agenda. Among some of the factors that contributed to the success story was China’s highly medicalized model of maternity care and a health delivery model were maternity care is provided close to the women’s homes. However, despite remarkable progress in maternal survival in China, substantial disparities remain, especially for the poor, less educated, and ethnic minority groups in remote areas in western China [6]. The findings of this study also reveal that socio-economic and demographic characteristics have an impact on maternal mortality. The evidence also shows that mortality rate can vary with socioeconomic characteristics of a geographical area. Based on the available IDSR data, the current study aimed at describing the prevalence of maternal mortality in Zambia and report on the factors contributing to maternal mortality in order to identify areas of need in terms of intervention development.
Methods
Data was extracted from the Integrated Disease Surveillance and Response (IDSR) system for the period August 2019 to June 2020. This data is national data that is submitted to the Zambia National Public Health Institute every week. This time zone was chosen because it was the data available so far and it was intended to observe in order to provide direction towards problem areas surrounding the fight against maternal mortality in Zambia which is a strong indicator of strength in a health care system of a country. The data was analyzed using Tableau and Microsoft Excel. Maternal deaths were presented using graphs generated from Microsoft Excel and Tableau and descriptive statistical data was presented using reports from Microsoft Excel.
Results
The table below shows results computed in Microsoft excel, 2013 which shows that there was a total of 528 cases of maternal deaths between August 2019 and
June 2020 with a mean (μ) 52.8 and SD (s) 31.77. Descriptive data also shows that the minimum number deaths per month was 14 and the maximum was 130 countrywide.
Figure 1: Descriptive statistics for maternal deaths occurring in Zambia between August 2019 and June 2020
| Total Maternal Deaths | |
| Mean Standard Deviation Minimum Maximum Sum | 52.8 31.76930734 14 130 528 |
Figure 2: Overall IDSR reported maternal deaths occurring in Zambia between August 2019 and June 2020 by month.
The data below on maternal mortality by province shows trends for the period between August 2019 and June 2020. From graph 1 below, the study shows that Lusaka had the highest reports of maternal mortality amounting to about 38 deaths followed by southern(18) and northern province(17), then central province(16), Copperbelt(13), Western(13), Eastern(11), North-western(8), Luapula(7) and Muchinga(6).
The findings in figure 3 below shows that the highest monthly number of cases was about 130 deaths in November 2019 which represented (24.6%) of the overall maternal mortality cases recorded. The data further shows a significant drop in maternal mortality to about 10.8% (57) in March and most of the months recording around 57 deaths and below. These monthly death statistics also mean that on average, about two lives of Zambian mothers are lost due to death.
Then figure 4.1 below shows cumulative estimated causes of maternal death by percentage from January 2019 to November 2019. Similarly, the main causes of deaths indicate that indirect causes (24%) and obstetric hemorrhage (30.4%) were the major contributors of maternal deaths. These factors were followed by hypertensive disorders (14.4%). About 9% of the deaths were caused by abortive outcomes,8% by caused by pregnancy related infection.
Based on figure 4.2 below, the findings are indicative that the major cause of maternal death were indirect causes (32.4%) and obstetric hemorrhage (36.3%). The rest of the causes share (35.3%) of the attribution which include abortive outcomes (9.7%), hypertensive disorders (11.9%), pregnancy related infections (5.0%) while the rest falling below 2% which includes unanticipated outcomes, incidentals, undetermined causes and unknown causes.
Discussion
The rates of maternal mortality seem to have reduced slightly compared to the findings of a similar study in 2018 [1]. Despite the reduction, maternal deaths are still relatively high in Zambia. Monthly data revealed that an average of 52 mothers died every month from August 2019 to June 2020. This finding raises concerns and calls for increased attention from the stakeholders. Another striking finding which has been consistent in previous studies is that Obstetric hemorrhage is the greatest contributing factor to maternal mortality [1]. This consistency means that this is a factor that calls for attention among policy makers and intervention developers towards reducing this cause. Research has shown that some of the interventions that can be used to manage obstetric hemorrhage can include vaginal delivery, maternal resuscitation, delivery of the fetus, and uterine hemostasis (e.g., contraction, tamponade, embolization of hypogastric surgical repair of tissue lacerations, and possibly hysterectomy) [10, 8]. Another factor that seemed as a strong predictor of maternal mortality in Zambia is hypertensive disorders. This suggests that there are a lot of women in Zambia who die as a result hypertension at pre-natal and perinatal stage. These findings are consistent with previous findings from East Africa that found that high morbidity was attributable to hypertensive disorders in pregnancy [9]. This suggests the need to prevent such deaths early interventions such as antihypertensive therapy and prophylactic magnesium sulphate treatment.
The study did not show significant changes in cases by month for the months that have been hit by the Covid-19 pandemic. This is in contrast with Brazilian context that has recorded an increase in Covid-19 related maternal deaths. The reason why we have no Covid-19 related maternal deaths is uncertain because the IDSR data used for this study does not have a graduation of such deaths yet. Increased surveillance by health care stations could help in making this particular aspect of the result clearer. On the positive side the absence of such deaths may mean the Zambian health care system is making significant effort in controlling the effect of COVID-19 on other areas of health such as maternal health.
Furthermore, the study also revealed that geographical factors can contribute to the differences in maternal mortality cases. For instance, data on cases of maternal death by province show that Lusaka recorded the highest cases of maternal mortality while Muchinga recorded the smallest proportion from August 2019 to June 2020. The reasons behind Lusaka having the highest cases is subject to research but roughly it can be assumed that maybe the population size among the provinces could be a factor or it could be healthcare factors or even health seeking behaviors among expecting mothers. Additional studies could add more flesh to this finding.
The Ministry of Health is committed to reducing the global mortality rate to 70per 100,000 live births by 2030 [1]. However, this target is most likely to be achieved if surveillance can be strengthened and attention can be given to all factors showing stronger attribution towards maternal mortality. For instance, increasing attention to the prevention of severe blood loss during and after delivery and hypertensive therapy before and after giving birth may lead to a significant drop in maternal mortality rates in Zambia.
Conclusion
Maintaining high rates of maternal mortality implies that a country is struggling to achieve its public health goals of improved women and infant’s health. It is important for a developing nation like Zambia and other nations in similar contexts to strengthen review processes that are utilized to assess potential preventability. Another important factor is to increase usage of evidence-based management strategies and increase capacity through increased budget allocation towards strengthening of healthcare systems and intervention development. Frequent studies on maternal mortality can provide direction in the process of developing interventions that may seek to reduce maternal mortality significantly.
Limitations
Just like any other study, this one had its own weaknesses. Firstly, was the sole reliance on the IDSR data and descriptive analysis because it may not give us full insight into the causes or significant differences or contribution like some inferential analyses could do. However, the study provides a good reminder of problem areas that are limiting the effectiveness of the Zambian healthcare system in protecting the health and lives of women in maternity and children.
LIST OF REFERENCES
1. Gianett B, Musakanya KE, Ngomah Moraes A, Chizuni C, Groeneveld C, Kapina M, Hamoonga R, Mazaba ML, Mukonka V. (2019). Maternal mortality trends and correlates in Zambia. Health Press Zambia Bull, 3(4&5); pp 12-16.
2. Mgawadere, F., Unkels, R., Kazembe, A., & van den Broek, N. (2017). Factors associated with maternal mortality in Malawi: application of the three delays model. BMC pregnancy and childbirth, 17(1), 1-9.
3. Smith, H., Ameh, C., Godia, P., Maua, J., Bartilol, K., Amoth, P., … & van den Broek, N. (2017). Implementing maternal death surveillance and response in Kenya: incremental progress and lessons learned. Global Health: Science and Practice, 5(3), 345- 354.
4. Melberg, A., Mirkuzie, A. H., Sisay, T. A., Sisay, M. M., & Moland, K. M. (2019). ‘Maternal deaths should simply be 0’: politicization of maternal death reporting and review processes in Ethiopia. Health policy and planning, 34(7), 492-498.
5. MacDorman, M. F., Declercq, E., Cabral, H., & Morton, C. (2016). Is the United States maternal mortality rate increasing? Disentangling trends from measurement issues short title: US maternal mortality trends. Obstetrics and gynecology, 128(3), 447.
6. Gao, Y., Zhou, H., Singh, N. S., Powell-Jackson, T., Nash, S., Yang, M., … & Pan, J. (2017). Progress and challenges in maternal health in western China: a Countdown to 2015 national case study. The Lancet Global Health, 5(5), e523-e536.
7. Takemoto, M. L., Menezes, M. D. O., Andreucci, C. B., Nakamura‐Pereira, M., Amorim, M. M., Katz, L., & Knobel, R. (2020). The tragedy of COVID‐19 in Brazil: 124 maternal deaths and counting. International Journal of Gynecology & Obstetrics.
8. Geller, S. E., Koch, A. R., Garland, C. E., MacDonald, E. J., Storey, F., & Lawton, B. (2018). A global view of severe maternal morbidity: moving beyond maternal mortality. Reproductive health, 15(1), 98.
9. Nakimuli, A., Nakubulwa, S., Kakaire, O., Osinde, M. O., Mbalinda, S. N., Kakande, N., … & Kaye, D. K. (2016). The burden of maternal morbidity and mortality attributable to hypertensive disorders in pregnancy: a prospective cohort study from Uganda. BMC pregnancy and childbirth, 16(1), 205.
10. Clark, S. L. (2016, March). Obstetric hemorrhage. In Seminars in Perinatology (Vol. 40, No. 2, pp. 109-111). WB Saunders.
11. Pacheco, L. D., Hankins, G. D., Saad, A. F., Costantine, M. M., Chiossi, G., & Saade, G. R. (2017). Tranexamic acid for the management of obstetric hemorrhage. Obstetrics & Gynecology, 130(4), 765-769.
12. Fardelmann, K. L., & Alian, A. A. (2020). Anesthesia for Obstetric Disasters. Anesthesiology Clinics, 38(1), 85-105.
By : T Munthali, S Hachizovu, M Washington National Health Research Authority
Citation Style For This Article: Munthali T, Hachizovu S, Washington M, . The last stride to 90-90-90: Improving viral suppression in children (under 16 years) through community-based ART in Zambia. Health Press Zambia Bull. 2020; 4(3); pp 6-9
Key Messages
• Viral suppression, remains low among children under 16 years in Zambia, two years before the endpoint of the UNAIDS 90-90-90 targets.
• Only 34% of HIV infected children on antiretroviral treatment (ART) are virally suppressed
• Community-based adherence counselling has been proven to increase viral suppression to 65%, while community-based drug dispensing coupled with community-based counselling could potentially increase viral suppression up to 90%.
Problem Statement
In Zambia, currently, there are 94 000 children (under 16 years) living with HIV, with about 52% in HIV care, and only 34.1% of them are virally suppressed (see Figure 1).1, 2 Two years before the year 2020, the end-point of the UNAIDS 90- 90-90 targets, the last 90 remains low among children under 16 years in Zambia (with the first 90 defined as those who know their status and the second as those that are in care, and the last 90% as those with viral load suppression). Broadly, adherence is one of the best determinants of viral suppression3. Unfortunately adherence is also an area of concern among children in Zambia
(see Figure 2).1 Non-adherence or suboptimal adherence may include missed or late doses, treatment interruptions and discontinuations of care, as well as sub-therapeutic dosing.3
Figure 2: Non-Adherence* and no viral suppression among children
Figure 1: Viral suppression among people living with HIV in Zambia by age group
A study was conducted on the association between adherence and viral suppression in Zambia. Even though it was done on adults older than 16 years, it revealed that individuals with suboptimal adherence had 30% increased risk of virological failure compared to individuals with optimal adherence.4 Empirically, children and adolescents have the lowest adherence levels compared to adults.5-7 There are a number of factors affecting childhood adherence and viral suppression: depending on caregivers to administer medication, anticipating community level stigma, fearing disclosure, forgetting doses, changing ones routine, being too busy, and the child refusing medication coupled with poor flexibility of clinic opening hours are some of the factors affecting adherence and in turn viral suppression among children.8-10
Community-based differentiated service delivery strategies have been identified as important strategies for improving ART adherence and viral suppression, and they could be an intervention that could help Zambia reach the final 90.11 In a South African study conducted at 57 ART sites, among children under 16 years starting ART, community-based adherence support (CBAS) yielded higher proportions of virological suppression (65%) compared to those not in the program (55%) after 4 years of follow up.12 Various community-based differentiated service delivery models have also proven to improve adherence and viral suppression up to 90% among adults in Zambia .13 A good example is a project in Zambia that provides community-based HIV testing, opportunistic infection screening, adherence counselling, and ART dispensing in six districts in the country. The project has yielded adherence and viral suppression levels above 90%.13 Although these findings are among adults, a call to action to implement a similar intervention among children is needed in order to reach 90% viral suppression by 2020, among Zambiaan HIV infected children.
Policy Options
What are the policy options? To meet the UNAIDS 90-90-90 targets, community-based differentiated service delivery models of care have to be implemented among children in Zambia. Policy options include providing community-based ART adherence counselling, providing community-based ART drug dispensing coupled with adherence counselling, or do nothing and maintain the status quo (see Table 1).
OPTION 1: Status Quo (Do Nothing) What: Leave things the way they are and hope viral suppression will increase. Unfortunately, viral suppression is unlikely to increase due to the many barriers mentioned above. Why: This is the current operation of the Ministry of Health. Feasibility: High. Health facilities already have staff in place to attend to HIV infected children and standards of care are already established.
OPTION 2: Community-Based Adherence What: Conduct home visits by ART nurses to provide adherence counselling and offer psychological support to children and caregivers. This option also ensures optimal drug dosage is being maintained
Why: Existing facility-based adherence counselling relies on the caregivers reports which may have biases. This option will aid in understanding child specific adherence needs through interaction with the child and the caregiver in the home environment, thus reducing most of the bias in addition to removing some of the barriers mentioned above related to low adherence. Feasibility: Medium. The intervention will require additional training for community health teams to improve health care workers skills in family centered adherence counselling. This option will build on the community-based medicine model being implemented by the Ministry of Health in the sub-district structures.
OPTION 3: Community-Based Adherence and Drug Dispensing What: Provide community-based drug adherence counselling and drug dispensing for clinically stable* children.
Why: Currently, health facilities are congested and experience staff shortages, making waiting time long and reduces quality of patient care. This will reduce both economic and time cost incurred by caregivers. This will also ensure child specific adherence counselling and reduce chances of missed appointments. Feasibility: Medium. Pediatric ART is complex due to delicate and evolving drug dosages as the child grows. Community-based drug dispensing models have only been tried for adults. Additional training will be required for current staff on pediatric ART drug dispensing and treatment monitoring to increase proficiency levels. Standards on community-based pediatric ART treatment and adherence will have to be developed. h interventions are cost savings, which means we are able to spend less money on the interventions compared to the status quo and increase the number of children with viral load suppression. With community-based adherence alone, the Ministry of Health saves USD 38 for every extra child whose viral load is suppressed when compared to no intervention. With the community-based adherence and drug dispensing, we save USD 34 per every child’s viral load suppressed when compared to no intervention.
The most cost-effective option is Community-Based Adherence, however, less children will be viral suppressed compared to the Community-Based Adherence and Drug Dispensing.
Recommendations and Next Steps
Community-based adherence counselling and drug dispensing is not the most feasible or most cost effective but, it is the most effective option to increase the proportion of children virally suppressed by 2020. To achieve this option, stigma reduction campaigns will have to be conducted across the country (those costs are not included above).
Community-health nurses will also have to be trained in community pediatric ART and adherence counselling. The Ministry of Health will have to lobby the Ministry of Finance to increase the budgetary allocation to employ more community-health nurses to improve the nurse-child ratio. The Ministry of Health will also have to develop standards and guidelines for community-based ART dispensing and adherence counselling among children.
In addition, the Ministry will also have to adopt strategies and work closely with partners that have implemented the differentiated service delivery models with success among adults in different project sites across the country.
LIST OF REFERENCES
1. MOH, Ministry of Health unpublished HIV SmartCare Data. Ministry of Health 2018. Lusaka, Zambia.
2. MOH, Population-based HIV Impact Assessment (ZAMPHIA) 2016: First Report, Ministry of Health, Editor 2016: Lusaka, Zambia.
3. AIDSinfo, Guidelines for the use of antiretroviral agents in pediatric HIV Infection. U.S. Department of Health and Human Services, 2017. Accessed on 12 April, 2018.
4. Goldman D. et al., Simple adherence assessments to predict virologic failure among HIV-infected adults with discordant immunologic and clinical responses to antiretroviral therapy. AIDS Research and Human Retroviruses 2008. 24(8).
5. Chi, B.H., et al., Adherence to first-line antiretroviral therapy affects non-virologic outcomes among patients on treatment for more than 12 months in Lusaka, Zambia. International Journal of Epidemiology, 2009. 38(3), p. 746-756.
6. Nachega J. et al., Achieving viral suppression in 90% of people living with human immunodeficiency virus on antiretroviral therapy in low- and middle-income countries: Progress, challenges, and opportunities. Clinical Infectious Diseases, 2018. 66(10), p. 1487-91.
7. Protopopescu et al., Factors associated with non-adherence to long-term highly active antiretroviral therapy: A 10-year follow-up analysis with for the bias induced by missing data. Journal of Antimicrobial chemotherapy, 2009. 64(3), p. 599-606
8. Mburu, G. et al., Adolescent HIV disclosure in Zambia: Barriers, facilitators and outcomes. International HIV/AIDS Alliance, 2014. 17(1), p. 18866.
9. Jobanputra K. et al., Factors associated with virological failure and suppression after enhanced adherence counselling, in children, adolescents and adults on antiretroviral therapy for HIV in Swaziland. PLoS ONE 2015. 10(2).
10. Denison J.A. et al., ‘‘The sky is the limit’’: Adhering to antiretroviral therapy and HIV self-management from the perspectives of adolescents living with HIV and their adult caregivers. International AIDS Society 2005. 18(1), p. 19358.
11. Nachega J. et al., Community-based interventions to improve and sustain antiretroviral therapy adherence, retention in HIV care and clinical outcomes in low- and middle-income countries for achieving the UNAIDS 90-90-90 targets. Current HIV/ AIDS Reports, 2016. 13(5), p. 241-55.
12. Fatti G. et al., Improved virological suppression in children on ART receiving community-based support: A multi cohort study from South Africa. AIDS Care, 2014. 26(4), 448-453
13. CIHEB, Fast-tracking towards HIV epidemic control while maintaining quality health care. 11th Annual National HIV Technical Conference, 2017. 12-14 December 2017.
14. Red ribbon from https://www.factretriever.com/hivaids-facts. Accessed 27, May 2018.
15. Picture of baby from https://www.michigan.gov/documents/mde/Item_A_PPT_HeadStart_507336_7.pdf . Accessed on 30 May, 2018. 9
By : F N’guni, N Kabelenga National Health Research Authority
Citation Style For This Article: N’guni F, Kabelenga N , . “MIND THE GAP” Improving Tuberculosis Care and Treatment in Correctional Facilities in Zambia. Health Press Zambia Bull. 2020; 4(3); pp 3-5
Key Messages
• Zambia ranks 13th among countries with the highest TB burden in the world.
• 6.3% of TB cases in Zambia are attributable to TB transmission within correctional facilities
• However, the National Tuberculosis and Leprosy Program (NTLP) currently does not have a robust recording and reporting mechanism on TB case detection and treatment outcomes from correctional facilities.
• There is need for a clear policy that includes guidance on data collection and reporting to NTLP from correctional facilities, without compromising human rights of inmates diagnosed with TB.
Problem Statement
In 2016, there were: -10.4 million people who fell ill with tuberculosis (TB); -1.4 million people who died from TB; -4.3 million cases missed by health systems across the globe.1 Many deaths and people missed with TB by the public health system each year are likely to be disproportionally concentrated among high risk population groups such as detainees (prisoners).2 In correctional facilities, TB incidence can be as high as 70 times that in the general population.3 Conditions in correctional facilities can fuel the spread of the disease through;
-Overcrowding
-Poor ventilation
-Week nutrition -Inaccessible or inadequate medical care Some of the consequences of high TB burden in correctional facilities may include:
-Transmitting the disease into the community through staff, visitors and inadequately treated former inmates;
-Developing of multi-drug resistant TB which has become a major public health problem in most developing countries.
In recognition of the importance in curbing the global TB epidemic, two of the three WHO Global Plan to End TB (2016- 2020)4 identify key populations as a group that needs special attention. Zambia is ranked 13th among the countries with high TB burden in the world.1 Correctional facilities are an important contributor to TB burden in Zambia. In 2015 there were 18,560 inmates crowded into 88 correctional facilities in Zambia, representing a 229% occupancy rate.5 An estimated 6.3% of TB in the general population is attributable to TB transmission within correctional facilities 6. End TB Strategy 2016 – 20204
Routine screening for TB is conducted in selected Zambian correctional facilities with support from cooperating partners. However, the NTLP has not yet established routine TB recording and reporting for TB cases diagnosed and their treatment outcomes in correctional services. This is attributed to the lack of a clear policy on how to address TB issues while ensuring confidentiality and observing human rights in correctional facilities. Comprehensive and updated data are key to informing the NTLP on the magnitude of TB in the correctional facilities and the various outcomes related to TB treatment. However, comprehensive data on national estimates for TB in Zambian correctional facilities do not exist.
A review of data from the Zambia Correctional Services Annual Report (2017) showed that 696 out of 21000 inmates (3.3%) were screened for TB, of which 171 (24.5%) were diagnosed with TB.7 This is far short of the second target of the WHO Global Plan to End TB. This target requires that TB testing and treatment reach at least 90% of key population.
Another Zambian study involving six correctional facilities demonstrated that of the 345 individuals initiated on TB treatment, the treatment success rate was only 66%,8 again below the 90% target.
Policy Option
This data highlights the need for ensuring a robust monitoring and evaluation system for TB control in correctional facilities in line with WHO recommendations. This will require:
What: Addressing the human rights concerns surrounding capturing TB data in TB treatment registers and cards from correctional facilities, which may include an electronic system. In addition, a robust support system for TB patients needs to be strengthened in all prisons.
Why: This will allow monitoring the level of TB detection and quality of TB treatment services in correctional facilities in line with the desired Global End TB Targets and improve public health in general.
Feasibility: High – It builds on the Ministry of Health’s strong commitment to eliminating TB in Zambia by 2030 as outlined in the National TB Strategic Plan 2017 – 2021.
Recommendations and next steps
Capturing TB data in treatment registers and cards in correctional facilities is an effective strategy to improve monitoring, reporting and assessing the performance of the TB control in correctional facilities. This reflects the need for a policy that: -Has clear guidance on data collection and reporting that covers data confidentiality and data protection. -Addresses human rights issues of concern to inmates and other stakeholders. -Has a requirement that data collected by cooperating partners should be submitted to NTP.
To develop such a policy, the following steps should be considered: -A policy dialogue forum to bring together stakeholders, Ministry of Home Affairs, Ministry of Health, relevant United Nations Agencies, Human Rights Commission and Civil Society Organizations. The expected outcome of this dialogue is to map out issues of human rights concern, learn from best practices in other countries and propose the road map to develop a TB in Prisons Policy for Zambia.
-An action plan for country wide scale up of the policy
LIST OF REFERENCES
1. World Health Organisation (2017). Global Tuberculosis Report (2017).
2. STOP TB Partnership – Working Document (September 2017). Data for Action for Tuberculosis Key, Vulnerable and Underserved Populations – https://www.health-e.org.za/wp content/uploads/2015/10/Global-TB-Report-2015-FINAL-2.pdf
3. USAID TB – Brochure. Tuberculosis In Prisons: A Growing Public Health Challenge (https://www.usaid.gov/sites/default/files/ documents/1864/USAID-TB-Brochure).
4. Stop TB Partnership (2015). “The Paradigm Shift: the Global Plan to End TB 2016 2020” (http://www.stoptb.org/assets/documents/global/plan/GlobalPlanToEndTB_TheParadigmShift_2016-2020_StopTBPartnership.pdf).
5. Telisinghe L, Charalambous S, Topp, SM, Herce ME, Hoffmann CJ, Barron P, & Beyrer C. (2016). HIV and tuberculosis in prisons in sub-Saharan Africa. The Lancet, 388(10050), 1215-1227.
6. Baussano, I, Williams BG, Nunn, P, Beggiato, M, Fedeli U, & Scano F. (2010). Tuberculosis incidence in correctional facilities: a systematic review. PLoS Medicine,7(12), 1470.
7. Zambia Correctional Services Annual Report (2017).
8. S. Hatwiinda, S. M. Topp, M. Siyambango, J. B. Harris, K. R. Maggard, C. Chileshe, N. Kapata, S. E. Reid, G. Henostroza, (December 2017). Article in Tropical Medicine & International Health – Poor continuity of care for TB diagnosis and treatment in Zambian Prisons: a situation analysis (DOI: 10.1111/tmi.13024)
By : ML. Mazaba Zambia National Public Health Institute
Citation Style For This Article: Mazaba ML. The Peril Of Antimicrobial Resistance A Global Public Health Emergency. Health Press Zambia Bull. 2020; 4(3); pp 1-2.
” Antimicrobial resistance (AMR) threatens the effective prevention and treatment of an ever-increasing range of infections caused by bacteria, parasites, viruses and fungi. AMR is an increasingly serious threat to global public health that requires action across all government sectors and society” according to the World Health Organisation report on February 15, 2018 [1].
Antibiotics historically were the greatest discovery in modern medicine providing a wide range of medical solutions to various infections caused by microbial organisms. However, over the recent years, resistance among infection causing organisms to the different antimicrobials used to treat them has been on the rise. This worrisome rise to dangerously high levels is as a result of overuse and misuse of antimicrobials in human and animal health; although most data available focuses on antibiotic resistance [1, 2].
Five years ago, Chajer and Ali stated that “Since antibiotics were first introduced into clinical practice some 80 years ago, microbes have been evolving ways to resist these drugs, but in recent years this problem of antimicrobial resistance (AMR) has been rapidly getting worse” [3].
Recognising the problem of AMR, moreso antibiotic resistance (ABR), its cause and the best approaches in mitigating it, members states at the Sixty-Eighth World Health Assembly held in 2016, endorsed the Global Action Plan on Antimicrobial Resistance. They called for a dedicated global campaign to raise public awareness and understanding of antibiotic resistance
[4]. Annually in November, many governments, health facilities, schools and communities across the globe celebrate an awareness campaign dubbed World Antibiotic Awareness Week (WAAW), The Health Press Zambia (THP-Z) alignthrough which best practices to stall further public, health workers and policy The Health Press Zambia (THP-Z) aligning to the 2019 World Antibiotic Awareness Week theme of “The future of antibiotics depends on us all” supported awareness campaign activities in Zambia including the media awards, the debates among secondary and tertiary institutions, an awareness walk and various media engagement. THP-Z encourages all governments, public and private institutions and individuals to take responsibility and be a part of the drive to mitigate antimicrobial resistance.
THP-Z also invites you to read beyond this editorial published in this issue; a policy brief on Hypertension: Reduce salt intake, Save a heart! Reduced Morbidity and Mortality Due to Hypertension, Awareness And Knowledge Of Glaucoma Among Eye Patients Attending The University Teaching Hospitals Eye Hospital, the November Influenza and IDSR reports. Enjoy!
LIST OF REFERENCES
1. WHO. Antimicrobial resistance. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance. 2018
2. Prestinaci F, Pezzotti P, Pantosti A. Antimicrobial resistance: a global multifaceted phenomenon. Pathog Glob Health. 2015;109(7):309–318.
3. Chhajer R, Ali N. Genetically modified organisms and visceral leishmaniasis. Front Immunol 2014;5:213.
4. WHO. Global Action Plan on Antimicrobial Resistance. https://www.who.int/antimicrobial-resistance/global-action-plan/ en/
Surveillance and Disease Intelligence Unit Zambia National Public Health Institute
Citation Style For This Article: Surveillance and Disease Intelligence Unit. Intergrated Disease Surveillance and Response. Health Press Zambia Bull 2020; 04(2); pp 16-20.
Weekly Summary
Current outbreaks and public health threats
cVDPV Outbreak: No new confirmed cases were recorded this week.
Measles Outbreak: Cumulatively, 5 suspected cases and One confirmed Measles positive IgM were reported from Lunte district but no new cases were reported from Kasama district in the week under review. Both of these districts are in Northern province.
Poliovirus: Two AFP specimens tested positive for PV2 and have been sent for sequencing.
Coronavirus (COVID-19): surveillance ongoing, especially at points of entry. For the week under review # of high risk arrivals screened are as follows: 288# of contacts: 288, # high risk persons/contacts monitored: 191, # suspected COVID-19: 4, # Probable COVID-19: 00, # Confirmed COVID-19: 00
Immediately notifiable diseases
Acute Flaccid Paralysis (AFP): Seven cases were reported from Northern (5), Central (1) and North western (1) provinces.
Maternal Deaths: Sixteen maternal deaths were recorded in Central (4), Lusaka (3), Southern (3) Copperbelt (2), Western (2) , North western (1) and Eastern (1) provinces. Measles: Seven suspected measles cases were reported in Northern (4), Eastern (2) and Lusaka (1) provinces.
Other diseases/events
Typhoid: Seven suspected cases were reported from North western (6) and Eastern (1) provinces.
Rabies: One suspected rabies death was recorded from Mporokoso district in Northern province .
Paper and Electronic Timeliness and Completeness, Health Facility Level
Provincial Report Timeliness
Summary Report Priority Diseases, Conditions and Events (Week 13)
Maternal Deaths
Week 13
Cumulative Number of Maternal Deaths by Province
14 maternal deaths were registered this week.
Obstetric hemorrhages and Indirect causes continue to be the leading cause of maternal deaths.
Lusaka province (45) has cumulatively recorded the highest number of deaths thus far.
In total 166 maternal deaths have been recorded since week 1.
Vaccine Preventable Diseases
AFP Surveillance
Districts with reported AFP Cases Week 1-13 2020
Three cases of AFP were reported from Chavuma (1) and Kabompo (1) districts of North Western province and Vubwi (1)distrct of Eastern province. All three samples were collected for laboratory investigation.
Cumulatively, 48 AFP cases have been recorded from 26 districts.
As a result of the cVDPV outbreak, non-AFP target rate has been increased to 4/100, 000 population below 15.
One case of PV1 has been isolated and sent for sequencing from Nchelenge district in Luapula province.
All results received so far from specimens submitted to the regional lab came out negative for cVDPV
The risk of cVDPV2 transmission in Zambia is high 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)
Measles Outbreak
No new cases were recorded from the ongoing Measles outbreak in Northern Province affecting Lunte district.
Cumulatively, 25 suspected cases have been reported since the outbreak was declared.
1 Igm positive case was reported in the affected district.
The affected health facilities in the district are Mulenga Mapesa and Mukupa Kaoma.
Measles & Rubella surveillance
2 suspected measles cases were reported in the week under review.
1 sample was collected and sent for laboratory investigations.
Cumulatively, 89 suspected measles cases , 9 measles Igm confirmed cases and 4 confirmed measles rubella cases have been recorded.
COVID-19
27 confirmed cases of COVID–19 were reported in the week under review from Lusaka (25)province and on the Copperbelt (2) province.
There have been no deaths recorded from the COVID–19 cases.
The confirmed cases are in quarantine at Levy Mwanawasa Hospital and Masaiti district hospital respectively and are receiving medical care.
A total of 3,142 high risk persons are under observation, this includes travelers from high risk countries as well as persons that may have come in contact with the confirmed cases.
The University Teaching Hospital Virology Lab (UTHVL) is conducting tests for suspected cases and has to date received 475 samples, 400 have been processed with 29 confirmed positive for COVID-19.
Non-Bloody Diarrhoea
Cumulatively, 181,621 cases of non-bloody diarrhea were reported from week 1 to week 13.
The highest number of cases reported are from Central province representing 15.8% (28,664).
The highest cumulative incidence reported is from Central province at 1,653 per 100,000 population.
Dog Bites
Cumulatively, 3,851 dog bites have been reported from Week 1 to Week 13.
Dog bites surveillance serves as a proxy for rabies surveillance both in human and animal health systems.
Central province has recorded the highest number of dog bites representing 20% (790).
Global/Regional/Public Health Events (Cases/Case Fatality Rate)
| Ebola | Measles | Cholera | Poliovirus (c VDPD) | CoronaVirus (COVID–19) |
| DRC : 3,453 CFR 66.0% | DRC: 29,981 CFR 1.30% | DRC: 4,998 CFR 1.30% Moz: 313 CFR 4.2% | Angola: 131 CFR 0.0% DRC: 108 CFR 0.0% | Global: 724,042 CFR 4.7% Africa: 3,217 CFR 2.1% |
COVID-19 WHO African Region
During the week under review 2 more countries (Guinea Bisau and Mali) have confirmed COVID-19 cases in the WHO African region bringing the total number of African country’s with COVID-19 to 39.
2477 new confirmed cases of COVID-19 were reported across all affected countries in week 13, the highest number of new cases so far during a single week.
Cumulatively, a total of 3,217 confirmed cases and 69 deaths have been reported in the WHO African region.
In addition to sporadic importation of cases, the majority of the countries in the region are now experiencing local transmission of COVID-19,
Ebola Virus, DRC 2018-2020
No new confirmed EVD case and no deaths were recorded from DRC outbreak in the week under review.
Cumulatively, 3,453 suspected cases, 3,310 confirmed cases, 134 probable cases and 2,273 deaths (CFR is 66%) have occurred since the outbreak started earlier in 2018.
The last day of the week under review marked the 40th consecutive day without recording a confirmed EVD case. This outbreak of EVD would appear to be coming under control.
***For more information look up the WHO Weekly Bulletin on Outbreaks and Other Emergencies and for Global updates on the coronavirus
Public Health Actions
Circulating Vaccine Derived Poliovirus Outbreak
All provinces are further encouraged to strengthen AFP surveillance using available technological tools and geo code all cases detected.
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.
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 COVID– 19 High Risk Districts
Surveillance (including Event Based Surveillance) is being actively conducted at POEs, health facilities, and sentinel sites.
Screening facilities have been set up at POEs; additionally, screening is being done at the dry port in Makeni for all buses coming in from outside the country.
Additional thermal scanners to be procured and placed at the POEs to avoid over-crowding and enhance social distancing; set up/identification of designated quarantine facilities to enforce guidelines on quarantine.
Isolation facilities have also been set up in all high risk districts across the ten provinces;
Provincial epidemic preparedness committees to engage all relevant government stakeholders and multisector partners required to prevent, control and stop transmission of COVID– 19.
Global Alert of the Coronavirus & Preparedness
Orientation of staff at points of entry on COVID-19 in all provinces is being conducted in cascade
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 is being done.
Report all suspected patients to higher authority immediately.
Daily monitoring & 14 day quarantine of all travelers from high risk countries is mandatory.
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: 909/+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) 25
By: E Kateule 1 , H Mzyece 1 , P Kalubula 3 , S Mwangala 2 , B Inambao 2 , N Mukanwa 2 , N Sinyange 1 , M Kapina 1 , VM Mukonka 1
1 Zambia National Public Health Institute, Lusaka, Zambia
2 Western Provincial Health Office, Mongu, Zambia
3 World Health Organisation Country Office, Lusaka, Zambia
4 Nalolo District Health Office, Nalolo, Zambia
Citation Style For This Article: Kateule E, MzyeceH, Kalubula P, Mwangala S, Inambao B, Mukanwa N, Sinyange N, Kapina M, Mukonka VM. An Outbreak of Diarrhoeal Disease Attributed to Contaminated Drinking Water, Nalolo District, Zambia – 2019.Health Press Zambia Bull 2020; 04(2); pp 11-15.
Abstract
On 10th January 2019, the Ministry of Health, through the Zambia National Public Health Institute, received notification from the Provincial Health Office in Western Province of 25 cases, presenting with symptoms of acute diarrhoea; two died. We investigated to describe the epidemiology and identify risk factors.
We reviewed medical records of patients who presented at the health facilities from December 2018 through January 2019. A suspected case was acute onset of watery diarrhoea with or without vomiting, fever, abdominal weakness, and body weakness in resident of Sumi or Situka villages, Nalolo district, from 1st December 2018 to January 2019. We collected stool and water samples for laboratory examination.
Of 30 patients reviewed, eight were confirmed and 13 probable cases. Most (53%) of cases were male, and 83% were aged < 15 years. The median age was 25 years. Fifty-three percent of cases were reported in Situka; 47% in Sumi. Escherichia coli was isolated in eight samples. Two water samples analysed indicated high levels of faecal contamination.
This was most likely a waterborne disease outbreak caused by faecal contamination of drinking water source, an ox-bow lake. Implementation of environmental and sanitary control measures brought the outbreak to an end.
Introduction
Diarrhoeal diseases remain a public health concern and are the leading cause of child morbidity and mortality in the world1. Despite being preventable, through safe drinking-water and adequate sanitation and hygiene, 780 million individuals lack access to improved drinking water, and 2.5 billion lack improved sanitation worldwide1. Diarrhoea disease-related outbreaks due to infection, are widespread throughout developing countries where sanitary conditions are relatively poor [1,2.]
In Zambia, sporadic diarrheal disease outbreaks such as cholera, typhoid fever, and dysentery have been reported annually3. Most of the reported diarrheal disease outbreaks are attributed to inadequate access to safe water, unsatisfactory functionality of sanitation systems as well as comprised food safety [4,5.]
Outbreak
On the 10th January 2019, the Ministry of Health (MOH), through the Zambia National Public Health Institute (ZNPHI), received an outbreak notification of non-bloody diarrhoea and vomiting with two deaths in Sumi and Situka villages of Nalolo district in Western Province. By 12th January 2019, the cases increased to 25, which prompted the district health office (DHO) to set up a screening and treatment centre (STC) at Situka village to heighten access to health services among the affected residents. The cases that reported at the STC were commenced on antibiotics. One severe case was referred to Lewanika General Hospital. Further, the DHO, with support from Provincial Health Office (PHO), distributed liquid chlorine for treatment of drinking water and provided health promotions and other environmental activities.
The Ministry of Health, through ZNPHI’s Public Health Emergence Operation Centre, in collaboration with the World Health Organisation (WHO) Country Office constituted a national investigation team to support the province and district response to the outbreak. The composition of the national investigation team included a Field Epidemiologist, a Public Health Officer, and a National Surveillance Officer. The team travelled to the province on 16th January 2019 and proceeded to Nalolo district on the 17th January 2019.
We investigated the outbreak to determine the extent of the outbreak; characterise the outbreak by place, person and time; confirm the aetiology of the outbreak, generate hypothesis for the risk factors, and develop and implement a plan to prevent additional infections and future outbreaks.
Methods Setting
Nalolo is a rural district located in Western Province of Zambia with total catchment population of 55,569. The district has an economy mainly supported by agriculture. The outbreak occurred in two villages located along the Zambezi river bank under the catchment area of the Situnga health facility with the population of 164 people. The two villages are approximately 300 meters apart.
Case definition
A suspected case was defined as acute onset of watery diarrhoea with or without vomiting, fever, abdominal weakness and body weakness in a resident of Sumi or Situka villages in Nalolo district from 1st December 2018 to January 2019. A probable case was defined as a suspected case epidemiologically linked to another clinically compatible case but without labourtory confirmation. A confirmed case was a case of diarrhea in person with positive laboratory test indicative of diarrhoea infection caused by bacterial, viral or parasitic organisms – Salmonellae serotype Typhi, Escherichia coli, Shigella, or Vibrio cholerae species.
Data Collection
This was a retrospective descriptive study based on data abstracted from medical records of patients presented at the health centres including STC and those admitted to the Lewanika General Hospital between 30th December 2018 and 16th January 2019. Data on disease surveillance and epidemic preparedness and response were also collected through interviews using a structured questionnaire and checklist administered to staff at the DHO and PHO. Specimen Collection
Eight stool samples were collected from cases seen at the STC for laboratory examination and sent to Lewanika General Hospital on the 10th January, 2019. Two food (nshima and sour milk from four affected households) and two water samples from an ox-bow lake (the only source for drinking water) were collected for bacteriological analysis. Stool specimens were also shipped to University Teaching Hospital laboratory for quality control on 17th January 2019.
Data Analysis
The data obtained from medical reviews, questionnaires, checklists and laboratory results were descriptively analysed by using proportions and presented in tables and graphs.
Ethical considerations
The study was conducted under the public health response authority from Ministry of Health. Therefore, the investigation was coordinated by Epidemic Preparedness and Response cluster at ZNPHI while permission to conduct data collection within the Ministry, was obtained from the Permanent Secretary, Technical Services. . However, verbal permission was sought from the district and hospital management to review medical records.
Results
From 11th December 2018 to 13th January 2019 a total of 30 cases were reported in Nalolo district. We identified eight confirmed cases, and 13 probable cases. Most (53%) of cases reviewed were among male, and 83% were among persons aged <15 years (Table). The median age was 25 years. Most (70%, n=21) of the cases were recorded between the 30th December 2018 and 5th January 2019 (Figure. Fifty-three percent of cases were among residents of Situka village and 47% (n=14) among residents of Sumi both under the catchment of Sunungu Rural Health Centre (Table). The index case was in a female aged 26 years reported on the 11th December 2018 at Itufa health centre of Senanga district. The outbreak was initially detected by the Senanga DHO on 7th January 2019, which later notified Nalolo DHO that one of its rural health centers, Itufa, had been receiving cases of non-bloody diarrhea, suspected to have been typhoid fever. Although the two affected villages are in Sinungu Health Centre catchment area on the west bank of Zambezi river, the communities prefer accessing health services from Itufa Health Centre located on the east-bank of the Zambezi because it takes less time to reach Itufa Health Centre than Sinungu despite the need to cross river
Figure 1: Cases of Diarrheal Disease by date onset, Nalolo, December 2018 – January 2019 (N=30).
The clinical characteristics for the cases included diarrhoea, vomiting, intermittent fever, abdominal pains, and body weakness. Nine cases were treated as in-patients while 21 were treated as out-patients (Table). Of the eight stool samples collected from patients microscopy, culture and sensitivity, none was positive for S.Typhi or Shigella, however, E. coli was isolated in eight samples and Enterobacter agglomeran was isolated in one sample. We did not perform further tests to determine the toxigenicity of the E. coli and Enterobacter agglomerans isolates. The only blood specimen tested for serology, was sero-negative. None of the food analysed had microorganisms isolated. All the water samples analysed indicated high levels of faecal contamination (i.e. >5000 colonies/100ml). Data from checklist revealed that all the health workers in Nalolo district had not been trained in Integrated Disease Surveillance and Response (IDSR); only one person was reported to have been trained at Lewanika General Hospital. In addition, Emergency Preparedness and Response Committee meetings were rarely held either at the district offices or the hospital.
Table: Demographic and clinical characteristic of diarrheal disease, Nalolo, 2019 (N=30)
Discussion
Our investigation revealed that there was an outbreak of diarrheal disease associated with exposure to contaminated drinking water, caused by E.coli infection, which mostly affected residents above 15 years. All the cases reported from the two villages in which the outbreak occurred relied on untreated water from a nearby ox-bow lake. Prevention of diarrhoeal diseases is an important public health strategy for reducing morbidity and mortality not only in children but also in older age groups. In enteric disease outbreaks, sources of infection have been traced to a variety of origins such as surface water, household water containers, foods and drinks, and poor sanitary conditions1,6. The local municipal council and cooperating partners, responsible for management of water and sanitation can effectively prevent such outbreaks by providing safe water to the community. Provision of safe water is vital to protecting public health in Zambia; most of the reported waterborne disease outbreaks during the period 2017–2018 were associated with drinking contaminated water, accounting for at least 5,097 cases of illness, 1006 hospitalizations, and 99 deaths[3].
Almost all the patients presented with abdominal pains, diarrhea, vomiting, fever and malaise suggestive of exposure to E. coli high toxigenic strains. Although we could not perform further tests to determine the toxigenicity of the E. coli and Enterobacter agglomerans isolates, our results reveal very high faecal contamination of water from the ox-bow lake. Studies have documented the potential human health risk associated with the exposure to water contamination from shallow wells, due to the very high level of human faecal indicator bacteria isolated strains such as E. coli and Enterococcus from water and surface sediment [7].
The diagnoses of diarrheal diseases caused by specific pathogens may be challenging because they are usually clinically diagnosed as common salmonella gastroenteritis or enteric fevers (including typhoid fever), or often misclassified as malaria. Studies have documented that people in endemic areas are at a risk of contracting both (typhoid fever and malaria) infections concurrently 8–10. There is a considerable overlap of signs and symptoms of malaria and typhoid fever; the similarity of clinical features of both diseases leads to misdiagnosis and mistreatment of the febrile patients thus the initial suspicion of typhoid fever by clinicians in affected villages. Most of the cases suspected to have typhoid fever were treated with oral rehydration therapy and antibiotics which included ciprofloxacin and metronidazole, despite both the stool and blood serological tests being negative. Therefore, a reliable diagnostic method is important for effective management of cases to avoid misuse and wastage of drugs1,8,11. Further, strengthening surveillance at all levels may play an important role in early detection of notifiable diseases. There was inadequate coordination and feedback among the key public health players (health centre, districts and referral hospital) during reporting, detection and confirmation. Although the health centre notified the hospital on the 7th January 2019, Senanga district DHO informed Nalolo DHO days later, contrary to standard reporting guidelines for immediately reportable diseases12. Additionally, the two DHO did not provide follow-up or feedback regarding the outbreak. Ideally, suspected outbreaks of epidemic-prone diseases are required to be reported to the next level within 48 hours of surpassing the epidemic threshold 13. However, this was not case as the national level was notified 10 days later. The DHO’s public health departments have a primary responsibility of detecting and investigating outbreaks.
Our investigation evaluation indicated deficiencies to timely notify, detect and respond to the outbreak. The heightened challenges could arise from the fact that none of staff in the district were trained in IDSR 13–15. Since the district has some hard-to-reach areas within its catchment attributed to distance and impassable terrains, training of staff in community-based surveillance could improve notification, detection and response to outbreaks 16. Regular supportive supervision could also have enhanced surveillance data validation. Delayed response to the outbreak was compounded by the fact that the district did not have the capacity to confirm any outbreaks because it had no laboratory and all the samples were sent to a level II referral hospital located over 40 kilometers away. Although Nalolo district is a new district, there is need to have a laboratory which can at least perform basic analyses such as bacteriological testing to improve timely confirmation of diarrhea diseases. Our investigation suggests poor health-seeking behavior among residents in the two affected villages. The positive change in health seeking behaviour could be enhanced by regular health education programs especially on good handwashing and other hygiene practices 17,18. Residents of Sumi and Situka villages had no access to safe drinking water and basic sanitary facilities[7]. The community was accessing water for both human consumption and domestic use from an oxbow lake with stagnant water without any form of water treatment. Equally, the lack of secure pit latrines in the area could have propagated the infection as the communities prefer open defecation to toilet use. There could be increased contamination of water sources due to rainwater and human/animal waste interaction4. The lack of access to safe drinking water was partly attributable to the fact that the villages are inhabited by the nomadic Mubyane families of the Lozi tribe, who migrate seasonally from flooded plain to highlands along the Zambezi river. Therefore, sinking of some permanent protected boreholes on the safe highlands could improve access to safe drinking water and reduce contamination of the water used in the community. To contain the outbreak, the DHO with support from PHO erected a tent for an onsite treatment centre at Situka village; distributed sodium hypochlorite solution for treatment of drinking water; and provided health education on personal hygiene including use of appropriate sanitary facilities such as pit latrines. Further, follow-up visits were conducted to further assess and collect information on the outbreak, and the national team provided technical support to DHO. The stool samples were subjected to further examination, while screening and active surveillance was continued. Limitations Our study was based on the descriptive secondary data analysis; we could not establish other risk factors accountable for increased diarrheal disease susceptibility in the study population. We could not perform further tests to determine the toxigenicity of the E. coli and Enterobacter agglomerans isolates.
Conclusion
Our investigation shows a waterborne disease outbreak caused by faecal contamination of drinking water source. Delayed confirmation and response by the local health could have contributed to spread of the outbreak among residents. Continued implementation of health education on water treatment (chlorination and boiling), use of toilets and good handwashing practices are highly recommendeded. Prompt confirmatory test should also be prioritised by clinicians as diarrheal patients may be misdiagnosed, e.g., presumed to have malaria. There is a need to provide training and capacity building for health personnel in disease surveillance to improve detection, response and coordination at all levels.
Acknowledgments
This outbreak investigation was conducted with financial support from the WHO Zambia through Zambia National Public Health Institute, Ministry of Health. The authors appreciate the Management of Nalolo and Mongu District Hospital for allowing us to extract the relevant data for the study from their patients’ case files. They also extend special thanks to Victor Daka for critical review of this article. The authors would like to acknowledge Provincial Health Office for participating and supporting the outbreak investigation and laboratory analysis.
Competing interests
The authors declare no competing interests.
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