Progress towards malaria elimination in Zimbabwe with special reference to the period 2003-2015

Climate change and malaria: some recent trends of malaria incidence rates and average annual temperature in selected sub-Saharan African countries from 2000 to 2018

BACKGROUND

Malaria is still a disease of massive burden in Africa, also influenced by climate change. The fluctuations and trends of the temperature and precipitation are well-known determinant factors influencing the disease's vectors and incidence rates. This study provides a concise account of malaria trends. It describes the association between average temperature and malaria incidence rates (IR) in nine sub-Saharan African countries: Nigeria, Ethiopia, South Africa, Kenya, Uganda, Ghana, Mozambique, Zambia and Zimbabwe. The incidence of malaria can vary both in areas where the disease is already present, and in regions where it is present in low numbers or absent. The increased vulnerability to the disease under increasing average temperatures and humidity is due to the new optimal level for vector breeding in areas where vector populations and transmission are low, and populations are sensitive due to low acquired immunity.

METHODS

A second source trend analysis was carried out of malaria cases and incidence rates (the number of new malaria cases per 1000 population at risk per year) with data from the World Health Organization (WHO) and average annual mean temperature from 2000 to 2018 from the World Bank's Climate Change Knowledge Portal (CCKP). Additionally, descriptive epidemiological methods were used to describe the development and trends in the selected countries. Furthermore, MS Excel was chosen for data analysis and visualization.

RESULTS

Findings obtained from this article align with the recent literature, highlighting a declining trend (20-80%) of malaria IR (incidence rate) from 2000 to 2018. However, malaria IR varies considerably, with high values in Uganda, Mozambique, Nigeria and Zambia, moderate values in Ghana, Zimbabwe, and Kenya, and low values in South Africa and Ethiopia in 2018. Evidence suggests varying IRs after average temperature fluctuations in several countries (e.g., Zimbabwe, Ethiopia). Also, an inverse temperature-IR relationship occurs, the sharp decrease of IR during 2012-2014 and 2000-2003, respectively, occurred with increasing average temperatures in Ghana and Nigeria. The decreasing trends and fluctuations, partly accompanying the temperature, should result from the intervention programmes and rainfall variability. The vulnerability and changing climate could arrest the recent trends of falling IR.

CONCLUSION

Thus, malaria is still a crucial public health issue in sub-Saharan Africa, although a robust decreasing IR occurred in most studied countries.

Reducing maternal mortality: a 10-year experience at Mpilo Central Hospital, Bulawayo, Zimbabwe

OBJECTIVES

Maternal mortality is one of the major Sustainable Development Goals (SDGs) of the global health community. The aim of the SDG 3.1 is to reduce global maternal mortality ratio considerably by 2030. The objective of this study was to document the epidemiological trends in maternal mortality for Mpilo Central Hospital.

METHODS

This was a 10 year retrospective study using readily available data from the maternity registers. The International Classification of Diseases-Maternal Mortality (ICD-MM) coding system for maternal deaths was used.

RESULTS

The maternal mortality ratio (MMR) declined from 655 per 100,000 live births in 2011 to 203 per 100,000 live births by 2020. The commonest groups of maternal mortality during the period 2011-2020 were hypertensive disorders, obstetric haemorrhage, pregnancy-related infection, and pregnancies with abortive outcomes. There were 273 maternal deaths recorded in the period 2011-2015, and 168 maternal deaths in the period 2016-2020. There was also a decline in maternal deaths due to obstetric haemorrhage (53 vs. 34). Maternal deaths due to pregnancy-related infection also declined (46 vs. 22), as well as pregnancies with abortive outcomes (40 vs. 26).

CONCLUSIONS

There was a 69% decline in the MMR over the 10 year period. The introduction of government interventions such as malarial control, the adoption of life-long Option B+ antiretroviral treatment for the pregnant women, the training courses of staff, and the introduction of strong clinical leadership and accountability were all associated with a significant decline in the causes of maternal deaths.

Prevalence, risk factors and short-term consequences of adverse birth outcomes in Zimbabwean pregnant women: a secondary analysis of a cluster-randomized trial

BACKGROUND

Globally, 15 million children are born preterm each year and 10.7 million are born at term but with low birthweight (<2500 g).

METHODS

The Sanitation Hygiene Infant Nutrition Efficacy (SHINE) cluster-randomized trial enrolled 5280 pregnant women between 22 November 2012 and 27 March 2015 to test the impact of improved water supply, sanitation and hygiene, and improved infant feeding, on child growth and anaemia. We conducted a secondary analysis to estimate the prevalence and risk factors of miscarriage, stillbirth, preterm birth, size small for gestational age (SGA), low birthweight (LBW), perinatal mortality, and neonatal mortality, and to estimate the effects of adverse birth outcomes on infant survival and growth.

RESULTS

The prevalence of adverse birth outcomes was: miscarriage: 5.0% [95% confidence interval (CI), 4.4, 5.7]; stillbirth: 2.3% (95% CI 1.9, 2.7); preterm birth: 18.2% (95% CI 16.9, 19.5); SGA: 16.1% (95% CI 15.0, 17.3); LBW: 9.8% (95% CI 9.0, 10.7); and neonatal mortality: 31.4/1000 live births (95% CI 26.7, 36.5). Modifiable risk factors included maternal HIV infection, anaemia, lack of antenatal care and non-institutional delivery. Preterm infants had higher neonatal mortality [risk ratio (RR): 6.1 (95% CI 4.0, 9.2)], post-neonatal infant mortality [hazard ratio (HR): 2.1 (95% CI 1.1, 4.1)] and stunting at 18 months of age [RR: 1.5 (95% CI 1.4, 1.7)] than term infants; 56% of stillbirths and 57% of neonatal deaths were among preterm births.

CONCLUSIONS

Neonatal mortality and stillbirth are high in Zimbabwe and appear to be driven by high preterm birth. Interventions for primary prevention of preterm birth and strengthened management of preterm labour and ill and small neonates are required to reduce neonatal mortality in Zimbabwe and other African countries with similar profiles.

Rebounding Malaria and the failures of eradication in Zanzibar: The World Health Organization campaign and the after effects, 1957-1985

This article presents a case study of the WHO's malaria elimination attempt in Zanzibar and the decades after the program's conclusion in 1968. Drawing on archival, ethnographic, and interview data, we find that Zanzibar experienced a rebound malaria epidemic in the 1970s-1980s when prevalence rates surged higher than they were prior to the WHO's intervention. We show that scientists were aware of the risks of rebound before it happened and recognized the rebound epidemic as it was happening. We argue that many of the challenges facing Zanzibar in the 1960s remain dilemmas today, and many of the ethical questions about rebound malaria remain unaddressed.

Changes in causes of pregnancy-related and maternal mortality in Zimbabwe 2007-08 to 2018-19: findings from two reproductive age mortality surveys

Background

Reducing maternal mortality is a priority of Sustainable Development Goal 3.1 which requires frequent epidemiological analysis of trends and patterns of the causes of maternal deaths. We conducted two reproductive age mortality surveys to analyse the epidemiology of maternal mortality in Zimbabwe and analysed the changes in the causes of deaths between 2007-08 and 2018-19.

Methods

We performed a before and after analysis of the causes of death among women of reproductive ages (WRAs) (12-49 years), and pregnant women from the two surveys implemented in 11 districts, selected using multi-stage cluster sampling from each province of Zimbabwe (n=10); an additional district selected from Harare. We calculated mortality incidence rates and incidence rate ratios per 10000 WRAs and pregnant women (with 95% confidence intervals), in international classification of disease groups, using negative binomial models, and compared them between the two surveys. We also calculated maternal mortality ratios, per 100 000 live births, for selected causes of pregnancy-related deaths.

Results

We identified 6188 deaths among WRAs and 325 PRDs in 2007-08, and 1856 and 137 respectively in 2018-19. Mortality in the WRAs decreased by 82% in diseases of the respiratory system and 81% in certain infectious or parasitic diseases' groups, which include HIV/AIDS and malaria. Pregnancy-related deaths decreased by 84% in the indirect causes group and by 61% in the direct causes group, and HIV/AIDS-related deaths decreased by 91% in pregnant women. Direct causes of death still had a three-fold MMR than indirect causes (151 vs. 51 deaths per 100 000) in 2018-19.

Conclusion

Zimbabwe experienced a decline in both direct and indirect causes of pregnancy-related deaths. Deaths from indirect causes declined mainly due to a reduction in HIV/AIDS-related and malaria mortality, while deaths from direct causes declined because of a reduction in obstetric haemorrhage and pregnancy-related infections. Ongoing interventions ought to improve the coverage and quality of maternal care in Zimbabwe, to further reduce deaths from direct causes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-13321-7.

Evaluating the efficacy, impact, and feasibility of community-based house screening as a complementary malaria control intervention in southern Africa: a study protocol for a household randomized trial

BACKGROUND

Concerted effort to control malaria has had a substantial impact on the transmission of the disease in the past two decades. In areas where reduced malaria transmission is being sustained through insecticide-based vector control interventions, primarily long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), non-insecticidal complementary tools will likely be needed to push towards malaria elimination. Once interruption in local disease transmission is achieved, insecticide-based measures can be scaled down gradually and eventually phased out, saving on costs of sustaining control programs and mitigating any unintended negative health and environmental impacts posed by insecticides. These non-insecticidal methods could eventually replace insecticidal methods of vector control. House screening, a non-insecticidal method, has a long history in malaria control, but is still not widely adopted in sub-Saharan Africa. This study aims to add to the evidence base for this intervention in low transmission settings by assessing the efficacy, impact, and feasibility of house screening in areas where LLINs are conventionally used for malaria control.

METHODS

A two-armed, household randomized clinical trial will be conducted in Mozambique, Zambia, and Zimbabwe to evaluate whether combined the use of house screens and LLINs affords better protection against clinical malaria in children between 6 months and 13 years compared to the sole use of LLINs. Eight hundred households will be enrolled in each study area, where 400 households will be randomly assigned the intervention, house screening, and LLINs while the control households will be provided with LLINs only. Clinical malaria incidence will be estimated by actively following up one child from each household for 6 months over the malaria transmission season. Cross-sectional parasite prevalence will be estimated by testing all participating children for malaria parasites at the beginning and end of each transmission season using rapid diagnostic tests. CDC light traps and pyrethrum spray catches (PSC) will be used to sample adult mosquitoes and evaluate the impact of house screening on indoor mosquito density, species distribution, and sporozoite rates.

DISCUSSION

This study will contribute epidemiological data on the impact of house screening on malaria transmission and assess the feasibility of its implementation on a programmatic scale.

TRIAL REGISTRATION

ClinicalTrials.gov PACTR202008524310568 . Registered on August 11, 2020.

Estimating malaria chemoprevention and vector control coverage using program and campaign data: A scoping review of current practices and opportunities

Background

Accurate estimation of intervention coverage is a vital component of malaria program monitoring and evaluation, both for process evaluation (how well program targets are achieved), and impact evaluation (whether intervention coverage had an impact on malaria burden). There is growing interest in maximizing the utility of program data to generate interim estimates of intervention coverage in the periods between large-scale cross-sectional surveys (the gold standard). As such, this study aimed to identify relevant concepts and themes that may guide future optimization of intervention coverage estimation using routinely collected data, or data collected during and following intervention campaigns, with a particular focus on strategies to define the denominator.

Methods

We conducted a scoping review of current practices to estimate malaria intervention coverage for insecticide-treated nets (ITNs); indoor residual spray (IRS); intermittent preventive treatment in pregnancy (IPTp); mass drug administration (MDA); and seasonal malaria chemoprevention (SMC) interventions; case management was excluded. Multiple databases were searched for relevant articles published from January 1, 2015 to June 1, 2018. Additionally, we identified and included other guidance relevant to estimating population denominators, with a focus on innovative techniques.

Results

While program data have the potential to provide intervention coverage data, there are still substantial challenges in selecting appropriate denominators. The review identified a lack of consistency in how coverage was defined and reported for each intervention type, with denominator estimation methods not clearly or consistently reported, and denominator estimates rarely triangulated with other data sources to present the feasible range of denominator values and consequently the range of likely coverage estimates.

Conclusions

Though household survey-based estimates of intervention coverage remain the gold standard, efforts should be made to further standardize practices for generating interim measurements of intervention coverage from program data, and for estimating and reporting population denominators. This includes fully describing any projections or adjustments made to existing census or population data, exploring opportunities to validate available data by comparing with other sources, and explaining how the denominator has been restricted (or not) to reflect exclusion criteria.

Malaria incidence and mortality in Zimbabwe during the COVID-19 pandemic: analysis of routine surveillance data

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has posed a unique challenge to health care systems globally. To curb COVID-19 transmission, mitigation measures such as travel restrictions, border closures, curfews, lockdowns, and social distancing have been implemented. However, these measures may directly and indirectly affect the delivery and utilization of essential health services, including malaria services. The suspension of indoor residual spraying (IRS) and insecticide-treated net (ITN) distribution, shortages of malaria commodities, and reduced demand for health services have hindered the continued delivery of malaria services. The overall goal of this analysis was to describe the trends in malaria incidence and mortality in Zimbabwe prior to and during the pandemic to understand the consequences of COVID-19-related changes in the delivery and utilization of malaria services.

METHODS

Monthly data on the number of malaria cases and deaths by district for the period January 2017 to June 2020 were obtained from the national health management information system (HMIS). District-level population data were obtained from the 2012 Census. Malaria incidence per 1000 population and malaria deaths per 100,000 population were calculated for 2017, 2018, 2019, and 2020 and mapped to describe the spatial and temporal variation of malaria at the district level.

RESULTS

Compared to the same period in 2017, 2018 and 2019, there was an excess of over 30,000 malaria cases from January to June 2020. The number of malaria deaths recorded in January to June 2020 exceeded the annual totals for 2018 and 2019. District level maps indicated that areas outside high malaria burden provinces experienced higher than expected malaria incidence and mortality, suggesting potential outbreaks.

CONCLUSIONS

The observed surge in malaria cases and deaths in January to June 2020 coincided with the onset of COVID-19 in Zimbabwe. While further research is needed to explore possible explanations for the observed trends, prioritizing the continuity of essential malaria services amid the COVID-19 pandemic remains crucial.

Spatial and spatio-temporal analysis of malaria cases in Zimbabwe

Background

Although effective treatment for malaria is now available, approximately half of the global population remain at risk of the disease particularly in developing countries. To design effective malaria control strategies there is need to understand the pattern of malaria heterogeneity in an area. Therefore, the main objective of this study was to explore the spatial and spatio-temporal pattern of malaria cases in Zimbabwe based on malaria data aggregated at district level from 2011 to 2016.

Methods

Geographical information system (GIS) and spatial scan statistic were applied on passive malaria data collected from health facilities and aggregated at district level to detect existence of spatial clusters. The global Moran’s I test was used to infer the presence of spatial autocorrelation while the purely spatial retrospective analyses were performed to detect the spatial clusters of malaria cases with high rates based on the discrete Poisson model. Furthermore, space-time clusters with high rates were detected through the retrospective space-time analysis based on the discrete Poisson model.

Results

Results showed that there is significant positive spatial autocorrelation in malaria cases in the study area. In addition, malaria exhibits spatial heterogeneity as evidenced by the existence of statistically significant (P < 0.05) spatial and space-time clusters of malaria in specific geographic regions. The detected primary clusters persisted in the eastern region of the study area over the six year study period while the temporal pattern of malaria reflected the seasonality of the disease where clusters were detected within particular months of the year.

Conclusions

Geographic regions characterised by clusters of high rates were identified as malaria high risk areas. The results of this study could be useful in prioritizing resource allocation in high-risk areas for malaria control and elimination particularly in resource limited settings such as Zimbabwe. The results of this study are also useful to guide further investigation into the possible determinants of persistence of high clusters of malaria cases in particular geographic regions which is useful in reducing malaria burden in such areas.

Using routine health information data for research in low- and middle-income countries: a systematic review

BACKGROUND

Routine health information systems (RHISs) support resource allocation and management decisions at all levels of the health system, as well as strategy development and policy-making in many low- and middle-income countries (LMICs). Although RHIS data represent a rich source of information, such data are currently underused for research purposes, largely due to concerns over data quality. Given that substantial investments have been made in strengthening RHISs in LMICs in recent years, and that there is a growing demand for more real-time data from researchers, this systematic review builds upon the existing literature to summarize the extent to which RHIS data have been used in peer-reviewed research publications.

METHODS

Using terms 'routine health information system', 'health information system', or 'health management information system' and a list of LMICs, four electronic peer-review literature databases were searched from inception to February 202,019: PubMed, Scopus, EMBASE, and EconLit. Articles were assessed for inclusion based on pre-determined eligibility criteria and study characteristics were extracted from included articles using a piloted data extraction form.

RESULTS

We identified 132 studies that met our inclusion criteria, originating in 37 different countries. Overall, the majority of the studies identified were from Sub-Saharan Africa and were published within the last 5 years. Malaria and maternal health were the most commonly studied health conditions, although a number of other health conditions and health services were also explored.

CONCLUSIONS

Our study identified an increasing use of RHIS data for research purposes, with many studies applying rigorous study designs and analytic methods to advance program evaluation, monitoring and assessing services, and epidemiological studies in LMICs. RHIS data represent an underused source of data and should be made more available and further embraced by the research community in LMIC health systems.

Coronavirus-19 and malaria: The great mimics

The use of SARS-CoV-2 rapid diagnostic test (RDT) kits by some African countries for screening has raised serious concerns over their role in malaria areas. Coupled with a lack of adequate personal protective equipment and the scarcity of knowledge on the possible interaction between malaria and COVID-19 both in terms of presentations and shared symptoms, this has left many frontline health workers with fears and anxieties. Several anecdotal reports have already raised questions pertaining to possible false-positive COVID-19 results in proven malaria cases by use of SARS-CoV-2 RDT kits with huge costs to already constrained budgets. The report raises concerns on the use of SARS-CoV-2 kits in malaria areas in terms of cost, to prompt research, allay fears and guide policy during this pandemic and beyond.

Malaria outbreak investigation in a rural area south of Zimbabwe: a case-control study

Background

Ninety percent of the global annual malaria mortality cases emanate from the African region. About 80–90% of malaria transmissions in sub-Saharan Africa occur indoors during the night. In Zimbabwe, 79% of the population are at risk of contracting the disease. Although the country has made significant progress towards malaria elimination, isolated seasonal outbreaks persistently resurface. In 2017, Beitbridge District was experiencing a second malaria outbreak within 12 months prompting the need for investigating the outbreak.

Methods

An unmatched 1:1 case–control study was conducted to establish the risk factors associated with contracting malaria in Ward 6 of Beitbridge District from week 36 to week 44 of 2017. The sample size constituted of 75 randomly selected cases and 75 purposively selected controls. Data were collected using an interviewer-administered questionnaire and Epi Info version 7.2.1.0 was used to conduct descriptive, bivariate and multivariate analyses of the factors associated with contracting malaria.

Results

Fifty-two percent of the cases were females and the mean age of cases was 29 ± 13 years. Cases were diagnosed using rapid diagnostic tests. Sleeping in a house with open eaves (OR: 2.97; 95% CI 1.44–6.16; p < 0.01), spending the evenings outdoors (OR: 2.24; 95% CI 1.04–4.85; p = 0.037) and sleeping in a poorly constructed house (OR: 4.33; 95% CI 1.97–9.51; p < 0.01) were significantly associated with contracting malaria while closing eaves was protective (OR: 0.45; 95% CI 0.20–1.02; p = 0.055). After using backward stepwise logistic regression, sleeping in a poorly constructed house was associated with five-fold odds of getting sick from malaria (AOR: 8.40; 95% CI 1.69–41.66; p = 0.009). Those who had mosquito nets did not use them consistently. The district health team and the rural health centre were well prepared to response despite having limited human resources.

Conclusion

Health promotion messages should emphasize the importance of closing the entry points of the malaria vector, and the construction of better houses in the future. Residents had to be educated in the importance of consistent use of mosquito nets. The district had to improve malaria preventive measures like distribution of mosquito nets and lobby for more human resources to assist with malaria surveillance thus, curbing the recurrence of malaria outbreaks.

Getting ready for integrated vector management for improved disease prevention in Zimbabwe: a focus on key policy issues to consider

Background

This paper outlines Zimbabwe’s potential readiness in harnessing integrated vector management (IVM) strategy for enhanced control of vector-borne diseases. The objective is to provide guidance for the country in the implementation of the national IVM strategy in order to make improvements required in thematic areas of need. The paper also assesses the existing opportunities and gaps to promote and adopt the approach as a national policy.

Main text

Despite recent gains in combating vector-borne diseases, especially malaria, management of vector control programmes still remains insecticide-based and vertical in nature. Therefore, concerns have been raised on whether the current long-standing conventional vector control strategy still remains with sufficient action to continue to break the transmission cycle to the levels of elimination. This is so, given the continuous dwindling resources for vector control, changes in vector behaviour, the emergence of resistance to medicines and insecticides, climate change, environmental degradation, as well as diversity in ecology, breeding habitats, and community habits. Cognizant of all that, elements of a surveillance-driven IVM approach are rapidly needed to move vector control interventions a step further. These include advocacy, policy formulation, capacity building, public and private partnerships, community engagement, and increasingly basing decisions on local evidence. Understanding the existing opportunities and gaps, and the recognition that some elements of IVM are already imbedded in the current health programmes is important to encourage stakeholders to promptly support its implementation. Leveraging on the existing opportunities, combined with sufficient advocacy, IVM could easily be accepted by the Zimbabwe government as part of a wider integrated disease management strategy. The strategy could represent an excellent breakthrough to establish much needed intra and inter-sectoral dialogue, and coordination for improved vector-borne disease prevention.

Conclusions

After synthesis of the opportunities and challenges clearly presented, it was concluded that it is imperative for Zimbabwe to adopt and implement IVM strategy that is informed by work already done, while addressing the bottlenecks. The significance of refocusing for improved disease prevention that has the potential to accomplish elimination of not only malaria but all vector borne diseases much earlier than anticipated under the existing vector control system is underscored.

Determinants of long-lasting insecticidal net ownership and utilization in malaria transmission regions: evidence from Zimbabwe Demographic and Health Surveys

Background

Long-lasting insecticidal nets (LLINs) were first introduced in 2010 as a vector control intervention, to complement indoor residual spraying, to reduce malaria transmission in Zimbabwe. The objective of this study was to investigate factors that were associated with LLIN ownership and utilization among households in malaria transmission regions of Zimbabwe.

Methods

A secondary analysis of cross sectional data from the Zimbabwe demographic and health survey (ZDHS) conducted in 2010 and 2015 surveys round was conducted. The analysis used household-level datasets from across the country to generate evidence for the study. Univariate analysis was used to yield descriptive statistics. Principal component analysis (PCA) was used to calculate wealth quintiles. Binary logistic regression approach was used to identify determinants of LLIN ownership and utilization after controlling for other factors. Data analyses were conducted using STATA version 14 software.

Results

There were no major changes in demographic characteristics of households sampled between 2010 and 2015 survey cycles. LLIN ownership increased significantly by 42 percentage points from 2010 to 2015. There was a tremendous increase in universal coverage of LLINs between 2010 and 2015. The overall utilization levels of LLINs among children under-5 years decreased by 11 percentage points between 2010 and 2015. LLIN usage amongst households followed the same trend with that of the under-fives. Using logistic regression model for 2015 data, region/province, type of place of residence, availability of electricity, radio, roof type, gender of head of household, having telephone, type of cooking fuel, presence of mobile phone, owning a bank account, IRS spraying in the previous 12 months, wealth index, and satellite television decorder were independently associated with net ownership among households. Type of place of residence, age of household head, type of cooking fuel, IRS in previous 12 months, and pregnancy were associated with LLIN utilization.

Conclusion

This study revealed increasing LLIN coverage and low usage in malaria-transmission regions of Zimbabwe. Strengthening of LLIN campaigns, social behaviour change communication (SBCC) interventions and programme routine monitoring are recommended.

Trends in reported malaria cases and the effects of malaria control in the Democratic Republic of the Congo

Background

Considerable upscaling of malaria control efforts have taken place over the last 15 years in the Democratic Republic of Congo, the country with the second highest malaria case load after Nigeria. Malaria control interventions have been strengthened in line with the Millenium Development Goals. We analysed the effects of these interventions on malaria cases at health facility level, using a retrospective trend analysis of malaria cases between 2005 and 2014. Data were collected from outpatient and laboratory registers based on a sample of 175 health facilities that represents all eco-epidemiological malaria settings across the country.

Methods

We applied a time series analysis to assess trends of suspected and confirmed malaria cases, by health province and for different age groups. A linear panel regression model controlled for non-malaria outpatient cases, rain fall, nightlight intensity, health province and time fixed effects, was used to examine the relationship between the interventions and malaria case occurrences, as well as test positivity rates.

Results

Overall, recorded suspected and confirmed malaria cases in the DRC have increased. The sharp increase in confirmed cases from 2010 coincides with the introduction of the new treatment policy and the resulting scale-up of diagnostic testing. Controlling for confounding factors, the introduction of rapid diagnostic tests (RDTs) was significantly associated with the number of tested and confirmed cases. The test positivity rate fluctuated around 40% without showing any trend.

Conclusion

The sharp increase in confirmed malaria cases from 2010 is unlikely to be due to a resurgence of malaria, but is clearly associated with improved diagnostic availability, mainly the introduction of RDTs. Before that, a great part of malaria cases were treated based on clinical suspicion. This finding points to a better detection of cases that potentially contributed to improved case management. Furthermore, the expansion of diagnostic testing along with the increase in confirmed cases implies that before 2010, cases were underreported, and that the accuracy of routine data to describe malaria incidence has improved.

Field-based evaluation of malaria outbreak detection and response in Mudzi and Goromonzi districts, Zimbabwe - 2017

National-level evaluations may fail to identify capacity improvements for detecting and responding to outbreaks which begin and are first detected at the local level. In response to this issue, we conducted a field-based assessment of the malaria outbreak surveillance system in Mashonaland East, Zimbabwe. We visited eleven clinics in Mudzi and Goromonzi districts. Twenty-one interviews were conducted with key informants from the provincial (n = 2), district (n = 7), and clinic (n = 12) levels. Interviews focused on surveillance system activities, preparedness, data quality, timeliness, stability, and usefulness. Main themes were captured utilising standard qualitative data analysis techniques. While the surveillance system detects malaria outbreaks at all levels, we identified several gaps. Clinics experience barriers to timely and reliable reporting of outbreaks to the district level and staff cross-training. Stability of resources, including transportation (33% of informants, n = 7) and staff capacity (48% of informants, n = 10), presented barriers. Strengthening these surveillance barriers may improve staff readiness to detect malaria outbreaks, resulting in timelier outbreak response and a reduction in malaria outbreaks, cases, and deaths. By focusing at the local level, our assessment approach provides a framework for identifying and addressing gaps that may be overlooked when utilising tools that evaluate surveillance capacity at the national level.

Incidence of sexually transmitted infections during pregnancy

Prevalence of sexually transmitted infections (STI) is high among pregnant women in certain settings. We estimated STI incidence and compared STI risk in pregnant and non-pregnant women. Data came from the Methods for Improving Reproductive Health in Africa (MIRA) study conducted in South Africa and Zimbabwe 2003-2006. Women aged 18-50 years with at least one follow-up visit within 6 months of enrollment were included. Follow-up visits included laboratory testing for pregnancy, chlamydia, gonorrhea, trichomoniasis, and HIV, as well as self-report of hormonal contraceptive (HC) use, sexual behaviors and intravaginal practices. All visits were classified according to pregnancy status. Incidence of each STI was calculated using follow-up time. Cox proportional hazards models were fitted using pregnancy as a time-varying exposure and sexual behaviors and intravaginal practices as time-varying covariates. Among 4,549 women, 766 (16.8%) had a positive pregnancy test. Median follow-up time was 18 months [IQR: 12-24]. The overall incidence rate of chlamydia was 6.7 per 100 person years (py) and 9.9/100py during pregnancy; gonorrhea incidence was 2.7/100py and 4.9/100py during pregnancy; trichomoniasis incidence was 7.1/100py overall and 9.2/100py during pregnancy. Overall HIV incidence was 3.9/100py and 3.8/100py during pregnancy. In crude models, pregnancy increased risk for chlamydia (hazard ratio (HR) 1.5, 95%CI: 1.1-1.2), however there was no increased risk of any measured STI in adjusted models. STI Incidence was high during pregnancy however pregnancy did not increase STI risk after adjustment for sexual behaviors. Greater efforts are needed to help pregnant women avoid STIs.