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ObjectivesThe study sought to understand the characteristics of community deaths due to cholera in Zambia. We sought to examine the drivers of mortality from cholera among communities in Zambia’s 2023–2024 outbreak.Design/settingThis is a descriptive study of the characteristics of community deaths due to cholera in three provinces in Zambia. Routine surveillance data collected between 14 October 2023 and 16 April 2024, comprising a national line list of cholera deaths, were used for this study.Participants178 participants were included in the study and completed it. All community deaths on the line list were eligible for inclusion. This comprised: deceased individuals whose death was associated with cholera or who met the national cholera case definition (suspected or confirmed); death occurring in the community, en route or on arrival to a health facility prior to admission; and death must have occurred between 14 October 2023 and 16 April 2024. Deceased individuals whose family members could not be traced or did not consent to participate in the interview were excluded.Primary and secondary outcome measuresThe primary outcome was identifying characteristics of cholera-related community deaths. There were no secondary outcomes measured.ResultsAmong 178 community deaths due to cholera, the majority were males (61.8%), with the highest mortality in adults aged 35–49 years (22.5%). Over half of the deaths occurred on arrival at healthcare facilities due to delays influenced by socioeconomic barriers. Comorbidities such as HIV/AIDS and hypertension were present in 23% of cases.ConclusionsThe study found that males, death on arrival at healthcare facilities, delays in seeking healthcare and comorbidities such as HIV/AIDS and hypertension were more frequently observed among those who died due to cholera in the community. These findings highlight the need for enhanced early care-seeking behaviours, improved access to timely treatment and targeted interventions for individuals with comorbidities to potentially reduce cholera mortality.

Cholera outbreaks are increasing in frequency and severity, particularly in Sub-Saharan Africa. Zambia, committed to ending cholera by 2025, instead experienced its most significant outbreak in 2024. This review examines the perceived regression in elimination efforts by addressing two questions: (i) What is known about cholera in Zambia? and (ii) What are the main suggested mechanisms and strategies to further elimination efforts in the region?. A scoping literature search was conducted in PUBMED to identify relevant qualitative and quantitative research studies published between 1st January 2013 and 30th June 2024 using the search terms 'cholera' and 'Zambia'. We identified 53 relevant publications. With the increasing influence of climate change, population growth, and rural-urban migration, further increases in outbreak frequency and magnitude are expected. Risk factors for recurrent outbreaks, including poor access to water, sanitation, and hygiene (WASH) services in unplanned urban settlements and rural fishing villages, continue to derail elimination efforts. Interventions are best planned at a decentralised, community-centric approach to prevent elimination and reintroduction at the district level. Pre-emptive vaccination campaigns before the rainy season and climate-resilient WASH infrastructure in cholera hotspots are also recommended. The goal to eliminate cholera by 2025 was unrealistic, as evidence points to the disease becoming endemic. Our findings confirm the need to align health and WASH investments with the Global Roadmap to Cholera Elimination by 2030 through a climate-focused lens. Recommendations for cholera elimination, including improved access to safe drinking water and sanitation, remain elusive in many low-income settings like Zambia. Patient-level information on survival and transmissibility is lacking. New research tailored to country-level solutions and enhancing community participation is urgently required. Insights from this review will be integrated into the next iteration of the National Cholera Control Plan and could apply to other countries with similar settings.

Background Despite progress towards HIV epidemic control, people living with HIV (PLHIV) in Zambia continue to face high mortality during and especially after hospitalization, with suboptimal post-discharge care leading to poor outcomes. We conducted a qualitative study to better understand factors influencing post-discharge engagement in care for HIV and associated comorbidities. Methods We conducted in-depth interviews with 16 recently discharged PLHIV, seven caregivers, and two doctors; and three focus group discussions with inpatient doctors ( n  = 8) and lay counsellors ( n  = 16) at two tertiary hospitals in Lusaka, guided by the social-ecological model. Data were audio-recorded, transcribed verbatim, managed with Atlas.ti 9 , and thematically analyzed. Results Individual and household-level barriers to post-discharge care for PLHIV included HIV status denial and stigma, limited disclosure, and limited social and emotional support. Health-related barriers included concomitant treatments for TB, HIV comorbidities, and behavioral health issues like depression and alcohol abuse. Health system barriers included limited confidentiality during admission and poor communication between healthcare providers and between facilities aftercare transitions following discharge. Social-economic factors included economic shocks of hospitalization and post-discharge recovery, which compounded pre-existing poverty and high transportation and food costs. Conversely, disclosure of HIV status, better social support, a financially stable household, and hospital follow-up appointment reminders facilitated better post-discharge care. Conclusion After hospital discharge with HIV, system and individual challenges exacerbate pre-existing interpersonal, health, environmental, and system-related factors to cause poor outcomes. Holistic community-based interventions to facilitate these patients’ re-engagement in care after discharge could help HIV programs reach the last mile in epidemic control.

Cholera remains a major public health challenge, and co-infections can complicate clinical outcomes. In a cross-sectional study, we investigated the prevalence and patterns of enteric co-infections during Zambia’s 2023–2024 cholera outbreak and evaluated their implications for disease severity. 240 suspected cholera patients were enrolled from five healthcare facilities in Lusaka. Stools were tested for 11 enteric pathogens using the Bosphore® Gastroenteritis Panel Kit v2 on the QuantStudio 5 qPCR, with Vibrio cholerae confirmed by real-time PCR (quantitative PCR). Co-infections were highly prevalent, affecting 79.2% of participants. Campylobacter was the most frequently detected pathogen (70.0%), followed by Norovirus GI/GII (20.0%). Persons living with HIV were significantly more likely to present with co-infections than their counterparts (adjusted PR 1.27, 95% CI: 1.07–1.51; p = 0.008). Participants with confirmed V. cholerae + coinfections (N = 62) were less likely to developed moderate to severe disease compared to those with mono-infections (adjusted PR 0.59, 95% CI: 0.38–0.90; p = 0.014). These findings highlight the high prevalence and complexity of co-infections during cholera outbreaks, potentially contributing to antimicrobial resistance. They also highlight the need for targeted clinical management, particularly among persons living with HIV.

Background Zambia recently achieved UNAIDS 90-90-90 treatment targets for HIV epidemic control; however, inpatient facilities continue to face a large burden of patients with advanced HIV disease and HIV-related mortality. Management of advanced HIV disease, following guidelines from outpatient settings, may be more difficult within complex inpatient settings. We evaluated adherence to HIV guidelines during hospitalization, including opportunistic infection (OI) screening, treatment, and prophylaxis. Methods We reviewed inpatient medical records of people living with HIV (PLHIV) admitted to the University Teaching Hospital in Lusaka, Zambia between December 1, 2018 and April 30, 2019. We collected data on patient demographics, antiretroviral therapy (ART), HIV biomarkers, and OI screening and treatment—including tuberculosis (TB), Cryptococcus, and OI prophylaxis with co-trimoxazole (CTX). Screening and treatment cascades were constructed based on the 2017 WHO Advanced HIV Guidelines. Results We reviewed files from 200 charts of patients with advanced HIV disease; of these 92% (184/200) had been on ART previously; 58.1% (107/184) for more than 12 months. HIV viral load (VL) testing was uncommon but half of VL results were high. 39% (77/200) of patients had a documented CD4 count result. Of the 172 patients not on anti-TB treatment (ATT) on admission, TB diagnostic tests (either sputum Xpert MTB/RIF MTB/RIF or urine TB-LAM) were requested for 105 (61%) and resulted for 60 of the 105 (57%). Nine of the 14 patients (64%) with a positive lab result for TB died before results were available. Testing for Cryptococcosis was performed predominantly in patients with symptoms of meningitis. Urine TB-LAM testing was rarely performed. Conclusions At a referral hospital in Zambia, CD4 testing was inconsistent due to laboratory challenges and this reduced recognition of AHD and implementation of AHD guidelines. HIV programs can potentially reduce mortality and identify PLHIV with retention and adherence issues through strengthening inpatient activities, including reflex VL testing, TB-LAM and serum CrAg during hospitalization.

Cholera has remained a persistent public health challenge in Zambia since the country’s first reported outbreak in 1977. The recent outbreak, which began in October 2023 and is ongoing as of June 2024, is the most severe in Zambia’s history and part of the larger 2022–2024 Southern Africa cholera outbreak, which has affected multiple countries in the region. This article describes the implementation of the integrated community strategy for cholera control (ICSCC) in three districts of the Copperbelt Province during this outbreak. The ICSCC is a comprehensive, community-centric public health approach that integrates surveillance, case management, water, sanitation and hygiene interventions, community engagement and infection prevention measures. The strategy’s implementation involved deploying multidisciplinary technical teams, training community-based volunteers and healthcare workers in the affected communities. This approach led to a rapid reduction in cholera cases and mortality, largely due to enhanced surveillance, community education sessions and improved sanitation practices. The ICSCC also improved stakeholder coordination and enabled rapid communication for early response to cholera hotspots. Key lessons learnt include the importance of robust coordination, early community involvement and context-specific adaptations. The strategy’s emphasis on data-driven decision-making and adaptation to local socio-cultural dynamics was crucial for its effectiveness. These findings underscore the potential of integrated community-based approaches in managing cholera outbreaks, enhancing public health preparedness and building long-term resilience. The ICSCC strategy offers a scalable model for regions facing similar public health challenges, providing valuable insights for policymakers and practitioners on the effectiveness of community involvement in managing public health crises.

Background The COVID-19 pandemic had a devastating impact on childhood routine immunization programs, resulting in increased measles mortalities and complications. In Zambia, the likelihood of measles-related deaths and complications in children was possibly increased because of high rates of unvaccinated children, late diagnosis, and poor case management, which could have been a consequence of exclusive focus on COVID-19 interventions. This study aimed at examining the effect of the COVID-19 pandemic on measles mortality and its predictors among patients seen at health facilities in Zambia. Methods We used longitudinal data (January 2020 to August 2023) from outbreak investigations and time series data from 2017 to 2023 to understand the impact of COVID-19 on measles immunization and know the predictors of measles mortalities. The period running from January 2017 to February 2020, just before the first reported COVID-19 case, was defined as pre-COVID-19, and March 2020 to December 2023 as post-COVID-19. Multivariable logistic regression analysis was used to determine predictors of mortality. A segmented Poisson regression model was used to determine the correlation between the underlying patterns of measles mortality and the commencement of the COVID-19 pandemic. Results A total of 3429 measles cases were reported during the study period. Of these, 1261 had complete metadata and were included in the analysis. The median age was 3 years (IQR, 1–7). Out of the 1261 enrolled, 54 (4.3%) were reported died. A total of 205 (21.0%) were IgM positive, and 207 (16.9%) were vaccinated. Monthly measles mortality increased by 220%, from 0.06 per 100,000 before COVID-19 to 0.23 during the pandemic. Predictors of mortality were younger age category (0–4) (AOR = 2.78; 95% CI 1.16–7.14), testing positive for measles IgM (AOR = 2.17; 95% CI 1.07–4.39), rush (AOR = 3.66; 95% CI 1.31, 6.21), and female sex (AOR = 1.90; 95% CI 1.04–3.50), which increased the odds of dying. However, being vaccinated (AOR = 0.06; 95% CI 0.01–0.42) reduced the odds of dying. Evidence for the COVID-19 effect was strongly associated with increased measles mortality (RR, 1.02; 95% CI 1.00, 1.04; 0.017) with a trend step change of 81% (RR, 1.81; 95% CI 1.14–2.87). There was also an increased trend of measles cases (RR, 1.04; 95% CI 1.01–1.06) during the pandemic. Measles dose 2 vaccination trends increased by about 0.3% during the COVID-19 pandemic due to the Supplementary Immunization Activity (SIA) (RR, 1.003; 95% CI 1.000–1.010). However, there was a dramatic drop of about 42% (RR = 0.58, 95% CI 0.46–0.72). Conclusions Measles caused a significant increase in child mortality during the pandemic period. A mix of systemic, clinical, and individual factors affected measles mortality. Prioritizing vaccine coverage, especially for younger children and marginalized populations; enhancing diagnostic and treatment capacities; and addressing gender and healthcare access disparities are all essential components of interventions aimed at lowering mortality. The findings suggest that public health interventions focusing on measles vaccination, rapid detection, and appropriate case management are crucial to reducing mortality and preventing further transmission. To achieve population immunity, sustained efforts are required to maintain high coverage rates.

Background Cholera outbreaks have plagued Zambia for decades, with Lusaka district, the capital, being particularly vulnerable. Although the lack of sanitary toilet facilities and inadequate drainage systems were shown to be associated with the high cholera incidence in the early 2000s, it is unknown whether these environmental risk factors persisted in the outbreak that occurred in 2023–2024, which turned out to be the largest outbreak in the country’s history. We investigated the geospatial patterns of cholera cases and associated environmental factors during the October 2023 to March 2024 cholera outbreak. Methods We conducted a geospatial analysis of the suspected cholera cases in Lusaka district, comprising seven constituencies and 94 townships. Patient information and geocoordinates were collected from suspected cases using electronic surveillance tools. The space–time scan statistics was performed to detect spatial and temporal clusters of cases. Spearman's rank correlation coefficient, were employed to examine the relationship between cholera incidence and various environmental factors, including access to Water, Sanitation, and Hygiene (WASH) facilities and equipment. Results Over the study period, 4,591 suspected cholera cases with geocoordinate data were identified, with incidence rates varying across the constituencies. Median cholera incidence (IQR) was 0.55 (0.27–1.44) in Lusaka, with higher incidence rates observed in unplanned residential areas. After the first case identification in Kanyama, cases and clusters were observed in different parts of Lusaka. Among 94 townships in Lusaka, cholera-suspected cases were identified in 86 of them. Among environmental factors analyzed for associations with the high cholera incidence, the proportion of individuals without soap and detergent at home (ρ = 0.457, p  < 0.001) and those without water for hand washing at home (ρ = 0.421, p  < 0.001) were significantly associated with increased cholera incidence. Conclusion The findings underscore the significance of environmental factors in cholera transmission, particularly in unplanned residential areas with inadequate access to WASH facilities which persist in the area. Improving WASH infrastructure and implementing tailored public health strategies, particularly for high-risk areas (e.g., unplanned residential areas), are crucial for mitigating cholera outbreaks in Lusaka District.

The global health exchange program between the University Teaching Hospitals (UTH) of Lusaka, Zambia and the University of Maryland, Baltimore (UMB) has been operating since 2015. As trainees and facilitators of this exchange program, we describe our experiences working in Lusaka and Baltimore, and strengths and challenges of the partnership. Since 2015, we have facilitated rotations for 71 UMB trainees, who spent four weeks on the Infectious Disease (ID) team at UTH. Since 2019 with funding from UMB, nine UTH ID trainee physicians spent up to six weeks each rotating on various ID consult services at University of Maryland Medical Center (UMMC). Challenges in global health rotations can include inadequate preparation or inappropriate expectations among high-income country trainees, low-value experiences for low- and middle-income country trainees, lack of appropriate mentorship at sites, and power imbalances in research collaborations. We try to mitigate these issues by ensuring pre-departure and on-site orientation for UMB trainees, cross-cultural mentored experiences for all trainees, and intentional sharing of authorship and credit on scientific collaborations. We present a description of our medical education collaboration as a successful model for building equitable and reciprocal collaborations between low- and middle-income countries and high-income countries, and offer suggestions for future program initiatives to enhance global health education equity among participants and organizations.

Cholera remains a global threat to health security, particularly in sub-Saharan Africa where outbreaks have become frequent, with increased magnitude and fatalities.1,2 While the world is preparing for the next pandemic, we explored clinical outcomes and patient survival if admitted at any treatment centre during the cholera outbreak in Lusaka between Jan 1, 2024 and April 30, 2024. Standard case record forms were introduced, and available patient records were digitised and documented in RedCap for further analysis creating an electronic medical record system for 11 110 patients admitted in any of the seven treatment centres in Lusaka. Oral cholera vaccinations have been shown to be protective during and after cholera outbreaks.4 However, there is a dearth of information on the appropriate case management of patients with cholera and comorbid conditions.5 Our findings suggest that rapid fluid resuscitation necessary in patients with cholera might be complicated without strict quantitative monitoring of hydration status (particularly in patients with hypertension) and worsen patient outcomes.