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Introduction Reliable and timely laboratory results are crucial for monitoring the Prevention of the Mother-to-Child Transmission (PMTCT) cascade, particularly to enable early HIV diagnosis and early intervention. We sought to explore whether and how laboratory services have been prepared to absorb new testing requirements following PMTCT Test-and-Treat policy changes in three districts of Zambia. Method We employed in-depth interviews and thematic data analysis, informed by the health system dynamic framework. Twenty-Six health workers were purposively selected and a document review of laboratory services in the context of PMTCT was undertaken. All face-to-face interviews were conducted in three local government areas in the Copperbelt Province (one urban and two rural) between February 2019 and July 2020. We extracted notes and markings from the transcripts for coding. Different codes were sorted into potential themes and the data extracted were put within the identified themes. Trustworthiness was confirmed by keeping records of all data field notes, transcripts, and reflexive journals. Results The findings revealed that the health system inputs (infrastructure and supplies, human resources, knowledge, and information and finance) and service delivery were unequal between the rural and urban sites, and this affected the ability of health facilities to apply the new testing requirements, especially, in the rural-based health facilities. The major barriers identified include gaps in the capacity of the existing laboratory system to perform crucial PMTCT clinical and surveillance functions in a coordinated manner and insufficient skilled human resources to absorb the increased testing demands. The centralized laboratory system for HIV testing of mothers and exposed neonates meant facilities had to send specimens to other facilities and districts which resulted in high turnaround time and hence delayed HIV diagnosis. Conclusion New guidelines implemented without sufficient capacitation of health system laboratory capacity severely limited the effectiveness of PMTCT program implementation. This study documented the areas relating to health system inputs and laboratory service delivery where greater support to enable the absorption of the new testing requirements is needed.

Zambia is focusing on attaining HIV epidemic control by 2021, including eliminating Mother to Child Transmission (eMTCT) of HIV. However, there is little evidence to understand frontline healthcare workers' experience with the policy changes and the readiness of different health system elements to contribute to this goal. To understand frontline healthcare workers' experience of preventing mother-to-child transmission (PMTCT) of human immunodeficiency (HIV) policy changes and to explore the health system readiness to respond to rapid changes in PMTCT policy by using the health system dynamic framework. We conducted a qualitative study in which 35 frontline healthcare workers were selected and interviewed using a snowball sampling technique. All transcripts were analysed through thematic content analysis and deductive coding. Themes were derived and presented according to the health system dynamics framework. Among the ten elements of the health system dynamics framework, service delivery, context, and resources (i.e. infrastructure and supplies, knowledge and information, human resource, and finance) were critical in implementing the continuously evolving PMTCT policies. Furthermore, due to the fragmented primary health care platform in Zambia, non-governmental organisations (NGOs) were instrumental in ensuring that the PMTCT programme met the demand and requirements of the general population. Frontline healthcare workers who participated in the study described inequity in access to ART services due to the service delivery model employed in the selected study sites. The study highlights challenges when policies are implemented without consideration for the readiness, context, and capacity in which the policy is implemented. We offer lessons that can inform implementation of universal health coverage of antiretroviral therapy (ART), a strategy many countries have adopted, despite weak health systems.

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.

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.

Achieving malaria elimination requires considering both Plasmodium falciparum and non–P. falciparum infections. We determined prevalence and geographic distribution of 4 Plasmodium spp. by performing PCR on dried blood spots collected within 8 regions of Tanzania during 2017. Among 3,456 schoolchildren, 22% had P. falciparum, 24% had P. ovale spp., 4% had P. malariae, and 0.3% had P. vivax infections. Most (91%) schoolchildren with P. ovale infections had low parasite densities; 64% of P. ovale infections were single-species infections, and 35% of those were detected in low malaria endemic regions. P. malariae infections were predominantly (73%) co-infections with P. falciparum. P. vivax was detected mostly in northern and eastern regions. Co-infections with >1 non–P. falciparum species occurred in 43% of P. falciparum infections. A high prevalence of P. ovale infections exists among schoolchildren in Tanzania, underscoring the need for detection and treatment strategies that target non–P. falciparum species.

Malaria remains a significant cause of morbidity and mortality in Malawi, with an estimated 18–19% prevalence of Plasmodium falciparum in children 2–10 years in 2015–2016. While children report the highest rates of clinical disease, adults are thought to be an important reservoir to sustained transmission due to persistent asymptomatic infection. The 2015–2016 Malawi Demographic and Health Survey was a nationally representative household survey which collected dried blood spots from 15,125 asymptomatic individuals ages 15–54 between October 2015 and February 2016. We performed quantitative polymerase chain reaction on 7,393 samples, detecting an overall P. falciparum prevalence of 31.1% (SE = 1.1). Most infections (55.6%) had parasitemias ≤ 10 parasites/µL. While 66.2% of individuals lived in a household that owned a bed net, only 36.6% reported sleeping under a long-lasting insecticide-treated net (LLIN) the previous night. Protective factors included urbanicity, greater wealth, higher education, and lower environmental temperatures. Living in a household with a bed net (prevalence difference 0.02, 95% CI − 0.02 to 0.05) and sleeping under an LLIN (0.01; − 0.02 to 0.04) were not protective against infection. Our findings demonstrate a higher parasite prevalence in adults than published estimates among children. Understanding the prevalence and distribution of asymptomatic infection is essential for targeted interventions.

Achieving malaria elimination requires considering both Plasmodium falciparum and non-P. falciparum infections. We determined prevalence and geographic distribution of 4 Plasmodium spp. by performing PCR on dried blood spots collected within 8 regions of Tanzania during 2017. Among 3,456 schoolchildren, 22% had P. falciparum, 24% had P. ovale spp., 4% had P. malariae, and 0.3% had P. vivax infections. Most (91%) schoolchildren with P. ovale infections had low parasite densities; 64% of P. ovale infections were single-species infections, and 35% of those were detected in low malaria endemic regions. P. malariae infections were predominantly (73%) co-infections with P. falciparum. P. vivax was detected mostly in northern and eastern regions. Co-infections with >1 non-P. falciparum species occurred in 43% of P. falciparum infections. A high prevalence of P. ovale infections exists among schoolchildren in Tanzania, underscoring the need for detection and treatment strategies that target non-P. falciparum species.Achieving malaria elimination requires considering both Plasmodium falciparum and non-P. falciparum infections. We determined prevalence and geographic distribution of 4 Plasmodium spp. by performing PCR on dried blood spots collected within 8 regions of Tanzania during 2017. Among 3,456 schoolchildren, 22% had P. falciparum, 24% had P. ovale spp., 4% had P. malariae, and 0.3% had P. vivax infections. Most (91%) schoolchildren with P. ovale infections had low parasite densities; 64% of P. ovale infections were single-species infections, and 35% of those were detected in low malaria endemic regions. P. malariae infections were predominantly (73%) co-infections with P. falciparum. P. vivax was detected mostly in northern and eastern regions. Co-infections with >1 non-P. falciparum species occurred in 43% of P. falciparum infections. A high prevalence of P. ovale infections exists among schoolchildren in Tanzania, underscoring the need for detection and treatment strategies that target non-P. falciparum species.

Background The 2022 malaria chemoprevention guidelines of the World Health Organization (WHO) recommend the provision of a full treatment course of an antimalarial medicine at predefined intervals, regardless of whether the child is infected with malaria, to prevent illness in moderate to high perennial malaria transmission settings. Sulfadoxine-pyrimethamine (SP) is usually used for this intervention, now called perennial malaria chemoprevention (PMC). The K540E mutation in the dihydropteroate synthase ( dhps ) gene circulating in Africa is thought to be associated with treatment failure and reduced chemoprevention efficacy in children but the exact effect remains unclear. Methods This protocol is for a two-arm, parallel, double-blind, placebo-controlled, randomised trial in Zambia that is designed to evaluate the effect of parasite genotypes on the efficacy of single-dose SP among asymptomatic children between 3 and 5 years of age. Children are randomly allocated to one of two groups for directly observed treatment. Over seven consecutive days (7 days before day 0), children in the SP group ( n  = 400) receive placebo artesunate (AS), then active SP (day 0). In contrast, children in the AS group ( n  = 200) receive active artesunate for seven consecutive days, followed by placebo SP (day 0). Then, on days 0, 2, 5, 7, and weekly thereafter until day 28, children provide blood for thick smear slides. Dried blood spots (DBS) are collected on the same days and weekly from day 28 to day 63 for quantitative polymerase chain reaction (qPCR) and genotype analyses using a platform based on PCR followed by targeted next-generation sequencing. Discussion We will report unblinded results including: (i) time-to-parasite clearance among SP recipients who were positive on day 0 by qPCR and measured to day 63; (ii) mean duration of SP protection against infection, and (iii) mean duration of symptom-free status among SP recipients who were parasite free on day 0 by qPCR. Our conclusions will reflect on the utility of WHO’s new malaria chemoprevention efficacy study protocol with its follow-up to day 28 versus day 63. Trial registration ClinicalTrials.gov NCT06166498 11/12/2023.

Background Mineworkers in Southern Africa have the highest rates of tuberculosis (TB) among working populations in the world (The World Bank, Benefits and costs associated with reducing tuberculosis among Southern Africa’s mineworkers, 2014), making mineworkers a key population for TB program efforts. The current evaluation aimed to characterize mineworkers and former (ex-) mineworkers, and assess knowledge, attitudes and practices related to TB and HIV care among mineworkers and healthcare workers (HCWs) in Zambia. Methods A mixed-methods evaluation of current and former (ex-) mineworkers and HCWs was conducted in the Copperbelt and North-Western provinces, Zambia. Knowledge, attitudes and practices (KAPs) related to TB care and policies were assessed using a structured survey. Focus Group Discussions (FGDs) were conducted with current and ex-mineworkers to understand perceptions, practices, and barriers related to accessing healthcare for TB. Results Overall, 2,792 mineworkers and 94 HCWs completed the KAP survey, and 206 (171 current, 71 ex-) mineworkers participated in FGDs. Mineworkers and ex-mineworkers were knowledgeable about TB symptoms (cough; 94%), transmission (81.7%) and treatment (99.2%). Yet, barriers to seeking care were evident with 30% of mineworkers experiencing cough, and 19% reporting 2 or more TB symptoms at the time of the survey. The majority of mineworkers (70.9%) were aware of policies barring persons from working after a diagnosis of TB, and themes from FGDs and HCW comments ( n  = 32/62; 51.6%) recognized fear of job loss as a critical barrier to providing timely screening and appropriate care for TB among mineworkers. The majority (76.9%) of mineworkers indicated they would not disclose their TB status to their supervisor, but would be willing to share their diagnosis with their spouse (73.8%). Conclusion Fear of job loss, driven by governmental policy and mistrust in mining companies, is a major barrier to healthcare access for TB among mineworkers in Zambia. As a result of these findings, the government policy prohibiting persons from working in the mines following TB disease is being repealed. However, major reforms are urgently needed to mitigate TB among mineworkers, including ensuring the rights of mineworkers and their communities to healthy living and working environments, improved social responsibility of mining companies, and facilitating choice and access to affordable, timely, and high-quality healthcare services.

Mineworkers in Southern Africa have the highest rates of tuberculosis (TB) among working populations in the world (The World Bank, Benefits and costs associated with reducing tuberculosis among Southern Africa's mineworkers, 2014), making mineworkers a key population for TB program efforts. The current evaluation aimed to characterize mineworkers and former (ex-) mineworkers, and assess knowledge, attitudes and practices related to TB and HIV care among mineworkers and healthcare workers (HCWs) in Zambia. A mixed-methods evaluation of current and former (ex-) mineworkers and HCWs was conducted in the Copperbelt and North-Western provinces, Zambia. Knowledge, attitudes and practices (KAPs) related to TB care and policies were assessed using a structured survey. Focus Group Discussions (FGDs) were conducted with current and ex-mineworkers to understand perceptions, practices, and barriers related to accessing healthcare for TB. Overall, 2,792 mineworkers and 94 HCWs completed the KAP survey, and 206 (171 current, 71 ex-) mineworkers participated in FGDs. Mineworkers and ex-mineworkers were knowledgeable about TB symptoms (cough; 94%), transmission (81.7%) and treatment (99.2%). Yet, barriers to seeking care were evident with 30% of mineworkers experiencing cough, and 19% reporting 2 or more TB symptoms at the time of the survey. The majority of mineworkers (70.9%) were aware of policies barring persons from working after a diagnosis of TB, and themes from FGDs and HCW comments (n = 32/62; 51.6%) recognized fear of job loss as a critical barrier to providing timely screening and appropriate care for TB among mineworkers. The majority (76.9%) of mineworkers indicated they would not disclose their TB status to their supervisor, but would be willing to share their diagnosis with their spouse (73.8%). Fear of job loss, driven by governmental policy and mistrust in mining companies, is a major barrier to healthcare access for TB among mineworkers in Zambia. As a result of these findings, the government policy prohibiting persons from working in the mines following TB disease is being repealed. However, major reforms are urgently needed to mitigate TB among mineworkers, including ensuring the rights of mineworkers and their communities to healthy living and working environments, improved social responsibility of mining companies, and facilitating choice and access to affordable, timely, and high-quality healthcare services.