Consumption of legal and illegal cigarettes in the Gambia.

BACKGROUND: The prevalence of cigarette smoking in the Gambia is relatively high, compared with most African countries. Little is known about the characteristics of the smokers and their habits, particularly with regard to tobacco tax avoidance and tax evasion. METHODS: A nationally representative survey of 1211 smokers conducted in November/December 2017 employed a three-stage stratified sampling method and resulted in 1205 complete observations. The sociodemographic characteristics and smoking behaviours were analysed, including smoking intensity and brand preferences. Information on the physical features of cigarette packs that smokers had, observed by enumerators, and self-reported cigarette prices were used to estimate the proportion of illegal cigarettes on the market. FINDINGS: As in many African countries, most smokers were male, between the ages of 25 and 54 years living primarily in urban areas. The three most popular cigarette brands are Piccadilly, Royal Business and Bond Street, which account for over three-quarters of all cigarette purchases. Price information suggests that about 7.3% of smokers purchased an illicit cigarette at their last purchase. When smoking intensity was taken into account, 8.6% of the total cigarette market was estimated to be illicit. Using an alternative method of evaluating pack's features revealed that only 0.9% of last purchases were illicit. CONCLUSION: Despite recent excise tobacco tax increases, the use of illicit cigarettes in the Gambia is low and does not represent a significant obstacle to reaching both the public health and fiscal goals of higher tobacco taxes.

Malaria case management in Zambia: A cross-sectional health facility survey.

Misdiagnosis of malaria could lead to the overuse of antimalarials resulting in the progression of underlying illness as well as increased risk of mortality. Misdiagnosis is an important consideration as a significant proportion of febrile illnesses in sub-Saharan Africa are attributable to conditions other than malaria. A health facility survey was carried out for a simple random sample of health facilities across 4 provinces of central Zambia in 2014. Twenty-nine facilities with at least 10 outpatients per day were included in the final sample. A modified service provision assessment questionnaire was used for data collection along with several other instruments. Primary outcomes included the quality and accuracy of diagnostic testing for malaria as well as health worker diagnostic and treatment practices. Laboratory technicians displayed 65.5% sensitivity and 86.0% specificity in performing malaria microscopy. Rapid diagnostic test results as reported by health workers were cross-checked by survey staff revealing 99.8% (95% CI: 98.0%-100.0%) concordance. Overall, 69.5% (177/286) (95% CI [58.8%-78.4%]) of patients were reported as febrile of which 37.0% (68/177) (95% CI [21.0%-56.6%]) had a malaria test requested or conducted by their health worker. Appropriate health worker adherence to recommended malaria case management practices (i.e. requesting/conducting malaria tests for febrile patients and providing appropriate antimalarial treatment for test positive cases or forgoing antimalarial treatment for test negative cases) was 30.5% (57/177) (95% CI [17.1%-48.4%]). Presence of fever (aOR = 10.6; 95% CI [3.6-31.2]) and self-reported headache (aOR = 2.2; 95% CI [1.0-4.9]) were significant factors in explaining health worker practices of requesting or performing malaria tests. Routine practice of IQA activities (aOR = 4.8; 95% CI [1.5-15.1]) and self-reported headache (aOR = 3.3; 95% CI [1.1-10.1])) were both significant predictors of antimalarial drug treatment or prescription among malaria untested patients. Prescriber adherence to malaria diagnostic test results in central Zambia is good, but the overall testing rate of febrile patients was low. Additionally, a number of patients observed during this survey were found to have received a clinical diagnosis of malaria without parasitological confirmation and many patients without test results received antimalarial treatment.

Decomposition of socioeconomic inequalities in cigarette smoking: the case of Namibia.

BACKGROUND: Namibia has one of the highest levels of income inequality in the world. Increased smoking prevalence, especially among the youth, may leave the country facing the spectre of higher smoking-related disease prevalence in the years to come. This study examines socioeconomic inequalities in smoking in Namibia and explores the drivers of this inequality. METHODS: Data are obtained from the Namibia 2013 Demographic and Health Survey, a nationally representative survey. Concentration curves and indices are calculated for cigarette smoking prevalence and intensity to assess the respective inequalities. Smoking intensity is defined as the number of cigarette sticks smoked within the last 24 h before the survey. We use a decomposition technique to identify the contribution of various covariates to socioeconomic inequalities in smoking prevalence and intensity. RESULTS: The concentration indices for socioeconomic inequality in cigarette smoking prevalence and smoking intensity are estimated at 0.021 and 0.135, respectively. This suggests that cigarette smoking is more prevalent among the wealthy and that they smoke more frequently compared to less wealthy Namibians. For smoking intensity, the biggest statistically significant contributors to inequality are marital status, wealth and region dummy variables while for smoking prevalence, education and place of dwelling (urban vs rural) are the main contributors. CONCLUSION: While overall inequality in smoking prevalence and intensity is focused among the wealthy, the contribution of region of residence and education warrant some attention from policy makers. Based on our results, we suggest an assessment of compliance and enforcement of the Tobacco Products Control Act, that initially focuses on regions with reportedly low education statistics followed by an appropriate implementation strategy to address the challenges identified in implementing effective tobacco control interventions.

Price, tax and tobacco product substitution in Zambia: findings from the ITC Zambia Surveys.

BACKGROUND: In Zambia, the number of cigarette users is growing, and the lack of strong tax policies is likely an important cause. When adjusted for inflation, levels of tobacco tax have not changed since 2007. Moreover, roll-your-own (RYO) tobacco, a less-costly alternative to factory-made (FM) cigarettes, is highly prevalent. DATA AND METHODS: We modelled the probability of FM and RYO cigarette smoking using individual-level data obtained from the 2012 and 2014 waves of the International Tobacco Control (ITC) Zambia Survey. We used two estimation methods: the standard estimation method involving separate random effects probit models and a method involving a system of equations (incorporating bivariate seemingly unrelated random effects probit) to estimate price elasticities of FM and RYO cigarettes and their cross-price elasticities. RESULTS: The estimated price elasticities of smoking prevalence are -0.20 and -0.03 for FM and RYO cigarettes, respectively. FM and RYO are substitutes; that is, when the price of one of the products goes up, some smokers switch to the other product. The effects are stronger for substitution from FM to RYO than vice versa. CONCLUSIONS: This study affirms that increasing cigarette tax with corresponding price increases could significantly reduce cigarette use in Zambia. Furthermore, reducing between-product price differences would reduce substitution from FM to RYO. Since RYO use is associated with lower socioeconomic status, efforts to decrease RYO use, including through tax/price approaches and cessation assistance, would decrease health inequalities in Zambian society and reduce the negative economic consequences of tobacco use experienced by the poor.

A qualitative review of implementer perceptions of the national community-level malaria surveillance system in Southern Province, Zambia.

BACKGROUND: Parts of Zambia with very low malaria parasite prevalence and high coverage of vector control interventions are targeted for malaria elimination through a series of interventions including reactive case detection (RCD) at community level. When a symptomatic individual presenting to a community health worker (CHW) or government clinic is diagnostically confirmed as an incident malaria case an RCD response is initiated. This consists of a CHW screening the community around the incident case with rapid diagnostic tests (RDT) and treating positive cases with artemether-lumefantrine (AL, Coartem™) in accordance with national policy. Since its inception in 2011, Zambia's RCD programme has relied on anecdotal feedback from staff to identify issues and possible solutions. In 2014, a systematic qualitative programme review was conducted to determine perceptions around malaria rates, incentives, operational challenges and solutions according to CHWs, their supervisors and district-level managers. METHODS: A criterion-based sampling framework based on training regime and performance level was used to select nine rural health posts in four districts of Southern Province. Twenty-two staff interviews were completed to produce English or bilingual (CiTonga or Silozi + English) verbatim transcripts, which were then analysed using thematic framework analysis. RESULTS: CHWs, their supervisors and district-level managers strongly credited the system with improving access to malaria services and significantly reducing the number of cases in their area. The main implementation barriers included access (e.g., lack of rain gear, broken bicycles), insufficient number of CHWs for programme coverage, communication (e.g. difficulties maintaining cell phones and "talk time" to transmit data by phone), and inconsistent supply chain (e.g., inadequate numbers of RDT kits and anti-malarial drugs to test and treat uncomplicated cases). CONCLUSIONS: This review highlights the importance of a community surveillance system like RCD in shaping Zambia's malaria elimination campaign by identifying community-based infections that might otherwise remain undetected. At this stage the system must ensure it can meet growing public demand by providing CHWs the tools and materials they need to consistently carry out their work and expand programme reach to more isolated communities. Results from this review will be used to plan programme scale-up into other parts of Zambia.

Malaria surveillance in low-transmission areas of Zambia using reactive case detection.

BACKGROUND: Repeat national household surveys suggest highly variable malaria transmission and increasing coverage of high-impact malaria interventions throughout Zambia. Many areas of very low malaria transmission, especially across southern and central regions, are driving efforts towards sub-national elimination. CASE DESCRIPTION: Reactive case detection (RCD) is conducted in Southern Province and urban areas of Lusaka in connection with confirmed incident malaria cases presenting to a community health worker (CHW) or clinic and suspected of being the result of local transmission. CHWs travel to the household of the incident malaria case and screen individuals living in adjacent houses in urban Lusaka and within 140 m in Southern Province for malaria infection using a rapid diagnostic test, treating those testing positive with artemether-lumefantrine. DISCUSSION: Reactive case detection improves access to health care and increases the capacity for the health system to identify malaria infections. The system is useful for targeting malaria interventions, and was instrumental for guiding focal indoor residual spraying in Lusaka during the 2014/2015 spray season. Variations to maximize impact of the current RCD protocol are being considered, including the use of anti-malarials with a longer lasting, post-treatment prophylaxis. CONCLUSION: The RCD system in Zambia is one example of a malaria elimination surveillance system which has increased access to health care within rural communities while leveraging community members to build malaria surveillance capacity.

Enhanced surveillance and data feedback loop associated with improved malaria data in Lusaka, Zambia.

BACKGROUND: Accurate and timely malaria data are crucial to monitor the progress towards and attainment of elimination. Lusaka, the capital city of Zambia, has reported very low malaria prevalence in Malaria Indicator Surveys. Issues of low malaria testing rates, high numbers of unconfirmed malaria cases and over consumption of anti-malarials were common at clinics within Lusaka, however. The Government of Zambia (GRZ) and its partners sought to address these issues through an enhanced surveillance and feedback programme at clinic level. METHODS: The enhanced malaria surveillance programme began in 2011 to verify trends in reported malaria, as well as to implement a data feedback loop to improve data uptake, use, and quality. A process of monthly data collection and provision of feedback was implemented within all GRZ health clinics in Lusaka District. During clinic visits, clinic registers were accessed to record the number of reported malaria cases, malaria test positivity rate, malaria testing rate, and proportion of total suspected malaria that was confirmed with a diagnostic test. RESULTS AND DISCUSSION: Following the enhanced surveillance programme, the odds of receiving a diagnostic test for a suspected malaria case increased (OR = 1.54, 95 % CI = 0.96-2.49) followed by an upward monthly trend (OR = 1.05, 95 % CI = 1.01-1.09). The odds of a reported malaria case being diagnostically confirmed also increased monthly (1.09, 95 % CI 1.04-1.15). After an initial 140 % increase (95 % CI = 91-183 %), costs fell by 11 % each month (95 % CI = 5.7-10.9 %). Although the mean testing rate increased from 18.9 to 64.4 % over the time period, the proportion of reported malaria unconfirmed by diagnostic remained high at 76 %. CONCLUSIONS: Enhanced surveillance and implementation of a data feedback loop have substantially increased malaria testing rates and decreased the number of unconfirmed malaria cases and courses of ACT consumed in Lusaka District within just two years. Continued support of enhanced surveillance in Lusaka as well as national scale-up of the system is recommended to reinforce good case management and to ensure timely, reliable data are available to guide targeting of limited malaria prevention and control resources in Zambia.

Reductions in artemisinin-based combination therapy consumption after the nationwide scale up of routine malaria rapid diagnostic testing in Zambia.

The National Malaria Control Center of Zambia introduced rapid diagnostic tests (RDTs) to detect Plasmodium falciparum as a pilot in some districts in 2005 and 2006; scale up at a national level was achieved in 2009. Data on RDT use, drug consumption, and diagnostic results were collected in three Zambian health districts to determine the impact RDTs had on malaria case management over the period 2004-2009. Reductions were seen in malaria diagnosis and antimalarial drug prescription (66.1 treatments per facility-month (95% confidence interval [CI] = 44.7-87.4) versus 26.6 treatments per facility-month (95% CI = 11.8-41.4)) pre- and post-RDT introduction. Results varied between districts, with significant reductions in low transmission areas but none in high areas. Rapid diagnostic tests may contribute to rationalization of treatment of febrile illness and reduce antimalarial drug consumption in Africa; however, their impact may be greater in lower transmission areas. National scale data will be necessary to confirm these findings.