Cholera Epidemic - Lusaka, Zambia, October 2017-May 2018.

On October 6, 2017, an outbreak of cholera was declared in Zambia after laboratory confirmation of Vibrio cholerae O1, biotype El Tor, serotype Ogawa, from stool specimens from two patients with acute watery diarrhea. The two patients had gone to a clinic in Lusaka, the capital city, on October 4. Cholera cases increased rapidly, from several hundred cases in early December 2017 to approximately 2,000 by early January 2018 (Figure). In collaboration with partners, the Zambia Ministry of Health (MoH) launched a multifaceted public health response that included increased chlorination of the Lusaka municipal water supply, provision of emergency water supplies, water quality monitoring and testing, enhanced surveillance, epidemiologic investigations, a cholera vaccination campaign, aggressive case management and health care worker training, and laboratory testing of clinical samples. In late December 2017, a number of water-related preventive actions were initiated, including increasing chlorine levels throughout the city's water distribution system and placing emergency tanks of chlorinated water in the most affected neighborhoods; cholera cases declined sharply in January 2018. During January 10-February 14, 2018, approximately 2 million doses of oral cholera vaccine were administered to Lusaka residents aged ≥1 year. However, in mid-March, heavy flooding and widespread water shortages occurred, leading to a resurgence of cholera. As of May 12, 2018, the outbreak had affected seven of the 10 provinces in Zambia, with 5,905 suspected cases and a case fatality rate (CFR) of 1.9%. Among the suspected cases, 5,414 (91.7%), including 98 deaths (CFR = 1.8%), occurred in Lusaka residents.

Uptake of four or more doses of sulfadoxine pyrimethamine for intermittent preventive treatment of malaria during pregnancy in Zambia: findings from the 2018 malaria in pregnancy survey.

OBJECTIVE: To determine the prevalence and predictors of the uptake of four or more doses of sulfadoxine pyrimethamine (IPTp-SP 4+) in Zambia. DESIGN: A cross-sectional study using secondary data from the malaria in pregnancy survey (Malaria Indicator Survey) data set conducted from April to May 2018. SETTING: The primary survey was conducted at community level and covered all the 10 provinces of Zambia. PARTICIPANTS: A total of 3686 women of reproductive age (15-45 years) who gave birth within the 5 years before the survey. PRIMARY OUTCOME: Proportion of participants with four or more doses of IPTp-SP. STATISTICAL ANALYSIS: All analyses were conducted using RStudio statistical software V.4.2.1. Descriptive statistics were computed to summarise participant characteristics and IPTp-SP uptake. Univariate logistic regression was carried out to determine association between the explanatory and outcome variables. Explanatory variables with a p value less than 0.20 on univariate analysis were included in the multivariable logistic regression model and crude and adjusted ORs (aORs) along with their 95% CIs were computed (p<0.05). RESULTS: Of the total sample of 1163, only 7.5% of participants received IPTp-SP 4+. Province of residence and wealth tertile were associated with uptake of IPTp-SP doses; participants from Luapula (aOR=8.72, 95% CI (1.72 to 44.26, p=0.009)) and Muchinga (aOR=6.67, 95% CI (1.19 to 37.47, p=0.031)) provinces were more likely to receive IPTp-SP 4+ compared with to those from Copperbelt province. Conversely, women in the highest wealth tertile were less likely to receive IPTp-SP 4+ doses compared with those in the lowest quintile (aOR=0.32; 95% CI (0.13 to 0.79, p=0.014)). CONCLUSION: These findings confirm a low uptake of four or more doses of IPTp-SP in the country. Strategies should focus on increased coverage of IPTp-SP in provinces with much higher malaria burden where the risk is greatest and the ability to afford healthcare lowest.

Risk Factors for Epidemic Cholera in Lusaka, Zambia-2017.

On October 6, 2017, the Zambia Ministry of Health declared a cholera outbreak in Lusaka. By December, 1,462 cases and 38 deaths had occurred (case fatality rate, 2.6%). We conducted a case-control study to identify risk factors and inform interventions. A case was any person with acute watery diarrhea (≥ 3 loose stools in 24 hours) admitted to a cholera treatment center in Lusaka from December 16 to 21, 2017. Controls were neighbors without diarrhea during the same time period. Up to two controls were matched to each case by age-group (1-4, 5-17, and ≥ 18 years) and neighborhood. Surveyors interviewed cases and controls, tested free chlorine residual (FCR) in stored water, and observed the presence of soap in the home. Conditional logistic regression was used to generate matched odds ratios (mORs) based on subdistricts and age-groups with 95% CIs. We enrolled 82 cases and 132 controls. Stored water in 71% of case homes had an FCR > 0.2 mg/L. In multivariable analyses, those who drank borehole water (mOR = 2.4, CI: 1.1-5.6), had close contact with a cholera case (mOR = 6.2, CI: 2.5-15), and were male (mOR = 2.5, CI: 1.4-5.0) had higher odds of being a cholera case than their matched controls. Based on these findings, we recommended health education about household water chlorination and hygiene in the home. Emergency responses included providing chlorinated water through emergency tanks and maintaining adequate FCR levels through close monitoring of water sources.

Risk and Protective Factors for Cholera Deaths during an Urban Outbreak-Lusaka, Zambia, 2017-2018.

The Republic of Zambia declared a cholera outbreak in Lusaka, the capital, on October 6, 2017. By mid-December, 20 of 661 reported cases had died (case fatality rate 3%), prompting the CDC and the Zambian Ministry of Health through the Zambia National Public Health Institute to investigate risk factors for cholera mortality. We conducted a study of cases (cholera deaths from October 2017 to January 2018) matched by age-group and onset date to controls (persons admitted to a cholera treatment center [CTC] and discharged alive). A questionnaire was administered to each survivor (or relative) and to a family member of each decedent. We used univariable exact conditional logistic regression to calculate matched odds ratios (mORs) and 95% CIs. In the analysis, 38 decedents and 76 survivors were included. Median ages for decedents and survivors were 38 (range: 0.5-95) and 25 (range: 1-82) years, respectively. Patients aged > 55 years and those who did not complete primary school had higher odds of being decedents (matched odds ratio [mOR] 6.3, 95% CI: 1.2-63.0, P = 0.03; mOR 8.6, 95% CI: 1.8-81.7, P < 0.01, respectively). Patients who received immediate oral rehydration solution (ORS) at the CTC had lower odds of dying than those who did not receive immediate ORS (mOR 0.1, 95% CI: 0.0-0.6, P = 0.02). Cholera prevention and outbreak response should include efforts focused on ensuring access to timely, appropriate care for older adults and less educated populations at home and in health facilities.