Factors associated with a malaria outbreak at Tongogara refugee camp in Chipinge District, Zimbabwe, 2021: a case-control study.

BACKGROUND: Malaria is a leading cause of morbidity and mortality among forcibly displaced populations, including refugees, approximately two-thirds of whom reside in malaria endemic regions. Data from the rapid disease notification system (RDNS) reports for Manicaland Province in Zimbabwe showed that despite implementation of malaria control initiatives, there was an increase in number of malaria cases above action thresholds at Tongogara refugee camp in Chipinge district during weeks 12-14 of 2021. An investigation that described the outbreak by person, place and time was conducted. Malaria emergency preparedness, response, and appropriateness of case management were assessed. The factors associated with contracting malaria were determined to enable the formulation of appropriate interventions, establish control, and prevent future malaria outbreaks among this vulnerable population. METHODS: A 1:1 unmatched case-control study involving 80 cases and 80 controls was conducted using interviewer-administered questionnaires at household level. Data was entered into Epi Data version 3.1 and quantitative analysis was done using Epi Info™ version 7.2.2.6 to generate medians, proportions, odds ratios and their 95% confidence intervals. RESULTS: Malaria cases were distributed throughout the 10 residential sections within Tongogara refugee camp, the majority being from section 7, 28 (35%). Despite constituting 11% of the total population, Mozambican nationals accounted for 36 (45%) cases. Males constituted 47 (59%) among cases which was comparable to controls 43 (54%), p = 0.524. The median age for cases was 15 years [Interquartile range (IQR), 9-26] comparable to controls, which was 17 years (IQR, 10-30) (p = 0.755). Several natural and man-made potential vector breeding sites were observed around the camp. Risk factors associated with contracting malaria were engaging in outdoor activities at night [AOR = 2.74 (95% CI 1.04-7.22), wearing clothes that do not cover the whole body during outdoor activities [AOR 4.26 (95% CI, 1.43-12.68)], while residing in a refugee housing unit reduced the risk of contracting malaria [AOR = 0.18 (CI, 0.06-0.55)]. CONCLUSIONS: The malaria outbreak at Tongogara refugee camp reemphasizes the role of behavioural factors in malaria transmission. Intensified health education to address human behaviours that expose residents to malaria, habitat modification, and larviciding to eliminate mosquito breeding sites were recommended.

An evaluation of childhood tuberculosis program in Chegutu District, Zimbabwe, 2020: a descriptive cross-sectional study.

BACKGROUND: Childhood tuberculosis (TB) is a major global public health concern contributing to significant child morbidity and mortality. A records review of the TB notification for Chegutu District Health Information System 2 (DHIS2) showed a low childhood TB case detection rate. For 2018 and 2019, childhood TB notifications were 4% and 7% respectively against the annual national childhood 12% case detection rate. We evaluated the performance of the childhood TB program in Chegutu. METHODS: We conducted a descriptive cross-sectional study. Sixty-six health workers (HW) participated in the study. Interviewer-administered questionnaires and checklists were used to collect data on reasons for low TB case detection, HW childhood TB knowledge, program inputs, processes, and outputs. Strengths, Weaknesses, Opportunities and Threats analysis was used to assess the childhood TB processes. We analyzed the data using Epi Info 7™ to generate frequencies, proportions and means. A Likert scale was used to assess health worker knowledge. RESULTS: The majority 51/66(77%) of HW were nurses and 51/66(67%) of respondents were females. Reasons for the low childhood TB case detection were lack of HW confidence in collecting gastric aspirates 55/66(83%) and HW's negative attitudes towards gastric aspirate collection 23/66(35%). HW 24/66 (37%) had a fair knowledge of childhood TB notification. The district had only one functional X-ray machine for 34 health facilities. Only 6/18 motorcycles were functional with inadequate fuel supply. No desk guide for the management of TB in children for HW (2018) was available in 34 health facilities. Ethambutol 400 mg was out of stock and adult 800 mg tablets were used. Funds allocated for motor vehicle and motorcycles service ($1612USD/year) were inadequate. The district failed to perform planned quarterly TB review meetings, contact tracing and childhood TB training due to funding and COVID-19 lockdown restrictions. CONCLUSION: The childhood TB program failed to meet its targets due to inadequate inputs, HW suboptimal knowledge and COVID-19 lockdown measures. Case detection and notification can be improved through on-job training, mentorship, support and supervision and adequate resources.

Evaluation of intensified provider initiated testing and counselling program in Harare City, 2017-2018.

BACKGROUND: Knowledge of HIV status remains a challenge despite implementation of various testing strategies including provider-initiated HIV testing (PITC). Harare City intensified provider-initiated HIV testing by targeting testing all eligible clients visiting facilities to achieve the UNAIDS first 95. This study aimed at evaluating the intervention to improve its effectiveness and inform programming decisions for universal access to HIV testing. METHODS: A descriptive cross-sectional study was conducted in Harare from April to June 2019. Evaluation of the intervention was conducted using the logic model approach to assess the inputs, processes and outputs. Health workers were interviewed using an interviewer administered questionnaire. Exit interviews were conducted for eligible clients > 18 years who refused to be tested. A checklist was used to assess the inputs used and a desk review of HIV screening and testing records was done. RESULTS: A total of (n-45) health care workers and (n = 70) clients were interviewed with a response rate of (92%) and (84%) respectively. The median age for clients was 31(Q1 = 24: Q3 = 38) and median years in service for health workers was 2 (Q1 = 1;Q3 = 26). Of the 133,899 clients who were eligible for testing after screening, 98,587 (74%) accepted the test leaving a gap of 35,312 (26%). However, 21/45 (47%) of health workers indicated high workload in the morning as the major reason for the leakage. In addition, 25/70 (36%) of the clients indicated long waiting time as the reason for opting out of HIV testing. CONCLUSION AND RECOMMENDATION: HIV testing coverage for eligible clients was not optimal, 26% opted out. We recommend strengthening of health facility systems such as review of patient flow, re-allocation of staff during busy HIV testing time and scaling up the use of HIV self-test kits for clients concerned with waiting time to improve HIV testing coverage.

Risk factors for contracting watery diarrhoea in Mzilikazi, Bulawayo City, Zimbabwe, 2020: a case control study.

Introduction: Mzilikazi clinic had an upsurge of diarrhoea cases with 41 cases from the 28th to the 30th of September 2020, against a threshold of 11. We therefore, investigated the risk factors associated with this outbreak to recommend prevention and control measures. Methods: we conducted a 1:1 unmatched case-control study. A case was any person who suffered from diarrhoea, and was resident in the clinic´s catchment since the 21st of September 2020. Demographic data, knowledge and practices related to diarrhoea were collected using a standard questionnaire for both cases and controls. Environmental assessment, water quality and stool testing was also done. We conducted univariate and multivariate analysis at 95% confidence interval, to determine factors independently associated with contracting diarrhoea. Results: the median age was 30 years (Q1=12, Q3=46) for cases and 30 years (Q1=22, Q3=48) for controls. The dominant gender was female for cases and male for controls. The independent risk factors were: drinking borehole water [adjusted Odds Ratio (aOR)=2.66; 95%CI=(1.41-5.00)], storing water in open container [aOR=2.76; 95%CI=(1.38-5.53)] and being under-five years old [aOR=5.73; 95%CI=(2.06-15.89)]. Boiling drinking water [aOR=0.39; 95%CI=(0.20-0.75)] was protective. Coliforms were detected from boreholes and stored water samples, and Shigella flexneri was isolated from 2 of the 13 stool specimens collected. Residents accessed water from decommissioned boreholes due to severe municipal water rationing. Conclusion: being under-five years old, drinking borehole water and storing water in open containers were independent risk factors. Health education on home water treatment, distribution of water storage containers, and Aquatabs was done.

An evaluation of the notifiable disease surveillance system in Chegutu District, Zimbabwe, 2020: a cross-sectional study.

Introduction: in 2018-2019 Chegutu District had one notification form Tally 1 (T1) that was completed instead of seven for detected notifiable diseases. Different figures of cholera were reported through weekly rapid disease notification system with 106 patients and Notifiable Diseases Surveillance System (NDSS) with 111 patients, causing data discrepancy. We evaluated the NDSS to determine reasons for underperformance and data discrepancy. Methods: we conducted descriptive cross-sectional study using updated centres for disease control and prevention guidelines for surveillance system evaluation. We recruited forty-six health workers. Interviewer-administered questionnaires and checklists were used to collect data on reasons for underperformance, reasons for data discrepancy, knowledge of NDSS, surveillance system attributes and usefulness. Epi InfoTM7 generated frequencies, proportions, and means. Likert scale was used to assess health worker knowledge. Results: of the forty-six health workers, 34 (78%) had fair knowledge of NDSS. The reason for system underperformance was lack of training in NDSS 42 (91%). Data discrepancy was attributed to typographical mistakes made during data entry on WhatsApp platform 32 (70%). Eighty per cent (37) were willing to complete T1 forms. Six participants who were timed took ten minutes to complete T1 forms. Among 17 health facilities, only three had fifteen T1 forms that were adequate to notify first five cases in an outbreak. Notifiable diseases surveillance system data was used for planning health education 28 (68%). Conclusion: the NDSS was unstable due to health workers' inadequate knowledge and unavailability of T1 forms. Notifiable diseases surveillance system was found to be simple, acceptable, and useful. We recommended NDSS training of health workers.

An evaluation of the isoniazid preventive therapy program performance for under-fives in Kwekwe City, January 2019 - December 2020: a descriptive cross-sectional study.

Childhood tuberculosis (TB) is underserved in resource-constrained endemic areas. Zimbabwe National Tuberculosis Program recommends tuberculosis prevention treatment for children aged <5 years who are close contacts of smear-positive TB cases. The Isoniazid Preventive Therapy (IPT) program performance had never been evaluated since its inception in 2010. We therefore, assessed the IPT program's inputs, processes, outputs, and outcomes. We conducted a process evaluation using the logic model in Kwekwe City. We recruited twenty-seven health care workers from all the five municipal health facilities. Smear-positive guardians of under 5 children, health care workers, and registers were the study population. Data were collected using a questionnaire and checklists and presented as frequencies and proportions. The IPT program met requirements in provision of guidelines (10/10), screening tools (15/15) and on-the-job trainings done in all five health facilities. Isoniazid tablets supply and quarterly budgeting did not meet meeting program requirements. Fifty-nine out of 231 (25.5%) children contacts of sputum-positive TB patients were screened. Fifty-one of the 59 (86.4%) children were initiated on IPT, 42/51 (82.4%) completed the course, one developed TB, 3/51 were still on treatment and 5/51 were lost to follow up. No dropouts and deaths were recorded. Unavailability of drugs was a barrier to the IPT and negatively impacts the TB elimination program. Contact screening was the bottleneck in the successful implementation of the program. Adequate staff and provision of drugs might improve the program. We recommended the recruitment of more healthcare workers and the budget for the program.

Evaluation of the measles case-based surveillance system in Kwekwe city, 2017-2020: a descriptive cross-sectional study.

Introduction: in 2011, WHO African region set a target for elimination of measles by 2020. During period 2017-2020, Kwekwe city, with an estimated population of 117,116, detected one case of suspected measles. This was against a target of 2 cases per year. We evaluated the system to establish why it was failing to detect at least 2 cases per year. Methods: we conducted a descriptive cross-sectional study using the Centre for Disease Control (CDC) Updated Guidelines. Nineteen health facilities were selected and fifty-seven health workers were randomly recruited. An interviewer-administered questionnaire and checklists were used to collect data. We generated frequencies, proportions, and means. Results: the mean years in service was 22.8 years (SD=12.6). Thirty (52.6%) respondents had fair knowledge. Fourteen (73.7%) of the nineteen respondents who had ever completed case investigation forms took between 10-20 minutes to complete. Only two (10.5%) of the nineteen facilities had case investigation forms. The majority of the respondents 54 (93%) were willing to continue participating in the measles Community Base Surveillance System (CBSS). None of the health facilities had used the system to inform decision-making. Reasons highlighted for poor suspected measles case detection included lack of health worker training 28/57 (49.1%). Conclusion: despite the high age in service, knowledge of the surveillance system was mostly fair. The system was found to be simple, not stable and not useful. The main reason for the system failure was lack of health worker training. We recommend retraining on Integrated Disease Surveillance and Response (IDSR) and case investigation forms distribution.

Evaluation of the weekly disease surveillance system for epidemic-prone diseases in Makonde District, Zimbabwe 2020: a descriptive cross-sectional study.

Introduction: the weekly disease surveillance system (WDSS) is a tool used to provide an early warning of potential public health threats in Zimbabwe. In 2020, Makonde District failed to detect an anthrax outbreak at one of its facilities, this untimely and poor response of the district increased morbidity. We evaluated the weekly disease surveillance system to determine reasons for missing outbreaks and determine the usefulness of the system in the detection of outbreaks. Methods: we conducted descriptive cross-sectional study using updated Centres for Disease Control and Prevention guidelines for surveillance system evaluation. We recruited 46 health workers. A structured pretested interviewer-administered questionnaire was used to collect data on reasons for missing outbreaks, knowledge, usefulness and surveillance system attributes. Data were cleaned and bivariate analysis was conducted. Results: health workers found the system simple (85%), acceptable (75%) and flexible (60%). However, we found only 5 (11%) health workers could correctly describe the surveillance system, only 2 (3%) were trained in disease surveillance, only 31 (65%) sent data on time, 57% of clinics had stock outs of forms, 60% of forms had entries with 100% of the data filled out and 22 (46%) of health workers analysed the data gathered and used it in meetings. Conclusion: the surveillance system was simple, flexible, acceptable, but unstable, untimely and not useful. There was poor knowledge on the surveillance system, health workers were not trained on disease surveillance, and quality of data was poor. Health workers should be trained in surveillance and data validation and adequate reporting tools provided.