Building a new platform to support public health emergency response in Africa: the AFENET Corps of Disease Detectives, 2018-2019.

Public health emergency (PHE) response in sub-Saharan Africa is constrained by inadequate skilled public health workforce and underfunding. Since 2005, the African Field Epidemiology Network (AFENET) has been supporting field epidemiology capacity development and innovative strategies are required to use this workforce. In 2018, AFENET launched a continental rapid response team: the AFENET Corps of Disease Detectives (ACoDD). ACoDD comprises field epidemiology graduates and residents and was established to support PHE response. Since 2018, AFENET has deployed the ACoDD to support response to several PHEs. The main challenges faced during ACoDD deployments were financing of operations, ACoDD safety and security, resistance to interventions and distrust of the responders by some communities. Our experience during these deployments showed that it was feasible to mobilise and deploy ACoDD within 48 hours. However, the sustainability of deployments will depend on establishing strong linkages with the employers of ACoDD members. PHEs are effectively controlled when there is a fast deployment and strong linkages between the stakeholders. There are ongoing efforts to strengthen PHE preparedness and response in sub-Saharan Africa. ACoDD members are a competent workforce that can effectively augment PHE response. ACoDD teams mentored front-line health workers and community health workers who are critical in PHE response. Public health emergence response in sub-Saharan Africa is constrained by inadequacies in a skilled workforce and underfunding. ACoDD can be utilised to overcome the challenges of accessing a skilled public health workforce. To improve health security in sub-Saharan Africa, more financing of PHE response is needed.

Foodborne illness among factory workers, Gweru, Zimbabwe, 2012: a retrospective cohort study.

BACKGROUND: On the 20th September 2012 the Gweru district medical officer (DMO) reported a sudden increase in the number of factory workers complaining of symptoms suggestive of gastrointestinal illness. We conducted a retrospective cohort study to determine factors associated with illness among factory workers. METHODS: A retrospective cohort study was conducted from September to October 2012 among 98 randomly selected factory workers. Interviewer administered questionnaires were used to evaluate possible risk factors from which food attack rates, relative risks (RR) and adjusted odds ratios (AOR) were calculated using Epi info version 3.5.1. Bacteriological examination of food samples was performed. In addition rectal swabs and specimens from food handlers and patients were collected for analysis. RESULTS: Of the 98 workers interviewed, 87/98 (89%) were males. Consumption of beef stew (AOR = 9.28, 95% CI 2.78-30.91) was independently associated with foodborne illness. Klebsiella spp. were isolated from beef stew and stool specimen of patients. Watery diarrhoea 51/98 (52%), fatigue 48/98 (49%) and abdominal cramps 41/98 (42%) were the most presenting symptoms. CONCLUSIONS: Klebsiella spp. was the aetiological agent for the food borne illness at the factory and this resulted from consumption of contaminated beef stew by the workers. As a result of this evidence, the implicated beef was withdrawn from the canteen and the menu cycle was revised to minimise exposure to the same food. Food handlers training in food safety and hygiene and regular canteen inspections for quality assurance were recommended and adopted. No further food borne illness has been reported from the factory.

Staphylococcus aureus food poisoning among Bulawayo City Council employees, Zimbabwe, 2014.

BACKGROUND: Bulawayo City Council held an Integrated Result Based Management workshop among 86 employees from August 18-22, 2014 at Ikhwezi Training Centre in Bulawayo City. On August 21, 2014, a report of diarrhoea among Council employees attending the workshop was received. We investigated the outbreak to determine the risk factors associated with diarrhoea at Ikhwezi Training Centre, Bulawayo City. METHOD: A retrospective cohort study was conducted where 74 Council employees were interviewed on food consumed and presenting signs and symptoms. Stool specimens and hand swabs were collected for culture. Water samples were collected for bacteriological analysis. Food samples were not available. Data were analysed using Epi Info™ to generate frequencies, means, proportions, risk ratios, and attributable risk. RESULTS: Of the 74 employees interviewed 34 (45.9%) were males and 40 (54%) were females. The response rate was 94%. The common signs and symptoms included abdominal cramps (88.7%), and watery diarrhoea (86.8%). The overall attack rate was 71.6%. Eating stewed chicken (RR = 2.52, 95% CI 1.30-4.89) served at hour 13:00 during lunch on August 20, 2014 at Ikhwezi Training Centre was the only significant risk factor associated with food poisoning. Drinking purified bottled water [RR = 0.67, 95% CI (0.57-0.79)] was found to be protective. Staphylococcus aureus was isolated from the hands and nails of food handlers. CONCLUSION: The outbreak was due to food poisoning and was most likely caused by the Staphylococcus aureus formed toxins. Stewed chicken served during lunch on August 20, 2014 was the possible source of infection. Contamination might have occurred during food handling and preparation. Training of food handlers in basic food hygiene and safety is recommended.

Effect of distribution of educational material to mothers on duration and severity of diarrhoea and pneumonia, Midlands Province, Zimbabwe: a cluster randomized controlled trial.

BACKGROUND: Exclusive breastfeeding rates remain low in most countries in sub-Saharan Africa. We assessed the effects of a mother-based intervention on duration of diarrhoea and pneumonia in communities that were trained and those not trained in community infant and young child feeding (cIYCF) in Midlands Province, Zimbabwe. METHODS: We evaluated communities with village health workers who received training in cIYCF and the distribution of educational materials (newsletter) to mothers in promotion of exclusive breastfeeding using a two-by-two factorial cluster randomized controlled trial. The trial arms included clusters trained in cIYCF only, clusters with mothers that received a newsletter only, clusters that received both interventions and clusters receiving no intervention. Consenting mother-infant pairs identified within 72 hours of delivery were followed up at 14 and 20 weeks where duration of diarrhoea and pneumonia as well as severity of diarrhoea was assessed. Clusters were facility catchment areas assigned by an independent statistician using randomization generated by a computer using Stata 10. All admitting facilities and facilities at borders were excluded as buffer zones and eight clusters were analysed. Nutritionists who collected data were not aware of the hypothesis being tested and analysis was by intention-to-treat. RESULTS: A total of 357 mother-infant pairs were available for analysis in all the clusters. The interaction between cIYCF training and the newsletter was statistically significant at 14 weeks (p = 0.022). The mean duration of diarrhoea was 2.9 (SD = 0.9) days among infants of mothers who resided in communities trained and received a newsletter compared to 5.2 (SD = 1.1) days in communities that received neither. The protective efficacy of the cIYCF plus newsletter was 76% during the first 20 weeks of life. In the two way ANOVA, the newsletter was more effective on duration of pneumonia (p = 0.010) at 14 weeks and remained significantly effective at 20 weeks (p < 0.0001). CONCLUSIONS: A combined community and distribution of a newsletter to mothers on promotion of exclusive breastfeeding reduces duration of diarrhoea at 14 weeks. At 20 weeks, the newsletter worked better for both duration of diarrhoea and pneumonia compared to cIYCF training alone.

Factors affecting diagnosis and management of hypertension in Mazowe District of Mashonaland Central Province in Zimbabwe: 2012.

BACKGROUND: From 2005 to 2011 Mazowe District recorded a gradual decline in prevalence of hypertension in the face of rising incidence of complications like stroke. This raised questions on whether diagnosis and management of hypertensive patients is being done properly. METHODS: We conducted an analytic cross sectional study at three hospitals in Mazowe District where we randomly selected 201 of 222 patients from out patients departments and interviewed a convenience sample of 23 healthcare workers. Structured interviewer administered questionnaires were used to collect data on demographic characteristics and knowledge from patients, as well as knowledge and practices from health workers. Physical measurements were done on all patients. Frequencies; proportions, odds ratios, Chi square test and stratified & logistic regression analysis were done using Epi info version 3.5.4 while graphs were generated using Microsoft excel®. Calculations were done at 95% confidence interval. RESULTS: Prevalence, awareness, control, compliance, and complication rate of hypertension were: 69.7%, 56.2%, 22.0%, 59.8% and 20.7% respectively. Independent risk factors for hypertension were age (POR 3.09; 95% CI: 1.27-7.5), obesity (POR 4.37; 95% CI: 1.83-10.4), and previous high blood pressure reading (POR 19.86; 95% CI: 8.61-45.8). Complications included cardiac failure (8.6%), visual defects (4.3%) and stroke (3.6%). Co-morbid human immunodeficiency virus (10.7%) and diabetes mellitus (12.1%) were identified among respondents. Knowledge was poor in 47.7% of health workers. CONCLUSIONS: Risk factors found in this study are consistent with other studies. Health service factors are the main reasons for poor diagnosis and management of hypertension. Health workers need training on diagnosis and management of hypertension. Guidelines, digital sphygmomanometers and adequate drug supply are needed. District has since purchased digital BP machines and requested assistance with training on clinical features of hypertension, use of digital machines, and how to properly measure BP. A policy document on non-communicable diseases including hypertension was subsequently developed by the Ministry of Health and Child Care and currently awaiting endorsement by parliament.

Risk factors for contracting watery diarrhoea in Kadoma City, Zimbabwe, 2011: a case control study.

BACKGROUND: Kadoma City experienced an increase in watery diarrhoea from 27 cases during week beginning 5th September, to 107 cases during week beginning 26th September 2011. The weekly diarrhoea cases crossed the threshold action line during week beginning 5th September at the children's clinic in Rimuka Township, and the remaining four clinics reported cases crossing threshold action lines between week beginning 12th September and week beginning 26th September. Eighty-two percent of the cases were children less than 5 years old. We conducted a case controlstudy to determine risk factorsfor contracting watery diarrhoea in children less than 5 years in Kadoma City. METHODS: An unmatched 1:1 case control study was conducted in Ngezi and Rimuka townships in Kadoma City, Zimbabwe. A case was a child less than 5 years old, who developed acute watery diarrhoea between 5th September and 1st October 2011. A control was a child less than 5 years old who stayed in the same township and did not suffer from diarrhoea. A structured questionnaire was administered to caregivers of cases and controls.Laboratory water quality tests and stool test results were reviewed.Epi Info™ statistical software was used to analyse data. RESULTS: A total of 109 cases and 109 controls were enrolled. Independent protective factors were: having been exclusively breastfed for six months [AOR = 0.44; 95% CI (0.24-0.82)]; using municipal water [AOR = 0.38; 95% CI (0.18-0.80)]; using aqua tablets, [AOR = 0.49; 95% CI (0.26-0.94)] and; storing water in closed containers, [AOR = 0.24; 95% CI (0.07-0.0.83). The only independent risk factor for contracting watery diarrhoea was hand washing in a single bowl, [AOR = 2.89; 95% CI (1.33-6.28)]. Salmonella, Shigella, Rotavirus, and Enteropathogenic Escherichia coli were isolated in the stool specimens. None of the 33 municipal water samples tested showed contamination with Escherichia coli, whilst 23 of 44 (52%) shallow well water samples and 3 of 15(20%) borehole water samples tested were positive for Escherichia coli. CONCLUSIONS: The outbreak resulted from inadequate clean water and use of contaminated water. Evidence from this study was used to guide public health response to the outbreak.

Factors associated with HIV infection among children born to mothers on the prevention of mother to child transmission programme at Chitungwiza Hospital, Zimbabwe, 2008.

BACKGROUND: Zimbabwe is one of the five countries worst affected by the HIV/AIDS pandemic with HIV infection contributing increasingly to childhood morbidity and mortality. Among the children born to HIV positive mothers participating in the PMTCT programme, 25% tested positive to HIV. We investigated factors associated with HIV infection among children born to mothers on the PMTCT programme. METHODS: A 1:1 unmatched case-control study was conducted at Chitungwiza Hospital, Zimbabwe, 2008. A case was defined as a child who tested HIV positive, born to a mother who had been on PMTCT programme. A control was a HIV negative child born to a mother who had been on PMTCT programme. An interviewer-administered questionnaire was used to collect data on demographic characteristics, risk factors associated with HIV infection and immunization status. RESULTS: A total of 120 mothers were interviewed. Independent risk factors associated with HIV infection among children included maternal CD4 count of less than 200 during pregnancy [aOR = 7.1, 95% CI (2.6-17)], mixed feeding [aOR = 29, 95% CI (4.2-208)], being hospitalized since birth [aOR = 2.9, 95% CI (1.2-4.8)] whilst being exclusively breast fed for less than 6 months [aOR = 0.1 (95% CI 0.03-0.4)] was protective. CONCLUSIONS: HIV infection among children increased if the mother's CD4 count was ≤200 cells/µL and if the child was exposed to mixed feeding. Breastfeeding exclusively for less than six months was protective. We recommended exclusive breast feeding period for the first six months and stop breast feeding after 6 months if affordable, sustainable and safe.

Measles outbreak investigation in Zaka, Masvingo Province, Zimbabwe, 2010.

BACKGROUND: A measles outbreak was detected at Ndanga Hospital in Zaka district Masvingo Province on the 5th of May 2010 and there were five deaths. Source of infection was not known and an investigation was carried out to determine factors associated with contracting measles in Zaka district. MATERIALS AND METHODS: A 1:1 unmatched case control study was conducted. A case was a person residing in Zaka district who developed signs and symptoms of measles or tested IgM positive from 06 May 2010 to 30 August 2010. A control was a person residing in the same community who did not have history of signs and symptoms of measles during the same period. A structured interviewer administered questionnaire (translated into shona) was used to solicit information from cases and controls. Ethical consideration like written consent from all participants, respect and confidentiality were observed. Permission to carry out the study was obtained from the medical research Council of Zimbabwe and the provincial Medical Directors Masvingo. Epi info was used to calculate frequencies, odds ratios and perform logistic regression to control for confounding variables. FINDINGS: A total of 110 cases and 110 controls were recruited. Most cases (63.03%) were from the apostolic sect while 44.7% of controls were from orthodox churches. Contact with a measles case [AOR= 41.14, 95% CI (7.47-226.5)],being unvaccinated against measles [AOR= 3.96, 95%CI (2.58-6.08)] and not receiving additional doses of measles vaccine [AOR 5.48, 95% CI (2.16-11.08)] were independent risk factor for contracting measles. Measles vaccination coverage for Zaka district was 75%. The median duration for seeking treatment after onset of illness was three days (Q1=2; Q3=7). There were no emergency preparedness plans in place. CONCLUSION: This outbreak occurred due to a large number of unvaccinated children and a boarding school that facilitated person to person transmission. We recommend mandatory vaccination for all children before enrolling into schools. As a result of the study one day training on outbreak management and surveillance was done with all District Nursing Officers and Environmental Health Officers in personnel in the province.

District health executives in Midlands province, Zimbabwe: are they performing as expected?

BACKGROUND: The cornerstone of the health system in Zimbabwe, the district health system has been under the responsibility of the district health executive since 1984. Preliminary information obtained from some provincial health managers in Midlands Province suggested a poor performance by most district health executives. We therefore investigated the reasons for this poor performance. METHODS: A descriptive cross sectional study was conducted. Structured interviewer administered questionnaires were used to obtain information from district health managers of five randomly selected districts in the province. Checklists were used to assess resource availability, staffing levels and proxy indicators to effective district health executive function. Data were analysed using Epi Info statistical package. RESULTS: Thirty district health managers were interviewed. Almost half of the participants could not list at least five functions of district health executives. Twenty nine managers reported having inadequate management skills requiring training. District health executives failed to meet their targets on expected activities in the year 2010 such as conducting monthly district health executive meetings, conducting quarterly supervision to health centres and submitting quarterly district health reports to the provincial level. CONCLUSION: Poor knowledge on expected functions could have resulted in poor performance. Without adequate management training district health managers are likely to underperform their duties. DHE guidelines were therefore distributed to all districts. Management trainings were conducted to all district health executives throughout the country from November 2011.