Factors influencing survival outcomes in patients with stroke in Zimbabwe: A 12-month longitudinal study.

Background: In this longitudinal study, we aimed to determine factors influencing survival outcomes among patients with stroke over a 12-month period. The investigation sought to uncover influential determinants to enhance the precision of prognostic assessments and inform targeted interventions for individuals affected by strokes. Methods: Employing a longitudinal study design, participants were observed for 12 months from baseline, censoring survivors at the endpoint. The dataset originated from a comprehensive study involving stroke patients treated at three referral hospitals in Zimbabwe: Parirenyatwa, Sally Mugabe, and Chitungwiza Central Hospital. The primary outcome variable, the duration of survival until death, was measured in days from the initiation of stroke treatment. Gompertz parametric regression analysis was utilized for data modeling following Accelerated Failure Time (AFT) model diagnostics. Results: In our study, 188 stroke patients were enrolled at baseline. However, 51 patients were excluded from the analysis due to either missing information or loss to follow-up. Among the remaining 137 patients who were tracked over a 12-month period, 42% were censored, and 58% were deceased. Individuals utilizing 'Free Service (older than 65/pensioners/retirees)' hospital bill payment methods showed a decreased risk of death (HR: 0.4, 95% CI: 0.20, 0.80), suggesting a protective effect compared to cash paying patients. Those with a secondary school level education displayed a significantly lower risk of death (HR: 0.2, 95% CI: 0.04, 0.69) compared to those without formal education. Age was a significant factor, with individuals aged 45-65 and those over 65 years showing higher adjusted hazard ratios (HR: 4.9, 95% CI: 1.80, 13.25; HR: 5.5, 95% CI: 1.92, 15.95, respectively) relative to those below 45 years of age. Housing status revealed a protective effect for those residing with parents/relatives (adjusted HR: 0.4, 95% CI: 0.20, 0.66), while individuals with a 'Very severe' functional outcome showed an increased hazard (adjusted HR: 4.9, 95% CI: 1.12, 21.33). Conclusion: The study findings demonstrate that hospital bill payment methods, housing status, educational attainment, functional outcome, and age significantly affect survival outcomes among stroke patients. This highlights the need to consider socio-demographic and clinical variables in the development of prognostic assessments and targeted interventions for individuals recovering from stroke.

Prevalence and risk factors for diabetic foot complications among people living with diabetes in Harare, Zimbabwe: a cross-sectional study.

BACKGROUND: Diabetic foot disease (DF) is a common diabetes-related complication; however, the prevalence and associated risk factors for DF are not well characterised among people living with diabetes (PLWD) in Zimbabwe. This may suggest the unavailability of adequate strategies to diagnose and treat DF in the country. This study aimed to determine the prevalence of DF and associated risk factors for PLWD in Harare, Zimbabwe. METHODS: This was a cross-sectional study, employing a quantitative approach. In total, 352 PLWD were recruited from 16 primary care clinics in Harare. Sociodemographic and clinical data were collected via face-to-face interviews and clinical records reviews. The DF screening included an evaluation for peripheral neuropathy, ankle-brachial index (ABI), ulceration, and amputation. Self-administered questionnaires were used to assess knowledge, attitudes, and practices (KAPs), and KAP was scored using Bloom's cut-off. Chi-Square goodness-of-fit tests were performed, and regression analyses were used for association analysis. The threshold for significance was p < 0.05. RESULTS: This group included 82 men and 279 women, with a combined mean age of 57.9 ± 14 years. Twenty one (~ 26%) men and 41 (15%) women had type 1 diabetes. The diabetes type distribution significantly differed by gender (p < 0.001). Oral hypoglycaemics (71%) were most commonly administered for management. DF was observed in 53% (95% CI = 50-56) of PLWD. Other DF symptoms observed were abnormal ABI (53%), peripheral neuropathy (53%), foot ulceration (17%) and amputation (3%). Peripheral neuropathy increased the risk of ulceration (OR = 1.7; 95% CI = 1.1-2.6; p = 0.019), while insulin use was protective against amputation (OR = 0.1; 95% CI = 0.1-0.9; p = 0.049). Most (87%) of the participants demonstrated good DF knowledge and the importance of adhering to medication to prevent DF. However, 96% did not know that smoking was a risk factor for DF. Nearly two-thirds (63%) demonstrated poor attitudes and practices. Poor attitudes and practices were not predictors of DF ulceration risk (p > 0.05). CONCLUSION: This study showed that there was a high prevalence of DF (53%) in PLWD in Zimbabwe, and insulin use was protective against DF. There is an urgent need for policy revisions to include foot screening in routine primary care and increasing insulin use for PLWD to prevent complications such as DF as an integral part of primary care.

Characterizing human movement patterns using GPS data loggers in an area of persistent malaria in Zimbabwe along the Mozambique border.

BACKGROUND: Human mobility is a driver for the reemergence or resurgence of malaria and has been identified as a source of cross-border transmission. However, movement patterns are difficult to measure in rural areas where malaria risk is high. In countries with malaria elimination goals, it is essential to determine the role of mobility on malaria transmission to implement appropriate interventions. METHODS: A study was conducted in Mutasa District, Zimbabwe, to investigate human movement patterns in an area of persistent transmission along the Mozambique border. Over 1 year, a convenience sample of 20 participants/month was recruited from active malaria surveillance cohorts to carry an IgotU® GT-600 global positioning system (GPS) data logger during all daily activities. Consenting participants were tested for malaria at data logger distribution using rapid antigen diagnostic tests and completed a survey questionnaire. GPS data were analyzed using a trajectory analysis tool, and participant movement patterns were characterized throughout the study area and across the border into Mozambique using movement intensity maps, activity space plots, and statistical analyses. RESULTS: From June 2016-May 2017, 184 participants provided movement tracks encompassing > 350,000 data points and nearly 8000 person-days. Malaria prevalence at logger distribution was 3.7%. Participants traveled a median of 2.8 km/day and spent a median of 4.6 h/day away from home. Movement was widespread within and outside the study area, with participants traveling up to 500 km from their homes. Indices of mobility were higher in the dry season than the rainy season (median km traveled/day = 3.5 vs. 2.2, P = 0.03), among male compared to female participants (median km traveled/day = 3.8 vs. 2.0, P = 0.0008), and among adults compared to adolescents (median total km traveled = 104.6 vs. 59.5, P = 0.05). Half of participants traveled outside the study area, and 30% traveled into Mozambique, including 15 who stayed in Mozambique overnight. CONCLUSIONS: Study participants in Mutasa District, Zimbabwe, were highly mobile throughout the year. Many participants traveled long distances from home, including overnight trips into Mozambique, with clear implications for malaria control. Interventions targeted at mobile populations and cross-border transmission may be effective in preventing malaria introductions in this region.

Scientific Findings of the Southern and Central Africa International Center of Excellence for Malaria Research: Ten Years of Malaria Control Impact Assessments in Hypo-, Meso-, and Holoendemic Transmission Zones in Zambia and Zimbabwe.

For a decade, the Southern and Central Africa International Center of Excellence for Malaria Research has operated with local partners across study sites in Zambia and Zimbabwe that range from hypo- to holoendemic and vary ecologically and entomologically. The burden of malaria and the impact of control measures were assessed in longitudinal cohorts, cross-sectional surveys, passive and reactive case detection, and other observational designs that incorporated multidisciplinary scientific approaches: classical epidemiology, geospatial science, serosurveillance, parasite and mosquito genetics, and vector bionomics. Findings to date have helped elaborate the patterns and possible causes of sustained low-to-moderate transmission in southern Zambia and eastern Zimbabwe and recalcitrant high transmission and fatality in northern Zambia. Cryptic and novel mosquito vectors, asymptomatic parasite reservoirs in older children, residual parasitemia and gametocytemia after treatment, indoor residual spraying timed dyssynchronously to vector abundance, and stockouts of essential malaria commodities, all in the context of intractable rural poverty, appear to explain the persistent malaria burden despite current interventions. Ongoing studies of high-resolution transmission chains, parasite population structures, long-term malaria periodicity, and molecular entomology are further helping to lay new avenues for malaria control in southern and central Africa and similar settings.

Policy Implications of the Southern and Central Africa International Center of Excellence for Malaria Research: Ten Years of Malaria Control Impact Assessments in Hypo-, Meso-, and Holoendemic Transmission Zones in Zambia and Zimbabwe.

The International Centers of Excellence for Malaria Research (ICEMR) were established by the National Institute of Allergy and Infectious Diseases more than a decade ago to provide multidisciplinary research support to malaria control programs worldwide, operating in endemic areas and contributing technology, expertise, and ultimately policy guidance for malaria control and elimination. The Southern and Central Africa ICEMR has conducted research across three main sites in Zambia and Zimbabwe that differ in ecology, entomology, transmission intensity, and control strategies. Scientific findings led to new policies and action by the national malaria control programs and their partners in the selection of methods, materials, timing, and locations of case management and vector control. Malaria risk maps and predictive models of case detection furnished by the ICEMR informed malaria elimination programming in southern Zambia, and time series analyses of entomological and parasitological data motivated several major changes to indoor residual spray campaigns in northern Zambia. Along the Zimbabwe-Mozambique border, temporal and geospatial data are currently informing investigations into a recent resurgence of malaria. Other ICEMR findings pertaining to parasite and mosquito genetics, human behavior, and clinical epidemiology have similarly yielded immediate and long-term policy implications at each of the sites, often with generalizable conclusions. The ICEMR programs thereby provide rigorous scientific investigations and analyses to national control and elimination programs, without which the impediments to malaria control and their potential solutions would remain understudied.

What Heterogeneities in Individual-level Mobility Are Lost During Aggregation? Leveraging GPS Logger Data to Understand Fine-scale and Aggregated Patterns of Mobility.

Human movement drives spatial transmission patterns of infectious diseases. Population-level mobility patterns are often quantified using aggregated data sets, such as census migration surveys or mobile phone data. These data are often unable to quantify individual-level travel patterns and lack the information needed to discern how mobility varies by demographic groups. Individual-level datasets can capture additional, more precise, aspects of mobility that may impact disease risk or transmission patterns and determine how mobility differs across cohorts; however, these data are rare, particularly in locations such as sub-Saharan Africa. Using detailed GPS logger data collected from three sites in southern Africa, we explore metrics of mobility such as percent time spent outside home, number of locations visited, distance of locations, and time spent at locations to determine whether they vary by demographic, geographic, or temporal factors. We further create a composite mobility score to identify how well aggregated summary measures would capture the full extent of mobility patterns. Although sites had significant differences in all mobility metrics, no site had the highest mobility for every metric, a distinction that was not captured by the composite mobility score. Further, the effects of sex, age, and season on mobility were all dependent on site. No factor significantly influenced the number of trips to locations, a common way to aggregate datasets. When collecting and analyzing human mobility data, it is difficult to account for all the nuances; however, these analyses can help determine which metrics are most helpful and what underlying differences may be present.

Needs assessment of diabetic foot services in Zimbabwe.

INTRODUCTION: Due to the increasing incidence of diabetes in Zimbabwe, complications such as diabetic foot (DF) are anticipated. Establishing local gaps and needs in DF healthcare is paramount for tailoring management strategies. AIMS: To determine the status of DF services in the healthcare system and explore awareness of DF management and practices among registered general nurses (RGNs) in Zimbabwe. METHODS: A mixed-methods approach was applied. Thirty-one RGNs from 16 public health facilities in Harare, Zimbabwe attending a DF workshop were administered with a cross-sectional survey instrument and a semi-structured questionnaire. Data collected included presence/absence of DF services and podiatrists in healthcare facilities, healthcare system approaches in DF care and availability of DF training/education programs for RGNs. Analysis was performed using Stata and Nvivo software. RESULTS: No respondents reported availability of podiatrists. Only 1 (3%) of RGNs reported DF screening in primary care. Sixty percent (18) did not know or had never screened for DF. The RGNs reported inadequate DF educational programs/modules in primary care settings. CONCLUSION: This data highlights a need to improve DF education for RGNs at the frontline of managing PLWD. Understanding the needs for DF services may guide interventions to improve education and awareness programs that are appropriately tailored to local constraints in the health system. The non-communicable diseases director is encouraged to develop DF educational programmes for frontline health care workers.

Factors associated with active syphilis among men and women aged 15 years and older in the Zimbabwe Population-based HIV Impact Assessment (2015-2016).

INTRODUCTION: Ulcerative STIs, including syphilis, increase the risk for HIV acquisition and transmission due to the presence of ulcers/chancres that serve as a point-of-entry and exit for HIV. In Zimbabwe, diagnosis of syphilis often occurs in pregnant women who seek ANC services where syphilis testing is offered, and among men and women who seek health care for STIs. Zimbabwe's national syphilis estimates are based on these diagnosed cases, with little information available about the prevalence of untreated syphilis among the general population. This analysis uses data from ZIMPHIA (2015-2016) to describe factors associated with active syphilis among men and women ages 15 years and older. METHODS: ZIMPHIA collected blood specimens for HIV and syphilis testing from 22,501 consenting individuals (ages 15 years and older). Household HIV testing used the national HIV rapid-testing algorithm with HIV-positive results confirmed at satellite laboratories using Geenius HIV-1/2 rapid test (Bio-rad, Hercules, California, USA). Point-of-care non-Treponemal and Treponemal syphilis testing was performed using Chembio's Dual-Path Platform Syphilis Screen & Confirm Assay. Factors associated with active syphilis were explored using multiple variable, weighted logistic regression and were stratified by gender. RESULTS: The likelihood of active syphilis in HIV-positive females was 3.7 times greater in HIV-positive females than HIV-negative females (aOR: 3.7, 95% CI 2.3-5.9). Among males odds of having active syphilis was 5 times higher among those that engaged in transactional sex than those who did not have sex or transactional sex (aOR: 5.3, 95% CI 1.9-14.7), and 6 times higher if HIV positive versus negative (aOR: 5.9, 95% CI 3.0-12.0). Urban residence, province, education (highest attended), marital status, number of sex partners, consistency of condom use, pregnancy status (females), and circumcision status (males) were not significant in the adjusted model for either females or males. CONCULSION: HIV status was found to be the only factor associated with active syphilis in both females and males. Given the persistent link between HIV and active syphilis, it is prudent to link individuals' diagnoses and treatments, as recommended by the WHO. Enhanced integration of STI and HIV services in health delivery points such as ANC, reproductive services, or male circumcision clinics, combined with consistent, targeted outreach to high-risk populations and their partners, may assist the MOHCC to eliminate active syphilis in Zimbabwe.

Progress Toward the 90-90-90 HIV Targets in Zimbabwe and Identifying Those Left Behind.

OBJECTIVE: We present findings from the nationally representative Zimbabwe Population-based HIV Impact Assessment that characterize Zimbabwe's progress toward the Joint United Nations Programme on HIV/AIDS 90-90-90 targets. DESIGN: We conducted a cross-sectional household survey. METHODS: Consenting adults and children in the household were eligible to participate in Zimbabwe Population-based HIV Impact Assessment (October 2015-August 2016). Participants completed face-to-face interviews and provided blood for HIV, CD4, viral load, and syphilis testing. Viral load suppression (VLS) was defined as HIV RNA <1000 copies/mL. HIV-positive specimens were tested for the presence of selected antiretroviral drugs. Data were weighted. Analysis was restricted to HIV-positive adults aged 15-64 years. RESULTS: We enrolled 11,098 men and 14,033 women aged 15-64 years. HIV prevalence was 14.1%. Of those living with HIV, 76.8% (95% confidence interval [CI]: 74.9 to 78.7) were aware of their HIV status or had detectable antiretroviral levels. Of these, 88.4% (95% CI: 87.1 to 89.7) were receiving antiretroviral therapy (ART), and of these people, 85.3% (95% CI: 83.4 to 87.1) had VLS. Male sex age 15-34 years and having 1 or more sexual partners were associated with being unaware of one's HIV-positive status. Age <50 years and not taking cotrimoxazole were associated with being less likely to be being both aware and taking ART. Male sex, age <50 years, and taking cotrimoxazole were associated with being on ART but not having VLS. CONCLUSIONS: Zimbabwe has made great strides toward epidemic control. Focusing resources on case finding, particularly among men, people aged <35 years, and sexually active individuals can help Zimbabwe attain 90-90-90 targets.

Detecting Plasmodium falciparum in community surveys: a comparison of Paracheck Pf® Test and ICT Malaria Pf® Cassette Test to polymerase chain reaction in Mutasa District, Zimbabwe.

BACKGROUND: Microscopy and rapid diagnostic tests (RDTs) are the main techniques used to diagnose malaria. While microscopy is considered the gold standard, RDTs have established popularity as they allow for rapid diagnosis with minimal technical skills. This study aimed to compare the diagnostic performance of two Plasmodium falciparum histidine-rich protein 2 (PfHRP2)-based RDTs (Paracheck Pf® Test (Paracheck) and Malaria Pf™ ICT (ICT)) to polymerase chain reaction (PCR) in a community survey. METHODS: A cross-sectional study was conducted between October 2012 and December 2014 in Mutasa District, Manicaland Province, eastern Zimbabwe. Households were randomly selected using satellite imagery, and 224 households were visited. Residents present in the household on the date of the visit were recruited for the study. Participants of all age groups from the selected households were screened with Paracheck and ICT RDTs in parallel. Dried blood spots (DBS) and thin and thick smears were collected. Parasite DNA extracted from the DBS was subjected to nested PCR targeting the Plasmodium cytochrome b mitochondrial gene. Data analysis was performed using the Cohen's Kappa test to determine the interrater agreement and the sensitivity and specificity of the diagnostic test were reported. RESULTS: Results from a total of 702 participants were analysed. Most were females, 397 (57%), and the median age of participants was 21 years with an interquartile range of 9-39 years. Of those who were screened, 8 (1.1%), 35 (5.0%), and 21 (2.9%) were malaria parasite positive by microscopy, RDT and PCR, respectively. Paracheck and ICT RDTs had a 100% agreement. Comparing RDT and PCR results, 34 participants (4.8%) had discordant results. Most of the discordant cases were RDT positive but PCR negative (n = 24). Half of those RDT positive, but PCR negative individuals reported anti-malarials to use in the past month, which is significantly higher than reported anti-malarial drug use in the population (p < 0.001). The participant was febrile on the day of the visit, but relying on PfHRP2-based RDT would miss this case. Among the diagnostic methods evaluated, with reference to PCR, the sensitivity was higher with the RDT (52.4%) while specificity was higher with the microscopy (99.9%). The positive predictive value (PPV) was higher with the microscopy (87.5%), while the negative predictive values were similar for both microscopy and RDTs (98%). Overall, a strong correlated agreement with PCR was observed for the microscopy (97.9%) and the RDTs (95.2%). CONCLUSIONS: Paracheck and ICT RDTs showed 100% agreement and can be used interchangeably. As malaria transmission declines and Zimbabwe aims to reach malaria elimination, management of infected individuals with low parasitaemia as well as non-P. falciparum infection can be critical.

Steep Rebound of Chloroquine-Sensitive Plasmodium falciparum in Zimbabwe.

Removal of chloroquine from national malaria formularies can lead to the reversion of resistant Plasmodium falciparum to wild-type. We report a steep decline in chloroquine-resistant P falciparum within 10 years of national discontinuation of chloroquine monotherapy in Zimbabwe. Drug resistance surveillance is a vital component of malaria control programs, and the experience with chloroquine in Zimbabwe and elsewhere in sub-Saharan Africa is illustrative of the potentially rapid and dramatic impact of drug policy on antimalarial resistance.

A survey of ethnomedicinal plants used to treat cancer by traditional medicine practitioners in Zimbabwe.

BACKGROUND: Traditional medicine plays an important role in health care provision in the developing world. A number of cancer patients have been found to be using traditional medicine as primary therapy and/or as complementary medicine. Cancer is one of the leading causes of morbidity and mortality globally among the non-communicable diseases. The aim of this study was to identify the plants used by traditional medicine practitioners (TMPs) in Zimbabwe to treat cancer. METHODS: A structured questionnaire was used to interview consenting registered TMPs on ethnomedicinal plants they use to treat cancer. A review of published literature on the cited plants was also carried out. The practitioners were asked about the plants that they use to treat cancer, the plant parts used, type of cancer treated, other medicinal uses of the plants and preparation and administration of the plant parts. RESULTS: Twenty (20) TMPs took part in the study. A total of 18 medicinal plant species were cited. The commonly treated types of cancer were breast, prostate, colon, skin and blood cancers with most plants being used to treat skin, blood and breast cancers, respectively. Of the medicinal plants cited, 44.4% were used to treat all cancer types. The most used plant parts were the roots (72.2%) and leaves (72.2%) followed by the bark (38.9%). The medicinal plants were used for multiple ailments. The most common plant preparation methods were infusion (72.2%) and decoction (66.7%) and the oral route of administration, as extracts and powder put in tea and porridge, was the most used. CONCLUSION: The frequently used plant parts were leaves and roots. The traditional uses of the medicinal plants cited in this study resonate well with their reported uses from other ethnopharmacological studies done in other parts of the world. The plants used by TMPs to treat cancer in Zimbabwe, if adequately explored, can be instrumental in the discovery and development of cancer drugs.

Comparison of HIV Incidence in the Zimbabwe Population-Based HIV Impact Assessment Survey (2015-2016) with Modeled Estimates: Progress Toward Epidemic Control.

Between October 2015 and August 2016, Zimbabwe conducted the Zimbabwe Population-Based HIV Impact Assessment (ZIMPHIA) cross-sectional survey to determine progress toward epidemic control. Of 25,131 eligible adults aged 15-64 years, 20,577 (81.8%) consented to face-to-face questionnaire and biomarker testing in this nationally representative household survey. Home-based rapid HIV testing was performed using Determine, First Response, and STAT-PAK as the tiebreaker. HIV-positive tests were confirmed in a laboratory using Geenius HIV-1/2; viral load (VL) was measured using Roche TaqMan and BioMerieux NucliSENS. Recency of infection was tested using Sedia HIV-1 Limiting Antigen (LAg)-Avidity. Presence of antiretroviral (ARV) drugs was detected using high performance liquid chromatography/mass spectrometry (HPLC/MS). The recent infection testing algorithm included LAg-avidity enzyme immunoassay [normalized optical density (ODn ≤1.5), VL ≥1,000 copies/mL, and absence of ARV drugs]. Weighted annual HIV incidence was compared with United Nations Joint Programme on HIV/AIDS (UNAIDS) Spectrum models estimates. Overall, 26 of 2,901 HIV-seropositive individuals had a recent infection (men, 8; women, 18). Overall weighted annual incidence among persons aged 15-64 years was 0.42% [95% confidence interval (CI): 0.25-0.59] and was 0.44% (95% CI: 0.25-0.62) for those aged 15-49 years, similar to 2016 Spectrum model estimate (0.54%, 95% CI: 0.49-0.66) for this age group. Among persons aged 15-49 years, HIV prevalence was 13.35% (95% CI: 12.71-14.02), estimated HIV-positive individuals were 968,951 (95% CI: 911,473-1,026,430), of these, 41,911 (95% CI: 37,412-44,787) were annual-new infections, and this was similar to 2016 Spectrum estimates. The observed HIV incidence in ZIMPHIA 2015-2016 validated the 2016 Spectrum estimates and Zimbabwe's progress toward epidemic control.

Distinct Antibody Signatures Associated with Different Malaria Transmission Intensities in Zambia and Zimbabwe.

Antibodies to Plasmodium falciparum are specific biomarkers that can be used to monitor parasite exposure over broader time frames than microscopy, rapid diagnostic tests, or molecular assays. Consequently, seroprevalence surveys can assist with monitoring the impact of malaria control interventions, particularly in the final stages of elimination, when parasite incidence is low. The protein array format to measure antibodies to diverse P. falciparum antigens requires only small sample volumes and is high throughput, permitting the monitoring of malaria transmission on large spatial and temporal scales. We expanded the use of a protein microarray to assess malaria transmission in settings beyond those with a low malaria incidence. Antibody responses in children and adults were profiled, using a P. falciparum protein microarray, through community-based surveys in three areas in Zambia and Zimbabwe at different stages of malaria control and elimination. These three epidemiological settings had distinct serological profiles reflective of their malaria transmission histories. While there was little correlation between transmission intensity and antibody signals (magnitude or breadth) in adults, there was a clear correlation in children younger than 5 years of age. Antibodies in adults appeared to be durable even in the absence of significant recent transmission, whereas antibodies in children provided a more accurate picture of recent levels of transmission intensity. Seroprevalence studies in children could provide a valuable marker of progress toward malaria elimination.IMPORTANCE As malaria approaches elimination in many areas of the world, monitoring the effect of control measures becomes more important but challenging. Low-level infections may go undetected by conventional tests that depend on parasitemia, particularly in immune individuals, who typically show no symptoms of malaria. In contrast, antibodies persist after parasitemia and may provide a more accurate picture of recent exposure. Only a few parasite antigens-mainly vaccine candidates-have been evaluated in seroepidemiological studies. We examined antibody responses to 500 different malaria proteins in blood samples collected through community-based surveillance from areas with low, medium, and high malaria transmission intensities. The breadth of the antibody responses in adults was broad in all three settings and was a poor correlate of recent exposure. In contrast, children represented a better sentinel population for monitoring recent malaria transmission. These data will help inform the use of multiplex serology for malaria surveillance.

Understanding Ethical, Legal and Societal Issues (ELSIs) in Human Biobanking and Genomics for Research and Healthcare in Zimbabwe: The Genomics Inheritance Law Ethics and Society (GILES) initiative.

Biobanks and human genomics applications are key for understanding health, disease and heredity in Africa and globally. Growing interest in these technologies calls for strengthening relevant legal, ethical and policy systems to address knowledge disparities and ensure protection of society, while supporting advancement of science. In Zimbabwe there is limited understanding of ethical, legal, and societal issues (ELSI) for biobanking and genomics. The Genomics Inheritance Law Ethics and Society (GILES) initiative was established in 2015 to explore the current status and gaps in the ethical and legal frameworks, knowledge among various stakeholders, and to establish capacity for addressing ELSI of biobanking and genomics as applied in biomedical and population research, and healthcare. A multi-methods approach was applied including document reviews, focus group discussions and in-depth interviews among health and research professionals, and community members in six provinces comprising urban, peri-urban and rural areas. Emerging findings indicates a need for updating guidelines and policies for addressing ELSI in biobanking and genomics research in Zimbabwe. Emerging terminologies such as biobanking and genomics lack clarity suggesting a need for increased awareness and educational tools for health professionals, research scientists and community members. Common concerns relating to consent processes, sample and data use and sharing, particularly where there is trans-national flow of biospecimens and data, call for nationally tailored ELSI frameworks aligned to regional and international initiatives. This paper describes the strategy undertaken for the development and implementation of the GILES project and discusses the importance of such an initiative for characterisation of ELSI of human biobanking and genomics in Zimbabwe and Africa. Conducting this explorative study among a wide range of stakeholders over a countrywide geographical regions, established one of the most comprehensive studies for ELSI of human biobanking and genomics in Africa.

HIV infection in patients with sexually transmitted infections in Zimbabwe - Results from the Zimbabwe STI etiology study.

BACKGROUND: HIV and other sexually transmitted infections (STI) frequently co-occur. We conducted HIV diagnostic testing in an assessment of the etiologies of major STI syndromes in Zimbabwe. METHODS: A total of 600 patients were enrolled at six geographically diverse, high-volume STI clinics in Zimbabwe in 2014-15: 200 men with urethral discharge, 200 women with vaginal discharge, and 100 men and 100 women each with genital ulcer disease (GUD). Patients completed a questionnaire, underwent a genital examination, and had specimens taken for etiologic testing. Patients were offered, but not required to accept, HIV testing using a standard HIV algorithm in which two rapid tests defined a positive result. RESULTS: A total of 489 participants (81.5%) accepted HIV testing; 201 (41.1%) tested HIV-1-positive, including 16 (11.9%) of 134 participants who reported an HIV-negative status at study enrollment, and 58 (28.2%) of 206 participants who reported their HIV status as unknown. Of 147 who self-reported being HIV-positive at study enrollment, 21 (14.3%) tested HIV negative. HIV infection prevalence was higher in women (47.3%) than in men (34.8%, p<0.01), and was 28.5% in men with urethral discharge, 40.5% in women with vaginal discharge, 45.2% in men with GUD, and 59.8% in women with GUD (p<0.001). CONCLUSIONS: The high prevalence of HIV infection in STI clinic patients in Zimbabwe underscores the importance of providing HIV testing and referral for indicated prevention and treatment services for this population. The discrepancy between positive self-reported and negative study HIV test results highlights the need for operator training, strict attention to laboratory quality assurance, and clear communication with patients about their HIV infection status.

The Etiology of Vaginal Discharge Syndrome in Zimbabwe: Results from the Zimbabwe STI Etiology Study.

INTRODUCTION: Symptomatic vaginal discharge is a common gynecological condition managed syndromically in most developing countries. In Zimbabwe, women presenting with symptomatic vaginal discharge are treated with empirical regimens that commonly cover both sexually transmitted infections (STIs) and reproductive tract infections, typically including a combination of an intramuscular injection of kanamycin, and oral doxycycline and metronidazole regimens. This study was conducted to determine the current etiology of symptomatic vaginal discharge and assess adequacy of current syndromic management guidelines. METHODS: We enrolled 200 women with symptomatic vaginal discharge presenting at 6 STI clinics in Zimbabwe. Microscopy was used to detect bacterial vaginosis and yeast infection. Nucleic acid amplifications tests were used to detect Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and Mycoplasma genitalium. In addition, serologic testing was performed to detect human immunodeficiency virus (HIV) infection. RESULTS: Of the 200 women, 146 (73%) had an etiology detected, including bacterial vaginosis (24.7%); N. gonorrhoeae (24.0%); yeast infection (20.7%); T. vaginalis (19.0%); C. trachomatis (14.0%) and M. genitalium (7.0%). Among women with STIs (N = 90), 62 (68.9%) had a single infection, 18 (20.0%) had a dual infection, and 10 (11.1%) had 3 infections.Of 158 women who consented to HIV testing, 64 (40.5%) were HIV infected.The syndromic management regimen covered 115 (57.5%) of the women in the sample who had gonorrhea, chlamydia, M. genitalium, or bacterial vaginosis, whereas 85 (42.5%) of women were treated without such diagnosis. CONCLUSIONS: Among women presenting with symptomatic vaginal discharge, bacterial vaginosis was the most common etiology, and gonorrhea was the most frequently detected STI. The current syndromic management algorithm is suboptimal for coverage of women presenting with symptomatic vaginal discharge; addition of point of care testing could compliment the effectiveness of the syndromic approach.

Malaria knowledge and bed net use in three transmission settings in southern Africa.

BACKGROUND: Insecticide-treated nets (ITNs) reduce malaria morbidity and mortality in endemic areas. Despite increasing availability, the use of ITNs remains limited in some settings. Poor malaria knowledge is a barrier to the widespread use of ITNs. The goal of this study was to assess the levels of malaria knowledge and evaluate factors associated with bed net use among individuals residing in three regions of southern Africa with different levels of malaria transmission and control. METHODS: A cross-sectional study was conducted on a sample of 7535 residents recruited from 2066 households in Mutasa District, Zimbabwe (seasonal malaria transmission), Choma District, Zambia (low transmission) and Nchelenge District, Zambia (high transmission), between March 2012 and March 2017. A standardized questionnaire was used to collect data on demographics, malaria-related knowledge and use of preventive measures. Multivariate logistic regression analyses were used to assess determinants of bed net use. RESULTS: Most of the 3836 adult participants correctly linked mosquito bites to malaria (85.0%), mentioned at least one malaria symptom (95.5%) and knew of the benefit of sleeping under an ITN. Bed net ownership and use were highest in Choma and Nchelenge Districts and lowest in Mutasa District. In multivariate analyses, knowledge of ITNs was associated with a 30-40% increased likelihood of bed net use after adjusting for potential confounders across all sites. Other factors significantly associated with bed net use were age, household size and socioeconomic status, although the direction, strength and size of association varied by study site. Importantly, participants aged 5-14 years had reduced odds of sleeping under a bed net compared to children younger than 5 years. CONCLUSION: Relevant knowledge of ITNs translated into the expected preventive behaviour of sleeping under a bed net, underscoring the need for continued health messaging on malaria prevention. The implementation and delivery of malaria control and elimination interventions needs to consider socioeconomic equity gaps, and target school-age children to ensure access to and improve utilization of ITNs.

Antimicrobial susceptibility in Neisseria gonorrhoeae isolates from five sentinel surveillance sites in Zimbabwe, 2015-2016.

OBJECTIVES: Gonorrhoea and antimicrobial resistance (AMR) in Neisseria gonorrhoeae are major public health concerns worldwide. Enhanced AMR surveillance for gonococci is essential globally. In Zimbabwe, very limited gonococcal AMR data were reported. Our aims were to (i) implement quality-assured gonococcal AMR surveillance in Zimbabwe and (ii) investigate gonococcal AMR at five health centres in 2015-2016. METHODS: Gonococcal isolates from 104 men with urethral discharge were tested for susceptibility to kanamycin, ceftriaxone, cefixime, ciprofloxacin and azithromycin using Etest. RESULTS: All isolates (102 possible to test) were susceptible to ceftriaxone and cefixime. The level of resistance (intermediate resistance) to kanamycin and ciprofloxacin was 2.0% (2.0%) and 18.6% (27.5%), respectively. The two kanamycin-resistant isolates (R≥128 mg/L) had a kanamycin minimum inhibitory concentration (MIC) of >256 mg/L. The ciprofloxacin resistance ranged from 9.5% to 30.8% in the five sentinel sites. Only 10 (9.6%) of the isolates were tested for susceptibility to azithromycin and 1 (10.0%) was resistant (MIC=4 mg/L). CONCLUSIONS: The emergence of multidrug-resistant gonorrhoea internationally is a major public health concern and gonococcal AMR surveillance is crucial globally. In Zimbabwe, gonococcal AMR surveillance has now been implemented and quality assured according to WHO standards. The results of this first surveillance will be used to directly inform revisions of the national treatment guidelines. It is imperative to further strengthen the surveillance of gonococcal AMR, and ideally also treatment failures, in Zimbabwe and most countries in the WHO African region, which requires continuous national and international support, including technical support, and political and financial commitment.

Clinical characteristics and outcomes of patients with stroke admitted to three tertiary hospitals in Zimbabwe: A retrospective one-year study.

BACKGROUND: Epidemiological data on stroke in Zimbabwe are scarce and few clinical studies have been performed to date. METHODS: A retrospective review of the medical records of patients admitted for stroke during the year 2012 was performed at three tertiary hospitals. Sociodemographic data were recorded alongside with comorbidities and outcomes. Scoping over a period of one year using records of patients admitted for stroke helped to quantify and qualify the stroke problem. Descriptive analysis was done using STATA version 13.0. RESULTS: A total of 450 stroke cases, (63% women) were included in the final analysis. The proportion of stroke cases among the admissions was 0.61%. Mean age of the stroke patients was 61.6±16.8 years (95% CI=60.1; 63.2). Risk factors were hypertension (58.5%), diabetes (18%) and HIV, (14%)). Diagnosis was clinical and 39.4% had a CT scan. Mean length of hospital stay was 8.1±5.6 days with a significance difference noted among hospitals (p<0.001). In-hospital mortality was 24.9%, 95% CI (20.9; 29.0%). Mortality was associated with place of admission (p<0.001). Gender and side of stroke were significantly associated (p<0.001). CONCLUSIONS: The sociodemographic characteristics mirrored findings from elsewhere. Mean age was higher than reported for Zimbabwe in the nineties and lately for Malawi. Majority of patients were female, elderly and hypertensive in line with findings from other countries. Presence of HIV is supported by recent studies from Malawi and South Africa. The relationship between gender and side affected needs further research. There is need to standardise acute care through proper diagnosis to reduce mortality. There is need to support caregivers post-discharge. Data-handling is poor and there is limited capacity for Sub Saharan Africa hospitals to provide optimal stroke care. This may have long term implications on the outcome of survivors and caregivers. There is need of vigilance in acute stroke care.