Where, when, and how many tuberculosis patients are lost from presumption until treatment initiation? A step by step assessment in a rural district in Zimbabwe.

OBJECTIVES: To describe the pre-diagnosis and pre-treatment loss to follow-up (LTFU) in the tuberculosis (TB) care cascade in Guruve (2015-16), a rural district in Zimbabwe. DESIGN: Guruve has 19 rural health centres (RHCs) and one district hospital. In this cohort study, persons ≥15 years of age with presumptive pulmonary TB were tracked from the facility presumptive TB registers to the laboratory registers; if laboratory diagnosed, they were tracked to the district TB register (contains details of all TB patients registered for treatment). Each patient was tracked for 90days after registration as presumptive TB and for 90days after laboratory diagnosis. Environmental health technicians transported sputum specimens from the health facilities to the laboratories (n=3). RESULTS: Of 2974 persons with presumptive TB, pre-diagnosis LTFU occurred in 575 (19%, 95% confidence interval 18-21%). Associated factors included registration at a RHC, at a facility more than 2km from the laboratory, and absence of an environmental health technician. Of 162 laboratory diagnosed pulmonary TB patients, pre-treatment LTFU occurred in 19 (12%, 95% confidence interval 8-18%). CONCLUSIONS: The presumptive TB register was helpful to assess the pre-diagnosis gaps beginning from presumption. Pre-diagnosis LTFU can be reduced by placement of an environmental health technician at all facilities.

Evaluation of severe malaria case management in Mazowe District, Zimbabwe, 2014.

INTRODUCTION: Malaria is a preventable and curable disease. Mazowe district had been experiencing a lower malaria transmission rate in comparison to other districts in the Mashonaland Central province but it experienced a huge outbreak in the 2013-2014 rainy seasons with a case fatality rate (CFR) of 0.21%. This CFR was the highest in the province and it was twice as much as the national CFR (0.12%) for the same period. We evaluated severe malaria case management in Mazowe district to determine if practice is as per standard treatment guidelines. METHODS: A descriptive cross sectional study was conducted in Mazowe district using the Logical Framework approach. District Health Executives (DHE) members, nurses and severe malaria case notes were purposively and conveniently selected into the study. Key informant Interviews and review of case notes were carried out. All data were analysed using Epi Info 3.5.1.to calculate means and frequencies. Permission to conduct the study was obtained from the Mashonaland Central Provincial Medical Directorate (PMD) Institutional Ethical Review Board (IRB). RESULTS: The median age in years of the cases was 16 (Q1=7.3; Q3=30.8) and up to 58.1% of the cases were female. Inputs including staff, medicines and medical and laboratory equipment for severe case management were inadequate in the district. Only 60% of severe cases were diagnosed using blood slides and up to 95.6% of cases presented with one or more of the clinical signs of severe malaria. All severe cases were treated using correct anti-malarial and analgesic doses. Patient monitoring was not done as per prerequisite intervals and up to 5% of cases died. The health workers had above average knowledge on severe malaria. CONCLUSION: Severe malaria case management inputs were inadequate in the district. For many cases, the district did not follow complicated malaria treatment guidelines for diagnosis, treatment and monitoring. Untrained staff needs training in Severe Malaria Case Management and monitoring of commodity stocks needs to be strengthened.

Factors associated with uptake of voluntary medical male circumcision, Mazowe District, Zimbabwe, 2014.

INTRODUCTION: Voluntary Medical Male Circumcision (VMMC) is the surgical removal of the foreskin by a trained health worker. VMMC was introduced in Zimbabwe in 2009. It is of concern that the programme performance has been below expectations nationally and in Mazowe district. Zimbabwe is unlikely to meet its 2015 target of circumcising 1 200 000 men aged between 15 and 29 years and unlikely to enjoy maximum benefits of VMMC which include prevention of HIV, sexually transmitted infections and cervical cancer. We therefore broadly aimed at identifying factors influencing the level of VMMC uptake in Mazowe district. METHODS: An analytic cross-sectional study was carried out in Mazowe district. A multi-stage probability sampling strategy was used to select 300 men aged between 18 and 49 years. Pretested interviewer administered questionnaires, key informant interviews and focus group discussions were used to collect data. Quantitative data was analysed using Epi info where odds ratios and p-values were calculated. Qualitative data was analysed thematically. RESULTS: Being of Shona origin (AOR= 7.69 (95%CI 1.78-33.20)), fear of pain (AOR= 7.09 (95%CI 2.58-19.47)) and fear of poor wound healing (AOR= 2.68 (95%CI 1.01-7.08)) were independently associated with being uncircumcised while having a circumcised friend and encouragement by a friend or relative were independently associated with being circumcised. CONCLUSION: Fear of pain, fear of poor wound healing and encouragement by a friend or relative were associated with circumcision status. Widening use of surgical devices and third part referrals may assist in scaling up the programme.