Last data update: Apr 29, 2024. (Total: 46658 publications since 2009)
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Query Trace: Hines JZ[original query] |
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Trends in SARS-CoV-2 seroprevalence among pregnant women attending first antenatal care visits in Zambia: A repeated cross-sectional survey, 2021-2022
Heilmann E , Tembo T , Fwoloshi S , Kabamba B , Chilambe F , Kalenga K , Siwingwa M , Mulube C , Seffren V , Bolton-Moore C , Simwanza J , Yingst S , Yadav R , Rogier E , Auld AF , Agolory S , Kapina M , Gutman JR , Savory T , Kangale C , Mulenga LB , Sikazwe I , Hines JZ . PLOS Glob Public Health 2024 4 (4) e0003073 SARS-CoV-2 serosurveys help estimate the extent of transmission and guide the allocation of COVID-19 vaccines. We measured SARS-CoV-2 seroprevalence among women attending ANC clinics to assess exposure trends over time in Zambia. We conducted repeated cross-sectional SARS-CoV-2 seroprevalence surveys among pregnant women aged 15-49 years attending their first ANC visits in four districts of Zambia (two urban and two rural) during September 2021-September 2022. Serologic testing was done using a multiplex bead assay which detects IgG antibodies to the nucleocapsid protein and the spike protein receptor-binding domain (RBD). We calculated monthly SARS-CoV-2 seroprevalence by district. We also categorized seropositive results as infection alone, infection and vaccination, or vaccination alone based on anti-RBD and anti-nucleocapsid test results and self-reported COVID-19 vaccination status (vaccinated was having received ≥1 dose). Among 8,304 participants, 5,296 (63.8%) were cumulatively seropositive for SARS-CoV-2 antibodies from September 2021 through September 2022. SARS-CoV-2 seroprevalence primarily increased from September 2021 to September 2022 in three districts (Lusaka: 61.8-100.0%, Chongwe: 39.6-94.7%, Chipata: 56.5-95.0%), but in Chadiza, seroprevalence increased from 27.8% in September 2021 to 77.2% in April 2022 before gradually dropping to 56.6% in July 2022. Among 5,906 participants with a valid COVID-19 vaccination status, infection alone accounted for antibody responses in 77.7% (4,590) of participants. Most women attending ANC had evidence of prior SARS-CoV-2 infection and most SARS-CoV-2 seropositivity was infection-induced. Capturing COVID-19 vaccination status and using a multiplex bead assay with anti-nucleocapsid and anti-RBD targets facilitated distinguishing infection-induced versus vaccine-induced antibody responses during a period of increasing COVID-19 vaccine coverage in Zambia. Declining seroprevalence in Chadiza may indicate waning antibodies and a need for booster vaccines. ANC clinics have a potential role in ongoing SARS-CoV-2 serosurveillance and can continue to provide insights into SARS-CoV-2 antibody dynamics to inform near real-time public health responses. |
COVID-19 mortality sentinel surveillance at a tertiary referral hospital in Lusaka, Zambia, 2020-2021
Hines JZ , Kapombe P , Mucheleng'anga A , Chanda SL , Hamukale A , Cheelo M , Kamalonga K , Tally L , Monze M , Kapina M , Agolory S , Auld AF , Lungu P , Chilengi R . PLOS Glob Public Health 2024 4 (3) e0003063 Deaths from COVID-19 likely exceeded official statistics in Zambia because of limited testing and incomplete death registration. We describe a sentinel COVID-19 mortality surveillance system in Lusaka, Zambia. We analyzed surveillance data on deceased persons of all ages undergoing verbal autopsy (VA) and COVID-19 testing at the University Teaching Hospital (UTH) mortuary in Lusaka, Zambia, from April 2020 through August 2021. VA was done by surveillance officers for community deaths and in-patient deaths that occurred <48 hours after admission. A standardized questionnaire about the circumstances proximal to death was used, with a probable cause of death assigned by a validated computer algorithm. Nasopharyngeal specimens from deceased persons were tested for COVID-19 using polymerase chain reaction and rapid diagnostic tests. We analyzed the cause of death by COVID-19 test results. Of 12,919 deceased persons at UTH mortuary during the study period, 5,555 (43.0%) had a VA and COVID-19 test postmortem, of which 79.7% were community deaths. Overall, 278 (5.0%) deceased persons tested COVID-19 positive; 7.1% during waves versus 1.4% during nonwave periods. Most (72.3%) deceased persons testing COVID-19 positive reportedly had fever, cough, and/or dyspnea and most (73.5%) reportedly had an antemortem COVID-19 test. Common causes of death for those testing COVID-19 positive included acute cardiac disease (18.3%), respiratory tract infections (16.5%), other types of cardiac diseases (12.9%), and stroke (7.2%). A notable portion of deceased persons at a sentinel site in Lusaka tested COVID-19 positive during waves, supporting the notion that deaths from COVID-19 might have been undercounted in Zambia. Many had displayed classic COVID-19 symptoms and been tested before death yet nevertheless died in the community, potentially indicating strained medical services during waves. The high proportion of cardiovascular diseases deaths might reflect the hypercoagulable state during severe COVID-19. Early supportive treatment and availability of antivirals might lessen future mortality. |
Comparison of HIV prevalence, incidence, and viral load suppression in Zambia population-based HIV impact assessments from 2016 and 2021
Mulenga LB , Hines JZ , Stafford KA , Dzekedzeke K , Sivile S , Lindsay B , Chola M , Ussery F , Patel HK , Abimiku A , Birhanu S , Minchella P , Stevens T Jr , Hanunka B , Chisenga T , Shibemba A , Fwoloshi S , Siame M , Mutukwa J , Chirwa L , Siwingwa M , Mulundu G , Agbakwuru C , Mapondera P , Detorio M , Agolory SG , Monze M , Bronson M , Charurat ME . AIDS 2024 BACKGROUND: The Zambian government has implemented a public health response to control the HIV epidemic in the country. Zambia conducted a population-based HIV impact assessment (ZAMPHIA) survey in 2021 to assess the status of the HIV epidemic to guide its public health programs. METHODS: ZAMPHIA 2021 was a cross-sectional two-stage cluster sample household survey among persons aged ≥15 years conducted in Zambia across all 10 provinces. Consenting participants were administered a standardized questionnaire and whole blood was tested for HIV according to national guidelines. HIV-1 viral load (VL), recent HIV infection, and antiretroviral medications were tested for in HIV-seropositive samples. Viral load suppression (VLS) was defined as <1000 copies/ml. ZAMPHIA 2021 results were compared to ZAMPHIA 2016 for persons aged 15-59 years (i.e., the overlapping age ranges). All estimates were weighted to account for nonresponse and survey design. RESULTS: During ZAMPHIA 2021, of 25 483 eligible persons aged ≥15 years, 18 804 (73.8%) were interviewed and tested for HIV. HIV prevalence was 11.0% and VLS prevalence was 86.2% overall, but was <80% among people living with HIV aged 15-24 years and in certain provinces. Among persons aged 15-59 years, from 2016 to 2021, HIV incidence declined from 0.6% to 0.3% (P-value: 0.07) and VLS prevalence increased from 59.2% to 85.7% (P-value: <0.01). DISCUSSION: Zambia has made substantial progress toward controlling the HIV epidemic from 2016 to 2021. Continued implementation of a test-and-treat strategy, with attention to groups with lower VLS in the ZAMPHIA 2021, could support reductions in HIV incidence and improve overall VLS in Zambia. |
Two-Month Follow-up of Persons with SARS-CoV-2 Infection—Zambia, September 2020 (preprint)
Zulu JE , Banda D , Hines JZ , Luchembe M , Sivile S , Siwingwa M , Kampamba D , Zyambo KD , Chirwa R , Chirwa L , Malambo W , Barradas D , Sinyange N , Agolory S , Mulenga LB , Fwoloshi S . medRxiv 2021 2021.06.15.21258964 Background COVID-19 is often characterized by an acute upper respiratory tract infection. However, information on longer-term clinical sequelae following acute COVID-19 is emerging. We followed a group of persons with COVID-19 in Zambia at two months to assess persistent symptoms.Methods In September 2020, we re-contacted participants from SARS-CoV-2 prevalence studies conducted in Zambia in July 2020 whose PCR tests were positive. Participants with valid contact information were interviewed using a structured questionnaire that captured demographics, pre-existing conditions, and types and duration of symptoms. We describe the frequency and duration of reported symptoms and used chi-square tests to explore variability of symptoms by age group, gender, and underlying conditions.Results Of 302 participants, 155 (51%) reported one or more acute COVID-19-related symptoms in July 2020. Cough (50%), rhinorrhoea (36%) and headache (34%) were the most frequently reported symptoms proximal to diagnosis. The median symptom duration was 7 days (IQR: 3-9 days). At a median follow up of 54 days (IQR: 46-59 day), 27 (17%) symptomatic participants had not yet returned to their pre-COVID-19 health status. These participants most commonly reported cough (37%), headache (26%) and chest pain (22%). Age, sex, and pre-existing health conditions were not associated with persistent symptoms.Conclusion A notable percentage of persons with SARS-CoV-2 infection in July still had symptoms nearly two months after their diagnosis. Zambia is implementing ‘post-acute COVID-19 clinics’ to care for patients with prolonged symptoms of COVID-19, to address their needs and better understand how the disease will impact the population over time.Competing Interest StatementThe authors have declared no competing interest.Funding StatementThis study was funded by the US Centres for Disease Control and PreventionAuthor DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:The University of Zambia Biomedical Research Ethics Committee Ridgeway Campus, P.O. Box 50110 Lusaka, Zambia E-mail: unzarec{at}zamtel.zmAll necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data referred to in this manuscript is available for viewing and verification |
SARS-CoV-2 mortality surveillance among community deaths brought to university teaching hospital mortuary in Lusaka, Zambia, 2020 (preprint)
Hamukale A , Hines JZ , Sinyange N , Fwoloshi S , Malambo W , Sivile S , Chanda S , Mucheleng'anga LA , Kayeyi N , Himwaze CM , Shibemba A , Leigh T , Mazaba ML , Kapata N , Zulu P , Zyambo K , Mupeta F , Agolory S , Mulenga LB , Malama K , Kapina M . medRxiv 2021 15 Introduction: During March-December 2020, Zambia recorded 20,725 confirmed COVID-19 cases, with the first wave peaking between July and August. Of the 388 COVID-19-related deaths occurring nationwide, most occurred in the community. We report findings from COVID-19 mortality surveillance among community deaths brought to the University Teaching Hospital (UTH) mortuary in Lusaka. Method(s): In Zambia, when a person dies in the community, and is brought into a health facility mortuary, they are recorded as 'brought in dead' (BID). The UTH mortuary accepts persons BID for Lusaka District, the most populated district in Zambia. We analyzed data for persons BID at UTH during 2020. We analyzed two data sources: weekly SARS-CoV-2 test results for persons BID and monthly all-cause mortality numbers among persons BID. For all-cause mortality among persons BID, monthly deaths during 2020 that were above the upper bound of the 95% confidence interval for the historic mean (2017-2019) were considered significant. Spearman's rank test was used to correlate the overall percent positivity in Zambia with all-cause mortality and SARS-CoV-2 testing among persons BID at UTH mortuary. Result(s): During 2020, 7,756 persons were BID at UTH (monthly range 556-810). SARS-CoV-2 testing began in April 2020, and through December 3,131 (51.9%) of 6,022 persons BID were tested. Of these, 212 (6.8%) were SARS-CoV-2 positive with weekly percent test positivity ranging from 0-32%, with the highest positivity occurring during July 2020. There were 1,139 excess persons BID from all causes at UTH mortuary in 2020 compared to the 2017-2019 mean. The monthly number of persons BID from all causes was above the upper bound of the 95% confidence interval during June-September and December. Conclusion(s): Increases in all-cause mortality and SARS-CoV-2 test positivity among persons BID at UTH mortuary corresponded with the first peak of the COVID-19 epidemic in June and August 2020, indicating possible increased mortality related to the COVID-19 epidemic in Zambia. Combining all-cause mortality and SARS-CoV-2 testing for persons BID provides useful information about the severity of the epidemic in Lusaka and should be implemented throughout Zambia. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. It is made available under a CC-BY-NC-ND 4.0 International license. |
Hypertension among persons living with HIV - Zambia, 2021; A cross-sectional study of a national electronic health record system (preprint)
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . medRxiv 2023 16 Background Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. Methods We did a cross-sectional study of hypertension prevalence among PLHIV aged >=18 years in Zambia during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with >=2 recorded blood pressure (BP) readings in 2021 were included. Hypertension was defined as >=2 elevated BP readings (i.e., systolic BP of >=140 mmHg or diastolic BP of >=90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR in the past five years. Multivariable logistic regression was used to assess associations between hypertension and independent variables. Results Among 750,098 PLHIV aged >=18 years with >=2 visits in SmartCare during 2021, 101,363 (13.5%) had >=2 blood pressure readings recorded in their EHR. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension during 2021. Only 8.9% of PLHIV with hypertension had an antihypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for >=60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and persons prescribed ART for >=6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Discussion Hypertension was common among a cohort of PLHIV in Zambia, with few having documentation of being on antihypertensive treatment. Most PLHIV were excluded from the analysis because of missing BP measurements in their EHR. Strengthening integrated management of non-communicable diseases in ART clinics might help to diagnose and treat hypertension in Zambia. Data completeness needs to be improved to routinely capture cardiovascular disease risk factors, including blood pressure readings consistently for PHLIV in their EHRs. Copyright The copyright holder for this preprint is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. This article is a US Government work. It is not subject to copyright under 17 USC 105 and is also made available for use under a CC0 license. |
Hypertension among persons living with HIV-Zambia, 2021; A cross-sectional study of a national electronic health record system
Hines JZ , Prieto JT , Itoh M , Fwoloshi S , Zyambo KD , Sivile S , Mweemba A , Chisemba P , Kakoma E , Zachary D , Chitambala C , Minchella PA , Mulenga LB , Agolory S . PLOS Glob Public Health 2023 3 (7) e0001686 Hypertension is a major risk factor for cardiovascular disease, which is a common cause of death in Zambia. Data on hypertension prevalence in Zambia are scarce and limited to specific geographic areas and/or populations. We measured hypertension prevalence among persons living with HIV (PLHIV) in Zambia using a national electronic health record (EHR) system. We did a cross-sectional study of hypertension prevalence among PLHIV aged ≥18 years during 2021. Data were extracted from the SmartCare EHR, which covers ~90% of PLHIV on treatment in Zambia. PLHIV with ≥2 clinical visits in 2021 were included. Hypertension was defined as ≥2 elevated blood pressure readings (systolic ≥140 mmHg/diastolic ≥90 mmHg) during 2021 and/or on anti-hypertensive medication recorded in their EHR ≤5 years. Logistic regression was used to assess for associations between hypertension and demographic characteristics. Among 750,098 PLHIV aged ≥18 years with ≥2 visits during 2021, 101,363 (13.5%) had ≥2 recorded blood pressure readings. Among these PLHIV, 14.7% (95% confidence interval [CI]: 14.5-14.9) had hypertension. Only 8.9% of PLHIV with hypertension had an anti-hypertensive medication recorded in their EHR. The odds of hypertension were greater in older age groups compared to PLHIV aged 18-29 years (adjusted odds ratio [aOR] for 30-44 years: 2.6 [95% CI: 2.4-2.9]; aOR for 45-49 years: 6.4 [95% CI: 5.8-7.0]; aOR for ≥60 years: 14.5 [95% CI: 13.1-16.1]), urban areas (aOR: 1.9 [95% CI: 1.8-2.1]), and on ART for ≥6-month at a time (aOR: 1.1 [95% CI: 1.0-1.2]). Hypertension was common among PLHIV in Zambia, with few having documentation of treatment. Most PLHIV were excluded from the analysis because of missing BP measurements. Strengthening integrated management of non-communicable diseases in HIV clinics might help to diagnose and treat hypertension in Zambia. Addressing missing data of routine clinical data (like blood pressure) could improve non-communicable diseases surveillance in Zambia. |
Using mortuary and burial data to place COVID-19 in Lusaka, Zambia within a global context
Sheppard RJ , Watson OJ , Pieciak R , Lungu J , Kwenda G , Moyo C , Chanda SL , Barnsley G , Brazeau NF , Gerard-Ursin ICG , Olivera Mesa D , Whittaker C , Gregson S , Okell LC , Ghani AC , MacLeod WB , Del Fava E , Melegaro A , Hines JZ , Mulenga LB , Walker PGT , Mwananyanda L , Gill CJ . Nat Commun 2023 14 (1) 3840 Reported COVID-19 cases and associated mortality remain low in many sub-Saharan countries relative to global averages, but true impact is difficult to estimate given limitations around surveillance and mortality registration. In Lusaka, Zambia, burial registration and SARS-CoV-2 prevalence data during 2020 allow estimation of excess mortality and transmission. Relative to pre-pandemic patterns, we estimate age-dependent mortality increases, totalling 3212 excess deaths (95% CrI: 2104-4591), representing an 18.5% (95% CrI: 13.0-25.2%) increase relative to pre-pandemic levels. Using a dynamical model-based inferential framework, we find that these mortality patterns and SARS-CoV-2 prevalence data are in agreement with established COVID-19 severity estimates. Our results support hypotheses that COVID-19 impact in Lusaka during 2020 was consistent with COVID-19 epidemics elsewhere, without requiring exceptional explanations for low reported figures. For more equitable decision-making during future pandemics, barriers to ascertaining attributable mortality in low-income settings must be addressed and factored into discourse around reported impact differences. |
Leveraging HIV program and civil society to accelerate COVID-19 vaccine uptake, Zambia
Bobo P , Hines JZ , Chilengi R , Auld AF , Agolory SG , Silumesii A , Nkengasong J . Emerg Infect Dis 2022 28 (13) S244-s246 To accelerate COVID-19 vaccination delivery, Zambia integrated COVID-19 vaccination into HIV treatment centers and used World AIDS Day 2021 to launch a national vaccination campaign. This campaign was associated with significantly increased vaccinations, demonstrating that HIV programs can be leveraged to increase COVID-19 vaccine uptake. |
Comparison of COVID-19 pandemic waves in 10 countries in Southern Africa, 2020-2021
Smith-Sreen J , Miller B , Kabaghe AN , Kim E , Wadonda-Kabondo N , Frawley A , Labuda S , Manuel E , Frietas H , Mwale AC , Segolodi T , Harvey P , Seitio-Kgokgwe O , Vergara AE , Gudo ES , Dziuban EJ , Shoopala N , Hines JZ , Agolory S , Kapina M , Sinyange N , Melchior M , Mirkovic K , Mahomva A , Modhi S , Salyer S , Azman AS , McLean C , Riek LP , Asiimwe F , Adler M , Mazibuko S , Okello V , Auld AF . Emerg Infect Dis 2022 28 (13) S93-s104 We used publicly available data to describe epidemiology, genomic surveillance, and public health and social measures from the first 3 COVID-19 pandemic waves in southern Africa during April 6, 2020-September 19, 2021. South Africa detected regional waves on average 7.2 weeks before other countries. Average testing volume 244 tests/million/day) increased across waves and was highest in upper-middle-income countries. Across the 3 waves, average reported regional incidence increased (17.4, 51.9, 123.3 cases/1 million population/day), as did positivity of diagnostic tests (8.8%, 12.2%, 14.5%); mortality (0.3, 1.5, 2.7 deaths/1 million populaiton/day); and case-fatality ratios (1.9%, 2.1%, 2.5%). Beta variant (B.1.351) drove the second wave and Delta (B.1.617.2) the third. Stringent implementation of safety measures declined across waves. As of September 19, 2021, completed vaccination coverage remained low (8.1% of total population). Our findings highlight opportunities for strengthening surveillance, health systems, and access to realistically available therapeutics, and scaling up risk-based vaccination. |
Measuring oral pre-exposure prophylaxis (PrEP) continuation through electronic health records during program scale-up among the general population in Zambia
Heilmann E , Okuku J , Itoh M , Hines JZ , Prieto JT , Phiri M , Watala K , Nsofu C , Luhana-Phiri M , Vlahakis N , Kabongo M , Kaliki B , Minchella PA , Musonda B . AIDS Behav 2022 27 (7) 2390-2396 HIV pre-exposure prophylaxis (PrEP) is being scaled-up in Zambia, but PrEP continuation data are limited by paper-based registers and aggregate reports. Utilization of Zambia's electronic health record (EHR) system, SmartCare, may address this gap. We analyzed individuals aged ≥ 15 years who initiated PrEP between October 2020 and September 2021 in four provinces in Zambia in SmartCare versus aggregate reports. We measured PrEP continuation using Kaplan-Meier survival analysis and Cox proportional hazards models. SmartCare captured 29% (16,791/58,010) of new PrEP clients; 49% of clients continued at one month, and 89% discontinued PrEP by February 2022. Women were less likely than men to discontinue PrEP (adjusted hazard ratio [aHR]: 0.89, 95% CI 0.86-0.92, z = - 6.99, p < 0.001), and PrEP clients aged ≥ 50 years were less likely to discontinue PrEP compared to clients 15-19 years (aHR: 0.53, 95% CI 0.48-0.58, z = - 13.04, p < 0.001). Zambia's EHR is a valuable resource for measuring individual-level PrEP continuation over time and can be used to inform HIV prevention programs. |
Clinical Characteristics and Outcomes of Patients Hospitalized With COVID-19 During the First 4 Waves in Zambia.
Minchella PA , Chanda D , Hines JZ , Fwoloshi S , Itoh M , Kampamba D , Chirwa R , Sivile S , Zyambo KD , Agolory S , Mulenga LB . JAMA Netw Open 2022 5 (12) e2246152 IMPORTANCE: Few epidemiologic studies related to COVID-19 have emerged from countries in Africa, where demographic characteristics, epidemiology, and health system capacity differ from other parts of the world. OBJECTIVES: To describe the characteristics and outcomes of patients admitted to COVID-19 treatment centers, assess risk factors for in-hospital death, and explore how treatment center admissions were affected by COVID-19 waves in Zambia. DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study assessed patients admitted to COVID-19 treatment centers in 5 Zambian cities between March 1, 2020, and February 28, 2022. EXPOSURES: Risk factors for in-hospital mortality, including patient age and severity of COVID-19, at treatment center admission. MAIN OUTCOMES AND MEASURES: Patient information was collected, including inpatient disposition (discharged or died). Differences across and within COVID-19 waves were assessed. Mixed-effects logistic regression models were used to assess associations between risk factors and in-hospital mortality as well as between characteristics of admitted patients and timing of admission. RESULTS: A total of 3876 patients were admitted during 4 COVID-19 waves (mean [SD] age, 50.6 [19.5] years; 2103 male [54.3%]). Compared with the first 3 waves (pooled), the proportion of patients who were 60 years or older admitted during wave 4, when the Omicron variant was circulating, was significantly lower (250 of 1009 [24.8%] vs 1116 of 2837 [39.3%]; P<.001). Factors associated with in-hospital mortality included older age (60 vs <30 years; adjusted odds ratio [aOR], 3.55; 95% CI, 2.34-5.52) and HIV infection (aOR, 1.39; 95% CI, 1.07-1.79). Within waves, patients who were admitted during weeks 5 to 9 had significantly higher odds of being 60 years or older (aOR, 2.09; 95% CI, 1.79-2.45) or having severe COVID-19 at admission (aOR, 2.49; 95% CI, 2.14-2.90) than those admitted during the first 4 weeks. CONCLUSIONS AND RELEVANCE: The characteristics of admitted patients during the Omicron wave and risk factors for in-hospital mortality in Zambia reflect data reported elsewhere. Within-wave analyses revealed a pattern in which it appeared that admission of higher-risk patients was prioritized during periods when there were surges in demand for health services during COVID-19 waves. These findings support the need to expand health system capacity and improve health system resiliency in Zambia and other countries with resource-limited health systems. |
COVID-19 Vaccine Effectiveness Against Progression to In-Hospital Mortality in Zambia, 2021-2022.
Chanda D , Hines JZ , Itoh M , Fwoloshi S , Minchella PA , Zyambo KD , Sivile S , Kampamba D , Chirwa B , Chanda R , Mutengo K , Kayembe MF , Chewe W , Chipimo P , Mweemba A , Agolory S , Mulenga LB . Open Forum Infect Dis 2022 9 (9) ofac469 BACKGROUND: Coronavirus disease 2019 (COVID-19) vaccines are highly effective for reducing severe disease and mortality. However, vaccine effectiveness data are limited from Sub-Saharan Africa. We report COVID-19 vaccine effectiveness against progression to in-hospital mortality in Zambia. METHODS: We conducted a retrospective cohort study among admitted patients at 8 COVID-19 treatment centers across Zambia during April 2021 through March 2022, when the Delta and Omicron variants were circulating. Patient demographic and clinical information including vaccination status and hospitalization outcome (discharged or died) were collected. Multivariable logistic regression was used to assess the odds of in-hospital mortality by vaccination status, adjusted for age, sex, number of comorbid conditions, disease severity, hospitalization month, and COVID-19 treatment center. Vaccine effectiveness of 1 vaccine dose was calculated from the adjusted odds ratio. RESULTS: Among 1653 patients with data on their vaccination status and hospitalization outcome, 365 (22.1%) died. Overall, 236 (14.3%) patients had received 1 vaccine dose before hospital admission. Of the patients who had received 1 vaccine dose, 22 (9.3%) died compared with 343 (24.2%) among unvaccinated patients (P < .01). The median time since receipt of a first vaccine dose (interquartile range) was 52.5 (28-107) days. Vaccine effectiveness for progression to in-hospital mortality among hospitalized patients was 64.8% (95% CI, 42.3%-79.4%). CONCLUSIONS: Among patients admitted to COVID-19 treatment centers in Zambia, COVID-19 vaccination was associated with lower progression to in-hospital mortality. These data are consistent with evidence from other countries demonstrating the benefit of COVID-19 vaccination against severe complications. Vaccination is a critical tool for reducing the consequences of COVID-19 in Zambia. |
COVID-19 Vaccine Effectiveness during a Prison Outbreak when Omicron was the Dominant Circulating Variant-Zambia, December 2021.
Simwanza J , Hines JZ , Sinyange D , Sinyange N , Mulenga C , Hanyinza S , Sakubita P , Langa N , Nowa H , Gardner P , Saasa N , Chitempa G , Simpungwe J , Malambo W , Hamainza B , Chipimo PJ , Kapata N , Kapina M , Musonda K , Liwewe M , Mwale C , Fwoloshi S , Mulenga LB , Agolory S , Mukonka V , Chilengi R . Am J Trop Med Hyg 2022 107 (5) 1055-1059 During a COVID-19 outbreak in a prison in Zambia from December 14 to 19, 2021, a case-control study was done to measure vaccine effectiveness (VE) against infection and symptomatic infection, when the Omicron variant was the dominant circulating variant. Among 382 participants, 74.1% were fully vaccinated, and the median time since full vaccination was 54 days. There were no hospitalizations or deaths. COVID-19 VE against any SARS-CoV-2 infection was 64.8%, and VE against symptomatic SARS-CoV-2 infection was 72.9%. COVID-19 vaccination helped protect incarcerated persons against SARS-CoV-2 infection during an outbreak while Omicron was the dominant variant in Zambia. These findings provide important local evidence that might be used to increase COVID-19 vaccination in Zambia and other countries in Africa. |
Maximizing the impact of voluntary medical male circumcision for HIV prevention in Zambia by targeting high-risk men: A pre/post program evaluation
Lukobo-Durrell M , Aladesanmi L , Suraratdecha C , Laube C , Grund J , Mohan D , Kabila M , Kaira F , Habel M , Hines JZ , Mtonga H , Chituwo O , Conkling M , Chipimo PJ , Kachimba J , Toledo C . AIDS Behav 2022 26 (11) 3597-3606 A well-documented barrier to voluntary medical male circumcision (VMMC) is financial loss due to the missed opportunity to work while undergoing and recovering from VMMC. We implemented a 2-phased outcome evaluation to explore how enhanced demand creation and financial compensation equivalent to 3 days of missed work influence uptake of VMMC among men at high risk of HIV exposure in Zambia. In Phase 1, we implemented human-centered design-informed interpersonal communication. In Phase 2, financial compensation of ZMW 200 (~ US$17) was added. The proportion of men undergoing circumcision was significantly higher in Phase 2 compared to Phase 1 (38% vs 3%). The cost of demand creation and compensation per client circumcised was $151.54 in Phase 1 and $34.93 in Phase 2. Financial compensation is a cost-effective strategy for increasing VMMC uptake among high-risk men in Zambia, and VMMC programs may consider similar interventions suited to their context. |
Two-month follow-up of persons with SARS-CoV-2 infection-Zambia, September 2020: a cohort study.
Zulu JE , Banda D , Hines JZ , Luchembe M , Sivile S , Siwingwa M , Kampamba D , Zyambo KD , Chirwa R , Chirwa L , Malambo W , Barradas D , Sinyange N , Agolory S , Mulenga LB , Fwoloshi S . Pan Afr Med J 2022 41 26 INTRODUCTION: COVID-19 is often characterized by an acute upper respiratory tract infection. However, information on longer-term clinical sequelae following acute COVID-19 is emerging. We followed a group of persons with COVID-19 in Zambia at two months to assess persistent symptoms. METHODS: in September 2020, we re-contacted participants from SARS-CoV-2 prevalence studies conducted in Zambia in July 2020 whose polymerase chain reaction (PCR) tests were positive. Participants with valid contact information were interviewed using a structured questionnaire that captured demographics, pre-existing conditions, and types and duration of symptoms. We describe the frequency and duration of reported symptoms and used chi-square tests to explore variability of symptoms by age group, gender, and underlying conditions. RESULTS: of 302 participants, 155 (51%) reported one or more acute COVID-19-related symptoms in July 2020. Cough (50%), rhinorrhoea (36%) and headache (34%) were the most frequently reported symptoms proximal to diagnosis. The median symptom duration was 7 days (IQR: 3-9 days). At a median follow up of 54 days (IQR: 46-59 day), 27 (17%) symptomatic participants had not yet returned to their pre-COVID-19 health status. These participants most commonly reported cough (37%), headache (26%) and chest pain (22%). Age, sex, and pre-existing health conditions were not associated with persistent symptoms. CONCLUSION: a notable percentage of persons with SARS-CoV-2 infection in July still had symptoms nearly two months after their diagnosis. Zambia is implementing ´post-acute COVID-19 clinics´ to care for patients with prolonged symptoms of COVID-19, to address their needs and better understand how the disease will impact the population over time. |
SARS-CoV-2 Prevalence among Outpatients during Community Transmission, Zambia, July 2020.
Hines JZ , Fwoloshi S , Kampamba D , Barradas DT , Banda D , Zulu JE , Wolkon A , Yingst S , Boyd MA , Siwingwa M , Chirwa L , Kapina M , Sinyange N , Mukonka V , Malama K , Mulenga LB , Agolory S . Emerg Infect Dis 2021 27 (8) 2166-2168 During the July 2020 first wave of severe acute respiratory syndrome coronavirus 2 in Zambia, PCR-measured prevalence was 13.4% among outpatients at health facilities, an absolute difference of 5.7% compared with prevalence among community members. This finding suggests that facility testing might be an effective strategy during high community transmission. |
Prevalence of Voluntary Medical Male Circumcision for HIV Infection Prevention - Chkw District, Mozambique, 2014-2019
Hines JZ , Thompson R , Toledo C , Nelson R , Casavant I , Pals S , Canda M , Bonzela J , Jaramillo A , Cardoso J , Ujamaa D , Tamele S , Chivurre V , Malimane I , Pathmanathan I , Heitzinger K , Wei S , Couto A , Come J , Vergara A , MacKellar D . MMWR Morb Mortal Wkly Rep 2021 70 (26) 942-946 Male circumcision is an important preventive strategy that confers lifelong partial protection (approximately 60% reduced risk) against heterosexually acquired HIV infection among males (1). In Mozambique, the prevalence of male circumcision was 51% when the voluntary medical male circumcision (VMMC) program began in 2009. The Mozambique Ministry of Health set a goal of 80% circumcision prevalence among males aged 10-49 years by 2019 (2). CDC analyzed data from five cross-sectional surveys of the Chókwè Health and Demographic Surveillance System (CHDSS) to evaluate progress toward the goal and guide ongoing needs for VMMC in Mozambique. During 2014-2019, circumcision prevalence among males aged 15-59 years increased 42%, from 50.1% to 73.5% (adjusted prevalence ratio [aPR] = 1.42). By 2019, circumcision prevalence among males aged 15-24 years was 90.2%, exceeding the national goal (2). However, circumcision prevalence among males in older age groups remained below 80%; prevalence was 62.7%, 54.5%, and 55.7% among males aged 25-34, 35-44, and 45-59 years, respectively. A multifaceted strategy addressing concerns about the safety of the procedure, cultural norms, and competing priorities that lead to lack of time could help overcome barriers to circumcision among males aged ≥25 years. |
COVID-19 Severity and COVID-19-Associated Deaths Among Hospitalized Patients with HIV Infection - Zambia, March-December 2020.
Chanda D , Minchella PA , Kampamba D , Itoh M , Hines JZ , Fwoloshi S , Boyd MA , Hamusonde K , Chirwa L , Nikoi K , Chirwa R , Siwingwa M , Sivile S , Zyambo KD , Mweemba A , Mbewe N , Mutengo KH , Malama K , Agolory S , Mulenga LB . MMWR Morb Mortal Wkly Rep 2021 70 (22) 807-810 The effect of HIV infection on COVID-19 outcomes is unclear. Studies in South Africa (1) and the United Kingdom (2) found an independent association between HIV infection and COVID-19 mortality; however, other studies have not found an association between poor COVID-19 outcomes and either HIV status among hospitalized patients (3-5) or HIV-associated factors such as CD4 count, viral load, or type of antiretroviral therapy (ART) (6). The effect of HIV infection on COVID-19 outcomes remains an urgent question in sub-Saharan Africa, where many countries are experiencing dual HIV and COVID-19 epidemics, and capacity to treat severe COVID-19 is limited. Using data from patients with probable or confirmed COVID-19 admitted to specialized treatment centers during March-December 2020 in Zambia, the Zambian Ministry of Health and CDC assessed the relationship between HIV infection and severe COVID-19 and COVID-19-associated death. Among 443 patients included in the study, 122 (28%) were HIV-positive, and of these, 91 (89%) were receiving ART at the time of hospitalization. HIV status alone was not significantly associated with severe COVID-19 at admission or during hospitalization or with COVID-19-associated death. However, among HIV-positive persons, those with severe HIV disease were more likely to develop severe COVID-19 and were at increased risk for COVID-19-associated death. Ensuring that persons maintain HIV disease control, including maintaining ART continuity and adherence, achieving viral suppression, and addressing and managing underlying medical conditions, could help reduce COVID-19-associated morbidity and mortality in sub-Saharan Africa. |
Prevalence of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) among Health Care Workers-Zambia, July 2020.
Fwoloshi S , Hines JZ , Barradas DT , Yingst S , Siwingwa M , Chirwa L , Zulu JE , Banda D , Wolkon A , Nikoi KI , Chirwa B , Kampamba D , Shibemba A , Sivile S , Zyambo KD , Chanda D , Mupeta F , Kapina M , Sinyange N , Kapata N , Zulu PM , Makupe A , Mweemba A , Mbewe N , Ziko L , Mukonka V , Mulenga LB , Malama K , Agolory S . Clin Infect Dis 2021 73 (6) e1321-e1328 INTRODUCTION: Healthcare workers (HCWs) in Zambia have become infected with SARS-CoV-2, the virus that causes coronavirus disease (COVID-19). However, SARS-CoV-2 prevalence among HCWs is not known in Zambia. METHODS: We conducted a cross-sectional SARS-CoV-2 prevalence survey among Zambian HCWs in twenty health facilities in six districts in July 2020. Participants were tested for SARS-CoV-2 infection using polymerase chain reaction (PCR) and for SARS-CoV-2 antibodies using enzyme-linked immunosorbent assay (ELISA). Prevalence estimates and 95% confidence intervals (CIs), adjusted for health facility clustering, were calculated for each test separately and a combined measure for those who had PCR and ELISA performed. RESULTS: In total, 660 HCWs participated in the study, with 450 (68.2%) providing nasopharyngeal swab for PCR and 575 (87.1%) providing a blood specimen for ELISA. Sixty-six percent of participants were females and the median age was 31.5 years (interquartile range 26.2-39.8 years). The overall prevalence of the combined measure was 9.3% (95% CI 3.8%-14.7%). PCR-positive prevalence of SARS-CoV-2 was 6.6% (95% CI 2.0%-11.1%) and ELISA-positive prevalence was 2.2% (95% CI 0.5%-3.9%). CONCLUSIONS: SARS-CoV-2 prevalence among HCWs was similar to a population-based estimate (10.6%) during a period of community transmission in Zambia. Public health measures such as establishing COVID-19 treatment centers before the first cases, screening for COVID-19 symptoms among patients accessing health facilities, infection prevention and control trainings, and targeted distribution of personal protective equipment based on exposure risk might have prevented increased SARS-CoV-2 transmission among Zambian HCWs. |
HIV incidence by male circumcision status from the population-based HIV impact assessment (PHIA) surveys-eight sub-Saharan African countries, 2015-2017
Hines JZ , Sachathep K , Pals S , Davis SM , Toledo C , Bronson M , Parekh B , Carrasco M , Xaba S , Mandisarisa J , Kamobyi R , Chituwo O , Kirungi WL , Alamo S , Kabuye G , Awor AC , Mmbando S , Simbeye D , Aupokolo MA , Zemburuka B , Nyirenda R , Msungama W , Tarumbiswa T , Manda R , Nuwagaba-Biribonwoha H , Kiggundu V , Thomas AG , Watts H , Voetsch AC , Williams DB . J Acquir Immune Defic Syndr 2021 87 S89-S96 BACKGROUND: Male circumcision (MC) offers men lifelong partial protection from heterosexually-acquired HIV infection. The impact of MC on HIV incidence has not been quantified in nationally-representative samples. Data from the Population-based HIV Impact Assessments (PHIAs) were used to compare incidence by MC status in countries implementing voluntary medical MC (VMMC) programs. METHODS: Data were pooled from PHIAs conducted in Eswatini, Lesotho, Malawi, Namibia, Tanzania, Uganda, Zambia and Zimbabwe from 2015-2017. Incidence was measured using a recent infection testing algorithm, and analyzed by self-reported MC status distinguishing between medical and non-medical MC. Country, marital status, urban setting, sexual risk behaviors, and mean population HIV viral load among women as an indicator of treatment scale-up were included in a random effects logistic regression model using pooled survey weights. Analyses were age-stratified (15-34 and 35-59 years). Annualized incidence rates and 95% confidence intervals (CIs) and incidence differences were calculated between medically circumcised and uncircumcised men. RESULTS: Men 15-34 years reporting medical MC had lower HIV incidence than uncircumcised men (0.04% [95% CI: 0.00, 0.10%] versus 0.34% [95% CI: 0.10, 0.57%], respectively; p-value = 0.01); whereas among men 35-59 years, there was no significant incidence difference (1.36% [95% CI: 0.32, 2.39%] versus 0.55% [95% CI: 0.14, 0.67%], respectively; p-value = 0.14). DISCUSSION: Medical MC was associated with lower HIV incidence in men aged 15-34 years in nationally-representative surveys in Africa. These findings are consistent with the expected ongoing VMMC program impact and highlight the importance of VMMC for the HIV response in Africa. |
Prevalence of SARS-CoV-2 in six districts in Zambia in July, 2020: a cross-sectional cluster sample survey.
Mulenga LB , Hines JZ , Fwoloshi S , Chirwa L , Siwingwa M , Yingst S , Wolkon A , Barradas DT , Favaloro J , Zulu JE , Banda D , Nikoi KI , Kampamba D , Banda N , Chilopa B , Hanunka B , Stevens TL Jr , Shibemba A , Mwale C , Sivile S , Zyambo KD , Makupe A , Kapina M , Mweemba A , Sinyange N , Kapata N , Zulu PM , Chanda D , Mupeta F , Chilufya C , Mukonka V , Agolory S , Malama K . Lancet Glob Health 2021 9 (6) e773-e781 BACKGROUND: Between March and December, 2020, more than 20 000 laboratory-confirmed cases of SARS-CoV-2 infection were reported in Zambia. However, the number of SARS-CoV-2 infections is likely to be higher than the confirmed case counts because many infected people have mild or no symptoms, and limitations exist with regard to testing capacity and surveillance systems in Zambia. We aimed to estimate SARS-CoV-2 prevalence in six districts of Zambia in July, 2020, using a population-based household survey. METHODS: Between July 4 and July 27, 2020, we did a cross-sectional cluster-sample survey of households in six districts of Zambia. Within each district, 16 standardised enumeration areas were randomly selected as primary sampling units using probability proportional to size. 20 households from each standardised enumeration area were selected using simple random sampling. All members of selected households were eligible to participate. Consenting participants completed a questionnaire and were tested for SARS-CoV-2 infection using real-time PCR (rtPCR) and anti-SARS-CoV-2 antibodies using ELISA. Prevalence estimates, adjusted for the survey design, were calculated for each diagnostic test separately, and combined. We applied the prevalence estimates to census population projections for each district to derive the estimated number of SARS-CoV-2 infections. FINDINGS: Overall, 4258 people from 1866 households participated in the study. The median age of participants was 18·2 years (IQR 7·7-31·4) and 50·6% of participants were female. SARS-CoV-2 prevalence for the combined measure was 10·6% (95% CI 7·3-13·9). The rtPCR-positive prevalence was 7·6% (4·7-10·6) and ELISA-positive prevalence was 2·1% (1·1-3·1). An estimated 454 708 SARS-CoV-2 infections (95% CI 312 705-596 713) occurred in the six districts between March and July, 2020, compared with 4917 laboratory-confirmed cases reported in official statistics from the Zambia National Public Health Institute. INTERPRETATION: The estimated number of SARS-CoV-2 infections was much higher than the number of reported cases in six districts in Zambia. The high rtPCR-positive SARS-CoV-2 prevalence was consistent with observed community transmission during the study period. The low ELISA-positive SARS-CoV-2 prevalence might be associated with mitigation measures instituted after initial cases were reported in March, 2020. Zambia should monitor patterns of SARS-CoV-2 prevalence and promote measures that can reduce transmission. FUNDING: US Centers for Disease Control and Prevention. |
Detection of B.1.351 SARS-CoV-2 Variant Strain - Zambia, December 2020.
Mwenda M , Saasa N , Sinyange N , Busby G , Chipimo PJ , Hendry J , Kapona O , Yingst S , Hines JZ , Minchella P , Simulundu E , Changula K , Nalubamba KS , Sawa H , Kajihara M , Yamagishi J , Kapin'a M , Kapata N , Fwoloshi S , Zulu P , Mulenga LB , Agolory S , Mukonka V , Bridges DJ . MMWR Morb Mortal Wkly Rep 2021 70 (8) 280-282 The first laboratory-confirmed cases of coronavirus disease 2019 (COVID-19), the illness caused by SARS-CoV-2, in Zambia were detected in March 2020 (1). Beginning in July, the number of confirmed cases began to increase rapidly, first peaking during July-August, and then declining in September and October (Figure). After 3 months of relatively low case counts, COVID-19 cases began rapidly rising throughout the country in mid-December. On December 18, 2020, South Africa published the genome of a SARS-CoV-2 variant strain with several mutations that affect the spike protein (2). The variant included a mutation (N501Y) associated with increased transmissibility.(†)(,)(§) SARS-CoV-2 lineages with this mutation have rapidly expanded geographically.(¶)(,)** The variant strain (PANGO [Phylogenetic Assignment of Named Global Outbreak] lineage B.1.351(††)) was first detected in the Eastern Cape Province of South Africa from specimens collected in early August, spread within South Africa, and appears to have displaced the majority of other SARS-CoV-2 lineages circulating in that country (2). As of January 10, 2021, eight countries had reported cases with the B.1.351 variant. In Zambia, the average number of daily confirmed COVID-19 cases increased 16-fold, from 44 cases during December 1-10 to 700 during January 1-10, after detection of the B.1.351 variant in specimens collected during December 16-23. Zambia is a southern African country that shares substantial commerce and tourism linkages with South Africa, which might have contributed to the transmission of the B.1.351 variant between the two countries. |
Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention - 15 African countries, 2015-2019
Lucas T , Hines JZ , Samuelson J , Hargreave T , Davis SM , Fellows I , Prainito A , Watts DH , Kiggundu V , Thomas AG , Ntsuape OC , Dare K , Odoyo-June E , Soo L , Toti-Mokoteli L , Manda R , Kapito M , Msungama W , Odek J , Come J , Canda M , Gaspar N , Mekondjo A , Zemburuka B , Bonnecwe C , Vranken P , Mmbando S , Simbeye D , Rwegerera F , Wamai N , Kyobutungi S , Zulu JE , Chituwo O , Xaba S , Mandisarisa J , Toledo C . BMC Urol 2021 21 (1) 23 BACKGROUND: Voluntary medical male circumcision (VMMC) is an HIV prevention strategy recommended to partially protect men from heterosexually acquired HIV. From 2015 to 2019, the President's Emergency Plan for AIDS Relief (PEPFAR) has supported approximately 14.9 million VMMCs in 15 African countries. Urethrocutaneous fistulas, abnormal openings between the urethra and penile skin through which urine can escape, are rare, severe adverse events (AEs) that can occur with VMMC. This analysis describes fistula cases, identifies possible risks and mechanisms of injury, and offers mitigation actions. METHODS: Demographic and clinical program data were reviewed from all reported fistula cases during 2015 to 2019, descriptive analyses were performed, and an odds ratio was calculated by patient age group. RESULTS: In total, 41 fistula cases were reported. Median patient age for fistula cases was 11 years and 40/41 (98%) occurred in patients aged < 15 years. Fistulas were more often reported among patients < 15 compared to ≥ 15 years old (0.61 vs. 0.01 fistulas per 100,000 VMMCs, odds ratio 50.9 (95% confidence interval [CI] = 8.6-2060.0)). Median time from VMMC surgery to appearance of fistula was 20 days (interquartile range (IQR) 14-27). CONCLUSIONS: Urethral fistulas were significantly more common in patients under age 15 years. Thinner tissue overlying the urethra in immature genitalia may predispose boys to injury. The delay between procedure and symptom onset of 2-3 weeks indicates partial thickness injury or suture violation of the urethral wall as more likely mechanisms of injury than intra-operative urethral transection. This analysis helped to inform PEPFAR's recent decision to change VMMC eligibility policy in 2020, raising the minimum age to 15 years. |
Case series of glans injuries during voluntary medical male circumcision for HIV prevention - eastern and southern Africa, 2015-2018
Lucas TJ , Toledo C , Davis SM , Watts DH , Cavanaugh JS , Kiggundu V , Thomas AG , Odoyo-June E , Bonnecwe C , Maringa TH , Martin E , Juma AW , Xaba S , Balachandra S , Come J , Canda M , Nyirenda R , Msungama W , Odek J , Lija GJI , Mlanga E , Zulu JE , O'Bra H , Chituwo O , Aupokolo M , Mali DA , Zemburuka B , Malaba KD , Ntsuape OC , Hines JZ . BMC Urol 2020 20 (1) 45 BACKGROUND: Male circumcision confers partial protection against heterosexual HIV acquisition among men. The President's Emergency Plan for AIDS Relief (PEPFAR) has supported > 18,900,000 voluntary medical male circumcisions (VMMC). Glans injuries (GIs) are rare but devastating adverse events (AEs) that can occur during circumcision. To address this issue, PEPFAR has supported multiple interventions in the areas of surveillance, policy, education, training, supply chain, and AE management. METHODS: Since 2015, PEPFAR has conducted surveillance of GIs including rapid investigation by the in-country PEPFAR team. This information is collected on standardized forms, which were reviewed for this analysis. RESULTS: Thirty-six GIs were reported from 2015 to 2018; all patients were < 15 years old (~ 0.7 per 100,000 VMMCs in this age group) with a decreasing annual rate (2015: 0.7 per 100,000 VMMCs; 2018: 0.4 per 100,000 VMMC; p = 0.02). Most (64%) GIs were partial or complete amputations. All amputations among 10-14 year-olds occurred using the forceps-guided (FG) method, as opposed to the dorsal-slit (DS) method, and three GIs among infants occurred using a Mogen clamp. Of 19 attempted amputation repairs, reattached tissue was viable in four (21%) in the short term. In some cases, inadequate DS method training and being overworked, were found. CONCLUSION: Following numerous interventions by PEPFAR and other stakeholders, GIs are decreasing; however, they have not been eliminated and remain a challenge for the VMMC program. Preventing further cases of complete and partial amputation will likely require additional interventions that prevent use of the FG method in young patients and the Mogen clamp in infants. Improving management of GIs is critical to optimizing outcomes. |
Progress in voluntary medical male circumcision for HIV prevention supported by the US President's Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data
Davis SM , Hines JZ , Habel M , Grund JM , Ridzon R , Baack B , Davitte J , Thomas A , Kiggundu V , Bock N , Pordell P , Cooney C , Zaidi I , Toledo C . BMJ Open 2018 8 (8) e021835 OBJECTIVE: This article provides an overview and interpretation of the performance of the US President's Emergency Plan for AIDS Relief's (PEPFAR's) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017. DESIGN: Longitudinal collection of routine programme data and disaggregations. SETTING: 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes. PARTICIPANTS: Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above. MAIN OUTCOME MEASURES: Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance. RESULTS: PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision. CONCLUSIONS: Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020. |
Heavy precipitation as a risk factor for shigellosis among homeless persons during an outbreak - Oregon, 2015-2016
Hines JZ , Jagger MA , Jeanne TL , West N , Winquist A , Robinson BF , Leman RF , Hedberg K . J Infect 2017 76 (3) 280-285 OBJECTIVES: Shigella species are the third most common cause of bacterial gastroenteritis in the United States. During a Shigella sonnei outbreak in Oregon from July 2015 through June 2016, Shigella cases spread among homeless persons with onset of the wettest rainy season on record. METHODS: We conducted time series analyses using Poisson regression to determine if a temporal association between precipitation and shigellosis incidence existed. Models were stratified by housing status. RESULTS: Among 105 infections identified, 45 (43%) occurred in homeless persons. With increasing precipitation, cases increased among homeless persons (relative risk [RR] = 1.36 per inch of precipitation; 95% confidence interval [CI] = 1.17-1.59), but not among housed persons (RR = 1.04; 95% CI 0.86-1.25). CONCLUSIONS: Heavy precipitation likely contributed to shigellosis transmission among homeless persons during this outbreak. When heavy precipitation is forecast, organizations working with homeless persons could consider taking proactive measures to mitigate spread of enteric infections. |
Scale-up of voluntary medical male circumcision services for HIV prevention - 12 countries in southern and eastern Africa, 2013-2016
Hines JZ , Ntsuape OC , Malaba K , Zegeye T , Serrem K , Odoyo-June E , Nyirenda RK , Msungama W , Nkanaunena K , Come J , Canda M , Nhaguiombe H , Shihepo EK , Zemburuka BLT , Mutandi G , Yoboka E , Mbayiha AH , Maringa H , Bere A , Lawrence JJ , Lija GJI , Simbeye D , Kazaura K , Mwiru RS , Talisuna SA , Lubwama J , Kabuye G , Zulu JE , Chituwo O , Mumba M , Xaba S , Mandisarisa J , Baack BN , Hinkle L , Grund JM , Davis SM , Toledo C . MMWR Morb Mortal Wkly Rep 2017 66 (47) 1285-1290 Countries in Southern and Eastern Africa have the highest prevalence of human immunodeficiency virus (HIV) infection in the world; in 2015, 52% (approximately 19 million) of all persons living with HIV infection resided in these two regions.* Voluntary medical male circumcision (VMMC) reduces the risk for heterosexually acquired HIV infection among males by approximately 60% (1). As such, it is an essential component of the Joint United Nations Programme on HIV/AIDS (UNAIDS) strategy for ending acquired immunodeficiency syndrome (AIDS) by 2030 (2). Substantial progress toward achieving VMMC targets has been made in the 10 years since the World Health Organization (WHO) and UNAIDS recommended scale-up of VMMC for HIV prevention in 14 Southern and Eastern African countries with generalized HIV epidemics and low male circumcision prevalence (3).(dagger) This has been enabled in part by nearly $2 billion in cumulative funding through the President's Emergency Plan for AIDS Relief (PEPFAR), administered through multiple U.S. governmental agencies, including CDC, which has supported nearly half of all PEPFAR-supported VMMCs to date. Approximately 14.5 million VMMCs were performed globally during 2008-2016, which represented 70% of the original target of 20.8 million VMMCs in males aged 15-49 years through 2016 (4). Despite falling short of the target, these VMMCs are projected to avert 500,000 HIV infections by the end of 2030 (4). However, UNAIDS has estimated an additional 27 million VMMCs need to be performed by 2021 to meet the Fast Track targets (2). This report updates a previous report covering the period 2010-2012, when VMMC implementing partners supported by CDC performed approximately 1 million VMMCs in nine countries (5). During 2013-2016, these implementing partners performed nearly 5 million VMMCs in 12 countries. Meeting the global target will require redoubling current efforts and introducing novel strategies that increase demand among subgroups of males who have historically been reluctant to undergo VMMC. |
Electronic cigarettes as an introductory tobacco product among eighth and 11th grade tobacco users - Oregon, 2015
Hines JZ , Fiala SC , Hedberg K . MMWR Morb Mortal Wkly Rep 2017 66 (23) 604-606 During 2011-2015, increased electronic cigarette (e-cigarette) and hookah use offset declines in cigarette and other tobacco product use among youths (persons aged <18 years) (1). Limited information exists about which tobacco product introduced youths to tobacco product use. Patterns of first use of e-cigarettes among Oregon youths who were tobacco users were assessed in the Oregon Healthy Teens 2015 survey, a cross-sectional survey of eighth and 11th grade students in Oregon. Respondents were asked, "The very first time you used any tobacco or vaping product, which type of product did you use?" Among students who had ever used any tobacco product (ever users), e-cigarettes were the most common introductory tobacco product reported by both eighth (43.5%) and 11th (34.4%) grade students. Among students who used a tobacco product for ≥1 day during the past 30 days (current users), e-cigarettes were the most common introductory tobacco product reported by eighth grade students (44.4%) and the second most common introductory tobacco product reported by 11th grade students (31.0%). Introductory use of e-cigarettes was commonly reported among youths in Oregon who were ever or current tobacco users, underscoring the importance of proven interventions to prevent all forms of tobacco use among youths (2,3). |
Case finding using syndromic surveillance data during an outbreak of Shiga toxin-producing Escherichia coli O26 infections, Oregon, 2015
Hines JZ , Bancroft J , Powell M , Hedberg K . Public Health Rep 2017 132 (4) 33354917708994 Shiga toxin-producing Escherichia coli (STEC) causes an estimated 265 000 infections in the United States annually. Of emerging non-O157:H7 STEC serotypes, O26 is the most commonly recognized. During an outbreak of STEC O26 in Oregon in 2015, we used syndromic surveillance data to supplement case finding by laboratory reporting. From 157 records retrieved by querying syndromic surveillance data, we detected 4 confirmed and 5 suspected cases. However, none of the suspected cases were confirmed by stool culture, and by the time that the data were being analyzed, the confirmed cases were already known to investigators. Syndromic surveillance data can potentially supplement case finding during outbreaks of foodborne disease. To be an effective case-finding strategy, timely completion of all steps, including collecting specimens from suspected cases, should be performed in real time. |
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