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September 9-10, 2020
Prof Lloyd Mulenga
Director Infectious Diseases
Ministry of Health
September 9 - 10, 2020
Overview of COVID-19 Trends in Zambia
Fast-Track Cities Virtual Conference • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
The Current Scenario on 95/95/95 strategy: May 2020
National TxCurr:
1,052,759
Lusaka
• 27% of HIV Burden is in Lusaka City
• Estimation attrition rates at 20%
• Lusaka Surge Launched WAD 2017
of those diagnosed are on ART
of those on ART are virally suppressed
94.1% 93.1% 94.7*%
*VLS rate calculated based on number of suppressed out of tests done in Q1 and the full cascade can only be done annually
at close of the year
Fast-Track Cities Virtual Conference • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Fast-Track Cities Virtual Conference • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
COVID-19 Trends in Zambia
• Initial cluster among the Asian community
• Disproportionate high admissions and mortality among Men, Asian, >45years old, Diabetics and hypertensives
• Reported cases from Urban and border towns
• Burden in rural areas unclear
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
SAR-CoV-2 Prevalence Survey in Zambia
• Methods• Three surveys:
1. General population: 16 randomly selected EAs per district. Within EA, HHs listed and 20 randomly selected
2. OPD patients: Randomly selected from 20 purposefully selected HFs*
3. HCWs: convenience sample from 20 HFs
• 6 districts: Kabwe, Livingstone, Lusaka, Nakonde,
Ndola, Solwezi• Purposefully selected: ongoing cases/outbreak or deemed high
risk, mix of urban/rural, travel corridors/PoEs• ~4.2 million people (24% of total population of Zambia) • 5610 people interviewed
Preliminary. Not for distribution
2
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Study Timing in Relation to SARS-CoV-2 Outbreak in Zambia
0
100
200
300
400
500
6002
0-M
ar
24
-Mar
28
-Mar
1-A
pr
5-A
pr
9-A
pr
13
-Ap
r
17
-Ap
r
21
-Ap
r
25
-Ap
r
29
-Ap
r
3-M
ay
7-M
ay
11
-May
15
-May
19
-May
23
-May
27
-May
31
-May
4-J
un
8-J
un
12
-Ju
n
16
-Ju
n
20
-Ju
n
24
-Ju
n
28
-Ju
n
2-J
ul
6-J
ul
10
-Ju
l
14
-Ju
l
18
-Ju
l
22
-Ju
l
26
-Ju
l
30
-Ju
l
3-A
ug
7-A
ug
11
-Au
g
15
-Au
g
19
-Au
g
23
-Au
g
27
-Au
g
31
-Au
g
No
. cas
es
Confirmed COVID cases 7-day moving average (COVID cases)
Prevalence study
Preliminary. Not for distribution
4
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Results: Age/Sex Distributions by Survey Type
0
100
200
300
400
500
600
700
No
. par
tici
pan
ts
OPD survey
0
200
400
600
800
1000
1200
No
. par
tici
pan
tsHH survey
0
50
100
150
200
250
300
No
. par
tici
pan
ts
HCW survey
39%, Male
60%, Female
39%, Male
61%, Female
34%, Male
66%, Female
Preliminary. Not for distribution
6
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Results: Comparison of HH Survey to Districts’ Population Age/Sex Distributions
49%, Male51%, Female
Population sex distribution - 6 districts (2020)
39%, Male61%,
Female
Sample sex distribution – HH Survey
Source: https://www.zamstats.gov.zm/phocadownload/Zambia%20Census%20Projection%202011%20-%202035.pdf
14%
23% 23%
15%
10%
7%4%
2%1%
0
200
400
600
800
1000
1200
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+
No
. par
tici
pan
tsSample age distribution – HH survey
30%
22%19%
14%
8%
4%2% 1% 0%
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+
No
. per
son
s
Population age structure - 6 districts (2020)
Preliminary. Not for distribution
7
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Prevalence by Survey Type
0%
5%
10%
15%
20%
PCR Serology
Perc
en
t SA
RS-
Co
V-2
po
siti
veHH survey
0%
5%
10%
15%
20%
PCR Serology
Perc
en
t SA
RS-
Co
V-2
po
siti
ve
OPD survey
0%
5%
10%
15%
20%
PCR Serology
Perc
en
t SA
RS-
Co
V-2
po
siti
ve
HCW survey
Preliminary. Not for distribution
8
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Prevalence by Age (HH Survey)
0%
5%
10%
15%
20%
0-9 10-19 20-29 30-39 40-49 ≥50
Perc
en
t SA
RS-
Co
V-2
po
siti
vePCR Positivity by Age Group (HH survey)
0%
5%
10%
15%
20%
0-9 10-19 20-29 30-39 40-49 ≥50
Perc
en
t SA
RS-
Co
V-2
po
siti
ve
Serology Positivity by Age Group (HH survey)
Preliminary. Not for distribution
11
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Prevalence by Sex (HH Survey)
0%
5%
10%
15%
20%
Female Male
Perc
en
t SA
RS-
Co
V-2
po
siti
vePCR Positivity by Sex (HH survey)
0%
5%
10%
15%
20%
Female Male
Perc
en
t SA
RS-
Co
V-2
po
siti
ve
Serology Positivity by Sex (HH survey)
Preliminary. Not for distribution
12
September 9 - 10, 2020
Impact of COVID-19 on HIV Services
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Impact of COVID-19 on the ART program
• Reduction in community and facility HIV services resulting in low HTS, new positive and new patient started on ART
• It is too early to tell the impact of COVID-19 on VLS and Retention in Care
• There has been substantial disruption in the supply chain of commodities including ABC, ATV-r and TLD
• TLE substitution for TLD has reduced gains in the ARVs drug optimization agenda
National HIV Program Focus for 2020/2021
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Reduction of HTS due to COVID-19 (Jan-Apri 20)
National HIV Program Focus for 2020/2021
0
50,000
100,000
150,000
200,000
250,000
300,000
CentralProvince
CopperbeltProvince
EasternProvince
Lusaka Province LuapulaProvince
MuchingaProvince
NorthernProvince
North WesternProvince
SouthernProvince
WesternProvince
National Total Source: DHIS2.0(HMIS)_28 May
2020.
HTS by Province Jan- April
January 2020 HIV Testing (HTS) February 2020 HIV Testing (HTS) March 2020 HIV Testing (HTS) April 2020 HIV Testing (HTS)
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Reduction of New HIV positive cases in the COVID-19 Period(Jan-Apr20)
National HIV Program Focus for 2020/2021
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
CentralProvince
CopperbeltProvince
EasternProvince
Lusaka Province LuapulaProvince
MuchingaProvince
NorthernProvince
North WesternProvince
SouthernProvince
WesternProvince
National Total Source: DHIS2.0(HMIS)_28 May
2020.
HTS_POS
Period January-HIV Positive Results (HTS) Period Febraury-HIV Positive Results (HTS) Period HIV Positive Results (HTS) Period HIV Positive Results (HTS)
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Reduction in Number of patients started on ART in COVID-19 period
National HIV Program Focus for 2020/2021
0
2,000
4,000
6,000
8,000
10,000
12,000
14,000
16,000
18,000
20,000
Central Province CopperbeltProvince
Eastern Province Lusaka Province Luapula Province MuchingaProvince
NorthernProvince
North WesternProvince
SouthernProvince
WesternProvince
National Total Source: DHIS2.0(HMIS)_28 May
2020.
TxNEW
Started on ART January 2020 Started on ART February 2020 Started on ART March 2020 Started on ART April 2020
September 9 - 10, 2020
Mitigation Measures
National HIV Program Focus for 2020/2021
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
1. 2020: TLD-TLE regimen Switch
• Due to COVID-19 and to deplete the short dated TLE, MOH instructed a temporal switch between TLD/TLE with only 224,500 patients plus new initiates remaining on TLD.
• As a result;• All patients are expected to be on 6-month MMD between now
and September - November 2020.• Once TLE is depleted, plan is to transition 90% back to TLD
around September - November 2020.
National HIV Program Focus for 2020/2021
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
2. 2020: Decongestion strategy at ART sites
• In addition to the TLE and TLD intervention due to COVID, MOH with support from GHSC-PSM designs and implemented a 6MMD allocation planned for other ARVs in a bid to ensure ART service decongestion at facilities.
• The Regimens included ARVs for;• 1st and 2nd Line ARVs for Paediatrics• Adult 2nd Line ARVs• PrEP
3. 2020: Enhanced central level collaboration.
• Biweekly updates by MOH/GF/USAID/GHSC-PSM to anticipate and prevent shortages of all commodities.• Policy on streamlined distribution of commodities from port of entry to MSL• Resource mobilization for additional funding for procurements e.g. TLD• Lopinavir/ritonavir temporal switch to atazanavir/ritonavir due to API challenges.
National HIV Program Focus for 2020/2021
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Guiding Principles for maintaining ART treatment gains
• Ensure safety of clients and providers• Provision of PPE
• Physical distancing
• Triage
• Reduce risk of transmission of COVID-19• Facility screening and setting up isolation centers
• Minimizing contact with health facilities
• Infection prevention control measures
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Multi-Month Dispensation of ART to Minimize Contact with Health Facilities
• Where possible, initial call in to take advantage and perform full clinical interaction
– Check adherence to ART
– COVID 19 prevention messaging
– VL testing if eligible
• Spaced appointment scheduling▪ Appointment by day and time
▪ Weekend and after-hours
• MMD for TPT
Urgent opportunity to scale-up MMD to all eligible!
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Engaging the Community
• Community index testing has resumed
• Training of Community Health Workers (CHWs)
• PPE for CHWs
• Community sensitization for HIV testing
• Messaging
• National policy on face masks has helped to ensure contacts are also wearing masks
• Measures for the public to protect themselves
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Strengthen Continuous Quality Improvement (CQI) for 3/6 MMD
Faci
lity
We
eke
nd
Se
rvic
e
Org
aniz
ed
? (Y
es/
No
)
Dru
gs A
vaila
ble
? (Y
es/
No
)
TX_C
UR
R a
s at
2
2n
d A
pri
l 20
20
# o
f C
lien
ts t
o b
e
Dis
pe
nse
d
# D
isp
en
sed
as
at
22
nd
Ap
ril 2
02
0
% D
isp
en
sed
as
at
22
nd
Ap
ril 2
02
0
Bauleni Urban Health Centre Yes Yes 3,920 3,894 5,026 129%Chainda Urban Health Centre Yes Yes 1,201 506 505 100%Chawama First Level Hospital Yes Yes 9,916 7,648 4,729 62%Chazanga Urban Health Centre Yes Yes 3,594 3,520 1,411 40%Chelstone Urban Health Centre Yes Yes 8,708 6,742 3,598 53%Chilenje First Level Hospital Yes Yes 7,767 7,486 10,346 138%Chipata First Level Hospital Yes Yes 10,929 5,760 2,570 45%George Urban Health Centre Yes Yes 8,561 8,303 4,240 51%Kabwata Urban Health Centre Yes Yes 5,278 5,133 5,564 108%Kalingalinga Urban Health Centre Yes Yes 7,856 5,084 2,378 47%Kamwala Urban Health Centre Yes Yes 7,260 4,718 3,157 67%Kanyama First Level Hospital Yes Yes 12,050 5,791 6,591 114%Makeni Urban Health Centre Yes Yes 5,897 3,025 2,480 82%Matero First Level Hospital Yes Yes 13,163 12,794 6,283 49%Matero Main Urban Health Centre Yes Yes 7,629 3,380 2,899 86%Mtendere Urban Health Centre Yes Yes 5,891 3,521 2,624 75%Ng'ombe Urban Health Centre Yes Yes 5,776 5,000 2,223 44%Railway Urban Health Centre Yes Yes 5,502 4,127 3,986 97%
Overall Yes Yes 130,898 96,432 70,610 73%
8%
53%
74%
0%
10%
20%
30%
40%
50%
60%
70%
80%
-
10,000
20,000
30,000
40,000
50,000
60,000
70,000
80,000
March31st
April17th
April24th
Total Dispensed % against Target
6 MMD in Lusaka
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Reliance on the ECHO™ Platform for tele-mentorship
• HIV/TB clinical and programmatic mentorship has relied on the virtual tele mentoring platform
• COVID-19 mentorship series held via ECHO
• Integrated COVD-19/HIV/TB
September 9 - 10, 2020
COVID-19 and Tuberculosis in Zambia
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Zambian Perspective of the impact of COVID 19 pandemic on the TB programme
• Like other essential health services, the delivery of TB services in Zambia has been affected by the COVID-19 pandemic
• Since the notification of the first 02 cases of COVID 19 on 18th
March 2020, modification of delivery of services was initiated in response to the outbreak of COVID 19
• This resulted in into a low turn out of patients in OPD resulting into reduced number of presumptive TB patients being identified
• Inadvertently TB notifications plummeted
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Impact of COVID 19 on TB Key indicators
4,414 4,626
4,999
5,601 5,456 5,665
7,097
9,113
6,119
6,952
6,205
9,228
9,661
7,087
5,012
5,613 5,335
5,101 4,924
5,474
5,979 6,328 6,188
7,584
8,393
3,278
4,541 4,822
5,669 5,334 5,261
6,038
7,798
5,584
6,112
5,496
7,861
8,335
5,745
4,622 4,887
4,559 4,380
4,111
5,090
5,689 5,908
5,684
6,674
7,556
-
2,000
4,000
6,000
8,000
10,000
12,000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Sum of No. TB PresumptivesSum of No. Presumptive TB cases examined in the Laboratory
First 2 cases of COVID 19
TB Situationlaunched
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Effects of COVID19 on Weekly TPT Surge Initiations
549 725
1,316
1,666
1,964
1,476
1,989
3,295
2,976
2,155
1,860 1,695
1,200
-
500
1,000
1,500
2,000
2,500
3,000
3,500
Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13
Feb 20 Mar 20 Apr 20
Before COVID19 Amidst COVID19
Virtual Fast-Track Cities 2020 • September 9-10, 2020
VIRTUAL FAST-TRACK CITIES 2020
Lessons Learnt
• COVID19 pandemic response has leveraged on the strong HIV/TB programme systems from community ,facility and management levels
• Virtual platforms for mentorship and programme supervision have provided an unprecedented versatility
• Granular monitoring and redistribution of commodities has averted stockouts
• Continuous Quality Improvement interventions have sustained some of the programme related indicators