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Allen S. Craig, MDResident Advisor
President’s Malaria Initiative – ZambiaCenters for Disease Control and Prevention
Presenter’s Title – Myriad Pro, 18pt
Tennessee Public Health Association& Southern Health Association Meeting
September 15‐17, 2010
Public Health from T(ennessee) to Z(ambia): More than Enough Challenges and Opportunities to Go Around
Center for Global HealthDivision of Parasitic Diseases and Malaria
Shopping in Lusaka
Socioeconomics of Zambia
• Population: 13 million
• Young population: 45% under age 15
• Average life expectancy: 43 years
• High levels of poverty: 70% live below the poverty level
• Income: two‐thirds live on <US$1 per day
• Languages: 7 major languages with 72 dialects
WHO, Human Papillomavirus and Related Cancers, Zambia, 2010;Demographic Health Survey, 2007
Health Care System in Zambia
• Government health budget US$274M (8% of total budget)
• Donor health budget >US$400M
• Health centers & health posts – 1465
• District hospitals – 72
• Provincial / general hospitals – 21
• Tertiary / specialist hospitals – 6
Health Care System in Zambia
• 70% of patients seen at Ministry of Health and 30% at mission facilities
• $62 per capita expenditure on health ($5464 in Tennessee)
Kaiser Family Foundation: Statehealthfacts.org
Unexplained Outbreak – September 2008
• 36 year old white South African female resident of Lusaka, Zambia developed fever, sore throat and diarrhea on September 4, 2008
• Worked as a safari guide, lived on a farm with cows and horses, never wore shoes
• Traveled to South Africa September 6‐8 and had vomiting and diarrhea
Unexplained Outbreak – September 2008
• Patient returned to Zambia, was seen at two facilities in Lusaka diagnosis sepsis
• Deterioration in condition resulted in emergent intubation and placement on ventilator September 12 – attended to by South African paramedic, British critical care physician and Vanderbilt Infectious Diseases fellow
• Died in Johannesburg one day after transfer
Unexplained Outbreak – September 2008
• Two days after transfer the paramedic developed fever, headache, sore throat, diarrhea, rash
• Lab: low platelets, low then high white blood count, elevated liver functions
• He was admitted to the same hospital in South Africa on September 27 with multiorgan failure and died September 30
Unexplained Outbreak – September 2008
• A nurse and housekeeper who cared for the index patient in South Africa developed fever, respiratory distress and died on October 5 and 6
• A 2nd nurse who cared for the paramedic became ill but recovered after aggressive intensive care
• 80% case fatality rate
Unexplained Outbreak – September 2008
• What would you do to investigate?– South African virologist travels to Zambia
– Laboratory tests sent to the National Infectious Diseases Laboratory in South Africa and to the CDC in Atlanta
– Interview relatives and close contacts
– Visit home ‐ just down the rural road from our daughters’ school
Unexplained Outbreak – September 2008
• These tests revealed an old world arenavirus never before seen– Immunohistochemistry at CDC and PCR in South Africa revealed a virus related to Lassa Fever virus which causes hemorrhagic fever in West Africa
– Lassa Fever‐like viruses seen in rodents in southern Africa but never in humans
– Spread by rodent excreta and easily transmitted from person to person – nosocomial outbreaks are common
• No further cases have been reported
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Lujo virus: a new member of the family Arenaviridae, the first old world hemorrhagic fever–associated arenavirus discovered in three decades
Emerg Infect Dis 2009 15:1598‐602
PLoS Pathog 2009 May;5:e1000455
Ten Major Causes of Visitation to Health Facilities, Zambia 2008
(All ages) – 2008
Disease Name Incidence per 1,000 pop1
Malaria 251.7Respiratory infection: non‐pneumonia 197.6Diarrhoea: non‐bloody 69.3Trauma2 46.6Skin infections 38Muscular skeletal &connective tissue 32.3Eye infection 31.3Respiratory infections: pneumonia 30.8Skin infections 30.5Ear/Nose/throat infections 26.9
2008 Annual HealthStatistical Bulletin,Zambia, MOH
Top 10 Reasons for Outpatient Visits in United States, 2006
National Health Statistics Reports, 3, August 6,2008
Top 10 Causes of Mortality (all ages) Zambia, 2002
1. HIV/AIDS 96,000 43%
2. Lower respiratory 26,000 12%
3. Malaria 19,000 9%
4. Diarrheal 15,000 7%
5. Perinatal conditions 7,000 4%
6. Tuberculosis 7,000 3%
7. Cerebrovascular disease 4,000 2%
8. Ischemic heart disease 4,000 2%
9. Measles 2,000 1%
10. Road traffic accidents 1,000 1%
WHO, Mortality Country Fact Sheet 2006,Zambia http://www.who.int/whosis/mort/profiles/mort_afro_zam_zambia.pdf
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Top 10 Causes of Death in Tennessee
• Heart disease• Cancer• Injuries• Cerebrovascular disease• Chronic lower respiratory track disease• Diabetes• Alzheimer’s Disease• Pneumonia• Chronic liver disease• Hypertension
Tennessee Dept of Health, Div of Health Statistics, 2009
H1N1 Pandemic, 2009 – 2010
• Tennessee– ~1.2M cases, 2494 deaths
• Zambia– Winter of 2009: 88 PCR confirmed cases, 1 death– Two real‐time PCR machines in country – one recently delivered in the north by Jennifer MacFarquhar
– Active surveillance at major teaching hospital– No 2nd wave detected
MOH Emergency Response Committee, 2009‐2010
Infant & Maternal Mortality
• Tennessee ‐ 2008– infant mortality 8 per 1000 live births– maternal mortality 8.6 per 100000 live births
• Zambia ‐ 2007– infant mortality 70 per 1000 live births– maternal mortality 591 per 100000 live births– 52% deliveries occur at home; 47% attended by a professional
– Emergency obstetric care training in progress
Zambia Demographic Health Survey 2007 / TN Department of Health, Vital Statistics
`
Cervical Cancer
• Tennessee – 8.5 per 100,000 population (2003‐2007)
• Zambia– 15 per 100,000 population (2010)
– Large numbers of cases due to HPV and HIV
– Screening conducted in Lusaka using cervical photographs with remote review by clinicians
– Discussions about introducing HPV vaccinesCancer in Tennessee, 2003‐2007; WHO, Human Papillomavirus and Related Cancers, Zambia, 2010
Measles
• Tennessee 2009– 1 indigenous case– Routine 2‐dose coverage 12‐15 months/4‐6 years
• Zambia 2010– >8000 cases and >110 deaths– One‐dose routine at 9 months of age– Low immunization rates in poor neighborhoods in Lusaka– The appearance of adequate immunization rates due to
inaccurate denominators– Logistical challenges of mounting a Supplemental
Immunization Activity – using Child Health Week to respond July 2010
• Malawi – >77,000 cases in current outbreak
Measles Cases and Measles Vaccination Coverage, Zambia, 1990‐2008
Data source: Measles cases‐ reported by national authorities to WHO annuallyMeasles vaccination coverage‐WHO/UNICEF immunization coverage estimates, as of August 2009Measles vaccination coverage 2nd dose‐ reported by national authorities to WHO annuallySIA activities: WHO/EPI supplementary immunization activities databaseDate of slide: 27‐08‐2009
CatchUp FollowUp
No data rep
orted
2002‐2003 2007
0
10
20
30
40
50
60
70
80
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100
Measles vaccinatio
n coverage (%
)
0
10000
20000
30000
Num
ber of re
ported
measles cases
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Measles cases Measles vaccination coverage
Measles Cases by Week, Lusaka, Zambia, 2010
Cholera
• Tennessee– 2005 - Hurricane Katrina evacuees
• Zambia– Annual outbreaks in Lusaka– Vibrio cholera O1 El Tor
• Fever• Severe watery diarrhea• Mortality <1% if well cared for
Cholera
• Cholera treatment centers– Oral or IV hydration -– Antibiotics for severe cases only
• Prevention– Clean water – no chlorine in city water,
expensive, use of shallow wells– Well cooked food – most homes use
expensive charcoal to cook with– Don’t play in flood waters
Cholera by Week, Lusaka, 2003‐2010
High School Project –Teaching Handwashing at a Community School
HIV and AIDS
• Tennessee (2007, CDC)– HIV prevalence: 0.14%– Men>women
• Zambia (HIV prevalence data, 2007, Ministry of Health)– Women 16%, men 12%– Urban 19%, rural 10%– Multiple concurrent partners– Maternal to child transmission– U.S. President’s Emergency Program for AIDS Relief (PEPFAR)
HIV Prevention
• Combination prevention– Biomedical – male circumcision, blood / injection safety
– Behavioral interventions – multiple concurrent sexual partners, couples counseling, condoms
• Prevention of maternal to child transmission– Increasing use of highly efficacious regimens– Early infant diagnosis by PCR now available– Breast feeding until age 1 year
HIV Care and Treatment
• Counseling and testing– Still a challenge
– Stigma
• Basic health care for HIV infected persons– Tenofovir‐based regimen
– >300,000 patients on antiretroviral drugs
– Major pharmaceutical supply chain improvements
– Electronic medical record (SmartCare)
HIV Care and Treatment
• Strong laboratory support– CD4 counts and viral load determinations available
• Palliative care / hospice
• TB care for co‐infected patients– Directly observed therapy
• Support for orphans and vulnerable children– 1,200,000 single or double orphans
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Health Information Systems• Tennessee
– NEDSS
• Zambia
– New Health Management Information System
– New system developed by South African contractors started in 2008
– Many more data elements
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Health Information Systems– Challenges with updating software and training
–Need to integrate private sector facilities
– Lag time in completing paper reports
–New web portal will improve access
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The President’s Malaria Initiative
• Support Ministry of Health malaria program
• Long‐lasting insecticide treated bed nets– Physical and chemical barrier
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The President’s Malaria Initiative
• Indoor residual spraying with insecticides– Repels and kills resting Anophelinemosquitoes
• Intermittent preventive treatment of malaria in pregnancy with sulfadoxine‐pyrimethamine (Fansidar®)– 2‐3 doses in 2nd and 3rd trimester
Malaria in Pregnancy Research
Malaria in Pregnancy Research
Dubowitz / Ballard Gestational Age Determination
The President’s Malaria Initiative
• Diagnostic testing – microscopy and rapid diagnostic test kits
• Effective treatment – artemisinin containing combination therapy
Drug of Choice for Malaria, Zambia
Malaria on the Bleeding Edge –What Does the Future Hold?
• We have never had the current abundance of resources, enthusiasm and will to deal with malaria
• We have never had so many bed nets distributed, homes sprayed, pregnant women protected and effective treatments available
• We hope the future will bring elimination if the funding continues – stay tuned….
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Tuberculosis
• Tennessee– 3.2 cases per 100,000 population• Zambia– 378 cases per 100,000 population– “The handmaiden of HIV” Sir Richard Feachem– #1 cause of death in HIV+ persons– 70% of patients co‐infected with HIV– Using Directly Observed Therapy Short Course– Laboratory support improving
2008 Annual Health Statistical Bulletin, Zambia, MOH
Human Resource Crisis
• Tennessee– 200 physicians and 991 registered nurses per 100,000 population
• Zambia– 14 physicians and 210 nurses per 100,000 population (Ministry of Health estimates 76 nurses per 100,000)
– MOH calculates it works with about 38% of clinicians it requires
– International brain drain
– Low pay – nurses earn $300‐$400 per month
Bull World Health Organ, 2009;87:225
Human Resource Crisis
– Internal brain drain – aid funds and explosion of Non‐Governmental Organizations
– HIV/AIDS– Task Shifting
• Environmental Health Technicians or day laborers see patients
• Nurses dispense antiretroviral drugs• Clinical officers do surgery• Community Health Workers test for and treat malaria
Zambia National Nursing and Midwifery Strategic Plan 2009‐2013
Human Resources, Zambia, 2009
0200040006000800010000120001400016000
Medical Doctor
Clinical Officer
Midw
ifeNurse
Pharmacy
Laboratorian
Exiting Staff Optimal Positions
Zambia National Nursing and Midwifery Strategic Plan 2009‐2013
Community Health Workers
• Great promise with an expansion of CHW skills and training
• Debate about compensation
• Six‐week training course
• Several studies have shown excellent skills– Diagnose and treat uncomplicated malaria ‐artemisinin‐containing drugs
– Diagnose and treat pneumonia ‐ amoxicillin
Community Health Workers
• New study: diagnosis and treat malaria, pneumonia and diarrhea (oral rehydration solution and zinc)
Population ‐ Growth
• Total Fertility rate– Tennessee
• ~2.1 per woman (average number of children per woman at the end of her child bearing years)
– Zambia• 6.2 per woman – one of the highest in the world
Tennessee Economic Report 2009 / Zambia DHS 2007
79 79
Comparative Fertility Rates
Projected Population Growth, Zambia, 2007‐2037
80
Number of Nurses Required,2007‐2037
81
(actual)
Cholera Cases by District, Zambia, 2010
