Independent and combined effects of improved water, sanitation, and hygiene, and improved complementary feeding, on child stunting and anaemia in rural Zimbabwe: a cluster-randomised trial.

BACKGROUND: Child stunting reduces survival and impairs neurodevelopment. We tested the independent and combined effects of improved water, sanitation, and hygiene (WASH), and improved infant and young child feeding (IYCF) on stunting and anaemia in in Zimbabwe. METHODS: We did a cluster-randomised, community-based, 2 × 2 factorial trial in two rural districts in Zimbabwe. Clusters were defined as the catchment area of between one and four village health workers employed by the Zimbabwe Ministry of Health and Child Care. Women were eligible for inclusion if they permanently lived in clusters and were confirmed pregnant. Clusters were randomly assigned (1:1:1:1) to standard of care (52 clusters), IYCF (20 g of a small-quantity lipid-based nutrient supplement per day from age 6 to 18 months plus complementary feeding counselling; 53 clusters), WASH (construction of a ventilated improved pit latrine, provision of two handwashing stations, liquid soap, chlorine, and play space plus hygiene counselling; 53 clusters), or IYCF plus WASH (53 clusters). A constrained randomisation technique was used to achieve balance across the groups for 14 variables related to geography, demography, water access, and community-level sanitation coverage. Masking of participants and fieldworkers was not possible. The primary outcomes were infant length-for-age Z score and haemoglobin concentrations at 18 months of age among children born to mothers who were HIV negative during pregnancy. These outcomes were analysed in the intention-to-treat population. We estimated the effects of the interventions by comparing the two IYCF groups with the two non-IYCF groups and the two WASH groups with the two non-WASH groups, except for outcomes that had an important statistical interaction between the interventions. This trial is registered with ClinicalTrials.gov, number NCT01824940. FINDINGS: Between Nov 22, 2012, and March 27, 2015, 5280 pregnant women were enrolled from 211 clusters. 3686 children born to HIV-negative mothers were assessed at age 18 months (884 in the standard of care group from 52 clusters, 893 in the IYCF group from 53 clusters, 918 in the WASH group from 53 clusters, and 991 in the IYCF plus WASH group from 51 clusters). In the IYCF intervention groups, the mean length-for-age Z score was 0·16 (95% CI 0·08-0·23) higher and the mean haemoglobin concentration was 2·03 g/L (1·28-2·79) higher than those in the non-IYCF intervention groups. The IYCF intervention reduced the number of stunted children from 620 (35%) of 1792 to 514 (27%) of 1879, and the number of children with anaemia from 245 (13·9%) of 1759 to 193 (10·5%) of 1845. The WASH intervention had no effect on either primary outcome. Neither intervention reduced the prevalence of diarrhoea at 12 or 18 months. No trial-related serious adverse events, and only three trial-related adverse events, were reported. INTERPRETATION: Household-level elementary WASH interventions implemented in rural areas in low-income countries are unlikely to reduce stunting or anaemia and might not reduce diarrhoea. Implementation of these WASH interventions in combination with IYCF interventions is unlikely to reduce stunting or anaemia more than implementation of IYCF alone. FUNDING: Bill & Melinda Gates Foundation, UK Department for International Development, Wellcome Trust, Swiss Development Cooperation, UNICEF, and US National Institutes of Health.The SHINE trial is funded by the Bill & Melinda Gates Foundation (OPP1021542 and OPP113707); UK Department for International Development; Wellcome Trust, UK (093768/Z/10/Z, 108065/Z/15/Z and 203905/Z/16/Z); Swiss Agency for Development and Cooperation; US National Institutes of Health (2R01HD060338-06); and UNICEF (PCA-2017-0002)

Clinical care given to victims of sexual assault at Kadoma General Hospital, Zimbabwe: a secondary data analysis, 2016

Abstract Background Despite the guidelines for managing sexual assault being in place, victims of sexual assault attended to at Kadoma General Hospital consistently raised complaints related to the quality of care offered. Medicolegal data for sexual assault has been collected at the hospital since 2012. However, no analysis had been done regardless of complaints having been raised. We analysed the dataset to determine the quality of clinical care offered to sexual assault victims. Methods A retrospective cross-sectional study based on secondary data was conducted. Epi. Info 7 software was used to analyse data and generate frequencies, measures of central tendency and proportions. Results We analysed 474 medical affidavits completed between January 2014 and July 2016. Thirty percent of the victims sought care within 72 h of the sexual assault. Baseline HIV testing was done in 23 (22%) and follow-up HIV test done in 2 (2%) of the victims. Post Exposure Prophylaxis for HIV was administered to 18 (51%), emergency contraception 9 (69%) and forensic evidence gathered in six (5%) of victims presenting within the prescribed 72 h of the sexual assault. Prophylactic antibiotics were given to 156 (33%). There were no documented counselling sessions for all victims whilst follow up care was given to 47 (10%) victims. Conclusion Suboptimal clinical care was given to victims of sexual assault during the period 2014-2016. These findings suggest possible delayed presentation by victims of sexual assault as well as suboptimal administration of prophylaxis by health care workers. We recommend adherence to guidelines in managing sexual assault. Further research to determine factors for delayed presentation among sexual assault victims and quality of care provided to them is recommended

Evaluation of the acute flaccid paralysis (AFP) surveillance system in Mwenezi district, Masvingo, 2018: a descriptive study

Abstract Objectives Poliomyelitis is an infectious disease caused by the polio virus which affects mostly young children below the age of 15 years. For surveillance children with acute flaccid paralysis (AFP) are tracked. In Zimbabwe every district should report two cases per 100,000 population of children under the age of 15 years old. In 2017, Mwenezi district failed to detect any AFP cases. We therefore evaluated the AFP surveillance system in Mwenezi district. We conducted a surveillance system evaluation using the updated Centers for Disease Control guidelines for evaluating public health surveillance systems. We interviewed health workers in Mwenezi district and looked at AFP records from January to December 2017. Results The main reasons for failure to report a case in 2017 were the vastness of the district with bad road networks as well as lack of a dedicated vehicle to carry out EPI outreach activities. About a quarter, 24%, of the health workers did not know the specimen that is used in AFP diagnosis. The AFP surveillance system in Mwenezi district was performing poorly due to lack of active search of cases in the community caused by disruption of EPI outreach activities

Evaluation of the adverse events following immunization surveillance system in Guruve district, Mashonaland Central 2017

Introduction: an adverse event following immunisation is any untoward medical occurrence which follows vaccination. Frequency of adverse events ranges from 13% to 34% and they should be reported regardless of severity. From the beginning of 2016 to mid-2017, Guruve district in Zimbabwe did not report any AEFIs. This suggests the surveillance system may be failing to detect adverse events. We therefore evaluated the AEFI surveillance system in Guruve district. Methods: we conducted a surveillance system evaluation using the updated Centers for Disease Control guidelines for evaluating public health surveillance systems. We interviewed health workers and caregivers of babies under 2 years in Guruve district. We also reviewed all records on AEFI surveillance for the period of January 2016 to November 2017. Results: we recruited 31 health workers and 33 caregivers into the study. Between January 2016 and mid-2017, 39% of the caregivers had children who had suffered AEFIs and 45% of the health workers had encountered AEFIs but none had been notified. The main reasons for failure to report AEFIs included health workers' fear of personal consequences and caregivers thinking that an adverse event was not serious enough to report. Knowledge of the surveillance system was good amongst the majority of health workers. All the resources needed by the surveillance system were available. Conclusion: we concluded that health workers in Guruve district were afraid to report adverse events following immunization and caregivers were reluctant to report mild adverse events hence the surveillance system was performing poorly and was not useful. However, the stability of the system and the good knowledge gives a good foundation for improving the surveillance system

Virological failure among adolescents on ART, Harare City, 2017- a case-control study

Abstract Background Zimbabwe is on track towards achieving viral suppression among adults (87%). However, adolescents have only achieved 44% by 2016. In Harare city, 57% of adolescents had attained viral suppression after 12 months on ART compared to 88% among adults. We determined factors associated with virological failure among adolescents (age 10–19 years) on antiretroviral therapy (ART) in Harare city. Methods We conducted a one to one unmatched case control study among 102 randomly recruited case: control pairs at the two main infectious disease hospitals in Harare. A case was any adolescent who presented with VL > 1000c/ml after at least 12 months on ART. A control was any adolescent who presented with VL < 1000c/ml after at least 12 months on ART. Interviewer administered questionnaires were used to collect data. Epi Info 7 was used to generate frequencies, means, proportions, ORs and p-values at 95% CI. Results We interviewed 102 case-control pairs. Poor adherence to ART [aOR = 8.15, 95% CI (2.80–11.70)], taking alcohol [aOR = 8.46, 95% CI (3.22–22.22)] and non- disclosure of HIV status [aOR = 4.56, 95% CI (2.20–9.46)] were independent risk factors for virological failure. Always using a condom [aOR = 0.04, 95% CI (0.01–0.35)], being on second line treatment [aOR = 0.04, 95% CI (0.23–0.81)] and belonging to a support group [aOR = 0.41, 95% CI (0.21–0.80)] were protective. Conclusion Poor adherence, alcohol consumption and non-disclosure increased the odds of virological failure. Based on these findings support should focus on behavior change and strengthening of peer to peer projects to help address issues related to disclosure and adherence. Further operational research should aim to define other components of effective adherence support for adolescents with virological failure

Cholera case management in Harare City, 2018: are we doing the right things right?

Introduction: On September 6, 2018, a cholera outbreak was declared in Harare City. By September 17,31 deaths out of 3564 cases had occurred with a case fatality rate of 0.9%. Despite having sensitised staff on cholera case management, resources and a rapid response team being in place, 20 of 31 deaths (65%) occurred within cholera treatment centers. A September 12 situation report revealed that the cholera strain was resistant to ceftriaxone and ciprofloxacin and sensitive to azithromycin and imipinem. We assessed the quality of cholera case management. Methods: We carried out a descriptive cross-sectional study of records and observations for case management. Using a data extraction form, we extracted and reviewed 264 records of clients who were treated at major health facility in Harare City. Observations of patient triaging and treatment were done and case management was compared to Zimbabwe Cholera Control Guidelines standards. Data were entered into Epi info 7TM to calculate frequencies, means and proportions. Results: Antibiotic prescribing, fluid management and laboratory investigations were the quality indicators assessed. Intravenous (IV) fluids and oral rehydration solution (ORS) were documented for 73/264 (28%) and 78/264 (29%) of cases respectively. Out of 252 who had prescribed fluids, only 17/252 (7%) of the cases received adequate amount of fluids as prescribed. Ciprofloxacin was prescribed for 166/264 (63%) of cases with only 9/264 (3%) receiving azithromycin. The majority 93/95 (98%) and 69/95 (64%) of cholera case strains were resistant to ceftrioxone and ciprofloxacin respectively. Conclusion: There was over prescription of antibiotics. Fluid management was not according to hydration status and weight as stipulated in the cholera treatment guidelines. The results were shared with Harare City Health department. We recommended strengthening of record documentation, continuous mentorship on case management and use of guidelines to ensure rational drug use

Virological failure among adolescents on ART, Harare City, 2017- a case-control study

Abstract Background Zimbabwe is on track towards achieving viral suppression among adults (87%). However, adolescents have only achieved 44% by 2016. In Harare city, 57% of adolescents had attained viral suppression after 12 months on ART compared to 88% among adults. We determined factors associated with virological failure among adolescents (age 10–19 years) on antiretroviral therapy (ART) in Harare city. Methods We conducted a one to one unmatched case control study among 102 randomly recruited case: control pairs at the two main infectious disease hospitals in Harare. A case was any adolescent who presented with VL > 1000c/ml after at least 12 months on ART. A control was any adolescent who presented with VL < 1000c/ml after at least 12 months on ART. Interviewer administered questionnaires were used to collect data. Epi Info 7 was used to generate frequencies, means, proportions, ORs and p-values at 95% CI. Results We interviewed 102 case-control pairs. Poor adherence to ART [aOR = 8.15, 95% CI (2.80–11.70)], taking alcohol [aOR = 8.46, 95% CI (3.22–22.22)] and non- disclosure of HIV status [aOR = 4.56, 95% CI (2.20–9.46)] were independent risk factors for virological failure. Always using a condom [aOR = 0.04, 95% CI (0.01–0.35)], being on second line treatment [aOR = 0.04, 95% CI (0.23–0.81)] and belonging to a support group [aOR = 0.41, 95% CI (0.21–0.80)] were protective. Conclusion Poor adherence, alcohol consumption and non-disclosure increased the odds of virological failure. Based on these findings support should focus on behavior change and strengthening of peer to peer projects to help address issues related to disclosure and adherence. Further operational research should aim to define other components of effective adherence support for adolescents with virological failure

Tuberculosis cohort analysis in Zimbabwe: The need to strengthen patient follow-up throughout the tuberculosis care cascade.

IntroductionGlobally people with tuberculosis (TB) continue to be missed each year. They are either not diagnosed or not reported which indicates possible leakages in the TB care cascade. Zimbabwe is not spared with over 12000 missed cases in 2020. A preliminary review of TB treatment outcomes indicated patient leakages throughout the presumptive cascade and undesirable treatment outcomes in selected cities. Chegutu District had pre-diagnosis and pretreatment losses to follow-up while Mutare City among others had 22.0% of outcomes not evaluated in the second quarter of 2021, and death rates as high as 14% were recorded in Gweru District. The problem persists despite training on data analysis and use. The TB cohorts were analysed to determine the performance of the care cascade and the spatial distribution of treatment outcomes in Zimbabwe.MethodsUsing data from district health information software version 2.3 (DHIS2.3), a secondary data analysis of 2020 drug-sensitive (DS) TB treatment cohorts was conducted. We calculated the percentage of pre-diagnosis, and pre-treatment loss to follow-up (LTFU). For TB treatment outcomes, 'cured' and 'treatment completed' were categorized as treatment success, while 'death', 'loss to follow-up (LTFU), and 'not evaluated' were categorized as undesirable outcomes. Univariate analysis of the data was conducted where frequencies were calculated, and data was presented in graphs for the cascade, treatment success, and undesirable outcomes while tables were created for the description of study participants and data quality. QGIS was used to generate maps showing undesirable treatment outcomes.ResultsAn analysis of national data found 107583 people were presumed to have TB based on symptomatic screening and or x-ray and 21.4% were LTFU before the specimen was investigated. Of the 84534 that got tested, 10.0% did not receive their results. The treatment initiation rate was 99.1%. Analysis of treatment outcomes done at the provincial level showed that Matabeleland South Province had the lowest treatment success rate of 77.3% and high death rates were recorded in Matabeleland South (30.0%), Masvingo (27.3%), and Matabeleland North (26.1%) provinces. Overall, there were high percentages of not-evaluated treatment outcomes.ConclusionPre-diagnosis LTFU was high, and high death and loss to follow-up rates were prevalent in provinces with artisanal and small-scale mining (ASM) activities. Unevaluated treatment outcomes were also prevalent and data quality remains a challenge within the national TB control program. We recommended strengthening patient follow-up at all levels within the TB care cascade, strengthening capacity-building for data analysis and use, further analysis to determine factors associated with undesirable outcomes and a study on why LTFU remains high

Utilisation of Medical Services and Outcomes at Adult Rape Clinic at Parirenyatwa Group of Hospitals, Zimbabwe

Sexual violence is a major public health problem due to the associated risk of acquiring sexually transmitted infections, behavioural disorders and risk of committing suicide. The Adult Rape Clinic (ARC) was established at Parirenyatwa Hospital, Harare in 2009 with the objective of providing medical and support services for survivors of sexual violence in a safe and private environment. The data collected had never been analysed since the  establishment of the clinic. We described the clients‘ profile and the services offered at the clinic to identify gaps in service provision and areas of improvement. A retrospective record review of data was carried out from the ARC collected from February 2009 to December 2017. We analyzed 2343 affidavits that were available. Out of 2343 records analysed, (2190) 93.5% were female and 6.5 % (153) were male. The median age was 23years (Q1=21; Q3= 29) for males and 19 years (Q1= 17; Q2=25) for females. Among the clients, 2164 (92.4%) received a baseline HIV test, and 263 females and 6 males tested positive. From 2010 to 2017, six clients‘ seroconversion was recorded. Only 863(36.8%) clients presented within 3 days after the sexual assault. About 40% of male victims were assaulted by someone they knew and 27% were married. The study recommends further research on the determinants of late presentation after sexual assault. (Afr J Reprod Health 2019; 23[4]: 99-107).Keywords: Sexual violence, HIV test, maleLa violence sexuelle est un problème de santé publique majeur en raison du risque associé de contracter des infections sexuellement transmissibles, des troubles du comportement et du risque de suicide. La Clinique du viol pour adultes (CVA) a été créée à l'hôpital Parirenyatwa de Harare en 2009 dans le but de fournir des services médicaux et de soutien aux victimes de violences sexuelles dans un environnement sûr et privé. Les données  recueillies n'avaient jamais été analysées depuis la création de la clinique. Nous avons décrit le profil des clients et les services offerts à la clinique pour identifier les lacunes dans la prestation de services et les domaines à améliorer. Un examen rétrospectif des données a été effectué auprès de la CVA recueilli de février 2009 à décembre 2017. Nous avons analysé 2343 déclarations disponibles. Sur 2343 enregistrements analysés, (2190)93, 5% étaient des femmes et 6,5% (153) étaient des hommes. L'âge médian était de 23 ans (Q1 = 21; Q3 = 29) pour les hommes et 19 ans (Q1 = 17; Q2 = 25) pour les femmes. Parmi les clients, 2164 (92,4%) ont reçu un test de base du VIH, et 263 femmes et 6 hommes ont été positifs. De 2010 à 2017, la séroconversion de six clients a été enregistrée. Seulement 863 clients (36,8%) se sont présentés dans les 3 jours suivant l'agression sexuelle. Environ 40% des victimes masculines ont été agressées par une personne qu'elles connaissaient et 27% étaient mariées. L'étude recommande de poursuivre les recherches sur les déterminants de la présentation tardive après une agression sexuelle.Mots-clés: Violence sexuelle, test VIH, homm