Typhoid outbreak investigation in Dzivaresekwa, suburb of Harare City, Zimbabwe, 2011

Introduction: Typhoid fever is a systemic infection caused by a Gram negative bacterium, Salmonella  typhi. Harare City reported 1078 cases of suspected typhoid fever cases from October  011 to January 2012. We initiated an investigation to identify possible source of transmission so as to institute control measures. Methods: An unmatched 1:1 case-control study was conducted. A questionnaire was administered to study participants to identify risk factors for contracting typhoid. A case was a resident of Dzivaresekwa who presented with signs and symptoms of typhoid between October and December 2011. Water  samples were collected for microbiological analysis. Results: 115 cases and 115 controls were enrolled. Drinking water from a well (OR= 6.2 95% CI  (2.01-18.7)), attending a gathering (OR= 11.3 95% CI (4.3-29.95)), boiling drinking water (OR= 0.21 95% CI (0.06-0.76)) and burst sewer pipe at home (OR= 1.19 95% CI (0.67-2.14)) were factors  associated with contracting typhoid. Independent risk factors for contracting typhoid were drinking water from a well (AOR=5.8; 95% CI (1.90-17.78)), and burst sewer pipe at home (AOR=1.20; 95% CI (1.10-2.19)). Faecal coli forms and E. coli were isolated from 8/8 well water samples. Stool, urine and blood specimens were cultured and serotyped for Salmonella typhi and 24 cases were confirmed positive. Shigella, Giardia and E coli were also isolated. Ciprofloxacin, X-pen and Rocephin were used for case  management. No complications were reported. Conclusion: Contaminated water from unprotected water sources was the probable source of the  outbreak. Harare City Engineer must invest in repairing water and sewage reticulation systems in the city.Key words: Typhoid, outbreak investigation, contaminated water, Zimbabwe

Evaluation of the adverse events following immunizations surveillance system in Harare City, Zimbabwe, 2016: a descriptive cross sectional study

Introduction: Vaccines safety are monitored by looking for Adverse Events Following Immunizations (AEFIs). A review of the 2014 Harare City consolidated monthly return form (T5) revealed that 28 AEFIs were seen in 2014. However, only 21 were reported through the system. We therefore evaluated the Harare City AEFI surveillance system to assess its usefulness. Methods: A descriptive cross sectional study was conducted. Twenty one of 41 clinics were randomly selected and 51 health workers were randomly recruited. Interviewer administered questionnaires were used to collect data. Epi info 7 was used to generate frequencies, means and proportions. Results: Out of 51 respondents, 50 (98%) knew the purpose of AEFI system, 48 (94%) knew at least two presenting symptoms of AEFIs and 39 (77%) knew the correct date of form submission to the next level. Receiving no feedback 24 (47.1%), fear of victimisation 16 (31.4%) and work overload 11 (21.6%) were the major reasons for under reporting. Eighty six percent perceived the system to be simple and 43 (84%) were willing to continue participating. Fifty three percent (27) reported taking public health actions (such as awareness campaigns & making follow ups) basing on AEFI data collected. All 46 reviewed forms were completely filled and submitted in time. All 21 clinics had written AEFI guidelines and case definitions. Only 14 of 21 clinics had adequately stocked emergency drugs. The total cost for a single notification was estimated at US$22.30. Conclusion: The system was useful, simple, acceptable, timely, stable, representative but costly. The good performance of the system reported in this evaluation could be attributed to high health worker knowledge. Following this evaluation, replenishment of out of stock drugs and follow up of missing 2014 AEFI feedback from MCAZ were done. In addition, making the system electronic is recommended

Evaluation of sexual and gender-based violence program in Harare City, Zimbabwe, 2016: a descriptive cross-sectional study

Introduction: in Zimbabwe, there is a gap between sexual violence (SV) survivors' health care needs versus the existing facilities. Harare city started Sexual Gender Based Violence (SGBV) project in 2011, with the aim to reduce SV morbidity.Only 592 (42%) of 1425 SV survivors reported for medical services within 72 hours in 2015. HIV post-exposure prophylaxis (PEP) is effective within 72hours of post exposure. We evaluated the program performance in Harare city. Methods: we conducted a process-outcome evaluation using a logic model. We purposively recruited all eight SGBV sites and key informants. We randomly selected 27nurses into the study. Interviewer-administered questionnaires and checklists were used to collect data. To generate frequencies, means and proportions we used Epi info 7. Results: the program adequately received inputs except for counselling rooms (1/8). About 4285 survivors were recorded from 2013-2016. Of these, 97% were counselled, 93% received HIV test, 41% reported to the clinic within 72hrs of post-rape, and 12% received PEP. About 16% of the total survivors were followed up. The programme failed to meet its targets on decentralised sites (8/10), awareness campaigns(16/32) and sensitisation activities(16/32). About 500(12.5%) IEC materials were distributed. All 96-targeted supervisory visits were achieved. Two ofeight district supervisors were trained. Majority of health workers(25/35) citedlack of awareness as major reasons for underperformance. Conclusion: availability of resources did not translate to program performance. Most survivors were not reporting to the clinic timeously due to the low level of awareness of the programme to the community, hence were not protected from getting HIV through PEP. The programme was not well disseminated, as most supervisors were not trained. Following this evaluation, we distributed150 IEC materials to each of the eight facilities. A follow-up study on outcomes of clients referred for services and training of district officers were recommended

Community health worker support to improve HIV treatment outcomes for older children and adolescents in Zimbabwe: a process evaluation of the ZENITH trial.

BACKGROUND: Community health worker (CHW)-delivered support visits to children living with HIV and their caregivers significantly reduced odds of virological failure among the children in the ZENITH trial conducted in Zimbabwe. We conducted a process evaluation to assess fidelity, acceptability, and feasibility of this intervention to identify lessons that could inform replication and scale-up of this approach. METHODS: Field manuals kept by each CHW, records from monthly supervisory meetings, and participant data collected throughout the trial were used to assess the intervention's implementation. Data extracted from field manuals included visit type, content, and duration. Minutes from monthly supervisory meetings were used to capture CHW attendance. RESULTS: The trial enrolled 172 participants in the intervention arm of whom 5 subsequently refused all visits, 1 died before the intervention could be delivered, and 1 could not be located. Manuals for 8 participants were not returned, 3 were incorrectly entered, and 1 manual was lost. We had 154 manuals available for analysis. A total of 1553 visits were successfully conducted (median 11 per participant, range 1-20). Additionally, CHWs made 85 visits where they were unable to make contact with the family. Thirteen (8.4%) participants received 5 or fewer visits, 10 moved out of the study area, and 3 died. CHWs discussed disclosure with the child/family for over 89% of participants and assisted clients with developing and reviewing their personal treatment plan with over 85% of participants. Of the 20 CHWs (3 male, 17 female) selected to implement the intervention, 19 were retained at the end of the trial. CONCLUSIONS: The intervention was acceptable to participants with most receiving and accepting the required number of visits. Key strenghts were high staff retention and fidelity to the intervention. This community-based intervention was an acceptable and feasible approach to reduce virological failure among children living with HIV. TRIAL REGISTRATION: The ZENITH trial was registered on 25 October 2012 in the Pan African Clinical Trials Registry under the trial registration number PACTR201212000442288 . It can be found at http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201212000442288

Chronic Morbidity Among Older Children and Adolescents at Diagnosis of HIV Infection.

BACKGROUND: Substantial numbers of children with HIV present to health care services in older childhood and adolescence, previously undiagnosed. These "slow-progressors" may experience considerable chronic ill health, which is not well characterized. We investigated the prevalence of chronic morbidity among children aged 6-15 years at diagnosis of HIV infection. METHODS: A cross-sectional study was performed at 7 primary care clinics in Harare, Zimbabwe. Children aged 6-15 years who tested HIV positive following provider-initiated HIV testing and counseling were recruited. A detailed clinical history and standardized clinical examination was undertaken. The association between chronic disease and CD4 count was investigated using multivariate logistic regression. RESULTS: Of the 385 participants recruited [52% female, median age 11 years (interquartile range 8-13)], 95% were perinatally HIV infected. The median CD4 count was 375 (interquartile range 215-599) cells per cubic millimeter. Although 78% had previous contact with health care services, HIV testing had not been performed. There was a high burden of chronic morbidity: 23% were stunted, 21% had pubertal delay, 25% had chronic skin disease, 54% had a chronic cough of more than 1 month-duration, 28% had abnormal lung function, and 12% reported hearing impairment. There was no association between CD4 count of <500 cells per cubic millimeter or <350 cells per cubic millimeter with WHO stage or these chronic conditions. CONCLUSIONS: In children with slow-progressing HIV, there is a substantial burden of chronic morbidity even when CD4 count is relatively preserved. Timely HIV testing and prompt antiretroviral therapy initiation are urgently needed to prevent development of chronic complications

The role of community health workers in improving HIV treatment outcomes in children: lessons learned from the ZENITH trial in Zimbabwe.

Reliance on community health workers (CHWs) for HIV care continues to increase, particularly in resource-limited settings. CHWs can improve HIV service use and adherence to treatment, but effectiveness of these programmes relies on providing an enabling work environment for CHWs, including reasonable workload, supportive supervision and adequate training and supplies. Although criteria for effective CHW programmes have been identified, these have rarely been prospectively applied to design and evaluation of new interventions. For the Zimbabwe study for Enhancing Testing and Improving Treatment of HIV in Children (ZENITH) randomized controlled trial, we based our intervention on an existing evidence-based framework for successful CHW programmes. To assess CHWs' experiences delivering the intervention, we conducted longitudinal, qualitative semi-structured interviews with all 19 CHWs at three times during implementation. The study aimed to explore CHWs' perceptions of how the intervention's structure and management affected their performance, and consider implications for the programme's future scale-up and adoption in other settings. CHWs expressed strong motivation, commitment and job satisfaction. They considered the intervention acceptable and feasible to deliver, and levels of satisfaction rose over interview rounds. Intensive supervision and mentoring emerged as critical to ensuring CHWs' long-term satisfaction. Provision of job aids, standardized manuals and refresher training were also important, as were formalized links between clinics and CHWs. Concerns raised by CHWs included poor remuneration, their reluctance to stop providing support to individual families following the requisite number of home visits, and disappointment at the lack of programme sustainability following completion of the trial. Furthermore, intensive supervision and integration with clinical services may be difficult to replicate outside a trial setting. This study shows that existing criteria for designing successful CHW programmes are useful for maximizing effectiveness, but challenges remain for ensuring long-term sustainability of 'task shifting' strategies

Familial silence surrounding HIV and non-disclosure of HIV status to older children and adolescents.

Increasing numbers of children with HIV are surviving to adolescence and beyond, many of whom are orphaned. Disclosure of childrens' and adolescents' HIV status has been shown to improve adherence and retention in HIV treatment programmes. We investigated caregiving arrangements and intra-familial experience of HIV and its relationship to HIV disclosure to older children and adolescents. Children aged 6-15 years, newly diagnosed with HIV infection or previously diagnosed but not engaged in HIV care, were recruited from seven primary care clinics in Harare, Zimbabwe. Their caregivers responded to a nurse-led questionnaire. Family history of HIV, disclosure of HIV status to the child and reasons for non-disclosure were ascertained. The association between sociodemographics, caregiving, family HIV history and other characteristics and non-disclosure of HIV status to the child was determined using univariate and multivariate logistic regression. We recruited 385 participants, median age = 11 years (IQR: 9-13); 52% were female. Disclosure had occurred in 79% of children aged 11-15 years and 19% of children aged 6-10 years. Age under 11 years (adjusted OR [aOR] = 18.89, 95% confidence interval [CI] = 10.64-33.55; p < 0.001), being male [aOR]= 2.56, 95% CI = 1.49-4.54; p = 0.001, being unaware of the parents' HIV status [aOR]= 32.42, 95% CI = 13.19-79.71; p < 0.001, and being newly diagnosed [aOR]= 2.52, 95% CI = 1.29-4.91; p = 0.007, were independently associated with non-disclosure. Disclosure outside of the family occurred infrequently and included friends of family (7%), school teacher (8%), school headmaster (4%) and church pastor (6%). High non-disclosure rates were present as well as a lack of discussion about HIV within the family. Disclosure outside of family was low reflecting difficulty in caregivers' ability to discuss HIV with their child or surrounding community. HIV programmes need to support families in the disclosure process

Economic incentives for HIV testing by adolescents in Zimbabwe: a randomised controlled trial.

BACKGROUND: HIV testing is the important entry point for HIV care and prevention service, but uptake of HIV testing and thus coverage of antiretroviral therapy are much lower in older children and adolescents than in adults. We investigated the effect of economic incentives provided to caregivers of children aged 8-17 years on uptake of HIV testing and counselling in Harare, Zimbabwe. METHODS: This randomised controlled trial was nested within a household HIV prevalence survey of children aged 8-17 years in Harare. Households with one or more survey participants whose HIV status was unknown were eligible to participate in the trial. Eligible households were randomly assigned (1:1:1) to either receive no incentive, receive a fixed US$2 incentive, or participate in a lottery for$5 or $10 if the participant presented for HIV testing and counselling at a local primary health-care centre. The survey fieldworkers who enrolled participants were not blinded to trial arm allocation, but the statistician was blinded for analysis of outcome. The primary outcome was the proportion of households in which at least one child had an HIV test within 4 weeks of enrolment. HIV test uptake in the incentivised groups was compared with uptake in the non-incentivised group using logistic regression, adjusting for community and number of children as fixed effects and research assistant as a random effect. All analyses were by intention to treat. The trial is registered with the Pan African Clinical Trials Registry, number PACTR201605001615280. FINDINGS: Between Aug 4, and Dec 18, 2015, 2050 eligible households were enrolled in the prevalence survey. 649 (32$2 incentive, and 661 (32%) households were assigned to lottery participation. Children were unavailable in 148 households in the no-incentive group, 63 households in the $2 incentive group, and 81 households in the lottery group. 1688 households had at least one child with unknown HIV status and were enrolled into the trial. 22 households had no undiagnosed child, and one household refused consent. The primary outcome of HIV testing was assessed in 472 (28$2 incentive group, and 562 (33%) households in the lottery group. At least one child was HIV tested in 93 (20%) households in the no-incentive group, in 316 (48%) households in the $2 incentive group (adjusted odds ratio 3·67, 95% CI 2·77-4·85; p<0·0001), and in 223 (40%) of 562 households in the lottery group (2·66, 2·00-3·55; p<0·0001). No adverse events were reported. INTERPRETATION: Fixed incentives and lottery-based incentives increased the uptake of HIV testing by older children and adolescents, a key hard-to-reach population. This strategy would be sustainable in the context of vertical HIV infection as repeated testing would not be necessary until sexual debut. FUNDING: Wellcome Trust

Clinical outcomes in children and adolescents initiating antiretroviral therapy in decentralized healthcare settings in Zimbabwe.

INTRODUCTION: Decentralized HIV care for adults does not appear to compromise clinical outcomes. HIV care for children poses additional clinical and social complexities. We conducted a prospective cohort study to investigate clinical outcomes in children aged 6-15 years who registered for HIV care at seven primary healthcare clinics (PHCs) in Harare, Zimbabwe. METHODS: Participants were recruited between January 2013 and December 2014 and followed for 18 months. Rates of and reasons for mortality, hospitalization and unscheduled PHC attendances were ascertained. Cox proportional modelling was used to determine the hazard of death, unscheduled attendances and hospitalization. RESULTS: We recruited 385 participants, median age 11 years (IQR: 9-13) and 52% were female. The median CD4 count was 375 cells/mm3 (IQR: 215-599) and 77% commenced ART over the study period, with 64% of those who had viral load measured achieving an HIV viral load <400 copies/ml. At 18 months, 4% of those who started ART vs. 24% of those who remained ART-naïve were lost-to-follow-up (p < 0.001). Hospitalization and mortality rates were low (8.14/100 person-years (pyrs) and 2.86/100 pyrs, respectively). There was a high rate of unscheduled PHC attendances (34.94/100 pyrs), but only 7% resulted in hospitalization. Respiratory disease was the major cause of hospitalization, unscheduled attendances and death. CD4 count <350cells/mm3 was a risk factor for hospitalization (aHR 3.6 (95%CI 1.6-8.2)). CONCLUSIONS: Despite only 64% of participants achieving virological suppression, clinical outcomes were good and high rates of retention in care were observed. This demonstrates that in an era moving towards differentiated care in addition to implementation of universal treatment, decentralized HIV care for children is achievable. Interventions to improve adherence in this age-group are urgently needed

Clinical and bacteriological outcomes in patients with urinary tract infections presenting to primary care in Harare, Zimbabwe: a cohort study

Background: Treatment for urinary tract infections (UTIs) is usually empiric and is based on local antimicrobial resistance data. These data, however, are scarce in low-resource settings. The aim of this study is to determine the impact of antibiotic treatment on clinical and bacteriological outcomes in patients presenting with UTI symptoms to primary care in Harare. Methods: This cohort study enrolled participants presenting with UTI symptoms to 10 primary healthcare clinics in Harare between July 2019 and July 2020. A questionnaire was administered and a urine sample was collected for culture. If the urine culture showed growth of ≥105 colony forming units/mL of a uropathogen, a follow up visit at 7-21 days was conducted. Results: The analysis included 168 participants with a median age of 33.6 years (IQR 25.1-51.4) and of whom 131/168 (78.0%) were female. Effective treatment was taken by 54/168 (32.1%) participants. The urine culture was negative at follow up in 41/54 (75.9%) of participants who took appropriate treatment and in 33/114 (28.9%, p&lt;0.001) of those who did not. Symptoms had improved or resolved in 52/54 (96.3%) of those on appropriate treatment and in 71/114 (62.3%, p&lt;0.001) of those without. Conclusion: The findings of this study show that effective treatment leads to symptom resolution and bacterial clearance in people presenting with UTIs to primary care. Although UTIs are not life-threatening and can resolve without treatment, they do impact on quality of life, highlighting the need for optimised treatment recommendations.</ns4:p