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[This corrects the article DOI: 10.1371/journal.pmed.1002811.].

BackgroundAlthough the success of HIV treatment programs depends on retention and viral suppression, routine program monitoring of these outcomes may be incomplete. We used data from the national electronic medical record (EMR) system in Zambia to enumerate a large and regionally representative cohort of patients on treatment. We traced a random sample with unknown outcomes (lost to follow-up) to document true care status and HIV RNA levels.Methods and findingsOn 31 July 2015, we selected facilities from 4 provinces in 12 joint strata defined by facility type and province with probability proportional to size. In each facility, we enumerated adults with at least 1 clinical encounter after treatment initiation in the previous 24 months. From this cohort, we identified lost-to-follow-up patients (defined as 90 or more days late for their last appointment), selected a random sample, and intensively reviewed their records and traced them via phone calls and in-person visits in the community. In 1 of 4 provinces, we also collected dried blood spots (DBSs) for plasma HIV RNA testing. We used inverse probability weights to incorporate sampling outcomes into Aalen-Johansen and Cox proportional hazards regression to estimate retention and viremia. We used a bias analysis approach to correct for the known inaccuracy of plasma HIV RNA levels obtained from DBSs. From a total of 64 facilities with 165,464 adults on ART, we selected 32 facilities with 104,966 patients, of whom 17,602 (17%) were lost to follow-up: Those lost to follow-up had median age 36 years, 60% were female (N = 11,241), they had median enrollment CD4 count of 220 cells/μl, and 38% had WHO stage 1 clinical disease (N = 10,690). We traced 2,892 (16%) and found updated outcomes for 2,163 (75%): 412 (19%) had died, 836 (39%) were alive and in care at their original clinic, 457 (21%) had transferred to a new clinic, 255 (12%) were alive and out of care, and 203 (9%) were alive but we were unable to determine care status. Estimates using data from the EMR only suggested that 42.7% (95% CI 38.0%-47.1%) of new ART starters and 72.3% (95% CI 71.8%-73.0%) of all ART users were retained at 2 years. After incorporating updated data through tracing, we found that 77.3% (95% CI 70.5%-84.0%) of new initiates and 91.2% (95% CI 90.5%-91.8%) of all ART users were retained (at original clinic or transferred), indicating that routine program data underestimated retention in care markedly. In Lusaka Province, HIV RNA levels greater than or equal to 1,000 copies/ml were present in 18.1% (95% CI 14.0%-22.3%) of patients in care, 71.3% (95% CI 58.2%-84.4%) of lost patients, and 24.7% (95% CI 21.0%-29.3%). The main study limitations were imperfect response rates and the use of self-reported care status.ConclusionsIn this region of Zambia, routine program data underestimated retention, and the point prevalence of unsuppressed HIV RNA was high when lost patients were accounted for. Viremia was prevalent among patients who unofficially transferred: Sustained engagement remains a challenge among HIV patients in Zambia, and targeted sampling is an effective strategy to identify such gaps in the care cascade and monitor programmatic progress.

Objective To determine whether the administration of rectal artesunate by trained community health volunteers before referral to a healthcare facility reduces the case fatality rate of severe malaria in young children in hard-to-reach communities in Zambia. Methods We implemented a pilot project in Serenje District between July 2017 and July 2018. The project involved: (i) training community health volunteers to administer rectal artesunate to children with suspected severe malaria and refer them to a health facility; (ii) ensuring emergency transport with bicycle ambulances was available; (iii) ensuring adequate drug supplies; and (iv) ensuring health-care workers could treat severe malaria with injectable artesunate. Surveys of health facilities, volunteers and bicycle ambulance riders were performed near the beginning and end of the intervention period. In addition, data on severe malaria cases and associated deaths were obtained from health facilities and a community monitoring system. Findings In the year before the intervention, 18 deaths occurred in 224 cases of confirmed severe malaria among children younger than 5 years seen at intervention health facilities (case fatality rate: 8%); during the intervention, 3 of 619 comparable children with severe malaria died (case fatality rate: 0.5%). Conclusion The administration of pre-referral rectal artesunate treatment to young children with severe malaria by community health volunteers was feasible, safe and effective in hard-to-reach communities in Zambia and was associated with a substantial decrease in the case fatality rate. The project's approach is highly adaptable and could be used in other countries with a high malaria burden. Objectif Determiner si l'administration d'artesunate par voie rectale par des agents de sante communautaires benevoles, avant transfert vers un etablissement de soins, reduit le taux de letalite du paludisme grave chez les jeunes enfants dans les communautes reculees de Zambie. Methodes Nous avons mis en reuvre un projet pilote dans le district de Serenje entre juillet 2017 et juillet 2018. Ce projet a implique de: (i) former des agents de sante communautaires benevoles a administrer de l'artesunate par voie rectale aux enfants chez lesquels un paludisme grave etait suspecte et a les transferer vers un etablissement de sante; (ii) garantir la disponibilite de velo-ambulances comme moyen de transport d'urgence; (iii) garantir des stocks suffisants de medicaments; (iv) s'assurer que les professionnels de sante puissent traiter le paludisme grave avec de l'artesunate injectable. Des enquetes ont ete effectuees aupres des etablissements de sante, des benevoles et des conducteurs de velo-ambulances vers le debut et la fin de la periode d'intervention. Des donnees sur les cas de paludisme grave et les deces associes ont egalement ete obtenues des etablissements de sante et des systemes de suivi communautaires. Resultats Lannee qui a precede l'intervention, 18 deces sont survenus, sur 224 cas de paludisme grave confirme chez des enfants de moins de 5 ans repus dans des etablissements de sante ayant participe a l'intervention (taux de letalite: 8%). Durant l'intervention, 3 enfants sont decedes, sur 619 cas comparables de paludisme grave (taux de letalite: 0,5%). Conclusion L'administration d'un traitement pre-transfert compose d'artesunate par voie rectale chez les jeunes enfants atteints de paludisme grave, par des agents de sante communautaires benevoles, s'est averee realisable, sure et efficace dans les communautes reculees de Zambie, et etait associee a une baisse consequente du taux de letalite. Lapproche adoptee dans ce projet est tout a fait adaptable et pourrait etre appliquee dans d'autres pays fortement touches par le paludisme. Objetivo Determinar si la administracion de artesunato rectal por parte de voluntarios sanitarios comunitarios capacitados antes de ser remitidos a un centro de atencion de la salud reduce la tasa de letalidad por paludismo grave en ninos pequenos de comunidades de dificil acceso en Zambia. Metodos Se implemento un proyecto piloto en el distrito de Serenje entre julio de 2017 y julio de 2018. El proyecto involucraba: (i) capacitar a voluntarios sanitarios comunitarios para que administren artesunato rectal a ninos con sospecha de paludismo grave y los remitan a un centro de salud; (ii) garantizar la disponibilidad de transporte de emergencia con bici-ambulancias; (iii) garantizar el suministro adecuado de medicamentos; y (iv) garantizar que los trabajadores de atencion a la salud puedan tratar el paludismo grave con artesunato inyectable. Las encuestas a los centros de salud, voluntarios y conductores de biciambulancias se realizaron cerca del comienzo y el final del periodo de intervencion. Ademas, se obtuvieron datos sobre los casos de paludismo grave y las muertes conexas de los centros de salud y de un sistema comunitario de vigilancia. Resultados El ano anterior a la intervencion, se produjeron 18 muertes en 224 casos confirmados de paludismo grave entre ninos menores de 5 anos atendidos en los centros de salud de la intervencion (tasa de letalidad: 8 %); durante la intervencion, murieron 3 de los 619 ninos comparables con paludismo grave (tasa de letalidad: 0,5 %). Conclusion La administracion de tratamiento con artesunato rectal previo a la remision a ninos pequenos con paludismo grave por parte de voluntarios sanitarios comunitarios fue factible, segura y eficaz en las comunidades de dificil acceso de Zambia, y se asocio a una reduccion sustancial de la tasa de letalidad de los casos. El enfoque del proyecto es muy adaptable y podria utilizarse en otros paises con una alta incidencia de malaria., Introduction Despite an estimated 60% reduction in deaths due to malaria over the past two decades, global progress in combatting the disease has stalled recently, in some countries, previous mortality [...]

Objective To describe the implementation and feasibility of an innovative mass vaccination strategy--based on single- dose oral cholera vaccine--to curb a cholera epidemic in a large urban setting. Method In April 2016, in the early stages of a cholera outbreak in Lusaka, Zambia, the health ministry collaborated with Medecins Sans Frontieres and the World Health Organization in organizing a mass vaccination campaign, based on single-dose oral cholera vaccine. Over a period of 17 days, partners mobilized 1700 health ministry staff and community volunteers for community sensitization, social mobilization and vaccination activities in 10 townships. On each day, doses of vaccine were delivered to vaccination sites and administrative coverage was estimated. Findings Overall, vaccination teams administered 424100 doses of vaccine to an estimated target population of 578043, resulting in an estimated administrative coverage of 73.4%. After the campaign, few cholera cases were reported and there was no evidence of the disease spreading within the vaccinated areas. The total cost of the campaign--2.31 United States dollars (US$) per dose-- included the relatively low cost of local delivery--US$ 0.41 per dose. Conclusion We found that an early and large-scale targeted reactive campaign using a single-dose oral vaccine, organized in response to a cholera epidemic within a large city, to be feasible and appeared effective. While cholera vaccines remain in short supply, the maximization of the number of vaccines in response toa cholera epidemic, by the use of just one dose per member of an at-risk community, should be considered. Objectif Rendre compte de la mise en oeuvre et de la faisabilite d'une strategie de vaccination de masse innovante--fondee sur un vaccin anticholerique oral a dose unique--pour enrayer une epidemie de cholera dans une vaste zone urbaine. Methodes En avril 2016, aux premiers stades d'une flambee de cholera a 'Lusaka, en Zambie, le ministere de la Sante a collabore avec Medecins Sans Frontieres et l'Organisation mondiale.de la Sante pour organiser une campagne de vaccination de masse fondee sur un vaccin anticholerique oral a dose unique. Pendant 17 jours, ees partenaires ont fait appel a 1700 membres du personnel du ministere de la Sante et benevoles communautaires pour mener des activites de sensibilisation des communautes, de mobilisation sociale et de vaccination dans 10 municipalites. Chaque jour, des doses de vaccins ont ete livrees sur les sites de vaccination et une estimation de la couverture administrative a ete effectuee. Resultats En tout, les equipes de vaccination ont administre 424 100 doses de vaccins a une population cible estimee a 578 043 individus, ce qui se traduit par une couverture administrative estimee a 73,4%. Apres la campagne, seuls de rares cas de cholera ont ete signales et aucun signe de propagation de la maladie dans les zones de vaccination n'a ete note. Le cout total de la campagne--2,31 dollars des Etats-Unis ($US) par dose--incluait le cout relativement bas de la livraison locale--0,41 $US par dose. Conclusion L'organisation d'une campagne de vaccination reactive precoce, ciblee et a grande echelle--fondee sur un vaccin oral a dose unique--pour repondre a une epidemie de cholera dans une grande ville s'est averee faisable et efficace. Alors que les vaccins anticholeriques demeurent rares, il convient d'envisager la maximisation du nombre de vaccins pour faire face a une epidemie de cholera a travers ('utilisation d'une seule dose par membre d'une communaute vulnerable. Objetivo describir la aplicacion y la viabilidad de una estrategia innovadora de vacunacion masiva, basada en una vacuna oral contra el colera de una sola dosis, para frenar una epidemia de colera en un entorno urbano grande. Metodo en abril de 2016, en las primeras etapas de un brote de colera en Lusaka, Zambia, el Ministerio de Salud colaboro con Medecins Sans Frontieres y la Organizacion Mundial de la Salud en la organizacion de una campana masiva de vacunacibn basada en una vacuna oral contra el colera de una sola dosis. Durante un periodo de 17 dias, los socios movilizaron a 1700 voluntarios de personal sanitario y voluntarios de la comunidad para sensibilizar a la comunidad y para actividades de vacunacion y movilizacion social en 10 municipios. Cada dia, las dosis de la vacuna se entregaron en los lugares de vacunacion y se estimo la cobertura administrativa. Resultados en general, los equipos de vacunacion administraron 424.100 dosis de la vacuna a una poblacion objetivo de unos 578.043 habitantes, lo que resulto en una cobertura administrativa estimada del 73,4%. Despues de la campana, se registraron pocos casos de colera y no hubo pruebas de propagacion de la enfermedad dentro de laszonas vacunadas. El costo total de la campana (2,31 dolares estadounidenses (USD) por dosis) incluyo el coste relativamente bajo de la entrega local (0,41 $ por dosis). Conclusion se descubrio que una campana reactiva temprana dirigida y en gran escala con una vacuna oral de dosis unica, organizada en respuesta a una epidemia de colera dentro de una gran ciudad, era factible y aparentemente efectiva. Si bien las vacunas contra el colera siguen siendoescasas, se debe considerar la maximizacion del numero de vacunados en respuesta a una epidemia de colera, mediante el uso de una sola dosis por miembro de una comunidad en riesgo., Introduction The World Health Organization (WHO) has estimated that there are 1.3-4 million cholera cases and 21000-143 000 cholera-related deaths each year. (1) Cholera is a poverty-related disease and large-scale [...]

Abstract Background Loop-mediated isothermal amplification (LAMP) is a novel strategy which amplifies DNA with high sensitivity and rapidity under isothermal conditions. In the present study, the performance of the repetitive insertion mobile element (RIME)-LAMP and human serum resistance-associated gene (SRA)-LAMP assays were evaluated using clinical specimens obtained from four male patients from Luangwa and Zambezi valleys in Zambia and Zimbabwe, respectively. Findings The cases reported in this preliminary communication were all first diagnosed by microscopy, through passive surveillance, and confirmed by both RIME-LAMP and SRA-LAMP. A good correlation between microscopy and LAMP was observed and contributed to staging and successful treatment of patient. RIME-LAMP and SRA-LAMP complimented each other well in all the cases. Conclusions Both RIME-LAMP and SRA-LAMP were able to detect Trypanosoma brucei rhodesiense DNA in patient blood and CSF and hence confirmed HAT in the parasitaemic patients. Our study indicates that the LAMP technique is a potential tool for HAT diagnosis, staging and may be useful for making therapeutic decisions. However, no statistically significant conclusion may be drawn due to the limited sample size used in the present study. It is thus imperative to conduct a detailed study to further evaluate the potential of LAMP as a bedside diagnostic test for HAT.

Outbreaks of plague have been recognized in Zambia since 1917 (1). On April 10, 2015, Zambia's Ministry of Health was notified by the Eastern Provincial Medical Office of possible bubonic plague cases in Nyimba District. Eleven patients with acute fever and cervical lymphadenopathy had been evaluated at two rural health centers during March 28-April 9, 2015; three patients died. To confirm the outbreak and develop control measures, the Zambia Ministry of Health's Field Epidemiology Training Program (ZFETP) conducted epidemiologic and laboratory investigations in partnership with the University of Zambia's schools of Medicine and Veterinary Medicine and the provincial and district medical offices. Twenty-one patients with clinically compatible plague were identified, with symptom onset during March 26-May 5, 2015. The median age was 8 years, and all patients were from the same village. Blood specimens or lymph node aspirates from six (29%) patients tested positive for Yersinia pestis by polymerase chain reaction (PCR). There is an urgent need to improve early identification and treatment of plague cases. PCR is a potential complementary tool for identifying plague, especially in areas with limited microbiologic capacity. Twelve (57%) patients, including all six with PCR-positive plague and all three who died, also tested positive for malaria by rapid diagnostic test (RDT). Plague patients coinfected with malaria might be misdiagnosed as solely having malaria, and appropriate antibacterial treatment to combat plague might not be given, increasing risk for mortality. Because patients with malaria might be coinfected with other pathogens, broad spectrum antibiotic treatment to cover other pathogens is recommended for all children with severe malaria, until a bacterial infection is excluded.