Zambia Center for Applied Health Research and Development

Lusaka, Zambia

Zambia Center for Applied Health Research and Development

Lusaka, Zambia

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Mendelson M.,University of Cape Town | Rottingen J.-A.,Norwegian Institute of Public Health | Rottingen J.-A.,University of Oslo | Rottingen J.-A.,Boston University | And 8 more authors.
The Lancet | Year: 2016

Access to quality-assured antimicrobials is regarded as part of the human right to health, yet universal access is often undermined in low-income and middle-income countries. Lack of access to the instruments necessary to make the correct diagnosis and prescribe antimicrobials appropriately, in addition to weak health systems, heightens the challenge faced by prescribers. Evidence-based interventions in community and health-care settings can increase access to appropriately prescribed antimicrobials. The key global enablers of sustainable financing, governance, and leadership will be necessary to achieve access while preventing excess antimicrobial use. © 2016 Elsevier Ltd.


Seidenberg P.D.,Zambia Center for Applied Health Research and Development | Hamer D.H.,Zambia Center for Applied Health Research and Development | Hamer D.H.,Boston University | Iyer H.,Boston University | And 5 more authors.
American Journal of Tropical Medicine and Hygiene | Year: 2012

Provision of integrated community case management (iCCM) for common childhood illnesses by community health workers (CHWs) represents an increasingly common strategy for reducing childhood morbidity and mortality. We sought to assess how iCCM availability influenced care-seeking behavior. In areas where two different iCCM approaches were implemented, we conducted baseline and post-study household surveys on healthcare-seeking practices among women who were caring for children L 5 years in their homes. For children presenting with fever, there was an increase incare sought from CHWs and a decrease in care sought at formal health centers between baseline and post-study periods. For children with fast/difficulty breathing, an increase in care sought from CHWs was only noted in areas where CHWs were trained and supplied with amoxicillin to treat non-severe pneumonia. These findings suggest that iCCM access influences local care-seeking practices and reduces workload at primary health centers. Copyright © 2012 by The American Society of Tropical Medicine and Hygiene.


Sialubanje C.,Ministry of Health | Sialubanje C.,Maastricht University | Massar K.,Maastricht University | Hamer D.H.,Zambia Center for Applied Health Research and Development | And 2 more authors.
Health Education Research | Year: 2014

This qualitative study aimed to identify psychosocial and environmental factors contributing to low utilization of maternal healthcare services in Kalomo, Zambia. Twelve focus group discussions (n = 141) and 35 in-depth interviews were conducted in six health centre catchment areas. Focus group discussions comprised women of reproductive age (15-45 years), who gave birth within the last year; in-depth interviews comprised traditional leaders, mothers, fathers, community health workers and nurse-midwives. Perspectives on maternal health complications, health-seeking behaviour and barriers to utilization of maternal healthcare were explored. Most women showed insight into maternal health complications. Nevertheless, they started antenatal care visits late and did not complete the recommended schedule. Moreover, most women gave birth at home and did not use postnatal care. The main reasons for the low utilization were the low perceived quality of maternal healthcare services in clinics (negative attitude), negative opinion of important referents (subjective norms), physical and economic barriers such as long distances, high transport and indirect costs including money for baby clothes and other requirements. To improve, our findings suggest need for an integrated intervention to mitigate these barriers. Our findings also suggest need for further research to measure the elicited beliefs and determine their relevance and changeability. © 2014 The Author 2014.


Scott C.A.,Boston University | Iyer H.S.,Zambia Center for Applied Health Research and Development | Lembela Bwalya D.,Zambia Center for Applied Health Research and Development | Bweupe M.,Zambian Ministry of Health | And 4 more authors.
PLoS ONE | Year: 2013

Background:Zambia adopted Option A for prevention of mother-to-child transmission of HIV (PMTCT) in 2010 and announced a move to Option B+ in 2013. We evaluated the uptake, outcomes, and costs of antenatal, well-baby, and PMTCT services under routine care conditions in Zambia after the adoption of Option A.Methods:We enrolled 99 HIV-infected/HIV-exposed (index) mother/baby pairs with a first antenatal visit in April-September 2011 at four study sites and 99 HIV-uninfected/HIV-unexposed (comparison) mother/baby pairs matched on site, gestational age, and calendar month at first visit. Data on patient outcomes and resources utilized from the first antenatal visit through six months postpartum were extracted from site registers. Costs in 2011 USD were estimated from the provider's perspective.Results:Index mothers presented for antenatal care at a mean 23.6 weeks gestation; 55% were considered to have initiated triple-drug antiretroviral therapy (ART) based on information recorded in site registers. Six months postpartum, 62% of index and 30% of comparison mother/baby pairs were retained in care; 67% of index babies retained had an unknown HIV status. Comparison and index mother/baby pairs utilized fewer resources than under fully guideline-concordant care; index babies utilized more well-baby resources than comparison babies. The average cost per comparison pair retained in care six months postpartum was $52 for antenatal and well-baby services. The average cost per index pair retained was $88 for antenatal, well-baby, and PMTCT services and increased to $185 when costs of triple-drug ART services were included.Conclusions:HIV-infected mothers present to care late in pregnancy and many are lost to follow up by six months postpartum. HIV-exposed babies are more likely to remain in care and receive non-HIV, well-baby care than HIV-unexposed babies. Improving retention in care, guideline concordance, and moving to Option B+ will result in increased service delivery costs in the short term. © 2013 Scott et al.


Scott C.A.,Boston University | Iyer H.S.,Zambia Center for Applied Health Research and Development | Mccoy K.,Boston University | Moyo C.,Zambian Ministry of Health | And 5 more authors.
BMC Public Health | Year: 2014

Background: Of the estimated 800,000 adults living with HIV in Zambia in 2011, roughly half were receiving antiretroviral therapy (ART). As treatment scale up continues, information on the care provided to patients after initiating ART can help guide decision-making. We estimated retention in care, the quantity of resources utilized, and costs for a retrospective cohort of adults initiating ART under routine clinical conditions in Zambia. Methods. Data on resource utilization (antiretroviral [ARV] and non-ARV drugs, laboratory tests, outpatient clinic visits, and fixed resources) and retention in care were extracted from medical records for 846 patients who initiated ART at ≥15 years of age at six treatment sites between July 2007 and October 2008. Unit costs were estimated from the provider's perspective using site- and country-level data and are reported in 2011 USD. Results: Patients initiated ART at a median CD4 cell count of 145 cells/μL. Fifty-nine percent of patients initiated on a tenofovir-containing regimen, ranging from 15% to 86% depending on site. One year after ART initiation, 75% of patients were retained in care. The average cost per patient retained in care one year after ART initiation was $243 (95% CI, $194-$293), ranging from $184 (95% CI, $172-$195) to $304 (95% CI, $290-$319) depending on site. Patients retained in care one year after ART initiation received, on average, 11.4 months' worth of ARV drugs, 1.5 CD4 tests, 1.3 blood chemistry tests, 1.4 full blood count tests, and 6.5 clinic visits with a doctor or clinical officer. At all sites, ARV drugs were the largest cost component, ranging from 38% to 84% of total costs, depending on site. Conclusions: Patients initiate ART late in the course of disease progression and a large proportion drop out of care after initiation. The quantity of resources utilized and costs vary widely by site, and patients utilize a different mix of resources under routine clinical conditions than if they were receiving fully guideline-concordant care. Improving retention in care and guideline concordance, including increasing the use of tenofovir in first-line ART regimens, may lead to increases in overall treatment costs. © 2014 Scott et al.; licensee BioMed Central Ltd.


PubMed | Zambia Center for Applied Health Research and Development., Boston University and Center for Global Health and Development.
Type: Journal Article | Journal: Clinical infectious diseases : an official publication of the Infectious Diseases Society of America | Year: 2016

Maternal vaccination with tetanus, reduced-dose diphtheria, and acellular pertussis vaccine (Tdap) could be an effective way of mitigating the high residual burden of infant morbidity and mortality caused by Bordetella pertussis To better inform such interventions, we conducted a burden-of-disease study to determine the incidence of severe and nonsevere pertussis among a population of Zambian infants.Mother-infant pairs were enrolled at 1 week of life, and then seen at 2- to 3-week intervals through 14 weeks of age. At each visit, nasopharyngeal (NP) swabs were obtained from both, and symptoms were catalogued. Using polymerase chain reaction (PCR) to identify cases, and a severity scoring system to triage these into severe/nonsevere, we calculated disease incidence using person-time at risk as the denominator.From a population of 1981 infants, we identified 10 with clinical pertussis, for an overall incidence of 2.4 cases (95% confidence interval [CI], 1.2-4.2) per 1000 infant-months and a cumulative incidence of 5.2 cases (95% CI, 2.6-9.0) per 1000 infants. Nine of 10 cases occurred within a 3-month window (May-July 2015), with highest incidence between birth and 6 weeks of age (3.5 cases per 1000 infant-months), concentrated among infants prior to vaccination or among those who had only received 1 dose of Diphtheria Tetanus whole cell Pertussis (DTwP). Maternal human immunodeficiency virus (HIV) modestly increased the risk of infant pertussis (risk ratio, 1.8 [95% CI, .5-6.9]). Only 1 of 10 infant cases qualified as having severe pertussis. The rest presented with the mild and nonspecific symptoms of cough, coryza, and/or tachypnea. Notably, cough durations were long, exceeding 30 days in several cases, with PCRs repeatedly positive over time.Pertussis is circulating freely among this population of Zambian infants but rarely presents with the classical symptoms of paroxysmal cough, whooping, apnea, and cyanosis. Maternal HIV appears to increase the risk, while lack of effective exposure to DTwP increased the risk.


Seidenberg P.,Boston University | Nicholson S.,Zambia Center for Applied Health Research and Development | Schaefer M.,United Nations Childrens Fund Zambia | Semrau K.,Boston University | And 6 more authors.
Bulletin of the World Health Organization | Year: 2012

Objective To see if, in the diagnosis of infant infection with human immunodeficiency virus (HIV) in Zambia, turnaround times could be reduced by using an automated notification system based on mobile phone texting. Methods In Zambia's Southern province, dried samples of blood from infants are sent to regional laboratories to be tested for HIV with polymerase chain reaction (PCR). Turnaround times for the postal notification of the results of such tests to 10 health facilities over 19 months were evaluated by retrospective data collection. These baseline data were used to determine how turnaround times were affected by customized software built to deliver the test results automatically and directly from the processing laboratory to the health facility of sample origin via short message service (SMS) texts. SMS system data were collected over a 7.5-month period for all infant dried blood samples used for HIV testing in the 10 study facilities. Findings Mean turnaround time for result notification to a health facility fell from 44.2days pre-implementation to 26.7days post-implementation. The reduction in turnaround time was statistically significant in nine (90%) facilities. The mean time to notification of a caregiver also fell significantly, from 66.8days pre-implementation to 35.0days post-implementation. Only 0.5% of the texted reports investigated differed from the corresponding paper reports. Conclusion The texting of the results of infant HIV tests significantly shortened the times between sample collection and results notification to the relevant health facilities and caregivers.


Larson B.A.,Boston University | Lembela-Bwalya D.,Zambia Center for Applied Health Research and Development | Bonawitz R.,Boston University | Bonawitz R.,Boston Medical Center | And 4 more authors.
PLoS ONE | Year: 2014

Background: In March 2012, The Elizabeth Glaser Pediatric AIDS Foundation trained maternal and child health workers in Southern Province of Zambia to use a new rapid syphilis test (RST) during routine antenatal care. A recent study by Bonawitz et al. (2014) evaluated the impact of this roll out in Kalomo District. This paper estimates the costs and cost-effectiveness from the provider's perspective under the actual conditions observed during the first year of the RST roll out. Methods: Information on materials used and costs were extracted from program records. A decision-analytic model was used to evaluate the costs (2012 USD) and cost-effectiveness. Basic parameters needed for the model were based on the results from the evaluation study.Results: During the evaluation study, 62% of patients received a RST, and 2.8% of patients tested were positive (and 10.4% of these were treated). Even with very high RST sensitivity and specificity (98%), true prevalence of active syphilis would be substantially less (estimated at <0.7%). For 1,000 new ANC patients, costs of screening and treatment were estimated at $2,136, and the cost per avoided disability-adjusted-life year lost (DALY) was estimated at $628. Costs change little if all positives are treated (because prevalence is low and treatment costs are small), but the cost-per-DALY avoided falls to just $66. With full adherence to guidelines, costs increase to $3,174 per 1,000 patients and the cost-per-DALY avoided falls to $60. Conclusions: Screening for syphilis is only useful for reducing adverse birth outcomes if patients testing positive are actually treated. Even with very low prevalence of syphilis (a needle in the haystack), cost effectiveness improves dramatically if those found positive are treated; additional treatment costs little but DALYs avoided are substantial. Without treatment, the needle is essentially found and thrown back into the haystack. © 2014 Larson et al.


Littrell M.,PATH Malaria Control and Evaluation Partnership MACEPA | Miller J.M.,PATH Malaria Control and Evaluation Partnership MACEPA | Ndhlovu M.,Chainama Hills College Hospital | Hamainza B.,National Malaria Control Center | And 5 more authors.
Malaria Journal | Year: 2013

Background: National malaria control programmes and their partners must document progress associated with investments in malaria control. While documentation has been achieved through population-based surveys for most interventions, measuring changes in malaria case management has been challenging because the increasing use of diagnostic tests reduces the denominator of febrile children who should receive anti-malarial treatment. Thus the widely used indicator, "proportion of children under five with fever in the last two weeks who received anti-malarial treatment according to national policy within 24 hours from onset of fever" is no longer relevant. Methods. An alternative sequence of indicators using a systems effectiveness approach was examined using data from nationally representative surveys in Zambia: the 2012 population-based Malaria Indictor Survey (MIS) and the 2011 Health Facility Survey (HFS). The MIS measured fever treatment-seeking behaviour among 972 children under five years (CU5) and 1,848 people age five years and above. The HFS assessed management of 435 CU5 and 429 people age five and above with fever/history of fever seeking care at 149 health facilities. Consultation observation and exit interviews measured use of diagnostic tests, artemisinin combination therapy (ACT) prescription, and patient comprehension of prescribed regimens. Results: Systems effectiveness for malaria case management among CU5 was estimated as follows: [100% ACT efficacy] x [55% fever treatment-seeking from an appropriate provider (MIS)] x [71% malaria blood testing (HFS)] x [86% ACT prescription for positive cases (HFS)] x [73% patient comprehension of prescribed ACT drug regimens (HFS)] = 25%. Systems effectiveness for malaria case management among people age five and above was estimated at 15%. Conclusions: Tracking progress in malaria case management coverage can no longer rely solely on population-based surveys; the way forward likely entails household surveys to track trends in fever treatment-seeking behaviour, and facility/provider data to track appropriate management of febrile patients. Applying health facility and population-based data to the systems effectiveness framework provides a cogent and feasible approach to documenting malaria case management coverage and identifying gaps to direct program action. In Zambia, this approach identified treatment-seeking behaviour as the largest contributor to reduction in systems effectiveness for malaria case management. © 2013 Littrell et al.; licensee BioMed Central Ltd.


Bridges D.J.,Akros Research Lusaka | Winters A.M.,Akros Research Lusaka | Hamer D.H.,Zambia Center for Applied Health Research and Development | Hamer D.H.,Boston University
Pathogens and Global Health | Year: 2012

In the last decade, substantial progress has been made in reducing malaria-associated morbidity and mortality across the globe. Nevertheless, sustained malaria control is essential to continue this downward trend. In some countries, where aggressive malaria control has reduced malaria to a low burden level, elimination, either nationally or subnationally, is now the aim. As countries or areas with a low malaria burden move towards elimination, there is a transition away from programs of universal coverage towards a strategy of localized detection and response to individual malaria cases. To do so and succeed, it is imperative that a strong surveillance and response system is supported, that community cadres are trained to provide appropriate diagnostics and treatment, and that field diagnostics are further developed such that their sensitivity allows for the detection and subsequent treatment of malaria reservoirs in low prevalence environments. To be certain, there are big challenges on the road to elimination, notably the development of drug and insecticide resistance. Nevertheless, countries like Zambia are making great strides towards implementing systems that support malaria elimination in target areas. Continued development of new diagnostics and antimalarial therapies is needed to support progress in malaria control and elimination. © W. S. Maney & Son Ltd 2012.

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