Update on Wild Poliovirus Type 1 Outbreak - Southeastern Africa, 2021-2022.

Since the Global Polio Eradication Initiative (GPEI) began in 1988, the number of wild poliovirus (WPV) cases has declined by >99.99%. Five of the six World Health Organization (WHO) regions have been certified free of indigenous WPV, and WPV serotypes 2 and 3 have been declared eradicated globally (1). WPV type 1 (WPV1) remains endemic only in Afghanistan and Pakistan (2,3). Before the outbreak described in this report, WPV1 had not been detected in southeastern Africa since the 1990s, and on August 25, 2020, the WHO African Region was certified free of indigenous WPV (4). On February 16, 2022, WPV1 infection was confirmed in one child living in Malawi, with onset of paralysis on November 19, 2021. Genomic sequence analysis of the isolated poliovirus indicated that it originated in Pakistan (5). Cases were subsequently identified in Mozambique. This report summarizes progress in the outbreak response since the initial report (5). During November 2021-December 2022, nine children and adolescents with paralytic polio caused by WPV1 were identified in southeastern Africa: one in Malawi and eight in Mozambique. Malawi, Mozambique, and three neighboring countries at high risk for WPV1 importation (Tanzania, Zambia, and Zimbabwe) responded by increasing surveillance and organizing up to six rounds of national and subnational polio supplementary immunization activities (SIAs).* Although no cases of paralytic WPV1 infection have been reported in Malawi since November 2021 or in Mozambique since August 2022, undetected transmission might be ongoing because of poliovirus surveillance gaps and testing delays. Efforts to further enhance poliovirus surveillance sensitivity, improve SIA quality, and strengthen routine immunization are needed to ensure that WPV1 transmission has been interrupted within 12 months of the first case, thereby preserving the WHO African Region's WPV-free status.

Equity dimensions of the availability and quality of reproductive, maternal and neonatal health services in Zambia.

OBJECTIVE: To assess how quality and availability of reproductive, maternal, neonatal (RMNH) services vary by district wealth and urban/rural status in Zambia. METHODS: We conducted a retrospective analysis of data from the Millennium Development Goal Acceleration Initiative baseline assessment of 117 health facilities in 9 districts. Quality was assessed through a composite score of 23 individual RMNH indicators, ranging from 0 to 1. Availability was evaluated by density of providers and facilities. Districts were divided into wealth groups based on the multidimensional poverty index (MPI). Relative inequity was calculated using the concentration index for quality indicators (positive favours rich, negative favours poor). Multivariable linear regression was performed for the dependent variable composite quality indicator using MPI, urban/rural, and facility level of care as independent variables. RESULTS: 13 hospitals, 85 health centres and 19 health posts were included. The RMNH composite quality indicator was 0.64. Availability of facilities and providers was universally low. The concentration index for the composite quality indicator was -0.015 [-0.043, 0.013], suggesting no clustering to favour either rich or poor districts. Rich districts had the highest absolute numbers of health facilities and providers, but lowest numbers per facility per 1 000 000 population. Urban districts had slightly better service quality, but not availability. Using regression analysis, only facility level of care was significantly associated with quality outcome. CONCLUSIONS: Composite quality of RMNH services did not vary by district wealth, but was slightly higher in urban districts. The availability data suggest that the higher population in richer districts outpaces health infrastructure.

Implementation and Operational Research: Integration of PMTCT and Antenatal Services Improves Combination Antiretroviral Therapy Uptake for HIV-Positive Pregnant Women in Southern Zambia: A Prototype for Option B+?

BACKGROUND: Early initiation of combination antiretroviral therapy (cART) for HIV-positive pregnant women can decrease vertical transmission to less than 5%. Programmatic barriers to early cART include decentralized care, disease-stage assessment delays, and loss to follow-up. INTERVENTION: Our intervention had 3 components: integrated HIV and antenatal services in 1 location with 1 provider, laboratory courier to expedite CD4 counts, and community-based follow-up of women-infant pairs to improve prevention of mother-to-child transmission attendance. Preintervention HIV-positive pregnant women were referred to HIV clinics for disease-stage assessment and cART initiation for advanced disease (CD4 count <350 cells/µL or WHO stage >2). METHODS: We used a quasi-experimental design with preintervention/postintervention evaluations at 6 government antenatal clinics (ANCs) in Southern Province, Zambia. Retrospective clinical data were collected from clinic registers during a 7-month baseline period. Postintervention data were collected from all antiretroviral therapy-naive, HIV-positive pregnant women and their infants presenting to ANC from December 2011 to June 2013. RESULTS: Data from 510 baseline women-infant pairs were analyzed and 624 pregnant women were enrolled during the intervention period. The proportion of HIV-positive pregnant women receiving CD4 counts increased from 50.6% to 77.2% [relative risk (RR) = 1.81; 95% confidence interval (CI): 1.57 to 2.08; P < 0.01]. The proportion of cART-eligible pregnant women initiated on cART increased from 27.5% to 71.5% (RR = 2.25; 95% CI: 1.78 to 2.83; P < 0.01). The proportion of eligible HIV-exposed infants with documented 6-week HIV PCR test increased from 41.9% to 55.8% (RR = 1.33; 95% CI: 1.18 to 1.51; P < 0.01). CONCLUSIONS: Integration of HIV care into ANC and community-based support improved uptake of CD4 counts, proportion of cART-eligible women initiated on cART, and infants tested.

Assessment of the impact of rapid syphilis tests on syphilis screening and treatment of pregnant women in Zambia.

OBJECTIVE: To evaluate the impact of rapid syphilis tests (RSTs) on syphilis testing and treatment in pregnant women in Kalomo District, Zambia. METHODS: In March 2012, health workers at all 35 health facilities in Kalomo Distract were trained in RST use and penicillin treatment. In March 2013, data were retrospectively abstracted from 18 randomly selected health facilities and stratified into three time intervals: baseline (6months prior to RST introduction), midline (0-6 months after RST introduction), and endline (7-12 months after RST introduction). RESULTS: Data collected on 4154 pregnant women showed a syphilis-reactive seroprevalence of 2.7%. The proportion of women screened improved from baseline (140/1365, 10.6%) to midline (976/1446, 67.5%), finally decreasing at endline (752/1337, 56.3%) (P<0.001). There was no significant difference in the proportion of syphilis-seroreactive pregnant women who received 1 dose of penicillin before (1/2, 50%) or after (5/48, 10.4%; P=0.199) RST introduction with low treatment rates throughout. CONCLUSION: With RST scale-up in Zambia and other resource-limited settings, same-day test and treatment with penicillin should be prioritized to achieve the goal of eliminating congenital syphilis.

Age at antiretroviral therapy initiation predicts immune recovery, death, and loss to follow-up among HIV-infected adults in urban Zambia.

We analyzed the association of age at antiretroviral therapy (ART) initiation with CD4(+) T cell count recovery, death, and loss to follow-up (LTFU) among HIV-infected adults in Zambia. We compared baseline characteristics of patients by sex and age at ART initiation [categorized as 16-29 years, 30-39 years, 40-49 years, 50-59 years, and 60 years and older]. We used the medication possession ratio to assess adherence and analysis of covariance to measure the adjusted change in CD4(+) T cell count during ART. Using Cox proportional hazard regression, we examined the association of age with death and LTFU. In a secondary analysis, we repeated models with age as a continuous variable. Among 92,130 HIV-infected adults who initiated ART, the median age was 34 years and 6,281 (6.8%) were aged ≥50 years. Compared with 16-29 year olds, 40-49 year olds (-46 cells/mm(3)), 50-59 year olds (-53 cells/mm(3)), and 60+ year olds (-60 cells/mm(3)) had reduced CD4(+) T cell gains during ART. The adjusted hazard ratio (AHR) for death was increased for individuals aged ≥40 years (AHR 1.25 for 40-49 year olds, 1.56 for 50-59 year olds, and 2.97 for 60+ year olds). Adherence and retention in care were poorest among 16-29 year olds but similar in other groups. As a continuous variable, a 5-year increase in age predicted reduced CD4(+) T cell count recovery and increased risk of death. Increased age at ART initiation was associated with poorer clinical outcomes, while age <30 years was associated with a higher likelihood of being lost to follow-up. HIV treatment guidelines should consider age-specific recommendations.