prof lloyd mulengaopd survey 200 400 600 800 1000 1200 hh survey 0 50 100 150 200 250 300 hcw survey...

September 9-10, 2020

Prof Lloyd Mulenga

Director Infectious Diseases

Ministry of Health

September 9 - 10, 2020

Overview of COVID-19 Trends in Zambia

Fast-Track Cities Virtual Conference • September 9-10, 2020

VIRTUAL FAST-TRACK CITIES 2020

The Current Scenario on 95/95/95 strategy: May 2020

National TxCurr:

1,052,759

Lusaka

• 27% of HIV Burden is in Lusaka City

• Estimation attrition rates at 20%

• Lusaka Surge Launched WAD 2017

of those diagnosed are on ART

of those on ART are virally suppressed

94.1% 93.1% 94.7*%

*VLS rate calculated based on number of suppressed out of tests done in Q1 and the full cascade can only be done annually

at close of the year



COVID-19 Trends in Zambia

• Initial cluster among the Asian community

• Disproportionate high admissions and mortality among Men, Asian, >45years old, Diabetics and hypertensives

• Reported cases from Urban and border towns

• Burden in rural areas unclear

Virtual Fast-Track Cities 2020 • September 9-10, 2020


SAR-CoV-2 Prevalence Survey in Zambia

• Methods• Three surveys:

1. General population: 16 randomly selected EAs per district. Within EA, HHs listed and 20 randomly selected

2. OPD patients: Randomly selected from 20 purposefully selected HFs*

3. HCWs: convenience sample from 20 HFs

• 6 districts: Kabwe, Livingstone, Lusaka, Nakonde,

Ndola, Solwezi• Purposefully selected: ongoing cases/outbreak or deemed high

risk, mix of urban/rural, travel corridors/PoEs• ~4.2 million people (24% of total population of Zambia) • 5610 people interviewed

Preliminary. Not for distribution

2



Study Timing in Relation to SARS-CoV-2 Outbreak in Zambia

0

100

200

300

400

500

6002

0-M

ar

24

-Mar

28

-Mar

1-A

pr

5-A

pr

9-A

pr

13

-Ap

r

17

-Ap

r

21

-Ap

r

25

-Ap

r

29

-Ap

r

3-M

ay

7-M

ay

11

-May

15

-May

19

-May

23

-May

27

-May

31

-May

4-J

un

8-J

un

12

-Ju

n

16

-Ju

n

20

-Ju

n

24

-Ju

n

28

-Ju

n

2-J

ul

6-J

ul

10

-Ju

l

14

-Ju

l

18

-Ju

l

22

-Ju

l

26

-Ju

l

30

-Ju

l

3-A

ug

7-A

ug

11

-Au

g

15

-Au

g

19

-Au

g

23

-Au

g

27

-Au

g

31

-Au

g

No

. cas

es

Confirmed COVID cases 7-day moving average (COVID cases)

Prevalence study


4



Results: Age/Sex Distributions by Survey Type

0

100

200

300

400

500

600

700

No

. par

tici

pan

ts

OPD survey

0

200

400

600

800

1000

1200

No

. par

tici

pan

tsHH survey

0

50

100

150

200

250

300

No

. par

tici

pan

ts

HCW survey

39%, Male

60%, Female

39%, Male

61%, Female

34%, Male

66%, Female


6



Results: Comparison of HH Survey to Districts’ Population Age/Sex Distributions

49%, Male51%, Female

Population sex distribution - 6 districts (2020)

39%, Male61%,

Female

Sample sex distribution – HH Survey

Source: https://www.zamstats.gov.zm/phocadownload/Zambia%20Census%20Projection%202011%20-%202035.pdf

14%

23% 23%

15%

10%

7%4%

2%1%

0

200

400

600

800

1000

1200

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+

No

. par

tici

pan

tsSample age distribution – HH survey

30%

22%19%

14%

8%

4%2% 1% 0%

0

200,000

400,000

600,000

800,000

1,000,000

1,200,000

1,400,000

0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79 80+

No

. per

son

s

Population age structure - 6 districts (2020)


7

https://www.zamstats.gov.zm/phocadownload/Zambia%20Census%20Projection%202011%20-%202035.pdf



Prevalence by Survey Type

0%

5%

10%

15%

20%

PCR Serology

Perc

en

t SA

RS-

Co

V-2

po

siti

veHH survey

0%

5%

10%

15%

20%

PCR Serology

Perc

en

t SA

RS-

Co

V-2

po

siti

ve

OPD survey

0%

5%

10%

15%

20%

PCR Serology

Perc

en

t SA

RS-

Co

V-2

po

siti

ve

HCW survey


8



Prevalence by Age (HH Survey)

0%

5%

10%

15%

20%

0-9 10-19 20-29 30-39 40-49 ≥50

Perc

en

t SA

RS-

Co

V-2

po

siti

vePCR Positivity by Age Group (HH survey)

0%

5%

10%

15%

20%

0-9 10-19 20-29 30-39 40-49 ≥50

Perc

en

t SA

RS-

Co

V-2

po

siti

ve

Serology Positivity by Age Group (HH survey)


11



Prevalence by Sex (HH Survey)

0%

5%

10%

15%

20%

Female Male

Perc

en

t SA

RS-

Co

V-2

po

siti

vePCR Positivity by Sex (HH survey)

0%

5%

10%

15%

20%

Female Male

Perc

en

t SA

RS-

Co

V-2

po

siti

ve

Serology Positivity by Sex (HH survey)


12


Impact of COVID-19 on HIV Services



Impact of COVID-19 on the ART program

• Reduction in community and facility HIV services resulting in low HTS, new positive and new patient started on ART

• It is too early to tell the impact of COVID-19 on VLS and Retention in Care

• There has been substantial disruption in the supply chain of commodities including ABC, ATV-r and TLD

• TLE substitution for TLD has reduced gains in the ARVs drug optimization agenda

National HIV Program Focus for 2020/2021



Reduction of HTS due to COVID-19 (Jan-Apri 20)


0

50,000

100,000

150,000

200,000

250,000

300,000

CentralProvince

CopperbeltProvince

EasternProvince

Lusaka Province LuapulaProvince

MuchingaProvince

NorthernProvince

North WesternProvince

SouthernProvince

WesternProvince

National Total Source: DHIS2.0(HMIS)_28 May

2020.

HTS by Province Jan- April

January 2020 HIV Testing (HTS) February 2020 HIV Testing (HTS) March 2020 HIV Testing (HTS) April 2020 HIV Testing (HTS)



Reduction of New HIV positive cases in the COVID-19 Period(Jan-Apr20)


0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

CentralProvince

CopperbeltProvince

EasternProvince

Lusaka Province LuapulaProvince

MuchingaProvince

NorthernProvince


SouthernProvince

WesternProvince


2020.

HTS_POS

Period January-HIV Positive Results (HTS) Period Febraury-HIV Positive Results (HTS) Period HIV Positive Results (HTS) Period HIV Positive Results (HTS)



Reduction in Number of patients started on ART in COVID-19 period


0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

20,000

Central Province CopperbeltProvince

Eastern Province Lusaka Province Luapula Province MuchingaProvince

NorthernProvince


SouthernProvince

WesternProvince


2020.

TxNEW

Started on ART January 2020 Started on ART February 2020 Started on ART March 2020 Started on ART April 2020


Mitigation Measures




1. 2020: TLD-TLE regimen Switch

• Due to COVID-19 and to deplete the short dated TLE, MOH instructed a temporal switch between TLD/TLE with only 224,500 patients plus new initiates remaining on TLD.

• As a result;• All patients are expected to be on 6-month MMD between now

and September - November 2020.• Once TLE is depleted, plan is to transition 90% back to TLD

around September - November 2020.




2. 2020: Decongestion strategy at ART sites

• In addition to the TLE and TLD intervention due to COVID, MOH with support from GHSC-PSM designs and implemented a 6MMD allocation planned for other ARVs in a bid to ensure ART service decongestion at facilities.

• The Regimens included ARVs for;• 1st and 2nd Line ARVs for Paediatrics• Adult 2nd Line ARVs• PrEP

3. 2020: Enhanced central level collaboration.

• Biweekly updates by MOH/GF/USAID/GHSC-PSM to anticipate and prevent shortages of all commodities.• Policy on streamlined distribution of commodities from port of entry to MSL• Resource mobilization for additional funding for procurements e.g. TLD• Lopinavir/ritonavir temporal switch to atazanavir/ritonavir due to API challenges.




Guiding Principles for maintaining ART treatment gains

• Ensure safety of clients and providers• Provision of PPE

• Physical distancing

• Triage

• Reduce risk of transmission of COVID-19• Facility screening and setting up isolation centers

• Minimizing contact with health facilities

• Infection prevention control measures



Multi-Month Dispensation of ART to Minimize Contact with Health Facilities

• Where possible, initial call in to take advantage and perform full clinical interaction

– Check adherence to ART

– COVID 19 prevention messaging

– VL testing if eligible

• Spaced appointment scheduling▪ Appointment by day and time

▪ Weekend and after-hours

• MMD for TPT

Urgent opportunity to scale-up MMD to all eligible!



Engaging the Community

• Community index testing has resumed

• Training of Community Health Workers (CHWs)

• PPE for CHWs

• Community sensitization for HIV testing

• Messaging

• National policy on face masks has helped to ensure contacts are also wearing masks

• Measures for the public to protect themselves



Strengthen Continuous Quality Improvement (CQI) for 3/6 MMD

Faci

lity

We

eke

nd

Se

rvic

e

Org

aniz

ed

? (Y

es/

No

)

Dru

gs A

vaila

ble

? (Y

es/

No

)

TX_C

UR

R a

s at

2

2n

d A

pri

l 20

20

# o

f C

lien

ts t

o b

e

Dis

pe

nse

d

# D

isp

en

sed

as

at

22

nd

Ap

ril 2

02

0

% D

isp

en

sed

as

at

22

nd

Ap

ril 2

02

0

Bauleni Urban Health Centre Yes Yes 3,920 3,894 5,026 129%Chainda Urban Health Centre Yes Yes 1,201 506 505 100%Chawama First Level Hospital Yes Yes 9,916 7,648 4,729 62%Chazanga Urban Health Centre Yes Yes 3,594 3,520 1,411 40%Chelstone Urban Health Centre Yes Yes 8,708 6,742 3,598 53%Chilenje First Level Hospital Yes Yes 7,767 7,486 10,346 138%Chipata First Level Hospital Yes Yes 10,929 5,760 2,570 45%George Urban Health Centre Yes Yes 8,561 8,303 4,240 51%Kabwata Urban Health Centre Yes Yes 5,278 5,133 5,564 108%Kalingalinga Urban Health Centre Yes Yes 7,856 5,084 2,378 47%Kamwala Urban Health Centre Yes Yes 7,260 4,718 3,157 67%Kanyama First Level Hospital Yes Yes 12,050 5,791 6,591 114%Makeni Urban Health Centre Yes Yes 5,897 3,025 2,480 82%Matero First Level Hospital Yes Yes 13,163 12,794 6,283 49%Matero Main Urban Health Centre Yes Yes 7,629 3,380 2,899 86%Mtendere Urban Health Centre Yes Yes 5,891 3,521 2,624 75%Ng'ombe Urban Health Centre Yes Yes 5,776 5,000 2,223 44%Railway Urban Health Centre Yes Yes 5,502 4,127 3,986 97%

Overall Yes Yes 130,898 96,432 70,610 73%

8%

53%

74%

0%

10%

20%

30%

40%

50%

60%

70%

80%

-

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

March31st

April17th

April24th

Total Dispensed % against Target

6 MMD in Lusaka



Reliance on the ECHO™ Platform for tele-mentorship

• HIV/TB clinical and programmatic mentorship has relied on the virtual tele mentoring platform

• COVID-19 mentorship series held via ECHO

• Integrated COVD-19/HIV/TB


COVID-19 and Tuberculosis in Zambia



Zambian Perspective of the impact of COVID 19 pandemic on the TB programme

• Like other essential health services, the delivery of TB services in Zambia has been affected by the COVID-19 pandemic

• Since the notification of the first 02 cases of COVID 19 on 18th

March 2020, modification of delivery of services was initiated in response to the outbreak of COVID 19

• This resulted in into a low turn out of patients in OPD resulting into reduced number of presumptive TB patients being identified

• Inadvertently TB notifications plummeted



Impact of COVID 19 on TB Key indicators

4,414 4,626

4,999

5,601 5,456 5,665

7,097

9,113

6,119

6,952

6,205

9,228

9,661

7,087

5,012

5,613 5,335

5,101 4,924

5,474

5,979 6,328 6,188

7,584

8,393

3,278

4,541 4,822

5,669 5,334 5,261

6,038

7,798

5,584

6,112

5,496

7,861

8,335

5,745

4,622 4,887

4,559 4,380

4,111

5,090

5,689 5,908

5,684

6,674

7,556

-

2,000

4,000

6,000

8,000

10,000

12,000

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

Sum of No. TB PresumptivesSum of No. Presumptive TB cases examined in the Laboratory

First 2 cases of COVID 19

TB Situationlaunched



Effects of COVID19 on Weekly TPT Surge Initiations

549 725

1,316

1,666

1,964

1,476

1,989

3,295

2,976

2,155

1,860 1,695

1,200

-

500

1,000

1,500

2,000

2,500

3,000

3,500

Wk1 Wk2 Wk3 Wk4 Wk5 Wk6 Wk7 Wk8 Wk9 Wk10 Wk11 Wk12 Wk13

Feb 20 Mar 20 Apr 20

Before COVID19 Amidst COVID19



Lessons Learnt

• COVID19 pandemic response has leveraged on the strong HIV/TB programme systems from community ,facility and management levels

• Virtual platforms for mentorship and programme supervision have provided an unprecedented versatility

• Granular monitoring and redistribution of commodities has averted stockouts

• Continuous Quality Improvement interventions have sustained some of the programme related indicators

prof lloyd mulengaopd survey 200 400 600 800 1000 1200 hh survey 0 50 100 150 200 250 300 hcw survey...

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