Zambia

Zambia remains a highly endemic malaria country, with the entire population considered to be at risk of contracting malaria. Risk is highest in the wetter, rural, impoverished provinces of Luapula, Northern, Muchinga and North Western (11–30% prevalence in 2018), and lowest in Lusaka Province (0.1% and Southern Province (<0.1%). [1]

Zambia is among the 20 countries with the highest malaria incidence and mortality globally.  The country carries 2% of the global malaria case burden and 5.2% of the case burden in East and Southern Africa. [2] At district level, malaria incidence varies widely, from less than 50 cases to over 500 cases per 1,000 population (2018 Zambia Malaria Indicator Survey (MIS), Health Management Information System (HMIS) 2018).

Zambia has made significant progress in malaria control. There was a 26.8% reduction in cases between 2016 and 2019, from 202 to 148 per 1000 of the population at risk, while mortality rates fell by 5.4% from 0.47 to 0.44 per 1000 of the population at risk. [2] Other encouraging trends identified in the 2018 MIS and 2018 HMIS include: [1]

  • The national infection rate in children under five decreased from 22% in 2006 to 9%percent in 2018.
  • 80% of households owned at least one insecticide-treated mosquito net (ITN), an increase from 38 percent in 2006.
  • 77% of children in rural areas, where risk is greatest, slept under ITN, an increase from 42% in 2008. 81 percent of pregnant women received medications to prevent malaria, an increase from 59% in 2006.

In the first half of 2020, however, epidemiologic trends in malaria indicators worsened: the National Malaria Elimination Centre (NMEC) reported a 30–50% increase in malaria cases, malaria deaths, and test positivity rates nationally, as compared with 2018 and 2019.[3] Contributing factors are likely to be:

  • Historically high rainfall in some provinces.
  • Ageing insecticide-treated mosquito nets (ITNs), the last mass campaign having occurred in 2017.
  • Operational challenges for indoor residual spraying – including late arrival of commodities, the late commencement and conclusion of spraying, poor household preparation, and limited supervision
  • Increased case reporting from community case management, reflecting improved access to care.

In March 2019, Zambia launched its first End Malaria Council (EMC). [1] The EMC is designed to increase resource mobilization to achieve and sustain malaria elimination. Zambia’s EMC convenes senior-level, multi-sectoral stakeholders (government, business, and community leaders) to complement Zambia’s National Malaria Elimination Programme (NMEP). [1] The EMC country-led and country-owned and is focused on three priority areas: 1) ensure the national strategic plan is implemented by driving action and holding stakeholders accountable; 2) pursuing traditional and innovative financing to mobilize domestic resources to close the existing funding gap; 3) and advocating for malaria elimination to remain high on public and private sector agendas. [1]

Malaria transmission

Plasmodium falciparum is responsible for 98% of all infections although there are four main malaria parasite species present in Zambia (P. malariae, P. ovale and P. vivax are the other three). [4]

Case management

Zambia’s Guidelines for the Diagnosis and Treatment of Malaria in Zambia (Ministry of Health, 5th Edition, 2017) recommend injectable artesunate as the first line treatment for severe malaria. Intramuscular artemether or intramuscular/intravenous quinine are alternatives. Injectable artesunate is also the first line treatment for pregnant women with severe malaria. WHO recommends that this should be done starting from the 2nd trimester onwards. [5]

At peripheral health facilities, pre-referral management of severe disease with artesunate rectal capsules (ARC) (for children less than 6 years old) or injectable artesunate is recommended. [5] If these two options are not available, intramuscular quinine is recommended. For community health workers, pre-referral management of severe disease with rectal artesunate (for children less than 6 years old) is recommended. [5]

Pregnancy

The percentage of women who received antenatal care (ANC) by a skilled provider has increased slightly from 94 percent in 2007 to 97 percent in 2018. [5] Both women attending 4 or more ANC visits and women receiving at least one ANC visit during their first trimester of pregnancy have also seen modest gains. Zambia continues to place significant emphasis on ANC attendance and expects to see continued gains in the area of ANC attendance. [5]

In 2014, the National Malaria Elimination Program (NMEP) aligned the national policy on IPTp with the updated WHO policy on intermittent preventive treatment for pregnant women (IPTp), including updating the HMIS/DHIS2 (Health management information system/District Health Information System 2) to capture three doses of IPTp. [5]

The current national policy calls for pregnant women to receive IPTp at every ANC visit at least one month apart up until the time of delivery, with the first dose starting as early as possible in the second trimester of pregnancy--between 13 and 16 weeks. [5]

An increasing percentage of women reported taking two and three doses of IPTp in 2018 with 81% of pregnant women reporting at least two doses. The percentage of women reporting taking a fourth dose stayed the same at 5% between 2015 and 2018. [1]

Healthcare system

Ministry of health structures have been established at four levels.[1]

  • National Level: the MoH headquarters manage the coordination of the entire health sector.
  • Provincial Level: provincial health offices coordinate health service delivery in their provinces.
  • District Level: district health offices manage health service delivery at the district and community level.
  • Community Level: neighbourhood health committees have been put in place to ease connections between communities and the health system.

Public health facilities (including community outreach centres) provide most of the health care delivery and malaria control services in Zambia. [1] Faith-based organisations (mostly under the umbrella of the Churches Health Association of Zambia) provide over 50% of formal health services in the rural areas and close to 30% of health care in the country. [1]

Zambia launched its National Malaria Elimination Strategic Plan (NMSP) in April 2018 to serve as a strategy towards a malaria-free Zambia. [3] Key tenets of the plan are equitable access to quality-assured, cost-effective malaria prevention and control interventions. [1]

In 2017, the National Malaria Elimination Program of Zambia and its partners revised the Guidelines for the Diagnosis and Treatment of Malaria to include artesunate rectal capsules for pre-referral treatment of severe malaria in children less than six years, including at the community level. [1] 

There is renewed MoH interest in scaling up the use of artesunate rectal capsules for the management of children with severe malaria at the time of referral from community settings and health posts. [1]

Severe malaria policy and practice

National treatment guidelines
Recommendation Treatment
Strong IV artesunate
Alternative IV quinine 
Alternative IM quinine 
Alternative IM Arthemether
Recommendation Pre-referral
Strong Rectal artesunate (for children less than 6 years)
Alternative Injectable artesunate
   
Severe malaria in pregnancy
Recommendation Treatment
First trimester Inj quinine
2nd and 3rd trimester Inj artesunate

 

 

 

 

 

 

 

 

 

 

 

Pregnancy
Recommendation Prevention
Strong Sulfadoxine-pyrimethamine (intermittent preventive treatment)