Coronavirus disease (COVID-19), an infectious disease caused by the SARS-CoV-2 virus continues to affect the lives, livelihoods and economies of individuals, communities and nations. While most people with COVID-19 will experience mild to moderate symptoms and recover, there are some who become seriously ill and require medical attentionin some cases critical care .
By the end of August 2021, approximately 216 million cases and 4.5 million deaths had been recorded globally, out of which close to 7.7 million, 195,475 and slightly over 6.9 million recoveries were reported in Africa. Meanwhile 5, 019,907,027 people had been vaccinated inequitably against COVID-19 among countries across the world with African continent averaging 3% coverage [2,3].
Zambia by end of August 2021 had reported over 206,000 COVID-19 cases with 97% recovery and 1.7% average death rate. This article outlines the country’s evolving epidemiology over time and the strategies employed to prevent and control the COVID-19.
Geography, Population and Health – Zambia
Zambia is a land linked country located in Southern Africa and it covers an estimated total area of 752,612 square kilometers. Zambia shares borders with eight (8) countries, namely: Angola, DRC, Tanzania, Malawi, Mozambique, Zimbabwe, Namibia and Botswana. Administratively, Zambia is divided into ten (10) provinces, which include: Central, Copperbelt, Eastern, Luapula, Lusaka, Muchinga, Northern, North-Western, Southern and Western provinces. The provinces are further divided into 116 districts.
Zambia’s population is currently estimated at 18,400,556 people; of which 50.5% are females and 49,5% males. Zambia’s population structure indicates a young population as the proportion of children less than 15 years of age making up 45.6% of the total population. This age structure has created a high overall dependency ratio of 92.5 and a child dependency ratio of 87.4. This dependency ratio is expected to continue with the high Total Fertility Rate (TFR) of 4.7 children per woman. The TFR is lower in urban areas (3.4 children per woman) than in rural areas (5.8 children per woman).
English continues to be Zambia’s official language of communication and instruction. But it has seven (7) main languages (namely: Bemba, Kaonde, Lozi, Lunda, Nyanja and Tonga) and 73 dialects are spoken across the 10 provinces of Zambia.
Zambia’s health system is divided into the following levels: Specialized Hospitals, General Hospitals, District Hospitals, Urban and Rural Health Centers and Health Posts. Primary health care services are provided through urban/rural health centers and health posts. Apart from the health facilities, Zambia utilizes the services of the community health assistants (CHAs) in the communities whose roles are to provide basic services in the community such as malaria RDT tests, etc. Like many sub-Saharan African countries, Zambia continues to experience high morbidity and mortality from communicable and non-communicable diseases. The top 5 cause of morbidity are Malaria, Respiratory Infections (non-pneumonia), Diarrhoea (non-bloody), musculoskeletal and connective tissue (not trauma) and Digestive system (not infectious). The top 10 causes of deaths excluding COVID-19 include: HIV/AIDS, Neonatal Disorders, Lower Respiratory Infections, Tuberculosis, Diarrheal Diseases, Ischemic Heart Diseases, Malaria, Stroke, Congenital Defects and Cirrhosis. According to the 2018 ZDHS, neonatal, infant, and under-5 mortality rates currently stand at 27, 42, and 61 deaths per 1000 live births, respectively, while maternal mortality ratio stands at 252 maternal deaths per 100,000 live deaths. Overall adult mortality rate is 5.11 per 1000 population.
COVID-19 situation and response in Zambia
Zambia recorded its first two cases of COVID-19 in March 2020, within four months of the declaration of the Outbreak in Wuhan China. By 18th May 2021, Zambia had recorded a cumulative 92,520 COVID-19 cases, 1,263 deaths (709 COVID-19 deaths, 554 COVID-19 associated deaths[kj1] [TI2] ) and 90,826 recoveries (https://apps.who.int/iris/rest/bitstreams/1328457/retrieve).
The multisectoral response is coordinated by Zambia’s Disease Intelligence wing, the Zambia National Public Health Institute whose mandate is to safeguard the public health security of the Country.
Coordination and resource mobilisation
A four[kj3] [TI4] level systems was used to coordinate the multisectoral COVID-19 response: National Disaster Management Council of Ministers chaired by the Vice President of the Republic of Zambia for policy direction; A high level technical committee of Permanent Secretaries chaired the Secretary to Cabinet as liaison between the technical and policy committees. To support the technical response aspects Zambia instituted Epidemics Preparedness Prevention Control and Management Committees at National and subnational level. This committee includes Heads of national and international organizations such as the UN family, Africa CDC, World Bank, and US-CDC among other cooperating partners. These multi-sectoral committees bring together the administrative and technical stakeholders in order to provide a comprehensive response to outbreaks. Furthermore, in line with international best practice, Zambia has adopted the Multisectoral Incident Management Technical Committee (IMS) at national, provincial and district level. A multisectoral response using an Incident Management System was launched to coordinate through the country’s Disease Intelligence arm, the Zambia National Public Health Institute, the technical response to the COVID-19 pandemic. Multisectoral Rapid Response Teams continually manage the response at all levels from national to community level. A multisectoral national contingency preparedness and response plan is in place to provide overall guidance for effective coordination and implementation of response activities and is coordinated through the Disaster Management and Mitigation Unit (DMMU). The response plan stipulates actions and responsibilities of all sector players, both governmental and non-governmental agencies.
The Zambian Government set up resources to manage acquisition of medical supplies and consumables, medical equipment and tools, as well as Personal Protective Equipment for the response. Further resources were received from foreign Governments and their agencies, local and international partners to support the different pillars in the response including capacity building. While ongoing resource mobilisation is conducted, a gap in the required resources for the response across the pillars is observed.
Epidemic Preparedness and response
Generally, the country has used Multisectoral Epidemic Preparedness Prevention Control and Management Committees at national and sub-national levels to prevent and manage epidemics. During the 2017/18 Cholera outbreak, the ZNPHI introduced an Incident Management meeting supported by Rapid Response Teams RRTs) to respond and manage the outbreak. This is the system that is used to respond to the COVID-19 outbreak.
The National Public Health Emergency Operations Center was activated to coordinate the national preparation, response, and recovery for the COVID-19. To strengthen coordination at Incident Management Structures were created to supplement the Multisectoral Epidemic Preparedness Prevention Control and Management Committees at sub-national levels. The IMS were capacity build to support the 9 pronged COVID-19 response strategies. RRT members were also capacitated to manage the technical aspects of the response, however it is noted that not all Districts were equally capacitated. Establishment and training of RRTs at District is on-going.
The nine pronged strategy approach includes the following pillars:
- Surveillance and case finding with a focus on heightened screening and testing at points-of-entry, healthcare facility and within communities; contact tracing; and community operations
- Case management approach which focused on admission of severe cases and those with underlining conditions admitted; establishment of High Dependency Units in District facilities to support non-COVID-19 critical cases; and improving oxygen supply and systems across the country.
- Infection prevention and control including monitoring and enforcement of prescribed COVID-19 prevention public health measures; as well as disinfection of public places. The prescribed public health measures were coined into a summary of 5 points and referred to as the five golden rules. The 5 golden rules enforced in all public places and gatherings included Masking up; hand hygiene practices, physical distancing; avoiding crowded places and seeking healthcare on displaying symptoms. However, the adherence to the prescribed public measures was low in certain populations and areas. An observation on poor mask wearing behavior and inadequate physical distancing was observed in many places throughout the outbreak, particularly during low incidence seasons.
- Risk communication and community engagement which entailed engagement with community leaders (traditional, religious, politicians, civil society, and youth groups); development, printing and publishing of IEC; and press briefs and other media engagement.
- Laboratory diagnosis focused on increased laboratory testing facilities across the country (Private and Public). During high incidence of COVID-19, targeted testing focused on symptomatic contacts was practiced.
- Logistics and supply chain management including resource mobilisation. The supplies for the response were generally procured centrally and distributed to Districts for deployment to facilities. Partners supporting acquisition of commodities and medical supplies throughout the outbreak.
- Appropriate competent and adequate workforce facilitated through trainings and re-orientation of responders in all pillars.
- Continuation of routine essential health services including resource mobilisation and supply of medicines and consumables.
- National COVID-19 Vaccination campaign which used various acquisition and deployment platforms including the COVAX facility; AVAT facility; Diplomatic ties; Public-Private –Partnership; and Government budget line.
Surveillance, contact tracing and laboratory testing
Enhanced surveillance, contact tracing, laboratory testing and infection prevention are critical for timely detection and management of COVID-19. Surveillance is conducted in communities, targeting hotspots and contacts to known cases, points-of-entry, healthcare facilities, alerts or self-reporting persons, among special populations such as international drivers and healthcare workers as well as community deaths.
Zambia has been using the Integrated Disease Surveillance System (IDSR) strategy since 2000 to conduct public health surveillance, respond to priority diseases, conditions and events of public health importance at community, health facility, district, province and national levels. The IDSR strategy has integrated Indicator-Based Surveillance (IBS) and Event-Based Surveillance (EBS) systems as part of the Early Warning Alert and Response (EWAR) system and epidemic intelligence. The IDSR system incorporates the basic functions of surveillance and response from case detection, reporting and notification, data analysis, outbreak investigation and epidemic preparedness and response to data dissemination and monitoring and evaluation of the system. These functions are specified for every level of the health care system. Routine surveillance data is reported weekly on the District Health Information Software (DHIS2) Platform which has an e- IDSR module.
For COVID-19 the data collection system remains largely paper-based, with excel sheets sent from the health facilities through the Provincial and District Surveillance Offices to national level on a daily basis. A specific electronic tracker system has been developed on the DHIS2 platform for data collection, however its utilization remains low.
In order to strengthen and effectively managed COVID-19 data, a COVID-19 Tracker was developed using DHIS2. The COVID-19 DHIS2 system supports timely data capture and analysis of cases and contacts. In addition, the DHIS2 also manages weekly Integrated Disease Surveillance and Response (IDSR) aggregated data and has been deployed to all the districts. Zambia currently has 2641 health facilities reporting weekly IDSR aggregated data. The reporting of aggregated data done electronically by the district health officers whilst the management of data at facility level is paper based due to lack of information and communication technology (ICT) equipment. In order to successfully manage the capturing of COVID-19 at data at facility lever there is urgent need to investment in ICT equipment.
Zambia has experiences 3 waves so far, with increasing intensity from one wave to the next. The first spike occurred from June to September 2020, the second wave between December, 2020 and May 2021; and then the third wave from June 2021 which waning off towards August 2021(figure 1). By 31st August 2021, Zambia had reported a cumulative 206,327 cases out of 2,275,267 tests were confirmed for SARS-CoV-2 giving an average positivity of 9%. Among these, 201,124 recoveries and 3.602 related deaths were recorded.
Figure 1: Daily cases by date of confirmation
Testing strategy including genotyping
A national SARS-CoV-2 testing strategy is in place and reviewed periodically to remain relevant to the evolving COVID-19 epidemiology and local context. Currently, testing for SARS-CoV-2 is focused on the following categories of individuals:
- All symptomatic individuals in the community or in healthcare facilities;
- All symptomatic contacts to positive cases;
- Asymptomatic contacts and vulnerable populations who are at risk of developing severe disease or may require hospitalization for advanced care;
- Health Care Workers;
- International travelers.
In view of the generalized spread of infection and limited resources, testing of the following are currently NOT recommended:
- Community mass testing;
- Testing of asymptomatic individuals;
- Testing of asymptomatic contacts (except those at higher risk of developing severe disease).
Laboratory Testing Platforms
In a bid to widen and decentralize access to COVID-19 diagnostics, Zambia is utilizing all available testing platforms including nucleic acid amplification tests (NAAT) and rapid diagnostic tests (RDTs). NAATs include traditional real-time RT-PCR based systems as well as various automated, instrument-specific (closed) systems, mainly the cobas® SARS-CoV-2 (Cobas 6800, Roche), the Aptima® SARS-CoV-2 (Panther® System, Hologic) and the Xpert® Xpress SARS-CoV-2 (GeneXpert, Cepheid). For specific situations, there has also been the limited use of serological (antibody) tests.
The ZNPHI established and coordinates the Zambia Genomic Sequencing Consortium (ZGSC) incorporating several players including research laboratories and cooperating partners. While addressing the current COVID-19 pandemic, the ZGSC seeks to build long-term national capacity for genetic sequencing through establishing facilities, equipment, human resource skills, computer systems, bioinformatics and other related capabilities which can be applied to other public health situations.
All cases with symptoms or underlining conditions that could threaten the outcome were admitted to the public healthcare facilities. As the numbers grew larger especially during the second wave, selected private sectors were supported to manage less severe cases.
The healthcare facilities were overwhelmed during the peaks with large requirement for oxygen and patients requiring as little as 3Liter/minute flow and others as high as 8Liter/minute. Therapeutics including antivirals and steroids were utilized to manage patients. The outcome on intubated patients was 100% mortality in both waves; however we note more severe cases and mortality in the second wave. Non-invasive respiratory supports (e.g., high-flow nasal cannula, continuous positive airway pressure) were carried out in intensive care units in Lusaka, however, access to such treatment options were limited in provincial hospitals.
Government with support of partners had to extend supply units and equip provincial hospitals to support the needs in their respective provinces. Training to build capacity among the frontline staff in the facilities to manage critical care was established.
Therapies and innovation
Zambia has included on its treatment regimen, remdesivir and monoclonal antibody therapy to control viral infection replication, as well as dexamethasone (a drug that has been for a very long time within Zambia to control immune response to infection. These treatment regimens assist with recovery for those diagnosed with COVID-19.conventionall oxygen therapy may be sufficient
In patients with COVID-19 and acute hypoxemic respiratory failure, conventional oxygen therapy may be insufficient to meet the oxygen needs of the patient. Options for providing enhanced respiratory support include HFNC, NIPPV, intubation and invasive mechanical ventilation. The mainstay of COVID-19 management still remains oxygen therapy which has seen demand for oxygen generation and delivery equipment soar.
Infection prevention and control
Zambia applied infection prevention and control measures in public places and healthcare facilities. In the height of the epidemic public places were cleaned and disinfected. Furthermore a multisectoral approach was used to manage compliance to prescribed public health interventions in public places and social events including wearing of masks, hand hygiene practices and controlled crowding.
In the healthcare facilities all responders were trained in donning and doffing PPEs and personal hygiene management. Frequent disinfection of healthcare facility spaces was implemented through the outbreak. However, there was evidence of some emerging nosocomial infections managed by disinfection and treatment.
Vaccination campaigns were integrated in to the COVID-19 response strategy as the 9th pillar. The approach to vaccine acquisition is managed through a three-pillar strategy involving the COVID Vaccine (COVAX ), a global vaccine initiative co-led by CEPI, Gavi and WHO, alongside key delivery partner UNICEF with an aim to accelerate the development and manufacture of COVID-19 vaccines, and to guarantee fair and equitable access for every country in the world; and Africa Vaccine Acquisition Trust (AVAT) scheme whose objective set up as a pooled procurement mechanism for the African Union Member States to be able to buy enough vaccines for at least 50% of their needs. The two initiatives complement one another. The second pillar is a Government and Private Sector collaborative initiative; and the third involves donations through diplomatic ties and local partners.
In the initial phase, the focus was on catering for 3% of the national population comprising individuals essential in sustaining COVID-19 response and those most essential in maintaining core societal functions, commonly referred to as the frontline including healthcare workers, teachers, defense and security among others. An additional 17% was to cover individuals at greatest risk of severe illness and death and their caregivers (7%) as well as populations in congregate settings (10%). The planned tier systems were unsustainable owing to hesitancy in targeted tiers. Vaccine delivery strategies have been dependent on vaccine properties, vaccine availability and characteristics of the target population. Vaccine administration occurs in fixed, outreach and temporary/mobile clinics site settings close to the target population, to reduce travel time, minimize costs and consider logistics.
By 31st August 2021 579,866 doses broken down as 310,353 Dose 1 and 269,513 fully vaccinated (of which 153,351 are the single doses Johnson and Johnson) had been administered in the ongoing exercise. According to our world data as of September 7, 2021, 1.64% of total population have received one dose of COVID-19 vaccine (cf. 5.46% in all African countries)
Figure 2: Background to COVID-19 vaccination in Zambia
A Basket approach to acquisition of vaccines is used and includes under Pillar 1, the COVAX facility (COVAX is co-led by the Coalition for Epidemic Preparedness Innovations (CEPI), Gavi and the World Health Organization (WHO), alongside key delivery partner UNICEF) to cover 20% of our eligible population (those aged 18 years and older); Pillar 2, the GRZ and private sector financed acquisition currently using the African Vaccine Acquisition Trust (AVAT) facility as guided by the Ministry of Health to ensure that there are no back room deals and no sub-standard vaccines brought into the country. The third pillar includes donations received from other countries through vaccine diplomacy channels; these vaccines will still have to meet the set criteria for safety and efficacy. We have received so far 1,120,800 vaccine doses, of which 649,919 doses (58%), have been used including 606,409 (54%) have been administered while the wastage rate accounts for the remaining 4%.
Risk communication and community engagement
Risk communication and community engagement (RCCE) remained an integral part of the whole response. RCCE is aimed at providing timely, relevant and culturally appropriate information to different target audiences, using various trusted communication channels in order to promote preventive behaviours and save lives. Timely information also serves to build trust in the communities.
To contribute to the prevention and control of COVID-19 in Zambia, community engagement with a focus on providing practical messaging at individual, families, community and key stakeholder level remained key throughout the outbreak. Focal points at provincial, district and community level were trained and capacitated with tools to support the management of compliance to prescribed COVID_19 prevention public health measures. Community leaders or gate keepers including those in the traditional, religious, political and civil society as well as media personnel, market and transport association leaders were engaged and capacitated with knowledge and tools to support further engagement of their subordinates. The community gate keepers continue to be our ambassadors our ambassadors in updating the populations under their leadership with prevention and control measures including vaccination.
Development, translation, publication and deployment of various information communication and education (IEC) materials including posters, jingles, and billboards into local languages characterized the RCCE. Furthermore, the media were an important partner in the community engagement platform providing airspace for discussion, adverts and press meetings. Community Based volunteers support the in-person efficient community engagement, however it is limited with inadequate personnel to manage this important role. Some partners have come on board to support this important cadre in the RCCE pillar.
Figure 3: Messaging for social media platforms
Studies in community knowledge, attitude and practice (KAP) indicate that while many people in the public were knowledgeable of COVID-19, its transmission, symptoms and prevention measures, the behavioural change was minimal hence low adherence to the prescribed interventions.
The COVID-19 pandemic remains a global challenge having affected all countries globally with over 222 million cases and almost 4.6 million deaths by 31 August 2021. Zambia was equally affected, however we can legitimately assume that the experience gained in using the incident management system during the response to the 2017/18 cholera outbreak that affected many districts nationally, made it easier to implement during the COVID-19 pandemic. After the cholera outbreak a number of districts were trained in utilisation of the IMS in providing coordinated and multisectoral technical support to epidemic response. Rapid Response teams have been established and ongoing training to support timely response to surges of COVID-19. Having an existing All Hazard Preparedness and Response Plan in place made it easier to develop the COVID-19 contingency plan. This led to a favorable coordinated response.
Behavioral change is a long term agenda and it is important that innovative methods are employed to engage communities. An integrated approach to communication strategies plan aligned to All Hazards and Response Plan remains important for continual management of risk communication and community engagement, timely updated with the current situation.
While we note a decreasing outbreak, Zambia may have a forth upsurge as is seen in other countries and therefore, further training to update responders’ capacities as well as safeguarding of resources to support the acquisition and deployment of medical supplies and consumables including therapeutics, oxygen and laboratory supplies is critical.
- World Health Organisation. https://www.who.int/news-room/q-a-detail/coronavirus-disease-covid-19-how-is-it-transmitted
- Africa CDC. https://africacdc.org/covid-19-vaccination/
- World Health Organisation. https://www.who.int/news-room/q-a-detail/coronavirus-disease-(covid-19)-vaccines
- Zambia National Public Health Institute.
- Zambia National Public Health Institute. 2021. Coronavirus disease 2019 (COVID-19) situation reports. Accessed from: http://znphi.co.zm/news/situation-reports-new-coronavirus-covid-19-sitreps
- Ministry of Health. https://www.moh.gov.zm/?wpfb_dl=68
About the authors
Mazyanga L Mazaba, Nathan Kapata, Muzala Kapina, Kunda Musonda, Dindi Miyoba, Paul Zulu, Victor M Mukonka, Nyambe Sinyange
Zambia National Public Health Institute, Lusaka, Zambia
Correspondence author: Mazyanga L Mazaba, firstname.lastname@example.org