Background Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis of both symptomatic and asymptomatic infections. Although RDTs are a reliable and practical diagnostic tool, the sensitivity of histidine-rich protein 2 (HRP2)-based RDTs can be reduced if pfhrp2 or pfhrp3 (pfhrp2/3) gene deletions exist in the Plasmodium falciparum parasite population. This study evaluated dried blood spot (DBS) samples collected from a national household survey to investigate the presence of pfhrp2/3 deletions and the performance of the RDT used in the cross-sectional survey in a low transmission setting. Methods The 2015 Ethiopia Malaria Indicator Survey tested household members by RDT and collected DBS samples. DBS (n = 2648) from three regions in northern Ethiopia were tested by multiplex bead-based antigen detection assay after completion of the survey. The multiplex assay detected pan-Plasmodium lactate dehydrogenase (LDH), pAldolase, and HRP2 antigens in samples. Samples suspected for pfhrp2/3 gene deletions (pLDH and/or pAldolase positive but low or absent HRP2) were further investigated by molecular assays for gene deletions. Antigen results were also compared to each individual’s RDT results. Dose–response logistic regression models were fit to estimate RDT level of detection (LOD) antigen concentrations at which 50, 75, 90, and 95% of the RDTs returned a positive result during this survey. Results Out of 2,648 samples assayed, 29 were positive for pLDH or pAldolase antigens but low or absent for HRP2 signal, and 15 of these samples (51.7%) were successfully genotyped for pfhrp2/3. Of these 15 P. falciparum infections, eight showed single deletions in pfhrp3, one showed a single pfhrp2 deletion, and six were pfhrp2/3 double-deletions. Six pfhrp2 deletions were observed in Tigray and one in Amhara. Twenty-five were positive for HRP2 by the survey RDT while the more sensitive bead assay detected 30 HRP2-positive samples. A lower concentration of HRP2 antigen generated a positive test result by RDT compared to pLDH (95% LOD: 16.9 ng/mL vs. 319.2 ng/mL, respectively). Conclusions There is evidence of dual pfhrp2/3 gene deletions in the Tigray and Amhara regions of Ethiopia in 2015. As the prevalence of malaria was very low (< 2%), it is difficult to make strong conclusions on RDT performance, but these results challenge the utility of biomarkers in household surveys in very low transmission settings.

Plasmodium falciparum and Plasmodium vivax are co-endemic in Ethiopia. This study investigated whether mixed infections were missed by microscopy from a 2017 therapeutic efficacy study at two health facilities in Ethiopia. All patients (N = 304) were initially classified as having single-species P. falciparum (n = 148 samples) or P. vivax infections (n = 156). Dried blood spots were tested for Plasmodium antigens by bead-based multiplex assay for pan-Plasmodium aldolase, pan-Plasmodium lactate dehydrogenase, P. vivax lactate dehydrogenase, and histidine-rich protein 2. Of 304 blood samples, 13 (4.3%) contained both P. falciparum and P. vivax antigens and were analyzed by polymerase chain reaction for species-specific DNA. Of these 13 samples, five were confirmed by polymerase chain reaction for P. falciparum/P. vivax co-infection. One sample, initially classified as P. vivax by microscopy, was found to only have Plasmodium ovale DNA. Plasmodium falciparum/P. vivax mixed infections can be missed by microscopy even in the context of a therapeutic efficacy study with multiple trained readers.

Background Determining malaria transmission within regions of low, heterogenous prevalence is difficult. A variety of malaria tests exist and range from identification of diagnostic infection to testing for prior exposure. This study describes concordance of multiple malaria tests using data from a 2015 household survey conducted in Ethiopia. Methods Blood samples (n= 2,279) from three regions in northern Ethiopia were assessed for Plasmodium falciparum and P. vivax by microscopy, rapid diagnostic test (RDT), multiplex antigen assay, and multiplex assay for IgG antibodies. Geospatial analysis was conducted with spatial scan statistics and kernel density estimation to identify hotspots of malaria by different test results. Results Prevalence of malaria infection was low (1.4% by RDT, 1.0% by microscopy, and 1.8% by laboratory antigen assay). For P. falciparum, overlapping spatial clusters for all tests and an additional five unique IgG clusters were identified. For P. vivax, clusters identified for bead antigen assay, microscopy, and IgG with partial overlap. Conclusions Assessing the spatial distribution of malaria exposure using multiple metrics can improve the understanding of malaria transmission dynamics in a region. The relative abundance of antibody clusters indicates that in areas of low-transmission, IgG antibodies are a more useful marker to assess malaria exposure.

Poor management of health care waste poses a serious threat to the health of health care workers, patients and communities. In developing countries, adequate health care waste management (HCWM) is often a challenge. To address this, the Zambian Health Services Improvement Project with HCWM as a component, was implemented in five Zambian provinces (Luapula, Muchinga, Northern, North-Western and Western Provinces), under which this cross-sectional study was conducted to identify the knowledge, attitudes, and practices of health care workers on HCWM. Fifty government hospitals and health posts from five provinces in Zambia were included in the study. Data was collected using a mixed-methods approach, which included surveys with health care workers (n = 394), in-depth interviews (n = 47) with health officials at the provincial, district, and facility levels, and observational checklists (n = 86). Overall, knowledge of proper waste segregation was average (mean knowledge score 4.7/ 7). HCWM knowledge varied significantly by job position (p = 0.02) and not by facility level, years of service, nor prior training. Only 37.3% of respondents recalled having received any sort of HCWM training. Poor waste segregation practice was found as only 56.9% of the facilities used an infectious waste bag (yellow, red or orange bin liner) and a black bag for general waste. This study revealed that only 43% of facilities had a functional incinerator on site for infectious waste treatment. Needle sticks were alarmingly high with 31.3% of all respondents reporting a prior needle stick. The system of HCWM remains below national and international standards in health facilities in Zambia. It is imperative that all health care workers undergo comprehensive HCWM training and sufficient health care waste commodities are supplied to all health facility levels in Zambia.

Plasmodium falciparum (Pf) is the dominant malaria parasite in Nigeria though P. vivax (Pv), P. ovale (Po), and P. malariae (Pm) are also endemic. Blood samples (n = 31,234) were collected from children aged 0-14 years during a 2018 nationwide HIV survey and assayed for Plasmodium antigenemia, Plasmodium DNA, and IgG against Plasmodium MSP1-19 antigens. Of all children, 6.6% were estimated to have Pm infection and 1.4% Po infection with no Pv infections detected. The highest household wealth quintile was strongly protective against infection with Pm (aOR: 0.11, 95% CI: 0.05–0.22) or Po (aOR= 0.01, 0.00–0.10). Overall Pm seroprevalence was 34.2% (95% CI: 33.3-35.2) with lower estimates for Po (12.1%, 11.6-12.5) and Pv (6.3%, 6.0-6.7). Pm seropositivity was detected throughout the country with several local government areas showing >50% seroprevalence. Serological and DNA indicators show widespread exposure of Nigerian children to Pm with lower rates to Po and Pv.

Background Malnutrition continues to be a major public health challenge in Zambia. To effectively address this, health systems must be well strengthened to deliver an effective continuum of care. This paper examines health systems issues and services in relation to nutritional support to children under five years, in order to identify gaps and propose interventions towards universal coverage of essential nutrition services. Methods This analysis utilized data from a cross sectional mixed-methods study on factors associated with Severe Acute Malnutrition (SAM) in under-five children to assess health facility nutrition services on offer at select level-one hospitals in five out of ten provinces in Zambia. Stata version 13 was used for analysis. We conducted univariate analysis to assess nutrition services offered, functionality of equipment and tools, availability of human resource and human resource development, and availability of drugs used for assessment and management of nutrition-related health outcomes. Results We found large variations in the level of nutrition services on offer across districts and provinces. Eighty-eight percent of all the hospitals sampled provided group nutrition counseling and 92% of the hospitals in our sample offered individual nutrition counseling to their clients. Overall, the existence of referral and counter-referral systems between the Community Based Volunteers and hospitals were the lowest among all services assessed at 48% and

The majority of symptomatic malaria in sub-Saharan Africa are caused by Plasmodium falciparum. Infection with Plasmodium ovale is often not recorded and not considered clinically relevant. Here, we describe eight cases of P. ovale infection from three African countries – all of which were misdiagnosed at the presenting health facility.

Background: Malnutrition continues to take the lives of millions of children every year. Children under the age of five years are especially susceptible to high rates of malnutrition and more than half of the deaths in under five children are caused by undernutrition in low- and middle-income countries. Zambia continues to have one of the highest rates of malnutrition in Southern Africa, specifically Severe Acute Malnutrition (SAM). The country’s prevalence of under-five malnutrition is above the WHO Public Health threshold which may linked to the observed under-mortality. In this study, we assessed the factors associated with under-5 mortality in children with SAM. Methods: This was a cross-sectional study assessing the factors associated with under-5 mortality in children hospitalized with severe acute malnutrition. The study used data from a cross-sectional study which was assessing factors associated with SAM in under-5 children in five underperforming provinces of Zambia. In this study, we reviewed hospital records from 2014 to 2016 and recorded length of hospital stay, co-morbidities, and death among under-5 children presenting with SAM to select level-one hospitals. Stata version 13 was used for analysis. We conducted both descriptive and bivariate logistic regression to assess the association between mortality and select key factors. Results: We found that over half of the records we extracted listed SAM as the main cause of hospital stay. About one-fourth of under-5 children (24%) were recorded as being HIV positive at time of hospital stay. Malnourished under-5 children who were diagnosed as HIV positive were 3.5 times more likely to die than malnourished under-5 children who were HIV negative.Conclusions: Malnutrition continues to be a problem in Zambia. Undernourished children with existing co-morbidities such as HIV are at greater risk for mortality and poor health outcomes. To combat high rates of SAM, continued efforts are needed to provide adequate nutrition services and care especially in rural areas of Zambia.