Maternal exposure to carbon monoxide and fine particulate matter during pregnancy in an urban Tanzanian cohort.

Low birthweight contributes to as many as 60% of all neonatal deaths; exposure during pregnancy to household air pollution has been implicated as a risk factor. Between 2011 and 2013, we measured personal exposures to carbon monoxide (CO) and fine particulate matter (PM2.5 ) in 239 pregnant women in Dar es Salaam, Tanzania. CO and PM2.5 exposures during pregnancy were moderately high (geometric means 2.0 ppm and 40.5 µg/m3 ); 87% of PM2.5 measurements exceeded WHO air quality guidelines. Median and high (75th centile) CO exposures were increased for those cooking with charcoal and kerosene versus kerosene alone in quantile regression. High PM2.5 exposures were increased with charcoal use. Outdoor cooking reduced median PM2.5 exposures. For PM2.5 , we observed a 0.15 kg reduction in birthweight per interquartile increase in exposure (23.0 µg/m3 ) in multivariable linear regression; this finding was of borderline statistical significance (95% confidence interval 0.30, 0.00 kg; P = 0.05). PM2.5 was not significantly associated with birth length or head circumference nor were CO exposures associated with newborn anthropometrics. Our findings contribute to the evidence that exposure to household air pollution, and specifically fine particulate matter, may adversely affect birthweight.

Case-fatality and disability in the Tanzanian Stroke Incidence Project cohort.

OBJECTIVES: The burden of stroke on healthcare services in sub-Saharan Africa (SSA) is increasing. However, long-term outcomes from stroke in SSA are not well described. We aimed to investigate case-fatality and health outcomes for stroke survivors at 7- to 10-year follow-up. MATERIALS AND METHODS: The Tanzanian Stroke Incidence Project (TSIP) recruited incidence stroke cases between 2003 and 2006. We followed up cases in 2013, recording date of death in those who had died. RESULTS: Of 130 stroke cases included in this study, case-fatality and date of death data were available for 124 at 7-10 years post-stroke. Of these, 102 (82.3%) had died by 7 years post-stroke. Functional disability, as measured by the Barthel index immediately post-stroke, was a significant predictor of case-fatality at seven-year follow-up with those with severe disability having an almost four-fold increase in the odds of death compared with those with no, mild or moderate disability. CONCLUSIONS: Case-fatality rates are higher than reported in high-income countries, with post-stroke disability a significant predictor of death. Sustainable interventions to reduce post-stroke disability in this setting should be investigated.

Pharmacokinetic and pharmacogenomic modelling of the CYP3A activity marker 4ß-hydroxycholesterol during efavirenz treatment and efavirenz/rifampicin co-treatment.

OBJECTIVES: To assess the effect of the major efavirenz metabolizing enzyme (CYP2B6) genotype and the effects of rifampicin co-treatment on induction of CYP3A by efavirenz. PATIENTS AND METHODS: Two study arms (arm 1, n = 41 and arm 2, n = 21) were recruited into this study. In arm 1, cholesterol and 4ß-hydroxycholesterol were measured in HIV treatment-naive patients at baseline and then at 4 and 16 weeks after initiation of efavirenz-based antiretroviral therapy. In arm 2, cholesterol and 4ß-hydroxycholesterol were measured among patients taking efavirenz during rifampicin-based tuberculosis (TB) treatment (efavirenz/rifampicin) just before completion of TB treatment and then serially following completion of TB treatment (efavirenz alone). Non-linear mixed-effect modelling was performed. RESULTS: A one-compartment, enzyme turnover model described 4ß-hydroxycholesterol kinetics adequately. Efavirenz treatment in arm 1 resulted in 1.74 (relative standard error = 15%), 3.3 (relative standard error = 33.1%) and 4.0 (relative standard error = 37.1%) average fold induction of CYP3A for extensive (CYP2B6*1/*1), intermediate (CYP2B6*1/*6) and slow (CYP2B6*6/*6) efavirenz metabolizers, respectively. The rate constant of 4ß-hydroxycholesterol formation [mean (95% CI)] just before completion of TB treatment [efavirenz/rifampicin co-treatment, 7.40 × 10(-7) h(-1) (5.5 × 10(-7)-1.0 × 10(-6))] was significantly higher than that calculated 8 weeks after completion [efavirenz alone, 4.50 × 10(-7) h(-1) (4.40 × 10(-7)-4.52 × 10(-7))]. The CYP3A induction dropped to 62% of its maximum by week 8 of completion. CONCLUSIONS: Our results indicate that efavirenz induction of CYP3A is influenced by CYP2B6 genetic polymorphisms and that efavirenz/rifampicin co-treatment results in higher induction than efavirenz alone.

Micronutrient supplementation and T cell-mediated immune responses in patients with tuberculosis in Tanzania.

Limited studies exist regarding whether incorporating micronutrient supplements during tuberculosis (TB) treatment may improve cell-mediated immune response. We examined the effect of micronutrient supplementation on lymphocyte proliferation response to mycobacteria or T-cell mitogens in a randomized trial conducted on 423 patients with pulmonary TB. Eligible participants were randomly assigned to receive a daily dose of micronutrients (vitamins A, B-complex, C, E, and selenium) or placebo at the time of initiation of TB treatment. We found no overall effect of micronutrient supplements on lymphocyte proliferative responses to phytohaemagglutinin or purified protein derivatives in HIV-negative and HIV-positive TB patients. Of HIV-negative TB patients, the micronutrient group tended to show higher proliferative responses to concanavalin A than the placebo group, although the clinical relevance of this finding is not readily notable. The role of nutritional intervention in this vulnerable population remains an important area of future research.

Elevated alanine aminotransferase in antiretroviral-naïve HIV-infected African patients: magnitude and risk factors.

BACKGROUND: Alanine aminotransferase (ALT) is commonly used to measure liver injury in resource-limited settings. Elevations in ALT are predictive of increased mortality from liver disease and may influence the choice of first-line antiretroviral therapy (ART). METHODS: A cross-sectional analysis of the prevalence and predictors of elevated ALT (defined as >40 IU/L) was conducted. ART-naïve, HIV-infected adults with a baseline ALT measurement who were enrolled in any of the 18 HIV Care and Treatment Clinics in Dar es Salaam, Tanzania between November 2004 and December 2009 were included in the study. Median values were calculated and log-binomial regression models were used to examine predictors of elevated ALT. RESULTS: During the study period, 41891 adults had a baseline ALT measurement performed. The prevalence of ALT >40, >120 and >200 IU/L was 13, 1 and 0.3%, respectively. In multivariate analyses, male sex, CD4 T lymphocyte count <200 cells/µL and higher World Health Organization (WHO) clinical stages were associated with a significantly higher risk of ALT >40 IU/L (all P<0.01). Hypertryglyceridaemia, hyperglycaemia and hepatitis B virus (HBV) coinfection (positive for HBV surface antigen) were significantly associated with a higher risk of elevated ALT. Pregnancy, anaemia, low-density lipoprotein cholesterol >130 mg/dL and current tuberculosis treatment were associated with a significantly reduced risk for elevated ALT. CONCLUSIONS: In this HIV-infected, ART-naïve Tanzanian population, extreme elevations in ALT were infrequent but minor elevations were not uncommon. Antiretrovirals with potentially hepatotoxic side effects should be initiated with caution in male patients, and in patients with HBV coinfection, advanced immunosuppression and components of the metabolic syndrome.

Enhancing adherence to antiretroviral therapy at the HIV clinic in resource constrained countries; the Tanzanian experience.

OBJECTIVE: To evaluate various strategies aimed at improving adherence to antiretroviral therapy (ART). METHODS: Patients initiated on ART at Muhimbili National Hospital HIV clinic were randomly assigned to either regular adherence counseling, regular counseling plus a calendar, or regular counseling and a treatment assistant. Patients were seen monthly; during these meetings self-reported adherence to treatment was recorded. Disease progression was monitored clinically and immunologically. RESULTS: Of the 621 patients randomized, 312 received regular counseling only, 242 regular counseling and calendars, while 67 had treatment assistants in addition to regular counseling. The mean (SD) follow-up time was 14.5 (4.6) months. During follow-up 20 (3.2%) patients died, and 102 (16.4%) were lost to follow-up; this was similar in all groups. In 94.8% of all visits, patients reported to have adhered to treatment. In only 39 (0.7%) visits did patients report a < or = 95% adherence. There were no differences in adherence (P = 0.573) or differences in CD4 count and weight changes over time in the interventions. CONCLUSIONS: Good adherence to ART is possible in resource constrained countries. Persistent adherence counseling in clinic settings by itself may be effective in improving adherence to ART.

Tuberculosis among the elderly in Tanzania: disease presentation and initial response to treatment.

BACKGROUND: Reports on tuberculosis (TB) presentation among the elderly in sub-Sahara Africa are scarce at a time when the elderly population is increasing. This dearth of information is likely to lead to an increase in the number of undetected TB cases in the region. OBJECTIVE: To describe TB presentation and response to anti-tuberculosis treatment at 2 months among elderly patients. METHODS: Consecutive patients referred to TB centres in Dar es Salaam, Tanzania, underwent clinical, microbiological and chest X-ray (CXR) evaluations at baseline and after 2 months of anti-tuberculosis treatment. Patients aged 60 years were considered elderly and those aged 18-59 years formed the comparison group. RESULTS: Elderly patients with TB were more likely to have smear-negative TB (76.7% vs. 49.3%, P < 0.0001) and lower-zone lesions on CXR (41% vs. 17%, P < 0.001), but less likely to have cavities on CXR (77.6% vs. 50.4%, P < 0.0001) than the comparison group. Hypertension and diabetes mellitus were more common among the elderly than among controls. Mortality at 2 months was respectively 18.6% and 8.1% among the elderly and among controls. Human immunodeficiency virus infection and smoking increased mortality, while hypertension was associated with reduced mortality. CONCLUSION: TB in the elderly was associated with atypical clinical and radiological presentations. A high index of suspicion could minimise delays in diagnosis and treatment.

HIV co-infection, CD4 cell counts and clinical correlates of bacillary density in pulmonary tuberculosis.

BACKGROUND: Sputum microscopy for acid-fast bacilli (AFB) is the commonest diagnostic method for pulmonary tuberculosis (PTB) in developing countries. The method is reported to be less sensitive in human immunodeficiency virus (HIV) positive compared to negative patients. We determined the bacillary density in sputum of smear-positive PTB patients and related it to the patients' HIV status, CD4 cell count, clinical and demographic characteristics. METHODS: Three sputum samples per patient were examined using microscopy before initiating therapy. The AFB density was graded according to World Health Organization recommendations. The smear with the highest density was used. High bacillary density was defined as >10 AFB/field. HIV status and CD4 cell count were determined according to the national guidelines. RESULTS: Of 844 patients, 433 (51.3%) were HIV-positive. High bacillary density was significantly less common among HIV-positive (39.0%) than -negative (75.7%) patients (prevalence ratio 0.52; 95%CI 0.45-0.59, P < 0.0001). Among HIV-positive patients, the proportion of those with high bacillary density increased progressively with CD4 cell counts (P = 0.003). CONCLUSION: HIV is associated with lower AFB concentration in sputum. The AFB density falls with falling CD4 cell count. Microscopy for AFB in sputum may be less sensitive in diagnosing PTB when HIV infection is present, especially in severely immunocompromised patients.

Wasting and body composition of adults with pulmonary tuberculosis in relation to HIV-1 coinfection, socioeconomic status, and severity of tuberculosis.

OBJECTIVE: To examine the impact of HIV coinfection, socioeconomic status (SES) and severity of tuberculosis (TB) on the body composition and anthropometric status of adults with pulmonary TB. DESIGN: Cross-sectional study. SETTING: Five TB clinics in Dar es Salaam, Tanzania. SUBJECTS: A total of 2231 adult men and women diagnosed with pulmonary TB, prior to the initiation of anti-TB therapy. METHODS: We compared the distribution of anthropometric characteristics including body mass index (BMI), mid-upper arm circumference (MUAC), triceps skin-fold (TSF), and arm muscle circumference (AMC) by HIV status, SES characteristics, and indicators of TB severity (bacillary density in sputum and Karnofsky performance score). Similar comparisons were carried out with body composition variables from bioelectrical impedance analysis and albumin concentrations, in a subsample of 731 subjects. RESULTS: In multivariate analysis, HIV infection was significantly associated with lower MUAC and AMC in both men and women, but not with BMI or TSF. Compared to HIV-uninfected women, those who were HIV infected had lower body cell mass (BCM) (adjusted difference = -0.85 kg, P = 0.04), intracellular water (-0.68 l, P = 0.04), and phase angle (-0.52, P = 0.02). Albumin concentrations were significantly lower in both men and women infected with HIV. Among HIV-infected men, CD4 cell counts <200/mm(3) were related to lower intracellular water, BCM, fat-free mass and phase angle. Independent of HIV infection, BMI and MUAC were positively related to SES indicators and the Karnofsky performance score; and inversely related to bacillary density. CONCLUSIONS: HIV infection is associated with indicators of low lean body mass in adults with TB; socioeconomic factors and TB severity are important correlates of wasting, independent of HIV. SPONSORSHIP: The National Institute of Allergy and Infectious Diseases (UO1 AI 45441-01).

Predictors of incident tuberculosis among HIV-1-infected women in Tanzania.

SETTING: The development of tuberculosis (TB) in HIV-1-infected individuals is associated with accelerated HIV-1 disease progression. OBJECTIVE: To examine the predictors of incident TB in HIV-1-infected Tanzanian women. DESIGN: A prospective cohort of 1078 HIV-1-infected pregnant women was enrolled in a randomized clinical trial to examine the role of vitamin supplements in HIV-1 disease progression and fetal outcomes. RESULTS: Of 1008 women evaluated for TB, 88 (8.7%) developed TB. After controlling for age, education and hemoglobin concentration, in multivariate analysis, low CD4 cell count, elevated erythrocyte sedimentation rate (ESR), decreased mid-upper arm circumference, and high viremia were associated with an increased risk of TB. CD4 <200 vs. > or = 500 cells/mm3 was associated with a 4.44-fold increase in risk of TB (95%CI 2.10-9.40). Individuals with high viremia (> or = 50,000 copies/ml) had a 2.43-fold increase in risk of TB (95%CI 1.24-4.76). Elevated malarial parasite density was slightly associated with a 65% (95%CI 19-85) decreased risk of TB. CONCLUSIONS: The risk of developing TB was elevated among women with low CD4 cell counts, elevated ESR, coinfections with other pathogens, poor nutrition and high viremia. There is a slight inverse association between malarial infection and TB, possibly because treating malaria may reduce the risk of TB.

The prevalence and incidence of HIV-1 infection and syphilis in a cohort of police officers in Dar es Salaam, Tanzania: a potential population for HIV vaccine trials.

OBJECTIVES: To assess the suitability of a cohort of police officers in Dar es Salaam for HIV vaccine trials by determining the prevalence and incidence of HIV-1 infection, active syphilis and their associated factors. DESIGN AND SETTING: An open cohort study of police officers in Dar es Salaam, Tanzania. METHODS: Recruitment of police officers began in 1994. A standardized questionnaire was completed at enrolment and subsequent visits. HIV antibodies were determined using two consecutive enzyme-linked immunosorbent assays. Samples repeatedly discordant on the two tests were tested by a Western blot assay. Treponema pallidum antibodies were first determined by Venereal Disease Research Laboratory (VDRL) test and reactive sera were confirmed by Treponema pallidum hemagglutination test. RESULTS: At the end of 1996 a total of 2850 police officers had been recruited of whom 2733 (96%) consented to be tested for HIV. The overall HIV-1 seroprevalence at recruitment was 13.8% (378 of 2733). Females had a significantly higher HIV-1 seroprevalence, 18.0% (55 of 306), as compared to males, 13.3% (323 of 2427), P< 0.05. From a total of 2215 married police officers, 585 (26.4%) responded to a question on extramarital sex within the previous 3 months of whom 36.2% (212 of 585) admitted to have had at least one extramarital sexual intercourse. Condoms were not used during these encounters by 178 of 212 (84.0%). As of 31st December 1998, among the 1524 males observed for 2553 person-years (PYAR), 50 had seroconverted and among 200 females observed for 357 PYAR, eight had seroconverted. The overall crude HIV-1 incidence was thus 19.9/1000 PYAR; 19.6 and 22.4/1000 PYAR for males and females, respectively. The overall prevalence and incidence of active syphilis were 3.1% (88 of 2850) and 8.6/1000 PYAR (26 of 3149), respectively. Males had a higher prevalence of active syphilis, 84 of 2525 (3.3%) than females, five of 325 (1.5%), P = 0.09. CONCLUSIONS: There was high risk sexual practice including low condom use in this cohort of police officers. The incidence and prevalence of HIV infection were high. Police officers in Dar es Salaam are therefore a potential population group for HIV vaccine evaluation.

Hypertension prevalence and care in an urban and rural area of Tanzania.

OBJECTIVE: To describe the prevalence, detection, treatment and control of hypertension in an urban and rural area of Tanzania. DESIGN: Two linked cross-sectional population-based surveys. SETTING: A middle-income urban district of Dar es Salaam (Ilala) and a village in the relatively prosperous rural area of Kilimanjaro (Shari). PARTICIPANTS: Seven hundred and seventy adults (> 15 years) in Ilala and 928 adults in Shari were studied. RESULTS: Hypertension prevalence (blood pressure > or = 140 and/or 90 mmHg, or known hypertensives receiving anti-hypertensive treatment) was 30% (95% confidence interval, 25.1-34.9%) in men and 28.6% (24.3-32.9%) in women in Ilala, and 32.2% (27.7-36.7%) in men and 31.5% (27.8-35.2%) in women in Shari. Age-standardized hypertension (to the New World Population) prevalence was 37.3% (32.2-42.5%) among men and 39.1% (34.2-44.0%) in women in Ilala, and 26.3% (22.4-30.4%) in men and 27.4% (24A-30.4%) in women in Shari. In both areas, just under 20% of hypertensive subjects were aware of their diagnosis, approximately 10% reported receiving treatment and less than 1% were controlled (blood pressure < 140/90 mmHg). Hypertensive subjects were older, had greater body mass indices and waist: hip ratios, and had more risk factors for hypertension and its complications (smoking, heavy alcohol consumption, physical inactivity, obesity and diabetes) than non-hypertensives. CONCLUSIONS: There is a high prevalence of hypertension in rural and urban areas of Tanzania, with low levels of detection, treatment and control. This demonstrates the need for cost-effective strategies for primary prevention, detection and treatment of hypertension and the growing public health challenge of non-communicable diseases in Sub-Saharan Africa.

Vitamin A status of patients presenting with pulmonary tuberculosis and asymptomatic HIV-infected individuals, Dar es Salaam, Tanzania.

Serum vitamin A was determined in a cross-sectional study of 100 HIV-positive and -negative tuberculosis patients and 144 blood donors. Tuberculosis patients were seen again after 2 months of treatment. Mean vitamin A was lowest among tuberculosis patients co-infected with HIV, and was lower among HIV-positive than -negative donors. Mean vitamin A rose significantly at 2 months in HIV-negative patients, and not in -positive patients. HIV infection was the strongest predictor of low vitamin A. Vitamin A deficiency is common in tuberculosis and HIV infection, particularly in those patients who are dually infected, and nutritional supplementation may be beneficial.

Methods for diagnosing tuberculosis among in-patients in eastern Africa whose sputum smears are negative.

SETTING: Two University hospitals in Eastern African capital cities where large prospective studies had been carried out on hospitalized patients to determine the cause of their respiratory diseases. OBJECTIVE: To identify features that differentiated between tuberculosis (TB) and non-tuberculous respiratory disease (non-TB) in hospitalized patients from Bujumbura, Burundi (n = 111) and Dar es Salaam, Tanzania (n = 71) whose sputum smears were negative on microscopic examination for acid-fast bacilli (AFB). DESIGN: Review of clinical findings, radiologic abnormalities, and laboratory test results from 182 patients, first by univariate and then by multivariate (stepwise logistic regression) analysis to assess the contribution of each factor to the final diagnosis. RESULTS: Of the 182 patients with two or more negative AFB smears, 41 had TB and 141 had non-TB. Stepwise regression analysis revealed four easily ascertained symptoms were associated with TB: 1) cough > 21 days; 2) chest pain > 15 days; 3) absence of expectoration; and 4) absence of shortness of breath. Any two of the four diagnosed TB with 85% sensitivity and 67% specificity; any three of the four with 49% sensitivity and 86% specificity. Multivariate analysis showed that adding lymphadenopathy and hematocrit < 30% improved discrimination. CONCLUSION: This methodological approach provides a means for diagnosing TB among all AFB smear-negative hospitalized patients. In this setting, simple clinical symptoms alone are helpful. Similar studies are needed to develop a system for out-patient TB suspects.

Hypoadrenalism in patients with pulmonary tuberculosis in Tanzania: an undiagnosed complication?

Addison's disease is rarely diagnosed in most African countries although tuberculosis, one of its major causes, is a widespread problem. In this study adrenal function was assessed using the Synacthen test in 50 patients with chronic pulmonary tuberculosis admitted to hospital in Dar es Salaam. Sixteen patients (32%) had an impaired response. Two had subnormal basal cortisol levels, one of whom had a normal response to Synacthen. There was no significant difference between the patients with an impaired cortisol response and those with a normal response with respect to frequency of non-specific symptoms, weight loss and body mass index. The mean supine and erect diastolic blood pressures were, however, significantly lower in those with an impaired cortisol response compared to the normal cortisol response group (64 mm Hg vs 74 mm Hg supine (P less than 0.01), and 62 mm Hg vs 73 mm Hg erect (P less than 0.005]. Basal and one-hour plasma cortisol levels correlated significantly with systolic and diastolic blood pressure, and correlated negatively with duration of tuberculosis and diastolic blood pressure. These findings are consistent with reported observations in Zulu patients with pulmonary tuberculosis, and suggest that impaired adrenal function may contribute to morbidity and even mortality among patients with tuberculosis in Africa. Adrenal hypofunction should be considered in any tuberculosis patient with hypotension and poor response to chemotherapy.

Rural and urban differences in diabetes prevalence in Tanzania: the role of obesity, physical inactivity and urban living.

A population-based survey in 1996 and 1997 of 770 adults (aged > or = 15 years) from an urban district of Dares Salaam and 928 from a village in rural Kilimanjaro district (Tanzania) revealed that the prevalence of diabetes, impaired fasting glucose (IFG), overweight, obesity, and physical inactivity was higher in the urban area for men and women. The difference between urban and rural prevalence of diabetes was 3.8 [1x1-6.5]% for men and 2x9 [0x8-4.9]% for women. For IFG, the difference was 2x8 [0x3-5x3]% for men and 3x9 [1x4-6x4]% for women; for overweight and obesity, the difference was 21.5 [15.8-27.1]% and 6.2 [3x5-8.9]% for men and 17x4 [11.5-23.3]% and 12.7 [8x5-16x8]% for women, respectively. The difference in prevalence of physical inactivity was 12x5 [7.0-18.3]% for men and 37.6 [31x9-43.3]% for women. For men with diabetes, the odds for being overweight, obese and having a large waist:hip ratio were 14.1, 5.3 and 12.5, respectively; for women the corresponding values were 9x0, 10x5 and 2x4 (the last not significant) with an attributable fraction for overweight between 64% and 69%. We conclude that diabetes prevalence is higher in the urban Tanzanian community and that this can be explained by differences in the prevalence of overweight. The avoidance of obesity in the adult population is likely to prevent increases in diabetes incidence in this population.

Outcome of clinical foot examination in relation to self-perceived health and glycaemic control in a group of urban Tanzanian diabetic patients.

Diabetic foot complications were studied in 153 patients at the university clinic in Dar es Salaam (56 insulin treated, 77 treated with oral agents and 20 with diet only). Neuropathy disability and symptoms scores were used to diagnose peripheral neuropathy (PN). Peripheral vascular disease (PVD) was classified as ankle/brachial pressure index less than one. The degree of metabolic control was assessed by glycated haemoglobin (HbA1c) and self-perceived health was measured with SF-36. PN was present in 28.1% of patients and 12.5% had PVD. Patients with PN had higher age and later onset of diabetes in comparison with patients without food complications. Patients with PVD had longer duration of diabetes and higher systolic and diastolic blood pressure compared with those free from PVD. HBA1c and body mass index did not seem to influence the occurrence of PN or PVD. Patients with PN had significantly poorer self-perceived health, whilst PVD-patients had health scorings equal to patients without any foot complications. PN, but not PVD, appeared to have a negative influence on patients self-perceived health. In comparison with studies from the industrial world, foot problems are as common in diabetic patients living in a developing country.

Immediate assessment of HbA1c under field conditions in Tanzania.

In Tanzania, assessment of blood glucose is the most frequently used method for evaluating glycaemic control in diabetic patients. The patients' metabolic control is often poor and the determination of glycated haemoglobin (HbA1c) for long-term control could be a valuable tool to better manage the treatment. The aim of this study was to determine whether an immediate assessment method for HbA1c (DCA 2000 analyzer) gives reliable results in the warm and moist climate of east Africa. The study was performed in two parts. One equipment test in Sweden where blood samples from 65 diabetic patients were analysed in a DCA 2000 kept at room temperature and in another kept in a climate chamber. The samples were also analysed with HPLC as a reference method. In the second part HbA1c was analysed in 159 Tanzanian diabetic patients with a DCA 2000 and with HPLC combined with a filter paper technique (HbA1c via Post). The study showed that the DCA 2000 gives reliable results at 85% humidity and a temperature not exceeding +31 degrees C. The correlation with the HPLC analysis varied between 0.94 and 0.98. The conclusion is that the DCA 2000 analyzer can be used in Tanzania during the winter but has to be placed in an air-conditioned room if the temperature exceeds +31 degrees C.

Blood pressure changes in diabetes in urban Tanzania.

Little is known of the natural history of blood pressure (BP) levels in diabetic patients from sub-Saharan Africa. BP levels were therefore recorded in such patients in Dar es Salaam, Tanzania, over 2, 5, and 7 years. Hypertension was found in 5% of insulin-treated diabetes mellitus (IDDM) and 29.2% of non-insulin-dependent diabetes mellitus (NIDDM) patients at presentation with diabetes. Hypertension developed in a further 2 IDDM (3.7%) and 27 NIDDM (15.6%) patients at 2 years, and in 3 IDDM (13.0%) and 9 NIDDM (9.8%) patients at 5 years. Seven NIDDM (18.4%) patients had developed hypertension by 7 years. In NIDDM patients with normal BP initially, the mean systolic BP rose from 131 to 141 mmHg (P < 0.001) 2 years later (n = 146); from 131 to 138 mmHg (P < 0.001) for those followed for 5 years (n = 82); and from 131 to 138 mmHg (P < 0.05) for those followed for 7 years (n = 31). The mean diastolic BP was 83 mmHg initially and 84 mmHg (NS) for those followed for 2 years (n = 146). There was no observed rise in mean diastolic BP at 5 or 7 years of follow-up. In IDDM patients without hypertension, only the systolic BP rose significantly by 5 years, from 124 to 132 mmHg (P < 0.001; n = 20). These changes were independent of age, sex, body mass index, and proteinuria.(ABSTRACT TRUNCATED AT 250 WORDS)

Self-perceived health in urban diabetic patients in Tanzania.

OBJECTIVES: To compare self-perceived health in a group of urban Tanzanian diabetic patients and the general population and to investigate validity of the Swahili version of the health questionnaire used. DESIGN: A health questionnaire and a symptom check list were filled in by diabetic patients after informed consent. The results were compared with data from the general population. SETTING: The study was carried out at the diabetes out-patient clinic at Muhimbili Medical Centre in Dar es Salaam, Tanzania. SUBJECTS: Adult diabetic patients (n = 518) with a mean diabetes duration of 5.5 years were consecutively included. Thirty one per cent of the patients were on insulin treatment. OUTCOME MEASURES: The Swahili version of a health questionnaire measuring eight health-domains and a check-list including 29 symptoms were used. RESULTS: Diabetic patients reported significantly poorer health when compared to the general population. Patients on insulin treatment reported poorer health than those on diet/oral treatment and those with less than ten years duration of diabetes had poorer self-perceived health than patients with shorter duration. Satisfactory concurrent and content validity of the Swahili version of the health questionnaire was found. All but the general health domain showed Cronbach's alpha levels exceeding .70. CONCLUSIONS: It is important to include validated health measures when assessing diabetes treatment and care. The health questionnaire used here was found to differentiate between diabetic patients and the general population. Underlying cultural factors might explain the unsatisfactory reliability of the general health domain.