Mortality and associated factors among children admitted to an intensive care unit in muhimbili national hospital, from the time of admission to three months after discharge: a prospective cohort study.

BACKGROUND: Mortality of children admitted to Intensive Care Units (ICU) is higher in low-to-middle-income countries (LMICs) as compared to high-income countries (HICs). There is paucity of information on outcomes following discharge from ICU, especially from sub-Saharan Africa region. This study was conducted to determine mortality and its associated factors among children admitted to Pediatric ICU (PICU) at Muhimbili National Hospital, from admission to three months after discharge. METHODOLOGY: This was a hospital-based prospective cohort study conducted between July 2021 and May 2022, among children admitted to PICU who were followed up for 3-month after discharge. Structured questionnaires were used to collect data from their medical charts. Telephone interviews were made after discharge. Medical records and verbal autopsy were used to determine the cause of death after discharge. Cox regression analysis was performed to assess the association between variables. A p-value of < 0.05 was considered statistically significant. Survival after PICU discharge was estimated by Kaplan - Meier curve. RESULTS: Of 323 children recruited, 177(54.8%) were male, with a median age of 17 months (1-168). The leading cause of PICU admission was severe sepsis 90/323(27.9%). A total of 161/323 children died, yielding an overall mortality of 49.8%. Of 173 children discharged from PICU, 33(19.1%) died. The leading cause of death among children who died in the general ward or as readmission into PICU was sepsis 4/17(23.5%). Respiratory diseases 4/16(25.0%) were the commonest cause of death among those who died after hospital discharge. Independent predictors of overall mortality included single organ dysfunction with hazard ratio(HR):5.97, 95% confidence interval (CI)(3.05-12.26)] and multiple organ dysfunction [HR:2.77,95%CI(1.03-2.21)]. Chronic illness[HR:8.13,95%CI(2.45-27.02)], thrombocytosis [HR:3.39,95%CI(1.32-8.73)], single[HR:3.57,95%CI(1.42-9.03)] and multiple organ dysfunction[HR:3.11,95%CI(1.01-9.61)] independently predicted post-PICU discharge mortality. CONCLUSION: Overall mortality and post- PICU discharge mortality were high and more likely to affect children with organ dysfunction, chronic illness, and thrombocytosis. The leading causes of mortality post- PICU discharge were sepsis and respiratory diseases. There is a need for a focused follow up plan of children post- PICU discharge, further research on the long term survival and strategies to improve it.

Patient and health provider costs of integrated HIV, diabetes and hypertension ambulatory health services in low-income settings - an empirical socio-economic cohort study in Tanzania and Uganda.

BACKGROUND: Integration of health services might be an efficient strategy for managing multiple chronic conditions in sub-Saharan Africa, considering the scope of treatments and synergies in service delivery. Proven to promote compliance, integration may lead to increased economies-of-scale. However, evidence on the socio-economic consequences of integration for providers and patients is lacking. We assessed the clinical resource use, staff time, relative service efficiency and overall societal costs associated with integrating HIV, diabetes and hypertension services in single one-stop clinics where persons with one or more of these conditions were managed. METHODS: 2273 participants living with HIV infection, diabetes, or hypertension or combinations of these conditions were enrolled in 10 primary health facilities in Tanzania and Uganda and followed-up for up to 12 months. We collected data on resources used from all participants and on out-of-pocket costs in a sub-sample of 1531 participants, while a facility-level costing study was conducted at each facility. Health worker time per participant was assessed in a time-motion morbidity-stratified study among 228 participants. The mean health service cost per month and out-of-pocket costs per participant visit were calculated in 2020 US$ prices. Nested bootstrapping from these samples accounted for uncertainties. A data envelopment approach was used to benchmark the efficiency of the integrated services. Last, we estimated the budgetary consequences of integration, based on prevalence-based projections until 2025, for both country populations. RESULTS: Their average retention after 1 year service follow-up was 1911/2273 (84.1%). Five hundred and eighty-two of 2273 (25.6%) participants had two or all three chronic conditions and 1691/2273 (74.4%) had a single condition. During the study, 84/2239 (3.8%) participants acquired a second or third condition. The mean service costs per month of managing two conditions in a single participant were $39.11 (95% CI 33.99, 44.33), $32.18 (95% CI 30.35, 34.07) and $22.65 (95% CI 21.86, 23.43) for the combinations of HIV and diabetes and of HIV and hypertension, diabetes and hypertension, respectively. These costs were 34.4% (95% CI 17.9%, 41.9%) lower as compared to managing any two conditions separately in two different participants. The cost of managing an individual with all three conditions was 48.8% (95% CI 42.1%, 55.3%) lower as compared to managing these conditions separately. Out-of-pocket healthcare expenditure per participant per visit was $7.33 (95% CI 3.70, 15.86). This constituted 23.4% (95% CI 9.9, 54.3) of the total monthly service expenditure per patient and 11.7% (95% CI 7.3, 22.1) of their individual total household income. The integrated clinics' mean efficiency benchmark score was 0.86 (range 0.30-1.00) suggesting undercapacity that could serve more participants without compromising quality of care. The estimated budgetary consequences of managing multi-morbidity in these types of integrated clinics is likely to increase by 21.5% (range 19.2-23.4%) in the next 5 years, including substantial savings of 21.6% on the provision of integrated care for vulnerable patients with multi-morbidities. CONCLUSION: Integration of HIV services with diabetes and hypertension control reduces both health service and household costs, substantially. It is likely an efficient and equitable way to address the increasing burden of financially vulnerable households among Africa's ageing populations. Additional economic evidence is needed from longer-term larger-scale implementation studies to compare extended integrated care packages directly simultaneously with evidence on sustained clinical outcomes.

Cryptococcal meningitis screening and community-based early adherence support in people with advanced HIV infection starting antiretroviral therapy in Tanzania and Zambia: an open-label, randomised controlled trial.

BACKGROUND: Mortality in people in Africa with HIV infection starting antiretroviral therapy (ART) is high, particularly in those with advanced disease. We assessed the effect of a short period of community support to supplement clinic-based services combined with serum cryptococcal antigen screening. METHODS: We did an open-label, randomised controlled trial in six urban clinics in Dar es Salaam, Tanzania, and Lusaka, Zambia. From February, 2012, we enrolled eligible individuals with HIV infection (age ≥18 years, CD4 count of <200 cells per µL, ART naive) and randomly assigned them to either the standard clinic-based care supplemented with community support or standard clinic-based care alone, stratified by country and clinic, in permuted block sizes of ten. Clinic plus community support consisted of screening for serum cryptococcal antigen combined with antifungal therapy for patients testing antigen positive, weekly home visits for the first 4 weeks on ART by lay workers to provide support, and in Tanzania alone, re-screening for tuberculosis at 6-8 weeks after ART initiation. The primary endpoint was all-cause mortality at 12 months, analysed by intention to treat. This trial is registered with the International Standard Randomised Controlled Trial Number registry, number ISCRTN 20410413. FINDINGS: Between Feb 9, 2012, and Sept 30, 2013, 1001 patients were randomly assigned to clinic plus community support and 998 to standard care. 89 (9%) of 1001 participants in the clinic plus community support group did not receive their assigned intervention, and 11 (1%) of 998 participants in the standard care group received a home visit or a cryptococcal antigen screen rather than only standard care. At 12 months, 25 (2%) of 1001 participants in the clinic plus community support group and 24 (2%) of 998 participants in the standard care group had been lost to follow-up, and were censored at their last visit for the primary analysis. At 12 months, 134 (13%) of 1001 participants in the clinic plus community support group had died compared with 180 (18%) of 998 in the standard care group. Mortality was 28% (95% CI 10-43) lower in the clinic plus community support group than in standard care group (p=0·004). INTERPRETATION: Screening and pre-emptive treatment for cryptococcal infection combined with a short initial period of adherence support after initiation of ART could substantially reduce mortality in HIV programmes in Africa. FUNDING: European and Developing Countries Clinical Trials Partnership.

Patient reported experience measures on HIV viral load testing at public health facilities in Dar es Salaam, Tanzania: A convergent mixed method study.

While viral load (VL) testing is critical to effective treatment of human immunodeficiency virus (HIV), little is known about patients' experiences with, and barriers to VL-testing in the context of HIV infection. We assessed patient reported experience measures (PREMs) on VL-testing in public HIV clinics in Tanzania. In a cross-sectional convergent mixed method study, we collected information on VL test related PREMs, clinical and sociodemographic factors. PREMs were measured using a 5-point Likert scale. Focus Group Discussions (FGDs) explored on experience, access, and barriers to VL-testing. Descriptive statistics summarized patients' factors and PREMs. Logistic regression was used to explore association of patient factors, PREMs and satisfaction with VL-testing services. Thematic analysis was used for qualitative data. A total of 439 (96.48%) respondents completed the survey, 331 (75.40%) were female, median (IQR) age was 41(34, 49) years. A total of 253(57.63%) had a VL test at least once in the past 12 months, of whom 242(96.0%) had VL<1000 copies/ml. Investigating barriers to VL-testing, most participants (>92.0%) reported good or very good health services responsiveness (HSR). A scale of very good was chosen by the majority for being treated with respect 174(39.6%), listened to 173(39.4%), following advice 109(24.8%), being involved in decisions 101(23.0%), and for communication 102(23.3%). Satisfaction on VL-testing services was significantly associated with respondents following care providers' advice, (aOR) = 2.07 [95%CI 1.13-3.78], involvement in decisions aOR = 4.16 [95%CI 2.26-7.66], and communication aOR = 2.27 [95%CI 1.25-4.14]. FGDs findings converged with the survey data, with identified barriers to VL test including lack of autonomy in decision making, little awareness on the benefits of the test, long waiting time, stigma, competing priorities for those with comorbidities and transport costs. Satisfaction on VL-testing was largely a result of involvement in decision making, following care provider's advice and good communication; entities needing universal improvement across the country.

The effect of reproductive, hormonal, nutritional and lifestyle on breast cancer risk among black Tanzanian women: A case control study.

PURPOSE: This study aimed to determine the effect of reproductive, hormonal, lifestyle and nutritional factors on breast cancer development among Tanzanian black women. METHODOLOGY: We undertook a case-control study age-matched to ±5years in 2018 at Muhimbili National Hospital. The study recruited 105 BC patients and 190 controls giving it 80% power to detect an odds ratio of ≥2 at the alpha error of <5% for exposure with a prevalence of 30% in the control group with 95% confidence. Controls were recruited from in patients being treated for non-cancer related conditions. Information regarding hormonal, reproductive, nutritional and lifestyle risk for breast cancer and demography was collected by interviews using a predefined data set. Conditional multinomial logistic regression used to determine the adjusted odds ratio for variables that had significant p-value in the binomial logistic regression model with 5% allowed error at 95% confidence interval. RESULTS: The study recruited 105 cases and 190 controls. Only old age at menopause had a significant risk, a 2.6 fold increase. Adolescent obesity, family history of breast cancer, cigarette smoking and alcohol intake had increased odds for breast cancer but failed to reach significant levels. The rural residency had 61% reduced odds for developing breast cancer though it failed to reach significant levels. CONCLUSION: Older age at menopause is a significant risk factor for the development of breast cancer among Tanzanian women. This study has shed light on the potential role of modifiable risk factors for breast cancer which need to be studied further for appropriate preventive strategies in similar settings.

Drug resistance is widespread among children who receive long-term antiretroviral treatment at a rural Tanzanian hospital.

OBJECTIVES: To assess long-term virological efficacy and the emergence of drug resistance in children who receive antiretroviral treatment (ART) in rural Tanzania. PATIENTS AND METHODS: Haydom Lutheran Hospital has provided ART to HIV-infected individuals since 2003. From February through May 2009, a cross-sectional virological efficacy survey was conducted among children (<15 years) who had completed >or=6 months of first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based ART. Genotypic resistance was determined in those with a viral load of >200 copies/mL. RESULTS: Virological response was measured in 19 of 23 eligible children; 8 of 19 were girls and median age at ART initiation was 5 years (range 2-14 years). Median duration of ART at the time of the survey was 40 months (range 11-61 months). Only 8 children were virologically suppressed (50% harboured drug resistance. Results for children were markedly poorer than for adults attending the same programme, underscoring the need for improved treatment strategies for children in resource-limited settings.

Red meat consumption and its association with hypertension and hyperlipidaemia among adult Maasai pastoralists of Ngorongoro Conservation Area, Tanzania.

BACKGROUND: Red meat is an important dietary source of protein and other essential nutrients. Its high intake has been associated with an increased risk of cardiovascular morbidity and mortality, including hypertension (HTN) and hyperlipidaemia (HLP). Despite being physically active, the Maasai at Ngorongoro Conservation Area (NCA) depend heavily on animals' products as their staple food with fewer intakes of vegetables or fruits due to restriction from carrying out agricultural activities within the NCA. This study aimed at determining the prevalence of HTN and HLP and their association with red meat consumption among adult Maasai of NCA. METHODS: A community-based cross-sectional study was conducted in October 2018 using multistage sampling technique. Eight hundred and ninety-four (894) participants enrolled from seven villages in three wards within NCA Data were collected using a modified WHO NCDs-STEPS tool. Anthropometric measurements, blood pressure (BP) measurements, and blood samples for glucose and cholesterol tests were obtained from the study participants. Crude and adjusted prevalence ratio (PR) for factors associated with HTN and HLP were estimated using Ordinal and Bayesian logistic regression models, respectively. RESULTS: The prevalence of HLP was 23.7 percent. The levels were higher among males than were among the females (29.0% vs. 20.1%, p = 0.002). The prevalence of HTN and pre-HTN (elevated BP) were 9.8 and 37.0 percent, respectively. Both HTN and elevated BP were higher among males than were among females (hypertensive [10.9% vs. 9.0%]; elevated BP [44.0% vs. 32.1%], p<0.001). The prevalence of HLP was significantly associated with level II (PR = 1.56, 95%CrI: 1.10-2.09) and level III (PR = 1.64, 95%CrI: 1.08-2.41) of red meat consumption as opposed to level I. CONCLUSION: The prevalence of hyperlipidaemia and elevated BP were high among NCA Maasai. We found a significant association between red meat consumption and hyperlipidaemia. Further follow-up studies are warranted to establish a temporal relationship between red meat consumption and both conditions.

Dried blood spots perform well in viral load monitoring of patients who receive antiretroviral treatment in rural Tanzania.

BACKGROUND: Monitoring of antiretroviral treatment (ART) with human immunodeficiency virus (HIV) viral loads, as recommended in industrialized countries, is rarely available in resource-limited settings because of the high costs and stringent requirements for storage and transport of plasma. Dried blood spots (DBS) can be an alternative to plasma, but the use of DBS has not been assessed under field conditions in rural Africa. The present study investigates the performance of DBS in HIV viral load monitoring of patients who received ART in rural Tanzania. PATIENTS AND METHODS: From November 2007 through June 2008, parallel plasma and DBS specimens were obtained from patients who received ART at Haydom Lutheran Hospital in rural Tanzania. DBS specimens were stored at tropical room temperature for 3 weeks before testing with the NucliSENS EasyQ HIV-1 v1.2 assay. Results obtained with DBS were compared with results obtained with use of a gold-standard plasma assay. RESULTS: Ninety-eight plasma-DBS pairs were compared, and plasma viral loads ranged from <40 to >1,000,000 copies/mL. The correlation between plasma and DBS viral load was strong (R(2) = 0.75). The mean difference (+/- standard deviation) was 0.04 +/ 0.57 log(10) copies/mL, and only 8 samples showed >1 log(10) copies/mL difference. HIV type 1 RNA was detected in 7%, 60%, and 100% of DBS specimens with corresponding plasma viral loads of 40-999, 1000-2999, and 3000 copies/mL, respectively. CONCLUSIONS: DBS, in combination with the NucliSENS EasyQ HIV-1 v1.2 asay, performed well in monitoring HIV viral loads in patients who received ART in rural Tanzania, although the sensitivity was reduced when viral burden was low. The use of DBS can simplify virological monitoring in resource-limited settings.

Virological efficacy and emergence of drug resistance in adults on antiretroviral treatment in rural Tanzania.

BACKGROUND: Virological response to antiretroviral treatment (ART) in rural Africa is poorly described. We examined virological efficacy and emergence of drug resistance in adults receiving first-line ART for up to 4 years in rural Tanzania. METHODS: Haydom Lutheran Hospital has provided ART to HIV-infected patients since October 2003. A combination of stavudine or zidovudine with lamivudine and either nevirapine or efavirenz is the standard first-line regimen. Nested in a longitudinal cohort study of patients consecutively starting ART, we carried out a cross-sectional virological efficacy survey between November 2007 and June 2008. HIV viral load was measured in all adults who had completed at least 6 months first-line ART, and genotypic resistance was determined in patients with viral load >1000 copies/mL. RESULTS: Virological response was measured in 212 patients, of whom 158 (74.5%) were women, and median age was 35 years (interquartile range [IQR] 29-43). Median follow-up time was 22.3 months (IQR 14.0-29.9). Virological suppression, defined as <400 copies/mL, was observed in 187 patients (88.2%). Overall, prevalence of > or =1 clinically significant resistance mutation was 3.9, 8.4, 16.7 and 12.5% in patients receiving ART for 1, 2, 3 and 4 years, respectively. Among those successfully genotyped, the most frequent mutations were M184I/V (64%), conferring resistance to lamivudine, and K103N (27%), Y181C (27%) and G190A (27%), conferring resistance to non-nucleoside reverse transcriptase inhibitors (NNRTIs), whereas 23% had thymidine analogue mutations (TAMs), associated with cross-resistance to all nucleoside reverse transcriptase inhibitors (NRTIs). Dual-class resistance, i.e. resistance to both NRTIs and NNRTIs, was found in 64%. CONCLUSION: Virological suppression rates were good up to 4 years after initiating ART in a rural Tanzanian hospital. However, drug resistance increased with time, and dual-class resistance was common, raising concerns about exhaustion of future antiretroviral drug options. This study might provide a useful forecast of drug resistance and demand for second-line antiretroviral drugs in rural Africa in the coming years.

Cytomegalovirus viremia in dried blood spots is associated with an increased risk of death in HIV-infected patients: a cohort study from rural Tanzania.

OBJECTIVES: The objectives of the study were to assess the utility of dried blood spots (DBS) for the detection of cytomegalovirus (CMV) antibody and viremia in a resource-poor setting, to study the prevalence of CMV antibody and viremia in HIV-infected patients with access to antiretroviral therapy (ART) in Tanzania, and to relate CMV viremia to outcome. METHODS: DBS were prepared from 168 ART-naïve patients at baseline. Demographic, clinical, and laboratory data were obtained from patient records. CMV antibody was analyzed by chemiluminescent microparticle immunoassay and viremia by quantitative PCR. RESULTS: All patients were CMV-seropositive. At baseline 38 (22.6%) had detectable CMV viremia and 14 (8.3%) had a CMV viral load ≥ 200 copies/ml. In 135 patients available for follow-up, CMV ≥ 200 copies/ml was an independent risk factor for death with a hazard ratio of 5.0 (95% confidence interval 2.1-11.9) after adjusting for confounders. Symptoms compatible with CMV disease were common with viremia ≥ 200 copies/ml and CD4+ T cell counts <100 cells/mm(3), but confirmatory diagnostic procedures were unavailable. CONCLUSIONS: DBS are suitable for the detection of CMV antibody and viremia in HIV patients in resource-poor areas. CMV viremia was frequent and associated with an increased risk of death. Improved diagnosis and treatment of CMV may improve the prognosis for HIV-infected patients in developing countries and should be addressed in future studies.

Public health concern and initiatives on the priority action towards non-communicable diseases in Tanzania.

Tanzania is already facing challenges caused by existing burden of communicable diseases, and the growing trend of nonconununicable diseases (NCDs), which raises a lot of concerns and challenges. The objective of this review is to provide broad insight of the "silent epidemic" of NCDs, existing policies, strategies and interventions, and recommendations on prioritized actions. A review of existing literature including published articles, technical reports, and proceedings from national and international NCDs meetings was carried out. The burden, existing interventions, socio-economic impact, lessons learnt, and potential for expanding cost effective interventions in Tanzania were explored. Challenges to catch up with global momentum on NCD agenda were identified and discussed. The review has indicated that the burden of NCDs and its underlying risk factors in Tanzania is alarming, and affects people of all socio-economic status. The costs of health care for managing NCDs are high, and thus impoverishing the already poor people. The country leadership has a high political commitment; there are policies and strategies, which need to be implemented to address the growing NCD burden. In conclusion, NCDs in Tanzania are a silent rising health burden and has enormous impact on an individual and country's social-economical status. From the experience of other countries, interventions for NCDs are affordable, feasible and some are income generating. Multisectoral approach, involving national and international partners has a unique role in intensifying action on NCDs. Tanzania should strategize on implementation research on how to adapt the interventions and apply multi-sectoral approach to control and prevent NCDs in the country.