Rapid Onsite Evaluation for Specimen Adequacy and Triage of Breast Masses in a Low-Resource Setting.

CONTEXT.­: Rapid onsite evaluation (ROSE) is critical in determining sample adequacy and triaging cytology samples. Although fine-needle aspiration biopsy (FNAB) is the primary method of initial tissue sampling in Tanzania, ROSE is not practiced. OBJECTIVE.­: To investigate the performance of ROSE in determining cellular adequacy and providing preliminary diagnoses in breast FNAB in a low-resource setting. DESIGN.­: Patients with breast masses were recruited prospectively from the FNAB clinic at Muhimbili National Hospital. Each FNAB was evaluated by ROSE for overall specimen adequacy, cellularity, and preliminary diagnosis. The preliminary interpretation was compared to the final cytologic diagnosis and histologic diagnosis, when available. RESULTS.­: Fifty FNAB cases were evaluated, and all were adequate for diagnosis on ROSE and final interpretation. Overall percentage of agreement (OPA) between preliminary and final cytologic diagnosis was 84%, positive percentage of agreement (PPA) was 33%, and negative percentage of agreement (NPA) was 100% (κ = 0.4, P < .001). Twenty-one cases had correlating surgical resections. OPA between preliminary cytologic and histologic diagnoses was 67%, PPA was 22%, and NPA was 100% (κ = 0.2, P = .09). OPA between final cytologic and histologic diagnoses was 95%, PPA was 89%, and NPA was 100% (κ = 0.9, P = <.001). CONCLUSIONS.­: False-positive rates of ROSE diagnoses for breast FNAB are low. While preliminary cytologic diagnoses had a high false-negative rate, final cytologic diagnoses had overall high concordance with histologic diagnoses. Therefore, the role of ROSE for preliminary diagnosis should be considered carefully in low-resource settings, and it may need to be paired with additional interventions to improve pathologic diagnosis.

Retention in an mHealth App Aiming to Promote the Use of HIV Pre-Exposure Prophylaxis Among Female Sex Workers in Dar es Salaam, Tanzania: Prospective Cohort Study.

Background: Increasing access to smartphones in sub-Saharan Africa offers an opportunity to leverage mobile health (mHealth) technology to improve access to health care in underserved populations. In the domain of HIV prevention, mHealth interventions can potentially contribute to solving the challenges of suboptimal adherence to pre-exposure prophylaxis (PrEP) and low retention in PrEP services among populations most vulnerable to HIV acquisition. However, there is a gap in the knowledge about the use of such interventions in sub-Saharan Africa. Objective: This study aims to evaluate the extent and predictors of retention in an mHealth app (Jichunge) that aims to promote adherence to PrEP and retention in PrEP care among female sex workers in Dar es Salaam, Tanzania. Methods: A prospective cohort of female sex workers residing in Dar es Salaam were recruited, using respondent-driven sampling. All participants were provided with the Jichunge app as they started PrEP. A questionnaire was used to collect data on sociodemographics and other structural factors, while app use data for the 60-day period following the first 150 days of being in the intervention arm were extracted from the app's back end. A multivariable log-binomial model was used to determine predictors of 6-month retention in the Jichunge app. Results: A total of 470 female sex workers were recruited. Nearly three-quarters of participants (206/284, 72.5%) who came to the 6-month follow-up interview no longer had the Jichunge app on their phones. The majority of these participants (193/206, 93.7%) no longer had access to the app because of issues related to their phones. Data extracted from the back end of the app showed that the use of the app declined over time, and only 13.4% (63/470) of the participants were retained (continued to use the app) after 6 months of intervention. At 6 months, women aged ≥35 years were >2 times more likely to use the app than women aged 18 to 24 years (adjusted risk ratio [aRR] 2.2, 95% CI 1.2-4.1; P=.01). Furthermore, retention in the app was higher among participants who demonstrated high PrEP awareness at baseline (aRR 1.8, 95% CI 1.1-3; P=.01) and among those who had experienced financial difficulties due to health care spending (aRR 1.9, 95% CI 1.2-3.2; P=.01). Conclusions: Most female sex workers (206/284, 72.5%) who were enrolled in PrEP care in Tanzania no longer used the Jichunge app after 6 months. Retention in the app at 6 months was predicted by older age, high PrEP awareness, and financial difficulties due to health care spending. Strategies for the long-term retention of participants in mHealth apps, such as systems for reinstallations of apps, should be considered during the design phase.

A Genomic Analysis of Esophageal Squamous Cell Carcinoma in Eastern Africa.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) comprises 90% of all esophageal cancer cases globally and is the most common histology in low-resource settings. Eastern Africa has a disproportionately high incidence of ESCC. METHODS: We describe the genomic profiles of 61 ESCC cases from Tanzania and compare them to profiles from an existing cohort of ESCC cases from Malawi. We also provide a comparison to ESCC tumors in The Cancer Genome Atlas (TCGA). RESULTS: We observed substantial transcriptional overlap with other squamous histologies via comparison with TCGA PanCan dataset. DNA analysis revealed known mutational patterns, both genome-wide as well as in genes known to be commonly mutated in ESCC. TP53 mutations were the most common somatic mutation in tumors from both Tanzania and Malawi but were detected at lower frequencies than previously reported in ESCC cases from other settings. In a combined analysis, two unique transcriptional clusters were identified: a proliferative/epithelial cluster and an invasive/migrative/mesenchymal cluster. Mutational signature analysis of the Tanzanian cohort revealed common signatures associated with aging and cytidine deaminase activity (APOBEC) and an absence of signature 29, which was previously reported in the Malawi cohort. CONCLUSIONS: This study defines the molecular characteristics of ESCC in Tanzania, and enriches the Eastern African dataset, with findings of overall similarities but also some heterogeneity across two unique sites. IMPACT: Despite a high burden of ESCC in Eastern Africa, investigations into the genomics in this region are nascent. This represents the largest comprehensive genomic analysis ESCC from sub-Saharan Africa to date.

Effect of an mHealth intervention on retention in HIV pre-exposure prophylaxis services among female sex workers: Preliminary evidence of the use of the Jichunge app in Dar es Salaam, Tanzania.

Background: Mobile health (mHealth) applications have been reported to be effective in promoting access and adherence to health services. However, knowledge about their effect on retention in HIV preventive services among at-risk populations in sub-Saharan Africa is limited. Objective: We aimed to evaluate the effect of the Jichunge mHealth application on retention in HIV pre-exposure prophylaxis (PrEP) services among female sex workers in Dar es Salaam, Tanzania. Methods: We used respondent-driven sampling to recruit female sex workers eligible for PrEP and who owned a smartphone. All study participants were provided with a smartphone application (Jichunge app) aiming to promote PrEP use through medication reminders, easy access to PrEP information, online consultations with a doctor and/or peer educator, and online discussions between PrEP users. The effect of optimal use of the Jichunge app on retention in PrEP services at 1-month was modelled using log-binomial regression. Results: A total of 470 female sex workers with a median age of 26 (interquartile range: 22-30) years were recruited. Overall, 27.7% of female sex workers were retained in PrEP services at 1 month. Retention was twice as high among optimal users of the app than among sub-optimal users (adjusted risk ratios = 2.00, 95% confidence interval (CI): 1.41-2.83, p < 0.001). Conclusion: The optimal use of the Jichunge mHealth application was significantly associated with higher retention in PrEP services among female sex workers in Dar es Salaam.

HIV testing and associated factors among female sex workers in Tanzania: approaching the first 90% target?

Use of HIV testing services among FSW in sub-Saharan Africa (SSA) is below the desired UNAIDS target of 90%. We estimated the prevalence and factors associated with HIV testing among FSW in Dar es Salaam, Tanzania. A respondent-driven sampling method was used to recruit FSW aged 18. Modified Poisson regression models were used to determine factors associated with recent HIV testing. Of 958 surveyed FSW (median age 26 years), 85.4% (95% CI: 82.3, 88.1) reported to have ever been tested for HIV and 65.3% (95% CI: 61.2, 69.3) tested in the past 12 months. Condom use on the last day worked (prevalence ratio (PR) = 1.17; 95% CI: 0.99, 1.38), no or low self-perceived risk of HIV acquisition (PR = 1.16; 95% CI: 1.02, 1.32), having never felt stigmatized as a sex worker (PR = 1.18; 95% CI: 1.04, 1.33), and having been in contact with a peer educator (PR = 1.33; 95% CI: 1.18, 1.49) during the past year preceding the survey were associated with recent HIV testing. Interventions aiming to mitigate stigma due to sex work, improve health education to address risk perception as a barrier to HIV testing, and scaling up peer educator's engagement should be given priority.

Testing for Drug-Related Infectious Diseases and Determinants among People Who Use Drugs in a Low-Resource Setting: A Respondent-Driven Cross-Sectional Survey.

(1) Background: There is a dearth of data on the levels and determinants of testing for drug-related infectious diseases among people who use drugs (PWUD). We assessed the proportions and determinants of testing for drug-related infectious diseases to inform ongoing interventions for PWUD. (2) Methods: A cross-sectional study involving 599 PWUD was conducted in Dar es Salaam and Tanga between January and February 2019. Data were collected through a researcher-administered questionnaire using handheld tablets. Logistic regression models were used to identify independent testing determinants for drug-related infectious diseases. (3) Results: A majority (98.0%) of participants were males, with a mean age of 36.8 (SD = 7.8) years. 75.0%, 40.6%, 38.6%, and 8.2% reported having ever tested for HIV, tuberculosis (TB), sexually transmitted infections (STIs), and viral hepatitis, respectively. The likelihood of HIV testing was higher among those living with someone (AOR = 2.18, 95% CI: 1.09-4.68) compared with those who were homeless and perceived treatment was appropriate (AOR = 2.18, 95% CI: 1.05-4.46), but was lower among those who experienced mild to moderate (AOR = 0.44, 95% CI: 0.21-0.95) and severe internalized stigma (AOR = 0.44, 95% CI: 0.22-0.94) compared with those reporting no internalized stigma, and among those who experienced financial difficulties resulting from spending on health care services (AOR = 0.60, 95% CI: 0.40-0.89). Perception of treatment appropriateness (AOR = 2.29, 96% CI: 1.10-5.06) and severe enacted stigma (AOR = 1.90, 95% CI: 1.06-3.42) were associated with increased odds of TB testing. The odds of STIs testing increased among those who were married (AOR = 2.31, 95% CI: 1.45-3.72) compared with those who were single and those who had experienced mild (AOR = 2.39, 95% CI: 1.28-4.53) or severe (AOR = 6.20, 95% CI: 1.99-23.83) sexual violence, compared with those who had not experienced sexual violence. However, the odds decreased among those who had been remanded in the past month (AOR = 0.64, 95% CI: 0.43-0.95) compared with those who were not remanded and among those who had financial difficulties resulting from spending on health care services (AOR = 0.66, 95% CI: 0.47-0.94). The likelihood of testing for viral hepatitis testing increased among those who had heard about the comprehensive HIV intervention package (CHIP) (AOR = 2.59, 95% CI: 1.40-4.94); however, it decreased among those who had financial difficulties resulting from spending on health care services (AOR = 0.48, 95% CI: 0.24-0.92). (4) Conclusions: Except for HIV, PWUD had undergone limited testing for drug-related infectious diseases. The study findings highlight some factors influencing testing for the selected infectious diseases investigated, which should be targeted for tailored interventions to improve diagnosis and treatment.

An international report on bacterial communities in esophageal squamous cell carcinoma.

The incidence of esophageal squamous cell carcinoma (ESCC) is disproportionately high in the eastern corridor of Africa and parts of Asia. Emerging research has identified a potential association between poor oral health and ESCC. One possible link between poor oral health and ESCC involves the alteration of the microbiome. We performed an integrated analysis of four independent sequencing efforts of ESCC tumors from patients from high- and low-incidence regions of the world. Using whole genome sequencing (WGS) and RNA sequencing (RNAseq) of ESCC tumors from 61 patients in Tanzania, we identified a community of bacteria, including members of the genera Fusobacterium, Selenomonas, Prevotella, Streptococcus, Porphyromonas, Veillonella and Campylobacter, present at high abundance in ESCC tumors. We then characterized the microbiome of 238 ESCC tumor specimens collected in two additional independent sequencing efforts consisting of patients from other high-ESCC incidence regions (Tanzania, Malawi, Kenya, Iran, China). This analysis revealed similar ESCC-associated bacterial communities in these cancers. Because these genera are traditionally considered members of the oral microbiota, we next explored whether there was a relationship between the synchronous saliva and tumor microbiomes of ESCC patients in Tanzania. Comparative analyses revealed that paired saliva and tumor microbiomes were significantly similar with a specific enrichment of Fusobacterium and Prevotella in the tumor microbiome. Together, these data indicate that cancer-associated oral bacteria are associated with ESCC tumors at the time of diagnosis and support a model in which oral bacteria are present in high abundance in both saliva and tumors of some ESCC patients.

Predictors of mHealth use in promoting adherence to pre-exposure prophylaxis among female sex workers: an evaluation of the Jichunge intervention in Dar es Salaam, Tanzania.

BACKGROUND: There is evidence that pre-exposure prophylaxis (PrEP) is effective in preventing HIV transmission, and PrEP is recommended by the World Health organization (WHO) for use by individuals at high risk of HIV infection. However, low adherence has been reported to hamper its effectiveness. Some evidence indicates that mHealth interventions may be a promising way of promoting PrEP adherence. Nevertheless, evaluations of mHealth interventions in Africa, the region most affected by HIV, are scarce. This study aimed at identifying the extent of and predictors for use of a smartphone based mHealth application among female sex workers in Dar es Salaam, Tanzania. METHODS: As part of a quasi-experimental study in Tanzania, 470 female sex workers who were eligible for PrEP and who owned a smartphone were recruited using respondent driven sampling. All participants were provided with an mHealth application called Jichunge, a smartphone-based app designed to promote adherence to PrEP by offering users information, advise and support during start-up and use of PrEP. We collected data through structured interviews at baseline and extracted user data from the app for a period of 30 days. Modified Poisson regression model with robust standard errors was used to identify predictors for the optimal use of the Jichunge app. RESULTS: Overall, the optimal use of the Jichunge app was 46.4%. Optimal use was significantly higher among women who were older (aPR = 1.3, 95% CI: 1.10-1.65, p = 0.004 for age 25-34 years, and aPR = 1.6, 95% CI: 1.19-2.07, p = 0.001 for age at least 35 years), who had secondary education or higher (aPR = 1.8, 95% CI: 1.08-2.94, p = 0.023), who had suboptimal social support (aPR = 1.2, 95% CI: 1.02-1.48, p = 0.030), who had high awareness of PrEP (aPR = 1.3, 95% CI: 1.08-1.55, p = 0.005), and who had experience using common mainstream social media applications (aPR = 1.4, 95% CI: 1.08-1.71, p = 0.009). CONCLUSION: Optimal use of the Jichunge app was substantially higher among women with higher age, higher education, higher PrEP awareness, less social support, and experience using common social media applications. Individual and interpersonal factors should be considered in planning mHealth interventions. Further studies to determine predictors of longer-term mHealth engagement are needed. TRIAL REGISTRATION: International Clinical Trials Registry Platform PACTR202003823226570 ; 04.03.2020.

Risk Factors Associated With Early-Onset Esophageal Cancer in Tanzania.

PURPOSE: Eastern Africa is one of several regions affected by high incidence rates of esophageal squamous cell carcinoma (ESCC). A unique epidemiologic feature of ESCC in Eastern Africa is the high incidence in young people, with one-third of cases diagnosed at age < 45 years. This study aimed to investigate risk factors for early-onset ESCC in Tanzania through a secondary analysis of a matched case-control study. MATERIALS AND METHODS: From 2013 to 2015, ESCC cases were recruited at Muhimbili National Hospital and Ocean Road Cancer Institute in Dar es Salaam, Tanzania. Hospital controls were identified from patients with nonmalignant conditions and matched 1:1 for sex and age (± 10 years). Questionnaires were used to assess sociodemographic characteristics and environmental, dietary, and lifestyle risk exposures. Multivariate logistic regression models were used to estimate age-specific odds ratios of ESCC for exposures among participants age 30-44 and ≥ 45 years. RESULTS: A total of 471 cases and 471 controls were enrolled. Among cases, 100 (21%) were < 45 years. Multiple exposures were identified as risk factors for early-onset ESCC, several of which were unique to this age group, including infrequent teeth cleaning, secondhand tobacco smoke exposure, and pest infestation of grain and/or nuts. Lower socioeconomic status, family history of ESCC, tobacco smoking, home-brewed alcohol consumption, home storage of grain and/or nuts, and use of firewood for cooking were associated in the older but not the younger age group. Hot beverage intake was associated with increased ESCC risk in both age groups. CONCLUSION: Our results suggest that ESCC risk factors in Tanzania vary between age groups. With the data currently available, environmental and behavioral risk factors appear to play an important role in the high incidence of ESCC among young people.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study.

BACKGROUND: Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined. METHODS: This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach. DISCUSSION: This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research. TRIAL REGISTRATION: This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021,  NCT05177393 .

Socio-cognitive factors influencing access to HIV prevention services among people who inject drugs in Dar es Salaam, Tanzania: An integrated bio-behavioural survey.

INTRODUCTION: People who inject drugs (PWID) in Sub-Saharan Africa have limited access to comprehensive HIV services. While it is important to inform programming, knowledge about factors influencing access to comprehensive HIV services is scarce. We assessed the proportions of PWID with access to HIV prevention services and associated socio-cognitive factors in Tanzania. METHODS: A cross-sectional survey was conducted among PWID between October and December 2017 in Dar es Salaam, Tanzania. Data on access to HIV prevention services, demographics and selected socio-cognitive factors were collected through structured face-to-face interviews. Weighted descriptive and forward selection multivariable logistics regression analyses were done to assess independent associations between HIV prevention services and predictors of interest. The results were two tailed and a p-value of less than 0.05 was considered statistically significant. RESULTS: The study included 611 PWID (males: 94.4%) with a median age of 34 years (Interquartile Range (IQR), 29-38). A large majority of participants reported to have access to condoms (87.8%), sterile needles/syringes (72.8%) and ever tested for HIV (66.0%). About half (52.0%) reported to have used condoms in the past one month and about a third (28.5%) accessed a peer educator. The odds of testing for HIV decreased among participants who perceived their HIV risk to be high (aOR = 0.29; 95%CI: 0.17-0.49) and those experienced sexual violence (aOR = 0.60; 95%CI 0.37-0.98). However, the odds of testing for HIV increased among participants with secondary level of education (aOR = 2.16; 95%CI: 1.06-5.55), and those who reported having correct comprehensive HIV knowledge (CCHK) (aOR = 1.63; 95%CI 1.12-2.41). The odds of access to condoms increased among females (aOR = 2.23; 95%CI: 1.04-5.02) but decreased among participants with secondary level of education (aOR = 0.41; 95%CI: 0.19-0.84), an income of >TZS 200,000 (aOR = 0.39; 95%CI: 0.23-0.66) and those who perceived their HIV risk to be high (aOR = 0.13; 95%CI: 0.03-0.36). The odds of access to peer educators was higher among participants with primary (aOR = 1.61; 95%CI: 1.01-2.26), and secondary (aOR = 2.71; 95%CI: 1.39-5.33) levels of education. The odds of access to sterile needle and syringe decreased among participants who perceived their HIV risk to be high (aOR = 0.11;95%CI 0.05-0.22), and low-medium (aOR = 0.25;95%CI 0.11-0.52) but increased among those with primary level of education (aOR = 1.72;95%CI 1.06-2.78). CONCLUSION: Access to condom, HIV testing, sterile needles and syringes were relatively high among PWID. However, condom use and access to peer educators was relatively low. HIV knowledge and risk perception, gender, education, and sexual violence influenced access to HIV prevention services. There is an urgent need to address the identified socio-cognitive factors and scale up all aspects of HIV prevention services to fast-track attainment of the 2025 UNAIDS goals and ending the HIV epidemic.

Development of a Mobile Health Application for HIV Prevention Among At-Risk Populations in Urban Settings in East Africa: A Participatory Design Approach.

BACKGROUND: There is limited evidence in Africa on the design and development of mobile health (mHealth) applications to guide best practices and ensure effectiveness. A pragmatic trial for HIV pre-exposure prophylaxis roll-out among key populations in Tanzania is needed. OBJECTIVE: We present the results of the development of a mobile app (Jichunge) intended to promote adherence to pre-exposure prophylaxis (PrEP) among men who have sex with men (MSM) and female sex workers (FSW) in Tanzania. METHODS: A participatory design approach was employed and guided by the information system research framework. MSM and FSW were the target populations. A total of 15 MSM and 15 FSW were engaged in the relevance and design cycles, while the piloting phase included 10 MSM and 20 FSW. RESULTS: The relevance cycle enabled the description of the existing problem, provided the compatible app features for the target population, and identified the need to develop an mHealth app that provides health services in a stigmatizing and discriminating environment. User involvement in the app's design and evaluation provided an opportunity to incorporate social, cultural, and community-specific features that ensured usability. In addition, the participants suggested valuable information to inform the app, text message services, medication registration, and chat platform designs. CONCLUSIONS: The participatory design approach in the development of mHealth apps is useful in identifying and validating population-specific functional features, improve usability, and ensuring future health impacts. Through this participatory process, the Jichunge app took end-user needs, perspectives, and experiences into account, eliciting enthusiasm regarding its potential role in supporting pre-exposure prophylaxis adherence for HIV and related behavioral change promotion. TRIAL REGISTRATION: International Clinical Trials Registry Platform PACTR202003823226570; https://trialsearch.who.int/Trial2.aspx?TrialID=PACTR202003823226570.

Improving Access to Self-Expanding Metal Stents for Patients With Esophageal Cancer in Eastern Africa: A Stepwise Implementation Strategy.

PURPOSE: The eastern corridor of Africa is affected by a high burden of esophageal cancer (EC), with > 90% of patients presenting with advanced disease. Self-expanding metal stents (SEMS) have been previously reported as safe and effective for palliation of malignant dysphagia in resource-limited settings; however, access is limited throughout Eastern Africa. METHODS: In response to demand for palliative interventions for patients with dysphagia because of EC, the African Esophageal Cancer Consortium (AfrECC) partnered with the Clinton Health Access Initiative to improve access to SEMS in Eastern Africa. We undertook a stepwise implementation approach to (1) identify barriers to SEMS access, (2) conduct a market analysis, (3) select an industry partner, (4) establish regulatory and procurement processes, (5) develop endoscopic training resources, (6) create a medical device registry, and (7) establish principles of accountability. RESULTS: Following an evaluation of market demand and potential SEMS manufacturers, Boston Scientific Corporation announced its commitment to launch an access program to provide esophageal SEMS to patients in Tanzania, Kenya, Malawi, and Zambia at a subsidized price. Parallel regulatory and procurement processes were established in each participating country. Endoscopy training courses were designed and conducted, using the Training-of-Trainers model. A device registry was created to centralize data for quality control and to monitor channels of SEMS distribution. Principles of accountability were developed to guide the sustainability of this endeavor. CONCLUSION: The AfrECC Stent Access Initiative is an example of a multisector partnership formed to provide an innovative solution to align regional needs with a supply chain for a high-priority medical device.

Feasibility of Fine-Needle Aspiration Biopsy and Rapid On-Site Evaluation for Immediate Triage in Breast Cancer Screening in Tanzania.

PURPOSE: Clinical breast examination (CBE) is one of the most common methods used for early detection of breast cancer in low- and middle-income countries. CBE alone is limited by lack of specificity and may result in unnecessary diagnostic procedures. We evaluated the feasibility of integrating CBE, fine-needle aspiration biopsy (FNAB), and rapid on-site evaluation (ROSE) in triaging palpable breast masses for specialized cancer care. MATERIALS AND METHODS: An intensive breast cancer screening event was conducted at a national trade fair by a multidisciplinary team of care providers targeting a healthy population in Dar es Salaam, Tanzania. All adults age ≥ 18 years were invited to participate. CBE was performed by oncologists and/or pathologists. FNAB was performed by a pathologist on palpable masses that were then categorized as benign, indeterminate, or suspicious for malignancy or definitively malignant based on ROSE. RESULTS: A total of 208 individuals (207 females, one male; median age, 36 years; range, 18-68 years) were screened. Most (90.8%, 189 of 208) had normal findings, whereas 7.2% (15 of 208), 1% (2 of 208), and 1% (2 of 208) had a palpable mass, breast pain, and nipple discharge, respectively. Two participants had lesions too small for palpation-guided biopsy and clinically consistent with fibroadenomas; the participants were counseled, and observation was recommended. FNAB was performed on 13 breast masses, with 9 of 13 (69%) categorized as benign and 4 of 13 (31%) suspicious for malignancy. Final cytopathologic review of referred patients confirmed one case to be breast adenocarcinoma, one was suggestive of fibroadenoma, and two showed inflammations. CONCLUSION: Integration of CBE with ROSE and FNAB was feasible in a breast cancer screening program in Tanzania. In settings with constrained resources for cancer care, this may be an effective method for triaging patients with breast masses.

Optimal management of esophageal cancer in Africa: A systemic review of treatment strategies.

Esophageal cancer (EC) is a leading cause of cancer morbidity and mortality in Africa. Despite the high burden of disease, optimal management strategies for EC in resource-constrained settings have yet to be established. This systematic review evaluates the literature on treatments for EC throughout Africa and compares the efficacy and safety of varying treatment strategies in this context (PROSPERO CRD42017071546). PubMed, Embase and African Index Medicus were searched for studies published on treatment strategies for EC in Africa from 1980 to 2020. Searches were supplemented by examining bibliographies of included studies and relevant conference proceedings. Methodological quality/risk of bias was assessed using the Cochrane Risk-of-Bias tool and the Newcastle-Ottawa Scale. Forty-six studies were included. Case series constituted the majority of studies: 13 were case series reporting on outcomes of esophagectomies, 17 on palliative luminal or surgical interventions, four on radiotherapy and three on concurrent chemoradiation. Nine randomized controlled trials were identified, of which four prospectively compared different treatment modalities (one investigating radiotherapy vs chemoradiation, three evaluating rigid plastic stents vs other treatments). This review summarizes the research on EC treatments in Africa published over the last four decades and outlines critical gaps in knowledge related to management in this context. Areas in need of further research include (a) evaluation of the safety and efficacy of neoadjuvant therapy in patients with locally advanced disease; (b) strategies to improve long-term survival in patients treated with definitive chemoradiation; and (c) the comparative effectiveness of modern palliative interventions, focusing on quality of life and survival as outcome measures.

A Case-Control Study to Evaluate Environmental and Lifestyle Risk Factors for Esophageal Cancer in Tanzania.

BACKGROUND: East Africa is affected by a disproportionately high burden of esophageal squamous cell carcinoma (ESCC). METHODS: We conducted an incident case-control study in Dar es Salaam, Tanzania with 1:1 matching for gender and age. A questionnaire evaluated known and putative risk factors for ESCC. Cochran-Mantel-Haenszel and multivariable conditional logistic regression analyses were applied to evaluate associations with ESCC risk, with adjustment for geographic zone. RESULTS: Of 471 cases and 471 controls, the majority were male (69%); median ages were 59 and 55, respectively. In a multivariable logistic regression model, a low International Wealth Index (IWI) score [OR 2.57; 95% confidence interval (CI), 1.41-4.68], former smoking (OR 2.45; 95% CI, 1.46-4.13), second-hand smoke in the household (OR 1.67; 95% CI, 1.01-2.77), daily spicy chilies (OR 1.62; 1.04-2.52), and daily salted foods (OR 2.02; 95% CI, 1.06-3.85) were associated with increased risk of ESCC. Daily consumption of raw greens (OR 0.36; 95% CI, 0.16-0.80), fruit (OR 0.47; 95% CI, 0.27-0.82), and smoked fish (OR 0.31; 95% CI, 0.15-0.66) were protective. Permanent residence in the Central (OR 5.03; 95% CI, 2.16-11.73), Northern-Lake (OR 2.40; 95% CI, 1.46-3.94), or Southern Highlands zones (OR 3.18; 95% CI, 1.56-6.50) of Tanzania were associated with increased risk compared with residence in the Eastern zone. CONCLUSIONS: Low IWI score, smoke exposure(s), geographic zone, and dietary factors were associated with risk for ESCC in Tanzania. IMPACT: These findings will inform the development of future hypothesis-driven studies to examine risk factors for the high burden of ESCC in East Africa.See related commentary by McCormack et al., p. 248.

Development of a theory-driven implementation strategy for cancer management guidelines in sub-Saharan Africa.

BACKGROUND: Despite recent international efforts to develop resource-stratified clinical practice guidelines for cancer, there has been little research to evaluate the best strategies for dissemination and implementation in low- and middle-income countries (LMICs). Guideline publication alone is insufficient. Extensive research has shown that structured, multifaceted implementation strategies that target barriers to guideline use are most likely to improve adherence; however, most of this research has been conducted in high-income countries. There is a pressing need to develop and evaluate guideline implementation strategies for cancer management in LMICs in order to address stark disparities in cancer outcomes. METHODS: In preparation for the launch of Tanzania's first National Cancer Treatment Guidelines, we developed a theory-driven implementation strategy for guideline-based practice at Ocean Road Cancer Institute (ORCI). Here, we use the Intervention Mapping framework to provide a detailed stepwise description of our process. First, we conducted a needs assessment to identify barriers and facilitators to guideline-based practice at ORCI. Second, we defined both proximal and performance objectives for our implementation strategy. Third, we used the Capability, Opportunity, Motivation and Behavior/Behavior Change Wheel (COM-B/BCW) framework to categorize the barriers and facilitators, choose behavior change techniques most likely to overcome targeted barriers and leverage facilitators, and select a feasible mode of delivery for each technique. Fourth, we organized these modes of delivery into a phased implementation strategy. Fifth, we operationalized each component of the strategy. Sixth, we identified the indicators of the process, outcome, and impact of our intervention and developed an evaluation plan to measure them using a mixed methods approach. DISCUSSION: We developed a robust, multifaceted guideline implementation strategy derived from a prominent behavior change theory for use in Tanzania. The barriers and strategies we generated are consistent with those well established in the literature, enhancing the validity and generalizability of our process and results. Through our rigorous evaluation plan and systematic account of modifications and adaptations, we will characterize the transferability of "proven" guideline implementation strategies to LMICs. We hope that by describing our process in detail, others may endeavor to replicate it, meeting a widespread need for dedicated efforts to implement cancer guidelines in LMICs.

Attitudes and Barriers to Research Among Oncology Trainees in East Africa.

BACKGROUND: East Africa is one of the fastest growing regions in the world and faces a rising burden of cancer; however, few people are equipped to effectively conduct research in this area. MATERIALS AND METHODS: A 31-item questionnaire was distributed to current trainees and recent graduates of the Master in Medicine in Clinical Oncology Program at Muhimbili University of Health and Allied Sciences in Tanzania. Areas that were assessed included (a) demographic information, (b) prior research training, (c) prior and current research activities, (d) attitudes toward the importance of research, and (e) supports and barriers to inclusion of research in an oncology career path. RESULTS: A total of 30 individuals responded to the survey, of whom 53% (n = 16) were male and 70% (n = 21) identified as current trainees. Among the majority of respondents, attitudes toward research were strongly favorable. Although only 37% (n = 11) reported receiving any formal training in research methodology, 87% (n = 26) reported intentions to incorporate research into their careers. The absence of protected time for research and lack of access to research funding opportunities were identified by a majority of respondents as critical barriers. CONCLUSION: A majority of current or recent oncology trainees in Tanzania desire to incorporate research into their careers, but most also lack adequate training in research methodology and longitudinal mentorship. Our future collaboration will focus on creation of appropriate research training curriculums and fostering an environment that catalyzes interprofessional development and transforms and extends context-specific cancer research in East Africa. IMPLICATIONS FOR PRACTICE: Current and recent oncology trainees in East Africa expressed a high enthusiasm for research, driven by a sense of urgency related to the burden from cancer that the region faces. This highlights the need for cancer research training and mentorship in this setting. This work hypothesizes that African principal investigators can operate effectively if proper attention is given to selection and provision of high-quality foundational didactic training to learn the theory and implementation of research as well as to the development of an environment conducive to mentoring.

Nasal Carriage of Methicillin-Resistant Staphylococcus aureus among Health Care Workers in Tertiary and Regional Hospitals in Dar es Salam, Tanzania.

Methicillin-resistant Staphylococcus aureus (MRSA) among health care workers (HCWs) increases the risk of spreading the organism in hospital settings. A cross-sectional study was conducted between June and October 2016 among HCWs in tertiary and regional hospitals in Dar es Salaam, Tanzania, to determine the MRSA nasal carriage rate. Nasal swabs were collected from HCWs and cultured on mannitol salt agar. S. aureus was identified based on colonial morphology, Gram staining, catalase, coagulase, and DNase test results. MRSA was detected using the cefoxitin disk. Among 379 HCWs enrolled, 157/379 (41.4%) were colonized with S. aureus, of whom 59 (37.6%) were MRSA carriers giving an overall prevalence of 59/379 (15.6%). MRSA carriage was high among HCWs in Temeke (56.9%) and Amana (37.5%) regional hospitals. A high proportion of MRSA carriage was detected among nurses (35, 45.5%). MRSA isolates showed high resistance toward kanamycin (83.7%), gentamicin (83.1%), ciprofloxacin (71.2%), and trimethoprim-sulphamethoxazole (46.8%) compared to methicillin-sensitive S. aureus isolates (p ≤ 0.001). In conclusion, we found a high nasal carriage of MRSA and resistance to commonly prescribed antimicrobial agents among HCWs. Implementation of infection control measures including contact precautions, urgent reporting of MRSA laboratory results, and routine MRSA screening of HCWs is highly needed to reduce MRSA spreading.

Efficacy of an Intensive, Ultrasound-Guided Fine-Needle Aspiration Biopsy Training Workshop in Tanzania.

BACKGROUND: Fine-needle aspiration biopsy (FNAB) is a minimally invasive, cost-effective diagnostic tool that can be used in low-resource settings. However, adequacy and accuracy of FNAB is highly dependent on the skills of the operator and requires specialized training. Poor technique can preclude definitive diagnoses because of insufficient quality or quantity of FNAB samples. We evaluated the efficacy of an intensive training experience in Tanzania on improving ultrasound-guided FNAB techniques. METHODS: A 2-day workshop offered didactic lectures, demonstrations, and hands-on practicum on fundamentals of ultrasound imaging and FNAB technique. A prospective interventional study design was used with pre- and postintervention surveys and assessments to measure the effect of the workshop on specific skills related to slide smearing and ultrasound-guidance among participants. RESULTS: Twenty-six pathologists and radiologists, including trainees in each specialty, participated in the workshop. Pre- and postworkshop assessments demonstrated that most participants improved significantly in nearly all technical skills for slide smearing and ultrasound-guided FNAB. After the workshop, most participants demonstrated substantial improvements in ability to prepare the ultrasound equipment, measure the lesion in three dimensions by ultrasound, target lesions in one pass using both parallel and perpendicular approaches, and prepare high-quality aspirate smears. CONCLUSION: An in-country 2-day workshop in Tanzania was efficacious in transferring basic skills in FNAB smear preparation and ultrasound-guided FNAB, resulting in skills enhancement among participating pathologists and radiologists. Although mastery of skills was not the goal of this short workshop, participants demonstrated proficiency in most technical elements after workshop completion, and the workshop generated interest among select participants to pursue additional intensive training in cytopathology.