Gender and willingness to pay for insecticides treated bed nets in a poor rural area in Tanzania.

OBJECTIVE: To examine socio-economic and malaria related differences between males and females that may cause gender differences in willingness to pay (WTP) for insecticide treated bed nets in a poor rural area. DESIGN: A two-week-interval (test re-test) cross-sectional study. SETTING: Kisarawe District in coastal Tanzania. SUBJECTS: Two hundred and fifty one males and two hundred dollars females were interviewed. RESULTS: Females had about 50% of the males' income. The monthly average income was about US dollars 10.50 for females and US dollars 20.20 for males. The proportion of respondents willing to pay for an ITN, for both males and females, declined as the ITN prices increased (P<0.05). The mean maximum WTP difference between men and women, between both rounds were not statistically significant (p>0.05). Male respondents reported a higher mean number of own underfives living in the household compared to women, the difference was not statistically significant (P>0.8). Willingness to pay for ITN was found to be independent of having an under five child with recent history of malaria. Among both males and females, there was an association between a recent experience with malaria episode and WTP, p=0.05 and p=0.02 respectively. Among females, the proportion of those willing to pay for another person, at the lowest ITN price, was significantly higher in those with under five children in their households than in those with no underfives. This was not the case among the male respondents as the association was not statistically significant. CONCLUSION: Contrary to expectations were was no statistically significant difference in WTP for an ITN between females and males. Further studies that link willingness and ability to pay are required in rural poor population, such studies may be valuable inputs to government policy on and planning of ITN interventions in the public and private sector.

Sexual behaviour among youths at high risk for HIV-1 infection in Dar es Salaam, Tanzania.

OBJECTIVES: To investigate sex specific sexual behaviour in youths visiting a youth clinic for sexual and reproductive health in Dar es Saalam. METHODS: A questionnaire was administered to a random sample of youths between 10 and 24 years of age attending the youth health clinic in Dar es Saalam. The clinical investigation included testing for syphilis and HIV-1 antibodies RESULTS: 1423 youths attended the clinic between September 1997 and August 1998. The study population comprised 213 (53.5%) males and 185 (46.5%) females. 97 (24.4%) were below 20 years. The mean age at coitarche was 16.5 and 17.0 years of age for males and females, respectively. The coitarche was involuntary in 15 females (8.6%). 49.5% males reported more than five lifetime partners compared with 14.1% for females (p<0.0001). Males reported recent partners to be 2.5 years younger, while females reported them to be 5.0 years older. No contraceptive use was reported by 29.7% of the males and 40.3% of females. 52.7% females had been pregnant and 26 (14.1%) reported induced abortions. Genital discharge was found in 69.5% and 73.9% and GUD in 36.6% and 27.1% of males and females respectively. 12 males (5.9%) and 43 females (24.6%) were found to be HIV-1 infected. 13.8% of the females with only one lifetime partner were HIV-1 infected compared with 40.9% with more than five partners (p = 0.028). CONCLUSIONS: Many youths in Dar es Salaam engage in sexual behaviours that put them at risk of unwanted pregnancies and STIs including HIV infection. Female youths were more likely to contract HIV infection than males. In African urban areas youth oriented clinics can have a pivotal role in HIV/STI prevention and control

Breast cancer during the HIV epidemic in an African population.

Both human immunodeficiency virus (HIV) infection and certain malignancies including breast cancer occur predominantly in premenopausal women in an African population. Cancers that are associated with HIV infection are Kaposi's sarcoma (KS), non-Hodgkin's lymphoma (NHL) and invasive cervical carcinoma. Recently, cases of breast cancer have been reported in patients with HIV infection but an association between breast cancer and HIV infection has yet to be determined. The present study investigated for association between HIV infection and breast cancer. Among the 101 patients studied, 50 were cases with breast cancer while the remaining 51 were referents with conditions other than mammary cancer. Patients with breast cancer 30 years of age and below recorded in the Cancer registry during 1974-1987 constituted 8% while those recorded during the ongoing AIDS epidemic amounted to only 2%. When a similar comparison was undertaken among patients below 50 years there was also an overall decrease in the proportion of patients from 76.1 to 58.0%. Conversely, in the age groups above 50 years the breast cancer cases increased from 33.9 to 42% respectively (chi2=1.83 on 1df, p=0.18). The overall prevalence of HIV infection among the control group was 35.5% (95% CI=22.2-48.4) while among breast cancer patients it was 6% (95% CI=0.6-12.6). Women below 50 years of age with breast cancer were less likely to be HIV positive; OR=0.18: (95% CI=0.04-0.76) chi2=5.95; p=0.01. However, there is no basis to suggest that HIV infection is protective against this malignancy. AIDS associated mortality commonly occurs in the second and third decades of life and probably these deaths have changed the demographic of the disease in an African population. The impact of AIDS associated mortality on cancer registries needs attention.

Current clinical efficacy of chloroquine for the treatment of Plasmodium falciparum infections in urban Dar es Salaam, United Republic of Tanzania.

Reported is the use of a 14-day WHO protocol, which takes into account the clinical, parasitological and haematological responses to antimalarial drugs, to determine the efficacy of chloroquine in the treatment of uncomplicated malaria in young children (n = 200) in urban Dar es Salaam. Chloroquine failure was found in 43% of the children. Of these, 12.5% were considered to be early treatment failures and were given a single dose of sulfadoxine-pyrimethamine. Fever subsided in all children treated with sulfadoxine-pyrimethamine and there were no parasitological failures. In addition, children treated with sulfadoxine-pyrimethamine because of early treatment failure with chloroquine had better haematological recovery than the chloroquine-sensitive group. It is concluded that chloroquine can no longer be considered an effective therapy for P. falciparum malaria in young children in Dar es Salaam.

A high prevalence of metabolic bone disease in exclusively breastfed very low birthweight infants in Dar-es-Salaam, Tanzania.

Metabolic bone disease (MBD), or rickets, is common in very low birthweight infants. A descriptive, cross-sectional, hospital-based study was carried out at Muhimbili Medical Centre, Dar-es-Salaam from 15 April to 30 June, 1995 to discover the magnitude, contributory factors, morbidity and suitable biochemical diagnostic tests for MBD. One hundred infants with a postnatal age of 6-12 weeks, whose birthweights were 1500 g or less were studied. Thirty-three of 100 (33%) infants, 16 boys and 17 girls, were radiographically diagnosed as having metabolic bone disease. The mean (SD) gestational age of those infants was 30.4 (2.7) weeks, while that of the infants without metabolic bone disease was 32.4 (3) weeks (p = 0.003). There was no significant difference in birthweight, serum calcium and serum phosphate levels between those infants with MBD and those without. The mean (SD) serum alkaline phosphatase in infants with MBD was 1052.9 (493.3) U/l and 766.8 (301.7) in those without MBD (p = 0.006). Thus, metabolic bone disease is common in very low birthweight infants. Wrist radiography and serum alkaline phosphatase levels remain important diagnostic tools. MBD should be considered seriously in very low birthweight infants.

Breast cancer and risk factors in an African population: a case referent study.

Numerous studies have investigated different aspects of breast cancer including the known risk factors in the Western world. In sub-Saharan Africa breast cancer in women despite being a public health problem has not received attention from national health providers. This case-referent study investigated the association between a number of risk factors and breast cancer in Tanzania. There was a strong evidence of breast cancer risk increasing with parity chi 2 = 10.6; p = 0.001. However lactation did not show a significant protective effect against breast cancer (OR = 0.6, p = 0.5). Other factors investigated included age at menarche, age at first sex, marital status, age at menopause and duration of menstruation. Statistical analysis revealed that these factors were not significantly associated with breast cancer in these Tanzanian women. The influence of these results are discussed in terms of possible intervention strategies.

Microbiological quality assessment of natural therapeutic herbal drug products prepared locally in Dar es Salaam, Tanzania.

One hundred and eighty one liquid and 183 powder preparations were purchased from different herbalists practising in open air markets in Hala District Dar es Salaam Region and analysed for total viable aerobic plate counts. Isolated microorganisms were identified by conventional microbiological and biochemical methods. The study revealed that the level of bacterial contamination in both liquid and powder drug samples was significantly higher (P <0.01) compared to the acceptable levels of 105/cfc/g. For fungi, the level of contamination in powders was highly significant (P <0.02) while in liquids the levels were not significant (P <0.2) when compared to the acceptable levels of 104/cfc/g. In both preparations, two potentially pathogenic organisms, Klebsiella spp. and Pseudomonas spp., were isolated. The level of contamination with these bacteria was significantly high (P <0.01) in both preparations. Other pathogenic micro notorganisms recovered were Candida spp. and Escherichia coll The level of contamination with these agents was significantly high (P < 0.01) in the powders. These results indicate that liquid and powder herbal preparations commonly sold by traditional herbalists in open air markets in Dar es Salaam are frequently contaminated by bacteria and fungi. Some of these microbial contaminants are potential pathogens of man, and may thus predispose the patients taking these preparations to the risk of acquiring infections. These contaminated medicinal preparations may also facilitate transfer of strains of microorganisms which harbour antibiotic resistance genes. In view of these findings, it is recommended to conduct further studies to find out how these herbalists collect, prepare, store and dispense the drugs. Attempts should also be made to train traditional herbalists the fundamental aspects of Good Manufacturing Practices, with a view to improving their skills in proper handling of drugs in order to minimise chances of contamination.

TNM classification and breast cancer in an African population: a descriptive study.

OBJECTIVE: To determine the stage of female breast cancer in an African population at presentation by using the TNM classification of the International Union Contra Cancer (UICC). DESIGN: A descriptive study. SETTING: Hospital based investigation. SUBJECTS: All 50 female patients with breast carcinoma admitted between March and October 1996 to the surgery wards at the Muhimbili Medical Centre, the largest referral centre in Tanzania were studied for the stage of the disease at presentation. RESULTS: A total of 50 cases were recruited in this study. There was not a single case in Stage I. In Stage II there was only one case (T2 N0, n = 1). There were seven cases in Stage IIIA (T3 N0, n = 5; T1 N2, n = 1; T3 N2, n = 1) while in Stage IIIB there were 37 cases (T3 N3, n = 1; T4 N1, n = 27; T4 N2, n = 9). There were five cases in Stage IV (M1, n = 5). Histological analysis revealed all tumours were infiltrating duct carcinoma. Metastatic disease (Stage IV) was observed only in patients aged above 50 years. CONCLUSIONS: Breast cancer presents predominantly as a locally advanced disease, with virtual absence of early disease. A majority of the patients are premenopausal in an African population. Self breast examination (SBE) including other strategies suggested earlier are recommended to aid in early detection of breast cancer.

Carcinoma of the male breast: a sexually transmitted disease?

Male breast cancer is a rare disease. In an African population, the occurrence of this cancer is high. The male/female ratio in Tanzania is 1:14 (0.071). This narrow ratio does not differ significantly in the majority of sub-Saharan African countries. The overall ratio being 0.0143 (CI = 0.0317-0.877). When this was compared with the ratio of the African American population with breast cancer in USA, it was observed to be significantly high (p < 0.05). The narrow male/female ratio amongst indigenous people with breast cancer in sub-Saharan countries was seen only in those geographical areas where cervical malignancy ranked in the leading position. There is a clear association, with a pronounced linear correlation between these two cancers (r = 0.8). In view of this association it is hypothesised that since cervical cancer behaves as a sexually transmitted disease, then possibly this could also be the case in respect to the male breast carcinoma in sub-Saharan Africa. If these results are confirmed by other investigators, an opportunity to examine the factors contributing to the oncogenesis of this disease may be invaluable in developing prevention and treatment strategies.

Anaemia and Plasmodium falciparum infections among young children in an holoendemic area, Bagamoyo, Tanzania.

Although the aetiology of anaemia in tropical areas is multifactorial, Plasmodium falciparum malaria is commonly associated with anaemia in children living in holoendemic malaria areas. Such an association was examined in a population based study of 338 children 6 to 40 months of age living in the Bagamoyo area of Tanzania. Stepwise regression analysis showed that fever and parasitaemia were effective in predicting anaemia and that the anaemic condition was age dependent. The majority of the children were iron deficient, followed by normochromic macrocytic anaemias. There was strong evidence in this age group that the anaemia was associated with malaria and not geohelminth infection. The importance of malaria and anaemia as a cause of childhood morbidity in Africa is discussed. This condition has taken on new significance with the realization that blood transfusions commonly used to treat severe anaemia are a major vehicle for Human Immunodeficiency Virus (HIV) transmission.

PIP: Anemia is an important cause of morbidity and probably mortality in patients with acute Plasmodium falciparum infection. The authors investigated the association between P. falciparum malaria and anemia in children living in holoendemic malaria areas in their population-based study of 338 children aged 6-40 months living in the Bagamoyo area of Tanzania. The study was conducted from late May to October 1992 when malaria transmission is high in coastal Tanzania. The children were selected at random from seven villages in the study area and not on the basis of a history of illness, suspected malaria, or any other health reason. All children were examined by a physician and detailed medical histories were taken. At enrollment, 2.5% of the children were severely anemic and 74.1% were anemic. With treatment and active surveillance, the incidence of severe anemia dropped to 1.4% and anemia to 69.5%. Stepwise regression analysis found fever and parasitemia to effectively predict anemia and that the anemic condition was age dependent. The majority of children infected with P. falciparum were iron deficient, followed by normochromic macrocytic anemias, with strong evidence that the anemia was associated with malaria and not geohelminth infection. The authors consider the importance of malaria and anemia as a cause of childhood morbidity in Africa and comment on the realization that blood transfusions commonly used to treat severe anemia are a major vehicle for HIV transmission.

The protective effect of measles vaccine under routine vaccination conditions in Dar es Salaam, Tanzania: a case-control study.

A case-control study was conducted to determine the protective effect of measles vaccine under routine vaccination conditions in Dar es Salaam, Tanzania. A total of 172 cases of measles were obtained over two six-week periods from hospitals likely to admit such cases in the city and their mothers interviewed using a questionnaire that had been developed for the purpose. In addition, each case was matched to four controls for age, sex and place of residence and their mothers were also interviewed using the same questionnaire as for the cases. Vaccination status of the cases and the controls was ascertained by asking the mothers as well as obtaining vaccination information from the Mother-and-Child or Road-to-Health (MCH) clinic cards normally issued to mothers at first vaccination of their children. The overall protective effect of measles vaccine in all age groups studied was found to be 54% (95% confidence limits (CL)36%-67%) when mothers' recall for vaccination status was used. This level of protection was considered to be low compared with the efficacy of the vaccine under experimental conditions in controlled trials previously reported. However when MCH Clinic cards were used to ascertain vaccination status the protective effect rose to as high as 96% (95% CL 83%-99%). Potential biases in the study design and their role in masking or exaggerating the vaccine efficacy are discussed. It was therefore concluded that the protective effect of measles vaccine under routine vaccination conditions prevailing in Dar es Salaam region at the time of this study was as high as observed under experimental conditions when ascertainment of vaccination status was record-based. The study therefore recommended that, whenever in doubt about vaccine efficacy, simple study designs like the case-control method should be used to quickly evaluate vaccine efficacy by utilizing record-based vaccination status ascertainment methods.