Performance evaluation of the highly sensitive histidine-rich protein 2 rapid test for plasmodium falciparum malaria in North-West Tanzania.

BACKGROUND: Precise detection of Plasmodium infections in community surveys is essential for effective malaria control. Microscopy and rapid diagnostic tests (RDTs) are the major techniques used to identify malaria infections in the field-based surveys. Although microscopy is still considered as the gold standard, RDTs are increasingly becoming versatile due to their rapid and adequate performance characteristics. METHODS: A malaria prevalence cross-sectional survey was carried out in north-western Tanzania in 2016, aimed at appraising the performance of high sensitivity Plasmodium falciparum (HSPf) tests compared to SD Bioline Pf and microscopy in detecting P. falciparum infections. A total of 397 individuals aged five years and above were tested for P. falciparum infections. The sensitivity, specificity, positive, and negative predictive values (PPV and NPV) of microscopy, Pf RDT and HSPf RDT was determined using PCR as the gold standard method. RESULTS: The prevalence of P. falciparum infections determined by microscopy, SD Bioline Pf, HSPf and PCR was 21.9, 27.7, 33.3 and 43.2%, respectively. The new HSPf RDT had significantly higher sensitivity (98.2%) and specificity (91.6%) compared to the routinely used SD Bioline Pf RDT(P < 0.001). The positive predictive value (PPV) was 81.8% and the negative predictive value (NPV) was 99.2% for the routinely used SD Bioline Pf RDT. Moreover, HSPf RDT had sensitivity of 69% and specificity of 76.8% compared to microscopy. The PPV was 45.5% and the NPV was 89.8% for microscopy. Furthermore, the analytical sensitivity test indicated that the newly developed HSPf RDT had lower detection limits compared to routinely used SD Bioline RDT. CONCLUSIONS: HSPf RDT had better performance when compared to both microscopy and the currently used malaria RDTs. The false negativity could be associated with the low parasite density of the samples. False positivity may be related to the limitations of the expertise of microscopists or persistent antigenicity from previous infections in the case of RDTs. Nevertheless, HS PfRDT performed better compared to routinely used Pf RDT, and microscopy in detecting malaria infections. Therefore, HS Pf RDT presents the best alternative to the existing commercial/regularly available RDTs due to its sensitivity and specificity, and reliability in diagnosing malaria infections.

Effect of Moringa Oleifera leaf powder supplementation on reducing anemia in children below two years in Kisarawe District, Tanzania.

Anemia is a nutritional disorder that affects mostly children below 2 years and is mainly contributed by iron deficiency. Moringa oleifera leaves are rich in iron and other essential nutrients necessary for iron metabolism. We investigated the effect of M. oleifera leaf powder supplementation on reducing anemia among children below 2 years. A community-based interventional study was conducted that enrolled 95 anemic children who were followed for 6 months. The intervention communities received M. oleifera leaf powder and nutrition education, while control communities only received nutrition education. Changes on mean hemoglobin (Hb) concentration and anemia prevalence were compared between the two groups using t test and proportional test where appropriate. At baseline, the mean Hb concentrations of control and intervention groups were 7.9 g/dl (SD = 1.3) and 8.3 g/dl (SD = 1.6) g/L, respectively (p-value = 0.0943). After 6 months, anemia prevalence significantly decreased in the intervention group by 53.6% (100%-46.4%; p < 0.001) compared to 13.6% (100%-86.4%; p = 0.005) in control community. The mean Hb was 10.9 g/dl (95% CI: 10.2-11.4) for intervention and 9.4 g/dl (95% 7.8-10.1) for control (p-value = 0.002). The effect was also observed in the reduction of the prevalence of moderate and severe anemia in the intervention communities by 68.2% and 77.9%, respectively, and by 23.3% and 56.9%, respectively, in the control communities. Increasing amount and time of using M. oleifera supplementation resulted to significant reduction in anemia cases therefore can be used as complementary solution in addressing anemia among children especially when the use of infant formulas and fortified food product is very poor.

Awareness and factors associated with reported intake of folic acid-fortified flour among women of reproductive age in Ifakara, Morogoro region, Tanzania: a cross-sectional study.

BACKGROUND: Folic acid fortification of staple foods has been in place in many countries for over two decades. Studies have shown that folic acid fortification can significantly reduce incidence of neural tube defects. Tanzania adopted a mandatory fortification policy for commercially-produced wheat and maize flour in 2011. We determined factors influencing intake of folic acid-fortified flour among women of reproductive age (WRA). METHODS: We conducted a cross-sectional study among WRA during March-April 2017 in Ifakara Town Council, Morogoro region. Multistage cluster sampling was used to select study participants. We used a questionnaire to capture information on demographics, awareness of folic acid, awareness of existence of folic acid fortified flour in community and intake of folic acid fortified flour. Intake was defined as reported consumption of folic acid fortified flour products at least once within 7 days before interview. Univariate, bivariate, and multivariable logistic analyses were done to evaluate factors associated with intake of folic acid fortified flour. RESULTS: The median age of the 698 participating WRA was 30 years (range: 18-49). Awareness of folic acid and folic acid fortified flour was 6.9% (95% CI: 5.2-9.0%) and 7.5% (95% CI: 5.7-9.6%), respectively. Consumption of folic acid fortified flour was 63.3% (95% CI: 59.7-66.8%). Independent factors associated with intake included being employed (aOR = 1.91; 95% CI: 1.19-3.06), having no children (nulliparity) (aOR = 2.59; 95% CI: 1.36-4.95) or having 1-4 children (aOR = 1.98; 95% CI: 1.17-3.33) (vs. 5 or more children), and folic acid awareness (aOR = 2.53; 95% CI: 1.30-4.92). CONCLUSION: Folic acid fortified flour was used by most respondents in our study despite low awareness of existence of folic acid fortified flour in the community. Being employed, having fewer than five children, and folic acid awareness were independent factors associated with intake. We recommend scaling up of mandatory flour fortification program and doing further studies on blood folate level among women of reproductive age in Ifakara to assess fortification program effectiveness.

Nationwide school malaria parasitaemia survey in public primary schools, the United Republic of Tanzania.

BACKGROUND: A nationwide, school, malaria survey was implemented to assess the risk factors of malaria prevalence and bed net use among primary school children in mainland Tanzania. This allowed the mapping of malaria prevalence at council level and assessment of malaria risk factors among school children. METHODS: A cross-sectional, school, malaria parasitaemia survey was conducted in 25 regions, 166 councils and 357 schools in three phases: (1) August to September 2014; (2) May 2015; and, (3) October 2015. Children were tested for malaria parasites using rapid diagnostic tests and were interviewed about household information, parents' education, bed net indicators as well as recent history of fever. Multilevel mixed effects logistic regression models were fitted to estimate odds ratios of risk factors for malaria infection and for bed net use while adjusting for school effect. RESULTS: In total, 49,113 children were interviewed and tested for malaria infection. The overall prevalence of malaria was 21.6%, ranging from < 0.1 to 53% among regions and from 0 to 76.4% among councils. The malaria prevalence was below 5% in 62 of the 166 councils and above 50% in 18 councils and between 5 and 50% in the other councils. The variation of malaria prevalence between schools was greatest in regions with a high mean prevalence, while the variation was marked by a few outlying schools in regions with a low mean prevalence. Overall, 70% of the children reported using mosquito nets, with the highest percentage observed among educated parents (80.7%), low land areas (82.7%) and those living in urban areas (82.2%). CONCLUSIONS: The observed prevalence among school children showed marked variation at regional and sub-regional levels across the country. Findings of this survey are useful for updating the malaria epidemiological profile and for stratification of malaria transmission by region, council and age groups, which is essential for guiding resource allocation, evaluation and prioritization of malaria interventions.

Prevalence and risk factors associated with female anal sex in the context of HIV/AIDS in the selected districts of Tanzania.

BACKGROUND: Female anal sex is a receptive type of sexual practice among heterosexual couples where the penis is inserted into the anus of a female partner. In the Western world, a number of studies and interventions have been carried out on anal sex among men due to its potential risks to HIV transmission. In African countries, including Tanzania, there is dearth of information on the risks inherent in practices associated with female anal sex in the general population. The objective of this study was to determine the prevalence and risk factors associated with female anal sex in fuelling HIV transmission in selected districts of Tanzania. METHODS: This study was conducted in four districts of Tanzania of Kinondoni, Tanga Urban, Makete and Siha. Both quantitative and qualitative methods i.e. household interviews and focus group discussions were employed in data collection. Study participants included community members of aged 15 and above such as heads of the household, adolescents, bar workers and commercial sex workers. FINDINGS: A total of 903 individuals were interviewed, 60.6% of whom were females. When respondents were asked to indicate whether they had ever been tempted to practise FAS, 167 (18.5%) reported to have been tempted in the past 12 months. Of these, 44 (26.3%) respondents had at least practised FAS. Risky practices associated with FAS were forced sex, multiple partners, frequency of engaging in FAS, low use of condoms during FAS, low rates of HIV testing among partakers, poor perception of the risks to acquire HIV through FAS and use of lubricants. CONCLUSIONS: In this population, the frequency of FAS practice was rather low. And yet, FAS practice attendant risk factors are likely to exacerbate HIV transmission. As such, there is a need for further exploratory studies to determine and document drivers of FAS. In addition, public health education should be provided with regard to the risks of contracting HIV associated with FAS practices.

Performance of health laboratories in provision of HIV diagnostic and supportive services in selected districts of Tanzania.

BACKGROUND: Roll-out and implementation of antiretroviral therapy (ART) necessitated many countries in Sub-Saharan Africa to strengthen their national health laboratory systems (NHLSs) to provide high quality HIV diagnostic and supportive services. This study was conducted to assess the performance of health laboratories in provision of HIV diagnostic and supportive services in eight districts (from four regions of Iringa, Mtwara, Tabora and Tanga), after nine years of implementation of HIV/AIDS care and treatment plan in Tanzania. METHODS: In this cross-sectional study, checklists and observations were utilized to collect information from health facilities (HFs) with care and treatment centres (CTCs) for HIV/AIDS patients; on availability of laboratories, CTCs, laboratory personnel, equipment and reagents. A checklist was also used to collect information on implementation of quality assurance (QA) systems at all levels of the NHLS in the study areas. RESULTS: The four regions had 354 HFs (13 hospitals, 41 Health Centres (HCs) and 300 dispensaries); whereby all hospitals had laboratories and 11 had CTCs while 97.5 and 61.0% of HCs had both laboratories and CTCs, respectively. Of the dispensaries, 36.0 and 15.0% had laboratories and CTCs (mainly in urban areas). Thirty nine HFs (12 hospitals, 21 HCs and six dispensaries) were assessed and 56.4% were located in urban areas. The assessed HFs had 199 laboratory staff of different cadres (laboratory assistants = 35.7%; technicians =32.7%; attendants = 22.6%; and others = 9.1%); with >61% of the staff and 72.3% of the technicians working in urban areas. All laboratories were using rapid diagnostic tests for HIV testing. Over 74% of the laboratories were performing internal quality control and 51.4% were participating in external QA programmes. Regional and district laboratories had all key equipment and harmonization was maintained for Fluorescence-Activated Cell Sorting (FACS) machines. Most of the biochemical (58.0%) and haematological analysers (74.1%) were available in urban areas. Although >81% of the equipment were functional with no mechanical faulty, 62.6% had not been serviced in the past three years. CONCLUSION: Diagnostic and supportive services for HIV were available in most of the HCs and hospitals while few dispensaries were providing the services. Due to limitations such as shortage of staff, serving of equipment and participation in QA programmes, the NHLS should be strengthened to ensure adequate human resource, implementation of QA and sustainable preventive maintenance services of equipment.

Optical characterization of red blood cells from individuals with sickle cell trait and disease in Tanzania using quantitative phase imaging.

Sickle cell disease (SCD) is common across Sub-Saharan Africa. However, the investigation of SCD in this area has been significantly limited mainly due to the lack of research facilities and skilled personnel. Here, we present optical measurements of individual red blood cells from healthy individuals and individuals with SCD and sickle cell trait in Tanzania using the quantitative phase imaging technique. By employing a quantitative phase imaging unit, an existing microscope in a clinic is transformed into a powerful quantitative phase microscope providing measurements on the morphological, biochemical, and biomechanical properties of individual cells. The present approach will open up new opportunities for cost-effective investigation and diagnosis of several diseases in low resource environments.

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania.

BACKGROUND: Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania. METHODS: A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs. RESULTS: Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs. CONCLUSION: RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals.

Determinants of demand for condoms to prevent HIV infections among barmaids and guesthouse workers in two districts, Tanzania.

BACKGROUND: Condoms are scientifically recommended as potential products for preventing infections attributable to human immuno-deficiency viruses (HIV). However, evidence on factors leading to their inadequate use in developing countries is still scanty. This paper reports an exploratory study of factors constraining condoms use in Tanzania from the perspectives of barmaids, guest-house workers and retailers. METHODS: Data were collected in two districts-Mpwapwa in Dodoma Region and Mbeya Rural in Mbeya Region-between October and December 2011, using structured interviews with 238 individuals including barmaids, guesthouse workers and 145 retailers. Data analysis was performed using STATA 11 software. RESULTS: Awareness about condoms was high among all study groups. Male condoms were more popular and available than female ones. A considerable proportion of the barmaids and guesthouses were disappointed with condoms being promoted and distributed to young children and disliked condom use during sexual intercourse. Accessibility of condoms was reported as being lowered by condom prices, shortage of information concerning their availability; short supply of condoms; some people shying away to be watched by children or adult people while purchasing condoms; retailers' using bad languages to condom customers; occasionally condom shops/kiosks found closed when they are urgently needed; and prevailing social perception of condoms to have low/no protective efficacy. Regression analysis of data from barmaids and guesthouse-workers indicated variations in the degree of condom acceptability and methods used to promote condoms among respondents with different demographic characteristics. CONCLUSION: A combination of psychosocial and economic factors was found contributing to lower the demand for and actual use of condoms in study communities. Concerted measures for promoting condom use need to address the demand challenges and making operational research an integral element of monitoring and evaluation of the launched interventions, hence widening the evidence for informed policy decisions.

In vivo antiplasmodial and toxicological effect of Maytenus senegalensis traditionally used in the treatment of malaria in Tanzania.

BACKGROUND: In Tanzania and elsewhere, medicinal plants, including Maytenus senegalensis, are still widely used in the treatment of malaria and other ailments. The aim of the present study was to investigate the in vivo antiplasmodial and toxic effects in mice. METHODS: Oral antiplasmodial and acute toxicity of the ethanolic root extract of M. senegalensis was evaluated in mice. The Peters 4-day in vivo antiplasmodial effect against early rodent malaria infection in chloroquine-sensitive Plasmodium berghei NK 65 strain in mice. RESULTS: The M. senegalensis extract was found non-toxic and the oral median lethal dose in mice was determined to be greater than 1,600 mg/kg body weight. The findings revealed a significant (P = 0.001) daily increase in the level of parasitaemia in the parasitized untreated groups and a significant (P < 0.001) dose dependent decrease in parasitaemia in the parasitized groups treated with varying doses ranging from 25 to 100 mg/kg body weight of M. senegalensis extract and the standard drug sulphadoxine/pyrimethamine at 25/1.25 mg/kg body weight. Overall, the dose dependent parasitaemia suppression effects were in the order of: 25/1.25 mg/kg body weight of sulphadoxine/pyrimethamine > 100 mg/kg > 75 mg/kg > 50 mg/kg > 25 mg/kg body weight of M. senegalensis extract. CONCLUSION: The implications of these findings is that M. senegalensis ethanolic root bark extract possess potent antiplasmodial effect and may, therefore, serve as potential sources of safe, effective and affordable anti-malarial drugs. The displayed high in vivo antiplasmodial activity and lack of toxic effect render M. senegalensis a candidate for the bioassay-guided isolation of compounds which could develop into new lead structures and candidates for drug development programmes against human malaria.

Acceptability of condom promotion and distribution among 10-19 year-old adolescents in Mpwapwa and Mbeya rural districts, Tanzania.

BACKGROUND: The HIV/AIDS pandemic remains a leading challenge for global health. Although condoms are acknowledged for their key role on preventing HIV transmission, low and inappropriate use of condoms persists in Tanzania and elsewhere in Africa. This study assesses factors affecting acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural districts of Tanzania. METHODS: Data were collected in 2011 as part of a larger cross-sectional survey on condom use among 10-19 year-olds in Mpwapwa and Mbeya rural districts of Tanzania using a structured questionnaire. Associations between acceptability of condom promotion and distribution and each of the explanatory variables were tested using Chi Square. Multivariate logistic regression model was used to examine independent predictors of the acceptability of condom promotion and distribution using STATA (11) statistical software at 5% significance level. RESULTS: Mean age of the 1,327 adolescent participants (50.5% being males) was 13.5 years (SD = 1.4). Acceptance of condom promotion and distribution was found among 37% (35% in Mpwapwa and 39% in Mbeya rural) of the adolescents. Being sexually active and aged 15-19 was the strongest predictor of the acceptability of condom promotion and distribution (OR = 7.78, 95% CI 4.65-12.99). Others were; not agreeing that a condom is effective in preventing transmissions of STIs including HIV (OR = 0.34, 95% CI 0.20-0.56), being a resident of Mbeya rural district (OR = 1.67, 95% CI 1.28-2.19), feeling comfortable being seen by parents/guardians holding/buying condoms (OR = 2.20, 95% CI 1.40-3.46) and living with a guardian (OR = 1.48, 95% CI 1.08-2.04). CONCLUSION: Acceptability of condom promotion and distribution among adolescents in Mpwapwa and Mbeya rural is low. Effect of sexual activity on the acceptability of condom promotion and distribution is age-dependent and was the strongest. Feeling comfortable being seen by parents/guardians buying or holding condoms, perceived ability of condoms to offer protection against HIV/AIDS infections, district of residence and living arrangements also offered significant predictive effect. Knowledge of these factors is vital in designing successful and sustainable condom promotion and distribution programs in Tanzania.

The potential of involving traditional practitioners in the scaling up of male circumcision in the context of HIV prevention in Tanzania.

Male circumcision (MC) has been practiced worldwide for religious, cultural, social and medical reasons. Recent studies in Africa have indicated MC to be highly protective against HIV transmission. However, incorporating MC in HIV/AIDS prevention programme will increase its demand in Tanzania where traditional male circumcision is common and the health care system is weak. The objective of this study was to determine the challenges and opportunities of involving traditional practitioners in scaling up safe MC in the context of HIV prevention in Tanzania. The study was conducted in Monduli, Bahi and Mkuranga districts of Tanzania. Both quantitative and qualitative methods were employed. Household survey involved community members from the selected villages. In-depth interviews involved traditional practitioners and key informants at national, district and facility levels. A total of 601 householders were interviewed. Most (71.4%) household respondents preferred traditional MC as it was part of their culture and tradition. A similar response was obtained from other respondents. It was mostly preferred because it was used as an initiation school, turning of boys to warriors and sense of social cohesion. Only 228 (37.9%) of the respondents were aware of the adverse events associated with MC. The most frequently mentioned adverse effects were severe bleeding (65.0%), delayed wound healing (17.5%) and wound sepsis (8.4%). The risk of acquiring HIV through male circumcision practice was poorly known among community members except medical respondents. Single unsterilized local surgical equipment was used to circumcise several initiates. It was observed that interference with traditional values associated with circumcision to be the main hindrance of linkage between traditional and conventional practitioners. On the other hand it was reported that there was no policy or guidelines on Traditional MC (TMC). Most of respondents supported the efforts to establish and promote formal linkages between traditional and conventional practitioners. In conclusion, under the current HIV pandemic and TMC being prevalent in Tanzania, it is high time for the government to establish a linkage between traditional and conventional practitioners for safe practices in order to minimize HIV transmission.

The Potential of Involving Traditional Practitioners in the Scaling Up of Male Circumcision in the Context of HIV Prevention in Tanzania

Abstract:Male circumcision (MC) has been practiced worldwide for religious; cultural; social and medical reasons. Recent studies in Africa have indicated that MC to be highly protective against HIV transmission. However; incorporating MC in HIV/AIDS prevention programme will increase its demand in Tanzania where traditional male circumcision is common and the health care system is weak. The objective of this study was to determine the challenges and opportunities of involving traditional practitioners in scaling up safe MC in the context of HIV prevention in Tanzania. The study was conducted in Monduli; Bahi and Mkuranga districts of Tanzania. Both quantitative and qualitative methods were employed. Household survey involved community members from the selected villages. Indepth interviews involved traditional practitioners and key informants at national; district and facility levels. A total of 601 householders were interviewed. Most (71.4) household respondents preferred traditional MC as it was part of their culture and tradition. A similar response was obtained from other respondents. It was mostly preferred because it was used as an initiation school; turning of boys to warriors and sense of social cohesion. Only 228 (37.9) of the respondents were aware of the adverse events associated with MC. The most frequently mentioned adverse effects were severe bleeding (65.0); delayed wound healing (17.5) and wound sepsis (8.4). The risk of acquiring HIV through male circumcision practice was poorly known among community members except medical respondents. Single unsterilized local surgical equipment was used to circumcise several initiates. It was observed that interference with traditional values associated with circumcision to be the main hindrance of linkage between traditional and conventional practitioners. On the other hand it was reported that there was no policy or guidelines on Traditional MC (TMC). Most of respondents supported the efforts to establish and promote formal linkages between traditional and conventional practitioners. In conclusion; under the current HIV pandemic and TMC being prevalent in Tanzania; it is high time for the government to establish a linkage between traditional and conventional practitioners for safe practices in order to minimize HIV transmission

Users' and health service providers' perception on quality of laboratory malaria diagnosis in Tanzania.

BACKGROUND: Correct diagnosis of malaria is crucial for proper treatment of patients and surveillance of the disease. However, laboratory diagnosis of malaria in Tanzania is constrained by inadequate infrastructure, consumables and insufficient skilled personnel. Furthermore, the perceptions and attitude of health service providers (laboratory personnel and clinicians) and users (patients/care-takers) on the quality of laboratory services also present a significant challenge in the utilization of the available services. This study was conducted to assess perceptions of users and health-care providers on the quality and utilization of laboratory malaria diagnostic services in six districts from three regions in Tanzania. METHODS: Questionnaires were used to collect information from laboratory personnel, clinicians and patients or care-takers. RESULTS: A total of 63 laboratory personnel, 61 clinicians and 753 patients/care-takers were interviewed. Forty-six (73%) laboratory personnel claimed to be overworked, poorly motivated and that their laboratories were under-equipped. About 19% (N = 12) of the laboratory personnel were lacking professional qualification. Thirty-seven clinicians (60.7%) always requested for blood smear examination to confirm malaria. Only twenty five (41.0%) clinicians considered malaria microscopy results from their respective laboratories to be reliable. Forty-five (73.8%) clinicians reported to have been satisfied with malaria diagnostic services provided by their respective laboratories. Majority (90.2%, N = 679) of the patients or care-takers were satisfied with the laboratory services. CONCLUSION: The findings show that laboratory personnel were not satisfied with the prevailing working conditions, which were reported to undermine laboratory performance. It was evident that there was no standard criteria for ordering malaria laboratory tests and test results were under-utilized. Majority of the clinicians and patients or care-takers were comfortable with the overall performance of laboratories, but laboratory results were having less impact on patient management.

Performance of ParaHit and OptiMAL tests in the diagnosis of malaria in Mwanza, north-western Tanzania.

Malaria rapid diagnostic tests (RDTs) are non microscopic tests that provide a rapid detection of malaria infections in infected individuals. The objective of this study was to evaluate the performance of ParaHit and OptiMAL tests for detection of malaria infections as compared with routine microscopy. This facility-based study was carried out in Mwanza, north-western Tanzania and involved outpatients attending Igoma Health Centre. Blood samples were tested for malaria infection using the two RDTs and compared with Giemsa stained blood films examined using microscope. A total of 243 individuals (median age= 22 years) were involved in the study. Microscopy had a higher detection rate of 19.7% (48/243) as compared to ParaHit (4.5%) and OptiMAL (3.7%). Low sensitivity of 21.2% and 17%, but high specificity of 99.4% for ParaHit and OptiMAL, respectively was observed. Of all positive blood slides for Plasmodium falciparum, 78.7% had low parasite density (80 -720 parasite/microl of blood). These slides were negative for malaria parasite for both RDTs. Over 80% of study participants who reported fever had negative blood slides for malaria parasites by microscopy. On the other hand, 44.7% of those who reported no fever had positive blood slides for P. falciparum. Study participants who reported to have fever and high parasite density above 720 parasite/ microl were likely to be positive by both RDTs (OR= 6.8; P= 0.031529). In conclusion, the overall performance of both RDTs in detecting asexual P. falciparum was low as compared to microscopy and their performance were highly affected by parasite density. This calls for further evaluation studies before RDTs are widely used in peripheral health facilities in order to minimize potential severe consequences.

Assessing the validity of health facility-based data on insecticide-treated bednet possession and use: comparison of data collected via health facility and household surveys--Lindi region and Rufiji district, Tanzania, 2005.

Objective To assess the validity of health facility (HF)-based data on bednet and insecticide-treated bednet possession and use by children <5 years old. Methods We compared estimates based on data collected via HF surveys of under-5s attending well-child visits (e.g. immunizations) and sick-child visits vs. representative household surveys (a 'gold standard' method for measuring insecticide-treated net coverage). In Lindi region, Tanzania, we collected contemporaneous data on 637 under-5s via a HF survey (444 well-child visits and 193 sick-child visits), and on 305 households with an under-5 (including 354 children) via a household survey. In Rufiji district, Tanzania, we collected contemporaneous data on 1433 under-5s via a HF survey (911 well-child visits and 522 sick-child visits), and on 328 households with an under-5 (including 455 children) via a household survey. Results Possession of bednets by households with an under-5 was similar using HF data and household data in both Lindi region and Rufiji district. However, reported use of bednets was significantly higher in HF data than household data in both Lindi and Rufiji, as was reported use of insecticide-treated bednets. HF-based data accurately estimated community-level bednet possession in households with an under-5, but overestimated community-level bednet use by 9-35% and insecticide-treated bednet use by 15-21%. Conclusions Information bias rather than selection bias appears to be a key cause for the overestimation of bednet and insecticide-treated bednet use (e.g. social desirability bias: caretakers of under-5s attending health facilities might be more likely to report using bednets and insecticide-treated bednets). Additional studies of the validity, cost and utility of HF-based data to monitor insecticide-treated bednet use are needed before recommending this monitoring strategy for widespread use. Overestimating insecticide-treated bednet use could lead to inappropriate public health actions and missed opportunities for achieving local and global public health goals.

Distribution of free untreated bednets bundled with insecticide via an integrated child health campaign in Lindi Region, Tanzania: lessons for future campaigns.

Use of insecticide-treated bednets (ITNs) to prevent malaria remains low, and effective distribution strategies are needed. An integrated child health campaign with free distribution of 162,254 untreated bednets bundled with insecticide, measles vaccination, vitamin A, and mebendazole for children < 5 years old ("under-5s") was conducted in Lindi Region, Tanzania. We conducted a representative household survey 3 months after the campaign. Altogether, 574 households with 354 under-5s were visited. In households with an under-5, possession of bednets and ITNs increased from 60.9% to 90.7% (P < 0.001) and from 16.5% to 37.3% (P < 0.001), respectively. Increases occurred in all wealth quintiles and equity improved. Reported bednet and ITN use the previous night among under-5s was 46.3% and 21.5%, respectively. Integrated campaigns rapidly and equitably increase bednet possession and use meriting continued large-scale implementation. However, our study found that bednets were rarely treated; thus, future campaigns should provide factory-treated long-lasting ITNs. Low ITN use underscores the need for further efforts to increase use after campaigns.

High reinfection rate and treatment failures in children treated with amodiaquine for falciparum malaria in Muheza villages, Northeastern Tanzania.

In May 2003, we studied amodiaquine (AQ) efficacy in children < 5 years of age with uncomplicated falciparum malaria in Magoda and Mpapayu (with insecticide treated nets [ITNs]) and Mgome (without ITNs) in Muheza, Tanzania. The trial involved 28 days of follow-up, and data were adjusted by polymerase chain reaction (PCR) genotyping of msp1 and msp2 genes. Additionally, Pfcrt codon 72-76 polymorphisms were studied by PCR and sequence-specific oligonucleotide probe (SSOP) ELISA. In 54 cases with complete follow-up, a significant difference in late treatment failure (LTF) rates was seen (60.7% in ITN versus 88.5% in non-ITN villages, P = 0.02) before PCR correction. However, after PCR correction, 23 cases (60.5%) were confirmed as reinfections, giving a true LTF rate of 21.4% (6/28) and 34.6% (9/26) in the above settings, respectively. Frequency of Pfcrt CVIET haplotype mutation pretreatment was high (97.0%); the remaining samples were CVMNK. We conclude that AQ alone is no longer effective in the study area.

Treatment of co-infection with bancroftian filariasis and onchocerciasis: a safety and efficacy study of albendazole with ivermectin compared to treatment of single infection with bancroftian filariasis.

BACKGROUND: In order to use a combination of ivermectin and albendazole for the elimination of lymphatic filariasis, it is important to assess the potential risk of increased adverse events in individuals infected with both lymphatic filariasis and onchocerciasis. We compared the safety and efficacy of albendazole (400 mg) in combination with ivermectin (150 micrograms/kg), for the treatment of co-infections of Wuchereria bancrofti and Onchocerca volvulus with single infection of W. bancrofti. METHODS: The safety study on co-infections was a crossover, double blind design, while for the single infection of bancroftian filariasis an open design comparing two treatments was used. For co-infection, one group was allocated a single dose of ivermectin (150 micrograms/kg) plus albendazole (400 mg) (Group A). The other group received placebo (Group B). Five days later the treatment regime was reversed, with the Group A receiving placebo and Group B receiving treatment. For the single bancroftian filariasis infection, one group received a single dose of albendazole (400 mg) plus ivermectin (150 microg/kg) (Group C) while the other group received a single dose of albendazole (400 mg) alone (Group D). Blood and skin specimens were collected on admission day, day 0, and on days 2, 3, and 7 to assess drug safety and efficacy. Thereafter, blood and skin specimens were collected during the 12 months follow up for the assessment of drug efficacy. Study individuals were clinically monitored every six hours during the first 48 hours following treatment, and routine clinical examinations were performed during the hospitalisation period and follow-up. RESULTS: In individuals co-infected with bancroftian filariasis and onchocerciasis, treatment with ivermectin and albendazole was safe and tolerable. Physiological indices showed no differences between groups with co-infection (W. bancrofti and O. volvulus) or single infection (W. bancrofti). The frequency of adverse events in co-infected individuals was 63% (5/8, Group A, albendazole + ivermectin) and 57% (4/7, Group B, placebo) and of mild or moderate intensity. In single W. bancrofti infection the frequency of adverse events was 50% (6/12, Group C, albendazole + ivermectin) and 38% (5/13, Group D, albendazole) and of a similar intensity to those experienced with co-infection. There were no differences in adverse events between treatment groups. There was no significant difference in the reduction of microfilaraemia following treatment with albendazole and ivermectin in groups with single or co-infection. CONCLUSION: Our findings suggest that ivermectin plus albendazole is a safe and tolerable treatment for co-infection of bancroftian filariasis and onchocerciasis.

Effect of intermittent treatment with amodiaquine on anaemia and malarial fevers in infants in Tanzania: a randomised placebo-controlled trial.

BACKGROUND: Malaria is a major cause of infant morbidity and mortality in sub-Saharan Africa, and is often complicated by severe anaemia. Resistance of Plasmodium falciparum to most affordable antimalarial drugs is an impediment to intermittent chemotherapy. We investigated the effect of presumptive intermittent treatment with amodiaquine and daily iron supplementation in infants on malarial fevers and anaemia, in a holoendemic area of Tanzania where malaria is largely resistant to chloroquine and sulfadoxine/ pyrimethamine. METHODS: 291 infants aged 12-16 weeks who attended three clinics were randomised to receive amodiaquine, iron supplementation, amodiaquine plus iron supplementation, or placebo. Over 6 months, we gave amodiaquine three times with intervals of 60 days; oral iron supplementation was given daily. Malarial fevers and anaemia were monitored at bimonthly treatment visits and by self-reporting to health centres. FINDINGS: The protective efficacy of intermittent amodiaquine treatment in prevention of malarial fevers and anaemia was 64.7% (95% CI, 42.4-77.2) and 67.0% (95% CI, 34.5-83.4), respectively. Protective efficacy was similar in the group receiving amodiaquine plus iron supplementation. Infants receiving iron supplementation only were partly protected against anaemia (protective efficacy 59.8%; 95% CI, 23.4-78.9), but not against malarial fevers. 4 months' follow-up did not show rebound morbidity. We noted no haematological or clinical adverse effects. INTERPRETATION: Presumptive intermittent treatment for malaria with amodiaquine reduced malarial fevers and anaemia in infants, in an area with high resistance to other antimalarials. Intermittent treatment strategies for malaria in highly endemic areas could be of great benefit to public health.