Treatment seeking behaviours, antibiotic use and relationships to multi-drug resistance: A study of urinary tract infection patients in Kenya, Tanzania and Uganda.

Antibacterial resistance (ABR) is a major public health threat. An important accelerating factor is treatment-seeking behaviour, including inappropriate antibiotic (AB) use. In many low- and middle-income countries (LMICs) this includes taking ABs with and without prescription sourced from various providers, including health facilities and community drug sellers. However, investigations of complex treatment-seeking, AB use and drug resistance in LMICs are scarce. The Holistic Approach to Unravel Antibacterial Resistance in East Africa (HATUA) Consortium collected questionnaire and microbiological data from adult outpatients with urinary tract infection (UTI)-like symptoms presenting at healthcare facilities in Kenya, Tanzania and Uganda. Using data from 6,388 patients, we analysed patterns of self-reported treatment seeking behaviours ('patient pathways') using process mining and single-channel sequence analysis. Among those with microbiologically confirmed UTI (n = 1,946), we used logistic regression to assess the relationship between treatment seeking behaviour, AB use, and the likelihood of having a multi-drug resistant (MDR) UTI. The most common treatment pathway for UTI-like symptoms in this sample involved attending health facilities, rather than other providers like drug sellers. Patients from sites in Tanzania and Uganda, where over 50% of patients had an MDR UTI, were more likely to report treatment failures, and have repeat visits to providers than those from Kenyan sites, where MDR UTI proportions were lower (33%). There was no strong or consistent relationship between individual AB use and likelihood of MDR UTI, after accounting for country context. The results highlight the hurdles East African patients face in accessing effective UTI care. These challenges are exacerbated by high rates of MDR UTI, suggesting a vicious cycle of failed treatment attempts and sustained selection for drug resistance. Whilst individual AB use may contribute to the risk of MDR UTI, our data show that factors related to context are stronger drivers of variations in ABR.

Predominance of multidrug-resistant bacteria causing urinary tract infections among symptomatic patients in East Africa: a call for action.

Background: In low- and middle-income countries, antibiotics are often prescribed for patients with symptoms of urinary tract infections (UTIs) without microbiological confirmation. Inappropriate antibiotic use can contribute to antimicrobial resistance (AMR) and the selection of MDR bacteria. Data on antibiotic susceptibility of cultured bacteria are important in drafting empirical treatment guidelines and monitoring resistance trends, which can prevent the spread of AMR. In East Africa, antibiotic susceptibility data are sparse. To fill the gap, this study reports common microorganisms and their susceptibility patterns isolated from patients with UTI-like symptoms in Kenya, Tanzania and Uganda. Within each country, patients were recruited from three sites that were sociodemographically distinct and representative of different populations. Methods: UTI was defined by the presence of >104 cfu/mL of one or two uropathogens in mid-stream urine samples. Identification of microorganisms was done using biochemical methods. Antimicrobial susceptibility testing was performed by the Kirby-Bauer disc diffusion assay. MDR bacteria were defined as isolates resistant to at least one agent in three or more classes of antimicrobial agents. Results: Microbiologically confirmed UTI was observed in 2653 (35.0%) of the 7583 patients studied. The predominant bacteria were Escherichia coli (37.0%), Staphylococcus spp. (26.3%), Klebsiella spp. (5.8%) and Enterococcus spp. (5.5%). E. coli contributed 982 of the isolates, with an MDR proportion of 52.2%. Staphylococcus spp. contributed 697 of the isolates, with an MDR rate of 60.3%. The overall proportion of MDR bacteria (n = 1153) was 50.9%. Conclusions: MDR bacteria are common causes of UTI in patients attending healthcare centres in East African countries, which emphasizes the need for investment in laboratory culture capacity and diagnostic algorithms to improve accuracy of diagnosis that will lead to appropriate antibiotic use to prevent and control AMR.

Hepatitis B virus infection, associated factors, knowledge and vaccination status among household contacts of hepatitis B index cases in Mwanza, Tanzania.

Objectives: To determine the prevalence of hepatitis B virus (HBV) infection, knowledge regarding HBV, vaccination status, and associated factors among household contacts of HBV index cases in Mwanza, Tanzania. Methods: Between July and August 2023, a cross-sectional study involving 97 index cases and 402 household contacts was conducted. Data were collected using pre-tested structured questionnaire and blood samples were collected from household contacts for HBV surface antigen (HBsAg) testing. Results: The prevalence of HBV among household contacts was 5.4% (95% confidence interval, 2.9-9.0) with a significantly high proportion observed in > 45 years (16.6%) and in males (9.9%). A total of 40.0% of the household contacts had completed the full HBV vaccination series. On multivariate analysis, being male was significantly associated with HBsAg positivity (odds ratio: 7.16, 95% confidence interval: 1.81-28.2, P = 0.005). Conclusion: About one-tenth of adults' male household contacts were HBsAg positive. In addition, the majority of household contacts had poor to fair knowledge regarding HBV infection with more than half being unvaccinated against HBV. There is a need to enhance awareness and education regarding HBV infection among household contacts in Tanzania and other low- and middle-income countries.

Treatment seeking and antibiotic use for urinary tract infection symptoms in the time of COVID-19 in Tanzania and Uganda.

Background: There is still little empirical evidence on how the outbreak of coronavirus disease 2019 (COVID-19) and associated regulations may have disrupted care-seeking for non-COVID-19 conditions or affected antibiotic behaviours in low- and middle-income countries (LMICs). We aimed to investigate the differences in treatment-seeking behaviours and antibiotic use for urinary tract infection (UTI)-like symptoms before and during the pandemic at recruitment sites in two East African countries with different COVID-19 control policies: Mbarara, Uganda and Mwanza, Tanzania. Methods: In this repeated cross-sectional study, we used data from outpatients (pregnant adolescents aged >14 and adults aged >18) with UTI-like symptoms who visited health facilities in Mwanza, Tanzania and Mbarara, Uganda. We assessed the prevalence of self-reported behaviours (delays in care-seeking, providers visited, antibiotics taken) at three different time points, labelled as 'pre-COVID-19 phase' (February 2019 to February 2020), 'COVID-19 phase 1' (March 2020 to April 2020), and 'COVID-19 phase 2' (July 2021 to February 2022). Results: In both study sites, delays in care-seeking were less common during the pandemic than they were in the pre-COVID phase. Patients in Mwanza, Tanzania had shorter care-seeking pathways during the pandemic compared to before it, but this difference was not observed in Mbarara, Uganda. Health centres were the dominant sources of antibiotics in both settings. Over time, reported antibiotic use for UTI-like symptoms became more common in both settings. During the COVID-19 phases, there was a significant increase in self-reported use of antibiotics like metronidazole (<30% in the pre-COVID-19 phase to 40% in COVID phase 2) and doxycycline (30% in the pre-COVID-19 phase to 55% in COVID phase 2) that were not recommended for treating UTI-like symptoms in the National Treatment Guidelines in Mbarara, Uganda. Conclusions: There was no clear evidence that patients with UTI-like symptoms attending health care facilities had longer or more complex treatment pathways despite strict government-led interventions related to COVID-19. However, antibiotic use increased over time, including some antibiotics not recommended for treating UTI, which has implications for future antimicrobial resistance.

The High Seropositivity of Mumps Virus IgG Antibodies among School-Aged Children in Rural Areas of the Mbarali District in the Mbeya Region, Tanzania: It Is High Time for Consideration in the National Immunization Program.

Mumps is an acute contagious viral disease caused by paramyxovirus characterized by complications that include orchitis, oophoritis, aseptic meningitis, and spontaneous abortion among many others. This study reports high mumps IgG seropositivity among school-aged children in rural areas of the Mbeya region, information that might be useful in understanding the epidemiology of mumps and instituting appropriate control measures including vaccination. Between May and July 2023, a cross-sectional study involving 196 enrolled children aged 5-13 years was conducted. Sociodemographic information and other relevant information were collected using a structured data collection tool. Blood samples were collected and used to detect mumps immunoglobulin G antibodies using indirect enzyme-linked immunosorbent assay (ELISA). A descriptive analysis was performed using STATA version 15. The median age of the enrolled children was 13 (interquartile range (IQR): 8-13) years. The seropositivity of mumps IgG antibodies was 88.8% (174/196, 95% CI: 83.5-92.5). By multivariable logistic regression analysis, history of fever (OR: 5.36, 95% CI: 1.02-28.22, p = 0.047) and sharing utensils (OR: 8.05, 95% CI: 1.99-32.65, p = 0.003) independently predicted mumps IgG seropositivity. More than three-quarters of school-aged children in rural areas of the Mbeya region are mumps IgG-seropositive, which is significantly associated with the sharing of utensils and history of fever. This suggests that the virus is endemic in this region, which calls for further studies across the country so as to institute evidence-based, appropriate control measures including a vaccination program.

The NLR SkinApp: Testing a Supporting mHealth Tool for Frontline Health Workers Performing Skin Screening in Ethiopia and Tanzania.

Background: The prevalence of skin diseases such as leprosy, and limited dermatological knowledge among frontline health workers (FHWs) in rural areas of Sub-Saharan Africa, led to the development of the NLR SkinApp: a mobile application (app) that supports FHWs to promptly diagnose and treat, or suspect and refer patients with skin diseases. The app includes common skin diseases, neglected tropical skin diseases (skin NTDs) such as leprosy, and HIV/AIDS-related skin conditions. This study aimed to test the supporting role of the NLR SkinApp by examining the diagnostic accuracy of its third edition. Methods: A cross-sectional study was conducted in East Hararghe, Ethiopia, as well as the Mwanza and Morogoro region, Tanzania, in 2018-2019. Diagnostic accuracy was measured against a diagnosis confirmed by two dermatologists/dermatological medical experts (reference standard) in terms of sensitivity, specificity, positive predictive value, and negative predictive value. The potential negative effect of an incorrect management recommendation was expressed on a scale of one to four. Results: A total of 443 patients with suspected skin conditions were included. The FHWs using the NLR SkinApp diagnosed 45% of the patients accurately. The values of the sensitivity of the FHWs using the NLR SkinApp in determining the correct diagnosis ranged from 23% for HIV/AIDS-related skin conditions to 76.9% for eczema, and the specificity from 69.6% for eczema to 99.3% for tinea capitis/corporis. The inter-rater reliability among the FHWs for the diagnoses made, expressed as the percent agreement, was 58% compared to 96% among the dermatologists. Of the management recommendations given on the basis of incorrect diagnoses, around one-third could have a potential negative effect. Conclusions: The results for diagnosing eczema are encouraging, demonstrating the potential contribution of the NLR SkinApp to dermatological and leprosy care by FHWs. Further studies with a bigger sample size and comparing FHWs with and without using the NLR SkinApp are needed to obtain a better understanding of the added value of the NLR SkinApp as a mobile health (mHealth) tool in supporting FHWs to diagnose and treat skin diseases.

Trends of measles in Tanzania: A 5-year review of case-based surveillance data, 2018-2022.

OBJECTIVES: Tanzania observed a gradual increase in the number of measles cases since 2019 with a large outbreak recorded during 2022. This study describes the trend of measles in Tanzania over a 5-year period from 2018-2022. METHODS: This was a descriptive study conducted using routine measles case-based surveillance system including 195 councils of the United Republic of Tanzania. RESULTS: Between 2018 and 2022 there were 12,253 measles cases reported. Out of 10,691 (87.25%) samples tested by enzyme-linked immunosorbent assay, 903 (8.4%) were measles immunoglobulin M positive. The highest number of laboratory-confirmed measles cases was in 2022 (64.8%), followed by 2020 (13.8%), and 2019 (13.5%). Out of 1279 unvaccinated cases, 213 (16.7%) were laboratory-confirmed measles cases compared to 77/723 (10.6%) who were partially vaccinated and 71/1121 (6.3%) who were fully vaccinated (P < 0.001). Children aged between 1-4 years constituted the most confirmed measles cases after laboratory testing, followed by those aged 5-9 years. There was a notable increase in the number of laboratory-confirmed measles cases in children <1 year and 10-14 years during 2022 compared to previous years. The vaccination coverage of the first dose of measles-containing vaccine (MCV1) was maintained >90% since 2013 while MCV2 increased gradually reaching 88% in 2022. CONCLUSIONS: Accumulation of susceptible children to measles due to suboptimal measles vaccination coverage over the years has resulted in an increase in the number of laboratory-confirmed measles cases in Tanzania with more cases recorded during the COVID-19 pandemic. Strengthening surveillance, routine immunization, and targeted strategies are key to achieving the immunity levels required to interrupt measles outbreaks.

Challenges in Diagnosing and Treating Acutely Febrile Children with Suspected Malaria at Health Care Facilities in the Lake Mwanza Region of Tanzania.

Acute febrile diseases transmitted by mosquitos are a diagnostic challenge for pediatricians working in sub-Saharan Africa. Misclassification due to the lack of rapid, reliable diagnostic tests leads to the overuse of antibiotics and antimalarials. Children presenting with acute fever and suspected of having malaria were examined at health care facilities in the Mwanza Region of Tanzania. The sensitivity and specificity of blood smear microscopy and malaria rapid diagnostic tests that targeted histidine-rich protein 2 and Plasmodium lactate dehydrogenase were compared with a multiplex reverse transcriptase-polymerase chain reaction (PCR)-ELISA. Six hundred ninety-eight children presented with acute fever and met the criteria for inclusion; 23% received antibiotics and 23% received antimalarials prior to admission. Subsequently, 20% were confirmed by PCR to have Plasmodium falciparum infection. Blood smear microscopy exhibited 33% sensitivity and 93% specificity. The malaria rapid test provided 87% sensitivity and 98% specificity in detecting acute malaria infections. Only 7% of malaria-negative children received antimalarials at Sengerema Designated District Hospital when treatment was guided by the results of rapid testing. In contrast, 75% of malaria-negative patients were treated with antimalarial drugs at health facilities that used blood smears as the standard diagnostic test. Misclassification and premedication of nonmalarial, febrile illnesses contribute to the emergence of antimalarial and antimicrobial resistance. The incorporation of malaria rapid diagnostic tests into the clinical routine translated into improved treatment and a significant reduction in antimalarial drug prescriptions.

Rotavirus genotype diversity in Tanzania during Rotavirus vaccine implementation between 2013 and 2018.

The study aims to determine Rotavirus genotypes between 2013 and 2018 during implementation of ROTARIX vaccine in Tanzania. The analysis of surveillance data obtained between 2013 and 2018 was done to determine circulating genotypes after introduction of Rotarix vaccine. From 2013 to 2018, a total of 10,557 samples were collected and screened for Rotavirus using an enzyme immunoassay. A significant decrease in Rotavirus positivity (29.3% to 17.8%) from 2013 to 2018 (OR 0.830, 95% CI 0.803-0.857, P < 0.001) was observed. A total of 766 randomly selected Rotavirus positive samples were genotyped. Between 2013 and 2018, a total of 18 Rotavirus genotypes were detected with G1P [8] being the most prevalent. The G1P [8] strain was found to decrease from 72.3% in 2015 to 13.5% in 2018 while the G9P [4] strain increased from 1 to 67.7% in the same years. G2P [4] was found to decrease from 59.7% in 2013 to 6.8% in 2018 while G3P [6] decreased from 11.2% in 2014 to 4.1% in 2018. The data has clearly demonstrated that ROTARIX vaccine has provided protection to varieties of the wild-type Rotavirus strains. Continuous surveillance is needed to monitor the circulation of Rotavirus strains during this era of vaccine implementation.

Patterns and outcomes of health-care associated infections in the medical wards at Bugando medical centre: a longitudinal cohort study.

BACKGROUND: The burden of healthcare associated infections (HCAIs) in low- and middle-income countries (LMICs) remains underestimated due to diagnostic complexity and lack of quality surveillance systems. We designed this study to determine clinical diagnosis, laboratory-confirmed, associated factors and risks of HCAIs. METHODS: This hospital-based longitudinal cohort study was conducted between March and June 2022 among adults (≥ 18 years) admitted in medical wards at BMC in Mwanza, Tanzania. Patients who were negative for HCAIs by clinical evaluations and laboratory investigations during admission were enrolled and followed-up until discharge or death. Clinical samples were collected from patients with clinical diagnosis of HCAIs for conventional culture and antimicrobial sensitivity testing. RESULTS: A total of 350 adult patients with a median [IQR] age of 54 [38-68] years were enrolled in the study. Males accounted for 54.6% (n = 191). The prevalence of clinically diagnosed HCAIs was 8.6% (30/350) of which 26.7% (8/30) had laboratory-confirmed HCAIs by a positive culture. Central-line-associated bloodstream infection (43.3%; 13/30) and catheter-associated urinary tract infection (36.7%; 11/30) were the most common HCAIs. Older age was the only factor associated with development of HCAIs [mean (± SD); [95%CI]: 58.9(± 12.5); [54.2-63.5] vs. 51.5(± 19.1); [49.4-53.6] years; p = 0.0391) and HCAIs increased the length of hospital stay [mean (± SD); [95%CI]: 13.8 (± 3.4); [12.5-15.1] vs. 4.5 (± 1.7); [4.3-4.7] days; p < 0.0001]. CONCLUSION: We observed a low prevalence of HCAIs among adult patients admitted to medical wards in our setting. Central-line-associated bloodstream infections and catheter-associated urinary tract infections are common HCAIs. Significantly, older patients are at higher risk of acquiring HCAIs as well as patients with HCAIs had long duration of hospital stays.

Seroprevalence of Dengue and Chikungunya Virus Infections in Children Living in Sub-Saharan Africa: Systematic Review and Meta-Analysis.

Dengue and chikungunya viruses are frequent causes of malarial-like febrile illness in children. The rapid increase in virus transmission by mosquitoes is a global health concern. This is the first systematic review and meta-analysis of the childhood prevalence of dengue and chikungunya in Sub-Saharan Africa (SSA). A comprehensive search of the MEDLINE (Ovid), Embase (Ovid), and Cochrane Library (Wiley) databases was conducted on 28 June 2019, and updated on 12 February 2022. The search strategy was designed to retrieve all articles pertaining to arboviruses in SSA children using both controlled vocabulary and keywords. The pooled (weighted) proportion of dengue and chikungunya was estimated using a random effect model. The overall pooled prevalence of dengue and chikungunya in SSA children was estimated to be 16% and 7%, respectively. Prevalence was slightly lower during the period 2010-2020 compared to 2000-2009. The study design varied depending on the healthcare facility reporting the disease outbreak. Importantly, laboratory methods used to detect arbovirus infections differed. The present review documents the prevalence of dengue and chikungunya in pediatric patients throughout SSA. The results provide unprecedented insight into the transmission of dengue and chikungunya viruses among these children and highlight the need for enhanced surveillance and controlled methodology.

A Point Prevalence Survey of Antimicrobial Use at Geita Regional Referral Hospital in North-Western Tanzania.

We conducted a point prevalence survey (PPS) to determine the prevalence of antibiotic use at Geita Regional Referral Hospital (GRRH) located along the shores of Lake Victoria in north-western Tanzania. This has led to the identification of gaps for improvement. This PPS study was conducted on 9-10 March 2023. Patient-related information, including sociodemographic and clinical data, was collected from medical records. STATA software version 15.0 was used to perform descriptive data analysis. About 94.8% (55/58) patients were on antibiotics with a mean (±SD) prescription of 2 (±0.5) antibiotic agents ranging from 1 to 4 different agents. The commonest indications of the antibiotic prescription were medical prophylaxis 47.3% (26/55) followed by empiric treatment 41.8% (23/55). In total, 110 prescriptions were made, of which metronidazole (25.5%; n = 28), ceftriaxone (23.6%; n = 26), and ampicillin-cloxacillin (23.6%; n = 26) were frequently observed. Only 67.3% (n = 74) of prescriptions complied with Tanzania Standard Treatment Guidelines. Moreover, according to the WHO-AWaRe classification, 50.9%, 23.6%, and 25.5% were under the Access category, Watch category, and Not Recommended category, respectively. The prevalence of antibiotic use among patients admitted to GRRH was high, whereby medical prophylaxis and empiric treatment were the commonest indications for antibiotic prescription. To support rational therapy and antimicrobial stewardship initiatives, we recommend that laboratories in regional hospitals be equipped to conduct sustained routine culture and antimicrobial susceptibility testing.

Efficacy of disinfectants on control and clinical bacteria strains at a zonal referral hospital in Mwanza, Tanzania: a cross sectional hospital-based study.

Contaminated-hospital surfaces are an important source of pathogenic bacteria causing health-care associated infection (HCAIs). Monitoring the performance of disinfectants that are routinely used to clean hospital surfaces is critical for prevention and control of HCAIs. Nevertheless, the evaluation of the performance of disinfectants and their efficacy are not routinely practiced in most resource-limited countries. This study was designed to determine the efficacy of sodium dichloroisocyanurate (NaDCC) and chloroxylenol against American Type Culture Collection (ATCC) and their respective multidrug resistant (MDR) strains causing neonatal sepsis at a zonal referral hospital in Mwanza, Tanzania. Four ATCC (n = 4) and their respective MDR strains of Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus and Pseudomonas aeruginosa were used. The suspension test was used with contact time of 1, 5 and 10 min with starting concentration of 105 bacterial colony forming unit per milliliters (CFU/mL). The log10 reduction value at specified bacteria-disinfectant contact time was used to assess the efficacy of 0.5%NaDCC and 4.8% chloroxylenol in-use and freshly prepared solutions. In-use 0.5%NaDCC demonstrated poor log reduction (˂ 5log) against MDR-clinical isolates. Freshly laboratory prepared 0.5% NaDCC had 100% microbial reduction at 1, 5 and 10 min of both ATCC and MDR strains up to 48 h after preparation when compared with freshly prepared 4.8% chloroxylenol (˂ 5log). Freshly, prepared 0.5% NaDCC should be used in health-care facilities for effective disinfection practices.

High Seropositivity of Brucella melitensis Antibodies among Pregnant Women Attending Health Care Facilities in Mwanza, Tanzania: A Cross-Sectional Study.

Background: Brucellosis is one of the most prevalent zoonotic neglected tropical diseases across the globe. Brucella melitensis (B. melitensis), the most pathogenic species is responsible for several pregnancy adverse outcomes in both humans and animals. Here, we present the data on the magnitude of B. melitensis antibodies among pregnant women in Mwanza, Tanzania, the information that might be useful in understanding the epidemiology of the disease and devising appropriate control interventions in this region. Methodology. A hospital-based cross-sectional study involving pregnant women was conducted at two antenatal clinics in Mwanza between May and July 2019. The pretested structured questionnaire was used for data collection. Blood samples were collected aseptically from all consenting women followed by the detection of B. melitensis antibodies using slide agglutination test. Descriptive data analysis was done using STATA version 17. Results: A total of 635 pregnant women were enrolled with the median age of 25 (interquartile range (IQR): 16-48) years and median gestation age of 21 (IQR: 3-39) weeks. Seropositivity of B. melitensis antibodies was 103 (16.2 (95% CI:13.3-19.1)). On the multivariate logistic regression analysis, as the gestation age increases, the odds of being seropositive decreases (aOR:0.972 (95% CI: 0.945-0.999), P = 0.045). Furthermore, being a housewife (aOR:3.902 (95% CI:1.589-9.577), P = 0.003), being employed (aOR:3.405 (95% CI:1.412-8.208), P = 0.006), and having history of miscarriage (aOR:1.940 (95% CI:1.043-3.606), P = 0.036) independently predicted B. melitensis seropositivity among pregnant women in Mwanza. Conclusion: High seropositivity of B. melitensis was observed among employed and housewife pregnant women in Mwanza. This calls for the need of more studies in endemic areas that might lead to evidence-based control interventions.

Unraveling virulence determinants in extended-spectrum beta-lactamase-producing Escherichia coli from East Africa using whole-genome sequencing.

Escherichia coli significantly causes nosocomial infections and rampant spread of antimicrobial resistance (AMR). There is limited data on genomic characterization of extended-spectrum ß-lactamase (ESBL)-producing E. coli from African clinical settings. This hospital-based longitudinal study unraveled the genetic resistance elements in ESBL E. coli isolates from Uganda and Tanzania using whole-genome sequencing (WGS). A total of 142 ESBL multi-drug resistant E. coli bacterial isolates from both Tanzania and Uganda were sequenced and out of these, 36/57 (63.1%) and 67/85 (78.8%) originated from Uganda and Tanzania respectively. Mutations in RarD, yaaA and ybgl conferring resistances to chloramphenicol, peroxidase and quinolones were observed from Ugandan and Tanzanian isolates. We reported very high frequencies for blaCTX-M-15 with 11/18(61.1%), and blaCTX-M-27 with 12/23 (52.1%), blaTEM-1B with 13/23 (56.5%) of isolates originating from Uganda and Tanzania respectively all conferring resistance to Beta-lactam-penicillin inhibitors. We observed chloramphenicol resistance-conferring gene mdfA in 21/23 (91.3%) of Tanzanian isolates. Extraintestinal E. coli sequence type (ST) 131 accounted for 5/59 (8.4%) of Tanzanian isolates while enterotoxigenic E. coli ST656 was reported in 9/34 (26.4%) of Ugandan isolates. Virulence factors originating from Shigella dysenteriae Sd197 (gspC, gspD, gspE, gspF, gspG, gspF, gspH, gspI), Yersinia pestis CO92 (irp1, ybtU, ybtX, iucA), Salmonella enterica subsp. enterica serovar Typhimurium str. LT2 (csgF and csgG), and Pseudomonas aeruginosa PAO1 (flhA, fliG, fliM) were identified in these isolates. Overall, this study highlights a concerning prevalence and diversity of AMR-conferring elements shaping the genomic structure of multi-drug resistant E. coli in clinical settings in East Africa. It underscores the urgent need to strengthen infection-prevention controls and advocate for the routine use of WGS in national AMR surveillance and monitoring programs.Availability of WGS analysis pipeline: the rMAP source codes, installation, and implementation manual can free be accessed via https://github.com/GunzIvan28/rMAP .

High Seropositivity of Markers of Viral Infections among Women with Unfavorable Pregnancy Outcomes in Mwanza, Tanzania: The Urgent Need for Control Interventions.

Background: Viral infections such as Human cytomegalovirus (HCMV), Rubella virus (RV) and Herpes simplex virus-2(HSV-2) are implicated in causing adverse pregnancy outcomes with limited data from Africa. Here we report the magnitude of these viruses among women with unfavorable pregnancy outcomes (WUP) in Mwanza, Tanzania. Methods: A cross sectional study involving 198 WUP was conducted between March and June 2019 in Mwanza. Enzyme linked immunosorbent assay was used to detect HCMV and RV IgM and IgG antibodies while immunochromatographic test was used to detect HSV-2 IgM and IgG antibodies. Data were analyzed by using STATA version13.0. Results: The median age of enrolled women was 28(IQR, 24-34) years. Of these 194(98%) were HCMV IgG seropositive while only 2(2.1%) were IgM seropositive. Out of 180 women tested for RV, 175(96.7%) were IgG seropositive while only 1(1.2%) was RV IgM seropositive. Regarding HSV2; out of the 146 women tested, 21(14.4%) were seropositive for HSV2 IgG, and only 3(2.1%) were HSV-2 IgM seropositive. Having primary education (p=.046) and being married (p=.035) were significantly associated with HSV-2 IgG seropositivity. Conclusion: A substantial proportion of WUP have markers of viral infections for potential pathogens that might be associated with unfavorable pregnancy outcomes necessitating further studies to establish causal effect relationship.

Practices and motives behind antibiotics provision in drug outlets in Tanzania: A qualitative study.

Dispensing antibiotics without prescription is among the major factors leading to antimicrobial resistance. Dispensing of antibiotics without prescription has negative impact at the individual and societal level leading to poor patient outcomes, and increased risks of resistant bacteria facilitated by inappropriate choice of antibiotics doses/courses. Antimicrobial resistance is a global public health threat which is projected to cause 10 million deaths by 2050 if no significant actions are taken to address this problem This study explored the practices and motives behind dispensing of antibiotics without prescription among community drug outlets in Tanzania. Finding of this study provides more strategies to antibiotics stewardship intervention. In-depth interviews with 28 drug dispensers were conducted for three months consecutively between November 2019 and January 2020 in 12 community pharmacies and 16 Accredited Drug Dispensing Outlets (ADDOs) in the Mwanza, Kilimanjaro and Mbeya regions of Tanzania. Transcripts were coded and analyzed thematically using NVivo12 software. Majority of dispensers admitted to providing antibiotics without prescriptions, selling incomplete courses of antibiotics and not giving detailed instructions to customers on how to use the drugs. These practices were motivated by several factors including customers' pressure/customers' demands, business orientation-financial gain of drug dispensers, and low purchasing power of patients/customers. It is important to address the motives behind the unauthorized dispensing antibiotics. On top of the existing regulation and enforcement, we recommend the government to empower customers with education and purchasing power of drugs which can enhance the dispensers adherence to the dispensing regulations. Furthermore, we recommend ethnographic research to inform antibiotic stewardship interventions going beyond awareness raising, education and advocacy campaigns. This will address structural drivers of AMR such as poverty and inadequate government health services, and the disconnect between public messaging and/or policy and the public itself.

Evaluation of the diagnostic performance of the urine dipstick test for the detection of urinary tract infections in patients treated in Kenyan hospitals.

Introduction: Culture is the gold-standard diagnosis for urinary tract infections (UTIs). However, most hospitals in low-resource countries lack adequately equipped laboratories and relevant expertise to perform culture and, therefore, rely heavily on dipstick tests for UTI diagnosis. Research gap: In many Kenyan hospitals, routine evaluations are rarely done to assess the accuracy of popular screening tests such as the dipstick test. As such, there is a substantial risk of misdiagnosis emanating from inaccuracy in proxy screening tests. This may result in misuse, under-use or over-use of antimicrobials. Aim: The present study aimed to assess the accuracy of the urine dipstick test as a proxy for the diagnosis of UTIs in selected Kenyan hospitals. Methods: A hospital-based cross-sectional method was used. The utility of dipstick in the diagnosis of UTIs was assessed using midstream urine against culture as the gold standard. Results: The dipstick test predicted 1416 positive UTIs, but only 1027 were confirmed positive by culture, translating to a prevalence of 54.1 %. The sensitivity of the dipstick test was better when leucocytes and nitrite tests were combined (63.1 %) than when the two tests were separate (62.6 and 50.7 %, respectively). Similarly, the two tests combined had a better positive predictive value (87.0 %) than either test alone. The nitrite test had the best specificity (89.8 %) and negative predictive value (97.4 %) than leucocytes esterase (L.E) or both tests combined. In addition, sensitivity in samples from inpatients (69.2 %) was higher than from outpatients (62.7 %). Furthermore, the dipstick test had a better sensitivity and positive predictive value among female (66.0 and 88.6 %) than male patients (44.3 and 73.9 %). Among the various patient age groups, the dipstick test's sensitivity and positive predictive value were exceptionally high in patients ≥75 years old (87.5 and 93.3 %). Conclusion: Discrepancies in prevalence from the urine dipstick test and culture, the gold standard, indicate dipstick test inadequacy for accurate UTI diagnosis. The finding also demonstrates the need for urine culture for accurate UTI diagnosis. However, considering it is not always possible to perform a culture, especially in low-resource settings, future studies are needed to combine specific UTI symptoms and dipstick results to assess possible increases in the test's sensitivity. There is also a need to develop readily available and affordable algorithms that can detect UTIs where culture is not available.

Unravelling patient pathways in the context of antibacterial resistance in East Africa.

BACKGROUND: A key factor driving the development and maintenance of antibacterial resistance (ABR) is individuals' use of antibiotics (ABs) to treat illness. To better understand motivations and context for antibiotic use we use the concept of a patient treatment-seeking pathway: a treatment journey encompassing where patients go when they are unwell, what motivates their choices, and how they obtain antibiotics. This paper investigates patterns and determinants of patient treatment-seeking pathways, and how they intersect with AB use in East Africa, a region where ABR-attributable deaths are exceptionally high. METHODS: The Holistic Approach to Unravelling Antibacterial Resistance (HATUA) Consortium collected quantitative data from 6,827 adult outpatients presenting with urinary tract infection (UTI) symptoms in Kenya, Tanzania, and Uganda between February 2019- September 2020, and conducted qualitative in-depth patient interviews with a subset (n = 116). We described patterns of treatment-seeking visually using Sankey plots and explored explanations and motivations using mixed-methods. Using Bayesian hierarchical regression modelling, we investigated the associations between socio-demographic, economic, healthcare, and attitudinal factors and three factors related to ABR: self-treatment as a first step, having a multi-step treatment pathway, and consuming ABs. RESULTS: Although most patients (86%) sought help from medical facilities in the first instance, many (56%) described multi-step, repetitive treatment-seeking pathways, which further increased the likelihood of consuming ABs. Higher socio-economic status patients were more likely to consume ABs and have multi-step pathways. Reasons for choosing providers (e.g., cost, location, time) were conditioned by wider structural factors such as hybrid healthcare systems and AB availability. CONCLUSION: There is likely to be a reinforcing cycle between complex, repetitive treatment pathways, AB consumption and ABR. A focus on individual antibiotic use as the key intervention point in this cycle ignores the contextual challenges patients face when treatment seeking, which include inadequate access to diagnostics, perceived inefficient public healthcare and ease of purchasing antibiotics without prescription. Pluralistic healthcare landscapes may promote more complex treatment seeking and therefore inappropriate AB use. We recommend further attention to healthcare system factors, focussing on medical facilities (e.g., accessible diagnostics, patient-doctor interactions, information flows), and community AB access points (e.g., drug sellers).

Bacterial etiology of urinary tract infections in patients treated at Kenyan health facilities and their resistance towards commonly used antibiotics.

BACKGROUND: Evidence-based empirical antibiotic prescribing requires knowledge of local antimicrobial resistance patterns. The spectrum of pathogens and their susceptibility strongly influences guidelines for empirical therapies for urinary tract infections (UTI) management. OBJECTIVE: This study aimed to determine the prevalence of UTI causative bacteria and their corresponding antibiotic resistance profiles in three counties of Kenya. Such data could be used to determine the optimal empirical therapy. METHODS: In this cross-sectional study, urine samples were collected from patients who presented with symptoms suggestive of UTI in the following healthcare facilities; Kenyatta National Hospital, Kiambu Hospital, Mbagathi, Makueni, Nanyuki, Centre for Microbiology Research, and Mukuru Health Centres. Urine cultures were done on Cystine Lactose Electrolyte Deficient (CLED) to isolate UTI bacterial etiologies, while antibiotic sensitivity testing was done using the Kirby-Bauer disk diffusion using CLSI guidelines and interpretive criteria. RESULTS: A total of 1,027(54%) uropathogens were isolated from the urine samples of 1898 participants. Staphylococcus spp. and Escherichia coli were the main uropathogens at 37.6% and 30.9%, respectively. The percentage resistance to commonly used drugs for the treatment of UTI were as follows: trimethoprim (64%), sulfamethoxazole (57%), nalidixic acid(57%), ciprofloxacin (27%), amoxicillin-clavulanic acid (5%), and nitrofurantoin (9%) and cefixime (9%). Resistance rates to broad-spectrum antimicrobials, such as ceftazidime, gentamicin, and ceftriaxone, were 15%, 14%, and 11%, respectively. Additionally, the proportion of Multidrug-resistant (MDR) bacteria was 66%. CONCLUSION: High resistance rates toward fluoroquinolones, sulfamethoxazole, and trimethoprim were reported. These antibiotics are commonly used drugs as they are inexpensive and readily available. Based on these findings, more robust standardised surveillance is needed to confirm the patterns observed while recognising the potential impact of sampling biases on observed resistance rates.