Dynamics of nasopharyngeal bacterial colonisation in HIV-exposed young infants in Tanzania.

OBJECTIVES: To estimate the prevalence of nasopharyngeal bacterial colonisation (NPBC) patterns in young Tanzanian HIV-exposed infants and to analyse the influence of maternal NPBC and of the infant's HIV status on the NPBC pattern. METHODS: Longitudinal cohort study of neonates born to HIV-infected mothers visiting Kilimanjaro Christian Medical Centre, Tanzania, between 2005 and 2009. Demographic and clinical data and nasopharyngeal bacterial cultures were obtained at the age of 6 weeks, 3 and 6 months, and at one time point, a paired mother-infant nasopharyngeal swab was taken. RESULTS: Four hundred and twenty-two swabs were taken from 338 eligible infants. At 6 weeks of age, colonisation rates were 66% for Staphylococcus aureus, 56% for Streptococcus pneumoniae, 50% for Moraxella catarrhalis and 14% for Haemophilus influenzae. Colonisation with S. aureus diminished over time and was more common in HIV-infected infants. S. pneumoniae and H. influenzae colonisation rose over time and was more prevalent in HIV-uninfected children. Co-colonisation of S. pneumoniae with H. influenzae or M. catarrhalis was mostly noticed in HIV-infected infants. S. pneumoniae and M.catarrhalis colonisation of the mother was a risk factor for colonisation in HIV-uninfected infants, while maternal S. aureus colonisation was a risk factor for colonisation in HIV-infected infants. Among the 104 S. pneumoniae isolates, 19F was most prevalent, and 57 (55%) displayed capsular serotypes represented in the 13-valent pneumococcal conjugate vaccine. CONCLUSIONS: NPBC was common in Tanzanian HIV-exposed infants. The significant prevalence of pneumococcal vaccine serotypes colonising this paediatric population justifies the use of the 13-valent pneumococcal vaccine to reduce the burden of pneumococcal invasive disease.

Malnutrition and socio-demographic factors associated with pulmonary tuberculosis in Timor and Rote Islands, Indonesia.

OBJECTIVE: To identify nutritional and socio-demographic factors for the development of tuberculosis (TB) in Timor and Rote Island, Indonesia, so that intervention programmes can be developed to address these factors. METHODS: In a case-control study, we enrolled new sputum smear-positive pulmonary TB patients as cases, and neighbours matched for sex and age as controls. Data obtained included history of TB, socio-demographic factors and nutritional status. RESULTS: In the study, 121 TB patients and 371 controls participated. The mean age was 30 years: 56.3% were male and 43.7% female. Of the TB patients, 87% had malnutrition compared to 33% among controls. The mean body mass index (BMI) of the patients was significantly lower than that of the controls (16.1 +/- 2.3 kg/m(2) vs. 19.4 +/- 3.0 kg/m(2)). Factors associated with the development of TB were BMI (OR 0.5, 95%CI 0.4-0.6), family history of TB (OR 3.2, 95%CI 1.6-6.4), living in an extended family (OR 2.7, 95%CI 1.5-4.8), being non-indigenous to Timor and Rote Islands (OR 2.9, 95%CI 1.2-6.8) and being unemployed (OR 3.8, 95%CI 1.7-8.6). CONCLUSION: Among patients with active pulmonary TB, the prevalence of malnutrition was very high. Malnutrition, which is a general problem for the whole community and particularly among people not indigenous to Timor and Rote, should be addressed in the fight against TB.

Vitamin A deficiency and other factors associated with severe tuberculosis in Timor and Rote Islands, East Nusa Tenggara Province, Indonesia.

BACKGROUND: Plasma zinc and vitamin A concentrations have been reported to be low in tuberculosis (TB) patients in some studies, although it is not clear whether this constitutes a risk for a more severe clinical presentation among TB patients. The acute phase reaction may also deplete zinc and vitamin A in the plasma. Therefore, we further studied these associations. METHODS: We carried out a cross-sectional study among newly diagnosed sputum smear-positive TB patients in East Nusa Tenggara. The patients were categorized as either mild TB when Karnofsky Score (KS) > or =80 or severe TB (KS <80). Body mass index (BMI), mid upper arm circumference (MUAC), chest radiograph, and the results of hemoglobin, erythrocyte sedimentation rate, albumin, C-reactive protein (CRP), zinc and vitamin A in plasma were correlated with TB category. RESULTS: A total of 300 TB patients participated in the study (63% male and 37% female), and were categorized as mild TB (53%) or severe TB (47%). Vitamin A, hemoglobin and plasma albumin were significantly lower, and CRP was significantly higher, in severe TB than in mild TB, and the active lesion area on the chest radiograph was greater among severe TB patients. In a multiple regression analysis, after adjustment for CRP, low vitamin A (beta=3.2, 95%CI (confidence interval) 1.6-4.9, P=0.000) but not zinc, correlated with the severity of TB. MUAC was better than BMI as a predictor of TB severity (beta=1.3, 95%CI 0.6-6.2, P=0.000). CONCLUSIONS: Severe TB was associated with vitamin A deficiency. MUAC can be applied as a measure of TB severity.

Aetiology and presentation of HIV/AIDS-associated pulmonary infections in patients presenting for bronchoscopy at a referral hospital in northern Tanzania.

OBJECTIVES: To determine the aetiological agents of pulmonary infections in HIV-infected Tanzanians and to correlate the causative agents with clinical, radiographic features, and mortality. DESIGN: A prospective study. SETTING: Kilimanjaro Christian Medical Centre (KCMC), Tanzania. SUBJECTS: Bronchoalveolar lavage fluid (BAL) were obtained from 120 HIV infected patients with pulmonary infections. BAL for causative agents was analysed and correlated with clinical and radiographic features, and one-month outcome. RESULTS: Causative agents were identified in 71 (59.2%) patients and in 16 of these patients, multiple agents were found. Common bacteria were identified in 35 (29.2%) patients, Mycobacterium tuberculosis in 28 (23.3%), Human Herpes Virus 8 (HHV8) in 12 (10%), Pneumocystis jiroveci in nine (7.5%) and fungi in five (4.2%) patients. Median CD4 T cell count of the patients with identified causes was 47 cells/microl (IQR 14-91) and in the 49 patients with undetermined aetiology was 100 cells/ microl (IQR 36-188; p = 0.01). Micronodular chest radiographic lesions were associated with presence of M. tuberculosis (p = 0.002). The one-month mortality was 20 (16.7%). The highest mortality was associated with HHV8 (41.7%) and M. tuberculosis (32.1%). Mortality in patients with undetermined aetiology was 11.3%. No death occurred in patients with PCP. CONCLUSION: In this population of severely immunosuppressed HIV-infected patients with pulmonary infection a variety of causative agents was identified. Micronodular radiographic lesions were indicative of TB. High mortality was associated with M. tuberculosis or HHV8. No death occurred in patients with P. jiroveci infection.

Hookworm infection of the duodenum associated with dyspepsia and diagnosed by oesophagoduodenoscopy: case report.

Hookworm infection and peptic ulcer disease are common in subtropical and tropical countries. While hookworm infection is endemic where sanitary conditions are poor, peptic ulcer disease is associated with a high prevalence of Helicobacter pylori infection. Dyspepsia and epigastric pain are common presenting symptoms of patients with either hookworm infection or peptic ulcer disease. Consequently it is common practice at our healthcare facility to examine stool for ova or parasites before considering empirical gastric acid suppressive therapy or Helicobacter pylori eradication therapy. We describe a patient who presented with dyspepsia and epigastric pain whose stool examination showed no ova or parasites. The patient's symptoms did not improve with proton pump inhibitor therapy. Endoscopy revealed hookworms in the first part of the duodenum. We review published reports of hookworms at this location. In hookworm endemic areas, when empirical treatment for dyspepsia and upper abdominal pain with acid suppressive agents does not offer remedy, antihelminthic agents should be considered even when stool for ova or parasites is negative.

Occupational exposure and health problems in small-scale industry workers in Dar es Salaam, Tanzania: a situation analysis.

BACKGROUND: Workers in informal small-scale industries (SSI) in developing countries involved in welding, spray painting, woodwork and metalwork are exposed to various hazards with consequent risk to health. Aim To assess occupational exposure and health problems in SSI in Dar es Salaam, Tanzania. METHODS: Focused group discussions (FGD) were conducted among SSI workers. Participants were assessed for exposure to occupational and environmental hazards, the use of protective equipment and health complaints by interview. The findings were discussed with participants and potential interventions identified. RESULTS: Three hundred and ten workers were interviewed (response rate 98%). There was a high level (>90%) of self-reported exposure to either dust, fumes, noise or sunlight in certain occupational groups. There was low reported use of personal protective equipment. There was a high level of self-reported occupational health problems, particularly amongst welders and metalworkers. Workers reported their needs as permanent workplaces, information on work related hazards, water and sanitation, and legislation for SSI. CONCLUSIONS: In SSI in Tanzania, our study suggests that workers have high levels of exposure to multiple health hazards and that use of protective equipment is poor. This group of workers warrants improved occupational health and safety provision.

Social aspects of patients with pulmonary tuberculosis in Indonesia.

Tuberculosis (TB) patients have not only medical but also social problems related to their illness, which may influence their motivation for the completion of treatment. This study investigated the social aspects of patients with TB in an urban area of Jakarta, Indonesia. Most TB patients had poor nutritional status and lived in crowded environments. They faced joblessness and negative attitudes from their neighbors and relatives. A few of the patients were afraid that they would not find a partner; others said that their diseases impaired their marriages. We found that patients with a subnormal body mass index restricted their social contact with their family more than patients with a normal body mass index. In general, patients were supported by their families, both financially and socially. Our findings suggest that priority should be given to developing programs aimed at strengthening the family support of TB patients.

HLA-DRB1*12 is associated with protection against complicated typhoid fever, independent of tumour necrosis factor alpha.

We investigated whether HLA-DR2 or -DR12 alleles in 63 Javanese patients with complicated or non-complicated typhoid fever were associated with severity of disease. No association was observed between HLA type and susceptibility to disease. However, in patients we did find a negative association of DR12 (DRB1*12021) with complicated typhoid fever (P = 0.05; OR = 0.3; 95% CI: 0.1-1.0). No effect of DR2 (DRB1*1502) on outcome (P = 0.46; OR = 1.5; 95% CI: 0.5-4.5) was demonstrated. The odds ratio for DR12 remained unchanged after adjusting for DR2. Tumour necrosis factor alpha (TNF-alpha) production capacity in lipopolysaccharide (LPS)-stimulated whole blood culture, as measured by non-equilibrium radioimmunoassay, was significantly lower in complicated than in non-complicated cases (P = 0.02), confirming previous data. No significant correlation of either DR12 (P = 0.47) or DR2 (P = 0.89) was found with TNF-alpha production capacity. Apparently, protection against complications by DR12 is attributable to other mechanisms.

A template for improved prevention and control of cardiovascular disease in sub-Saharan Africa.

Cardiovascular disease (CVD) is rapidly becoming an important public health problem in sub-Saharan Africa, yet the response so far is often minimal and inadequate. While there is, undoubtedly, a 'double burden of disease' (persisting infectious diseases co-existing with emerging non-communicable disease), this is hardly reflected in current health planning, possibly due to a limited appreciation of the changing pattern of CVD and CVD risk factor exposure. In a situation where there are also considerable budget constraints and well-established infectious disease priorities, it is difficult to implement effective interventions for prevention or treatment of CVD. Yet such planning is urgently needed and a template for a comprehensive programme, adaptable to local situations, is presented here. The first step is to raise awareness and create evidence-based commitment among policy-makers, which could lead to the establishment of a multi-sectoral CVD unit at national level. Programmes need to focus on prevention of modifiable risk factors at population level, involving a wide range of institutions and individuals. Recommended strategies include decentralizing the design and implementation of programmes, with appropriate standardized surveillance of major risk factors, all complemented by operational, epidemiological and basic research.

Geographical variation in prevalence of hypertension within The Gambia.

Hypertension has become an important public health problem for sub-Sahara Africa. In a previous nationwide study, we observed a high degree of geographical variation in the prevalence of diastolic hypertension. Geographical variation provides essential background information for the development of community randomised trials could suggest aetiological mechanisms, inform control strategies and prompt further research questions. We designed a follow-up study from the nine high-prevalence communities, and from 18 communities where hypertension was found least prevalent (controls). In each community, 50 households were randomly selected. In each household, an (unrelated) man and woman were enrolled. The risk for hypertension (blood pressure > or =160/95 mm Hg) was higher in the high prevalence communities compared to the control villages (adjusted OR = 1.7, 95% CI 1.3-2.2). The observed coefficient of variation in hypertension prevalence, k, was 0.30. Thus we confirmed significant geographical variation in prevalence of hypertension over time, which has implications for planning of interventions.

Poor food hygiene and housing as risk factors for typhoid fever in Semarang, Indonesia.

To identify risk factors for typhoid fever in Semarang city and its surroundings, 75 culture-proven typhoid fever patients discharged 2 weeks earlier from hospital and 75 controls were studied. Control subjects were neighbours of cases with no history of typhoid fever, not family members, randomly selected and matched for gender and age. Both cases and controls were interviewed at home by the same trained interviewer using a standardized questionnaire. A structured observation of their living environment inside and outside the house was performed during the visit and home drinking water samples were tested bacteriologically. Univariate analysis showed the following risk factors for typhoid fever: never or rarely washing hands before eating (OR = 3.28; 95% CI = 1.41-7.65); eating outdoors at least once a week (OR = 3.00; 95% CI = 1.09-8.25); eating outdoors at a street food stall or mobile food vendor (OR = 3.86; 95% CI = 1.30-11.48); consuming ice cubes in beverage in the 2-week period before getting ill (OR = 3.00, 95% CI = 1.09-8.25) and buying ice cubes from a street vendor (OR = 5.82; 95% CI = 1.69-20.12). Water quality and living environment of cases were worse than that of controls, e.g. cases less often used clean water for taking a bath (OR = 6.50; 95% CI = 1.47-28.80), for brushing teeth (OR = 4.33; 95% CI = 1.25-15.20) and for drinking (OR = 3.67; 95% CI = 1.02-13.14). Cases tended to live in houses without water supply from the municipal network (OR=11.00; 95% CI = 1.42-85.2), with open sewers (OR = 2.80; 95% CI = 1.0-7.77) and without tiles in the kitchen (OR = 2.67; 95% CI = 1.04-6.81). Multivariate analysis showed that living in a house without water supply from the municipal network (OR = 29.18; 95% CI = 2.12-400.8) and with open sewers (OR = 7.19; 95% CI = 1.33-38.82) was associated with typhoid fever. Never or rarely washing hands before eating (OR = 3.97; 95% CI = 1.22-12.93) and being unemployed or having a part-time job (OR = 31.3; 95% CI = 3.08-317.4) also were risk factors. In this population typhoid fever was associated with poor housing and inadequate food and personal hygiene.

Poor micronutrient status of active pulmonary tuberculosis patients in Indonesia.

Malnutrition is observed frequently in patients with pulmonary tuberculosis (TB), but their nutritional status, especially of micronutrients, is still poorly documented. The objective of this study was to investigate the nutritional status of patients with active TB compared with that of healthy controls in Jakarta, Indonesia. In a case-control study, 41 out-patients aged 15-55 y with untreated active pulmonary TB were compared with 41 healthy controls selected from neighbors of the patients and matched for age and sex. Cases had clinical and radiographic abnormalities consistent with pulmonary TB and at least two sputum specimens showing acid-fast bacilli. Anthropometric and micronutrient status data were collected. Compared with the controls, TB patients had significantly lower body mass index, skinfold thicknesses (triceps, biceps, subscapular, suprailiac), mid-upper arm circumference, proportion of fat, and concentrations of serum albumin, blood hemoglobin, plasma retinol and plasma zinc, whereas plasma zinc protoporphyrin concentration, as a measure of free erythrocyte protoporphyrin concentration, was greater. When patients and controls were subdivided on the basis of nutritional status, concentrations of serum albumin, blood hemoglobin, and zinc and retinol in plasma were lower in malnourished TB patients than in well-nourished healthy controls, well-nourished TB patients and malnourished healthy controls. In conclusion, the nutritional status of patients with active pulmonary TB was poor compared with healthy subjects, i.e., significantly more patients were anemic and more had low plasma concentrations of retinol and zinc. Low concentrations of hemoglobin, and of retinol and zinc in plasma were more pronounced in malnourished TB patients.

Blood pressure patterns and cardiovascular risk factors in rural and urban gambian communities.

Hypertension is emerging as an important public health problem in sub-Saharan Africa. We studied blood pressure (BP) patterns, hypertension and other cardiovascular risk factors in a rural and an urban area of The Gambia. A total of 5389 adults (> or =15 years) were selected by cluster sampling in the capital Banjul and a rural area around Farafenni. A questionnaire was completed, BP, pulse rate, height and weight were recorded. Glucose was measured 2 h after a 75 g glucose load among participants > or =35 years (n = 2301); total cholesterol, triglycerides, creatinine and uric acid were measured among a stratified subsample (n = 1075). A total of 7.1% of the study participants had a BP > or =160/95 mm Hg; 18.4% of them had a BP > or =140/90 mm Hg. BP was significantly higher in the urban area. BP increased with age in both sexes in both areas. Increasing age was the major independent risk factor for hypertension. Related cardiovascular risk factors (obesity, diabetes and hyperlipidaemia) were significantly more prevalent in the urban area and among hypertensives; 17% of measured hypertensives were aware of this, 73% of people who reported to have been diagnosed as hypertensive before had discontinued treatment; 56% of those who reported being on treatment were normotensive. We conclude that hypertension is no longer rare in either urban or rural Gambians. In the urban site hypertension and related cardiovascular risk factors were more prevalent. Compliance with treatment was low. Interventions aimed at modifying risk factors at the population level, and at improving control of diagnosed hypertension are essential to prevent future increases of cardiovascular morbidity and mortality. In view of limited resources and feasibility of intervention in rural Gambia, these could initially be directed towards urbanised populations.

Review: infectious diseases and coagulation disorders.

Infection, both bacterial and nonbacterial, may be associated with coagulation disorders, resulting in disseminated intravascular coagulation and multiorgan failure. In the last few decades a series of in vivo and in vitro studies has provided more insight into the pathogenetic mechanisms and the role of cytokines in these processes. Because of the growing interest in this field, the complexity of the subject, and the fact that many physicians must deal with a variety of infections, current data are reviewed on the association between infectious diseases and the coagulation system. Novel therapeutic intervention strategies that will probably become available in the near future are mentioned, along with those of special interest for infectious disorders for which only supportive care can be given.

Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania.

OBJECTIVE: To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes. METHODS: In 1991, 66 randomly selected health units in Mwanza Region, Tanzania, were visited and factors were determined that might contribute to HIV transmission by injections. In a workshop with all senior health workers from the region, findings were presented and treatment and sterilization guidelines developed. Thereafter, seminars were held at each health centre of the region. Four months after the intervention, data were collected at the same health facilities in order to assess changes in prescribing practices, sterilization procedures, and sterility of needles and syringes. RESULTS: The knowledge on indications for injections improved markedly for paramedical staff. The proportion of outpatients receiving an injection dropped from 23% to 10% and the proportion of patients receiving an avoidable injection dropped from 16% to 6%. Procedures for sterilization, keeping sterilized equipment, and administration of injections improved. A smaller proportion of sterilized needles and syringes tended to be contaminated in dispensaries, but this reduction from 44% to 22% was not significant. CONCLUSION: Considerable improvement in knowledge, prescription practices and sterility procedures was observed at dispensary level after carrying out a training programme.

The aetiology of low birthweight in a rural area of Tanzania.

In a hospital-based study, birthweights of 3162 consecutive births were related to perinatal mortality, multiple birth, and gestational age. Independent associations between 15 potential determinants and low birthweight, prematurity and small-at-term factors were also assessed. A newly constructed local curve of birthweight-for-gestational age is compared with the existing curves. The variables positively associated with low birthweight (< 2500 g) were nulliparity, vomiting as a self-reported complaint, spleen enlargement, sex of the infant and previous perinatal mortality. Nulliparity and spleen enlargement were positively associated with preterm birth, while small-at-birth was mostly associated with nulliparity and sex of the infant. Further study on spleen enlargement, the only modifiable factor in this study of possible public health importance, is warranted. Other factors of potential importance which deserve further investigations are hard physical work, maternal morbidity and antenatal care.

Occupational exposure to the risk of HIV infection among health care workers in Mwanza Region, United Republic of Tanzania.

During 1993, we collected data on knowledge of human immunodeficiency virus (HIV) transmission, availability of equipment, protective practices and the occurrence of prick and splash incidents in nine hospitals in the Mwanza Region in the north-west of the United Republic of Tanzania. Such incidents were common, with the average health worker being pricked five times and being splashed nine times per year. The annual occupational risk of HIV transmission was estimated at 0.27% for health workers. Among surgeons, the risk was 0.7% (i.e. more than twice as high) if no special protective measures were taken. Health workers' knowledge and personal protective practices must therefore be improved and the supply of protective equipment supported. Reduction of occupational risk of HIV infection among health workers should be an integral part of acquired immunodeficiency syndrome (AIDS) control strategies.

PIP: An investigation of occupational exposure to human immunodeficiency virus (HIV) among health workers in hospitals in Tanzania's Mwanza region raised serious concerns about a lack of protective measures against such risk. Data, including questionnaires and direct observation, were collected during May-September 1993 in 9 hospitals in the region. Among the 403 hospital workers who completed an acquired immunodeficiency syndrome (AIDS)-related questionnaire, 71% had adequate knowledge scores. On the other hand, observation of hospital wards revealed insufficient measures to reduce the risk of HIV transmission (e.g., non-functioning water taps, lack of plastic bags for disposal of soiled linen, widespread shortage of gloves). 9.2% of 623 nurses and 1.3% of 118 doctors and medical assistants interviewed had pricked themselves in the preceding week; 22% of nurses working in labor wards and 25% of those working in operating theaters had pricked themselves in the previous month. Among the 50 laboratory technicians interviewed, 25% had been pricked in the previous month. In addition, more than half of nursing and medical personnel has been splashed, largely by blood and amniotic fluid, in the preceding month. Assuming an HIV prevalence of 20% among hospital patients in Mwanza, the estimated annual incidence of HIV infection due to occupational exposure is 0.27%, with percutaneous exposure contributing 93% of this risk. Among surgeons, this risk is even higher: 0.7% per year. Prevention of pricking accidents through use of double gloving, forceps to remove syringes, and appropriate containers for needle disposal should be a priority to reduce the risk of occupational HIV exposure.

[Recurrent Plasmodium vivax malaria in spite of primaquine follow-up treatment]. / Recidiverende malaria door Plasmodium vivax ondanks nabehandeling met primaquine.

Two patients, a 25-year-old woman and a 62-year-old man, with Plasmodium vivax infection, suffered repeated attacks of malaria despite standard treatment with chloroquine and subsequently primaquine. The relapses were due to a combination of decreased primaquine sensitivity and incorrect prescription of primaquine. Primaquine is administered as diphosphate (salt), but the required amount has to be prescribed as base (26.3 mg diphosphate corresponds to 15 mg base).