Correct diagnosis of childhood pneumonia in public facilities in Tanzania: a randomised comparison of diagnostic methods.

OBJECTIVE: This study compares two methods for clinical diagnosis of childhood pneumonia that aim to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by examining the sensitivity of Integrated Management of Childhood Diseases implementation in routine care against lung ultrasound (LUS) diagnosis. SETTING: We conducted observations in 83 public health facilities (dispensaries, health centres and district hospitals) in Pwani, Dodoma and Tabora, Tanzania between October and December 2017. METHODS: We used a novel method to estimate rates of underdiagnosis and overdiagnosis of childhood pneumonia by comparing directly observed public provider diagnoses to the results of diagnoses made by trained clinicians using Mindray DP-10 ultrasound machines. We perform multivariate analysis to identify confounding effects and robustness checks to bound the result. We also explore a number of observable characteristics correlated with higher rates of agreement between provider diagnoses and ultrasound diagnoses. RESULTS: We observed 93 providers conducting exams on patients aged 2 months-5 years who presented respiratory symptoms or were given a respiratory diagnosis by the provider. Of these 957 patients, 110 were excluded from analysis resulting in a final sample of 847.17.6% of cases identified as pneumonia via LUS examinations in our sample were diagnosed as pneumonia by providers, suggesting that a significant number of pneumonia cases for which care is sought in the public sector go undiagnosed. Provider knowledge of breath counting and years of experience are positively correlated with higher agreement. While clinical examination rates are not statistically correlated with agreement, it is notable that providers conducted a clinical examination on only about one-third of patients in the sample. CONCLUSION: Our results suggest that provider training and knowledge of clinical examination protocols for pneumonia diagnosis are predictive of correct diagnosis of pneumonia and should be further explored in future research as a tool for improving quality of care.

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.

Risk factors associated with under nutrition among children aged 6-59 months in Ngorongoro, Arusha region, Tanzania: a case-control study, 2017.

INTRODUCTION: childhood undernutrition is one of the leading causes of morbidity and mortality in children below five years of age especially in developing countries like Tanzania, particularly in rural area. Inappropriate child caring and feeding practices have been strongly associated with it. Many actions have been taken to reduce prevalence of undernutrition in children in Ngorongoro district, however, the problem persist. This study identified risk factors associated with undernutrition in children under-five years of age in Ngorongoro district, Arusha region. METHODS: a health facility-based unmatched case-control study was conducted with 400 (100 cases and 300 controls) children aged 6-59 months. Cases included children with undernutrition according to the WHO anthropometric indicators. Controls were children within the normal range of these indicators. Both cases and controls, were obtained from children attending the Reproductive and Child Health (RCH) for assessment of growth and development or admitted in pediatric ward. A questionnaire was used to collect demographic characteristics, child health and caring practices and environmental factors. Height, weight and Mid Upper Arm Circumference (MUAC) were measured using standard approaches. We employed logistic regression analysis to identify significant risk factors for undernutrition. RESULTS: undernutrition was associated with young age of mothers/caregivers (adjusted Odds Ratio (aOR)=38.8, 95% CI: 15.38-59.03.); early age of initiation complementary foods (aOR=13.6, 95%CI: 3.15-59.06); a child having diarrhoea in past one month (aOR=4.0; 95%CI: 1.76-12.85); large family size (aOR=6.1, 95% CI: 2.16-16.90); low frequency of feeding (aOR=3.9, 95%CI: 1.59-9.58); low birth weight (aOR:=7.3, 95%: CI: 1.15-46.70); and source of drinking water; well (aOR=16.3, 95%: CI: 1.81-147.05) and surface water (aOR=16.18, 95%CI: 1.85-141.71). CONCLUSION: household and individual characteristics of the children and mother/caregiver are important predictors of undernutrition in this community. Tailored interventions, instead of blanket approaches, should be designed to mitigate and eliminate childhood undernutrition in Ngorongoro.

Factors associated with non-uptake of measles-rubella vaccine second dose among children under five years in Mtwara district council, Tanzania, 2017.

INTRODUCTION: in 2014, Tanzania introduced the combined measles-rubella vaccine in the routine immunization schedule. Two doses of measles-rubella vaccine (MR1 and MR2) are recommended at 9 and 18 months, respectively. In 2015, MR2 coverage among eligible 18-month-old children in Tanzania was only 57%, lower than the WHO-recommended coverage (95%). During the same period Mtwara District Council (MDC) reported a coverage of 52% which is lower than the nation average. We determined factors associated with non-uptake of MR2 among children in MDC Tanzania. METHODS: we conducted a community-based cross-sectional survey using cluster sampling during January - April 2017 in MDC. Caretakers of children born during January 2014 - January 2015 and residing in MDC for the past three years were recruited. We interviewed participants and reviewed vaccination cards. Logistic regression modeling was employed to identify independent factors associated with uptake of MR2. RESULTS: of 1,000 children assessed, 558 (55.8%) were unvaccinated with MR2. Factors independently associated with non-uptake of MR2 included the caretaker being unaware of the ages for MR1 and MR2 administration [aOR=3.50; 95%CI 1.98-6.21; p<0.001], having MR2 vaccination services offered at the local vaccination station fewer than three days per week [aOR=1.50; 95%CI 1.42-5.59; p<0.001], not having the vaccine available during vaccination days [aOR=3.38; 95%CI 1.08-10.61; p<0.01], unwillingness of health workers to open multi-dose vaccine vials for a single child [aOR=3.80; 95% CI 2.12-6.79; p<0.001], and long waiting times for vaccination services [aOR=1.80; 95% CI 1.08-3.00; p<0.01]. CONCLUSION: more than half the children under five years in MDC were not vaccinated with MR2. Lack of caretaker knowledge about appropriate vaccination age, unavailability of vaccine, having insufficient numbers of children waiting to warrant multidose vial use, and long clinic waiting times were associated with MR2 non-uptake. The community should receive education about MR vaccine; we recommend thorough screening of children?s vaccination status at each clinic visit and provision of vaccine whenever possible. Vaccine distribution should be improved in MDC.

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.

Practice of emergency obstetric care signal functions and reasons for non-provision among health centers and hospitals in Lake and Western zones of Tanzania.

BACKGROUND: The Lake and Western Zones of Tanzania that encompass eight regions namely; Kagera, Geita, Simiyu, Shinyanga, Mwanza, Mara Tabora and Kigoma have consistently been reported with the poorest Maternal Newborn and Child Health (MNCH) indicators in the country. This study sought to establish the provision of Emergency Obstetric Care (EmOC) signal functions and reasons for the failure to do so among health centers and hospitals in the two zones. METHODS: All the 261 public and private hospitals and health centers providing Obstetric Care services in Lake and Western Zones were surveyed in 2014. Data were collected using questionnaires adapted from the Averting Maternal Deaths and Disabilities (AMDD) tool to assess EmOC indicators. Managers in all facilities were interviewed and services, medicines and equipment were observed. Spatial Mapping was done using a calibrated Global Positioning System (GPS) Essential Software for Android and coordinates represented on digitalized map with Arc Geographical Information System (GIS) software. Population data were according to the 2012 Housing and Population National Census. RESULTS: In total 261 health facilities were identified as providers of Obstetric care services, including 69 hospitals and 192 health centres which constitute an overall facility density of 8 per 500,000 population. The three most common EmOC signal functions available in the 3 months preceding the survey were oxytocics (95.7%), injectable antibiotics (88.9%) and basic newborn resuscitation (83.4%). The lowest proportions of facilities performed Cesarean section (25.7%) and blood transfusion (34.6%). Policy restrictions were the most frequent reasons given in relation to nonperformance of blood transfusion and Cesarean section when needed. Lack of training and supplies were the most common reasons for non availability of assisted vaginal delivery and uterine evacuation. Overall the Direct Case fatality Rate for direct obstetric causes was 3%. The referral system highly depended on hired or shared ambulance. CONCLUSION: The provision of EmOC signal functions in Lake and Western zones of Tanzania is inconsistent, being mainly compromised by policy restrictions, lack of supplies and professional development, and by operating under lowly developed referral services.

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.

Magnitude of HIV infection among older people in Mufindi and Babati districts of the Tanzania mainland.

INTRODUCTION: According to the 2011-2012 HIV and Malaria Indicator Survey, the prevalence of HIV infection in Tanzania is 5.1%, with limited information on its magnitude among older people, as the community believes that the elderly are not at risk. Consequently, little attention is given to the fight against HIV and AIDS in this group. The present study investigated the magnitude of HIV and AIDS infection among older people in rural and urban areas of the Tanzania mainland. SUBJECTS AND METHODS: The study was conducted in Mufindi and Babati districts of Iringa and Manyara regions, respectively, through multistage sampling procedures. Dried blood spot cards were used to collect blood samples for HIV testing among consenting participants. HIV testing was done and retested using different enzyme-linked immunosorbent assay kits. RESULTS: A total of 720 individuals, 340 (47.2%) males and 380 (52.8%) females, were randomly selected, of whom 714 (99.2%) consented to HIV testing while six (0.8%) refused to donate blood. The age ranged from 50 to 98 years, with a mean age of 64.2 years. Overall, a total of 56 (7.8%) participants were HIV-positive. Females had a higher prevalence (8.3%) than males (7.4%), with Mufindi district recording the higher rate (11.3%) compared to the 3.7% of Babati district. The prevalence was higher in the rural population (9.4%) compared to 6.4% of their urban counterparts. CONCLUSION: Although HIV/AIDS is considered a disease of individuals aged 15-49 years, the overall prevalence among the older people aged 50 years and above for Mufindi and Babati districts was higher than the national prevalence in the general population. These findings point to the need to consider strengthening interventions targeting older populations against HIV/AIDS in these districts while establishing evidence countrywide to inform policy decisions.

Early versus delayed initiation of highly active antiretroviral therapy for HIV-positive adults with newly diagnosed pulmonary tuberculosis (TB-HAART): a prospective, international, randomised, placebo-controlled trial.

BACKGROUND: WHO guidelines recommend early initiation of antiretroviral therapy (ART) irrespective of CD4 cell count for all patients with tuberculosis who also have HIV, but evidence supporting this approach is poor quality. We assessed the effect of timing of ART initiation on tuberculosis treatment outcomes for HIV-positive patients with CD4 counts of 220 cells per µL or more. METHODS: We did this randomised, placebo-controlled trial between Jan 1, 2008, and April 31, 2013 at 26 treatment centres in South Africa, Tanzania, Uganda, and Zambia. We enrolled HIV-positive patients with culture-confirmed tuberculosis who had tolerated 2 weeks of tuberculosis short course chemotherapy. Participants were randomly allocated (1:1) to early ART (starting after 2 weeks of tuberculosis treatment) or delayed ART (placebo, then starting ART at the end of 6 months of tuberculosis treatment). Randomisation was computer generated, with permuted blocks of size eight, and stratified by CD4 count (220-349 cells per µL vs ≥350 cells per µL). Patients and investigators were masked to treatment allocation until completion of 6-months' tuberculosis treatment, after which the study was open label. The primary endpoint was a composite of failure of tuberculosis treatment, tuberculosis recurrence, and death within 12 months of starting tuberculosis treatment in the modified intention-to-treat population. Secondary endpoints included mortality. The study is registered with controlled-trials.com (ISRCTN77861053). FINDINGS: We screened 13,588 patients and enrolled 1675: 834 assigned early ART, 841 delayed ART. The primary endpoint was reached by 65 (8·5%) of 767 patients in the early ART group versus 71 (9·2%) of 771 in the delayed ART group (relative risk [RR] 0·91, 95% CI 0·64-1·30; p=0·9). Of patients with a CD4 cell count of 220-349 cells per µL, 26 (7·9%) of 331 patients versus 33 (9·6%) of 342 reached the primary endpoint (RR 0·80, 95% CI 0·46-1·39; p=0·6). For those with 350 cells per µL or more, 39 (8·9%) of 436 versus 38 (8·9%) of 429 reached the primary endpoint (RR 1·01, 95% CI 0·63-1·62; p=0·4). Mortality did not differ significantly between treatment groups (RR 1·4, 95% CI 0·8-2·3; p=0·23). Grade 3 and 4 adverse events occurred in 149 (18%) of 834 patients assigned early ART versus 174 (21%) of 841 assigned delayed ART (p=0·37). 87 (10%) of 834 versus 84 (10%) of 841 had immune reconstitution inflammatory syndrome (p=0·56). INTERPRETATION: ART can be delayed until after completion of 6 months of tuberculosis treatment for HIV-positive patients with tuberculosis who have CD4 cell counts greater than 220 cells per µL. WHO guidelines should be updated accordingly. FUNDING: USAID, Zambia Ministry of Health, Tanzania Commission for Science and Technology, WHO-TDR.

Diffusion of subsidized ACTs in accredited drug shops in Tanzania: determinants of stocking and characteristics of early and late adopters.

BACKGROUND: Many households in sub-Saharan Africa utilize the private sector as a primary source of treatment for malaria episodes. Expanding access to effective treatment in private drug shops may help reduce incidence of severe disease and mortality. This research leveraged a longitudinal survey of stocking of subsidized artemisinin combination therapies (ACTs), an effective anti-malarial, in Accredited Drug Dispensing Outlets (ADDOs) in two regions of Tanzania. This provided a unique opportunity to explore shop and market level determinants of product diffusion in a developing country retail market. METHODS: 356 ADDOs in the Rukwa and Mtwara regions of Tanzania were surveyed at seven points between Feb 2011 and May 2012. Shop level audits were used to measure the availability of subsidized ACTs at each shop. Data on market and shop level factors were collected during the survey and also extracted from GIS layers. Regression and network based methodologies were used. Shops classified as early and late adopters, following Rogers' model of product diffusion, were compared. The Bass model of product diffusion was applied to determine whether shops stocked ACTs out of a need to imitate market competitors or a desire to satisfy customer needs. RESULTS: Following the introduction of a subsidy for ACTs, stocking increased from 12% to nearly 80% over the seven survey rounds. Stocking was influenced by higher numbers of proximal shops and clinics, larger customer traffic and the presence of a licensed pharmacist. Early adopters were characterized by a larger percentage of customers seeking care for malaria, a larger catchment and sourcing from specific wholesalers/suppliers. The Bass model of product diffusion indicated that shops were adopting products in response to competitor behavior, rather than customer demand. CONCLUSIONS: Decisions to stock new pharmaceutical products in Tanzanian ADDOs are influenced by a combination of factors related to both market competition and customer demand, but are particularly influenced by the behavior of competing shops. Efforts to expand access to new pharmaceutical products in developing country markets could benefit from initial targeting of high profile shops in competitive markets and wholesale suppliers to encourage faster product diffusion across all drug retailers.

Do price subsidies on artemisinin combination therapy for malaria increase household use? Evidence from a repeated cross-sectional study in remote regions of Tanzania.

BACKGROUND: The Affordable Medicines Facility-malaria (AMFm) is a pilot program that uses price subsidies to increase access to Artemisinin Combination Therapies (ACTs), currently the most effective malaria treatment. Recent evidence suggests that availability and affordability of ACTs in retail sector drug shops (where many people treat malaria) has increased under the AMFm, but it is unclear whether household level ACT use has increased. METHODS AND FINDINGS: household surveys were conducted in two remote regions of Tanzania (Mtwara and Rukwa) in three waves: March 2011, December 2011 and March 2012, corresponding to 3, 13 and 16 months into the AMFm implementation respectively. Information about suspected malaria episodes including treatment location and medications taken was collected. Respondents were also asked about antimalarial preferences and perceptions about the availability of these medications. Significant increases in ACT use, preference and perceived availability were found between Rounds 1 and 3 though not for all measures between Rounds 1 and 2. ACT use among suspected malaria episodes was 51.1% in March 2011 and increased by 10.9 percentage points by Round 3 (p = .017). The greatest increase was among retail sector patients, where ACT use increased from 31% in Round 1 to 49% in Round 2 (p = .037) and to 61% (p<.0001) by Round 3. The fraction of suspected malaria episodes treated in the retail sector increased from 30.2% in Round 1 to 46.7% in Round 3 (p = .0009), mostly due to a decrease in patients who sought no treatment at all. No significant changes in public sector treatment seeking were found. CONCLUSIONS: The AMFm has led to significant increases in ACT use for suspected malaria, especially in the retail sector. No evidence is found supporting the concerns that the AMFm would crowd out public sector treatment or neglect patients in remote areas and from low SES groups.

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.

Trends in availability and prices of subsidized ACT over the first year of the AMFm: evidence from remote regions of Tanzania.

BACKGROUND: The Affordable Medicines Facility for malaria (AMFm) is a pilot supra-national subsidy program that aims to increase access and affordability of artemisinin combination therapy (ACT) in public sector clinics and private retail shops. It is unclear to what extent the AMFm model will translate into wide scale availability and price reductions in ACT, particularly for rural, remote areas where disparities in access to medicines often exist. This study is the first to rigorously examine the availability and price of subsidized ACT during the first year of the AMFm, measured through retail audits in remote regions of Tanzania. METHODS: Periodic retail audits of Accredited Drug Dispensing Outlets (ADDOs) were conducted in two remote regions of Tanzania (Mtwara and Rukwa). Temporal and spatial variation in ACT availability and pricing were explored. A composite measure of ADDO remoteness, using variables, such as distance to suppliers and towns, altitude and population density, was used to explore whether ACT availability and price vary systematically with remoteness. RESULTS: Between February 2011 and January 2012, the fraction of ADDOs stocking AMFm-ACT increased from 25% to 88% in Mtwara and from 3% to 62% in Rukwa. Availability was widespread, though diffusion throughout the region was achieved more quickly in Mtwara. No significant relationship was found between ACT availability and remoteness. Adult doses of AMFm-ACT were much more widely available than any other age/weight band. Average prices fell from 1529 TZS (1.03 USD) to 1272 TZS (0.81 USD) over the study period, with prices in Rukwa higher than Mtwara. The government recommended retail price for AMFm- ACT is 1,000 TZS ($0.64 USD). The median retail ACT price in the final round of data collection was 1,000 TZS. CONCLUSIONS: The AMFm led to large increases in availability of low priced ACT in Tanzania, with no significant variation in availability based on remoteness. Availability did remain lower and prices remained higher in Rukwa, which is a more remote region overall. Low availability of child and adolescent ACT doses could be due in part to lower quantities of non-adult packs imported into Tanzania. Future research will explore whether increased availability and affordability persists and whether it translates into higher ACT use in Tanzania.