Reduction of mortality due to tetanus by immunisation and proper wound management of the patients in Sengerema Designated District Hospital, Tanzania.

Tetanus is a life-threatening, preventable infection with a high mortality. Our aim was to determine the changes in incidence and case fatality rate at Sengerema Designated District Hospital in a retrospective review of patients who had been hospitalised with tetanus between 1962 and 2012. In the 1970s and 1980s a vaccination campaign was organised in order to cover the whole district and to provide immunity for tetanus. Data are based on 476 cases with a fatal outcome in 305 cases. The case fatality rate has declined from 74% between 1982 and 1991 to 11.1% currently. Improved facilities are required in order to significantly reduce adverse outcome from tetanus.

TETANUS NEARLY ELIMINATED AFTER 40 YEARS OF VACCINATION IN RURAL SENGEREMA DISTRICT, TANZANIA.

OBJECTIVE: To study the incidence of tetanus during the last 50 years in Sengerema, Tanzania. DESIGN: Analysing the annual reports in the only district hospital, focusing on the number of admissions and mortality for tetanus and malaria. SETTING: Sengerema Hospital, Sengerema district, Tanzania. SUBJECT: Number of admissions and mortality in Sengerema Hospital due to tetanus. INTERVENTIONS: In the seventies and eighties a vaccination campaign was started end organised in order to cover the whole district and to provide immunity for tetanus. MAIN OUTCOME MEASURES: From 1962 to 2012, we analysed the incidence and fatality rate of tetanus. RESULT: One hundred and fifteen admissions in the sixties, increasing to 183 in the seventies, dropping to 30 in the nineties. For the last ten years 18 patients with tetanus were seen in the only district hospital. Then last year no admissions for tetanus were registered. The number of deaths due to tetanus decreased simultaneously, during the last decade a single fatality case was reported. CONCLUSION: During the last decades, we have witnessed the disappearing of tetanus in Sengerema Hospital. The incidence of tetanus can be reduced significantly or eliminated by an effective immunisation programme, even in rural Tanzania.

Tetanus nearly Eliminated after 40 Years of Vaccination in Rural Sengerema District; Tanzania

Objective: To study the incidence of tetanus during the last 50 years in Sengerema; Tanzania. Design: Analysing the annual reports in the only district hospital; focusing on the number of admissions and mortality for tetanus and malaria. Setting: Sengerema Hospital; Sengerema district; Tanzania. Subject: Number of admissions and mortality in Sengerema Hospital due to tetanus. Interventions: In the seventies and eighties a vaccination campaign was started end organised in order to cover the whole district and to provide immunity for tetanus. Main outcome measures: From 1962 to 2012; we analysed the incidence and fatality rate of tetanus. Result: One hundred and fifteen admissions in the sixties; increasing to 183 in the seventies; dropping to 30 in the nineties. For the last ten years 18 patients with tetanus were seen in the only district hospital. Then last year no admissions for tetanus were registered. The number of deaths due to tetanus decreased simultaneously; during the last decade a single fatality case was reported. Conclusion: During the last decades; we have witnessed the disappearing of tetanus in Sengerema Hospital. The incidence of tetanus can be reduced significantly or eliminated by an effective immunisation programme; even in rural Tanzania

RELAPSING FEVER, A DISAPPEARING CAUSE OF FEVER AND MATERNAL DEATH IN SENGEREMA, TANZANIA, EAST AFRICA.

OBJECTIVE: To study the incidence of tick borne relapsing fever (TBRF) during the last 50 years, once like malaria an endemic disease in Sengerema, Tanzania. DESIGN: By analyzing the annual reports, focusing on the number of admissions, maternal deaths, blood smears of patients with fever for Borrelia. SETTING: Sengerema district, Tanzania. SUBJECT: Admissions in Sengerema Hospital due to TBRF. MAIN OUTCOME MEASURES: From 1960 to 2010, we analyzed the incidence of TBRF. RESULT: Forty annual admissions in the sixties/seventies, 200 in the eighties (range from 37 in 1964 to 455 in 1988), dropping to 30 in the nineties. For the last nine years no Borrelia spirochetes were found in blood smears at the laboratory anymore and no admissions for TBRF were registered. The number of maternal deaths due to relapsing fever decreased simultaneously; the last one recordedwas in 2002. CONCLUSION: During the last century, we have witnessed the disappearing of tick borne relapsing fever in Sengerema. Increase of gold mining, improved local economy, housing and standards of living after the nineties resulted in an almost complete eradication of the incidence of TBRF.

Human papillomavirus DNA and genotypes: prognostic factors for progression of cervical intraepithelial neoplasia.

A retrospective study of 227 patients presenting with abnormal cervical cytology was conducted to investigate the relationship between human papillomavirus (HPV) and progression of untreated cervical intraepithelial neoplasia (CIN) lesions. All patients had colposcopically directed biopsies for histologic diagnosis. The patients were followed cytologically and colposcopically for a mean of 19 months (range 6-42 months). Progression of a cervical lesion was defined as progression to a higher CIN grade confirmed histologically by directed biopsy. HPV DNA detection was done on material remaining from the cervical swabs by the general primer polymerase chain reaction (PCR) and type-specific PCR method, which made the detection of HPV types 6, 11, 16, 18, 31, 33 and not yet sequenced DNA types (X) possible. The presence of HPV DNA increased with the severity of the lesion (P < 0.001). In CIN III, a 100% HPV DNA prevalence was found, with HPV type 16 being the most prevalent type in 75%. Progression was significantly related to the presence of HPV DNA, in particular HPV type 16. The percentage of progressive disease was 21% in the case of HPV DNA positive lesions (n = 130) and 29% in the presence of HPV type 16, whereas HPV DNA negative lesions (n = 97) showed no progression. The detection of HPV DNA and HPV genotype can be used to identify patients with high-risk cervical lesions, since the presence of HPV DNA and genotype 16 in particular are closely related to CIN progression.

Prevalence of HPV in cytomorphologically normal cervical smears, as determined by the polymerase chain reaction, is age-dependent.

The prevalence of human papillomavirus (HPV) genotypes in relation to age was investigated by the polymerase chain reaction (PCR) method in cytologically normal smears from 4 different groups of women. Group A consisted of young women from a district population, aged 15-34 years, using oral contraceptives and visiting general practitioners for a check-up (n = 156); group B were asymptomatic women, aged 35-55, in a district population participating in a triennial screening program for cervical cancer (n = 1555); group C and D consisted of women, seen at the gynecological outpatient department for a wide spectrum of gynecological complaints or for control of their hormonal contraception, aged 15-34 years (n = 2320), and aged 35-55 years (n = 1826) respectively. An HPV (all types) prevalence of 14.1%, 4.1%, 13.9% and 6.6% and an HPV 16/18 prevalence of 3.8%, 0.9%, 3.3% and 1.5% were found in groups A, B, C and D respectively. Statistically significant differences (p value < 0.001) in HPV prevalence were found between women aged 15-34 years and women aged 35-55 years in the district population and in the hospital population. No statistically significant differences in HPV 16/18 were observed after age-matching between women in corresponding age-classes of both populations. In a 5-year interval analysis a strong age-dependent relationship was demonstrated, with a maximum between 20 and 24 years. After the age of 35 a constant level of 1-2% HPV 16/18 was observed. These results indicate that genital HPV infections are age-dependent and suggest that HPV infections at young age can be transient. The implications of these findings in the context of cervical cancer screening are discussed.

Multiple HPV 16-related squamous cell carcinomas of the vulva, vagina, anus, skin and cervix in a 31-year-old woman.

A 31-year-old woman is reported with in the genital region multiple squamous carcinomas of the skin (buttock), vulva, vagina, anus and cervix uteri. All these carcinomas were HPV 16 positive as tested by DNA in situ hybridization. The existence of areas with normal epithelium between all tumor localisations and the absence of distant metastases indicate multicentric development of these multiple carcinomas. The presence of HPV 16 DNA in all carcinoma cells, as detected by DNA in situ hybridisation, argues for an etiological role of HPV 16 in the development of these multiple tumors.

Neonatal Borrelia infections (relapsing fever): report of 5 cases and review of the literature.

Tick borne relapsing fever is an endemic disease in Sengerema district, Mwanza region, Tanzania, East Africa. Five cases of neonatal relapsing fever occurring in this endemic area are described. Two neonates showed signs of septicaemia, clumping of spirochetes (Borrelia index is uncountable) in the thick blood smear and they died the day of admission. Two neonates showed severe spirochetaemia (Borrelia index: 3). The neonate treated with low dose penicillin died, the other neonate, treated with erythromycin, survived. One neonate had only a mild spirochetaemia (Borrelia index is 0.5) and responded well to penicillin treatment. Jaundice was seen in four of the five cases, three of them died. Only twenty cases of neonatal relapsing fever were previously reported. Findings are discussed in comparison with those of former reports on relapsing fever in the literature. Based on the fact that in a relatively short time (1 year), 5 cases of neonatal relapsing fever were diagnosed in an endemic area in East Africa, we conclude that neonatal relapsing fever is probably underdiagnosed.

Mortality in high risk patients with tick-borne relapsing fever analysed by the Borrelia-index.

Clinical findings on 25 patients with a high spirochaetemia are presented. The diagnosis was established by demonstration of Borrelia spirochaetes in the thick blood smear and a Borrelia-index was estimated to calculate the density of the spirochaetemia. Causes of death were septicaemia (3x), severe spirochaetemia in a neonate (1x), and successive relapses in complicated cases without adequate treatment (2x). The results show a positive correlation between the degree of spirochaetemia and severity of complications and the Borrelia-index shows to have a prognostic value.

Derangement of adipose tissue: a case report of multicentric retroperitoneal liposarcomas, retroperitoneal lipomatosis and multiple subcutaneous lipomas.

No aetiological factors are at present known in the pathogenesis of liposarcomas. Benign lipomatous disorders, such as lipomas and lipomatosis, generally do not predispose to the development of liposarcomas. A case is presented of a patient with multicentric retroperitoneal liposarcomas, associated with retroperitoneal lipomatosis and preceded by a long history of multiple subcutaneous lipomas. In the literature this combination has not been described. This rare combination of lipomatous disorders seems to indicate a common derangement of adipose tissue.

Fine needle aspiration cytology of bone lesions. Analysis of a three-year experience in rural Africa.

FNA biopsies were performed on 24 patients with bone lesions. Cytology diagnosed ten of the cases as classic Burkitt's lymphomas. The cytodiagnoses in the remaining 14 cases were primary bone tumors (5 cases), bone cysts (2 cases), inflammatory lesions (4 cases) and inadequate material (3 cases). Smears of the Burkitt's lymphomas of the jaw contained starry sky macrophages and neoplastic lymphoid cells with deep basophilic cytoplasms and fine vacuolizations. Taking into consideration the load of Burkitt's lymphoma cases in Africa, FNA cytology appears to be a very simple method for getting a quick tissue diagnosis (results were available within 24 hours). For doctors working in tropical hospitals with limited facilities, FNA cytopathology is very useful for distinguishing between tumors and inflammations and for differentiating between benign and malignant tumors.

Relapsing fever in pregnancy: analysis of high-risk factors.

The diagnosis of tick-borne relapsing fever was established in 27 pregnant patients by demonstration of Borrelia spirochaetes in a thick blood smear and the borrelia index was estimated to calculate the density of the spirochaetaemia. Clinical findings are described and compared with those reported from Rwanda. The results suggest that the density of the spirochaetaemia and the gestational age are the main high-risk factors.

Fatal-Jarisch Herxheimer reaction in a case of relapsing fever misdiagnosed as lobar pneumonia.

A fatal Jarisch-Herxheimer reaction developed after treatment with high doses of penicillin in a case of lobar pneumonia caused by Borrelia duttoni. Penicillin given on the first day and tetracycline on subsequent days to avoid severe Jarisch-Herxheimer reactions, has the disadvantage of a longer period of spirochetemia and hypotension as compared with tetracycline on the first day. Treatment may have contributed to the death of this patient.