Implementing adaptive e-learning for newborn care in Tanzania: an observational study of provider engagement and knowledge gains.

INTRODUCTION: To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment. The objectives of this study were to (1) assess implementation success with use of in-person support and nudging strategy and (2) describe baseline provider knowledge and metacognition. METHODS: 6-month observational study at one zonal hospital and three health centres in Mwanza, Tanzania. To assess implementation success, we used the Reach, Efficacy, Adoption, Implementation and Maintenance framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity. RESULTS: aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centres. Median clinical experience was 4 years (IQR 1-9) and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD ±17%). Providers averaged 78% (SD ±31%) completion of initial learning and 7% (SD ±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% (IQR: 38%-63%), unconscious-incompetence 32% (IQR: 23%-42%), conscious-incompetence 7% (IQR: 2%-15%), and unconscious-competence 2% (IQR: 0%-3%). Higher baseline conscious-competence (OR 31.6 (95% CI 5.8 to 183.5)) and being a nursing officer (aOR: 5.6 (95% CI 1.8 to 18.1)), compared with medical officer, were associated with initial learning completion or persistent activity. CONCLUSION: aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalisation is needed.

Development of pediatric acute care education (PACE): An adaptive electronic learning (e-learning) environment for healthcare providers in Tanzania.

Globally, inadequate healthcare provider (HCP) proficiency with evidence-based guidelines contributes to millions of newborn, infant, and child deaths each year. HCP guideline proficiency would improve patient outcomes. Conventional (in person) HCP in-service education is limited in 4 ways: reach, scalability, adaptability, and the ability to contextualize. Adaptive e-learning environments (AEE), a subdomain of e-learning, incorporate artificial intelligence technology to create a unique cognitive model of each HCP to improve education effectiveness. AEEs that use existing internet access and personal mobile devices may overcome limits of conventional education. This paper provides an overview of the development of our AEE HCP in-service education, Pediatric Acute Care Education (PACE). PACE uses an innovative approach to address HCPs' proficiency in evidence-based guidelines for care of newborns, infants, and children. PACE is novel in 2 ways: 1) its patient-centric approach using clinical audit data or frontline provider input to determine content and 2) its ability to incorporate refresher learning over time to solidify knowledge gains. We describe PACE's integration into the Pediatric Association of Tanzania's (PAT) Clinical Learning Network (CLN), a multifaceted intervention to improve facility-based care along a single referral chain. Using principles of co-design, stakeholder meetings modified PACE's characteristics and optimized integration with CLN. We plan to use three-phase, mixed-methods, implementation process. Phase I will examine the feasibility of PACE and refine its components and protocol. Lessons gained from this initial phase will guide the design of Phase II proof of concept studies which will generate insights into the appropriate empirical framework for (Phase III) implementation at scale to examine effectiveness.

Feasibility of an Adaptive E-Learning Environment to Improve Provider Proficiency in Essential and Sick Newborn Care in Mwanza, Tanzania.

Introduction: To improve healthcare provider knowledge of Tanzanian newborn care guidelines, we developed adaptive Essential and Sick Newborn Care (aESNC), an adaptive e-learning environment (AEE). The objectives of this study were to 1) assess implementation success with use of in-person support and nudging strategy and 2) describe baseline provider knowledge and metacognition. Methods: 6-month observational study at 1 zonal hospital and 3 health centers in Mwanza, Tanzania. To assess implementation success, we used the RE-AIM framework and to describe baseline provider knowledge and metacognition we used Howell's conscious-competence model. Additionally, we explored provider characteristics associated with initial learning completion or persistent activity. Results: aESNC reached 85% (195/231) of providers: 75 medical, 53 nursing, and 21 clinical officers; 110 (56%) were at the zonal hospital and 85 (44%) at health centers. Median clinical experience was 4 years [IQR 1,9] and 45 (23%) had previous in-service training for both newborn essential and sick newborn care. Efficacy was 42% (SD±17%). Providers averaged 78% (SD±31%) completion of initial learning and 7%(SD±11%) of refresher assignments. 130 (67%) providers had ≥1 episode of inactivity >30 day, no episodes were due to lack of internet access. Baseline conscious-competence was 53% [IQR:38-63%], unconscious-incompetence 32% [IQR:23-42%], conscious-incompetence 7% [IQR:2-15%], and unconscious-competence 2% [IQR:0-3%]. Higher baseline conscious-competence (OR 31.6 [95%CI:5.8, 183.5) and being a nursing officer (aOR: 5.6 [95%CI:1.8, 18.1]), compared to medical officer) were associated with initial learning completion or persistent activity. Conclusion: aESNC reach was high in a population of frontline providers across diverse levels of care in Tanzania. Use of in-person support and nudging increased reach, initial learning, and refresher assignment completion, but refresher assignment completion remains low. Providers were often unaware of knowledge gaps, and lower baseline knowledge may decrease initial learning completion or activity. Further study to identify barriers to adaptive e-learning normalization is needed.

Rotavirus Diarrhoea among Children Aged <5 Years in Hospital Setting in Dar Es Salaam, Tanzania.

BACKGROUND: Diarrhoea remains among the highest causes of death in children under 5 years of age in developing countries. Before the introduction of rotavirus vaccine in Tanzania, rotavirus infection was the leading cause of severe diarrhoea in children below the age of 5 years but there is a paucity of studies reporting the severity of this infection after the introduction of rotavirus vaccine. This hospital-based study reports the proportion of children with rotavirus-associated diarrhoea in Dar es Salaam, its severity and associated factors. METHODS: A hospital-based cross-sectional study was conducted at the inpatient and outpatient paediatrics departments of the selected health facilities from September 2018 to February 2019. A total of 314 children meeting inclusion criteria were enrolled into the study. A structured questionnaire was used to collect demographic and medical history, anthropometric measurements were taken and a stool sample was collected from each patient for rotavirus antigen detection using CTK Biotech Onsite rotavirus antigen rapid test. RESULTS: A total of 314 children were included in the study with age range between 2 and 59 months. The median age was 12 months with an interquartile range of 8-19 months. Symptoms of rotavirus diarrhoea were vomiting (p-value = 0.018) and severe dehydration (p-value = 0.000). Independent associated factors of rotavirus diarrhoea included: age of mother between 35 and 49 years (AoR 4.1, 95% CI 1.0-17.1, p-value = 0.05), geographical distribution (Ilala District, AoR 4.0, 95% CI 1.1-10.4, p-value = 0.039), poor hand hygiene (AoR 8.5, 95% CI 2.6-28.1, p-value = 0.000) and drinking bottled/home-treated water (AoR 5.4, 95% CI 1.3-22.7, p-value = 0.02). CONCLUSION: Rotavirus infection is still prevalent and severe among children with diarrhoea. The difference in prevalence among the districts is also of concern and hence larger community-based cohort studies are needed to assess the association of rotavirus diarrhoea with the geographical variation across districts and regions. Improving sanitation and hygiene through health education amongst households is crucial for disease prevention.

Kangaroo mother care: EN-BIRTH multi-country validation study.

BACKGROUND: Kangaroo mother care (KMC) reduces mortality among stable neonates ≤2000 g. Lack of data tracking coverage and quality of KMC in both surveys and routine information systems impedes scale-up. This paper evaluates KMC measurement as part of the Every Newborn Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. METHODS: The EN-BIRTH observational mixed-methods study was conducted in five hospitals in Bangladesh, Nepal and Tanzania from 2017 to 2018. Clinical observers collected time-stamped data as gold standard for mother-baby pairs in KMC wards/corners. To assess accuracy, we compared routine register-recorded and women's exit survey-reported coverage to observed data, using different recommended denominator options (≤2000 g and ≤ 2499 g). We analysed gaps in quality of provision and experience of KMC. In the Tanzanian hospitals, we assessed daily skin-to-skin duration/dose and feeding frequency. Qualitative data were collected from health workers and data collectors regarding barriers and enablers to routine register design, filling and use. RESULTS: Among 840 mother-baby pairs, compared to observed 100% coverage, both exit-survey reported (99.9%) and register-recorded coverage (92.9%) were highly valid measures with high sensitivity. KMC specific registers outperformed general registers. Enablers to register recording included perceptions of data usefulness, while barriers included duplication of data elements and overburdened health workers. Gaps in KMC quality were identified for position components including wearing a hat. In Temeke Tanzania, 10.6% of babies received daily KMC skin-to-skin duration/dose of ≥20 h and a further 75.3% received 12-19 h. Regular feeding ≥8 times/day was observed for 36.5% babies in Temeke Tanzania and 14.6% in Muhimbili Tanzania. Cup-feeding was the predominant assisted feeding method. Family support during admission was variable, grandmothers co-provided KMC more often in Bangladesh. No facility arrangements for other family members were reported by 45% of women at exit survey. CONCLUSIONS: Routine hospital KMC register data have potential to track coverage from hospital KMC wards/corners. Women accurately reported KMC at exit survey and evaluation for population-based surveys could be considered. Measurement of content, quality and experience of KMC need consensus on definitions. Prioritising further KMC measurement research is important so that high quality data can be used to accelerate scale-up of high impact care for the most vulnerable.

Guillain-Barré syndrome associated with COVID-19 infection.

We are reporting a case of Acute Post-Infectious Flaccid paralysis also commonly known as Guillain-Barré Syndrome (GBS) in a patient with confirmed COVID-19 infection. GBS often occurs following an infectious trigger which induces autoimmune reaction causing damage to peripheral nerves. So far, only 8 cases have been described in association with COVID-19. This is the first to be described in Tanzania in an African Child, and probably the first in the continent. This report is presented for clinicians to be aware and for the medical fraternity to look into this unusual presentation which may shed some more light on possible pathways of the pathogenesis and clinical manifestations. We recommend that the presentation of GBS with acute respiratory distress should warrant extra precaution and a testing for COVID-19 especially when the symptoms of COVID-19 are protean.

Labour and delivery ward register data availability, quality, and utility - Every Newborn - birth indicators research tracking in hospitals (EN-BIRTH) study baseline analysis in three countries.

BACKGROUND: Countries with the highest burden of maternal and newborn deaths and stillbirths often have little information on these deaths. Since over 81% of births worldwide now occur in facilities, using routine facility data could reduce this data gap. We assessed the availability, quality, and utility of routine labour and delivery ward register data in five hospitals in Bangladesh, Nepal, and Tanzania. This paper forms the baseline register assessment for the Every Newborn-Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study. METHODS: We extracted 21 data elements from routine hospital labour ward registers, useful to calculate selected maternal and newborn health (MNH) indicators. The study sites were five public hospitals during a one-year period (2016-17). We measured 1) availability: completeness of data elements by register design, 2) data quality: implausibility, internal consistency, and heaping of birthweight and explored 3) utility by calculating selected MNH indicators using the available data. RESULTS: Data were extracted for 20,075 births. Register design was different between the five hospitals with 10-17 of the 21 selected MNH data elements available. More data were available for health outcomes than interventions. Nearly all available data elements were > 95% complete in four of the five hospitals and implausible values were rare. Data elements captured in specific columns were 85.2% highly complete compared to 25.0% captured in non-specific columns. Birthweight data were less complete for stillbirths than live births at two hospitals, and significant heaping was found in all sites, especially at 2500g and 3000g. All five hospitals recorded count data required to calculate impact indicators including; stillbirth rate, low birthweight rate, Caesarean section rate, and mortality rates. CONCLUSIONS: Data needed to calculate MNH indicators are mostly available and highly complete in EN-BIRTH study hospital routine labour ward registers in Bangladesh, Nepal and Tanzania. Register designs need to include interventions for coverage measurement. There is potential to improve data quality if Health Management Information Systems utilization with feedback loops can be strengthened. Routine health facility data could contribute to reduce the coverage and impact data gap around the time of birth.

Magnitude of Overweight, Obesity and Insufficient Physical Sports Activities Among Secondary School Students in Kinondoni Municipal, Dar es Salaam.

INTRODUCTION: There is an overwhelming increase of Non-Communicable Disease worldwide such as diabetes and cardiovascular diseases. Overweight and obesity are highly associated with development of these diseases. Unhealthy lifestyle such as excessive sugar, alcohol intake and lack of adequate physical activities has been associated with development of obesity. However, these risk factors are not well elucidated among adolescents in Tanzania. We conducted this survey to determine obesity, overweight, self-reported physical activities, and preferred foods among secondary school students in Kinondoni Municipal in Dar es salaam, Tanzania. METHODS: A cross sectional descriptive survey was conducted among secondary school students at Kambangwa and Makumbusho secondary schools in Kinondoni municipal in Dar es Salaam city. A simple random sampling technique was used to select participating schools with systemic random selection procedure was used to select participants. A pre structured, self-administered questionnaire was used to collect demographic information from the participants. Anthropometric measurement for Body Mass Index (BMI) was done using standard tools. Interpretation of the findings was done using World Health Organization (WHO) standard charts for age and sex. Data were analysed using Statistical Package for Social Sciences (SPSS version 20; SPSS Inc., Chicago, US). RESULTS: A total of 234 participants were enrolled in the study. A total of 204 (87.2%) of study participants reported to regularly participate in physical sports activities. Furthermore, Males reported to participate more in physical sports activities compared to females (χ2 (1) =8.13., p = 0.004). During sex-wise comparison, 30 (46.2%) of males reported to participate in sports once per week compared to 71 (51.5%) of females. Reported frequency was influenced by participants' sex (χ2 (3) =16.4., p= 0.001). A total of 28 (12%) participants reported fruits as their favourite food. Food preference was influenced by the participants' sex (X 2 (5) =13.1., p < 0.02). 32(47.7%) of males reported fresh fruits juice as their favourite drink compared to 106(63.5%) of females) while 6(9%) of males reported to prefer commercial industrial juice compared to 4 (2.4%) of females. CONCLUSION: Obesity and overweight are prevalent among secondary school adolescents in Kinondoni Municipal, Dar es salaam. In addition, the magnitude of physical activities was below the recommended amount. Therefore, awareness campaigns and advocacy programs aiming at preventive measures against NCDs such as healthy eating behaviour and promotion of physical activities among adolescents should be given high priority.

Guillain- Barré syndrome associated with COVID-19 infection

We are reporting a case of Acute Post-Infectious Flaccid paralysis also commonly known as Guillain-Barré Syndrome (GBS) in a patient with confirmed COVID-19 infection. GBS often occurs following an infectious trigger which induces autoimmune reaction causing damage to peripheral nerves. So far, only 8 cases have been described in association with COVID-19. This is the first to be described in Tanzaniain an African Child, and probably the first in the continent. This report is presented for clinicians to be aware and for the medical fraternity to look into this unusual presentation which may shed some more light on possible pathways of the pathogenesis and clinical manifestations. We recommend that the presentation of GBS with acute respiratory distress should warrant extra precaution and a testing for COVID-19 especially when the symptoms of COVID-19 are protean

"Every Newborn-BIRTH" protocol: observational study validating indicators for coverage and quality of maternal and newborn health care in Bangladesh, Nepal and Tanzania.

BACKGROUND: To achieve Sustainable Development Goals and Universal Health Coverage, programmatic data are essential. The Every Newborn Action Plan, agreed by all United Nations member states and >80 development partners, includes an ambitious Measurement Improvement Roadmap. Quality of care at birth is prioritised by both Every Newborn and Ending Preventable Maternal Mortality strategies, hence metrics need to advance from health service contact alone, to content of care. As facility births increase, monitoring using routine facility data in DHIS2 has potential, yet validation research has mainly focussed on maternal recall surveys. The Every Newborn - Birth Indicators Research Tracking in Hospitals (EN-BIRTH) study aims to validate selected newborn and maternal indicators for routine tracking of coverage and quality of facility-based care for use at district, national and global levels. METHODS: EN-BIRTH is an observational study including >20 000 facility births in three countries (Tanzania, Bangladesh and Nepal) to validate selected indicators. Direct clinical observation will be compared with facility register data and a pre-discharge maternal recall survey for indicators including: uterotonic administration, immediate newborn care, neonatal resuscitation and Kangaroo mother care. Indicators including neonatal infection management and antenatal corticosteroid administration, which cannot be easily observed, will be validated using inpatient records. Trained clinical observers in Labour/Delivery ward, Operation theatre, and Kangaroo mother care ward/areas will collect data using a tablet-based customised data capturing application. Sensitivity will be calculated for numerators of all indicators and specificity for those numerators with adequate information. Other objectives include comparison of denominator options (ie, true target population or surrogates) and quality of care analyses, especially regarding intervention timing. Barriers and enablers to routine recording and data usage will be assessed by data flow assessments, quantitative and qualitative analyses. CONCLUSIONS: To our knowledge, this is the first large, multi-country study validating facility-based routine data compared to direct observation for maternal and newborn care, designed to provide evidence to inform selection of a core list of indicators recommended for inclusion in national DHIS2. Availability and use of such data are fundamental to drive progress towards ending the annual 5.5 million preventable stillbirths, maternal and newborn deaths.

Improving feeding and growth of HIV-positive children through nutrition training of frontline health workers in Tanga, Tanzania.

BACKGROUND: Nutrition training can boost competence of health workers to improve children's feeding practices. In this way, child undernutrition can be ameliorated in general populations. However, evidence is lacking on efficacy of such interventions among Human Immunodeficiency Virus (HIV)-positive children. We aimed to examine the efficacy of a nutrition training intervention to improve midlevel providers' (MLPs) nutrition knowledge and feeding practices and the nutrition statuses of HIV-positive children in Tanga, Tanzania. METHODS: This cluster-randomized controlled trial was conducted in 16 out of 32 care and treatment centers (CTCs) in Tanga. Eight CTCs were assigned to the intervention arm and a total of 16 MLPs received nutrition training and provided nutrition counseling and care to caregivers of HIV-positive children. A total of 776 pairs of HIV-positive children and their caregivers were recruited, of whom 397 were in the intervention arm. Data were analyzed using instrumental variable random effects regression with panel data to examine the efficacy of the intervention on nutrition status through feeding practices. RESULTS: Mean nutrition knowledge scores were higher post-training compared to pre-training among MLPs (37.1 vs. 23.5, p < 0.001). A mean increment weight gain of 300 g was also observed at follow-up compared to baseline among children of the intervention arm. Feeding frequency and dietary diversity improved following the intervention and a 6 months follow-up (p < 0.001). An increase in each unit of feeding frequency and dietary diversity were associated with a 0.15-unit and a 0.16-unit respectively decrease in the child underweight (p < 0.001). CONCLUSIONS: Nutrition training improved nutrition knowledge among MLPs caring for HIV-positive children attending CTCs in Tanga, Tanzania. Caregivers' feeding practices also improved, which in turn led to a modest weight gain among HIV-positive children. To sustain weight gain, efforts should be made to also improve households' food security and caregivers' education in addition to inservice nutrition trainings. The protocol was registered on 15/02/2013, before the recruitment at ISRCTN trial registry with the trial registration number: ISRCTN65346364.

High nasal carriage of methicillin-resistant Staphylococcus aureus among healthy Tanzanian under-5 children.

This study aimed to determine the prevalence of Staphylococcus aureus and methicillin-resistant S. aureus (MRSA) carriage, risk factors of colonization and antimicrobial susceptibility patterns of S. aureus strains. The study was conducted at the Muhimbili National Hospital in Dar es Salaam, Tanzania. Nasal swabs were obtained from children and S. aureus was isolated and identified using conventional culture methods. MRSA was screened and confirmed using the cefoxitin disk and multiplex real-time polymerase chain reaction, respectively. Antibiotic susceptibility was performed using the Kirby-Bauer disk diffusion method. MRSA isolates were further characterized by pulsed field gel electrophoresis (PFGE) profiling. Of 285 children included in the study, S. aureus was detected in 114 (40%). Of the 114 isolates, 12 (10.5%) were MRSA. PFGE results showed that these MRSA isolates are epidemiologically unrelated. Resistance of all S. aureus to trimethoprim-sulfamethoxazole, tetracycline, gentamicin, and ciprofloxacin was 65.8%, 23.7%, 27.2%, and 4.4%, respectively. No resistance to vancomycin was found. The prevalence of inducible clindamycin resistance, constitutive clindamycin resistance, MS phenotype (resistance to erythromycin alone), and multidrug resistance was 16.7%, 1.8%, 14.0%, and 16.8%, respectively. None of the risk factors examined was found to be significant. This is the first report of S. aureus and nasal carriage of MRSA and a high rate of S. aureus carriage was found in Tanzanian under-5 children. The study findings support the need for proper health education and effective infection control measures for healthcare workers.

Ready to Use Therapeutic Foods (RUTF) improves undernutrition among ART-treated, HIV-positive children in Dar es Salaam, Tanzania.

BACKGROUND: HIV/AIDS is associated with an increased burden of undernutrition among children even under antiretroviral therapy (ART). To treat undernutrition, WHO endorsed the use of Ready to Use Therapeutic Foods (RUTF) that can reduce case fatality and undernutrition among ART-naïve HIV-positive children. However, its effects are not studied among ART-treated, HIV-positive children. Therefore, we examined the association between RUTF use with underweight, wasting, and stunting statuses among ART-treated HIV-positive children in Dar es Salaam, Tanzania. METHODS: This cross-sectional study was conducted from September-October 2010. The target population was 219 ART-treated, HIV-positive children and the same number of their caregivers. We used questionnaires to measure socio-economic factors, food security, RUTF-use, and ART-duration. Our outcome variables were underweight, wasting, and stunting statuses. RESULTS: Of 219 ART-treated, HIV-positive children, 140 (63.9%) had received RUTF intervention prior to the interview. The percentages of underweight and wasting among non-RUTF-receivers were 12.4% and 16.5%; whereas those of RUTF-receivers were 3.0% (P = 0.006) and 2.8% (P = 0.001), respectively. RUTF-receivers were less likely to have underweight (Adjusted Odd Ratio (AOR) =0.19, CI: 0.04, 0.78), and wasting (AOR = 0.24, CI: 0.07, 0.81), compared to non RUTF-receivers. Among RUTF receivers, children treated for at least four months (n = 84) were less likely to have underweight (P = 0.049), wasting (P = 0.049) and stunting (P < 0.001). CONCLUSIONS: Among HIV-positive children under ART, the provision of RUTF for at least four months was associated with low proportions of undernutrition status. RUTF has a potential to improve undernutrition among HIV-positive children under ART in the clinical settings in Dar es Salaam, Tanzania.

Penicillin resistance and serotype distribution of Streptococcus pneumoniae in nasopharyngeal carrier children under 5 years of age in Dar es Salaam, Tanzania.

This study aimed to determine the magnitude of nasopharyngeal carriage, antimicrobial resistance and serotype distribution of Streptococcus pneumoniae in healthy children under 5 years of age in Tanzania. Nasopharyngeal swabs were obtained from 300 healthy children attending a child health clinic at Muhimbili National Hospital in Dar es Salaam, Tanzania. S. pneumoniae was isolated and identified using conventional methods. Antimicrobial susceptibility testing was performed using the Kirby-Bauer disc diffusion method. Penicillin MICs and serotypes were determined by an agar gradient diffusion method and the Quellung reaction, respectively. A total of 105 samples (35 .0%) were positive for S. pneumoniae and 115 serotypes were detected (ten specimens yielded two serotypes each). Overall, 78 of 115 isolates (67.8 %) were penicillin-non-susceptible pneumococci (PNSP). The resistance levels of S. pneumoniae to trimethoprim-sulfamethoxazole, tetracycline, erythromycin, chloramphenicol and ceftriaxone were 82.6, 10.4, 6.0, 3.5 and 0.0 %, respectively. Multidrug resistance was detected in 19 isolates (16.5 %). The most prevalent serotypes were 19F (n = 25, 21.7 %), 6B (n = 15, 13.0 %), 9V (n = 14, 12.2 %) and 13 (n = 14, 12.2 %). Of the 64 pneumococcal isolates potentially covered by the seven-valent pneumococcal conjugate vaccine (PCV7), 44 (68.8 %) were PNSP. A high prevalence of PNSP, common pneumococcal serotypes circulating worldwide, was found, and many of the resistant pneumococci strains are covered by the PCV7. These findings indicate that the carriage rate of such resistant strains could be influenced by an appropriate vaccination programme in the study setting and by reinforcing regulations on the rational use of antimicrobial agents.

Undernutrition among HIV-positive children in Dar es Salaam, Tanzania: antiretroviral therapy alone is not enough.

BACKGROUND: The prevalence of HIV/AIDS has exacerbated the impact of childhood undernutrition in many developing countries, including Tanzania. Even with the provision of antiretroviral therapy, undernutrition among HIV-positive children remains a serious problem. Most studies to examine risk factors for undernutrition have been limited to the general population and ART-naive HIV-positive children, making it difficult to generalize findings to ART-treated HIV-positive children. The objectives of this study were thus to compare the proportions of undernutrition among ART-treated HIV-positive and HIV-negative children and to examine factors associated with undernutrition among ART-treated HIV-positive children in Dar es Salaam, Tanzania. METHODS: From September to October 2010, we conducted a cross-sectional survey among 213 ART-treated HIV-positive and 202 HIV-negative children in Dar es Salaam, Tanzania. We measured the children's anthropometrics, socio-demographic factors, food security, dietary habits, diarrhea episodes, economic status, and HIV clinical stage. Data were analyzed using both univariate and multivariate methods. RESULTS: ART-treated HIV-positive children had higher rates of undernutrition than their HIV-negative counterparts. Among the ART-treated HIV-positive children, 78 (36.6%) were stunted, 47 (22.1%) were underweight, and 29 (13.6%) were wasted. Households of ART-treated HIV-positive children exhibited lower economic status, lower levels of education, and higher percentages of unmarried caregivers with higher unemployment rates. Food insecurity was prevalent in over half of ART-treated HIV-positive children's households. Furthermore, ART-treated HIV-positive children were more likely to be orphaned, to be fed less frequently, and to have lower body weight at birth compared to HIV-negative children.In the multivariate analysis, child's HIV-positive status was associated with being underweight (AOR = 4.61, 95% CI 1.38-15.36 P = 0.013) and wasting (AOR = 9.62, 95% CI 1.72-54.02, P = 0.010) but not with stunting (AOR = 0.68, 95% CI 0.26-1.77, P = 0.428). Important factors associated with underweight status among ART-treated HIV-positive children included hunger (AOR = 9.90, P = 0.022), feeding frequency (AOR = 0.02, p < 0.001), and low birth weight (AOR = 5.13, P = 0.039). Factors associated with wasting among ART-treated HIV-positive children were diarrhea (AOR = 22.49, P = 0.001) and feeding frequency (AOR = 0.03, p < 0.001). CONCLUSION: HIV/AIDS is associated with an increased burden of child underweight status and wasting, even among ART-treated children, in Dar es Salaam, Tanzania. In addition to increasing coverage of ART among HIV-positive children, interventions to ameliorate poor nutrition status may be necessary in this and similar settings. Such interventions should aim at promoting adequate feeding patterns, as well as preventing and treating diarrhea.