The role of community pharmacies in early detection of suspected COVID-19 cases in 2020: lessons from Dar es Salaam, Tanzania.

Tanzania reported its first COVID-19 case on 16 March 2020. We conducted event-based surveillance of COVID-19 suspect cases among pharmacy clients presenting with respiratory symptoms and influenza-like illness to increase early and rapid detection of COVID-19 cases and mitigate transmission. We conveniently sampled 103 pharmacies from Dar es Salaam, the epicentre for the COVID-19 pandemic in Tanzania at the time. Between 23 April 2020 and 18 May 2020, 67% of the pharmacies (69/103) reported an observed increase in the number of clients presenting with respiratory symptoms and influenza-like illness compared with the 1 month before the COVID-19 outbreak. In the 1-month surveillance period, the participating pharmacies recorded 75 alerts of COVID-19 suspect cases and referred all suspected COVID-19 cases to rapid response teams for additional symptomatic screening and SARS-CoV-2 testing. A key implementation challenge was that some clients identified as COVID-19 suspected cases were hesitant to provide follow-up information for linkage to rapid response teams. Addressing concerns among drug dispensers in the participating pharmacies and informing them of the benefits of the surveillance activity were important implementation components. Our approach demonstrates the overall feasibility of rapidly implementing an event-based surveillance system for an emerging health threat through an existing network of pharmacies within the community. The approach and tools used in this surveillance activity could be adapted in similar settings to detect and generate alerts of disease outbreaks in the community that other surveillance systems may otherwise miss.

High efficacy of artemether-lumefantrine and dihydroartemisinin-piperaquine for the treatment of uncomplicated falciparum malaria in Muheza and Kigoma Districts, Tanzania.

BACKGROUND: Artemether-lumefantrine (AL) is the recommended first-line artemisinin-based combination therapy (ACT) for the treatment of uncomplicated falciparum malaria in most of the malaria-endemic countries, including Tanzania. Recently, dihydroartemisinin-piperaquine (DP) has been recommended as the alternative anti-malarial to ensure effective case management in Tanzania. This study assessed the parasite clearance rate and efficacy of AL and DP among patients aged 6 months to 10 years with uncomplicated falciparum malaria in two sites with different malaria transmission intensity. METHODS: This was an open-label, randomized trial that was conducted at two sites of Muheza Designated District Hospital and Ujiji Health Centre in Tanga and Kigoma regions, respectively. Patients meeting inclusion criteria were enrolled, treated with either AL or DP and followed up for 28 (extended to 42) and 42 (63) days for AL and DP, respectively. Parasite clearance time was monitored in the first 72 h post treatment and the clearance rate constant and half-life were calculated using an established parasite clearance estimator. The primary outcome was parasitological cure on days 28 and 42 for AL and DP, respectively, while secondary outcome was extended parasitological cure on days 42 and 63 for AL and DP, respectively. RESULTS: Of the 509 children enrolled (192 at Muheza and 317 at Ujiji), there was no early treatment failure and PCR uncorrected cure rates on day 28 in the AL group were 77.2 and 71.2% at Muheza and Ujiji, respectively. In the DP arm, the PCR uncorrected cure rate on day 42 was 73.6% at Muheza and 72.5% at Ujiji. With extended follow-up (to day 42 for AL and 63 for DP) cure rates were lower at Ujiji compared to Muheza (AL: 60.2 and 46.1%, p = 0.063; DP: 57.6 and 40.3% in Muheza and Ujiji, respectively, p = 0.021). The PCR corrected cure rate ranged from 94.6 to 100% for all the treatment groups at both sites. Parasite clearance rate constant was similar in the two groups and at both sites (< 0.28/h); the slope half-life was < 3.0 h and all but only one patient cleared parasites by 72 h. CONCLUSION: These findings confirm high efficacy of the first- and the newly recommended alternative ACT for treatments for uncomplicated falciparum malaria in Tanzania. The high parasite clearance rate suggests absence of suspected artemisinin resistance, defined as delayed parasite clearance. Trial registration This trial is registered at ClinicalTrials.gov under registration number NCT02590627.

Non-communicable disease training for public health workers in low- and middle-income countries: lessons learned from a pilot training in Tanzania.

BACKGROUND: Non-communicable diseases (NCDs) are increasing worldwide. A lack of training and experience in NCDs among public health workers is evident in low- and middle- income countries. METHODS: We describe the design and outcomes of applied training in NCD epidemiology and control piloted in Tanzania that included a 2-week interactive course and a 6-month NCD field project. Trainees (n=14 initiated; n=13 completed) were epidemiology-trained Ministry of Health or hospital staff. We evaluated the training using Kirkpatrick's evaluation model for measuring reactions, learning, behavior and results using pre- and post-tests and closed-ended and open-ended questions. RESULTS: Significant improvements in knowledge and self-reported competencies were observed. Trainees reported applying competencies at work and supervisors reported improvements in trainees' performance. Six field projects were completed; one led to staffing changes and education materials for patients with diabetes and another to the initiation of an injury surveillance system. Workplace support and mentoring were factors that facilitated the completion of projects. Follow-up of participants was difficult, limiting our evaluation of the training's outcomes. CONCLUSIONS: The applied NCD epidemiology and control training piloted in Tanzania was well received and showed improvements in knowledge, skill and self-efficacy and changes in workplace behavior and institutional and organizational changes. Further evaluations are needed to better understand the impact of similar NCD trainings and future trainers should ensure that trainees have mentoring and workplace support prior to participating in an applied NCD training.

The Southern African Centre for infectious disease surveillance: a one health consortium.

Formed in 2008, the Southern African Centre for Infectious Disease Surveillance (SACIDS) is a One Health consortium of academic and research institutions involved with infectious diseases of humans and animals. Operating in partnership with world-renowned centres of research in industrialised countries, its mission is to harness innovations in science and technology for improving southern Africa's capacity to detect, identify, monitor (DIM) and manage the risk posed by infectious diseases of humans, animals, and ecosystems. The consortium's major capacity development activities include a series of One Health-based Master of Science (MSc) courses and a five-year DIM-driven research program. Additionally, SACIDS organized Africa's first One Health conference, in July 2011. This paper describes these and other major activities that SACIDS has undertaken to improve infectious disease surveillance across southern Africa. The paper also describes the role and collaboration of SACIDS with other national, regional and international consortia/networks that share a vision and interest in promoting novel approaches to infectious disease surveillance and outbreak response.

Are we prepared for emerging and re-emerging diseases? Experience and lessons from epidemics that occurred in Tanzania during the last five decades.

This paper reviews preparedness for containing and controlling emerging and re-emerging diseases drawing lessons from disease events that occurred in animal and human populations in the last five decades (1961-2011). A comprehensive analysis based on retrieval and analysis of grey and published literature as well as reported cases was carried out to document type and trend of occurrence of emerging and re-emerging infectious diseases in different parts of Tanzania. Overall, the majority of diseases reported in the country were viral in nature followed by bacterial diseases. The trend for the occurrence shows a number of new emerging diseases as well as re-occurrence of old diseases in both animal (domestic and wild) and human populations. In humans, the major disease epidemics reported in the last five decades include cholera, influenza A H1N1, plague and rubella. In animals, the major epidemic diseases reported were Contagious Bovine Pleuropneumonia, Contagious Caprine Pleuropneumonia, Peste des petits ruminants and Giraffe Ear and Skin Diseases. Some epidemics have been reported in both human and animal populations including Rift Valley fever and anthrax. The emergence of the 'fit-for purpose' approaches and technologies such as the discipline of One Health, use of participatory epidemiology and disease surveillance and mobile technologies offers opportunity for optimal use of limited resources to improve early detection, diagnosis and response to disease events and consequently reduced impact of such diseases in animal and human populations.

The Tanzania Field Epidemiology and Laboratory Training Program: building and transforming the public health workforce.

The Tanzania Field Epidemiology and Laboratory Training Program (TFELTP) was established in 2008 as a partnership among the Ministry of Health and Social Welfare (MOHSW), Muhimbili University of Health and Allied Sciences, National Institute for Medical Research, and local and international partners. TFELTP was established to strengthen the capacity of MOHSW to conduct public health surveillance and response, manage national disease control and prevention programs, and to enhance public health laboratory support for surveillance, diagnosis, treatment and disease monitoring. TFELTP is a 2-year full-time training program with approximately 25% time spent in class, and 75% in the field. TFELTP offers two tracks leading to an MSc degree in either Applied Epidemiology or, Epidemiology and Laboratory Management. Since 2008, the program has enrolled a total of 33 trainees (23 males, 10 females). Of these, 11 were enrolled in 2008 and 100% graduated in 2010. All 11 graduates of cohort 1 are currently employed in public health positions within the country. Demand for the program as measured by the number of applicants has grown from 28 in 2008 to 56 in 2011. While training the public health leaders of the country, TFELTP has also provided essential service to the country in responding to high-profile disease outbreaks, and evaluating and improving its public health surveillance systems and diseases control programs. TFELTP was involved in the country assessment of the revised International Health Regulations (IHR) core capabilities, development of the Tanzania IHR plan, and incorporation of IHR into the revised Tanzania Integrated Disease Surveillance and Response (IDSR) guidelines. TFELTP is training a competent core group of public health leaders for Tanzania, as well as providing much needed service to the MOHSW in the areas of routine surveillance, outbreak detection and response, and disease program management. However, the immediate challenges that the program must address include development of a full range of in-country teaching capacity for the program, as well as a career path for graduates.

Epidemiologic and clinical aspects of a Rift Valley fever outbreak in humans in Tanzania, 2007.

In January 2007, an outbreak of Rift Valley fever (RVF) was detected among humans in northern Tanzania districts. By the end of the outbreak in June, 2007, 511 suspect RVF cases had been recorded from 10 of the 21 regions of Tanzania, with laboratory confirmation of 186 cases and another 123 probable cases. All confirmed RVF cases were located in the north-central and southern regions of the country, with an eventual fatality rate of 28.2% (N = 144). All suspected cases had fever; 89% had encephalopathy, 10% hemorrhage, and 3% retinopathy. A total of 169 (55%) of the 309 confirmed or probable cases were also positive for malaria as detected by peripheral blood smear. In a cohort of 20 RVF cases with known outcome that were also positive for human immunodeficiency virus, 15 (75%) died. Contact with sick animals and animal products, including blood, meat, and milk, were identified as major risk factors of acquiring RVF.