Opportunities and Challenges for Implementation of Harmonized Competence-Based Curricula in Medicine and Nursing Programmes in Tanzania: Experiences of Biomedical Sciences' Stakeholders.

Background: In 2012, the Muhimbili University of Health and Allied Sciences (MUHAS) embarked on structured competency-based curricula (CBC) for its programmes. Other health profession training institutions continued with their traditional way of teaching and thus causing variability in the competencies of the graduates. We aimed to analyze the experiences of different stakeholders on the implementation of CBC specifically on biomedical sciences by MUHAS to inform the development of harmonized competency-based curricula in three health professional training institutions in Tanzania. Methods: We adopted an exploratory case study to analyse the implementation of CBC in programmes of Medicine and Nursing involving MUHAS graduates, immediate supervisors at the employment sites, faculty, and continuing students at MUHAS. Kiswahili guides were used to conduct the in-depth interviews (IDIs) and focus group discussions (FGDs). Qualitative content analysis was adopted for analysis. Results: From the 38 IDIs and 15 FGDs, four categories of human resources teaching and learning environment; curriculum content; and support systems emerged. Human resources were attributed to the shortage of an adequate number of faculty and teaching skills variation. The curriculum content category was linked to the redundancy of courses or topics, poor sequencing of some topics or courses, and limited time for teaching some essential courses or topics. Training and practice area mismatch, accommodation to students, teaching space, and library were the sub-categories linked to teaching and learning environment. Lastly, support systems related to teaching methods and opportunities for improving teaching and learning were revealed. Conclusion: The findings of this study highlight the challenges and opportunities for the implementation of CBC. The solutions to the revealed challenges are beyond the training institutions' capacity. The latter call for multi-stakeholder engagement including those from the public and private sectors in health, higher education and finance for common and sustainable solutions.

The process of harmonizing competency-based curricula for medicine and nursing degree programmes: A Multi-institutional and multi-professional experience from Tanzania.

In many low- and middle-income countries, there seems to be a mismatch between graduate skills and healthcare industry requirements due to variability in curricula. With the current increased global demand for competent health profession graduates, harmonizing competency-based curricula (CBC) is necessary to address this mismatch. This paper describes how three health professions training universities in Tanzania and their two long-standing United States partners embarked on developing harmonized CBC for undergraduate medicine and nursing degrees. The main goal of the activity was to develop templates to harmonize curricula that would support graduates to acquire mandatory national Graduate Minimum Essential Competencies (GMEC) irrespective of the institution of their training. The paper describes the processes of engaging multiple institutions, the professions of medicine and nursing and various stakeholders to develop mandatory curricula generic competencies, creating milestones for assessing competencies, training faculty at each of the three partnering institutions in curriculum delivery and assessments, resulting in the adoption of the curricula by the University leadership at each institution. Ultimately the Tanzania Commission for Universities (TCU) a regulatory body required all schools of medicine and nursing in the country to adopt the curricula, thus creating a harmonized national standard for teaching medicine and nursing beginning October 2022.

Perforated Meckel's diverticulum in omphalocele in a newborn: A case report of an uncommon presentation from northern Tanzania.

INTRODUCTION AND IMPORTANCE: The concurrent existence of Omphalocele and Meckel's diverticulum is not unheard of but is relatively uncommon. A few cases of their coexistence have been reported. Due to the uncommon dual presentation, it is easy to delay or even miss the diagnosis, delaying management. Meckel's diverticulum should be considered if there is a bowel opening on an omphalocele. CASE PRESENTATION: Herein we present a newborn male baby who was referred to us presenting with an omphalocele that was leaking faeces. The baby also had a cleft lip and palate. He was born at term to a 30-year-old mother whose pregnancy was otherwise normal. The fistulated omphalocele was surgically repaired, and the child continued to do well. CLINICAL DISCUSSION: Omphalocele and Meckel's diverticulum are both relatively rare congenital malformations that are uncommonly present together. Other congenital malformations can be associated; hence thorough investigations should be carried out when resources are available. The search for associated malformation should not delay the management of the pathology as it can have serious consequences on the health and outcome of the child. CONCLUSION: Fistulation of Meckel's diverticulum on an Omphalocele is rare. Treatment involves surgical resection and repair. Though other co-morbidities should be investigated, investigation for cause and other co-morbidities should not delay surgery.

Glycemic control, associated factors, acute complications of Type 1 Diabetes Mellitus in children, adolescents and young adults in Tanzania.

Objective: To determine the factors associated with poor glycemic control in children (1-10 years), adolescents (11-18 years) and young adults (19-40 years) with Type 1 Diabetes Mellitus (T1DM) in Kilimanjaro Christian Medical Center (KCMC) in Moshi, Mount Meru Regional Referral Hospital (MMRRH) and Meru District Hospital (MDH) in Arusha, Tanzania. Methods: Cross sectional study of 150 participants conducted from January to June 2019, data was collected by structured questionnaire and analyzed using SPSS version 23. Results: The mean HbA1c was 12.3 ± 2.2%, 146 had poor glycemic control (HbA1c > 7.5%). BMI, insulin regime and caretaker education were associated with poor glycemic control. There were 16 participants diagnosed in DKA and the most frequently reported complications in the prior 3 months were hyperglycemia (n = 25), DKA (n = 18) and hypoglycemia (n = 4). Conclusions: Glycemic control is still very poor particularly in adolescents. Significant associations with glycemic control were higher BMI, insulin regime and guardian education. The study revealed lower prevalence of DKA at diagnosis compared to previous studies.

Effectiveness of FIBEROPTIC phototherapy compared to conventional phototherapy in treating HYPERBILIRUBINEMIA amongst term neonates: a randomized controlled trial.

BACKGROUND: Neonatal jaundice is one of the most common problems in neonates. Effective treatment of jaundice requires therapeutic intervention with high quality phototherapy. Over recent years, several studies reported fiberoptic phototherapy to be less effective than conventional phototherapy in term neonates. Our study aimed to compare the effectiveness of fiberoptic phototherapy with a larger illuminated area and higher irradiance to conventional phototherapy methods. METHODS: This was a randomized controlled trial conducted at the Kilimanjaro Christian Medical Centre (KCMC). A total of 41 term neonates, less than 7 days of age with unconjugated hyperbilirubinemia were randomized. Thirteen (13) neonates were allocated to receive fiberoptic phototherapy, 13 to blue light conventional phototherapy and 15 to white light conventional phototherapy. Effectiveness was assessed by comparing the duration of phototherapy, bilirubin reduction rate and side effects of treatment. The data was analyzed with the independent t-test. RESULTS: The mean overall bilirubin reduction rate was comparable in the fiberoptic phototherapy group (0.74%/h) and the blue light conventional phototherapy group (0.84%/h), with no statistically significant difference (p-value 0.124). However, white light conventional phototherapy had a significantly lower mean overall bilirubin reduction rate (0.29%/h) as compared to fiberoptic phototherapy (p-value < 0.001). The mean treatment duration of phototherapy was 69 h, 68 h and 90 h in the fiberoptic, blue light conventional and white light conventional phototherapy groups respectively. Side effects such as loose stool and skin rash were noted in some participants who received conventional phototherapy. No side effects of treatment were noted in the fiberoptic phototherapy group. CONCLUSION: The effectiveness of fiberoptic PT and blue light conventional PT were comparable in terms of bilirubin reduction rate and treatment duration, whereas fiberoptic phototherapy was more effective than white light conventional PT, with a significantly higher bilirubin reduction rate and shorter treatment duration. Fiberoptic phototherapy may mitigate side effects caused by conventional phototherapy. TRIAL REGISTRATION: The Pan African Clinical Trial Registry, PACTR202004723570110 . Registered 22nd April 2020- Retrospectively registered.

Feasibility of home-based HIV counselling and testing and linking to HIV services among women delivering at home in Geita, Tanzania: a household longitudinal survey.

BACKGROUND: Substantial number of women who deliver at home (WDH) are not captured in prevention of mother-to-child transmission (PMTCT) services. This delays HIV infection detection that negatively impacts endeavours to fight the HIV pandemic and the health of mothers and children. The study objective was to determine the feasibility of home-based HIV testing and linking to care for HIV services among WDH in Geita District Council, Tanzania. METHODS: A longitudinal household survey was conducted. The study involved all mentally-able women who delivered within 2 years (WDTY) preceding the survey and their children under the age of two. The study was conducted in Geita District Council in Geita Region, Tanzania from June to July 2017. Geita is among the region with high HIV prevalence and proportion of women delivering at home. RESULTS: Of the 993 women who participated in the study, 981 (98.8%) accepted household-based HIV counselling and testing (HBHCT) from the research team. HIV prevalence was 5.3% (52 women). HBHCT identified 26 (2.7%) new HIV infections; 23 (23.4%) were those tested negative at ANC and the remaining three (0.3%) were those who had no HIV test during the ANC visit. Among the 51 HIV+ women, 21 (40.4%) were enrolled in PMTCT services. Of the 32 HIV+ participants who delivered at home, eight (25.8%) were enrolled in the PMTCT compared to 100% (13/13) of the women who delivered at a health facility. CONCLUSION: HBHCT uptake was high. HBHCT detected new HIV infection among WDH as well as seroconversion among women with previously negative HIV tests. The study findings emphasize the importance of extending re-testing to women who breastfeed. HBHCT is feasible and can be used to improve PMTCT services among WDH.

Seroprevalence, risk factors and comorbidities associated with Helicobacter pylori infection amongst children receiving care at Kilimanjaro Christian Medical Center.

BACKGROUND: Helicobacter pylori frequently causes gastritis and peptic ulcers, and affected children are at risk of developing gastric carcinoma later in adulthood. METHODS: This was a Hospital based cross sectional study. A total of 200 children aged 6 months to 14 years were enrolled. Study subjects were tested for H. pylori using a standard serology rapid test measuring immunoglobulin G for H. pylori. For risk factors, Chi-square tests were used to test for association and then, odds ratios and their corresponding 95% confidence intervals and p-values were computed using logistic regression. RESULTS: The overall seroprevalence of H. pylori was 11.5%. The following factors were associated with H. pylori infection: Age group above 10 years, keeping a dog and household size. The independent predictors of H. pylori were: Fathers' occupation, keeping a dog, indoor tap water, age group, household size and diabetes mellitus type 1.. CONCLUSION: The seroprevalence of H. pylori antibodies was lower compared to most developing countries. Keeping a dog, household size, indoor tap water, fathers' occupation and diabetes mellitus type 1 were found to be independent predictors of presence of H. pylori antibodies.

Prevalence and antimicrobial sensitivity pattern of urinary tract infection among children with cerebral palsy, Moshi, Tanzania.

BACKGROUND: Urinary tract infection (UTI) in children with cerebral palsy (CP) is a challenging yet common clinical condition. Children with CP bare the greatest risk of contracting UTI because of their difficulties in neuromotor control which lead to delay of bladder control, causing incomplete bladder emptying and urine retention. METHOD: This was an analytical cross-sectional study that was conducted from September 2016 to March 2017 at Comprehensive Community Based Rehabilitation in Tanzania - Moshi and Kilimanjaro Christian Medical Centre Neurological Pediatrics Outpatient Clinic. All children who met the inclusion criteria were studied. Urine samples were collected at one point by catheterization, and urine dipstick and urine culture were done. Data were analyzed using SPSS version 20. RESULTS: A total of 99 children were enrolled in the study. The median age was 4 years (3-8 years); 53.5% were aged between 2 and 4 years. More than half were male. UTI was detected in 13.1% (n=13) of the children. Five causative agents of UTI were isolated, namely Escherichia coli, Proteus mirabilis, Klebsiella pneumonia, Staphylococcus aureus, and Enterococcus faecalis. The two most common organisms, E. coli and P. mirabilis, both had low sensitivity to ampicillin and co-trimoxazole while they were sensitive to ciprofloxacin and ceftriaxone. CONCLUSION: UTI is a common finding among children with CP. E. coli and P. mirabilis are the commonest causative agents and are sensitive to ciprofloxacin and ceftriaxone but have low sensitivity to ampicillin and co-trimoxazole.

Prevalence, Aetiology, and Antimicrobial Susceptibility Patterns of Urinary Tract Infection Amongst Children Admitted at Kilimanjaro Christian Medical Centre, Moshi, Tanzania.

BACKGROUND: Urinary tract infections (UTIs) in the paediatric population are well recognised as a cause of acute morbidity and chronic medical conditions, such as hypertension and renal insufficiency later in adulthood. Although antimicrobial treatment of UTIs is simple, the disease is still largely misdiagnosed and mismanaged. Moreover, increasing resistance to conventional antimicrobials is eroding the success of empiric therapy. OBJECTIVE: To determine prevalence, aetiological agents, and antimicrobial sensitivity patterns of UTIs amongst children admitted at Kilimanjaro Christian Medical Centre (KCMC). METHODOLOGY: A cross-sectional, hospital-based study was conducted at the KCMC Department of Paediatrics and Child Health between December 2013 and April 2014. All children ages 2 months to 14 years who were admitted in the paediatric ward during the study period and fulfilled study criteria were enrolled. Data were collected by structured questionnaires. A urine dipstick test was done to detect the presence of nitrites and leucocytes, and to perform microscopic analysis of leucocytes and bacteria. All positive cases with the urine dipstick were cultured to determine bacterial species and antimicrobial susceptibility. Urine culture is considered the gold standard to confirm UTI. RESULTS: A total of 343 children enrolled in the study. Of these, 208 (60.6%) were male and 135 (39.4%) were female. The urine dipstick test was positive for leucocyte esterase and nitrate in 87 (25.4%) and 33 (9.6%), respectively, and urine microscopy showed leucocytes and bacteria by microscope in 38 (11.1%) and 24 (7.0%) samples, respectively. UTI was confirmed by culture in 11.4% (39/343) of the samples. Female children and children less than 24 months old had a higher prevalence of UTI (17% and 15.8%, respectively). Female sex (odds ratio [OR] 2.46, 95% confidence interval [CI], 1.25-4.86), presence of leucocytes esterase (OR 32.20, 95% CI, 12.03-86.19), and nitrate in urine dipstick (OR 5.87, 95% CI, 3.44-3.65) were associated with UTI. Leucocyte esterase, nitrite, microscopic leucocyte, and bacteria were positive in 34 (87.2%), 24 (61.5%), 30 (78.9%), and 23 (59%) samples, respectively, using culture as a gold standard. Antimicrobial sensitivity of nitrites, leucocyte esterase, microscopic leucocyte, and bacteria was 38.1%, 87.2%, 97.4%, and 59.0%, respectively, and specificity was 94.1%, 82.6%, 82.2%, and 99.7%. The most common bacterial species isolated were Escherichia coli 46.2% (18/39) and Klebsiella pneumoniae 30.8% (12/39); both exhibited low susceptibility to ampicillin, co-trimoxazole, and clindamycin, but they were susceptible to ciprofloxacin, nalidixic acid, and ceftazidime. CONCLUSIONS: UTIs are common conditions affecting children admitted at KCMC. The prevalence is higher in infants and children younger than 24 months. E coli and K pneumoniae were the most common isolated organisms with low susceptibility in commonly used antibiotics. Antimicrobials, such as ciprofloxacin, ceftriaxone, and gentamicin, are more likely to be successful for empirical treatment of UTIs.

Nevirapine- Versus Lopinavir/Ritonavir-Based Antiretroviral Therapy in HIV-Infected Infants and Young Children: Long-term Follow-up of the IMPAACT P1060 Randomized Trial.

BACKGROUND: The International Maternal Pediatric Adolescent AIDS Clinical Trials Network (IMPAACT) P1060 study demonstrated short-term superiority of lopinavir/ritonavir (LPV/r) over nevirapine (NVP) in antiretroviral therapy (ART), regardless of prior NVP exposure. However, NVP-based ART had a marginal benefit in CD4 percentage (CD4%) and growth. We compared 5-year outcomes from this clinical trial. METHODS: Human immunodeficiency virus (HIV)-infected, ART-eligible children were enrolled into 2 cohorts based on prior NVP exposure and randomized to NVP- or LPV/r-based ART. The data safety monitoring board recommended unblinding results in both cohorts due to superiority of LPV/r for the primary endpoint: stopping randomized treatment, virologic failure (VF), or death by 6 months. Participants were offered a switch in regimens (if on NVP) and continued observational follow-up. We compared time to VF or death, death, and CD4% and growth changes using intention-to-treat analyses. Additionally, inverse probability weights were used to account for treatment switching and censoring. RESULTS: As of September 2014, 329 of the 451 (73%) enrolled participants were still in follow-up (median, 5.3 years; interquartile range [IQR], 4.3-6.4), with 52% on NVP and 88% on LPV/r as originally randomized. NVP arm participants had significantly higher risk of VF or death (adjusted hazard ratio [aHR], 1.90; 95% confidence interval [CI], 1.37-2.65) but not death alone (aHR, 1.65; 95% CI, .72-3.76) compared with participants randomized to LPV/r. Mean CD4% was significantly higher in the NVP arm up to 1 year after ART initiation, but not beyond. Mean weight-for-age z scores were marginally higher in the NVP arm, but height-for-age z scores did not differ. Similar trends were observed in sensitivity analyses. CONCLUSIONS: These findings support the current World Health Organization recommendation of LPV/r in first-line ART regimens for HIV-infected children. CLINICAL TRIALS REGISTRATION: NCT00307151.

Providing Safe and Effective Preventative Antiretroviral Prophylaxis to HIV-exposed Newborns via a Novel Drug Delivery System in Tanzania.

BACKGROUND: In developing countries, antiretroviral therapy provides life-saving treatment to HIV-positive women and their children before, during and after birth. However, supply chain challenges such as long distances, medication shortages and nonfacility deliveries often compromise consistent access to prophylactic treatment for at-risk infants. A proposed intervention to address these challenges, often referred to as the "Pratt Pouch," allows for liquid-formulation medications, such as nevirapine (NVP), to be repackaged into single-dose pouches. These pouches are distributed antenatally. METHODS: HIV-positive women at Kilimanjaro Christian Medical Centre in Moshi, Tanzania received 14 pouches each containing a single dose of NVP for prevention of mother-to-child transmission. Women were trained on how to open the pouch and dispense the medication to their infants after delivery. All participating women were asked to return to Kilimanjaro Christian Medical Centre 7-14 days after delivery, where infant blood spots were collected to assess NVP levels. RESULTS: All enrolled women (21/21) administered NVP to their infants within 24 hours of birth. All enrolled infants (22/22) had NVP blood concentrations over 100 ng/mL and exhibited no health concerns attributable to over or under dosing. CONCLUSIONS: The Pratt Pouch intervention provides a clinically appropriate solution for addressing liquid-formulation antiretroviral access challenges in developing countries.

Factors associated with HIV-status disclosure to HIV-infected children receiving care at Kilimanjaro Christian Medical Centre in Moshi, Tanzania.

INTRODUCTION: With the introduction of antiretroviral drugs HIV-infected children live longer. Disclosure of HIV diagnosis is increasingly an important and inevitable issue. Both healthcare providers and caregivers face challenges of disclosure to children. The objective of the study was to explore factors associated with HIV-status disclosure to HIV-infected children receiving care at Kilimanjaro Christian Medical Centre (KCMC). METHODS: A cross-sectional hospital-based study was conducted from October 2011 to April 2012. Study population included HIV-infected children aged 5 to 14 years, their caregivers and healthcare providers. Structured questionnaires were used to collect information. Children were asked the reason for hospital visits. Outcome of interest was HIV disclosure status. Data was processed and analysed using SPSS version 16.0. Multivariate logistic regression at 5% margin error was used to account for confounders. RESULTS: A total of 211 children were enrolled with mean age of 9.7 (SD±2.6; range 5-14) years. Only 47 (22.3%) children knew their HIV-status. The mean age of disclosure was 10.6 years. Most of disclosed children were aged above 10 years (p). CONCLUSION: Most of children were not disclosed. Ages, self medication, getting other support and parents/caregivers prior discussion were strong predictors of disclosure status.

Adherence to antiretroviral therapy among HIV-infected children receiving care at Kilimanjaro Christian Medical Centre (KCMC), Northern Tanzania: A cross- sectional analytical study.

INTRODUCTION: Paediatric adherence to Highly Active Antiretroviral Therapy (HAART) is a dynamic process involving many factors. Adherence for the majority on therapy matters to prevent failure of 1(st) and 2(st) line therapy. The purpose of this study was to determine the rate of adherence to antiretroviral therapy in HIV infected children. METHODS: We conducted a cross-sectional hospital based analytical study, from October 2011 to April 2012. HIV-infected children aged 2 to 17 years who had been on treatment for at least six months were enrolled. Data were collected by a standard questionnaire. Two-day self-report, one month self-recall report, and pill count were used to assess adherence. RESULTS: One hundred and eighty three respondents participated in this research. There were 92 (51%) males and 91 (49%) females. Only 45 (24.6%) had good adherence to their drug regimen when subjected to all three methods of assessment. Males were more adherent to ART than females (OR= 2.26, CI 1.05-4.87, p = 0.04). Adherence was worse among children who developed ART side effects (OR= 0.19, CI 0.07- 0.56;p = 0.01), could not attend clinic on regular basis (OR= 3.4, CI 1.60- 7.36, p = 0.01) and missed drug doses in the six months period prior to interview (OR= 0.40, CI 0.18-0.82, p= 0.01). CONCLUSION: Only 24.6% of paediatric patients had good adherence to ART when subjected to all three measures. Drug side-effects, missing drug doses in the six months period prior to study start, monthly income and affording transportation to the clinic were strong predictors of adherence.

A randomized controlled trial of standard versus intensified tuberculosis diagnostics on treatment decisions by physicians in Northern Tanzania.

BACKGROUND: Routine tuberculosis culture remains unavailable in many high-burden areas, including Tanzania. This study sought to determine the impact of providing mycobacterial culture results over standard of care [unconcentrated acid-fast (AFB) smears] on management of persons with suspected tuberculosis. METHODS: Adults and children with suspected tuberculosis were randomized to standard (direct AFB smear only) or intensified (concentrated AFB smear and tuberculosis culture) diagnostics and followed for 8 weeks. The primary endpoint was appropriate treatment (i.e. antituberculosis therapy for those with tuberculosis, no antituberculous therapy for those without tuberculosis). RESULTS: Seventy participants were randomized to standard (n = 37, 53%) or intensive (n = 33, 47%) diagnostics. At 8 weeks, 100% (n = 22) of participants in follow up randomized to intensive diagnostics were receiving appropriate care, vs. 22 (88%) of 25 participants randomized to standard diagnostics (p = 0.14). Overall, 18 (26%) participants died; antituberculosis therapy was associated with lower mortality (9% who received antiuberculosis treatment died vs. 26% who did not, p = 0.04). CONCLUSIONS: Under field conditions in a high burden setting, the impact of intensified diagnostics was blunted by high early mortality. Enhanced availability of rapid diagnostics must be linked to earlier access to care for outcomes to improve.

Prevalence of mycobacteremia among HIV-infected infants and children in northern Tanzania.

Mycobacterium tuberculosis is a common cause of bloodstream infections among HIV-infected adults in sub-Saharan Africa, and is associated with high morbidity and mortality. We found no cases of mycobacteremia among 93 ill, HIV-infected children in northern Tanzania, despite optimization of laboratory methods and selection of patients thought to be at highest risk for disseminated infection.

Improved glycemic control and acute complications among children with type 1 diabetes mellitus in Moshi, Tanzania.

OBJECTIVE: There are an estimated 1000 children with diabetes in Tanzania. Recently, the first two pediatric endocrinologists, trained in the European Society for Paediatric Endocrinology (ESPE)/International Society for Paediatric and Adolescent Diabetes (ISPAD) program in Nairobi, Kenya, entered practice. The purpose of this study was to prospectively assess the impact of a 6-month diabetes management and education program on glycemic control and acute complications in children and adolescents in Tanzania. RESEARCH DESIGN AND METHODS: Eighty-one patients aged 3-19 yr were enrolled. All were on split-dose Insulatard (Neutral Protamine Hagedorn) and Actrapid (soluble, regular) insulin, and were given three glucose test strips per week. Children were seen in clinic an average of six times over 6 months and received 3 h of diabetes education. A structured questionnaire evaluated social demographic data and acute complications. RESULTS: Despite regular clinic attendance, diabetes education, and provision of insulin, hemoglobin A1c (HbA1c) levels did not improve. Four children (5%) had HbA1c 7.5%, 22 (28%) HbA1c 7.5-10%, 9 (24%) HbA1c 11-12.5%, and 36 (44%) HbA1c >12.5%. There was a substantial reduction in severe hypoglycemia, with 17% of subjects experiencing this acute complication compared to 52% in the 6 months prior to study enrolment. Six children were admitted in diabetic ketoacidosis during the study compared to three during the previous 6 months. Twenty-six children (36%) reported missing >6 doses of insulin (but only two lacked insulin). CONCLUSIONS: Diabetes education significantly reduced the risk of severe hypoglycemia, but better glycemic control of diabetes was not attained. Further study is needed to explore factors to improve glycemic control including increased testing, or perhaps different insulin regimens.

Prevalence of lipodystrophy in HIV-infected children in Tanzania on highly active antiretroviral therapy.

OBJECTIVE: Highly active antiretroviral therapy (HAART) has been associated with lipodystrophy (LD) in adults but data are more limited for children. The purpose of this study was to determine the prevalence of and risk factors for LD in Tanzanian children receiving HAART by clinical assessment and to compare the results with anthropometric data. DESIGN AND METHODS: A cross-sectional study was performed in a cohort of HIV-infected children aged 1-18 years receiving HAART in a single center in Moshi, Tanzania. Age, gender, past and current medication regimens and anthropometric measurements were recorded. A clinical scoring method was used to assess LD. Backward binary multivariate logistic regression was used to determine relationships between anthropometric measurements and the presence of clinical LD. RESULTS: Among 210 HIV-infected children, the prevalence of LD was 30% (95% confidence interval [CI]: 23.8-36.2) overall, 19% (95% CI: 13.7-24.3) for lipoatrophy only, 3.8% (95% CI: 1.2-6.4) for lipohypertrophy only and 7.1% (95% CI: 3.6-10.6) for the mixed type. Most cases were mild. Older age and use of stavudine increased the risk of LD. Overall, the study population was stunted but not underweight. In children with relatively lower weight-for-height (<1), only the mid-upper arm circumference was found to be associated with lipoatrophy, while nearly all anthropometric measurements were associated with lipoatrophy in the well-nourished (weight-for-height ≥1) children. CONCLUSIONS: Our findings demonstrate that LD is a significant problem among Tanzanian HIV-infected children receiving HAART. Anthropometric measurements predicted LD in well-nourished children but generally failed to do so in relatively wasted children. Our findings support current efforts to avoid stavudine use in children.

Predicting mortality for paediatric inpatients where malaria is uncommon.

OBJECTIVE: As the proportion of children living low malaria transmission areas in sub-Saharan Africa increases, approaches for identifying non-malarial severe illness need to be evaluated to improve child outcomes. DESIGN: As a prospective cohort study, we identified febrile paediatric inpatients, recorded data using Integrated Management of Childhood Illness (IMCI) criteria, and collected diagnostic specimens. SETTING: Tertiary referral centre, northern Tanzania. RESULTS: Of 466 participants with known outcome, median age was 1.4 years (range 2 months-13.0 years), 200 (42.9%) were female, 11 (2.4%) had malaria and 34 (7.3%) died. Inpatient death was associated with: Capillary refill >3 s (OR 9.0, 95% CI 3.0 to 26.7), inability to breastfeed or drink (OR 8.9, 95% CI 4.0 to 19.6), stiff neck (OR 7.0, 95% CI 2.8 to 17.6), lethargy (OR 5.2, 95% CI 2.5 to 10.6), skin pinch >2 s (OR 4.8, 95% CI 1.9 to 12.3), respiratory difficulty (OR 4.0, 95% CI 1.9 to 8.2), generalised lymphadenopathy (OR 3.6, 95% CI 1.6 to 8.3) and oral candidiasis (OR 3.4, 95% CI 1.4 to 8.3). BCS <5 (OR 27.2, p<0.001) and severe wasting (OR 6.9, p<0.001) were independently associated with inpatient death. CONCLUSIONS: In a low malaria transmission setting, IMCI criteria performed well for predicting inpatient death from non-malarial illness. Laboratory results were not as useful in predicting death, underscoring the importance of clinical examination in assessing prognosis. Healthcare workers should consider local malaria epidemiology as malaria over-diagnosis in children may delay potentially life-saving interventions in areas where malaria is uncommon.

Histoplasmosis among hospitalized febrile patients in northern Tanzania.

Histoplasmosis may be common in East Africa but the diagnosis is rarely confirmed. We report 9 (0.9%) cases of probable histoplasmosis retrospectively identified among 970 febrile inpatients studied in northern Tanzania. Median (range) age was 31 (6, 44) years, 6 (67%) were female, 6 (67%) HIV-infected; 7 (78%) were clinically diagnosed with tuberculosis or bacterial pneumonia. Histoplasmosis is an important cause of febrile illness in Tanzania but is rarely considered in the differential diagnosis. Increased clinician awareness and availability of reliable diagnostic tests may improve patient outcomes.

Invasive bacterial and fungal infections among hospitalized HIV-infected and HIV-uninfected children and infants in northern Tanzania.

OBJECTIVE: To describe the contribution of paediatric HIV and of HIV co-infections to admissions to a hospital in Moshi, Tanzania, using contemporary laboratory methods. METHODS: During 1 year, we enrolled consecutively admitted patients aged ≥2 months and <13 years with current or recent fever. All patients underwent standardized clinical history taking, a physical examination and HIV antibody testing; standard aerobic blood cultures and malaria film were also done, and hospital outcome was recorded. Early infant HIV diagnosis by HIV-1 RNA PCR was performed on those aged <18 months. HIV-infected patients also received serum cryptococcal antigen testing and had their CD4-positive T-lymphocyte count and percent determined. RESULTS: A total of 467 patients were enrolled whose median age was 2 years (range 2 months-13 years); Of those patients, 57.2% were female and 12.2% were HIV-infected. Admission clinical diagnosis of HIV disease was made in 10.7% and of malaria in 60.4%. Of blood cultures, 5.8% grew pathogens; of these 25.9% were Salmonella enterica (including 6 Salmonella Typhi) and 22.2%Streptococcus pneumoniae. Plasmodium falciparum was identified on blood film of 1.3%. HIV infection was associated with S. pneumoniae (odds ratio 25.7, 95% CI 2.8, 234.0) bloodstream infection (BSI), but there was no evidence of an association with Escherichia coli or P. falciparum; Salmonella Typhi BSI occurred only among HIV-uninfected participants. The sensitivity and specificity of an admission clinical diagnosis of malaria were 100% and 40.3%; and for an admission diagnosis of bloodstream infection, they were 9.1% and 86.4%, respectively. CONCLUSION: Streptococcus pneumoniae is a leading cause of bloodstream infection among paediatric admissions in Tanzania and is closely associated with HIV infection. Malaria was over-diagnosed clinically, whereas invasive bacterial disease was underestimated. HIV and HIV co-infections contribute to a substantial proportion of paediatric febrile admissions, underscoring the value of routine HIV testing.