Emergency and surgery services of primary hospitals in the United Republic of Tanzania.

OBJECTIVE: The primary objective was to evaluate the capacity of first-referral health facilities in Tanzania to perform basic surgical procedures. The intent was to assist in planning strategies for universal access to life-saving and disability-preventing surgical services. DESIGN: Cross-sectional survey. SETTING: First-referral health facilities in the United Republic of Tanzania. PARTICIPANTS: 48 health facilities. MEASURES: The WHO Tool for Situational Analysis to Assess Emergency and Essential Surgical Care was employed to capture a health facility's capacity to perform basic surgical (including obstetrics and trauma) and anaesthesia interventions by investigating four categories of data: infrastructure, human resources, interventions available and equipment. The tool queried the availability of eight types of care providers, 35 surgical interventions and 67 items of equipment. RESULTS: The 48 facilities surveyed served 18.6 million residents (46% of the population). Supplies for basic airway management were inconsistently available. Only 42% had consistent access to oxygen, and only six functioning pulse oximeters were located in all facilities surveyed. 37.5% of facilities reported both consistent running water and electricity. While very basic interventions (suturing, wound debridement, incision and drainage) were provided in nearly all facilities, more advanced life-saving procedures including chest tube thoracostomy (30/48), open fracture management (29/48) and caesarean section delivery (32/48) were not consistently available. CONCLUSIONS: Based on the results in this WHO country survey, significant gaps exist in the capacity for emergency and essential surgical services in Tanzania including deficits in human resources, essential equipment and infrastructure. The information in this survey will provide a foundation for evidence-based decisions in country-level policy regarding the allocation of resources and provision of emergency and essential surgical services.

Cryptosporidium, enterocytozoon, and cyclospora infections in pediatric and adult patients with diarrhea in Tanzania.

Cryptosporidiosis, microsporidiosis, and cyclosporiasis were studied in four groups of Tanzanian inpatients: adults with AIDS-associated diarrhea, children with chronic diarrhea (of whom 23 of 59 were positive [+] for human immunodeficiency virus [HIV]), children with acute diarrhea (of whom 15 of 55 were HIV+), and HIV control children without diarrhea. Cryptosporidium was identified in specimens from 6/86 adults, 5/59 children with chronic diarrhea (3/5, HIV+), 7/55 children with acute diarrhea (0/7, HIV+), and 0/20 control children. Among children with acute diarrhea, 7/7 with cryptosporidiosis were malnourished, compared with 10/48 without cryptosporidiosis (P < .01). Enterocytozoon was identified in specimens from 3/86 adults, 2/59 children with chronic diarrhea (1 HIV+), 0/55 children with acute diarrhea, and 4/20 control children. All four controls were underweight (P < .01). Cyclospora was identified in specimens from one adult and one child with acute diarrhea (HIV-). Thus, Cryptosporidium was the most frequent and Cyclospora the least frequent pathogen identified. Cryptosporidium and Enterocytozoon were associated with malnutrition. Asymptomatic fecal shedding of Enterocytozoon in otherwise healthy, HIV children has not been described previously.

Predictive markers of survival in HIV-seropositive and HIV-seronegative Tanzanian patients with extrapulmonary tuberculosis.

SETTING: Prediction of survival in Tanzanian patients with extrapulmonary tuberculosis (TB). OBJECTIVE: To evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary TB. DESIGN: Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral centre in Tanzania, were enrolled in the study. Their symptoms, signs and PPD skin test were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors. RESULTS: Of the 192 patients 126 (65%) were HIV-infected, and 29.7% had disseminated TB. Thirty-five patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102HHIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (P < 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio (HRR) 5.2, 95% Confidence Interval [CI] 1. 7-16.2), a decreased activity score (bedridden > 50%/day (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of < 1000/microL (HRR 4.4, 95% CI 1.7-11.8), and mycobacteraemia (HRR 4.0, 95% CI 1.2-13-.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54% and 0% for presence of 0, 1, 2, and > 2 risk factors respectively. CONCLUSION: Estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts.

PIP: This study sought to evaluate the prognostic value of clinical and laboratory parameters on survival in human immunodeficiency virus (HIV) seropositive and HIV seronegative patients with extrapulmonary tuberculosis (TB) from Tanzania. Over an 8-month period 192 consecutive patients with extrapulmonary TB, admitted to a major referral center in Tanzania, were enrolled in the study. Their symptoms, signs, and PPD skin test results were noted. Their sera were tested for HIV and analyzed for beta-2-microglobulin content. Univariate risk factors for 12 months' survival after the start of anti-TB chemotherapy were entered into a stepwise Cox regression model. Survival probabilities were estimated according to the number of risk factors. Of the 192 patients, 126 (65.6%) were HIV-infected, and 29.7% had disseminated TB. 35 patients, of whom 24 (68.6%) were HIV-positive, withdrew from the study immediately after hospital discharge. For survival analysis 157 patients remained. Within 12 months' follow-up after initiation of anti-TB therapy, the case fatality rate of the 102 HIV-infected patients was 22% and of the 55 HIV seronegative patients 2% (p 0.001). In the HIV seropositive patients the following independent risk factors were significantly associated with a decreased probability of survival: peripheral lymphadenopathy (Hazard Rate Ratio [HRR] 5.2, 95% confidence interval [CI] 1.7-16.2), a decreased activity score (bedridden 50%/day) (HRR 4.5, 95% CI 1.7-11.7), lymphopenia of 1000/mcl (HRR 4.4, 95% CI 1.7-11.8), and mycobacteremia (HRR 4.0, 95% CI 1.2-13.1). An anergic PPD skin test reaction proved to be another independent risk factor when the analysis was performed on 89 patients with available Mantoux test results. In the HIV seropositive patients, the 12 months' survival probabilities were 93%, 86%, 54%, and 0% for the presence of 0, 1, 2, and 2 risk factors respectively. The conclusion is that estimation of survival probabilities in patients with extrapulmonary TB may be possible without performing CD4 cell counts. (author's modified)

Humoral response to Mycobacterium tuberculosis-specific antigens in African tuberculosis patients with high prevalence of human immunodeficiency virus infection.

SETTING: The applicability of serodiagnosis of tuberculosis using Mycobacterium tuberculosis-complex-specific antigens in a Tanzanian population with high prevalence of HIV. OBJECTIVE: This study was performed to evaluate the usefulness, sensitivity and specificity of serology using M. tuberculosis-specific antigens in the diagnosis of tuberculosis in patients with and without HIV co-infection. DESIGN: Patients with proven pulmonary and extrapulmonary tuberculosis at a major referral centre in Tanzania were enrolled in the study. The control group consisted of patients without a history of previous tuberculosis admitted to the trauma ward and of healthy volunteers. Sera were analysed by an enzyme linked immunoassay (ELISA) using two M. tuberculosis specific proteins as antigen: the 38 kDa protein [3T] and a 17 kDa protein. In addition was recorded presence or absence of BCG scar and tuberculin sensitivity and the sera were tested for HIV and analysed for beta-2-microglobulin content. RESULT: Sensitivity and specificity were markedly reduced in tuberculosis patients with HIV co-infection compared to patients without this disease (73% and 70% versus 52% and 50% respectively). CONCLUSION: Serology for diagnosis of tuberculosis is not feasible in an HIV endemic region.

Long-term prognosis of well-differentiated adenocarcinoma in endoscopically removed colorectal adenomas.

Thirty-six malignant polyps were identified that met the following criteria: well-differentiated adenocarcinoma and complete excision endoscopically. Location, type, size, distance of the cancer to the cautery mark, and lymphovascular involvement were analyzed to determine if they affected findings at surgery or risk of recurrent cancer. There were 20 patients and 21 polyps in the nonsurgical group, and 15 patients and polyps in the surgical group. One patient from each group had residual cancer after endoscopic removal of the polyp. The only factor that had an adverse effect on outcome was the distance of the cancer to the cautery mark (< 1 mm). Although rectal location was associated with the residual cancer, poor prognosis could have been predicted by the inadequate margins. This long-term follow-up (65 months average) study supports previous observations that an adequate margin is the most important factor in predicting the prognosis of endoscopically resected colorectal adenomas containing well-differentiated adenocarcinomas.

Diagnosis of tuberculous lymphadenitis in an area of HIV infection and limited diagnostic facilities.

In order to evaluate procedures leading to the diagnosis of tuberculous lymphadenitis, a prospective clinical study was carried out of patients with lymphadenopathy admitted to the medical wards of a referral hospital in Tanzania. The yield of diagnostic procedures (direct auramine/Ziehl-Neelsen (ZN) stained smears, Löwenstein-Jensen (LJ) cultures, cytology and histological examinations of fine needle aspirations (FNA) and biopsy material of lymph nodes, respectively, was compared. We also tried to identify clinical diagnostic markers. One hundred and twenty-eight (99 HIV-seropositive) patients were included. In 89 (67 HIV-positive) patients TB lymphadenitis could be proven. Histology and LJ culture of a lymph node biopsy had the highest diagnostic yield, 85% and 88% respectively, followed by detection of acid-fast bacilli (AFB) in biopsy smear (53%) and in fine-needle aspirations (35%). The diagnostic yield of the several procedures was not affected by associated HIV infection. Macroscopic caseation was 100% predictive for TB with a sensitivity of 69%. Firm and matted lymph nodes, ESR > 100 mm/hr, a positive PPD skin test and pleural opacity on a chest x-ray proved to be independent predictors for TB. Retrospective testing of a stepwise diagnostic approach based on direct smears of FNA, macroscopic visible caseation and direct smear of biopsy tissue, suggests that in 93% of the patients a definite diagnosis of TB lymphadenitis could have been made. Our data suggest that in HIV/TB epidemic areas most of the cases of TB lymphadenitis can be diagnosed correctly by simple and cheap methods which are generally available at district hospitals. Our findings need further prospective validation, however.

PIP: In order to evaluate procedures leading to the diagnosis of tuberculous lymphadenitis, a prospective clinical study was carried out on patients with lymphadenopathy admitted to four medical wards of the Muhibili Medical Center, Dar es Salaam, Tanzania, from January to August 1991. The yield of diagnostic procedures (direct auramine/Ziehl-Neelsen stained smears, Lowenstein-Jensen [LJ] cultures, cytology and histological examinations of fine needle aspirations [FNA], and biopsy material of lymph nodes) was compared. Clinical diagnostic markers were also identified. 128 (99 HIV-seropositive) patients with a mean age of 30 years were included. 41% were male. In 89 (67 HIV-positive) patients, TB lymphadenitis could be demonstrated. 46 (30 HIV-positive) had TB lymphadenitis only and 43 (37 HIV-positive) had disseminated TB. In 10 patients TB was found in specimens other than the lymph node, making the total of TB patients 99. Histology and LJ culture of lymph node biopsy had the highest diagnostic yield, 85% and 88%, respectively, followed by detection of acid-fast bacilli in biopsy smears (53%) and in FNAs (35%). The diagnostic yield of the procedures was not affected by associated HIV infection. Macroscopic caseation was 100% predictive of TB with a sensitivity of 69%. Multivariate logistic regression analysis demonstrated four independent predictors of TB: 1) firm and matted lymph nodes (odds ratio [OR] 11.8); 2) erythrocyte sedimentation rate (ESR) 100 mm/hr (OR 4.6); 3) a positive purified protein derivative (PPD) skin test (OR 10.2); and 4) pleural opacity on a chest X-ray (OR 9.5). Retrospective testing of a stepwise diagnostic approach based on direct smears of FNA, macroscopic visible caseation, and direct smears of biopsy tissue suggests that in 93% of the patients a definite diagnosis of TB lymphadenitis could have been made. These data suggest that in HIV/TB epidemic areas most of the cases of TB lymphadenitis can be diagnosed correctly by simple and cheap methods which are generally available at district hospitals.

Diagnosis of tuberculosis in patients with pleural effusion in an area of HIV infection and limited diagnostic facilities.

In a prospective study of 118 patients with pleural effusion, tuberculosis (TB) was diagnosed in 112. In 84 patients the diagnosis of TB was made by detection of acid-fast bacilli by stain (auramine, Ziehl-Neelsen) or by culture of mycobacteria (Löwenstein-Jensen medium) in pleural fluid or pleural tissue (obtained by closed biopsy) or by the presence of caseating granulomas in histological sections. In 28 patients the diagnosis of TB was considered probable, based on good response to anti-tuberculous therapy. The highest diagnostic yield was obtained by histology (85%), followed by culture of pleural biopsy (37%) and pleural fluid culture (36%). Pulmonary tuberculosis was found in 8 patients and dissemination of TB to other sites in 25 patients of whom 20 were HIV positive. By logistic regression analysis we identified 2 independent diagnostic markers for TB pleuritis: pleural fluid protein > 50 g/l (Odds ratio 12.1, 95% confidence interval (CI): 1.1-128.3) and adenosine deaminase of > 10 U/l (Odds ratio 11.08, 95% CI: 1.3-96.4). We conclude that conventional facilities of a referral hospital are sufficient to diagnose tuberculous pleuritis as well as disseminated tuberculosis irrespective of HIV infection. However, for regions with overstretched health services and high prevalences of tuberculous pleurisy in patients with pleural effusion we suggest a simplified diagnostic approach based on exclusion of other causes of pleural effusion by simple means and use of these diagnostic markers.

PIP: In a prospective study of 118 patients with pleural effusion admitted to four medical wards in Muhimbili Medical Center between January and August 1991, Dar es Salaam, Tanzania, tuberculosis (TB) was diagnosed in 112. In 84 patients the diagnosis of TB was made by detection of acid-fast bacilli by stain (auramine, Ziehl-Neelsen) or by culture of mycobacteria (Lowenstein-Jensen medium) in pleural fluid or pleural tissue obtained by closed biopsy or by the presence of caseating granulomas in histological sections. In 28 patients the diagnosis of TB was considered probable, based on good response to anti-tuberculous therapy. In the remaining 6 non-TB patients adenocarcinoma (1), bacterial infection (2), and aspecific inflammation (3) were diagnosed. 58% of the TB and 3 of the non-TB patients were infected with HIV. The diagnostic procedures were evaluated in 75 patients. The highest diagnostic yield was obtained by histology (85%), followed by culture of pleural biopsy (37%), and pleural fluid culture (36%). Pulmonary tuberculosis was found in 8 (4 HIV-positive) patients and dissemination of TB to other sites in 25 patients, of whom 20 were HIV-positive. By logistic regression analysis, two independent diagnostic markers for TB pleuritis were identified: pleural fluid protein 50 g/l (odds ratio [OR] 12.1) and pleural fluid adenosine deaminase level of 10 U/l (OR 11.08). The sensitivity of these two diagnostic tests was 82% and 97.3%, and the specificity was 83.6% and 50%, respectively. TB was the underlying cause in nearly all patients who presented with pleural effusion (94.9%). TB was confirmed in 75% of these using the referral hospital. Conventional facilities of a referral hospital are sufficient to diagnose tuberculous pleuritis as well as disseminated tuberculosis irrespective of HIV infection. However, in regions with overburdened health facilities and high prevalence of tuberculous pleurisy in patients with pleural effusion, a simplified diagnostic approach is suggested based on exclusion of other causes of pleural effusion by simple use of these diagnostic markers.

Severe cutaneous hypersensitivity reactions during treatment of tuberculosis in patients with HIV infection in Tanzania.

Concurrent infection with HIV-1 and Mycobacterium tuberculosis is increasingly common in East Africa. In the past, a drug regimen consisting of 2 months of intramuscular streptomycin plus 12 months of isoniazid and thiacetazone has been used in tuberculosis control programs with acceptable efficacy and low incidence of adverse reactions. Anecdotal reports of increasing cases of Stevens-Johnson syndrome prompted a 2 month prospective search for cases of severe cutaneous hypersensitivity reactions at Muhimbili Medical Centre in Dar es Salaam, Tanzania. Five such patients were admitted to a single ward during this time, 4 of whom were HIV-seropositive and all of whom were being treated with isoniazid and thiacetazone. These findings have implications for the management of tuberculosis in East Africa and perhaps other countries with high prevalence of both HIV-1 and tuberculosis.

PIP: Concurrent infection with HIV-1 and Mycobacterium tuberculosis (TB) is increasingly common in East Africa. In HIV-infected individuals, pulmonary TB tends to occur before the onset of opportunistic infections. A common treatment regimen in developing countries is two months of intramuscular streptomycin combined with twelve months of isoniazid and thiacetazone. TB control programs have found this approach to be of acceptable efficacy with a low incidence of adverse reactions. Anecdotal reports of increasing cases of Stevens-Johnson syndrome, however, prompted a two-month prospective search for cases of severe cutaneous hypersensitivity reactions at Muhimbili Medical Center in Dar es Salaam, Tanzania. Five such patients were admitted to an hospital ward over the two-month period, four of whom were HIV-seropositive and all of whom were being treated with isoniazid and thiacetazone. Two were also receiving streptomycin. Four had extensive mucosal involvement of the eyelids, lips, and mouth, consistent with Stevens-Johnson syndrome. The remaining patient had bullous skin lesions, without mucosal involvement, consistent with an exfoliative dermatitis. On admission, medications were discontinued and patients underwent routine management, including the administration of steroids. Four patients were discharged from the hospital 3-7 weeks after admission with improved conditions. One patient died suddenly after five weeks of hospitalization due to unknown causes. These patients give extra support to observations that thiacetazone is associated with the increased incidence of severe cutaneous hypersensitivity syndrome in people infected with HIV-1. Further studies are needed to quantify the excess morbidity and mortality resulting from this treatment regimen.

Diagnostic yield of endoscopy in upper gastrointestinal bleeding.

On a total of 934 fibreoptic oesophagogastroduodenoscopies, performed between September, 1978 and September 1981, 122 patients presented with symptoms of upper gastrointestinal bleeding of less than two weeks duration. The most frequent findings were peptic ulcer (40.9%), oesophageal varices (16.4%) and mucosal lesions (7.4% as an isolated finding and a further 16.4% associated with peptic ulcer or varices). Negative endoscopies comprised 24.6% of all 122 patients, but in 19 in whom the bleeding episode preceded the endoscopy by not more than 48 hours, there were none. In 105 patients whose history of haematemesis and/or melaena was not recent, endoscopy was negative in 30%, but in patients without such history in 50%. Haematemesis and melaena are important symptoms and add weight to the indication for endoscopy. The earlier the endoscopy can be done, the greater is the diagnostic yield.

Oesophageal malignancies in Dar es Salaam.

The clinical, radiological, endoscopic and histological aspects of 46 oesophageal cancers seen over a period of three years are analysed. A history of dysphagia was obtained in 93% of the cases while 87% of them had evident weight loss of varying degrees, making the two the most consistent clinical features; 24% of patients had pulmonary complications. The lower third of the oesophagus was the commonest location of tumours, accounting for 63% of the cases, while 61% of all cancers were of the squamous cell histological variety. Six biopsy specimens yielded negative histology, although the endoscopic visualization and radiological features were consistent with malignant growths.