Early surgical outcome for Tetralogy Of Fallot In An African Setting; A Tanzanian experience using retrospective analysis of hospital data.

BACKGROUND: Tetralogy of Fallot (TOF) is typically treated in infancy but often done late in many resource-limited countries, jeopardizing surgical outcomes. This study examined the early results of children undergoing primary complete TOF repair at the Jakaya Kikwete Cardiac Institute (JKCI) in Tanzania, an emerging cardiac center in Eastern Africa. METHODS: A retrospective cohort study of children ≤ 18 years undergoing primary TOF complete repair between 2019 and 2021 was conducted. Patients with complex TOF and those with obvious genetic syndrome were excluded. Data on socio-demography, pre-and postoperative cardiac complications, Intensive Care Unit (ICU) and hospital stay, and in-hospital and 30-day mortality were analyzed. Logistic regressions were employed to find the factors for mortality, ICU, and hospital stays. RESULTS: The I02 children underwent primary TOF complete repair were majority male (65.7%; n = 67), with a median age of 3.0 years (IQR: 2-6), ranging from 3 months to 17 years.Only 20 patients (19.6%) were below one year of age. Almost all (90%; n = 92) were underweight, with a mean BMI of 14.6 + 3.1 kg/m2 Haematocrits were high, with a median of 48.7 (IQR: 37.4-59.0). The median oxygen saturation was 81% (IQR:72-93). Over a third of patients (38.2%; n = 39) needed Trans annular patch (TAP) during surgery. The median ICU stay was 72 h (IQR:48-120), with ICU duration exceeding three days for most patients. The median hospital stay was 8.5 days (IQR:7-11), with 70 patients (68.2%)experiencing an extended hospital stay of > 7 days. Bacterial sepsis was more common than surgical site infection (5.6%; n = 6 vs. 0.9%;n = 1). No patient needed re-operation for the period of follow up. The in-hospital mortality rate was 5.9%, with no deaths occurring in children less than one year of age nor after discharge during the 30-day follow-up period. No statistically significant differences were observed in outcomes in relation to age, sex, levels of hematocrit and saturations, presence of medical illnesses, and placement of TAP. CONCLUSION: TOF repairs in this African setting at a national cardiac referral hospital face challenges associated with patients' older age and compromised nutritional status during the surgery. Perioperative mortality rates and morbidity for patients operated at an older age remain elevated. It's important to address these issues to improve outcomes in these settings.

Adapting and usability testing of the Kansas city cardiomyopathy questionnaire (KCCQ) in a heart failure clinic in Tanzania: the Swahili KCCQ.

BACKGROUND: The integration of patient-reported outcome measures (PROMS) into health care delivery systems is being increasingly recognized as an important component of quality, person-centered care, especially for chronic illnesses like congestive heart failure (CHF). However, while PROMS are increasingly being used to follow up CHF patients in high income countries, their use in sub-Saharan Africa is still limited. We adapted the Kansas City Cardiomyopathy Questionnaire (KCCQ-23), an internationally validated, CHF-specific PROM and tested its use in measuring outcomes in an outpatient CHF clinic at a cardiac referral hospital in Tanzania. METHODS: Adaptation of the KCCQ-23 included translation into Swahili by linguistic experts, in-depth cognitive debriefing in native Swahili-speaking CHF patients, and input from Tanzanian Cardiologists, PROMS experts, and the tool developer. Using a cross-sectional design, we tested the usability and observed the results of the translated KCCQ-23 in a convenience sample of 60 CHF patients attending outpatient clinic at the Jakaya Kikwete Cardiac Institute (JKCI) in Dar es Salaam. RESULTS: The survey was successfully completed by 59 (98.3%) of 60 enrolled participants. The mean (SD) age of participants was 54.9 (14.8) years (range 22-83), 30.5% were women and 72.2% had class 3 or 4 New York Heart Association (NYHA) symptoms at enrollment. The overall KCCQ-23 score was low, with a mean (SD) score of 21.7 (20.4) indicating generally very poor to poor patient reported outcomes in this population. The mean (SD) scores for the specific KCCQ-23 domains were 15.25 (24.2) for social limitation, 23.8 (27.4) for physical limitation, 27.1 (24.1) for quality of life and 40.7 (17.0) for self-efficacy. No socio-demographic or clinical characteristics were associated with their overall KCCQ-23 scores. Comparing the short version (KCCQ-12) with the full KCCQ-23 revealed excellent correlation between the two (r = 0.95; p < 0.0001). CONCLUSIONS: We successfully translated a validated tool, the Swahili KCCQ, for use in improving the care of patients with CHF in Tanzania and a broader population of Swahili-speaking patients. Both the Swahili KCCQ-12 and KCCQ-23 can be used, with similar outcomes. Work to expand the use of the tool in the clinic and other settings is planned.

Burden and correlates of cognitive impairment among hypertensive patients in Tanzania: a cross-sectional study.

BACKGROUND: The evolution of cognitive impairment of vascular origin is increasingly becoming a prominent health threat particularly in this era where hypertension is the leading contributor of global disease burden and overall health loss. Hypertension is associated with the alteration of the cerebral microcirculation coupled by unfavorable vascular remodeling with consequential slowing of mental processing speed, reduced abstract reasoning, loss of linguistic abilities, and attention and memory deficits. Owing to the rapidly rising burden of hypertension in Tanzania, we sought to assess the prevalence and correlates of cognitive impairment among hypertensive patients attending a tertiary cardiovascular hospital in Tanzania. METHODOLOGY: A hospital-based cross-sectional study was conducted at Jakaya Kikwete Cardiac Institute, a tertiary care public teaching hospital in Dar es Salaam, Tanzania between March 2020 and February 2021. A consecutive sampling method was utilized to recruit consented hypertensive outpatients during their scheduled clinic visit. General Practitioner Assessment of Cognition (GPCOG) Score was utilized in the assessment of cognitive functions. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with cognitive impairment. Odd ratios with 95% confidence intervals and p-values are reported. All tests were 2-sided and p < 0.05 was used to denote a statistical significance. RESULTS: A total of 1201 hypertensive patients were enrolled in this study. The mean age was 58.1 years and females constituted nearly two-thirds of the study population. About three quarters had excess body weight, 16.6% had diabetes, 7.7% had history of stroke, 5.7% had heart failure, 16.7% had renal dysfunction, 53.7% had anemia, 27.7% had hypertriglyceridemia, 38.5% had elevated LDL, and 2.4% were HIV-infected. Nearly two-thirds of participants had uncontrolled blood pressure and 8.7% had orthostatic hypotension. Overall, 524 (43.6%) of participants had cognitive impairment. During bivariate analysis in a logistic regression model of 16 characteristics, 14 parameters showed association with cognitive functions. However, after controlling for confounders, multivariate analysis revealed ≤primary education (OR 3.5, 95%CI 2.4-5.2, p < 0.001), unemployed state (OR 1.7, 95%CI 1.2-2.6, p < 0.01), rural habitation (OR 1.8, 95%CI 1.1-2.9, p = 0.01) and renal dysfunction (OR 1.7, 95%CI 1.0-2.7, p = 0.04) to have independent association with cognitive impairment. CONCLUSION: This present study underscore that cognitive decline is considerably prevalent among individuals with systemic hypertension. In view of this, it is pivotal to incorporate cognitive assessment in routine evaluation of hypertensive patients.

Prevalence and risk factors for Subclinical Rheumatic Heart Disease among primary school children in Dar es Salaam, Tanzania: a community based cross-sectional study.

BACKGROUND: Rheumatic heart disease (RHD) is the most common acquired heart disease occurring in children and adolescents. RHD is associated with significant morbidity and mortality particularly in low and middle- income countries (LMICs) where the burden is estimated to be higher compared to high income countries. Subclinical RHD is the presence of valvular lesion diagnosed by echocardiography in a person with no clinical manifestation of RHD. This study aimed at determining the prevalence, types and factors associated with subclinical RHD among primary school children in Dar Es Salaam, Tanzania. METHODS: A descriptive community-based cross-sectional study was conducted in primary school children from February to May 2019. A standardized structured questionnaire was used to collect demographic characteristics, history of upper respiratory tract infections (URTIs), anthropometric measurements, and chest auscultation findings. Moreover echocardiographic screening was done to all children recruited into the study. World Heart Federation echocardiographic classification was used to define the types and prevalence of subclinical RHD. RESULTS: A total of 949 primary school children were enrolled with females being predominant (57.1%). The prevalence of subclinical RHD was 34 per 1000. All the participants had mitral valve disease only whereby 17 had definite disease and 15 had a borderline disease. The associated factors for subclinical RHD were older age of more than 9 years (OR 10.8, 95% CI 1.4-82.2, P = 0.02) having three or more episodes of URTI in previous six months (OR 21, 95% CI 9.6-46, P = 0.00) and poor hygiene (OR 3, 95% CI 1.3-6.8, P = 0.009). CONCLUSION: Subclinical RHD as detected by echocardiographic screening is prevalent in primary school children, uniformly affects the mitral valve, and is associated with potentially modifiable risk factors. Children with a history of more than three episodes of URTI in six months represents a high-risk population that should be targeted for RHD screening.

Feasibility of point-of-care cardiac ultrasound performed by clinicians at health centers in Tanzania.

BACKGROUND: Point-of-care cardiac ultrasound (cardiac POCUS) has potential to become a useful tool for improving cardiovascular care in Tanzania. We conducted a pilot program to train clinicians at peripheral health centers to obtain and interpret focused cardiac POCUS examinations using a hand-held portable device. METHODS: Over a 5-day period, didactic and experiential methods were used to train clinicians to conduct a pre-specified scanning protocol and recognize key pathologies. Pre- and post-training knowledge and post-training image acquisition competency were assessed. In their usual clinical practices, trainees then scanned patients with cardiovascular signs/symptoms, recorded a pre-specified set of images for each scan, and documented their interpretation as to presence or absence of key pathologies on a case report form. A cardiologist subsequently reviewed all images, graded them for image quality, and then documented their interpretation of key pathologies in a blinded fashion; the cardiologist interpretation was considered the gold standard. RESULTS: 8 trainees (6 Clinical Officers, 1 Assistant Medical Officer, and 1 Medical Doctor) initiated and completed the training. Trainees subsequently performed a total of 429 cardiac POCUS examinations in their clinical practices over a 9 week period. Stratified by trainee, the median percent of images that were of sufficient quality to be interpretable was 76.7% (range 18.0-94.2%). For five of eight trainees, 75% or more of images were interpretable. For detection of pre-specified key pathologies, kappa statistics for agreement between trainee and cardiologist ranged from - 0.03 (no agreement) for detection of pericardial effusion to 0.42 (moderate agreement) for detection of tricuspid valve regurgitation. Mean kappa values across the key pathologies varied by trainee from 0 (no agreement) to 0.32 (fair agreement). CONCLUSIONS: The 5-day training program was sufficient to train most clinicians to obtain basic cardiac images but not to accurately interpret them. Proficiency in image interpretation may require a more intensive training program.

Obesity epidemic in urban Tanzania: a public health calamity in an already overwhelmed and fragmented health system.

BACKGROUND: Worldwide, the epidemiological and demographic transitions have resulted in nutrition shift characterized by an increased consumption of high energy fast food products. In just over 3 decades, overweight and obesity rates have nearly tripled to currently affecting over a third of the global population. Notwithstanding the ever present under-nutrition burden, sub Saharan Africa (SSA) is witnessing a drastic escalation of overweight and obesity. We aimed to explore the prevalence and associated factors for obesity among residents of Dar es Salaam city in Tanzania. METHODS: Participants from this study were recruited in a community screening conducted during the Dar es Salaam International Trade Fair. Sociodemographic and clinical data were gathered using a structured questionnaire during enrollment. Dietary habits and anthropometric measurements were assessed using standard methods. All statistical analyses utilized STATA v11.0 software. Pearson Chi square and Student's T-test were used to compare categorical and continuous variables respectively. Logistic regression analyses were used to assess for factors associated with BMI ≥ 25. All tests were 2-sided and p < 0.05 was used to denote a statistical significance. RESULTS: A total of 6691 participants were enrolled. The mean age was 43.1 years and males constituted 54.2% of all participants. Over two-thirds of participants were alcohol consumers and 6.9% had a positive smoking history. 88.3% of participants were physically inactive, 4.7% had a history of diabetes mellitus and 18.1% were known to have elevated blood pressure. Overweight and obesity were observed in 34.8 and 32.4% of participants respectively. Among overweight and obese participants, 32.8% had a misperception of having a healthy weight. Age ≥ 40, female gender, a current working status, habitual breakfast skipping, poor water intake, high soft drink consumption, regular fast food intake, low vegetable and fruit consumption, alcohol consumption and hypertension were found to be independent associated factors for obesity. CONCLUSION: Amidst the ever present undernutrition in SSA, a significant proportion of participants had excess body weight. Concomitantly, the rates of physical inactivity and unhealthy eating are disproportionately high in Dar es Salaam. In view of this, community-based and multilevel public health strategies to promote and maintain healthy eating and physical activity require an urgent step-up in urban Tanzania.

Burden and correlates of atrial fibrillation among hypertensive patients attending a tertiary hospital in Tanzania.

BACKGROUND: Atrial fibrillation (AF) is the most common supra ventricular cardiac arrhythmia, which presents with variety of clinical symptoms. Hypertension increases risk of developing Atrial fibrillation by 1.5 fold. Together Atrial fibrillation and hypertension doubles the risk of morbidity and mortality. We aimed to determine the prevalence of AF and describe associated factors among hypertensive patients attending tertiary hospital in Tanzania. METHODS: A cross-sectional hospital-based study, involving 391 hypertensive patients visiting the Jakaya Kikwete Cardiac Institute was conducted between October to December 2017. Categorical variables were analyzed using chi square while student t- test was used to analyze continuous variables. Multivariate logistic regression analysis was performed to determine factors associated with AF. All analysis was two sided and p- value of < 0.05 was used to be not significant. RESULTS: AF was detected in 40 (10.2%) patients. Atrial fibrillation was associated with BMI ≥ 25 (OR 4.4, 95% CI 1.1-7.7, p-value 0.02), ejection fraction < 50% (OR 3.0, 95%CI 1.1-8.2, p-value 0.03), Left Atrial diameter > 40 mm (OR 9.4,95%CI 2.1-43.2, p-value < 0.01) and eGFR< 60 (OR 2.9, 95%CI 1.1-7.8, p-value 0.04). CONCLUSION: Atrial fibrillation is considerably prevalent among the hypertensive sub-population. Prompt diagnosis and timely management is vital to prevent complications and premature mortality.

Knowledge of cardiovascular risk factors among caretakers of outpatients attending a tertiary cardiovascular center in Tanzania: a cross-sectional survey.

BACKGROUND: Health literacy on cardiovascular diseases (CVDs) plays an effective role in preventing or delaying the disease onset as well as in impacting the efficacy of their management. In view of the projected low health literacy in Tanzania, we conducted this cross-sectional survey to assess for CVD risk knowledge and its associated factors among patient escorts. METHODS: A total of 1063 caretakers were consecutively enrolled in this cross-sectional study. An adopted questionnaire consisting of 22 statements assessing various CVD risk behaviors was utilized for assessment of knowledge. Logistic regression analyses were performed to assess for factors associated with poor knowledge of CVD risks. RESULTS: The mean age was 40.5 years and women predominated (55.7%). Over two-thirds had a body mass index (BMI) ≥25 kg/m2, 18.5% were alcohol drinkers, 3.2% were current smokers, and 47% were physically inactive. The mean score was 78.2 and 80.0% had good knowledge of CVD risks. About 16.3% believed CVDs are diseases of affluence, 17.4% thought CVDs are not preventable, and 56.7% had a perception that CVDs are curable. Low education (OR 2.6, 95%CI 1.9-3.7, p < 0.001), lack of health insurance (OR 1.5, 95%CI 1.1-2.3, p = 0.03), and negative family history of CVD death (OR 2.2, 95%CI 1.4-3.5, p < 0.001), were independently associated with poor CVD knowledge. CONCLUSIONS: In conclusion, despite of a good level of CVD knowledge established in this study, a disparity between individual's knowledge and self-care practices is apparent.

Cardiorenal Anemia Syndrome and Survival among Heart Failure Patients in Tanzania: A Prospective Cohort Study.

BACKGROUND: Cardiorenal anemia syndrome (CRAS) is an evolving global epidemic associated with increased morbimortality and cost of care. The management of patients with CRAS remains a challenging undertaking worldwide and the lack of evidence-based clinical guidelines adds to the challenge. We aimed to explore the prevalence and survival rates of heart failure patients with CRAS in Tanzania. METHODS: We screened 789 patients and consecutively recruited 463 who met the inclusion criteria. Each participant underwent an interview, physical examination, anthropometric measurements, anemia, renal functions and echocardiographic assessment. All participants were followed until death or for up-to 180 days, whichever came first. Bivariate comparison and subsequent Cox proportional-hazards regression model were used to compare the CRAS and non-CRAS groups with respect to the primary end point. RESULTS: The mean age of participants was 46.4 ± 18.9 years, and 56.5% were women. Overall, 51.9% of participants had renal insufficiency, 72.8% were anemic and 44.4% had CRAS. During a mean follow-up of 103 ± 75 days, 57.8% of participants died. Patients with CRAS displayed a higher mortality rate (73.5%) compared to those free of CRAS (45.8%), (p < 0.001). During multivariate analysis in a cox regression model of 21 potential predictors of mortality; renal dysfunction (HR 1.9; 95% CI 1.0-3.5; p = 0.03), severe anemia (HR 1.8; 95% CI 1.0-3.1; p = 0.04), hyponatremia (HR 2.2; 95% CI 1.3-3.7; p = 0.004) and rehospitalization (HR 4.3; 95% CI 2.2-8.4; p < 0.001) proved to be the strongest factors. CONCLUSION: Cardiorenal anemia syndrome is considerably prevalent and is associated with an increase in mortality amongst patients with heart failure. In view of this, timely, aggressive and collaborative measures to improve renal functions and/or correct anemia are crucial in the management of CRAS patients. Furthermore, these findings call for guideline committees to revise and/or develop evidence-based recommendations for management of patients with CRAS.

A community-based study on prevalence and correlates of erectile dysfunction among Kinondoni District Residents, Dar Es Salaam, Tanzania.

BACKGROUND: Globally, erectile dysfunction burden (ED) is rising appreciably and it is projected to affect about 332 million men by the year 2025. This rise is attributable to the rising incidence of conditions associated with ED including obesity, diabetes, hypertension, coronary artery disease and depression. We conducted this community-based screening to elucidate on the prevalence of ED and its associated factors among men residing in an urban community in Tanzania. METHODS: We conducted a cross-sectional community-based study and interviewed 441 men aged at least 18 years. Diabetes and hypertension were defined as per the International Diabetes Federation (IDF) and the 7th Report of the Joint National Committee (JNC 7) respectively. The 5-item version of the International Index of Erectile Function (IIEF-5) Scale was used to assess for erectile dysfunction. Multivariate logistic regression analyses were performed to explore the factors associated with ED. RESULTS: The mean age was 47.1 years, 57.6 % had excess body weight, 8.2 % had diabetes and 61.5 % had high blood pressure. Overall, 24 % (106/441) of men in this study had some form of ED. Participants with age ≥55, positive smoking history, obesity, diabetes and hypertension displayed highest rates of ED in their respective subgroups. However, age ≥40 and diabetes were ultimately the strongest factors for ED after multivariate logistic regression analyses, (OR 5.0, 95 % CI 2.2-11.2, p < 0.001 and OR 5.3, 95 % CI 2.2-12.7, p < 0.001 respectively). CONCLUSION: Erectile dysfunction affects about a quarter of adult men living in Kinondoni district. Old age, obesity, smoking, hypertension and diabetes have the potential to increase the odds of ED up-to 5 times. In view of this, men with diabetes and hypertension should be offered screening services and treatment of ED as an integral component in their management.

Spectrum of Heart Diseases in Children in a National Cardiac Referral Center Tanzania, Eastern Africa: A Six-Year Overview.

Background: While communicable diseases have long been the primary focus of healthcare in Africa, the rising impact of paediatric and congenital heart disease (CHD) cannot be overlooked. This research aimed to estimate the frequency and pattern of heart diseases in children who underwent their first echocardiography at a national cardiac referral hospital in Tanzania. Methods: A retrospective observational study was conducted on children aged 0 to 18 years referred for first-time cardiological evaluation from January 2017 to December 2022. Retrieval of social and echocardiogram data and descriptive analysis were performed. Results: There were 6,058 children with complete reports. Of these, 52.8% (3,198) had heart disease, of whom 2,559 (80%) had CHD, while (340/639; 53.2%) with acquired heart disease (AHD) had rheumatic heart disease (RHD). Children with CHD had a median age 1.0 years (IQR: 0.3-3.5) and were predominantly 51.2% male. Children with RHD had a median age 9.7 years (IQR: 3.2-13.8) with equal gender distribution. Shunt lesions were common in 1,487 (58.1%), mainly VSD 19.3%, PDA 19.1%, ASD 15.1%, and atrioventricular septal defect (AVSD) 4.6%. Pulmonary valve stenosis was in 97 (3.8%). Around 35% (718) had cyanotic CHD, with TOF being most common (13.3%), followed by double outlet right ventricle (DORV) (3.6%). Compared to global average truncus arteriosus was higher in 69 (2.3%) children. In contrast, TGA and hypoplastic left heart syndrome (HLHS) were lower than the estimated global average seen in 2.3% and 0.5% of the cases, respectively. Atresia of the right-side valves was more common (174 vs. 24), and approximately 40% of the patients referred for first-time echocardiographic evaluation required hospitalization. Conclusion: Congenital heart disease is the primary cause of heart disease in children presenting at a national referral hospital, surpassing RHD. With its distinct distribution pattern, acyanotic lesions are more frequent than cyanotic heart diseases. The observed late referral tendencies suggest improving the referral system, enhancing CHD awareness among healthcare professionals, and instituting nationwide screening programs.

Declining HIV-1 prevalence and incidence among Police Officers - a potential cohort for HIV vaccine trials, in Dar es Salaam, Tanzania.

BACKGROUND: A safe effective and affordable HIV vaccine is the most cost effective way to prevent HIV infection worldwide. Current studies of HIV prevalence and incidence are needed to determine potentially suitable cohorts for vaccine studies. The prevalence and incidence of HIV-1 infection among the police in Dar es Salaam in 1996 were 13.8% and 19.6/1000 PYAR respectively. This study aimed at determining the current prevalence and incidence of HIV in a police cohort 10 years after a similar study was conducted. METHODS: Police officers in Dar es Salaam, Tanzania were prospectively enrolled into the study from 2005 and followed-up in an incidence study three years later. HIV infection was determined by two sequential enzyme linked immunosorbent assays (ELISAs) in the prevalence study and discordant results between two ELISAs were resolved by a Western blot assay. Rapid HIV assays (SD Bioline and Determine) were used for the incidence study. RESULTS: A total of 1,240 police participated in the HIV prevalence study from August 2005 to November 2008. Of these, 1101 joined the study from August 2005-September 2007 and an additional 139 were recruited between October 2007 to November 2008 while conducting the incidence study. A total of 726 (70%) out of the 1043 eligible police participated in the incidence study.The overall HIV-1 prevalence was 65/1240 (5.2%). Females had a non-statistically significant higher prevalence of HIV infection compared to males 19/253, (7.5%) vs. 46/987 (4.7%) respectively (p=0.07). The overall incidence of HIV-1 was 8.4 per 1000 PYAR (95% CI 4.68-14.03), and by gender was 8.8 and 6.9 per 1000 PYAR, among males and females respectively, (p=0.82). CONCLUSIONS: The HIV prevalence and incidence among the studied police has declined over the past 10 years, and therefore this cohort is better suited for phase I/II HIV vaccine studies than for efficacy trials.

Experiences on recruitment and retention of volunteers in the first HIV vaccine trial in Dar es Salam, Tanzania - the phase I/II HIVIS 03 trial.

BACKGROUND: Eventual control of HIV/AIDS is believed to be ultimately dependent on a safe, effective and affordable vaccine. Participation of sub-Saharan Africa in the conduct of HIV trials is crucial as this region still experiences high HIV incidences. We describe the experience of recruiting and retaining volunteers in the first HIV vaccine trial (HIVIS03) in Tanzania. METHODS: In this trial enrolled volunteers from amongst Police Officers (POs) in Dar es Salaam were primed with HIV-1 DNA vaccine at months 0, 1 and 3; and boosted with HIV-1 MVA vaccine at months 9 and 21. A stepwise education provision/sensitization approach was employed to eventual recruitment. Having identified a "core" group of POs keen on HIV prevention activities, those interested to participate in the vaccine trial were invited for a first screening session that comprised of provision of detailed study information and medical evaluation. In the second screening session results of the initial assessment were provided and those eligible were assessed for willingness to participate (WTP). Those willing were consented and eventually randomized into the trial having met the eligibility criteria. Voluntary participation was emphasized throughout. RESULTS: Out of 408 POs who formed the core group, 364 (89.0%) attended the educational sessions. 263 out of 364 (72.2%) indicated willingness to participate in the HIV vaccine trial. 98% of those indicating WTP attended the pre-screening workshops. 220 (85.0%) indicated willingness to undergo first screening and 177 POs attended for initial screenings, of whom 162 (91.5%) underwent both clinical and laboratory screenings. 119 volunteers (73.5%) were eligible for the study. 79 were randomized into the trial, while 19 did not turn up, the major reason being partner/family advice. 60 volunteers including 15 females were recruited during a one-year period. All participated in the planned progress updates workshops. Retention into the schedule was: 98% for the 3 DNA/placebo vaccinations, while it was 83% and 73% for the first and second MVA/placebo vaccinations respectively. CONCLUSION: In this first HIV vaccine trial in Tanzania, we successfully recruited the volunteers and there was no significant loss to follow up. Close contact and updates on study progress facilitated the observed retention rates. TRIAL REGISTRATION NUMBERS: ISRCTN90053831 ISRNCT01132976 and ATMR2009040001075080.

Characteristics and immediate outcomes of patients who underwent percutaneous balloon mitral valvuloplasty at the Jakaya Kikwete Cardiac Institute, Tanzania.

BACKGROUND: For rheumatic mitral stenosis (MS), a multidisciplinary evaluation is mandatory to determine the optimal treatment: medical, percutaneous balloon mitral valvuloplasty (PBMV) or valve surgery. Clinical and imaging evaluations are essential for procedural risk assessment and outcomes. PBMV interventions are increasingly available in Africa and are feasible options for selected candidates. Enhancing PBMV training/skills transfer across most of African countries is possible. OBJECTIVES: The aim of this study was to provide insight into the clinical practice of patients with rheumatic MS evaluated for PBMV in a Tanzanian teaching hospital and to define the role of imaging, and evaluate the heart team and training/skills transfer in PBMV interventions. METHODS: From August 2019 to May 2022, 290 patients with rheumatic MS were recruited consecutively in the Tanzania Mitral Stenosis study. In total, 43 (14.8%) patients were initially evaluated for eligibility for PBMV by a heart team. We carried out the clinical assessment, laboratory investigations, transthoracic/oesophageal echocardiography (TTE/TEE) and electrocardiography. RESULTS: The median age was 31 years (range 11-68), and two-thirds of the patients were female (four diagnosed during pregnancy). Two patients had symptomatic MS at six and eight years. Nine patients had atrial fibrillation with left atrial thrombus in three, and two were detected by TEE. Nine patients in normal sinus rhythm had spontaneous echo contrast. The mean Wilkins score was 8.6 (range 8-12). With re-evaluation by the local and visiting team, 17 patients were found to have unfavourable characteristics: Bi-commissural calcification (four), ≥ grade 2/4 mitral regurgitation (six), high scores and left atrial thrombus (three), left atrial thrombus (two), and severe pulmonary hypertension (two). Three patients died before the planned PBMV. Eleven patients were on a waiting list. We performed PBMV in 12 patients, with success in 10 of these, and good short-term outcomes [mean pre-PBMV (16.03 ± 5.52 mmHg) and post-PBMV gradients (3.08 ± 0.44 mmHg, p < 0.001)]. There were no complications. CONCLUSIONS: PBMV had good outcomes for selected candidates. TEE is mandatory in pre-PBMV screening and for procedural guidance. In our cohort, patients with Wilkins score of up to 11 underwent successful PBMV. We encourage PBMV skills expansion in low- and middle-income countries, concentrating on expertise centres.

Medication Adherence and Blood Pressure Control Among Hypertensive Outpatients Attending a Tertiary Cardiovascular Hospital in Tanzania: A Cross-Sectional Study.

Background: Notwithstanding the availability of effective treatments, asymptomatic nature and the interminable treatment length, adherence to medication remains a substantial challenge among patients with hypertension. Suboptimal adherence to BP-lowering agents is a growing global concern that is associated with the substantial worsening of disease, increased service utilization and health-care cost escalation. This study aimed to explore medication adherence and its associated factors among hypertension outpatients attending a tertiary-level cardiovascular hospital in Tanzania. Methods: The pill count adherence ratio (PCAR) was used to compute adherence rate. In descriptive analyses, adherence was dichotomized and consumption of less than 80% of the prescribed medications was used to denote poor adherence. Logistic regression analyses was used to determine factors associated with adherence. Results: A total of 849 outpatients taking antihypertensive drugs for ≥1 month prior to recruitment were randomly enrolled in this study. The mean age was 59.9 years and about two-thirds were females. Overall, a total of 653 (76.9%) participants had good adherence and 367 (43.2%) had their blood pressure controlled. Multivariate logistic regression analysis showed; lack of a health insurance (OR 0.5, 95% CI 0.3-0.7, p<0.01), last BP measurement >1 week (OR 0.6, 95% CI 0.4-0.8, p<0.01), last clinic attendance >1 month (OR 0.4, 95% CI 0.3-0.6, p<0.001), frequent unavailability of drugs (OR 0.6, 95% CI 0.3-0.9, p = 0.03), running out of medication before the next appointment (OR 0.6, 95% CI 0.4-0.9, p = 0.01) and stopping medications when asymptomatic (OR 0.6, 95% CI 0.4-0.8, p<0.001) to be independent associated factors for poor adherence. Conclusion: A substantial proportion of hypertensive outpatients in this tertiary-level setting had good medication adherence. Nonetheless, observed suboptimal blood pressure control regardless of a fairly satisfactory adherence rate suggests that lifestyle modification plays a central role in hypertension management.

Newborn Screening for Critical Congenital Heart Disease in a Low-Resource Setting; Research Protocol and Preliminary Results of the Tanzania Pulse Oximetry Study.

Background: Critical Congenital Heart Disease (CCHD) is the leading cause of early new-born mortality. Its early detection and intervention is crucial for the survival of affected new-born. Pulse Oximetry (POX) has shown to be one of the feasible, accurate and cost-effective tools in screening CCHD in developed nations, it is yet to be practiced and established as standard of care in a low-resource setting. Objectives: This paper reports on the research protocol and preliminary results of an ongoing study regarding the performance of POX in detecting CCHD in new-borns in a low resource setting. Secondary objectives include investigating the burdens of CCHD and outcome at 12 months of age. Methods: The Tanzanian Pulse Oximetry Study (TPOXS) is a prospective cohort study which plans to enrol 30,000 mothers and new-borns delivered at two referral hospitals in Tanzania. New-borns are offered POX test 12 hours after birth, those positively undergoes echocardiography examinations. Confirmed with CCHD are placed under observation for up to first birthday. Results: During a 5-months pilot period, a total of 1,592 infants at the Muhimbili National Hospital, received POX test .65% of them were post-caesarean section and 52% being male. Most babies delivered through Spontaneous Vertex Delivery (SVD) were promptly discharge and did not get screened. The detection-rate of CCHD was 2.5 per 1,000 live births (at 95% confidence interval [CI] 0.9 to 6.7 per 1000 live birth); with a POX false positive rate of 0.6%. Seven false-positive infants out of 10 were found to carry significant other neonatal conditions, including persistent pulmonary hypertension of the new-born, transient tachypnoeic and neonatal sepsis. Conclusion: This paper provides the protocol of the ongoing TPOXS with the preliminary results showing prevalence matching closely the global data. It shows acceptability of POX screening for CCHD in a well-prepared low resource setting. Highlight: This study addresses the utilization of pulse oximeter in detecting critical congenital heart disease (CCHD) in a low-resource setting (such as sub-Saharan African countries).

Non-Communicable Disease Risk Factors Among Caregivers of Patients Attending a Tertiary Cardiovascular Hospital in Tanzania.

Background: Notwithstanding the ever-present burden of infectious diseases, the sub-Saharan Africa (SSA) region has experienced a 67% rise in the non-communicable disease (NCD) burden in less than three decades. Furthermore, regardless of the increased recognition of NCDs threat in the region, reliable local estimates and associated drivers are generally lacking. We therefore conducted this cross-sectional study to establish the pattern and correlates of the modifiable NCD risk factors among caregivers of patients attending a tertiary cardiovascular centre in Tanzania. Methods: A cross-sectional survey was conducted at Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania. We used a structured questionnaire bearing a modified WHO STEPwise Approach to NCD Risk Factor Surveillance (STEPS) tool to explore the modifiable behavioral and modifiable biological NCD risk factors. Results: A total of 1063 caregivers were enrolled in this study. The mean age was 40.5 years, and 55.7% were female. Nearly 80% of participants had a good knowledge regarding NCDs and 85.4% had a positive family history of NCDs. Overall, 1027 (96.6%) participants had at least one modifiable NCD risk factor while 510 (48.0%) had three or more (i.e., clustering). With respect to modifiable behavioral NCD risk factors, 34 (3.2%) were tobacco users, 56 (5.3%) had harmful alcohol consumption, 691 (65%) had unhealthy eating behavior, and 820 (77.1%) were physically inactive. Pertaining to modifiable biological NCD risk factors, 710 (66.8%) had excess body weight, 420 (39.5%) had hypertension and 62 (5.8%) were diabetic. Conclusion: A vast majority of caregivers of NCD patients in this tertiary setting were found to have modifiable NCD risk factors with a strong tendency of clustering. These findings call for intensification of both population strategies and targeted group interventions for better control of the NCD threat and its correlates.

Complete heart block ensuing from a metastatic small cell carcinoma: a case report.

INTRODUCTION: Notwithstanding the diagnostic and therapeutic advancements, the incidence of cardiac metastases has increased in recent decades. Lung cancers are the most common primary malignant neoplasms with cardiac metastasis potential. The clinical presentation of cardiac metastases is either silent or vague, and largely depends on the infiltrated location and tumor burden. Although arrhythmias are not uncommon in metastatic cardiac tumors, complete heart block is relatively a rare manifestation. We present a case of complete heart block due to a metastatic small cell carcinoma in a 67-year-old male of African origin. CASE PRESENTATION: A 67-year-old male of African origin from rural Tanzania was referred to us for expert management. He is a retired agromechanic with over 30 years exposure to asbestos-containing brake linings. His past medical history was unremarkable, but the family-social history was evident for a heavy alcohol intake and chronic cigarette smoking. He presented with a 24-week history of progressive shortness of breath and an 8-week history of recurrent syncopal attacks coupled with a significant weight loss. He had normal echocardiographic findings, however, the electrocardiogram showed features of complete heart block. Chest X-ray showed a homogeneous opacification on the right side and computed tomography scan revealed a solid right lung mass with metastases to the liver, heart, bowels, and bone. He underwent bronchoscopy, which revealed an endobronchial mass obstructing the bronchus intermedius. Histological examination of a section of lung biopsy taken during bronchoscopy confirmed the diagnosis of a small cell carcinoma. The patient underwent dual chamber pacemaker implantation with successful sinus rhythm restoration. He made an informed refusal of chemotherapy and inevitably died 18 months post pacing. CONCLUSIONS: Despite the advancements in medical diagnostics and management, lung cancers are often diagnosed in advanced stages, with an inevitable grave prognosis. Small cell carcinoma has the potential to metastasize to the heart, resulting in complete heart block.

Human immunodeficiency virus transmission from a 24-year-old woman to her 78-year-old grandmother: a case report.

INTRODUCTION: Since its debut recognition in 1981, human immunodeficiency virus/acquired immunodeficiency syndrome has affected over 77 million people and has resulted in premature cessation of 35.4 million lives worldwide. Commonly, human immunodeficiency virus is transmitted by sexual contact across mucosal surfaces, by sharing of injecting equipment, through contaminated blood transfusions, and by maternal-infant exposure. Nevertheless, accidental transmission incidences involving family members are rare but possible. CASE PRESENTATION: A 78-year-old woman of African descent from Mtwara Region south of Tanzania was referred to us for further evaluation and treatment. She is 30 years postmenopausal and has a 35-year history of hypertension. Her last attendance to our institute was 11 months prior the index visit and she tested negative for human immunodeficiency virus. She came with complaints of weight loss, recurrent fevers, and cough. Her hematological tests revealed leukopenia with lymphocytosis, together with a normocytic normochromic anemia. Enzyme-linked immunosorbent assay for human immunodeficiency virus was positive, and she had a CD4 count of 177 cells/µL. We went back to history taking to identify the potential source of infection. We were informed that for the past 6 months, the 78-year-old lady has been living with her unwell 24-year-old granddaughter who has been divorced. The granddaughter had a history of recurrent fevers, significant weight loss, and a suppurative skin condition. As a way to show love and care, the old lady was puncturing the suppurative lesions with bare hands; then she would suck them to clear away the discharge. We requested to see the young lady, and she tested positive for human immunodeficiency virus. Both were started on tenofovir/lamivudine/dolutegravir combination plus cotrimoxazole 960 mg. The family was in total disarray following these findings. The patient was discharged through infectious diseases department and died of Pneumocystis jirovecii pneumonia 12 weeks later. CONCLUSIONS: Certain sociocultural norms that are believed to express love, care, and togetherness in developing rural communities, particularly Sub-Saharan Africa, have a potential of spreading human immunodeficiency virus, thus warranting prompt transformation.

Rationale, design and protocol of a cross-sectional study on pregnancy-related cardiovascular diseases in Tanzania (PRECARDT): burden, characterisation and prognostic significance at delivery.

INTRODUCTION: The paucity of data describing cardiovascular disease (CVD) in pregnancy in many parts of Africa including Tanzania has given rise to challenges in proper management by the healthcare providers. This study is set out to (1) determine the prevalence of a range of CVDs during pregnancy in women attending antenatal clinics in Tanzania and (2) determine the impact of these CVDs on maternal and fetal outcomes at delivery. METHODS AND ANALYSIS: This is a cross-sectional study with a prospective component to be conducted in two referral hospitals in Tanzania. Pregnant women aged ≥18 years diagnosed with a CVD during the antenatal period are being identified and extensively characterised by performing clinical assessment, modified WHO staging, electrocardiography, echocardiography and laboratory tests. Patients identified with CVDs (exposed) and a subset without (unexposed) will be followed up to determine maternal and fetal outcomes at delivery. A minimum sample of 1560 will be sufficient to estimate the prevalence of CVDs with a 95% CI of 2.75% to 5.25%. ETHICS AND DISSEMINATION: The study is being conducted in accordance with the Helsinki declaration on studies involving human subjects. Ethical approvals have been obtained from Muhimbili University (reference number DA.282/298/01.C/) and Bugando Medical Centre (reference number CREC/330/2019) Ethics Committees. Informed consent is sought from all potential participants before any interview or investigations are performed. Study findings will be disseminated to the scientific community through different methods. Results will also be communicated to policymakers and to the public, as appropriate.