Browsing by Subject "Tanzania"
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Item Open Access A Longitudinal Cohort Study of Malaria Exposure and Changing Serostatus in a Malaria Endemic Area of Rural Tanzania(Malaria Journal, 2017-08-02) Simmons, RA; Mboera, L; Stresman, A; Turner, E; Kramer, R; Drakeley, C; O'Meara, WPBackground
Measurements of anti-malarial antibodies are increasingly used as a proxy of transmission intensity. Most serological surveys are based on the use of cross-sectional data that, when age-stratified, approximates historical patterns of transmission within a population. Comparatively few studies leverage longitudinal data to explicitly relate individual infection events with subsequent antibody responses.Methods
The occurrence of seroconversion and seroreversion events for two Plasmodium falciparum asexual stage antigens (MSP-1 and AMA-1) was examined using three annual measurements of 691 individuals from a cohort of individuals in a malaria-endemic area of rural east-central Tanzania. Mixed-effect logistic regression models were employed to determine factors associated with changes in serostatus over time.Results
While the expected population-level relationship between seroprevalence and disease incidence was observed, on an individual level the relationship between individual infections and the antibody response was complex. MSP-1 antibody responses were more dynamic in response to the occurrence and resolution of infection events than AMA-1, while the latter was more correlated with consecutive infections. The MSP-1 antibody response to an observed infection seemed to decay faster over time than the corresponding AMA-1 response. Surprisingly, there was no evidence of an age effect on the occurrence of a conversion or reversion event.Conclusions
While the population-level results concur with previously published sero-epidemiological surveys, the individual-level results highlight the more complex relationship between detected infections and antibody dynamics than can be analysed using cross-sectional data. The longitudinal analysis of serological data may provide a powerful tool for teasing apart the complex relationship between infection events and the corresponding immune response, thereby improving the ability to rapidly assess the success or failure of malaria control programmes.Item Open Access A prospective study of Escherichia coli bloodstream infection among adolescents and adults in northern Tanzania.(Transactions of the Royal Society of Tropical Medicine and Hygiene, 2020-05) Madut, Deng B; Rubach, Matthew P; Kalengo, Nathaniel; Carugati, Manuela; Maze, Michael J; Morrissey, Anne B; Mmbaga, Blandina T; Lwezaula, Bingileki F; Kilonzo, Kajiru G; Maro, Venance P; Crump, John ABackground
Characterization of the epidemiology of Escherichia coli bloodstream infection (BSI) in sub-Saharan Africa is lacking. We studied patients with E. coli BSI in northern Tanzania to describe host risk factors for infection and to describe the antimicrobial susceptibility of isolates.Methods
Within 24 h of admission, patients presenting with a fever at two hospitals in Moshi, Tanzania, were screened and enrolled. Cases were patients with at least one blood culture yielding E. coli and controls were those without E. coli isolated from any blood culture. Logistic regression was used to identify host risk factors for E. coli BSI.Results
We analyzed data from 33 cases and 1615 controls enrolled from 2007 through 2018. The median (IQR) age of cases was 47 (34-57) y and 24 (72.7%) were female. E. coli BSI was associated with (adjusted OR [aOR], 95% CI) increasing years of age (1.03, 1.01 to 1.05), female gender (2.20, 1.01 to 4.80), abdominal tenderness (2.24, 1.06 to 4.72) and urinary tract infection as a discharge diagnosis (3.71, 1.61 to 8.52). Of 31 isolates with antimicrobial susceptibility results, the prevalence of resistance was ampicillin 29 (93.6%), ceftriaxone three (9.7%), ciprofloxacin five (16.1%), gentamicin seven (22.6%) and trimethoprim-sulfamethoxazole 31 (100.0%).Conclusions
In Tanzania, host risk factors for E. coli BSI were similar to those reported in high-resource settings and resistance to key antimicrobials was common.Item Open Access A randomized controlled trial of standard versus intensified tuberculosis diagnostics on treatment decisions by physicians in Northern Tanzania.(BMC Infect Dis, 2014-02-20) Reddy, Elizabeth A; Njau, Boniface N; Morpeth, Susan C; Lancaster, Kathryn E; Tribble, Alison C; Maro, Venance P; Msuya, Levina J; Morrissey, Anne B; Kibiki, Gibson S; Thielman, Nathan M; Cunningham, Coleen K; Schimana, Werner; Shao, John F; Chow, Shein-Chung; Stout, Jason E; Crump, John A; Bartlett, John A; Hamilton, Carol DBACKGROUND: 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.Item Open Access Acute myocardial infarction under-diagnosis and mortality in a Tanzanian emergency department: A prospective observational study.(American heart journal, 2020-08) Hertz, Julian T; Sakita, Francis M; Kweka, Godfrey L; Limkakeng, Alexander T; Galson, Sophie W; Ye, Jinny J; Tarimo, Tumsifu G; Temu, Gloria; Thielman, Nathan M; Bettger, Janet P; Bartlett, John A; Mmbaga, Blandina T; Bloomfield, Gerald SBACKGROUND:Growing evidence suggests that under-diagnosis of acute myocardial infarction (AMI) may be common in sub-Saharan Africa. Prospective studies of routine AMI screening among patients presenting to emergency departments in sub-Saharan Africa are lacking. Our objective was to determine the prevalence of AMI among patients in a Tanzanian emergency department. METHODS:In a prospective observational study, consecutive adult patients presenting with chest pain or shortness of breath to a referral hospital emergency department in northern Tanzania were enrolled. Electrocardiogram (ECG) and troponin testing were performed for all participants to diagnose AMI types according to the Fourth Universal Definition. All ECGs were interpreted by two independent physician judges. ECGs suggesting ST-elevation myocardial infarction (STEMI) were further reviewed by additional judges. Mortality was assessed 30 days following enrollment. RESULTS:Of 681 enrolled participants, 152 (22.3%) had AMI, including 61 STEMIs and 91 non-STEMIS (NSTEMIs). Of AMI patients, 91 (59.9%) were male, mean (SD) age was 61.2 (18.5) years, and mean (SD) duration of symptoms prior to presentation was 6.6 (12.2) days. In the emergency department, 35 (23.0%) AMI patients received aspirin and none received thrombolytics. Of 150 (98.7%) AMI patients completing 30-day follow-up, 65 (43.3%) had died. CONCLUSIONS:In a northern Tanzanian emergency department, AMI is common, rarely treated with evidence-based therapies, and associated with high mortality. Interventions are needed to improve AMI diagnosis, care, and outcomes.Item Open Access Agricultural Drivers of Children’s Nutrition and Food Security in Mvomero, Tanzania(2017-04-26) Lamy, JenniferThe main research question assessed in this paper is: What land use and agricultural practices most significantly influence nutritional and food security outcomes? In particular, are there specific crop growing or selling or irrigation practices that, when performed by a household, help to reduce the risk that children under five years old in that household are stunted or anemic or help to increase perceived food security by the household head? I use data collected in 2011 and 2013 in the Mvomero district of Tanzania in order to answer these questions. Using a combination of data at the household level on land use practices and on the individual level for health measures, I perform logit and linear regression analysis to identify any consistent significant associations between the two groups. My results are varied: some agricultural practices are associated with stunting or anemia, while others are more strongly associated with measures of food security. The number of children in a household is negatively associated with both food security measures, implying that larger households in the region have difficulty keeping up with food demands. My findings point to the fact that there is no silver bullet in the quest to improve childhood nutrition and food security in Mvomero, Tanzania and worldwide.Item Open Access Alcohol Use and Violence-Related Injury in Moshi, Tanzania: A Mixed Methods Study(2019) Friedman, KaitlynBackground: Harmful alcohol use and violence are both major contributors to global mortality and morbidity rates, despite being both predictable and preventable. This study seeks to quantitatively determine the scope of violence-related injury and Alcohol Use Disorders in a referral hospital in Moshi, and qualitatively determine 1) how violence-related injury patients perceive alcohol use influences the occurrence of violence and 2) how experiencing a violence-related injury influences patients’ subsequent alcohol use behavior.
Methods: This study was conducted at Kilimanjaro Christian Medical Center (KCMC). Survey data was obtained from a trauma registry including all injury patients ≥ 18 years admitted to the emergency room. Interview participants were included if they reported their injury was due to violence, tested positive for alcohol (by breathalyzer) upon admittance, medically stable, able to communicate and provide informed consent in Swahili or English, and clinically sober at the time of enrollment.
Results: From the 500 injury patients enrolled in the trauma registry from April 17, 2018 to January 12, 2019, 84 (16.8%) reported that their injury was due to violence. Patients with violent injuries were 2.21 times more likely to have a positive alcohol status compared to non-violent injuries (95% CI 1.36, 3.60, p<0.01). Among violent injuries, those with a positive alcohol status were 6.26 times more likely to have an Alcohol Use Disorder compared to those with a negative alcohol status (95% CI 2.13, 18.39, p<0.001). Interview respondents reported a perception that violent injuries were worse from other injuries, that the perpetrator was also under the influence of alcohol, that alcohol contributes to violence, and a desire to change alcohol use behavior following their injury.
Conclusion: Alcohol use and violence-related injury pose a significant threat to health and well-being globally. In Moshi, Tanzania, both issues are prevalent and contribute to a sufficient disease burden. This study has added to the data on alcohol-attributable harm, contributing to expanding information available on this issue from LMICs. To adequately reduce violence-related injuries in this setting, it is necessary to address harmful alcohol use as well.
Item Open Access Alcohol use perceptions and risky behaviors—a mixed method study in Moshi, Tanzania(2019) Zhao, DuanBackground: The Kilimanjaro region has one of the highest rates of reported alcohol use per capita in Tanzania. Alcohol-related risky behaviors pose substantial threats to the health and well-being of alcohol users and people around them. This study sought to provide a better understanding of how risky behaviors are associated with alcohol use perceptions. Methods: This mixed method study took place in the Kilimanjaro Christian Medical Center. Quantitative data on alcohol use, the alcohol use disorder identification tool, alcohol-related consequences, and qualitative data on alcohol use perception and risky behaviors were collected from a hospital- and non-hospital-based sample in Moshi, Tanzania. Latent class analysis was applied to examine alcohol-related risky behaviors. Results: Three classes of risky behavior patterns were identified: “no risky behavior”, “moderate risky behaviors” and “high risky behaviors”. Membership of classes 3 was associated with the most alcohol use quantity and frequency. No association between classes and alcohol-stigma was found. Our qualitative results explored alcohol perceptions and risky behaviors and illustrated their possible associations. Conclusions: Although alcohol stigma may not associate the number of risky behaviors directly, our qualitative result helped us to understand how stigma associates with risky behaviors. This study may serve as a reference for designing and adjusting interventions for alcohol-related injury patients' needs; we can improve interventions by using our knowledge about misconception and stigma and the identified risky behaviors classes as a form of classification system.
Item Open Access An analysis of emergency care delays experienced by traumatic brain injury patients presenting to a regional referral hospital in a low-income country.(PloS one, 2020-01) Zimmerman, Armand; Fox, Samara; Griffin, Randi; Nelp, Taylor; Thomaz, Erika Bárbara Abreu Fonseca; Mvungi, Mark; Mmbaga, Blandina T; Sakita, Francis; Gerardo, Charles J; Vissoci, Joao Ricardo Nickenig; Staton, Catherine A; Staton, Catherine ABackground
Trauma is a leading cause of death and disability worldwide. In low- and middle-income countries (LMICs), trauma patients have a higher risk of experiencing delays to care due to limited hospital resources and difficulties in reaching a health facility. Reducing delays to care is an effective method for improving trauma outcomes. However, few studies have investigated the variety of care delays experienced by trauma patients in LMICs. The objective of this study was to describe the prevalence of pre- and in-hospital delays to care, and their association with poor outcomes among trauma patients in a low-income setting.Methods
We used a prospective traumatic brain injury (TBI) registry from Kilimanjaro Christian Medical Center in Moshi, Tanzania to model nine unique delays to care. Multiple regression was used to identify delays significantly associated with poor in-hospital outcomes.Results
Our analysis included 3209 TBI patients. The most common delay from injury occurrence to hospital arrival was 1.1 to 4.0 hours (31.9%). Most patients were evaluated by a physician within 15.0 minutes of arrival (69.2%). Nearly all severely injured patients needed and did not receive a brain computed tomography scan (95.0%). A majority of severely injured patients needed and did not receive oxygen (80.8%). Predictors of a poor outcome included delays to lab tests, fluids, oxygen, and non-TBI surgery.Conclusions
Time to care data is informative, easy to collect, and available in any setting. Our time to care data revealed significant constraints to non-personnel related hospital resources. Severely injured patients with the greatest need for care lacked access to medical imaging, oxygen, and surgery. Insights from our study and future studies will help optimize resource allocation in low-income hospitals thereby reducing delays to care and improving trauma outcomes in LMICs.Item Open Access AN ANALYSIS OF LANDSCAPE CHARACTERISTICS INFLUENCING LIVESTOCK DEPREDATION BY LIONS, HYENAS, AND LEOPARDS IN LOIBOR SIRET, TANZANIA(2012-04-30) Baraso, SamThe African lion has declined precipitously across its entire range from nearly 500,000 in the early 1900s to roughly 35,000 individuals today. While a multitude of factors contributes to the lions’ decline, conflict with traditional pastoralists is one of the gravest threats. Lions, hyenas and leopards opportunistically prey on livestock including cattle, donkeys, goats, and sheep in pastoral regimes. However, lions are disproportionately blamed for livestock depredation and are common targets in retaliatory killings in many communities. Several NGOs including the African People & Wildlife Fund are finding ways to minimize predation incidences and thereby reduce retaliatory killings. Strategies such as corral fortification have reduced predation events within the homestead, however, a significant percentage of attacks are at the pasture. Using 54 months of carnivore/livestock conflict data in the Maasai Steppe of Tanzania, I assess the influence of landscape features to characterize the risk of predation at the pasture. By identifying factors contributing to greater predation risk, strategies to mitigate attacks at pasture can be designed. This way, herders will have greater capacity to protect their primary source of wealth and can better co-exist with predators. I found that proximity to bomas (corrals) is the most relevant landscape feature explaining the likelihood of attack across all three carnivores. After accounting for boma proximity, no other variable contributes a significant explanatory role, and attacks cannot be accounted for by landscape features alone. Fifty-three percent of all pasture predation occurs at night. Of these, roughly 71% occur on lost livestock. This study suggests that “lost livestock” represents an area of further research. After, the initiation of the Living Walls corral fortification program, boma predation declined by over ninety percent. Pasture predation also declines, though the causal mechanism is unclear. This study shows that environmental characteristics may be less important than social or behavioral characteristics of the herders in determining livestock predation at pasture.Item Embargo Antibacterial Utilization for Febrile Illnesses and Laboratory-confirmed Bloodstream Infections in Northern Tanzania(2023) Moorthy, Ganga S.Antibacterial management of febrile patients in low-resource settings is challenging and adherence to treatment guidelines is variable. We describe antibacterial use in febrile patients, use of effective therapy for laboratory-confirmed bloodstream infections, and adherence to published guidelines for common febrile illnesses among patients enrolled in prospective hospital-based fever surveillance studies in Moshi, Tanzania.
We compared data from two hospital-based prospective cohort studies, Cohort 1 (2011–2014) and Cohort 2 (2016–2019), that enrolled febrile infants, children, and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures on all participants. Ceftriaxone, ciprofloxacin, amoxicillin-clavulanate, or azithromycin were categorized as broad-spectrum antibacterials based on published frameworks and local antimicrobial availability. Participants with laboratory-confirmed bloodstream infections were categorized as receiving effective or ineffective antibacterials based on culture and susceptibility data. Antimicrobials prescribed for preliminary or final diagnosis of pneumonia, urinary tract infection, or presumed sepsis were compared with syndrome-specific recommendations from the World Health Organization (WHO) and the Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe factors associated with antibacterial use.
We analyzed data from 2175 participants. The median age of participants in Cohort 1 was 29 (IQR: 5-41) and 22 in Cohort 2 (IQR: 2-45). Among all participants, 50% were female. There were 430 (42.0%) and 501 (45.1%) participants who reported use of antibacterials prior to admission in Cohort 1 and Cohort 2, respectively. There were 989 (91.4%) participants who received antibacterials during admission for febrile illness in Cohort 1 versus 1060 (93.6%) in Cohort 2 (p < 0.001); 548 (52.5%) in Cohort 1 and 682 (60.2%) in Cohort 2 (p < 0.001) received broad-spectrum therapy. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between the two cohorts (ceftriaxone p = < 0.001; metronidazole p = 0.02; ampicillin p = < 0.001). Laboratory-confirmed bacteremia was found in 38 (3.6%) participants in Cohort 1 and 47 (4.2%) participants in Cohort 2. Complete data to determine appropriateness of antibacterial prescription were available for 81 (95.3%) of 85 participants and 52 (63.0%) participants were prescribed effective therapy. Guideline-consistent therapy for pneumonia, urinary tract infection, and sepsis increased over time.
Receipt of antibacterials prior to and after hospital admission were high and use of broad-spectrum medications was common. A large proportion of participants with culture-confirmed bloodstream infections were treated with ineffective antibacterials but consistency of antibacterial prescribing with WHO and Tanzanian treatment guidelines improved over time. Our results highlight the need for improved diagnostics for febrile illness, data on local antimicrobial resistance patterns, institution-specific clinical guidelines, and provider education to improve prescribing practices and rational use of antimicrobials in Tanzania.
Item Open Access Antibacterial Utilization for Febrile Illnesses and Laboratory-Confirmed Bloodstream Infections in Northern Tanzania.(Open forum infectious diseases, 2023-08) Moorthy, Ganga S; Madut, Deng B; Kilonzo, Kajiru G; Lwezaula, Bingileki F; Mbwasi, Ronald; Mmbaga, Blandina T; Ngocho, James S; Saganda, Wilbrod; Bonnewell, John P; Carugati, Manuela; Egger, Joseph R; Hertz, Julian T; Tillekeratne, L Gayani; Maze, Michael J; Maro, Venance P; Crump, John A; Rubach, Matthew PBackground
We describe antibacterial use in light of microbiology data and treatment guidelines for common febrile syndromes in Moshi, Tanzania.Methods
We compared data from 2 hospital-based prospective cohort studies, cohort 1 (2011-2014) and cohort 2 (2016-2019), that enrolled febrile children and adults. A study team member administered a standardized questionnaire, performed a physical examination, and collected blood cultures. Participants with bloodstream infection (BSI) were categorized as receiving effective or ineffective therapy based upon antimicrobial susceptibility interpretations. Antibacterials prescribed for treatment of pneumonia, urinary tract infection (UTI), or presumed sepsis were compared with World Health Organization and Tanzania Standard Treatment Guidelines. We used descriptive statistics and logistic regression to describe antibacterial use.Results
Among participants, 430 of 1043 (41.2%) and 501 of 1132 (44.3%) reported antibacterial use prior to admission in cohorts 1 and 2, respectively. During admission, 930 of 1043 (89.2%) received antibacterials in cohort 1 and 1060 of 1132 (93.6%) in cohort 2. Inpatient use of ceftriaxone, metronidazole, and ampicillin increased between cohorts (P ≤ .002 for each). BSI was detected in 38 (3.6%) participants in cohort 1 and 47 (4.2%) in cohort 2. Of 85 participants with BSI, 81 (95.3%) had complete data and 52 (64.2%) were prescribed effective antibacterials. Guideline-consistent therapy in cohort 1 and cohort 2 was as follows: pneumonia, 87.4% and 56.8%; UTI, 87.6% and 69.0%; sepsis, 84.4% and 61.2% (P ≤ .001 for each).Conclusions
Receipt of antibacterials for febrile illness was common. While guideline-consistent prescribing increased over time, more than one-third of participants with BSI received ineffective antibacterials.Item Open Access Assessing BRAC's Community Health Volunteer Program in Tanzania(2012-04-20) Lamb, JadeLife expectancy in Tanzania is 58 years for women, and 53 for men (WHO 2011). Tanzania’s maternal mortality ratio is among the world’s highest at 454 per 100,000 births (UNDP); likewise, its infant mortality ratio is high at 51 per 1,000 live births (TDHS 2010). Overall, under-five mortality (U5M) is 81 per 1,000 (TDHS 2011), 16% of which is due to malaria, and an additional 13% to diarrheal diseases. To address these ongoing health issues in a low-cost, scalable way, BRAC began to implement a Community Health Volunteer Program in Tanzania in 2007. BRAC trained volunteers, all of whom were female and most of whom were also active in BRAC’s microfinance programs, to go out into their communities and educate community members on common diseases, identify pregnant women and new infants and encourage them to seek prenatal and antenatal care, sell over the counter medications, and post contact information for emergency first aid for children. The intervention was conducted for 3 years, until 2010. BRAC collected survey data in treatment and comparison communities assessing health behaviors such as insecticide treated net use, sanitary latrine access, contraceptive use, and antenatal care in 2007 and 2010 in order to evaluate the program. Though the scaling up of the program before 2010 meant that comparison communities received the treatment, the program was still associated with increased contraceptive use and piped water access, and a small but statistically significant decrease in insecticide treated net use. I recommend that BRAC focus any additional health programs in Tanzania on contraceptive promotion, where there seems to be an effect, and postnatal care access and antenatal care quality, where there appears to be unmet need.Item Open Access Association Between E-learning System Usage and Medical Student Academic Performance at the Kilimanjaro Christian Medical University College in Moshi, Tanzania(2018) Murray, MargaretAbstract
Introduction: Due to Tanzania’s rising population and shortage of physicians, there has been an emphasis on the expansion of medical schools in the past two decades, both in number and class size. In order to teach a growing student body, faculty adopted e-learning (electronic learning) systems to distribute materials and educate students. At Kilimanjaro Christian Medical University College (KCMUCo) faculty adopted the e-learning system called Learning Management Content System (LCMS+) in 2011. LCMS+ allowed students to access and download course materials during the year; but the association between the downloaded course materials and final grade was unknown. This study aimed to analyze the association between the downloaded materials and final grade in a course between 2011 and 2016.
Methods: To determine the association between downloaded materials and grade, a retrospective analysis study studied first- and second-year medical students in seven courses from 2011-2016 at KCMUCo. The study initially measured the frequency of downloaded course material (i.e. powerpoints, readings, assignments, course outlines and discussion board posts) from LCMS+ per first and second-year student. The final course grades were then obtained. A linear regression was used to assess the association between (1) downloads and grade and (2) sociodemographic variables and grade.
Results: Of the 1,527 students and 5,205 student-course-years studied, there was a weak or null association between downloaded materials and grade for each year and for different types of downloaded material. The distributions of the grades were approximately normal from 2011-2014 and in 2014-2016 there was a left shift of grade distribution. Additionally the female sex and post-service history were associated with slightly lower grades in some of the student years.
Conclusion: This study demonstrated there was no strong association between the number of downloads and grade. There was also no association between the type of downloaded material and grade and the number of materials did not increase the longer the e-learning system was at KCMUCo. More research on how e-learning systems can benefit students is required and may lead to better training for future generations of health care providers.
Item Open Access Associations of Adverse Childhood Experiences With Key Health Outcomes and Viral Suppression Maintenance Among Tanzanian Youth Living With HIV(2022) Brtek, Veronica RaquelBackground: Despite improved access to HIV testing and medication, AIDS remains a leading cause of death among youth living with HIV (YLWH) in Tanzania. YLWH are prone to worse HIV outcomes than other age groups, which may be caused or mediated by mental health, social determinants of health (SDH), and adverse childhood experiences (ACEs). In this study, the investigators sought to determine if ACEs were correlated with key health variables in hopes of better understanding the factors associated with negative HIV and mental health outcomes among Tanzanian youth. Additionally, the investigators aimed to observe longitudinal trends in virologic suppression to understand the extent to which undetectable = untransmittable or “U=U” messaging applies to the more volatile youth demographic. Finally, the investigators sought to identify patterns and predictors that could aid in understanding risk of virologic failure in this population. Methods: The investigators incorporated and merged secondary data from participants who were enrolled in both of two distinct studies to create a longitudinal database spanning from 2013 to 2020. Participant ACE scores were derived from trauma exposure questionnaires and were compared with data about mental health, stigma, SDH, sexual experiences, self-reported adherence and HIV RNA (viral load). Associations of ACEs and other key variables were performed using linear regression. Results: ACEs were common among YLWH, especially loss of a parent and physical abuse. ACEs were also correlated with both mental health outcomes and virologic failure. Of the 48 participants who were virologically suppressed at the beginning of the study, one third had subsequent virologic failure, which was often associated with changes in ACEs, medication regimen, and SDH. Conclusion: Understanding common ACEs in this vulnerable population has direct relevance for the design of targeted interventions to prevent and treat repercussions of childhood trauma and improve mental health and HIV outcomes. ACEs, experiences with suicide risk, and low social support are important correlates of virologic failure and should be an alert when considering repeat HIV RNA testing and eligibility for supportive services.
Item Open Access A Risk‐Risk Trade‐off: Insecticide Use for Malaria Control(2011-04-29) Pfau, KristenMalaria is among the top causes of death in low-income countries. Because it is transmitted through a mosquito vector, programs to reduce or control these insects receive much attention. Recently, concerns have increased regarding possible chronic reproductive impairment following exposure to insecticides used in mosquito control. This project examines the human health benefits and potential human health consequences of indoor residual spraying (IRS), an increasingly popular method of insecticide use for malaria control. Meta-analysis was used to aggregate the results of published trials on efficacy of IRS in reducing malaria prevalence in a region. Statistical analysis incorporating results of all these studies led to general conclusions about the impact of any IRS program, and provided insight as to what variables resulted in greater effects in one community over another—for example, the type of insecticide used, the initial malaria prevalence in the community, and the time frame of the program. Next, the potential chronic human health consequences were assessed through a review of chemical, toxicological and epidemiological studies. Research focused on two chemicals, lambda-cyhalothrin and DDT. Screening of chemical properties and toxicological studies indicate a potential risk for negative human health outcomes from exposure to both chemicals. Identification and critique of several epidemiological studies that link exposure to IRS with negative reproductive health outcomes verify this risk for DDT. Finally, a series of interviews with malaria control experts in Tanzania provided insight on the cumulative perceptions of decision-makers regarding both the benefits and the consequences illustrated in the previous sections, as well as a variety of other facets of malaria prevention. While this project only presents a small portion of benefits and risks associated with using insecticides for malaria control, it is evident that the current risk assessment-risk management paradigm is not adequate for informing decisions on risk tradeoffs. The benefits and risks need to be considered holistically, not independently, in order to inform quality risk policies. Based on the case study of insecticide use for malaria control, a new framework is suggested in which risk tradeoffs are approached in an interdisciplinary, collaborative manner.Item Open Access Bacteremic disseminated tuberculosis in sub-saharan Africa: a prospective cohort study.(Clin Infect Dis, 2012-07) Crump, John A; Ramadhani, Habib O; Morrissey, Anne B; Saganda, Wilbrod; Mwako, Mtumwa S; Yang, Lan-Yan; Chow, Shein-Chung; Njau, Boniface N; Mushi, Godfrey S; Maro, Venance P; Reller, L Barth; Bartlett, John ABACKGROUND: Disseminated tuberculosis is a major health problem in countries where generalized human immunodeficiency virus (HIV) infection epidemics coincide with high tuberculosis incidence rates; data are limited on patient outcomes beyond the inpatient period. METHODS: We enrolled consecutive eligible febrile inpatients in Moshi, Tanzania, from 10 March 2006 through 28 August 2010; those with Mycobacterium tuberculosis bacteremia were followed up monthly for 12 months. Survival, predictors of bacteremic disseminated tuberculosis, and predictors of death were assessed. Antiretroviral therapy (ART) and tuberculosis treatment were provided. RESULTS: A total of 508 participants were enrolled; 29 (5.7%) had M. tuberculosis isolated by blood culture. The median age of all study participants was 37.4 years (range, 13.6-104.8 years). Cough lasting >1 month (odds ratio [OR], 13.5; P< .001), fever lasting >1 month (OR, 7.8; P = .001), weight loss of >10% (OR, 10.0; P = .001), lymphadenopathy (OR 6.8; P = .002), HIV infection (OR, undefined; P < .001), and lower CD4 cell count and total lymphocyte count were associated with bacteremic disseminated tuberculosis. Fifty percent of participants with M. tuberculosis bacteremia died within 36 days of enrollment. Lower CD4 cell count (OR, 0.88; P = .049) and lower total lymphocyte count (OR, 0.76; P = .050) were associated with death. Magnitude of mycobacteremia tended to be higher among those with lower CD4 cell counts, but did not predict death. CONCLUSIONS: In the era of free ART and access to tuberculosis treatment, almost one half of patients with M. tuberculosis bacteremia may die within a month of hospitalization. Simple clinical assessments can help to identify those with the condition. Advanced immunosuppression predicts death. Efforts should focus on early diagnosis and treatment of HIV infection, tuberculosis, and disseminated disease.Item Open Access Brucellosis among hospitalized febrile patients in northern Tanzania.(Am J Trop Med Hyg, 2012-12) Bouley, Andrew J; Biggs, Holly M; Stoddard, Robyn A; Morrissey, Anne B; Bartlett, John A; Afwamba, Isaac A; Maro, Venance P; Kinabo, Grace D; Saganda, Wilbrod; Cleaveland, Sarah; Crump, John AAcute and convalescent serum samples were collected from febrile inpatients identified at two hospitals in Moshi, Tanzania. Confirmed brucellosis was defined as a positive blood culture or a ≥ 4-fold increase in microagglutination test titer, and probable brucellosis was defined as a single reciprocal titer ≥ 160. Among 870 participants enrolled in the study, 455 (52.3%) had paired sera available. Of these, 16 (3.5%) met criteria for confirmed brucellosis. Of 830 participants with ≥ 1 serum sample, 4 (0.5%) met criteria for probable brucellosis. Brucellosis was associated with increased median age (P = 0.024), leukopenia (odds ratio [OR] 7.8, P = 0.005), thrombocytopenia (OR 3.9, P = 0.018), and evidence of other zoonoses (OR 3.2, P = 0.026). Brucellosis was never diagnosed clinically, and although all participants with brucellosis received antibacterials or antimalarials in the hospital, no participant received standard brucellosis treatment. Brucellosis is an underdiagnosed and untreated cause of febrile disease among hospitalized adult and pediatric patients in northern Tanzania.Item Open Access Challenges and facilitators of transition from adolescent to adult HIV care among young adults living with HIV in Moshi, Tanzania.(Journal of the International AIDS Society, 2019-10) Masese, Rita V; Ramos, Julia V; Rugalabamu, Leonia; Luhanga, Severa; Shayo, Aisa M; Stewart, Kearsley A; Cunningham, Coleen K; Dow, Dorothy EINTRODUCTION:Scale up of anti-retroviral therapy has enabled millions of children infected with HIV to survive into adulthood, requiring transition of care to the adult HIV clinic. This transition period is often met with anxiety and reluctance. Youth who fail to transition may create strain on capacity in the pediatric and adolescent clinics or result in individuals dropping out of care entirely. This study examined challenges and facilitators to the transition among young adults living with HIV in Moshi, Tanzania. METHODS:From April to June 2017, in-depth interviews were conducted with young adults aged 18 to 27 years living with HIV in order to capture the spectrum of experiences from pre-transitioning youth to those who successfully transitioned to adult care. Young adults were purposively recruited based on prior study enrollees and recommendations from healthcare staff. Recruitment occurred in the adolescent, adult HIV and the prevention of mother to child transition clinics at Kilimanjaro Christian Medical Centre. Two separate in-depth interviews were conducted with eligible participants. Medical records were reviewed retrospectively to collect information on HIV-related outcomes. RESULTS:In-depth interviews were held with 19 young adults. Participants mean age was 23.8 years (interquartile range 22.2 to 26.3 years); 53% were female. Most (78.9%) participants had been receiving anti-retroviral therapy for nearly a decade and 72.2% were virologically suppressed (HIV RNA <200 copies/mL). Barriers to transition included fear of losing peer networks formed in the adolescent clinic, the abrupt manner in which young adults were asked to transition, stigma, financial constraints and a lower quality of care in the adult clinic. Facilitators of transition included family and social support, positive perspectives on living with HIV and maintenance of good health. Recommendations for transition included transition preparation, transition as a group and adoption of desirable aspects of the adolescent clinic (peer networks and education) in the adult clinic. CONCLUSIONS:Transition is a complex process influenced by many factors. As the number of young adults living with HIV continues to grow, it is vital to develop a transition protocol that addresses these challenges and is feasible to implement in low-resource settings.Item Open Access Challenges and Facilitators of Transition from Adolescent to Adult HIV Care among Youth Living with HIV in Moshi, Tanzania(2018) Masese, Rita VanessaBackground: AIDS is the leading killer of adolescents in Africa, the continent most impacted by the AIDS pandemic. The East African nation of Tanzania is one of the top five countries with the highest burden of HIV in the world. Despite these challenges, scale up of anti-retroviral therapy (ART) has enabled millions of children infected with HIV to survive into adolescence and adulthood. These children attend family-centered and adolescent clinics where they not only receive HIV care, but also form close knit bonds with their healthcare providers and peers. As patients age into adulthood, they require to transition to the adult HIV clinic. Failure to transition results in an adolescent treatment bulge and strain on capacity in the family centered and adolescent clinics. This adolescent to adult transition period is a point of frequent loss to follow-up in the HIV care continuum, which may be partially due to fear and anxiety about the change. As clinics seek guidance on how best to manage the transition, few established protocols exist, and those available were primarily written for well-resourced settings. This study examined challenges and facilitators of the transition of care among youth living with HIV in Moshi, Tanzania.
Methods: Purposive sampling methods were used to recruit youth living with HIV who attended an adolescent specific clinic, Teen Club, and the adult HIV clinic at Kilimanjaro Christian Medical Centre. Two native Swahili speaking research assistants trained in qualitative research conducted in-depth interviews. Medical records were reviewed retrospectively to collect data on factors associated with HIV outcomes. Preliminary results were presented to key stakeholders. Youth and key stakeholders separately suggested solutions to identified challenges associated with transition of care. Results: 19 youth participated in the study. A slight majority were female (53%) and on first-line ART. Participants’ age of HIV diagnosis ranged from 5 to 18 years with a mean ART duration of 9.8 years. Barriers and facilitators of transition were categorized into four domains based on the Health Care Transition Research Consortium (HCTRC) framework. Individual domain: Barriers included long ART duration and financial constrains due to low socio-economic status. Facilitators to care were a positive perspective on living with HIV, high sense of maturity and responsibility, and good health maintenance. Family/Social Support Domain: Barriers were stigma and lack of social events in the adult clinic. Facilitators were family and peer support. Health care system domain: Barriers were lack of preparation for transition and concern about the quality of care in the adult clinic which entailed payment for services, few physicians, long waiting times and poor patient-provider communication. Environment domain: Barriers were lack of national guidelines for transition and inadequate investment in adolescent health and education by the government.
Conclusion: Transition is a complex, dynamic process influenced by many factors. With projections indicating that the number of youth living with HIV in Tanzania is likely to increase in the coming years, it is vital to develop a transition protocol that addresses the challenges identified and is feasible to implement in low resource settings. A strong protocol may influence the use of health system resources, facilitate continuity of care, and improve long term disease outcomes.
Item Open Access Changes in HIV risk behavior and seroincidence among clients presenting for repeat HIV counseling and testing in Moshi, Tanzania.(AIDS Care, 2012) Fiorillo, Suzanne P; Landman, Keren Z; Tribble, Alison C; Mtalo, Antipas; Itemba, Dafrosa K; Ostermann, Jan; Thielman, Nathan M; Crump, John AWhile HIV counseling and testing (HCT) has been considered an HIV preventive measure in Africa, data are limited describing behavior changes following HCT. This study evaluated behavior changes and estimated HIV seroincidence rate among returning HCT clients. Repeat and one-time testing clients receiving HCT services in Moshi, Tanzania were identified. Information about sociodemographic characteristics, HIV-related behaviors and testing reasons were collected, along with HIV serostatus. Six thousand seven hundred and twenty-seven clients presented at least once for HCT; 1235 (18.4%) were HIV seropositive, median age was 29.7 years and 3712 (55.3%) were women. 1382 repeat and 4272 one-time testers were identified. Repeat testers were more likely to be male, older, married, or widowed, and testing because of unfaithful partner or new sexual partner. One-time testers were more likely to be students and testing due to illness. At second test, repeat testers were more likely to report that partners had received HIV testing, not have concurrent partners, not suspect partners have HIV, and have partners who did not have other partners. Clients who intended to change behaviors after the first test were more likely to report having changed behaviors by remaining abstinent (OR 2.58; p<0.0001) or using condoms (OR 2.00; p=0.006) at the second test. HIV seroincidence rate was 1.49 cases/100 person-years (PY). Clients presenting for repeat HCT reported some reduction of risky behavior and improved knowledge of sexual practices and HIV serostatus of their partners. Promoting behavior change through HCT should continue to be a focus of HIV prevention efforts in sub-Saharan Africa.