Epidemiology of injury patients at Bugando Medical Centre, Tanzania.

OBJECTIVE: To describe the epidemiologic characteristics of injury cases at Bugando Medical Centre. SETTING: Bugando Medical Centre, Mwanza, Tanzania. DATA SOURCES: Records, registries and case notes in the surgical wards and clinic, casualty, medical record department, radiology and theatre from January 1995 to December 1997. STUDY SAMPLE: Cases attended to at Bugando and diagnosed to have had an injury during the stated period. Only those whose records were complete and available were recruited in the study. DATA EXTRACTION: A special data sheet was used to collect the required information from the registries in surgical wards clinic, casualty, theatre, radiology and medical records. Data analysis was Dbase IV and SPSS (version 9.0). RESULTS: There were 3,590 cases of injury recorded at the centre of whom 3340 (93%) whose data were complete were available for analysis. Of the cases, 2,443 (73.1%) were males and 897 (26.9%) females while 252 (7.7%) were children under five years. The most affected age group were the 20-59 year category comprising of mostly males. The leading causes of injuries were falls, assault (28.7%) and motor traffic accidents (17.9%). Mortality was (2.2%) for all causes, and permanent disability was two per cent. The mean length of stay in hospital was 21 days (range: 1-321 days). CONCLUSION: A more comprehensive study isrecommended to determine risk factors and magnitude of the problem.

Improved injection practices after the introduction of treatment and sterility guidelines in Tanzania.

OBJECTIVE: To evaluate the effect of introduction of treatment and sterilization guidelines on the number of avoidable injections and on the sterility of needles and syringes. METHODS: In 1991, 66 randomly selected health units in Mwanza Region, Tanzania, were visited and factors were determined that might contribute to HIV transmission by injections. In a workshop with all senior health workers from the region, findings were presented and treatment and sterilization guidelines developed. Thereafter, seminars were held at each health centre of the region. Four months after the intervention, data were collected at the same health facilities in order to assess changes in prescribing practices, sterilization procedures, and sterility of needles and syringes. RESULTS: The knowledge on indications for injections improved markedly for paramedical staff. The proportion of outpatients receiving an injection dropped from 23% to 10% and the proportion of patients receiving an avoidable injection dropped from 16% to 6%. Procedures for sterilization, keeping sterilized equipment, and administration of injections improved. A smaller proportion of sterilized needles and syringes tended to be contaminated in dispensaries, but this reduction from 44% to 22% was not significant. CONCLUSION: Considerable improvement in knowledge, prescription practices and sterility procedures was observed at dispensary level after carrying out a training programme.

Sexual transmission of hepatitis B in Mwanza, Tanzania.

BACKGROUND: Hepatitis B virus (HBV) is endemic and poses a grave public health problem in Africa where it is mainly transmitted from mother to baby or during childhood. Sexual transmission has also been suggested to play a role in East Africa, but this has never been properly demonstrated. Additional preventive strategies may be proposed if sexual transmission of HBV occurred in this region where HIV and other STDs are highly prevalent. GOALS: To determine the prevalence of markers for hepatitis B virus (HBV)and other sexually transmitted diseases (STD) in routine blood samples taken from three populations in Mwanza, Tanzania, and to use the data collected to look at the association between hepatitis B and other STDs, including human immunodeficiency virus (HIV). STUDY DESIGN: Routine blood samples were collected from 1,025 patients attending a clinic for STDs, 253 voluntary blood donors from secondary schools, and 952 blood donors who gave blood in a hospital specifically for a relative who needed a blood transfusion. All samples were tested for HIV by double enzyme-linked immunosorbent assay (ELISA), and for syphilis using the Treponema pallidum hemagglutination (TPHA) and rapid plasma reagin (RPR) tests. Two markers for HBV were examined by the double ELISA method, the presence of the anti-hepatitis B core antigen (anti-HBc) and the hepatitis B surface antigen (HBsAg). RESULTS: There were high prevalences of HBV, syphilis, and HIV in relative donors and STD patients. Although HBV markers were more prevalent in men of increasing ages, syphilis and HIV markers were more prevalent in young women. Evidence of past infection with HBV (presence of anti-HBc) was associated with serologic markers of recent treponemal infection (both TPHA and RPR positive) in both sexes (men odds ratio [OR] = 1.91, P < 0.011; women OR = 2.34, P < 0.02) and with HIV in men (OR = 1.93, P < 0.003). Current infection with HBV (presence of HBsAg) was associated with recent syphilis in men (OR = 2.13, P < 0.006). In STD patients, current infection with HBV was associated with Trichomonas vaginalis in women (OR = 3.57, P < 0.002) and recent syphilis in men (OR = 3.46, P < 0.001). There was no further association between HBV markers and any other STD pathogen or any particular STD syndrome, nor was there any association between current HBV infection and HIV in both sexes. The population attributable fraction for sexual acquisition of hepatitis B is estimated at 7.2% in men and 3.0% in women, based on the association between hepatitis B and syphilis. CONCLUSIONS: These findings suggest that sexual acquisition of hepatitis B occurs at low levels in Mwanza, and that HBV can be prevented through enhancement of the current HIV/STD control activities, in addition to improved vaccination strategies.

PIP: To investigate the role of sexual transmission of hepatitis B virus (HBV) in East Africa, a cross-sectional serosurvey was conducted in 3 populations with potentially divergent exposure to sexually acquired pathogens. Included were 253 voluntary blood donors (predominantly secondary school students), 952 relative blood donors, and 1025 patients with sexually transmitted diseases (STDs) from Mwanza, Tanzania. The overall prevalence of hepatitis B surface antigen (HBsAg)--a measure of current infection--was 9.9% in voluntary donors, 11.2% in relative donors, and 8.1% in STD patients, with a 2.2:1 carrier ratio of men to women. The prevalences of human immunodeficiency virus (HIV), anti-hepatitis B core antigen (anti-HBc), and past or recent syphilis were significantly lower among voluntary donors than in the other 2 groups. Evidence of past infection with HBV (anti-HBc) was associated with recent syphilis in both men and women (odds ratios (ORs), 1.91 and 2.34, respectively) and with HIV in men (OR, 1.93). Current infection with HBV (HBsAg) was associated with recent syphilis in men (OR, 2.13). In STD patients, current HBV was associated with Trichomonas vaginalis in women (OR, 3.57) and recent syphilis in men (OR, 3.46). There was no significant association between HBV and gonorrhea. Based on the association between syphilis and HBV, the population attributable fraction for sexual acquisition of HBV is estimated at 7.2% in men and 3.0% in women. Overall, these findings suggest that the sexual acquisition of HBV occurs at low levels in Mwanza. Improved vaccination strategies, early detection and treatment of syphilis, and programs aimed at reducing HIV transmission should enhance the control of HBV.

Occupational exposure to the risk of HIV infection among health care workers in Mwanza Region, United Republic of Tanzania.

During 1993, we collected data on knowledge of human immunodeficiency virus (HIV) transmission, availability of equipment, protective practices and the occurrence of prick and splash incidents in nine hospitals in the Mwanza Region in the north-west of the United Republic of Tanzania. Such incidents were common, with the average health worker being pricked five times and being splashed nine times per year. The annual occupational risk of HIV transmission was estimated at 0.27% for health workers. Among surgeons, the risk was 0.7% (i.e. more than twice as high) if no special protective measures were taken. Health workers' knowledge and personal protective practices must therefore be improved and the supply of protective equipment supported. Reduction of occupational risk of HIV infection among health workers should be an integral part of acquired immunodeficiency syndrome (AIDS) control strategies.

PIP: An investigation of occupational exposure to human immunodeficiency virus (HIV) among health workers in hospitals in Tanzania's Mwanza region raised serious concerns about a lack of protective measures against such risk. Data, including questionnaires and direct observation, were collected during May-September 1993 in 9 hospitals in the region. Among the 403 hospital workers who completed an acquired immunodeficiency syndrome (AIDS)-related questionnaire, 71% had adequate knowledge scores. On the other hand, observation of hospital wards revealed insufficient measures to reduce the risk of HIV transmission (e.g., non-functioning water taps, lack of plastic bags for disposal of soiled linen, widespread shortage of gloves). 9.2% of 623 nurses and 1.3% of 118 doctors and medical assistants interviewed had pricked themselves in the preceding week; 22% of nurses working in labor wards and 25% of those working in operating theaters had pricked themselves in the previous month. Among the 50 laboratory technicians interviewed, 25% had been pricked in the previous month. In addition, more than half of nursing and medical personnel has been splashed, largely by blood and amniotic fluid, in the preceding month. Assuming an HIV prevalence of 20% among hospital patients in Mwanza, the estimated annual incidence of HIV infection due to occupational exposure is 0.27%, with percutaneous exposure contributing 93% of this risk. Among surgeons, this risk is even higher: 0.7% per year. Prevention of pricking accidents through use of double gloving, forceps to remove syringes, and appropriate containers for needle disposal should be a priority to reduce the risk of occupational HIV exposure.

Injection practices in Mwanza Region, Tanzania: prescriptions, patient demand and sterility.

This paper describes prescription and sterilization practices in Mwanza Region, Tanzania, before the introduction of interventions aiming at reducing HIV transmission by injections. Sixty-six health facilities from Mwanza Region were included in the study. Data were collected in interviews and questionnaires, through structured observation, bacteriological culture and record analysis. Criteria for avoidable injections were based on recommendations of the Essential Drugs Programme and on a regional consensus workshop. One in 4 out-patients received an injection 70% of which were avoidable. Most were given for acute respiratory infections, skin diseases and urinary tract infections. Forty per cent of cultures taken from sterilized needles and syringes yielded growth of microorganisms. Of 120 patients interviewed most preferred to be treated with injections for almost any complaint. Patient demand for injections was felt to be a problem in 85% of the health facilities and may have contributed to overprescription of injectables. Consensus treatment and sterilization guidelines as well as a health education programme were developed and introduced to all health workers through seminars.

Acute isovolaemic haemodilution: the best option for autologous blood transfusion in Africa?

The purpose of this study was to identify the best method of autologous blood transfusion to be applied in an East African hospital. One hundred and nine consecutive patients for whom major blood loss was anticipated were enrolled. Seventeen patients donated 1 unit of blood 3 days preoperatively and 92 underwent acute isovolaemic haemodilution prior to induction of anaesthesia. For the haemodiluted patients a 2:1 ratio of sterile pryogen-free saline to collected blood was used. One of the 16 patients from whom 2 units were withdrawn by haemodilution experienced hypovolaemia which was rapidly restored by additional transfusion of colloid. Of the patients who donated blood preoperatively only 23.5% were autotransfused compared to 98.9% of the haemodiluted patients. Of the latter 23.9% (22) had an intraoperative blood loss exceeding 15% of their total blood volume and 7.6% (7) lost more than 25%. Only one received homologous blood in addition. For hospitals with limited blood bank facilities and regular cancellation of surgery, the use of acute isovolaemic haemodilution is recommended. A 3:1 ratio of saline to blood is now advised when 1 unit is withdrawn and a part replacement with crystalloid when 2 units are collected.

Attitudes and beliefs about blood donation among adults in Mwanza Region, Tanzania.

A study was carried out to assess the attitudes and beliefs about blood donation among the population of Mwanza Region, Tanzania, in order to target better the voluntary blood donor recruitment and retention. A random sample of 1141 adults, 743 residents of Mwanza town and 398 from Mwanza rural areas were interviewed on aspects related to blood donation. A high proportion (26.4%) of interviewees had already given blood but only 3.8% had donated voluntarily within the last 10 years. Voluntary blood donation was correlated with secondary school attendance. We noted a positive attitude towards voluntary blood donation although the majority of people would do so only for an incentive in the form of remuneration. Respondents frequently thought that blood donation would infect them with HIV or damage their health. No correlation was found between fear to donate and self perceived risk for HIV infection. We found that a substantial number of men would accept pre-test counselling on HIV in order to "infect others" if found positive. Thus we recommend that HIV counselling should be done with extreme care and defer individuals with wrong intentions from blood donation. Donor recruitment campaigns should also focus on clearing wrong conceptions about blood donation through providing information on all aspects related to blood donation. Based on these findings, a scheme for blood donor recruitment and retention in Mwanza Region is proposed.

Reducing the cost of HIV-testing through use of the IgG antibody captured particle adherence test (GACPAT) in district hospitals.

Though the World Health Organization (WHO) has acted to reduce the price of anti-HIV assays for developing countries, the cost of the large-scale testing to be done may still be prohibitive to the health budget of these countries. GACPAT, a modified commercial particle assay, is ten times cheaper than the WHO price of ELISAs. In this study GACPAT was introduced in three district hospital laboratories (DHL) in Tanzania, and the results compared with those on the same sera in a reference laboratory (RL). Sensitivity and specificity were 92.6% and 98.7%, respectively at DHL. It is concluded that GACPAT is a valid, feasible and cheap alternative for ELISA anti-HIV-testing also at district hospital laboratory level.

PIP: In developing countries, routine HIV testing has largely been used in the screening of blood donors, sentinel surveillance, and for epidemiological purposes. There is, however, an increasing individual demand for voluntary HIV testing and diagnostic HIV testing in hospitals. Testing remains very expensive in developing countries relative to available resources. The IgG antibody captured particle adherence test (GACPAT) is a modification of the Serodia particle agglutination test. This modification substantially lowers the cost per HIV antibody test without loss of specificity and sensitivity; the GACPAT is 10 times cheaper than the World Health Organization price for ELISAs. Using plates coated at a regional reference laboratory, GACPAT was evaluated in a government district hospital, a voluntary agency district hospital, and a designated district hospital. Test sensitivity and specificity were 92.6% and 98.7%, respectively in the district hospital laboratories. The authors deem GACPAT to be a valid, feasible, and cheap alternative for ELISA anti-HIV testing also at the district hospital laboratory level.

Secondary school students: a safer blood donor population in an urban with high HIV prevalence in east Africa.

We evaluated the enrollment of secondary school students as voluntary unremunerated blood donors in a city where the HIV-1 prevalence among the adult population is 11.8%. Between 1st July, 1992 and 1st December, 1993, consecutive blood donors were screened for anti-HIV-1, TPHA, HBsAg and anti-HBc. Test results were related to age, sex, voluntary or relative donor status. 525 (22.4%) of 2345 were voluntary donors aged 24 years or less and 529 (29.6%) of 1820 of the relative donors were of the same age group. Voluntary donors had statistically significant lower prevalence rates of anti-HIV-1, TPHA, and anti-HBc, 1.5%, 2.1% and 50.2% respectively, compared to relative donors of the same age group, 4.7%, 9.0% and 70.3% respectively. We conclude that secondary school students constituted a safer donor population. The student population offered the additional advantage of being easily accessible for donation and lesser blood units needed to be discarded. For a blood transfusion centre in an urban settlement, recruitment of secondary school students as voluntary unremunerated blood donors should be considered as a cost-effective strategy.

Changes in blood transfusion practices after the introduction of consensus guidelines in Mwanza region, Tanzania.

OBJECTIVE: To assess the effect of introducing consensus guidelines on avoidable blood transfusions in Mwanza region, Tanzania. METHODS: Avoidable blood transfusions were determined among 842 blood transfusion recipients in eight hospitals in 1991. In a workshop with senior health workers from the region, consensus guidelines for the prescription of blood transfusions were developed and introduced in the hospitals and after 7 months intervention data were collected on 1042 blood transfusion recipients. The 1991 and 1992 data were compared to estimate the change in the proportion of avoidable blood transfusions. RESULTS: In blood transfusion recipients aged < 5 years there was a significant reduction in the proportion of avoidable blood transfusions from 257 (52%) out of 498 to 197 (33%) out of 595 (P < 0.001), especially at the peripheral hospitals. For children the proportion decreased from 25 to 17% (P < 0.05) and for operated patients the percentage remained at 24%. In pregnant women there was a significant increase in the proportion of avoidable blood transfusions from 10 to 27% and in adults from 37 (25%) out of 146 to 121 (50%) out of 242. The improvement in peripheral hospitals was offset by a similar deterioration in the referral hospital, thus no overall reduction was achieved in the proportion of avoidable blood transfusions. CONCLUSION: The development and introduction of consensus guidelines was not sufficient to change prescribing practice. The proportion of avoidable blood transfusions decreased only in hospitals where compliance was maintained through regular clinic meetings and strict supervision by senior medical staff.

PIP: In 1991, senior health staff in the Mwanza region of Tanzania achieved consensus guidelines for the prescription of blood transfusions and introduced these guidelines through training workshops to staff of all hospitals providing blood transfusions. Seven months after the workshops, researchers collected data on 1042 blood transfusion recipients to evaluate the effect of the introduction of the consensus guidelines on avoidable blood transfusions. A significant reduction in the proportion of avoidable blood transfusions occurred among the 595 5-year-old children (52% vs. 33%; p .001). The reduction was even greater in the peripheral hospitals (59% vs. 32%; p .001). The proportion of avoidable blood transfusions fell considerably among 5-14 year old children (25% vs. 17%; p .05). Avoidable blood transfusions did not decline among operated patients (24%). They increased significantly among adults (25% vs. 50%) and among pregnant women (10% vs. 27%). The referral hospitals had more avoidable blood transfusions at evaluation than at baseline (45% vs. 26%; p .001), while the peripheral hospitals performed significantly better in 1992 than in 1991 (28% vs. 46%). Most of the improvement in peripheral hospitals was limited to 1 hospital (61% vs. 23%; p .001). Among the remaining peripheral hospitals, the improvement was slight (35% vs. 30%; p .05). Hospitals with regular clinic meetings to discuss the consensus guidelines and senior medical staff who strictly supervised and provided feedback to interns either improved significantly or maintained their already good blood transfusion practices. The hospital that maintained an already low proportion of avoidable blood transfusions required physicians to include the indication for blood transfusion in patient records. These findings show that there was no overall reduction in avoidable blood transfusions, and that the development and introduction of consensus guidelines alone did not change prescribing practices.