Training of village health workers in Tanzania; a comparison of two approaches.

The paper compares the costs of training for two groups of Village Health Workers (VHWs) in Tanzania, where the policy of developing a system based on Primary Health Care principles will require the training of more than 16,000 VHWs during the next decade. In the Kilombero District, one group of VHWs was trained according to the guidelines of the National Programme of the Ministry of Health, and another group followed the training programme of the Kilombero Project, based on the Swiss Tropical Institute Field Laboratory. The training scheme of the Kilombero project cost almost 80% less for one VHW, largely because it depended on on-the-spot training by local staff. The results of a first investigation of the efficacy of the training were encouraging; a long-term evaluation is in progress. The curricula for the two programmes also differed; the Kilombero programme had shorter blocks of theory, interspersed with supervised practical work, and introduced curative medicine earlier in the course. The advantage and disadvantages of the two programmes are discussed, not only in terms of cost but also in terms of their efficacy in training VHWs who will be motivated, efficient and accepted by the community.

Liver disease in rural Tanzania--a diagnostic approach.

In a prospective study on the aetiology of liver disease and its diagnostic approach in a District hospital in rural Tanzania, 48 consecutive patients with evidence of liver disorders were investigated by physical examination, biochemical tests, laparoscopy and histology. Liver cirrhosis (posthepatic, alcoholic) was found in 31%; non cirrhotic alcoholic liver disease in 15%; viral, bacterial and protozoal liver disorders in 33%, and neoplastic liver changes in 21% of all patients. Clinical impression alone coincided with the final diagnosis in 40% of all cases. This figure was increased to 46%, when haematological and biochemical results were included, and to 71%, when laparoscopy (without histology) was used in addition. Laparoscopy was particularly decisive in the diagnosis and further management of cirrhosis, liver abscess and neoplastic liver disorders. The additional information obtained from histology led to the final diagnosis. Histology was specially useful for the diagnosis of alcoholic liver disease, tropical splenomegaly syndrome and non specific reactive hepatitis. The usefulness of laparoscopy as a diagnostic tool in a district hospital is discussed.

Longitudinal study on the health status of children in a rural Tanzanian community: parasitoses and nutrition following control measures against intestinal parasites.

Three repeated cross-sectional surveys were undertaken among children (1 month to 15 years) of a rural community in southeastern Tanzania. The study was part of a longitudinal project on the interactions among nutrition, parasitic infections and immunity within a primary health care programme emphasizing village health workers. All children underwent interviews and parasitological, anthropometric, anamnestic and clinical examinations. Out of 550-590 children examined each year, a cohort of 170 children could be followed for three consecutive years. Malaria was holo- to hyperendemic in the community, P. falciparum accounting for greater than 90% of the infections. The parasite and spleen rates were 88% and 67%, respectively, and the average enlarged spleen index was 2.0 among children from 2-9 years in 1982. Transmission of malaria was high and stable as indicated by a parasite rate of 80% among infants between 1 month and 1 year during the whole period of study. G. lamblia, hookworm (N. americanus), Strongyloides spp. and Schistosoma haematobium were highly prevalent and annual incidence rates were high, while Entamoeba histolytica, Ascaris and Trichuris were of minor importance. Prevalence and incidence of parasitic infections did not differ by sex. Multiparasitism was very frequent and less than 11% of all children were parasite-free in each year. Not a single child remained parasite-free for three consecutive years. An anthropometric assessment showed a high degree of stunting (35-71%) and a substantial proportion of wasting (3-20%). The growth potential was normal in girls and boys during the whole period of study. There were indications that malaria was the main contributory factor to growth retardation among young children. Hookworm infection did not significantly affect the packed-cell volume of the children, probably owing to the low intensity of infection. Due to the multiparasitism and the lack of parasite-free individuals, single-parasite and single-nutrient effects were difficult to unravel. A latrine campaign followed by a single mass treatment against hookworm (single oral dose of albendazole, 400 mg) and/or G. lamblia (single oral dose of ornidazole, 40 mg/kg) only temporarily affected the prevalence and incidence of G. lamblia, and only resulted in a decrease in the intensity of hookworm infections up to six months after the interventions. As the effects of the latrine campaign and a single mass treatment on the parasite load were only transient, no sustained impact on nutritional variables was observed.(ABSTRACT TRUNCATED AT 400 WORDS)

Longitudinal study on the health status of children in a rural Tanzanian community: comparison of community-based clinical examinations, the diseases seen at village health posts and the perception of health problems by the population.

Standardised household interviews among adults and children, open-ended questionnaires, and clinical examinations administered during cross-sectional health status surveys, as well as the registers of village health posts (VHP), were used to assess the pattern of health problems of a rural community in southeastern Tanzania, and their results compared. All four approaches gave very similar results for the two major health problems (fever/malaria and abdominal pain or discomfort) which were mentioned by both children and adults. The parasitological data from the cross-sectional surveys also revealed hyperendemic P. falciparum malaria and a high prevalence and incidence for infections with hookworm (N. americanus), Strongyloides, and G. lamblia. However besides consistently revealing the two major health problems, each approach showed a distinct pattern for the additional health problems: household interviews and open-ended questionnaires resulted in a higher ranking of problems that had not yet been solved by the health care facilities available in the community at the time of the interview. This view was further biased by the fact that the interviews were done by people representing the health professionals. The statistics from the registers of VHP clearly reflected the types of treatment provided by this service. Malnutrition and various eye problems only became evident during the clinical examination of the population. However, the clinical examination did not identify the importance of the abdominal problems in the community. The cross-sectional survey (questionnaires, clinical examination) chiefly showed the health problems affecting the population around the time of the surveys (end of the dry season). Interestingly, the registers of the VHP did not show marked seasonal variations in the morbidity statistics for this community. Both questionnaire approaches and the registers of VHP showed a change in both the morbidity and the disease perception pattern that may reflect the effects of interventions launched at community level (activities of village health workers, mass-treatment against hookworm and G. lamblia). The study indicated that the individual ranking of the major health problems matched with data from health status surveys. It also pointed to the possibility that disease perception patterns could become a tool for community diagnosis and for the monitoring of health care programs.

A longitudinal study on relations of retinol with parasitic infections and the immune response in children of Kikwawila village, Tanzania.

From 1982 to 1984 170 children of Kikwawila village (Kilombero district, Tanzania) were followed for nutritional (anthropometric measures, hematocrit, serum retinol, prealbumin, and zinc concentrations), parasitological (malaria parasitemia, urinary schistosomiasis, intestinal parasites) and immunological characteristics. Between 2.9% and 12.4% had serum retinol levels less than 100 micrograms/l which indicate deficiency. Retinol concentrations were correlated with age, hematocrits, prealbumin levels and mid upperarm circumferences. The latter correlation may be useful in nutritional surveys and primary health care programs for the identification of populations at risk of retinol deficiency. No association was found between average retinol levels and the presence of parasites, with the exception of malaria. Retinol levels were inversely correlated with malaria parasitemia in 1982, and directly correlated with antibody titers to synthetic sporozoite peptide in 1984. Since retinol, malaria parasitemia, and antisporozoite antibodies increased with age, confounding by age could not be excluded. Six months after administration of ornidazole in a single oral dose of 10 mg/kg, a significant effect on the prevalence of Giardia lamblia was found. Following treatment, average retinol levels were increased in persons with confirmed G. lamblia infections, but not in uninfected or untreated controls.

Chloroquine administration for malaria suppression after abdominal surgery.

Administration of chloroquine after major surgery is indicated in malaria endemic areas. In emergencies it is commonly administered parenterally after the operation. The present study, undertaken at St. Francis Hospital, Ifakara (Kilombero District), Tanzania, compared plasma chloroquine levels after oral and subcutaneous administration of 300 mg of chloroquine base in 14 patients after abdominal, non-bowel-resective surgery and in 12 controls. There were no significant differences in the plasma chloroquine levels of all groups, and the chloroquine concentrations reached suppressive levels for at least 3 days (greater than 0.1 nmol/ml). Oral administration was well tolerated in both patients and controls. In all areas where the Plasmodium strains are still sensitive to chloroquine and where parenteral chloroquine may not be easily available, oral chloroquine represents a cheap, easy and safe alternative for postoperative prophylactic malaria suppression. It can be applied after abdominal non-bowel-resective emergency surgery.

Community participation within a primary health care programme.

Based on experiences made in rural communities of Tanzania, aspects of community participation in schistosomiasis control within a primary health care (PHC) programme are discussed. Community participation is seen as prerequisite for PHC. Building up community participation can not be disease- or even symptom-orientated, it must be community problem-orientated. The assessment of village priorities as they are recognized by the community governs any control strategy based on PHC. As schistosomiasis is often not first ranking among community problems, schistosomiasis control must become part of a multisectorial approach to improve community health. This process can initiate and ensure community participation and may lead to cost-effective control measures within PHC.

Comparison of ultrasonography, intravenous pyelography and cystoscopy in detection of urinary tract lesions due to Schistosoma haematobium.

The use of ultrasound in detecting urinary tract alterations by Schistosoma haematobium such as hydronephrosis and bladder calcifications was studied in 125 patients of the out-patients department of a district hospital in SE Tanzania, in an area highly endemic for this disease. Ultrasound was compared with plain abdominal X-ray (in 33 patients), intravenous pyelography (29), cystoscopy (31) and simple urine examination (125). Except for bladder calcifications which could not be demonstrated other than by X-ray, sonography compared favorably with IVP and cystoscopy and proved therefore to be a valuable tool in assessing S.h. related morbidity. In children moderate and advanced hydronephrosis were always associated with an irregular bladder wall and correlated strongly with the prevalence and intensity of S.h. infections as well as with haematuria and proteinuria. Important congestive pathology was observed in 1 out of 10 infected children and in 1 out of 20 examined adults.

Value of ultrasonography in investigating morbidity due to Schistosoma haematobium infection.

In an area where urinary schistosomiasis was endemic 349 patients were examined by ultrasonography. To evaluate the sensitivity and specificity of this technique, intravenous pyelography and cystoscopies were also done on 29 and 31 patients, respectively. Ultrasonography compared favourably with pyelography and cystoscopy except in demonstrating bladder calcifications. It was a valuable tool for rapid mass detection of Schistosoma haematobium related morbidity. Major renal congestion and irregularity of the bladder wall as seen on ultrasonography correlated strongly with the prevalence and the intensity of S haematobium infection as well as with microhaematuria and proteinuria, thus indicating the usefulness of urine dip sticks for S haematobium case-finding, especially during attempts at morbidity control in endemic areas.

Nonmalignant monoclonal immunoglobulinemia, pernicious anemia and gastric carcinoma. A model of immunologic dysfunction. Report of two cases and review of the literature.

The association of an autoimmune disease with a monoclonal immunoglobulin is not exceptional and most probably results from a dysfunction of the immunologic apparatus. This study describes two patients with monoclonal immunoglobulin A (IgA) and M (IgM) gammopathy, respectively, in whom pernicious anemia and finally gastric carcinoma developed. One patient had autoantibodies to gastric parietal cell and to thyroid microsomal antigen which could not be identified with the M-component. This observation, together with the fact that pernicious anemia occurred in one case before and in the other case after the discovery of M-component, suggests that different clones of cells were responsible for both disorders. Sixteen cases in which the patients had the same association have been collected from the literature and the data are compared with ours.