Risk factors for gonococcal and chlamydial cervical infection in pregnant and non-pregnant women in Zimbabwe.

OBJECTIVE: To identify demographic, behavioural and clinical characteristics of symptomatic and asymptomatic women with gonococcal and/or chlamydial cervicitis a study was conducted among women attending antenatal clinics and primary care clinics in Harare, Zimbabwe. DESIGN: Cross sectional study. SETTING: Primary care clinics and antenatal clinics in Harare. SUBJECTS: 467 women with vaginal discharge and 1,189 asymptomatic pregnant women. MAIN OUTCOME MEASURES: Behavioural and clinical correlates of gonococcal and chlamydial cervical infection. RESULTS: The mean age of symptomatic women was 26.11 +/- 6.84 years (range: 15 to 52 years) and that of asymptomatic pregnant women was 24.67 +/- 5.43 years (range: 15 to 45 years). Gonococcal and/or chlamydial cervical infection was found in 69 of 1,189 (5.8%) pregnant women and in 77 of 467 (16.5%) non-pregnant women. Logistic regression analysis identified the following predictors of gonococcal or chlamydial infection in women with vaginal discharge: being separated from the partner for a month or more (p = 0.002), having had sex with a new partner in the last three months (p = 0.002), current use of condoms (p = 0.011), and the finding on examination of a purulent vaginal discharge (p = 0.004). Amongst these women an increasing educational level was inversely associated with cervical infection (p = 0.007). Amongst asymptomatic pregnant women the following were identified as predictors of cervical infection: the patient admitting to having a vaginal discharge on direct questioning (p = 0.004), and the finding of a purulent vaginal discharge on examination (p = 0.001). CONCLUSIONS: Amongst symptomatic and asymptomatic women certain behavioural factors and some clinical findings are associated with cervical gonococcal or chlamydial infection. Women with multiple partners and with partners who are currently using condoms with them and those women with a purulent vaginal discharge are likely to be infected. The age and marital status of subjects was not associated with cervical infection. These findings are useful in providing appropriate care for women with overt or minimal symptoms.

Epidemiological features of drug resistant tuberculosis in Harare, 1994 to 1996.

OBJECTIVES: To characterise the prevalence, clinical and radiological features of drug resistant tuberculosis in selected patients with pulmonary tuberculosis in Harare between 1994 and 1996. DESIGN: A retrospective review of medical and microbiological records. SETTING: Beatrice Road Infectious Diseases Hospital, Harare, Zimbabwe. SUBJECTS: 381 smear-positive tuberculosis patients who had samples submitted to the National Tuberculosis Reference Laboratory for culture and susceptibility testing. MAIN OUTCOME MEASURES: Prevalence of resistance of isolated cultures of Mycobacterium tuberculosis to anti-tuberculosis drugs; clinical, radiological and microbiological response to treatment with recommended anti-tuberculosis regimens. RESULTS: Resistance to one or more drugs was detected in 16 isolates (16/165, 9.7%), single drug resistance in five (3.0%) and resistance to two or more drugs in 11 (6.7%). There were no distinctive clinical or radiological features of drug-resistant tuberculosis, although a higher percent of drug resistant cases had evidence of pleural disease (25% vs 2.5%, p = 0.005). Neither past history of tuberculosis or known or suspected HIV infection was associated with the presence of drug resistance. CONCLUSIONS: In spite of the resurgence of tuberculosis and the high prevalence of HIV infection in Zimbabwe, the rates of drug resistance have remained relatively low, even among a selected population at high risk of resistance. A significant proportion of cases of drug-resistant tuberculosis appear to be due to new transmission of drug resistant strains, which reinforces the importance of maintaining a surveillance system for the monitoring of drug susceptibility. Ongoing prospective studies should provide more reliable estimates of the prevalence and determinants of drug resistance in Zimbabwe.

Behaviour patterns which may predispose to HIV infection or further transmission and possible intervention strategy in the City of Harare. Part II.

The proportion of people with AIDS is increasing rapidly in Zimbabwe. Several strategies have been adopted to check the further spread of the disease. This paper discusses the behaviour patterns which may predispose to HIV infection and possible intervention strategies that may be taken in the City of Harare. Over a third (33.9 pc, n = 1,526) of the married respondents reported that they were living separately from their spouses. There was a high proportion (76.6 pc, n = 564) of single respondents who admitted to engaging in premarital sex. Fifteen pc of total respondents were engaging in casual sex. The proportion of single respondents (31.2 pc) engaging in casual sex was higher than among the married (11.1 pc). More single respondents (10.9 pc) had been paid for sex than the married (4.1 pc) whilst the proportion that had been paid for sex was similar for the single (21.2 pc) and the married (22.9 pc). The median age for starting sex was 17 years (range = three to 26) for the single and 18 years (range = four to 35) for the married respondents. Sixteen pc stated that they had an STD in 1989. Condom usage was low with only 9.2 pc always using a condom. Forty eight pc of the married respondents who have engaged in casual sexual relationships never use condoms. The main source of information on AIDS/HIV was the radio (74 pc). Most parents (66 pc) had not talked about AIDS to their children.

PIP: HIV transmission is spread in sub-Saharan Africa mainly through heterosexual intercourse, with most infected people in the age group 20-39 years. Findings are reported from a 1989 knowledge, attitudes, and practice study conducted in the city of Harare, Zimbabwe, among 2109 adults undertaken to identify and document behavior patterns which may predispose individuals to HIV infection and possible intervention strategies. The median age for initiating sex was 17 years among single respondents and 18 years for those married. 33.9% of married respondents reported living away from their spouses, 76.6% of singe respondents admitted to engaging in premarital sex, and 15% of all respondents were having casual sex. Only 9.2%, however, reported always using a condom, while 48% of the married respondents who have engaged in casual sexual relationships never use condoms. 16% reported having a sexually transmitted disease in 1989. 10.9% of single respondents and 4.1% of married respondents had been paid for sex. 66% of parents had not talked about AIDS to their children and the main source of information on HIV/AIDS was the radio at 74%. All types of education/prevention campaigns should be encouraged as long as health education messages do not further stigmatize people with HIV or AIDS. The poorly educated and illiterate should be specially targeted.

Knowledge and attitudes on AIDS relevant for the establishment of community care in the city of Harare.

Part I: Because of the increasing number of people with the HIV infection or AIDS, health resources and facilities are becoming over burdened. Many projects are looking towards involving communities more in caring and supporting those living with HIV/AIDS. In view of this, features of knowledge and attitudes have been drawn out of a main study on knowledge, attitudes and practices on 2 109 respondents in the City of Harare, to demonstrate areas where urgent preparation is needed to facilitate community care. The majority of respondents (96 pc) were aware that AIDS is a sexually transmitted disease. About 70 pc of the respondents thought that there were many people infected with HIV in Zimbabwe. Most of the respondents (83.3 pc) were frightened by the idea of catching AIDS. However, 82 pc would want to know if they are infected with the AIDS virus. About nine pc of the respondents said that they would commit suicide on discovering that they had HIV. Only 10 pc would have another child after becoming infected. A quarter of the respondents would not be supportive of people with AIDS. They stated that they would evict lodgers with AIDS, would avoid either neighbour, coworker or school mate with AIDS. People were generally more willing to look after their own children (76 pc) and less supportive of other relatives (68 pc) who had AIDS. Gender differences are also highlighted.

Alcohol problems among patients attending five primary health care clinics in Harare city.

Modified versions of the CAGE and WHO AUDIT (Alcohol Use Disorders Identification Test) questionnaires were used to investigate drinking habits of patients attending primary care clinics in Harare in 1989. The questionnaires were administered to 483 consecutive patients of whom 63 pc were male and 37 pc female. The results showed that 41 pc of the patients were current drinkers, and over 60 pc of them were drinking to and beyond "safe limits". Thirty nine pc of the current drinkers drank at least three or more times per week. On an average drinking day 66 pc of the male drinkers consume 10 or more units of alcohol per day. On heavy drinking days 38.5 pc of the drinkers or 16 pc of the total sample consume more than 21 units per day. These sessions occurred around paydays. Thirteen (13.2 pc) of those who consume more than 10 units per heavy drinking session exceeded the recommended frequency levels i.e. not more than three times per week. Seventy five pc of drinkers stated that they drink to socialize or for recreational purposes. About 60 pc of the current drinkers had tried unsuccessfully to cut down or stop drinking. The main reason for such an attempt reported by 92 pc of them was health problems. More current drinkers presented with STD and work-related injuries compared to non-drinkers. None of the current drinkers were asked about their drinking habits by the health workers who attended to them at the clinic. No diagnosis of alcohol dependence or an alcohol problem was made by the Primary Health Care worker at the clinic.

PIP: The proportion of individuals who abuse alcohol is growing rapidly in developing countries, especially in Zimbabwe. The authors used modified versions of the CAGE and WHO AUDIT questionnaires to investigate the drinking habits of 483 consecutive patients attending primary care clinics in Harare in 1989. 63% were male and 41% were current drinkers of whom more than 60% were drinking to and beyond safe limits. 39% of current drinkers drank at least 3 or more times per week. On an average drinking day, 66% of the male drinkers consume 10 or more units of alcohol. On heavy drinking days, however, 38.5% of the drinkers or 16% of the total sample consume more than 21 units. These latter sessions occurred around payday. 13.2 of those who consume more than 10 units per heavy drinking session exceeded the recommended frequency levels of not more than 3 times per week. 75% of drinkers stated that they drank to socialize or for recreational purposes. Further, 60% of the current drinkers had tried unsuccessfully to end or reduce their levels of drinking largely due to health problems. More current drinkers than non-drinkers presented with sexually transmitted diseases and work-related injuries. It is noted that none of the current drinkers were asked about their drinking habits by the health workers who attended to them at the clinic and that no diagnosis of alcohol dependence was made.

Hypertension control in Harare municipal clinics.

Treatment of hypertension is a growing burden on urban health services in Zimbabwe. In 1980, the Harare Health Department began a separate registry, staffed by a nurse, for management of patients with stable hypertension (diastolic blood pressure (DBP less than 100 mmHg) on treatment). We evaluated this programme in a retrospective review of 437 medical records. The average age of patients was 17.5 years; two-thirds were women. Upon referral 324 patients (74 percent) had a DBP less than mmHg. Sixty-five percent of patients had no DBP greater than 100 mmHg during follow-up. Patients with DBP greater than 20 mmHg were more likely to be treated with two drugs, seen more often or referred (p less than 05). One-third of patients enrolled between 1980-1986 were lost to follow-up. Of those who did not default, few attended regularly. We conclude that a nurse can successfully manage patients with stable hypertension, although more aggressive treatment and improved compliance would have resulted in better control. At current levels of loss to follow-up, this programme is unlikely to have much effect on the public health impact of hypertension. The main challenge is to improve patient compliance.

Is thiacetazone necessary or useful in the intensive phase of anti-tuberculous chemotherapy?

A retrospective study of 596 case notes of 1195 patients notified for tuberculosis during a three year period, in one district, was conducted. Drug reactions occurred in 75 patients (12.6 percent) and required discontinuation of therapy in 59 (10 percent). In 69 patients the skin was involved. Thiacetazone was by far the commonest drug implicated: two patients died with the Stevens Johnson syndrome. This study suggests that in the all important first two months of anti-tuberculous chemotherapy, thiacetazone, a therapeutically unnecessary agent, should be omitted as its inclusion results in an unacceptably high rate of side effects.

The decentralisation of the sexually transmitted diseases service and its integration into primary health care.

PIP: As part of National Health Policy, the City Health Department in Harare, Zimbabwe decentralized sexually transmitted diseases (STD) services and integrated it into primary health care. A central referral STD clinic was created to concentrate expertise. Simplified treatment protocols were distributed to primary care clinics, and nurses in these clinics received an intensive 2-week training course at the central clinic. This was part of a larger plan to provide comprehensive health care in easily accessible settings. The Harare City Health Department has 14 primary care clinics and 9 polyclinics staffed mainly by nursing personnel. The training course taught curative treatment of STDs and prevention by patient education and locating sexual contacts. Participants were expected to be able to utilize physical and laboratory diagnostic techniques accurately to identify common STDs, and to order appropriate treatment. The program emphasized "bedside" teaching with continuous exposure to clinical problems and discussion of those problems. The textbook used included management guidelines in the form of flow charts adapted from World Health Organization guidelines. Over 16 weeks, 49 trainees attended the course. Trainees were mainly female, while patients are mainly male. Trainees performed well, gaining self confidence and ability to manage STDs. The main problems encountered were overwork of staff in clinics when 1 lest for the program, and reluctance of male patients to be examined by female trainees.^ieng

An activity sampling study of primary care staff of two Harare polyclinics.

PIP: As part of an exercise in which clinical operations were examined, an activity sampling study was carried out at the primary care units of 2 polyclinics in Harare, Zimbabwe. 1 clinic served a population of 59,791 in a newly developed area, receiving 187,240 primary care visits, 90,830 of which were initial visits. The other clinic, situated in a more established area, served a population of 23,546, experiencing 47,705 initial primary care visits out of a totsl of 148,912 visits in 1983. The work measurement technic involved making instantaneous observations of staff member activities. 7 consecutive days were spent by the research team at each of the clinics, observing the activities of state registered nurses (SRNs), medical assistants (MAs), clinic orderlies (upgraded literate domestic workers given in-service training), and maids. 50 observation times were randomly selected daily between 7:30 a.m. and 4:00 p.m. from Monday to Friday; and 33 random times between 7:30 a.m. and 1:00 p.m. on Saturdays and Sundays. The study found that at the clinic where MAs were engaged more in consulting patients, the SRNs and sister-in-charge had more time to supervise and administer staff, and screen patients (they spent 12.4% of their time in administration, as opposed to the other clinic, where they spent 2.3%). It is suggested that increasing the delegation of duties to the MAs can improve clinic operations.^ieng

Immunization status of children living in Harare, Zimbabwe.

PIP: Surveys to ascertain the immunization status of children living in Harare, the capital of Zimbabwe (population 658,364 as of the 1982 census) were carried out over a period of 10 days in May/June 1982 and a period of 6 weeks in October/November 1983, using World Health Organization prescribed cluster sampling methods. 206 children were examined in 1982 and 234 in 1983. 82.5% of children were found to have record cards in the 1982 survey, 88.5% in 1983. 47.6% were considered fully immunized in 1982, 55.6% in 1983. In 1982, 74.0% of children were recorded as having BCG scars, 79.4% in 1983. 64.6% and 71.4% had measles innoculations respectively. DPT (dyptheria, pertussis, tetanus) injections had been given to 69.9% in 1982 and 76.5% in 1983. Figures for 2nd and 3rd DPT boosters were 65.5% and 58.7% for 1982 and 76.5 and 75.6% for 1983. Figures for 1st innoculations with OPV (polio) were 69.9 and 76.5% for 1982 and 1983 respectively. 2nd and 3rd polio booster figures were 66.0 and 57.8% for 1982 and 76.5 and 74.8% for 1983. The study was part of an evaluation of immunization integrated with maternal and child health services in the city, administered by nursing personnel, health visitors, and medical assistants in various clinics. Dropout rates for 1st to 2nd dose and 1st to 3rd dose for DPT and OPV improved markedly. Increased usage of immunization probably reflects publicity generated by the 1982 program launching. The extent of infection by these 6 diseases in Zimbabwe is not known, although most are frequently encountered. Survey studies will be required to ascertain reasons for nonimmunization, in order to attain total immunization by 1990.^ieng