Tuberculosis among the elderly in Tanzania: disease presentation and initial response to treatment.

BACKGROUND: Reports on tuberculosis (TB) presentation among the elderly in sub-Sahara Africa are scarce at a time when the elderly population is increasing. This dearth of information is likely to lead to an increase in the number of undetected TB cases in the region. OBJECTIVE: To describe TB presentation and response to anti-tuberculosis treatment at 2 months among elderly patients. METHODS: Consecutive patients referred to TB centres in Dar es Salaam, Tanzania, underwent clinical, microbiological and chest X-ray (CXR) evaluations at baseline and after 2 months of anti-tuberculosis treatment. Patients aged 60 years were considered elderly and those aged 18-59 years formed the comparison group. RESULTS: Elderly patients with TB were more likely to have smear-negative TB (76.7% vs. 49.3%, P < 0.0001) and lower-zone lesions on CXR (41% vs. 17%, P < 0.001), but less likely to have cavities on CXR (77.6% vs. 50.4%, P < 0.0001) than the comparison group. Hypertension and diabetes mellitus were more common among the elderly than among controls. Mortality at 2 months was respectively 18.6% and 8.1% among the elderly and among controls. Human immunodeficiency virus infection and smoking increased mortality, while hypertension was associated with reduced mortality. CONCLUSION: TB in the elderly was associated with atypical clinical and radiological presentations. A high index of suspicion could minimise delays in diagnosis and treatment.

Determinants of timely uptake of ITN and SP (IPT) and pregnancy time protected against malaria in Bukoba, Tanzania.

OBJECTIVE: Insecticides treated nets (ITNs) and intermittent preventive therapy with two doses of sulfadoxine-pyrimethamine (SP IPTp) are the cornerstone for malaria control in pregnancy. Despite the coverage of these interventions being high, it is not known whether they confer optimal protection time against malaria in pregnancy. This study investigated the timing and determinants of timely uptake of SP(IPTp) and ITNs and the pregnancy time protected. METHODS: A health facility based cross-sectional study was carried out in Bukoba urban district from 16th April to 29 May 2013. Involving pregnant women and post natal mothers attending Reproductive and Child Health (RCH) clinics. Data on their socio-economic background, pregnancy history and attendance to RCH, receipt of a voucher and acquisition of an ITN as well as SP for IPTp were collected. Their responses were validated from the records of antenatal cards. Data was analysed using SPSS computer program version 20. RESULTS: A total of 530 mothers were recruited. The overall uptake of SP IPTp was 96 % and the uptake of two SP (IPTp) doses was 86 %. Timely uptake of 1st dose was predicted by early antenatal booking, [AOR 2.59; 95 % CI 1.51-4.46; P = 0.001], and the availability of SP at the facility [AOR 4.63; 95 % CI 2.51-8.54; P < 0.0001]. Uptake of 2nd dose was independent of any predictor factors. A total of 486 (91.6 %) women received ITNs discount vouchers at different gestational age and of these, less than a quarter (21.4 %) received timely. Timely receipt of discount voucher was highly predicted by early antenatal booking [AOR 200; 95 % CI 80.38-498; P < 0.0001]. CONCLUSION: Although there is a high coverage of SP IPTp and discount vouchers for ITNs, timely uptake and therefore optimal protection time depended on early antenatal booking, the availability of (SP IPTp) and discount voucher at the health facility.

HIV patients presenting common adverse drug events caused by highly active antiretroviral therapy in Tanzania.

Antiretroviral (ARV) drug toxicities pose treatment challenges and contribute to poor adherence. This study was carried out to document the commonly reported adverse reactions caused by ARV drugs in HIV patients in Tanzania. Information on drug induced adverse reactions (ADRs) in patients using ARV drugs was collected from the databases maintained in HIV clinics of Dar es Salaam and Mbeya. A total of 7502 and 1234 records of patients under ARV therapy by December 2006 were analysed in Dar es Salaam and Mbeya, respectively. In May, 2008 a cross-sectional study was conducted in which, the association between nevirapine (NVP) plasma concentrations and skin rashes problems was determined in 50 patients put on NVP based HAART for less than 2 weeks. Determination of NVP plasma concentration was carried out using a validated HPLC method in which patients from Dar es Salaam were involved. The study revealed that, anaemia, liver toxicity, skin rash and peripheral neuropathy were the most reported ADRs. The NVP plasma level determination revealed that there was no difference between those who had experienced skin rashes and those who did not (mean of 6.05 and 5.5 microg/ml respectively). There was a slight increase in reported ADRs between 2005 and 2006. A total of 932 (12.4%) patients changed their regimen in Dar es Salaam between January 2005 and December, 2006. Similarly, a total of 542 (44%) patients in Mbeya changed their regimen during that period. It can be concluded that, in both Dar es Salaam and Mbeya patients developed ARV related ADRs which are similar to those reported elsewhere.

Risky sexual practices among youth attending a sexually transmitted infection clinic in Dar es Salaam, Tanzania.

BACKGROUND: Youth have been reported to be at a higher risk of acquiring STIs with significant adverse health and social consequences. Knowledge on the prevailing risky practices is an essential tool to guide preventive strategies. METHODS: Youth aged between 18 and 25 years attending an STI clinic were recruited. Social, sexual and demographic characteristics were elicited using a structured standard questionnaire. Blood samples were tested for syphilis and HIV infections. Urethral, high vaginal and cervical swabs were screened for common STI agents. RESULTS: A total of 304 youth were studied with mean age of 21.5 and 20.3 years for males and females respectively. 63.5% of youth were seeking STI care. The mean age of coitache was 16.4 and 16.2 years for males and females respectively. The first sexual partner was significantly older in females compared to male youth (23.0 vs 16.8 years) (p < 0.01). 93.2% of male youth reported more than one sexual lifetime partner compared to 63.0% of the females. Only 50% of males compared to 43% of females had ever used a condom and fewer than 8.3% of female youth used other contraceptive methods. 27.1% of pregnancies were unplanned and 60% of abortions were induced. 42.0% of female youth had received gifts/money for sexual favours. The HIV prevalence was 15.3% and 7.5% for females and males respectively. The prevalence of other STIs was relatively low. Among male youth, use of alcohol or illicit drugs was associated with increased risk of HIV infection. However, the age of sexual initiation, number of sexual partners or the age of the first sexual partner were not associated with increased risk of being HIV infected. CONCLUSION: Most female youth seen at the STI clinic had their first sexual intercourse with older males. Youth were engaging in high risk unprotected sexual practices which were predisposing them to STIs and unplanned pregnancies. There is a great need to establish more youth-friendly reproductive health clinics, encourage consistent and correct use of condoms, delay in sexual debut and avoid older sexual partners in females.

Prevalence and risk factors for vaginal candidiasis among women seeking primary care for genital infections in Dar es Salaam, Tanzania.

OBJECTIVE: To determine the prevalence and risk factors for vaginal candidiasis (VC) among women seeking primary care for genital infections. DESIGN: Cross-sectional study. SETTING: Ilala Municipal Hospital in Dar es Salaam, Tanzania. SUBJECTS: Four hundred and sixty four women presenting with complaints of genital infections. RESULTS: Of the 464 women examined, 177 (38.1%) had abnormal vaginal discharge, 68(14.7%) had genital ulcers, 272 (58.6%) had genital pruritus, 18 (3.9%) had genital warts and 58 (12.5%) had chancre. The prevalencies of VC, bacterial vaginosis, HIV, T vaginalis, N. gonorrhoeae and syphilis were 45%, 48.4%, 22%, 93%, 1.5% and 4.3%, respectively. The occurrence of VC was positively associated with HIV, (OR = 1.81, 95% CI (1.0-2.67), bacterial vaginosis; (OR = 2.6, 95% CI (1.7-3.9), genital pruritus; (OR = 1.8 1, 95% CI (1.2-2.7) genital discharge; (OR = 1.867, 95% (1.28-2.73) and negatively with T. vaginalis (OR = 0.27, 95% CI (0.12 - 0.6), occupation (OR = 0.65, 95% CI (0.35-0.86)) and with education (OR = 0.43, 95% CI (0.11-0.73). There were increased but non-significant odds for VC in patients with syphilis (OR = 1.6 95% CI (0.6-4.3) and venereal warts (OR = 2.5 95% CI (0.92-6.8) VC was not associated with N. gonorrhoeae, genital ulcers, age at first intercourse, number of sexual partners, marital status or antibiotic usage. CONCLUSION: The high prevalence of vaginal candidiasis among women with genital infections should be taken into account when updating policies concerning syndromic management of sexually transmitted diseases. More gender specific approach to syndromic management of sexually transmitted infections in females should be considered.

Effect of recall on estimation of non-fatal injury rates: a community based study in Tanzania.

STUDY OBJECTIVE: To investigate the effect of recall on estimation of non-fatal injury rates in Tanzania. DESIGN: Retrospective population based survey. SETTING: Eight branches in an urban area and six villages in a relatively prosperous rural area in Tanzania. SUBJECTS: Individuals of all ages living in households selected by cluster sampling. MAIN OUTCOME MEASURES: Estimated non-fatal injury rates calculated at each of the 12 recall periods (one to 12 months before the interview). RESULTS: Out of a population of 15 223 persons, 509 individuals reported 516 injuries during the preceding year. Of these 313 (61.5%) were males and 196 (38.5%) females. The data showed notable declining incidence rates from 72 per 1000 person-years when based on a one month recall period to 32.7 per 1000 person-years for a 12 month recall period (55% decline). The decline was found for injuries resulting in fewer than 30 days of disability whereas rates for severe injuries (disability of 30 days or more) did not show a consistent variation with recall period. Decline in injury rates by recall period was higher in rural than in urban areas. Age, sex, and education did not notably affect recall. CONCLUSIONS: Longer recall periods underestimate injury rates compared with shorter recall periods. For severe injuries, a recall period of up to 12 months does not affect the rate estimates. It is essential that a recall period of less than three months be used to calculate injury rates for less severe injuries.

Assessment of clinical case-definition for HIV/AIDS in Tanzania.

OBJECTIVE: To evaluate the usefulness of World Health Organisation (WHO's) clinical case-definition (CCD) for AIDS in a private hospital. DESIGN: A prospective study. SETTING: Shree Hindu Mandal Hospital, Dar es Salaam, Tanzania. SUBJECTS: A total of 601 patients (> 14 years) were studied from January 1995 to December 1997. METHODS: Using HIV test results as a reference standard, sensitivity, specificity, positive predictive values (PPV) and negative predictive values of signs and symptoms were calculated. Multiple logistic regression was used to determine a set of predictive symptoms and signs. Stepwise logistic regression modelling was used to choose the final model. RESULTS: The frequently occurring signs and symptoms among the 473 sero-positive patients were fever (226), oral candidiasis (167), weight loss (161), chronic cough (157), diarrhoea (100) and pulmonary tuberculosis in 69 cases. The presence of anorectal lesions and the rarity of pneumocystis carinii pneumonia in this study are important findings. Seven clinical characteristics predicted HIV infection. These included pulmonary tuberculosis (p=0.009), lymphadenopathy (p=0.007), diarrhoea (p=0.000), chronic cough (p=0.001), dermatitis (p=0.003), herpes zoster (p=0.01) and oral candidiasis (p=0.000). CONCLUSIONS: A greater number of HIV positive patients presented with signs and symptoms different from those proposed by WHO's CCD were observed in this study. With environmental pathogens varying from one geographical region to another and new ones appearing, opportunistic disease cannot be constant in AIDS patients. Therefore, AIDS diagnosis based on clinical case definition alone without at least one positive HIV antibody test is inaccurate and no longer justified.

Cancer of the cervix: knowledge and attitudes of female patients admitted at Muhimbili National Hospital, Dar es Salaam.

OBJECTIVES: To determine the level of knowledge of basic symptoms of cancer of the cervix among Tanzanian females and to determine causes of late presentation with advanced disease among cancer patients. DESIGN: Hospital based cross-sectional study. SETTING: Muhimbili National Hospital, Dar es Salaam, Tanzania. SUBJECTS: Eighty nine cervical cancer patients and 178 controls were interviewed between August 1999 and January 2000. Data was analyzed using Epi-Info version 6.04. RESULTS: At Muhimbili National Hospital most patients are admitted in very advanced stages of the disease (Stage IIb and IV). We determined, using a structured questionnaire, knowledge of basic symptoms of cancer of the cervix, attitude and reasons for late presentation among female patients admitted at Muhimbili National Hospital gynaecological ward. The mean age of cases was 48.8(SD11.1) years and the mean parity was 6.7 years were comparable to that of control, which were 45 years(SD10.8) and mean parity of 6.6 respectively. Mean age in years at marriage was lower for cases 17.5(SD 2.9) than controls 18.8(SD3.5). Majority of cases (50.6%) and controls (23.6%) were illiterate, and 21.3% of cases and 33.7% of controls had incomplete primary education. Majority of both cases (47.23%) and controls (56.7%) had no routine gynaecological examination and they did not find it necessary. More than 90% of the cases were in advanced stages of the disease (stage IIb-IV). CONCLUSION: Both cases and controls had low knowledge of basic symptoms of cancer of the cervix and as a result most of those who happen to have problems reported late with advanced disease.

The importance of injury as a cause of death in sub-Saharan Africa: results of a community-based study in Tanzania.

This paper describes rates and causes of injury deaths among community members in three districts of the United Republic of Tanzania. A population-based study was carried out in two rural districts and one urban area in Tanzania. Deaths occurring in the study areas were monitored prospectively during a period of six years. Censuses were conducted annually in the rural areas and biannually in the urban area to determine the denominator populations. Cause-specific death rates and Years of Life Lost (YLL) due to injury were calculated for the three study areas. During a 6 year period (1992-1998), 5047 deaths were recorded in Dar es Salaam, 9339 in Hai District and 11 155 in Morogoro Rural District. Among all ages, deaths due to injuries accounted for 5% of all deaths in Dar es Salaam, 8% in Hai and 5% in Morogoro. The age-standardised injury death rates among men were approximately three times higher than among women in all study areas. Transport accidents were the commonest cause of mortality in all injury-related deaths in the three project areas, except for females in Hai District, where it ranked second after intentional self-harm. We conclude that injury deaths impose a considerable burden in Tanzania. Strategies should be strengthened in the prevention and control of avoidable premature deaths due to injuries.

Susceptibility pattern of Neisseria gonorrhoeae to antimicrobial agents in Dar es Salaam.

OBJECTIVE: To determine the susceptibility pattern of local strains of Neisseria gonorrhoeae from Dar es salaam, Tanzania to locally used antibiotics. METHOD: Out of 429 Neisseria gonorrhoeae strains isolated between 1993 and 1995, one hundred and ninety nine were recovered and tested. Minimum inhibitory concentrations (MIC) of penicillin, doxycycline, erythromycin, cefuroxime and ciprofloxacin were determined by the E-test method while that of spectinomycin was measured by the agar dilution method. Penicillinase producing N. gonorrhoeae were identified by the chromogenic cephalosporin method. RESULTS: Of the 199 strains tested 128 (64%) were found to be penicillinase producing Neisseria gonorrhoeae (PPNG). Only 19 (10%) were penicillin sensitive while all penicillin resistant strains were found to be PPNG. One hundred and seventy five (88%), 11(5%) and 13 (7%) of the tested isolates were resistant, less susceptible and fully susceptible to doxycycline respectively. Resistance to cotrimoxazole, cefuroxime and ciprofloxacin was 36 (18%), 11 (6%), and 3 (2%) respectively. The trend of antibiotic susceptibility rates over the three year period of study showed a significant increase in the proportion of susceptible strains to cotrimoxazole. All of the 75 strains tested against spectinomycin were susceptible. There was a statistically significant difference between the susceptibility patterns of non-PPNG and PPNG. Non-PPNG isolates were more susceptible to doxycycline (chi 2 = 78.2, df 2, p = < 0.0001). CONCLUSION: These findings have shown that spectinomycin, ciprofloxacin and cefuroxime could continue to be used to treat gonorrhoea in our settings. Continuous surveillance of susceptibility to the commonly used antibiotics is important in order to detect emergence of resistance early and control the possible wide spread of resistant strains.

PIP: This article presents a study on the susceptibility pattern of local strains of Neisseria gonorrheae (NG) to antimicrobial agents (penicillin, doxycyline, erythromycin, cefuroxime, ciprofloxacin, cotrimoxazole, and spectinomycin) in Dar Es Salaam, Tanzania. Out of the 429 isolated strains of NG in 1993-95, 199 were included in the study. Susceptibility patterns to the six antimicrobials was determined through the E-test method, a test that measures their minimum inhibitory concentrations (MICs). On the other hand, the spectinomycin MIC was determined through the antibiotic agar dilution method. Results revealed the following patterns of susceptibility of isolates: spectinomycin (100%), ciprofloxacin (97%), Cefuroxime (89%), erythromycin (57%), cotrimoxazole (40%), doxycycline (7%), and penicillin (10%). It was also noted that NG strains are highly resistant to penicillin (64%) and doxycycline (88%). The study concludes that three drugs--spectinomycin, ciprofloxacin, and spectinomycin--could be effective in treating gonorrhea. However, a continued surveillance of common antibiotics against gonococcus is necessary for the early detection and control of strain resistance.

Impact of human immunodeficiency virus infection on the outcome of treatment and survival of tuberculosis patients in Mwanza, Tanzania.

SETTING: Little is known about the outcome of tuberculosis (TB) treatment and subsequent survival of human immunodeficiency virus (HIV) infected patients treated under routine programme conditions in a developing country. We followed a cohort of HIV-positive and HIV-negative tuberculosis patients during therapy and assessed their vital and tuberculosis status 3 years after completion of treatment in Mwanza, Tanzania. METHODS: Newly diagnosed and relapse tuberculosis cases consecutively registered over a 6-month period were enrolled into an epidemiological study of TB/HIV. Treatment outcome was based on information in tuberculosis treatment registers. Patients surviving treatment were assessed 3 years later by personal interview. Cause of death was determined by verbal autopsy. RESULTS: Of 561 patients enrolled into the study, 505 patients alive at completion of treatment were eligible for assessment at 3 years. Except for mortality, HIV infection was not statistically associated with differing treatment outcomes. At time of follow-up, the overall mortality was 19% and was associated with HIV infection (hazard ratio [hr] 3.7, 95% confidence interval [CI] 2.6-5.2) and age 35 years and over (hr 1.5, 95% CI 1.02-2.1), but not with type of tuberculosis, gender, or initial drug resistance. By life table analysis, probability of survival at 4 years was 35% for HIV-positive patients compared to 90% for HIV-negative patients. Although no relapse cases were diagnosed, verbal autopsy suggested equivalent low rates of relapse in both groups. CONCLUSION: These results demonstrate the effectiveness of the current approach to the treatment of tuberculosis patients regardless of HIV status. However, HIV-related mortality remains high both during and following completion of treatment, and further studies are needed to determine if this mortality might be reduced by simple interventions which are feasible in developing countries.

Assessment of behavioural risk factors associated with HIV infection among youth in Moshi rural district, Tanzania.

To determine behavioural risk factors associated with human immunodeficiency virus (HIV) seropositivity among 1104 youth aged 15-24 years we conducted a cross-sectional survey in Moshi rural district in northern Tanzania. Information was obtained about sociodemographic characteristics as well as sexual and reproductive health behaviour. Anonymous blood samples were taken for HIV testing. Positive HIV antibodies were determined and confirmed by two Enzyme-Linked Immunosorbent Assays (ELISA). Of 1104 youth interviewed, 91% (1003) consented for blood specimen taking. Seven out of ten youth volunteered to have had sexual intercourse at least once in their lifetime; 60% reported to consume alcohol and 50% of the sexually experienced females reported to have received a gift for their sexual encounter. The overall HIV seroprevalence was 7.5% (75/1003); females compared to males were twice as likely to be HIV positive, 9.7% and 5% respectively. Behavioural risk factors associated with HIV seropositivity were different in male compared to female youth. Among male subjects, cigarette smoking, ever use of marijuana and having a past history of sexually transmitted diseases (STDs) were significant risk factors associated with increased risk of HIV seropositivity. On the other hand, in females, those with a past or current history of STDs, those who volunteered that they practiced oral sex and subjects with four or more lifetime sexual partners were more likely to be HIV positive than subjects without a history of an STD, those with single sexual partner or had never practiced oral sex. A four fold increased risk of HIV seropositivity was also observed among female subjects with a history of blood transfusion in the previous 10 years compared to having received none, the Odds ratio was 4.1 (95% CI = 1.5, 11.1). The profile of risk behaviour associated with HIV seropositivity calls for an urgent need to target health information and education interventions to bring about a change in behaviour among the youth and hopefully help to reduce the rate of transmission of HIV infection.

Carcinoma of the male breast: a sexually transmitted disease?

Male breast cancer is a rare disease. In an African population, the occurrence of this cancer is high. The male/female ratio in Tanzania is 1:14 (0.071). This narrow ratio does not differ significantly in the majority of sub-Saharan African countries. The overall ratio being 0.0143 (CI = 0.0317-0.877). When this was compared with the ratio of the African American population with breast cancer in USA, it was observed to be significantly high (p < 0.05). The narrow male/female ratio amongst indigenous people with breast cancer in sub-Saharan countries was seen only in those geographical areas where cervical malignancy ranked in the leading position. There is a clear association, with a pronounced linear correlation between these two cancers (r = 0.8). In view of this association it is hypothesised that since cervical cancer behaves as a sexually transmitted disease, then possibly this could also be the case in respect to the male breast carcinoma in sub-Saharan Africa. If these results are confirmed by other investigators, an opportunity to examine the factors contributing to the oncogenesis of this disease may be invaluable in developing prevention and treatment strategies.

Outlook for survivors of childhood in sub-Saharan Africa: adult mortality in Tanzania. Adult Morbidity and Mortality Project.

OBJECTIVE: To measure age and sex specific mortality in adults (15-59 years) in one urban and two rural areas of Tanzania. DESIGN: Reporting of all deaths occurring between 1 June 1992 and 31 May 1995. SETTING: Eight branches in Dar es Salaam (Tanzania's largest city), 59 villages in Morogoro rural district (a poor rural area), and 47 villages in Hai district (a more prosperous rural area). SUBJECTS: 40,304 adults in Dar es Salaam, 69,964 in Hai, 50,465 in Morogoro rural. MAIN OUTCOME MEASURES: Mortality and probability of death between 15 and 59 years of age (45Q15). RESULTS: During the three year observation period a total of 4929 deaths were recorded in adults aged 15-59 years in all areas. Crude mortalities ranged from 6.1/1000/year for women in Hai to 15.9/1000/year for men in Morogoro rural. Age specific mortalities were up to 43 times higher than rates in England and Wales. Rates were higher in men at all ages in the two rural areas except in the age group 25 to 29 years in Hai and 20 to 34 years in Morogoro rural. In Dar es Salaam rates in men were higher only in the 40 to 59 year age group. The probability of death before age 60 of a 15 year old man (45Q15) was 47% in Dar es Salaam, 37% in Hai, and 58% in Morogoro; for women these figures were 45%, 26%, and 48%, respectively. (The average 45Q15s for men and women in established market economies are 15% and 7%, respectively.) CONCLUSION: Survivors of childhood in Tanzania continue to show high rates of mortality throughout adult life. As the health of adults is essential for the wellbeing of young and old there is an urgent need to develop policies that deal with the causes of adult mortality.