Infection prevention and control of highly infectious pathogens in resource-limited countries: an experience from Marburg viral disease outbreak in Kagera Region - Tanzania.

Marburg viral disease (MVD) is a highly infectious disease with a case fatality rate of up to 90%, particularly impacting resource-limited countries where implementing Infection Prevention and Control (IPC) measures is challenging. This paper shares the experience of how Tanzania has improved its capacity to prevent and control highly infectious diseases, and how this capacity was utilized during the outbreak of the MVD disease that occurred for the first time in the country in 2023.In 2016 and the subsequent years, Tanzania conducted self and external assessments that revealed limited IPC capacity in responding to highly infectious diseases. To address these gaps, initiatives were undertaken, including the enhancement of IPC readiness through the development and dissemination of guidelines, assessments of healthcare facilities, supportive supervision and mentorship, procurement of supplies, and the renovation or construction of environments to bolster IPC implementation.The official confirmation and declaration of MVD on March 21, 2023, came after five patients had already died of the disease. MVD primarily spreads through contact and presents with severe symptoms, which make patient care and prevention challenging, especially in resource-limited settings. However, with the use of a trained workforce; IPC rapid needs assessment was conducted, identifying specific gaps. Based on the results; mentorship programs were carried out, specific policies and guidelines were developed, security measures were enhanced, all burial activities in the area were supervised, and both patients and staff were monitored across all facilities. By the end of the outbreak response on June 1, 2023, a total of 212 contacts had been identified, with the addition of only three deaths. Invasive procedures like dialysis and Manual Vacuum Aspiration prevented some deaths in infected patients, procedures previously discouraged.In summary, this experience underscores the critical importance of strict adherence to IPC practices in controlling highly infectious diseases. Recommendations for low-income countries include motivating healthcare providers and improving working conditions to enhance commitment in challenging environments. This report offers valuable insights and practical interventions for preparing for and addressing highly infectious disease outbreaks through implementation of IPC measures.

The development of a digital NGO mapping platform in Tanzania, as a tool to strengthen civil society engagement, in pursuit of universal health coverage.

The role of civil society in economic development, improving livelihoods and in providing pathways towards achieving health for all has become increasingly evident. By mapping these organizations, the scope and scale as well as existing capacities, gaps, and opportunities are brought to light. This paper describes the implementation of a digital mapping platform for NGOs; an interactive site which collects, analyses, and visualizes data from a variety of sources about NGOs in Tanzania, through a series of interactive maps, graphs, and charts. We describe the approach and the technology used to develop the platform and its potential contribution towards improving health outcomes. A situation analysis and needs assessment exercise was conducted in February 2023. The developed system requirement specification document served as the guiding document in the design and development of new modules. Participatory techniques and agile iterative methodologies comprising regular stakeholder engagement were employed. A distributed revision control system was used to keep track of system revisions. The modules were deployed to the production server at the National Internet Data Center (NIDC) server room, followed by a system commissioning activity in October 2023. The NGO Information System, NGO Digital Mapping tool, NGO Analytic tool, NGO Search tool and NGO Opportunities module were designed, developed, and commissioned to support NGO operations in Tanzania. The platform was launched during the annual NGO Forum in Dodoma, Tanzania, on October 5, 2023. The modules are publicly accessible and are housed within the NGO Information System (NIS) platform. Investment in whole-of-society engagement to build health systems resilience for universal health coverage is crucial. Leveraging the unique positioning of NGOs draws us a step closer to the ambitious goal of achieving health for all. Through this one-stop web application system, information on the near real-time status, existing gaps, and opportunities for collaboration to serve communities is readily available for all stakeholders. Wide dissemination and enhancement of utilization of the platform across all sectors is now needed, for data to truly inform action.

The development of a digital NGO mapping platform in Tanzania, as a tool to strengthen civil society engagement, in pursuit of Universal Health Coverage

The role of civil society in economic development, improving livelihoods and in providing pathways towards achieving health for all has become increasingly evident. By mapping these organizations, the scope and scale as well as existing capacities, gaps, and opportunities are brought to light. This paper describes the implementation of a digital mapping platform for NGOs; an interactive site which collects, analyses, and visualizes data from a variety of sources about NGOs in Tanzania, through a series of interactive maps, graphs, and charts. We describe the approach and the technology used to develop the platform and its potential contribution towards improving health outcomes. A situation analysis and needs assessment exercise was conducted in February 2023. The developed system requirement specification document served as the guiding document in the design and development of new modules. Participatory techniques and agile iterative methodologies comprising regular stakeholder engagement were employed. A distributed revision control system was used to keep track of system revisions. The modules were deployed to the production server at the National Internet Data Center (NIDC) server room, followed by a system commissioning activity in October 2023. The NGO Information System, NGO Digital Mapping tool, NGO Analytic tool, NGO Search tool and NGO Opportunities module were designed, developed, and commissioned to support NGO operations in Tanzania. The platform was launched during the annual NGO Forum in Dodoma, Tanzania, on October 5, 2023. The modules are publicly accessible and are housed within the NGO Information System (NIS) platform. Investment in whole-of-society engagement to build health systems resilience for universal health coverage is crucial. Leveraging the unique positioning of NGOs draws us a step closer to the ambitious goal of achieving health for all. Through this one-stop web application system, information on the near real-time status, existing gaps, and opportunities for collaboration to serve communities is readily available for all stakeholders. Wide dissemination and enhancement of utilization of the platform across all sectors is now needed, for data to truly inform action.

Reduction in Rubella Virus Active Cases among Children and Adolescents after Rubella Vaccine Implementation in Tanzania: A Call for Sustained High Vaccination Coverage.

Rubella virus (RV) infection in susceptible women during the first trimester of pregnancy is associated with congenital Rubella syndrome (CRS). In countries where a vaccination program is implemented, active case surveillance is emphasized. This report documents the magnitude of active cases before and after vaccine implementation in Tanzania. A total of 8750 children and adolescents with signs and symptoms of RV infection were tested for Rubella IgM antibodies between 2013 and 2019 using enzyme immunoassay followed by descriptive analysis. The median age of participants was 3.8 (IQR: 2−6.4) years. About half (4867; 55.6%) of the participants were aged 1−5 years. The prevalence of RV active cases was 534 (32.6%, 95% CI: 30.2−34.9) and 219 (3.2%, 95% CI: 2.7−3.6) before and after vaccine implementation, respectively. Before vaccination, the highest prevalence was recorded in Pemba (78.6%) and the lowest was reported in Geita (15.6%), whereas, after vaccination, the prevalence ranged between 0.5% in Iringa and 6.5% in Pemba. Overall, >50% of the regions had a >90% reduction in active cases. The significant reduction in active cases after vaccine implementation in Tanzania underscores the need to sustain high vaccination coverage to prevent active infections and eventually eliminate CRS, which is the main goal of Rubella vaccine implementation.

Domestic funding opportunities for Tanzania as five new Middle-Income countries brace for reduced Gavi support for immunization.

Vaccines have produced remarkable impact in reducing the global burden of disease. Thanks to Gavi-the Vaccine Alliance, which supports eligible countries to increase access to the new and underused vaccines. Gavi support depends on economic growth, whereby low-income countries contribute 0.2 USD per dose of supported vaccines, while middle-income countries contribute by price fraction that increases gradually by 15% annually. A country must become fully self-financing within five years when its economy reaches 1,630 USD GNI per capita. Recently, Tanzania, Benin, Haiti, Nepal, and Tajikistan became middle-income countries triggering gradual reduction in Gavi support. This paper first compares the socio-demographic characteristics, immunization program performance, and health financing strategies of these countries and second, explores domestic financing strategies that Tanzania can use to close the funding gap. Although the five countries are similar economically, they vary in demography, health financing strategies, extent of donor dependency, and strength of immunization programs. Some health indicators are not any better than those in low-income countries. Tanzania receives the largest financial support from Gavi and is projected to be fully self-financing by 2043. The potential domestic funding opportunities include to increase Government budget, use of innovative financing strategies, and health insurance, complemented with enhanced program efficiency.

National introduction of human papillomavirus (HPV) vaccine in Tanzania: Programmatic decision-making and implementation.

BACKGROUND: Cervical cancer is the leading cause of cancer among women in Tanzania, with approximately 10,000 new cases and 7,000 deaths annually. In April 2018, the Government of Tanzania introduced 2 doses of human papillomavirus (HPV) vaccine nationally to adolescent girls to prevent cervical cancer, following a successful 2-year pilot introduction of the vaccine in the Kilimanjaro Region. METHODS: We interviewed key informants at the national level in Tanzania from February to November 2019, using a semi-structured tool to better understand national decision-making and program implementation. We conducted a comprehensive desk review of HPV vaccine introduction materials and reviewed administrative coverage data. RESULTS: Ten key informants were interviewed from the Ministry of Health, Community Development, Gender, Elderly, and Children, the World Health Organization, and other partners, and HPV vaccine planning documents and administrative coverage data were reviewed during the desk review. Tanzania introduced HPV vaccine to a single-age cohort of 14-year-old girls, with the decision-making process involving the Tanzania Immunization Technical Advisory Group and the national Interagency Coordination Committee. HPV vaccine was integrated into the routine immunization delivery strategy, available at health facilities and through outreach services at community sites, community mobile sites (>10 km from the health facility), and primary and secondary schools. Pre-introduction activities included trainings and microplanning workshops for health workers and school personnel at the national, regional, council, and health facility levels. Over 6,000 health workers and 22,000 school personnel were trained nationwide. Stakeholder and primary health care committee meetings were also conducted at the national level and in each of the regions as part of the advocacy and communication strategy. Administrative coverage of the first dose of HPV vaccine at the end of 2019 was 78%, and second dose coverage was 49%. No adverse events following HPV vaccination were reported to the national level. DISCUSSION: Tanzania successfully introduced HPV vaccine nationally targeting 14-year-old girls, using routine delivery strategies. Continued monitoring of vaccination coverage will be important to ensure full 2-dose vaccination of eligible girls. Tanzania can consider periodic intensified vaccination and targeted social mobilization efforts, as needed.

Tanzania's human papillomavirus (HPV) vaccination program: Community awareness, feasibility, and acceptability of a national HPV vaccination program, 2019.

BACKGROUND: In April 2018, Tanzania introduced the human papillomavirus (HPV) vaccine nationally to 14-year-old girls, utilizing routine delivery strategies (i.e. vaccinating girls at health facilities and community outreach, including schools). We sought to assess awareness, feasibility, and acceptability of the HPV vaccination program among health workers and community-level stakeholders. METHODS: We conducted cross-sectional in-person surveys among health workers, school personnel, community leaders, and council leaders in 18 council areas across six regions of Tanzania in October-November 2019. Regions were purposively selected to provide demographic, geographic, and vaccination coverage variability; sub-regional levels used random or stratified random sampling. Surveys included questions on HPV vaccine training and knowledge, delivery strategy, target population, and vaccine and program acceptability. Descriptive analysis was completed for all variables stratified by respondent groups. RESULTS: Across the 18 councils, there were 461 respondents, including health workers (165), school personnel (135), community leaders (143), and council leaders (18). Over half of each respondent group (50-78%) attended a training or orientation on HPV vaccine. Almost 75% of the health workers and school personnel respondent groups, and less than half (45%) of community leaders correctly identified the target age group for HPV vaccine. Most (80%) of the health workers indicated HPV vaccination was available at health facilities and schools; most (79%) indicated that the majority of girls receive HPV vaccine in school. Approximately half (52%) of all respondents reported hearing misinformation about HPV vaccine, but 97% of all respondents indicated that HPV vaccine was either "very accepted" or "somewhat accepted" in their community. CONCLUSION: The HPV vaccination program in Tanzania was well accepted by community stakeholders in 18 councils; adequate knowledge of HPV vaccine and the HPV vaccination program was demonstrated by health workers and school personnel. However, continued technical support for integration of HPV vaccination as a routine immunization activity and reinforcement of basic knowledge about HPV vaccine in specific community groups is needed. The Tanzania experience provides an example of how this vaccine can be integrated into routine immunization delivery strategies and can be a useful resource for countries planning to introduce HPV vaccine as well as informing global partners on how to best support to countries in operationalizing their HPV vaccine introduction plans.

Factors affecting non-coverage of measles-rubella vaccination among children aged 9-59 months in Tanzania.

Globally, measles remains a major cause of child mortality, and rubella is the leading cause of birth defects among all infectious diseases. In 2012, the World Health Assembly endorsed the Global Vaccine Action Plan that set a target to eliminate Measles-Rubella (MR) in five of the six World Health Organization (WHO) regions by 2020. This was cross-sectional study employed both quantitative and qualitative research methods. The sample size was calculated to provide overall, age- and sex-specific coverage estimates for MR vaccine among children aged between 9 and 59 months at the national level. Using desired precision of ±5% with an expected coverage of 95%, a total of 15,235 households were required. The age of children, a child who had received the MR vaccine before the campaign, household wealth quintile, the age of caregivers, and their marital status were associated with non-coverage of MR vaccination among children aged 9-59 months in Tanzania. Nationally, an estimated 88.2% (95% CI: 87.3-89%) of children aged 9-59 months received the MR campaign dose, as assessed by caregivers' recall. These estimates revealed slightly higher coverage in Zanzibar 89.6% (95% CI: 84.7-93%) compared to Mainland Tanzania 88.1% (95% CI 87.2-88.9%). These associated factors revealed causes of unvaccinated children and may be some of the reasons for Tanzania's failure to meet the MR campaign target of 95 percent vaccination coverage. Thus, vaccine development must increase programmatic oversight in order to improve immunization activities and communication strategies in Tanzanian areas with low MR coverage.

Polio Eradication Initiative: Contribution to improved communicable diseases surveillance in WHO African region.

INTRODUCTION: Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, there has been a tremendous progress in the reduction of cases of poliomyelitis. The world is on the verge of achieving global polio eradication and in May 2013, the 66th World Health Assembly endorsed the Polio Eradication and Endgame Strategic Plan (PEESP) 2013-2018. The plan provides a timeline for the completion of the GPEI by eliminating all paralytic polio due to both wild and vaccine-related polioviruses. METHODS: We reviewed how GPEI supported communicable disease surveillance in seven of the eight countries that were documented as part of World Health Organization African Region best practices documentation. Data from WHO African region was also reviewed to analyze the performance of measles cases based surveillance. RESULTS: All 7 countries (100%) which responded had integrated communicable diseases surveillance core functions with AFP surveillance. The difference is on the number of diseases included based on epidemiology of diseases in a particular country. The results showed that the polio eradication infrastructure has supported and improved the implementation of surveillance of other priority communicable diseases under integrated diseases surveillance and response strategy. CONCLUSION: As we approach polio eradication, polio-eradication initiative staff, financial resources, and infrastructure can be used as one strategy to build IDSR in Africa. As we are now focusing on measles and rubella elimination by the year 2020, other disease-specific programs having similar goals of eradicating and eliminating diseases like malaria, might consider investing in general infectious disease surveillance following the polio example.

Malaria prevention in north-eastern Tanzania: patterns of expenditure and determinants of demand at the household level.

OBJECTIVE: This study aims to provide a better understanding of the amounts spent on different malaria prevention products and the determinants of these expenditures. METHODS: 1,601 households were interviewed about their expenditure on malaria mosquito nets in the past five years, net re-treatments in the past six months and other expenditures prevention in the past two weeks. Simple random sampling was used to select villages and streets while convenience sampling was used to select households. Expenditure was compared across bed nets, aerosols, coils, indoor spraying, using smoke, drinking herbs and cleaning outside environment. FINDINGS: 68% of households owned at least one bed net and 27% had treated their nets in the past six months. 29% were unable to afford a net. Every fortnight, households spent an average of US $0.18 on nets and their treatment, constituting about 47% of total prevention expenditure. Sprays, repellents and coils made up 50% of total fortnightly expenditure (US$0.21). Factors positively related to expenditure were household wealth, years of education of household head, household head being married and rainy season. Poor quality roads and living in a rural area had a negative impact on expenditure. CONCLUSION: Expenditure on bed nets and on alternative malaria prevention products was comparable. Poor households living in rural areas spend significantly less on all forms of malaria prevention compared to their richer counterparts. Breaking the cycle between malaria and poverty is one of the biggest challenges facing malaria control programmes in Africa.

How equitable is bed net ownership and utilisation in Tanzania? A practical application of the principles of horizontal and vertical equity.

BACKGROUND: Studies show that the burden of malaria remains huge particularly in low-income settings. Although effective malaria control measures such as insecticide-treated nets (ITNs) have been promoted, relatively little is known about their equity dimension. Understanding variations in their use in low-income settings is important for scaling up malaria control programmes particularly ITNs. The objective of this paper is to measure the extent and causes of inequalities in the ownership and utilisation of bed nets across socioeconomic groups (SEGs) and age groups in Tanga District, north-eastern Tanzania. METHODS: A questionnaire was administered to heads of 1,603 households from rural and urban areas. Households were categorized into SEGs using both an asset-based wealth index and education level of the household head. Concentration indices and regression-based measures of inequality were computed to analyse both vertical and horizontal inequalities in ownership and utilisation of bed nets. Focus Group Discussions (FGDs) were used to explore community perspectives on the causes of inequalities. RESULTS: Use of ITNs remained appallingly low compared to the RBM target of 80% coverage. Inequalities in ownership of ITNs and all nets combined were significantly pro-rich and were much more pronounced in rural areas. FGDs revealed that lack of money was the key factor for not using ITNs followed by negative perceptions about the effect of insecticides on the health of users. Household SES, living within the urban areas and being under-five were positively associated with bed net ownership and/or utilisation. CONCLUSION: The results highlight the need for mass distribution of ITN; a community-wide programme to treat all untreated nets and to promote the use of Long-Lasting Insecticidal nets (LLINs) or longer-lasting treatment of nets. The rural population and under-fives should be targeted through highly subsidized schemes and mass distribution of free nets. Public campaigns are also needed to encourage people to use treated nets and mitigate negative perceptions about insecticides.

'To help them is to educate them': power and pedagogy in the prevention and treatment of malaria in Tanzania.

OBJECTIVES: Acknowledging that mothers are often the primary caregivers at the household level, malaria control efforts have emphasized educating women in its early recognition. This fails to consider the context in which knowledge will be transformed into action, as women lack decision-making responsibility and financial resources. We examine the knowledge and power dynamics of provider-patient interactions and the implications for malaria treatment of educating mothers during consultations. METHODS: We conducted in-depth interviews in Tanga, Tanzania, with 79 household participants over 2 years to explore knowledge and perceptions of febrile illness, its treatment and prevention. We also interviewed 55 clinicians at government and private healthcare facilities about their patients' knowledge and treatment-seeking behaviour. We analysed our data using a grounded theory approach. RESULTS: Informants had good knowledge of malaria aetiology, symptoms and treatment. Healthcare workers reported that mothers were able to give them sufficient information about their child for accurate diagnosis. However, health staff continued to see mothers who present 'late' as uneducated, intellectually incapable and lazy. Whilst evidence shows that decisions about treatment do not rest with mothers, but with male family members, it is women who continue to be blamed and targeted by health education. CONCLUSIONS: Aggressive didactic teaching methods used by health staff may be disempowering those already equipped with knowledge, yet unable to control treatment decisions within the household. This may lead to further delays in presentation at a healthcare facility. We propose a rethinking of health education that is context-sensitive, acknowledges class and gendered power relations, and targets men as well as women.

Treatment of plague with gentamicin or doxycycline in a randomized clinical trial in Tanzania.

BACKGROUND: Over the past 50 years, antibiotics of choice for treatment of plague, including streptomycin, chloramphenicol, and tetracycline, have mostly become outdated or unavailable. To test gentamicin in the treatment of naturally occurring plague and the implications of its use in the treatment of bioterrorist plague, a randomized, comparative, open-label, clinical trial comparing monotherapy with gentamicin or doxycycline was conducted in Tanzania. METHODS: Sixty-five adults and children with symptoms of bubonic, septicemic, or pneumonic plague of < or =3 days duration were enrolled in the study. Bubo aspirates and blood were cultured for Yersinia pestis. Acute-phase and convalescent-phase serum samples were tested for antibody against fraction 1 antigen of Y. pestis. Thirty-five patients were randomized to receive gentamicin (2.5 mg/kg intramuscularly every 12 h for 7 days), and 30 patients were randomized to receive doxycycline (100 mg [adults] and 2.2 mg/kg [children] orally every 12 h for 7 days). Serum creatinine concentrations were measured before and after treatment, and peak and trough concentrations of antibiotics were measured. RESULTS: Three patients, 2 of whom were treated with gentamicin and 1 of whom was treated with doxycycline, died on the first or second day of treatment, and these deaths were attributed to advanced disease and complications including pneumonia, septicemia, hemorrhage, and renal failure at the start of therapy. All other patients experienced cure or an improved condition after receiving therapy, resulting in favorable response rates of 94% for gentamicin (95% CI, 81.1%-99.0%) and 97% for doxycycline (95% CI, 83.4%-99.8%). Y. pestis isolates obtained from 30 patients belonged to biotype antigua and were susceptible to gentamicin and doxycycline, which had MICs of 0.13 mg/L and 0.25-0.5 mg/L, respectively. Serum concentrations of antibiotics were within therapeutic ranges, and adverse events were infrequent. Patients treated with gentamicin demonstrated a modest increase in the mean serum creatinine concentration after treatment (P<.05, by paired t test). CONCLUSIONS: Both gentamicin and doxycycline were effective therapies for adult and pediatric plague, with high rates of favorable responses and low rates of adverse events.