Dynamics of nasopharyngeal bacterial colonisation in HIV-exposed young infants in Tanzania.

OBJECTIVES: To estimate the prevalence of nasopharyngeal bacterial colonisation (NPBC) patterns in young Tanzanian HIV-exposed infants and to analyse the influence of maternal NPBC and of the infant's HIV status on the NPBC pattern. METHODS: Longitudinal cohort study of neonates born to HIV-infected mothers visiting Kilimanjaro Christian Medical Centre, Tanzania, between 2005 and 2009. Demographic and clinical data and nasopharyngeal bacterial cultures were obtained at the age of 6 weeks, 3 and 6 months, and at one time point, a paired mother-infant nasopharyngeal swab was taken. RESULTS: Four hundred and twenty-two swabs were taken from 338 eligible infants. At 6 weeks of age, colonisation rates were 66% for Staphylococcus aureus, 56% for Streptococcus pneumoniae, 50% for Moraxella catarrhalis and 14% for Haemophilus influenzae. Colonisation with S. aureus diminished over time and was more common in HIV-infected infants. S. pneumoniae and H. influenzae colonisation rose over time and was more prevalent in HIV-uninfected children. Co-colonisation of S. pneumoniae with H. influenzae or M. catarrhalis was mostly noticed in HIV-infected infants. S. pneumoniae and M.catarrhalis colonisation of the mother was a risk factor for colonisation in HIV-uninfected infants, while maternal S. aureus colonisation was a risk factor for colonisation in HIV-infected infants. Among the 104 S. pneumoniae isolates, 19F was most prevalent, and 57 (55%) displayed capsular serotypes represented in the 13-valent pneumococcal conjugate vaccine. CONCLUSIONS: NPBC was common in Tanzanian HIV-exposed infants. The significant prevalence of pneumococcal vaccine serotypes colonising this paediatric population justifies the use of the 13-valent pneumococcal vaccine to reduce the burden of pneumococcal invasive disease.

Helicobacter pylori infection and typhoid fever in Jakarta, Indonesia.

We evaluated the association between typhoid fever and Helicobacter pylori infection, as the latter microorganism may influence gastric acid secretion and consequently increase susceptibility to Salmonella typhi infection. Anti-H. pylori IgG and IgA antibody titres (ELISA) and gastrin concentration (RIA) were determined in the plasma of 87 blood culture-confirmed typhoid fever cases (collected after clinical recovery) and 232 random healthy controls without a history of typhoid fever, in the Jatinegara district, Jakarta. Patients with typhoid fever more often than controls were seropositive for H. pylori IgG (67% vs. 50%, P<0.008), when antibody titres were dichotomized around median titres observed in controls. H. pylori IgA seropositivity was not associated with typhoid fever. Plasma gastrin concentrations indicative of hypochlorhydria (i.e. gastrin > or =25 or > or =100 ng/l) were not significantly elevated in typhoid fever cases compared to controls (P=0.54 and P=0.27 respectively). In a multivariate analysis, typhoid fever was independently associated with young age (<33 years, median age of the controls) [odds ratio (OR) 7.93, 95% confidence interval (CI) 3.90-16.10], and H. pylori IgG seropositivity (OR 1.93, 95% CI 1.10-3.40). Typhoid fever was independently associated with H. pylori IgG seropositivity, but not with elevated gastrin concentration. Therefore, the association suggests a common risk of environmental exposure to both bacteria, e.g. poor hygiene, rather than a causal relationship via reduced gastric acid production.

Risk factors for transmission of foodborne illness in restaurants and street vendors in Jakarta, Indonesia.

In a previous risk factor study in Jakarta we identified purchasing street food as an independent risk factor for paratyphoid. Eating from restaurants, however, was not associated with disease. To explain these findings we compared 128 street food-vendors with 74 food handlers from restaurants in a cross-sectional study in the same study area. Poor hand-washing hygiene and direct hand contact with foods, male sex and low educational level were independent characteristics of street vendors in a logistic regression analysis. Faecal contamination of drinking water (in 65 % of samples), dishwater (in 91 %) and ice cubes (in 100 %) was frequent. Directly transmittable pathogens including S. typhi (n = 1) and non-typhoidal Salmonella spp. (n = 6) were isolated in faecal samples in 13 (7 %) vendors; the groups did not differ, however, in contamination rates of drinking water and Salmonella isolation rates in stools. Poor hygiene of street vendors compared to restaurant vendors, in combination with faecal carriage of enteric pathogens including S. typhi, may help explain the association found between purchasing street food and foodborne illness, in particular Salmonella infections. Public health interventions to reduce transmission of foodborne illness should focus on general hygienic measures in street food trade, i.e. hand washing with soap, adequate food-handling hygiene, and frequent renewal of dishwater.

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.

The aetiology of low birthweight in a rural area of Tanzania.

In a hospital-based study, birthweights of 3162 consecutive births were related to perinatal mortality, multiple birth, and gestational age. Independent associations between 15 potential determinants and low birthweight, prematurity and small-at-term factors were also assessed. A newly constructed local curve of birthweight-for-gestational age is compared with the existing curves. The variables positively associated with low birthweight (< 2500 g) were nulliparity, vomiting as a self-reported complaint, spleen enlargement, sex of the infant and previous perinatal mortality. Nulliparity and spleen enlargement were positively associated with preterm birth, while small-at-birth was mostly associated with nulliparity and sex of the infant. Further study on spleen enlargement, the only modifiable factor in this study of possible public health importance, is warranted. Other factors of potential importance which deserve further investigations are hard physical work, maternal morbidity and antenatal care.

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.

Single pre-delivery symphysis-fundal height measurement as a predictor of birthweight and multiple pregnancy.

OBJECTIVE: To compare the value of different pre-delivery maternal indices for predicting birthweight, and to examine the usefulness of a single pre-delivery symphysis-fundal height measurement for the detection of low birthweight and twin pregnancy or macrosomia. DESIGN: Symphysis-fundal height measurements were gathered from 1509 women who had both a singleton delivery and available data of pre-delivery weight, height and mid-upper arm circumference, and from 73 women who had a twin delivery. SETTING: A district hospital in rural Tanzania. RESULTS: Symphysis-fundal height, pre-delivery weight and mid-upper arm circumference, respectively, explain 41%, 13% and 4% of the observed variation in birthweight. At a cut-off level of 30 cm for symphysis-fundal height, the detection rate for birthweight below 2500 g and 2000 g was 66% and 68%, respectively, and the false positive rate was 9% and 14%, respectively. At a cut-off level of 38 cm for symphysis-fundal height the detection rate for twin pregnancy or birthweight > or = 4000 g was 76%, and the false positive rate was 4%. CONCLUSION: Symphysis-fundal height was a better predictor of birthweight than maternal height, pre-delivery weight or mid-upper arm circumference. It seems justified to investigate the value of a simple tricoloured symphysis-fundal height measuring tape for use in antenatal care in developing countries at village level.

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.

Abortions in a hospital setting: hidden realities in Dar es Salaam, Tanzania.

This study investigates the extent of unwanted pregnancy, the use of illegally induced abortion, and the attitudes toward and practice of contraception among women admitted to a hospital with the diagnosis of abortion in Dar es Salaam, Tanzania. (In Tanzania, induced abortion is permitted only to save the mother's life.) A random sample of 300 women with early pregnancy loss admitted to Muhimbili Medical Centre, the teaching hospital in Dar es Salaam, were interviewed between September and November 1987, using a structured questionnaire. Among the 300 respondents, 155 said that their pregnancy had been unwanted: 94 of them presented with an illegally induced abortion and 61 with a spontaneous abortion. The number of spontaneous abortions of unwanted pregnancies increased with age and stability in a relationship. Having a small child to look after and having completed the family were the most common reasons for the pregnancy to be unwanted in this group. Induced abortion was more a problem of the young, unmarried woman. The 61 women with spontaneous abortion but unwanted pregnancy suggest that a much larger group of pregnant women continue to term with what are, at least initially, unwanted pregnancies--precisely the group of women family planning programs want to reach. The low prevalence of contraceptive use in this group indicates the failure of family planning clinics to motivate their target group. Recommendations are made for improved functioning of family planning clinics.