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Background Asymptomatic malaria infections largely remain undetected and act as a reservoir for continuous transmission. The study assessed the prevalence of submicroscopic asymptomatic malaria infections and anaemia in two rural low (300 m above sea level) and highland (700 m asl) settings of Korogwe District north-eastern Tanzania. Methods A cross-sectional malariometric survey involving individuals aged 0–19 years was conducted in June 2018 in the two rural villages. Venous blood was collected from eligible study participants for estimation of haemoglobin level, detection of malaria by rapid diagnostic test (RDT), quantification of malaria parasitaemia by microscopy, as well as dried blood spot (DBS) for determining submicroscopic infections by PCR targeting the small subunit of the ribosomal ribonucleic acid (ssrRNA) of human Plasmodium. Results Out of 565 individuals tested, 211 (37.3%) were malaria positive based on RDT, whereas only 81 (14.3%) were positive by microscopy. There was no significant difference in the prevalence between the highland and the lowland village, p = 0.19 and p = 0.78 microscopy and RDT, respectively. Three out of 206 (1.5%) RDT/microscopy negative samples were P. falciparum positive by PCR. Of the 211 RDT and 81 microscopy positive, 130 (61.6%) and 33 (40.7%), respectively, were defined as being asymptomatic. Of the 565 individuals, 135 (23.9%) were anaemic (haemoglobin Conclusions Asymptomatic malaria is associated with an increased risk of having anaemia in the study communities. The findings highlight the need for targeted interventions focusing on asymptomatic infections which is an important risks factor for anaemia in the community and act as a source of continued transmission of malaria in the study area.

Targeted nanomaterials for cancer theranostics have been the subject of an expanding volume of research studies in recent years. Mesoporous silica nanoparticles (MSNs) are particularly attractive for such applications due to possibilities to synthesize nanoparticles (NPs) of different morphologies, pore diameters and pore arrangements, large surface areas and various options for surface functionalization. Functionalization of MSNs with different organic and inorganic molecules, polymers, surface-attachment of other NPs, loading and entrapping cargo molecules with on-desire release capabilities, lead to seemingly endless prospects for designing advanced nanoconstructs exerting multiple functions, such as simultaneous cancer-targeting, imaging and therapy. Describing composition and multifunctional capabilities of these advanced nanoassemblies for targeted therapy (passive, ligand-functionalized MSNs, stimuli-responsive therapy), including one or more modalities for imaging of tumors, is the subject of this review article, along with an overview of developments within a novel and attractive research trend, comprising the use of MSNs for CRISPR/Cas9 systems delivery and gene editing in cancer. Such advanced nanconstructs exhibit high potential for applications in image-guided therapies and the development of personalized cancer treatment.

This study examined some factors associated with the utilization of maternal health care servicesby adolescent mothers (15-19 years) in Tanzania in order to provide advice accordingly. The studyused cross-sectional study of adolescent mothers aged 15-19 years using Demographic HealthSurvey and Malaria indicator Survey 2015/16 data. The dependent variables were number ofantenatal care visits, the place where an adolescent mother delivered and post-natal checkup(adolescent mother’s health checking after being discharged or after a home delivery). Theindependent variables were birth order, education level of a mother, marital status of a mother,media exposure, wealth index, distance to health facility. Multiple binary logistic regression wasused to examine an association between each dependent variable and their respective independentvariables. Data was analyzed using IBM SPSS statistics and STATA. This study used 550adolescent mothers in the analysis. Majority of the adolescent mothers had less than four AntenatalCare (ANC) visits (53.5%), while 68.5% of adolescent mothers delivered at a health facility.Adolescent mothers with two or more children had less odds of having at least four ANCscompared to those with one child, whereas adolescent mothers with at least secondary educationhad greater odds of delivering at a health facility compared to those who had no education.Adolescent mothers who had at least four antenatal care visits and those who are married hadgreater odds of checking their health after being discharged compared to adolescent mothers whohad less than 4 ANCs and single adolescent mothers. It was advised that provision of maternaleducation to young girls on the importance of safe delivery and health checking after delivery isvery important to reduce adolescent maternal morbidity and mortality in the country. Keywords: Adolescent; Maternal Health; Logistic regression; Chi-square

One strategy for improving detection of fetal growth restriction (FGR) is developing biosensors identifying placental dysfunction as a leading pathogenesis for FGR. The aim of this pilot study was to investigate the performance of a biosensor specified to detect placental dysfunction by means of maternal arterial turbulence acoustics in a low-resource setting. A cohort of 147 singleton pregnant women were prospectively followed with double-blinded biosensor tests, sonographic estimation of fetal weight (EFW) and Doppler flow at 26–28, 32–34 and 37–39 weeks of pregnancy. Full term live births with recorded birth weights (BWs) and without major congenital malformations were included. Outcomes were defined as (A) a solitary biometric measure (BW &lt, 3rd centile) and as (B) a biometric measure and contributory functional measure (BW &lt, 10th centile and antenatally detected umbilical artery pulsatility index &gt, 95th centile). Data from 118 women and 262 antenatal examinations were included. Mean length of pregnancy was 40 weeks (SD ± 8 days), mean BW was 3008 g (SD ± 410 g). Outcome (A) was identified in seven (6%) pregnancies, whereas outcome (B) was identified in one (0.8%) pregnancy. The biosensor tested positive in five (4%) pregnancies. The predictive performance for outcome (A) was sensitivity = 0.29, specificity = 0.97, p = 0.02, positive predictive value (PPV) was 0.40 and negative predictive value (NPV) was 0.96. The predictive performance was higher for outcome (B) with sensitivity = 1.00, specificity = 0.97, p = 0.04, PPV = 0.20 and NPV = 1.00. Conclusively, these pilot-study results show future potential for biosensors as screening modality for FGR in a low-resource setting.

Oral administration of statins for the treatment of familial hypercholesterolemia results in poor therapeutic outcomes and patient compliance. An alternative administration route is proposed to circumvent the current limitations. This research is aimed at developing nano-emulsions and nano-emulgels as the ultimate potential delivery systems of statins for administrationOil-in-water (o/w) nano-formulations (nano-emulsions and nano-emulgels) containing 2% (w/w) of the selected statin and 8% apricot kernel oil as oil phase were formulated. The nano-formulations were characterized using transmission electron microscopy (TEM), pH, viscosity, droplet size and zeta-potential.Nano-emulsions' and nano-emulgels' droplet size ranged between 114.23-169.83 nm and 149.83-267.53 nm, respectively. The addition of Carbopol® Ultrez 20 increased the nano-emulsions' viscosity (3.59-8.38 cP) resulting in the formation of nano-emulgels (viscosity: 1911.00-46,090.00 cP). The entrapment efficiency (90.77-99.55%) confirmed the incorporation of the statins. Membrane release studies indicated that statins were released at higher flux values in nano-emulsions compared to their respective nano-emulgels.The results indicate the benefits of nano-emulsions and nano-emulgels as potential alternative delivery systems for the transdermal delivery of statins.

Despite the steps taken to improve support in universities, many students and graduates with autism face a substantial employment gap when completing university as compared to any other student group with disabilities. The literature shows that often students with autism do not have appropriate support to prepare them for entering the workforce. Therefore, it is imperative that this under-researched topic be studied. Utilising a participatory approach, in this article, we sought to investigate perceptions of students and graduates with autism about the employment support they received when preparing for university-to-work transition. The study involved semi-structured interviews with 30 university students and graduates with autism from Finland, France, the Netherlands, and the UK. Data were analysed using an inductive content analysis approach. Findings indicate that organisational enablers consisting of career-focused support and internships and practicums facilitated preparation for employment. Supportive and caring relationships emerged as forms of support that included mentors, committed and caring academics, and family members. Further, the findings indicated the aspiration for individualisation that consists of improving work and academic support, and awareness and understanding. These findings have also important practical implications.

Although an unprecedented number of autistic students are entering higher education, research focusing on their sense of belonging is scarce. Autistic students’ sense of belonging can be jeopardized due to the students’ encounters with a network of social expectations, activities, responses and biased attitudes. Using a participatory approach, our objective was to examine autistic university students’ perceptions about their sense of belonging whilst at university. The study involved semi-structured interviews with 12 autistic university students and graduates from the Netherlands. Data were analysed using theory-guided content analysis and elaborative coding approaches. Findings indicate that autistic students’ sense of belonging is multi-dimensional, fluid, and located within affective, spatial, temporal, social and political contexts. Our findings offer a novel and theoretically robust framework to conceptualise and further understand the sense of belonging. Important practical implications are also given.

Peter Stephen Shija,1,2 Joshua Alexander Karaba,1,2 Rune Nathaniel Philemon,1,3 Bernard Lucas Minja,1 Philbert Patrick Mtenga,1,2 Denis Robert Katundu1,2 1Kilimanjaro Christian Medical Center Moshi (KCMC), Moshi, Tanzania; 2Department of Ear Nose and Throat (ENT) Head and Neck Surgery, Kilimanjaro Christian Medical University College (KCMUCo), Moshi, Tanzania; 3Kilimanjaro Christian Medical University College, Institute of Public Health Moshi, Moshi, TanzaniaCorrespondence: Peter Stephen ShijaDepartment of ENT Head and Neck Surgery, Kilimanjaro Christian Medical University College, P.O Box 2240, Moshi, TanzaniaTel +255754392916Email shijapsn@yahoo.comBackground: To date, HIV/AIDS remains a threat of the 21st century. The overall rate of new HIV infection continues to decline in several countries, but there is still a remarkable burden of disease seen in sub-Saharan Africa. Several studies observed that 70% to 90% of HIV-infected patients present with ear, nose and throat symptoms. The aim of this study was to identify the magnitude of ENT manifestations among HIV-infected patients attended HIV clinics at KCMC based on age, sex, and CD4 count.Methods: This was a descriptive cross-sectional study conducted at KCMC hospital involving HIV-infected patients who attended HIV clinics from February to July 2018. Convenient sampling was employed to get study participants, and 200 patients were recruited in the study. Data were collected through a questionnaire from patients, and results were analyzed using SPSS version 20.Results: Sixty-eight (34%) of 200 HIV-infected patients had ENT manifestations. The most affected age group was 0– 9 years. ENT manifestations were more prevalent in females (23.5%) than in males (10.5%). Those with CD4 count less than 200cells/μL also it was a high prevalence (56.3%).Conclusion: This study observed that one-third of the studied population had ENT manifestations. All medical practitioners should be aware of ENT manifestations in HIV-infected patients in order to assure early and appropriate intervention.Keywords: ENT manifestations, HIV, magnitude, seropositive, Tanzania

Background Utilization of antiretroviral therapy (ART) is crucial for better health outcomes among people living with the human immunodeficiency virus (PLHIV). Nearly 30% of the 1.6 million PLHIV in Tanzania are not on treatment. Since HIV positive status is the only eligibility criterion for ART use, it is critical to understand the obstacles to ART access and uptake to reach universal coverage of ART among PLHIV. For the caregivers of orphans and vulnerable children (OVC) LHIV and not on ART, attempts to identify them and ensure that they initiate and continue using ART is critical for their wellbeing and their ability to care for their children. Methods Data are from the community-based, United States Agency for International Development (USAID)-funded Kizazi Kipya project that aims at scaling up the uptake of HIV/AIDS and other health and social services by orphans and vulnerable children (OVC) and their caregivers. HIV positive caregivers of OVC who were enrolled in the USAID Kizazi Kipya project between January 2017 and June 2018 were included in this cross-sectional study. The caregivers were drawn from 11 regions: Arusha, Iringa, Katavi, Kigoma, Mara, Mbeya, Morogoro, Ruvuma, Simiyu, Singida, and Tanga. The outcome variable was ART status (either using or not), which was enquired of each OVC caregiver LHIV at enrollment. Data analysis involved multivariable analysis using random-effects logistic regression to identify correlates of ART use. Results In total, 74,999 caregivers living with HIV with mean age of 44.4 years were analyzed. Of these, 96.4% were currently on ART at enrollment. In the multivariable analysis, ART use was 30% lower in urban than in rural areas (adjusted odds ratio (OR) = 0.70, 95% confidence interval (CI) 0.61–0.81). Food security improved the odds of being on ART (OR = 1.29, 95% CI 1.15–1.45). Disabled caregivers were 42% less likely than non-disabled ones to be on ART (OR = 0.58, 95% CI 0.45–0.76). Male caregivers with health insurance were 43% more likely than uninsured male caregivers to be on ART (OR = 1.43, 95% CI 1.11–1.83). Caregivers aged 40–49 years had 18% higher likelihood of being on ART than the youngest ones. Primary education level was associated with 26% increased odds of being on ART than no education (OR = 1.26, 95% CI 1.13–1.41). Conclusions Although nearly all the caregivers LHIV in the current study were on ART (96.4%), more efforts are needed to achieve universal coverage. The unreached segments of the population LHIV, even if small, may lead to worse health outcomes, and also spur further spread of the HIV epidemic due to unachieved viral suppression. Targeting caregivers in urban areas, food insecure households, who are uninsured, and those with mental or physical disability can improve ART coverage among caregivers LHIV.

Breast imaging capacity in Tanzania is currently very limited. In a country of almost 60 million people, mammographic units are exceedingly rare. The few existing units are compromised by lack of maintenance and quality control and extremely limited technologist training. Breast cancer incidence continues to increase in East Africa, while the ability to accurately diagnose and differentiate benign and malignant breast disease remains a challenge. However, as ultrasound technology improves and becomes more affordable, there is increased access to devices including hand-held point of care ultrasound. Additionally, there has been a recent expansion in the training of academic radiologists in Tanzania, creating an opportunity for possible sustainable improvement of breast imaging and intervention. Our initial efforts at the Muhimbili Academic Medical Center (MAMC) included social media advertising for symptomatic and asymptomatic women, followed by screening (clinical breast exam) and subsequent ultrasound imaging of symptomatic women. We then initiated a workflow for ultrasound-guided breast intervention, performed biopsies, reviewed results by local pathologists, and brought the postbiopsy patients back for radiologic–pathologic correlation, wound assessment, and coordination of follow-up and treatment.

In head and neck squamous cell carcinoma, immune checkpoint inhibitors (ICI) lead to improved outcomes. There has been reports of accelerated disease progression, or hyperprogression, after ICI initiation. We present a case of hyperprogression after one dose of nivolumab in maxillary sinus squamous cell carcinoma. The patient had complete vision loss due to disease progression into the orbit, as well as intracranial invasion, lytic metastases, and new widespread distal metastases. Hyperprogression can occur after the first dose of immunotherapy. Absent biomarkers regarding individual risk of hyperprogression, caution should be exercised in using ICI in sinonasal cancers with orbital abutting disease. Laryngoscope, 130:907-910, 2020.

Objective The aim of our research was to evaluate the relationship involving left ventricular ejection fraction, low density lipoprotein, B-type natriuretic peptide, Troponin I and coronary flow reserve, and to determine the predictors of left ventricular ejection fraction in patients with coronary microvascular disease and obstructive coronary artery disease, and in patients with coronary microvascular disease. Results The mean age was 58.5 ± 12.5 years. In patients with obstructive coronary disease and coronary microvascular disease we found low density lipoprotein-c had significant inverse relationship with left ventricular ejection fraction, left ventricular ejection fraction also had significant negative relationship with B-type natriuretic peptide, and Troponin-I. While a significant direct relationship turned out to be observed linking left ventricular ejection fraction with coronary flow reserve. Left ventricular ejection fraction had significant negative relationship with low density lipoprotein, and B-type natriuretic peptide in patients with obstructive coronary artery disease only. Age, blood pressure, lipid levels, red cell distribution width, glycated hemoglobin, symptoms, New York heart association classification, alcohol drinking, hypertension, diabetes mellitus, troponin levels and B-type natriuretic peptide were the predictors for left ventricular ejection fraction in coronary microvascular disease patients.

Intracranial high-resolution vessel wall magnetic resonance imaging is an imaging paradigm that complements conventional imaging modalities used in the evaluation of neurovascular pathology. This review focuses on the emerging utility of vessel wall magnetic resonance imaging in the characterization of intracranial aneurysms. We first discuss the technical principles of vessel wall magnetic resonance imaging highlighting methods to determine aneurysm wall enhancement and how to avoid common interpretive pitfalls. We then review its clinical application in the characterization of ruptured and unruptured intracranial aneurysms, in particular, the emergence of aneurysm wall enhancement as a biomarker of aneurysm instability. We offer our perspective from a high-volume neurovascular center where vessel wall magnetic resonance imaging is in routine clinical use.

Background: Oral diseases, such as dental caries, tooth wear, dental erosion and periodontal diseases are major health problems in many societies. The study aim was to explore the association between oral health related behaviors and the presence of oral diseases in adolescents living in Maasai population areas in the northern part of Tanzania. Methods: A cross sectional study was conducted in 2016 using one stage cluster sample design. A total of 989 adolescents were invited and 906 (91.6%; (Maasais n = 721, non Maasais n = 185) accepted the invitation and completed an interview and clinical oral examination in a school setting (mean age 13.4 years, SD 1.2, range 12–17 years). Chi-square test, bivariate analysis and logistic regression were performed to analyze data. Results: Logistic regression revealed that: adolescents with low frequency of tooth cleaning (OR = 10.0, CI 4.3–20.0) was associated with poor oral hygiene and that more regular tooth cleaning (OR = 0.1, CI 0.04–0.14) and the use of plastic type of tooth brush (OR = 0.7, CI 0.53–0.99) were associated with less gingival bleeding. High consumption of biscuits (OR = 2.5, CI 1.7–3.8) was associated with presence of dental caries and the use of magadi (OR = 24.2, CI 11.6–50.6) as a food additive was the covariate for more severe dental fluorosis (TF grade 5–9). Regular intake of carbonated soft drinks (OR = 1.6, CI 1.1–2.5) and regular tooth cleaning (OR = 1.7, CI 1.1–2.6) were independently associated with dental erosion. Using teeth as a tool for: biting nails (OR = 1.9, CI 1.4–2.4), opening soda (OR = 1.8, CI 1.4–2.4) and holding needles (OR = 1.6, CI 1.3–2.1) were covariates for tooth wear. Adolescents who reported to clench/grind their teeth (OR = 2.3, CI 1.5–3.7) was the only covariate for TMD. In several of the investigated factors, there were significant differences between the Maasai and non Maasai ethnic groups. Conclusion: Oral health related behaviors have a significant impact on oral diseases/conditions among adolescents attending primary schools in Maasai population areas with obvious differences in behavior between the Maasai and non Maasai ethnic groups. There is a need for addressing oral health and to encourage behaviors that promote good oral health and dental care service utilization in this society. publishedVersion

SETTING: India and South Africa shoulder the greatest burden of tuberculosis (TB) and human immunodeficiency virus (HIV) infection respectively, but care retention is suboptimal.OBJECTIVE: We conducted a study in Pune, India, and Matlosana, South Africa, 1) to identify the factors associated with mobile phone access and comfort of use, 2) to assess access patterns.DESIGN: A cross-sectional study assessed mobile phone access, and comfort; a longitudinal study assessed access patterns.RESULTS: We enrolled 261 participants: 136 in India and 125 in South Africa. Between 1 week and 6 months, participant contact decreased from 90% (n = 122) to 57% (n = 75) in India and from 93% (n = 116) to 70% (n = 88) in South Africa. In the latter, a reason for a clinic visit for HIV management was associated with 63% lower odds of contact than other priorities (e.g., diabetes mellitus, maternal health, TB). In India, 57% (n = 78) reported discomfort with texting; discomfort was higher in the unemployed (adjusted OR [aOR] 4.97, 95%CI 1.12-22.09) and those aged ≥35 years (aOR 1.10, 95%CI 1.04-1.16) participants, but lower in those with higher education (aOR 0.04, 95% CI 0.01-1.14). In South Africa, 91% (n = 114) reported comfort with texting.CONCLUSION: Mobile phone contact was poor at 6 months. While mHealth could transform TB-HIV care, alternative approaches may be needed for certain subpopulations.

Background. Liver enzymes abnormalities have been found to be common among patients on antiretroviral treatment (ART). Apart from the effects of ART on these changes, other factors that can potentially contribute to the abnormal levels of these enzymes have been found to vary in different geographical locations. This study investigated factors associated with liver enzymes abnormalities among human immunodeficiency virus (HIV) infected individuals on ART from the Lake Victoria zone, Tanzania. Methods. A cross-sectional study involving a total of 230 sera from HIV seropositive patients from different regions of the Lake Victoria zone was carried out in July 2017. All samples with required variables/parameters such as age, sex, ART regimen, and residence were serially included in the study. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) detection and liver enzymes assays (alanine transaminase (ALAT) and aspartate transaminase (ASAT)) were assessed following the standard procedures. Data were analyzed by using STATA version 13. Results. The median age of the study participants was 38 (interquartile range [IQR]:30-48) years. The overall prevalence of abnormal liver enzymes was 43.04% (99/230, 95% CI: 36.6-49.3). A total of 26.09% (60/230) had elevated ASAT while 23.9% (55/230) patients had elevated ALAT levels. ASAT levels were significantly high among patients with high HIV viral load (P= 0.002) while ALAT levels were significantly high among those coinfected with hepatitis C virus (P=0.017) and hepatitis B virus (P Conclusion. A significant proportion of HIV seropositive individuals on ART have abnormal levels of liver enzymes, which is significantly associated with high HIV viral load and viral hepatitis. This calls for the need to emphasize screening of viral hepatitis and provision of appropriate management among HIV seropositive individuals in this setting.

Introduction: Anemia during pregnancy may compromise fetal and newborn's health, however, little is known about how and when the fetoplacental vascularization is most vulnerable to anemia. Methods: Using systematic and isotropic uniform random sampling, placental samples were collected from 189 placentas in a cohort study of Tanzanian women whose hemoglobin concentration was measured throughout pregnancy. Fetoplacental vessels and villi were defined as exerting either a transport or diffusion function. The vascularization patterns for transport and diffusion vessels and villi were assessed by stereology. Blood vessel length, surface area and diffusion distance as well as placental villi volume were calculated. Results: Anemia from a gestational age of 23 weeks was significantly associated with increased fetoplacental vascularization in vessels and villi compared to women who were non-anemic throughout pregnancy. Transport surface vessel area: 0.31 m 2 [95% CI: 0.18–0.55], P = 0.01; Transport villi volume 19.8 cm 3 [95% CI: 6.37–33.2], P = 0.004, Transport vessel diameter 7.23 μm [95% CI: 1.23–13.3], P = 0.02. Diffusion vessel surface: 3.23 m 2 [95% CI: 1.55–4.91], P < 0.001 and diffusion villi volume: 29.8 cm 3 [95% CI: 10.0–49.5], P = 0.003). Finally, all the measured transport vessel and villi significantly parameters and diffusion vessel surface, vessel diameter and diffusion distance were associated with birth weight. Discussion: Increased fetoplacental vascularization related to anemia from a gestational age of 23 weeks in pregnancy together with the association between fetoplacental vascularity and birth weight suggest that the timing of anemia determines the effect on fetoplacental vascularization and underlines the clinical relevance for proper development of fetoplacental vasculature.

Despite the availability of vaccines and antibiotics, pneumonia remains the leading cause of mortality among children under 5 years of age. The objective of this study was to identify modifiable risk factors for community-acquired pneumonia (CAP) in children under 5 years of age in a vaccinated population.A case-control study was conducted between January and December 2017. The cases included children aged 2-59 months with X-ray-confirmed pneumonia, whereas the controls were children from the community with no history of respiratory infection. A multivariable logistic regression model was used to determine the modifiable risk factors for CAP.A total of 113 children with X-ray-confirmed pneumonia and 350 healthy children were enrolled in this study. The median ages for the cases and controls were 13.7 (IQR = 7.2-25.3) and 13.4 (IQR = 6.0-24.8) months respectively. One (0.9%) child died after the enrolment. The independent predictors of CAP included a lack of exclusive breastfeeding for 6 months (aOR = 1.7, 95% CI = 1.0-2.9), underweight (aOR = 2.1, 95% CI = 1.0-4.5), unclean cooking fuel (aOR = 1.8, 95% CI = 1.0-3.3) and low income (aOR = 2.9, 95% CI = 1.6-5.4). No association was found between vaccination status and CAP.In addition to a lack of exclusive breastfeeding, children from families of low-economic status were at risk of contracting CAP. Since the risk factors are complex, the study results call for more concerted efforts by and collaboration among the health, agriculture and development sectors to address mortality caused by CAP.Malgré la disponibilité des vaccins et des antibiotiques, la pneumonie reste la principale cause de mortalité chez les enfants de moins de cinq ans. L'objectif de cette étude était d'identifier les facteurs de risque modifiables pour la pneumonie acquise en communauté (PAC) chez les enfants de moins de cinq ans dans une population vaccinée. MÉTHODES: Une étude cas-témoins a été menée entre janvier et décembre 2017. Les cas concernaient des enfants âgés de 2 à 59 mois atteints de pneumonie confirmée par la radiographie, alors que les témoins étaient des enfants de la communauté sans antécédents d'infection respiratoire. Un modèle de régression logistique multivariée a été utilisé pour déterminer les facteurs de risque modifiables pour la PAC. RÉSULTATS: Au total, 113 enfants atteints de pneumonie confirmée par la radiographie et 350 enfants en bonne santé ont été inclus dans cette étude. Les âges médians pour les cas et les témoins étaient respectivement de 13,7 (IQR = 7,2 - 25,3) et de 13,4 (IQR = 6,0 - 24,8) mois. Un enfant (0,9%) est décédé après l'inscription. Les prédicteurs indépendants de la PAC comprenaient une absence d'allaitement exclusif pendant six mois (aOR = 1,7; IC95%: 1,0 - 2,9), un poids insuffisant (aOR = 2,1; IC95%: 1,0 - 4,5), un combustible de cuisson non propre (aOR = 1,8; IC95%: 1,0 - 3,3) et un faible revenu (aOR = 2,9; IC95%: 1,6 - 5,4). Aucune association n'a été trouvée entre le statut de vaccination et la PAC.Outre l'absence d'allaitement maternel exclusif, les enfants issus de familles à faible statut économique étaient à risque de contracter la PAC. Les facteurs de risque étant complexes, les résultats de l’étude appellent à des efforts plus concertés et une collaboration accrue entre les secteurs de la santé, de l'agriculture et du développement afin de lutter contre la mortalité causée par la PAC.

Background A few reliable national data concerning the etiology of non-traumatic spinal cord injury (SCI) in sub-Sahara Africa exists, mainly because of the limitations of diagnostic imaging. These are both expensive and mostly unavailable in several resource-limited settings. Only a few studies have employed the magnetic resonance imaging (MRI) in documenting non-traumatic SCI and most of these studies are from South Africa. We sought to describe the clinical presentation, MRI radiological patterns, and one-year survival among subjects with non-traumatic SCI in Uganda. Methods We enrolled a prospective cohort of 103 participants with non-traumatic SCI at Mulago National Referral Hospital Kampala, Uganda in 2013–2015. Participants received standard of care management, with surgical intervention as needed, with one-year follow up. Data were analyzed using Descriptive statistics. Results In 103 participants with non-traumatic SCI, the median (IQR) age was 37 (18, 85) years and 25% of the participants were HIV-infected. Paraplegia/paraparesis was the most common clinical presentation in 70% (n = 72). Severe disease was present in 82% (n = 85) as per American Spinal Injury Association (ASIA) scale A-C. On MRI, 50% had extradural lesions. However, bone lesions accounted for only 75% of all the extradural lesions. More than 60% of the patients had lesions that could only be diagnosed on MRI. Deaths occurred in 42% (n = 44) of participants, with the highest mortality among those with extradural lesions (60%). Conclusion The mortality following non-traumatic spinal cord injuries in Uganda is high. We demonstrated an equal distribution between extradural and intradural lesions, which differs from the historical predominance of extradural lesions. Increased utilization of MRI particularly among young age groups is needed to make a diagnosis. Electronic supplementary material The online version of this article (10.1186/s12883-019-1236-3) contains supplementary material, which is available to authorized users.

Human immunodeficiency virus (HIV), hepatitis B virus (HBV) and Hepatitis C virus (HCV) infections have been a major public health problem. HIV patients with HBV and HCV infection are at high risk of liver diseases which is associated with increased mortality. This study aims at determining the prevalence of hepatitis B surface antigen (HBsAg), HCV antibodies and HBV antibodies (anti-HBsAg) among HIV seropositive adults attending care and treatment clinic at Sengerema district hospital in Mwanza, Tanzania. A cross-sectional hospital based study was conducted between February and March 2017 among 243 HIV adult patients at Sengerema designated district hospital, Mwanza, Tanzania. Socio-demographic and other relevant information were collected using pre-tested questionnaires. Detection of HBsAg and HCV antibodies was done by commercial rapid immunochromatographic test while the detection of anti-HBsAg was done using enzyme linked immunosorbent assay. Data were analyzed by using STATA version 13. The median age of the study participants was 43, interquartile range (IQR): 37 - 51 years. The majority 172 (70.8) of study participants were female and the majority (88%) of participants had CD4 count of greater than 200 counts/μl. The prevalence of HBsAg, HCV antibodies and anti-HBsAg were 26/243 (10.7%, 95% confidence interval [CI]: 7 - 14), 20/243 (8.2%, 95% CI: 4.7 - 11.6) and (100/243) 41.2%, 95% CI: 35 - 47, respectively. Co-infection with HCV (OR: 4.45, 95% CI: 1.51 - 13.21, P = 0.007) was independenlty found to predict HbsAg positivity. History of blood transfusion (OR: 2.34, 95% CI: 1.08 - 5.06, P = 0.028) was significantly associated with anti-HBsAg among HIV infected individuals while, the rate of anti-HBsAg was found to decrease by 2.02 IU/L in a year increase in age. About one tenth of HIV infected individuals are co-infected with HCV and HBV with more than one third being positive for anti-HBsAg. There is a paramount need to emphasize the need for regular screening and proper management of these patients to reduce associated complications in resource limited countries where these infections are common.

For pregnant women living with HIV (WLWH), feelings about pregnancy may influence their emotional well-being and health seeking behaviors. This study examined attitudes toward pregnancy and associated factors among women enrolled in prevention of mother-to-child transmission of HIV (PMTCT) services in Moshi, Tanzania. 200 pregnant WLWH were enrolled during their second or third trimester of pregnancy and completed a structured survey. Univariable and multivariable regression models examined factors associated with attitudes toward pregnancy, including demographics, interpersonal factors, and emotional well-being. Attitudes toward the current pregnancy were generally positive, with 87% of participants reporting feeling happy about being pregnant. In the final multivariable model, having higher levels of partner support, being newly diagnosed with HIV, and having fewer children were significantly associated with more positive attitudes toward their pregnancy. Findings point to a need for tailored psychosocial support services in PMTCT, as well as comprehensive reproductive health care for WLWH.

Introduction: Transient ischemic attack (TIA) can portend impending stroke, but it is unclear whether a TIA evaluation necessitates inpatient admission. We assessed feasibility and safety of a TIA protocol in the emergency room for low-risk TIA patients. Methods: We studied low-risk TIA patients (ABCD2 score < 4, no significant vessel stenosis) before (January 2018-July 2019) and after (August 2019-March 2020) the implementation of an expedited, emergency room TIA protocol at a comprehensive stroke center. The pre-intervention cohort consisted of TIA patients in the institutional Get-With-The-Guidelines database who met pre-specified criteria ( Figure ) and were admitted. The post-intervention patients met the same criteria and underwent an expedited MRI with selected sequences. If the MRI showed no ischemia, patients were scheduled with rapid, outpatient stroke clinic follow-up and outpatient echocardiogram as indicated. We compared differences in outcomes of interest between the pre-and post-intervention cohorts including length of stay, radiographic and echocardiogram findings, and recurrent neurovascular events within 30 days. Results: In total, 120 TIA patients met criteria (71 pre-intervention, 49 patient post-intervention). Demographic and clinical characteristics were similar except the pre-intervention pathway had a higher proportion of patients with a smoking history and presenting symptom of aphasia and dysarthria. Median time from MRI order to completion was 2.3 hours in the post-intervention cohort. Median length of stay was 7.7 hours (IQR 5.2-9.7) in the post-intervention cohort compared to 28.8 hours (IQR 24.4-42.4) pre-intervention. There were no differences in neuroimaging or echocardiographic findings and 30-day re-presentation for stroke, TIA, or mortality. Conclusions: Our study demonstrates the feasibility and suggests safety of an expedited TIA protocol. Further study is needed to determine its generalizability.

BackgroundEarly access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings.MethodsUsing the implementation of WHO approved TB diagnostics, Xpert Mycobacterium tuberculosis/rifampicin (MTB/RIF) and Line Probe Assay (LPA) as a benchmark, we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics.ResultsHealth officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policy-maker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1%, respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district, regional and national referral hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) used it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate—utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a national health tax and decentralising its management was proposed by policy-makers as a booster of domestic financing needed to increase access to diagnostics.ConclusionOur findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics.

Objective To determine the prevalence of tuberculosis (TB) disease and infection as well as incident TB disease among people who use drugs (PWUD) attending Medication Assisted Treatment (MAT) clinics in Dar-es-Salaam, Tanzania. Methods In this prospective cohort study, a total of 901 consenting participants were enrolled from November 2016 to February 2017 and a structured questionnaire administered to them through the open data kit application on android tablets. Twenty-two months later, we revisited the MAT clinics and reviewed 823 of the 901 enrolled participant’s medical records in search for documentation on TB disease diagnosis and treatment. Medical records reviewed included those of participants whom at enrolment were asymptomatic, not on TB disease treatment, not on TB preventive therapy and those who had a documented tuberculin skin test (TST) result. Results Of the 823 medical records reviewed 22 months after enrolment, 42 had documentation of being diagnosed with TB disease and initiated on TB treatment. This is equivalent to a TB disease incidence rate of 2,925.2 patients per 100,000 person years with a total follow up time of 1,440 person-years. At enrolment the prevalence of TB disease and TB infection was 2.6% and 54% respectively and the HIV prevalence was 44% and 16% among females and males respectively. Conclusion PWUD attending MAT clinics bear an extremely high burden of TB and HIV and are known to have driven TB epidemics in a number of countries. Our reported TB disease incidence is 12 times that of the general Tanzanian incidence of 237 per 100,000 further emphasizing that this group should be prioritized for TB screening, testing and treatment. Gender specific approaches should also be developed as female PWUDs are markedly more affected with HIV and TB disease than male PWUDs.

Mutations in the Plasmodium falciparum genes Pfdhfr and Pfdhps, particularly the sextuple mutant haplotype threatens the antimalarial effectiveness of sulfadoxine-pyrimethamine (SP) as intermittent preventive treatment during pregnancy (IPTp). To explore the impact of sextuple mutant haplotype infections on outcome measures after provision of IPTp with SP, we monitored birth outcomes in women followed up from before conception or from the first trimester until delivery. Women infected with sextuple haplotypes, in the early second trimester specifically, delivered newborns with a lower birth weight compared with women who did not have malaria during pregnancy (difference, −267 g; 95% confidence interval, −454 to −59; P = .01) and women infected with less SP-resistant haplotypes (−461 g; −877 to −44; P = .03). Thus, sextuple haplotype infections seem to affect the effectiveness of SP for IPTp and directly affect birth outcome by lowering birth weight. Close monitoring and targeted malaria control during early pregnancy is therefore crucial to improving birth outcomes.

Objective Pregnant and postpartum women living with HIV face disproportionate risk of depression and suicide, particularly in low-income and middle-income countries. This study examined patterns and predictors of suicidal ideation among women living with HIV in antenatal care in Kilimanjaro, Tanzania. Design We conducted a longitudinal cohort study of 200 pregnant women living with HIV, with surveys conducted during pregnancy and 6 months postpartum. Methods Pregnant women were recruited during HIV and antenatal care visits at nine clinics. A structured questionnaire was verbally administered in Kiswahili by a trained study nurse. We used simple frequencies and t-tests to measure patterns of suicidal ideation and logistic regression to assess factors associated with suicidal ideation. Results Suicidal ideation was endorsed by 12.8% of women during pregnancy and decreased significantly to 3.9% by 6 months postpartum. Ideation was not significantly greater among participants newly diagnosed with HIV. In univariable analyses, suicidal ideation was associated with depression, anxiety, HIV stigma, single relationship status, unknown HIV status of the father of the baby, negative attitudes about antiretroviral medication, and low social support. In the multivariable model, women experiencing anxiety and HIV stigma were significantly more likely to endorse suicidal ideation during pregnancy. Conclusion Suicidal ideation and associated feelings of hopelessness are a critical challenge in antenatal care among women living with HIV, with important implications for quality of life, care engagement, and survival. To better support patients, targeted approaches to address anxiety, depression, stigma, and hopelessness must be prioritized, including crisis support for suicide prevention.

Cat bites represent the second most common mammalian bites after dog bites and are responsible for three-quarters of bites that result in infection. We report a case of a 60-year-old retired woman who was admitted to the surgery daily clinic due to fever and pain with three necrotic bite wounds on her hand and lymphangitis, which developed one day after she had been bitten by her cat. Prompt debridement, irrigation and drainage combined with empiric oral amoxicillin/clavulanic acid, resulted in clinical improvement and reduction of elevated inflammatory parameters specifically C-reactive protein. While wound cultures remained sterile, serology results were positive for Bartonella henselae.

Gestational diabetes mellitus (GDM) is associated with poor pregnancy outcomes and increased long-term risk of metabolic diseases for both mother and child. In Tanzania, GDM prevalence increased from 0% in 1991 to 19.5% in 2016. Anaemia has been proposed to precipitate the pathogenesis of GDM. We aimed to examine the prevalence of GDM in a rural area of Tanzania with a high prevalence of anaemia and to examine a potential association between haemoglobin concentration and blood glucose during pregnancy. The participants were included in a population-based preconception, pregnancy and birth cohort study. In total, 538 women were followed during pregnancy and scheduled for an oral glucose tolerance test (OGTT) at week 32&ndash, 34 of gestation. Gestational diabetes mellitus was diagnosed according to the WHO 2013 guidelines. Out of 392 women screened, 39% (95% CI: 34.2&ndash, 44.1) had GDM, the majority of whom (94.1%) were diagnosed based solely on the fasting blood sample from the OGTT. No associations were observed between haemoglobin or ferritin and glucose measurements during pregnancy. A very high prevalence of GDM was found in rural Tanzania. In view of the laborious, costly and inconvenient OGTT, alternative methods such as fasting blood glucose should be considered when screening for GDM in low- and middle-income countries.

Background Real-life experience with idarucizumab, which reverses the anticoagulant effect of dabigatran, is currently limited. Objective To evaluate efficacy and safety of the clinical use of idarucizumab after its availability in Slovenia. Methods We analysed consecutive cases treated with idarucizumab in Slovenia from January to October 2016. The decision to reverse dabigatran with idarucizumab was made by the treating clinicians, as was the assessment of clinical outcomes and blood sampling/monitoring (activated partial thromboplastin time, thrombin time and diluted thrombin time) before and after use. Results Idarucizumab was used in 17 cases. One patient was treated with the antidote twice with an interval of 2 months between treatments. The indications for idarucizumab use were: emergency surgery (4/17), severe bleeding (11/17; seven with intracranial bleeding) and ischaemic stroke (2/17). During surgery, no excessive bleeding was reported. Five patients died due to cardiogenic, haemorrhagic or septic shock, intracranial bleeding or multiple organ failure. Among cases with laboratory data available, baseline coagulation tests were prolonged in 12/13 cases with bleeding or emergency surgery. After idarucizumab administration, normal coagulation parameters were confirmed in 10/11. However, re-occurrence of dabigatran effect was noted later in four patients with creatinine clearance less than 30 ml min, and one patient with persistent bleeding required retreatment with idarucizumab. Conclusion Our first experiences with idarucizumab use in daily-care settings support a rapid and efficient decrease in the anticoagulant effect of dabigatran in emergency situations. Late re-occurrence of dabigatran effect was noted in a subset of patients with severe renal failure.

Background: In high transmission settings, up to 70% of school-aged children harbour malaria parasites without showing any clinical symptoms. Thus, epidemiologically, school aged children act as a substantial reservoir for malaria transmission. Asymptomatic Plasmodium infections induce inflammation leading to iron deficiency anaemia. Consequently, anaemia retards child growth, predisposes children to other diseases and reduces cognitive potential that could lead to poor academic performance. School aged children become increasingly more vulnerable as compared to those aged less than five years due to delayed acquisition of protective immunity. None of the existing Intermittent Preventive Treatment (IPT) strategies is targeting school-aged children. Here, we describe the study protocol of a clinical trial conducted in north-eastern Tanzania to expand the IPT by assessing the effectiveness and safety of two antimalarial drugs, Dihydroartemisinin-Piperaquine (DP) and Artesunate-Amodiaquine (ASAQ) in preventing malaria related morbidities in school-aged children (IPTsc) living in a high endemic area. Methods/design: The trial is a phase IIIb, individual randomized, open label, controlled trial enrolling school children aged 5–15 years, who receive either DP or ASAQ or control (no drug), using a “balanced block design” with the “standard of care” arm as reference. The interventional treatments are given three times a year for the first year. A second non-interventional year will assess possible rebound effects. Sample size was estimated to 1602 school children (534 per group) from selected primary schools in an area with high malaria endemicity. Thick and thin blood smears (to measure malaria parasitaemia using microscope) were obtained prior to treatment at baseline, and will be obtained again at month 12 and 20 from all participants. Haemoglobin concentration using a haemoglobinometer (HemoCue AB, Sweden) will be measured four monthly. Finger-prick blood (dried bloodspot-DBS) prepared on Whatman 3 M filter paper, will be used for sub-microscopic malaria parasite detection usingPCR, detect markers of drug resistance (using next generation sequencing (NGS) technology), and malaria serological assays (using enzyme-linked immunosorbent assay, ELISA). To determine the benefit of IPTsc on cognitive and psychomotor ability test of everyday attention for children (TEA-Ch) and a ‘20 m Shuttle run’ respectively, will be conducted at baseline, month 12 and 20. The primary endpoints are change in mean haemoglobin from baseline concentration and reduction in clinical malaria incidence at month 12 and 20 of follow up. Mixed design methods are used to assess the acceptability, cost-effectiveness and feasibility of IPTsc as part of a more comprehensive school children health package. Statistical analysis will be in the form of multilevel modelling, owing to repeated measurements and clustering effect of participants. Discussion: Malaria intervention using IPTsc strategy may be integrated in the existing national school health programme. However, there is limited systematic evidence to assess the effectiveness and operational feasibility of this approach. School-aged children are easily accessible in most endemic malaria settings. The evidence from this study will guide the implementation of the strategy to provide complementary approach to reduce malaria related morbidity, anaemia and contribute to the overall burden reduction. Trial registration: Clinicaltrials.gov: NCT03640403, registered on Aug 21, 2018, prospectively registered.Url https://www.clinicaltrials.gov/ct2/show/NCT03640403?term=NCT03640403&rank=1. Keywords: Malaria, Effectiveness, Dihydroartemisinin-piperaquine, Artesunate-amodiaquine, Anaemia, Randomized controlled trial, Cognitive ability

Objective To examine the association between bacterial-viral co-occurrence in the nasopharynx and the risk of community acquired pneumonia (CAP) in young children living in resource-limited settings. Methods A case-control study was conducted between January and December 2017 in Moshi, Tanzania. Children 2–59 months with CAP and healthy controls were enrolled. RSV and Influenza A/B were detected with a standardized polymerase chain reaction (PCR) method, and a simplified real-time quantitative PCR method, without sample pre-processing, was developed to detect bacterial pathogens in nasopharyngeal samples. Results A total of 109 CAP patients and 324 healthy controls were enrolled. Co-detection of H. influenzae and S. pneumoniae in nasopharyngeal swabs was linked with higher odds of CAP (aOR=3.2, 95% CI=1.1–9.5). The majority of the H. influenzae isolated in cases and controls (95.8%) were non-typeable. Of the viruses examined, respiratory syncytial virus (RSV) was most common (n = 31, 7.2%) in cases and controls. Children with RSV had 8.4 times higher odds to develop pneumonia than healthy children (aOR=8.4, 95%CI= 3.2 – 22.1). Conclusions Co-occurence of H. influenzae and S. pneumoniae in the nasopharynx was strongly associated with CAP. The high prevalence of non-typeable H. influenzae might be a sign of replacement as a consequence of Haemophilus influenzae type b vaccination.

IntroductionHousehold contacts of patients with active pulmonary tuberculosis (TB) often have latent TB infection, and are at risk of progression to disease. We set out to investigate whether index TB case HIV status was linked to a higher probability of latent TB infection among household contacts.Materials and methodsData were collected prospectively from participants in the intervention arm of a household cluster-randomised trial in two South Africa provinces (Mangaung, Free State, and Capricorn, Limpopo). In intervention group households, TB contacts underwent HIV testing and tuberculin skin testing (TST). TST induration was estimated at two cut-offs (≥5mm, ≥10mm). Multilevel Bayesian regression models estimated posterior distributions of the percentage of household contacts with TST induration ≥5mm and ≥10mm by age group, and compared the odds of latent TB infection by key risk factors including HIV status index case age and study province.ResultsA total of 2,985 household contacts of 924 index cases were assessed, with most 2,725 (91.3%) undergoing TST. HIV prevalence in household contacts was 14% and 10% in Mangaung and Capricorn respectively. Overall, 16.8% (458/2,725) had TST induration of ≥5mm and 13.1% (359/2,725) ≥10mm. In Mangaung, children aged 0-4 years had a high TST positivity prevalence compared to their peers in Capricorn (22.0% vs. 7.6%, and 20.5% vs. 2.3%, using TST thresholds of ≥5mm and ≥10mm respectively). Compared to contacts from Capricorn, household contacts living in Mangaung were more likely to have TST induration ≥5mm (odds ratio [OR]: 3.08, 95% credibility interval [CI]: 2.13-4.58) and ≥10mm (OR: 4.52, 95% CI: 3.03-6.97). There was a 90% and 92% posterior probability that the odds of TST induration ≥5mm (OR: 0.79, 95% CI: 0.56-1.14) and ≥10mm (OR: 0.77, 95% CI: 0.53-1.10) respectively were lower in household contacts of HIV-positive compared to HIV-negative index cases.ConclusionsHigh TST induration positivity, especially among young children and people living in Mangaung indicates considerable TB transmission despite high antiretroviral therapy coverage. Household contact of HIV-positive index TB cases were less likely to have evidence of latent TB infection than contacts of HIV-negative index cases.

Uterine fibroids are the most common benign uterine tumors affecting > 50% of premenopausal women. The incidence, burden and symptoms from uterine fibroids are higher in women of African descent compared to Caucasians. Despite increasing number of African American females being evaluated for and undergoing kidney transplantation (KT), perioperative management guidelines for uterine fibroids currently do not exist. We present a case of a 40 y/o African American female with known symptomatic uterine fibroids preoperatively and medically managed, who underwent a successful KT and 4 years later progressively developed massive leiomyomatous uterine proliferation, causing a complete lateral displacement of the transplanted kidney with severe hydronephrosis, transplant ureteral obstruction and secondary urinary tract infections with bacteremia. This obstruction required a percutaneous nephrostomy tube placement followed by an interval transabdominal hysterectomy, which was complicated by transplant ureteral transection requiring ureteral reimplantation, resulting in prolonged hospitalization, follow-up and outpatient antibiotic regimen. There is a need for management guidelines for uterine fibroids incidentally encountered during the KT evaluation process to avoid similar preventable post-KT complications in patient populations most commonly affected. Literature review and perioperative management/surveillance strategies are provided.

Prevention of mother-to-child transmission of HIV (PMTCT) is a foundational component of a comprehensive HIV treatment program. In addition to preventing vertical transmission to children, PMTCT is an important catch-point for universal test-and-treat strategies that can reduce community viral load and slow the epidemic. However, systematic reviews suggest that care engagement in PMTCT programs is sub-optimal. This study enrolled a cohort of 200 women initiating PMTCT in Kilimanjaro, Tanzania, and followed them to assess HIV care engagement and associated factors. Six months after delivery, 42/200 (21%) of participants were identified as having poor care engagement, defined as HIV RNA >200 copies/mL or, if viral load was unavailable, being lost-to-follow-up in the clinical records or self-reporting being out of care. In a multivariable risk factor analysis, younger women were more likely to have poor postpartum care engagement; with each year of age, women were 7% less likely to have poor care engagement (aRR: 0.93; 95% CI: 0.89, 0.98). Additionally, women who had told at least one person about their HIV status were 47% less likely to have poor care engagement (aRR: .53; 95% CI: 0.29, 0.97). Among women who entered antenatal care with an established HIV diagnosis, those who were pregnant for the first time had increased risk of poor care engagement (aRR 4.16; 95% CI 1.53, 11.28). The findings suggest that care engagement remains a concern in PMTCT programs, and must be addressed to realize the goals of PMTCT. Comprehensive counseling on HIV disclosure, along with community-based stigma reduction programs to provide a supportive environment for people living with HIV, are crucial to address barriers to care engagement and support long-term treatment. Women presenting to antenatal care with an established HIV status require support for care engagement during the crucial period surrounding childbirth, particularly those pregnant for the first time.

OBJECTIVE: In 2013, Tanzania adopted the World Health Organization’s Option B+ guidelines for prevention of mother-to-child transmission of HIV (PMTCT), whereby all HIV-infected pregnant women initiate lifelong antiretroviral therapy. This study examined retention in PMTCT across critical junctures in the care continuum. METHODS: This was a retrospective study of patient-level data for a cohort of women enrolled in PMTCT during the first year of Option B+ in Tanzania. Retention in care was described across three periods: (1) the first month of antenatal care (ANC), (2) pregnancy, and (3) the postpartum period. Logistic regression was used to identify factors associated with loss to follow up (LTFU) during the first month of ANC. Survival analyses were used to identify factors associated with LTFU during pregnancy and the postpartum periods. RESULTS: 650 participants were included in the cohort; 262 (40.3%) were newly diagnosed with HIV. Two years after delivery, 383/650 (58.7%) were LTFU. Of the 383 LTFU, 73 (19.1%) were lost during the first month of ANC, 44 (11.5%) during pregnancy, and 266 (69.5%) after delivery. Being newly diagnosed with HIV predicted higher LTFU during the first month of ANC (aOR 1.76; 95% CI: 1.06 – 2.94) and faster time to LTFU during the postpartum period (adjusted relative time, 0.68; 95% CI: 0.51 – 0.89). CONCLUSIONS: High LTFU occurred across the PMTCT continuum, including immediately after enrollment into ANC and the postpartum period. Ongoing research is needed to encourage treatment uptake and sustained engagement after delivery.

Background\ud Human-to-animal transmission of M. tuberculosis (Mtb) is reported in South Africa but there is a paucity of epidemiological data. The aim of this One Health manuscript is to describe zooanthroponotic exposure of domestic animals to TB patients, virtually all of whom had laboratory confirmed pulmonary Mtb disease.\ud \ud Methods\ud This cross-sectional study was nested within two TB contact tracing studies and collected data from 2017 to 2019. TB index patients and their households in three provinces of South Africa were recruited. A questionnaire was administered to households, assessing type and number of animals owned, degree of exposure of animals to humans, and veterinary consultations. For this analysis, we compared descriptive variables by animal-keeping status (animal-keeping vs non-animal keeping households), calculated the chi square and respective p-values.\ud \ud Results\ud We visited 1766 households with at least one confirmed case of TB, 33% (587/1766) had livestock or companion animals. Of non-animal-owning households, 2% (27/1161) cared for other community members' livestock. Few (16%, 92/587) households kept animals in their dwelling overnight, while 45% (266/587) kept animals outside the home, but within 10 m of where people slept and ate. Most (81%, 478/587) of people in animal-owning households were willing for their animal/s to have a TB skin test, but

Female sex workers (FSWs) are at increased risk of mental health problems, including mood disorders and substance abuse, and we need to understand the origins of these to treat and prevent them, and particularly understand how the context in which they sell sex impacts their mental health. We conducted a multi-stage, community-centric, cross-sectional survey of 3005 FSWs linked to SW programmes in twelve sites across all nine provinces of South Africa. We interviewed adult women who had sold sex in the preceding six months, who were recruited via SW networks. We found that FSWs have very poor mental health as 52.7% had depression and 53.6% has post-traumatic stress disorder (PTSD). The structural equation model showed direct pathways from childhood trauma and having HIV+ status to mental ill-health. Indirect pathways were mediated by food insecurity, controlling partners, non-partner rape, harmful alcohol use, substance use to cope with SW, indicators of the circumstances of SW, i.e., selling location (on streets, in taverns and brothels), frequency of selling and experiencing SW stigma. All paths from childhood trauma had final common pathways from exposure to gender-based violence (non-partner rape or intimate partner violence) to mental ill-health, except for one that was mediated by food insecurity. Thus, FSWs’ poor mental health risk was often mediated by their work location and vulnerability to violence, substance abuse and stigma. The potential contribution of legal reform to mitigate the risks of violence and mental ill-health are inescapable. Treatment of mental ill-health and substance abuse should be an essential element of FSW programmes.

Transient ischemic attack (TIA) can be a warning sign of an impending stroke. The objective of our study is to assess the feasibility, safety, and cost savings of a comprehensive TIA protocol in the emergency room for low-risk TIA patients.This is a retrospective, single-center cohort study performed at an academic comprehensive stroke center. We implemented an emergency department-based TIA protocol pathway for low-risk TIA patients (defined as ABCD2 score4 and without significant vessel stenosis) who were able to undergo vascular imaging and a brain MRI in the emergency room. Patients were set up with rapid outpatient follow-up in our stroke clinic and scheduled for an outpatient echocardiogram, if indicated. We compared this cohort to TIA patients admitted prior to the implementation of the TIA protocol who would have qualified. Outcomes of interest included length of stay, hospital cost, radiographic and echocardiogram findings, recurrent neurovascular events within 30 days, and final diagnosis.A total of 138 patients were assessed (65 patients in the pre-pathway cohort, 73 in the expedited, post-TIA pathway implementation cohort). Average time from MRI order to MRI end was 6.4 h compared to 2.3 h in the pre- and post-pathway cohorts, respectively (p 0.0001). The average length of stay for the pre-pathway group was 28.8 h in the pre-pathway cohort compared to 7.7 h in the post-pathway cohort (p 0.0001). There were no differences in neuroimaging or echocardiographic findings. There were no differences in the 30 days re-presentation for stroke or TIA or mortality between the two groups. The direct cost per TIA admission was $2,944.50 compared to $1,610.50 for TIA patients triaged through the pathway at our institution.This study demonstrates the feasibility, safety, and cost-savings of a comprehensive, emergency department-based TIA protocol. Further study is needed to confirm overall benefit of an expedited approach to TIA patient management and guide clinical practice recommendations.

BackgroundGlobal mortality attributable to non-communicable diseases (NCDs) occurs in more than 36 million people annually with 80% of these deaths occurring in resource limited countries. Among people living with HIV and AIDS (PLHA) studies have reported higher prevalence’s of NCDs compared to the general population but most studies do report a narrow range of NCDs commonly hypertension, diabetes and neoplasms and not all. In addition, there is limited reporting, integration of systematic screening and treatment for all NCDs among PLHA attending care, suggesting the NCD burden among PLHA is likely an underestimate. Little is known about factors facilitating or hindering integration of the care and treatment of NCDs within HIV care and treatment clinics (CTCs) in Tanzania.ObjectiveTo explore the perceptions of PLHA and health workers on factors facilitate or hinder the recognition and integration of care for NCDs within CTCs in Dar es Salaam.MethodsInductive content analysis of transcripts from 41 in-depth interviews were conducted with 5 CTC managers (CTC Managers), 9 healthcare providers (DHCP) and 27 people living with HIV (PLHA) attending CTCs and with co-morbid NCDs.ResultsFour themes emerged; the current situation of services available for care and treatment of NCDs among PLHA in CTCs, experiences of PLHA with co-morbid NCDs with access to care and treatment services for NCDs, facilitators of integrating care and treatment of NCDs within CTCs and perceived barriers for accessing and integration of care and treatment of NCDs within CTCs.ConclusionsThere was a positive attitude among PLHA and healthcare workers towards integration of NCD services within CTC services. This was enhanced by perceived benefits inherent to the services. Factors hindering integration of NCD care and services included; limited and inconsistent supplies such as screening equipment, medications; insufficient awareness of NCDs within PLHA; lack of adequate training of healthcare workers on management of NCD and treatment costs and payment systems.

Purpose: The current study evaluates the impact of immunohistochemistry (IHC) on diagnostic accuracy for pediatric cancer in Tanzania, and identifies the most common biomarkers used for diagnostic differentiation in our setting. Methods: Pathology samples for children diagnosed with cancer at Bugando Medical Centre (Mwanza, Tanzania) in 2018 were evaluated using H&E staining. Basic demographic information from histology form was recorded, including patient age, sex, and sample collection, as well as the reported histopathology results from BMC. Additional tissue from histology block was sent to Muhimbili National Hospital for IHC review. The histopathology results were compared for diagnostic agreement, change in diagnosis, and identified which biomarkers were necessary for diagnostic confirmation. Results: One hundred and five (105) pediatric cancer patients were reviewed. 58 (55.2%) were female median age of 6 years (IQR 3-9 years). Most common pediatric diagnoses were Burkitt lymphoma and Non Hodgkin Lymphoma specifically Diffuse Large B-cell lymphoma, anaplastic large cell lymphoma, FL, LL. Overall histology concordance between H&E and IHC was 51.0%. Most common discordant diagnosis was NHL of ALCL (ALK1-negative, CD-45, 30-positivity). Most concordant was Leukemia (BCR-ABL). Diagnostic specificity (example: in Non-Hodgkin Lymphoma) improved for 17.6% (n=18). The most common diagnosis with increased specificity was DLBCL. Among NHL, 39% (n=7) were ALCL, 27% (n=5) DLBCL, 17% (n=3) Lymphoblastic Lymphoma, 17% (n=3) Follicular lymphoma. The use of immunohistochemistry resulted in a change in diagnosis for 31.4% (n=32) of patient. The most common changed diagnosis was Burkitt Lymphoma and Sarcoma. Conclusion: Immunohistochemistry is critically important for accurate diagnosis of pediatric cancer, with over 30% of all cases identified as having treatment changing diagnoses. IHC training is critical and a limited common biomarker panel can successfully be used in low resource countries to improve treatment selection. Citation Format: Jeffer Bhuko, Caroline Minja, Michael McDermott, Maureen Osullivan, Trish Scanlan, Kristin Schroeder. Impact of Immunohistochemistry on Diagnostic Accuracy for Pediatric Cancer in Tanzania [abstract]. In: Proceedings of the 9th Annual Symposium on Global Cancer Research; Global Cancer Research and Control: Looking Back and Charting a Path Forward; 2021 Mar 10-11. Philadelphia (PA): AACR; Cancer Epidemiol Biomarkers Prev 2021;30(7 Suppl):Abstract nr 4.

Malaria during pregnancy constitutes a large health problem in areas of endemicity. The World Health Organization recommends that interventions are initiated at the first antenatal visit, and these improve pregnancy outcomes. This study evaluated fetal growth by ultrasonography and birth outcomes in women who were infected prior to the first antenatal visit (gestational age

We aimed to develop forest therapy programs (FTPs) to prevent dementia and related health problems in the elderly population, with the assumption that health benefits are FTP-type specific and depend on the participant&rsquo, s psychophysiological traits. For this purpose, we developed two distinct FTPs, namely, a guided-breathing meditation program (BP) and a walking program (WP), we adopted the approach of Sasang constitutional (SC) medicine, which categorizes individuals into one of three SC types (SC1, SC2, or SC3) for medical care. The FTPs ran 11 sessions over 11 weeks. We recruited 29/31/28 participants who were 65 years of age or older for the BP/WP/control groups, respectively, obtained electrophysiological measurements via electroencephalogram (EEG), heart rate variability (HRV), and bioimpedance, and analyzed the intervention effects with analysis of covariance. Compared with the control, the BP and WP resulted in benefits for neural activity and parasympathetic nervous activity (PNA), respectively, and both FTPs yielded distinct beneficial effects on bioimpedance. Constitution-specific effects were also present. The SC1- and SC2-type participants gained positive effects in neural activity from the BP and WP, respectively. The SC3-type participants showed improvements in PNA from the WP. In conclusion, for older individuals, both programs conferred health benefits that would help prevent dementia, and the benefits were program-specific and constitution-specific.

Background Household contact tracing of index TB cases has been advocated as a key part of TB control for many years, but has not been widely implemented in many low-resource setting because of the current dearth of high quality evidence for effectiveness. Innovative strategies for earlier, more effective treatment are particularly important in contexts with hyper-endemic levels of HIV, where levels of TB infection remain extremely high. Methods We present the design of a household cluster-randomised controlled trial of interventions aimed at improving TB-free survival and reducing childhood prevalence of Mycobacterium tuberculosis infection among household contacts of index TB cases diagnosed in two provinces of South Africa. Households of index TB cases will be randomly allocated in a 1:1 ratio to receive either an intensified home screening and linkage for TB and HIV intervention, or enhanced standard of care. The primary outcome will compare between groups the TB-free survival of household contacts over 15 months. All participants, or their next-of-kin, will provide written informed consent to participate. Discussion Evidence from randomised trials is required to identify cost-effective approaches to TB case-finding that can be applied at scale in sub-Saharan Africa. Trial registration ISRCTN16006202 (01/02/2017: retrospectively registered) and NHREC4399 (11/04/2016: prospectively registered). Protocol version: 4.0 (date: 18th January 2018).

We present the participatory design process of a robotic tutor of assistive sign language for children with autism spectrum disorder (ASD). Robots have been used in autism therapy, and to teach sign language to neurotypical children. The application of teaching assistive sign language - the most common form of assistive and augmentative communication used by people with ASD - is novel. The robot's function is to prompt children to imitate the assistive signs that it performs. The robot was therefore co-designed to appeal to children with ASD, taking into account the characteristics of ASD during the design process: impaired language and communication, impaired social behavior, and narrow flexibility in daily activities. To accommodate these characteristics, a multidisciplinary team defined design guidelines specific to robots for children with ASD, which were followed in the participatory design process. With a pilot study where the robot prompted children to imitate nine assistive signs, we found support forthe effectiveness of the design. The children successfully imitated the robot and kept their focus on it, as measured by their eye gaze. Children and their companions reported positive experiences with the robot, and companions evaluated it as potentially useful, suggesting that robotic devices could be used to teach assistive sign language to children with ASD.

BackgroundChildren with sickle cell anemia (SCA) are highly susceptible to stroke and other manifestations of pediatric cerebral vasculopathy. Detailed evaluations in sub-Saharan Africa are limited.MethodsWe aimed to establish the frequency and types of pediatric brain injury in a cross-sectional study at a large SCA clinic in Kampala, Uganda in a randomly selected sample of 265 patients with HbSS ages 1–12 years. Brain injury was defined as one or more abnormality on standardized testing: neurocognitive impairment using an age-appropriate test battery, prior stroke by examination or transcranial Doppler (TCD) velocities associated with stroke risk in children with SCA (cerebral arterial time averaged mean maximum velocity ≥ 170 cm/second).ResultsMean age was 5.5 ± 2.9 years; 52.3% were male. Mean hemoglobin was 7.3 ± 1.01 g/dl; 76.4% had hemoglobin p p = 0.04). In adjusted models, neurocognitive dysfunction was strongly related to prior stroke (OR 6.88, 95%CI 1.95–24.3,p = .003) and to abnormal TCD (OR 4.37, 95%CI 1.30,p = 0.02). In a subset of 81 subjects who were enriched for other abnormal results, magnetic resonance imaging and angiography (MRI/MRA) detected infarcts and/or arterial stenosis in 52%. Thirteen subjects (25%) with abnormal imaging had no other abnormalities detected.ConclusionsThe high frequency of neurocognitive impairment or other abnormal results describes a large burden of pediatric SCA brain disease in Uganda. Evaluation by any single modality would have underestimated the impact of SCA. Testing the impact of hydroxyurea or other available disease-modifying interventions for reducing or preventing SCA brain effects is warranted.

Background Epidemiological surveys of malaria currently rely on microscopy, polymerase chain reaction assays (PCR) or rapid diagnostic test kits for Plasmodium infections (RDTs). This study investigated whether mid-infrared (MIR) spectroscopy coupled with supervised machine learning could constitute an alternative method for rapid malaria screening, directly from dried human blood spots. Methods Filter papers containing dried blood spots (DBS) were obtained from a cross-sectional malaria survey in 12 wards in southeastern Tanzania in 2018/19. The DBS were scanned using attenuated total reflection-Fourier Transform Infrared (ATR-FTIR) spectrometer to obtain high-resolution MIR spectra in the range 4000 cm−1 to 500 cm−1. The spectra were cleaned to compensate for atmospheric water vapour and CO2 interference bands and used to train different classification algorithms to distinguish between malaria-positive and malaria-negative DBS papers based on PCR test results as reference. The analysis considered 296 individuals, including 123 PCR-confirmed malaria positives and 173 negatives. Model training was done using 80% of the dataset, after which the best-fitting model was optimized by bootstrapping of 80/20 train/test-stratified splits. The trained models were evaluated by predicting Plasmodium falciparum positivity in the 20% validation set of DBS. Results Logistic regression was the best-performing model. Considering PCR as reference, the models attained overall accuracies of 92% for predicting P. falciparum infections (specificity = 91.7%; sensitivity = 92.8%) and 85% for predicting mixed infections of P. falciparum and Plasmodium ovale (specificity = 85%, sensitivity = 85%) in the field-collected specimen. Conclusion These results demonstrate that mid-infrared spectroscopy coupled with supervised machine learning (MIR-ML) could be used to screen for malaria parasites in human DBS. The approach could have potential for rapid and high-throughput screening of Plasmodium in both non-clinical settings (e.g., field surveys) and clinical settings (diagnosis to aid case management). However, before the approach can be used, we need additional field validation in other study sites with different parasite populations, and in-depth evaluation of the biological basis of the MIR signals. Improving the classification algorithms, and model training on larger datasets could also improve specificity and sensitivity. The MIR-ML spectroscopy system is physically robust, low-cost, and requires minimum maintenance.

Adherence to antiretroviral therapy (ART) during pregnancy and the postpartum period is necessary to prevent vertical HIV transmission and to secure the long-term health of an HIV-infected woman. Health behavior theory suggests that patients’ attitudes towards medication can predict their medication-taking behaviour. This study sought to understand how women’s attitudes towards ART changes between the pregnancy and postpartum periods, and the factors associated with these attitudes. The study enrolled 200 pregnant women living with HIV. Structured surveys were administered during pregnancy and at three and six months postpartum. Overall, attitudes towards ART were stable over time. More positive attitudes towards ART were associated with HIV acceptance, lower levels of depression, and lower levels of shame. Counselling interventions are needed to help HIV-infected women accept their status and reduce shameful emotions. Depression screening and treatment should be integrated into PMTCT services. This study emphasizes the importance of early attention to attitudes towards ART, in order to establish a trajectory of sustained care engagement.

Background Adherence to tuberculosis (TB) treatment is challenging because of many factors. The World Health Organization has recommended the use of digital adherence monitoring technologies in its End TB Strategy. However, evidence on improving adherence is limited. EvriMED is a real-time medication-monitoring device which was found to be feasible and acceptable in a few studies in Asia. In Tanzania, however, there may be challenges in implementing evriMED due to stigmatization, network and power access, accuracy, and cost effectiveness, which may have implications for treatment outcome. We propose a pragmatic cluster randomized trial to investigate the effectiveness of evriMED with reminder cues and tailored feedback on adherence to TB treatment in Kilimanjaro, Tanzania. Methods/design We will create clusters in Kilimanjaro based on level of health care facility. Clusters will be randomized in an intervention arm, where evriMED will be implemented, or a control arm, where standard practice directly observed treatment will be followed. TB patients in intervention clusters will take their medication from the evriMED pillbox and receive tailored feedback. We will use the ‘Stages of Change’ model, which assumes that a person has to go through the stages of pre-contemplation, contemplation, preparation, action, and evaluation to change behavior for tailored feedback on adherence reports from the device. Discussion If the intervention shows a significant effect on adherence and the devices are accepted, accurate, and sustainable, the intervention can be scaled up within the National Tuberculosis Programmes. Trial registration Pan African Clinical Trials Registry, PACTR201811755733759. Registered on 8 November 2018. Electronic supplementary material The online version of this article (10.1186/s13063-019-3483-4) contains supplementary material, which is available to authorized users.

To accelerate malaria elimination in areas where core interventions such as insecticide-treated nets (ITNs) are already widely used, it is crucial to consider additional factors associated with persistent transmission. Qualitative data on human behaviours and perceptions regarding malaria risk was triangulated with quantitative data on Anopheles mosquito bites occurring indoors and outdoors in south-eastern Tanzania communities where ITNS are already used but lower level malaria transmission persists. Each night (18:00h-07:00h), trained residents recorded human activities indoors, in peri-domestic outdoor areas, and in communal gatherings. Host-seeking mosquitoes were repeatedly collected indoors and outdoors hourly, using miniaturized exposure-free double net traps (DN-Mini) occupied by volunteers. In-depth interviews were conducted with household representatives to explore perceptions on persistent malaria and its control. Higher proportions of people stayed outdoors than indoors in early-evening and early-morning hours, resulting in higher exposures outdoors than indoors during these times. However, exposure during late-night hours (22:00h-05:00h) occurred mostly indoors. Some of the popular activities that kept people outdoors included cooking, eating, relaxing and playing. All households had at least one bed net, and 83.9% of people had access to ITNs. Average ITN use was 96.3%, preventing most indoor exposure. Participants recorgnized the importance of ITNs but also noted that the nets were not perfect. No complementary interventions were reported being used widely. Most people believed transmission happens after midnight. We conclude that insecticide-treated nets, where properly used, can still prevent most indoor exposures, but significant risk continues unabated before bedtime, outdoors and at communal gatherings. Such exposure is greatest for rural and low-income households. There is therefore an urgent need for complementary interventions, particularly those targeting outdoor-biting and are applicable for all people including the marginalised populations such as migratory farmers and fishermen. Besides, the differences in community understanding of ongoing transmission, and feedback on imperfections of ITNs should be considered when updating malaria-related communication and interventions.