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Chibuike Ibe,1 Nicholaus P Mnyambwa,2,3 Sayoki G Mfinanga2 1Department of Microbiology, Faculty of Biological Sciences, Abia State University, Uturu, Nigeria; 2National Institute for Medical Research, Muhimbili Research Centre, Dar es Salaam, Tanzania; 3Alliance for Africa Health and Research (A4A), Dar es Salaam, TanzaniaCorrespondence: Chibuike Ibe, Email c.ibe@abiaistateuniversity.edu.ngAbstract: Emergomycosis is an emerging deadly infectious disease caused primarily by a little-known airborne pathogen Emergomyces africanus, which can cause clinical management challenge especially in patients with advanced HIV disease. This minireview describes Es. africanus as the main cause of emergomycosis in Africa as well as considers contributing factors to the difficulties encountered in managing this infection. Emergomycosis is common in HIV-positive persons with low CD4 lymphocyte count and has an estimated fatality of 50%. The infection exhibits airborne transmission with pulmonary and extrapulmonary manifestations leading to skin lesions. However, the pathogenesis of Es. africanus is still poorly understood. The management of the infection is complicated due to lack of defined diagnostic and therapeutic guidelines. Limited expertise, poor research funding, and lack of awareness and national surveillance are thought to impact the recognition and prioritisation of the infection. These factors may ultimately assign emergomycosis a ‘neglected infection status’ even as it is suspected to be prevalent in more African countries than previously recognised. Increased awareness and integrated and targeted strategies such as mobilising manpower in clinical mycology are of paramount importance in managing emergomycosis in Africa and beyond.Keywords: emergomycosis, Es. africanus, epidemiology, pathogenesis, HIV

Ahmed Gharib Khamis,1 Akwilina Wendelin Mwanri,2 Mbazi Senkoro,3 Katharina Kreppel,4,5 Bassirou Bonfoh,6 Sayoki Godfrey Mfinanga,3 Gideon Kwesigabo1 1Department of Epidemiology and Biostatistics, Muhimbili University of Health and Allied Sciences, Dar-es-Salaam, Tanzania; 2Department of Food Technology, Nutrition and Consumer Sciences, Sokoine University of Agriculture, Morogoro, Tanzania; 3National Institute for Medical Research, Muhimbili Research Centre, Dar-es-Salaam, Tanzania; 4School of Life Sciences and Bio-Engineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania; 5Department of Environmental Health and Ecological Sciences, Ifakara Health Institute, Dar-es-salaam, Tanzania; 6Centre Suisse de Recherches Scientifiques en Côte d’Ivoire, Abidjan, Côte d’IvoireCorrespondence: Ahmed Gharib Khamis, Email ahmadboycd@gmail.comBackground: Unhealthy dietary patterns have contributed to the increase in metabolic syndromes in Tanzania. This study aimed to examine dietary patterns, nutrient intakes and investigate the association with obesity and high blood pressure among adults in agro-pastoral communities in Monduli district, Tanzania.Methods: We conducted a cross-sectional study involving 283 adults aged from 18 years old. Blood pressure and anthropometry were measured from each participant. Dietary intake was assessed using a validated food frequency questionnaire. Principal component analysis was used to identify types of dietary patterns. Logistic regression model was used to examine the associations.Results: Three types of dietary patterns were identified labeled as maize, beans and dairy; meat based; and fruits and vegetables. Higher intake of carbohydrates was found in maize dietary pattern. Meat dietary pattern was associated with higher intake of calcium and protein. Higher intakes of fiber and vitamin B2 was found in the fruits and vegetables dietary pattern. Participants on the third quartile of the maize pattern had higher odds of abdominal obesity (AOR=2.81; 95% CI: 1.09– 7.26). Participants in the third and fourth quartiles of meat based pattern had increased odds of abdominal obesity by five (AOR=5.03; 95% CI: 2.31– 10) and three folds (AOR=3.07; 95% CI: 1.36– 6.92). Participants in the third quartile of fruits and vegetables dietary pattern have lower odds of general obesity (AOR = 0.25, 95% CI: 0.07, 0.9) and abdominal obesity (AOR = 0.25, 95% CI: 0.09, 0.71). No association between dietary patterns and high blood pressure was observed.Conclusion: Three dietary patterns were identified in agro-pastoral communities. This study suggests that higher adherence to maize, beans and dairy dietary pattern and meat based dietary pattern may increase the risk of general and abdominal obesity. The fruits and vegetables dietary pattern may prevent from obesity. Further investigation is recommended to guide the preventive nutrition interventions.Keywords: dietary pattern, obesity, high blood pressure, maize, dairy, red meat, vegetables, pastoral

Nicholaus Peter Mnyambwa,1,2 Esther S Ngadaya,2 Godfather Kimaro,2 Dong-Jin Kim,1 Rudovick Kazwala,3 Pammla Petrucka,1,4 Sayoki G Mfinanga2 1School of Life Sciences and Bioengineering, Nelson Mandela African Institution of Science and Technology, Arusha, Tanzania; 2National Institute for Medical Research, Muhimbili Medical Research Center, Dar es Salaam, Tanzania; 3Department of Veterinary Medicine, Sokoine University of Agriculture, Morogoro, Tanzania; 4College of Nursing, University of Saskatchewan, Saskatoon, Canada Abstract: Diagnosis of pulmonary tuberculosis (TB) in technology-limited countries is widely achieved by smear microscopy, which has limited sensitivity and specificity. The frequency and clinical implication of smear-positive but culture-negative among presumptive TB patients remains unclear. A cross-sectional substudy was conducted which aimed to identify the proportion of nontuberculous mycobacteria (NTM) infections among 94 “smear-positive culture-negative” patients diagnosed between January 2013 and June 2016 in selected health facilities in Tanzania. Out of 94 sputa, 25 (26.60%) were GeneXpert® mycobacteria TB positive and 11/94 (11.70%) repeat-culture positive; 5 were Capilia TB-Neo positive and confirmed by GenoType MTBC to be Mycobacterium tuberculosis/Mycobacterium canettii. The remaining 6 Capilia TB-Neo negative samples were genotyped by GenoType® CM/AS, identifying 3 (3.19%) NTM, 2 Gram positive bacteria, and 1 isolate testing negative, together, making a total of 6/94 (6.38%) confirmed false smear-positives. Twenty-eight (29.79%) were confirmed TB cases, while 60 (63.83%) remained unconfirmed cases. Out of 6 (6.38%) patients who were HIV positive, 2 patients were possibly coinfected with mycobacteria. The isolation of NTM and other bacteria among smear-positive culture-negative samples and the presence of over two third of unconfirmed TB cases emphasize the need of both advanced differential TB diagnostic techniques and good clinical laboratory practices to avoid unnecessary administration of anti-TB drugs. Keywords: nontuberculous mycobacteria, pulmonary TB, smear-positive, culture-negative, tuberculosis diagnosis

Abstract Background A comprehensive care and treatment program requires a well functioning laboratory services. We assessed satisfaction of medical personnel to the laboratory services to guide process of quality improvement of the services. Methodology A cross-sectional survey in 24 randomly selected health facilities in Mainland Tanzania was conducted to assess the satisfaction of the medical personnel with the laboratory services. Results Of 235 medical personnel interviewed, 196 were valid for analysis and about one quarter were dissatisfied with the laboratory services. Personnel dissatisfied with the services were 38.3% in timely test result, 24.5% in correct and accurate results and 22.4% in clear complete results. The personnel in public laboratories were more dissatisfied with timely test results (OR = 3.6, 95% CI 1.8, 7.3), correct results (OR = 4.1, 95% CI 1.6, 10.8) and clear complete results (OR = 5.0 95% CI 1.6, 15.2). Personnel dissatisfied with the services in 15 laboratories sending specimens to referral laboratories, varied from 13% in availability of equipment to 57% in timely results feedback from the referral laboratories. Personnel dissatisfied with the services in 14 referral laboratories, varied from 28.6% in properly identified specimen to 42.9% in clear, accurate test request and communication. Conclusion About one quarter of medical personnel in sending or receiving laboratories were dissatisfied with the services. Comparing the personnel in public and private, the personnel in public laboratories were 4 times more dissatisfied with the timely test and correct results; and 5 times more dissatisfied with clear and complete test results.

Abstract Background Patient's satisfaction with both private and public laboratory services is important for the improvement of the health care delivery in any country. Methods A cross-sectional survey was conducted in 24 randomly selected health facilities with laboratories that are conducting HIV related testing, in Mainland Tanzania. The study assessed patient's satisfaction with the laboratory services where by a total of 295 patients were interviewed. Results Of data analyzed for a varying totals from 224 to 294 patients, the percentage of dissatisfaction with both public and private laboratory services, ranged from 4.3% to 34.8%, with most of variables being more than 15%. Patients who sought private laboratory services were less dissatisfied with the cleanness (3/72, 4.2%) and the privacy (10/72, 13.9%) than those sought public laboratory service for the same services of cleanness (41/222, 18.5%) and privacy (61/222, 27.5%), and proportional differences were statistically significant (X2 = 8.7, p = 0.003 and X2 = 5.5, p = 0.01, respectively). Patients with higher education were more likely to be dissatisfied with privacy (OR = 1.8, 95% CI: 1.1–3.1) and waiting time (OR = 2.5, 95% CI: 1.5 – 4.2) in both private and public facilities. Patients with secondary education were more likely to be dissatisfied with the waiting time (OR = 5.2; 95%CI: 2.2–12.2) and result notification (OR = 5.1 95%CI (2.2–12.2) than those with lower education. Conclusion About 15.0% to 34.8% of patients were not satisfied with waiting time, privacy, results notification cleanness and timely instructions. Patients visited private facilities were less dissatisfied with cleanness and privacy of laboratory services than those visited public facilities. Patients with higher education were more likely to be dissatisfied with privacy and waiting time in both private and public facilities.

Objective: To assess the magnitude and factors responsible for delay in TB management.Design: A cross sectional hospital based survey in Dar es Salaam region, May 2006.Results: We interviewed 639 TB patients. A total of 78.4% of patients had good knowledge on TB transmission. Only 35.9% had good knowledge on the symptoms. Patient delay was observed in 35.1% of the patients, with significantly (X2 = 5.49, d.f. = 1, P = 0.019) high proportion in females (41.0%) than in males (31.5%). Diagnosis delay was observed in 52.9% of the patients, with significantly (X2 = 10.1, d.f. = 1, P = 0.001) high proportion in females (62.1%) than in males (47.0%). Treatment delay was observed in 34.4% of patients with no significant differences among males and females. Several risk factors were significantly associated with patient's delays in females but not in males. The factors included not recognizing the following as TB symptoms: night sweat (OR = 1.92, 95% CI 1.20, 3.05), chest pain (OR = 1.62, 95% CI 1.1, 2.37), weight loss (OR = 1.55, 95% CI 1.03, 2.32), and coughing blood (OR = 1.47, 95% CI 1.01, 2.16). Other factors included: living more than 5 Km from a health facility (OR = 2.24, 95% CI 1.41, 3.55), no primary education (OR = 1.74, 95% CI 1.01, 3.05) and no employment (OR = 1.77, 95% CI 1.20, 2.60). In multiple logistic regression, five factors were more significant in females (OR = 2.22, 95% CI 1.14, 4.31) than in males (OR = 0.70, 95% CI 0.44, 1.11). These factors included not knowing that night sweat and chest pain are TB symptoms, a belief that TB is always associated with HIV infection, no employment and living far from a health facility.Conclusion: There were significant delays in the management of TB patients which were contributed by both patients and health facilities. However, delays in most of patients were due to delay of diagnosis and treatment in health facilities. The delays at all levels were more common in females than males. This indicates the need for education targeting health seeking behaviour and improvement in health system. [ABSTRACT FROM AUTHOR]

Background: A drug resistance survey is an essential public health management tool for evaluating and improving the performance of National Tuberculosis control programmes. The current manuscript describes the implementation of the first national drug resistance survey in Tanzania.Methods: Description of the implementation process of a national anti-tuberculosis drug resistance survey in Tanzania, in relation to the study protocol and Standard Operating Procedures.Results: Factors contributing positively to the implementation of the survey were a continuous commitment of the key stakeholders, the existence of a well organized National Tuberculosis Programme, and a detailed design of cluster-specific arrangements for rapid sputum transportation. Factors contributing negatively to the implementation were a long delay between training and actual survey activities, limited monitoring of activities, and an unclear design of the data capture forms leading to difficulties in form-filling.Conclusion: Careful preparation of the survey, timing of planned activities, a strong emphasis on data capture tools and data management, and timely supervision are essential for a proper implementation of a national drug resistance survey. [ABSTRACT FROM AUTHOR]

Introduction: Early diagnosis of tuberculosis (TB) and universal access to drug-susceptibility testing (DST) are critical elements of the WHO End TB Strategy. Current rapid tests (e.g., Xpert ® MTB/RIF and Ultra-assays) can detect rifampicin resistance-conferring mutations, but cannot detect resistance to Isoniazid and second-line anti-TB agents. Although Line Probe Assay is capable of detecting resistance to second-line anti-TB agents, it requires sophisticated laboratory infrastructure and advanced skills which are often not readily available in settings replete with TB. A rapid test capable of detecting Isoniazid and second-line anti-TB drug resistance is highly needed., Methods: We conducted a diagnostic accuracy study to evaluate a new automated Xpert MTB/XDR 10-colour assay for rapid detection of Isoniazid and second-line drugs, including ethionamide, fluoroquinolones, and injectable drugs (Amikacin, Kanamycin, and Capreomycin). Positive Xpert MTB/RIF respiratory specimens were prospectively collected through routine diagnosis and surveillance of drug resistance at the Central TB Reference Laboratory in Tanzania. Specimens were tested by both Xpert XDR assay and LPA against culture-based phenotypic DST as the reference standard., Findings: We analysed specimens from 151 TB patients with a mean age (SD) of 36.2 (12.7) years. The majority (n = 109, 72.2%) were males. The sensitivity for Xpert MTB/XDR was 93.5% (95% CI, 87.4-96.7); for Isoniazid, 96.6 (95% CI, 92.1-98.6); for Fluoroquinolone, 98.7% (95% Cl 94.8-99.7); for Amikacin, 96.6%; and (95% CI 92.1-98.6) for Ethionamide. Ethionamide had the lowest specificity of 50% and the highest was 100% for Fluoroquinolone. The diagnostic performance was generally comparable to that of LPA with slight variations between the two assays. The non-determinate rate (i.e., invalid M. tuberculosis complex detection) of Xpert MTB/XDR was 2·96%., Conclusion: The Xpert MTB/XDR demonstrated high sensitivity and specificity for detecting resistance to Isoniazid, Fluoroquinolones, and injectable agents. This assay can be used in clinical settings to facilitate rapid diagnosis of mono-isoniazid and extensively drug-resistant TB., (© 2024. The Author(s).)

Background: Subclinical pulmonary tuberculosis, which presents without recognisable symptoms, is frequently detected in community screening. However, the disease category is poorly clinically defined. We explored the prevalence of subclinical pulmonary tuberculosis according to different case definitions., Methods: We did a one-stage individual participant data meta-analysis of nationally representative surveys that were conducted in countries with high incidence of tuberculosis between 2007 and 2020, that reported the prevalence of pulmonary tuberculosis based on chest x-ray and symptom screening in participants aged 15 years and older. Screening and diagnostic criteria were standardised across the surveys, and tuberculosis was defined by positive Mycobacterium tuberculosis sputum culture. We estimated proportions of subclinical tuberculosis for three case definitions: no persistent cough (ie, duration ≥2 weeks), no cough at all, and no symptoms (ie, absence of cough, fever, chest pain, night sweats, and weight loss), both unadjusted and adjusted for false-negative chest x-rays and uninterpretable culture results., Findings: We identified 34 surveys, of which 31 were eligible. Individual participant data were obtained and included for 12 surveys (620 682 participants) across eight countries in Africa and four in Asia. Data on 602 863 participants were analysed, of whom 1944 had tuberculosis. The unadjusted proportion of subclinical tuberculosis was 59·1% (n=1149/1944; 95% CI 55·8-62·3) for no persistent cough and 39·8% (773/1944; 36·6-43·0) for no cough of any duration. The adjusted proportions were 82·8% (95% CI 78·6-86·6) for no persistent cough and 62·5% (56·6-68·7) for no cough at all. In a subset of four surveys, the proportion of participants with tuberculosis but without any symptoms was 20·3% (n=111/547; 95% CI 15·5-25·1) before adjustment and 27·7% (95% CI 21·0-36·4) after adjustment. Tuberculosis without cough, irrespective of its duration, was more frequent among women (no persistent cough: adjusted odds ratio 0·79, 95% CI 0·63-0·97; no cough: adjusted odds ratio 0·76, 95% CI 0·62-0·93). Among participants with tuberculosis, 29·1% (95% CI 25·2-33·3) of those without persistent cough and 23·1% (18·8-27·4) of those without any cough had positive smear examinations., Interpretation: The majority of people in the community who have pulmonary tuberculosis do not report cough, a quarter report no tuberculosis-suggestive symptoms at all, and a quarter of those not reporting any cough have positive sputum smears, suggesting infectiousness. In high-incidence settings, subclinical tuberculosis could contribute considerably to the tuberculosis burden and to Mycobacterium tuberculosis transmission., Funding: Mr Willem Bakhuys Roozeboom Foundation., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2024 World Health Organization. Published by Elsevier Ltd. All rights reserved. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Tracking of blood glucose levels by patients and care providers remains an integral component in the management of diabetes mellitus (DM). Evidence, primarily from high-income countries, has illustrated the effectiveness of self-monitoring of blood glucose (SMBG) in controlling DM. However, there is limited data on the feasibility and impact of SMBG among patients in the rural regions of sub-Saharan Africa. This study is aimed at assessing SMBG, its adherence, and associated factors on the effect of glycaemic control among insulin-treated patients with DM in northeastern Tanzania. Materials and Methods: This was a single-blinded, randomised clinical trial conducted from December 2022 to May 2023. The study included patients with DM who had already been on insulin treatment for at least 3 months. A total of 85 participants were recruited into the study and categorised into the intervention and control groups by a simple randomization method using numbered envelopes. The intervention group received glucose metres, test strips, logbooks, and extensive SMBG training. The control group received the usual care at the outpatient clinic. Each participant was followed for a period of 12 weeks, with glycated haemoglobin (HbA 1c ) and fasting blood glucose (FBG) being checked both at the beginning and at the end of the study follow-up. The primary and secondary outcomes were adherence to the SMBG schedule, barriers associated with the use of SMBG, and the ability to self-manage DM, logbook data recording, and change in HbA 1c . The analysis included descriptive statistics, paired t -tests, and logistic regression. Results: Eighty participants were analysed: 39 in the intervention group and 41 in the control group. In the intervention group, 24 (61.5%) of patients displayed favourable adherence to SMBG, as evidenced by tests documented in the logbooks and glucometer readings. Education on SMBG was significantly associated with adherence. Structured SMBG improved glycaemic control with a HbA 1c reduction of -1.01 (95% confidence interval (CI) -1.39, -0.63) in the intervention group within 3 months from baseline compared to controls of 0.18 (95% CI -0.07, 0.44) ( p < 0.001). Conclusion: Structured SMBG positively impacted glycaemic control among insulin-treated patients with DM in the outpatient clinic. The results suggest that implementing a structured testing programme can lead to significant reductions in HbA 1c and FBG levels. Trial Registration: Pan African Clinical Trials Registry identifier: PACTR202402642155729., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2024 Sophia S. Muhali et al.)

This paper presents a mathematical model to understand how rabies spreads among humans, free-range, and domestic dogs. By analyzing the model, we discovered that there are equilibrium points representing both disease-free and endemic states. We calculated the basic reproduction number, R 0 using the next generation matrix method. When R 0 < 1 , the disease-free equilibrium is globally stable, whereas when R 0 ≥ 1 , the endemic equilibrium is globally stable. To identify the most influential parameters in disease transmission, we used the normalized forward sensitivity index. The simulations revealed that the contact rates between the infectious agent and humans, free-range dogs, and domestic dogs, have the most significant impact on rabies transmission. The study also examines how periodic changes in transmission rates affect the disease dynamics, emphasizing the importance of transmission frequency and amplitude on the patterns observed in rabies spread. To reduce disease sensitivity, one should prioritize effective disease control measures that focus on keeping both free-range and domestic dogs indoors. This is a crucial factor in preventing the spread of disease and should be implemented as a primary disease control measure., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2024 Published by Elsevier Ltd.)

Introduction: Sub-Saharan Africa continues to experience a syndemic of HIV and non-communicable diseases (NCDs). Vertical (stand-alone) HIV programming has provided high-quality care in the region, with almost 80% of people living with HIV in regular care and 90% virally suppressed. While integrated health education and concurrent management of HIV, hypertension and diabetes are being scaled up in clinics, innovative, more efficient and cost-effective interventions that include decentralisation into the community are required to respond to the increased burden of comorbid HIV/NCD disease., Methods and Analysis: This protocol describes procedures for a process evaluation running concurrently with a pragmatic cluster-randomised trial (INTE-COMM) in Tanzania and Uganda that will compare community-based integrated care (HIV, diabetes and hypertension) with standard facility-based integrated care. The INTE-COMM intervention will manage multiple conditions (HIV, hypertension and diabetes) in the community via health monitoring and adherence/lifestyle advice (medicine, diet and exercise) provided by community nurses and trained lay workers, as well as the devolvement of NCD drug dispensing to the community level. Based on Bronfenbrenner's ecological systems theory, the process evaluation will use qualitative methods to investigate sociostructural factors shaping care delivery and outcomes in up to 10 standard care facilities and/or intervention community sites with linked healthcare facilities. Multistakeholder interviews (patients, community health workers and volunteers, healthcare providers, policymakers, clinical researchers and international and non-governmental organisations), focus group discussions (community leaders and members) and non-participant observations (community meetings and drug dispensing) will explore implementation from diverse perspectives at three timepoints in the trial implementation. Iterative sampling and analysis, moving between data collection points and data analysis to test emerging theories, will continue until saturation is reached. This process of analytic reflexivity and triangulation across methods and sources will provide findings to explain the main trial findings and offer clear directions for future efforts to sustain and scale up community-integrated care for HIV, diabetes and hypertension., Ethics and Dissemination: The protocol has been approved by the University College of London (UK), the London School of Hygiene and Tropical Medicine Ethics Committee (UK), the Uganda National Council for Science and Technology and the Uganda Virus Research Institute Research and Ethics Committee (Uganda) and the Medical Research Coordinating Committee of the National Institute for Medical Research (Tanzania). The University College of London is the trial sponsor. Dissemination of findings will be done through journal publications and stakeholder meetings (with study participants, healthcare providers, policymakers and other stakeholders), local and international conferences, policy briefs, peer-reviewed journal articles and publications., Trial Registration Number: ISRCTN15319595., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: The healthy plate model (HPM) is a practical guide to modulate the portion of staple food in main meals, subsequently affecting the risks associated with Non-communicable Diseases include type2 diabetes mellitus (T2DM)., Objective: This study investigated the effectiveness of health information and the healthy plate model on cardio-metabolic risk factors, knowledge and attitude towards T2DM prevention measures., Methods: A pre-post analysis, as part of a cluster randomized trial with street food vendors and their customers, was implemented in three randomly selected districts in Dar es Salaam, Tanzania. Two vendor-customer clusters each with 15 and more vendors from each district were randomly assigned to receive either T2DM health information only (Intervention package1 [IP1]) or IP1 plus a subsidized meal with vegetables and fruits, following the principles of the HPM (Intervention package2 [IP2]). Within the clusters the participants were informed on the importance of the intervention they received. An intervention period lasted for three months from 1st April to 31st June 2019. We applied Generalized Linear Mixed Models and Bayesian Modelling (for sensitivity analysis) to assess the effectiveness of the interventions., Results: Overall, 336 (IP2 = 175 and IP1 = 161) out of 560 (280/arm) previous study participants participated in evaluation. Diastolic BP was lower among IP2 participants in the evaluation than baseline AβC = -4.1mmHg (95%CI:-5.42 to -2.76). After adjusting for the interaction between IP2 and age of the consumers, the BMI was significantly lower among IP2 in the evaluation than baseline AβC = -0.7kg/m2 (95%CI: -1.17 to -0.23). With interaction between IP2 and income, BMI was higher in the IP2 in the evaluation than baseline AβC = 0.73kg/m2 (95%CI: 0.08 to 1.38). Systolic and diastolic BP were significantly lower among IP1 in the evaluation than baseline AβC = -3.5mmHg (95%CI:-5.78 to -1.24) and AβC = -5.9mmHg (95%CI:-7.34 to -4.44) respectively. Both the knowledge scores and positive attitudes towards T2DM prevention measures were higher in the evaluation than baseline in both interventions arms., Conclusion: The positive effects on cardio-metabolic risk factors, knowledge and attitude were observed in both intervention arms. Due to interactions between IP2, age and income; designing interventions relating to food and cardio-metabolic risk factors, should consider combining socio-economic factors., Competing Interests: Gibson B. Kagaruki received partial support from Novo Nordisk to travel to Glasgow and Liverpool Universities for a four months attachment course on Advanced Statistics analysis and Modelling. There are no patents, products in development or marketed products associated with this research to declare. This does not alter our adherence to PLOS ONE policies on sharing data and materials., (Copyright: © 2023 Kagaruki et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Competing Interests: We declare no competing interests.

Background: Data for latent tuberculosis in patients with type 1 Diabetes in Africa is limited. We assessed the prevalence of latent tuberculosis in youth and children with type 1 Diabetes in Dar es Salaam -Tanzania., Methods: Our cross-sectional study recruited children and youth with T1DM by stage of puberty, glycaemic control, and age at diagnosis from January to December 2021 in Dar es Salaam. Participants were screened for the presence of latent Tuberculosis using the QuantiFERON test. A positive test was considered to have latent TB., Results: Of the 281 participants, the mean age was 19 (± 6) years, 51.2% were female, and 80.8% had either a primary or secondary level of education at baseline. The prevalence of latent TB was 14.9% and was slightly higher in females (52.4%) than in males. This difference, however, was insignificant (p > 0.05). On the other hand, the proportion of latent TB was significantly higher in uncontrolled HbA1c levels (76.2%) than in those with controlled HbA1c (23.8%) [p = 0.046]. Duration of diabetes and age at diagnosis did not affect the occurrence of latent Tuberculosis [p > 0.05]. Meanwhile, in the regression model, participants with latent TB were more likely to have uncontrolled HbA1c. [p = 0.045] CONCLUSIONS: Despite the methodological limitations, this survey highlights the high prevalence of latent TB among children and youth with diabetes; shouting for better control. These results clearly show the need to screen for Tuberculosis in children and youth with diabetes and start them on prevention as per protocol, especially in tuberculosis-endemic areas like Tanzania., (© 2023. The Author(s).)

Competing Interests: I declare no competing interests.

While viral load (VL) testing is critical to effective treatment of human immunodeficiency virus (HIV), little is known about patients' experiences with, and barriers to VL-testing in the context of HIV infection. We assessed patient reported experience measures (PREMs) on VL-testing in public HIV clinics in Tanzania. In a cross-sectional convergent mixed method study, we collected information on VL test related PREMs, clinical and sociodemographic factors. PREMs were measured using a 5-point Likert scale. Focus Group Discussions (FGDs) explored on experience, access, and barriers to VL-testing. Descriptive statistics summarized patients' factors and PREMs. Logistic regression was used to explore association of patient factors, PREMs and satisfaction with VL-testing services. Thematic analysis was used for qualitative data. A total of 439 (96.48%) respondents completed the survey, 331 (75.40%) were female, median (IQR) age was 41(34, 49) years. A total of 253(57.63%) had a VL test at least once in the past 12 months, of whom 242(96.0%) had VL<1000 copies/ml. Investigating barriers to VL-testing, most participants (>92.0%) reported good or very good health services responsiveness (HSR). A scale of very good was chosen by the majority for being treated with respect 174(39.6%), listened to 173(39.4%), following advice 109(24.8%), being involved in decisions 101(23.0%), and for communication 102(23.3%). Satisfaction on VL-testing services was significantly associated with respondents following care providers' advice, (aOR) = 2.07 [95%CI 1.13-3.78], involvement in decisions aOR = 4.16 [95%CI 2.26-7.66], and communication aOR = 2.27 [95%CI 1.25-4.14]. FGDs findings converged with the survey data, with identified barriers to VL test including lack of autonomy in decision making, little awareness on the benefits of the test, long waiting time, stigma, competing priorities for those with comorbidities and transport costs. Satisfaction on VL-testing was largely a result of involvement in decision making, following care provider's advice and good communication; entities needing universal improvement across the country., Competing Interests: The authors have declared that no competing interests exist., (Copyright: © 2023 Karoli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Type 1 diabetes mellitus (T1DM) complications corelate with C-peptide levels. However, the C-Peptide role has not been explored in resource limited countries. This study explored the relationship between C-peptide and complications. A cross-sectional study involving participants aged 0 to 25 years with T1DM in Dar es salaam Tanzania, between 2021 and 2022 was done. Diabetes nephropathy and retinopathy were assessed. About 281 (92.4%) participants were screened, 144 (51.2%) were females. Mean age was 19 ± 6 years. Majority 175 (62.3%) had poor glycemic control (HbA1c) > 10%, and low C-Peptide level 201 (71.5%). Retinopathy was 11.7% and risk for nephropathy was 41.3%. About 13.4% and 41.8% with low C peptide had Retinopathy and high-risk nephropathy respectively. Age at diagnosis, poor glycemic control, low c peptide and duration of diabetes were associated with complications. Further prospective studies are needed to capture when complications set in, so to have better strategies to prevent complications., Competing Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2023.)

Introduction: Survival from type 1 diabetes Mellitus is low in lower-income countries with underdeveloped health systems. Support programs from partners like life for a child (LFAC) and changing diabetes in children (CDiC) were implemented in Tanzania in 2005 to provide diabetes care to children and youth. No evaluation of survival has been done since their implementation., Objective: To assess the survival of children and youth living with diabetes mellitus (CYLDM) in Tanzania., Methods: A retrospective data collection from 39 clinics of CYLDM was done by extracting data from the diabetes registry between 1991 and 2019. Three cohort were analyzed (1) Cohort 1991-2004 (pre-implementation), (2) Cohort 2005-2010 (during implementation), and (3) 2011-2019 (after the implementation of LFAC/CDiC). Data were analyzed using STATA-version 14., Results: A total of 3822 data of CYLDM were extracted, mean age at diagnosis was 13.8 (±5) years. Approximately fifty-one percent (50.8%) were male. The total observation time was 28 years, and the Median duration of diabetes of 5 (IQR2, 8) years. Total death was 95 (3%), with a mean age at death of 17.7 (SD 4.7) years. The last cohort (2011-2019) had more diagnosis 2353 (72.7%), as compared to the <2005 cohort with only 163(5%). The survival improved from 59% before 2005 to 69% in the last cohort (2011-2019)., Conclusion: The implemented programs have facilitated the diagnosis and retention of CYLDM in the health care system. In doing so, it has also increased the survival probability in Tanzania compared to the early 90s., (© 2022 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.)

Introduction: The healthy plate model is considered one of the practical approaches to reduce the average portion of staple food in main meals, consequently reducing the risks associated with diabetes and other Non-communicable Diseases (NCDs). Despite its potential benefits, studies on the implementation of the healthy plate model are limited in Africa. An inquiry explored barriers to implementation, uptake, and scaling up of the healthy plate model among street food vendors and consumers in three districts of Dar-es-Salaam city in Tanzania., Methods: A qualitative research design was adopted. Qualitative data collection techniques were employed including; Key Informant Interviews (KIIs) with purposefully selected food and nutrition stakeholders at the National, Regional, District and Ward levels. Focus Group Discussions (FGDs) were conducted with purposefully selected street food consumers and vendors. A total of (13) KIIs were conducted as well as (6) FGDs with street food vendors (2 FGDs) and consumers (4 FGDs). Interview data was managed using Nvivo 12 Software and analyzed thematically., Results: Three key themes emerged from participants' accounts: (i) strategic policy barriers, (ii) food production and preparation environment barriers (producers and vendors), and (iii) individual barriers (consumers and vendors). The strategic policy barriers included absence of guidelines and regulations that focus on NCDs linked to nutrition and lack of education guidance for vendors and consumers. The food production and preparation environment barriers included safety and risks concerns regarding the quality of water used for irrigation and washing fruits and vegetables and the areas where vegetables and fruits are grown and prepared. Individual barriers included low consumer income, knowledge on nutrition, unhealthy eating practices and; low vendors' knowledge as well as low investment capital., Conclusion: Implementation, uptake and scaling up of the healthy plate model for street food consumers in Dar es Salaam City continues to be constrained by barriers in policy, food production and preparation environment, and individual obstacles. Strengthening of food and nutrition policies, ensuring safety of the food production and preparation environment and, consumer and vendor awareness creation and income generation efforts, provide useful entry points for the successful scaling up of a healthy plate model. This could consequently contribute towards prevention of diet related NCDs, including diabetes., (© 2022. The Author(s).)

Background: Timely vaccination maximizes efficacy for preventing infectious diseases. In the absence of national vaccination registries, representative sample survey data hold vital information on vaccination coverage and timeliness. This study characterizes vaccination coverage and timeliness in Tanzania and provides an analytic template to inform contextually relevant interventions and evaluate immunization programs., Methods: Cross-sectional data on 6,092 children under age 3 from the 2015-16 Tanzania Demographic and Health Survey were used to examine coverage and timeliness for 14 vaccine doses recommended in the first year of life. The Kaplan-Meier method was used to model time to vaccination. Cox proportional hazard models were used to examine factors associated with timely vaccination., Results: Substantial rural-urban disparities in vaccination coverage and timeliness were observed for all vaccines. Across 14 recommended doses, documented coverage ranged from 52 % to 79 %. Median vaccination delays lasted up to 35 days; gaps were larger among rural than urban children and for later doses in vaccine series. Among rural children, median delays exceeded 35 days for the 3 rd doses of the polio, pentavalent, and pneumococcal vaccines. Median delays among urban children were < 21 days for all doses. Among rural and urban children, lower maternal education and delivery at home were associated with increased risk of delayed vaccination. In rural settings, less household wealth and greater distance to a health facility were also associated with increased risk of delayed vaccination., Discussion: This study highlights persistent gaps in uptake and timeliness of childhood vaccinations in Tanzania and substantial rural-urban disparities. While the results provide an informative situation assessment and outline strategies for identifying unvaccinated children, a national electronic registry is critical for comprehensive assessments of the performance of vaccination programs. The timeliness measure employed in this study-the amount of time children are un- or undervaccinated-may serve as a sensitive performance metric for these programs., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: The Latent Autoimmune Diabetes in Adults (LADA) is a slowly progressive Type 1 diabetes subgroup with onset during middle age. Studies report that about 10% of adults initially diagnosed with clinical Type 2 diabetes (T2D) have LADA. Inappropriate diagnosis and mismanagement of the LADA can increase the risk of diabetic complications, which affect the quality of life and is the cause of increased mortality. In low-income countries setting, data regarding the magnitude of LADA is limited. We carried out this study to estimate the burden of misdiagnosed LADA among T2D patients in selected health facilities in Dar es Salaam and to bring awareness to the use of Glutamic Acid Decarboxylase (GAD) autoantibody in screening for LADA., Methodology: We enrolled 186 phenotypically T2D patients in this cross-sectional study, through a standardized data collection tool we obtained participants' demographic and clinical information. For testing GAD levels, we used a double-antibody Enzyme-Linked Immunosorbent Assay (ELISA). The Fisher's Exact and student t-tests were used to test the significance of the statistical associations of the glycaemic control and diabetes complications between T2D and LADA., Results: Out of 186 patients, 156 gave conclusive GAD Ab ELISA reading with LADA accounting for 5.1% (95% CI: 2.5 - 10.0). The mean age of subjects was 54.3 years (Range: 33-85 years). The parameters such as mean age, family history of diabetes mellitus status, Fasting Blood Glucose, clinical characteristics, and complications did not show significant statistical differences between patients with LADA and Type 2 diabetes. However, all LADA- Human Immunodeficiency Virus (HIV) comorbid patients had retinopathy, which was statistically insignificant in 20 (87%) T2D-HIV comorbid patients (p = 0.669). Neither neuropathy, nephropathy, nor Diabetic Mellitus (D.M.) foot syndrome was observed among LADA-HIV comorbid patients. Nevertheless, 22 (95.7%), 3 (13%), and 2 (8.7%) of T2D-HIV comorbidity had neuropathy, nephropathy, or D.M. foot syndrome, respectively., Conclusions: The study established a LADA prevalence of 5.1% among T2D patients and has shown the role of GAD autoantibody in the screening for LADA. The study calls for a well- designed larger longitudinal study to generate strong evidence on the association of risk factors and complications associated with the LADA. This will develop robust evidence on the association of risk factors and complications associated with the LADA and T2D., (© 2022. The Author(s).)

There is an excessive burden of diabetes complications in low-resource settings. We conducted a systematic review to determine the nature and frequency of diabetes complications in newly diagnosed with type 2 diabetes. A systematic search was performed using Medline, CINAHL and Global Health online databases from inception to July 2020. Articles reporting prevalence of microvascular or macrovascular complications within six months of type 2 diabetes diagnosis and published in English or French from low- and middle-income countries (LMICs) were eligible for analysis. Data were extracted using a standardized data extraction tool. Descriptive statistics were used to describe the prevalence of micro and macrovascular complications in newly diagnosed type 2 diabetes. Assessment of heterogeneity was conducted using the inconsistency index (I2) and Cochran-Q chi2 statistical tests. Publication bias was assessed by the Funnel plot and Egger test. A total of 3 292 records underwent title or abstract screening and 95 articles underwent full text review. Thirty-three studies describing 13 283 participants (aged 20 years and older) met the inclusion criteria. The eligible studies were from Asia (n = 24), Africa (n = 4), Oceania (n = 2), South America (n = 2) and the Caribbean (n = 1). For microvascular complications, the median prevalence (interquartile range) of retinopathy, nephropathy and neuropathy were 12% (6%-15%), 15% (7%-35%) and 16% (10%25%) respectively. For macrovascular complications, the median prevalence (interquartile range) was 10% (7%-17%) for ischaemic heart disease, 6% (1%-20%) for peripheral arterial disease and 2% (1%-4%) for stroke. There was evidence of substantial heterogeneity between studies for all outcomes (I2 > 90%. We found a high prevalence of complications in newly diagnosed type 2 diabetes in LMICs. Findings suggest that many people live with diabetes and are only diagnosed when they present with complications in LMICs. Research is needed to guide timely and effective identification of people living with diabetes in these settings., Competing Interests: The authors declared that no competing interests exist., (Copyright: © 2022 Aikaeli et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.)

Background: The commonest causes of mortality in people living with HIV (PLHIV) are preventable and the majority can be attributed to undiagnosed tuberculosis (TB). National HIV/AIDS control programs are encouraged to implement the WHO package of interventions to improve survival among PLHIV. We assessed the implementation of the WHO TB-related package of care for Advanced HIV Disease (AHD) and its impact on treatment outcomes among HIV/TB patients in Tanzania., Methods: A retrospective cohort study was employed among HIV/AIDS patients on antiretroviral therapy from 21 public health facilities in three regions (Dar es Salaam, Coastal, and Morogoro) of Tanzania. Patients enrolled in care between January 2013- June 2017 (before the introduction of the WHO guidelines) and July 2017-Sept 2018 (during the implementation of the guidelines) were recruited. Data abstraction was done from patient hospital files using a structured questionnaire uploaded on a tablet., Results: Data from 2624 patients records were collected. Overall, 50% of patients with HIV had AHD with 7.8% of these co-infected with TB. Among AHD participants, 58.3% were female, 80.7% were from urban areas and 40.0% visited care and treatment centres as self-referrals. Implementation of the WHO AHD package of care was very low, ranging from 0% for Urine LF-LAM test done among patients with symptoms and signs of TB to 39.7% AHD concurrent with TB patients whose ART initiation was deferred for 2 weeks. Overall, the Proportion of AHD patients diagnosed with TB was 4.8%, Of which sputum Xpert as the first test for TB diagnosis was 4.4%. Five patients (0.6%) were documented to have received IPT at enrolment. Tailored counselling to ensure optimal adherence to ART for viral suppression was given to 12.1%. AHD patients co-infected with TB were retained in care more before the introduction of WHO AHD guideline (82.1%) compared to the period after the introduction of the guideline (53.9%) (p = 0.008). Clinical failure at 6 months among AHD patients was 10.6% before the guideline and 11.4% after the guideline. Immunological failure was observed in 1 patient (9.1%) before the guideline and 1 patient (7.1%) after the guideline. After the introduction of the guideline, mortality was 5.9% and no mortality was observed before the guideline. All the differences were not statistically significant., Conclusions: Implementation of the TB related WHO packages of care for AHD is very low. Except for TB diagnosis, other parameters did not improve with the introduction of the guidelines. More research is recommended to ascertain the effectiveness of guidelines as well as an understanding of the mechanisms involved., (© 2022. The Author(s).)

Background: In sub-Saharan Africa, the prevalence of non-communicable diseases (NCDs) has risen sharply amidst a high burden of communicable diseases. An integrated approach to HIV and NCD care offers the potential of strengthening disease control programmes. We used qualitative methods to explore patients' and care-providers' experiences and perspectives on the acceptability of integrated care for HIV-infection, diabetes mellitus (DM), and hypertension (HT) in Tanzania., Methods: A qualitative study was conducted in selected health facilities in Dar es Salaam and Coastal regions, which had started to provide integrated care and management for HIV, DM, and HT using a single research clinic for patients with one or more of these conditions. In-depth interviews were held with patients and healthcare providers at three time points: At enrolment (prior to the patient receiving integrated care, at the mid-line and at the study end). A minimum of 16 patients and 12 healthcare providers were sampled for each time point. Observation was also carried out in the respective clinics during pre- and mid-line phases. The Theoretical Framework of Acceptability (TFA) underpinned the structure and interpretation of the combined qualitative and observational data sets., Results: Patients and healthcare providers revealed a positive attitude towards the integrated care delivery model at the mid-line and at study end-time points. High acceptability was related to increased exposure to service integration in terms of satisfaction with the clinic setup, seating arrangements and the provision of medical care services. Satisfaction also centred on the patients' freedom to move from one service point to another, and to discuss the services and their own health status amongst themselves. Adherence to medication and scheduling of clinic appointments appeared central to the patient-provider relationship as an aspect in the provision of quality services. Multi-condition health education, patient time and cost-saving, and detection of undiagnosed disease conditions emerged as benefits. On the other hand, a few challenges included long waiting times and limited privacy in lower and periphery health facilities due to infrastructural limitations., Conclusion: The study reveals a continued high level of acceptability of the integrated care model among study participants in Tanzania. This calls for evaluation in a larger and a comparative study. Nevertheless, much more concerted efforts are necessary to address structural challenges and maximise privacy and confidentiality., (© 2022. The Author(s).)

Introduction: There is an urgent need to reduce the burden of non-communicable diseases (NCDs), particularly in low-and middle-income countries, where the greatest burden lies. Yet, there is little research concerning the specific issues involved in scaling up NCD interventions targeting low-resource settings. We propose to examine this gap in up to 27 collaborative projects, which were funded by the Global Alliance for Chronic Diseases (GACD) 2019 Scale Up Call, reflecting a total funding investment of approximately US$50 million. These projects represent diverse countries, contexts and adopt varied approaches and study designs to scale-up complex, evidence-based interventions to improve hypertension and diabetes outcomes. A systematic inquiry of these projects will provide necessary scientific insights into the enablers and challenges in the scale up of complex NCD interventions., Methods and Analysis: We will apply systems thinking (a holistic approach to analyse the inter-relationship between constituent parts of scaleup interventions and the context in which the interventions are implemented) and adopt a longitudinal mixed-methods study design to explore the planning and early implementation phases of scale up projects. Data will be gathered at three time periods, namely, at planning (T P ), initiation of implementation (T 0 ) and 1-year postinitiation (T 1 ). We will extract project-related data from secondary documents at T P and conduct multistakeholder qualitative interviews to gather data at T 0 and T 1. We will undertake descriptive statistical analysis of T P data and analyse T 0 and T 1 data using inductive thematic coding. The data extraction tool and interview guides were developed based on a literature review of scale-up frameworks., Ethics and Dissemination: The current protocol was approved by the Monash University Human Research Ethics Committee (HREC number 23482). Informed consent will be obtained from all participants. The study findings will be disseminated through peer-reviewed publications and more broadly through the GACD network., Competing Interests: Competing interests: JvO reports Horizon2020 grants (643 692 and 825432) outside the submitted work. AGT declares funding from the National Health & Medical Research Council (NHMRC, Australia: GNT1042600, GNT1122455, GNT1171966, GNT1143155, GNT1182017), Stroke Foundation Australia (SG1807), and Heart Foundation Australia (VG102282) outside the submitted work. ML-P declares support from Fogarty International Centre, National Institutes of Health [R21TW009982], under the Global Alliance for Chronic Diseases (GACD) Diabetes ProgramProgramme. MEE reports grant funding from the Argentinian Ministry of Health (MoH) under the GACD program. AS declares funding from the Japan Agency for Medical Research & Development, as part of the GACD, outside the submitted work. FJH is partially funded by the National Institute for Health Research (NIHR) and the Medical Research Council (MRC), and is a member of the Action on Salt, and World Action on Salt, Sugar and Health (WASSH). AB declares grants from the MoH Argentina, National Institutes of Health, and World Diabetes Foundation, outside the submitted work. AP declares grant and fellowship support from the NHMRC outside the submitted work, Member of the Board of Directors, The George Institute India, and past Member of the Board of Directors, Heart Health Research Center, Beijing, PRC. RJ declares grant, outside the submitted work, from WHO Geneva, WHO South-East Asia Region (SEARO), Elrha Research for Health in Humanitarian Crises (R2HC), (Wellcome Trust, UK AID and NHS), DBT/ Wellcome Trust India Alliance and Gates Foundation. In the past 3 years, MDH has received research funding from American Heart Association, Verily, and AstraZeneca for research unrelated to this manuscript and has patents pending for heart failure polypills. The George Institute for Global Health has a patent, license, and has received investment funding with intent to commercialize fixed-dose combination therapy through its social enterprise business, George Medicines. None of the others authors has any conflict of interest to declare., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: While most Non-tuberculous mycobacteria (NTM) are saprophytic, several species have been associated with human diseases, from localized infection to disseminated diseases. Pulmonary NTM infections lead to TB-like disease called NTM pulmonary disease (NTM-PD). Due to variation in treatment options among NTM species, it is necessary to identify the species and determine drug susceptibility profiles to inform the choice of appropriate regimen for the disease., Design: A total of 188 culture-positive isolates from patients diagnosed with TB were screened for NTM at the Central Tuberculosis Reference Laboratory. All NTM were further speciated using GenoType® Mycobacterium-Common Mycobacterium and Additional species (GenoType® CM/AS) kit. Mycobacteria avium complex (MAC) and Mycobacteria abscessus complex (MABC) which could not be identified with the test to species were subjected to GenoType® Mycobacteria NTM-DR for further speciation. Using the same test, identified MAC and MABC were genotyped to determine the drug susceptibility profile for each isolate to macrolide and aminoglycosides., Results: Of all isolates identified as mycobacteria, 24 (13%) were NTM. Fifteen isolates could be identified to species level of which prevalent species was M. avium sub. intracellulare 4 (27%). A total of 10 isolates were MAC (n = 6) and MABC (n = 4) were subjected to GenoType® Mycobacteria NTM-DR for determination of macrolide and aminoglycoside susceptibility. Three of the four MABC had a mutation at the T28 position of the erm (41). All MAC were susceptible to both drugs., Conclusion: In this study, MAC was the most frequently isolated NTM species followed by MABC. While all MAC and MABC identified, were susceptible to aminoglycosides, three MABC were resistant to the macrolides due to mutation at position 28 of the erm (41) gene. For this, it is important for clinicians need to rule out NTM, understand species and their drug susceptibility for optimal case management., Competing Interests: The authors have declared that no competing interests exist.

Background: A prospective cohort study of the clinical presentations and management outcomes of laboratory-confirmed COVID-19 patients in the early months of the pandemic was performed at two hospitals in Dar es Salaam, Tanzania., Methods: Between April 1 and May 31, 2020, laboratory-confirmed COVID-19 patients seen at two tertiary facilities were consecutively enrolled in the study and followed up for 21 days., Results: 121 COVID-19 patients were enrolled; 112 (92.6%) were admitted while nine (7.4%) were seen as outpatients. The median (IQR) age of patients was 41 (30-54) years; 72 (59.5%) were male. The median (IQR) reported days from hospital admission to recovery and to death were 10 (6-18) and 5.5 (3-9), respectively. Forty-four (36.4%) patients had at least one underlying condition. Of the 112 admissions, 17 (15.2%) went to ICU, of whom 14 (82.3%) died. At the end of follow-up, 93 (76.9%) recovered, 18 (14.9%) died, seven (5.8%) remained asymptomatic, and one (0.8%) remained ill., Conclusion: Three-quarters of all COVID-19 patients were less than 60 years, reflecting Africa's young population . High ICU admissions and mortality were observed., Competing Interests: All authors declare no competing interests., (© 2022 The Author(s).)

Background: HIV, diabetes and hypertension have a high disease burden in sub-Saharan Africa. Healthcare is organised in separate clinics, which may be inefficient. In a cohort study, we evaluated integrated management of these conditions from a single chronic care clinic., Objectives: To determined the feasibility and acceptability of integrated management of chronic conditions in terms of retention in care and clinical indicators., Design and Setting: Prospective cohort study comprising patients attending 10 health facilities offering primary care in Dar es Salaam and Kampala., Intervention: Clinics within health facilities were set up to provide integrated care. Patients with either HIV, diabetes or hypertension had the same waiting areas, the same pharmacy, were seen by the same clinical staff, had similar provision of adherence counselling and tracking if they failed to attend appointments., Primary Outcome Measures: Retention in care, plasma viral load., Findings: Between 5 August 2018 and 21 May 2019, 2640 patients were screened of whom 2273 (86%) were enrolled into integrated care (832 with HIV infection, 313 with diabetes, 546 with hypertension and 582 with multiple conditions). They were followed up to 30 January 2020. Overall, 1615 (71.1%)/2273 were female and 1689 (74.5%)/2266 had been in care for 6 months or more. The proportions of people retained in care were 686/832 (82.5%, 95% CI: 79.9% to 85.1%) among those with HIV infection, 266/313 (85.0%, 95% CI: 81.1% to 89.0%) among those with diabetes, 430/546 (78.8%, 95% CI: 75.4% to 82.3%) among those with hypertension and 529/582 (90.9%, 95% CI: 88.6 to 93.3) among those with multimorbidity. Among those with HIV infection, the proportion with plasma viral load <100 copies/mL was 423(88.5%)/478., Conclusion: Integrated management of chronic diseases is a feasible strategy for the control of HIV, diabetes and hypertension in Africa and needs evaluation in a comparative study., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: HIV programmes in sub-Saharan Africa are well funded but programmes for diabetes and hypertension are weak with only a small proportion of patients in regular care. Healthcare provision is organised from stand-alone clinics. In this cluster randomised trial, we are evaluating a concept of integrated care for people with HIV infection, diabetes or hypertension from a single point of care., Methods and Analysis: 32 primary care health facilities in Dar es Salaam and Kampala regions were randomised to either integrated or standard vertical care. In the integrated care arm, services are organised from a single clinic where patients with either HIV infection, diabetes or hypertension are managed by the same clinical and counselling teams. They use the same pharmacy and laboratory and have the same style of patient records. Standard care involves separate pathways, that is, separate clinics, waiting and counselling areas, a separate pharmacy and separate medical records. The trial has two primary endpoints: retention in care of people with hypertension or diabetes and plasma viral load suppression. Recruitment is expected to take 6 months and follow-up is for 12 months. With 100 participants enrolled in each facility with diabetes or hypertension, the trial will provide 90% power to detect an absolute difference in retention of 15% between the study arms (at the 5% two-sided significance level). If 100 participants with HIV infection are also enrolled in each facility, we will have 90% power to show non-inferiority in virological suppression to a delta=10% margin (ie, that the upper limit of the one-sided 95% CI of the difference between the two arms will not exceed 10%). To allow for lost to follow-up, the trial will enrol over 220 persons per facility. This is the only trial of its kind evaluating the concept of a single integrated clinic for chronic conditions in Africa., Ethics and Dissemination: The protocol has been approved by ethics committee of The AIDS Support Organisation, National Institute of Medical Research and the Liverpool School of Tropical Medicine. Dissemination of findings will be done through journal publications and meetings involving study participants, healthcare providers and other stakeholders., Trial Registration Number: ISRCTN43896688., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: Differences among Mycobacterium tuberculosis complex (MTC) species may predict drug resistance or treatment success. Thus, we optimised and deployed the genotype MTBC assay (gMTBC) to identify MTC to the species level, and then performed comparative genotypic drug-susceptibility testing to anti-tuberculosis drugs from direct sputum of patients with presumed multidrug-resistant tuberculosis (MDR-TB) by the MTBDRplus/sl reference method., Methods: Patients with positive Xpert ® MTB/RIF (Xpert) results were consented to provide early-morning-sputum for testing by the gMTBC and the reference MTBDRplus/sl. Chi-square or Fisher's exact test compared proportions. Modified Poisson regression modelled detection of MTC by gMTBC., Results: Among 73 patients, 53 (73%) were male and had a mean age of 43 (95% CI; 40-45) years. In total, 34 (47%), 36 (49%) and 38 (55%) had positive gMTBC, culture and MTBDR respectively. Forty patients (55%) had low quantity MTC by Xpert, including 31 (78%) with a negative culture. gMTBC was more likely to be positive in patients with chest cavity 4.18 (1.31-13.32, P = 0.016), high-quantity MTC by Xpert 3.03 (1.35-6.82, P = 0.007) and sputum smear positivity 1.93 (1.19-3.14, P = 0.008). The accuracy of gMTBC in detecting MTC was 95% (95% CI; 86-98; κ = 0.89) compared to MTBDRplus/sl. All M. tuberculosis/canettii identified by gMTB were susceptible to fluoroquinolone and aminoglycosides/capreomycin., Conclusions: The concordance between the gMTBC assay and MTBDRplus/sl in detecting MTC was high but lagged behind the yield of Xpert MTB/RIF. All M. tuberculosis/canettii were susceptible to fluoroquinolones, a core drug in MDR-TB treatment regimens., (© 2021 The Authors Tropical Medicine & International Health Published by John Wiley & Sons Ltd.)

Objective: Food frequency questionnaires are widely used as a dietary assessment tool in nutritional epidemiology to determine the relationship between diet and diseases. In Tanzania, there are several cultural variations in food intake which makes it necessary to design and validate a culture-specific food frequency questionnaire (CFFQ). Therefore, we designed a 27-items CFFQ and examine its validity in pastoral communities. Validity of CFFQ was assessed by comparing nutrient intake estimated from the CFFQ against the average from two 24-h diet recall (2R24). Spearman's correlation coefficients, cross classification and Bland-Altman's methods were used to assess the validity of CFFQ., Results: A total of 130 adults aged 18 years and above completed both CFFQ and 2R24. Correlation coefficients between CFFQ and 2R24 ranged from low (r = - 0.07) to moderate (r = 0.37). The correlation coefficients were moderately significant for kilocalories (r = 0.31, p < 0.001), carbohydrate (r = 0.33, p < 0.001), magnesium (r = 0.37, p < 0.001), and iron (r = 0.34, p < 0.001). On average, about 69% of participants were correctly classified into the same or adjacent quartile of energy and nutrient intake, while 9% were misclassified by the CFFQ. Bland-Altman's plot demonstrated that the CFFQ had acceptable agreement with the 2R24., (© 2021. The Author(s).)

Setting: Six health facilities in Dar es Salaam, Tanzania., Objective: To evaluate the use of stool specimens in the diagnostic workup of paediatric TB using the Xpert ® MTB/RIF assay., Design: Between December 2018 and May 2019, we performed a cross-sectional diagnostic study of children aged between 1 month and 14 years with presumptive TB. A single stool specimen was tested using Xpert. The result was compared with the reference microbiological standard for respiratory or gastric specimens tested using Xpert and/or solid culture. The sensitivity, specificity and predictive values of stool Xpert assay were assessed., Results: A total of 225 children with a median age of 2.17 years (IQR 1.16-5.19) were enrolled; 165/225 (73.3%) were aged <5 years. Of 225 children, 8 (3.6%) were diagnosed with TB as they were culture- or Xpert-positive on sputum/gastric aspirate. The stool Xpert assay showed a sensitivity of 62.5% (95% CI 25-92) and specificity of 100% (95% CI 98-100) against the reference standard., Conclusion: Use of the Xpert assay on stool specimens had a moderate sensitivity and high specificity in the diagnosis of pulmonary TB in children. Our data adds to the body of evidence for the use of Xpert assay on stool as a non-respiratory specimen to complement conventional methods used to diagnose the disease., Competing Interests: Conflict of interests: none declared., (© 2021 The Union.)

Background: Nomadic life not only prevents the community from accessing and utilising HIV services but also deters them from obtaining reliable information on HIV., Methods: We conducted a cross-sectional study of youth aged 10-24 years from the Kilindi and Ngorongoro Districts in Tanzania to assess knowledge, accessibility and utilisation of HIV/AIDS services among nomadic and agricultural youths., Results: Of 518 youths interviewed, 279 (53.9%) were males, and 276 (53.3%) were from agricultural communities. A significant proportion of youths from agricultural communities had correct knowledge of AIDS ( n = 126, 45.8%; P = 0.002), HIV transmission ( n = 273, 98.9%; P = 0.001) and comprehensive knowledge of HIV/AIDS ( n = 78, 28.5%; P = 0.009) compared to nomads. Youths from agricultural communities were two times (OR 1.8, 95% CI 1.2-2.6) more likely to be aware of the availability of formal HIV services. Awareness of the availability of HIV services was higher among married individuals than in unmarried ones (OR 3.8, 95% CI 2.0-7.4), and significantly higher among youths with secondary/college education than in those who did not have formal education (OR 5.3, 95% CI 2.3-12.4). The uptake of HIV services was lower among nomadic youths., Conclusion: Knowledge, awareness and utilisation of HIV/AIDS transmission services were low in general, and even lower among nomadic youths, calling for more targeted interventions., Competing Interests: Conflict of interests: none declared., (© 2021 The Union.)

Background: The prevalence of overweight and obesity is rising at a rapid pace and is associated with negative health consequences like cardiovascular diseases, type 2 diabetes and cancer. Obesity is a multifactorial problem that develops mainly from lifestyle factors including physical inactivity and poor dietary intake. Dietary diversity is a simplified method for assessing the adequacy and quality of diet and is associated with nutritional need and overall health status. Therefore, we conducted this study to synthesize the associations between consumption of a diversified diet and overweight/ obesity among adults living in pastoral communities in Monduli district in Tanzania., Methods: This was a cross-sectional study conducted among 510 adults aged ≥ 18 years old in the Monduli district, Arusha region in Tanzania. We conducted face-to-face interviews to collect information about socio-demographic characteristics, 24-hours dietary recall, and anthropometric measurements. The dietary diversity score (DDS) was constructed and used to determine the diversity of the diet consumed. We performed the multivariate Poisson regressions to determine the prevalence ratio (PR) with 95% confidence intervals (CI). The dependent variables were overweight and general obesity as measured by body mass index (BMI), abdominal obesity measured by waist-hip ratio (WHR) and waist circumference (WC)., Results: The prevalence of general obesity based on BMI was 20.2% (95%CI; 16.9-23.9), abdominal obesity based on WHR was 37.8% (95%CI; 33.7-42.1), and WC was 29.1% (95%CI; 25.2-33.1). More than half (54.3%) of the participants consumed an adequate dietary diversity (DDS ≥4). After adjustment for potential confounders, the prevalence of abdominal obesity by WHR decreased with higher DDS among male (APR = 0.42; 95% CI, 0.22-0.77) and female participants (APR = 0.63; 95% CI, 0.41-0.94). There were inconsistent positive associations between DDS and prevalence of overweight and general obesity among male and female. There was no association between DDS and abdominal obesity by WC., Conclusion: More than half of the pastoralists have consumed an adequate diversified diet. Given the inconsistent findings on associations between dietary diversity and obesity measures, this study suggests that targeting dietary diversity as an overweight/obesity prevention strategy requires careful consideration., Competing Interests: The authors have declared that no competing interests exist.

Background: Vaccine hesitancy has been recognized as an important barrier to timely vaccinations around the world, including in sub-Saharan Africa. In Tanzania, 1 in 4 children is not fully vaccinated. The objective of this mixed methods study was to describe and contextualize parental concerns towards vaccines in Tanzania., Methods: Between 2016 and 2017, we conducted a cross-sectional survey (n = 134) and four focus group discussions (FGDs, n = 38) with mothers of children under 2 years of age residing in Mtwara region in Southern Tanzania. The survey and FGDs assessed vaccination knowledge and concerns and barriers to timely vaccinations. Vaccination information was obtained from government-issued vaccination cards., Results: In the cross-sectional survey, 72% of mothers reported missed or delayed receipt of vaccines for their child. Although vaccine coverage was high, timeliness of vaccinations was lower and varied by vaccine. Rural mothers reported more vaccine-related concerns compared to urban mothers; literacy and access to information were identified as key drivers of the difference. Mothers participating in FGDs indicated high perceived risk of vaccine-preventable illnesses, but expressed concerns related to poor geographic accessibility, unreliability of services, and missed opportunities for vaccinations resulting from provider efforts to minimize vaccine wastage., Conclusions: Findings from our cross-sectional survey indicate the presence of vaccination delays and maternal concerns related to childhood vaccines in Tanzania. In FGDs, mothers raised issues related to convenience more often than issues related to vaccine confidence or complacency. Further research is necessary to understand how these issues may contribute to the emergence and persistence of vaccine hesitancy and to identify effective mitigation strategies.

Background: Hypertension is among the growing non-communicable diseases (NCDs) in developing countries and the leading cause of death worldwide. Pastoral areas have been identified to be at a higher risk of diseases due to challenges in their daily food production, livelihoods or mobility. Unfortunately, the prevalence of hypertension and the risk factors particularly affecting rural and pastoral populations are not fully understood, making intervention efforts challenging. The aim of this study was to determine the prevalence of hypertension and identify the risk factors among adults living in Monduli district in Tanzania. The findings will be useful for the provision of tailored interventions focused on community-specific nutritional and behavioral practices., Methods: We conducted a community based cross-sectional study involving a sample of 510 adults aged above 18 years selected using a multistage cluster sampling in the Monduli district of Arusha region, Tanzania. Data were collected by using interviewer-administered questionnaires containing socio-demographic, physical activity, smoking and alcohol consumption. Anthropometry, systolic (SBP) and diastolic blood pressure (DBP) levels were measured. A one-day 24 h diet recall was conducted to evaluate the dietary habits of all participants. Both linear and logistic regression analysis were used to identify the independent predictors for hypertension and blood pressure levels., Results: The prevalence of hypertension in this study was 25.7% ( n =  131, 95% CI; 22.1-29.7). The odds of hypertension increased with being male (AOR = 1.75, 95%CI, 1.06-2.88), belonging to the older age group of 30-39 year olds (AOR = 3.3, 95%CI, 1.76-6.38), 40-59 year olds (AOR = 3.34, 95%CI, 1.75-6.37) and ≥ 60 year olds (AOR = 4.2, 95%CI, 2.02-8.87), being overweight or obese (AOR = 3.37, 95%CI, 1.18-9.62), have more hours spent sedentary (AOR = 3.19, 95%CI, 1.61-6.32), and consumption of fatty foods (AOR = 2.23, 95%CI, 1.27-3.93). The odds for hypertension was significantly reduced among participants who reported higher income (AOR = 0.47, 95% CI, 0.25-0.91), high level of physical activity (AOR = 0.55, 95%CI, 0.31-0.96) and those reported to consume fruit (AOR = 0.37, 95% CI, 0.18-0.77). Consumption of cereals was negatively associated with levels of SBP (β = - 17.4, 95% CI, - 23.8; - 11.0) and DBP (β = - 6.6, 95% CI, - 11.5,-1.79)., Conclusion: About one in every four adults living in pastoral communities have been found to have hypertension in this study. Our findings suggest that older age, obesity or overweight, low physical activity, low income, and consumption of fatty foods increase the risk of hypertension among study population. Their diet was dominated by cereals with moderate intake of meat and milk and low fruits. There is a need to promote physical activities and consumption of fruits in the study population in order to fight against hypertension. Further research should be done to confirm the associations., Competing Interests: Competing interestsThe authors declare no conflict of interest., (© The Author(s) 2020.)

Introduction: In sub-Saharan Africa, the burden of non-communicable diseases (NCDs), particularly diabetes mellitus (DM) and hypertension, has increased rapidly in recent years, although HIV infection remains a leading cause of death among young-middle-aged adults. Health service coverage for NCDs remains very low in contrast to HIV, despite the increasing prevalence of comorbidity of NCDs with HIV. There is an urgent need to expand healthcare capacity to provide integrated services to address these chronic conditions., Methods and Analysis: This protocol describes procedures for a qualitative process evaluation of INTE-AFRICA, a cluster randomised trial comparing integrated health service provision for HIV infection, DM and hypertension, to the current stand-alone vertical care. Interviews, focus group discussions and observations of consultations and other care processes in two clinics (in Tanzania, Uganda) will be used to explore the experiences of stakeholders. These stakeholders will include health service users, policy-makers, healthcare providers, community leaders and members, researchers, non-governmental and international organisations. The exploration will be carried out during the implementation of the project, alongside an understanding of the impact of broader structural and contextual factors., Ethics and Dissemination: Ethical approval was granted by the Liverpool School of Tropical Medicine (UK), the National Institute of Medical Research (Tanzania) and TASO Research Ethics Committee (Uganda) in 2020. The evaluation will provide the opportunity to document the implementation of integration over several timepoints (6, 12 and 18 months) and refine integrated service provision prior to scale up. This synergistic approach to evaluate, understand and respond will support service integration and inform monitoring, policy and practice development efforts to involve and educate communities in Tanzania and Uganda. It will create a model of care and a platform of good practices and lessons learnt for other countries implementing integrated and decentralised community health services., Trial Registration Number: ISRCTN43896688; Pre-results., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: Red meat is an important dietary source of protein and other essential nutrients. Its high intake has been associated with an increased risk of cardiovascular morbidity and mortality, including hypertension (HTN) and hyperlipidaemia (HLP). Despite being physically active, the Maasai at Ngorongoro Conservation Area (NCA) depend heavily on animals' products as their staple food with fewer intakes of vegetables or fruits due to restriction from carrying out agricultural activities within the NCA. This study aimed at determining the prevalence of HTN and HLP and their association with red meat consumption among adult Maasai of NCA., Methods: A community-based cross-sectional study was conducted in October 2018 using multistage sampling technique. Eight hundred and ninety-four (894) participants enrolled from seven villages in three wards within NCA Data were collected using a modified WHO NCDs-STEPS tool. Anthropometric measurements, blood pressure (BP) measurements, and blood samples for glucose and cholesterol tests were obtained from the study participants. Crude and adjusted prevalence ratio (PR) for factors associated with HTN and HLP were estimated using Ordinal and Bayesian logistic regression models, respectively., Results: The prevalence of HLP was 23.7 percent. The levels were higher among males than were among the females (29.0% vs. 20.1%, p = 0.002). The prevalence of HTN and pre-HTN (elevated BP) were 9.8 and 37.0 percent, respectively. Both HTN and elevated BP were higher among males than were among females (hypertensive [10.9% vs. 9.0%]; elevated BP [44.0% vs. 32.1%], p<0.001). The prevalence of HLP was significantly associated with level II (PR = 1.56, 95%CrI: 1.10-2.09) and level III (PR = 1.64, 95%CrI: 1.08-2.41) of red meat consumption as opposed to level I., Conclusion: The prevalence of hyperlipidaemia and elevated BP were high among NCA Maasai. We found a significant association between red meat consumption and hyperlipidaemia. Further follow-up studies are warranted to establish a temporal relationship between red meat consumption and both conditions., Competing Interests: The authors have declared that no competing interests exist.

Background: A randomized trial demonstrated that among people living with late-stage human immunodeficiency virus (HIV) infection initiating antiretroviral therapy, screening serum for cryptococcal antigen (CrAg) combined with adherence support reduced all-cause mortality by 28%, compared with standard clinic-based care. Here, we present the cost-effectiveness., Methods: HIV-infected adults with CD4 count <200 cells/μL were randomized to either CrAg screening plus 4 weekly home visits to provide adherence support or to standard clinic-based care in Dar es Salaam and Lusaka. The primary economic outcome was health service care cost per life-year saved as the incremental cost-effectiveness ratio (ICER), based on 2017 US dollars. We used nonparametric bootstrapping to assess uncertainties and univariate deterministic sensitivity analysis to examine the impact of individual parameters on the ICER., Results: Among the intervention and standard arms, 1001 and 998 participants, respectively, were enrolled. The annual mean cost per participant in the intervention arm was US$339 (95% confidence interval [CI], $331-$347), resulting in an incremental cost of the intervention of US$77 (95% CI, $66-$88). The incremental cost was similar when analysis was restricted to persons with CD4 count <100 cells/μL. The ICER for the intervention vs standard care, per life-year saved, was US$70 (95% CI, $43-$211) for all participants with CD4 count up to 200 cells/μL and US$91 (95% CI, $49-$443) among those with CD4 counts <100 cells /μL. Cost-effectveness was most sensitive to mortality estimates., Conclusions: Screening for cryptococcal antigen combined with a short period of adherence support, is cost-effective in resource-limited settings., (© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America.)

Background: There is a paucity of subnational data on patterns of mobile phone ownership and use in Tanzania to inform the development of digital health interventions., Objective: The aim of this study is to assess patterns of mobile phone ownership and use in pregnant women to inform the feasibility and design of digital health interventions for promoting timely uptake of childhood vaccines in southern Tanzania., Methods: Between August and November 2017, pregnant women in their third trimester were enrolled at health facilities and from surrounding communities, and asked about their patterns of mobile phone ownership and use in an interviewer administered survey., Results: Of 406 women, only 3 had never used a phone. Most women (>98%) could make and receive phone calls. Compared to urban women, rural women reported higher mobile phone use rates but were less likely to be sole owners of phones, and less likely to send or receive SMS, transact money, browse the internet, or use social media via mobile phones., Conclusions: The findings suggest high feasibility for digital health interventions delivered via mobile phones to pregnant women in southern Tanzania. The feasibility of smartphone-based interventions or strategies relying on the use of social media or the internet is limited., (©Lavanya Vasudevan, Jan Ostermann, Sara Marwerwe Moses, Esther Ngadaya, Sayoki Godfrey Mfinanga. Originally published in JMIR mHealth and uHealth (http://mhealth.jmir.org), 08.04.2020.)

Background: Vaccination is a cost-effective strategy for reducing morbidity and mortality among children under 5 years old. To be fully protected from diseases such as tuberculosis, diphtheria, pertussis, and polio, children must receive all recommended vaccinations in a timely manner. In many countries, including Tanzania, high overall vaccination rates mask substantial regional variation in vaccination coverage and low rates of vaccination timeliness. This study evaluates the efficacy of mobile phone-based (mHealth) reminders and incentives for improving vaccination timeliness in the first year of life., Methods: The study, conducted in Mtwara Region in Tanzania, includes 400 late-stage pregnant women enrolled from rural and urban health facilities and surrounding communities. The primary outcome is timeliness of vaccinations among their children at 6, 10, and 14 weeks after birth. Timeliness is defined as vaccination receipt within 28 days after the vaccination due date. The quasi-randomized controlled trial includes three arms: (1) standard of care (no reminders or incentives), (2) mobile phone-based reminders, and (3) mobile phone-based reminders and incentives in the form of conditional financial transfers. Assignment into study arms is based on scheduled vaccination dates. Reminder messages are sent to arms 2 and 3 participants via mobile phones 1 week and 1 day prior to each scheduled vaccination. For arm 3 participants, reminder messages offer an incentive that is provided in the form of a mobile phone airtime recharge voucher code for each timely vaccination. Vaccination dates are recorded via participant contact with an mHealth system, phone calls with mothers, and a review of government-issued vaccination cards during an end-line survey. Random effects logistic regression models will be used to estimate the effects of reminders and incentives on the timeliness of vaccinations., Discussion: The results will inform implementation science research on the effectiveness of reminders and incentives as a means of improving vaccination timeliness., Trial Registration: ClinicalTrials.gov, NCT03252288 . Registered on 17 August 2017 (retrospectively registered).

Background: The 2014 Ebola outbreak reminded us of the importance of preparedness for addressing health security threats. Learning from this experience, we aim to (1) enhance the understanding of preparedness by policy and decision makers, (2) discuss opportunities for Africa to invest in the prevention of health security threats, (3) highlight the value of investing in preventing health security threats, and (4) propose innovations to enhance investments for the prevention or containment of health security threats at the source., Methods: We used observations of governments' attitudes towards investing in preparedness for health security prevention or containment at the source. We conducted a literature review through PubMed, the World Wide Web, and Mendeley using the keywords: "health emergency financing", "investing in health threats prevention", and "stopping outbreaks at the source"., Results: Countries in sub-Saharan Africa invest inadequately towards building and maintaining critical capacities for preventing, detecting, and containing outbreaks at the source. Global health security emergency funding schemes target responses to outbreaks but neglect their prevention. Governments are not absorbing and maintaining adequately capacity built through GHS, World Bank, and development aid projects - a lost opportunity for building and retaining outbreak prevention capacity., Recommendations: Governments should (1) allocate adequate national budgets for health honouring the Abuja and related commitments; (2) own and maintain capacities developed through International Development Aids, OH networks, research consortia and projects; (3) establish a regional health security threats prevention fund. The global community and scientists should (1) consider broadening existing health emergency funds to finance the prevention and containment outbreaks at the source and (2) Strengthen economic analyses and case studies as incentives for governments' budget allocations to prevent health security threats., Competing Interests: Competing Interests: None declared., (© The East African Health Research Commission 2019.)

Early and accurate diagnosis and rigorous clinical and microbiological monitoring of multidrug-resistant tuberculosis (MDR-TB) treatment can curb morbidity and mortality. While others are still under evaluation, the World Health Organization has recommended few novel molecular methods for MDR-TB diagnosis only. We present current molecular methods for diagnosis and monitoring of MDR-TB treatment in TB-endemic settings. A systematic meta-narrative review was conducted according to the RAMESES recommendations. Electronic databases were searched for relevant articles published in English language from January 2013 to June 2018. Based on predefined criteria, two independent reviewers extracted the key messages from relevant articles. Disagreement between them was resolved through discussion and the involvement of a third reviewer, if needed. Key messages were synthesized to create the meta-narratives for method's accuracy, drug-susceptibility capability, and laboratory infrastructure required. We included 33 articles out of 1213 records retrieved, of which 16 (48%) and 12 (36%) were conducted in high- and low-TB-endemic settings, respectively. Xpert ® MTB/RIF, GenoType MTBDRplus, GenoType MTBDRsl, FlouroType™ MTBDR, TB TaqMan ® array card, and DNA sequencers can accurately guide effective treatment regimens. Molecular bacterial load assay quantifies mycobactericidal impact of these regimens. Although they present inherent advantages compared to the current standard of care, they carry important limitations to implementation and/or scale-up. Therefore, considerable effort must now be directed to implementation and health systems research to maximize these forecasted benefits for individual patient's health outcomes., Competing Interests: None