Do Health Workers' Preferences Influence their Practices? Assessment of Providers' Attitude and Personal use of new Treatment Recommendations for Management of Uncomplicated Malaria, Tanzania.

\ud \ud Due to growing antimalarial drug resistance, Tanzania changed malaria treatment policies twice within a decade. First in 2001 chloroquine (CQ) was replaced by sulfadoxine-pyrimethamine (SP) for management of uncomplicated malaria and by late 2006, SP was replaced by artemether-lumefantrine (AL). We assessed health workers' attitudes and personal practices following the first treatment policy change, at six months post-change and two years later. Two cross-sectional surveys were conducted in 2002 and 2004 among healthcare workers in three districts in South-East Tanzania using semi-structured questionnaires. Attitudes were assessed by enquiring which antimalarial was considered most suitable for the management of uncomplicated malaria for the three patient categories: i) children below 5; ii) older children and adults; and iii) pregnant women. Practice was ascertained by asking which antimalarial was used in the last malaria episode by the health worker him/herself and/or dependants. Univariate and multivariate logistic regression was used to identify factors associated with reported attitudes and practices towards the new treatment recommendations. A total of 400 health workers were interviewed; 254 and 146 in the first and second surveys, respectively. SP was less preferred antimalarial in hospitals and private health facilities (p<0.01) in the first round, and the preference worsened in the second round. In the first round, clinicians did not prefer SP for children below age of 5 and pregnant women (p<0.01), but two years later, they did not prefer it for all patient scenarios. SP was the most commonly used antimalarial for management of the last malaria episode for health workers and their dependants in both rounds, in the public sector (p<0.01). Health workers in the dispensaries had the highest odds of using SP for their own treatment [adjusted OR- first round: 6.7 (95%CI: 1.9-23.4); crude OR- second round: 4.5 (1.5-13.3)]. Following changes in malaria treatment recommendations, most health workers did not prefer the new antimalarial drug, and their preferences worsened over time. However, many of them still used the newly recommended drug for management of their own or family members' malaria episode. This indicates that, other factors than providers' attitude may have more influence in their personal treatment practices

Relationship Between Child Survival and Malaria Transmission: An Analysis of the Malaria Transmission Intensity and Mortality Burden Across Africa (MTIMBA) Project Data in Rufiji Demographic Surveillance System, Tanzania.

The precise nature of the relationship between malaria mortality and levels of transmission is unclear. Due to methodological limitations, earlier efforts to assess the linkage have lead to inconclusive results. The malaria transmission intensity and mortality burden across Africa (MTIMBA) project initiated by the INDEPTH Network collected longitudinally entomological data within a number of sites in sub-Saharan Africa to study this relationship. This work linked the MTIMBA entomology database with the routinely collected vital events within the Rufiji Demographic Surveillance System to analyse the transmission-mortality relation in the region. Bayesian Bernoulli spatio-temporal Cox proportional hazards models with village clustering, adjusted for age and insecticide-treated nets (ITNs), were fitted to assess the relation between mortality and malaria transmission measured by entomology inoculation rate (EIR). EIR was predicted at household locations using transmission models and it was incorporated in the model as a covariate with measure of uncertainty. Effects of covariates estimated by the model are reported as hazard ratios (HR) with 95% Bayesian confidence interval (BCI) and spatial and temporal parameters are presented. Separate analysis was carried out for neonates, infants and children 1-4 years of age. No significant relation between all-cause mortality and intensity of malaria transmission was indicated at any age in childhood. However, a strong age effect was shown. Comparing effects of ITN and EIR on mortality at different age categories, a decrease in protective efficacy of ITN was observed (i.e. neonates: HR = 0.65; 95% BCI: 0.39-1.05; infants: HR = 0.72; 95% BCI:0.48-1.07; children 1-4 years: HR = 0.88; 95% BCI: 0.62-1.23) and reduction on the effect of malaria transmission exposure was detected (i.e. neonates: HR = 1.15; 95% BCI:0.95-1.36; infants: HR = 1.13; 95% BCI:0.98-1.25; children 1-4 years: HR = 1.04; 95% BCI:0.89-1.18). A very strong spatial correlation was also observed. These results imply that assessing the malaria transmission-mortality relation involves more than the knowledge on the performance of interventions and control measures. This relation depends on the levels of malaria endemicity and transmission intensity, which varies significantly between different settings. Thus, sub-regions analyses are necessary to validate and assess reproducibility of findings

Health Worker Factors Associated with Prescribing of Artemisinin Combination Therapy for Uncomplicated Malaria in Rural Tanzania.

Improving malaria case management is partially dependent on health worker compliance with clinical guidelines. This study assessed health worker factors associated with correct anti-malarial prescribing practices at two sites in rural Tanzania. Repeated cross-sectional health facility surveys were conducted during high and low malaria transmission seasons in 2010 and collected information on patient consultations and health worker characteristics. Using logistic regression, the study assessed health worker factors associated with correct prescription for uncomplicated malaria defined as prescription of artemisinin-based combination therapy (ACT) for patients with fever and Plasmodium falciparum asexual infection based on blood slide or malaria rapid diagnostic test (RDT) according to national treatment guidelines. The analysis included 685 patients with uncomplicated malaria who were seen in a health facility with ACT in stock, and 71 health workers practicing in 30 health facilities. Overall, 58% of malaria patients were correctly treated with ACT. Health workers with three or more years' work experience were significantly more likely than others to prescribe correctly (adjusted odds ratio (aOR) 2.9; 95% confidence interval (CI) 1.2-7.1; p = 0.019). Clinical officers (aOR 2.2; 95% CI 1.1-4.5; p = 0.037), and nurse aide or lower cadre (aOR 3.1; 95% CI 1.3-7.1; p = 0.009) were more likely to correctly prescribe ACT than medical officers. Training on ACT use, supervision visits, and availability of job aids were not significantly associated with correct prescription. Years of working experience and health worker cadre were associated with correct ACT prescription for uncomplicated malaria. Targeted interventions to improve health worker performance are needed to improve overall malaria case management

Using rapid research to develop a national strategy to assist families affected by AIDS in Tanzania

Although information on African family adaptation to the AIDS epidemic is critical to planning and managing government, donor and NGO programs of assistance, current knowledge is limited to a small number of research studies. An AIDS prevention project in Tanzania undertook a rapid national assessment to identify the major problems for families in Tanzania in adapting to the epidemic. The methodology used for the work was distinct from prior studies: the research covered a wide cross-section of Tanzanian population groups to gauge the extent of ethnic, urban–rural and regional variation; it was rapid and qualitative, to gather data on broad trends in a short time; and it was designed in co-operation with policymakers so they could understand the approach being used and were receptive to the findings. The study identified common problems in AIDS care, counselling and survivor assistance. Many of the problems for families with AIDS have their origin in poverty and changes in African family structures over the past 20 years, which African demographers are just beginning to describe. Stresses arising from these changes are now being aggravated by AIDS, but families with sufficient resources, whether female or male-headed, are coping better than those without

Predictors of Antibiotics Co-prescription with Antimalarials for Patients Presenting with Fever in Rural Tanzania.

Successful implementation of malaria treatment policy depends on the prescription practices for patients with malaria. This paper describes prescription patterns and assesses factors associated with co-prescription of antibiotics and artemether-lumefantrine (AL) for patients presenting with fever in rural Tanzania. From June 2009 to September 2011, a cohort event monitoring program was conducted among all patients treated at 8 selected health facilities in Ifakara and Rufiji Health and Demographic Surveillance System (HDSS).It included all patients presenting with fever and prescribed with AL. Logistic regression was used to model the predictors on the outcome variable which is co-prescription of AL and antibiotics on a single clinical visit. A cohort of 11,648 was recruited and followed up with 92% presenting with fever. Presumptive treatment was used in 56% of patients treated with AL. On average 2.4 (1 -- 7) drugs was prescribed per encounter, indicating co-prescription of AL with other drugs. Children under five had higher odds of AL and antibiotics co-prescription (OR = 0.63, 95% CI: 0.46 -- 0.85) than those aged more than five years. Patients testing negative had higher odds (OR = 2.22, 95%CI: 1.65 -- 2.97) of AL and antibiotics co-prescription. Patients receiving treatment from dispensaries had higher odds (OR = 1.45, 95% CI: 0.84 -- 2.30) of AL and antibiotics co-prescription than those from served in health centres even though the deference was not statistically significant. Regardless the fact that Malaria is declining but due to lack of laboratories and mRDT in most health facilities in the rural areas, clinicians are still treating malaria presumptively. This leads them to prescribe more drugs to treat all possibilities

Mobile-based and open-source case detection and infectious disease outbreak management systems: a review [version 1; peer review: awaiting peer review]

In this paper we perform a rapid review of existing mobile-based, open-source systems for infectious disease outbreak data collection and management. Our inclusion criteria were designed to match the PANDORA-ID-NET consortium’s goals for capacity building in sub-Saharan Africa, and to reflect the lessons learned from the 2014–16 West African Ebola outbreak. We found eight candidate systems that satisfy some or most of these criteria, but only one (SORMAS) fulfils all of them. In addition, we outline a number of desirable features that are not currently present in most outbreak management systems

Correct Dosing of Artemether-Lumefantrine for Management of Uncomplicated Malaria in Rural Tanzania: Do facility and Patient Characteristics Matter?

Use of artemisinin-based combination therapy (ACT), such as artemether-lumefantrine (AL), requires a strict dosing schedule that follows the drugs' pharmacokinetic properties. The quality of malaria case management was assessed in two areas in rural Tanzania, to ascertain patient characteristics and facility-specific factors that influence correct dosing of AL for management of uncomplicated malaria. Exit interviews were conducted with patients attending health facilities for initial illness consultation. Information about health workers' training and supervision visits was collected. Health facilities were inventoried for capacity and availability of medical products related to care of malaria patients. The outcome was correct dosing of AL based on age and weight. Logistic regression was used to assess health facility factors and patient characteristics associated with correct dosing of AL by age and weight. A total of 1,531 patients were interviewed, but 60 pregnant women were excluded from the analysis. Only 503 (34.2%) patients who received AL were assessed for correct dosing. Most patients who received AL (85.3%) were seen in public health facilities, 75.7% in a dispensary and 91.1% in a facility that had AL in stock on the survey day. Overall, 92.1% (463) of AL prescriptions were correct by age or weight; but 85.7% of patients received correct dosing by weight alone and 78.5% received correct dosing by age alone. In multivariate analysis, patients in the middle dosing bands in terms of age or weight, had statistically significant lower odds of correct AL dosing (p < 0.05) compared to those in the lowest age or weight group. Other factors such as health worker supervision and training on ACT did not improve the odds of correct AL dosing. Although malaria treatment guidelines indicate AL dosing can be prescribed based on age or weight of the patient, findings from this study show that patients within the middle age and weight dosing bands were least likely to receive a correct dose by either measure. Clinicians should be made aware of AL dosing errors for patients aged three to 12 years and advised to use weight-based prescriptions whenever possible