Clustering of under-five mortality in Rufiji Health and Demographic Surveillance System in rural Tanzania

BACKGROUND\ud \ud Less than 5 years remain before the 2015 mark when countries will be evaluated on their achievements for the Millennium Development Goals (MDGs). The MDG 4 and 6 call for a reduction of child mortality by two-thirds and combating malaria, HIV/AIDS, TB, and other diseases, respectively. To accelerate the achievement of these goals, focused allocation of resources and high deployment of cost-effective interventions is paramount. The knowledge of spatial and temporal distribution of diseases is important for health authorities to prioritize and allocate resources.\ud \ud METHODS\ud \ud To identify possible significant clusters, we used SatTScan software, and analyzed 2,745 cases of under-five with 134,099 person-years for the period between 1999and 2008. Mortality rates for every year were calculated, likewise a spatial scan statistic was used to test for clusters of total under-five mortalities in both space and time.\ud \ud RESULTS\ud \ud A number of significant clusters from space, time, and space-time analysis were identified in several locations for a period of 10 years in the Rufiji Demographic Surveillance Site (RDSS). These locations show that villages within the clusters have an elevated risk of under-five deaths. The spatial analysis identified three significant clusters. The first cluster had only one village, Kibiti A (p < 0.05, the second cluster involved five villages (Mtawanya, Pagae, Kibiti A, Machepe, and Kibiti B; p < 0.05), the third cluster involved one village, Jaribu Mpakani (p < 0.05). A space-time cluster of 10 villages for the period between 1999 and 2002 with a radius of 14.73 km was discovered with the highest risk (RR 1.6, p < 0.001). The mortality rates were very high for the years 1999-2002 according to the analysis. The death rates were 33.5, 26.4, 24.1, and 24.9, respectively. Total childhood mortality rates calculated for the period of 10 years were 21.0 per 1,000 person-years.\ud \ud CONCLUSION\ud \ud During the 10 years of analysis, mortality seemed to decrease in RDSS. The mortality decline should be taken with caution because the Demographic Surveillance System is not statistically representative of the whole population; therefore, inference should not be made to the general population of Tanzania. The pattern observed could be attributed to demographic and weather characteristics of RDSS. This should provide new insights for further studies and interventions toward reducing under-five mortality

Relationship Between Household Socio-Economic Status and under-five Mortality in Rufiji DSS, Tanzania.

Disparities in health outcomes between the poor and the better off are increasingly attracting attention from researchers and policy makers. However, policies aimed at reducing inequity need to be based on evidence of their nature, magnitude, and determinants. The study aims to investigate the relationship between household socio-economic status (SES) and under-five mortality, and to measure health inequality by comparing poorest/least poor quintile mortality rate ratio and the use of a mortality concentration index. It also aims to describe the risk factors associated with under-five mortality at Rufiji Demographic Surveillance Site (RDSS), Tanzania. This analytical cross sectional study included 11,189 children under-five residing in 7,298 households in RDSS in 2005. Principal component analysis was used to construct household SES. Kaplan-Meier survival incidence estimates were used for mortality rates. Health inequality was measured by calculating and comparing mortality rates between the poorest and least poor wealth quintile. We also computed a mortality concentration index. Risk factors of child mortality were assessed using Poisson regression taking into account potential confounders. Under-five mortality was 26.9 per 1,000 person-years [95% confidence interval (CI) (23.7-30.4)]. The poorest were 2.4 times more likely to die compared to the least poor. Our mortality concentration index [-0.16; 95% CI (-0.24, -0.08)] indicated considerable health inequality. Least poor households had a 52% reduced mortality risk [incidence rate ratio (IRR) = 0.48; 95% CI 0.30-0.80]. Furthermore, children with mothers who had attained secondary education had a 70% reduced risk of dying compared to mothers with no education [IRR = 0.30; 95% CI (0.22-0.88)]. Household socio-economic inequality and maternal education were associated with under-five mortality in the RDSS. Targeted interventions to address these factors may contribute towards accelerating the reduction of child mortality in rural Tanzania

Bio-efficacy of an organophosphorous bait (Snip®) against wild populations of synanthropic flies Musca domestica and Lucilia species

The common housefly, Musca domestica and the green-bottle fly Lucilia species are Diptera belonging to the Suborder Cyclorrapha. The former species is associated with mechanical transmission of certain diarrhoeal diseases such as dysentery, typhoid fever, and cholera, which afflict man. Other important diseases include, anthrax, eye infections and bovine mastitis. It is the manner in which M. domestica exudes a “vomit-drop” to sugar, dried blood, pus, excreta, sputum and other substances that makes it an efficient vector of human diseases. Bacteria may also adhere to the hairy body of the fly and to the hairy puvilli on the feet. Lucilia sp. is mostly associated with diseases of livestock such as sheep and fowls. This species causes myiasis of sheep called “strike”, which results in larval development in the skin. Usually, environmental sanitation involving elimination of fly breeding sites by proper disposal of refuse, manure, compost, human excreta and other waste is the fundamental measure for fly control. However, there are instances where control has to be supplemented with insecticides. Among the most commonly used insecticidal methods of control is the use of baits. These are placed or applied to surfaces where adult flies congregate to feed. This control measure takes advantage of the fly's mechanism of feeding. This paper discusses findings of an experiment designed to test attractiveness and bio-efficacy of an organophosphate-based bait against M. domestica and Lucilia species. Tanzania Health Research Bulletin Vol.6(2) 2004: 69-7

"Even if the test result is negative, they should be able to tell us what is wrong with us": a qualitative study of patient expectations of rapid diagnostic tests for malaria.

BACKGROUND: The debate on rapid diagnostic tests (RDTs) for malaria has begun to shift from whether RDTs should be used, to how and under what circumstances their use can be optimized. This has increased the need for a better understanding of the complexities surrounding the role of RDTs in appropriate treatment of fever. Studies have focused on clinician practices, but few have sought to understand patient perspectives, beyond notions of acceptability. METHODS: This qualitative study aimed to explore patient and caregiver perceptions and experiences of RDTs following a trial to assess the introduction of the tests into routine clinical care at four health facilities in one district in Ghana. Six focus group discussions and one in-depth interview were carried out with those who had received an RDT with a negative test result. RESULTS: Patients had high expectations of RDTs. They welcomed the tests as aiding clinical diagnoses and as tools that could communicate their problem better than they could, verbally. However, respondents also believed the tests could identify any cause of illness, beyond malaria. Experiences of patients suggested that RDTs were adopted into an existing system where patients are both physically and intellectually removed from diagnostic processes and where clinicians retain authority that supersedes tests and their results. In this situation, patients did not feel able to articulate a demand for test-driven diagnosis. CONCLUSIONS: Improvements in communication between the health worker and patient, particularly to explain the capabilities of the test and management of RDT negative cases, may both manage patient expectations and promote patient demand for test-driven diagnoses

Access to Artemisinin-Based Anti-Malarial Treatment and its Related Factors in Rural Tanzania.

Artemisinin-based combination treatment (ACT) has been widely adopted as one of the main malaria control strategies. However, its promise to save thousands of lives in sub-Saharan Africa depends on how effective the use of ACT is within the routine health system. The INESS platform evaluated effective coverage of ACT in several African countries. Timely access within 24 hours to an authorized ACT outlet is one of the determinants of effective coverage and was assessed for artemether-lumefantrine (Alu), in two district health systems in rural Tanzania. From October 2009 to June 2011we conducted continuous rolling household surveys in the Kilombero-Ulanga and the Rufiji Health and Demographic Surveillance Sites (HDSS). Surveys were linked to the routine HDSS update rounds. Members of randomly pre-selected households that had experienced a fever episode in the previous two weeks were eligible for a structured interview. Data on individual treatment seeking, access to treatment, timing, source of treatment and household costs per episode were collected. Data are presented on timely access from a total of 2,112 interviews in relation to demographics, seasonality, and socio economic status. In Kilombero-Ulanga, 41.8% (CI: 36.6-45.1) and in Rufiji 36.8% (33.7-40.1) of fever cases had access to an authorized ACT provider within 24 hours of fever onset. In neither of the HDSS site was age, sex, socio-economic status or seasonality of malaria found to be significantly correlated with timely access. Timely access to authorized ACT providers is below 50% despite interventions intended to improve access such as social marketing and accreditation of private dispensing outlets. To improve prompt diagnosis and treatment, access remains a major bottle neck and new more innovative interventions are needed to raise effective coverage of malaria treatment in Tanzania

Determinants of isoniazid preventive therapy completion among people living with HIV attending care and treatment clinics from 2013 to 2017 in Dar es Salaam Region, Tanzania. A cross-sectional analytical study.

BACKGROUND: Tuberculosis (TB) disease is a common opportunistic infection among people living with HIV (PLHIV). WHO recommends at least 6 months of isoniazid Preventive Therapy (IPT) to reduce the risk of active TB. It is important to monitor the six-month IPT completion since a suboptimal dose may not protect PLHIV from TB infection. This study determined the six-month IPT completion and factors associated with six-month IPT completion among PLHIV aged 15 years or more in Dar es Salaam region, Tanzania. METHODS: Secondary analysis of routine data from PLHIV attending 58 care and treatment clinics in Dar es Salaam region was used. PLHIV, aged 15 years and above, who screened negative for TB symptoms and initiated IPT from January, 2013 to June, 2017 were recruited. Modified Poisson regression with robust standard errors was used to estimate prevalence ratios (PR) and 95% confidence interval (CI) for factors associated with IPT completion. Multilevel analysis was used to account for health facility random effects in order to estimate adjusted PR (APR) for factors associated with IPT six-month completion. RESULTS: A total of 29,382 PLHIV were initiated IPT, with 21,808 (74%) female. Overall 17,092 (58%) six-month IPT completion, increasing from 42% (773/1857) in year 2013 to 76% (2929/3856) in 2017. Multilevel multivariable model accounting for health facilities as clusters, showed PLHIV who were not on ART had 46% lower IPT completion compared to those were on ART (APR: 0.54: 95%CI: 0.45-0.64). There was 37% lower IPT completion among PLHIV who transferred from another clinic (APR: 0.63: 95% CI (0.54-0.74) compared to those who did not transfer. PLHIV aged 25-34 years had a 6% lower prevalence of IPT completion as compared to those aged 15 to 24 years (APR:0.94 95%CI:0.89-0.98). CONCLUSION: The IPT completion rate in PLHIV increased over time, but there was lower IPT completion in PLHIV who transferred from other clinics, who were aged 25 to 34 years and those not on ART. Interventions to support IPT in these groups are urgently needed

Addressing Inequity to Achieve the Maternal and Child Health Millennium Development Goals: Looking Beyond Averages.

Inequity in access to and use of child and maternal health interventions is impeding progress towards the maternal and child health Millennium Development Goals. This study explores the potential health gains and equity impact if a set of priority interventions for mothers and under fives were scaled up to reach national universal coverage targets for MDGs in Tanzania. We used the Lives Saved Tool (LiST) to estimate potential reductions in maternal and child mortality and the number of lives saved across wealth quintiles and between rural and urban settings. High impact maternal and child health interventions were modelled for a five-year scale up, by linking intervention coverage, effectiveness and cause of mortality using data from Tanzania. Concentration curves were drawn and the concentration index estimated to measure the equity impact of the scale up. In the poorest population quintiles in Tanzania, the lives of more than twice as many mothers and under-fives were likely to be saved, compared to the richest quintile. Scaling up coverage to equal levels across quintiles would reduce inequality in maternal and child mortality from a pro rich concentration index of -0.11 (maternal) and -0.12 (children) to a more equitable concentration index of -0,03 and -0.03 respectively. In rural areas, there would likely be an eight times greater reduction in maternal deaths than in urban areas and a five times greater reduction in child deaths than in urban areas. Scaling up priority maternal and child health interventions to equal levels would potentially save far more lives in the poorest populations, and would accelerate equitable progress towards maternal and child health MDGs

Multiple Sexual Partners and Condom use among 10 - 19 Year-olds in four Districts in Tanzania: What do we Learn?

Although some studies in Tanzania have addressed the question of sexuality and STIs among adolescents, mostly those aged 15 - 19 years, evidence on how multiple sexual partners influence condom use among 10 - 19 year-olds is limited. This study attempts to bridge this gap by testing a hypothesis that sexual relationships with multiple partners in the age group 10 - 19 years spurs condom use during sex in four districts in Tanzania. Secondary analysis was performed using data from the Adolescents Module of the cross-sectional household survey on Maternal, Newborn and Child Health (MNCH) that was done in Kigoma, Kilombero, Rufiji and Ulanga districts, Tanzania in 2008. A total of 612 adolescents resulting from a random sample of 1200 households participated in this study. Pearson Chi-Square was used as a test of association between multiple sexual partners and condom use. Multivariate logistic regression model was fitted to the data to assess the effect of multiple sexual partners on condom use, having adjusted for potential confounding variables. STATA (10) statistical software was used to carry out this process at 5% two-sided significance level. Of the 612 adolescents interviewed, 23.4% reported being sexually active and 42.0% of these reported having had multiple (> 1) sexual partners in the last 12 months. The overall prevalence of condom use among them was 39.2%. The proportion using a condom at the last sexual intercourse was higher among those who knew that they can get a condom if they want than those who did not. No evidence of association was found between multiple sexual partners and condom use (OR = 0.77, 95% CI = 0.35 - 1.67, P = 0.504). With younger adolescents (10 - 14 years) being a reference, condom use was associated with age group (15 - 19: OR = 3.69, 95% CI = 1.21 - 11.25, P = 0.022) and district of residence (Kigoma: OR = 7.45, 95% CI = 1.79 - 31.06, P = 0.006; Kilombero: OR = 8.89, 95% CI = 2.91 - 27.21, P < 0.001; Ulanga: OR = 5.88, 95% CI = 2.00 - 17.31, P = 0.001), Rufiji being a reference category. No evidence of association was found between multiple sexual partners and condom use among adolescents in the study area. The large proportion of adolescents who engage in sexual activity without using condoms, even those with multiple partners, perpetuates the risk of transmission of HIV infections in the community. Strategies such as sex education and easing access to and making a friendly environment for condom availability are important to address the risky sexual behaviour among adolescents