Policy environment and male circumcision for HIV prevention: Findings from a situation analysis study in Tanzania

<p>Abstract</p> <p>Background</p> <p>Male circumcision (MC) has been shown to be effective against heterosexual acquisition of HIV infection and is being scaled up as an additional strategy against HIV in several countries of Africa. However, the policy environment (whether to formulate new specific policy on MC or adapts the existing ones); and the role of various stakeholders in the MC scale up process in Tanzania was unclear. We conducted this study as part of a situation analysis to understand the attitudes of policy makers and other key community and health authority decision makers towards MC, policy and regulatory environment, and the readiness of a health system to accommodate scaling up of MC services.</p> <p>Methods</p> <p>We conducted 36 key informants' interviews with a broad range of informants including civil servants, religious leaders, cultural and traditional gatekeepers and other potential informants. Study informants were selected at the national level, regional, district and community levels to represent both traditionally circumcising and non-circumcising communities.</p> <p>Results</p> <p>Study informants had positive attitudes and strong beliefs towards MC. Key informants in traditionally non-circumcising districts were willing to take their sons for medically performed MC. Religious leaders and traditional gatekeepers supported MC as it has been enshrined in their holy scripts and traditional customs respectively. Civil servants highlighted the need for existence of enabling policy and regulatory environment in the form of laws, regulations and guidelines that will ensure voluntary accessibility, acceptability, quality and safety for those in need of MC services. Majority of informants urged the government to make improvements in the health system at all levels to ensure availability of adequate trained personnel, infrastructure, equipment, and supplies for MC scale up, and insisted on the involvement of different MC stakeholders as key components in effective roll out of medically performed MC programme in the country.</p> <p>Conclusions</p> <p>Findings from the situation analysis in Tanzania have shown that despite the absence of a specific policy on MC, basic elements of enabling policy environment at national, regional, district and community levels are in place for the implementation of MC scale up programme.</p

Knowledge, attitude and practice in relation to Antimicrobial residues in beef among residents in Dodoma Region

The safety of food of animal origin is of concern in the developing countries. Some of the antimicrobial agents that are used for the treatment of animal diseases seem to occur in the animal products. The knowledge, attitude and practice in relation to oxytetracycline (OTC) residues in beef among residents in Dodoma Region, Tanzania were evaluated. A cross sectional study included interviewing 254 randomly chosen respondents was conducted. Fifty two percent of the respondents were not aware of drug residues, 57% never heard about drug residues in food of animal origin such as milk and meat, 35% know residues can be harmful to human and 61% did not know if animals are treated with antimicrobial drugs when they were sick. Only 27% of the respondents knew common antimicrobial agents that cause residues in animal meat and milk and were able to mention. Majority of respondents (74%) did not know any method for the prevention of antimicrobial residues. Fifty six percent of the age group of 20-35 years purchased meat from butcheries. Secondary school (68.4%) and College (52.9%) respondents purchased meat from butcheries&nbsp; compared to informal (23.8%) and primary (49.2%) respectively that purchased meat locally within the villages. Majority of informal (66.7%) and primary (47.6%) respondents purchased meat locally within the villages. The differences were strongly significant p&lt; 0.0001. Women (57.1%) used one hour to prepare meat. Age group 20-35 years (88.1%) prepared meat by cooking. Age group of 36-45 years prepared meat for 1 hour and 2 hours. College respondents (68.8%) barbequing meat compared to smoking and freezing. The results in this study indicate that respondents had low knowledge and awareness on antimicrobial use and drug residues. This might be due to low level of education of respondents as majority of them had informal and primary education. Many of the drug respondents were not aware of the drug residues and did not know antibiotic residues can have effects in human health. Community based health education and promotion on antimicrobial use and preventing drug residues is highly recommended to this population. Key words: knowledge, attitude, practice, residues in beef, residents, Dodoma Region, Tanzani

Foot-and-mouth disease in Tanzania from 2001 to 2006.

Foot-and-mouth disease (FMD) is endemic in Tanzania, with outbreaks occurring almost each year in different parts of the country. There is now a strong political desire to control animal diseases as part of national poverty alleviation strategies. However, FMD control requires improving the current knowledge on the disease dynamics and factors related to FMD occurrence so control measures can be implemented more efficiently. The objectives of this study were to describe the FMD dynamics in Tanzania from 2001 to 2006 and investigate the spatiotemporal patterns of transmission. Extraction maps, the space-time K-function and space-time permutation models based on scan statistics were calculated for each year to evaluate the spatial distribution, the spatiotemporal interaction and the spatiotemporal clustering of FMD-affected villages. From 2001 to 2006, 878 FMD outbreaks were reported in 605 different villages of 5815 populated places included in the database. The spatial distribution of FMD outbreaks was concentrated along the Tanzania-Kenya, Tanzania-Zambia borders, and the Kagera basin bordering Uganda, Rwanda and Tanzania. The spatiotemporal interaction among FMD-affected villages was statistically significant (P≤0.01) and 12 local spatiotemporal clusters were detected; however, the extent and intensity varied across the study period. Dividing the country in zones according to their epidemiological status will allow improving the control of FMD and delimiting potential FMD-free areas

The costs of accessible quality assured syphilis diagnostics: informing quality systems for rapid syphilis tests in a Tanzanian setting.

OBJECTIVES: To determine the costs of Rapid Syphilis Test (RSTs) as compared with rapid plasma reagin (RPR) when implemented in a Tanzanian setting, and to determine the relative impact of a quality assurance (QA) system on the cost of RST implementation. METHODS: The incremental costs for RPR and RST screening programmes in existing antenatal care settings in Geita District, Tanzania were collected for 9 months in subsequent years from nine health facilities that varied in size, remoteness and scope of antenatal services. The costs per woman tested and treated were estimated for each facility. A sensitivity analysis was constructed to determine the impact of parameter and model uncertainty. FINDINGS: In surveyed facilities, a total of 6362 women were tested with RSTs compared with 224 tested with RPR. The range of unit costs was $1.76-$3.13 per woman screened and $12.88-$32.67 per woman treated. Unit costs for the QA system came to $0.51 per woman tested, of which 50% were attributed to salaries and transport for project personnel. CONCLUSIONS: Our results suggest that rapid syphilis diagnostics are very inexpensive in this setting and can overcome some critical barriers to ensuring universal access to syphilis testing and treatment. The additional costs for implementation of a quality system were found to be relatively small, and could be reduced through alterations to the programme design. Given the potential for a quality system to improve quality of diagnosis and care, we recommend that QA activities be incorporated into RST roll-out

Medication exposure during pregnancy: a pilot pharmacovigilance system using health and demographic surveillance platform.

BACKGROUND: There is limited safety information on most drugs used during pregnancy. This is especially true for medication against tropical diseases because pharmacovigilance systems are not much developed in these settings. The aim of the present study was to demonstrate feasibility of using Health and Demographic Surveillance System (HDSS) as a platform to monitor drug safety in pregnancy. METHODS: Pregnant women with gestational age below 20 weeks were recruited from Reproductive and Child Health (RCH) clinics or from monthly house visits carried out for the HDSS. A structured questionnaire was used to interview pregnant women. Participants were followed on monthly basis to record any new drug used as well as pregnancy outcome. RESULTS: 1089 pregnant women were recruited; 994 (91.3%) completed the follow-up until delivery. 98% women reported to have taken at least one medication during pregnancy, mainly those used in antenatal programmes. Other most reported drugs were analgesics (24%), antibiotics (17%), and antimalarial (15%), excluding IPTp. Artemether-lumefantrine (AL) was the most used antimalarial for treating illness by nearly 3/4 compared to other groups of malaria drugs. Overall, antimalarial and antibiotic exposures in pregnancy were not significantly associated with adverse pregnancy outcome. Iron and folic acid supplementation were associated with decreased risk of miscarriage/stillbirth (OR 0.1; 0.08 - 0.3). CONCLUSION: Almost all women were exposed to medication during pregnancy. Exposure to iron and folic acid had a beneficial effect on pregnancy outcome. HDSS proved to be a useful platform to establish a reliable pharmacovigilance system in resource-limited countries. Widening drug safety information is essential to facilitate evidence based risk-benefit decision for treatment during pregnancy, a major challenge with newly marketed medicines

Evaluation of the effectiveness of a clean delivery kit intervention in preventing cord infection and puerperal sepsis among neonates and their mothers in rural Mwanza Region, Tanzania

A study was carried out in Misungwi and Kwimba Districts, Tanzania to determine the effectiveness of clean delivery kits in preventing cord infection and puerperal sepsis and to provide qualitative information on community acceptability, correct use, and appropriateness of the kits. This study involved pregnant women aged 18-45 years old. In the delivery kit intervention population, the Maternal and Child Health Aide (MCHA) assigned to the health facility provided pregnant mothers with a clean delivery kit on their first antenatal visit. She explained how to use each of the kit components, with the aid of pictorial instructions included in the kit. The pregnant mothers were asked to convey the information to whoever assisted them during delivery. The MCHA also gave them health education based on the principles of the “six cleans” recognized by WHO (i.e., clean hands, clean perineum, clean delivery surface, clean cord cutting and tying instruments, clean cutting surface). Women received the clean delivery kit free of charge in accordance with the randomised stepped-wedge design schedule. During the first week following delivery, the Village Health Workers (VHWs) from both the intervention and control groups made two visits to the households of mothers who had delivered. They administered questionnaire about delivery to mother and birth attendant. During the two scheduled postpartum visits, those who were suspected to have puerperal sepsis or cord infection of the baby were referred to the health facility clinician for confirmation. Results indicated that use of clean delivery kit had a positive effect on reducing both cord infection and puerperal sepsis. The use of a clean home delivery kit coupled with an educational intervention about the “six cleans” had a significant effect on reducing the incidence of cord infection and puerperal sepsis among women enrolled in the study. In low resource settings where home birth is common and clean delivery supplies are scarce, disposable kits can be made available through health clinics, markets, pharmacies or other channels to help reduce rates of infection. Keywords: delivery, neonates, mothers, cord infection, puerperal sepsis, TanzaniaTanzania Health Research Bulletin Vol. 7(3) 2005: 185-18

The Sexual health of pupils in years 4 to 6 of primary schools in rural Tanzania

Background/objectives: There is an urgent need for effective interventions to improve the sexual and\ud reproductive health of adolescents. Reliable data on the sexual health of adolescents are needed to guide\ud the development of such interventions. The aim was to describe the sexual health of pupils in years 4 to 6 of\ud 121 rural primary schools in north western Tanzania, before the implementation of an innovative sexual\ud health intervention in 58 of the schools.\ud Methods: A cross sectional survey of primary school pupils in rural Tanzania was carried out. The study\ud population comprised pupils registered in years 4 to 6 of 121 primary schools in 20 rural communities in\ud 1998. Basic demographic information was collected from all pupils seen. Those born before 1 January\ud 1985 (aged approximately 14 years and over) were invited to participate in the survey, and asked about\ud their knowledge and attitudes towards sexual health issues, and their sexual experience. A urine specimen\ud was requested and tested for HIV, Chlamydia trachomatis (CT), Neisseria gonorrhoeae (NG) and, for\ud females, pregnancy.\ud Results: 9283 pupils born before 1 January 1985 were enrolled and provided demographic information\ud and a urine sample. Male pupils were significantly older than females (mean age 15.5 years v 14.8 years,\ud p,0.001), but all other demographic characteristics were similar between the sexes. 14 (0.2%) of the\ud enrolled pupils (four male and 10 female) were HIV positive, 83 (0.9%) were positive for CT, and 12\ud (0.1%) for NG. 32 female pupils (0.8%) were positive by pregnancy test. Sexual experience was reported\ud by one fifth of primary school girls, and by almost half of boys. Only 45/114 (39%) girls with biological\ud markers of sexual activity reported having had sex.\ud Conclusions: HIV, CT, NG, and pregnancy were present though at relatively low levels among pupils in\ud years 4 to 6 of primary school. A high proportion of pupils with a biological marker of sexual activity\ud denied ever having had sex. Alternative ways of collecting sensitive data about the sexual behaviour of\ud school pupils should be explored

Effectiveness of a long-lasting piperonyl butoxide-treated insecticidal net and indoor residual spray interventions, separately and together, against malaria transmitted by pyrethroid-resistant mosquitoes: a cluster, randomised controlled, two-by-two factorial design trial.

BACKGROUND: Progress in malaria control is under threat by wide-scale insecticide resistance in malaria vectors. Two recent vector control products have been developed: a long-lasting insecticidal net that incorporates a synergist piperonyl butoxide (PBO) and a long-lasting indoor residual spraying formulation of the insecticide pirimiphos-methyl. We evaluated the effectiveness of PBO long-lasting insecticidal nets versus standard long-lasting insecticidal nets as single interventions and in combination with the indoor residual spraying of pirimiphos-methyl. METHODS: We did a four-group cluster randomised controlled trial using a two-by-two factorial design of 48 clusters derived from 40 villages in Muleba (Kagera, Tanzania). We randomly assigned these clusters using restricted randomisation to four groups: standard long-lasting insecticidal nets, PBO long-lasting insecticidal nets, standard long-lasting insecticidal nets plus indoor residual spraying, or PBO long-lasting insecticidal nets plus indoor residual spraying. Both standard and PBO nets were distributed in 2015. Indoor residual spraying was applied only once in 2015. We masked the inhabitants of each cluster to the type of nets received, as well as field staff who took blood samples. Neither the investigators nor the participants were masked to indoor residual spraying. The primary outcome was the prevalence of malaria infection in children aged 6 months to 14 years assessed by cross-sectional surveys at 4, 9, 16, and 21 months after intervention. The endpoint for assessment of indoor residual spraying was 9 months and PBO long-lasting insecticidal nets was 21 months. This trial is registered with ClinicalTrials.gov, number NCT02288637. FINDINGS: 7184 (68·0%) of 10 560 households were selected for post-intervention survey, and 15 469 (89·0%) of 17 377 eligible children from the four surveys were included in the intention-to-treat analysis. Of the 878 households visited in the two indoor residual spraying groups, 827 (94%) had been sprayed. Reported use of long-lasting insecticidal nets, across all groups, was 15 341 (77·3%) of 19 852 residents after 1 year, decreasing to 12 503 (59·2%) of 21 105 in the second year. Malaria infection prevalence after 9 months was lower in the two groups that received PBO long-lasting insecticidal nets than in the two groups that received standard long-lasting insecticidal nets (531 [29%] of 1852 children vs 767 [42%] of 1809; odds ratio [OR] 0·37, 95% CI 0·21-0·65; p=0·0011). At the same timepoint, malaria prevalence in the two groups that received indoor residual spraying was lower than in groups that did not receive indoor residual spraying (508 [28%] of 1846 children vs 790 [44%] of 1815; OR 0·33, 95% CI 0·19-0·55; p<0·0001) and there was evidence of an interaction between PBO long-lasting insecticidal nets and indoor residual spraying (OR 2·43, 95% CI 1·19-4·97; p=0·0158), indicating redundancy when combined. The PBO long-lasting insecticidal net effect was sustained after 21 months with a lower malaria prevalence than the standard long-lasting insecticidal net (865 [45%] of 1930 children vs 1255 [62%] of 2034; OR 0·40, 0·20-0·81; p=0·0122). INTERPRETATION: The PBO long-lasting insecticidal net and non-pyrethroid indoor residual spraying interventions showed improved control of malaria transmission compared with standard long-lasting insecticidal nets where pyrethroid resistance is prevalent and either intervention could be deployed to good effect. As a result, WHO has since recommended to increase coverage of PBO long-lasting insecticidal nets. Combining indoor residual spraying with pirimiphos-methyl and PBO long-lasting insecticidal nets provided no additional benefit compared with PBO long-lasting insecticidal nets alone or standard long-lasting insecticidal nets plus indoor residual spraying. FUNDING: UK Department for International Development, Medical Research Council, and Wellcome Trust

Risk factors for malaria infection prevalence and household vector density between mass distribution campaigns of long-lasting insecticidal nets in North-western Tanzania.

BACKGROUND: Long-lasting insecticidal nets (LLINs) are the most widely deployed vector control intervention in sub-Saharan Africa to prevent malaria. Recent reports indicate selection of pyrethroid insecticide resistance is widespread in mosquito vectors. This paper explores risk factors associated with malaria infection prevalence and vector density between mass distribution campaigns, changes in net coverage, and loss of protection in an area of high pyrethroid resistance in Northwest Tanzania. METHODS: A cross sectional malaria survey of 3456 children was undertaken in 2014 in Muleba district, Kagera region west of Lake Victoria. Vector density was assessed using indoor light traps and outdoor tent traps. Anophelines were identified to species using PCR and tested for Plasmodium falciparum circumsporozoite protein. Logistic regression was used to identify household and environmental factors associated with malaria infection and regression binomial negative for vector density. RESULTS: LLIN use was 27.7%. Only 16.9% of households had sufficient nets to cover all sleeping places. Malaria infection was independently associated with access to LLINs (OR: 0.57; 95% CI 0.34-0.98). LLINs less than 2 years old were slightly more protective than older LLINs (53 vs 65% prevalence of infection); however, there was no evidence that LLINs in good condition (hole index < 65) were more protective than LLINs, which were more holed. Other risk factors for malaria infection were age, group, altitude and house construction quality. Independent risk factors for vector density were consistent with malaria outcomes and included altitude, wind, livestock, house quality, open eaves and LLIN usage. Indoor collections comprised 4.6% Anopheles funestus and 95.4% Anopheles gambiae of which 4.5% were Anopheles arabiensis and 93.5% were Anopheles gambiae sensu stricto. CONCLUSION: Three years after the mass distribution campaign and despite top-ups, LLIN usage had declined considerably. While children living in households with access to LLINs were at lower risk of malaria, infection prevalence remained high even among users of LLINs in good condition. While effort should be made to maintain high coverage between campaigns, distribution of standard pyrethroid-only LLINs appears insufficient to prevent malaria transmission in this area of intense pyrethroid resistance

Duration of Protection Against Clinical Malaria Provided by Three Regimens of Intermittent Preventive Treatment in Tanzanian Infants

BACKGROUND: Intermittent preventive treatment in infants (IPTi) is a new malaria control tool. However, it is uncertain whether IPTi works mainly through chemoprophylaxis or treatment of existing infections. Understanding the mechanism is essential for development of replacements for sulfadoxine-pyrimethamine (SP) where it is no longer effective. This study investigated how protection against malaria given by SP, chlorproguanil-dapsone (CD) and mefloquine (MQ), varied with time since administration of IPTi. METHODS AND FINDINGS: A secondary analysis of data from a randomised, placebo-controlled trial in an area of high antifolate resistance in Tanzania was conducted. IPTi using SP, CD, MQ or placebo was given to 1280 infants at 2, 3 and 9 months of age. Poisson regression with random effects to adjust for potential clustering of malaria episodes within children was used to calculate incidence rate ratios for clinical malaria in defined time strata following IPTi. The short-acting antimalarial CD gave no protection against clinical malaria, whereas long-acting MQ gave two months of substantial protection (protective efficacy (PE) 73.1% (95% CI: 23.9, 90.5) and 73.3% (95% CI: 0, 92.9) in the first and second month respectively). SP gave some protection in the first month after treatment (PE 64.5% (95% CI: 10.6, 85.9)) although it did not reduce the incidence of malaria up to 12 months of age. There was no evidence of either long-term protection or increased risk of malaria for any of the regimens. CONCLUSION: Post-treatment chemoprophylaxis appears to be the main mechanism by which IPTi protects children against malaria. Long-acting antimalarials are therefore likely to be the most effective drugs for IPTi, but as monotherapies could be vulnerable to development of drug resistance. Due to concerns about tolerability, the mefloquine formulation used in this study is not suitable for IPTi. Further investigation of combinations of long-acting antimalarials for IPTi is needed. TRIAL REGISTRATION: Clinicaltrials.gov NCT00158574