Bush animal attacks: management of complex injuries in a resource-limited setting

Though animal-related injuries and fatalities have been documented throughout the world, the variety of attacks by wild animals native to rural East Africa are less commonly described. Given the proximity of our northwestern Tanzania hospital to Lake Victoria, Lake Tanganyika, and the Serengeti National Park, and presentation of several patients attacked by bush animals and suffering a variety of complex injuries, we sought to report the pattern of attacks and surgical management in a resource-limited setting. Four patients who were admitted to the northwestern Tanzania tertiary referral hospital, Bugando Medical Centre (BMC), in 2010-2011 suffered attacks by different bush animals: hyena, elephant, crocodile, and vervet monkey. These patients were triaged as trauma patients in the Casualty Ward, then admitted for inpatient monitoring and treatment. Their outcomes were followed to discharge. The age and gender of the patients attacked was variable, though all but the pediatric patient were participating in food gathering or guarding activities in rural locations at the time of the attacks. All patients required surgical management of their injuries, which included debridement and closure of wounds, chest tube insertion, amputation, and external fixation of an extremity fracture. All patients survived and were discharged home. Though human injuries secondary to encounters with undomesticated animals such as cows, moose, and camel are reported, they often are indirect traumas resulting from road traffic collisions. Snake attacks are well documented and common. However, this series of unique bush animal attacks describes the initial and surgical management of human injuries in the resource-limited setting of the developing world. Animal attacks are common throughout the world, but their pattern may vary in Africa throughout jungle and bush environmental settings. It is important to understand the management of these attacks in resource-limited health care environment. Further, the growing population and human encroachment on previously wild habitats such as the northwestern Tanzania bush argues for increased community awareness to assist in prevention of human injuries by animals

Using High-Resolution Data to Assess Land Use Impact on Nitrate Dynamics in East African Tropical Montane Catchments

Land use change alters nitrate (NO3-N) dynamics in stream water by changing nitrogen cycling, nutrient inputs, uptake and hydrological flow paths. There is little empirical evidence of these processes for East Africa. We collected a unique 2 year high-resolution data set to assess the effects of land use (i.e., natural forest, smallholder agriculture and commercial tea plantations) on NO3-N dynamics in three subcatchments within a headwater catchment in the Mau Forest Complex, Kenya's largest tropical montane forest. The natural forest subcatchment had the lowest NO3-N concentrations (0.44 ± 0.043 mg N L−1) with no seasonal variation. NO3-N concentrations in the smallholder agriculture (1.09 ± 0.11 mg N L−1) and tea plantation (2.13 ± 0.19 mg N L−1) subcatchments closely followed discharge patterns, indicating mobilization of NO3-N during the rainy seasons. Hysteresis patterns of rainfall events indicate a shift from subsurface flow in the natural forest to surface runoff in agricultural subcatchments. Distinct peaks in NO3-N concentrations were observed during rainfall events after a longer dry period in the forest and tea subcatchments. The high-resolution data set enabled us to identify differences in NO3-N transport of catchments under different land use, such as enhanced NO3-N inputs to the stream during the rainy season and higher annual export in agricultural subcatchments (4.9 ± 0.3 to 12.0 ± 0.8 kg N ha−1 yr−1) than in natural forest (2.6 ± 0.2 kg N ha−1 yr−1). This emphasizes the usefulness of our monitoring approach to improve the understanding of land use effects on riverine N exports in tropical landscapes, but also the need to apply such methods in other regions

Ready-to-use food supplement, with or without arginine and citrulline, with daily chloroquine in Tanzanian children with sickle-cell disease: a double-blind, random order crossover trial

Background: Sickle cell disease increases malnutrition risk. Low arginine and nitric oxide [NO] bioavailability are implicated in sickle-related morbidity. Simple interventions are required, especially in low-income settings. We aimed to test the hypotheses: (1) supplementary arginine, citrulline and daily chloroquine increases bioavailable arginine and flow-mediated-dilatation (FMDmax%; a measure of NO-dependent endothelial function), and (2); protein energy supplementation in the form of ready-to-use supplementary-food (RUSF) improves nutritional status in children with sickle cell disease. Methods: A random-order, double-blind, cross-over trial with two four-month intervention periods (each followed by four-months wash-out) was conducted in Dar-es-Salaam, Tanzania. 119 children aged 8-12 years, naïve to hydroxyurea, were enrolled from the Muhimbili National Hospital Sickle Cohort. The random order sequence and allocation codes were generated centrally. Two formulations of RUSF (500kcal/day) were tested: ‘basic’ with weekly chloroquine (150/225mg base, depending on weight) (RUSF-b) and ‘vascular’ (RUSF-v) fortified with arginine, citrulline designed to achieve mean intakes of 0.2g/0.1g/kg/day and daily chloroquine (max 3mg base/kg/day). The primary outcomes of the comparison of the 2 RUSF formulations were mean FMDmax%, mean plasma arginine to ornithine ratio and mean plasma arginine to asymmetric-di-methylated-arginine (ADMA) ratio. The primary outcomes of the combined effect of both RUSF interventions were mean height and body mass index for age z-scores with analysis by intention to treat. Trial registration: ISRCTN74331412 Findings: 114/119 children had complete data for all reported endpoints. There was no treatment effect of RUSF-v compared to RUSF-b on the ratio of arginine to ornithine (mean within individual difference -0.09, 95% CI -0.03/0.2, p=0.12), or on FMDmax% (-1.00 95% CI -2.47/0.47, p=0.18) but the arginine:ADMA ratio was significantly increased (-0.56, 95% CI -0.81/-0.31, P<0.001). In planned analyses using random effects models to estimate the effect of each intervention compared to baseline/washout, the arginine:ADMA ratio increased following both RUSF-v or RUSF-b (+86%, p<0.001; +41%, p<0.001). Similarly, FMDmax% was higher after 2 RUSF-v (+0.92, p<0.001) but not after RUSF-b intervention (+0.39, p=0.22). Adjusted for covariates, effect estimates for FMDmax% increased: RUSF-v (+1.19, p<0.001) and RUSF-b (+0.93, p=0.008). Following either intervention (RUSF-b and RUSF-v pooled) compared to baseline/wash-outs, body-mass-index-z-score (+0.091, P=0.001) and height-for-age-z-score (+0.013, P=0.081) increased. There were 71 and 81 adverse events of which 21 and 26 were serious during intervention and washout (P=0.31) in 83 participants, 1 of whom died in the 2nd washout period. Interpretation: RUSF providing 500kcal/day results in small weight gains in children with sickle cell disease. However, RUSF even without arginine and citrulline fortification improves arginine dysregulation and may improve endothelial function. Long-term studies are required to assess if these physiological effects translate to improved clinical outcomes and better growth and development in sickle cell disease

Prevalence and Evolution of Renal Impairment in People Living With HIV in Rural Tanzania

Background: We assessed the prevalence, incidence, and predictors of renal impairment among people living with HIV (PLWHIV) in rural Tanzania. Methods: In a cohort of PLWHIV aged >/=15 years enrolled from January 2013 to June 2016, we assessed the association between renal impairment (estimated glomerural filtration rate < 90 mL/min/1.73 m(2)) at enrollment and during follow-up with demographic and clinical characteristcis using logistic regression and Cox proportional hazards models. Results: Of 1093 PLWHIV, 172 (15.7%) had renal impairment at enrollment. Of 921 patients with normal renal function at baseline, 117 (12.7%) developed renal impairment during a median follow-up (interquartile range) of 6.2 (0.4-14.7) months. The incidence of renal impairment was 110 cases per 1000 person-years (95% confidence interval [CI], 92-132). At enrollment, logistic regression identified older age (adjusted odds ratio [aOR], 1.79; 95% CI, 1.52-2.11), hypertension (aOR, 1.84; 95% CI, 1.08-3.15), CD4 count <200 cells/mm(3) (aOR, 1.80; 95% CI, 1.23-2.65), and World Health Organization (WHO) stage III/IV (aOR, 3.00; 95% CI, 1.96-4.58) as risk factors for renal impairment. Cox regression model confirmed older age (adjusted hazard ratio [aHR], 1.85; 95% CI, 1.56-2.20) and CD4 count <200 cells/mm(3) (aHR, 2.05; 95% CI, 1.36-3.09) to be associated with the development of renal impairment. Conclusions: Our study found a low prevalence of renal impairment among PLWHIV despite high usage of tenofovir and its association with age, hypertension, low CD4 count, and advanced WHO stage. These important and reassuring safety data stress the significance of noncommunicable disease surveillance in aging HIV populations in sub-Saharan Africa

Pattern of childhood burn injuries and their management outcome at Bugando Medical Centre in Northwestern Tanzania

Burn injuries constitute a major public health problem and are the leading cause of childhood morbidity and mortality worldwide. There is paucity of published data on childhood burn injuries in Tanzania, particularly the study area. This study was conducted to describe the pattern of childhood burn injuries in our local setting and to evaluate their management outcome. A cross sectional study was conducted at Bugando Medical Centre (in Northwestern Tanzania) over a 3-year period from January 2008 to December 2010. Data was collected using a pre-tested coded questionnaire and statistical analyses performed using SPSS software version 15.0. A total of 342 burned children were studied. Males were mainly affected. Children aged = 2 were the majority accounting for 45.9% of cases. Intentional burn injuries due to child abuse were reported in 2.9% of cases. Scald was the most common type of burns (56.1%). The trunk was the most commonly involved body region (57.3%). Majority of patients (48.0%) sustained superficial burns. Eight (2.3%) patients were HIV positive. Most patients (89.8%) presented to the hospital later than 24 h. The rate of burn wound infection on admission and on 10th day were 32.4% and 39.8% respectively.Staphylococcus aureus were more common on admission wound swabs, with Pseudomonas aeruginosa becoming more evident after 10th day. MRSA was detected in 19.2% of Staphylococcus aureus. Conservative treatment was performed in 87.1% of cases. Surgical treatment mainly skin grafting (65.9%) was performed in 44 (12.9%) of patients. The overall average of the length of hospital stay (LOS) was 22.12 ± 16.62 days. Mortality rate was 11.7%. Using multivariate logistic regression analysis; age of the patient, type of burn, delayed presentation, clothing ignition, %TBSA and severity of burn were found to be significantly associated with LOS (P < 0.001), whereas mortality rate was found to be independently and significantly related to the age of the patient, type of burn, HIV positive with stigmata of AIDS, CD4 count, inhalation injury, %TBSA and severity of burn (P < 0.001). Childhood burn injuries still remain a menace in our environment with virtually unacceptable high morbidity and mortality. There is need for critical appraisal of the preventive measures and management principles currently being practiced

Effects of conversion of native cerrado vegetation to pasture on soil hydro-physical properties, evapotranspiration and streamflow on the Amazonian agricultural frontier

Understanding the impacts of land-use change on landscape-hydrological dynamics is one of the main challenges in the Northern Brazilian Cerrado biome, where the Amazon agricultural frontier is located. Motivated by the gap in literature assessing these impacts, we characterized the soil hydro-physical properties and quantified surface water fluxes from catchments under contrasting land-use in this region. We used data from field measurements in two headwater micro-catchments with similar physical characteristics and different land use, i.e. cerrado sensu stricto vegetation and pasture for extensive cattle ranching. We determined hydraulic and physical properties of the soils, applied ground-based remote sensing techniques to estimate evapotranspiration, and monitored streamflow from October 2012 to September 2014. Our results show significant differences in soil hydro-physical properties between the catchments, with greater bulk density and smaller total porosity in the pasture catchment. We found that evapotranspiration is smaller in the pasture (639 ± 31% mm yr-1) than in the cerrado catchment (1,004 ± 24% mm yr-1), and that streamflow from the pasture catchment is greater with runoff coefficients of 0.40 for the pasture and 0.27 for the cerrado catchment. Overall, our results confirm that conversion of cerrado vegetation to pasture causes soil hydro-physical properties deterioration, reduction in evapotranspiration reduction, and increased streamflow

Socializing One Health: an innovative strategy to investigate social and behavioral risks of emerging viral threats

In an effort to strengthen global capacity to prevent, detect, and control infectious diseases in animals and people, the United States Agency for International Development’s (USAID) Emerging Pandemic Threats (EPT) PREDICT project funded development of regional, national, and local One Health capacities for early disease detection, rapid response, disease control, and risk reduction. From the outset, the EPT approach was inclusive of social science research methods designed to understand the contexts and behaviors of communities living and working at human-animal-environment interfaces considered high-risk for virus emergence. Using qualitative and quantitative approaches, PREDICT behavioral research aimed to identify and assess a range of socio-cultural behaviors that could be influential in zoonotic disease emergence, amplification, and transmission. This broad approach to behavioral risk characterization enabled us to identify and characterize human activities that could be linked to the transmission dynamics of new and emerging viruses. This paper provides a discussion of implementation of a social science approach within a zoonotic surveillance framework. We conducted in-depth ethnographic interviews and focus groups to better understand the individual- and community-level knowledge, attitudes, and practices that potentially put participants at risk for zoonotic disease transmission from the animals they live and work with, across 6 interface domains. When we asked highly-exposed individuals (ie. bushmeat hunters, wildlife or guano farmers) about the risk they perceived in their occupational activities, most did not perceive it to be risky, whether because it was normalized by years (or generations) of doing such an activity, or due to lack of information about potential risks. Integrating the social sciences allows investigations of the specific human activities that are hypothesized to drive disease emergence, amplification, and transmission, in order to better substantiate behavioral disease drivers, along with the social dimensions of infection and transmission dynamics. Understanding these dynamics is critical to achieving health security--the protection from threats to health-- which requires investments in both collective and individual health security. Involving behavioral sciences into zoonotic disease surveillance allowed us to push toward fuller community integration and engagement and toward dialogue and implementation of recommendations for disease prevention and improved health security