The impact of HIV on clinical-microbiologic features and mortality among patients with invasive nontyphoidal Salmonella infection in South Africa

Introduction: Nontyphoidal Salmonella (NTS) has been associated with HIV from the outset of the HIV pandemic. The few NTS studies done in Africa and America have not documented the impact of HIV on clinical-microbiologic features and mortality in patients with NTS infection. This study determined the association between HIV serostatus and mortality proportion, clinical presentation, length of hospital stay, frequency of invasive NTS infection recurrence, NTS serotypes and estimated the population attributable fraction of mortality due to HIV among patients with invasive NTS infection in South Africa. Methods: Secondary data from enteric diseases national surveillance in South Africa from 2003 to 2006 were analysed as a cross sectional study. A total of 1 398 subjects with known HIV serostatus were obtained after data cleaning. Data analysis was done in Stata using chi squared test for categorical variables and Wilcoxon rank sum test / Kruskal- Wallis test for continuous variables. Logistic regression models were used to quantify the associations, and adjust for confounders and effect modification. Population attributable fraction was calculated to quantify the impact of HIV on mortality. Results: Majority (82.26%) of patients were HIV positive. The frequency pattern of HIV positive serostatus in different age groups coincided with that of invasive NTS. The overall mortality was 32.00%. HIV positive patients had a higher proportion (35.79 %) of mortality than HIV negative patients (15.55 %) (P<0.001). Fifty five percent of deaths in this study population were attributed to HIV infection. In multivariate models, HIV positive patients were more likely than HIV negative patients to die (OR = 2.50, 95% CI 1.69- 3.70), to develop lower respiratory tract infection (LRTI) (OR = 1.89, 95% CI,1.34- 2.65), to have recurrence of invasive NTS (OR = 3.90, 95% CI 1.41-10.77), to stay less than 16 days in hospitals (OR = 1.61, 95% CI, 1.08-2.40) and to be infected with Salmonella serotype Typhimurium infection (OR = 2.59, 95% CI 1.91-3.51). There were no significant differences in temperature, cardiac arrest, meningitis and site of specimen isolation (p>0.05). Discussion: The major limitation to this study was poor data quality of the surveillance system, including missing HIV serostatus hence the findings cannot be generalized to patients with unknown HIV status. Conclusion: HIV infection is common among patients with invasive NTS and is associated with excess mortality, LRTI, fewer than 16 days of hospital stay, recurrent invasive NTS infection and Salmonella Typhimurium. It is important for clinicians to rule out HIV infection in patients with invasive NTS especially those presenting with LRTI and Salmonella Typhimurium infection in addition to recurrent NTS infection, which is a wellknown feature associated with HIV. Recommendation: Since these patients received antimicrobials and had considerable mortality, the first line treatment of invasive NTS should be reviewed especially to HIV positive patients by investigating resistance patterns and conducting a clinical trial of newer and effective antimicrobials

Health facility-based Active Management of the Third Stage of Labor: findings from a national survey in Tanzania

Hemorrhage is the leading cause of obstetric mortality. Studies show that Active Management of Third Stage of Labor (AMTSL) reduces Post Partum Hemorrhage (PPH). This study describes the practice of AMTSL and barriers to its effective use in Tanzania. A nationally-representative sample of 251 facility-based vaginal deliveries was observed for the AMTSL practice. Standard Treatment Guidelines (STG), the Essential Drug List and medical and midwifery school curricula were reviewed. Drug availability and storage conditions were reviewed at the central pharmaceutical storage site and pharmacies in the selected facilities. Interviews were conducted with hospital directors, pharmacists and 106 health care providers in 29 hospitals visited. Data were collected between November 10 and December 15, 2005. Correct practice of AMTSL according to the ICM/FIGO definition was observed in 7% of 251 deliveries. When the definition of AMTSL was relaxed to allow administration of the uterotonic drug within three minutes of fetus delivery, the proportion of AMTSL use increased to 17%. The most significant factor contributing to the low rate of AMTSL use was provision of the uterotonic drug after delivery of the placenta. The study also observed potentially-harmful practices in approximately 1/3 of deliveries. Only 9% out of 106 health care providers made correct statements regarding the all three components of AMTSL. The national formulary recommends ergometrine (0.5 mg/IM) or oxytocin (5 IU/IM) on delivery of the anterior shoulder or immediately after the baby is delivered. Most of facilities had satisfactory stores of drugs and supplies. Uterotonic drugs were stored at room temperature in 28% of the facilities. The knowledge and practice of AMTSL is very low and STGs are not updated on correct AMTSL practice. The drugs for AMTSL are available and stored at the right conditions in nearly all facilities. All providers used ergometrine for AMTSL instead of oxytocin as recommended by ICM/FIGO. The study also observed harmful practices during delivery. These findings indicate that there is a need for updating the STGs, curricula and training of health providers on AMTSL and monitoring its practice

The magnitude and factors associated with delays in management of smear positive tuberculosis in Dar es Salaam, Tanzania

To assess the magnitude and factors responsible for delay in TB management. A cross sectional hospital based survey in Dar es Salaam region, May 2006. 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. 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

Where is the ‘C’ in antenatal care and postnatal care: A multi‐country survey of availability of antenatal and postnatal care in low‐ and middle‐income settings

Objective: Antenatal (ANC) and postnatal care (PNC) are logical entry points for prevention and treatment of pregnancy‐related illness and to reduce perinatal mortality. We developed signal functions and assessed availability of the essential components of care. Design: Cross‐sectional survey. Setting: Afghanistan, Chad, Ghana, Tanzania, Togo. Sample: Three hundred and twenty‐one healthcare facilities. Methods: Fifteen essential components or signal functions of ANC and PNC were identified. Healthcare facility assessment for availability of each component, human resources, equipment, drugs and consumables required to provide each component. Main outcome measure: Availability of ANC PNC components. Results: Across all countries, healthcare providers are available (median number per facility: 8; interquartile range [IQR] 3–17) with a ratio of 3:1 for secondary versus primary care. Significantly more women attend for ANC than PNC (1668 versus 300 per facility/year). None of the healthcare facilities was able to provide all 15 essential components of ANC and PNC. The majority (>75%) could provide five components: diagnosis and management of syphilis, vaccination to prevent tetanus, BMI assessment, gestational diabetes screening, monitoring newborn growth. In Sub‐Saharan countries, interventions for malaria and HIV (including prevention of mother to child transmission [PMTCT]) were available in 11.7–86.5% of facilities. Prevention and management of TB; assessment of pre‐ or post‐term birth, fetal wellbeing, detection of multiple pregnancy, abnormal lie and presentation; screening and support for mental health and domestic abuse were provided in <25% of facilities. Conclusions: Essential components of ANC and PNC are not in place. Focused attention on content is required if perinatal mortality and maternal morbidity during and after pregnancy are to be reduced