Risk factors of road traffic injuries among motorcyclists in Dar es Salaam, Tanzania

Background: Commercial motorcycling has become an alternative mode of transport and employment in low and middle-income countries, contributing to road traffic injuries and deaths. Still, there is limited context-specific knowledge regarding risk factors associated with commercial motorcycling. Thus, there is a need to deepen the understanding of factors associated with road traffic injuries among commercial motorcycle drivers to provide evidence-based data that can be used to support preventive strategies for road traffic injuries in Tanzania. Aim: The overall aim of the thesis was to identify risk factors associated with motorcycle-related injuries in the context of the road environment, human behaviour, and work-related factors among motorcyclists in Dar es Salaam, Tanzania. Methods: The thesis is based on four studies with different study designs. Article I is a cross-sectional and observational study using motorcycle-related crash data extracted from the Tanzanian police force. Multiple correspondences and hierarchical cluster analysis were used to assess the profile of high-risk locations for motorcycle crashes. Articles II and III are based on a population-based case-control study of commercial motorcycle drivers. Article II was used to assess the effect of alcohol consumption and marijuana use on the risk of road traffic injuries. The cases were commercial motorcycle drivers who sustained road traffic injuries leading to hospital attendance, while controls were drivers recruited from the parking stage from the same source population as the case and who had not experienced any road traffic injuries leading to hospital attendance in the past six months. Logistic regression models were used to estimate the associations. Article III was performed to determine the effect of motorcycle ownership on the risk of road traffic injuries and the mediating roles of risky driving behaviour and the number of working hours. The associations were estimated using binary logistic regression and decomposition analysis. Assess the mediating roles of risky driving behaviour and the number of working hours. In Article IV, a cross-sectional study was performed to study the association between financial stress and risky driving behaviour and to assess if types of motorcycle ownership moderate that relationship. Modified Poisson regression with the robust error was used to estimate the prevalence ratio. Results: Article I: We identified three clusters of hot spots of motorcycle crashes with different levels of injury severity differing according to road infrastructure and traffic density attributes. High-risk locations for fatal motorcycle crashes were overrepresented with areas located on trunk roads, with a mixture of different types of road users, and where trunk or collector roads ran through residential and commercial areas. Article II: Risky drinking was associated with 2.41 times higher odds (95% CI: 1.01 - 5.76) of road traffic injuries among commercial motorcycle drivers. Article III: Regarding occupational exposure, the odds of road traffic injuries were significantly higher among drivers who co-owned their motorcycles (OR=3.65, 95% CI: 2.12 - 6.28) and renters (OR=2.25, 95% CI: 1.36 - 3.75). Mediation analyses showed that risky driving behaviour and the number of working hours partially mediated the associations between types of motorcycle ownership and the risk of road traffic injuries. Article IV: Financial stress was associated with 3.27 times higher (95% CI: 2.07 - 5.17) prevalence ratio of risky driving behaviour. Risky driving behaviours were significantly higher among co-owners (PR=2.43, 95% CI: 1.48 - 4.00) and renters (PR =2.33, 95% CI: =1.43 - 3.80) compared to self-owners. There was a significant interaction effect of high financial stress on risky driving behaviours with co-owners (PR=0.46, 95% CI: 0.23 - 0.77) and renters (PR=0.44, 95%CI: 0.26 - 0.76). Conclusion: Clusters of hotspots of motorcycle-related injuries were characterized by unseparated two ways, trunk roads, at T-junctions, in residential and commercial areas with a mixture of different road users. Risky alcohol use was associated with increased odds of road traffic injuries among commercial motorcycle drivers. The findings showed that co-owning or renting a motorcycle exacerbates the odds of road traffic injuries. Further, financial stress was associated with increased odds of risky driving behaviour. Co-ownership or rental modifies the association between financial stress and risky driving behaviour. These findings underscore the need to consider human and work-related factors when implementing preventive measures for road traffic injuries involving motorcycles

Strengthening Pharmacovigilance System to Capture Safety Data from HIV Clients on ART in Tanzania: Identification of Gaps in Safety Reporting System

In Tanzania, pharmacovigilance system is implemented by Tanzania Food and Drugs Authority (TFDA) that monitors drug use countrywide. TFDA is the main national custodian for recording, analyzing and disseminating safety information that is generated through conventional health care facilities. Since the introduction of Care and Treatment Centre (CTC) in the health care system, little has been achieved on translating safety information from these facilities to the TFDA. Since the inception of national pharmacovigilance framework in 2003 there has been no systematic operational research to map the gaps in the existing pharmacovigilance system. Furthermore, it is not clear if there is adequate training and supervision. It is, therefore, important to strengthen antiretroviral therapy (ART) related adverse drug reactions (ADRs) reporting by mapping gaps in implementation of pharmacovigilance (PV) system. Information obtained will assist in addressing training needs to ensure effective reporting of ADRs through coordinated approach involving TFDA and National AIDS Control Program (NACP) in Tanzania. A cross-sectional study was conducted in four regions (Tanga, Singida, Dodoma and Mtwara) in two PV zones. Qualitative and quantitative data collection techniques with triangulation design were used. These included; desk document review of PV recording and reporting of drug safety information; in-depth interviews with various implementation stakeholders, exit interviews with patients, in-interviews with care takers and community based organizations (CBOs) involved in the provision of care and treatment of HIV/AIDS. A total of 801 respondents participated in the quantitative data component which included; 545 exit interviews to CTC clients, 177 health service providers, 62 in-depth interviews to CTC in-charges and 17 regional and district pharmacists. Ownership of these CTCs included 83.9% government, 12.9% faith based organizations and 3.2% co-owned by the government and faith based organizations. High proportions (97.2%) of the CTC health care providers had wide knowledge on ART related ADRs. However, more than half (53.4%) of the CTC service providers had not attended any training on ART related ADRs. Among the service providers, majority (67.8%) mentioned there was no guideline in place for reporting ART related ADRs. Only, 32.1% of health care providers indicated to be aware of the tool used for collection of ART related ADRs events. Of those, 37.5% mentioned that the forms were mainly obtained from district or regional pharmacists. The ADR reports were submitted to district and regional pharmacists 48.3%, TFDA 7.0%, and NACP 7.0%. Of those who indicated to have filled and submitted ADR form, only 7.4% received feedback. The proportion of ART clients who provided information was significantly different between urban and rural in Dodoma region (p=0.002). There was variation in proportions of ART clients who had mentioned seen/heard of ART related ADR by regions and difference was significant between rural and urban for all regions except Tanga (p<0.05). Majority (47.9%) of the ART clients reported ART related ADRs to the health provider for duration ranging from 3-7 days. The qualitative results revealed that that most of the guidelines from TFDA were not known and unavailable according to most of the respondents at national level (NACP), regional, district, and at health facility level. It was surprising that one of the district pharmacists interviewed was unaware of existence of guidelines in place for ADR and PV for use in the districts. It was also found that Sometimes even when available at health facilities, there was inadequate knowledge on how to fill the ADR forms according to Key Informant at national level. Moreover, several health workers admitted that that they were not reporting ADR due to a lack of forms according to some CTC in-charges interviewed. This study has shown that despite the established PV system in Tanzania, the frequency of reporting of ART related ADRs to TFDA is low. This is due to inadequate training of health care providers on ADR reporting, shortage of staff, unavailability of TFDA ADR reporting forms and lack of regular supportive supervision. Based on these results therefore we recommend TFDA should ensure that ADR reporting forms as well as guidelines are adequately supplied and utilized at CTC level NACP should ensure sharing of safety information with TFDA and recommend dedicated focal person liable for documenting and reporting ART related ADRs recorded in CTC II patient file. Regular training, supportive supervision and feedback on ART related ADR reporting system for health care providers is needed. The financial support was provided by the Global Fund Round 8. The total budget for the project was Tsh. 69,993,000/-

Relationship Between Alpha+-Thalassaemia and Glutathione-S-Transferases Polymorphisms in Children with Severe Malaria in Tanzania

Alpha+-thalassaemia is well known for conferring partial protection to against severe malaria. On the other, Glutathione –S-transferase (GST) polymorphism has recently been associated to severe malaria in children. A retrospective cross sectional study was carried out to determine the relationship between genotypic polymorphisms of alpha+-thalassaemia and glutathione-S-transferase in children with severe malaria. A total of 148 DNA samples from children aged between 1 and 15 years with mild and severe malaria were retrieved and determined by polymerase chain reaction. Children with Glutathione-S-transferase-pi1 (GSTP1)-polymorphism were observed to have three fold risk (OR = 2.9; 95% CI =1.3- 6.1; P = 0.006) of developing severe malaria compared to mild malaria in Mnyuzi-Korogwe, north-eastern, Tanzania. In the presence of Glutathione- S-transferase-pi1 polymorphism, children were found to have 3% decreased protective effect of alpha+- thalassaemia polymorphisms (homozygotes and heterozygotes) against severe malaria although this was not statistically significant [ OR = 0.81 (95% CI = 0.5-1.5; P = 0.5) to OR = 0.78 (95% CI = 0.4-1.5; P = 0.44)]. We conclude that Glutathione-S-transferase-pi1 polymorphism increases risk of developing severe malaria due to Plasmodium falciparum in children. The observed inverse relationship between GSTP1 polymorphisms and alpha+-thalassaemia to children with severe malaria need further investigation

Using Community-Owned Resource Persons to Provide Early Diagnosis and Treatment and Estimate Malaria Burden at Community Level in North-Eastern Tanzania.

Although early diagnosis and prompt treatment is an important strategy for control of malaria, using fever to initiate presumptive treatment with expensive artemisinin combination therapy is a major challenge; particularly in areas with declining burden of malaria. This study was conducted using community-owned resource persons (CORPs) to provide early diagnosis and treatment of malaria, and collect data for estimation of malaria burden in four villages of Korogwe district, north-eastern Tanzania.In 2006, individuals with history of fever within 24 hours or fever (axillary temperature ≥37.5°C) at presentation were presumptively treated using sulphadoxine/pyrimethamine. Between 2007 and 2010, individuals aged five years and above, with positive rapid diagnostic tests (RDTs) were treated with artemether/lumefantrine (AL) while under-fives were treated irrespective of RDT results. Reduction in anti-malarial consumption was determined by comparing the number of cases that would have been presumptively treated and those that were actually treated based on RDTs results. Trends of malaria incidence and slide positivity rates were compared between lowlands and highlands. Of 15,729 cases attended, slide positivity rate was 20.4% and declined by >72.0% from 2008, reaching <10.0% from 2009 onwards; and the slide positivity rates were similar in lowlands and highlands from 2009 onwards. Cases with fever at presentation declined slightly, but remained at >40.0% in under-fives and >20.0% among individuals aged five years and above. With use of RDTs, cases treated with AL decreased from <58.0% in 2007 to <11.0% in 2010 and the numbers of adult courses saved were 3,284 and 1,591 in lowlands and highlands respectively. Malaria incidence declined consistently from 2008 onwards; and the highest incidence of malaria shifted from children aged <10 years to individuals aged 10-19 years from 2009. With basic training, supervision and RDTs, CORPs successfully provided early diagnosis and treatment and reduced consumption of anti-malarials. Progressively declining malaria incidence and slide positivity rates suggest that all fever cases should be tested with RDTs before treatment. Data collected by CORPs was used to plan phase 1b MSP3 malaria vaccine trial and will be used for monitoring and evaluation of different health interventions. The current situation indicates that there is a remarkable changing pattern of malaria and these areas might be moving from control to pre-elimination levels

Lost to follow up and clinical outcomes of HIV adult patients on antiretroviral therapy in care and treatment centres in Tanga City, north-eastern Tanzania

Scaling up of Antiretroviral (ARV) drugs is crucial and should be a perpetual venture in developing countries in-order to increase the survival period of HIV/AIDS individuals. In Tanzania, information on the rate of patients considered as lost to follow up during treatment with ARVs is scarce. The objective of this study was to determine the rate of lost to follow up and treatment outcome among patients attending two care and treatment clinics (CTCs) in Tanga City in north-eastern Tanzania. A descriptive observational study was carried out on cohorts from Tanga AIDS Working Group and Bombo Regional Hospital. The total number of patients identified as “lost to follow up” were 89 of which 14 (15.7%) died. Among those who died, 3 (21.4%) died between the second week and 3 months after ARV initiation. Of those still alive (84.3%; 75/89), 25% (19/75) were still on ARVs, whereas 47 (62.7%) self transferred to other CTCs. Proper patient documentation with actual residence address is a crucial aspect for adherence. Similarly, frequent prompt tracing of patient should be part of any drug interventional programme linking   facility and communities

Possible causes of fever among patients with blood smear negative for malaria parasites at Bombo Regional Referral Hospital in Tanga, Tanzania

Background: Due to its diverse and non‐specific clinical presentations, malaria has been associated with most infections causing febrile illnesses. Despite being non-specific, clinical diagnosis is still the main method of malaria diagnosis in most health facilities in sub-Saharan Africa. This study aimed to establish the probable diagnoses among fever cases admitted at Bombo Hospital in north-eastern Tanzania.Methods: This study involved patients admitted in Medical and Paediatric wards with a clinical diagnosis of severe malaria but having negative blood smears (BS) for malaria parasites. Finger prick blood specimens were collected for blood smear microscopy and rapid diagnostic test. Blood and urine cultures were done for all specimens collected.  Some patients were also screened for HIV infection.Results: A total of 227 patients were recruited and the majority (62.1%) were under-five children. Out of the 227 blood specimens cultured, 25 (11.0%) grew different bacteria species. Staphylococcus aureus was the most frequent pathogen (68.0%), followed by S. pneumoniae (24.0%), Salmonella species (4.0%) and Streptococcus pyogenes (4.0%).  Only 7 (3.2%) out of 219 urine specimens cultured showed growth of Escherichia coli, Pseudomonas aeruginosa, S. aureus and Klebsiella pneumoniae. Of the 215 patients screened for HIV, 17 (7.9%) had positive reaction.Conclusion: The findings indicate that S. aureus and S. pneumoniae as the commonest bacteria isolates from blood and P. aeruginosa, S. aureus and K. pneumoniae from urine cultures. These bacteria and HIV should be considered as important contributors to febrile illness cases among patients found with negative BS for malaria parasites

Acceptability of malaria rapid diagnostic tests administered by village health workers in Pangani District, North eastern Tanzania.

BACKGROUND: Malaria continues to top the list of the ten most threatening diseases to child survival in Tanzania. The country has a functional policy for appropriate case management of malaria with rapid diagnostic tests (RDTs) from hospital level all the way to dispensaries, which are the first points of healthcare services in the national referral system. However, access to these health services in Tanzania is limited, especially in rural areas. Formalization of trained village health workers (VHWs) can strengthen and extend the scope of public health services, including diagnosis and management of uncomplicated malaria in resource-constrained settings. Despite long experience with VHWs in various health interventions, Tanzania has not yet formalized its involvement in malaria case management. This study presents evidence on acceptability of RDTs used by VHWs in rural northeastern Tanzania. METHODS: A cross-sectional study using quantitative and qualitative approaches was conducted between March and May 2012 in Pangani district, northeastern Tanzania, on community perceptions, practices and acceptance of RDTs used by VHWs. RESULTS: Among 346 caregivers of children under 5 years old, no evidence was found of differences in awareness of HIV rapid diagnostic tests and RDTs (54 vs. 46 %, p = 0.134). Of all respondents, 92 % expressed trust in RDT results, 96 % reported readiness to accept RDTs by VHWs, while 92 % expressed willingness to contribute towards the cost of RDTs used by VHWs. Qualitative results matched positive perceptions, attitudes and acceptance of mothers towards the use of RDTs by VHWs reported in the household surveys. Appropriate training, reliable supplies, affordability and close supervision emerged as important recommendations for implementation of RDTs by VHWs. CONCLUSION: RDTs implemented by VHWs are acceptable to rural communities in northeastern Tanzania. While families are willing to contribute towards costs of sustaining these services, policy decisions for scaling-up will need to consider the available and innovative lessons for successful universally accessible and acceptable services in keeping with national health policy and sustainable development goals

Epidemiology of Malaria in an Area Prepared for Clinical Trials in Korogwe, North-eastern Tanzania.

Site preparation is a pre-requesite in conducting malaria vaccines trials. This study was conducted in 12 villages to determine malariometric indices and associated risk factors, during long and short rainy seasons, in an area with varying malaria transmission intensities in Korogwe district, Tanzania. Four villages had passive case detection (PCD) of fever system using village health workers. Four malariometric cross-sectional surveys were conducted between November 2005 and May 2007 among individuals aged 0-19 years, living in lowland urban, lowland rural and highland strata. A total of 10,766 blood samples were collected for malaria parasite diagnosis and anaemia estimation. Blood smears were stained with Giemsa while haemoglobin level was measured by HaemoCue. Socio-economic data were collected between Jan-Apr 2006. Adjusting for the effect of age, the risk of Plasmodium falciparum parasitaemia was significantly lower in both lowland urban, (OR = 0.26; 95%CI: 0.23-0.29, p < 0.001) and highlands, (OR = 0.21; 95%CI: 0.17-0.25, p < 0.001) compared to lowland rural. Individuals aged 6-9 years in the lowland rural and 4-19 years in both lowland urban and highlands had the highest parasite prevalence, whilst children below five years in all strata had the highest parasite density. Prevalence of splenomegaly and gametocyte were also lower in both lowland urban and highlands than in lowland rural. Anaemia (Hb <11 g/dl) prevalence was lowest in the lowland urban. Availability of PCD and higher socio-economic status (SES) were associated with reduced malaria and anaemia prevalence. Higher SES and use of bed nets in the lowland urban could be the important factors for low malaria infections in this stratum. Results obtained here were used together with those from PCD and DSS in selecting a village for Phase 1b MSP3 vaccine trial, which was conducted in the study area in year 2008

Relationships between sickle cell trait, malaria, and educational outcomes in Tanzania

Background: Sickle Cell Trait (SCT) has been shown to be protective against malaria. A growing literature suggests that malaria exposure can reduce educational attainment. This study assessed the relationship and interactions between malaria, SCT and educational attainment in north-eastern Tanzania. Methods: Seven hundred sixty seven children were selected from a list of individuals screened for SCT. Febrile illness and malaria incidence were monitored from January 2006 to December 2013 by community health workers. Education outcomes were extracted from the Korogwe Health and Demographic Surveillance system in 2015. The primary independent variables were malaria and SCT. The association between SCT and the number of fever and malaria episodes from 2006 to 2013 was analyzed. Main outcomes of interest were school enrolment and educational attainment in 2015. Results: SCT was not associated with school enrolment (adjusted OR 1.42, 95% CI [0.593,3.412]) or highest grade attained (adjusted grade difference 0.0597, 95% CI [−0.567, 0.686]). SCT was associated with a 29% reduction in malaria incidence (adjusted IRR 0.71, 95% CI [0.526, 0.959]) but not with fever incidence (adjusted IRR 0.905, 95% CI [0.709-1.154]). In subgroup analysis of individuals with SCT, malaria exposure was associated with reduced school enrollment (adjusted OR 0.431, 95% CI [0.212, 0.877]). Conclusions: SCT appears to reduce incidence of malaria. Overall, children with SCT do not appear to attend more years of school; however children who get malaria despite SCT appear to have lower levels of enrolment in education than their peers

Accuracy of Malaria Rapid Diagnostic Tests in Community Studies and their Impact on Treatment of Malaria in an Area with Declining Malaria Burden in North-Eastern Tanzania.

Despite some problems related to accuracy and applicability of malaria rapid diagnostic tests (RDTs), they are currently the best option in areas with limited laboratory services for improving case management through parasitological diagnosis and reducing over-treatment. This study was conducted in areas with declining malaria burden to assess; 1) the accuracy of RDTs when used at different community settings, 2) the impact of using RDTs on anti-malarial dispensing by community-owned resource persons (CORPs) and 3) adherence of CORPs to treatment guidelines by providing treatment based on RDT results. Data were obtained from: 1) a longitudinal study of passive case detection of fevers using CORPs in six villages in Korogwe; and 2) cross-sectional surveys (CSS) in six villages of Korogwe and Muheza districts, north-eastern, Tanzania. Performance of RDTs was compared with microscopy as a gold standard, and factors affecting their accuracy were explored using a multivariate logistic regression model. Overall sensitivity and specificity of RDTs in the longitudinal study (of 23,793 febrile cases; 18,154 with microscopy and RDTs results) were 88.6% and 88.2%, respectively. In the CSS, the sensitivity was significantly lower (63.4%; χ2=367.7, p<0.001), while the specificity was significantly higher (94.3%; χ2=143.1, p<0.001) when compared to the longitudinal study. As determinants of sensitivity of RDTs in both studies, parasite density of<200 asexual parasites/μl was significantly associated with high risk of false negative RDTs (OR≥16.60, p<0.001), while the risk of false negative test was significantly lower among cases with fever (axillary temperature ≥37.5 °C) (OR≤0.63, p≤0.027). The risk of false positive RDT (as a determinant of specificity) was significantly higher in cases with fever compared to afebrile cases (OR≥2.40, p<0.001). Using RDTs reduced anti-malarials dispensing from 98.9% to 32.1% in cases aged ≥5 years. Although RDTs had low sensitivity and specificity, which varied widely depending on fever and parasite density, using RDTs reduced over-treatment with anti-malarials significantly. Thus, with declining malaria prevalence, RDTs will potentially identify majority of febrile cases with parasites and lead to improved management of malaria and non-malaria fevers