Predictors of Early Onset Neonatal Sepsis among Neonates in Dodoma, Tanzania: A Case Control Study

OBJECTIVE

To assess the predictors of early onset neonatal sepsis (EONS) among neonates in Dodoma Tanzania.

METHODS

A hospital-based case-control study of randomly selected 105 cases and 217 controls in three hospitals in Dodoma region. Cases were neonates diagnosed with neonatal sepsis. Controls were matched to the cases by mother's age and parity at a ratio of 1 case to 2 controls. A semi-structured questionnaire was used to collect data on the potential mother, neonate and interventional predictors of EONS. Both descriptive and inferential statistical analysis were employed to test for independent association.

RESULTS

Most (92.5%) of neonates were born at term (≥37 weeks) and 84% had normal birth weight of ≥3 kg. After adjusting for confounders, the maternal factors which showed significant association with EONS were maternal history of chorioamnionitis [adjusted odds ratios (AOR) = 1.910, p = 0.042, 95% confidence interval (CI): 1.0223.56], HIV status (AOR = 2.909, p = 0.012, 95% CI: 1.020-8.296), prolonged rupture of membrane (AOR = 2.857, p = 0.014, 95% CI: 1.233-6.619) and multiple digital vaginal examinations during labor (AOR = 5.178, p = 0.026, 95% CI: 1.220-21.986). The neonatal history of perinatal asphyxia was observed to have a significant association with EONS (AOR = 6.781, p = 0.006, 95% CI: 1.725-26.652).

CONCLUSION

Both maternal and neonatal predictors had significant contribution to EONS. Results shed light on critical factors for consideration to prevent this disease and poor outcomes.

Adrenal Insufficiency: A Forgotten Diagnosis in HIV/AIDS Patients in Developing Countries

Adrenal insufficiency (AI) is one of the most common endocrine disease in patients with HIV/AIDS, leading to high morbidity and mortality in HIV patients who become critically ill. Various etiologies are associated with the condition, including cytomegalovirus (CMV), Mycobacterium tuberculosis, lymphoma, Kaposi's sarcoma, and drugs such as rifampin, among others. HIV patients with advanced disease develop relative cortisol deficiency largely due to the reduction of cortisol reserve, which predisposes patients to adrenal crisis in periods of stress or critical illness. The prevalence of AI in HIV/AIDS patients during HAART era is higher in developing than developed countries, probably due to limited access to both diagnosis and adequate treatments which increases the risk of opportunistic infections. The clinical features of functional adrenal insufficiency in HIV/AIDS patients can be masked by various infectious, noninfectious, and iatrogenic causes, which reduce clinical recognition of the condition. Development of simple screening algorithms may help clinicians reach the diagnosis when approaching these patients. In many low-income countries, most HIV patients are diagnosed with advanced disease; thus, further research is necessary to elucidate the prevalence of adrenal insufficiency in HIV/AIDS patients and the condition's impact on mortality in this population.

Cervical Cancer Screening among Women Receiving Antiretroviral Therapy in a Resource-Limited Environment

Background:

Cervical cancer is among the most prevalent cancer among women worldwide and women living with HIV are at increased risk, especially in a resource-limited environment.

Objective:

This study aimed to determine levels of awareness, knowledge, uptake, and willingness to screen for cervical cancer among women receiving care in an HIV clinic at Dodoma Regional Referral Hospital (DRRH), Tanzania.

Methods:

Data were collected for a period of three weeks from July 21 to August 11, 2017 using a mobile phone data collection App. A total of 421 Women aged 18-50 years old were included in the study.

Results:

Majority of the women interviewed (n=306, 73%) were aware of cervical cancer. Among those who were aware, 84% (n=257) did not recall ever being screened for cervical cancer, and majority had a poor knowledge of cervical cancer. Educational level completed (p=0.01), income per month (p=0.02), age group (p<0.0001), and area of residence (p<0.0001) were all significantly associated to awareness of cervical cancer. Most of the women who have never screened (n=231, 91%) expressed willingness to be screened. Prior uptake of cervical cancer screening was associated with number of live births (p=0.001) and area of residence (p=0.04). And Willingness to screen was significantly associated with age groups (p=0.03) and the number of live births (p=0.03). Moreover, we found that younger age and urban residence was positively associated with awareness and uptake of cervical cancer screening. Willingness was found to decrease as age increased.

Conclusion:

The study found that despite older women’s higher risk of cervical cancer, those who indicated willingness to screen were younger. Additional education, health promotion, and integration of cervical cancer screening services is needed to improve cervical cancer awareness and screening uptake at the HIV clinic.

Prevalence, aetiology, antimicrobial susceptibility testing, and predictors of urinary tract infection among neonates with clinical sepsis: a cross-sectional study

Background

Urinary tract infection (UTI) is the most common and life-threatening bacterial infection among neonates. This study aimed to determine the prevalence, aetiology, and susceptible antimicrobial agents among neonates with UTI.

Methods

This was a cross-sectional analytical hospital-based study that included 152 neonates with clinical sepsis who were admitted at Dodoma regional referral hospital from January to June 2020. Bacterial growth of 1 × 103 colony forming units/mL of a single uropathogen was used to define the presence of UTI. Statistical analysis was performed using SPSS version 23.0 and multivariate analysis was used to determine the predicting factors of UTI. P <0.05 was regarded statistically significant.

Results

The prevalence of UTI was 18.4% (28/152). Klebsiella pneumoniae 64.3% (18/28) and Enterobacter spp. 35.7% (10/28) were the bacterial agents isolated. The bacterial isolates were 90%, and 60% sensitive to ciprofloxacin and amikacin, respectively. Low Apgar score (AOR = 12.76, 95% CI = 4.17–39.06, p<0.001), prolonged labour (AOR = 5.36, 95% CI = 1.28–22.52, p = 0.022), positive urine nitrite test (AOR = 26.67, 95% CI = 7.75–91.70, p<0.001), and positive leucocyte esterase test (AOR = 6.64, 95% CI = 1.47–29.97, p = 0.014) were potential predictors of UTI.

Conclusion

The prevalence of UTI confirmed by urine culture among neonates that were included in the present study indicates that this problem is common in the population where the study was conducted. Klebsiella pneumoniae and Enterobacter spp. were the uropathogens which were isolated. Ciprofloxacin, nitrofurantoin, and amikacin were sensitive to the isolated uropathogens.

Risk factors for infertility and barriers to treatment in Tanzania: a survey and medical records study

Background

The burden of infertility is serious for women in high-fertility countries.

Objectives

We sought to identify demographic, behavioral/environmental, and reproductive risk factors for various infertility factors (i.e., ovarian, tubal, uterine/cervical, male/other) among women seeking infertility treatment in central Tanzania; to determine the association between pelvic inflammatory disease (PID) and tubal factor infertility (TFI); and to identify barriers to infertility treatment by women's home regional zone.

Methods

We conducted a cross-sectional survey of women seeking infertility treatment in Dodoma, Tanzania from January-March 2020. We surveyed 168 participants aged 18-49 years and reviewed their medical records to confirm infertility status and potential risk factors. We estimated prevalence ratios for factors associated with infertility using logistic regression. Treatment barriers were compared by women's regional zone to see if barriers varied geographically.

Results

The median age of participants was 32 years (range: 18-48). Infertility factors did not vary greatly by patient demographics, behavioral/environmental, or reproductive risk factors. Approximately 31.48% of women had PID diagnoses. Those with PID had 1.94 (95% CI: 1.30, 2.90) times the prevalence of TFI diagnosis as those with other infertility factors, after adjusting for age, pesticide use, alcohol use, age at sexual debut, prior obstetric events, and family history of infertility. Logistical barriers to treatment, such as time and cost, were more frequently reported than emotional, stigma, or other barriers, regardless of regional zone.

Conclusions

PID was strongly associated with TFI after adjustment for confounders. Infertility treatment access due to cost remains a challenge in Tanzania.

Duration on ART, Alcohol Use and HIV Stage May Predict Risky Sexual Behavior in a Resource-Limited Environment: A Cross-Sectional Study

BACKGROUND

The intention of antiretroviral therapy (ART) and regular clinic visits is to engender safe sex attitudes among HIV-infected individuals. However, this may not be the case due to the perceived therapeutic benefits of ART and may result in exposure to drug-resistant HIV strains.

OBJECTIVE

We aimed to determine the prevalence and predict the factors associated with risky sexual behaviors among ART users in a resource-limited environment.

METHODS

Two hundred and ninety-one sexually active ART users aged 18-50 years and seeking care at the HIV clinic in Dodoma, Tanzania, participated in this study. The outcome variables modeled in a logistic regression were condom use, multiple sex partners, casual sex partners, and payment for sex. The predictors included in the models were the patients' socio-demographic characteristics. In addition, a new variable, sexual risk scores, was generated by culminating all the outcome variables. Finally, multiple Poisson regression with the socio-demographic variables of the participants was used to model the sexual risk scores.

RESULTS

Patients reported inconsistent/no condom use (44%), payment for sex (4%), casual sex encounters (13%), multiple sex partners (21%), and STD symptoms (15%). While having a casual sexual partner was significantly associated with age group in a Pearson Chi-square (p=0.0147), participants ≤35 years old were less likely to have single-sex partners than older participants (AOR: 0.188, 95 C.I: 0.042-0.849). Meanwhile, the likelihood of condom use was higher among participants with no HIV-infected family members (AOR= 2.409, 95% C.I:1.236,4.697) and among participants who have single-sex partners (AOR= 2.721, 95% C.I.: 1.115,6.640); these participants were less likely to report STD symptoms (AOR=0.265, 95% C.I.: 0.081-0.865). Adjusted analysis showed that estimated mean sexual risk scores significantly increased (mean, λ=1.61, 95% C.I:1.0817-2.4063) for recent ART recipients (within 1-3 years vs. ≥eight years). However, sexual risk scores of participants with HIV stage 3 were 38.8% lower than participants at stage 4 (95% C.I.: 0.3910-0.9558), and non-alcohol drinkers had an adjusted mean sexual risk score 29% lower than participants who were alcohol drinkers (95% C.I.: 0.5102-0.9879).

CONCLUSION

Researchers should prioritize patients at HIV CTC for education concerning safe sexual practices for those characterized by alcohol consumption, younger age (less than 35 years old), HIV stage 4, or commencement of ART within three years.

Exploring the preferred integration approach for HIV, diabetes and hypertension care and associated barriers and facilitators in Central Tanzania: An exploratory qualitative study

Timely diagnosis and management of diabetes and hypertension among people living with HIV (PLWH) is imperative; however, many barriers exist within the current model of care for these comorbidities. We aimed to understand how HIV, diabetes, and hypertension care should be delivered and the associated barriers and facilitators for the preferred delivery approach. We conducted semi-structured interviews with 16 PLWH with comorbidities of diabetes and/or hypertension (referred to hereafter as non-communicable diseases [NCDs]), 10 healthcare professionals (HCPs) that provide care for NCDs, and 10 HCPs that provide care for HIV. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and interviewed in Swahili. Interviews were audio recorded, transcribed verbatim and translated into English. We used the differentiated service delivery building blocks as a framework to determine where, who, what and when care should be provided. We applied the Theoretical Domains Framework (TDF) to HCP transcripts to determine barriers and facilitators for the preferred integration approach. There was a consensus among participants that all care for NCDs should be provided for PLWH at HIV clinics (known as care and treatment centres [CTCs]) by either CTC doctors or NCD specialists. Participants preferred flexible follow-up care for NCDs and for it to be aligned with HIV follow-up appointments. The main barriers were mapped to the TDF domains of environmental context and resources, and social influences; the former included the lack of NCD medications, NCD diagnostic equipment, space, staff and guidelines whereas the latter included negative influences from peers and traditional healers. Several facilitators were mentioned regarding CTC HCPs' knowledge, skills, optimism and beliefs regarding their capabilities to care for PLWH with NCDs. The preferred integration approach should be tested, utilising the enabling factors described. The barriers described must be addressed with or without integration to achieve optimal care for PLWH with NCDs.

Symptomatic Cryptococcal Meningitis with Negative Serum and Cerebrospinal Fluid Cryptococcal Antigen Tests

Background

Cryptococcal meningitis is a leading cause of mortality in advanced HIV disease. A positive cerebrospinal fluid cryptococcal antigen (CrAg) test defines cryptococcal meningitis. Herein, we present a patient with serum and cerebrospinal fluid CrAg negative cryptococcal meningitis, despite a positive cerebrospinal fluid India ink examination and quantitative culture.

Case Details

A 56-year-old HIV-positive Ugandan woman, with an undetectable HIV RNA viral load and CD4+ T-cell count of 766 cells per microlitre presented with signs and symptoms consistent with cryptococcal meningitis. Her serum and cerebrospinal fluid CrAg tests were negative despite having a positive cerebrospinal fluid India ink and quantitative culture. On day 1, she was commenced on intravenous amphotericin B deoxycholate (1mg/kg) for 3 days (considering 10 CFU growth of Cryptococcus spp) in combination with oral flucytosine (100mg/kg) for 7 days and then fluconazole 1200mg once daily for the next 11 days. By day 7, she was symptom free and quantitative cerebrospinal fluid culture was negative for Cryptococcus spp. She was discharged on day 9. At 10 weeks (day +40) and 18 weeks (day +72), she was well and adherent to her antiretroviral therapy and on maintenance phase of cryptococcal meningitis on fluconazole at a dose of 400mg once daily.

Conclusion

This report alerts clinicians managing patients with HIV-associated cryptococcal meningitis to four uncommon clinical scenarios; first, the possibility of negative serum and cerebrospinal fluid CrAg lateral flow assay results in the context of low cerebrospinal fluid fungal burden in a symptomatic patient. Second, possible occurrence of cryptococcal meningitis in a patient with high CD4 T-cell lymphocyte counts. Third, an early seroconversion of cryptococcal antigenaemia following effective fluconazole therapy. Fourth, an early symptomatic relapse of cryptococcal meningitis albeit negative serum CrAg.

Barriers and facilitators of people living with HIV receiving optimal care for hypertension and diabetes in Tanzania: a qualitative study with healthcare professionals and people living with HIV

BACKGROUND

People living with HIV (PLWH) are at a higher risk for developing diabetes and hypertension. Often services are separate for HIV and non-communicable diseases (NCDs), but how this impacts NCD care among PLWH is unknown. We aimed to understand the barriers and facilitators for prevention, early diagnosis and safe effective care for diabetes and hypertension among PLWH.

METHODS

Semi-structured interviews (SSIs) were conducted with 10 healthcare professionals (HCPs) that care for PLWH, 10 HCPs that care for people with diabetes and hypertension and 16 PLWH with a comorbidity of diabetes and/or hypertension. Participants were recruited from two healthcare facilities in Dodoma, Tanzania and purposively sampled based on age and sex. Interviews were conducted in Swahili using pre-developed topic guides, audio recorded then translated verbatim into English. An inductive thematic analysis was conducted using The Framework Method.

RESULTS

Three themes were found: organisational/healthcare system factors, individual factors and syndemic factors. Organisational/healthcare system factors comprised the only facilitators for prevention (education on lifestyle behaviours and counselling on adherence), but included the most barriers overall: fragmented services, no protocol for NCD screening and lack of access to diagnostic equipment were barriers for early diagnosis whereas the former plus lack of continuity of NCD care were barriers for safe effective care. Individual factors comprised four sub-themes, three of which were considered facilitators: HCPs' knowledge of NCDs for early diagnosis, self-monitoring of NCDs for safe effective care and HCPs' personal practice for both early diagnosis and safe effective care. HCPs' knowledge was simultaneously a barrier for prevention and PLWH knowledge was a barrier for prevention and safe effective care. Syndemic factors comprised three sub-themes; all were barriers for prevention, early diagnosis and/or safe effective care: poverty and mental health of PLWH and HIV stigma.

CONCLUSIONS

Organisational/healthcare system, individual and syndemic factors were found to be interlinked with barriers and facilitators that contribute to the prevention, early diagnosis and safe effective care of diabetes and hypertension among PLWH in Tanzania; these findings can inform future initiatives for making small and large health system changes to improve the health of aging PLWH.