Preliminary insights into the occurrence of similar clones of extended-spectrum beta-lactamase-producing bacteria in humans, animals and the environment in Tanzania: A systematic review and meta-analysis between 2005 and 2016

The emergence and spread of extended-spectrum beta-lactamase producing Enterobacteriaceae (ESBL-PE) are complex and of the public health concern across the globe. This review aimed at assessing the ESBL-PE clones circulating in humans, animals and the environment to provide evidence-based insights for combating ESBL-PE using One Health approach. Systematic search from Medline/PubMed, Google Scholar and African Journals Online was carried out and retrieved nine eligible articles (of 131) based on phenotypic and genotypic detection of ESBL-PE between 2005 and 2016 in Tanzania. Analysis was performed using STATA 11.0 software to delineate the prevalence of ESBL-PE, phenotypic resistance profiles and clones circulating in the three interfaces. The overall prevalence of ESBL-PE in the three interfaces was 22.6% (95% CI: 21.1-24.2) with the predominance of Escherichia coli (E. coli) strains (51.6%). The majority of ESBL-PE were resistant to the commonly used antimicrobials such as trimethoprim-sulfamethoxazole and tetracycline/doxycycline, 38%-55% were resistant to ciprofloxacin and all were sensitive to meropenem/imipenem. ESBL-PE infections were more associated with deaths compared to non-ESBL-PE infections. Strikingly, E. coli ST38, ST131 and ST2852 were found to intersect variably across the three interfaces. The predominant allele, bla_CTX-M-15, was found mostly in the conjugative IncF plasmids connoting transmission potential. The high prevalence of ESBL-PE and shared clones across the three interfaces, including the global E. coli ST131 clone, indicates wide and inter-compartmental spread that calls for One Health genomic-driven studies to track the resistome flow.

Nutritional status of HIV-infected women with tuberculosis in Dar es Salaam, Tanzania

SETTING

Tuberculosis (TB) treatment clinics in Dar es Salaam, Tanzania.

OBJECTIVE

To quantify anthropometrics and intake of en-ergy and protein among human immunodeficiency virus (HIV) positive women with TB.

DESIGN

HIV-positive women with newly diagnosed TB were assessed on their anthropometric characteristics and dietary intake. Energy and protein intake were determined using Tanzania food composition tables and compared with standard recommendations. Patients were re-evaluated after 4-6 months of anti-tuberculosis treatment.

RESULTS

Among 43 women, the baseline median CD4 count was 209 cells/µl (range 8-721); 19 (44%) had a CD4 count of <200; 20 (47%) were on antiretroviral therapy. Body mass index was <18.5 kg/m(2) in 25 (58%); the median food insecurity score was 6. The median level of kcal/day was 1693 (range 1290-2633) compared to an estimated need of 2658; the median deficit was 875 kcal (range -65-1278). The median level of protein/day was 42 g (range 27-67) compared to 77 g estimated need; the median protein deficit was 35 g (range 10-50). The median weight gain among 29 patients after 4-6 months was 6 kg.

CONCLUSION

HIV-positive women with TB have substantial 24-h deficits in energy and protein intake, report significant food insecurity and gain minimal weight on anti-tuberculosis treatment. Enhanced dietary education together with daily supplementation of 1000 kcal with 40 g protein may be required.

Completion of isoniazid preventive therapy and survival in HIV-infected, TST-positive adults in Tanzania

SETTING

The World Health Organization recommends the use of isoniazid preventive therapy (IPT) for human immunodeficiency virus (HIV) infected patients with a positive tuberculin skin test (TST). However, due to concerns about the effectiveness of IPT in community health care settings and the development of drug resistance, these recommendations have not been widely implemented in countries where tuberculosis (TB) and HIV co-infection is common.

OBJECTIVE

To evaluate the effectiveness of IPT on survival and TB incidence among HIV-infected patients in Tanzania.

DESIGN

A cohort study nested within a randomized trial of HIV-infected adults with baseline CD4 counts of ≥ 200 cells/μ l was conducted to compare survival and incidence of active TB between TST-positive subjects who did or did not complete 6 months of IPT in the period 2001-2008.

RESULTS

Of 558 TST-positive subjects in the analytic cohort, 488 completed 6 months of IPT and 70 did not. Completers had a decrease in mortality compared to non-completers (HR 0.4, 95%CI 0.2-0.8). However, the protective effect of IPT on the incidence of active TB was non-significant (HR 0.6, 95%CI 0.3-1.3).

CONCLUSION

Completion of IPT is associated with increased survival in HIV-infected adults with CD4 counts ≥ 200 cells/μ l and a positive TST.

Disseminated tuberculosis in human immunodeficiency virus infection: ineffective immunity, polyclonal disease and high mortality

BACKGROUND

Disseminated tuberculosis (TB) is a major cause of death in patients with the acquired immune-deficiency syndrome (AIDS), but its pathogenesis and clinical features have not been defined prospectively.

METHODS

Human immunodeficiency virus (HIV) infected adults with a CD4 count ≥ 200 cells/μl and bacille Calmette-Guérin scar underwent immunologic evaluation and subsequent follow-up.

RESULTS

Among 20 subjects who developed disseminated TB, baseline tuberculin skin tests were ≥15 mm in 14 (70%) and lymphocyte proliferative responses to Mycobacterium tuberculosis were positive in 14 (70%). At the time of diagnosis, fever ≥2 weeks plus ≥5 kg weight loss was reported in 16 (80%) patients, abnormal chest X-rays in 7/17 (41%), and positive sputum cultures in 10 (50%); median CD4 count was 30 cells/μl (range 1-122). By insertion sequence (IS) 6110 analysis, 14 (70%) blood isolates were clustered and 3/8 (37%) concurrent sputum isolates represented a different strain (polyclonal disease). Empiric TB treatment was given to eight (40%) patients; 11 (55%) died within a month.

CONCLUSIONS

Disseminated TB in HIV occurs with cellular immune responses indicating prior mycobacterial infection, and IS6110 analysis suggests an often lethal combination of reactivation and newly acquired infection. Control will require effective prevention of both remotely and recently acquired infection, and wider use of empiric therapy in patients with advanced AIDS and prolonged fever.

Low BMI and falling BMI predict HIV-associated tuberculosis: a prospective study in Tanzania

BACKGROUND

Low body mass index (BMI) is a known risk factor for tuberculosis (TB) in people without human immunodeficiency virus (HIV), but there are no prospective studies linking BMI to the risk of HIV-associated TB.

DESIGN

In HIV-infected adults with CD4 counts ≥ 200 cells/μl receiving placebo in a TB booster vaccine trial in Dar es Salaam, Tanzania, we measured BMI at baseline and Year 1, and related baseline BMI and change in BMI to the risk of developing TB.

RESULTS

We documented 92 cases of TB among 979 subjects followed for a mean of 3.2 years. Compared to subjects who did not develop TB, subjects who developed TB had a lower baseline BMI (23.2 vs. 24.6 kg/m(2), P = 0.006), and a greater BMI decline from baseline to Year 1 (-0.4 vs. 0.6 kg/m(2), P < 0.001). In multivariate analyses, baseline BMI was associated with the risk of developing TB (hazard ratio [HR] per kg/m(2) 0.94, 95%CI 0.90-0.99, P = 0.028), as was the change in BMI from baseline to Year 1 (HR per kg/m(2) 0.79, 95%CI 0.71-0.87, P < 0.001). Subjects with a baseline BMI < 17 kg/m(2) were more likely to develop TB (HR 3.72, 95%CI 1.16-12.0, P = 0.028).

CONCLUSION

Low and falling BMI predict HIV-associated TB.

Three years of HIV/AIDS care and treatment services in Tanzania: achievements and challenges

The Tanzania HIV Care and Treatment Plan was launched in October 2004 aiming at providing 440,000 AIDS patients with antiretroviral drugs (ARVs) and track disease progression in 1.2 million HIV+ persons by the end of the 2008. This paper is intended to provide information to stake holders of the achievements and challenges of the HIV Care and Treatment Plan since its inception in 2004. Facility patient reports are aggregated at district and then regional level before being sent to the national level where they are aggregated to form a national report. By December 2007, 210 health facilities were offering HIV care and treatment services in Tanzania. About 123,147 (5%) of the 2,636,785 estimated people living with HIV and AIDS were enrolled, and 71,439 (13.6%) of the estimated 527,357 AIDS cases commenced ART. More females than males started ART, F:M ratio being 3:2. Most (49%) patients were started ART due to low CD4 counts (< 200). About 6,618 patients had their initial ARV regimen changed due to starting anti-TB treatment 679 (10%), peripheral neuropathy 812 (12%), skin rash 378 (6%), and stock out 247 (4%) or other reasons (18%), while 2,653 (42%) had no reason recorded. The proportion of patients still alive and on ART at 6, 12 and 24 months after initiation of treatment was 60%, 60%, and 50%, respectively, while those collecting ARVs on schedule was 34%, 25% and 10% respectively. About 3,084 patients developed TB after starting ART, of whom 1,557 (approximately 50%) patients during the first three months of treatment. During the three years (2004-2007) of HIV care and treatment services in Tanzania, there has been an increase in the number of CTC facilities, geographical coverage of services, the number of enrolled patients and those on ART. However, the set target for ART services has not been achieved and there are significant geographical variations in these achievements, which do not correspond with either population density or disease burden. Efforts should be made to i) ensure equitable accessibility when scaling up ART services in Tanzania, ii) improve the recording and reporting system and iii) armonize the activities of various stakeholders.

Participation of primary school teachers in oral health education in Rungwe District, Tanzania

BACKGROUND

Tanzanian primary school teachers have long been utilised as oral health educators but little is known about their level of participation.

OBJECTIVES

To asses the participation of primary school teachers as general and oral health educators.

DESIGN

Cross-sectional, using structured self-administered questionnaires.

SETTING

Rural and urban Primary Schools in Rungwe District, Mbeya Tanzania.

PARTICIPANTS

Primary school teachers from 15 rural and 4 urban schools.

MAIN OUTCOME VARIABLES

Provision of oral health education.

RESULTS

Teachers with primary education, who are teaching in lower grades were significantly more active in providing general and oral health education (OHE) than those with secondary education and who teach pupils in higher grades.

CONCLUSION

Oral health education seems to be given mainly to primary school pupils in lower grades; teachers involved in oral health education provision were mainly female juniors in the profession and relatively young by age (below 40 years old).

RECOMMENDATION

There is a need for influencing teachers of pupils in higher grades and males to be involved in oral health education programmes throughout their teaching profession.

Post-transfusion hepatitis C seroprevalence in Tanzanian children

In Tanzania, children with malaria-associated anaemia are frequently given blood transfusions, and donor blood is not screened for hepatitis C virus (HCV) infection. To determine the seroprevalence of HCV infection in Tanzanian children previously transfused with blood, 184 children (92 transfused, 92 not transfused) aged between 15 and 59 months matched for age and sex were screened for HCV antibodies by the particle agglutination test using Serodia anti-HCV (Fujirebio Inc., Japan). The overall prevalence of HCV infection was 7.1% (13/184). HCV seropositivity was 5.4% (5/92) among children with a history of blood transfusion and 8.6% (8/92) among the non-transfused. There was no significant difference in the prevalence of HCV infection between transfused and non-transfused children. None of the factors investigated, such as gender, the nutrition and HIV serostatus of the children and the marital and education status of their mothers, was associated with HCV seropositivity. Further studies are recommended to identify the factors associated with HCV infection in Tanzanian children.

Post-extraction complications seen at a referral dental clinic in Dar Es Salaam, Tanzania

AIM

To investigate the types and magnitude of post extraction complications.

SETTING

A referral hospital in Dar es Salaam, Tanzania.

SUBJECTS

All dental patients who had their teeth extracted at the Muhimbili Medical Centre dental outpatient clinic during the study period (May September 1999). A total of 3,818 extractions were performed under local anaesthetic in 3,732 patients.

METHOD

Oral examination of all patients who reported back with post-extraction problems.

RESULTS

The frequency of post extraction complications was low (1.1 per cent), and was mainly due to; infected sockets (48.7 per cent), followed by bleeding sockets (41.0 per cent) and retained roots (10.3 per cent). There were eight 'other' complications suffered by 11 patients: necrotising fasciitis (n=l), herpes zoster (n=l), Ludwig's angina (n=l), infections of the submandibular (n=l), parapharyngeal (n=2), masticator (n=2) and submasseteric spaces (n =2), and reaction to local anaesthesia (2ml of 2 per cent lignocaine hydrochloride) (n=1).

CONCLUSION

The results of this study indicate that post-extraction complications are few, mostly minor, self-limiting and easily treatable. The study does not support routine antibiotic prophylaxis or special pre-extraction procedures, even in this patient population with poor oral hygiene and high HIV seroprevalence.

Utilisation of dental services in Tanzania before and after the introduction of cost-sharing

OBJECTIVE

The objective of this study was to evaluate the effect of cost-sharing, introduced in July 1994, on the utilisation of dental services in Tanzania.

METHODS

The study compared dental attendance, demand for dental services and treatment pattern of patients in 17 out of 20 regions of mainland Tanzania in 1993 and 1995, a year before and after the introduction of user fees.

OUTCOMES MEASURES

Dental attendance and demand for treatment.

RESULTS

Results revealed a 33.2 per cent overall reduction in dental attendance but no effect on either the demand for treatment or treatment pattern. The exceptions were increases in referral cases by 14.5 times and prosthetic work by 3.9 times, and a reduction in surgical cases by 18.8 per cent.

CONCLUSIONS

In order to improve attendance and decrease referrals it is necessary to enforce the first line of oral primary health care to meet the simple treatment demands. Furthermore, the revenue generated by cost-sharing should be used to improve services.

Cranio-facial fibrous dysplasia in a 38-year-old African woman: a case history

A 38-year-old woman sought treatment with cranio-facial dysplasia involving the cranium, maxilla and the mandible. Her chief complaint was a mandibular swelling, which had appeared about 2 years previously, had gradually enlarged, and was associated with spontaneous pain. X-ray film examination revealed a ground-glass opacity with blurred demarcation and a 99 Tc medronate bone scan disclosed an increase in tracer uptake in the cranium, maxilla and mandible. The rest of the skeleton was not affected. Histological examination of the lesions revealed solid proliferation of spindle-shaped cells associated with islands of osteid and bone trabecullae with Chinese letter pattern and numerous multinucleated giant cells consistent with fibrous dysplasia. The continued osteoblastic activity of involved bones, coupled with the medical condition of the patient, restricted the management of the patient to largely supportive and palliative care.

HIV infection, dental treatment demands and needs among patients seeking dental services at the Muhimbili Medical Centre in Dar-es-Salaam, Tanzania

The objectives of this cross-sectional study were to determine the frequency of HIV infection among dental patients attending the three dental facilities at Muhimbili Medical Centre (MMC) in Dar-es-Salaam, Tanzania, and to compare the dental treatment demands and needs of the patients found to be HIV-infected with those of their HIV-seronegative counterparts. The facilities were; the dental outpatient department (DOPD) clinic, the dental minor surgery department, and the dental ward. This study which was conducted between March and April, 1996 enrolled a total of 460 patients. The investigations involved detection of anti-HIV IgG antibodies in saliva, examination of oral and peri-oral tissues, and assessment of dental and periodontal status. The overall HIV frequency among the dental patients was 10.9 per cent. The frequencies of HIV infection among patients attending the dental OPD clinic, minor surgery, and those admitted in the dental ward were 9.4 per cent, 26.3 per cent, and 25.0 per cent, respectively. The dental treatment demands and needs of HIV-seropositive patients were not different from that of HIV-seronegative patients. The high frequency of HIV infection calls for institution of infection control measures in the dental clinics. However, such measures need to be tailored for the poor countries, with potentially high frequency of HIV infection and minimal resources, in order to make them relevant.

Nursing caries, linear hypoplasia, and nursing and weaning habits in Tanzanian infants

A cross-sectional survey on the prevalence of rampant caries in infants and a case-control study were executed to determine the prevalence of rampant caries and its etiology. A total of 2192 infants aged between 1 and 4.0 yr from nine regions of Tanzania comprised the sample of the prevalence survey. The overall prevalence of rampant caries resembling nursing caries was 6.8%. The prevalence varied considerably between 1.5% and 12.8% in the different regions and was closely associated with the varying prevalence of linear hypoplasia but not with fluoride content in drinking water. The relative risk of developing rampant caries in the presence of linear hypoplasia was 14.5. The case-control study comprised 116 cases, infants with rampant caries and 243 controls, without the disorder. Risk factors such as breast feeding frequency and duration during day and night, bottle feeding and weaning habits were assessed through a structured interview with the mother. Bottlefeeding was performed in only a minority of the infants for a short period (1.1 months) and in a low exposure frequency (0.4 daily) and was not associated with rampant caries. The frequency of sugar moments in the supplementary diet was on average 1.5 times per day and was not associated with rampant caries. The duration and frequency of breast feeding during the day was also not associated. The habit of allowing infants to sleep with the breast nipple in their mouths and the presence of linear hypoplasia were strongly associated with rampant caries. Odds ratios for these variables were 17.8 and 15.6 respectively. Based on these associations it is concluded that rampant caries in this sample was caused by the habit of allowing infants to sleep with the breast nipple in their mouths, whereas linear hypoplasia is considered to be a predisposing factor.

Caries prevalence ratios in a Tanzanian child population

The use of risk ratios, odds ratios and prevalence ratios is limited within dental epidemiological research. These measures of association have been applied to relate the risk indicators' geographical location and sex to the caries prevalence in the maxilla, the mandible and the total dentition of 7-11-yr-old Tanzanian schoolchildren examined in 1986. The risk indicators were studied by means of odds ratio, using logistic regression. There were no associations found between the risk indicators studied and caries prevalence in the maxilla and the total dentition: a significant association was found only in the mandible. This resulted in girls having a greater (PR = 1.4) chance of developing caries than boys, and children living in naturally fluoridated (greater than or equal to 0.5 ppm) rural areas having a lower (PR = 0.5) chance of developing caries than those living in urban and rural areas.