Assessing the utility of pregnant women as a sentinel surveillance population for malaria in Geita, Tanzania, 2019 - 2021

OBJECTIVES

Estimates of malaria burden and intervention uptake in Africa are primarily based on household surveys. However, their expense and infrequency limit their utility. We investigated whether data collected during antenatal care (ANC) can provide relevant information for decision-makers.

METHODS

Malaria test positivity rates and questionnaire data from ANC attendees at 39 health facilities were compared to questionnaire data and positivity rates among children from two cross-sectional surveys in the facilities' corresponding catchment areas.

RESULTS

Trends in parasitemia among ANC attendees were predictive of trends in parasitemia among children at the council level (mean absolute error 6.0%). Primigravid ANC attendees had the lowest rates of net ownership (modeled odds ratio [OR] 0.28, 95% CI 0.19-0.40) and use (OR 0.58, 95% CI 0.42-0.79). ANC attendees reported higher levels of care-seeking (OR 1.78, 95% CI 1.48-2.14), malaria testing (OR 4.16, 95% CI 3.44-5.04), and treatment for children with fever (OR 7.66, 95% CI 4.89-11.98) compared to women surveyed in households, raising concerns about social desirability bias disproportionately impacting ANC surveys.

CONCLUSION

ANC surveillance is an effective strategy for tracking trends in malaria burden. More work is required to elucidate the value of administering questionnaires to ANC attendees.

Using antenatal care as a platform for malaria surveillance data collection: study protocol

BACKGROUND

While many malaria-endemic countries have health management information systems that can measure and report malaria trends in a timely manner, these routine systems have limitations. Periodic community cross-sectional household surveys are used to estimate malaria prevalence and intervention coverage but lack geographic granularity and are resource intensive. Incorporating malaria testing for all women at their first antenatal care (ANC) visit (i.e., ANC1) could provide a more timely and granular source of data for monitoring trends in malaria burden and intervention coverage. This article describes a protocol designed to assess if ANC-based surveillance could be a pragmatic tool to monitor malaria.

METHODS

This is an observational, cross-sectional study conducted in Benin, Burkina Faso, Mozambique, Nigeria, Tanzania, and Zambia. Pregnant women attending ANC1 in selected health facilities will be tested for malaria infection by rapid diagnostic test and administered a brief questionnaire to capture key indicators of malaria control intervention coverage and care-seeking behaviour. In each location, contemporaneous cross-sectional household surveys will be leveraged to assess correlations between estimates obtained using each method, and the use of ANC data as a tool to track trends in malaria burden and intervention coverage will be validated.

RESULTS

This study will assess malaria prevalence at ANC1 aggregated at health facility and district levels, and by gravidity relative to current pregnancy (i.e., gravida 1, gravida 2, and gravida 3 +). ANC1 malaria prevalence will be presented as monthly trends. Additionally, correlation between ANC1 and household survey-derived estimates of malaria prevalence, bed net ownership and use, and care-seeking will be assessed.

CONCLUSION

ANC1-based surveillance has the potential to provide a cost-effective, localized measure of malaria prevalence that is representative of the general population and useful for tracking monthly changes in parasite prevalence, as well as providing population-representative estimates of intervention coverage and care-seeking behavior. This study will evaluate the representativeness of these measures and collect information on operational feasibility, usefulness for programmatic decision-making, and potential for scale-up of malaria ANC1 surveillance.

Onsite healthcare worker acceptability and performance of the point-of-care Pima CD4 assay in Dar es Salaam, Tanzania

Background: Healthcare workers’ acceptance of and ability to perform point-of-care testing is important for reliable and accurate results. The Alere Pima™ CD4 assay (Pima CD4) is the CD4 point-of-care test for HIV management in Tanzania.Objectives: To evaluate healthcare workers’ acceptance and performance of Pima CD4 testing.Methods: The study was implemented in five high volume sites in Dar es Salaam, Tanzania, in 2011. Trained healthcare workers performed Pima testing using three whole-blood specimens collected from each patient: venous blood, fingerstick blood directly applied to a Pima cartridge (capillary-direct), and fingerstick blood collected in a microtube (capillary-microtube). Using a semi-structured interview guide, we interviewed 11 healthcare workers about specimen collection methods and Pima CD4 acceptability. Quantitative responses were analysed using descriptive statistics. Open-ended responses were summarised by thematic areas. Pima CD4 results were analysed to determine variation between cadres.Results: Healthcare workers found Pima CD4 user-friendly and recommended its use in low volume, peripheral facilities. Both venous and capillary-direct blood were considered easy to collect, with venous preferred. Advantages noted with venous and capillary-microtube methods were the ability to retest, perform multiple tests, or delay testing. Pima CD4 results were trusted by the healthcare workers and were in agreement with laboratory Pima testing.Conclusion: In this point-of-care testing setting, the Pima CD4 assay was accepted by healthcare workers. Both venous and fingerstick capillary blood specimens can be used with Pima CD4, but fingerstick methods may require more intensive training on technique to minimise variation in results and increase acceptability.

Perspectives on maternal, infant, and young child nutrition and family planning: Considerations for rollout of integrated services in Mara and Kagera, Tanzania

In Lake Zone, Tanzania, low contraceptive prevalence, closely spaced births, and child stunting are common. Synergies exist between postpartum family planning (PPFP) and maternal, infant, and young child nutrition (MIYCN), yet health services are often provided in silos. This qualitative formative research study aimed to identify barriers and facilitating factors for optimal nutrition and PPFP practices in Mara and Kagera, Tanzania. Results informed the program design of an integrated nutrition and family planning (FP) implementation approach. The study involved in‐depth interviews with mothers of infants under 1 year (n = 24), grandmothers (n = 12), health providers (n = 6), and traditional birth attendants (n = 12), and 14 focus group discussions with community health workers, fathers, and community leaders. Findings reveal that breastfeeding initiation was often delayed, and prelacteal feeding was common. Respondents linked insufficient breast milk to inadequate maternal nutrition—in terms of the quality of the diet and small quantities of food consumed by mothers. Breast milk insufficiency was addressed through early introduction of foods and liquids. Mothers believed that breastfeeding prevents pregnancy, regardless of the frequency or duration of breastfeeding, yet were generally not aware of the lactational amenorrhea method (LAM) of FP. Joint decision‐making on FP was viewed as important, and women often discussed it with their partner. Future programming should address misconceptions about return to fecundity1 knowledge gaps and concerns about FP methods including LAM; and perceptions regarding insufficient breast milk and early introduction of foods which are impediments to optimal MIYCN and FP practices.

Factors associated with institutional delivery: Findings from a cross-sectional study in Mara and Kagera regions in Tanzania

In Tanzania, maternal mortality has stagnated over the last 10 years, and some of the areas with the worst indicators are in the Lake and Western Zones. This study investigates the factors associated with institutional deliveries among women aged 15-49 years in two regions of the Lake Zone. Data were extracted from a cross-sectional household survey of 1,214 women aged 15-49 years who had given birth in the 2 years preceding the survey in Mara and Kagera regions. Logistic regression analyses were conducted to explore the influence of various factors on giving birth in a facility. About two-thirds (67.3%) of women gave birth at a health facility. After adjusting for possible confounders, six factors were significantly associated with institutional delivery: region (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.54 [0.41-0.71]), number of children (aOR, 95% CI: 0.61 [0.42-0.91]), household wealth index (aOR, 95% CI: 1.47 [1.09-2.27]), four or more antenatal care visits (aOR, 95% CI: 1.97 [1.12-3.47]), knowing three or more pregnancy danger signs (aOR, 95% CI: 1.87 [1.27-2.76]), and number of birth preparations (aOR, 95% CI: 6.09 [3.32-11.18]). Another three factors related to antenatal care were also significant in the bivariate analysis, but these were not significantly associated with place of delivery after adjusting for all variables in an extended multivariable regression model. Giving birth in a health facility was associated both with socio-demographic factors and women's interactions with the health care system during pregnancy. The findings show that national policies and programs promoting institutional delivery in Tanzania should tailor interventions to specific regions and reach out to low-income and high-parity women. Efforts are needed not just to increase the number of antenatal care visits made by pregnant women, but also to improve the quality and content of the interaction between women and service providers.

Evaluation of Specimen Types for Pima CD4 Point-of-Care Testing: Advantages of Fingerstick Blood Collection into an EDTA Microtube

INTRODUCTION

Effective point-of-care testing (POCT) is reliant on optimal specimen collection, quality assured testing, and expedited return of results. Many of the POCT are designed to be used with fingerstick capillary blood to simplify the blood collection burden. However, fingerstick blood collection has inherent errors in sampling. An evaluation of the use of capillary and venous blood with CD4 POCT was conducted.

METHODS

Three different specimen collection methods were evaluated for compatibility using the Alere Pima CD4 assay at 5 HIV/AIDS healthcare sites in Dar es Salaam, Tanzania. At each site, whole blood specimens were collected from enrolled patients by venipuncture and fingerstick. Pima CD4 testing was performed at site of collection on venipuncture specimens (Venous) and fingerstick blood directly applied to a Pima CD4 cartridge (Capillary-Direct) and collected into an EDTA microtube (Capillary-Microtube). Venous blood was also tested at the laboratory by the reference CD4 method and Pima for comparison analysis.

RESULTS

All three specimen collection methods were successfully collected by healthcare workers for use with the Pima CD4 assay. When compared to the reference CD4 method, Pima CD4 testing with the Capillary-Microtube method performed similarly to Venous, while Pima CD4 counts with the Capillary-Direct method were slightly more biased (-20 cells/μL) and variable (-229 to +189 cells/μL limit of agreement). Even though all three collection methods had similar invalid Pima testing rates (10.5%, 9.8%, and 8.3% for Capillary-Direct, Capillary-Microtube, and Venous respectively), the ability to perform repeat testing with Capillary-Microtube and Venous specimens increased the likelihood of acquiring a valid CD4 result with the Pima assay.

CONCLUSIONS

Capillary blood, either directly applied to Pima CD4 cartridges or collected in an EDTA microtube, and venous blood are suitable specimens for Pima CD4 testing. The advantages of capillary blood collection in an EDTA microtube are that it uses fingerstick collection which mimics venous blood and allows extra testing without additional blood collection.

Tracking facility-based perinatal deaths in Tanzania: Results from an indicator validation assessment

BACKGROUND

Globally, an estimated 2.7 million babies die in the neonatal period annually, and of these, about 0.7 million die from intrapartum-related events. In Tanzania 51,000 newborn deaths and 43,000 stillbirths occur every year. Approximately two-thirds of these deaths could be potentially prevented with improvements in intrapartum and neonatal care. Routine measurement of fetal intrapartum deaths and newborn deaths that occur in health facilities can help to evaluate efforts to improve the quality of intrapartum care to save lives. However, few examples exist of indicators on perinatal mortality in the facility setting that are readily available through health management information systems (HMIS).

METHODS

From November 2016 to April 2017, health providers at 10 government health facilities in Kagera region, Tanzania, underwent refresher training on perinatal death classification and training on the use of handheld Doppler devices to assess fetal heart rate upon admission to maternity services. Doppler devices were provided to maternity services at the study facilities. We assessed the validity of an indicator to measure facility-based pre-discharge perinatal mortality by comparing perinatal outcomes extracted from the HMIS maternity registers to a gold standard perinatal death audit.

RESULTS

Sensitivity and specificity of the HMIS neonatal outcomes to predict gold standard audit outcomes were both over 98% based on analysis of 128 HMIS-gold standard audit pairs. After this validation, we calculated facility perinatal mortality indicator from HMIS data using fresh stillbirths and pre-discharge newborn death as the numerator and women admitted in labor with positive fetal heart tones as the denominator. Further emphasizing the validity of the indicator, FPM values aligned with expected mortality by facility level, with lowest rates in health centers (range 0.3%- 0.5%), compared to district hospitals (1.5%- 2.9%) and the regional hospital (4.2%).

CONCLUSION

This facility perinatal mortality indicator provides an important health outcome measure that facilities can use to monitor levels of perinatal deaths occurring in the facility and evaluate impact of quality of care improvement activities.

Addressing the First 90: A Highly Effective Partner Notification Approach Reaches Previously Undiagnosed Sexual Partners in Tanzania

To meet UNAIDS' 90-90-90 treatment goals, effective approaches to HIV testing services (HTSs) are urgently needed. In 2015, a cross-sectional study was conducted to evaluate effectiveness and feasibility of partner notification for HTS in Tanzania. Men and women newly diagnosed with HIV were enrolled as index clients, listed sexual partners, and given options to notify and link their partners to HTS. Of 653 newly diagnosed individuals, 390 index clients were enrolled, listed 438 sexual partners, of whom 249 (56.8%) were successfully referred. Of 249 partners reaching the facilities, 96% tested for HIV, 148 (61.9%) tested HIV+ (all newly diagnosed), and 104 (70.3%) of partners testing positive were enrolled into HIV care and treatment. Results showed good acceptability, feasibility and effectiveness, as evidenced by high uptake of partner notification among newly diagnosed individuals, over half of listed partners successfully referred, and a very high positivity rate among referred sexual partners.