Tropical Diseases in Africa – Malaria

July 28, 2021Leave a comment

by Shravya Murali – Art in Tanzania internship

As a significant health problem in several tropical regions of the world, malaria costs almost 435,000 lives annually. A substantial fraction of these deaths occurs in Africa. The proportion of cases and deaths In Tanzania alone constitutes to 3% of those globally. Over the past few years, the number of malaria cases have been on the rise, with a staggering increase by 3.5 million from 2016 to 2017 as reported by the WHO.

How does malaria spread?

Malaria in humans is caused by four kinds of parasites from the Plasmodium genus – Plasmodium falciparum, Plasmodium vivax, Plasmodium ovale, and Plasmodium malariae. A fifth species Plasmodium knowlesi, is a zoonotic species infecting animals. Of the five species, P.falciparum results in the most severe form of malaria and is responsible for the majority of malaria-related deaths, especially among children below the age of five.

Malaria is transmitted to humans through the bite of a female Anopheles mosquito that is infected by one of the malaria-causing parasites. The Anopheles mosquito can also spread the parasite from a human to another human when it feeds on an infected human’s blood meal, and later goes to bite another human.

Human-to-human transmission can also occur through blood transfusion, organ transplant, or sharing needles containing contaminated blood as the malaria parasite can be found on red blood cells. Malaria can also be transmitted from a pregnant mother to her child before or during delivery, which is also known as congenital malaria.

However, malaria is not contagious and cannot be transmitted through casual contact (i.e., by sitting next to someone infected) or sexual contact.

What are the effects of the disease?

Those infected with malaria often experience flu like illnesses and fever. Symptoms often include headache, fatigue, chills, muscle soreness, nausea, vomiting, and diarrhoea. As malaria can cause a loss of red blood cells it may lead to anemia, and jaundice, which is the yellow colouring of skin and eyes. If left untreated malaria becomes life-threatening as it can cause kidney failure, mental confusion, seizures, coma, and death. Usually, these symptoms occur about 10 days after a malaria infection.

Malaria caused by P.vivax and P.ovale may occur again and the parasites may reside in the liver for up to around four years after an individual has been bitten by an Anopheles mosquito. These dormant parasites may become active later and invade the individual’s red blood cells, causing another malarial infection.

How is malaria treated?

If a patient is suspected to be infected with malaria, a drop of his/her blood is often observed under a microscope to detect the malaria parasite. Treatments for malaria vary based on the severity of malaria, clinical status of the patient, the Plasmodium species causing the infection, and prior use of anti-malarial drugs.

In Mainland Tanzania, artemether lumefantrine, a drug that can be orally consumed, is used for uncomplicated malaria. In Zanzibar, however, artesunate and amodiaquine are used. For severe malaria, artesunate and quinine are injected in patients in both Mainland Tanzania and Zanzibar. Quinine is another drug that is only used when other drugs are ineffective, as quinine is known to have more side effects than the others. However, quinine is used to treat malaria in the first trimester of pregnancy as it is not known to have significant effects on the child at therapeutic doses.

What could be done to prevent the disease?

To prevent malaria, one could consume anti-malarial drugs (i.e., atovaquone, chloroquine, doxycycline). While it is possible to provide infants and children some of these drugs, not all drugs are suitable for children and doses are based on the weight of the child.

Apart from anti-malarial drugs, one should also prevent mosquito bites (specifically at night), which could be done by sleeping under insecticide-treated bed nets, wearing fully covered / long-sleeved clothing at night, and carrying an insect repellent.

With the increase in the number of malaria cases over the years, it is crucial that members of the public and healthcare professionals cooperate in fight against the disease. While the research for vaccination against malaria is ongoing, it is also essential for everyone to play a part by taking precautions to avoid malaria.

References:

1. Carfagno, J. (2018, July 16). Noninvasive Malaria Test Wins Royal Academy of Engineering’s Africa Prize. Docwire News. https://www.docwirenews.com/docwire-pick/future-of-medicine-picks/noninvasive-malaria-test-wins-royal-academy-of-engineerings-africa-prize/.

2. Centers for Disease Control and Prevention. (2021, January 26). CDC – Malaria – About Malaria – FAQs. Centers for Disease Control and Prevention. https://www.cdc.gov/malaria/about/faqs.html.

3. Mutabazi, T. (2021, June 6). Assessment of the accuracy of malaria microscopy in private

health facilities in Entebbe Municipality, Uganda: a cross-sectional study. Malaria Journal. https://malariajournal.biomedcentral.com/articles/10.1186/s12936-021-03787-y

4. Ryan, S. J. (2020, May 1). Shifting transmission risk for malaria in Africa with climate

change: a framework for planning and intervention. Malaria Journal. https://malariajournal.biomedcentral.com/articles/10.1186/s12936-020-03224-6

5. Tanzania. Severe Malaria Observatory. (2007, January 17). https://www.severemalaria.org/countries/tanzania.

6. Thomas, D. L. (2020, March 13). Triple therapies effective and safe in malaria. News. https://www.news-medical.net/news/20200312/Triple-therapies-effective-and-safe-in-malaria.aspx.

HIV AND AIDS IN TANZANIA

June 23, 2021June 29, 2021Leave a comment

By Gwamaka Mwakyusa – Art in Tanzania internship

2018, 1.6 million people were living with HIV in Tanzania. This equates to an estimated HIV prevalence among adults of 4.6%. In the same year, 72,000 people were newly infected with HIV, and 24,000 people died from an AIDS-related illness.

Despite the numbers, Tanzania has done well to control the HIV epidemic over the last decade. Scaling up access to antiretroviral treatment (ART) has meant that between 2010 and 2018, the number of new infections declined by 13% and the number of people dying from an AIDS-related illness has halved.

Key affected populations in Tanzania

Tanzania’s HIV epidemic is generalized, meaning it affects all sections of society, but there are also concentrated epidemics among certain population groups, such as people who inject drugs, men who have sex with men, mobile populations, and sex workers. Heterosexual sex accounts for the vast majority (80%) of HIV infections in the country and women are particularly affected.

The severity of the epidemic varies geographically. Some regions of Tanzania report no HIV prevalence (Kusini Unguja and Kaskazini Pemba) while other regions have prevalence as high as 11.4% (Njombe). Overall, the epidemic has remained steady due to ongoing new infections, population growth and increased access to treatment.

Bar graph showing HIV prevalence by age and sex in Tanzania

Women

Women are disproportionately affected by HIV in Tanzania. In 2018, 880,000 women aged 15 and over were living with HIV, compared to 580,000 adult men. In the same year, more than 36,000 women acquired HIV, compared to around 27,000 men.

The nationally representative 2016-2017 Tanzania Impact Survey (THIS) found that women aged 15-39 are more than twice as likely to be living with HIV as their male counterparts. HIV prevalence is highest among women aged 45-49, at 12% (compared with 8.4% among men of this age

Gender inequality is widespread among women of all ages in Tanzania. In 2016, around 30% of women aged 15-49 who had ever been married or in a long-term relationship were estimated to have experienced physical or sexual violence from a male intimate partner in the past 12 months.9 This increases many women’s vulnerability to HIV, either directly, through sexual violence, or indirectly, through an inability to negotiate condoms or prevent their partner from having other sexual relationships.

In addition, women tend to become infected earlier because they have older partners and get married earlier.

Young people

It is estimated that more than half the population in Tanzania are aged 19 and under.11

THIS reported HIV prevalence among young people (ages 15-24) at 1%, with young women around four times more likely than young men to be living with HIV (2% prevalence among young women, compared to 0.6% prevalence among young men). Prevalence among children (ages 0-14) is 0.3%.

In 2018, just under 24,000 young people in Tanzania became HIV-positive; roughly two-thirds of whom were young women (16,000 new infections among young women, compared to 7,600 among young men).13 In 2016/17, 3.4% of women aged 20-24 were living with HIV, compared to 0.9% of their male counterparts.

The disparity between the sexes is linked to age-related vulnerabilities experienced by young women that intersect with widespread gender inequality. For instance, Tanzania’s ‘sugar daddy’ culture, in which young women embark on sexual relationships with older men in exchange for material goods or social advancement, is a key driver of HIV among young women.

Even though their partners come from age groups with higher HIV prevalence than younger men, and may also engage in other sexual relationships, young women are often unable to negotiate condom use due to the unequal power balance in these relationships. This is demonstrated by a study involving 18 to 24 year-old women in Dar es Salaam, which found that in couples of the

Same age decisions about condom use were together (48%) or by young women alone (34%). Decision-making during sex with older men was predominantly made by the male partner (79%).

Many young people are also unaware about how to prevent transmission. In 2016/17, just 37% of young people demonstrated adequate knowledge on how to prevent HIV and could correctly reject common misconceptions about how the virus is transmitted.17 Young people, particularly young men, are also less likely than older age groups to test for HIV. As a result, in 2016/17 it was estimated that only half of young people living with HIV were aware of their status.

People who inject drugs (PWID)

Tanzania is home to a significant population of people who inject drugs (sometimes referred to as PWID). In 2014, Tanzania National AIDS Control Program (NACP) estimated there were 30,000 people who inject drugs in the country, 35% of whom were living with HIV.

HIV prevalence among women who inject drugs is thought to be twice that of their male peers. The reasons for this are not fully known although possible factors include women who inject drugs being involved in sex work or being last in line when syringes are shared.

Data on people who inject drugs varies widely between studies, due to the hidden nature of this population. Existing evidence suggests heroin use is on the rise and this population group is growing.

Most studies involving people who inject drugs in Tanzania have been conducted in Dar es Salaam and Zanzibar. Zanzibar is a gateway to the African continent and is also situated along a major corridor for drug trafficking. Around one in six people who live in Zanzibar and inject drugs is living with HIV, according to 2010 estimates, although some believe this figure be higher

A 2015 study of 480 people who use drugs in the northwestern city of Mwanza found that 13.5% of respondents injected drugs, 67% of whom shared needles. This study suggests that injecting drug use, particularly heroin, is now a significant issue in a major city outside Dar es Salaam and Zanzibar.

Mobile populations

Migration is common in Tanzania. In particular, the expansion of the mining sector has led to greater urbanization and mobility between rural and urban areas. This means that young and sexually active men come into close contact with ‘high risk sexual networks’ made up of sex workers, women at truck stops and miners: all of whom have high levels of HIV prevalence.

Long-distance truck drivers, agricultural plantation workers and fishermen working along coastal trading towns are also at an increased risk of HIV. For example, a 2015 study by the International Organization for Migration on truck drivers in Dar es Salaam found all those surveyed had established sexual relationships with partners at truck stops whom they considered permanent or second wives (described as ‘Mapoza’). A 2018 study involving around 400 people from fishing communities in Tanzania found an overall HIV prevalence of 14%, although this varied widely depending on location, from 7.2% to 23.8%. Around 38% of study participants living with HIV who had been diagnosed had not started treatment.

It is not only mobile men who are at increased risk of HIV infection. Women who travel away from home five or more times in a year have been found to be twice as likely to be infected with HIV than women who do not travel.

Sex workers

Tanzania criminalizes sex work, and it is punishable by law. Despite this, it is estimated that around 150,000 people, mainly women, sell sex, especially in Dar-es-Salaam.

In 2018, HIV prevalence among female sex workers was estimated at 15.4%. However, as with many other key population groups, data is limited and previous estimates suggest HIV prevalence among this group is much higher, at around 31%. Around 70% of sex workers are estimated to use condoms. This is despite sex workers having poor access to HIV prevention

programs, which are thought to reach around one in five.

The gender inequalities that result in women being disproportionately affected by HIV in Tanzania are acutely felt by female sex workers. The fact that sex work is also illegal means sex workers are subject to abuse and human rights violations from clients and from those in authority, including police officers and healthcare workers.

This means many sex workers are reluctant to access HIV prevention, testing and treatment services while also being exposed to high levels of sexual violence, multiple partners and condom less sex.

Men who have sex with men (MSM)

Same-sex sexual relations are illegal in Tanzania. As a result, data on this population group is extremely limited, a situation made worse by a government-sanctioned crackdown on LGBT people that began in 2015.

In 2018, 8.4% of men who have sex with men (sometimes referred to as MSM) in Tanzania were estimated to be living with HIV.36 However previous estimates released in 2014 put prevalence much higher, at 25%. This data suggested there were 49,700 men who have sex with men in the country.

In 2014, only around 14% of men who have sex with men reported using condoms consistently. However, data from 2013 put condom use levels at 63%, highlighting how patchy the evidence currently is.

HIV testing and counselling (HTC) in Tanzania

Results from THIS suggests around 65% of adults in Tanzania have taken an HIV test at least once (59% of men and 71% of women) but only a third regularly test for HIV (every 12 months). Around 16% of adults who tested positive during THIS had never been tested for HIV before (20% of men and 14% of women).

Adolescents (ages 15-19) have particularly low testing levels, despite high levels of sexual activity. THIS found that around 79% of adolescent men and 61% of adolescent women had never tested for HIV before.

Over the last decade, Tanzania has increased its efforts to get more people testing for HIV. The number of voluntary counselling and testing (VCT) sites in the country has rapidly expanded (around 2,100 as of 2013).

In the same year Tanzania introduced new HIV testing approaches such as home-based testing, community testing and provider-initiated testing.

Since other testing approaches, such as index testing, have also been introduced. As a result of these accelerated efforts, in 2018 the number of people living with HIV who were aware of their status was 78%, compared with 64% in 2015.

In 2018 the Tanzanian government began to fully scale-up self-testing for HIV and is focusing on providing self-testing kits for hard-to-reach groups. For example, using antennal clinics to provide pregnant women with self-testing kits to pass onto their husbands or boyfriends. Pilot programs are also being carried out to learn how best to provide self-testing kits to the partners of sex workers and other key and vulnerable populations.

The Tanzanian government has also begun a campaign called Furaha Yangu! (My Happiness!) to increase the number of young men and adolescent boys testing for HIV.

HIV prevention programs in Tanzania

In 2018, 72,000 people became HIV-positive in Tanzania. Although new infections have declined by 13% since 2010, more needs to be done to reduce HIV transmission.

Tanzania is currently implementing its fourth Health Sector HIV and AIDS Strategic Plan (HSHSP IV), which runs between 2017 and 2022. The strategy aims to increase access to combination prevention services for the general population in order to reduce new HIV infections. The guidelines also commit to implementing comprehensive prevention services for a number of key populations, including adolescent girls and young women, female sex workers, men who have sex with men, people who inject drugs, prisoners and migrant populations.

Significant progress that has been made in the prevention of mother-to-child transmission (PMTCT) in the past few years in Tanzania. In 2018, 93% of pregnant women living with HIV were receiving effective ART, compared to 75% in 2010. It is estimated that ART coverage among pregnant women living with HIV has averted around 14,000 new infections among newborns. However, 8,600 children still acquired HIV in 2018.

One of the reasons for HIV transmission still occurring vertically (from parent to child) is that not all pregnant women are tested for HIV. In 2018, 91% of pregnant women attending antenatal services received HIV testing. In addition, only half (47%) of infants exposed to HIV during pregnancy were tested for HIV within eight weeks of birth (known as ‘early infant diagnosis’).

To reach as many women as possible, the vast majority of PMTCT services are now integrated with reproductive and child health services.

Inefficient antiretroviral drug regimens for pregnant women and new mothers, drug stock-outs and poor adherence to treatment also contribute to the continuing transmission of HIV via this route.

Condom promotion

The Tanzanian government recognizes condom promotion as an integral part of its fight against the epidemic. The goal of its 2017-2022 HIV prevention strategy is to ensure 85% of people engaged in multiple sexual partnerships use condoms correctly and consistently.

To achieve this, around 260 million free condoms must be made available annually. However, weak supply lines and a lack of funding means this may not be achievable. In 2018, it was reported that the Global Fund to Fight AIDS, Tuberculosis and Malaria would finance 120 million public sector condoms, PSI would contribute around 18 million and an additional 20 million would be provided by other sources. This leaves an impending shortfall of around 100 million condoms.

In addition, more effective promotion is needed to encourage people to use condoms. In 2017, it was reported that just 30% of women and 46% of men used a condom the last time they had a sex with a non-marital, non-cohabiting partner. These levels are lower than previously reported, suggesting more people are engaging in risky sexual behavior that leaves them vulnerable to HIV infection

Low condom use is also occurring among high-risk groups. For instance, a study involving 18 to 24 year-old women in Dar-es-salaam found that only 32% used a condom during sex with regular boyfriends. Condom use declined even further if the women were involved in transactional sexual relationships with older men, with only 2% saying they always used a condom during these types of sexual encounters.

HIV awareness and sex education

While Tanzania has a broad sex education curriculum, only a third of schoolteachers have been trained on how to deliver these lessons, meaning access is patchy. In addition, certain subjects, such as the examination of minority sexualities, are not covered. Condom demonstration and condom distribution is also not allowed during sex education lessons. On top of this, the number of people attending school beyond primary level is low, with only around 19% of people having some form of secondary education. This limits the opportunities to reach older adolescents with sexual health education.

To fill these gaps, a number of civil society organizations provide additional sexual and reproductive health and HIV education, in and out of school settings.

Voluntary medical male circumcision (VMMC)

Circumcision is an effective HIV prevention strategy, reducing a man’s risk of acquiring HIV by approximately 60%. When used in combination with other prevention measures, circumcision is an important addition to HIV-prevention options for men.

In 2010 the government prioritized 11 regions for scaling VMMC and set a target of 2.8 million circumcisions by 2016.60 Around 2.6 million men were circumcised between 2015 and 2018, equating to around 80% of 15 to 49-year-old men.

CASE STUDY: Creating demand for VMMC

When a VMMC project was first established in the Kaliua District, Tabora, many men were put off by rumors that the removed foreskins would be used for conducting rituals. To dispel these rumors and create demand for the service, peer educators from the project hold meeting with community leaders to answer specific questions and address any concerns about the safety of VMMC and the disposal of foreskins.

Targeting influential people within the community paid off. The number of people presenting for voluntary circumcision, which had previously been visited predominantly by boys from a nearby primary school, subsequently increased to an average of between 20-28 adult men each day.

The local outreach site and dispensary conducted more than 1,000 VMMCs in 2015.

Cash transfer programs

Cash transfer programs form part of a new arm of HIV prevention that focuses on integrated programs for social protection schemes and sexual health. Across sub-Saharan Africa these types of programs have been shown to have a positive effect on preventing HIV and other sexually transmitted infections (STIs).

In one Tanzanian pilot, cash incentives of US$10 or US$20 were given to young adults aged between 18 and 30, as long as they were free from STIs. One year into the study, there was a 25% risk reduction in STIs. These programs show that economic benefit can positively influence people to use condoms more frequently.

In 2017 the Tanzanian government, in collaboration with UNICEF, began a cash transfer scheme called Cash Plus as part of a program to empower and strengthen the resilience and wellbeing of adolescents from the country’s poorest households. Cash Plus participants receive tailored, life skills training on various subjects, including sexual and reproductive health, as well as being linked to sexual and reproductive health and HIV services. They also receive financial support to either stay in school or start a small business and are supported by mentors and peer educators throughout.

Harm reduction

In 2011, with assistance from PEPFAR, Tanzania became the first country in sub-Saharan Africa to implement a harm reduction program for people who inject drugs. A methadone treatment clinic opened up in Tanzania’s largest health facility, based in Dar es Salaam, then extended to a second hospital in the city. Although there has since been an increase in opioid substitution therapy (OST) interventions outside Dar es Salaam, access remains limited, with just 20% of people who inject drugs able to access OST in 2018.

This is also the case with needle and syringe exchanges. In 2017, just 15 needles and syringes were distributed per person per year. As a result, it is estimated that around 14% of Tanzanian-based people who inject drugs are sharing needles when injecting.

Harm Reduction International also reports that the Tanzanian government has taken “regressive steps” in its harm reduction-related policy in recent years, with policy-makers continuing to favor abstinence-based approaches above harm reduction.

Pre exposure prophylaxis (PrEP)

In 2018 Tanzania began to scale up pre-exposure prophylaxis (PrEP), a daily course of antiretroviral drugs taken by HIV-negative people to protect themselves from infection, for key populations. The following year, the government announced plans to extend this nationwide, including expanding eligibility criteria to include adolescent girls and young women.

As of 2019, it was estimated that between 3,200 and 3,700 people were using PrEP in Tanzania. Most of these people are adolescent girls and young women, although female sex workers and their partners and the HIV-negative partners of people living with HIV are also being targeted by implementation or demonstration projects.

Antiretroviral treatment (ART) in Tanzania

Tanzania has significantly scaled up its antiretroviral (ART) programs in recent years, and the number of people on ART has been steadily increasing since 2010.

In 2017, Tanzania introduced the World Health Organization (WHO) recommended ‘test and treat’ guidelines, which makes anyone testing positive for HIV eligible for immediate treatment regardless of the level of HIV in their body. This has seen ART coverage expand significantly: in 2018, 71% of people living with HIV in Tanzania were receiving ART, equivalent to 1.1 million people.

This is around a 20% increase from 2015, when 52% of HIV-positive people were on ART. As of 2018, around 90% of people diagnosed with HIV began ART in less than seven days.

HIV-positive women are far more likely to be on treatment than HIV-positive men. In 2018, 82% of women and 57% of men living with HIV were receiving ART.

Children (ages 0-14) are less able to access treatment than adults, with 65% of HIV-positive children on ART in 2018. However, this is an improvement on 2015 levels when just 53% of HIV- positive children were on treatment.

More than 95% of people on treatment are still in care after 12 months, according to 2018 data. This is closely linked to good levels of viral suppression. In 2018, 87% of people diagnosed and on treatment were virally suppressed, with men and women enjoying similar levels of viral suppression (86% and 89% respectively). However, due to gaps in testing and linkage to care, overall, only 62% of people living with HIV are virally suppressed.

Studies conducted in various regions of Tanzania have reported low linkage to care for people who test HIV-positive. For example, a study following around 1,000 people newly diagnosed with HIV in Mbeya, a rural area, found just 28% were successfully linked to care. Under-resourced, poorly coordinated health services, as well as high levels of HIV-related stigma were the main reasons these people did not begin treatment.

The Tanzanian government has begun to simplify drug regimens and move to fixed-dose combinations while phasing out toxic drugs such as Stavudine. Evidence is currently mixed as to whether levels of pre-treatment and acquired drug-resistant HIV are high enough to be considered a public health issue in Tanzania.

Civil society’s role

Poverty, poor institutional and infrastructural support, and social and cultural neglect are impeding an effective and progressive HIV response in Tanzania. In 2017, Civicus, the global alliance of civil society organizations and activists dedicated to strengthening citizen action and civil society, placed the country on a watch list due to growing threats to civic space. In February of the same year, the government closed 40 healthcare facilities providing HIV services under the premise that they were promoting homosexuality. In June 2017, President Magufuli severely criticized NGOs working for the rights of LGBTI people.

In 2018, Tanzania’s sustained anti-gay crackdown was part of a broader trend of suppression and a disappearing civil society voice. The repercussions have been felt through all key population groups, affecting access to HIV and sexual health services, and increasing stigma and discrimination.86 It has also resulted in hundreds of LGBT activists going into hiding in order to avoid punishment.

They are raiding houses. It is a horrible thing. It is just going to get worse. So many people are leaving the city, running away. They are targeting the activists, saying we are promoting homosexuality.

The WHO classifies Tanzania within the top 20 high burden countries for tuberculosis (TB) and for TB/HIV.

In 2017, just under 70,000 cases of TB were presented and 98% had a known HIV status. Of this group, 31% were co-infected with HIV, of whom 95% were on antiretroviral treatment. In the same year, 22,000 people living with HIV died due to TB. The death rate has halved since 2010 when there were 44,000 TB-related deaths among HIV-positive people in Tanzania.

The government has prioritized the integration of TB services with HIV services to minimize the burden of these two co-morbidities. Ensuring that people living with HIV are on antiretroviral treatment means that they are in a better place to fight off TB infection. Integrating these two services will also ensure greater access to TB treatment.

The Tanzanian government has done well to keep the country on track to reaching all of the TB targets set within the Millennium Development Goal (MDG) frameworks.

The number of people living with HIV who presented with TB and received treatment for HIV and TB increased from 16% in 2012 to 42% in 2017.92 However, this still leaves a large portion of people with HIV/TB co-infected without comprehensive treatment.

Taking actions to reduce neonatal disorders

June 18, 2021June 29, 2021Leave a comment

By Pooja Senthamaraiselvan – Art in Tanzania internship

Tanzania is making great strides in reducing child mortality, but has demonstrated slower progress in reducing neonatal deaths. There has been a declining trend in NMR over the past decade but it indicates a very gradual improvement. In order to meet the Millennium Development Goal (MDG) 4 for child survival, the number of newborn deaths in Tanzania must be greatly reduced. At the current rate of progress, Millennium Development Goal 4 could be met, if more attention is given to newborn survival [1].

Most neonatal deaths are due to preventable and treatable causes. Up to two-thirds of newborn lives could be saved if essential care reached mothers and babies [1]. Hence, there are opportunities to lower mortality rates even further with interventions at both the health facility level and the community level in Tanzania to ensure better healthcare provision to these parties.

This will mainly require implementing improvements in resources for maternal and neonatal care in terms of quality, availability, accessibility, and affordability as well as creating more awareness about birth plans for labour and delivery among the people in Tanzania, particularly pregnant women.

Actions at the health facility level to save newborn lives

Improve infrastructure and supplies – ensuring every district hospital has a neonatal unit, practices Kangaroo Mother Care (KMC) and all health facilities have functional equipment and essential drugs such as gentamicin for treating neonatal sepsis

Recruit and retain quality staff – filling vacant posts and addressing turnover among existing staff; ensuring competence in key skills such as neonatal resuscitation

Improve guidelines and service delivery – establishing or improving procedures for routine postnatal care and management of preterm and sick newborns

Integrate services – linking emergency obstetric services with newborn care and improving transport and referral mechanisms

Use data locally for quality improvement – recording and auditing neonatal deaths and stillbirths [1]

Actions at the family and community level to save newborn lives

Identify a means to reach every mother and baby in the early postnatal period (within the first two days after birth)

Invest in primary health care at the village level by ensuring appropriate supervision, remuneration and working conditions for village health workers

Strengthen community – Integrated Management of Childhood Illness (IMCI) to effectively reinforce healthy behaviours, recognition of danger signs and timely care seeking, to identify harmful traditional practices and awareness of key newborn health packages, such as routine postnatal care, KMC and IMCI

Engage communities in birth preparedness, including planning to give birth at a health facility and emergency transport

Reduce the economic burden of a facility birth on women and their families [1]

These actions depend on leadership at all levels. Tanzania’s decentralised health system ensures that public health interventions are linked to those who need them but more effort is needed to integrate newborn health packages into district level budgets and planning. Newborn lives can be saved by implementing appropriate policies, improving staffing levels and supervision in health facilities and providing an enabling environment for community-level care.

There is an immediate opportunity for Tanzania to implement the recommendations within the Road Map/One Plan to improve newborn health from the highest level in both public and private health facilities and to infl uence the care newborns receive at home.

Tanzania’s future depends on the ability of these newborns to survive and thrive. This situation analysis sheds light on the current state of care and the opportunities to save lives. While better data, policy change and revised guidelines will make a difference, it takes people to act to save newborn lives. Will you use this information to become a champion of the country’s most vulnerable and precious citizens?

References

[1]https://www.countdown2015mnch.org/wp-content/uploads/2013/02/Tanzania_SituationAnalysis_Newborn.pdf

Fight Against Tuberculosis

May 31, 2021July 4, 2021Leave a comment

by Senthamaraiselvan Pooja – Art in Tanzania internship

Background of Tuberculosis

Tuberculosis (TB) is an airborne infectious disease caused by a bacterium called Mycobacterium tuberculosis. The United Republic of Tanzania is one of the 30 countries with the highest burden of TB in the world. According to WHO, 142 000 people (253 per 100 000 population) fell ill with TB in 2018 [1].

A large proportion of persons with the illness (90% to 95%) have latent TB infection (LTBI) in which case they do not exhibit any symptoms as the immune system will contain and control the infection. However, the infection typically does not get eliminated and most people with LTBI do not know that they are infected because they do not feel sick.

The bacteria can remain inactive for many years and the chance of developing active TB decreases over time [2].

Approximately 5% to 10% of individuals are not able to control the initial infection and will develop primary tuberculosis. The dormant bacteria can also become active again in a few of those with LTBI due to various factors that compromise the immune system. Active tuberculosis among this group is referred to as reactivation tuberculosis [3].

Main Differences between Latent and Active TB
Latent TB
●                     TB bacteria are “asleep” in your body
●                     You do not have symptoms and you feel well
●                     You cannot pass TB on to others
●                     It can only be detected through a blood test or TB skin test

Active TB
●                     TB bacteria are “awake” and making you ill
●                     You will have symptoms that make you feel unwell
●                     You can pass TB to others if it is in your lungs
●                     It shows up on a chest x-ray if you have TB in the lungs [4]

Symptoms of Active TB
Tuberculosis most often affects the lungs and respiratory tract. This is known as pulmonary TB. However, TB can affect almost any organ system. Active tuberculosis can manifest as pulmonary or extrapulmonary disease irrespective of whether the individual is a primary or reactivation case. However, approximately 80% of clinically manifested tuberculosis is pulmonary among individuals with good immune function, while extrapulmonary tuberculosis can be seen more frequently in immunocompromised people.

Pulmonary TB can be mild or severe and present with any of the following symptoms: excessive coughing (sometimes with blood in the sputum), chest pain, general weakness, lack of appetite, weight loss, swollen lymph glands, fever, night sweats, chills, and fatigue. Extrapulmonary TB can also present with fever, fatigue, night sweats, and progressive weakness, but prominent symptoms will typically stem from the affected organ system.

Extrapulmonary TB commonly involve the pericardium (thin sac surrounding the heart), lymph nodes (small, oval-shaped cluster of immune cells located throughout the body), urogenital area, gastrointestinal tract, central nervous system, adrenal glands, bones, eyes, and skin [3]. If untreated, active TB can be life-threatening.

TB Transmission

TB is spread to susceptible individuals when they breathe in contaminated droplets that are released into the air when an infected person (with Active Tuberculosis) nearby sneezes, coughs, talks or laughs. Humans can also get ill with TB by ingesting unpasteurized milk products contaminated with Mycobacterium bovis, also known as Bovine Tuberculosis [2].

Risk Factors for Progression and Development of Active TB Disease

In general, people at high risk for developing active TB once infected with M. tuberculosis include:

People living with HIV/AIDS
Children younger than 5 years of age
Persons who are receiving immunosuppressive therapy
Persons who were recently infected with M. tuberculosis (within the past 2 years)
Persons with a history of untreated or inadequately treated TB disease
Persons with silicosis, diabetes, chronic renal failure, leukemia, lymphoma, or cancer of the head, neck, or lung
Persons who have had a gastrectomy or jejunoileal bypass
Persons who weigh less than 90% of their ideal body weight
Cigarette smokers and persons who abuse drugs or alcohol
Populations defined locally as having an increased incidence of TB disease, possibly including medically underserved or low-income populations [5]

TB Control and Prevention

Individual Level

Keep your immune system strong by eating healthy and exercising
Avoid exposure to people known to who have active TB.
Surgical masks should be worn by patients with active TB to prevent infectious droplets from being expelled into the air.
Only consume pasteurized milk products.
Travellers at higher risk should have a pre-departure tuberculin skin test (TST) and be re-tested upon their return home.
Those at increased risk should also consult their healthcare provider to determine if the Bacillus Calmette-Guérin (BCG) vaccine is recommended [2].

Community Level

There are several critical factors that need to be taken into account to implement an effective tuberculosis control and prevention program to protect the community.

Significant resources including public health infrastructure and personnel are required to enact and sustain tuberculosis control programs. Sustainability is critical because control of this disease requires a long-term effort. As such, a strong commitment by government agencies, which can mobilize the necessary resources and infrastructure, is essential for regional control of tuberculosis.

Rigorous case finding and treatment is obviously critical to save the affected individuals as well as stop transmission of infection to contacts. Case identification must combine microscopy and clinical symptoms, and treatment should consist of the short-course of directly observed therapy (DOTS) elaborated below.

Exhaustive contact tracing for contacts of each active tuberculosis case should be carried out in the field so that new infections can be identified and treated before becoming active cases.

A good surveillance system is fundamental to the control of any infectious disease. An administrative system for recording cases and monitoring outcomes is necessary to estimate the occurrence of disease and identify temporal trends and spatial clusters.

An adequate supply of tuberculosis medications must be available to populations with endemic tuberculosis. This may seem obvious, and it is, but unfortunately the lack of a consistent supply of medication has hampered many control programs particularly in poor areas of the developing world [3].

Technology

Germicidal ultraviolet lamps can be installed to kill airborne bacteria in buildings where people at high risk of tuberculosis live or congregate. A germicidal lamp is an electric light that produces ultraviolet C (UVC) light. UVC light kills tuberculosis bacteria, including drug-resistant strains, by damaging their DNA so they cannot infect people, grow or divide [6].

TB Treatment

Treating tuberculosis requires a long-term commitment. Specifically, at least 6 months of treatment are required because of the heterogeneous population of M. tuberculosis in an infected individual, which is composed of bacteria in active and dormant states. Medication that is effective against active mycobacteria may not work against latent mycobacteria and, thus, extended treatment ensures that the whole population of M. tuberculosis will eventually be exposed to the drug. Inactive tuberculosis may be treated with an antibiotic, isoniazid (INH), to prevent the TB infection from becoming active. Active tuberculosis is treated, usually successfully, with isoniazid in combination with one or more of several drugs, including rifampin, ethambutol, pyrazinamide, and streptomycin.

However, drug-resistant TB is a serious, as yet unsolved, public-health problem, among several regions including Africa. Undergoing treatment over a long time favors the emergence of drug-resistance gene mutations in the M. tuberculosis population.

Thus, at least two effective drugs must be administered: this reduces the probability of developing drug-resistant bacilli.

Poor patient compliance, lack of detection of resistant strains, and unavailable therapy are also key reasons for the development of drug-resistant TB. Non-adherence can lead to treatment failure in the individual as well as the development of antibiotic resistant forms of M. tuberculosis.

Therefore, adherence to treatment with the full regimen is essential for treatment success. To effect complete resolution of infection in the individual and mitigate the spread of antibiotic resistance in the population, WHO recommends the short-course strategy of directly observed therapy (DOTS) regimen, comprised of four drugs (typically isoniazid, rifampicin, pyrazinamide, and ethambutol) for two months, followed by two drugs (typically isoniazid and rifampicin) for four months.

DOTS regimen requires a healthcare worker to monitor each tuberculosis patient closely and observe the patient taking each dose of anti-tuberculosis medication to ensure proper compliance [3].