Bugando Medical Centre Research Articles

Using digital health to facilitate compliance with standardized pediatric cancer treatment guidelines in Tanzania: protocol for an early-stage effectiveness-implementation hybrid study

BackgroundIn high-income countries (HICs), increased rates of survival among pediatric cancer patients are achieved through the use of protocol-driven treatment. Compared to HICs, differences in infrastructure, supportive care, and human resources, make compliance with protocol-driven treatment challenging in low- and middle-income countries (LMICs). For successful implementation of protocol-driven treatment, treatment protocols must be resource-adapted for the LMIC context, and additional supportive tools must be developed to promote protocol compliance. In Tanzania, an LMIC where resource-adapted treatment protocols are available, digital health applications could promote protocol compliance through incorporation of systematic decision support algorithms, reminders and alerts related to patient visits, and up-to-date data for care coordination. However, evidence on the use of digital health applications in improving compliance with protocol-driven treatment for pediatric cancer is limited. This study protocol describes the development and evaluation of a digital health application, called mNavigator, to facilitate compliance with protocol-driven treatment for pediatric cancer in Tanzania.MethodsmNavigator is a digital case management system that incorporates nationally-approved and resource-adapted treatment protocols for two pediatric cancers in Tanzania, Burkitt lymphoma and retinoblastoma. mNavigator is developed from an open-source digital health platform, called CommCare, and guided by the Consolidated Framework for Implementation Research. From July 2019–July 2020 at Bugando Medical Centre in Mwanza, Tanzania, all new pediatric cancer patients will be registered and managed using mNavigator as the new standard of care for patient intake and outcome assessment. Pediatric cancer patients with a clinical diagnosis of Burkitt lymphoma or retinoblastoma will be approached for participation in the study evaluating mNavigator. mNavigator users will document pre-treatment and treatment details for study participants using digital forms and checklists that facilitate compliance with protocol-driven treatment. Compliance with treatment protocols using mNavigator will be compared to historical compliance rates as the primary outcome. Throughout the implementation period, we will document factors that facilitate or inhibit mNavigator implementation.DiscussionStudy findings will inform implementation and scale up of mNavigator in tertiary pediatric cancer facilities in Tanzania, with the goal of facilitating protocol-driven treatment.Trial registrationThe study protocol was registered in ClinicalTrials.gov (NCT03677128) on September 19, 2018.

Methicillin resistant Staphylococcus aureus causing osteomyelitis in a tertiary hospital, Mwanza, Tanzania

BackgroundCulture results of fluid/pus from sinuses or open wound are not reliable in establishing the causative agent of osteomyelitis due to the high chances of contamination of superficial contaminants. Bone fragments obtained during surgery have been recommended as ideal sample to establish pathogens causing osteomyelitis. This study investigated pathogens causing osteomyelitis among patients undergoing orthopedic surgical treatment at Bugando Medical Centre.MethodsA cross-sectional hospital-based study was conducted from December 2017 to July 2018 among 74 patients with osteomyelitis who underwent surgical treatments at Bugando Medical Centre, Mwanza, Tanzania. Bone fragments were collected using sterile 10 ml of in-house prepared brain heart infusion broth (Oxoid, UK) during surgery. Specimens were processed according to standard operating procedures within an hour of collection. Data were analyzed using STATA 13.0.ResultsThe median age of study participants was 12 with inter quartile range of 8–20 years. The majority 45 (60.8%) of participants were male. All 74 non-repetitive bone fragment specimens had positive culture, of which 17 had dual growth of bacteria resulting to 91 bacterial isolates. Out of 91 isolates, 63 (85.1%) were Staphylococcus aureus (S. aureus) of which 18 (28.6%) were confirmed to be methicillin resistant Staphylococcus aureus strains. Fever was significantly associated with Staphylococcal osteomyelitis (100% vs. 79.6%, p = 0.029).ConclusionAbout one third of cases of Staphylococcal osteomyelitis in the current study were caused by methicillin resistant Staphylococcus aureus. There is a need of tailoring antibiotic management of osteomyelitis based on culture and sensitivity results for the better treatment outcome of the patients.

Use of HBA1c and potentiality of gender, missed medication and fasting glucose in the prediction of poor glycemic control in resource-limited setting; a clinic-based case-control study

INTRODUCTION: Diabetes Mellitus (DM) type 2 is a rapidly growing health problem in the world especially in resource limited countries. Even with availability of affordable medication still a large proportion of patients don´t attain a well-controlled glycemic state thus putting them at high risk of morbidity and mortality due to irreversible complications. Availability of glycated hemoglobin test (HBA1c) for better monitoring of glycemic control is still a setback in most resource restricted setting including Tanzania. This study was designed to determine the magnitude of uncontrolled DM type 2 using HBA1c and assess the utility of different factors in sorting patients at high risk of having uncontrolled DM in a clinic based setting in north western Tanzania. METHODS: this was a case control study involving diabetes type 2 patients at Bugando Medical Centre. A cross sectional measurement of glycated hemoglobin (HBA1c) and fasting glucose were done, medical history and adherence status to anti diabetes were assessed. Data analysis was done using STATA 13. Uncontrolled Diabetes was defined as an HBA1c of more than 7.0 and its correlates were assessed by logistic regression model. The predictive ability of independent variables was determined by calculating their sensitivity and specificity. RESULTS: in total 229 patients were included in this study, where 114 (49.8%; 95%CI: 43.3-56.3) had uncontrolled DM2 by HBA1c. In this study uncontrolled DM was independently associated with female gender, (AOR: 2.1; 95%CI: 1.1-3.9; p=0.022), frequently missed medications (AOR: 1.1; 95%CI: 1.03-1.2; p=0.006), and higher fasting median blood glucose, (10.5 vs. 6.9; AOR: 7.3; IQR: 3.7-14.7; P<0.001). Fasting glucose had higher predictive values to uncontrolled DM2 (sensitivity: 79.0%; 95%CI: 70.3-86.0; specificity: 84.4%; 95%CI: 76.4-90.4, cut point: 8.5; area under ROC curve: 0.8584)as compared to gender and missed medications. CONCLUSIONS: uncontrolled DM type 2 is common in Notherwestern Tanzania, and is well predicted by fasting hyperglycemia. Fasting hyperglycemia can be used in selecting patients that could benefit from timely intensification of treatment where HBA1c is not available.

Spectrum of heart diseases in children presenting to a paediatric cardiac echocardiography clinic in the Lake Zone of Tanzania: a 7\u2009years overview

BackgroundCongenital heart diseases (CHD) are among the most common congenital malformations. It is estimated that the incidence of CHD is constant worldwide, but data are rare for most African countries including Tanzania. Even less data are available on the prevalence of acquired heart diseases (AHD) in African children. Rheumatic heart disease (RHD) is the leading cause of AHD and is remaining a public health concern in Sub-Saharan Africa affecting especially the younger population. Both, CHD and AHD contribute substantially to morbidity and mortality during infancy and childhood.MethodsThis hospital-based, retrospective review of the registry at the paediatric cardiac clinic of Bugando Medical Centre in the Lake Zone of Tanzania analysed the spectrum of heart diseases of paediatric patients during their first presentation by using simple descriptive statistics.ResultsBetween September 2009 and August 2016, a total of 3982 patients received cardiac evaluation including echocardiography studies. 1830 (46.0%) pathologic findings were described, out of these 1371 (74.9%) patients had CHD, whereas 459 (25.1%) presented with AHD.53.9% of the patients with CHD were female and the most common associated syndrome was Down syndrome in 12.8% of patients. In 807 patients (58.9%) diagnosis of CHD was established within the first year of life. The majority of patients (60.1%) were in need of surgical or interventional therapy at time of diagnosis and 6.3% of patients were judged inoperable at the time of first presentation. Nearly 50% of cases with AHD were RHDs followed by dilated cardiomyopathy and pulmonary hypertension without underlying CHD.ConclusionsThe spectrum of CHD and AHD from one centre in Tanzania is comparable to findings reported in other countries from the African continent. Echocardiography is a valuable diagnostic tool and the widespread use of it should be enhanced to diagnose heart diseases in a large number and reasonable time. Most patients present late and majority is in need of surgical or interventional treatment, which is still not readily available. Untreated heart diseases contribute substantially to morbidity and mortality during infancy and childhood. Adequate cardiac services should be established and strengthened.

The magnitude and correlates of esophageal Varices among newly diagnosed cirrhotic patients undergoing screening fibre optic endoscope before incident bleeding in North-Western Tanzania; a cross-sectional study

BackgroundBleeding esophageal varices is a deadly complication of liver cirrhosis. Guidelines recommend an early diagnosis of esophageal varices before incident bleeding by screening all patients diagnosed with liver cirrhosis. Though it has been reported elsewhere that the presence of esophageal varices varies widely among cirrhotic patients this has not been assessed in Tanzania since endoscopy is not readily available for routine use in our setting. This study was designed to determine the prevalence of esophageal varices and assess the utility of clinical parameters in predicting the presence of varices among cirrhotic patients in northwestern Tanzania.MethodsA cross-sectional analysis of adult patients with liver cirrhosis was done at Bugando Medical Centre. Demographic, clinical, laboratory and endoscopic data were collected and analyzed using STATA 13. The presence of esophageal varices was detected using endoscopic examination and associated factors were assessed by logistic regression. The predictive value of clinical predictors was also assessed by calculating sensitivity and specificity.ResultsA total of 223 patients were enrolled, where 88 (39.5%; 95%CI: 33.0–45.9) had esophageal varices. The varices were independently associated with increased age (OR: 1.02; 95%CI: 1.0–1.04; p = 0.030); increased splenic diameter (OR:1.3; 95%CI:1.2–1.5; p < 0.001), increased portal vein diameter (OR:1.2; 95%CI: 1.07–1.4; p = 0.003), having ascites (OR: 3.0; 95%CI: 1.01–8.7; p = 0.046), and advanced liver disease (OR: 2.9; 95%CI: 1.3–6.7; p = 0.008). PSDR least performed in predicting varices, (AUC: 0.382; 95%CI: 0.304–0.459; cutoff: < 640; Sensitivity: 58.0%; 95%CI: 46.9–68.4; specificity: 57.0%; 95%CI: 48.2–65.5). SPD had better prediction; (AUC: 0.713; 95%CI: 0.646–0.781; cut off: > 15.2 cm; sensitivity: 65.9%; (95% CI: 55–75.7 and specificity:65.2%; 95%CI: 56.5–73.2), followed by PVD, (AUC: 0.6392; 95%CI: 0.566–0.712;cutoff: > 1.45 cm; sensitivity: 62.5%; 95CI: 51.5–72.6; specificity: 61.5%; 95%CI: 52.7–69.7).ConclusionEsophageal varices were prevalent among cirrhotic patients, most of which were at risk of bleeding. The non-invasive prediction of varices was not strong enough to replace endoscopic diagnosis. However, the predictors in this study can potentially assist in the selection of patients at high risk of having varices and prioritize them for endoscopic screening and appropriate management.

Impact of Capacity Development Program on Outcomes for Pediatric Hematologic Malignancies in Tanzania

Background: Globally, over 400,000 children are diagnosed with cancer each year, with hematologic malignancies being the most common diagnosis. However, there is a 60% survival gap between high income and low to middle income countries. Causes of this disparity are multifactorial and require comprehensive capacity development to improve outcomes. In 2014, a twinning program was started between Duke University and Bugando Medical Centre (BMC) in Mwanza Tanzania, focused on the development of treatment capacity for pediatric hematologic malignancies. We report on the program development and impact on outcomes for leukemia. Methods: Key stakeholder interviews were completed at BMC to identify areas for capacity development. A Duke University pediatric hematology/oncology faculty member spends 6 months per year on site to provide training and clinical care. Capacity development was completed through a step-wise approach based on identified needs, with one new area of focus per year. Outcome evaluation includes 1-year overall survival by diagnosis and year. Results: Stakeholder identified needs included development of a patient registry for monitoring, reducing cost of care, and improving provider knowledge about pediatric cancer. In 2014 the partnership established a cancer registry for outcome monitoring, and provided medical and laboratory training on the resource adapted diagnostic and treatment protocols for hematologic malignancies. In 2015, partnerships with local non-profit organizations provided chemotherapy and diagnostic testing at no cost to the patients. In 2016, the focus was on providing social support through the use of a patient navigation program and provision of local housing during treatment; in 2017 formalized treatment collaboration between BMC and the Tanzanian National Pediatric Hospital (MNH) was established. Additional local non-governmental support allowed for the transfer of patients between hospitals and care coordination. New pediatric cancer diagnoses at BMC increased from 100 in 2014 to 170 in 2018. From 2014-2018, leukemia represented 5-17 % of total cases, and lymphomas 20-30%. 1-year overall survival for ALL was 0% prior to 2016, and an average of 56% for 2016-2018. AML 1-yr OS remained 0% over the 5-year period. CML 1-yr OS increased from 0% in 2014-2015 to 25% in 2016-2018. From 2017-2018, 38% of patients diagnosed at BMC received national care coordination with 13% of these patients receiving part of their treatment plan at MNH. Discussion Despite increased training and reduced treatment costs, social support through patient navigation and a structured treatment collaboration were critical to improved outcomes for children with hematologic malignancies. These should be a priority for the development of future pediatric cancer programs in low resource settings. Additional focus on myeloid malignancies is needed to identify potential areas for outcome improvement. Disclosures No relevant conflicts of interest to declare.

Genetic Analysis in the Tanzania Sickle Surveillance Study (TS3): Modifiers of Sickle Cell Disease and Identification of Hemoglobin Variants

Introduction. Based on sparse historical data, Tanzania ranks fourth globally for the estimated number of annual births with sickle cell disease. Northwest Tanzania is projected to have an especially high burden of sickle cell disease, but no contemporary surveillance data exist to verify this projection. We designed a large prospective study to determine the prevalence of both sickle cell trait and sickle cell disease in northwest Tanzania. Additional objectives included an analysis of two known genetic modifiers of sickle cell disease [alpha thalassemia trait and glucose-6-phosphate dehydrogenase (G6PD) deficiency], as well as genetic variants affecting fetal hemoglobin (HbF) expression and characterization of hemoglobin variants. Methods. The Tanzania Sickle Surveillance Study (TS3) is a prospective cross-sectional study to determine the prevalence of sickle cell trait and disease in an area projected to be at high risk. Dried blood spots (DBS) from all children born to HIV-infected mothers in the 9 regions across northwest Tanzania were collected by the HIV Early Infant Diagnosis (EID) program and transported to a central laboratory at Bugando Medical Centre, a teaching and consultancy hospital in Mwanza. DBS were tested by isoelectric focusing and scored as normal, trait, disease, or variant. Samples scored as disease or variant were retested for confirmation, and then frozen for subsequent genetic analysis. In the US, genomic DNA was extracted from each DBS, and sickle cell disease status was confirmed by PCR and TaqMan genotyping. All confirmed samples were then analyzed for alpha thalassemia trait (rightward -3.7 gene deletion) using quantitative real time PCR, and for G6PD deficiency using three real time PCR probes to distinguish A and B G6PD isoforms, to identify the G6PD A- variant, and to confirm the sex, respectively. Single nucleotide polymorphisms within 3 quantitative trait loci [BCL11A, the HBS1L-MYB intergenic polymorphism (HMIP) region, and the gamma-globin promoter XmnI site] that modify baseline HbF were analyzed using TaqMan genotyping. DBS with hemoglobin variants were investigated for the presence of common variants found in East Africa. Results. Between February 2017 and May 2018, a total of 232 IEF gels were completed by local staff in Tanzania. Among EID samples from children &amp;lt;24 months of age, the median age was 52 days (IQR 41-93 days), and 17,278 unique DBS samples were scored. With 20 samples uninterpretable and 54 samples with missing results, the primary analysis was performed on 17,204 samples. The overall prevalence of sickle cell trait and disease in the entire cohort was 20.3% and 1.2%, respectively, for a sickle allele frequency of 0.114 with Hardy-Weinberg equilibrium. There was some geographical variation between individual districts in both sickle trait (15.2-27.8%) and disease (0.0-4.3%). Hemoglobin variants were rare (0.1%) and included 4 Hb G-Pest, 2 Hb Kenya, and 1 Hb P-Nilotic. Of 143 DBS confirmed to have sickle cell disease and available for further testing, 61 (43%) had one-gene deletion alpha thalassemia trait and 21 (15%) had two-gene deletion. A- G6PD deficiency was detected in 19.2% of males, and 25.7% of females were heterozygous carriers. The minor allelic frequency for known modifiers of HbF were 32.2% C at rs11886868 (BCL11A), 26.6% T at rs1427407 (BCL11A), 32.5% A at rs4671393 (BCL11A), 23.8% G at rs28384513 (HMIP), 4.5% C at rs9399137 (HMIP), and 0% A at rs7482144 (XmnI). Conclusion. The prevalence of sickle cell trait and disease among infants in northwest Tanzania is very high, exceeding 20% trait and 1.2% disease. Regional prevalence data paired with region-specific crude birth rates predict 10,055 births annually in the northwest regions, more than doubling previous estimates. Concomitant alpha thalassemia trait and G6PD deficiency are frequently co-inherited and may affect the phenotype, as well as common genetic modifiers of HbF expression. Our detailed genetic analysis of a geographically representative surveillance cohort provides a foundation for future targeted screening and the introduction of hydroxyurea for treatment of sickle cell disease in northwest Tanzania. Disclosures Ware: Bristol Myers Squibb: Other: Research Drug Donation; Addmedica: Other: Research Drug Donation; Global Blood Therapeutics: Membership on an entity's Board of Directors or advisory committees; Agios: Membership on an entity's Board of Directors or advisory committees; Nova Laboratories: Membership on an entity's Board of Directors or advisory committees; CSL Behring: Membership on an entity's Board of Directors or advisory committees; Novartis: Other: DSMB.

Evaluating the appropriateness of chemotherapy in a low-resource cancer centre in sub-Saharan Africa.

BackgroundTo evaluate the appropriateness of chemotherapy use at the Oncology Department of the Bugando Medical Centre of Mwanza, Tanzania.MethodsThe study was an observational prevalence‐based study designed to evaluate a single‐chemotherapy cycle during a defined time period for a cross‐section of patients at varying stages of their clinical history. The sample included 103 consecutive subjects who were treated during January‐March 2017 and had at least one previous cycle. Chemotherapy treatment omissions, cycle delays, and dose reductions and their causes were recorded using a standard form that included demographic, anthropometric, and clinical items. The data were analyzed descriptively.ResultsThere were 59 males (57.3%) and 44 females (42.7%). Ninety‐four patients were aged ≥18 years. Considering cancer type/site, there were 23 distinct groups of patients. The recorded number of drugs in the chemotherapy regimens varied between one and five. The median cycle number was three (range: 2‐11). Sixty‐eight (66.0%) patients were treated in a standard fashion. For the remaining, cycle delay and dose reduction were the most common cause for nonstandard treatment. Hematologic toxicity was responsible for the greater part of cycle delays, whereas dose reductions were accounted for by a larger spectrum of causes. Overall, toxicity explained 21/35 (60.0%) patients receiving nonstandard treatment. The distribution of toxic events was skewed toward grade 1 and grade 2.ConclusionsThe observed level of appropriateness of chemotherapy was encouraging. The proportion of patients experiencing severe toxic effects was lower than expected.

Indications for and complications of intestinal stomas in the children and adults at a tertiary care hospital in a resource-limited setting: a Tanzanian experience

BackgroundAn intestinal stoma, though a life-saving procedure on the care of many gastrointestinal conditions, carries significant number of complications. This study describes the common indications, complications, and management of stomas and identifies the factors that are associated with these complications in a tertiary care hospital in Tanzania.MethodsA cross-sectional study of patients with intestinal stomas was conducted at Bugando Medical Centre (BMC) between July 2016 and June 2017. Ethical approval to conduct the study was obtained from relevant authority before the commencement of the study.ResultsA total of 167 patients (M: F = 1.2:1) were enrolled in the study. The mean age at diagnosis was 0.6 ± 1.4 years for children and mean age for adults was 36.7 ± 15.8 years. Anorectal malformation (110, 89.4%) was the most common indication for intestinal stoma formation in children, while bowel perforation (14, 31.8%) was the main indications in adults. The sigmoid colon (137, 82.0%) was the most common anatomical site for stoma formation followed by the ileum (18, 10.8%). Stoma prolapse (18, 41.9%) was the most frequent complication of a stoma, whereas, surgical site infection (9, 34.6%) was the most frequent complication after stoma closure. Thirty five (26.7.%) of the children developed stomal complications, while only 8 (22.2%) of the adults developed complications. The level of training of operating surgeon and timing of surgery were the main predictors of stoma-related complications (p < 0.034 and 0.013), whereas the level of training of the operating surgeon and the type of stoma closure were significantly associated with the complications related to stoma closure (p < 0.001).ConclusionThe intestinal stomas performed at BMC are associated with various complications, which in turn, become a burden to the patients. The insights observed in the current study may apply to other tertiary hospitals in Tanzania and Africa at large. We suggest that the keystones for improvement and control in the formation and complications of intestinal stomas are the following; colostomy formation should rarely be done in transverse colon, the procedure should be carried out by senior doctors (specialist) or junior doctors under close and direct supervision of the specialists, using proper meticulous techniques, and the need to determine and/or improve techniques for early detection of complications.

Helicobacter pylori Mutations Conferring Resistance to Fluoroquinolones and Clarithromycin among Dyspeptic Patients Attending a Tertiary Hospital, Tanzania.

Objectives. Helicobacter pylori (H. pylori) isolates resistant to clarithromycin and quinolones are increasing worldwide. Data regarding the magnitude of H. pylori resistance are limited in developing countries. Here, we report the prevalence of mutations conferring resistance to clarithromycin and fluoroquinolones among dyspeptic patients attending a tertiary hospital, Tanzania. Methods. Between August 2014 and August 2016, patients undergoing upper gastrointestinal endoscopy at the Bugando Medical Centre were enrolled. Biopsies were taken for polymerase chain reaction (PCR) and sequencing to detect mutations conferring resistance to clarithromycin and fluoroquinolones. Results. A total of 208 nonrepetitive biopsies were examined of which 188 (90.4%) tested positive for H. pylori specific 23S rRNA PCR. Clarithromycin resistance mutations were detected in 54/188 (28.7%) of patients tested. The most frequently detected mutation was A2143G (30) followed by A2142G (20). Out of 131 nonrepetitive biopsies tested for fluoroquinolones resistance mutations, 77/131 (58.8%) were positive, with N87I (20) mutation being the most frequently detected mutation followed by A92T mutation which was detected in 16 samples. Conclusion. A significant proportion of dyspeptic patients attending tertiary hospital in Tanzania are infected with H. pylori strains harbouring clarithromycin or fluoroquinolones resistance mutations. Detection of more than 50% of strains with fluoroquinolones resistance mutations makes the H. pylori second line treatment questionable in our setting. There is a need of surveillance of H. pylori resistance patterns in Tanzania to provide data that can guide empirical treatment to reduce associated morbidity of H. pylori infections. The correlation between A92T fluoroquinolone mutation and phenotypic resistance requires further investigations.

The role of patients and healthcare workers Staphylococcus aureus nasal colonization in occurrence of surgical site infection among patients admitted in two centers in Tanzania

BackgroundColonization with Staphylococcus aureus has been identified as a risk for subsequent occurrence of infection. This study investigated the relationship between S. aureus colonization of patients and healthcare workers (HCWs), and subsequent surgical site infections (SSI).MethodsBetween December 2014 and September 2015, a total of 930 patients and 143 HCWs were enrolled from the Bugando Medical Centre and Sekou Toure hospital in Mwanza, Tanzania. On admission and discharge nasal swabs, with an additional of wound swab for those who developed SSI were collected from patients whereas HCWs were swabbed once. Identification and antimicrobial susceptibility testing were done by VITEK-MS and VITEK-2, respectively. Detection of Panton Valentine leukocidin (PVL) and mecA genes was done by PCR. S. aureus isolates were further characterized by spa typing and Multi-Locus Sequence Typing (MLST).ResultsAmong 930 patients screened for S. aureus on admission, 129 (13.9%) were positive of which 5.4% (7/129) were methicillin-resistant S. aureus (MRSA). Amongst 363 patients rescreened on discharge, 301 patients had been tested negative on admission of whom 29 (9.6%) turned positive after their hospital stay. Three (10.3%) of the 29 acquired S. aureus were MRSA. Inducible Clindamycin resistance occurred more often among acquired S. aureus isolates than among isolates from admission [34.5% (10/29) vs. 17.1% (22/129), P = 0.018]. S. aureus contributed to 21.1% (n = 12) of the 57 cases of investigated SSIs among 536 patients followed. Seven out of eight S. aureus carriage/infection pairs had the same spa and sequence types. The previously reported dominant PVL-positive ST88 MRSA strain with spa type t690 was detected in patients and HCW.ConclusionA significant proportion of patients acquired S. aureus during hospitalization. The finding of more than 90% of S. aureus SSI to be of endogenous source underscores the need of improving infection prevention and control measures including screening and decolonization of high risk patients.

In Situ Simulation for Pediatric Emergencies in a Busy Emergency Department in Mwanza, Tanzania

Emergency medicine is a relatively new field of practice in sub-Saharan Africa, and the first specialty training in Tanzania started in 2010. Despite this, the majority of emergency care for children is done by providers with little formal emergency medicine or pediatric emergency training. A low-fidelity, in situ simulation curriculum was held at Bugando Medical Center in Western Tanzania in 2018. There were 11 simulation cases that covered core topics in pediatric emergency care, and these were done on an ad hoc basis during available education time in a busy emergency department using available resources. These cases were well received and represent an opportunity for using external specialists to assist with provider education.

Predictors of triple therapy treatment failure among H. pylori infected patients attending at a tertiary hospital in Northwest Tanzania: a prospective study

BackgroundHelicobacter pylori (H.pylori) infection is a common medical problem in resource limited areas. The treatment outcome after triple therapy has not been well studied in developing countries and preliminary data suggests a high rate of treatment failure. This study investigated the triple therapy treatment failure rate and associated factors among dyspeptic patients receiving H. pylori first line therapy at a tertiary hospital, Tanzania.MethodsA prospective study in the Gastroenterology unit of the Bugando Medical Centre (BMC) was conducted between October 2015 and May 2017. All dyspeptic patients with stool antigen tests positive for H.pylori were given first line therapy, and stool antigen testing was repeated within 7 days and 5 weeks after completion of the treatment. Biopsies were taken before initiation of therapy and analysed for clarithromycin and quinolone resistance mutations using polymerise chain reaction (PCR) and sequencing. Adherence and other social-demographic characteristics were documented.ResultsA total of 210 patients were enrolled; the median age was 35 years (interquartile range, 27–48). First line treatment failure as defined by positive stool antigen 5 weeks post treatment was observed in 65/210 (31%) of patients. Independent predictors of first line treatment failure were presence of clarithromycin resistance mutations (OR: 23.12, 95% CI (9.38–56.98), P < 0.001) and poor adherence (OR: 7.39, 95% CI (3.25–16.77), P < 0.001). The sensitivity and specificity of stool antigen testing within 7 days after completion therapy in detecting treatment failure was 100 and 93.2%, respectively.ConclusionNearly one-third of patients with clarithromycin resistance mutations and poor adherence develop first line treatment failure. Routine stool antigen testing within seven days after completion of therapy can be considered in order to initiate second line treatment early to prevent associated morbidities.

Impact of a pilot patient navigator program on pediatric cancer outcomes in a low resource setting.

e18152 Background: Oncology patient navigation programs have been successfully implemented at hospitals throughout the U.S., enhancing the quality of canceer care. In low resource settings, the barriers to receiving cancer care are increased and a patient navigator in this setting has the potential to significantly impact outcomes. However, research on efficacy is limited. Methods: At Bugando Medical Centre (BMC) in Mwanza, Tanzania, semi-structured qualitative interviews of 15 key stakeholders in the oncology department and 15 families of patient with pediatric cancer diagnoses were completed to identify health system delivery and patient related barriers to timeliness of diagnosis, treatment initiation, and treatment completion. Based on identified barriers, a pilot patient navigation program was established to assist patients and their families with care coordination throughout the diagnosis and treatment process. A retrospective analysis of hospital records was conducted of all pediatric oncology patients seen at BMC from 2010-2016, separated by presentation date before or after establishment of navigation program. Collected data includes demographics, diagnosis, time from presentation to oncology evaluation and diagnosis, and treatment completion. Results: Identified patient related barriers included patient diagnosis and treatment knowledge, and complexity of care. Health system delivery barriers included limited provider capacity, and poor care coordination between the oncology providers, other health care services and patient families. A total of 238 patient files were reviewed, with 169 pre- and 69 post- program initiation. Patient groups did not differ by age or gender (p = 0.329 and 0.744), or diagnosis distribution. The average time to oncology evaluation decreased from 49.7 to 16.6 days (p = 0.015), and time to diagnosis decreased from 49.1 to 23.6 days (p = 0.07). Treatment abandonment decreased from 50% to 38% (p &lt; 0.001). Conclusions: In pediatric oncology, early diagnosis is critical to the initiation of chemotherapy and improving outcomes. These data suggest that a patient navigation program is feasible in a LMIC and can impact both health system inefficiency and treatment abandonment, with the potential to improve pediatric cancer outcomes.

Feasibility of visual inspection with acetic acid (VIA) screening for cervical cancer in Tanzania with emphasis on special populations.

5527 Background: Following the report that VIA screening reduced cervical cancer mortality by 31% in India (ASCO LBA2 2013; Shastri SS, et al JNCI 2014), the W.H.O. endorsed VIA guidelines for Africa, where the global disease burden is highest. In Tanzania, cervical cancer is a major source of morbidity and mortality, with nearly 10,000 new cases and 7,000 deaths annually. Due to lack of resources, therapies are limited and patient outcomes are further confounded by the relatively high prevalence of concurrent HIV infection. We report on the feasibility of VIA screening in Tanzania with emphasis on unique populations. Methods: Our two 5-day VIA screen-and-treat workshops in Buzuruga and Sangabuye Health Centres in Mwanza, Tanzania were approved by the University of California, Irvine IRB and local health authorities. Participants were recruited from surrounding communities and offered free cervical VIA screening, cryotherapy when indicated, and HIV rapid testing. Acetowhite lesions and/or abnormal vascular markings were VIA+. Chi-square and Fisher exact tests were performed with statistical significance assigned at 0.05. Results: During July 2018, 825 of 917 registered participants underwent VIA screening and 25.1% (n=207) were VIA+. 147 VIA+ non-pregnant women received same day cryotherapy and 15 (1.8%) with lesions suspicious for cancer were referred to Bugando Medical Center. In the subanalysis of 64 HIV+ patients (23 diagnosed at the workshops, 41 with prior diagnosis on ART), HIV infection was not associated with VIA positivity (p=0.497). Additionally, a non-significant trend of higher VIA+ screens among newly diagnosed untreated HIV patients (27.7%) vs patients with known HIV on ART (17.5%) was observed (p=0.556). Conclusions: VIA screening for cervical cancer, while feasible in Tanzania, will require follow-up and repetitive screening. Although cervical cancer is an AIDS-defining illness, lack of correlation between HIV infection and VIA-positivity may reflect the availability of W.H.O.-subsidized ART in sub-Saharan Africa to attenuate HPV-mediated neoplastic transformation, as previously reported by others. Further study of this phenomenon is warranted.

Prevalence and factors associated with renal dysfunction in children admitted to two hospitals in northwestern Tanzania

BackgroundIt is evident that renal dysfunction (RD) is associated with unique infectious and non-infectious causes in African children. However, little data exists about the prevalence and factors associated with RD in children admitted to African hospitals.MethodsIn this cross-sectional study, we enrolled all children admitted to pediatric wards of Bugando Medical Centre (BMC) and Sekou-Toure Regional Referral hospital (SRRH) during a 6 month time period. Socio-demographical, clinical and laboratory data were collected using a structured questionnaire. Estimated glomerular filtration rate (eGFR) was calculated using modified Schwartz equation and those with < 60 ml/min/1.73m2were considered to have RD. Data analysis was done using STATA version 13 and considered significant when p-value was < 0.05.ResultsA total of 513 children were enrolled, of which 297 (57.9%) were males. Median age of children with and without RD was 34 months (27–60) and 46.5 (29–72) respectively. Prevalence of RD was 16.2%. Factors associated with RD were herbal medication use (p = 0.007), history of sore throat or skin infection (p = 0.024), sickle cell disease (SCD) (p = 0.006), dehydration (p = 0.001), malaria (p = 0.01) and proteinuria (p = < 0.001).ConclusionsHigh prevalence of RD was observed among children admitted to referral hospitals in Mwanza. Screening for RD should be performed on admitted children, particularly those with history of herbal medication use, sore throat/skin infection, SCD, dehydration and malaria. Where creatinine measurement is not possible, screening for proteinuria is a reasonable alternative.

Deciphering risk factors for blood stream infections, bacteria species and antimicrobial resistance profiles among children under five years of age in North-Western Tanzania: a multicentre study in a cascade of referral health care system

BackgroundBlood stream infections (BSIs) cause a complex cascade of inflammatory events, resulting in significant morbidity and mortality in children in Tanzania. This study was designed to delineate circulating bacterial species, antimicrobial resistance (AMR) profiles and risk factors for BSIs and mortality among children in the cascade of referral health care facilities so as to guide comprehensive BSIs management.MethodsA multiple cross sectional analytical study was conducted between July 20, 2016 to October 04, 2017 involving 950 children less than five years of age in the North-western part of Tanzania. Children with clinical features suggestive of BSIs were included. Demographic, clinical and laboratory information on culture and antimicrobial susceptibility testing was collected from children; and analyzed using STATA version 13.0 software.ResultsThe prevalence of BSIs among children was 14.2% (95% CI: 12.1–16.6%), with specific prevalence in the district, regional and tertiary hospitals being 8.3, 6.4 and 20.0%, respectively. The most common bacterial pathogens isolated from 135 culture-positive children were Klebsiella pneumoniae (55, 40.4%), Staphylococcus aureus (23, 17.0%), and Escherichia coli (17, 12.6%). Multi-drug resistance (MDR) was higher in isolates from children at Bugando Medical Centre (BMC) tertiary hospital than isolates from district and regional hospitals [OR (95% CI): 6.36 (2.15–18.76); p = 0.001]. Independent risk factors for BSIs were neonatal period [OR (95% CI): 1.93 (1.07–3.48); p = 0.003] and admission at BMC [2.01 (1.08–3.74); p = 0.028)]. Approximately 6.6% (61/932) of children died, and risk factors for mortality were found to be children attending BMC [OR (95% CI): 4.95 (1.95–12.5); p = 0.001)], neonatal period [OR (95% CI): 2.25 (1.02–5.00); p = 0.045)], and children who had blood culture positive results [OR (95% CI): 1.95 (1.07–3.56); p = 0.028)].ConclusionsThe prevalence of BSIs (14.2%) in this multi-centre study is high and predominantly caused by the MDR K. pneumoniae. Priority interventional measures to combat BSIs and mortality, specifically among neonates at BMC are urgently recommended.

Geospatial Mapping of Sickle Cell Disease in Northwest Tanzania: The Tanzania Sickle Surveillance Study (TS3)

Tanzania ranks third in Africa for the estimated number of annual births with sickle cell disease, but these estimates are based on sparse data from small studies reported over the past 50 years. A recently completed surveillance study from Uganda documented substantial variation in the prevalence of sickle cell trait and disease across the country. Tanzania lacks a national newborn screening program, and no contemporary multi-regional screening of infants has been undertaken. We designed and conducted a prospective study to determine the prevalence of sickle cell trait and disease by region and district in northwest Tanzania, where the prevalence of sickle cell is thought to be highest. The study used existing public health infrastructure while building local capacity for accurate diagnosis of sickle cell disease. Secondary objectives included characterization of hemoglobin variants and exploration of associations between sickle cell trait, sickle cell disease, malaria, and HIV.The Tanzania Sickle Surveillance Study (TS3) is a prospective cross-sectional study of HIV-exposed infants born in 9 regions across the Lake Zone of northwest Tanzania. In Tanzania, the HIV early infant diagnosis (EID) program collects dried blood spots (DBS) from all children born to HIV-infected mothers. DBS are transported to a central laboratory for prompt detection of HIV vertical transmission. In northwest Tanzania, the DBS are transported to Bugando Medical Centre, a teaching and consultancy hospital in Mwanza, where they are tested for HIV and then stored on-site, and thus available for further testing. Isoelectric focusing (IEF) equipment was donated to Bugando Medical Centre along with reagents and supplies. Two laboratory staff were trained by a board certified hematologist, and then attended a two day seminar by the IEF manufacturer. One pediatrician completed a 2-month observership at Cincinnati Children's Hospital. All DBS samples were tested by IEF using appropriate controls. Completed gels were scored independently by two Tanzanian staff members as normal, disease, trait, variant, or uninterpretable. DBS samples scored as disease or variant were repeated for confirmation and preserved for later genotyping. Regular Skype calls were convened with US-based collaborators to improve quality and interpretation. HIV test results were obtained from the local EID program.Between February 2017 and May 2018, 232 IEF gels were completed by the local staff. After children >24 months of age were excluded to obtain a more accurate newborn prevalence, the median age of children tested was 52 days (IQR 41-93 days), and a total of 17,278 unique DBS samples were scored. The quality of laboratory testing was extremely high with only 20 samples scored as uninterpretable and 54 with missing results, and the primary analysis was performed on the 17,204 remaining samples. The overall prevalence of sickle cell trait and disease in the entire cohort was 20.3% and 1.2%, respectively, with a 0.1% prevalence of hemoglobin variants. This corresponds to an allelic frequency of 0.114 for the sickle gene mutation and demonstrates perfect Hardy-Weinberg equilibrium. No HbC or other common beta-globin variants were identified. Geospatial mapping revealed some variation across regions, with sickle trait ranging from 16.6% to 22.5% and disease ranging from 0.5% to 1.5%. Analysis of individual districts with >100 samples revealed wider geographic variability, with sickle trait ranging from 15.2% to 27.8% and disease ranging from 0.0% to 4.3%. Co-morbidity between HIV and sickle cell disease was analyzed to compare it with the effect on mortality previously observed in Uganda. The prevalence of sickle cell disease was the same among HIV-infected and HIV-negative children (1.2%), suggesting no difference in mortality.The prevalence of sickle cell trait and disease among infants born in northwest Tanzania is very high, exceeding 20% trait and 1.2% disease. All regions in the Lake Zone are affected possibly due to lack of immigration to the area and similar environmental exposures. Targeted newborn screening can be started in high prevalence districts, using existing public health infrastructure with minimal start-up cost and training. Future work will evaluate the correlation between historical malaria prevalence and sickle cell prevalence, and identify hemoglobin variants. [Display omitted] DisclosuresWare:Addmedica: Research Funding; Novartis: Membership on an entity's Board of Directors or advisory committees; Bristol Myers Squibb: Research Funding; Agios: Other: advisory board; Global Blood Therapeutics: Other: advisory board; Biomedomics: Research Funding; Nova Laboratories: Consultancy.

AWARENESS OF CHEMOTHERAPY SIDE EFFECTS AND ATTITUDE TOWARDS CHEMOTHERAPY USE AMONG CANCER PATIENTS ATTENDING ONCOLOGY CLINIC AT BUGANDO MEDICAL CENTRE, IN MWANZA, NORTHERN TANZANIA

Background: Chemotherapy is the use of drugs to kill cancer cells. Because cancer cells generally grow and divide faster than normal cells, they are more susceptible to the action of these drugs. However, damage to healthy cells is unavoidable, and this damage accounts for the side effects linked to these drugs.&#x0D; Methodology: A cross section study was conducted at oncology department in Bugando Medical Centre. A sample of 216 people was recruited into the study. The data was collected by using the pre-constructed questionnaire. After data collection, the data was transferred into SPSS version 20 and analyzed.&#x0D; Results: The study found that 88 (40.7%) of the respondents were aware of the chemotherapy side effects whereby majority, 68 (77.3%) of these had been informed by the doctor. Most of the respondents, 197 (92.1%) had a positive attitude towards the use of chemotherapy.&#x0D; Conclusion: There is still poor awareness of the chemotherapy side effects among the cancer patients attending and receiving chemotherapy in oncology department at Bugando Medical Centre. However, most of the respondents had positive attitude towards the use of chemotherapy&#x0D; Keywords: Awareness, attitude, chemotherapy, side effects and Tanzania.

Pre-post effects of a tetanus care protocol implementation in a sub-Saharan African intensive care unit.

BackgroundTetanus is a vaccine-preventable, neglected disease that is life threatening if acquired and occurs most frequently in regions where vaccination coverage is incomplete. Challenges in vaccination coverage contribute to the occurrence of non-neonatal tetanus in sub-Saharan countries, with high case fatality rates. The current WHO recommendations for the management of tetanus include close patient monitoring, administration of immune globulin, sedation, analgesia, wound hygiene and airway support [1]. In response to these recommendations, our tertiary referral hospital in Tanzania implemented a standardized clinical protocol for care of patients with tetanus in 2006 and a subsequent modification in 2012. In this study we aimed to assess the impact of the protocol on clinical care of tetanus patients and their outcomes.Methods and findingsWe examined provision of care and outcomes among all patients admitted with non-neonatal tetanus to the ICU at Bugando Medical Centre between 2001 and 2016 in this retrospective cohort study. We compared three groups: the pre-protocol group (2001–2005), the Early protocol group (2006–2011), and the Late protocol group (2012–2016) and determined associations with mortality by univariable logistic regression.We observed a significant increase in provision of care as per protocol between the Early and Late groups. Patients in the Late group had a significantly higher utilization of mechanical ventilation (69.9% vs 22.0%, p< 0.0001), provision of surgical wound care (39.8% vs 20.3%, p = 0.011), and performance of tracheostomies (36.8% vs 6.7%, <0.0001) than patients in the Early group. Despite the increased provision of care, we found no significant decrease in overall mortality in the Early versus the Late groups (55.4% versus 40.3%, p = 0.069), or between the pre-protocol and post-protocol groups (60.7% versus 50.0%, p = 0.28). There was also no difference in 7-day ICU mortality (30.1% versus 27.8%, p = 0.70). Analysis of the causes of death revealed a decrease in deaths related to airway compromise (30.0% to 1.8%, p<0.001) but an increase in deaths due to presumed sepsis (15.0% to 44.6%, p = 0.018).ConclusionThe overall mortality in patients suffering non-neonatal tetanus is high (>40%). Institution of a standardized tetanus management protocol, in accordance with WHO recommendations, decreased immediate mortality related to primary causes of death after tetanus. However, this was offset by an increase in death due to later ICU complications such as sepsis. Our results illustrate the complexity in achieving mortality reduction even in illnesses thought to require few critical care interventions. Improving basic ICU care and strengthening vaccination programs to prevent tetanus altogether are essential components of efforts to decrease the mortality caused by this lethal, neglected disease.