The spectrum and burden of in-patient paediatric musculoskeletal diseases in Northern Tanzania

Background
Musculoskeletal diseases (MSD) are a major contributor to the global burden of disease and disability, and disproportionally affect low- and middle-income countries; however, there is a dearth of epidemiological data. Affected children often face increased morbidity, social isolation and economic hardship.

Aim
To assess the spectrum and burden of paediatric MSD in children aged 5–18 years admitted to a major referral hospital in Tanzania.

Methods
This was a retrospective cohort study of children aged 5–18 years admitted to Kilimanjaro Christian Medical Centre (KCMC) whose initial diagnosis was recognised as a musculoskeletal condition by the International Classification of Diseases-10 between 1 January and 31 December 2017.

Results
During 2017, 163 cases of confirmed paediatric MSD were admitted to KCMC, representing 21.2% of all admissions of children aged 5–18 years (n = 769). Bone disease was the most common diagnosis. They comprised 106 (65.0%) traumatic fractures, 31 (19.0%) osteo-articular infections, 9 (5.5%) malunions and 3 (1.8%) pathological fractures. Congenital defects and rheumatic disease were relatively uncommon, accounting for only 6 (3.7%) and 4 (2.5%) MSD admissions, respectively.

Conclusion
The majority of cases of MSD were related to fractures, followed by osteo-articular infections, while recognised cases of rheumatic disease were rare. The study, although small, identified the sizeable burden and spectrum of paediatric MSD admitted to a hospital in Tanzania over a 12-month period and highlights the need for larger studies to inform the optimal allocation of health resources.

The role of telepathology in diagnosis of pre-malignant and malignant cervical lesions: Implementation at a tertiary hospital in Northern Tanzania

Introduction
Adequate and timely access to pathology services is a key to scale up cancer control, however, there is an extremely shortage of pathologists in Tanzania. Telepathology (scanned images microscopy) has the potential to increase access to pathology services and it is increasingly being employed for primary diagnosis and consultation services. However, the experience with the use of telepathology in Tanzania is limited. We aimed to investigate the feasibility of using scanned images for primary diagnosis of pre-malignant and malignant cervical lesions by assessing its equivalency to conventional (glass slide) microscopy in Tanzania.

Methods
In this laboratory-based study, assessment of hematoxylin and eosin stained glass slides of 175 cervical biopsies were initially performed conventionally by three pathologists independently. The slides were scanned at x 40 and one to three months later, the scanned images were reviewed by the pathologists in blinded fashion. The agreement between initial and review diagnoses across participating pathologists was described and measured using Cohen’s kappa coefficient (κ).

Results
The overall concordance of diagnoses established on conventional microscopy compared to scanned images across three pathologists was 87.7%; κ = 0.54; CI (0.49–0.57).The overall agreement of diagnoses established by local pathologist on conventional microscopy compared to scanned images was 87.4%; κ = 0.73; CI (0.65–0.79). The concordance of diagnoses established by senior pathologist compared to local pathologist on conventional microscopy and scanned images was 96% and 97.7% respectively. The inter-observer agreement (κ) value were 0.93, CI (0.87–1.00) and 0.94, CI (0.88–1.00) for conventional microscopy and scanned images respectively.

Conclusions
All κ coefficients expressed good intra- and inter-observer agreement, suggesting that telepathology is sufficiently accurate for primary diagnosis in surgical pathology. The discrepancies in interpretation of pre-malignant lesions highlights the importance of p16 immunohistochemistry in definitive diagnosis in these lesions. Sustainability factors including hardware and internet connectivity are essential components to be considered before telepathology may be deemed suitable for widely use in Tanzania.

A Journey Undertaken by Families to Access General Surgical Care for their Children at Muhimbili National Hospital, Tanzania; Prospective Observational Cohort Study

Background
A majority of the 2 billion children lacking access to safe, timely and affordable surgical care reside in low-and middle-income countries. A barrier to tackling this issue is the paucity of information regarding children’s journey to surgical care. We aimed to explore children’s journeys and its implications on accessing general paediatric surgical care at Muhimbili National Hospital (MNH), a tertiary centre in Tanzania.

Methods
A prospective observational cohort study was undertaken at MNH, recruiting patients undergoing elective and emergency surgeries. Data on socio-demographic, clinical, symptoms onset and 30-days post-operative were collected. Descriptive statistics and Mann–Whitney, Kruskal–Wallis and Fisher’s exact tests were used for data analysis.

Result
We recruited 154 children with a median age of 36 months. The majority were referred from regional hospitals due to a lack of paediatric surgery expertise. The time taken to seeking care was significantly greater in those who self-referred (p = 0.0186). Of these participants, 68.4 and 31.1% were able to reach a referring health facility and MNH, respectively, within 2 h of deciding to seek care. Overall insurance coverage was 75.32%. The median out of pocket expenditure for receiving care was $69.00. The incidence of surgical site infection was 10.2%, and only 2 patients died.

Conclusion
Although there have been significant efforts to improve access to safe, timely and affordable surgical care, there is still a need to strengthen children’s surgical care system. Investing in regional hospitals may be an effective approach to improve access to children surgical care.

Clinicopathological Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania:a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Patterns and Surgical Outcomes of Primary Brain Tumors Managed at a Tertiary Hospital in Arusha, Tanzania: a Cross-sectional Analysis

Purpose: The epidemiology of brain tumors varies globally between different countries and there is observed poor outcomes in lower- and middle-income countries. Our aim is to analyze the clinicopathological pattern of intracranial tumors in our setting and their post-surgical outcomes.

Methods: This is a retrospective study. Data was obtained from clinical records of patients with intracranial tumors treated at our neurosurgery unit between 2019 and 2020. Only patients with primary brain tumors who underwent surgical intervention were included. Analysis was done to identify factors associated with patient outcomes (mortality/survival and performance status).

Results: 39 patients with primary brain tumors underwent surgery (adults 72.8%, males 53.8%, mean age 35.8years). Gliomas (46.2%) comprised the most common tumor diagnosis overall and craniopharyngiomas were the most common tumors in pediatric patients (27.3%). Most patients (83.3%) had a poor performance status before surgery. Gross tumor resection (25.6%) was low and few patients (31.4%) underwent adjuvant therapy. 30-day mortality rate (10.3%) and one year mortality rate (46.2%) were high. Pediatric patients had a much worse outcome (46.2% mortality rate compared to 25% in adults, and 80% with poor performance status) as did males (38.1% mortality rate compared to 27.8% in females). Gliomas accounted for majority (69.2%) of the deaths.

Conclusion: Delayed presentation and poor access to adjuvant therapies are important contributors of the high mortality and abandonment of treatment. Inadequate long-term follow-up is a hinderance to optimal neurooncological care in our setting.

Development and Implementation of an Antimicrobial Stewardship Checklist in Sub-saharan Africa: a Co-creation Consensus Approach

Background:

Antimicrobial stewardship (AMS) initiatives promote the responsible use of antimicrobials in healthcare settings as a key measure to curb the global threat of antimicrobial resistance (AMR). Defining the core elements of AMS is essential for developing and evaluating comprehensive AMS programmes. This project used co-creation and Delphi-consensus procedures to adapt and extend the existing published international AMS checklist. The overall objective was to arrive at a contextualised checklist of core AMS elements and key behaviours for use within healthcare settings in Sub-Saharan Africa as well as to implement the checklist in health institutions in four African countries.

Method:

The AMS checklist tool was developed using a modified Delphi approach to achieve local, expert consensus on items to be included on the checklist. Fourteen healthcare/public health professionals from Tanzania, Zambia, Uganda, and Ghana were invited to review, score and comment on items from a published, global AMS checklist. Following their feedback, eight items were re-phrased and 25 new items added to the checklist. The final AMS checklist tool was deployed across 19 healthcare sites and used to assess AMS programmes before and after an AMS intervention in 14 of the 19 sites.

Findings:

The final tool comprised 54 items. Across the 14 sites, the checklist consistently showed improvements for all AMS components following the intervention. The greatest improvements observed were the presence of formal multidisciplinary AMS structures (79%) and the execution of a point-prevalence survey (72%). Elements with the least improvement were access to laboratory/imaging services (7%) and the presence of adequate financial support for AMS (14%). In addition to capturing quantitative and qualitative changes associated with the AMS intervention, project evaluation suggested that administering the AMS checklist made unique contributions to ongoing AMS activities. Furthermore, 29 additional AMS activities were reported as a direct result of the prompting checklist questions.

Conclusion:

Contextualised, co-created AMS tools are necessary for managing antimicrobial use across healthcare settings and increasing local AMS ownership and commitment. This study led to the development of a new AMS checklist which proved successful in capturing AMS improvements in Tanzania, Zambia, Uganda, and Ghana. The tool also made unique contributions to furthering local AMS efforts. The study extends existing AMS materials for low and middle-income countries and provides empirical evidence for successful use in practice.

Two decades of Tanzanian health policy

Tanzania has undertaken important health sector reforms in the new millennium, and the most recent Health Sector Strategic Plan (2021–26) lays out ambitious targets to achieve universal health coverage. Yet, women in Tanzania continue to face significant barriers in accessing healthcare and the country is grappling with important gender-biased health challenges disadvantaging women. The aims of this paper are two-fold. First, we examine the evolution of Tanzania’s health policy over the past two decades (2000–21) from the perspective of enhancing financial protection for working-age women. Second, we explore policy options for genderresponsive health insurance expansion in the context of Tanzania. Methodologically, the paper draws on a scoping study of diverse literature and data and a review of evidence from other contexts with public health insurance schemes. We find that Tanzania has a fragmented health system that relies on several independent schemes introduced throughout the years, characterized by insufficient risk-pooling. Such a system provides insufficient financial protection for workingage women and female-headed households, which are financially less secure than dual-earner households. Although expanding health insurance coverage represents a viable corrective measure, future reforms must account for women’s lower financial contribution capacity to enable equitable access. Additionally, the policy design requires gender-mainstreamed investments in awarenessraising, service quality, and benefit packages

Pediatric Hydrocephalus in Northwest Tanzania: a descriptive cross-sectional study of clinical characteristics and early surgical outcomes from the Bugando Medical Centre.

Objectives
In this study, we present data from a neurosurgical training program in Tanzania for the treatment of pediatric hydrocephalus. The objectives of the study were to identify the demographics and clinical characteristics of pediatric patients with hydrocephalus that were admitted to Bugando Medical Centre in Mwanza, Tanzania as well as to describe their surgical treatment and early clinical outcomes.

Methods
This cross-sectional study included 38 pediatric patients. Physical examinations were conducted pre- and post-operatively, and their mothers completed a questionnaire providing demographic and clinical characteristics.

Results
There was a slight preponderance of male sex (21/38; 55.3%) with median age at the time of admission of 98.5 days. The majority of patients were surgically treated (33/38; 86.8%). Among those surgically treated, most received a ventriculoperitoneal shunt (23/33; 69.7%), while seven were treated with an endoscopic third ventriculostomy (7/33; 21.2%). At the time of admission, the majority of patients (86%) had head circumferences that met criteria for macrocephaly. The median time between admission and surgery was 23 days (2-47 days). Overall, five patients (13.2%) died, including two that did not receive surgical intervention.

Conclusions
We found that in our population, pediatric patients with hydrocephalus often present late for treatment with additional significant delays prior to receiving any surgical intervention. Five patients died, of which two had not undergone surgery. Our study reinforces that targeted investments in clinical services are needed to enable access to care, improve surgical capacity, and alleviate the burden of neurosurgical disease from pediatric hydrocephalus in sub-Saharan Africa.

Treatment outcomes of esophageal cancer in Eastern Africa: protocol of a multi-center, prospective, observational, open cohort study

Background
Esophageal squamous cell carcinoma (ESCC) is a major cause of cancer morbidity and mortality in Eastern Africa. The majority of patients with ESCC in Eastern Africa present with advanced disease at the time of diagnosis. Several palliative interventions for ESCC are currently in use within the region, including chemotherapy, radiation therapy with and without chemotherapy, and esophageal stenting with self-expandable metallic stents; however, the comparative effectiveness of these interventions in a low resource setting has yet to be examined.

Methods
This prospective, observational, multi-center, open cohort study aims to describe the therapeutic landscape of ESCC in Eastern Africa and investigate the outcomes of different treatment strategies within the region. The 4.5-year study will recruit at a total of six sites in Kenya, Malawi and Tanzania (Ocean Road Cancer Institute and Muhimbili National Hospital in Dar es Salaam, Tanzania; Kilimanjaro Christian Medical Center in Moshi, Tanzania; Tenwek Hospital in Bomet, Kenya; Moi Teaching and Referral Hospital in Eldoret, Kenya; and Kamuzu Central Hospital in Lilongwe, Malawi). Treatment outcomes that will be evaluated include overall survival, quality of life (QOL) and safety. All patients (≥18 years old) who present to participating sites with a histopathologically-confirmed or presumptive clinical diagnosis of ESCC based on endoscopy or barium swallow will be recruited to participate. Key clinical and treatment-related data including standardized QOL metrics will be collected at study enrollment, 1 month following treatment, 3 months following treatment, and thereafter at 3-month intervals until death. Vital status and QOL data will be collected through mobile phone outreach.

Discussion
This study will be the first study to prospectively compare ESCC treatment strategies in Eastern Africa, and the first to investigate QOL benefits associated with different treatments in sub-Saharan Africa. Findings from this study will help define optimal management strategies for ESCC in Eastern Africa and other resource-limited settings and will serve as a benchmark for future research.

Trial registration
This study was retrospectively registered with the ClinicalTrials.gov database on December 15, 2021, NCT05177393.

Building Capacity and Infrastructure at Hospitals Implementing Minimally Invasive Tissue Sampling: Experience and Lessons Learned From Nepal, Rwanda, and Tanzania

Background
Minimally invasive tissue sampling (MITS) is a useful tool to determine cause of death in low- and middle-income countries (LMICs). In 2019 the MITS Surveillance Alliance supported the implementation of small-scale postmortem studies using MITS in several LMICs.

Methods
In this article we describe the preparations, challenges, and lessons learned as part of implementing MITS across 4 study sites in 3 countries: Nepal, Rwanda, and Tanzania. We describe the process for building capacity to conduct MITS, which consisted of training in MITS sample collection, individual site assessment to determine readiness and gaps prior to implementation, site visits as sites began implementation of MITS, and feedback based on remote evaluation of histology slides via an online portal.

Results
The 4 study sites each conducted 100 MITS, for a total of 400. All 4 sites lacked sufficient infrastructure and facilities to conduct MITS, and upgrades were required. Common challenges faced by sites included that clinical autopsies were neither routinely conducted nor widely accepted. Limited clinical records made cause of death determination more difficult. Lessons learned included the importance of sensitization of the community and medical staff to MITS to enhance understanding and increase consent.

Conclusions
The study sites accomplished MITS and utilized the available support systems to overcome the challenges. The quality of the procedures was satisfactory and was facilitated through the organized capacity-building programs