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Objective: To investigate individual socio-demographic characteristics of suicides, the reasons, methods and means employed to commit suicide., Design: A descriptive prospective study of suicides. A structured questionnaire was employed to enquire the details of the itemised objectives., Setting: Muhimbili National Hospital--in urban Dar es Salaam., Subjects: Fifty three males and 47 females consecutive suicides aged 15 to 59 years, Results: The mean age for suicides was found to be 28.2 years. Males were more than females and were ten years older. Sixty two percent of the subjects were single, 30% married. Seventy two percent had primary school education, 19% secondary education. Main reasons for committing suicide were established in 61 cases of which 57.3% (35/61) were due to severe marital and family conflicts, overwhelming disappointments in love affairs and unwanted pregnancies. Eleven subjects with chronic somatic illnesses killed themselves due to unbearable physical pain and overwhelming economic deprivations motivated ten subjects to take their lives. Sixty nine subjects poisoned themselves predominantly using anti-malarials and pesticides while 27 hanged themselves. A third of the suicides consumed alcohol frequently and a quarter of the suicides were HIV positive, a rate twice the national prevalence for sexually active adults., Conclusion: Comparatively, women became vulnerable to suicide at a younger age. Dysfunctional social networks played a predominant role among suicides. Family and marital conflicts need closer social attention and timely counseling. Patients with chronic medical conditions and frequent alcohol use need effective exploration concerning suicidal ideation to avert self-annihilation. A policy to control prescriptions of toxic drugs including pesticides is overdue.

Background: In Tanzania information is lacking on the prevalence of HIV infection in surgical patients in tertiary care facilities, in whom there are many points of special interest., Objective: To determine the prevalence of HIV infection and associated clinical and demographic features among hospitalised surgical patients at Muhimbili National Hospital (MNH)., Setting: Muhimbili National Hospital., Materials and Methods: Consecutive newly admitted patients were tested for HIV antibodies after pre-test counselling. Sera were tested using a dual ELISA algorithm. The data were analysed to determine the prevalence of HIV infection and relationships of serostatus with clinical and socio-demographic characteristics., Results: Of 1,534 patients admitted during the study, 1,031(67.2%) consented to HIV testing following pre-test counselling. The prevalence of AIDS-related clinical features in patients who declined to be HIV tested was similar to that of seronegative patients, but significantly lower than that of seropositive patients. The overall age-adjusted HIV prevalence was 10.5% (95% CI = 9.9-14.0). The highest age-specific HIV prevalence was in the age group 35-44 years at 27.9%. No one was infected in the age group 0-4 years (n = 111). Differences in prevalence between age groups were statistically significant (p < 0.0001). Patients with granulomatous and suppurative infections had HIV prevalence of 28.3%. Twenty of 124 seropositive patients (16.1%) died in hospital compared to 58 of 907(6.4%) of seronegative patients (p = 0.0001)., Conclusion: At Muhumbili National Hospital overall HIV prevalence in hospitalised surgical patients were 10.5%, compared to an overall national prevalence of 6.7%. Patients in the age groups 25 to 34 and 35 to 44 years had HIV seroprevalence of 26.8% and 27.9% respectively. Patients with infective conditions had the highest HIV prevalence. HIV seropositive patients were associated with higher hospital mortality than seronegative patients.

Objective: To determine immunity to tetanus in male blood donors with previous diphtheria-pertussis-tetanus (DPT)/tetanus toxoid (TT) vaccination., Design: A cross sectional study, conducted in September 1999., Setting: Blood bank, Muhimbili Medical Centre, Dar es Salaam, Tanzania., Methods: Using an antigen competition ELISA technique, serum tetanus anti-toxin levels in two hundred male blood donors were determined., Results: Vaccination history was absent in 43 (21.5%) blood donors, whereas 60 (30%) and 97 (48.5%) reported childhood DPT and TT vaccination, respectively. Tetanus anti-toxin was undetectable in 47 (23.5%) blood donors and the levels were below that considered protective (> or = 0.1 IU/ml) in 25 (12.5%). Among those with undetectable level, 43 (91.5%) had no vaccination history. Time after last DPT/TT vaccination correlated significantly with tetanus anti-toxin levels (r2=-0.331, p=0.001). In multivariate analysis, TT doses received and time after last vaccination explained 4.8% and 29.4%, respectively, of the variations in tetanus anti-toxin levels., Conclusion: Seventy two (36%) male blood donors were susceptible to tetanus and the susceptibility was highest from 48 years. A regular TT booster dose at 10 yearly intervals is recommended to provide adequate and long lasting immunity in male adults. Proper keeping of vaccination records is emphasised.

Objective: To determine immunoglobulin levels in HIV-1 seronegative and HIV-1 seropositive children at different clinical stages of HIV infection., Design: Cross-sectional study., Setting: Lugalo and Mwanayamala mother and child clinics in Dar es Salaam., Subjects: Two hundred and ninety-nine children aged 18 months to five years., Main Outcome Measures: Estimation of immunoglobulin classes (IgG, IgA, IgM, IgD and IgE)., Results: Mean serum levels of all immunoglobulin classes were significantly higher (p < 0.0001) among the HIV-1 seropositive children (IgG = 22.9 g/l, IgA = 2.2 g/l, IgM 2.7 g/l, IgD 101.5 IU/ml and IgE 887.7 IU/ml) than among the HIV-1 seronegative children (IgG = 11.3 g/l, IgA = 1.0 g/l, IgM = 1.5 g/l, IgD = 27.8 UI/ml and IgE 341.3 UI/ml). The percentages of HIV-infected children with immunoglobulin concentrations above mean level were 83% for IgG, 77% for IgA, 78% for IgM, 73% for IgD and 78% for IgE., Conclusion: HIV seropositive children have higher levels of immunoglobulin than seronegative children. There was no correlation between the levels of immunoglobulin classes and CDC clinical staging.

Objective: To determine the seroprevalence of the main transfusion-associated viral infections and syphilis among blood donors in Muhimbili Medical Centre, Dar es salaam, Tanzania., Design: Cross sectional study., Setting: The blood bank unit of Muhimbili Medical Centre in Dar es salaam, Tanzania., Subjects: A consecutive sample of 300 blood donors., Investigations: Search for the presence of antibodies to: human immunodeficiency virus (anti-HIV), hepatitis C virus (anti-HCV), hepatitis B surface antigen (anti-HBs), human T-lymphotropic virus type 1 (anti-HTLV-1), syphilis and for hepatitis B surface antigen (HbsAg)., Results: The overall frequency of anti-HIV, anti-HCV, anti-HBs, HbsAg, anti-HTLV-1, and syphilis antibodies were 8.7%, 8%, 20%, 11%, 0%, and 12.7%, respectively. Among the HIV seronegative donors, the frequency of anti-HCV, anti-HBs, HBsAg, anti-HTLV-1, and syphilis antibodies were 8.8%, 22%, 11%, 0%, and 10.9%, respectively. HIV-seropositive donors had an increased risk for being positive for syphilis antibodies (OR = 3.6, 95% CI 1.4-9.0) and HBsAg (OR = 4.0, 95% CI 1.0-18.8), but not anti-HCV (OR = 0.9, 95% CI 0.86-0.97), anti-HBs (OR = 1.0, 95% CI 0.2-5.3) or anti-HTLV-1 (OR = 0.0)., Conclusion: Donor blood including that from HIV-seronegative donors, has high frequency of HCV, HBV, and syphilis antibodies but not anti-HTLV-1. A significant association exists in the occurrence of HIV, HBV and syphilis; and due to the association of syphilis and HIV, clients with history of sexually transmitted disease should be excluded during donor selection. From these observations were recommend: (i) routine screening of donor blood for HIV, HCV, HBV, and syphilis antibodies but not HTLV-1 and; (ii) a larger study to generate more accurate estimates of the magnitude the transfusion-transmissible infectious diseases.

We designed a study to assess the nutritional status of children under five years of age attending MCH clinics in Dar es Salaam. This was a cross-sectional anthropometric study involving children 6-24 months who from July to August 1993 were attending Magomeni MCH clinic and those aged 18 months to five years who were attending Lugalo and Mwananyamala MCH clinics for routine growth monitoring and for vaccination between May to August 1994. The data collected included age, birthweight, sex, weight, height, breastfeeding status and HIV-1 serostatus. Of the 1854 children enrolled (961 boys and 893 girls) 31.6% were stunted, 14.6% were underweight and 2.9% were wasted. The highest percentage of stunting and wasting was observed between 11 and 25 months and 36 to 40 months. Of the 849 children tested for HIV-1, 14 (1.7%) were seropositive and two out of 770 (0.3%) were born with low weight. HIV seropositivity and low birthweight were both associated with stunting and wasting. We conclude that malnutrition is still a sizeable problem among children attending urban MCH clinics in Dar es Salaam especially among those aged less than three years, to whom special malnutrition control strategies should be targeted. There is also a need to identify factors responsible for the observed decline in MCH attendance with age and correct the situation.

Antimicrobial resistance has become a major medical and public health problem. The main factor responsible for development and spread of bacterial resistance is injudicious use of antimicrobial agents which has resulted in most gram positive and gram negative bacteria continuously developing resistance to the antimicrobials in regular use at different time periods. In East Africa, among E. coli in urinary tract infections, more than 80% are currently resistant to ampicillin, cotrimoxazole and tetracycline while more than 80% of the isolates are still susceptible to nitrofurantoin, gentamicin and third generation cephalosporins. Penicillin G resistant strains of pneumococci were first reported in 1967 but had gradually increased to about 20% in 1991. Among group A streptococci, all natural strains are still sensitive to penicillin G while resistance to tetracycline has reached alarming proportions. In Tanzania, more than 65% of N. gonorrhoeae isolates are beta-lactamase producers, however, spectinomycin, second and third generation cephalosporins and ciprofloxacin are effective against most strains. Vibrio cholerae 01 strains resistant to multiple antibiotics are widely spread globally, however, there are recent reports indicating that withdrawal of the drugs can lead to loss of the antibiotic resistance factors. Despite varied susceptibility of N. meningitidis strains world wide, isolates in Tanzania are still susceptible to commonly available drugs including penicillin G and chloramphenicol. Available methods for control of spread of bacterial resistance include rational use of antimicrobial agents including control in animal husbandry, change to newer antimicrobials, rotational use of drugs and constant surveillance for emerging bacterial resistance.

In order to assess the prognostic value of lymphocyte subsets and immune activation markers in HIV-1 infected Tanzanian patients, peripheral white blood cell(WBC) count, total lymphocytes, CD4+ and CD8+ T-lymphocytes and Beta-2 microglobulin (B-2M) concentrations were determined among healthy HIV-1 seronegative Tanzanian blood donors and in infected Tanzania individuals in different clinical stages of HIV-1 infection. CD4+ T-lymphocytes, CD8+ T-lymphocyte percentages, CD4:CD8 lymphocyte ratios and the concentrations of B-2M were strongly correlated with the clinical stages of HIV-1 infection. These results suggest that B-2M could be a useful prognostic marker in HIV-1 infection in settings where T-lymphocyte subset determinations cannot be done.

The present study, based on 158 HIV seropositives and 167 HIV seronegatives, demonstrates that saliva collected with the Omni-SAL device and tested with GACELISA (an IgG antibody capture ELISA) is an effective non-invasive alternative to serum for anti-HIV IgG antibody screening. The study also shows that a conventional serum Western blot kit can be used, with slight modifications, for confirmatory testing of saliva specimens. Collecting saliva with the Omni-SAL device had a very good acceptance rate among Tanzanian subjects, and although this diagnostic method is not yet known by the general public, 65% of the study participants preferred to give saliva instead of blood for HIV testing.

Human immunodeficiency infection and AIDS are a major recent microbial infection in east Africa with serious health and socioeconomic impacts in the region. At present HIV infection and AIDS account for more than 50% of adult medical admissions into some of the national and provincial hospitals as well as for 10-15% of paediatric admissions. AIDS is also at present the commonest cause of death among those aged 15-45 years. Tuberculosis, a closely associated disease to HIV infection, has increased more than three fold in some countries in the region. The prevalence of HIV infection currently ranges from 10-30% among adults in urban areas and from less than 1% to 25% in adults in rural areas; since this prevalence is still rising, the full impact of the AIDS problem in east Africa is yet to be realised. This is different from the situation in many developed countries where AIDS is no longer a priority health issue and where peak prevalences of the infection have been reached. The differences in HIV prevalences between east Africa and developed countries are due to poverty, ignorance, high prevalence of other STDs and associated cultural and traditional practices which prevail and facilitate HIV transmission in the region. While more than 80% of HIV infection in east Africa is transmitted through heterosexual intercourse, 5-15% of cases are perinatally transmitted and the remaining cases are transmitted through blood and blood products. While a lot of scientific advances have been made in immunopathology of AIDS, diagnostics and in social behavioural studies, we are still a long way towards getting curative therapy and or effective preventive vaccines. Recent discovery that use of zidovudine can significantly reduce perinatal HIV transmission is an additional breakthrough. While knowledge and tools for preventing HIV transmission are available in the world, prospects for AIDS control in east Africa appear gloomy unless major efforts are made in the reduction of poverty, ignorance and in the control of other common sexually transmitted diseases.

Seroprevalence of HIV-1 infection was determined in children aged between eighteen months and five years, attending maternal and child health (MCH) clinics in Dar es Salaam, Tanzania. A total of 889 children were eligible for the study, however seven children could not be enrolled because their mothers/guardians absconded and blood could not be drawn from 21 children due to refusal of mothers/guardians and from another 12 children due to technical reasons. Therefore, the participation rate was 95.5%. Of the 849 children screened, 14 (1.65%) were found to have IgG anti HIV-1 antibodies in their sera. The main clinical features found in children with symptomatic HIV-1 disease were weight loss, generalized lymphadenopathy, recurrent fevers, and prolonged diarrhoea. The utility of clinical features suggestive of HIV-1 infection (according to CDC classification) in identifying HIV-1 infection in children was evaluated and found to have high sensitivity (100%), specificity (96.9%) and negative predictive value (100%), but a low positive predictive value (35%). Marked variations in progression to symptomatic phase were noted, whereby some relatively young children had progressed to symptomatic phase (CDC class P-2A), while some older children were still in the asymptomatic stage (CDC class P-1 C). None of the symptomatic HIV-1 infected children presented with neurological disease, severe opportunistic infections, or malignancies. Although reduced mid-upper arm circumference and weight-for-age were associated with HIV seropositivity, these clinical parameters had low positive predictive values compared to the CDC classification.

Serum levels of immunoglobulin classes and IgG subclasses were determined in healthy seronegative (n = 50) and in HIV-1 seropositive adults (n = 50) from Tanzania, a region with heterosexual HIV-1 transmission pattern. The mean levels of total IgG, IgG1, IgG3, IgA, IgM, and IgD obtained were found to be significantly higher in HIV-1 seropositive sera than in control sera. The mean IgA, IgM, IgD and IgG3 levels showed an increasing trend with progression from asymptomatic phase to AIDS phase. The mean levels for total IgG, IgG1 and IgG2 remained constant while that for IgG4 decreased with progression to AIDS phase. From the findings, it is concluded that polyisotypic hypergammaglobulinaemia and serum IgG subclass changes occur in HIV-1 seropositive individuals in Tanzania. The characteristic changes observed for IgD, IgG3 and IgG4 levels with evolution from asymptomatic to AIDS phases could be of value in monitoring disease progression.