Francis M. Sakita

The Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC) was developed to address gaps in AMI diagnosis and treatment in norther

Background: The presence of multiple medical chronic conditions is a growing burden across Africa, where people experience a double burden of communicable and non-communicable diseases (NCD). Integrated chronic disease care at the primary healthcare level is a means to improve person-centred care for people living with multimorbidity. This study aimed to assess public primary healthcare facilities’ service availability and readiness to manage multimorbidity in Malawi, through the lens of HIV, type 2 diabetes, hypertension and chronic kidney disease. We explored healthcare workers’ perceptions of their capacity to provide care for individuals with multimorbidity and the availability of services and resources at their facility. Methods: We conducted a mixed-methods health facility cross-sectional study in primary healthcare facilities in Blantyre and Chiradzulu districts, Malawi. We used the modified WHO Service Availability and Readiness Assessment Tool to assess 12 facilities, and conducted in-depth interviews with 12 purposively selected health facility leads. Availability is presented as the proportion of facilities offering each service. Facility readiness is defined as the mean(percentage) availability of 44 tracer items with a cutoff point of ≥70%, classified as ‘ready’ to manage multimorbidity. Readiness score for individual conditions was also calculated based on the availability of tracer items of that condition with a cutoff point of ≥70%. Results: Of the surveyed facilities, 83%(10/12) offered services for all four selected conditions. Only 30%(3/10) of all facilities had a readiness score of ≥70%, indicative of minimum service delivery requirements for multimorbidity were met. The mean readiness score for type 2 diabetes (65.7%) was the highest, followed by HIV (63.8%), hypertension (60.4%), and chronic kidney disease had the lowest readiness score (22.9%). Barriers to service readiness included nonfunctional diagnostic equipment, frequent drug stockouts and insufficient staffing and supervision, and a lack of clinical guidelines or protocols. Conclusion: The assessed sites were inadequately prepared to provide integrated care for chronic kidney disease, type 2 diabetes, HIV and hypertension. The ability to provide integrated screening and management will require functional diagnostic equipment and consistent drugs. Periodic quality assurance and combined multimorbidity audits could further highlight the gaps in service delivery and give clues to improvement.

Background: Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI. Objective: This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania. Methods: This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment. Results: Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024. Conclusions: This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability. Trial Registration: ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546 International Registered Report Identifier (IRRID): DERR1-10.2196/59917

Background: Rates of prenatal alcohol use in Sub-Saharan Africa (SSA) are increasing, despite regulatory bodies urging pregnant women to abstain from alcohol. Tanzania has minimal policies, interventions, and young female education addressing alcohol consumption during pregnancy (ACDP), leading to a considerable number of pregnancies being exposed to alcohol and consequent health consequences like fetal alcohol spectrum disorder (FASD). Research investigating the prevalence of ACDP in SSA —specifically in Tanzania— is abundant. In Tanzania, there is a limited understanding of alcohol use practices among pregnant women who consume alcohol (PWCA), as well as community knowledge, attitudes, and cultural beliefs related to ACDP. Methods: A total of 655 individuals were enrolled in this sequential, explanatory mixed-methods study using systematic random sampling between October 2021 and May 2022. Quantitative survey data from 533 female patients presenting for care at KCMC ED or RHC were analyzed to compare sociodemographic factors and alcohol use practices among pregnant, younger non-pregnant, and older non-pregnant women using descriptive frequencies in RStudio. Nineteen participants were purposively selected based on quantitative survey data for qualitative semi-structured IDIs exploring knowledge, attitudes, and cultural beliefs surrounding ACDP. A grounded theory approach was used to analyze in-depth interviews (IDIs) in NVivo. Results: A large percent of pregnant women reported alcohol consumption of at least once per week (42.2%). Older non-pregnant women had the highest rates of alcohol use per week (66.0%) and were more likely to believe alcohol use was acceptable during pregnancy. Younger non-pregnant women reported the highest weekly alcohol expenses and held the highest prevalence of harmful or hazardous drinking (HHD) (16.4%). Average [SD] AUDIT scores were 1.70 [3.28] for pregnant women, 2.94 [4.79] for younger non-pregnant women, and 2.51 [4.36] for older non-pregnant women. Older non-pregnant women exhibited the highest prevalence of depression (31.4%). Average [SD] PHQ-9 scores were 4.71 [3.12] for pregnant women, 5.85 [4.80] for younger non-pregnant women, and 7.29 [5.55] for older non-pregnant women. Qualitative analyses demonstrated that (1) cultural beliefs are intricately tied to perceived benefits of ACDP, (2) a history of alcohol use preceding pregnancy largely influences ACDP, and (3) community views of PWCA are negative. Significance: Our findings demonstrate a concerning trend of ACDP in Moshi, Tanzania. Cultural and community beliefs, along with limited knowledge of ACDP, among women of all ages appear to influence ACDP and community views of PWCA. Consequently, community-wide education initiatives and pre-pregnancy interventions highlighting the dangers of ACDP are necessary. Holistic support services may help curb alcohol use and improve birth experiences. Further research is needed to explore ACDP as a form of self-medication for depression, fear, anxiety, and pain in pregnant women in SSA.

BACKGROUND Although the incidence of acute myocardial infarction (AMI) is rising in sub-Saharan Africa, the uptake of evidence-based care for the diagnosis and treatment of AMI is limited throughout the region. In Tanzania, studies have revealed common misdiagnosis of AMI, infrequent administration of aspirin, and high short-term mortality rates following AMI. OBJECTIVE This study aims to evaluate the implementation and efficacy outcomes of an intervention, the Multicomponent Intervention to Improve Acute Myocardial Infarction Care (MIMIC), which was developed to improve the delivery of evidence-based AMI care in Tanzania. METHODS This single-arm pilot trial will be conducted in the emergency department (ED) at a referral hospital in northern Tanzania. The MIMIC intervention will be implemented by the ED staff for 1 year. Approximately 400 adults presenting to the ED with possible AMI symptoms will be enrolled, and research assistants will observe their care. Thirty days later, a follow-up survey will be administered to assess mortality and medication use. The primary outcome will be the acceptability of the MIMIC intervention, which will be measured by the Acceptability of Intervention Measurement (AIM) instrument. Acceptability will further be assessed via in-depth interviews with key stakeholders. Secondary implementation outcomes will include feasibility and fidelity. Secondary efficacy outcomes will include the following: the proportion of participants who receive electrocardiogram and cardiac biomarker testing, the proportion of participants with AMI who receive aspirin, 30-day mortality among participants with AMI, and the proportion of participants with AMI taking aspirin 30 days following enrollment. RESULTS Implementation of MIMIC began on September 1, 2023. Enrollment is expected to be completed by September 1, 2024, and the first results are expected to be published by December 31, 2024. CONCLUSIONS This study will be the first to evaluate an intervention for improving AMI care in sub-Saharan Africa. If MIMIC is found to be acceptable, the findings from this study will inform a future cluster-randomized trial to assess effectiveness and scalability. CLINICALTRIAL ClinicalTrials.gov NCT04563546; https://clinicaltrials.gov/study/NCT04563546 INTERNATIONAL REGISTERED REPORT DERR1-10.2196/59917

Annals of Global Health is a peer-reviewed, fully open access, online journal dedicated to publishing high quality articles dedicated to all aspects of global health. The journal's mission is to advance global health, promote research, and foster the prevention and treatment of disease worldwide. Its goals are to improve the health and well-being of all people, advance health equity, and promote wise stewardship of the earth's environment. The latest journal impact factor is 2.90. Annals of Global Health is supported by the Program for Global Public Health and the Common Good at Boston College. It was founded in 1934 by the Icahn School of Medicine at Mount Sinai as the Mount Sinai Journal of Medicine. It is a partner journal of the Consortium of Universities for Global Health. From time to time, Annals of Global Health publishes Special Collections, a series of articles organized around a common theme in global health. Recent Special Collections have included "Local evidence and strategies in addressing NCDs Non-Communicable Diseases in Tanzania", "Universal Health Coverage through Integrated Care", and "The Minderoo-Monaco Commission on Plastics and Human Health". Global health workers interested in developing a Special Collection are strongly encouraged to contact the Managing Editor in advance to discuss the project.

Background: COVID-19 disease is a global public health disaster causing a range of social, economic, and healthcare difficulties, border restrictions, high human loss, lockdown, and transportation challenges. Despite it being a global pandemic, there are few studies conducted in Tanzania to examine the predictors of mortality. This disease has caused a significant number of mortalities worldwide but literature shows low mortality and better survival in Africa than in other WHO regions. Therefore, this study aimed to determine the predictors of mortality among COVID-19 patients at KCMC Hospital in Northern Tanzania. Methodology: This was the hospital-based retrospective cohort study, conducted at KCMC Hospital in Northern Tanzania among all admitted patients with confirmed COVID-19, from 10 ^th March 2020 to 26 ^th January 2022. The main study event was COVID-19 mortality. The predictors of mortality were determined by using the Weibull survival regression model and the statistically significant results were declared at a p-value of <0.05. Results: A total of 547 confirmed COVID-19 patient records were included in the study. Their median age was 63 (IQR; 53-83), about 60% were aged 60 years and above, and 56.7% were males. The most common clinical features were; fever (60.8%), a severe form of the disease (44.4%), difficulty in breathing (73.3%), chest pain (46.1%), and generalized body weakness (71.3%). Of all participants, over one-third (34.6%) died (95%CI; 0.31-0.39). The median survival time was 7 days (IQR; 3-12). The overall mortality rate was 32.33 per 1000 person-days while the independent predictors of higher mortality risk were age ≥60 years (AHR=2.01; 95%CI 1.41-2.87; P<0.001), disease severity (AHR=4.44; 95%CI 2.56-7.73; P<0.001) and male sex (AHR=1.28; 95%CI; 0.93-1.73; P=0.128). Conclusion: Mortality was higher in elderly male patients, with a severe form of the disease and those with any comorbidities. Therefore, more attention should be provided to older patients including uptake of the current vaccine and ensuring standard and supportive care at primary health facilities is available.

Background: COVID-19 caused a profound global impact, resulting in significant cases and deaths. The progression of COVID-19 clinical manifestations is influenced by a dysregulated inflammatory response. Early identification of the subclinical progression is crucial for timely intervention and improved patient outcomes. While there are various biomarkers to predict disease severity and outcomes, their accessibility and affordability pose challenges in resource-limited settings. We explored the potentiality of the neutrophil-to-lymphocyte ratio (NLR) as a cost-effective inflammatory marker to predict disease severity, clinical deterioration, and mortality in affected patients. Methodology: A hospital-based retrospective cohort study was conducted at KCMC Hospital among COVID-19 patients followed from admission to discharge between 1 ^st March 2020 and 31 ^st March 2022. NLR was calculated as the absolute neutrophil count in µL divided by the absolute lymphocyte count in µL. The NLR cut-off value was determined using Receiver Operating Characteristic (ROC) analysis and assessed its predictive ability at admission for in-hospital mortality. The Chi-square test compared the proportion of NLR by patient characteristics. The association of NLR with disease severity and mortality was analyzed using the modified Poisson and Cox regression models, respectively. Results: The study included 504 patients, with a median age of 64 years, 57.1% were males, and 68.3% had severe COVID-19. The in-hospital COVID-19 mortality rate was 37.7%. An NLR cutoff value of 6.1 or higher had a sensitivity of 92.1% (95% CI 89.2%–94.0%) and a specificity of 92.0% (95% CI 89.7%–94.4%). Additionally, 39.5% of patients with an NLR value of 6.1 or higher had increased risk of severe disease, subsequent clinical deterioration, and mortality. Conclusion and recommendation: An NLR value of 6.1 or higher at the time of hospital admission associated with severe disease, clinical deterioration, and mortality in patients with COVID-19. Integration of NLR as a prognostic parameter in COVID-19 prognosis scales could improve risk assessment and guide appropriate management strategies for COVID-19 patients, as well as for potential future viral-related pneumonias. Further prospective studies are necessary to validate these findings and evaluate the clinical utility of NLR in larger cohorts of patients.

Background The prevalence of multimorbidity (the presence of two or more chronic health conditions) is rapidly increasing in sub–Saharan Africa. Hospital care pathways that focus on single presenting complaints do not address this pressing problem. This has the potential to precipitate frequent hospital readmissions, increase health system and out-of-pocket expenses, and may lead to premature disability and death. We aim to present a description of inpatient multimorbidity in a multicentre prospective cohort study in Malawi and Tanzania. Primary objectives Clinical: Determine prevalence of multimorbid disease among adult medical admissions and measure patient outcomes. Health Economic: Measure economic costs incurred and changes in health-related quality of life (HRQoL) at 90 days post-admission. Situation analysis: Qualitatively describe pathways of patients with multimorbidity through the health system. Secondary objectives Clinical: Determine hospital readmission free survival and markers of disease control 90 days after admission. Health Economic: Present economic costs from patient and health system perspective, sub-analyse costs and HRQoL according to presence of different diseases. Situation analysis: Understand health literacy related to their own diseases and experience of care for patients with multimorbidity and their caregivers. Methods This is a prospective longitudinal cohort study of adult (≥18 years) acute medical hospital admissions with nested health economic and situation analysis in four hospitals: 1) Queen Elizabeth Central Hospital, Blantyre, Malawi; 2) Chiradzulu District Hospital, Malawi; 3) Hai District Hospital, Boma Ng’ombe, Tanzania; 4) Muhimbili National Hospital, Dar-es-Salaam, Tanzania. Follow-up duration will be 90 days from hospital admission. We will use consecutive recruitment within 24 hours of emergency presentation and stratified recruitment across four sites. We will use point-of-care tests to refine estimates of disease pathology. We will conduct qualitative interviews with patients, caregivers, healthcare providers and policymakers; focus group discussions with patients and caregivers, and observations of hospital care pathways.