Objective To study the diagnosis and outcomes in people admitted to hospital with a diagnosis of severe malaria in areas with differing intensities of malaria transmission. Design Prospective observational study of children and adults over the course a year. Setting 10 hospitals in north east Tanzania. Participants 17 313 patients were admitted to hospital; of these 4474 (2851 children aged under 5 years) fulfilled criteria for severe disease. Main outcome measure Details of the treatment given and outcome. Altitudes of residence (a proxy for transmission intensity) measured with a global positioning system. Results Blood film microscopy showed that 2062 (46.1%) of people treated for malaria had Plasmodium falciparum (slide positive). The proportion of slide positive cases fell with increasing age and increasing altitude of residence. Among 1086 patients aged ≥ 5 years who lived above 600 metres, only 338 (31.1%) were slide positive, while in children < 5 years living in areas of intense transmission ( < 600 metres) most (958/1392, 68.8%) were slide positive. Among 2375 people who were slide negative, 1571 (66.1%) were not treated with antibiotics and of those, 120 (7.6%) died. The case fatality in slide negative patients was higher (292/2412, 12.1%) than for slide positive patients (142/2062, 6.9%) (P < 0.001). Respiratory distress and altered consciousness were the strongest predictors of mortality in slide positive and slide negative patients and in adults as well as children. Conclusions In Tanzania, malaria is commonly overdiagnosed in people presenting with severe febrile illness, especially in those living in areas with low to moderate transmission and in adults. This is associated with a failure to treat alternative causes of severe infection. Diagnosis needs to be improved and syndromic treatment considered. Routine hospital data may overestimate mortality from malaria by over twofold.

Background Trachoma, caused by repeated ocular infection with Chlamydia trachomatis, is an important cause of blindness. Current recommended dosing intervals for mass azithromycin treatment for trachoma are based on a mathematical model. Methods We collected conjunctival swabs for quantitative polymerase-chain-reaction assay of C. trachomatis before and 2, 6, 12, 18, and 24 months after mass treatment with azithromycin in a Tanzanian community in which trachoma was endemic. For ethical reasons, at 6, 12, and 18 months, we gave tetracycline eye ointment to residents who had clinically active trachoma. Results At baseline, 956 of 978 residents (97.8 percent) received either one oral dose of azithromycin or (if azithromycin was contraindicated) a course of tetracycline eye ointment. The prevalence of infection fell from 9.5 percent before mass treatment to 2.1 percent at 2 months and 0.1 percent at 24 months. The quantitative burden of ocular C. trachomatis infection in the community was 13.9 percent of the pretreatment level at 2 months and 0.8 percent at 24 months. At each time point after baseline, over 90 percent of the total community burden of C. trachomatis infection was found among subjects who had been positive the previous time they were tested. Conclusions The prevalence and intensity of infection fell dramatically and remained low for two years after treatment. One round of very-high-coverage mass treatment with azithromycin, perhaps aided by subsequent periodic use of tetracycline eye ointment for persons with active disease, can interrupt the transmission of ocular C. trachomatis infection.

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while Salmonella Typhi and S. pneumoniae were the most common causes of invasive infection overall, M. tuberculosis and C. neoformans were the leading causes of bloodstream infection among HIV-infected inpatients in Tanzania in the ART era. We demonstrate a protective effect of HIV against Salmonella. Typhi bloodstream infection in this setting. HIV co-infections continue to account for a large proportion of febrile admissions in Tanzania.

Human herpesvirus 8 (HHV-8) infection is common in Africa. We examined the distribution of HHV-8 within families in rural Tanzania to determine routes of spread. HHV-8 infection was assessed by measuring antibody reactivity with a K8.1 (lytic-phase antigen) immunoassay. The prevalence increased from 3.7% (1/27) among infants to 58.1% (36/62) among children aged 3-4 years and 89.0% (65/73) among adults aged > or =45 years. Women with HHV-8-seropositive husbands had a 7-fold risk for infection (odds ratio [OR], 6.9; 95% confidence interval [CI], 1.9-25.3). HHV-8 seropositivity in children was associated with having at least 1 seropositive first-degree relative (OR, 14.7; 95% CI, 5.9-43.1), a seropositive mother (OR, 7.4; 95% CI, 3.2-16.8), a seropositive father (OR, 4.8; 95% CI, 2.3-10.1), or a seropositive next-older sibling (OR, 4.2; 95% CI, 1.9-9.4). Our data are consistent with the occurrence of HHV-8 transmission within families, from mothers and other relatives to children via nonsexual routes and between spouses via sexual routes.

Summary OBJECTIVE To describe the contribution of paediatric HIV and of HIV co-infections to admissions to a hospital in Moshi, Tanzania, using contemporary laboratory methods. METHODS During 1 year, we enrolled consecutively admitted patients aged ≥2 months and <13 years with current or recent fever. All patients underwent standardized clinical history taking, a physical examination and HIV antibody testing; standard aerobic blood cultures and malaria film were also done, and hospital outcome was recorded. Early infant HIV diagnosis by HIV-1 RNA PCR was performed on those aged <18 months. HIV-infected patients also received serum cryptococcal antigen testing and had their CD4-positive T-lymphocyte count and percent determined. RESULTS A total of 467 patients were enrolled whose median age was 2 years (range 2 months–13 years); Of those patients, 57.2% were female and 12.2% were HIV-infected. Admission clinical diagnosis of HIV disease was made in 10.7% and of malaria in 60.4%. Of blood cultures, 5.8% grew pathogens; of these 25.9% were Salmonella enterica (including 6 Salmonella Typhi) and 22.2% Streptococcus pneumoniae. Plasmodium falciparum was identified on blood film of 1.3%. HIV infection was associated with S. pneumoniae (odds ratio 25.7, 95% CI 2.8, 234.0) bloodstream infection (BSI), but there was no evidence of an association with Escherichia coli or P. falciparum; Salmonella Typhi BSI occurred only among HIV-uninfected participants. The sensitivity and specificity of an admission clinical diagnosis of malaria were 100% and 40.3%; and for an admission diagnosis of bloodstream infection, they were 9.1% and 86.4%, respectively. CONCLUSION Streptococcus pneumoniae is a leading cause of bloodstream infection among paediatric admissions in Tanzania and is closely associated with HIV infection. Malaria was over-diagnosed clinically, whereas invasive bacterial disease was underestimated. HIV and HIV co-infections contribute to a substantial proportion of paediatric febrile admissions, underscoring the value of routine HIV testing.

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To the Editor: Single-dose azithromycin is the first-choice antibiotic for the treatment of trachoma. The World Health Organization (WHO) currently recommends annual mass azithromycin treatment for 3 years in communities in which the prevalence of the clinical sign "trachomatous inflammation-follicular" in children between 1 and 9 years of age is 10% or more.We previously reported the effect of high-coverage, single-dose mass azithromycin treatment on ocular Chlamydia trachomatis infection in Kahe Mpya, Tanzania. 1 In all, 97.6% of residents were treated; the prevalence of ocular C. trachomatis fell from 9.5% at baseline to 0.1% 24 months later. We subsequently carried out a second round of mass treatment at 24 months, examined residents at 42 and 60 months, and took conjunctival swabs for testing for C. trachomatis by means of a polymerase-chain-reaction assay at 60 months. Just as at 6, 12, and 18 months, at 42 months, persons with active disease (21 of the 821 residents examined at 42 months) were offered tetracycline eye ointment. Field, laboratory, and statistical methods have been described previously, 1,2 although because we expected the prevalence of infection to be low after the two mass treatments, we combined aliquots from each of five eluted swabs for each assay, intending to retest individual samples if results were positive or equivocal. 3 Approval for the study was obtained from ethics committees at the London School of Hygiene and Tropical Medicine and Tumaini University.At 24 months (when the prevalence of infection was 0.1% 1 ), the rate of antibiotic coverage was 93.1% (917 of 985 persons). At 42 months, 821 of 975 residents (84.2%) were examined, as were 859 of 964 (89.1%) at 60 months. The prevalence of trachomatous inflammation-follicular in children between 1 and 9 years of age fell from 16.3% at 24 months to 4.6% at 42 months and 2.6% at 60 months. At 60 months (3 years after the second mass treatment), C. trachomatis DNA was not detected in the conjunctiva of any of the 859 residents from whom swab specimens were obtained, suggesting that infection may have been eliminated.One or two rounds of high-coverage mass treatment with azithromycin may be sufficient to eliminate ocular C. trachomatis in communities with moderate levels of infection. In this Tanzanian community, the fall in the prevalence of trachomatous inflammation-follicular lagged considerably behind the fall in the prevalence of infection (Fig. 1). Had WHO recommendations on antibiotic use been followed, three or possibly five annual rounds of mass treatment would have been offered, whereas our data suggest that one round was sufficient. A field-based assay for estimating the prevalence of infection 4 is needed to guide treatment decisions in the 3 to 5 years after the first distribution of antibiotics for trachoma control.