By Faheem Sheriff, MD, and Hamisi K. Shabani, MD
The Muhimbili National Hospital is the largest referral hospital in Tanzania, handling a broad spectrum of pathology, including critically ill neurologic and neurosurgical cases of the highest complexity. It is affiliated with the Muhimbili Orthopedic Institute (MOI), which is the only tertiary center for neurosurgery and orthopedics in Tanzania. The World Health Organization recommends that all countries have one neurosurgeon for each 100,000 residents. In Tanzania, the ratio is 1 to 13 million.1
In addition, Tanzania has only seven practicing neurologists (serving a population of 53 million), with a small number of trainee neurologists in various stages of their training at home or abroad.2
Lack of expertise is compounded by a high incidence of emergent neurologic conditions ranging from TBI to ischemic and hemorrhagic stroke requiring expert neurocritical and neurosurgical care. As an example, the incidence of ischemic stroke in Dar es Salaam (largest city in Tanzania) was 315.9 per 100,000 (281.6-352.3) compared with urban United States - 93 per 100,000 in whites and 223 per 100,000 for blacks in the Northern Manhattan Stroke study.3
There is high in-hospital mortality among these patients (33.3 percent in first 30 days) according to a recent study,4
with sepsis and aspiration pneumonia being major contributors. Even if patients survive the acute period, there is significant socioeconomic burden and long term mortality (82.3 percent in seven years) primarily driven by severity of disability.5 Neurosurgery Operating Room at Muhimbili Orthopedic Institute
Compounding lack of expertise and paucity of resources, a lack of transport infrastructure and referral networks often mean many patients with neurovascular and neurotrauma emergencies arrive too late. Despite the multiple hurdles, given evidence for benefit of intra-arterial stroke therapies in the extended window as well as reduction of morbidity and mortality with decompressive hemicraniectomy in malignant MCA stroke within 48 hours6
, there may be reason to believe that expert stroke, neurocritical and neurosurgical care may change the outlook in an otherwise grim situation.
We communicated with Dr. Hamisi Shabani, the chair of neurosurgery at MOI and Muhimbili National Hospital, who is dedicated to improving the state of neurocritical care in Tanzania. These were his responses:
Is there a dedicated neurocritical care specialist at your center (Muhimbili National Hospital / Muhimbili Orthopedic Institute) for neurosurgical and neurocritically ill patients?
There is not a single neurocritical care specialist at MOI or Muhimbili National Hospital (or in Tanzania that I know of).
What are your plans in this regard?
We have several plans, but due to lack of funding, some programs fall back due to overriding priorities. We would love to have a boost in this respect. The essential surgical skills training is ongoing under the funding from Canadian Network for International Surgery. That way at least the basic life support skills are learned.
What is the size of your neurocritical care unit (beds)?
MOI is now in phase three of expansion. We shall have a 20-bed ICU and 30 bed step down ICU. This is excluding the human workforce development requirement necessary at the beginning.
What is the nursing-to-patient ratio in your neurocritical care unit?
The current ratio is two patients to one nurse.
Who is in charge of your neurocritically ill patients?
Our unit is staffed primarily by anaesthesiologists.
Do you have a fellowship or other formal training program for trainees in your neurocritical care unit?
Most staff are trained at the Muhimibili Univeristy of Health and Allied Sciences (MUHAS); currently, there is no such a training program at MUHAS
Are your trainees trained in ENLS (Emergency Neurologic Life Support)?
There is no ENLS training in Tanzania (responds with a laugh). Please introduce this.
Is your institution represented in the Neurocritical Care Society or any other local neurocritical care societies?
We are unfortunately not involved in the Neurocritical Care Society. Let’s get started if possible.
Are there resources that you would like to have to serve your patient population better?
These are important questions! I don’t know where to start. My advice is to welcome anyone interested in this so we can work together. We also need to engage in resource needs analysis and plan the way forward. Currently, Dr. Halinder Mangat, a neurointensivist from Weil Cornell is paying regular annual visits here during the neurotrauma course.
What is your vision for neurocritical care in Tanzania and East Africa in the next five years?
The future is bright if we establish one center of excellence; then all expansion starts from there. MOI is ready to support such innovation.
2. Dekker MCJ, Urasa SJ, Howlett WP. Neurological letter from Kilimanjaro. Practical Neurology 2017;17:412-416.
3. Walker, Richard et al. Stroke incidence in rural and urban Tanzania: a prospective, community-based study. The Lancet Neurology , Volume 9 , Issue 8 , 786 – 792
4. Kigocha Okeng’o, Pilly Chillo, William K. Gray, Richard W. Walker, William Matuja, Early Mortality and Associated Factors among Patients with Stroke Admitted to a Large Teaching Hospital in Tanzania, Journal of Stroke and Cerebrovascular Diseases, 2017, 26, 4, 871
5. R.W. Walker, K. Wakefield, W.K. Gray, et al. Case-fatality and disability in the Tanzanian Stroke Incidence Project cohort Acta Neurol Scand, 133 (2016), pp. 49-54
6. Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. DOI: 10.1056/NEJMoa1706442
7. Jüttler E, Schwab S, Schmiedek P, Unterberg A, Hennerici M, Woitzik J, Witte S, Jenetzky E, Hacke W; DESTINY Study Group. Decompressive Surgery for the Treatment of Malignant Infarction of the Middle Cerebral Artery (DESTINY): a randomized, controlled trial. Stroke. 2007 Sep;38(9):2518-25.
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