Community and Physician Perceptions of Barriers to Care for Acute Coronary Syndrome Among HIV-infected and -Uninfected Patients in Moshi, Tanzania_1
Phase: NA
Conditions: Hypertension, HIV
Sponsor: Duke University

  
Community and physician perceptions of chest pain and prevalence of acute 
coronary syndrome among emergency department patients in Moshi, 
Tanzania 
Principal Investigator 
Julian Hertz, MD 
Global Health Fellow 
Division of Emergency Medicine 
Duke Global Health Institute 
Julian.hertz@duke.edu 
Cell (703) 297 7431 
 
Co-Investigators: 
Blandina T. Mmbaga, MD, PhD 
Director, KCMC/Duke Collaboration 
Kilimanjaro Christian Medical Center 
blaymt@gmail.com 
 
 
Catherine A. Staton, MD 
Assistant Professor 
Division of Emergency Medicine 
Duke Global Health Institute 
Catherine.staton@duke.edu 
US cell (908) 872-9208 
 
John Bartlet, MD 
Professor 
Division of Infectious Disease 
Duke Global Health Institute 
Bartl004@duke.edu 
 
NCT06503991 
Document Date: November 5, 2024 
 

 
2
Abstract:  
Despite the rapid increase in cardiovascular risk factors across sub-Saharan Africa such as 
hypertension, little is known about the prevalence of acute coronary syndrome (ACS) in the 
region.  Very few studies have described ACS in the continent, and it remains unclear whether or 
not the disease is rare or simply underrecognized.  Possible explanations for under-detection of 
ACS include patient factors such as healthcare seeking behavior and physician factors such as 
failure to consider the diagnosis of ACS.  In Tanzania, no data are available regarding the 
prevalence of ACS, and it is unknown to what degree patient and physician knowledge, attitude, 
and practices may be contributing to under-diagnosis of ACS in the country.  This project will 
aim to explore patient and physician perceptions of chest pain and ACS, to describe the current 
patterns of care for patients with ACS-related symptoms in northern Tanzania, and to determine 
the prevalence of ACS in the emergency department in Moshi.   
 
Abbreviations: 
ACS Acute Coronary Syndrome 
ED Emergency Department 
ECG Electrocardiogram 
HIC High Income Countries 
ICER Incremental Cost Effective Ratio 
KAP Knowledge, Attitude, and Practice 
KCMC Kilimanjaro Christian Medical Center  
LMIC Low and Middle Income Countries 
WHO World Health Organization 

 
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Introduction: 
 
Acute coronary syndrome (ACS), colloquially known as the “heart attack,” is a leading cause of 
morbidity and mortality from poorly controlled hypertension 1. In sub-Saharan Africa, ACS has 
long been considered of less importance due to the relatively high burden of communicable 
diseases 2. In recent years, however, countries across sub-Saharan Africa have faced a sharp 
increase in ACS risk factors, such as longer life span, reduced exercise, poor diet, hypertension 
and diabetes 3. Given the well-documented rise of these risk factors in the region, several authors 
have highlighted the increased need for accurate data regarding the burden of disease of ACS in 
sub-Saharan Africa 4.  This study will determine the prevalence of ACS in the emergency 
department setting in northern Tanzania and assess patient and physician beliefs and practices 
which may be contributing to a low rate of ACS diagnosis. 
Literature Review: 
Despite the need for data regarding ACS prevalence, very little is known about the burden of 
ACS across the African continent. Our team’s recent systematic review found there are very few 
studies on the incidence of ACS in sub-Saharan Africa; studies were mostly performed in small, 
narrowly-defined patient populations and were generally of low quality 5. None of these studies 
were performed in Tanzania.  Based on the sparse data available, however, researchers have 
pointed out that the incidence of ACS in the region seems to be much lower than what would be 
expected given the local prevalence of ACS risk factors 6.  It remains unclear whether or not 
ACS in sub-Saharan Africa is actually a rare phenomenon, or just an under-reported one. 
 

 
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There are many possible explanations for the apparent relative scarcity of ACS in sub-Saharan 
Africa. One such explanation is related to care-seeking behavior. Since most data regarding ACS 
incidence comes from hospital-based studies, if large numbers of patients do not present to a 
hospital for symptoms such as chest pain, then the local incidence of ACS may be significantly 
under-reported. In developed countries, there is already ample evidence that care-seeking 
behavior for patients with ACS symptoms is significantly affected by socioeconomic factors, 
health literacy, and cultural factors 7. It is unknown to what extent, if any, similar factors are 
affecting patient healthcare seeking behavior, and in turn, under-reporting of ACS in Tanzania.   
 
Physician beliefs and practices may also be contributing to under-diagnosis of ACS.  If 
physicians do not consider the diagnosis of ACS or do not pursue diagnostic workups (such as 
ECGs) for patients with symptoms suggestive of ACS, their behavior may be reinforcing a 
misperception that ACS is a relatively uncommon and unimportant disease in the region.  Studies 
performed elsewhere in sub-Saharan Africa have shown that physician beliefs and practices 
contribute to misdiagnosis and inappropriate treatment for infectious syndromes 8.  The degree to 
which physician practices may be similarly contributing to under-appreciation of ACS in 
Tanzania is unknown. 
 
Statement of the Problem:                
Little is known about the prevalence of ACS in sub-Saharan Africa or the ways in which patient 
and physician practices may be affecting detection of this disease. 
Rationale: 

 
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This project will gather information in order to determine the prevalence of ACS in emergency 
department in Moshi, Tanzania. Patient and physician perceptions and practices which may be 
contributing to ACS under-diagnosis will also be explored. 
Broad Objective: 
To determine the prevalence of ACS among adults in the emergency department.    
 
Specific Objectives: 
Specific Objective 1: To explore the knowledge, attitudes, and practices (KAP) of community 
members and physicians regarding ACS and ACS-related symptoms in northern Tanzania. 
Specific Objective 2: To determine the prevalence of ACS-related symptoms in an emergency 
department in northern Tanzania and describe current patterns of care for such patients. 
Specific Objective 3: To determine the prevalence of acute myocardial infarction in an ED 
population in northern Tanzania. 
 
Methods:  
Setting: Moshi is located in the Kilimanjaro region of Northern Tanzania. It has a population of 
184, 292 people and includes both Moshi Rural and Moshi Urban. It is home to Kilimanjaro 
Christian Medical Center (KCMC) which is a referral hospital for northwestern Tanzania and a 
regional training center. Duke and KCMC have developed a research infrastructure with proven 
success in NIH funded grants. Many successful research projects have been conducted through 
the Casualty department with the help of an experienced team of Tanzanian research nurses and 
data entry technicians.  
 

 
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Study Design:  The prevalence of ACS will be ascertained with a cross-sectional survey of a 
representative sample of all casualty department patients presenting with chest pain or shortness 
of breath.  The prevalence of acute myocardial infarction will be determined by obtaining 
electrocardiograms (ECGs) and point-of-care troponins on all patients presenting with symptoms 
suggestive of ACS.  Quantitative data concerning ACS knowledge and barriers will be obtained 
by patient knowledge, attitude, and practice (KAP) surveys. Qualitative information regarding 
barriers to care, healthcare seeking behaviors, and management of ACS will be obtained using 
patient focus groups and in-depth interviews with ED providers.   
 
Study Population: All participants will be >17 years of age and be able to speak Swahili 
(patients or families) or English (healthcare practitioners). We will exclude patients with an 
inability to respond to the survey due to the severity of their illness or injury.  We plan to enroll 
500 patients in the observational study of patients with ACS-related symptoms and 500 patients 
in the ACS prevalence study.   
Inclusion/ Exclusion Criteria: 
Patients will be included in the prospective observational study of ACS-related symptoms and 
prevalence of myocardial infarction study if they have a primary or secondary chief complaint of 
chest pain or shortness of breath.  All patients must be >17 years of age, be seeking care at 
KCMC in the casualty department, be clinically sober at the time of enrollment, be able to 
communicate in Swahili or English and consent to participate. Patients will be excluded from 
enrollment if they are medically unstable or have a deteriorating condition, are too critically ill to 
participate, are <18 years of age.  
 

 
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Sample Size Calculation:  
 
Reported prevalence of myocardial ischemia among various African sub-populations (not 
general ED populations presenting with chest pain) range from 0.2%9 to 10.4%10.  Assuming the 
prevalence of ischemic ECGs among ED patients with chest pain will be at the high end of this 
range (10%), then 210 patients will need to be enrolled in order to report this prevalence with a 
precision of +/- 5%. 
 
The proportion of ED patients with chest pain in Tanzania is unknown, but in developed 
settings is typically around 10%.11, 12  Assuming a similar proportion of patients will be eligible 
for inclusion in our study, and given current patient volumes at KCMC (25 adults/dayshift), 
enrollment will need to be conducted for 5 months to achieve the desired sample size. 
 
Instruments/Procedures: 
 
KAP (Specific Objective 1): A focused knowledge, attitude, and practice survey (KAP) survey 
will be developed, adapting questions from existing cardiovascular KAP surveys used elsewhere 
13-16.  The survey will piloted on a small sample (N<20) of persons (who will be excluded from 
the final study) in order to report upon the internal consistency or reliability of the survey in 
Kiswahili and to assess the content validity of the survey in Kiswahili. It will be necessary to 
audio record the pilot interview sessions in order to allow for complete translation into English. 
Participants will not be identified by name on the tapes, and all recordings will be discarded after 
translation. This pilot will occur before the start of the study recruitment. After acceptability is 
assured the survey will then be given to all patients enrolled in the study.   
 

 
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Focus Group Methodology (Specific Objective 1): Focus groups will be held in Swahili with 
patients to better assess their understanding of chest pain and acute coronary syndrome, 
adherence with treatment, and any cultural barriers or culturally relevant solutions for a 
successful intervention and follow-up plan. Community members from randomly selected 
communities in Moshi Urban or Moshi Rural will participate in the focus groups.  All patients 
who agree will be included until 3-4 focus groups are complete with a minimum of 10 
participants each.  Patients will be offered transportation money if they elect to return for focus 
groups. The focus groups will occur in a small quiet room near to the Casualty Department or in 
the local community.  
 
In-depth Interview Methodology (Specific Objective 1): Approximately twenty in-depth 
interviews with a semi-structured format will be conducted in English or Swahili with casualty 
department physicians to assess their current practice surrounding the management of ACS in the 
emergency department. Implied consent language will be utilized. These conversations will be 
recorded and transcribed.  
 
Retrospective Chart Review (Specific Objective 2): Patient logs from the Emergency 
Department for a six-month period prior to study initiation date will be reviewed.  From these 
logs, data will be collected including patient age, sex, and diagnosis.  No identifying information 
such as name or date of birth will be collected. This data will allow for an analysis of current 
patterns of ACS-related diagnoses in the ED. 
 

 
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Prospective observational study of patients with ACS-related symptoms (Specific Objective 
2):  A triage system in the KCMC ED is about to be implemented to improve quality of care. The 
triage nurse, as part of routine care, will begin obtaining all five vital signs (blood pressure, heart 
rate, temperature, respiratory rate, and oxygen saturation).  Patient complaints will be entered 
into a triage registry, along with patient age, sex, and vital signs.  This registry data will be 
collected for our research purposes.  No identifying information will be entered into this registry 
or our data collection.  This triage registry will act as a quality improvement initiative to evaluate 
the triage process in the ED. As this registry will become part of routine care as a quality 
improvement project for the ED, patients will not undergo informed consent to have their vital 
signs and chief complaints in the triage registry.  The de-identified data from this registry will be 
used to determine the prevalence of ACS-related chief complaints such as chest pain and 
shortness of breath among emergency department patients.  This registry will be screened and 
patients presenting with a primary or secondary complaint of chest pain or shortness of breath 
will be enrolled for this prospective observational study.  The ACS Patient survey (attached 
below) will be administered to all participants.  Patients will be followed through their 
emergency department stay; their diagnostic workup, treatment, diagnosis, and disposition will 
be observed and recorded.   
 
ACS prevalence study (Specific Objective 3):  Following the observational study, all adult 
patients presenting to the KCMC Emergency Department with a primary or secondary complaint 
of chest pain or shortness of breath will be prospectively enrolled in the prevalence study. At 
time of enrollment, these patients will undergo testing with ECG and point-of-care troponin 
level, and a second point-of-care troponin level will be obtained two hours later.  The results of 

 
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these studies will be shared with the clinical team.  The ECGs will be reviewed by two separate 
physicians, trained in either emergency medicine or cardiology to determine whether or not the 
ECG meets STEMI criteria. If there is a disagreement, a third physician will serve as the 
tiebreaker.   
 
Survey Data Collection: Data will be collected on tablets and stored in a secure database by a 
trained data entry technician.  Surveys for all components of this study will be verbally 
administered to patients and families due to variable literacy rates. They will be administered by 
healthcare providers in the standard medical language of English or Swahili. Results of urine 
dipstick will be recorded for the presence or absence of proteinuria. Results of troponins will be 
recorded and digital images of ECGs will be uploaded. Phone number of the patient and will be 
recorded in the log and de identified. No PHI will be entered into Redcap or any study database. 
The log will remain in a secure, locked cabinet the research office.  
 
Focus Group Data Collection: Participants will take part in an informed consent process 
approved by the Duke and Tanzanian ethics committees before joining the focus group that is 
included in the survey consent form. Focus groups will be formed once 5-10 eligible interested 
participants are identified. Focus groups, led by trained research nurses or other trained research 
personnel, will be audiotaped and transcribed for formal qualitative analysis utilizing thematic 
analyses. Transcriptions will occur within four days of the focus group and research nurse notes 
will be included in these transcriptions about the content. We expect to host approximately 3-4 
focus groups. 
 

 
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Data Analysis: Survey results will be analyzed through analytical techniques. Continuous 
variables will be reported as mean and standard deviation (SD) or median and inter-quartile 
range (IQR). Pertinent outcome variables are expected to be dichotomous. (e.g., tobacco use, 
gender, alternative medicine use).  
 
Focus Group/In-Depth Interview Data Analysis: After transcription, each of the focus groups 
and in-depth interviews will be translated and the final transcript will be discussed by the 
research nurses present in the focus group for content validation. Then a thematic analysis will 
be undertaken for each of the main questions from the focus groups/in depth interviews. All data 
will be analyzed with NVivo 10.0. Latent Semantic Analysis and Sentiment Analysis will be 
used to investigate latent concepts or positive/negative tones behind the qualitative answers.  All 
transcripts, audiotapes and other study documents will be kept for 6 years following conclusion 
of the data the conclusion of the study. 
 
 
Study Timeline: The first steps of the project included IRB submission and planning which is 
currently ongoing. IRB approval has already been obtained from both NIMR (National Institute 
of Medical Research) in Tanzania and the KCMC IRB. Data collection will occur from July 
2018 – June 2019, followed by data analysis and manuscript publication. 
 
Investigators: 
Dr. Blandina Mmbaga is a co-investigator and the onsite research director at KCMC she will 
ensure that the study is carried out with fidelity. As a native swahili-speaker,medical provider, 

 
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and clinical researcher, she will provide critical cultural and clinical expertise. She will 
additionally be relied on throughout the project to assist with any cultural and language issues 
that may arise at later stages of the project. 
Dr. Julian Hertz is a co-investigator. He will assist with project planning, implementation, data 
analysis, and manuscript preparation. 
Dr. Catherine Staton is a co-investigator. She will also assist with study design, study 
oversight, data analysis, and manuscript preparation. 
Dr. John Bartlett is a co-investigator. He will also assist with study design, study oversight, data 
analysis, and manuscript preparation. 
 
Ethical Considerations: 
Capacity Development:  
This project was based on the local needs, available resources and standard practices in the 
KCMC Emergency Department. We have sought out collaborators both at Duke as well as at 
KCMC and have adapted our project to their suggestions and experiences. We will employ and 
train, Tumsifu Tarimo, a Masters student in sociology at the Open University of Tanzania, who 
has considerable experience performing focus groups with the Duke-KCMC research 
collaboration. He will oversee both the focus groups and the administration of the KAP survey. 
We will continue to recruit junior facility at KCMC to assist with all research concerns and plan 
to collaborate with Dr. Kijaro Kilonzo, nephrologist and chair of the internal medicine 
department at KCMC for future publications and research project. 
 
Subject Recruitment and Compensation: 

 
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All patients at KCMC Casualty Department who meet inclusion criteria will be offered 
enrollment in the study.  The only cost to participants is the time spent performing the survey.  
The participants will not be compensated for their time for this study.  Participants will not be 
compensated for their time spent completing the survey. They will be compensated for travel and 
food if they return for focus groups. 
  
Consent Process: 
For patients we will be utilizing a written informed consent.  Participants will be provided with a 
description of the study objectives and procedures, along with information on data safety. 
Agreement to participate in the survey will serve as consent to participate in the study. The in-
depth interviews will have an implied consent language. The participants will be enrolled by 
study nurses.  
 
Dissemination and Publications: 
Dissemination of results will occur for both the academic literature in the form of international 
presentations and research manuscripts as well as the clinical environment at KCMC. We will 
offer to KCMC leadership to discuss our results during the weekly Clinical Case Conference in 
order to educate KCMC Clinicians. Similarly, presentations in the Casualty Department will take 
place for KCMC Casualty Department staff and all healthcare providers.  We also hope to share 
these results with emergency department providers and health policy officials in order to 
understand the burden of disease suffered by our patients in hopes of planning for the needs of 
healthcare professionals for these patients.  
 

 
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Budget: 
Item 
Cost in US Dollars 
RN time x 12 months 
9,600 
RN data/internet time x 8 months 
500 
Printing .13 x sheet 
3328 
Automatic BP cuff x 2 
100 
Alcohol pads (1/per subject) 
donated 
POC troponin machines 
donated 
EKG paper 
donated 
ECG machines 
donated 
Patient focus group transportation/food/time x 100 subjects 
300 
MD indepth interview food x 3 
100 
KCMC overhead 10% total budget 
3213 
Total  
15,321 
Budget Justification: 
PERSONNEL 
Research nurse: One full time research nurse will be required for all the aims of this study. 
They will be employed according to the research project requirements and will be active on other 
projects thus supplementing their salary during periods when less participant contact is needed. 
The research nurses will be responsible for recruiting patients for the surveys, follow-up groups 
and performing blood pressure measurements, ECGs, and troponins. They will also be 
responsible for informed consent of participants, conducting all interviews, maintaining 
participant files, and communicating progress to Dr. Hertz. Nurses will be paid $800 per month, 
which is standard for Duke/KCMC Collaboration research nurses. One nurse will be full-time for 
12 months ($9,600).  
  

 
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SUPPLIES: 
Laboratory equipment: One alcohol pad will be required for each patient and these supplies 
will be donated.  
Two automatic blood pressure cuffs will be needed. ($100) ECG machines, POC troponin 
machines, and cartridges will be donated.   
 
 Paper and printing costs: ($3,328) We request funds in order to cover paper and printing costs 
for the project. Informed consent, surveys and any regulatory paperwork will need printing 
estimating 16 pages/participant x 1600 participants at 25,600 pages at 0.13 cents for paper and 
printing costs. Total funds requested $3,328. 
  
Patient focus group transportation and food: Ten focus group will be held x 10 patients each. 
Each participant will be reimbursed (5,000 TSH)= ($3USD) for transportation plus food.($300) 
 
In-depth interview: Interviewee will be paid for their time and provided with a meal. ($100) 
  
KCMC overhead According to our funders, the US National Institute of Health guidelines, we 
are requesting 10% of the total KCMC budget be paid to the Good Samaritan Foundation 
account at KCMC hospital for the privilege of being housed at KCMC and other administrative 
costs.  
 
 
 

 
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BMC infectious diseases. 2015;15:421. 
28. 
Muhamad R, Yahya R, Yusoff H, Rao B and Rao D. Knowledge, Attitude and Practice 
on Cardiovascular Disease among Women in North-Eastcoast Malaysia. International Journal of 
Collaborative Research on Internal Medicine & Public Health. 2012;4:85-98. 
29. 
Vaidya A, Aryal UR and Krettek A. Cardiovascular health knowledge, attitude and 
practice/behaviour in an urbanising community of Nepal: a population-based cross-sectional 
study from Jhaukhel-Duwakot Health Demographic Surveillance Site. BMJ open. 
2013;3:e002976. 
30. 
Mirza A, Aslam S, Perrin K, Curtis T, Stenback J, Gipson J and Alrabaa S. Knowledge, 
attitudes, and practices among patients with coronary artery disease in Dhaka, Bangladesh. Int 
J Community Med Public Health. 2016;3:2740-2748. 
31. 
Redcap Duke Database. 2016;2016. 
 
 
Curriculum Vitae 
CRERC FORM 13 
TUMAINI UNIVERSITY 
KILIMANJARO CHRISTIAN MEDICAL COLLEGE 
P. O. Box 2240, Moshi   Tel. 027-27-53909 
CURRICULUM VITAE OF INVESTIGATORS 
1. 
1.1 Name …Blandina Theophil Mmbaga 

 
19
1.2. Nationality ……Tanzania Citizen 
2. 
Contact : 
2.1.        Address: CCFCC Building, 1st floor, Sokoine Rd PO Box 3010 Moshi, Tz 
2.2.        Phone: … 
2.3.        Email: …blaymt@gmail.com………………………. 
3. 
Academic Qualifications (University degrees) 
3.1.        …MD Nizhny Novgorod State Medical Academy, Russia 
3.2.        …MMed, KCM-College, Tumaini University 
3.3.        …PhD University of Bergen, Norway 
3.4.        Employer: Kilimanjaro Christian Medical Center 
3.5.        Current position …Pediatric Consultant, Director KCRI, Director, KCMC/Duke 
Collaboration 
3.6.        Profession …Physician… 
4. 
 Not more than 10 publications, within past 5 years. 
1. Mmbaga BT, Lie RT, Kibiki GS, Olomi R, Kvale G, Daltveit AK.  Transfer of newborns to neonatal care 
unit: a registry based study in Northern Tanzania. BMC Pregnancy and Childbirth 2011, 11:68. PMCID: 
PMC3206461 
2. Mmbaga BT, Lie RT, Mahande MJ, Olomi R, Kvale G, Daltveit AK. Cause-specific neonatal mortality in 
a neonatal care unit in Northern Tanzania. A registry based cohort study. BMC Paediatrics 2012, 12:116. 
PMCID: PMC3469393 
3. Mmbaga BT, Lie RT, Mahande MJ, Olomi R, Olola O, Daltveit AK.  Causes of perinatal death at a 
tertiary care hospital in Northern Tanzania 2000-2010: a registry based study. BMC Pregnancy and 
Childbirth 2012, 12:139. PMCID: PMC3533832 
4. Mahande MJ, Dalveit AK, Mmbaga BT, Obure J, Masenga G, Manongi R, Lie RT. Recurrence of 
perinatal deaths in Northern Tanzania: A registry-based study. BMC Pregnancy and Childbirth. 2013; 
13:166. 
5. Mahande MJ, Dalveit AK, Obure J, Mmbaga BT, Masenga G, Manongi R, Lie RT. Recurrence of 
preterm birth and perinatal mortality in northern Tanzania: registry-based cohort study. Tropical Medicine 
and International Health.2013; 18(8): 962–967. 
6. Mahande MJ, Dalveit AK, Mmbaga BT, Masenga G, Obure J, Manongi R, Lie RT. Recurrence of 
preeclampsia in Northern Tanzania: a registry-based cohort study. PLoS One 2013, 8(11)e79116. 
PMCID: PMC3815128 
7. Susan D. Emmett, Coleen K. Cunningham, Blandina T. Mmbaga, Grace D. Kinabo Werner Schimana, 
Mark E. Swai, John A. Bartlett, John A. Crump, and Elizabeth A. Reddy. Predicting Virologic Failure 
among HIV-1-Infected Children Receiving Antiretroviral Therapy in Tanzania. a Cross-Sectional Study.  J 
Acquir Immune Defic Syndr. 2010. 54 (4).  PMCID: PMC4185279 
8. Opemipo O. Johnson, Daniel K. Benjamin, Daniel K. Benjamin Jr, Werner Schimana, L. Gayani 
Tillekeratne,, John A. Crump, Keren Z. Landman, Grace D. Kinabo, MD,  Blandina T. Mmbaga, Levina J. 
Msuya, John F. Shao,  Mark E. Swai, and Coleen K. Cunningham. Total Lymphocyte Count and World 
Health Organization Pediatric Clinical Stage as Markers to Assess Need to Initiate AntiretroviralTherapy 
among Human Immunodeficiency Virus-Infected Children in Moshi, Northern Tanzania: Pediatr Infect Dis 
J. 2009 June; 28(6): 493–497. PMCID: PMC2724760 
9. L. Gayani Tillekeratne, Sheng Feng, Werner Schiman, Opemipo O. Johnson, Grace D. Kinabo, 
Blandina T. Mmbaga, Levina J. Msuya, John F. Shao, Mark E. Swai, John A. Crump and Coleen K. 
Cunningham. Identifying HIV-infected children who may benefit from early initiation of antiretrovirals. 
Journal of Pediatric Infectious Diseases 4 (2009) 387–392. 
10. Cecilie Nilsen, Truls Østbye, Anne Kjersti Daltveit, Blandina Theophil Mmbaga and Ingvild 
Fossgard Sandøy. Trends in and socio-demographic factors associated with caesarean section 
at a Tanzanian referral hospital, 2000 to 2013. International Journal for Equity in Health 2014, 
13:87. 
 
 
 

 
20
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
CRERC FORM 13 
TUMAINI UNIVERSITY 
KILIMANJARO CHRISTIAN MEDICAL COLLEGE 
P. O. Box 2240, Moshi   Tel. 027-27-53909 
 
CURRICULUM VITAE OF INVESTIGATORS 
1. 1.1 Name …Julian Hertz, MD ………………………… 
1.2. Nationality ……United States Citizen 
2. 
Contact :  

 
21
2.1 Address: …310 Trent Drive Rm 231, Durham NC, 27705………… 
2.2 Phone: … Tz +255 785 539 819……………… 
2.3 Email: …julian.hertz@duke.edu………………………………. 
3. 
Academic Qualifications (University degrees) 
3.1…BA, Princeton University, Princeton, NJ, USA  
3.2…MD, Duke University, Durham, NC, USA 
4. 
Employment  
4.1 Employer: Duke University Medical Center/Duke Global Health Institute 
4.2 Current position …Professor of Surgery… 
4.3 Profession …Physician… 
5. 
Not more than 10 publications, within past 5 years.  
1. Biggs HM, Hertz JT, Munishi OM, Galloway RL, Marks F, Saganda W, Maro VP, Crump 
JA. Estimating Leptospirosis incidence using hospital-based surveillance and a population-based 
health care utilization survey in Tanzania. PLoS Negl Trop Dis 2013; 7(12): e2589. 
2. Hertz JT, Munishi OM, Sharp JP, Reddy EA, Crump JA. Comparing actual and perceived 
causes of fever among community members in a low malaria transmission setting in northern 
Tanzania. Trop Med Int Health 2013; 18: 1406-15. 
3. Hertz JT, Reardon JM, Rodrigues CG, de Andrade L, Limkakeng AT, et al. (2014) Acute 
myocardial infarction in sub-Saharan Africa: the need for data. PLoS ONE 9(5): e96688.  
4. Hertz JT, Lescallette RD, Barrett TW, Ward MJ, Self WH. (2015) External validation of an 
ED protocol for reflex urine culture cancellation. Am J Emerg Med 33(12): 1838.  
5. Hertz JT, Lyaruu LJ, Ooi EE, Mosha FW, Crump JA. (2016) Distribution of Aedes 
mosquitoes in the Kilimanjaro Region of northern Tanzania. Pathog Glob Health 110: 108. 
6. Maze MJ, Biggs HM, Rubach MP, Galloway RL, Cash-Goldwasser S, Allan KJ, Halliday JE, 
Hertz JT, Saganda W, Lwezaula BF, Cleaveland S, Mmbaga BT, Maro VP, Crump JA. (2016) 
Comparison of the estimated incidence of acute leptospirosis in the Kilimanjaro Region of 
Tanzania between 2007-08 and 2012-14. PLoS Negl Trop Dis 10: 12. 
7. Reardon JM, Andrade L, Hertz J, Kiwango G, Teu A, Pesambili M, El-Gabri D, Hocker M, 
Mvungi M, Vissoci JRN, Staton CA. (2017) The epidemiology and hotspots of road 
 
 
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Cardiovascular health knowledge and preventive practices in people living with HIV in Kenya. 
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14. 
Muhamad R, Yahya R, Yusoff H, Rao B and Rao D. Knowledge, Attitude and Practice 
on Cardiovascular Disease among Women in North-Eastcoast Malaysia. International Journal of 
Collaborative Research on Internal Medicine & Public Health. 2012;4:85-98. 
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Vaidya A, Aryal UR and Krettek A. Cardiovascular health knowledge, attitude and 
practice/behaviour in an urbanising community of Nepal: a population-based cross-sectional 
study from Jhaukhel-Duwakot Health Demographic Surveillance Site. BMJ open. 
2013;3:e002976. 
16. 
Mirza A, Aslam S, Perrin K, Curtis T, Stenback J, Gipson J and Alrabaa S. Knowledge, 
attitudes, and practices among patients with coronary artery disease in Dhaka, Bangladesh. Int 
J Community Med Public Health. 2016;3:2740-2748.