Exploring factors associated with Trichuris trichiura infection in school children in a high-transmission setting in Kenya.

Objectives: Kenya has implemented a national school-based deworming program, which has led to substantial decline in the prevalence of soil-transmitted helminths (STHs), although some pockets of infections remain. To effectively design an STH control program that leads to significant reductions of Trichuris trichiura, there is a need to understand the drivers of persistent infection despite ongoing treatment programs. Methods: This study was conducted between July and September 2019 at the south coast of Kenya, using a two-stage sampling design. First, a school-based cross-sectional survey was conducted in 2265 randomly selected school children from selected schools in areas known to be endemic for T. trichiura. After this, we conducted a nested case-control study wherein all children positive for T. trichiura (142) were matched to 148 negative controls based on age and village. A household survey was then conducted with all household members of cases and controls. In addition, a subsample of 116 children found to be infected with T. trichiura were followed up to assess the efficacy of albendazole at day 21 post-treatment. The predictors of presence of T. trichiura were investigated through multilevel logistic regression, considering clustering of infection. Results: Overall, 34.4% of the children were infected with at least one STH species; T. trichiura was the most common (28.3%), 89.1% of those with T. trichiura had light-intensity infections. The prevalence of T. trichiura was significantly higher in male children and was positively associated with younger age and number of people infected with T. trichiura in a household. The parasitological cure rate and egg reduction rate of T. trichiura were 35% and 51%, respectively. Other STHs identified were hookworm (9.6%) and Ascaris lumbricoides (5.7%). Conclusions: T. trichiura remains a significant public health challenge in the study area with albendazole treatment efficacy against the parasite, remaining lower than the World Health Organization-recommended thresholds. Because of the observed focal transmission of T. trichiura in the current area, control efforts tailored to local conditions and targeting lower implementation units should be used to achieve optimal results on transmission.

Impact of a disability-targeted microentrepreneurship programme in Kenya: study protocol for a randomised controlled trial of the InBusiness programme.

BACKGROUND: There is a lack of evidence on the effectiveness of livelihood interventions amongst people with disabilities. In many countries, self-employment or microentrepreneurship is a dominant source of livelihoods for people with disabilities and their caregivers. However, this group may face heightened barriers to successful microentrepreneurship, including discrimination, exclusion from training or inaccessible transport, infrastructure and communication systems. The InBusiness programme is a livelihoods programme targeted to microentrepeneurs with disabilities or their caregivers delivered by a consortium of non-governmental organisations. The programme focuses on improving the skills, practices and opportunities of microentrepreneurs while linking them with procurement opportunities with private and public institutions. This protocol describes a randomised controlled trial of the InBusiness programme in eight counties of Kenya. METHODS: The randomised controlled trial will involve 495 microentrepreneurs who have been verified as eligible for InBusiness by programme implementers. Individuals will be randomised within counties, either being invited to enrol in InBusiness in March 2023 or allocated to a control group. Participants in the control arm will receive information about compliance with business-related laws and available social protection programmes. The trial will assess the impact of InBusiness on household consumption and individual economic empowerment (primary outcomes) as well as food security, well-being, social attitudes, unmet need for disability-related services and microenterprise profits (secondary outcomes). Baseline was conducted in March 2023, and follow-up will be 24 months from baseline (12 months from completion of the programme). Analysis will be through intention to treat. A process evaluation will explore fidelity, mechanisms of impact and the role of context, and complementary qualitative research with participants will be used to triangulate findings across the trial. DISCUSSION: This study will provide evidence on the impact of a large-scale disability-targeted livelihood programme on household and individual financial security and well-being. Currently, there is a lack of evidence on the effectiveness of livelihood programmes amongst people with disabilities, and so this trial can help inform the design and delivery of InBusiness as well as other livelihood programmes targeted to people with disabilities. TRIAL REGISTRATION: ClinicalTrials.gov ISRCTN13693137. Registered on April 24, 2023.

Spatial variation and clustering of anaemia prevalence in school-aged children in Western Kenya.

Anaemia surveillance has overlooked school-aged children (SAC), hence information on this age group is scarce. This study examined the spatial variation of anaemia prevalence among SAC (5-14 years) in western Kenya, a region associated with high malaria infection rates. A total of 8051 SAC were examined from 82 schools across eight counties in Western Kenya in February 2022. Haemoglobin (Hb) concentrations were assessed at the school and village level and anaemia defined as Hb<11.5g/dl for age 5-11yrs and Hb <12.0g/dl for 12-14yrs after adjusting for altitude. Moran's I analysis was used to measure spatial autocorrelation, and local clusters of anaemia were mapped using spatial scan statistics and local indices of spatial association (LISA). The prevalence of anaemia among SAC was 27.8%. The spatial variation of anaemia was non-random, with Global Moran's I 0.2 (p-value < 0.002). Two significant anaemia cluster windows were identified: Cluster 1 (LLR = 38.9, RR = 1.4, prevalence = 32.0%) and cluster 2 (LLR = 23.6, RR = 1.6, prevalence = 45.5%) at schools and cluster 1 (LLR = 41.3, RR = 1.4, prevalence = 33.3%) and cluster 2 (LLR = 24.5, RR = 1.6, prevalence = 36.8%) at villages. Additionally, LISA analysis identified ten school catchments as anaemia hotspots corresponding geographically to SatScan clusters. Anaemia in the SAC is a public health problem in the Western region of Kenya with some localised areas presenting greater risk relative to others. Increasing coverage of interventions, geographically targeting the prevention of anaemia in the SAC, including malaria, is required to alleviate the burden among children attending school in Western Kenya.

Towards an integrated vector management approach for sustainable control of schistosomiasis and malaria in Mwea, Kirinyaga County, Kenya: Baseline epidemiological and vector results.

Background: Vector control is an important approach in the control of most parasitic and vector-borne diseases including malaria, and schistosomiasis. Distribution of these two infections often overlaps and in such areas it's more economically viable to employ an integrated approach in the control of their vectors which largely shares the same breeding ecosystem. We carried out a baseline epidemiological and vector surveys for malaria and schistosomiasis in Mwea, Kirinyaga County, in preparation for the upscaling of integrated vector management (IVM) for the two diseases. Methods: This was a repeated cross sectional survey, where mosquito and snails were sampled during dry and wet seasons in three different ecological zones, Kiamaciri, Thiba and Murinduko to identify possible breeding sites. Mosquito larvae were collected using standard dippers, adults using CDC miniature light traps while snail vectors were sampled using standard snail scoops in different breeding habitats. A total of 1200 pupils from 12 primary schools were tested for malaria using rapid diagnostic tests (Malaria Pf/PAN Ag combo). Stool samples were processed using the Kato Katz technique for intestinal schistosomiasis. Results: The overall prevalence of intestinal schistosomiasis was 9.08 % (95 % CI: 07.00-11.00), with Kiamaciri zone recording the highest prevalence at 19 % (95%CI: 15.00-23.00) and Murinduko zone the least at 0.17 % (95%CI: 0.00-0.01). Majority of the infections were of light intensity 78.9 % (95%CI: 70.04-86.13). There was no positive malaria case detected in this study. Of the 3208 adult mosquitoes sampled during the dry season, 20.6 % (95 % CI: 19.25-22.08) were Anopheles gambiae s.l while 79.4 % (95 % CI: 77.92-80.75) were culicines. During the wet season, 3378 adult mosquitoes were collected, of which 14.7 % (95 % CI: 13.56-15.98) were Anopheles gambiae s.l and 85.3 % (95 % CI: 84.02-86.44) culicines. Overall, 4085 mosquito larvae were collected during the two seasons, of which, 57.3 % and 42.7 % were anopheles and culicine respectively. Majority of the larvae (85.1 % (95%CI: 84.01-86.10) were collected during the wet season, with only 14.9 % (95%CI: 14.10-16.00) being collected during the dry season. A total of 2292 fresh water vector snails were collected with a majority (69.6 % (95%CI: 68.00-71.10) being Biomphalaria pffeiferi responsible for transmission of intestinal schistosomiasis. Conclusion: This study demonstrates that intestinal schistosomiasis is prevalent in Kiamaciri and Thiba zones, and points to the possibility of active transmission of schistosomiasis in Murinduko zone. Malaria vectors were predominantly observed in all sites despite there being no malaria positive case. Culex quinquefaciatus responsible for the spread of several arboviruses was also observed. The presence of these vectors may lead to future disease outbreaks in the area if concerted control initiatives are not undertaken. The disease vectors shared the same breeding sites and thus its economical and feasible to adopt an integrated vector management approach in control efforts for these disease in the study area.

Bioefficacy and durability of Olyset® Plus, a permethrin and piperonyl butoxide-treated insecticidal net in a 3-year long trial in Kenya.

BACKGROUND: Long-lasting insecticide nets (LLINs) are a core malaria intervention. LLINs should retain efficacy against mosquito vectors for a minimum of three years. Efficacy and durability of Olyset® Plus, a permethrin and piperonyl butoxide (PBO) treated LLIN, was evaluated versus permethrin treated Olyset® Net. In the absence of WHO guidelines of how to evaluate PBO nets, and considering the manufacturer's product claim, Olyset® Plus was evaluated as a pyrethroid LLIN. METHODS: This was a household randomized controlled trial in a malaria endemic rice cultivation zone of Kirinyaga County, Kenya between 2014 and 2017. Cone bioassays and tunnel tests were done against Anopheles gambiae Kisumu. The chemical content, fabric integrity and LLIN survivorship were monitored. Comparisons between nets were tested for significance using the Chi-square test. Exact binomial distribution with 95% confidence intervals (95% CI) was used for percentages. The WHO efficacy criteria used were ≥ 95% knockdown and/or ≥ 80% mortality rate in cone bioassays and ≥ 80% mortality and/or ≥ 90% blood-feeding inhibition in tunnel tests. RESULTS: At 36 months, Olyset® Plus lost 52% permethrin and 87% PBO content; Olyset® Net lost 24% permethrin. Over 80% of Olyset® Plus and Olyset® Net passed the WHO efficacy criteria for LLINs up to 18 and 12 months, respectively. At month 36, 91.2% Olyset® Plus and 86.4% Olyset® Net survived, while 72% and 63% developed at least one hole. The proportionate Hole Index (pHI) values representing nets in good, serviceable and torn condition were 49.6%, 27.1% and 23.2%, respectively for Olyset® Plus, and 44.9%, 32.8% and 22.2%, respectively for Olyset® Net but were not significantly different. CONCLUSIONS: Olyset® Plus retained efficacy above or close to the WHO efficacy criteria for about 2 years than Olyset® Net (1-1.5 years). Both nets did not meet the 3-year WHO efficacy criteria, and showed little attrition, comparable physical durability and survivorship, with 50% of Olyset® Plus having good and serviceable condition after 3 years. Better community education on appropriate use and upkeep of LLINs is essential to ensure effectiveness of LLIN based malaria interventions.

Impact of Different Sampling Schemes for Decision Making in Soil-Transmitted Helminthiasis Control Programs.

Starting and stopping preventive chemotherapy (PC) for soil-transmitted helminthiasis is typically based on the prevalence of infection as measured by Kato-Katz (KK) fecal smears. Kato-Katz-based egg counts can vary highly over repeated stool samples and smears. Consequentially, the sensitivity of KK-based surveys depends on the number of stool samples per person and the number of smears per sample. Given finite resources, collecting multiple samples and/or smears means screening fewer individuals, thereby lowering the statistical precision of prevalence estimates. Using population-level data from various epidemiological settings, we assessed the performance of different sampling schemes executed within the confines of the same budget. We recommend the use of single-slide KK for determining prevalence of moderate-to-heavy intensity infection and policy decisions for starting and continuing PC; more sensitive sampling schemes may be required for policy decisions involving stopping PC. Our findings highlight that guidelines should include specific guidance on sampling schemes.

Domains of transmission and association of community, school, and household sanitation with soil-transmitted helminth infections among children in coastal Kenya.

INTRODUCTION: Few studies have simultaneously examined the role of sanitation conditions at the home, school, and community on soil-transmitted helminth (STH) infection. We examined the contribution of each domain that children inhabit (home, village, and school) to STH infection and estimated the association of STH infection with sanitation in each domain. METHODS: Using data from 4,104 children from Kwale County, Kenya, who reported attending school, we used logistic regression models with cross-classified random effects to calculate measures of general contextual effects and estimate associations of village sanitation coverage (percentage of households with reported access to sanitation), school sanitation coverage (number of usable toilets per enrolled pupil), and sanitation access at home with STH infection. FINDINGS: We found reported use of a sanitation facility by households was associated with reduced prevalence of hookworm infection but not with reduced prevalence of T. trichiura infection. School sanitation coverage > 3 toilets per 100 pupils was associated with lower prevalence of hookworm infection. School sanitation was not associated with T. trichiura infection. Village sanitation coverage > 81% was associated with reduced prevalence of T. trichiura infection, but no protective association was detected for hookworm infection. General contextual effects represented by residual heterogeneity between village and school domains had comparable impact upon likelihood of hookworm and T. trichiura infection as sanitation coverage in either of these domains. CONCLUSION: Findings support the importance of providing good sanitation facilities to support mass drug administration in reducing the burden of STH infection in children.

Heterogeneity in transmission parameters of hookworm infection within the baseline data from the TUMIKIA study in Kenya.

BACKGROUND: As many countries with endemic soil-transmitted helminth (STH) burdens achieve high coverage levels of mass drug administration (MDA) to treat school-aged and pre-school-aged children, understanding the detailed effects of MDA on the epidemiology of STH infections is desirable in formulating future policies for morbidity and/or transmission control. Prevalence and mean intensity of infection are characterized by heterogeneity across a region, leading to uncertainty in the impact of MDA strategies. In this paper, we analyze this heterogeneity in terms of factors that govern the transmission dynamics of the parasite in the host population. RESULTS: Using data from the TUMIKIA study in Kenya (cluster STH prevalence range at baseline: 0-63%), we estimated these parameters and their variability across 120 population clusters in the study region, using a simple parasite transmission model and Gibbs-sampling Monte Carlo Markov chain techniques. We observed great heterogeneity in R0 values, with estimates ranging from 1.23 to 3.27, while k-values (which vary inversely with the degree of parasite aggregation within the human host population) range from 0.007 to 0.29 in a positive association with increasing prevalence. The main finding of this study is the increasing trend for greater parasite aggregation as prevalence declines to low levels, reflected in the low values of the negative binomial parameter k in clusters with low hookworm prevalence. Localized climatic and socioeconomic factors are investigated as potential drivers of these observed epidemiological patterns. CONCLUSIONS: Our results show that lower prevalence is associated with higher degrees of aggregation and hence prevalence alone is not a good indicator of transmission intensity. As a consequence, approaches to MDA and monitoring and evaluation of community infection status may need to be adapted as transmission elimination is aimed for by targeted treatment approaches.

Community-level epidemiology of soil-transmitted helminths in the context of school-based deworming: Baseline results of a cluster randomised trial on the coast of Kenya.

TRIAL REGISTRATION: ClinicalTrials.gov NCT02397772.

Long Term School Based Deworming against Soil-Transmitted Helminths Also Benefits the Untreated Adult Population: Results from a Community-Wide Cross Sectional Survey.

BACKGROUND: Soil-transmitted helminths (STH) are a public health problem in Kenya. The primary control strategy for these infections is preventive chemotherapy (PC) delivered through school based deworming (SBD) programs. The World Health Organization (WHO) recommends the inclusion of other at-risk groups in the PC. The untreated groups in endemic areas have been shown to act as reservoirs for STH transmission. Few field based studies have focused on the possible benefits of SBD to the untreated groups in the community. This study sought to determine the levels of STH among all age groups in a community where SBD has been going on for more than 10 years. METHODS: This was a cross sectional study where 3,292 individuals, ranging from 2 to 98 years, were enrolled. Stool samples were analyzed using duplicate Kato Katz thick smear technique for presence of STH eggs. Statistical analysis was conducted using STATA software 14.0 (Stata corporation). RESULTS: Out of the total 3,292 stool samples analyzed, only 13 were positive for any STH. Of these, 12 were infected with Trichuris trichiura and one case was of hookworm. There was no Ascaris lumbricoides infection detected. Of the 13 STH infections, seven of the infections were of school going age (6-18 years), 5 were of preschool age (<6 years), and one was of adult age group (18>). More male (61.5%) than female were infected with STH. CONCLUSION: This study shows very low prevalence of STH among all age groups in Mwea, suggesting that long term SBD may also be benefitting the untreated groups in the community and thus the potential to achieve STH elimination in such endemic areas.

Association between Schistosoma mansoni infection and access to improved water and sanitation facilities in Mwea, Kirinyaga County, Kenya.

BACKGROUND: Schistosomiasis remains a public health problem in Central Kenya despite concerted control efforts. Access to improved water and sanitation has been emphasized as important control measures. Few studies have assessed the association between access to improved water sources and sanitation facilities with Schistosoma mansoni infection in different environmental settings. This study assessed the association between S. mansoni infection and household access to improved water sources and sanitation facilities in Mwea, Kirinyaga County, Kenya. METHODS: A cross sectional study was conducted between the months of August and October 2017. A total of 905 household heads from seven villages were interviewed and their stool samples screened for S. mansoni using the Kato Katz technique. Comparisons of demographic factors by S. mansoni infection were tested for significance using the chi-square test (χ2) or the Fisher exact test for categorical variables. Variables associated with S. mansoni infection were analyzed using univariable analysis and the strength of the association measured as odds ratio (OR) using mixed effects logistic regression at 95% CI, with values considered significant at p < 0.05. RESULTS: The overall prevalence of S. mansoni was, 23.1% (95% CI: 20.5-26.0%), with majority of the infections being of light intensity. Rurumi village had the highest prevalence at 33.3%, with Kirogo village having the least prevalence at 7.0%. Majority (84.1%) of the households lacked access to improved water sources but had access to improved sanitation facilities (75%). Households with access to piped water had the lowest S. mansoni infections. However, there was no significant association between S. mansoni infections with either the main source of water in the household (Odds Ratio (OR) =0.782 (95% CI: 0.497-1.229) p = 0.285 or sanitation facilities (OR = 1.018 (95% CI: 0.705-1.469) p = 0.926. CONCLUSION: Our study suggests that S. mansoni is still a public health problem among all age groups in Mwea irrigation scheme, Kirinyaga County, Central Kenya. Majority of the households lacks access to improved water sources but have access to improved sanitation facilities. This study recommends initiatives to ensure adequate provision of improved water sources, and the inclusion of the adult community in preventive chemotherapy programs.

Effects, equity, and cost of school-based and community-wide treatment strategies for soil-transmitted helminths in Kenya: a cluster-randomised controlled trial.

BACKGROUND: School-based deworming programmes can reduce morbidity attributable to soil-transmitted helminths in children but do not interrupt transmission in the wider community. We assessed the effects of alternative mass treatment strategies on community soil-transmitted helminth infection. METHODS: In this cluster-randomised controlled trial, 120 community units (clusters) serving 150 000 households in Kenya were randomly assigned (1:1:1) to receive albendazole through annual school-based treatment targeting 2-14 year olds or annual or biannual community-wide treatment targeting all ages. The primary outcome was community hookworm prevalence, assessed at 12 and 24 months through repeat cross-sectional surveys. Secondary outcomes were Ascaris lumbricoides and Trichuris trichiura prevalence, infection intensity of each soil-transmitted helminth species, and treatment coverage and costs. Analysis was by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT02397772. FINDINGS: After 24 months, prevalence of hookworm changed from 18·6% (95% CI 13·9-23·2) to 13·8% (10·5-17·0) in the annual school-based treatment group, 17·9% (13·7-22·1) to 8·0% (6·0-10·1) in the annual community-wide treatment group, and 20·6% (15·8-25·5) to 6·2% (4·9-7·5) in the biannual community-wide treatment group. Relative to annual school-based treatment, the risk ratio for annual community-wide treatment was 0·59 (95% CI 0·42-0·83; p<0·001) and for biannual community-wide treatment was 0·46 (0·33-0·63; p<0·001). More modest reductions in risk were observed after 12 months. Risk ratios were similar across demographic and socioeconomic subgroups after 24 months. No adverse events related to albendazole were reported. INTERPRETATION: Community-wide treatment was more effective in reducing hookworm prevalence and intensity than school-based treatment, with little additional benefit of treating every 6 months, and was shown to be remarkably equitable in coverage and effects. FUNDING: Bill & Melinda Gates Foundation, the Joint Global Health Trials Scheme of the Medical Research Council, the UK Department for International Development, the Wellcome Trust, and the Children's Investment Fund Foundation.

High prevalence of helminths infection and associated risk factors among adults living in a rural setting, central Kenya: a cross-sectional study.

BACKGROUND: Schistosome infection and soil-transmitted helminths (STHs) are major public health problems in many developing countries where they contribute to the suffering of populations living in poor settings. A cross-sectional survey was conducted in four rural villages in central region of Kenya to provide information on the status of schistosome and STH infections. Previous studies conducted in the area among primary school children showed that there were high STH and Schistosoma mansoni infections. This paper presents the results of a parasitological investigation and the associated risk factors of infection among adults living in the study villages. METHODS: A total of 495 adults (18-84 years) from systematically selected households were sampled during this cross-sectional survey. They were interviewed and screened for S. mansoni and STHs using duplicate Kato-Katz thick smears. Comparison of prevalence by age group and gender was explored by confidence interval plots, and 95% CI were obtained by generalized least squares (GLS) random effects model. Risk factors associated with S. mansoni infection were determined using mixed effects logistic regression at 95% CI taking into account household clusters. RESULTS: The study revealed that the prevalence of S. mansoni infection was 33.5% (95% CI 29.6-38.0) among adults in the study villages, while the prevalence of STH infection was 0.2% (95% CI 0-1.4) with hookworm being the only detected STH species. However, the village and education level were the only risk factors which showed significant evidence of association with S. mansoni infections. CONCLUSIONS: The current study shows that adult communities in the study area were highly infected with S. mansoni. The study suggests that it may be necessary to develop contemporary approaches towards preventive chemotherapy interventions to adults in high endemic areas to complement the ongoing school-based deworming programme.

Interrupting transmission of soil-transmitted helminths: a study protocol for cluster randomised trials evaluating alternative treatment strategies and delivery systems in Kenya.

INTRODUCTION: In recent years, an unprecedented emphasis has been given to the control of neglected tropical diseases, including soil-transmitted helminths (STHs). The mainstay of STH control is school-based deworming (SBD), but mathematical modelling has shown that in all but very low transmission settings, SBD is unlikely to interrupt transmission, and that new treatment strategies are required. This study seeks to answer the question: is it possible to interrupt the transmission of STH, and, if so, what is the most cost-effective treatment strategy and delivery system to achieve this goal? METHODS AND ANALYSIS: Two cluster randomised trials are being implemented in contrasting settings in Kenya. The interventions are annual mass anthelmintic treatment delivered to preschool- and school-aged children, as part of a national SBD programme, or to entire communities, delivered by community health workers. Allocation to study group is by cluster, using predefined units used in public health provision-termed community units (CUs). CUs are randomised to one of three groups: receiving either (1) annual SBD; (2) annual community-based deworming (CBD); or (3) biannual CBD. The primary outcome measure is the prevalence of hookworm infection, assessed by four cross-sectional surveys. Secondary outcomes are prevalence of Ascaris lumbricoides and Trichuris trichiura, intensity of species infections and treatment coverage. Costs and cost-effectiveness will be evaluated. Among a random subsample of participants, worm burden and proportion of unfertilised eggs will be assessed longitudinally. A nested process evaluation, using semistructured interviews, focus group discussions and a stakeholder analysis, will investigate the community acceptability, feasibility and scale-up of each delivery system. ETHICS AND DISSEMINATION: Study protocols have been reviewed and approved by the ethics committees of the Kenya Medical Research Institute and National Ethics Review Committee, and London School of Hygiene and Tropical Medicine. The study has a dedicated web site. TRIAL REGISTRATION NUMBER: NCT02397772.