TB training in Kenya: building capacity for care and prevention.

BACKGROUND: Devolution of healthcare services in Kenya resulted in a large number of newly recruited tuberculosis (TB) coordinators. We describe a unique collaboration between a national tuberculosis program (NTP), a local, and an international non-governmental organization to build human resource capacity in TB care and prevention. METHODS: From 2016 to 2021, the Kenya Division of National Tuberculosis, Leprosy and Lung Disease Program, Centre for Health Solutions-Kenya, and the International Union Against Tuberculosis and Lung Disease developed and conducted a series of 7-day training courses. A key focus of training was the introduction of TBData4Action, an approach involving the local use of routinely available data to strengthen decision-making and support supervision. RESULTS: Implementation outcomes included training 331 (96%) coordinators out of 344, representing all 47 counties, 37 national officers and 21 other stakeholders using the country-tailored curriculum, including hands-on group work by county teams and field practicals. Thirty-five national facilitators were identified and mentored as local faculty. Training costs were reduced by 75% compared with international alternatives. CONCLUSION: The collaboration resulted in the training of the majority of the coordinators in a standardized approach to TB care. A sustainable approach to capacity building in local data use was found feasible; the model could be adapted by other NTPs.

CONTEXTE: La décentralisation des services de santé au Kenya a conduit au recrutement d'un grand nombre de nouveaux coordinateurs TB. Nous décrivons une collaboration unique entre un programme national de lutte contre la TB (NTP), une organisation non gouvernementale locale et une organisation non gouvernementale internationale visant à renforcer les capacités humaines en matière de prévention et de soins de la TB. MÉTHODES: De 2016 à 2021, la division kényane du programme national de lutte contre la tuberculose, la lèpre et les maladies respiratoires, le Centre for Health Solutions-Kenya et l'Union internationale contre la tuberculose et les maladies respiratoires ont développé et dispensé une série de formations en 7 jours. La formation mettait l'accent sur l'introduction de l'approche TBData4Action, qui promeut une utilisation locale des données disponibles en routine afin de renforcer la prise de décision et d'épauler les activités de supervision. RÉSULTATS: Les résultats de la mise en place de cette formation comprenaient la formation de 331 (96%) coordinateurs sur 344, représentant l'ensemble des 47 pays, 37 administrateurs nationaux et 21 autres acteurs formés à l'aide du programme adapté aux besoins du pays concerné (dont travail de groupe pratique par les équipes nationales et travaux pratiques sur le terrain). Trente-cinq facilitateurs nationaux ont été identifiés et formés comme enseignants locaux. Les coûts de la formation ont été réduits de 75% par rapport aux alternatives internationales. CONCLUSION: La collaboration a permis de former la majorité des coordinateurs à l'aide d'une approche standardisée de soins de la TB. Une approche durable de renforcement des capacités en matière d'utilisation des données locales s'est avérée réalisable. Ce modèle peut être adapté à d'autres NTP.

The HIV cascade of care among serodiscordant couples in four high HIV prevalence settings in sub-Saharan Africa.

BACKGROUND:  HIV-serodiscordant couples are at high risk of HIV transmission. In sub-Saharan Africa, HIV-serodiscordant couples contribute ~30% of all new infections in the region. OBJECTIVES: To quantify the prevalence of HIV-serodiscordant couples and evaluate steps of the HIV cascade of care among people living with HIV in serodiscordant relationships in four high-prevalence settings in sub-Saharan Africa. METHODS:  Four HIV prevalence surveys were conducted: in Ndhiwa (Kenya) in 2012, in Chiradzulu (Malawi) in 2013, and in Gutu (Zimbabwe) and Nsanje (Malawi) in 2016. Eligible individuals aged 15 - 59 years were asked to participate in voluntary rapid HIV testing. Viral load and CD4 counts were measured on those who tested HIV-positive. A couple was defined as a man and a woman who reported being married or cohabiting and were living together in the same household. RESULTS: Among 4 385 couples, the prevalence of HIV serodiscordancy was 10.9% (95% confidence interval (CI) 10.2 - 11.5) overall, ranging from 6.7% (95% CI 5.6 - 7.9) in Nsanje to 15.8% (95% CI 14.5 - 17.3) in Ndhiwa. Men were the HIV-positive partner in 62.7% of the serodiscordant couples in Ndhiwa, in 60.4% in Gutu, in 48.8% in Chiradzulu and in 50.9% in Nsanje. Status awareness among HIV-positive partners in serodiscordant couples ranged from 45.4% in Ndhiwa to 70.7% in Gutu. Viral load suppression (VLS) ranged from 33.9% in Ndhiwa to 68.5% in Nsanje. VLS was similar by sex in three settings, Ndhiwa (37.8% (men) v. 27.8% (women); p=0.16), Nsanje (60.7% v. 76.9%; p=0.21) and Gutu (48.2% v. 55.6%; p=0.63), and dissimilar by sex in Chiradzulu (44.4% v. 62.7%; p=0.03). CONCLUSIONS: Low HIV status awareness and poor VLS among HIV-positive partners are major gaps in preventing transmission among serodiscordant couples. Intensifying programmes that target couples to test for HIV and timely antiretroviral therapy initiation could increase VLS and reduce HIV transmission.

Introducing new and repurposed TB drugs: the endTB experience.

In 2015, the initiative Expand New Drug Markets for TB (endTB) began, with the objective of reducing barriers to access to the new and repurposed TB drugs. Here we describe the major implementation challenges encountered in 17 endTB countries. We provide insights on how national TB programmes and other stakeholders can scale-up the programmatic use of new and repurposed TB drugs, while building scientific evidence about their safety and efficacy. For any new drug or diagnostic, multiple market barriers can slow the pace of scale-up. During 2015-2019, endTB was successful in increasing the number of patients receiving new and repurposed TB drugs in 17 countries. The endTB experience has many lessons, which are relevant to country level introduction of new TB drugs, as well as non-TB drugs and diagnostics. For example: the importation of TB drugs is possible even in the absence of registration; emphasis on good clinical monitoring is more important than pharmacovigilance reporting; national guidelines and expert committees can both facilitate and hinder innovative practice; clinicians use new and repurposed TB drugs when they are available; data collection to generate scientific evidence requires financial and human resources; pilot projects can drive national scale-up.

Outcomes from the first multidrug-resistant tuberculosis programme in Kenya.

SETTING: In March 2006, the first multidrug-resistant tuberculosis (MDR-TB) treatment programme was implemented in Kenya. OBJECTIVE: To describe patients' treatment outcomes and adverse events. DESIGN: A retrospective case note review of patients started on MDR-TB treatment at two Médecins Sans Frontières-supported sites and the national referral hospital of Kenya was undertaken. Sites operated an ambulatory model of care. Patients were treated for a minimum of 24 months with at least 4-5 drugs for the intensive phase of treatment, including an injectable agent. RESULTS: Of 169 patients, 25.6% were human immunodeficiency virus (HIV) positive and 89.3% were culture-positive at baseline. Adverse events occurred in 67.4% of patients: 45.9% had nausea/vomiting, 43.9% electrolyte disturbance, 41.8% dyspepsia and 31.6% hypothyroidism. The median time to culture conversion was 2 months. Treatment outcomes were as follows: 76.6% success, 14.5% deaths, 8.3% lost to follow-up and 0.7% treatment failure. HIV-positive individuals (adjusted odds ratio [aOR] 3.51, 95% confidence interval [CI] 1.12-11.03) and women (aOR 2.73, 95%CI 1.01-7.39) had a higher risk of unfavourable outcomes, while the risk was lower in those with culture conversion at 6 months (aOR 0.11, 95%CI 0.04-0.32). CONCLUSION: In Kenya, where an ambulatory model of care is used for MDR-TB treatment, treatment success was high, despite high rates of HIV. Almost half of the patients experienced electrolyte disturbance and one third had hypothyroidism; this supports the view that systematic regular biochemical monitoring is needed in Kenya.

The value of ultrasonography in the diagnosis of ectopic pregnancy at the Kenyatta National Hospital, Nairobi.

Over a six-month-period, from 1st March 1988 to 30th September 1988, 127 patients suspected of having ectopic gestation at the Kenyatta National Hospital (KNH) were referred for sonographic examination, of whom 100 (78.7%) had enough data for a final diagnosis. During sonography, ectopic pregnancy was diagnosed in 31 (31%) patients, out of whom 15 (48.4%) were confirmed to have ectopic gestation at laparotomy. Of the 69 who were thought to have other gynaecological disorders at sonographic examination, 2 (2.9%) were later found to have other ectopic gestation at surgery. Of the 17 patients who had ectopic gestation finally, extrauterine gestational sac with a demonstrable foetal pole were observed in only 6 (35.3%) cases, thus allowing a confident diagnosis of ectopic pregnancy by sonography. An empty, bulky uterus, demonstrable adnexal mass, pseudo-gestational sac and fluid in the culde-sac, together improved the sonographic positive predictive value to 67.0%. This study has shown that sonography can be used in the diagnosis of ectopic pregnancy at the KNH. However, in order to improve its reliability, further studies are recommended involving a combination of pregnancy test and sonography.

PIP: Between March and September 1988 at the Kenyatta National Hospital in Nairobi, Kenya, clinicians included all patients (127) referred for ultrasonography due to suspected ectopic pregnancy (age range, 18-45 years) in a study to determine whether ultrasonography can be used to accurately diagnose ectopic pregnancy. The researchers examined only the records of 100 patients who had data adequate enough to make a final diagnosis. Based on sonography, clinicians believed 31 women had an ectopic pregnancy, but laparotomy confirmed that just 15 (48.4%) of these women actually had an ectopic pregnancy. Based on sonography, they did not suspect ectopic pregnancy in the other 69 patients, but laparotomy revealed that 2 patients (2.9%) did indeed have an ectopic pregnancy. Thus, the overall ectopic pregnancy rate among the 100 women was 17%. The remaining 83 women had other gynecological conditions. 52.9% of the women with an actual ectopic pregnancy had a pseudogestational sac, which had a positive predictive value of 53% and a negative predictive value of 90%. A pseudogestational sac had a sensitivity of 53% and specificity of 90%. Just 6 ectopic pregnancy cases (35.3%) had an extrauterine gestational sac with a clear fetal pole and a fetal heart beat. An enlarged uterus was more common in women with an ectopic pregnancy than in those with other conditions (82.4% vs. 51.8%; p .05). Every ectopic pregnancy case had a complex adnexal mass compared to just 48.2% of those with other conditions (p .001). When a woman had all these conditions combined--an empty, enlarged uterus; distinct adnexal mass; a pseudogestational sac; and fluid in the cul-de-sac-sonography's positive predictive value increased to 67%. The researchers recommended additional studies using a combination of the urinary pregnancy test and sonography to improve sonography's reliability.

HIV infection among patients with acute pelvic inflammatory disease at the Kenyatta National Hospital, Nairobi, Kenya.

AIDS continues to exert considerable strain on the economy, as well as social aspects of our lives. Previous studies have identified the categories of people most at risk of contracting and developing HIV infection and AIDS. In this study, 20.9% of women with acute pelvic infection at the Kenyatta National Hospital, were found to be seropositive for HIV, much higher than the general population in Kenya. Though there was no direct correlation between one's age and serological status, most of the women with pelvic inflammatory disease (PID) were young, quite sexually active, and involved with several partners. 49.0% of the entire group and 53.7% of the women who were seropositive, were married. This underlines the fact that marital status does not appear to offer any protection against HIV infection. The fact that majority of these women had started coitus quite early, they were not using any protective measure against STDs or HIV infection, and that they were involved with several partners, indicate that we are very far from winning the fight against HIV infection and AIDS. There is need to revise the currently operative programmes with a view to making them more effective, in preventing transmission and spread of HIV infection.

Rupture of the gravid uterus: a review.

A total of 105 patients were treated for ruptured gravid uteri at the Kenyatta National Hospital, Nairobi, Kenya, over a five year period, January, 1984 to December, 1988. During the same period, there were 44,156 deliveries, giving an incidence of uterine rupture of 1:425 deliveries. Of these, records for 95 patients were traced and analysed, and the results are presented here. Majority (61.0%) of these patients were aged less than 30 years, and 62.1% were gravida 5 or less. 54 (56.8%) of them had rupture of scarred uteri, 33 (34.7%) had spontaneous rupture, while 8 (8.4%) had traumatic rupture. 56 (59.0%) ruptured while at the Kenyatta National Hospital. Repair of the uterus without tubal ligation was the treatment offered to most of them, while total abdominal hysterectomy was rarely done. The perinatal case fatality rate was 60% and there were two maternal deaths giving a maternal case fatality rate of 2.1%. Factors associated with uterine rupture at the Kenyatta National Hospital are discussed, and possible ways of reducing the incidence suggested.

PIP: Physicians treated 105 patients with uterine rupture at Kenyatta National Hospital (KNH) in Nairobi, Kenya between January 1984-December 1988. The ruptured gravid uterus incidence during the study period was 1:425. 56.8% of the mothers were between 20-29 years old. 62.1% were gravida 5. 21.1% had received no prenatal care. 59% ruptured at this hospital. Adequate labor monitoring would have prevented rupturing. 56.8% experienced at least 1 previous cesarean section (C-section). Only 2 women had had a classical C-section. Moreover 21.1% of mothers who had prenatal care at KNH underwent a previous C-section. Perhaps health workers did not evaluate these women properly. 74% of the mothers were at least 38 weeks gestation. 34.7% had a spontaneous rupture due to prolonged labor (12 hours). 8.4% experienced a traumatic rupture. 94.7% happened during labor. Most of the tears (51.6%) occurred along the lower anterior uterine segment primarily on the transverse or on a C-section scar. Surgeons were able to repair the uterus without tubal ligation in 47.4% of the cases. They could repair the uterus of 11.6%, but also had to perform a tubal ligation. They conducted a partial hysterectomy on 38% and total hysterectomy on 3.2%. 38.9% gave birth to their infants vaginally. 55.8% of the mothers gave birth to a stillborn infant. 35.8% of the infants were delivered in good condition and survived. 4.2% were in poor condition and survived and 4.2% were in poor condition and died. All the infants in the peritoneal cavity were already dead, but not all of those in the uterus died. The case fatality rate stood at 60%. 2.1% of the mothers died, all after surgery. 1 mother actually died of injuries from an earlier assault. In conclusion, C-section was the major predisposing factor. Ruptured gravida uteri continued to be a major obstetric problem in Kenya.

A review of the medical aspects of adolescent fertility in Kenya.

PIP: In 1990, the annual population growth rate in Kenya was 3.8%, among the highest rates world wide. The ever growing adolescent fertility rate (111-152/1000 from 1969-1989) contributed to this rapid growth. Further repeat pregnancies among adolescents remained high in the 1980's and ranged from 20%-28.6%, depending on the survey. Even though overall prevalence of pregnancy fell 15.4% between 1978-1984, it remained the same for the 15-19 year old group. Teenage births have made up at least 35% of total deliveries. 1985 data revealed that even though adolescents represent 11-35% of the total obstetric population, problems ranked high among them: 38% of all eclampsia cases and high maternal mortality (102/100,000 vs. 57/100,000 older mothers). Studies showed that adolescents are sexually active, are ignorant about contraception, and do not use contraception. Yet contraceptive and family planning services are free in Kenya. Nevertheless the teenagers are at high risk of an unwanted pregnancy, sexually transmitted diseases (STDs), and AIDS. In the early 1980s, Kenyatta National Hospital reported 53% of 74.1% of septic abortion cases being single women were between 14-20 years old. Similar results emerged from other studies. Health professionals believed these results to be underestimated, however. In the 1980s, 33% of all adolescents between 13-15 years old in a rural area had gonorrhea. In Kenyatta, 36% of pregnant 15-24 year olds had at least 1 STD while,e only 16% of those 24 years old did. Further, teenagers are especially vulnerable to psychological problems when they 1st learn of their pregnancy. Health services should be geared to meet the specific needs of adolescents, such as contraception education and antenatal services.^ieng

Mortality due to abortion at Kenyatta National Hospital, 1974-1983.

A retrospective analysis of 95 deaths due to abortion at the Kenyatta National Hospital between 1974 and 1983 showed that the average death rate over the 10-year period was high: nearly three deaths per 1000 abortion admissions. The mean hospital stay was 12 days. Of the 95 abortions 76 (80%) were induced or were likely to have been induced. Septic abortion with its complications accounted for 97.4% of the deaths from induced abortion. Among the deaths from spontaneous abortion, 52.6% were due to haemorrhagic shock compared to 47.4% due to sepsis. In this study 76.9% of the deaths occurred among women who were widowed, divorced or unmarried. Adolescents (age 19 or younger) accounted for 23 (24.2%) of the deaths. In this latter group there was evidence of interference in 22 (95.7%).