Determinants of aflatoxin exposures in Kenyan School-aged children.

Aflatoxins are naturally occurring food toxins known to contaminate cereals with a carry-over effect in milk and meat products from farm animals raised on contaminated feed. In children, continuous consumption of aflatoxin-contaminated food is linked to immune suppression, vaccine interference and growth faltering while in adult populations, carcinogenesis in the liver has been established. We evaluate the main determinants of aflatoxin exposures among children recruited from primary schools in Makueni and Siaya Counties. A five-part questionnaire was administered to collect information from randomly selected participants. AflatoxinB1-lysine adducts in children's sera and total aflatoxins in food samples were analyzed by High-Performance Liquid Chromatography with Fluorescence detection. Using Chi-squared tests and Kruskal-Wallis tests, children from low-income households had the highest aflatoxin exposure, p-value = 0.0029. Smaller family size, greater food diversity, and good farming practices were associated with low aflatoxin exposures p < 0.001. Individual households living under severe levels of poverty were evidently exposed to higher levels of aflatoxins.

Eradicating Measles: A Call for an Exceptional Coordinated Global Effort.

There are compelling epidemiological, economic, and ethical arguments for setting a global measles eradication goal. The 6 chairpersons of Regional Verification Commissions for Measles and Rubella elimination advocate that the time for courageously accelerating efforts to ensure a world where no child dies of measles, is NOW!

Validation of urinary sphingolipid metabolites as biomarker of effect for fumonisins exposure in Kenyan children.

Context: Fumonisins (FNs), a group of mycotoxins produced mainly by Fusarium species, are ubiquitous food contaminants, especially for maize. Fumonisin B1 (FB1) caused severe toxicities in farm animals, induced kidney and liver tumours in rodents and is associated with many human adverse health effects, including oesophageal cancer. International Agency for Research on Cancer (IARC) categorizes FB1 as a possible human carcinogen (Group 2B). Inhibition of ceramide synthesis and disruption of sphingolipids metabolism are well studied as the major mechanisms of FB1-induced toxicity. Increases in sphinganine (Sa) and decrease in sphingosine (So) levels and their ratio are validated biomarkers of FB1 effects. Methods: In this study, we measured urinary levels of Sa, So and Sa/So in 284 children aged 1-14 years who consume maize as a staple diet. Exfoliated cells from urine were processed and sphingolipids quantified by High Pressure Liquid Chromatography. Results and conclusions: Sa and So were detectable in 95.07% and 98.94% of samples, respectively. Creatinine adjusted mean levels and standard deviation of Sa, So and Sa/So ratio were 1.23 ± 2.18, 4.99 ± 8.3 and 0.296 ± 0.587 nM. These results further confirmed the findings in studies with human adults, i.e. urinary Sa, So levels and Sa/So ratio are good biomarkers to assess FNs exposure in children.

Evaluating quality neonatal care, call Centre service, tele-health and community engagement in reducing newborn morbidity and mortality in Bungoma county, Kenya.

BACKGROUND: Neonatal mortality is a major health burden in Bungoma County with the rate estimated at 31 per 1000 live births and is above the national average of 22 per 1000. Nonetheless, out of the nine sub county hospitals, only two are fairly equipped with necessary infrastructure and skilled personnel to manage neonatal complications such as prematurity, neonatal sepsis, neonatal jaundice, birth asphyxia and respiratory distress syndrome. Additionally, with more than 50% of neonates delivered without skilled attendance, in below par hygiene environments such as home and on the roadsides, with non-existent community based referral system, the situation is made worse. The study aims to evaluate the progress made by an intervention "Collaborative Newborn Support Project" geared towards reducing neonatal mortality rate by 30% between October 2015 and December 2018 in Bungoma County, Kenya. METHODS/DESIGN: This intervention will take a quasi-experimental design approach with experimental and control sites. The project will involve pre- and post-intervention data collection with comparison group to assess intervention effects. The primary outcome will be the percentage reduction of neonatal mortality in Bungoma County. Secondary outcomes include; a) Percentage of mothers or care givers able to identify at least three danger signs in neonates in the project area, b) Proportion of neonates with complications referred to specialized neonatal centers, through the call center, c) Percentage of health providers in neonatal care units who adhere to expected neonatal standards of care (rapid and complete application of standard protocols), d) Percentage increase in neonates with severe complications in the specialized neonatal units and e) Percentage of neonates who stay in neonatal care units beyond 5 days. DISCUSSION: We outline implementation details of the ongoing 'Collaborative Newborn Support Project' in Bungoma County, Kenya. This includes strategies in the operations of the telehealth platform, call centre service, community engagement and measuring of the outputs and outcomes. The funding and ethical approvals have been obtained and the study commenced. TRIAL REGISTRATION: PACTR201712002802638 Retrospectively registered on 5th December 2017 at Pan African Clinical Trials Registry.

What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals?

BACKGROUND: The creation of a clinical network was proposed as a means to promote implementation of a set of recommended clinical practices targeting inpatient paediatric care in Kenya. The rationale for selecting a network as a strategy has been previously described. Here, we aim to describe network activities actually conducted over its first 2.5 years, deconstruct its implementation into specific components and provide our 'insider' interpretation of how the network is functioning as an intervention. METHODS: We articulate key activities that together have constituted network processes over 2.5 years and then utilise a recently published typology of implementation components to give greater granularity to this description from the perspective of those delivering the intervention. Using the Behaviour Change Wheel we then suggest how the network may operate to achieve change and offer examples of change before making an effort to synthesise our understanding in the form of a realist context-mechanism-outcome configuration. RESULTS: We suggest our network is likely to comprise 22 from a total of 73 identifiable intervention components, of which 12 and 10 we consider major and minor components, respectively. At the policy level, we employed clinical guidelines, marketing and communication strategies with intervention characteristics operating through incentivisation, persuasion, education, enablement, modelling and environmental restructuring. These might influence behaviours by enhancing psychological capability, creating social opportunity and increasing motivation largely through a reflective pathway. CONCLUSIONS: We previously proposed a clinical network as a solution to challenges implementing recommended practices in Kenyan hospitals based on our understanding of theory and context. Here, we report how we have enacted what was proposed and use a recent typology to deconstruct the intervention into its elements and articulate how we think the network may produce change. We offer a more generalised statement of our theory of change in a context-mechanism-outcome configuration. We hope this will complement a planned independent evaluation of 'how things work', will help others interpret results of change reported more formally in the future and encourage others to consider further examination of networks as means to scale up improvement practices in health in lower income countries.

Accelerating Global Measles and Rubella Eradication-Saving Millions of Lives, Preventing Disability, and Averting the Next Pandemic.

No vaccine has been more effective in reducing disease burden, especially in preventing child deaths, than measles-containing vaccine. The return on investment makes measles-containing vaccine one of the most cost-effective public health measures available. Exhaustive reviews of biological, technical, economic and programmatic evidence have concluded that measles can and should be eradicated, and by including rubella antigen in measles-containing vaccine, congenital rubella syndrome will also be eradicated. All World Health Organisation Regions have pledged to achieve measles elimination. Unfortunately, not all countries and global partners have demonstrated an appropriate commitment to these laudable public health goals, and the negative impact of the COVID-19 pandemic on coverage rates has been profound. Unsurprisingly, large disruptive outbreaks are already occurring in many countries with a global epidemic curve ominously similar to that of 2018/2019 emerging. The Immunization Agenda 2030 will fail dismally unless measles and rubella eradication efforts are accelerated. Over half of all member states have been verified to have eliminated rubella and endemic rubella transmission has not been re-established in any country to date. In 2023, 84 countries and areas were verified to have sustained elimination of measles. However, without a global target, this success will be difficult to sustain. Now is the time for a global eradication goal and commitment by the World Health Assembly. Having a galvanising goal, with a shared call for action, will demand adequate resourcing from every country government and global partners. Greater coordination across countries and regions will be necessary. Measles, rubella and congenital rubella syndrome eradication should not remain just a technically feasible possibility but rather be completed to ensure that future generations of children do not live under the shadow of preventable childhood death and lifelong disability.

Institutionalizing the Management of Sick Young Infants: Kenya's Experience in Revising National Guidelines on Integrated Management of Newborn and Childhood Illnesses.

INTRODUCTION: In 2015, the World Health Organization (WHO) developed guidelines for the management of sick young infants (SYIs) with possible serious bacterial infection (PSBI) where referral is not feasible. The Ponya Mtoto project was designed as an implementation research project to demonstrate how to adopt the WHO PSBI guidelines in the Kenyan context. PONYA MTOTO PROJECT DESCRIPTION: Between October 2017 and June 2021, Ponya Mtoto was implemented in 4 Kenyan counties with higher infant and newborn mortality rates than the national mean. A total of 48 health facilities stratified by level of services were selected as study sites. IMPLEMENTATION APPROACH: The following activities were done to institutionalize the management of SYIs with PSBI where referral is not feasible in Kenya's health system: (1) participating in a cocreation workshop and development of a theory of change; (2) revising the national integrated management of newborn and childhood illnesses guidelines to incorporate the management of PSBI where referral is not feasible; (3) improving availability of essential commodities; (4) strengthening provider confidence in the management of SYIs; (5) strengthening awareness about PSBI services for SYIs at the community level; and (6) harmonizing the national integrated management of newborn and childhood illnesses guidelines to address discrepancies in the content on the management of PSBI. In addition, the project focused on strengthening quality of care for SYIs and using implementation research to track progress in achieving project targets and outcomes. CONCLUSION: Using an implementation research approach to introduce new WHO guidelines on PSBI where referral is not feasible into Kenya's health care service was critical to fostering engagement of a diverse range of stakeholders, monitoring provider skills and confidence-building, strengthening provision of key commodities for managing SYIs with PSBI, and sustaining community-facility linkages.

Devolved health system capacity in the provision of care for sick newborns and young infants in four counties serving vulnerable populations in Kenya.

Possible severe bacterial infections (PSBI) is one of the three leading causes of newborn and young infant mortality globally that can be prevented by timely diagnosis and treatment using suitable antibiotics. High impact interventions such as use of out-patient injectable gentamicin and dispersible Amoxicillin with community-based follow up have been shown to reduce mortality in clinical trials. The objective of this study was to assess the health systems' preparedness and organizational gaps that may impact execution in providing care for newborns and sick young infants. This formative research study was embedded within a three-year implementation research project in 4 Counties in Kenya. The indicators were based on facility audits for existing capacity to care for newborns and young infants as well as County organizational capacity assessment. The organizational capacity assessment domains were derived from the World Health Organization's Health Systems Building blocks for health service delivery. The scores were computed by adding average scores in each domain and calculated against the total possible scores to generate a percentage outcome. Statistical analyses were descriptive with adjustment for clustering of data. Overall, the Counties have inadequate organizational capacity for management of sick young infants with Organizational Capacity Index scores of between 61-64%. Among the domains, the highest score was in Health Management Information System and service delivery. The lowest scores were in monitoring and evaluation (M&E). Counties scored relatively low scores in human resources for health and health products and commodities with one scoring poorly for both areas while the rest scored average performance. The four counties revealed varying levels of organizational capacity deficit to effectively manage sick young infants. The key underlying issues for the below par performance include poor coordination, low funding, inadequate supportive supervision, and M&E to enable data utilisation for quality improvement. It was evident that newborn and young infant health services suffer from inadequate infrastructure, equipment, staffing, and coordination. As Kenya, continuously rolls out the guidelines on management of sick young infants, there is need to focus attention to these challenges to enhance sustainable adoption and reduction of young infant morbidity and mortality.

Nutrition and growth outcomes are affected by aflatoxin exposures in Kenyan children.

Aflatoxin exposure, malnutrition and growth impairment in children present significant public health problems in low- and middle-income countries. Recent epidemiology studies show that exposure to aflatoxins through dietary sources in early life contributes to growth retardation among children. However, the findings remain inconclusive due to limited comparative studies in high versus low aflatoxin exposure regions. This cross-sectional study presents aflatoxin exposure levels among children aged 6 to 12 years, and further evaluates the association between aflatoxin exposure levels, malnutrition and growth impairment in Kenya, East Africa. AFB1-lysine adducts are validated biomarkers of exposure and were quantified using HPLC with fluorescence detection. All children (n = 746) had detectable levels of AFB1-lysine adducts in serum, range 0.65-518.9 pg/mg albumin with a geometric mean (GM) of 10.5 (95%CI 9.4-11.7) pg/mg albumin. The Geometric Means (GM) of AFB1-lysine adducts were 14.0 (95%CI 12.5, 15.7) pg/mg albumin and 8.2 (95%CI 7.6, 8.8) pg/mg albumin (p-value < 0.001), among children recruited from Makueni and Siaya Counties, respectively. While the study confirms higher human exposure levels in Makueni county, it provides an initial data set for aflatoxin exposure levels among children recruited from Siaya County. In multivariate analysis, after adjusting for socio-economic indicators, farming practices, and household dietary patterns, increasing one unit of log AFB1-lysine was associated with decreasing Weight-for-age z-score (WAZ) by -0.13, p-value = 0.019 among all children aged 6-12 years. Among children 6 to 9 years, WAZ decreases by -0.11 (-0.54, -0.01), p-value = 0.049. Additional growth parameters Height-for-age z-score (HAZ) and Weight-for-height z-score (WHZ) do not reach statistical significance. HAZ decreases by -0.08, p-value = 0.337 and WHZ decreases by -0.17, p-value = 0.437 with every increase in log AFB1-lysine. These data suggest that efforts must be put in place to control for aflatoxin exposure in order to achieve better growth outcomes.

Aflatoxin exposure in children age 6-12 years: a study protocol of a randomized comparative cross-sectional study in Kenya, East Africa.

BACKGROUND: Aflatoxins (AFs) are naturally occurring fungal metabolites produced by the Aspergilla species of fungi. The staple food grain, maize (Zea mays), is highly susceptible to AF contamination. In Kenya, contamination of maize supplies by AFs is a recognized public health problem which has resulted in over 600 human deaths. Human exposure to AFs can occur in utero, via breast milk, through weaning foods, and throughout an individual's lifetime. Recent epidemiological studies have shown that exposure to AFs in early life through diet is a contributing factor to immune suppression, micronutrient deficiency, possible vaccine interference, and impaired growth in children. However, these results remain inconsistent and inconclusive due to lack of randomized controlled studies. METHODS: A randomized school-based cross-sectional study was designed to study AF exposure levels and associated health effects in children between ages 6 and 12 years. Participants were recruited from primary schools within Siaya and Makueni Counties of Kenya, East Africa. The Joint Ethics Committee of the University of Nairobi and Kenyatta National Hospital in Kenya approved the research protocol and procedures for the study. Both parental consent and child assent were obtained before enrollment in the study. Parents were requested to provide household grain samples and fill out questionnaires detailing their sociodemographic information, household dietary patterns, farming practices, and knowledge of AF contamination. Blood samples were collected from children participants, and sera were prepared for analysis of AFB1-lysine which is one of the validated biomarkers for AF exposure. DISCUSSION: This protocol describes a school-based, cross-sectional study whose objective is to comparatively evaluate the role of AF exposure on adverse health outcomes in children. Specifically, effects of cumulative AF exposure on nutritional status, immune markers, and growth parameters will be assessed. TRIAL REGISTRATION: This study is not a clinical trial, rather a cross-sectional study aimed at providing baseline data on AF exposures in children who live in presumably high versus low AF exposure regions. Results from the study can be used to design interventions and/or prospective cohort studies aimed at studying adverse health effects associated with cumulative AF exposure through diets. The study reference number is P741/12/2017 and registered with KNH-UoN Ethics and Research Committee.

The African Pediatric Fellowship Program: Training in Africa for Africans.

Africa has a significant burden of childhood disease, with relatively few skilled health care professionals. The African Paediatric Fellowship Programme was developed by the Department of Pediatrics and Child Health at the University of Cape Town to provide relevant training for African child health professionals, by Africans, within Africa. Trainees identified by partner academic institutions spend 6 months to 2 years training in the Department of Pediatrics and allied disciplines. They then return to their home institution to build practice, training, research, and advocacy. From 2008 to 2015, 73 physicians have completed or are completing training in general pediatrics or a pediatric subspecialty. At 1 year posttraining, 98% to 100% are practicing back in their home institution. The impact of the returning fellows is evident from their practice interventions, research collaborations, and positions as stakeholders who can change health care policies. Thirty-three centers in 13 African countries are partners with the program, and the program template is now followed by other partner sites in Africa. Increasing and retaining the skills pool of African child health specialists is building a network of motivated, highly skilled clinicians who are equipped to advance child health in Africa.

Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network.

BACKGROUND: Lack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data collection and use, informing wider health system development in time, but are rare in LIC. We report baseline data from a new Clinical Information Network (CIN) in Kenya seeking to promote data-informed improvement and learning. METHODS: Data from 13 hospitals engaged in the Kenyan CIN between April 2014 and March 2015 were captured from medical and laboratory records. We use these data to characterise clinical care and outcomes of hospital admission. RESULTS: Data were available for a total of 30 042 children aged between 2 months and 15 years. Malaria (in five hospitals), pneumonia and diarrhoea/dehydration (all hospitals) accounted for the majority of diagnoses and comorbidity was found in 17 710 (59%) patients. Overall, 1808 deaths (6%) occurred (range per hospital 2.5%-11.1%) with 1037 deaths (57.4%) occurring by day 2 of admission (range 41%-67.8%). While malaria investigations are commonly done, clinical health workers rarely investigate for other possible causes of fever, test for blood glucose in severe illness or ascertain HIV status of admissions. Adherence to clinical guideline-recommended treatment for malaria, pneumonia, meningitis and acute severe malnutrition varied widely across hospitals. CONCLUSION: Developing clinical networks is feasible with appropriate support. Early data demonstrate that hospital mortality remains high in Kenya, that resources to investigate severe illness are limited, that care provided and outcomes vary widely and that adoption of effective interventions remains slow. Findings suggest considerable scope for improving care within and across sites.