Socio-cultural practices of deciduous canine tooth bud removal among Maasai children.

The removal of teeth amongst the Maasai is a traditional practice as part of an initiation or to make space for feeding in an event of diseases locking the jaw. Removal of deciduous canine tooth buds (DCB) among infants below 2 years has been reported in several studies to be common mainly amongst communities in East Africa, Ethiopia and Sudan. The main reason for the practice revolves around the belief that tooth buds or 'maggots' are false teeth, nylon or worms and are responsible for diarrhoea, vomiting, fever and growth retardation in children, amongst other illnesses. The main objective of this study was to assess the socio-cultural factors which contribute to this practice. The main methods of data collected included Focus Group Discussions (FGD) with mothers of children in that age group and Traditional Birth Attendants (TBA). In-depth interviews (IDI)were conducted with key informants versed with Maasai traditions whereas observations were done within the manyattas where participants live. Proceedings at both the FGD and the IDI were recorded on paper and were analysed thematically. The study showed that the removal of canine tooth buds amongst children that started initially with calves--that diseases that cause diarrhoea in calves were brought about by the canine tooth buds that were turning reddish in colour--is deeply rooted and practised in the community despite sensitisation interventions mounted jointly by the University of Nairobi, Kenya Medical Research Institute and the Kenya Medical Training College, among others. This study discovered that canine tooth buds are associated with bad spirits that cause diarrhoea and vomiting and the belief that removing them is a sure way of providing a cure for all children's ailments.

Malnutrition and cachexia among cancer out-patients in Nairobi, Kenya.

Cancer is the third leading cause of death in Kenya. However, there is scarce information on the nutritional status of cancer patients to guide in decision making. The present study sought to assess the risk of malnutrition, and factors associated with malnutrition and cachexia, among cancer out-patients, with the aim of informing nutrition programmes for cancer management in Kenya and beyond. This was a facility-based cross-sectional study performed at Kenyatta National Hospital and Texas Cancer Centre in Nairobi, Kenya. The risk of malnutrition was assessed using the Malnutrition Universal Screening Tool (MUST). Diagnoses of malnutrition and cachexia were done using the European Society of Clinical Nutrition and Metabolism (ESPEN) and Fearon criteria, respectively. A total of 512 participants were assessed. Those at risk of malnutrition were 33·1 % (12·5 % at medium risk, 20·6 % at high risk). Prevalence of malnutrition was 13·4 %. The overall weight loss >5 % over 3 months was 18·2 % and low fat-free mass index was 43·1 %. Prevalence of cachexia was 14·1 % compared with 8·5 % obtained using the local criteria. Only 18·6 % participants had received any form of nutrition services. Age was a predictor of malnutrition and cachexia in addition to site of cancer for malnutrition and cigarette smoking for cachexia. The use of the MUST as a screening tool at the first point of care should be explored. The predictive value of current nutrition assessment tools, and the local diagnostic criteria for malnutrition and cachexia should be reassessed to inform the development of appropriate clinical guidelines and future capacity-building initiatives that will ensure the correct identification of patients at risk for timely care.

Pattern of bone loss in dry mandibles of individuals who died before 1957.

OBJECTIVE: To map out the pattern of periodontal disease in individuals who died before 1957 and were not exposed to formal dental services. DESIGN: Descriptive cross-sectional study. SETTING: National Museums of Kenya. SUBJECTS: The skeletons of people who died before independence are preserved at the National Museums of Kenya in Nairobi. Sixty four out of the 170 dry mandibles stored at the Museum were assessed for periodontal bone loss using a calibrated ruler. RESULTS: All the 64 mandibles assessed were of individuals who died before 1957. Two thousand two hundred and seventy four sites were examined. Most of the subjects were adults aged 30-45 years and the age range was 18-80 years. Majority of the mandibles examined were of the ethnic group from Central Kenya. Of the teeth examined, premolars and molars were the teeth most frequently preserved intact in the sockets. The total mean bone loss for all teeth was 2.51 (SD 1.15) with a range of 0.85-5.80. When the different sites were examined, values for bone loss were 2.59 for mesial surfaces; 2.55 buccal surfaces; 2.38 for distal surfaces. Three categories were identified as follows:- 70% of the individuals had minimal or no bone loss, 26.5% had 3-4 mm or moderate bone loss and 3.5% had >5 mm bone loss or advanced bone loss. Further analysis showed that when bone loss of >3 mm was examined, only 28.12% of the individuals were in this group, 10.93% had >4 mm bone loss and 3.12% had 5 mm or more bone loss. The first molars were the teeth most commonly affected by bone loss of 3mm or more followed by second molars then the premolars. CONCLUSIONS: In this group of individuals mainly from Central Kenya, the bone loss pattern showed that only a small number had experienced periodontal destruction as recorded by bone loss levels. Three groups were identified; those who had no or minimal destruction, those who had experienced moderate destruction and those where obvious bone destruction was evident. Thus susceptibility to periodontal disease is evident in a small proportion of individuals even in populations not exposed to modern diet and formal dental services. Periodontal destruction seems to affect a fraction of the population even when older populations are examined, thus it would save on resources both human and physical if these susceptible individuals could be identified early and treatment provided.

Serum retinol concentrations and Schistosoma mansoni, intestinal helminths, and malarial parasitemia: a cross-sectional study in Kenyan preschool and primary school children.

Parasitic determinants of serum retinol concentrations were studied in 159 preschool (0.25-5.1 y) and 695 primary school (9.2-17 y) children in western Kenya. Mean serum retinol was 0.63 micromol/L in preschool and 0.94 micromol/L in primary school children; 62% and 24%, respectively, had serum retinol < 0.70 micromol/L. Serum retinol was lower in boys than in girls among both preschool (P = 0.04) and primary school children (P = 0.0001). Schistosoma mansoni, Ascaris lumbricoides, hookworm, and Trichuris trichiura egg output and malarial parasitemia were determined and their relation with serum retinol assessed. Among preschool children, sex, elevated serum concentrations of C-reactive protein, and malarial parasitemia were significant predictors of serum retinol. Among the 63 children from whom stool samples were available, none of the helminth infections were significant predictors of serum retinol. For primary school children, age, sex, and S. mansoni egg output were predictors of serum retinol. Malarial parasitemia among nonimmune preschool children may contribute to low serum retinol, whereas malarial parasitemia did not have any effects in semiimmune primary school children. In contrast, the inverse relation between S. mansoni and serum retinol found in primary school children could be due to an effect of infection on serum retinol or an increased susceptibility to infection among children with low serum retinol. Although parasitic infections may contribute to poor vitamin A status in children, they do not explain the age and sex differences.

The effects of malaria control on nutritional status in infancy.

Both malaria and undernutrition are major causes of paediatric mortality and morbidity in sub-Saharan Africa. The introduction of insecticide-treated bed nets (ITBN) during a randomized controlled trial on the Kenyan coast significantly reduced severe, life-threatening malaria and all-cause childhood mortality. This paper describes the effects of the intervention upon the nutritional status of infants aged between 1 and 11 months of age. Seven hundred and eighty seven infants who slept under ITBN and 692 contemporaneous control infants, were seen during one of three cross-sectional surveys conducted during a one year period. Standardized weight-for-age and mid-upper arm circumference measures were significantly higher among infants who used ITBN compared with control infants. Whether these improvements in markers of nutritional status were a direct result of concomitant reductions in clinical malaria episodes remains uncertain. Never-the-less evidence suggests that even moderate increases in weight-for-age scores can significantly reduce the probability of mortality in childhood and ITBN may provide additional gains to child survival beyond their impressive effects upon malaria-specific events.

Effects on serum retinol of multi-micronutrient supplementation and multi-helminth chemotherapy: a randomised, controlled trial in Kenyan school children.

OBJECTIVE: To assess the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on serum retinol concentration, using schools as a health delivery system. STUDY AREA AND POPULATION: From 19 primary schools in Bondo District, western Kenya, 977 children between 9 and 18 y were included in the trial. The 644 (65.9%) children on whom baseline serum retinol was available were included in this study. DESIGN: A randomised, placebo-controlled, double-blind, two-by-two factorial trial on the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on serum retinol after 8 months. INTERVENTION: Single treatment with albendazole (600 mg) and praziquantel (40 mg/kg of body weight) and daily multi-micronutrient supplementation with tablet containing 1000 microg vitamin A. RESULTS: Micronutrient supplementation (0.08 micromol/l, 95% CI 0.01, 0.14; P=0.025), but not treatment (0.03 micromol/l, 95% CI -0.04, 0.10; P=0.38), increased serum retinol. However, treatment did increase serum retinol in S. mansoni-infected (0.09, 95% CI 0.02, 0.16; P=0.009), but not in uninfected children (-0.07, 95% CI -0.18, 0.03; P=0.18; interaction, P=0.01). Similarly, reduction in egg output of S. mansoni, but none of the geohelminth, was a predictor, corresponding to a 0.008 micromol/l (95% CI 0.00002, 0.02; P=0.049) increase in serum retinol per 100 epg reduction. Interestingly, interactions were found between age and sex (P=0.046), and malaria parasitaemia and sickle cell phenotype (P=0.04). CONCLUSION: Multi-micronutrient supplementation and reduction in S. mansoni egg output increased serum retinol, irrespective of initial serum retinol. SPONSORSHIP: The Danish International Development Assistance.

Effects on haemoglobin of multi-micronutrient supplementation and multi-helminth chemotherapy: a randomized, controlled trial in Kenyan school children.

OBJECTIVE: To assess the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on haemoglobin concentration (Hb), using schools as a health delivery system. STUDY AREA AND POPULATION: Nine hundred seventy-seven children between 9 and 18 y of age from 19 primary schools in Bondo District, western Kenya, were included in the trial. The 746 (76.4%) children on whom baseline Hb was available were included in this study. DESIGN: The study was a randomized, placebo-controlled, double-blind, two-by-two factorial trial of the effects of multi-micronutrient supplementation and multi-helminth chemotherapy on Hb after 8 months. INTERVENTION: Single treatment of infected children with albendazole (600 mg) for geohelminths and praziquantel (40 mg/kg) for Schistosoma mansoni and daily supplementation with 13 micronutrients. RESULTS: : Multi-micronutrient supplementation (3.5 g/l, 95% CI 1.7, 5.3; P=0.0002) and anthelminthic treatment (2.0 g/l, 95% CI 0.2, 3.9; P=0.03) increased Hb independently (interaction, P=0.33). The effects were also independent of baseline Hb and general nutritional status. The treatment effect was due to reductions in S. mansoni and hookworm intensities of infection, in that Hb increased by 0.4 and 0.2 g/l, respectively, per 100 epg reductions in egg output. Interestingly, among S. mansoni-infected children, the effect of treatment seemed stronger in those with compared to those without co-existing malaria parasitaemia (interaction, P=0.09). CONCLUSION: Multi-micronutrient supplementation and multi-helminth chemotherapy increased Hb among school children, irrespective of initial Hb and nutritional status.

Minor surgery at hospitals and clinics in a Kenyan district.

BACKGROUND: Minor surgical operations are performed at almost all hospitals, health centres and dispensaries in Africa. A large proportion of the operations are urgent, prompted by injuries and acute infections. They are rarely recorded and reported systematically, and rates and patterns are poorly known. OBJECTIVE: To describe of all minor surgery performed on a rural African population during one year. DESIGN: Prospective recording and analysis of minor surgical procedures and of the patients undergoing the same procedures. SETTING: Hospitals, health centres, dispensaries and mission clinics in Meru district, Kenya. RESULTS: Out of 26,858 minor operations performed (2,066/100,000 people/year) 22,838 were done at the five hospitals in the district while 2,510 were done at 49 mission clinics (4.3/clinic/month), 764 at ten health centres (6.4/health centre/month) and 620 at 29 dispensaries (1.8/dispensary/month). The most common operations were episiotomy, tooth extraction, wound suture and incision and drainage of abscess. More minor surgery is done on women than on men, and the difference is related to obstetrical procedures. CONCLUSIONS: Relatively few operations were performed at health centres, dispensaries and mission clinics. Possible explanations include perceived quality of care, staff motivation, poor service access outside office hours and service charges.

Hospital catchment areas and surgery in Meru district, Kenya.

This study of the geographical locations of homesteads of patients undergoing surgery at three hospitals in Meru district, Kenya, showed largely overlapping catchment areas. It also showed catchment areas varying in size with the type of surgical operation under study: Caesarean section, exploratory laparotomy, uterine evacuation, tubal ligation, and normal child delivery. We conclude that catchment areas vary with the disease condition and the health care intervention under study. A precise definition of the catchment area population concept should be developed by ministries of health and then explained to district health teams and health care facility managers for local use in epidemiological surveillance and health care planning.

Aetiology and implications of domestic injuries in the elderly.

This study was conducted in ten major city hospitals and twelve city council health clinics in Nairobi. Hospital records covering the period 1986 to 1990 were reviewed. Information on age, sex, occupation, type and cause of injury, the management and outcome of treatment was extracted from the records. This article focuses on the elderly, aged 55 years and above. The results indicate that falls inside the house accounted for most (69%) of the injuries. This was followed by accidental cuts (27%) and injuries resulting from domestic violence (26%). The main types of injuries recorded were open wounds (56%), followed by head injuries (24%) and fractures (21%). Most of the injuries (more than 63%) occurred in the low income areas (mainly Mathare and Eastlands). These injuries have implications on care for the elderly and on the cost to the individual, the health facilities and the nation. The results indicate that domestic injuries are a common occurrence among the elderly and there is need to focus on prevention and cost-effective case management strategies.

Fatal non-transport injuries in Nairobi, Kenya.

Records from the office of the Registrar of Births and Deaths in Nairobi, Kenya, were studied with the aim of determining the magnitude of fatalities due to injuries sustained in the living environment. This information covered the period between 1986 and 1990. Data were collected over a one month period from 3rd July 1991 to 9th August 1991. The information which was collected from the death certificates included type of injury resulting in death, age and sex of the victim. The results from a total of 944 records revealed that males suffered more deaths than females (M:F ratio was 2.67:1). The most commonly occurring type of injury resulting in death was burns (22.5%). This was followed by drowning (18.1%), head injuries (18%) and suicide by hanging (12%). Stab wounds and poisoning (excluding food poisoning) each accounted for 6% of the total deaths, inhalation of vomit (5.2%) and crush injuries due to falling from a height (3.8%). Bullet wounds, asphyxia due to choking, abortion and electrocution each contributed less than 3% of total deaths. The age bracket with the highest number of deaths was between 20 years to 39 year's (51.4%) while infants and children 0-4 years alone contributed 16% of the total deaths. Since non-transport fatalities are common in all age groups, health education programmes must target both children and the adult population.

Accidents involving adults in the home environment in Nairobi, Kenya.

Hospital records covering the period between 1986 and 1990 obtained from 10 major city hospitals and 12 City Council Health clinics were reviewed and information on age, sex, occupation, type and cause of injury and its management was extracted. Also extracted was information on outcome of treatment. This paper deals only with information related to persons aged 18 years and above. The results show that out of 9648 hospital records reviewed, 48% were adult cases, with a male to female ratio of 1.5:1. Age group 18-35 years constituted more than 70% of all the cases, declining markedly with increasing age. The slums and low income group residential areas contributed 63% of the cases. The main types of injuries attended to were open wounds (34%), burns (13%), swellings (7%), lacerations and bruises (6%), bites and limb injuries (5%), respectively. The results show that there is a clear case for a community operational research project with a strong accident prevention component.

Childhood accidents in an urban community in Kenya.

A retrospective study was conducted over a twenty-month period from March 1991 to October 1992. The purpose of the study was to determine the types and causes of domestic accidents/injuries in the city of Nairobi. A total of 9,648 case files were perused and out of this figure 52% or 5009 records belonged to persons aged below 18 years. The male:female ratio was 1.6:1. Burns were identified as the most prevalent type of injury (37%) followed by cuts/wounds (24.9%) and body swellings (4.9%). The main causes of these accidents were: fire, falls inside and outside the house and cutting implements. These results are only an index to a problem that has been given little prominence in the field of public health.

Mixed infections in childhood diarrhoea: results of a community study in Kiambu District, Kenya.

One thousand four hundred and twenty diarrhoea specimens from 846 children aged 0 to 60 months were collected and analysed for bacteria, parasites and rotavirus over a 16 month period, from June 1985 to September 1986 inclusive. The study was conducted in 4 villages situated in Kiambu District, Kenya. All the specimens were analysed for rotavirus and parasites, including Cryptosporidium. The majority of the specimens were analysed for enteropathogenic Escherichia coli (EPEC), Shigella, Salmonella, Campylobacter and Aeromonas. Only 387 specimens were analysed for enterotoxigenic E. coli (ETEC). However, of this proportion analysed for ETEC, 33% were positive. A total of 344 specimens were negative for any organisms while a further 140 were only positive for parasites which have been implicated as being pathogenic, including Ascaris lumbricoides, Hymenolepis nana, Trichomonas hominis and Blastocysts hominis were considered to be at least potentially pathogenic and capable of causing diarrhoea. An average of only 29.4% of these organisms occurred as single isolates. The remaining infections were mixed, with a maximum of 7 potentially pathogenic organisms occurring together in a single specimen. The associations of certain organisms were significant, notably Campylobacter with Giardia lamblia. Campylobacter with EPEC, EPEC with Ascaris, and G. lamblia with rotavirus. The latter was a negative association.

The influence of inflammation on plasma zinc concentration in apparently healthy, HIV+ Kenyan adults and zinc responses after a multi-micronutrient supplement.

BACKGROUND/OBJECTIVES: Plasma zinc is an important biomarker of zinc status, but the concentration is depressed by inflammation. SUBJECTS/METHODS: Apparently healthy adults, who tested positive twice for human immunodeficiency virus (HIV) but who had not reached stage IV or clinical AIDS, were randomly allocated to receive a food supplement (n=17 and 21) or the food plus a micronutrient capsule (MN; n=10 men and n=33 women) containing 15 mg zinc/day. We used the inflammation biomarkers, C-reactive protein (CRP) and alpha1-acid glycoprotein (AGP), to identify subjects with and without inflammation and determine the effect of inflammation on the response of plasma zinc concentrations to the MN and food supplements. RESULTS: There were no differences between men and women either in plasma zinc or in the responses to the supplements and their data were combined. Plasma zinc was lower in those with inflammation than without. Repeated measures analysis of variance (ANOVA) showed that inflammation blocked increases in plasma zinc, and there was an approximate 10% increase in plasma zinc concentration in response to the MN supplement (P=0.023) in those without inflammation. Subgroup analysis showed mean changes in plasma zinc of 0.95 and -0.83 micromol/l (P=0.031) in response to the MN and food treatments, respectively, in those without inflammation at both time points. CONCLUSIONS: Inflammation seems to block any increase in plasma zinc after MN supplement and it is important to identify those without inflammation to determine the effectiveness of a zinc supplementation program.

Hydrocelectomy: a proxy for hydrocele prevalence in coastal Kenya.

To assess the value of hydrocelectomy as an indicator of the prevalence of lymphatic filariasis, the frequency of hydrocelectomy was investigated in five hospitals in an area of coastal Kenya where filariasis is endemic. Two of the hospitals studied (Kinango and Msambweni) were in Kwale district, two (Kilifi and Malindi) in Kilifi district and one (the Coast Provincial General Hospital) in Mombasa. Surgical operations performed between January 1991 and August 1993 were tallied from the main theatre registers. Additionally, admission files for hydrocelectomy patients were examined prospectively between September 1993 and February 1994, to obtain age profiles. Hydrocelectomies accounted for 27.6%, 16.6%, 13.6%, 4.3% and 2.0% of the major operations (totalling 6339) recorded in Kinango, Msambweni, Kilifi, Malindi and Coast Provincial General Hospital, respectively. The proportion of operations involving hydrolectomy was significantly higher in the two hospitals in Kwale district, in the southern part of the study area, than in the two hospitals in Kilifi district, in the northern part (23.4%, with 95% confidence intervals of 20.9%-25.9%, v. 10.3%, with 95% confidence intervals of 8.7%-11.9%; P < 0.001). The generally high frequencies of hydrocelectomy in the study area are evidence of the heavy social and economic burden imposed by hydrocele-attributable morbidity and its management. The age distribution pattern of the hydrocelectomy patients paralleled that of the individuals with hydrocele in the surrounding area.

Antibody reactivity with Skinner HSV vaccine.

Antibody reactivity against herpes simplex virus (HSV) was investigated in 15 subjects who received three subcutaneous immunisations with Skinner HSV vaccine. Humoral antibody responses were detected against type 1 HSV in every subject and against type 2 HSV in all but one subject; immuno-precipitating antibody responses were infrequently detected. There was no antibody reactivity against host-cell (MRC-5), foetal calf serum or rubella virus antigen. None of the vaccinated subjects developed clinical evidence of herpes genitalis.