Targeted Amplicon Deep Sequencing for Monitoring Antimalarial Resistance Markers in Western Kenya.

Molecular surveillance of Plasmodium falciparum parasites is important to track emerging and new mutations and trends in established mutations and should serve as an early warning system for antimalarial resistance. Dried blood spots were obtained from a Plasmodium falciparum malaria survey in school children conducted across eight counties in western Kenya in 2019. Real-time PCR identified 500 P. falciparum-positive samples that were amplified at five drug resistance loci for targeted amplicon deep sequencing (TADS). The absence of important kelch 13 mutations was similar to previous findings in Kenya pre-2019, and low-frequency mutations were observed in codons 569 and 578. The chloroquine resistance transporter gene codons 76 and 145 were wild type, indicating that the parasites were chloroquine and piperaquine sensitive, respectively. The multidrug resistance gene 1 haplotypes based on codons 86, 184, and 199 were predominantly present in mixed infections with haplotypes NYT and NFT, driven by the absence of chloroquine pressure and the use of lumefantrine, respectively. The sulfadoxine-pyrimethamine resistance profile was a "superresistant" combination of triple mutations in both Pfdhfr (51I 59R 108N) and Pfdhps (436H 437G 540E), rendering sulfadoxine-pyrimethamine ineffective. TADS highlighted the low-frequency variants, allowing the early identification of new mutations, Pfmdr1 codon 199S and Pfdhfr codon 85I and emerging 164L mutations. The added value of TADS is its accuracy in identifying mixed-genotype infections and for high-throughput monitoring of antimalarial resistance markers.

Schistosomiasis, soil transmitted helminthiasis, and malaria co-infections among women of reproductive age in rural communities of Kwale County, coastal Kenya.

BACKGROUND: Schistosoma haematobium, soil transmitted helminthes (STH), and malaria lead to a double burden in pregnancy that eventually leads to poor immunity, increased susceptibility to other infections, and poor pregnancy outcomes. Many studies have been carried out on pre-school and school aged children but very little has been done among the at risk adult population including women of reproductive age (WRA). Our current study sought to establish the risk factors and burden of co-infection with S. haematobium, STH, and Plasmodium sp. among WRA in Kwale County, Coastal Kenya. METHODS: A total of 534 WRA between the ages of 15-50 were enrolled in this cross-sectional study from four villages; Bilashaka and Mwaluphamba in Matuga sub-County, and Mwachinga and Dumbule in Kinango sub-County. Socio-demographic information was collected using a pre-tested standardized questionnaire. Parasitological examination was done using urine filtration method for Schistosoma haematobium, Kato Katz for STH (Ascaris lumbricoides, Hookworm, Trichuris trichiura), and standard slide microscopy for Plasmodium sp. Statistical analyses were carried out using STATA version 15.1. RESULTS: The overall prevalence of S. haematobium was 3.8% (95% CI: 2.6-5.4) while that for malaria was 4.9% (95% CI: 2.0-11.7). The prevalence of STH was 5.6% (95% CI: 2.8-11.3) with overall prevalence of 5.3% (95% CI: 2.5-10.9) for hookworm and 0.6% (95% CI: 0.2-1.9) for T. trichiura. The occurrence of co-infection was low and was recorded between S. haematobium and P. falciparum (0.6%), followed by S. haematobium and STH (0.4%). Among pregnant women, 2.6% had co-infection with S. haematobium and P. falciparum. Only 1.3% had co-infection with S. haematobium and hookworm or T. trichiura. Among non-pregnant women, co-infection with S. haematobium and P. falciparum was 0.2%. Similarly, co-infection with S. haematobium and hookworm or T. trichiura was 0.2%. Bed net ownership and usage among pregnant women was 87.8 and 96.6%, respectively. 66.3% of the women reported using improved water sources for drinking while 78.1% reported using improved sanitation facilities. CONCLUSION: The use of improved WASH activities might have contributed to the low prevalence of STHs and S. haematobium infections. Further, bed net ownership and usage might have resulted in the low prevalence of Plasmodium sp. infections observed.

Model-Based Geostatistical Methods Enable Efficient Design and Analysis of Prevalence Surveys for Soil-Transmitted Helminth Infection and Other Neglected Tropical Diseases.

Maps of the geographical variation in prevalence play an important role in large-scale programs for the control of neglected tropical diseases. Precontrol mapping is needed to establish the appropriate control intervention in each area of the country in question. Mapping is also needed postintervention to measure the success of control efforts. In the absence of comprehensive disease registries, mapping efforts can be informed by 2 kinds of data: empirical estimates of local prevalence obtained by testing individuals from a sample of communities within the geographical region of interest, and digital images of environmental factors that are predictive of local prevalence. In this article, we focus on the design and analysis of impact surveys, that is, prevalence surveys that are conducted postintervention with the aim of informing decisions on what further intervention, if any, is needed to achieve elimination of the disease as a public health problem. We show that geospatial statistical methods enable prevalence surveys to be designed and analyzed as efficiently as possible so as to make best use of hard-won field data. We use 3 case studies based on data from soil-transmitted helminth impact surveys in Kenya, Sierra Leone, and Zimbabwe to compare the predictive performance of model-based geostatistics with methods described in current World Health Organization (WHO) guidelines. In all 3 cases, we find that model-based geostatistics substantially outperforms the current WHO guidelines, delivering improved precision for reduced field-sampling effort. We argue from experience that similar improvements will hold for prevalence mapping of other neglected tropical diseases.

Patterns and Drivers of Household Sanitation Access and Sustainability in Kwale County, Kenya.

Many sanitation interventions suffer from poor sustainability. Failure to maintain or replace toilet facilities risks exposing communities to environmental pathogens, yet little is known about the factors that drive sustained access beyond project life spans. Using data from a cohort of 1666 households in Kwale County, Kenya, we investigated the factors associated with changes in sanitation access between 2015 and 2017. Sanitation access is defined as access to an improved or unimproved facility within the household compound that is functional and in use. A range of contextual, psychosocial, and technological covariates were included in logistic regression models to estimate their associations with (1) the odds of sustaining sanitation access and (2) the odds of gaining sanitation access. Over two years, 28.3% households sustained sanitation access, 4.7% lost access, 17.7% gained access, and 49.2% remained without access. Factors associated with increased odds of households sustaining sanitation access included not sharing the facility and presence of a solid washable slab. Factors associated with increased odds of households gaining sanitation access included a head with at least secondary school education, level of coarse soil fragments, and higher local sanitation coverage. Results from this study can be used by sanitation programs to improve the rates of initial and sustained adoption of sanitation.

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.

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.

Comparing the performance of circulating cathodic antigen and Kato-Katz techniques in evaluating Schistosoma mansoni infection in areas with low prevalence in selected counties of Kenya: a cross-sectional study.

BACKGROUND: Kato-Katz technique has been the mainstay test in Schistosoma mansoni diagnosis in endemic areas. However, recent studies have documented its poor sensitivity in evaluating Schistosoma mansoni infection especially in areas with lower rates of transmission. It's the primary diagnostic tool in monitoring impact of the Kenya national school based deworming program on infection transmission, but there is need to consider a more sensitive technique as the prevalence reduces. Therefore, this study explored the relationship between results of the stool-based Kato-Katz technique with urine-based point-of-care circulating cathodic antigen (POC-CCA) test in view to inform decision-making by the program in changing from Kato-Katz to POC-CCA test. METHODS: We used two cross-sectional surveys conducted pre- and post- mass drug administration (MDA) using praziquantel in a representative random sample of children from 18 schools across 11 counties. A total of 1944 children were randomly sampled for the study. Stool and urine samples were tested for S. mansoni infection using Kato-Katz and POC-CCA methods, respectively. S. mansoni prevalence using each technique was calculated and 95% confidence intervals obtained using binomial regression model. Specificity (Sp) and sensitivity (Sn) were determined using 2 × 2 contingency tables and compared using the McNemar's chi-square test. RESULTS: A total of 1899 and 1878 children were surveyed at pre- and post-treatment respectively. S. mansoni infection prevalence was 26.5 and 21.4% during pre- and post-treatment respectively using POC-CCA test, and 4.9 and 1.5% for pre- and post-treatment respectively using Kato-Katz technique. Taking POC-CCA as the gold standard, Kato-Katz was found to have significantly lower sensitivity both at pre- and post-treatment, Sn = 12.5% and Sn = 5.2% respectively, McNemar test χ2m = 782.0, p < 0.001. In overall, the results showed a slight/poor agreement between the two methods, kappa index (k) = 0.11, p < 0.001, inter-rater agreement = 77.1%. CONCLUSIONS: Results showed POC-CCA technique as an effective, sensitive and accurate screening tool for Schistosoma mansoni infection in areas of low prevalence. It was up to 14-fold accurate than Kato-Katz which had extremely inadequate sensitivity. We recommend usage of POC-CCA alongside Kato-Katz examinations by Schistosomiasis control programs in low prevalence areas.

Effect of Repeated Anthelminthic Treatment on Malaria in School Children in Kenya: A Randomized, Open-Label, Equivalence Trial.

BACKGROUND: School children living in the tropics are often concurrently infected with plasmodium and helminth parasites. It has been hypothesized that immune responses evoked by helminths may modify malaria-specific immune responses and increase the risk of malaria. METHODS: We performed a randomized, open-label, equivalence trial among 2436 school children in western Kenya. Eligible children were randomized to receive either 4 repeated doses or a single dose of albendazole and were followed up during 13 months to assess the incidence of clinical malaria. Secondary outcomes were Plasmodium prevalence and density, assessed by repeat cross-sectional surveys over 15 months. Analysis was conducted on an intention-to-treat basis with a prespecified equivalence range of 20%. RESULTS: During 13 months of follow-up, the incidence rate of malaria was 0.27 episodes/person-year in the repeated treatment group and 0.26 episodes/person-year in the annual treatment group (incidence difference, 0.01; 95% confidence interval, -.03 to .06). The prevalence and density of malaria parasitemia did not differ by treatment group at any of the cross-sectional surveys. CONCLUSIONS: Our findings suggest that repeated deworming does not alter risks of clinical malaria or malaria parasitemia among school children and that school-based deworming in Africa may have no adverse consequences for malaria. CLINICAL TRIALS REGISTRATION: NCT01658774.

Plasmodium falciparum parasitaemia and clinical malaria among school children living in a high transmission setting in western Kenya.

BACKGROUND: Malaria among school children is increasingly receiving attention, yet the burden of malaria in this age group is poorly defined. This study presents data on malaria morbidity among school children in Bungoma county, western Kenya. METHOD: This study investigated the burden and risk factors of Plasmodium falciparum infection, clinical malaria, and anaemia among 2346 school children aged 5-15 years, who were enrolled in an individually randomized trial evaluating the effect of anthelmintic treatment on the risks of malaria. At baseline, children were assessed for anaemia and nutritional status and information on household characteristics was collected. Children were followed-up for 13 months to assess the incidence of clinical malaria by active detection, and P. falciparum infection and density evaluated using repeated cross-sectional surveys over 15 months. RESULTS: On average prevalence of P. falciparum infection was 42% and ranged between 32 and 48% during the five cross-sectional surveys. Plasmodium falciparum prevalence was significantly higher among boys than girls. The overall incidence of clinical malaria was 0.26 episodes per person year (95% confidence interval, 0.24-0.29) and was significantly higher among girls (0.23 versus 0.31, episodes per person years). Both infection prevalence and clinical disease varied by season. In multivariable analysis, P. falciparum infection was associated with being male, lower socioeconomic status and stunting. The risk of clinical malaria was associated with being female. CONCLUSION: These findings show that the burden of P. falciparum parasitaemia, clinical malaria and anaemia among school children is not insignificant, and suggest that malaria control programmes should be expanded to include this age group.

Comparing insecticide-treated bed net use to Plasmodium falciparum infection among schoolchildren living near Lake Victoria, Kenya.

BACKGROUND: Under trial conditions insecticide-treated nets have been shown to provide significant clinical and mortality protection under a range of malaria transmission intensity conditions. There are, however, few operational impact data, notably in very intense transmission conditions. This study, reports on malaria infection among Kenyan schoolchildren living in areas of intense malaria transmission and their reported use of insecticide-treated bed nets. METHODS: 5188 children in 54 schools were randomly sampled from seven counties surrounding Lake Victoria between May and June 2014. A questionnaire was administered to schoolchildren in classes 2-6 on the use of a long-lasting, insecticide-treated net (LLIN) the night before the survey and provided a single blood sample for a rapid diagnostic test for malaria infection. Analysis of the impact of insecticide-treated net use on malaria prevalence was undertaken using a multivariable, mixed effects, logistic regression at 95% confidence interval (CI), taking into account hierarchical nature of the data and results adjusted for school clusters. RESULTS: The overall prevalence of malaria infection was 48.7%, two-thirds (67.9%) of the children reported using LLIN, 91.3% of the children reported that their households own at least one LLIN and the household LLIN coverage was 2.5 persons per one LLIN. The prevalence of infection showed variation across the counties, with prevalence being highest in Busia (66.9%) and Homabay (51.8%) counties, and lowest in Migori County (29.6%). Generally, malaria parasite prevalence differed between age groups and gender with the highest prevalence occurring in children below 7 years (50.6%) and males (52.2%). Adjusting for county and school, there was a significant reduction in odds of malaria infection among the schoolchildren who reported LLIN use the previous night by 14 % (aOR 0.86, 95% CI 0.74-0.98, P < 0.027). CONCLUSION: Malaria transmission continues to be high around Lake Victoria. Despite evidence of increasing pyrethroid resistance and the likely overall efficacy of LLIN distributed several years prior to the survey, LLIN continue to provide protection against infection among school-aged children.

Helminthiasis and malaria co-infection among women of reproductive age in a rural setting of Kilifi County, coastal Kenya: A mixed method study.

Soil transmitted helminthiasis (STH), Schistosoma haematobium and malaria co-infection lead to increased susceptibility to other infections and poor pregnancy outcomes among women of reproductive age (WRA). This study sought to establish risk factors, burden of co-infection with STH, S. haematobium and Plasmodium sp. among WRA in Kilifi County, Kenya.A mixed method cross-sectional study was conducted on 474 WRA in 2021. Simple random sampling was used to select WRA from four villages in two purposively sampled sub-counties. Study participants were interviewed, and stool samples collected and analysed using Kato-Katz technique for STH. Urine samples were collected for examination of S. haematobium while malaria microscopic test was done using finger prick blood samples. Further, 15 focus group discussions (FGDs) were conducted with purposively selected WRA and qualitative data analyzed thematically using Nvivo software. Quantitative and qualitative methods were triangulated to comprehensively strengthen the study findings. Prevalence of S. haematobium was 22.3% (95%CI: 13.5-36.9), any STH 5.2% (95%CI: 1.9-14.3) and malaria 8.3% (95%: 3.8-18.2). Co-infections between any STH and S. haematobium was 0.8% (95%CI: 0.2-3.2) and between S. haematobium and malaria 0.8% (95%CI: 0.2-3.1). Multivariable analysis showed increased odds of any STH infections among participants in Rabai Sub-County, (aOR = 9.74; p = 0.026), businesswomen (aOR = 5.25; p<0.001), housewives (aOR = 2.78; p = 0.003), and casual laborers (aOR = 27.03; p<0.001). Qualitative analysis showed that the three parasitic diseases were common and responsible for possible causes of low birth weight, susceptibility to other infections and complications such as infertility and cancer later in life.The study demonstrated that STH, S. haematobium and malaria are still a public health problem to WRA. Some of the associated risks of infection were geographical location, socio-economic and WASH factors. Hence the need to implement integrated control efforts of the three parasitic infection.

Epidemiology of soil-transmitted helminthiasis among school-aged children in pastoralist communities of Kenya: A cross-sectional study.

INTRODUCTION: Soil-transmitted helminthiasis (STH) are a major public health problem in Sub-Saharan Africa. In Kenya, the National School Based Deworming Program (NSBDP) was launched in 2012 with a goal of reducing STH prevalence in school-aged children (SAC) to <1%, however monitoring and evaluation results have consistently showed > 20% prevalence in Narok County. We conducted a study to investigate factors associated with STH infections among SAC in Narok County. METHODOLOGY: A cross-sectional study was conducted among 514 SAC from five schools in Trans Mara West sub-county, Narok County. The sub-county was selected because it had participating schools within the NSBDP with a high prevalence of STH infection. Participants were selected using systematic random sampling. Stool samples collected from participants were examined for STH eggs using Kato-Katz technique. An open data kit questionnaire was used to collect socio-demographics, household, and STH knowledge information from 139 of the 514 SAC. Descriptive statistics was used to summarize the data, prevalence and mean intensity of infections were calculated, and logistic regression used to determine factors associated with STH infections. RESULTS: The overall prevalence of any STH infection was 24.6% (95%CI: 21.1-28.6). Trichuris trichiura 14.4% (95%CI: 11.7-17.8), Ascaris lumbricoides 12.5% (95%CI: 9.9-15.7) and hookworm 0%. From multivariable analysis the only factors significantly associated with increased risk of STH infection were, children attending Karda and Nkarano schools with aOR = 5.29 (95%CI: 1.45-19.24); p = 0.011 and aOR = 4.53 (95%CI: 1.29-15.97); p = 0.019 respectively. For A. lumbricoides, children attending Nkarano School were associated with a significant risk of infection with aOR = 7.81 (95%CI: 1.81-33.63); p = 0.006. CONCLUSIONS: Despite the ongoing work of NSBDP, the STH prevalence is still ≥ 20% in Trans Mara West sub-county Narok County, among SAC. This underscores the need for continued annual MDA. Additionally, if possible, drug combinations may effectively manage T. trichiura, the region's most common helminth. The study found a correlation between children attending specific schools and STH infection risk, suggesting the importance of health education and improved water, sanitation, and hygiene practices holistically both in schools and associated catchment areas that can act as STH reservoirs to alleviate the burden of STH.

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.

Identifying Potential Determinants of Faecal Contamination on Domestic Floors in Three Settings in Rural Kenya: A Mixed Methods Analysis.

Observational evidence suggests that household floors may be an important domain for the transmission of enteric and parasitic infections. However, little work has been done to investigate how household floors can become contaminated with human and animal faeces. This study uses a mixed methods approach to postulate the proximal and distal determinants of household floor contamination with faeces in groups of rural villages in 3 counties in Kenya (Bungoma, Kwale and Narok). Quantitative data was collected through a household census and analysed descriptively and using mixed effects logistic regression models. Qualitative data was collected through unstructured observations of daily routines and in-depth interviews. These data were analysed thematically with case memos produced for routine activities that were hypothesised to be determinants of floor contamination. Possible proximal determinants of floor contamination included; (1) animal contact with floors; (2) child faeces disposal, and; (3) floor cleaning routines. Distal determinants are suggested to be rooted in the socioeconomic, environmental, and cultural context in which households were located and included; (1) the type and number of animals owned by households; (2) presence/absence of dedicated shelters for housing animals at night, which impacted whether sleeping or cooking areas were exposed to animals; (3) Accessibility of inside spaces to poultry and other roaming animals; (4) ownership of an improved floor; (5) ability of animals to access neighbours compounds; (6) seasonal changes in weather. These results will be of use in identifying the contexts in which faecal contamination of domestic floors may be contributing towards transmission of enteric and parasitic infections and in designing effective interventions to prevent this exposure.

How important is the spatial movement of people in attempts to eliminate the transmission of human helminth infections by mass drug administration?

Human mobility contributes to the spatial dynamics of many infectious diseases, and understanding these dynamics helps us to determine the most effective ways to intervene and plan surveillance. In this paper, we describe a novel transmission model for the spatial dynamics of hookworm, a parasitic worm which is a common infection across sub-Saharan Africa, East Asia and the Pacific islands. We fit our model, with and without mobility, to data obtained from a sub-county in Kenya, and validate the model's predictions against the decline in prevalence observed over the course of a clustered randomized control trial evaluating methods of administering mass chemotherapy. We find that our model which incorporates human mobility is able to reproduce the observed patterns in decline of prevalence during the TUMIKIA trial, and additionally, that the widespread bounce-back of infection may be possible over many years, depending on the rates of people movement between villages. The results have important implications for the design of mass chemotherapy programmes for the elimination of human helminth transmission. This article is part of the theme issue 'Challenges and opportunities in the fight against neglected tropical diseases: a decade from the London Declaration on NTDs'.

Optimal control analysis of a transmission interruption model for the soil-transmitted helminth infections in Kenya.

Kenya is among the countries endemic for soil-transmitted helminthiasis (STH) with over 66 subcounties and over 6 million individuals being at-risk of infection. Currently, the country is implementing mass drug administration (MDA) to all the at-risk groups as the mainstay control strategy. This study aimed to develop and analyze an optimal control (OC) model, from a transmission interruption model, to obtain an optimal control strategy from a mix of three strategies evaluated. The study used the Pontryagin's maximum principle to solve, numerically, the OC model. The analysis results clearly demonstrated that water and sanitation when implemented together with the MDA programme offer the best chances of eliminating these tenacious and damaging parasites. Thus, we advocate for optimal implementation of the combined mix of the two interventions in order to achieve STH elimination in Kenya, and globally, in a short implementation period of less than eight years.

Understanding factors responsible for the slow decline of soil-transmitted helminthiasis following seven rounds of annual mass drug administration (2012-2018) among school children in endemic counties of Kenya: A mixed method study.

BACKGROUND: Soil-transmitted helminthiasis (STH) continue to be a significant health problem in Sub-Saharan Africa especially among school children. In Kenya, treatment of over five million children has been conducted annually in 28 endemic counties since the year 2012. However, the latest monitoring and evaluation (M&E) results indicated a slow decline of prevalence and intensity of STH in some counties after the seven rounds of annual mass drug administration (MDA). The current study sought to determine the factors associated with the slow decline in prevalence and intensity of STH among school children participating in the school deworming programme. METHODOLOGY: Mixed methods cross-sectional study was conducted in three endemic counties of Kenya. For quantitative technique, simple random sampling was used to select 1,874 school children from six purposively selected primary schools. The school children were interviewed, and a single stool collected and analysed using Kato-Katz technique. While for qualitative methods, 15 focus group discussions (FGDs) were conducted with purposively selected parents/guardians of school children. Data was collected through voice records using FGD and analyzed using NVIVO. FINDINGS: Prevalence of any STH infection was 30.8% (95%CI: 28.7-32.9), with the highest prevalence observed in Vihiga County (40.7%; 95%CI: 37.4-44.4). Multivariable analysis revealed that geographical location (OR = 3.78, (95%CI: 1.81-7.88) p<0.001), and not washing hands after defecation (OR = 1.91, (95%CI: 1.13-3.20) p = 0.015) were significantly associated with any STH infection. For qualitative analysis, majority of the parents/guardians of SAC felt that poor water sanitation and hygiene practices (WASH) both in school and household level could be a cause of continued STH infection. Also failing to include the rest of the community members in the MDAs were mentioned as possible contributors to observed slow decline of STH. CONCLUSIONS: There was moderate STH prevalence and mean intensity despite the seven rounds of repeated annual MDA. The study recommends a revamped awareness creation on WASH and community wide treatment.

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.

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.

Model-based geostatistical design and analysis of prevalence for soil-transmitted helminths in Kenya: Results from ten-years of the Kenya national school-based deworming programme.

Background: Kenya is endemic for soil-transmitted helminths (STH) with over 6 million children in 27 counties currently at-risk. A national school-based deworming programme (NSBDP) was launched in 2012 with a goal to eliminate parasitic worms as a public health problem. This study used model-based geostatistical (MBG) approach to design and analyse the impact of the NSBDP and inform treatment strategy changes. Methods: A cross-sectional study was used to survey 200 schools across 27 counties in Kenya. The study design, school selection and analysis followed the MBG approach which incorporated historical data on treatment, morbidity and environmental covariates to efficiently predict the helminths prevalence in Kenya. Results: Overall, the NSBDP geographic area prevalence for any STH was estimated to sit between 2 % and <10 % with a high predictive probability of >0.999. Species-specific thresholds were between 2 % and <10 % for Ascaris lumbricoides, 0 % to <2 % for hookworm, and 0 % to <2 % for Trichuris trichiura, all with high predictive probability of >0.999. Conclusions: Based on the World Health Organization guidelines, STH treatment requirements can now be confidently refined. Ten counties may consider suspending treatment and implement appropriate surveillance system, while another 10 will require treatment once every two years, and the remaining seven will require treatment once every year.