Adherence to national malaria treatment guidelines in private drug outlets: a cross-sectional survey in the malaria-endemic Kisumu County, Kenya.

BACKGROUND: Malaria prevalence in Kenya is 6%, with a three-fold higher prevalence in western Kenya. Adherence to malaria treatment guidelines improves care for suspected malaria cases and can reduce unnecessary anti-malarial use. Data on adherence to guidelines in retail drug outlets (DOs) is limited, yet approximately 50% of people with fever access treatment first in these outlets. This study assessed adherence to the national malaria treatment guidelines among DOs in a high transmission area of Western Kenya. METHODS: In a cross-sectional survey of DOs in Kisumu Central and Seme sub-counties in 2021, DO staff were interviewed using structured questionnaires to assess outlet characteristics (location, testing services), staff demographics (age, sex, training), and health system context (supervision, inspection). Mystery shoppers (research assistants disguised as clients) observed malaria management practices and recorded observations on a standardized tool. Adherence was defined as dispensing artemether-lumefantrine (AL) to patients with a confirmed positive test, accompanied by appropriate medication counseling. Logistic regression was used to test for association between adherence to guidelines and DO-related factors. RESULTS: None of the 70 DOs assessed had a copy of the guidelines, and 60 (85.7%) were in an urban setting. Staff adhered to the guidelines in 14 (20%) outlets. The odds of adherence were higher among staff who had a bachelor's degree {odds ratio (OR) 6.0, 95% confidence interval (95% CI) 1.66-21.74}, those trained on malaria rapid diagnostic test (RDT) {OR 4.4, 95% CI 1.29-15.04}, and those who asked about patient's symptoms {OR 3.6, 95% CI 1.08-12.25}. DOs that had higher odds of adherence included those with functional thermometers {OR 5.3, 95% CI 1.46-19.14}, those recently inspected (within three months) by Pharmacy and Poisons Board (PPB) {OR 9.4, 95% CI 2.55-34.67}, and those with all basic infrastructure {OR 3.9, 95% CI 1.01-15.00}. On logistic regression analysis, recent PPB inspection {adjusted OR (AOR) 4.6, 95% CI 1.03-20.77} and malaria RDT-trained staff (aOR 4.5, 95% CI 1.02-19.84) were independently associated with adherence. CONCLUSION: Most outlets didn't adhere to malaria guidelines. Regular interaction with regulatory bodies could improve adherence. Ministry of Health should enhance private sector engagement and train DOs on RDT use.

Risk factors for poor treatment outcomes among opioid-dependent clients taking methadone in Mombasa, Kenya.

Background: The Methadone Maintenance Treatment (MMT) program has been proven to be beneficial in reducing illicit opioid use, increasing access to and retention of HIV treatment and other therapies, and reducing HIV transmission, and other drug-related morbidities and mortalities. However, determinants of treatment retention and outcomes for opioid-dependent persons accessing MMT in Kenya are limited. We sought to identify factors contributing to poor treatment outcomes among opioid-dependent persons enrolled in the Mombasa MMT program, between 2017 and 2019. Method: We conducted a retrospective records review for opioid-dependent persons receiving Methadone treatment in the Kisauni MAT clinic enrolled during 2017-2019. We defined poor clinical or health-related treatment outcome as any client Lost-To-Follow-Up (LTFU), turned HIV or Viral hepatitis positive, and/or missed two or more antiretroviral therapy (ART) appointments intake during MMT. Variables abstracted from clinical and pharmacological MMT service delivery tools included socio-demographic characteristics, clinical history, risk factors, and MMT outcomes. Data were analyzed using Epi Info7. We calculated Prevalence Odds Ratios (POR) and 95% Confidence Intervals (CI) to identify factors associated with adverse health outcomes. Results: Of the total 443 eligible records, the mean age was 37 years (SD ± 7.2) and males comprised 90.7%. The majority of females clients, 79.1% (34/43), were aged ≤35 years, 7.0% (3/43) had no education, 32.6% (14/43) were employed, 39.5% (17/43) were HIV positive and 18.6% (8/43) were HCV-positive. Overall, adverse treatment outcomes were at 27.5% (122/443), namely: LTFU at 22.8% (101/443), new HIV cases at 1.0% (4/391), HCV at 1.2% (5/405), and Hepatitis B Virus (HBV) at 1.2% (5/411), and 1.1% (5/443) died. Of HIV-infected clients linked to Comprehensive Care Clinic (CCC), 3.6% (2/56) defaulted from ART, and 25% (2/8) had detectable Viral Load of those retested. Lack of formal education (POR: 2.7, 95% CI: 1.3-5.7), unemployment (POR: 2.4, 95% CI: 1.4-4.0), and being a Non-Injector (POR: 1.7, 95% CI: 1.0-2.9) were negatively associated with treatment retention. Conclusion: Females were younger, and more educated with higher HIV and HCV prevalence. Being a Non-injector, unemployment, and lack of formal education may increase the likelihood of poor treatment outcomes among MMT clients. Closer monitoring of MMT clients with these characteristics is recommended with the integration of CCC into MMT services.

Improved latrine coverage may reduce porcine cysticercosis: a comparative cross-sectional study, Busia County, Kenya 2021.

Introduction: Smallholder pig farming is an important economic activity for many poor, rural communities in developing countries. Porcine cysticercosis is a growing public health risk in countries where pig rearing is popular. A sanitation-based intervention to reduce the prevalence of open defecation was completed in Busia County, Kenya in 2016. We capitalized on this third party intervention to evaluate its impact on porcine cysticercosis prevalence. Methods: We conducted a comparative cross-sectional survey from August through to September 2021. Household selection was done using multistage sampling. Household questionnaire data on pig production, transmission, risk factors and awareness of porcine cysticercosis were collected from 251 households. Lingual palpation was used to test for cysticerci in 370 pigs while serum was tested for circulating antigen using Ag-ELISA. We compared results of our survey to an effective baseline, which was a near equivalent cross sectional survey conducted in 2012 before the third party sanitary intervention was established. The difference in prevalence was measured using Chi-square tests. Multivariable logistic regression analysis was used to identify risk factors for lingual cysts in pigs. Results: The prevalence of palpable lingual cysts was estimated to be 3.8% (95% CI 2.3-6.3%) (14/370). This was 6% (95% CI 0.8-13.9%; p-value 0.0178) lower than the prevalence reported in the pre-implementation period of 9.7% (95% CI: 4.5-17.6%). Circulating antigen was detected in 2 samples (0.54%, 95% CI: 0.2-1.9). Latrine coverage was 86% (95% CI: 81-90%), which was 11% (95% CI: 4.8-16.8%; p < 0.001) higher than the pre-implementation period coverage of 75% (95% CI: 71-79%). There was reduced prevalence of lingual cysts in pigs from households that had a latrine (OR = 0.14; 95% CI: 0.05-0.43; p < 0.001) and where pigs were confined or tethered (OR = 0.27; 95% CI: 0.07-1.02; p = 0.053). Conclusion: There was a reduction in the prevalence of porcine cysticercosis in Busia County over the study period from 2012 to 2021. This was not a trial design so we are unable to directly link the decline to a specific cause, but the data are consistent with previous research indicating that improved sanitation reduces porcine cysticercosis. Programs for controlling porcine cysticercosis should include a focus on sanitation in addition to other integrated One Health approaches.

Assessment of community perceptions and risk to common zoonotic diseases among communities living at the human-livestock-wildlife interface in Nakuru West, Kenya: A participatory epidemiology approach.

BACKGROUND: Zoonoses account for most of the emerging and re-emerging infections in Kenya and in other low to medium-income countries across the world. The human-livestock-wildlife interface provides a nexus where transmission and spread of these zoonotic diseases could occur among communities farming in these areas. We sought to identify perceptions of the community living near the Lake Nakuru National Park in Kenya. METHODS: We used participatory epidemiology techniques (PE) involving Focus Group Discussion (FGD) among community members and Key Informant Interviews (KII) with the health, veterinary, and administration officers in July 2020. We used listing, pairwise matching, and proportional piling techniques during the FGDs in the randomly selected villages in the study area from a list of villages provided by the area government officers. Kruskal-Wallis test was used to compare the median scores between the zoonotic diseases, source of information, and response to disease occurrence. Medians with a z-score greater than 1.96 at 95% Confidence Level were considered to be significant. Content analysis was used to rank qualitative variables. RESULTS: We conducted seven FGDs and four KIIs. A total of 89 participants took part in the FGDs with their ages ranging from 26 to 85 years. Common zoonotic diseases identified by participants included anthrax, rabies, and brucellosis. Anthrax was considered to have the greatest impact by the participants (median = 4, z>1.96), while 4/7 (57%) of the FGDs identified consumption of uninspected meat as a way that people can get infected with zoonotic diseases. Community Health Volunteers (Median = 28, z = 2.13) and the government veterinary officer (median = 7, z = 1.8) were the preferred sources of information during disease outbreaks. CONCLUSION: The participants knew the zoonotic diseases common in the area and how the diseases can be acquired. We recommend increased involvement of the community in epidemio-surveillance of zoonotic diseases at the human-wildlife-livestock interface.

Campylobacter positivity and public health risks in live bird markets in Busia, Kenya: A value chain analysis.

Live bird markets (LBMs) provide integral hubs for 95% of poultry produced for food. Surveillance systems in LBMs serving smallholder farmers in sub-saharan Africa are often non-functional, and data about public health risks and emerging pathogens are lacking. Studies in Kenya have reported 29-44% Campylobacter prevalence in poultry. We analysed such LBMs in Kenya for likely transmission of Campylobacter from poultry to humans. We conducted a cross-sectional survey among 186 live poultry traders (LPTs) in 14 LBMs in a region with widespread backyard poultry systems. A pretested structured questionnaire was administered to all LPTs having regular contacts with poultry to gather market data and risk information on campylobacteriosis. Campylobacter was detected in individual cloacal cultures and identified through PCR. The median score obtained from the outcome of risk assessment dichotomized respondents into high and low risk categories. We performed logistic regression at 95% confidence interval (CI) to compare market characteristics and Campylobacter positivity to risk categories to identify LBM-associated public health risks. Markets had a median of 13 traders, and mean age of 46.3 ± 13.7 years. Majority 162/186 (87.1%) were males. Market behavioural processes by LPTs varied: Only 58.6% LPTs held bird species separate; onsite slaughter (38.7%); encountered sick-bird (93%) and dead-bird (83%) amidst limited health inspection (31.2%). Campylobacter positivity in live birds was 43/112 (38.4%, 95% CI: 29.4-48.1). Risk information on campylobacteriosis was low 41/114 (36%, 95% CI: 27.2-45.5). Sanitary risks were related to accumulation of litter (adjusted prevalence odds ratio [aPOR]: 19.67, 95% CI: 3.01-128.52). Accessing hand-wash facilities (aPOR: .32, 95% CI: .13-.78) and access to information (aPOR: .24, 95% CI: .09-.61) were protective. Sanitary risks were related to poor hygiene. LBMs could be central surveillance sites for Campylobacter. Public health authorities/actors should consider appropriate targeting to improve sanitary measures and Campylobacter control strategies.

Reduction in malaria burden following the introduction of indoor residual spraying in areas protected by long-lasting insecticidal nets in Western Kenya, 2016-2018.

BACKGROUND: Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the main malaria vector control measures deployed in Kenya. Widespread pyrethroid resistance among the primary vectors in Western Kenya has necessitated the re-introduction of IRS using an organophosphate insecticide, pirimiphos-methyl (Actellic® 300CS), as a pyrethroid resistance management strategy. Evaluation of the effectiveness of the combined use of non-pyrethroid IRS and LLINs has yielded varied results. We aimed to evaluate the effect of non-pyrethroid IRS and LLINs on malaria indicators in a high malaria transmission area. METHODS: We reviewed records and tallied monthly aggregate of outpatient department (OPD) attendance, suspected malaria cases, those tested for malaria and those testing positive for malaria at two health facilities, one from Nyatike, an intervention sub-county, and one from Suba, a comparison sub-county, both located in Western Kenya, from February 1, 2016, through March 31, 2018. The first round of IRS was conducted in February-March 2017 in Nyatike sub-county and the second round one year later in both Nyatike and Suba sub-counties. The mass distribution of LLINs has been conducted in both locations. We performed descriptive analysis and estimated the effect of the interventions and temporal changes of malaria indicators using Poisson regression for a period before and after the first round of IRS. RESULTS: A higher reduction in the intervention area in total OPD, the proportion of OPD visits due to suspected malaria, testing positivity rate and annual malaria incidences were observed except for the total OPD visits among the under 5 children (59% decrease observed in the comparison area vs 33% decrease in the intervention area, net change -27%, P <0.001). The percentage decline in annual malaria incidence observed in the intervention area was more than twice the observed percentage decline in the comparison area across all the age groups. A marked decline in the monthly testing positivity rate (TPR) was noticed in the intervention area, while no major changes were observed in the comparison area. The monthly TPR reduced from 46% in February 2016 to 11% in February 2018, representing a 76% absolute decrease in TPR among all ages (RR = 0.24, 95% CI 0.12-0.46). In the comparison area, TPR was 16% in both February 2016 and February 2018 (RR = 1.0, 95% CI 0.52-2.09). A month-by-month comparison revealed lower TPR in Year 2 compared to Year 1 in the intervention area for most of the one year after the introduction of the IRS. CONCLUSIONS: Our findings demonstrated a reduced malaria burden among populations protected by both non-pyrethroid IRS and LLINs implying a possible additional benefit afforded by the combined intervention in the malaria-endemic zone.

'We dry contaminated meat to make it safe': An assessment of knowledge, attitude and practices on anthrax during an outbreak, Kisumu, Kenya, 2019.

INTRODUCTION: Anthrax is the highest-ranked priority zoonotic disease in Kenya with about ten human cases annually. Anthrax outbreak was reported in Kisumu East Sub County after some villagers slaughtered and ate beef from a cow suspected to have died of anthrax. We aimed at establishing the magnitude of the outbreak, described associated factors, and assessed community knowledge, attitude, and practices on anthrax. METHODS: We reviewed human and animal records, conducted case search and contact tracing using standard case definitions in the period from July 1through to July 28, 2019. A cross-sectional study was conducted to assess community knowledge, attitude, and practices towards anthrax. The household selection was done using multistage sampling. We cleaned and analyzed data in Ms. Excel and Epi Info. Descriptive statistics were carried out for continuous and categorical variables while analytical statistics for the association between dependent and independent variables were calculated. RESULTS: Out of 53 persons exposed through consumption or contact with suspicious beef, 23 cases (confirmed: 1, probable: 4, suspected: 18) were reviewed. The proportion of females was 52.17% (12/23), median age 13.5 years and range 45 years. The attack rate was 43.4% (23/53) and the case fatality rate was 4.35% (1/23). Knowledge level, determined by dividing those considered to be 'having good knowledge' on anthrax (numerator) by the total number of respondents (denominator) in the population regarding cause, transmission, symptoms and prevention was 51% for human anthrax and 52% for animal anthrax. Having good knowledge on anthrax was associated with rural residence [OR = 5.5 (95% CI 2.1-14.4; p<0.001)], having seen a case of anthrax [OR = 6.2 (95% CI 2.8-14.2; p<0.001)] and among those who present cattle for vaccination [OR = 2.6 (95% CI 1.2-5.6; p = 0.02)]. About 23.2% (26/112) would slaughter and sell beef to neighbors while 63.4% (71/112) would bury or burn the carcass. Nearly 93.8% (105/112) believed vaccination prevents anthrax. However, 5.4% (62/112) present livestock for vaccination. CONCLUSION: Most anthrax exposures were through meat consumption. Poor knowledge of the disease might hamper prevention and control efforts.

Knowledge, attitude and practices on cholera in an arid county, Kenya, 2018: A mixed-methods approach.

BACKGROUND: Cholera remains a public health problem in Kenya despite increased efforts to create awareness. Assessment of knowledge, attitude and practice (KAP) in the community is essential for the planning and implementation of preventive measures. We assessed cholera KAP in a community in Isiolo County, Kenya. METHODS: This cross-sectional study involved a mixed-methods approach utilizing a questionnaire survey and focus group discussions (FGDs). Using multistage sampling with household as the secondary sampling unit, interviewers administered structured questionnaires to one respondent aged ≥18 years old per household. We created knowledge score by allotting one point for each correct response, considered any total score ≥ median score as high knowledge score, calculated descriptive statistics and used multivariate logistic regression to examine factors associated with high knowledge score. In FGDs, we randomly selected the participants aged ≥18 years and had lived in Isiolo for >1 year, conducted the FGDs using an interview guide and used content analysis to identify salient emerging themes. RESULTS: We interviewed 428 participants (median age = 30 years; Q1 = 25, Q3 = 38) comprising 372 (86.9%) females. Of the 425/428 (99.3%) who had heard about cholera, 311/425 (73.2%) knew that it is communicable. Although 273/428 (63.8%) respondents knew the importance of treating drinking water, only 216/421 (51.3%) treated drinking water. Those with good defecation practice were 209/428 (48.8%). Respondents with high knowledge score were 227/428 (53.0%). Positive attitude (aOR = 2.88, 95% C.I = 1.34-6.20), treating drinking water (aOR = 2.21, 95% C.I = 1.47-3.33), age <36 years (aOR = 1.75, 95% C.I = 1.11-2.74) and formal education (aOR = 1.71, 95% C.I = 1.08-2.68) were independently associated with high knowledge score. FGDs showed poor latrine coverage, inadequate water treatment and socio-cultural beliefs as barriers to cholera prevention and control. CONCLUSIONS: There was a high knowledge score on cholera with gaps in preventive practices. We recommend targeted health education to the old and uneducated persons and general strengthening of health education in the community.

Prevalence and spatial distribution of Trematode cercariae in Vector Snails within different Agro-Ecological Zones in Western Kenya, 2016.

INTRODUCTION: Freshwater vector snails' distribution, infection with cercariae, preferred habitat and possible trematodiases transmission foci is not well known in Western Kenya. We sought to determine the distribution and prevalence of infection of snails per agro-ecological zone and environmental factors in vector snail habitats. METHODS: We conducted a cross-sectional survey from March, 2016 - May, 2016, harvested and identified snails using shell morphology, determined their infection with trematode cercariae using microscopy, used descriptive statistics to estimate the prevalence of infection and relationship between snail abundance and environmental factors. RESULTS: We sampled a total of 1,678 vector snails from 47 sampling sites of which 42% were Lymnaeid, 23% Biomphalaria, 10% Bulinus, 22% Oncomelaniae and 2% Melanoides. Lower Midland I Ago-Ecological Zones had 44% of the snails and streams from springs had 41% of the snails. Overall, 26.5% (445/1678) (95% CI: 24.4 - 28.6) of the snails shed cercariae. Cercariae were found in 11 (23%) of the sites and in all zones. F. gigantica cercariae were shed by L. natalensis, B. pfeifferi, B. sudanica. Lakeshore had both F. gigantica and S. mansoni cercariae shed by B. sudanica. About 72% (1,202/1,678) of snails were found in water with a pH 6.5 - 7.5. Grass habitat had 54% (912/1,678) of the snails. CONCLUSION: Lymnaeid snails were present in all the zones, while streams from springs and near neutral habitats had most of the snails. Infection with trematode cercariae was noted in all the zones. Trematodiases control should be focused on all zones especially in freshwater streams and lakeshores.

Investigation of anthrax in an endemic region in Kenya: a mixed methods approach.

In Kenya, human anthrax cases most often occur linked to animal anthrax. In most cases, human behaviors, especially slaughter and consumption of meat from animal anthrax cases, has been implicated. This case study is based on an anthrax outbreak investigation conducted in an endemic region in Kenya in May 2016.The case study simulates how a mixed methods approach can be used in epidemiologic research.To fully benefit from this case study, participants should have had prior lectures or other instruction in quantitative and qualitative study designs and sampling approachesused in epidemiologic research. The case study is ideally suited for trainees at intermediate or advance level training in field epidemiology who should be able to complete the case study in approximately 3 hours.

Minyoo Matata - The Vicious Worm - A Taenia solium Computer-Based Health-Education Tool - in Swahili.

Lack of knowledge is one of the main risk factors for the spread of the zoonotic parasite Taenia solium. The computer-based health-education tool 'The Vicious Worm' was developed to create awareness and provide evidence-based health education as a specific measure in control strategies. To increase the reach of the tool, a new version in Swahili was developed and can now be downloaded for free from http://theviciousworm.sites.ku.dk.