The differential effect of the free maternity services policy in Kenya.

BACKGROUND: The Government of Kenya introduced the free maternity services (FMS) policy to enable mothers deliver at a health facility and thus improve maternal health indicators. AIM: The aim of this study was to determine if there was a differential effect of the policy by region (sub-county) and by facility type (hospitals vs. primary healthcare facilities [PHCFs]). SETTING: The study was conducted in Nyamira County in western Kenya. METHODS: This was an interrupted time series study where 42 data sets (24 pre- and 18 post-intervention) were collected for each observation. Monthly data were abstracted from the District Health Information System-2, verified, keyed into and analysed by using IBM-Statistical Package for the Social Sciences (SPSS-17). RESULTS: The relative effect of the policy on facility deliveries in the county was an increase of 22.5%, significant up to the 12th month (p < 0.05). The effect of the policy on deliveries by region was highest in Nyamira North and Masaba North (p < 0.001 up to the 18th month). The effect was larger (46.5% vs. 18.3%) and lasted longer (18 months vs. 6 months) in the hospitals than in the PHCFs. The increase in hospital deliveries was most significant in Nyamira North (61%; p < 0.001). There was a medium-term effect on hospital deliveries in Borabu (up to 9 months) and an effect that started in the sixth month in Manga. The relative effect of the policy on facility deliveries in PHCFs was only significant in Nyamira North and Masaba North (p < 0.001). CONCLUSION: The effect of the FMS policy was varied by region (sub-county) and by facility type.

Spatial distribution and habitat characterization of mosquito species during the dry season along the Mara River and its tributaries, in Kenya and Tanzania.

BACKGROUND: Vector-borne diseases are increasingly becoming a major health problem among communities living along the major rivers of Africa. Although larger water bodies such as lakes and dams have been extensively researched, rivers and their tributaries have largely been ignored. This study sought to establish the spatial distribution of mosquito species during the dry season and further characterize their habitats along the Mara River and its tributaries. METHODS: In this cross-sectional survey, mosquito larvae were sampled along the Mara River, its two perennial tributaries (Amala and Nyangores), drying streams, and adjacent aquatic habitats (e.g. swamps, puddles that receive direct sunlight [open sunlit puddles], rock pools, hippo and livestock hoof prints, and vegetated pools). Each habitat was dipped 20 times using a standard dipper. Distance between breeding sites and human habitation was determined using global positioning system coordinates. The collected mosquito larvae were identified using standard taxonomic keys. Water physico-chemical parameters were measured in situ using a multiparameter meter. Mean mosquito larvae per habitat type were compared using analysis of variance and chi-square tests, while the relationship between mosquito larvae and physico-chemical parameters was evaluated using a generalized linear mixed model. The Cox-Stuart test was used to detect trends of mosquito larvae distribution. The test allowed for verification of monotonic tendency (rejection of null hypothesis of trend absence) and its variability. RESULTS: A total of 4001 mosquito larvae were collected, of which 2712 (67.8%) were collected from river/stream edge habitats and 1289 (32.2%) were sampled from aquatic habitats located in the terrestrial ecosystem about 50 m away from the main river/streams. Anopheles gambiae s.s, An. arabiensis, and An. funestus group, the three most potent vectors of malaria in Sub-Saharan Africa, together with other anopheline mosquitoes, were the most dominant mosquito species (70.3%), followed by Culex quinquefasciatus and Cx. pipiens complex combined (29.5%). Drying streams accounted for the highest number of larvae captured compared to the other habitat types. A stronger relationship between mosquito larvae abundance and dissolved oxygen (Z = 7.37, P ≤ 0.001), temperature (Z = 7.65, P ≤ 0.001), turbidity (Z = -5.25, P ≤ 0.001), and distance to the nearest human habitation (Z = 4.57, P ≤ 0.001), was observed. CONCLUSIONS: Presence of malaria and non-malaria mosquito larvae within the Mara River basin calls for immediate action to curtail the insurgence of vector-borne diseases within the basin. A vector control program should be conducted during the dry period, targeting drying streams shown to produce the highest number of larval mosquitoes.

Malaria hotspot areas in a highland Kenya site are consistent in epidemic and non-epidemic years and are associated with ecological factors.

BACKGROUND: Malaria epidemics in highland areas of East Africa have caused considerable morbidity and mortality in the past two decades. Knowledge of "hotspot" areas of high malaria incidence would allow for focused preventive interventions in resource-poor areas, particularly if the hotspot areas can be discerned during non-epidemic periods and predicted by ecological factors. METHODS: To address this issue, spatial distribution of malaria incidence and the relationship of ecological factors to malaria incidence were assessed in the highland area of Kipsamoite, Kenya, from 2001-2004. RESULTS: Clustering of disease in a single geographic "hotspot" area occurred in epidemic and non-epidemic years, with a 2.6 to 3.2-fold increased risk of malaria inside the hotspot, as compared to outside the area (P < 0.001, all 4 years). Altitude and proximity to the forest were independently associated with increased malaria risk in all years, including epidemic and non-epidemic years. CONCLUSION: In this highland area, areas of high malaria risk are consistent in epidemic and non-epidemic years and are associated with specific ecological risk factors. Ongoing interventions in areas of ecological risk factors could be a cost-effective method of significantly reducing malaria incidence and blunting or preventing epidemics, even in the absence of malaria early warning systems. Further studies should be conducted to see if these findings hold true in varied highland settings.

Presence and distribution of mosquito larvae predators and factors influencing their abundance along the Mara River, Kenya and Tanzania.

Among all the malaria controlling measures, biological control of mosquito larvae may be the cheapest and easiest to implement. This study investigated baseline predation of immature mosquitoes by macroinvertebrate predators along the Mara River, determined the diversity of predators and mosquito larvae habitats and the range of their adaptive capacity to water physico-chemical parameters. Between July and August 2011, sampling sites (n=39) along the Mara River were selected and investigated for the presence of macroinvertebrate predators and mosquito larvae. The selected sampling sites were geocoded and each dipped 20 times using standard mosquito larvae dipper to sample mosquito larvae, while a D-frame dip net was used to capture the macroinvertebrate predators. Water physico-chemical parameters (dissolved oxygen, temperature, pH, conductivity, salinity and turbidity) were taken in situ at access points, while hardness and alkalinity were measured titrimetically. The influence of macroinvertebrate predator occurrence was correlated with mosquito larvae and water quality parameters using Generalized Linear Model (GLM). Predators (n=297) belonging to 3 orders of Hemiptera (54.2%), Odonata (22.9%) and Coleoptera (22.9%), and mosquito larvae (n=4001) belonging to 10 species, which included An.gambiae s.l (44.9%), Culex spp. (34.8%) and An. coustani complex (13.8%), An. maculipalpis (3.6%), An. phaorensis (1.2%), An. funestus group (0.5%), An. azaniae (0.4%), An. hamoni (0.3%), An. christyi (0.3%), An. ardensis (0.08%), An. faini (0.07%), An. sergentii (0.05%) and 0.05% of Aedes mosquito larvae which were not identified to species level, due to lack of an appropriate key, were captured from different habitats along the Mara river. It was established that invasion of habitats by the macroinvertebrate predators were partially driven by the presence of mosquito larvae (p < 0.001), and the prevailing water physico-chemical parameters (DO, temperature, and turbidity, p <0.001). Understanding abiotic and biotic factors which favour mosquitoes and macroinveterbrate co-occurrence may contribute to the control of malaria.

Distribution and abundance of schistosomiasis and fascioliasis host snails along the Mara River in Kenya and Tanzania.

We purposively selected 39 sampling sites along the Mara River and its two perennial tributaries of Amala and Nyangores and sampled snails. In addition, water physicochemical parameters (temperature, turbidity, dissolved oxygen, conductivity, alkalinity, salinity and pH) were taken to establish their influence on the snail abundance and habitat preference. Out of the 39 sites sampled, 10 (25.6%) had snails. The snail species encountered included Biomphalaria pfeifferi Krauss - the intermediate host of Schistosoma mansoni Sambon, Bulinus africanus - the intermediate host of Schistosoma haematobium, and Lymnaea natalensis Krauss - the intermediate host of both Fasciola gigantica and F. hepatica Cobbold. Ceratophallus spp., a non-vector snail was also encountered. Most (61.0%) of the snails were encountered in streamside pools. Schistosomiasis-transmitting host snails, B. pfeifferi and B. africanus, were fewer than fascioliasis-transmitting Lymnaea species. All the four different snail species were found to be attached to different aquatic weeds, with B. pfeifferi accounting for over half (61.1%) of the snails attached to the sedge, followed by B. africanus and Lymnaea spp., accounting for 22.2 and 16.7%, respectively. Ceratophallus spp. were non-existent in sedge. The results from this preliminary study show that snails intermediate hosts of schistosomiasis and fascioliasis exists in different habitats, in few areas along the Mara River, though their densities are still low to have any noticeable impacts on disease transmission in case they are infected. The mere presence of the vector snails in these focal regions calls for their immediate control and institution of proper regulations, management, and education among the locals that can help curtail the spread of the snails and also schistosomiasis and fascioliasis within the Mara River basin.