Informing etiologic research priorities for squamous cell esophageal cancer in Africa: A review of setting-specific exposures to known and putative risk factors.

Esophageal squamous cell carcinoma (ESCC) is one of the most common cancers in most Eastern and Southern African countries, but its etiology has been understudied to date. To inform its research agenda, we undertook a review to identify, of the ESCC risk factors which have been established or strongly suggested worldwide, those with a high prevalence or high exposure levels in any ESCC-affected African setting and the sources thereof. We found that for almost all ESCC risk factors known to date, including tobacco, alcohol, hot beverage consumption, nitrosamines and both inhaled and ingested PAHs, there is evidence of population groups with raised exposures, the sources of which vary greatly between cultures across the ESCC corridor. Research encompassing these risk factors is warranted and is likely to identify primary prevention strategies.

International cancer seminars: a focus on esophageal squamous cell carcinoma.

The International Agency for Research on Cancer (IARC) and the US National Cancer Institute (NCI) have initiated a series of cancer-focused seminars [Scelo G, Hofmann JN, Banks RE et al. International cancer seminars: a focus on kidney cancer. Ann Oncol 2016; 27(8): 1382-1385]. In this, the second seminar, IARC and NCI convened a workshop in order to examine the state of the current science on esophageal squamous cell carcinoma etiology, genetics, early detection, treatment, and palliation, was reviewed to identify the most critical open research questions. The results of these discussions were summarized by formulating a series of 'difficult questions', which should inform and prioritize future research efforts.

Heterogeneity in health seeking behaviour for treatment, prevention and urgent care in four districts in western Kenya.

OBJECTIVES: The impact of effective, life-saving health interventions is limited by access to and use of health services. Health seeking behaviour is likely to vary geographically and by type of health concern. However, little is known about the extent of this heterogeneity. STUDY DESIGN: A representative cluster-randomized sample of households in four districts in western Kenya was interviewed using a structured, interviewer-administered survey. GPS coordinates of all households and all local health facilities were also collected. METHODS: Household surveys measured health seeking behaviour for three distinct health needs: family planning which is a form of prevention, delivery which is an urgent care need but can be planned in advance, and childhood febrile illness which is an unexpected and potentially life-threatening concern. Logistic regression models were used to explore the relationship between seeking health services and maternal and household characteristics, with special attention to geographic and financial access to care. RESULTS: Use of health services for these three different health issues varied between the districts and also differed from national estimates. Place of delivery was most strongly correlated with the type of health services available to the family, whereas family planning was correlated with the relationship of the mother to the head of household. There was no strong interaction between socio-economic status and distance to services. CONCLUSIONS: The level of services available nearest to households rather than the distance to travel influences treatment-seeking behaviour, particularly for urgent care. Maternal factors and household wealth were often important but, even within the same households, their effect changes based on the type of health concern. Generalizing from nationwide surveys may obscure important local heterogeneity, particularly in delivery location and fever treatment.

A cluster-randomized trial of client and provider directed financial interventions to align incentives with appropriate case management in private medicine retailers: results of the TESTsmART Trial in Lagos, Nigeria.

Malaria remains a major health priority in Nigeria. Among children with fever who seek care, less than a quarter gets tested for malaria, leading to inappropriate use of the recommended treatment for malaria; Artemether Combination Therapies (ACT). Here we test an innovative strategy to target ACT subsidies to clients seeking care in Nigeria's private retail health sector who have a confirmed malaria diagnosis. We supported point-of-care malaria testing (mRDTs) in 48 Private Medicine Retailers (PMRs) in the city of Lagos, Nigeria and randomized them to two study arms; a control arm offering subsidized mRDT testing for USD $0.66, and an intervention arm where, in addition to access to subsidized testing as in the control arm, clients who received a positive mRDT at the PMR were eligible for a free (fully subsidized) first-line ACT and PMRs received USD $0.2 for every mRDT performed. Our primary outcome was the proportion of ACTs dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients who were tested at the PMR and adherence to diagnostic test results. Overall, 23% of clients chose to test at the PMR. Test results seemed to inform treatment decisions and resulted in enhanced targeting of ACTs to confirmed malaria cases with only 26% of test-negative clients purchasing an ACT compared to 58% of untested clients. However, the intervention did not offer further improvements, compared to the control arm, in testing rates or dispensing of ACTs to test-positive clients. We found that ACT subsidies were not passed on to clients testing positive in the intervention arm. We conclude that RDTs could reduce ACT overconsumption in Nigeria's private retail health sector, but PMR-oriented incentive structures are difficult to implement and may need to be complemented with interventions targeting clients of PMRs to increase test uptake and adherence. Clinical Trials Registration Number: NCT04428307.

A cluster-randomized trial of client and provider-directed financial interventions to align incentives with appropriate case management in retail medicine outlets: results of the TESTsmART Trial in western Kenya.

ACTs are responsible for a substantial proportion of the global reduction in malaria mortality over the last ten years. These reductions would not have been possible without publicly-funded subsidies making these drugs accessible and affordable in the private sector. However, inexpensive ACTs available in retail outlets have contributed substantially to their overconsumption. We test an innovative, scalable, and sustainable strategy to target ACT subsidies to clients with a confirmatory diagnosis. We supported point-of-care malaria testing (mRDTs) in 39 retail medicine outlets in western Kenya and randomized them to three study arms; control arm offering subsidized RDT testing for 0.4USD, client-directed intervention where all clients who received a positive RDT at the outlet were eligible for a free (fully subsidized) first-line ACT, and a combined client and provider directed intervention where clients with a positive RDT were eligible for free ACT and outlets received 0.1USD for every RDT performed. Our primary outcome was the proportion of ACT dispensed to individuals with a positive diagnostic test. Secondary outcomes included proportion of clients tested at the outlet and adherence to diagnostic test results. 43% of clients chose to test at the outlet. Test results informed treatment decisions and resulted in targeting of ACTs to confirmed malaria cases - 25.3% of test-negative clients purchased an ACT compared to 75% of untested clients. Client-directed and client+provider-directed interventions did not offer further improvements, compared to the control arm, in testing rates (RD=0.09, 95%CI:-0.08,0.26) or dispensing of ACTs to test-positive clients (RD=0.01,95% CI: -0.14, 0.16). Clients were often unaware of the price they paid for the ACT leading to uncertainty in whether the ACT subsidy was passed on to the client. We conclude that mRDTs could reduce ACT overconsumption in the private retail sector, but incentive structures are difficult to scale and their value to private providers is uncertain.

Developing and validating a perinatal depression screening tool in Kenya blending Western criteria with local idioms: A mixed methods study.

BACKGROUND: Routine screening for perinatal depression is not common in most primary health care settings. The U.S. Preventive Services Task Force only recently updated their recommendation on depression screening to specifically recommend screening during the pre- and postpartum periods. While practitioners in high-income countries can respond to this new recommendation by implementing one of several existing depression screening tools developed in Western contexts, such as the Edinburgh Postnatal Depression Scale (EPDS) or the Patient Health Questionnaire-9 (PHQ-9), these tools lack strong evidence of cross-cultural equivalence, validity for case finding, and precision in measuring response to treatment in developing countries. Thus, there is a critical need to develop and validate new screening tools for perinatal depression that can be used by lay health workers, primary health care personnel, and patients. METHODS: Working in rural Kenya, we used free listing, card sorting, and item analysis methods to develop a locally-relevant screening tool that blended Western psychiatric concepts with local idioms of distress. We conducted a validation study with a random sample of 193 pregnant women and new mothers to test the diagnostic accuracy of this scale along with the EPDS and PHQ-9. RESULTS: The sensitivity/specificity of the EPDS and PHQ-9 was estimated to be 0.70/0.72 and 0.70/0.73, respectively. This compared to sensitivity/specificity of 0.90/0.90 for a new 9-item locally-developed tool called the Perinatal Depression Screening (PDEPS). Across these three tools, internal consistency reliability ranged from 0.77 to 0.81 and test-retest reliability ranged from 0.57 to 0.67. The prevalence of depression ranges from 5.2% to 6.2% depending on the clinical reference standard. CONCLUSION: The EPDS and PHQ-9 are valid and reliable screening tools for perinatal depression in rural Western Kenya, the PDEPS may be a more useful alternative. At less than 10%, the prevalence of depression in this region appears to be lower than other published estimates for African and other low-income countries.

The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya.

Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.

Perception of risk, sexual behaviour and STD/HIV prevalence in western Kenya.

OBJECTIVE: To determine the feasibility and acceptability of collecting data on sexual practices, knowledge, attitudes and perception of risk with regard to HIV and STD infection in two clinic populations. DESIGN: A cross sectional survey carried out between June and July 1992. SETTING: An urban and a rural health centre in western Kenya. SUBJECTS: One hundred and sixty women attending Maternal Child Health (MCH) and Family Planning Clinics (FP). INTERVENTIONS: Screening STDs including N. gonorrhoea, C. trachomatis, T. vaginalis and syphilis. In addition subjects were interviewed about sexual practices, knowledge, attitudes and perception of risk with regard to HIV and STD infection. RESULTS: The presence of any STD including HIV was detected in 36.2% of women at the urban clinic and 21.2% of women at the rural clinic. The demographics of the two populations were similar with respect to age but were significantly different for several variables including marital status, ethnicity and education. Knowledge of STDs and HIV was nearly universal in both clinic populations with > 96% of patients being aware of the existence of such diseases. 76.3% of women at the urban clinic felt they could get an STD as compared to 48.8% at the rural clinic (p < 0.02). This awareness of vulnerability among the urban population was also seen for HIV. CONCLUSION: It appears to be feasible to conduct studies of sexual practices and perceptions of risk for STD/HIV acquisition in women attending health centres in Kenya.

A randomised controlled trial to assess the relative efficacy of chloroquine, amodiaquine, halofantrine and Fansidar in the treatment of uncomplicated malaria in children.

A randomised controlled trial was carried out to determine the relative efficacy of four commonly used antimalarial drugs in children aged three to twelve years presenting with uncomplicated malaria at the Eldoret District Hospital, Kenya. One hundred and eighty eight children were studied between July 1993 and July 1994. There were no significant baseline differences between treatment groups with respect to age, sex, weight, ethnicity, haemoglobin, white blood cell (WBC) counts, parasite counts, previous exposure to malaria and prior treatment. Of the 188 patients, eleven were lost to follow-up while twelve were discontinued from the study due to poor clinical response. Most of the latter (eight out of twelve) were in the chloroquine group. By day seven, there were significant differences (p = 0.004) in parasite clearance between groups. There were no significant statistical differences between the groups (p = 0.12) with regard to the fever clearance time. However, there was a significant statistical difference (p = 0.00003) between the treatment groups in the cure rates. Halofantrine was the most efficacious drug with 82% of the cases cured followed by fansidar(R)(62%), amodiaquine (55%) and chloroquine (29%). RI and RII resistance were observed in all the treatment groups, i.e. halofantrine (18%), fansidar (38%), amodiaquine (45%) and chloroquine (67%) while RIII resistance was only observed in the chloroquine group(3%).

Use of the Automated Disaster and Emergency Planning Tool in developing district level public health emergency operating procedures in three East African countries.

BACKGROUND: Sub-Saharan Africa is vulnerable to several natural and man-made disasters. We used the CDC Automated Disaster and Emergency Planning Tool (ADEPT) to develop all-hazards disaster management plans at district level in three eastern African countries. METHODS: During July 2008-February 2011, we used the automated disaster and emergency planning tool to conduct training on disaster planning and management in the three east African countries namely Kenya, Tanzania and Uganda. We trained district disaster teams per country. We held 7 trainings in Tanzania, 8 in Uganda and 10 in Kenya respectively. The district disaster management teams trained comprised five district administrative personnel and a national Red Cross officer. The training took 5 days. RESULTS: A total of 100 districts teams (40 in Uganda and 35 in Kenya and Tanzania respectively) were trained using the ADEPT and consequently 100 district disaster response plans were developed during 2008-2011. A total 814 district disaster team members from these districts were trained. Our experience has shown that the Automated Disaster Emergency Planning Tool is a relatively quick, easy, practical, participatory and inexpensive approach to developing emergency operating plans at the sub-national (district) level. CONCLUSIONS: The ADEPT can be used relatively easily, quickly and inexpensively at the sub-national levels to develop emergency operating procedures to improve disaster management. Although the ADEPT enables district disaster response teams to generate their disaster response plans, the use of the ADEPT may be hampered by lack of computer skills and knowledge of MS computer programme by district personnel in resource limited settings.

Webuye Health and Demographic Surveillance Systems Baseline Survey of Soil-Transmitted Helminths and Intestinal Protozoa among Children up to Five Years.

Background. The intestinal parasitic infections (IPIs) are globally endemic, and they constitute the greatest cause of illness and disease worldwide. Transmission of IPIs occurs as a result of inadequate sanitation, inaccessibility to potable water, and poor living conditions. Objectives. To determine a baseline prevalence of IPIs among children of five years and below at Webuye Health and Demographic Surveillance (HDSS) area in western Kenya. Methods. Cross-sectional survey was used to collect data. Direct saline and formal-ether-sedimentation techniques were used to process the specimens. Descriptive and inferential statistics such as Chi-square statistics were used to analyze the data. Results. A prevalence of 52.3% (417/797) was obtained with the male child slightly more infected than the female (53.5% versus 51%), but this was not significant (χ (2) = 0.482, P > 0.05). Giardia lamblia and Entamoeba histolytica were the most common pathogenic IPIs with a prevalence of 26.1% (208/797) and 11.2% (89/797), respectively. Soil-transmitted helminths (STHs) were less common with a prevalence of 4.8% (38/797), 3.8% (30/797), and 0.13% (1/797) for Ascaris lumbricoides, hookworms, and Trichuris trichiura, respectively. Conclusions. Giardia lamblia and E. histolytica were the most prevalent pathogenic intestinal protozoa, while STHs were less common. Community-based health promotion techniques are recommended for controlling these parasites.

HIV co-infection with tuberculous and non-tuberculous mycobacteria in western Kenya: challenges in the diagnosis and management.

BACKGROUND: Tuberculosis (TB) and HIV co-infections have a global prevalence with devastating morbidity and massive mortality, Sub-Saharan Africa being the worst hit. OBJECTIVES: To evaluate the prevalence of TB-HIV co-infection and demonstrate the confusion caused by NTM and HIV/AIDS co-infection in TB diagnosis and treatment in western Kenya. METHODS: In a cross-sectional study carried out at 10 hospitals in western Kenya, sputa from consenting 872 TB suspects underwent microscopy, and culture on Lowenstein-Jensen and Mycobacteria Growth Index Tube media. Isolates were identified using the Hain's GenoType(®) Mycobacterium CM and GenoType(®) Mycobacterium AS kits. A total of 695 participants were screened for HIV using Uni-Gold™ test and positives confirmed with the enzyme linked immunosorbent assay. RESULTS: A total of 346 (39.7%) participants were diagnosed with TB. Out of the 346 TB cases, 263 (76%) were tested for HIV infection and 110 (41.8%) of these were sero-positive (co-infected). The female to male TB-HIV co-infection prevalence ratio (PR) was 1.35. This study reports isolation of non-tuberculous mycobacteria from TB suspects at a rate of 1.7%. CONCLUSION: A high TB-HIV co-infection rate was observed in this study. The NTM disease could be misdiagnosed and treated as TB in western Kenya.