Viral etiology and epidemiology of acute respiratory infections in children in Nairobi, Kenya.

Acute respiratory infection (ARI) is the most common cause of illness and death in young children worldwide. Because of inadequate laboratory facilities and financial resources the etiological agents responsible for most cases in developing countries remain unknown, thus obviating appropriate management. Therefore, an ARI program was commenced at the Kenyatta National Hospital, Nairobi, Kenya in 1981 with the objectives of establishing the microbial causes, clinical presentations, and diagnoses of ARI in children under 5 years of age and of developing simple, rapid, and inexpensive diagnostic techniques. Viruses were demonstrated in 54% of the 822 children studied, but over half of the viruses identified were types not commonly associated elsewhere with the causation of severe ARI. Respiratory syncytial, parainfluenza, and adenoviruses occurred in the same age groups and during similar weather conditions as elsewhere. Measles virus occurred most frequently in those 7 to 9 months old. Herpes simplex, rhino-, and enteroviruses play causative roles in some cases of severe ARI in Kenyan children. A combination of immunofluorescent and cell culture techniques were shown to be essential for the detection of viruses.

Effect of improved stoves on prevalence of acute respiration infection and conjunctivitis among children and women in a rural community in Kenya.

OBJECTIVES: To estimate the effect of improved stoves on the prevalence of ARI and conjunctivitis among children aged below five years and women aged between 15 and 60 years. METHOD: A field trial or intervention study design, in which cluster and random sampling were used to recruit households with improved stoves. Nearest households with traditional three-stone stoves were recruited as controls. Prevalence of ARI and conjunctivitis among the study subjects was estimated by clinical evaluation and physical observation, and by history (including clinical and socioeconomic information), and compared between the two study groups. RESULTS: The prevalence of ARI among children aged below five years and among women aged between 15 and 60 years were significantly higher in households with the traditional three-stone stoves than in those with the improved stove chi 2 = 31.45 rho = 0.00000, relative risk = 2.6, C.I. 1.86,3.63, and chi 2 = 30.13, rho = 0.00000, Relative Risk = 2.8, C.I. 1.93, 4.06, respectively). Similarly the prevalence of conjunctivitis among children aged below five years and among women aged between 15 and 60 years were significantly higher in households with traditional three-stone stoves than in those with the improved stoves (c2 = 24.18, p = 0.00000, Relative Risk = 3.3, C.I. 2.05,5.32, and chi 2 = 7.6, rho = 0.0057, Relative Risk = 3, C.I. 1.38, 6.54, respectively). CONCLUSION: Prevalence of ARI and conjunctivitis among children aged below five years and also among women aged between 15 and 60 years in households with the traditional three-stone stoves was significantly higher than that in households with improved stoves.

Effects of passive smoking and breastfeeding on childhood bronchial asthma.

OBJECTIVE: To evaluate the effect of passive smoking and breastfeeding on the severity and age of onset of bronchial asthma. DESIGN: Cross-sectional study. SETTING: Paediatric observation ward and paediatric chest clinic, Kenyatta National Hospital. PATIENTS: Children aged between one and 120 months. RESULTS: More than fifty per cent of the children had their first wheeze at less than 12 months of age and 68% were categorised as having moderate to severe asthma. Passive smoking was positively significantly associated with early onset of wheezing (chi 2 = 6.22, p = 0.012, Odds ratio = 2.44, 95% CI 1.2,5.0), and also, at a non significant level, to severity of asthma (chi 2 = 2.8, p = 0.09, Odds ratio = 2.1, 95% CI 0.9,4.7). On the other hand, exclusive breastfeeding was significantly negatively associated with severity of bronchial asthma (chi 2 = 4.02, p = 0.045, Odds ratio = 0.4, 95% CI 0.14,0.98), but did not seen to have effect on age of onset of the disease (chi 2 = 0.0006, p = 0.94, Odds ratio = 0.9, 95% CI 0.4,2.2). CONCLUSION: Passive smoking is associated with early onset of asthma and possibly with development of severe asthma while exclusive breastfeeding is protective against development of severe asthma but does not seem to affect the age of onset of this disease.

Iron deficiency anaemia in children of a peri-urban health facility.

OBJECTIVE: To ascertain the prevalence of iron deficiency anaemia(IDA) and its risk factors. DESIGN: A cross-sectional survey. SETTING: A peri-urban health centre in Nairobi, Kenya. SUBJECTS: Four hundred and three children, aged six months to six years. INTERVENTION: Demographic data were obtained and each child examined for signs of iron deficiency anaemia. Blood was drawn for haemoglobin determination. MAIN OUTCOME MEASURE: The diagnosis of iron deficiency anaemia was made using a pre-defined criteria. RESULTS: Iron deficiency anaemia had a prevalence of 7.4% (95% CI = 4.8-10.0) and was predominantly mild (93.6%). Age was found to be significantly associated with iron deficiency anaemia with a prevalence of (14.6%) in infants. No association was found between IDA and sex, birthweight, weaning age and weaning diet, sanitation, water source or mother's education. CONCLUSION: The prevalence of iron deficiency anaemia in this health facility was relatively low and was predominantly mild.

PIP: This cross-sectional survey, conducted in a periurban health center in Nairobi, Kenya, determined the prevalence of iron deficiency anemia (IDA) and its risk factors among 403 children aged 6 months to 6 years. Demographic data were obtained and each child was assessed for signs of IDA. Blood was drawn for hemoglobin determination. The diagnosis of IDA was made using predefined criteria. Findings revealed that the prevalence of IDA was 7.4% (95% confidence interval = 4.8-10.0) and was predominantly mild (93.6%). Age was found to be significantly associated with IDA, with a 14.6% prevalence rate in infants. No association was found between IDA and factors such as sex, birth weight, weaning age and weaning diet, sanitation, water source, or education of the mother. Although the study showed that IDA was not a major health problem in the area, as evidenced by the low prevalence rate and presence of only mild cases, there is still a need for emphasis on health education at the health facility since young children are at high risk of IDA.

Mothers' knowledge, attitudes and practices regarding acute respiratory infections in children in Baringo District, Kenya.

BACKGROUND: Control of acute respiratory infections (ARI) is a major public health problem in developing countries. Implementation of case management protocols requires participation of the community to reduce morbidity and mortality from ARI. Health education programmes can only be effective when designed to take into account the prevailing knowledge, attitudes and practices (KAP) of the community towards ARI in their children. OBJECTIVE: To determine the KAP of mothers regarding ARI in their children aged less than five years. DESIGN: Community based cross-sectional survey. SETTING: Baringo District, Kenya. SUBJECTS: Mothers with children aged 0-5 years were recruited following stratified random sampling in three areas of Baringo District to represent low, medium and high potential areas based on agricultural productivity. INTERVENTION: A mixed structured and unstructured questionnaire was administered to each of the respondent mothers by the investigator; with the help of an interpreter where necessary. RESULTS: A total of 309 mothers were interviewed. Their mean age was 31.5 years (range 16-51) and 34% had no formal education. Only 18% of mothers described pneumonia satisfactorily. 60.2% knew that measles is preventable by immunisation. 87.1% of the mothers said they would seek health centre services for severe ARI. Formal education had a positive influence on the KAP of the mothers. CONCLUSION: The study reveals that the mothers had good knowledge of mild forms of ARI but not the severe forms. Their attitude to ARI was appropriate but subsequent practices were not. Low utilisation of health services for moderate ARI may result in continued high mortality because of delayed identification of seriously ill children.

The diagnostic value of various features for acute lower respiratory infection among under fives.

One hundred and fifty children aged between 5 months and 5 years with cough of less than 2 weeks duration, and presenting at the paediatric filter clinic and paediatric observation ward of the Kenyatta National Hospital between July and December 1985 were each evaluated by a complete history, physical examination, and a chest X-ray. Ninety of them (or 60%) had radiological evidence of pneumonia. Respiratory rate of over 50 per minute, chest indrawing, flaring of alae nasae, and a history of rapid breathing were found to be valuable indicators of pneumonia.

Bacteriology and sensitivity patterns of pyogenic meningitis at Kenyatta National Hospital, Nairobi, Kenya.

A descriptive cross sectional study on bacteriology and sensitivity patterns of laboratory-proven pyogenic meningitis was carried out over a six month period. A total of 92 patients (52 adults, 40 children) were studied. In 75 (82%) of the cases, the cerebrospinal fluid cultures were bacteriologically positive. Common isolates included Streptococcus pneumoniae (45%), Neisseria meningitidis (14%) and Haemophilus influenzae (12%). Other isolates included Cryptococcus neoformans from four (4.3%) adults who were also HIV-l positive. Sensitivity to antibiotics was determined using the disk diffusion method. There was no resistance to chloramphenicol among the three most common bacterial isolates. However, 7% and 15% of Streptococcus pneumoniae and N. meningitidis isolates, respectively, were resistant to crystalline penicillin. Twenty seven percent of Haemophilus influenzae was resistant to ampicillin. Sensitivity of the three organisms to the third generation cephalosporin (ceftazidime, cefotaxime, ceftriaxone) a second generation cephalosporin (cefuroxime) and augmentin was almost 100%. We recommend that chloramphenicol and crystalline penicillin or ampicillin be initial blind therapy for adults and older children with pyogenic meningitis and ampicillin and chloramphenicol for pre-school children. The above cephalosporins and augmentin are alternative therapy but their use will be limited by cost.

PIP: A total of 92 patients (52 adults and 40 children) admitted to Kenyatta National Hospital in Nairobi, Kenya, with pyogenic meningitis were enrolled in a descriptive cross-sectional analysis of the bacteriology and sensitivity factors associated with this disease. In 75 cases (82%), cerebrospinal fluid cultures were bacteriologically positive. Common isolates included Streptococcus pneumoniae (45%), Neisseria meningitidis (14%), and Haemophilus influenzae (12%). Although all 3 of these isolates were responsive to chloramphenicol, 7% of Streptococcus pneumoniae and 15% of Neisseria menigitidis isolates were resistant to crystalline penicillin and 27% of Haemophilus influenzae isolates were resistant to ampicillin. Sensitivity of these 3 organisms to the third-generation cephalosporins (ceftazidime, cefotaxime, and ceftriaxone), a second-generation cephalosporin (cefuroxime), and augmentin was almost 100%; however, their use is limited by cost. On the basis of these findings, it is recommended that chloramphenicol and crystalline penicillin or ampicillin be initial blind therapy for adults and older children with pyogenic meningitis, while ampicillin and chloramphenicol should be used in preschool children.

Bacteraemia, urinary tract infection and malaria in hospitalised febrile children in Nairobi: is there an association?

BACKGROUND: There is laboratory evidence of altered immune function in children with malaria. Bacterial infections have been documented to complicate severe forms of malaria. However, it remains unclear whether such infections are attributable to the malaria, other risk factors, or are coincidental. OBJECTIVE: To determine the prevalence of bacteraemia and urinary tract infections (UTI) in febrile hospitalised children with and without malaria. DESIGN: A cross-sectional survey. SETTING: General paediatric wards, Kenyatta National Hospital, Nairobi. SUBJECTS: Children aged between three months and 12 years admitted with an acute febrile illness, with no obvious focus of bacterial infection. MATERIALS AND METHODS: Using a standardised questionnaire, information on socio-demography, symptomatology, and nutritional status was obtained. Malaria slides, blood and urine cultures were performed on each child. RESULTS: Malaria parasitaemia was present in 158 (60%) of 264 children presenting with acute febrile illness with no obvious focus of bacterial infection. Bacteria were isolated from blood and/or urine of 62 (23%) of all enrolled children. Bacteraemia was prevalent among 11.4% of 158 children with malaria and among 13.2% of 106 without malaria. Gram-positive organisms comprised 28.1% of blood isolates, gram-negative 62.5%, and atypical bacteria 9.4%. UTI was prevalent among 13.3% of 158 children with malaria and 16.0% of 106 children without malaria. Gram-positive organisms comprised 18.4%, gram-negative 78.9%, and atypical bacteria 2.6% of the urine isolates. Presence of malaria parasitaemia was not associated with an increased risk of bacteraemia (OR 0.9, 95% CI [0.4-0.7], or UTI (OR 0.8 95% CI [0.4-1.6] in this study population. CONCLUSION: Among children hospitalised in Nairobi with fever and no obvious bacterial infective focus, there should be a high index of suspicion for malaria, followed by bacteraemia and UTI. Malaria parasitaemia does not appear to be associated with increased risk of bacterial co-infection.

X-ray diagnosable pneumonia in children with severe malnutrition at Kenyatta National Hospital.

OBJECTIVES: To estimate the prevalence of radiologically evident pneumonia among children with severe malnutrition and to evaluate the diagnostic utility of commonly used clinical indicators of pneumonia among children with severe malnutrition. METHODS: All children with severe malnutrition and admitted at the then Paediatric Observation Ward without congestive cardiac failure, severe anaemia, or severe dehydration, were clinically evaluated and a posteroanterior chest X-ray taken for each child. Pneumonia was diagnosed on the basis of radiological changes consistent with pneumonia as reported by an experienced radiologist. The performance of the various clinical parameters as diagnostic tests for pneumonia were also evaluated. SETTING: Kenyatta National Hospital, a tertiary level teaching institution for the University of Nairobi. RESULTS: One hundred and seven children comprising 68 males and 39 females were recruited into the study. Of these children, 38 had kwashiorkor, 40 had marasmus, while 29 had marasmic kwashiorkor. Radiological evidence of pneumonia was found in 58% of children with kwashiorkor, 75% with marasmic kwashiorkor, and 82% with marasmus. All the commonly used clinical parameters performed poorly as diagnostic tests for pneumonia among children with severe malnutrition. CONCLUSION: Prevalence of pneumonia was very high among children with severe malnutrition. Available clinical parameters, singly or in combination, are poor diagnostic tools for pneumonia in children with severe malnutrition. It is advisable to treat children with severe malnutrition as if they had pneumonia, even in the absence of suggestive clinical signs.

Verbal autopsy: a tool for determining cause of death in a community.

Verbal autopsy was used to determine causes of death in 239 children under the age of 5 years. The diagnosis derived from verbal autopsy was corroborated with hospital diagnosis in 39 cases. There was concurrence of diagnosis in 72% of the cases. Using the diagnosis of bronchopneumonia to validate the method, verbal autopsy was found to have a sensitivity of 71%, specificity of 92%, a positive predictive value of 85%. Reliability index of agreement was 0.654. Recall period up to 29 months after death was found to be reliable.

Evaluation of a proposed clinical case definition of paediatric acquired immune deficiency syndrome.

OBJECTIVE: To evaluate the proposed criteria against the laboratory parameters and to identify the clinical features with the highest predictive value in the diagnosis of paediatric AIDS. DESIGN: A cross sectional study. SETTING: Kenyatta National Hospital, Nairobi. RESULTS: More than twenty three per cent of the children studied were seropositive and 14% were diagnosed as having AIDS. Almost 70% of the children studied were below 24 months. AIDS was significantly associated with mouth lesions, both ulcers and oral candidiasis, skin lesions especially eczema and generalised pruritic dermatitis, prolonged cough, prolonged fever and generalised lymphadenopathy. The WHO criteria had a sensitivity of 60%, a specificity of 94%, positive predictive value of 60%, and negative predictive value of 94%. The Nairobi diagnostic criteria had a sensitivity of 80%, a specificity of 79%, a positive predictive value of 38% and a negative predictive value of 96%. CONCLUSION: The Nairobi Diagnostic Criteria are superior to the WHO criteria as a screening test due to their higher sensitivity, 80% against 60% for WHO.

Mortality patterns in a rural Kenyan community.

Causes of death of 239 children below the age of 5 years in a rural community were determined using structured questionnaires. It was found that mortality was highest in infancy, accounting for 63% of all deaths with a trend of decreasing mortality with increasing age. The commonest cause of death was ARI (pneumonia and measles) accounting for 49% of the deaths, followed by diarrhoeal illnesses (8.8%). Only half of the deaths (51.5%) occurred at some health facility, though 77% of all children had been taken to a health facility for treatment during the fatal illness.

Childhood asthma at Kenyatta National Hospital, Nairobi.

Between January 1986 and July 1988, 356 children with bronchial asthma below 14 years of age were evaluated at the Kenyatta National Hospital. 21.3% experienced initial asthmatic attacks before the age of six months and 55.1% before 2 years. Only 8% of the study patients were below the age of 2 years at recruitment. The male:female ratio was 1:1. Physical exercise led to precipitation or worsening of attacks in 43.4% while 71.6% of the patients experienced attacks in the evening or at night. 18.5% and 42.9% had personal history of atopic dermatitis and allergic rhinitis respectively. The study shows that a substantial number of patients experience initial asthmatic attacks before the age of 6 months contrary to what has been previously believed.

Pattern of use of skin care products in children with and without eczematous skin lesions.

OBJECTIVE: To compare the pattern of use of skin care products between children with eczematous skin lesions and those without. DESIGN: Case control study. SETTING: Two well baby clinics at the Kenyatta National Hospital and the Mbagathi District Hospital in Nairobi. SUBJECTS: Eighty nine infants with eczematous skin lesions and 89 age and sex matched controls without skin lesions. MAIN OUTCOME MEASURES: Presence and severity of skin lesions related to the type of skin care products used by the child. RESULTS: Exposure to various products was not significantly different between infants with skin lesions and those without. However, more mothers whose children had a skin rash had made a change in the type of soap and or skin cream used for their child (p<0.0001). The principal reason for changing products was skin rash in the baby and most mothers made changes away from scented baby soap products. CONCLUSION: The study found no significant difference between the cases and controls regarding the type of skin care products used.

Indoor air pollution in a Kenyan village.

In April 1986, a study was carried out within rural households in Maragua area, Muranga District, Republic of Kenya, to assess the degree of indoor air pollution and to find its relationship, if any, to acute respiratory infections (ARI) among children aged below 5 years within the study. This study was carried out within an ongoing aetiological and epidemiological community study on ARI as a collaborative effort between the Department of Paediatrics, University of Nairobi; the Department of Chemistry, Kenyatta University; the Department of Environmental Sciences, Agricultural University, Wagenigen, The Netherlands; the World Health Organization; and the Ministry of Health, Republic of Kenya. Repeated 24 hour measurements of respirable suspended particles (RSP) and nitrogen dioxide (NO2), were carried out in 36 randomly selected houses where most of the cooking was done on open fires using firewood and crop residues as fuel. Data on house characteristics and activity in the study were gathered by questionnaire. The mean of 24 hour average RSP concentration (1400mg/m3), average during the 7 hours of daily burning (3000-4000mg/m3), and evening peak levels (up to 3600mg/m3) indicate that deleterious health effects due to exposure to excessive levels of toxic pollutants in smoke from biomass combustion are likely to occur especially among pre-school children and women. Concentrations of selected polycyclic hydrocarbons in the particulate material were found to be high. It was not possible to demonstrate a relationship between the indoor air pollution and episodes of ARI partly because of small sample size and also the more or less homogeneous nature of pollution among all the households.

Hypoxaemia in young Kenyan children with acute lower respiratory infection.

OBJECTIVES: To determine the prevalence, clinical correlates, and outcome of hypoxaemia in acutely ill children with respiratory symptoms. DESIGN: Prospective observational study. SETTING: Paediatric casualty ward of a referral hospital at 1670 m altitude in Nairobi, Kenya. SUBJECTS: 256 Infants and children under 3 years of age with symptoms of respiratory infection. MAIN OUTCOME MEASURES: Prevalence of hypoxaemia, defined as arterial oxygen saturation < 90% determined by pulse oximetry, and condition of patient on the fifth day after admission. RESULTS: Over half (151) of the children were hypoxaemic, and short term mortality was 4.3 times greater in these children. In contrast, the relative risk of a fatal outcome in children with radiographic pneumonia was only 1.03 times that of children without radiographic pneumonia. A logistic regression model showed that in 3-11 month old infants a respiratory rate > or = 70/min, grunting, and retractions were the best independent clinical signs for the prediction of hypoxaemia. In the older children a respiratory rate of > or = 60/min was the single best clinical predictor of hypoxaemia. The presence of hypoxaemia predicted radiographic pneumonia with a sensitivity of 71% and specificity of 55%. CONCLUSIONS: Over half the children presenting to this referral hospital with respiratory symptoms were hypoxaemic. A group of specific clinical signs seem useful in predicting hypoxaemia. The clear association of hypoxaemia with mortality suggests that the detection and effective treatment of hypoxaemia are important aspects of the clinical management of acute infections of the lower respiratory tract in children in hospital in developing regions.

PIP: In 1989, pediatricians followed 256 children 7 days to 36 months old with symptoms of respiratory infection at Kenyatta National Hospital (1670 m altitude) in Nairobi, Kenya. The symptoms were serious enough to warrant hospital admission for 209 of these children. The most common clinical diagnoses were pneumonia (53%) and bronchiolitis (33%). 59% of the children admitted to the hospital were hypoxemic (arterial oxygen saturation or + to 90%). 10% of all admitted children died. 90.4% of them were hypoxemic with arterial oxygen saturations ranging from 40-88%. Children with hypoxemia were 4.3 times more apt to die within 5 days than those with no hypoxemia (p = .02). On the other hand, children with radiographic pneumonia had a relative risk of short-term mortality of only 1.03. Hypoxemia on admission predicted short-term mortality with 90% sensitivity and 34% specificity. It predicted pneumonia with 71% sensitivity and 55% specificity (p .0001). Children who lived for at least 5 days had arterial oxygen saturations ranging from 41-98. Even though all of the children with clinically evident cyanosis were less than a year old, 89% of the hypoxemic infants less than 1 year old did not exhibit cyanosis. Mothers' reports of blueness in newborns and infants less than 2 months was the best predictor of hypoxemia (62% accuracy; p .05). For children 3-11 months old, the best predictors of hypoxemia, with an accuracy of 70%, were a respiratory rate of at least 70/minute (odds ratio [OR] 2.6; p .001). For children at least 12 months old, the sole best predictor was a respiratory rate of at least 60/minute (70% accuracy; OR 5.1; p .01). This study should be followed by well-designed studies of the clinical effectiveness of proper treatment with oxygen in preventing mortality in hypoxemic infants and children.