Impact of implementation of free high-quality health care on health facility attendance by sick children in rural western Kenya.

OBJECTIVES: To explore whether implementation of free high-quality care as part of research programmes resulted in greater health facility attendance by sick children. METHODS: As part of the Intermittent Preventive Treatment for Malaria in Infants (IPTi), begun in 2004, and population-based infectious disease surveillance (PBIDS), begun in 2005 in Asembo, rural western Kenya, free high-quality care was offered to infants and persons of all ages, respectively, at one Asembo facility, Lwak Hospital. We compared rates of sick-child visits by children <10 years to all seven Asembo clinics before and after implementation of free high-quality care in 10 intervention villages closest to Lwak Hospital and 8 nearby comparison villages not participating in the studies. Incidence rates and rate ratios for sick-child visits were compared between intervention and comparison villages by time period using Poisson regression. RESULTS: After IPTi began, the rate of sick-child visits for infants, the study's target group, in intervention villages increased by 191% (95% CI 75-384) more than in comparison villages, but did not increase significantly more in older children. After PBIDS began, the rate of sick-child visits in intervention villages increased by 267% (95% CI 76-661) more than that in comparison villages for all children <10 years. The greatest increases in visit rates in intervention villages occurred 3-6 months after the intervention started. Visits for cough showed greater increases than visits for fever or diarrhoea. CONCLUSIONS: Implementation of free high-quality care increased healthcare use by sick children. Cost and quality of care are potentially modifiable barriers to improving access to care in rural Africa.

Mortality and health among internally displaced persons in western Kenya following post-election violence, 2008: novel use of demographic surveillance.

OBJECTIVE: To evaluate mortality and morbidity among internally displaced persons (IDPs) who relocated in a demographic surveillance system (DSS) area in western Kenya following post-election violence. METHODS: In 2007, 204 000 individuals lived in the DSS area, where field workers visit households every 4 months to record migrations, births and deaths. We collected data on admissions among children < 5 years of age in the district hospital and developed special questionnaires to record information on IDPs. Mortality, migration and hospitalization rates among IDPs and regular DSS residents were compared, and verbal autopsies were performed for deaths. FINDINGS: Between December 2007 and May 2008, 16 428 IDPs migrated into the DSS, and over half of them stayed 6 months or longer. In 2008, IDPs aged 15-49 years died at higher rates than regular residents of the DSS (relative risk, RR: 1.34; 95% confidence interval, CI: 1.004-1.80). A greater percentage of deaths from human immunodeficiency virus (HIV) infection occurred among IDPs aged > or = 5 years (53%) than among regular DSS residents (25-29%) (P < 0.001). Internally displaced children < 5 years of age did not die at higher rates than resident children but were hospitalized at higher rates (RR: 2.95; 95% CI: 2.44-3.58). CONCLUSION: HIV-infected internally displaced adults in conflict-ridden parts of Africa are at increased risk of HIV-related death. Relief efforts should extend to IDPs who have relocated outside IDP camps, particularly if afflicted with HIV infection or other chronic conditions.

Geospatial distribution and determinants of child mortality in rural western Kenya 2002-2005.

OBJECTIVE: To describe local geospatial variation and geospatial risk factors for child mortality in rural western Kenya. METHODS: We calculated under-5 mortality rates (U5MR) in 217 villages in a Health and Demographic Surveillance System (HDSS) area in western Kenya from 1 May 2002 through 31 December 2005. U5MRs by village were mapped. Geographical positioning system coordinates of residences at the time of death and distances to nearby locations were calculated. Multivariable Poisson regression accounting for clustering at the compound level was used to evaluate the association of geospatial factors and mortality for infants and children aged 1-4 years. RESULTS: Among 54 057 children, the overall U5MR was 56.5 per 1000 person-years and varied by village from 21 to 177 per 1000 person-years. High mortality villages occurred in clusters by location and remained in the highest mortality quintile over several years. In multivariable analysis, controlling for maternal age and education as well as household crowding, higher infant mortality was associated with living closer to streams and further from public transport roads. For children 1-4 years, living at middle elevations (1280-1332 metres), living within lower population densities areas, and living in the northern section of the HDSS were associated with higher mortality. CONCLUSIONS: Childhood mortality was significantly higher in some villages. Several geospatial factors were associated with mortality, which might indicate variability in access to health care or exposure and transmission of infectious diseases. These results are useful in prioritising areas for further study and implementing directed public health interventions.

Rotavirus disease burden and impact and cost-effectiveness of a rotavirus vaccination program in kenya.

BACKGROUND: The projected impact and cost-effectiveness of rotavirus vaccination are important for supporting rotavirus vaccine introduction in Africa, where limited health intervention funds are available. METHODS: Hospital records, health utilization surveys, verbal autopsy data, and surveillance data on diarrheal disease were used to determine rotavirus-specific rates of hospitalization, clinic visits, and deaths due to diarrhea among children <5 years of age in Nyanza Province, Kenya. Rates were extrapolated nationally with use of province-specific data on diarrheal illness. Direct medical costs were estimated using record review and World Health Organization estimates. Household costs were collected through parental interviews. The impact of vaccination on health burden and on the cost-effectiveness per disability-adjusted life-year and lives saved were calculated. RESULTS: Annually in Kenya, rotavirus infection causes 19% of hospitalizations and 16% of clinic visits for diarrhea among children <5 years of age and causes 4471 deaths, 8781 hospitalizations, and 1,443,883 clinic visits. Nationally, rotavirus disease costs the health care system $10.8 million annually. Routine vaccination with a 2-dose rotavirus vaccination series would avert 2467 deaths (55%), 5724 hospitalizations (65%), and 852,589 clinic visits (59%) and would save 58 disability-adjusted life-years per 1000 children annually. At $3 per series, a program would cost $2.1 million in medical costs annually; the break-even price is $2.07 per series. CONCLUSIONS: A rotavirus vaccination program would reduce the substantial burden of rotavirus disease and the economic burden in Kenya.

The impact of distance of residence from a peripheral health facility on pediatric health utilisation in rural western Kenya.

OBJECTIVE: To explore the impact of distance on utilisation of peripheral health facilities for sick child visits in Asembo, rural western Kenya. METHODS: As part of a demographic surveillance system (DSS), censuses of all households in the Asembo population of 55,000 are conducted three times a year, data are collected at all outpatient pediatric visits in seven DSS clinics in Asembo, and all households are GIS-mapped and linkable to a child's unique DSS identification number. Between May 1, 2003 and April 30, 2004, 3501 clinic visits were linked to 2432 children among 10,973 DSS-resident children < 5 years of age. RESULTS: Younger children and children with more severe illnesses travelled further for clinic visits. The median distance travelled varied by clinic. The rate of clinic visits decreased linearly at 0.5 km intervals up to 4 km, after which the rate stabilised. Using Poisson regression, controlling for the nearest DSS clinic for each child, socio-economic status and maternal education, and accounting for household clustering of children, for every 1 km increase in distance of residence from a DSS clinic, the rate of clinic visits decreased by 34% (95% CI, 31-37%) from the previous kilometer. CONCLUSION: Achieving equity in access to health care for children in rural Kenya will require creative strategies to address a significant distance-decay effect in health care utilisation.

Patterns of age-specific mortality in children in endemic areas of sub-Saharan Africa.

Understanding of the age- and season- dependence of malaria mortality is an important prerequisite for epidemiologic models of malaria immunity. However, most studies of malaria mortality have aggregated their results into broad age groups and across seasons, making it hard to predict the likely impact of interventions targeted at specific age groups of children. We present age-specific mortality rates for children aged < 15 years for the period of 2001-2005 in 7 demographic surveillance sites in areas of sub-Saharan Africa with stable endemic Plasmodium falciparum malaria. We use verbal autopsies (VAs) to estimate the proportion of deaths by age group due to malaria, and thus calculate malaria-specific mortality rates for each site, age-group, and month of the year. In all sites a substantial proportion of deaths (ranging from 20.1% in a Mozambican site to 46.2% in a site in Burkina Faso) were attributed to malaria. The overall age patterns of malaria mortality were similar in the different sites. Deaths in the youngest children (< 3 months old) were only rarely attributed to malaria, but in children over 1 year of age the proportion of deaths attributed to malaria was only weakly age-dependent. In most of the sites all-cause mortality rates peaked during the rainy season, but the strong seasonality in malaria transmission in these sites was not reflected in strong seasonality in the proportion of deaths attributed to malaria, except in the two sites in Burkina Faso. Improvement in the specificity of malaria verbal autopsies would make it easier to interpret the age and season patterns in such data.

Use of antenatal services and delivery care among women in rural western Kenya: a community based survey.

BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0-2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5-6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5-5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age >or= 30 years, parity >or= 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity >or= 5 (AOR 5.7, 95% CI 2.8-11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation.

Health and demographic surveillance in rural western Kenya: a platform for evaluating interventions to reduce morbidity and mortality from infectious diseases.

We established a health and demographic surveillance system in a rural area of western Kenya to measure the burden of infectious diseases and evaluate public health interventions. After a baseline census, all 33,990 households were visited every four months. We collected data on educational attainment, socioeconomic status, pediatric outpatient visits, causes of death in children, and malaria transmission. The life expectancy at birth was 38 years, the infant mortality rate was 125 per 1000 live births, and the under-five mortality rate was 227 per 1,000 live births. The increased mortality rate in younger men and women suggests high human immunodeficiency virus/acquired immunodeficiency syndrome-related mortality in the population. Of 5,879 sick child visits, the most frequent diagnosis was malaria (71.5%). Verbal autopsy results for 661 child deaths (1 month to <12 years) implicated malaria (28.9%) and anemia (19.8%) as the most common causes of death in children. These data will provide a basis for generating further research questions, developing targeted interventions, and evaluating their impact.

Sustainability of reductions in malaria transmission and infant mortality in western Kenya with use of insecticide-treated bednets: 4 to 6 years of follow-up.

CONTEXT: Insecticide-treated bednets reduce malaria transmission and child morbidity and mortality in short-term trials, but this impact may not be sustainable. Previous investigators have suggested that bednet use might paradoxically increase mortality in older children through delayed acquisition of immunity to malaria. OBJECTIVES: To determine whether adherence to and public health benefits of insecticide-treated bednets can be sustained over time and whether bednet use during infancy increases all-cause mortality rates in older children in an area of intense perennial malaria transmission. DESIGN AND SETTING: A community randomized controlled trial in western Kenya (phase 1: January 1997 to February 2000) followed by continued surveillance of adherence, entomologic parameters, morbidity indicators, and all-cause mortality (phase 2: April 1999 to February 2002), and extended demographic monitoring (January to December 2002). PARTICIPANTS: A total of 130,000 residents of 221 villages in Asembo and Gem were randomized to receive insecticide-treated bednets at the start of phase 1 (111 villages) or phase 2 (110 villages). MAIN OUTCOME MEASURES: Proportion of children younger than 5 years using insecticide-treated bednets, mean number of Anopheles mosquitoes per house, and all-cause mortality rates. RESULTS: Adherence to bednet use in children younger than 5 years increased from 65.9% in phase 1 to 82.5% in phase 2 (P<.001). After 3 to 4 years of bednet use, the mean number of Anopheles mosquitoes per house in the study area was 77% lower than in a neighboring area without bednets (risk ratio, 0.23; 95% confidence interval [CI], 0.15-0.35). All-cause mortality rates in infants aged 1 to 11 months were significantly reduced in intervention villages during phase 1 (hazard ratio [HR], 0.78; 95% CI, 0.67-0.90); low rates were maintained during phase 2. Mortality rates did not differ during 2002 (after up to 6 years of bednet use) between children from former intervention and former control households born during phase 1 (HR, 1.01; 95% CI, 0.86-1.19). CONCLUSIONS: The public health benefits of insecticide-treated bednets were sustained for up to 6 years. There is no evidence that bednet use from birth increases all-cause mortality in older children in an area of intense perennial transmission of malaria.

Mortality trends from 2003 to 2009 among adolescents and young adults in rural Western Kenya using a health and demographic surveillance system.

BACKGROUND: Targeted global efforts to improve survival of young adults need information on mortality trends; contributions from health and demographic surveillance system (HDSS) are required. METHODS AND FINDINGS: This study aimed to explore changing trends in deaths among adolescents (15-19 years) and young adults (20-24 years), using census and verbal autopsy data in rural western Kenya using a HDSS. Mid-year population estimates were used to generate all-cause mortality rates per 100,000 population by age and gender, by communicable (CD) and non-communicable disease (NCD) causes. Linear trends from 2003 to 2009 were examined. In 2003, all-cause mortality rates of adolescents and young adults were 403 and 1,613 per 100,000 population, respectively, among females; and 217 and 716 per 100,000, respectively, among males. CD mortality rates among females and males 15-24 years were 500 and 191 per 100,000 (relative risk [RR] 2.6; 95% confidence intervals [CI] 1.7-4.0; p<0.001). NCD mortality rates in same aged females and males were similar (141 and 128 per 100,000, respectively; p = 0.76). By 2009, young adult female all-cause mortality rates fell 53% (χ(2) for linear trend 30.4; p<0.001) and 61.5% among adolescent females (χ(2) for linear trend 11.9; p<0.001). No significant CD mortality reductions occurred among males or for NCD mortality in either gender. By 2009, all-cause, CD, and NCD mortality rates were not significantly different between males and females, and among males, injuries equalled HIV as the top cause of death. CONCLUSIONS: This study found significant reductions in adolescent and young adult female mortality rates, evidencing the effects of targeted public health programmes, however, all-cause and CD mortality rates among females remain alarmingly high. These data underscore the need to strengthen programmes and target strategies to reach both males and females, and to promote NCD as well as CD initiatives to reduce the mortality burden amongst both gender.

Profile: the KEMRI/CDC Health and Demographic Surveillance System--Western Kenya.

The KEMRI/Centers for Disease Control and Prevention (CDC) Health and Demographic Surveillance System (HDSS) is located in Rarieda, Siaya and Gem Districts (Siaya County), lying northeast of Lake Victoria in Nyanza Province, western Kenya. The KEMRI/CDC HDSS, with approximately 220 000 inhabitants, has been the foundation for a variety of studies, including evaluations of insecticide-treated bed nets, burden of diarrhoeal disease and tuberculosis, malaria parasitaemia and anaemia, treatment strategies and immunological correlates of malaria infection, and numerous HIV, tuberculosis, malaria and diarrhoeal disease treatment and vaccine efficacy and effectiveness trials for more than a decade. Current studies include operations research to measure the uptake and effectiveness of the programmatic implementation of integrated malaria control strategies, HIV services, newly introduced vaccines and clinical trials. The HDSS provides general demographic and health information (such as population age structure and density, fertility rates, birth and death rates, in- and out-migrations, patterns of health care access and utilization and the local economics of health care) as well as disease- or intervention-specific information. The HDSS also collects verbal autopsy information on all deaths. Studies take advantage of the sampling frame inherent in the HDSS, whether at individual, household/compound or neighbourhood level.

A reversal in reductions of child mortality in western Kenya, 2003-2009.

We report and explore changes in child mortality in a rural area of Kenya during 2003-2009, when major public health interventions were scaled-up. Mortality ratios and rates were calculated by using the Kenya Medical Research Institute/Centers for Disease Control and Prevention Demographic Surveillance System. Inpatient and outpatient morbidity and mortality, and verbal autopsy data were analyzed. Mortality ratios for children less than five years of age decreased from 241 to 137 deaths/1,000 live-births in 2003 and 2007 respectively. In 2008, they increased to 212 deaths/1,000 live-births. Mortality remained elevated during the first 8 months of 2009 compared with 2006 and 2007. Malaria and/or anemia accounted for the greatest increases in child mortality. Stock-outs of essential antimalarial drugs during a time of increased malaria transmission and disruption of services during civil unrest may have contributed to increased mortality in 2008-2009. To maintain gains in child survival, implementation of good policies and effective interventions must be complemented by reliable supply and access to clinical services and essential drugs.

Geohelminth Infections among pregnant women in rural western Kenya; a cross-sectional study.

BACKGROUND: Geohelminth infections are common in rural western Kenya, but risk factors and effects among pregnant women are not clear. METHODOLOGY: During a community-based cross-sectional survey, pregnant women were interviewed and asked to provide a blood sample and a single fecal sample. Hemoglobin was measured and a blood slide examined for malaria. Geohelminth infections were identified using the concentration and Kato-Katz method. RESULTS: Among 390 participants who provided a stool sample, 76.2% were infected with at least one geohelminth: 52.3% with Ascaris lumbricoides, 39.5% with hookworm, and 29.0% with Trichuris trichiura. Infection with at least one geohelminth species was associated with the use of an unprotected water source (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI] 1.1-3.0) and the lack of treatment of drinking water (AOR 1.8, 95% CI 1.1-3.1). Geohelminth infections were not associated with clinical symptoms, or low body mass index. A hookworm infection was associated with a lower mid upper arm circumference (adjusted mean decrease 0.7 cm, 95% CI 0.3-1.2 cm). Hookworm infections with an egg count > or =1000/gram feces (11 women) were associated with lower hemoglobin (adjusted mean decrease 1.5 g/dl, 95% CI 0.3-2.7). Among gravidae 2 and 3, women with A. lumbricoides were less likely to have malaria parasitemia (OR 0.4, 95% CI 0.2-0.8) compared to women without A. lumbricoides, unlike other gravidity groups. CONCLUSION: Geohelminth infections are common in this pregnant population; however, there were few observed detrimental effects. Routine provision of antihelminth treatment during an antenatal clinic visit is recommended, but in this area an evaluation of the impact on pregnancy, malaria, and birth outcome is useful.

Mortality of sick children after outpatient treatment at first-level health facilities in rural western Kenya.

OBJECTIVES: (1) To determine whether mortality rates were raised in sick children in the 30 days after visiting first-level health facilities in an area under demographic surveillance in western Kenya, (2) to identify the types of illnesses associated with increased mortality and (3) to estimate the effectiveness of appropriate treatment. METHODS: All sick children (2-59 months of age) who attended one of the seven participating first-level health facilities from May to August 2003 were identified. A standardized mortality ratio was computed to compare their mortality rate in the 30 days after a sick visit with that of the community under active demographic and health surveillance. A multivariate Cox Proportional Hazards model was used to identify illnesses associated with death and to estimate the protective effectiveness of appropriate treatment for potentially life-threatening diseases. RESULTS: A total of 1383 eligible children made 1697 sick visits; 33 (2.4%) died within 30 days. Compared with children 2-59 months in the general population, sick children had a 5.3 times greater mortality rate [95% confidence interval (CI) 3.8-7.5]. In a multivariate survival analysis, significant risk factors for mortality included age <24 months [Hazard Ratio (HR) 4.4, 95% CI 1.5-12.6], malnutrition (HR 15.5, 95% CI 6.1-39.8), severe pneumonia (HR 12.9, 95% CI 3.0-56.4) and anaemia (HR 3.3, 95% CI 1.5-7.2). Appropriate treatment for a child's most severe illness reduced mortality by 78% (95% CI 57-89%). CONCLUSION: We estimate that improvements in diagnosis and appropriate treatment at first-level health facilities for children 2-59 months could reduce overall under-5 mortality in the area by 12-14%.

Cause-specific mortality rates in sub-Saharan Africa and Bangladesh.

OBJECTIVE: To provide internationally comparable data on the frequencies of different causes of death. METHODS: We analysed verbal autopsies obtained during 1999 -2002 from 12 demographic surveillance sites in sub-Saharan Africa and Bangladesh to find cause-specific and age-specific mortality rates. The cause-of-death codes used by the sites were harmonized to conform to the ICD-10 system, and summarized with the classification system of the Global Burden of Disease 2000 (Version 2). FINDINGS: Causes of death in the African sites differ strongly from those in Bangladesh, where there is some evidence of a health transition from communicable to noncommunicable diseases, and little malaria. HIV dominates in causes of mortality in the South African sites, which contrast with those in highly malaria endemic sites elsewhere in sub-Saharan Africa (even in neighbouring Mozambique). The contributions of measles and diarrhoeal diseases to mortality in sub-Saharan Africa are lower than has been previously suggested, while malaria is of relatively greater importance. CONCLUSION: The different patterns of mortality we identified may be a result of recent changes in the availability and effectiveness of health interventions against childhood cluster diseases.