Pediatric Tuberculosis and a Unique Method of Case Finding and Default Prevention: The Case of Baby 'Lucky', Moyale Sub-County, Kenya, 2019.

We report the case of a 9-month-old male infant diagnosed in the field with extra-pulmonary tuberculosis (TB). Use of innovative global positioning system tracking of pregnant pastoralist women allowed staff to find the mother, locate the infant and enroll the infant in care and treatment. Due to this innovative intervention of case finding and tracking, the infant was prevented from defaulting and completed his anti-TB regimen.

Potassium iodate levels in processed edible salts available in retail shops throughout Kenya, 2013.

OBJECTIVE: Iodine-deficiency disorders, due to insufficiency of iodine in the diet, are a global public health problem. The Kenyan Food, Drugs and Chemical Substances Act stipulates that processed retail-available edible salts contain 50-84 mg of potassium iodate (KIO3) per kilogram of salt. The present study determined the status of KIO3 levels in commercial salts, for public health action.Design/Setting/SubjectsAs part of the Kenya Demographic and Health Survey 2013, field workers collected salt samples from seven different local manufacturers/packers across eight regions of the country and sent them to the National Public Health Laboratory (NPHL) for KIO3 titration analysis. RESULTS: A total of 539 samples were collected and analysed at NPHL. The samples had a mean KIO3 of 62 mg/kg. Thirty-three (6 %) samples had KIO3 of 84 mg/kg. CONCLUSIONS: The study found that 62 % of salts sampled met the Kenyan standards, 24 % were below the required limits and 13 % were above the recommended range. Continuous monitoring of edible salts at the retail level is important to detect brands not adhering to standards and trace them for remedy. However, governmental efforts should be directed to the quality control and quality assurance of the salt-manufacturing industries.

Late entry to HIV and AIDS care and treatment, Juba Teaching Hospital, Juba, South Sudan, 2013-2016.

Late diagnosis of HIV and enrolment to care are global public health challenges. This study aimed to characterise late HIV diagnoses and initiation of treatment among patients at Juba Teaching Hospital (JTH) in South Sudan. We conducted a retrospective review of lab-confirmed HIV patients at JTH, 2013-2016. Demographic, clinical, and laboratory data were entered into and descriptive statistics were calculated using Microsoft Excel. We identified 401 patients, with mean age 33.71±4.54 years, 235 (59%) were female, 307 (77%) were late entry, 64 (16%) were lost to follow-up, and 57 (14%) died within 12 months of diagnosis. Among patients who presented late, 122 (57%) were female, and 112 (53%) were <34 years old. Among patients who died, 33 (58%) were male, and 52 (91%) had CD4 counts <350 cells/mm3 and World Health Organization (WHO) stage >2 at diagnosis. Late diagnosis of HIV infection is a significant public health problem in South Sudan, particularly for younger and female patients.

Effect of routine probiotic, Lactobacillus reuteri DSM 17938, use on rates of necrotizing enterocolitis in neonates with birthweight < 1000 grams: a sequential analysis.

BACKGROUND: Necrotizing enterocolitis (NEC) is a disease in neonates, often resulting in death or serious medical or neurodevelopmental complications. The rate of NEC is highest in the smallest babies and many efforts have been tried to reduce the rate of NEC. In neonates born below 1500 grams, the rate of NEC has been significantly reduced with the use of various probiotics. This study examines the impact of routine use of a probiotic, Lactobacillus reuteri DSM 17938 (BioGaia®), on the rate of NEC in neonates at highest risk for developing NEC, those with birth weight ≤1000 grams. METHODS: This is a retrospective cohort study comparing the rates of NEC in neonates with birth weight ≤ 1000 grams. The groups are separated into those neonates born from January 2004 to June 30, 2009, before introduction of L. reuteri , and neonates born July 2009 through April 2011 who received routine L. reuteri prophylaxis. The chart review study was approved by our institutional review board and exempted from informed consent.Neonates were excluded if they died or were transferred within the first week of life. The remainder were categorized as having no NEC, medical NEC, surgical NEC, or NEC associated death. Since no major changes occurred in our NICU practice in recent years, and the introduction of L. reuteri as routine prophylaxis was abrupt, we attributed the post-probiotic changes to the introduction of this new therapy. Rates of NEC were compared using Chi square analysis with Fisher exact t-test. RESULTS: Medical records for 311 neonates were reviewed, 232 before- and 79 after-introduction of L. reuteri prophylaxis. The incidence of NEC was significantly lower in the neonates who received L. reuteri (2 of 79 neonates [2.5%] versus 35 of 232 untreated neonates [15.1%]). Rates of late-onset gram-negative or fungal infections (22.8 versus 31%) were not statistically different between treated and untreated groups. No adverse events related to use of L reuteri were noted. CONCLUSIONS: Prophylactic initiation of L. reuteri as a probiotic for prevention of necrotizing enterocolitis resulted in a statistically significant benefit, with avoidance of 1 NEC case for every 8 patients given prophylaxis.

Is there an association between local health department organizational and administrative factors and childhood immunization coverage rates?

BACKGROUND: Vaccines are valuable, cost-effective tools for preventing disease and improving community health. Despite the importance and ubiquity of vaccinations, childhood immunization coverage rates vary widely by geography, race, and ethnicity. These differences have been documented for nearly two decades, but their sources are poorly understood. Between 2005 and 2008, immunization staff of the National Association of County & City Health Officials (NACCHO) visited 17 local health department (LHD) immunization programs in 10 states to assess their immunization service delivery (ISD) practices and their impact on community childhood immunization coverage rates. PURPOSE: To qualitatively characterize LHD immunization programs and specific organizational factors underlying ISD performance challenges and successes related to community childhood immunization coverage rates. METHODS: Case studies were conducted in a convenience sample of 17 geographically and demographically diverse LHDs, predicated on each LHD's childhood immunization coverage rates per data from the National Immunization Survey and/or Kindergarten Retrospective Survey. NACCHO staff selected LHDs with high (> or = 80% up to date [UTD]), moderate (> or = 75% UTD but < 80% UTD), and low (< 75% UTD) coverage rates. All immunization staff members interviewed (n = 112) were included in focus group interviews at each LHD per a standard semi-structured interview script developed by NACCHO staff. Supporting documents from each LHD immunization program were also collected for inclusion in the analysis. Content and thematic analyses of interview transcripts and supporting documents were conducted. RESULTS: Two thematic dimensions and six key factors emerged from the data. The dimensions of the themes were success and challenge elements. The organizational factors that were associated with success and/or challenges with regard to improving childhood immunization coverage rates included 1) leadership: organizational leadership and management related to aligning ISD with other child-focused services within the LHD; 2) resources: organizational efforts focused on aligning federal and state ISD financing with local ISD needs; 3) politics: political advocacy and partnering with local community stakeholders, including local political entities and boards of health to better organize ISD; 4) community engagement/coalitions and partnerships: partnerships, coalitions, and community engagement to support local immunization-related decision-making and prioritization; 5) credibility: agency credibility and its ability to influence community attitudes and perspectives on the health department's value in terms of child health; and 6) cultural competency of LHD staff: LHD staff members' perceptions and understandings of its community's cultural, economic, and demographic attributes shaped their responses to and understandings of the community and how they interacted with it in terms of service delivery. DISCUSSION: Public health researchers are in a nascent stage of understanding how health department organizational factors may contribute to specific community health outcomes, such as childhood immunization coverage rates. An implicit challenge to LHD immunization programs is to implement strategies that lead to equitable and high vaccination coverage among children, despite shrinking resources and community demographic differences. Community-specific attributes (e.g., poverty, lack of health insurance, or geographic isolation) affect childhood immunization coverage rates, but internal LHD aspects such as leadership and organizational culture also likely have a significant impact.

Impact Evaluation of the Kenya Frontline Field Epidemiology Training Program: Repeated-Measures Study.

BACKGROUND: In 2014, Kenya's Field Epidemiology and Laboratory Training Program (FELTP) initiated a 3-month field-based frontline training, Field Epidemiology Training Program (FETP-F), for local public health workers. OBJECTIVE: This study aimed to measure the effect of FETP-F on participant workplace practices regarding quality and consistency of public health data, critical interaction with public health data, and improvements in on-time reporting (OTR). METHODS: Between February and April 2017, FELTP conducted a mixed methods evaluation via online survey to examine outcomes achieved among all 215 graduates from 2014 and 2015. Data quality assessment (DQA) and data consistency assessment (DCA) scores, OTR percentages, and ratings of the training experience were the quantitative measures tracked from baseline and then at 6-month intervals up to 18 months postcompletion of the training. The qualitative component consisted of semistructured face-to-face interviews and observations. Quantitative data were analyzed using descriptive statistics and one-way analysis of variance (ANOVA). Qualitative data were transcribed and analyzed to identify key themes and dimensions. RESULTS: In total, 103 (47%) graduates responded to the survey. Quantitative analyses showed that the training significantly increased the mean DQA and OTR scores but there was a nonsignificant increase in mean DCA scores. Qualitative analyses found that 68% of respondents acquired new skills, 83% applied those skills to their day-to-day work, and 91% improved work methods. CONCLUSIONS: FETP-F improved overall data quality and OTR at the agency level but had minimal impact on data consistency between local, county, and national public health agencies. Participants reported that they acquired practical skills that improved data collation and analysis and OTR.

Epidemiology of HIV Infection Among HIV-Exposed Infants, Nairobi County, Kenya, 2015.

OBJECTIVE: To characterize human immunodeficiency virus (HIV)-positive infants among HIV-exposed infants (HEIs) in Nairobi County for public health action. METHODS: We conducted a retrospective review of records of HEIs' HIV polymerase chain reaction (PCR) results in Nairobi County in 2015, excluding confirmatory PCR-positive results. HIV-exposed infant registry data were entered into Microsoft Excel and descriptive and associative statistics were calculated with OpenEpi software. RESULTS: A total of 5802 HEI records were analyzed, with a median age of 4.5 (interquartile range, 8.5) months; 342 (5.9%) tested positive, 51% were female, and 4420 (76.2%) were seen at maternal and child health clinics. Standard highly active antiretroviral therapy intervention was given to 184 (60.3%) of the mothers of exposed infants, and 178 (53%) of the HIV-positive infants received active antiretroviral therapy. A total of 3464 (59.7%) HEIs had PCR done within the first 2 months, and 119 (3.4%) tested positive. The average turnaround time for PCR samples was 28 ± 22 days, and a total of 191 (3.3%) HIV-positive HEIs were exclusively breastfed for the first 6 months of life. CONCLUSION: The recorded mother-to-child transmission (MTCT) rate of 5.9% in Nairobi County is lower than the 2015 national rate, which suggests the Nairobi prevention of mother-to-child transmission efforts are moderately effective. However, results from this study show that Kenya will struggle to meet the MTCT 2020 target rate of <5%.

Characteristics and outcomes of HIV-exposed infants in Homa Bay County, Kenya, 2015.

Homa Bay County in south-western Kenya has a low uptake of antenatal care services and the highest prevalence of HIV in the country. We present the findings of a retrospective review of HIV-exposed infants (HEI) who sought early infant diagnosis services in the county throughout 2015. HEI who were breastfed >6 months, had replacement feeding and did not receive prophylaxis were 2-6 times more likely to be HIV-positive.

Factors associated with malnutrition in children < 5 years in western Kenya: a hospital-based unmatched case control study.

BACKGROUND: Globally, under-nutrition accounts for > 3 million deaths annually among children < 5 years, with Kenya having ~ 35,000 deaths. This study aimed to identify factors associated with malnutrition in children aged < 5 years in western Kenya. METHODS: We conducted a hospital-based unmatched case-control study between May and June 2017. Cases were defined as children aged 6-59 months with either z-score for weight-for-height ≤ -2SD or ≥ +2SD; weight-for-age ≤ -2SD or ≥ +2SD; or height-for-age ≤ -2SD. Controls were children aged 6-59 months with age-appropriate anthropometric measurements. Cases were consecutively recruited while systematic random sampling was used to select controls. Data from interviews and clinical records were collected and entered into Epi-Info, which was used to run unconditional logistic regression analyses. RESULTS: A total of 94 cases and 281 controls were recruited. Of the cases, 84% (79/94) were under-nourished. Mother not having attended ante-natal clinic (OR = 7.9; 95% CI: 1.5-41.2), deworming (OR = 0.8; 95% CI: 0.4-1.2), and pre-lacteal feeding (OR = 1.8; 95% CI: 1.1-3.0) were associated with under-nutrition. Delayed developmental milestones (AOR = 13.9; 95% CI: 2.8-68.6); low birth weight (AOR = 3.3; 95% CI: 1.4-7.6), and paternal lack of formal education (AOR = 4.9; 95% CI: 1.3-18.9) were independently associated with under-nutrition. CONCLUSION: Proper pre-natal care, child feeding practices and deworming programs should be enhanced to reduce pediatric malnutrition.

Factors Affecting Uptake of PMTCT Services, Lodwar County Referral Hospital, Turkana County, Kenya, 2015 to 2016.

Kenya is one of 22 countries globally that account for 90% of all HIV-positive pregnant women. This study aimed to determine factors affecting uptake of prevention of mother-to-child transmission (PMTCT) services among HIV-positive pregnant women at Lodwar County Referral Hospital in Turkana County, an arid area in northern Kenya. We conducted a retrospective review of HIV-positive pregnant women attending antenatal care (ANC) and accessing PMTCT services between January 2015 and December 2016. We used infant prophylaxis as a proxy measure of PMTCT uptake, and records across programs were linked using the mother's unique medical identification number. A total of 230 participants were included in the study. Bivariate analyses showed maternal prophylaxis (odds ratio [OR] = 45.71; 95% confidence interval [CI]: 10.35-202.00), residing in urban center (OR = 2.64, 95% CI: 1.45-4.81), and having at least one ANC visit (OR = 2.78; 95% CI: 1.25-6.17) were significantly associated with uptake of PMTCT.

Point of care testing evaluation of lateral flow immunoassay for diagnosis of cryptococcus meningitis in HIV-positive patients at an urban hospital in Nairobi, Kenya, 2017.

OBJECTIVES: The objective of this study was to evaluate the performance of lateral flow immunoassay (LFA) against latex agglutination (LA), India ink and culture in point-of-care diagnosis of cryptococcus meningitis (CM). We conducted cross-sectional study among HIV-positive patients with suspected CM at Mbagathi Hospital, Nairobi, April-July 2017. RESULTS: Of 124 capillary blood and serum and 99 cerebrospinal fluid (CSF) samples, LFA and LA had a concurrence on serum of 94.4%, kappa (0.88), sensitivity (100%) and specificity (91%). LFA and LA on CSF, was 97.9%, kappa (0.96), sensitivity (100%) and specificity (96%). LFA and India ink was 96.9%, kappa (0.94), sensitivity (100%) and specificity (94.1%). On CSF culture, concurrence was 72.7%, kappa (0.43), sensitivity (100%) and specificity (64%) and of LFA on capillary blood, serum and CSF was 100% with kappa (1.00), sensitivity and specificity of 100%.

Ethics, public health, and immunization mandates.

The National Association of County and City Health Officials (NACCHO) is the national organization representing local health departments. NACCHO supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.

Antenatal care attendance and uptake of skilled delivery, Lokitaung Sub-County Hospital, Turkana County, Kenya.

Globally, nearly 500,000 women die annually from pregnancy- and childbirth-related complications. Antenatal care (ANC) is one of the most important factors in preventing maternal and infant mortality. This study investigated whether ANC attendance and sociodemographic characteristics of pregnant women influence uptake of skilled delivery at Lokitaung Sub-County Hospital, Turkana County, Kenya.

Investigation of a typhoid fever epidemic in Moyale Sub-County, Kenya, 2014-2015.

AIM: Typhoid fever is a vaccine-preventable bacterial disease that causes significant morbidity and mortality throughout Africa. This paper describes an upsurge of typhoid fever cases in Moyale Sub-County (MSC), Kenya, 2014-2015. METHODS: We conducted active hospital and health facility surveillance and laboratory and antimicrobial sensitivity testing for all patients presenting with headache, fever, stomach pains, diarrhea, or constipation at five MSC health facilities between December 2014 and January 2015. We also conducted direct observation of the residential areas of the suspected cases to assess potential environmental exposures and transmission mechanisms. Demographic, clinical, and laboratory data were entered into, and descriptive statistics were calculated with, MS Excel. RESULTS: A total of 317 patients were included in the study, with mean age 24 ± 8.1 years, and 51% female. Of the 317 suspect cases, 155 (49%) were positive by Widal antigen reaction test. A total of 188 (59%) specimens were subjected to culture and sensitivity testing, with 71 (38%) culture positive and 54 (76%), 43 (60%), and 33 (46%) sensitive to ceftriaxone, cefuroxime, and ciprofloxacin, respectively. Environmental assessments through direct observations showed that commercial and residential areas had limited (1) clean water sources, (2) latrines, and (3) hygiene stations for street food hawkers and their customers. CONCLUSIONS: Typhoid fever is endemic in MSC and causes significant disease across age and sex groups. The local health department should develop policies to (1) assure community access to potable water and hygiene stations and (2) vaccinate specific occupations, such as food and drink handlers, against typhoid.

Transfusion Transmissible Infections Among Walk-In Blood Donors at Kisumu Regional Blood Transfusion Centre, Kisumu County, Kenya, 2015.

BACKGROUND: Transfusion transmissible infections (TTIs) are threats to blood safety. This study investigated TTIs among volunteer blood donors at the Kisumu Regional Blood Transfusion Centre (KRBTC) in Kenya. METHODS: We performed a retrospective record review of blood donor registers at KRBTC, 2015. Walk-in donors accepted for donation were analyzed to determine prevalence of human immunodeficiency virus (HIV), hepatitis B (HBV), hepatitis C (HCV), and syphilis. Descriptive and associative statistics were calculated using Microsoft Excel and Open-Epi software. RESULTS: The records of a total of 3690 walk-in donors were reviewed, and 2046 were included in the analysis. Mean age was 30 ± 9.6 years, 76% male, 51% married, and 80% were Kisumu residents. Seroprevalence of HIV, HBV, HCV, and syphilis was 2.4%, 3.1%, 2.3%, and 1%, respectively. CONCLUSIONS: HBV was the most common TTI among the volunteers. KRBTC should be proactive and address issues of donor self-exclusion, strict adherence to donor selection criteria, and vaccination.

Strengthening health systems in Africa: a case study of the Kenya field epidemiology training program for local frontline health workers.

The logistical and operational challenges to improve public health practice capacity across Africa are well documented. This report describes Kenya's Field Epidemiology and Laboratory Training Program's (KFELTP) experience in implementing frontline public health worker training to transfer knowledge and practical skills that help strengthen their abilities to detect, document, respond to, and report unusual health events. Between May 2014 and May 2015, KFELTP hosted five training courses across the country to address practice gaps among local public health workers. Participants completed a 10-week process: two 1-week didactic courses, a 7-week field project, and a final 1-week course to present and defend the findings of their field project. The first year was a pilot period to determine whether the program could fit into the existing 2-year KFELTP model and whether this frontline-level training would have an impact on local practice. At the end of the first year, KFELTP certified 167 frontline health workers in field epidemiology and data management. This paper concludes that local, national, and international partnerships are critical for improving local public health response capacity and workforce development training in an African setting.

Holistic risk-based environmental decision making: a Native perspective.

Native American Nations have become increasingly concerned about the impacts of toxic substances. Although risk assessment and risk management processes have been used by government agencies to help estimate and manage risks associated with exposure to toxicants, these tools have many inadequacies and as a result have not served Native people well. In addition, resources have not always been adequate to address the concerns of Native Nations, and involvement of Native decision makers on a government-to-government basis in discussions regarding risk has only recently become common. Finally, because the definitions of health used by Native people are strikingly different from that of risk assessors, there is also a need to expand current definitions and incorporate traditional knowledge into decision making. Examples are discussed from the First Environment Restoration Initiative, a project that is working to address toxicant issues facing the Mohawk territory of Akwesasne. This project is developing a community-defined model in which health is protected at the same time that traditional cultural practices, which have long been the key to individual and community health, are maintained and restored.

School-located influenza vaccination clinics: local health department perspectives.

Universal childhood influenza vaccination presents challenges and opportunities for health care and public health systems to vaccinate the children who fall under the new recommendation. Advisory Committee on Immunization Practices (ACIP) recommendations and guidelines are helpful, but they do not provide strategies on how to deliver immunization services to the groups affected by their recommendations. Community stakeholders need to develop and sustain new partnerships to achieve the goals of universal childhood immunization recommendations, including expanding the points of access to influenza vaccination. Schools are a key community venue for annual delivery of influenza vaccination. Over the past 2 years, the National Association of County and City Health Officials has examined local health department-school system relationships in regard to delivery of influenza vaccination to identify and document common elements of success, challenges, and key lessons learned.

Key findings: a qualitative assessment of provider and patient perceptions of HIV/AIDS in South Africa.

In 1997, at the Davos International Economic Forum, Nelson Mandela stated that "the poor, the vulnerable, the unschooled, the socially marginalized, the women, and the children, those who bear the burden of colonial legacy-these are the sectors of society which bear the burden of AIDS" (Richter, 2001). Nearly a decade later, that statement still holds true, especially in Mr. Mandela's home country. South Africa continues to have one of the world's highest prevalence ratios of HIV infection (UNAIDS, 2002). This paper explores the significance of perceptions, knowledge, practices, and attitudes toward HIV/AIDS in two important groups in South Africa: health care providers based in public health clinics and their patients. This paper will assess the provider-patient interaction from the perspective of members of the South African HIV/AIDS treatment and prevention community. The analysis will examine the results of in-depth interviews and focus group discussions with providers and patients, respectively, in two of South Africa's nine provinces. Between December 2002 and April 2003 in Guateng and KwaZulu-Natal provinces, we conducted (1) in-depth interviews of a spectrum of health care providers at five local public health clinics and (2) focus groups of patients who patronize those clinics. The results show that there are gaps in the HIV/AIDS knowledge of some of the health care providers and that the participants' health beliefs and practices are embedded in the social conditions in which they live and work, which has a ripple effect on their risk behaviors and trumps any intervention messages from their health care providers and larger public health intervention messages.

Combating influenza and pneumococcal disease: the public health system needs some magic.

The National Association of County and City Health Officials (NACCHO) is the national organization representing local health departments. NACCHO supports efforts that protect and improve the health of all people and all communities by promoting national policy, developing resources and programs, seeking health equity, and supporting effective local public health practice and systems.