Alcohol use, drunkenness and tobacco smoking in rural western Kenya.

OBJECTIVES: To describe the prevalence of smoking and alcohol use and abuse in an impoverished rural region of western Kenya. METHODS: Picked from a population-based longitudinal database of demographic and health census data, 72 292 adults (≥18 years) were asked to self-report their recent (within the past 30 days) and lifetime use of tobacco and alcohol and frequency of recent 'drunkenness'. RESULTS: Overall prevalence of ever smoking was 11.2% (11.0-11.5) and of ever drinking, 20.7% (20.4-21.0). The prevalence of current smoking was 6.3% (6.1-6.5); 5.7% (5.5-5.9) smoked daily. 7.3% (7.1-7.5) reported drinking alcohol within the past 30 days. Of these, 60.3% (58.9-61.6) reported being drunk on half or more of all drinking occasions. The percentage of current smokers rose with the number of drinking days in a month (P < 0.0001). Tobacco and alcohol use increased with decreasing socio-economic status and amongst women in the oldest age group (P < 0.0001). CONCLUSIONS: Tobacco and alcohol use are prevalent in this rural region of Kenya. Abuse of alcohol is common and likely influenced by the availability of cheap, home-manufactured alcohol. Appropriate evidence-based policies to reduce alcohol and tobacco use should be widely implemented and complemented by public health efforts to increase awareness of their harmful effects.

What are the most sensitive and specific sign and symptom combinations for influenza in patients hospitalized with acute respiratory illness? Results from western Kenya, January 2007-July 2010.

Influenza causes severe illness and deaths, and global surveillance systems use different clinical case definitions to identify patients for diagnostic testing. We used data collected during January 2007-July 2010 at hospital-based influenza surveillance sites in western Kenya to calculate sensitivity, specificity, positive predictive value, and negative predictive value for eight clinical sign/symptom combinations in hospitalized patients with acute respiratory illnesses, including severe acute respiratory illness (SARI) (persons aged 2-59 months: cough or difficulty breathing with an elevated respiratory rate or a danger sign; persons aged ≥5 years: temperature ≥38 °C, difficulty breathing, and cough or sore throat) and influenza-like illness (ILI) (all ages: temperature ≥38 °C and cough or sore throat). Overall, 4800 persons aged ≥2 months were tested for influenza; 416 (9%) had laboratory-confirmed influenza infections. The symptom combination of cough with fever (subjective or measured ≥38 °C) had high sensitivity [87·0%, 95% confidence interval (CI) 83·3-88·9], and ILI had high specificity (70·0%, 95% CI 68·6-71·3). The case definition combining cough and any fever is a simple, sensitive case definition for influenza in hospitalized persons of all age groups, whereas the ILI case definition is the most specific. The SARI case definition did not maximize sensitivity or specificity.

In-vivo efficacy of amodiaquine-artesunate in children with uncomplicated Plasmodium falciparum malaria in western Kenya.

OBJECTIVES: To assess the efficacy of amodiaquine-artesunate in an area with high chloroquine resistance in western Kenya. METHODS: Twenty-eight day in-vivo efficacy trial of amodiaquine-artesunate in 103 children aged 6-59 months in western Kenya with smear-confirmed uncomplicated Plasmodium falciparum malaria. RESULTS: The 28-day uncorrected adequate clinical and parasitological response (ACPR) was 69.0%, with 15.5% Late Clinical Failure and 15.5% Late Parasitologic Failure rates. The PCR-corrected 28-day ACPR was 90.2%. Clinical risk factors for recurrent infection (recrudescences and reinfections) were lower axillary temperature at enrollment and low weight-for-age Z-score. The presence of single nucleotide polymorphisms pfcrt 76T and pfmdr1 86Y at baseline was associated with increased risk of recurrent infections, both reinfections and recrudescences. CONCLUSION: Although artemether-lumefantrine (Coartem) is the first line ACT in Kenya, amodiaquine-artesunate is registered as an option for treatment of uncomplicated P. falciparum and remains an effective alternative to Coartem in western Kenya. Continued amodiaquine monotherapy in the private sector may jeopardize the future use of amodiaquine-artesunate as an alternative artemisinin-based combination therapy.

Impact of sustained use of insecticide-treated bednets on malaria vector species distribution and culicine mosquitoes.

Insecticide-treated bednets (ITNs) significantly reduce malaria vector populations. Susceptibility to ITNs differs by vector species, and culicine mosquitoes have not been shown to be significantly affected by the use of ITNs. We examined the impact of 2-4 yr of ITN use on malaria vector species distribution and culicine mosquitoes. Routine entomological surveillance was conducted in adjacent areas with and without ITNs from November 1999 to January 2002. Use of ITNs reduced the proportion of Anopheles gambiae Giles relative to Anopheles arabiensis Giles. The number of culicines per house was significantly lower in the ITN area than in the neighboring area. Changes in the An. gambiae sibling species distribution may help to explain apparent mosquito behavioral changes attributed to ITNs. Reductions in culicines by ITNs may have implications for community perceptions of ITN effectiveness and for control of other diseases such as lymphatic filariasis.

Aerobic and facultative bacterial isolates from blood cultures of children with clinically diagnosed septicaemia.

A total of 120 sets of blood cultures were performed aerobically from 60 children with clinically diagnosed septicaemia at Kenyatta National Hospital, Nairobi. Out of these, 36 (30%) sets from 19 (31.7%) patients yielded bacterial growth while 84 (70%) sets from 41 (68.3%) were negative. Salmonella typhimurium was the most frequently isolated bacteria (63%), followed by Staphylococcus aureus (15.8%). Salmonella typhimurium isolates were mostly multi-antibiotic resistant, most of them only sensitive to amikacin and cefotaxime, while all were resistant to ampicillin and co-trimoxazole, the most frequently used antibiotic in this hospital.

PIP: Between March 1987-January 1988, physicians enrolled 60 pediatric patients with a fever who were admitted to the Kenyatta National Hospital in Nairobi, Kenya for various clinical conditions in a study to determine the types, frequency, and antibiotic sensitivity patterns of aerobic and facultative bacterial isolates. Most of the patients were 13 months-4 years old (45%). 31.7% of the patients had positive blood cultures. Staphylococcus aureus was the 2nd most common bacteria (15.8%) among these patients. Laboratory personnel isolated Salmonella typhimurium in most patients (63%). In fact, during the same period, the Diagnostic Microbiology Laboratory at the hospital identified Salmonella species in 48% of all isolated bacteria and 35% of these were S. typhimurium. S. typhimurium tended to be present in children with gastroenteritis (41.8%) or a fever of unknown origin (33.3%). S. typhimurium was very sensitive to amikacin and cefotaxime, but resistant to ampicillin and sulfamethoxazole-trimethoprim. Health workers in Kenya have frequently administered ampicillin and sulfamethoxazole-trimethoprim, but not amikacin and cefotaxime. 67% of the strains of S. typhimurium were resistant to gentamicin and 33% to chloramphenicol. These results along with those of other reports from this hospital indicated a dramatic rise in Gram negative bacteria resistance to antibiotics. Therefore physicians should no longer consider gentamicin as a 1st line antibiotic in treating suspected septicemia patients.

Survey of penicillin resistant pneumococci at Kenyatta National Hospital, Nairobi.

During a four year period, a survey of antibiotic sensitivity patterns in clinical isolates of pneumococci was conducted at Kenyatta National Hospital, Nairobi. The isolation and characterisation of Streptococcus pneumoniae was done using standard laboratory procedures. Sensitivity testing was by disc diffusion method using discs supplied by Oxoid. During the period, 45 clinical isolates were recorded. This figure is somewhat lower than the expected rate of pneumococcal isolation at the hospital. Penicillin resistance of 24% among the pneumococcal isolates was recorded. Among the antibiotics tested, amoxycillin/clavulanic acid, ceftazidime, erythromycin and chloromphenicol had highest activity against the pneumococci. Surprisingly low sensitivity rates were recorded for trimethoprim/ sulphamethoxazole and cefuroxime. Implications of these findings in the management of pneumococcal infections are discussed.

Detection rate of Cryptococcus neoformans in cerebrospinal fluid specimens at Kenyatta National Hospital, Nairobi.

A ten-year retrospective review of laboratory detection of Cryptococcus neoformans in cerebrospinal fluid was undertaken using past laboratory and clinical records at Kenyatta National Hospital. A total of 1462 India-ink tests were carried out, 76 (5.2%) of these tested positive for C. neoformans. An increasing number of clinical requests for India-ink test mirrored by increasing number of patients with immunological disorders were noted over the study period although no obvious trend emerged in the detection pattern of C. neoformans. The use of a more sensitive test such as the latex agglutination technique is suggested.

The effect of health care worker training on the use of intermittent preventive treatment for malaria in pregnancy in rural western Kenya.

BACKGROUND: In 1998, Kenya adopted intermittent preventive treatment (IPTp) with sulphadoxine-pyrimethamine (SP) for malaria prevention during pregnancy. We conducted a survey in 2002 among women who had recently delivered in the rural neighbouring areas Asembo and Gem and reported coverage of 19% of at least one dose and 7% of two or more doses of SP. Health care workers (HCW) in Asembo were retrained on IPTp in 2003. OBJECTIVES: To evaluate if IPTp coverage increased and if the training in Asembo led to better coverage than in Gem, and to identify barriers to the effective implementation of IPTp. METHODS: Community-based cross-sectional survey among a simple random sample of women who had recently delivered in April 2005, interviews with HCW of antenatal clinics (ANC) in Asembo and Gem. RESULTS: Of the 724 women interviewed, 626 (86.5%) attended the ANC once and 516 (71.3%) attended two or more times. Overall IPTp coverage was 41% for at least one dose, and 21% for at least two doses of SP. In Asembo, coverage increased from 19% in 2002 to 61% in 2005 for at least one dose and from 7% to 17% for two doses of SP. In Gem, coverage increased from 17% to 28% and 7% to 11%, respectively. Interviews of HCW in both Asembo and Gem revealed confusion about appropriate timing, and lack of direct observation of IPTp. CONCLUSION: Training of HCW and use of simplified IPTp messages may be a key strategy in achieving Roll Back Malaria targets for malaria prevention in pregnancy in Kenya.

Use of intermittent preventive treatment for malaria in pregnancy in a rural area of western Kenya with high coverage of insecticide-treated bed nets.

Kenya established intermittent preventive treatment (IPT) with sulfadoxine-pyrimethamine (SP) for malaria in pregnancy as national policy in 1998. We assessed the coverage of IPT among women who had recently delivered in a rural area of western Kenya with perennial malaria transmission and high coverage with insecticide treated nets (ITNs) through a cross-sectional, community-based survey in December 2002. Antenatal clinic (ANC) attendance was high (89.9% of the 635 participating women); 77.5% of attendees visited an ANC before the third trimester and 91.9% made more than one visit. Delivery of SP by the ANC was reported by 19.1% of all women but only 6.8% reported receiving more than one dose. Given the high rate of use of ANC services, if SP were given at each visit after the first trimester, the potential coverage of IPT (two doses of SP) would be 80.3% in this study population. ITNs were used by 82.4% of women during pregnancy, and almost all mothers (98.5%) who slept under an ITN shared the nets with their newborns after delivery. Women who thought malaria in pregnancy caused foetal problems were more likely to have used an ITN (adjusted odds ratio [AOR] 1.6, 95% confidence interval [CI] 1.0-2.4), and to have visited ANC more than once (AOR 2.4, 95% CI 1.2-4.7) compared to women who thought malaria in pregnancy was either not a problem or caused problems for the mother only. These findings illustrate the need for improved IPT coverage in this rural area. Identification and removal of the barriers to provision of IPT during ANC visits can help to increase coverage. In this area of Kenya, health messages stressing that foetal complications of malaria in pregnancy may occur in the absence of maternal illness may improve the demand for IPT.