Planning for PPM-DOTS implementation in urban slums in Kenya: knowledge, attitude and practices of private health care providers in Kibera slum, Nairobi.

SETTING: Kibera, the largest slum in Nairobi, Kenya. OBJECTIVE: To determine the tuberculosis (TB) knowledge, attitude and practices (KAP) of private health care providers (PHCPs) to identify their training needs and willingness to participate in a National Leprosy and Tuberculosis Control Programme (NLTP) guided TB control effort in the slum. DESIGN AND METHODOLOGY: A cross-sectional survey. The KAP of PHCPs was assessed using an interviewer administered questionnaire. RESULTS: Of 75 PHCPs interviewed, the majority (96.0%) were paramedics; 51 (77.1%) did not consider sputum smear microscopy crucial in patients presenting with prolonged cough or when a chest X-ray was suggestive of TB; of 29 (38.7%) who indicated familiarity with the drugs used in TB treatment, 20 (58.5%) would have chosen the NLTP-recommended regimens for the treatment of the various types of TB; 16 (21.3%) PHCPs indicated that they treated TB, six (37.5%) of whom were not familiar with anti-tuberculosis drug regimens. All the PHCPs referred TB suspects to the public sector for diagnosis. CONCLUSION: This study reveals a significant gap in TB knowledge among the PHCPs in Kibera slum. However, given appropriate training and supervision, there is potential for public-private mix for DOTS implementation in this setting.

Tobacco consumption among primary school teachers in Nairobi.

OBJECTIVE: To determine the extent, pattern and the attendant risk factors of cigarette smoking and tobacco consumption among primary school teachers in Nairobi. DESIGN: A descriptive cross-sectional study. SETTING: The study was carried out among randomly selected Nairobi City Council primary schools in 1996. PARTICIPANTS: All the teachers in the selected primary schools were included in the study. RESULTS: Out of 910 teachers contacted, 813 responded (a response rate of 89.3%). A total of 800 teachers completed the questionnaire correctly and are the subject of the present analysis. Fifty per cent of male and three per cent of female teachers were cigarette smokers at the time of the study. The median age for starting to smoke was between 15 and 24 years. At this age, the teachers were secondary school and tertiary college students. It was observed that the age of smoking initiation seems to determine the individual's smoking status later in life. CONCLUSION: Since 57% of smokers started smoking during their secondary school days, secondary school students seem to be at a higher risk of initiating smoking. It is therefore important to target them for smoking control initiatives before they start the habit. A number of smokers were willing to quit smoking but did not know how to go about it. External assistance is therefore required for them to achieve their wish. It is also important to emphasise the need by the relevant authorities to initiate programmes for anti-smoking education in secondary schools and colleges in the country.

Urban-rural differences in questionnaire-derived markers of asthma in Kenyan school children.

Grade 4 Kenyan children attending 10 randomly selected public primary schools in Nairobi (urban) and the Muranga District (rural) were surveyed to establish the prevalence of symptom markers of asthma and to assess the impact of urbanization. A respiratory health and home environment questionnaire was administered at school to parents or guardians. The questionnaire response rates were 94.2% (568/ 603) for Nairobi and 89.6% (604/674) for Muranga. The prevalence rates for asthma, defined as "attacks of shortness of breath with wheeze", were 9.5% for urban and 3.0% for rural children (odds ratio (OR) urban versus rural: 3.42; 95% confidence interval (CI): -1.96-5.91). This urban-rural gradient persisted after adjusting for urban-rural differences in host factors (including duration of breastfeeding and family history of asthma and/or allergy), but was largely explained by urban-rural differences in environmental factors, including indoor animals, sharing a bedroom with a smoker, parental education, house ventilation and exposure to motor vehicle fumes en route to school (adjusted OR: 1.59; 95% CI: 0.70-3.55). Similar results were obtained for all other symptoms. These findings confirm the clinical impression that asthma is an important illness in Kenya and underline the need for the further study of environmental factors amenable to intervention, particularly in urban areas.

Prevalence of exercise induced bronchospasm in Kenyan school children: an urban-rural comparison.

BACKGROUND: Higher rates of exercise induced bronchospasm (EIB) have been reported for urban than for rural African schoolchildren. The change from a traditional to a westernized lifestyle has been implicated. This study was undertaken to examine the impact of various features of urban living on the prevalence of EIB in Kenyan school children. METHODS: A total of 1226 children aged 8-17 years attending grade 4 at five randomly selected schools in Nairobi (urban) and five in Muranga district (rural) underwent an exercise challenge test. A respiratory health and home environment questionnaire was also administered to parents/guardians. This report is limited to 1071 children aged < or = 12 years. Prevalence rates of EIB for the two areas were compared and the differences analysed to model the respective contributions of personal characteristics, host and environmental factors implicated in childhood asthma. RESULTS: A fall in forced expiratory volume in one second (FEV1) after exercise of > or = 10% occurred in 22.9% of urban children and 13.2% of rural children (OR 1.96, 95% CI 1.41 to 2.71). The OR decreased to 1.65 (95% CI 1.10 to 2.47) after accounting for age, sex, and host factors (a family history of asthma and breast feeding for less than six months), and to 1.21 (95% CI 0.69 to 2.11) after further adjustment for environmental factors (parental education, use of biomass fuel and kerosene for cooking, and exposure to motor vehicle fumes). CONCLUSIONS: The EIB rates in this study are higher than any other reported for African children, even using more rigorous criteria for EIB. The study findings support a view which is gaining increasing credence that the increase in prevalence of childhood asthma associated with urbanisation is the consequence of various harmful environmental exposures acting on increasingly susceptible populations.

Exercise-induced bronchospasm: a pilot survey in Nairobi school children.

Exercise-induced bronchospasm (EIB), a common feature of asthma in children, has been used as the outcome measure in community-based surveys of childhood asthma to circumvent difficulties arising from relative lack of objectivity in the use of questionnaires in communities with different cultural and language orientations. We report here the results of the first community-based study of childhood asthma in Kenya using EIB as the outcome measurement. The data was collected in a pilot study to develop methodology for a larger subsequent study. The survey targeted grade four children in five Nairobi City Council school each representing a neighbourhood social economic status (SES). Out of 597 eligible, 408 children took part in the study (68% participation rate). EIB defined as decline in FEV1 of 15% or more, post-exercise was found in 10.5% (95% CI; 10.3, 10.7) of the children studied, the highest rate reported so far in Africa. While boys were more likely to exhibit EIB compared to girls, the prevalence of EIB tended to decrease with age, especially among children residing in low SES neighbourhoods where the EIB prevalence rates tended to be lower compared to those among children from higher SES neighbourhoods. However, none of these differences was statistically significant. This study confirms the feasibility of undertaking exercise challenge tests in the African context and we recommend that additional studies of similar nature be carried out in other populations of Africa to explore the potential of using an exercise test as a marker of asthma in epidemiologic studies.

The effect of human immunodeficiency virus type-1 on the infectiousness of tuberculosis.

SETTING: Developing country tertiary referral hospital plus catchment community. OBJECTIVE: To determine the infectiousness of culture-confirmed pulmonary tuberculosis in patients infected with Human Immunodeficiency Virus type-1 (HIV-1). DESIGN: Comparison of the incidence of tuberculosis and the prevalence of tuberculin skin test positivity among the household contacts of both HIV-1 positive and negative cases with pulmonary tuberculosis. RESULTS: Of 255 contacts of HIV-1 negative index cases, 2 were HIV-1 positive and of 102 contacts of HIV-1 positive index cases, 14 were HIV-1 positive (odds ratio (OR) = 20.0 95% Confidence Interval (CI) 4.4-193). 21 cases of tuberculosis were diagnosed among contacts, of whom 3 were HIV-1 positive. The overall unadjusted OR for tuberculosis among contacts of HIV-1 positive index cases was 1.6 (95% CI 0.6-4.3) compared to contacts of HIV-1 negative index cases. Amongst HIV-1 negative contacts alone the OR was 1.5 (95% CI 0.4-4.4). In this group the best predictors of tuberculosis among contacts were female sex of the index case (OR = 3.4 95% CI 1.1-12), sharing the same bed as the index case (OR = 2.6 95% CI 0.9-7.4), and contact's age less than 5 years (OR = 3.3 95% CI 1.1-9.5). HIV-1 positive contacts were more likely to develop tuberculosis than HIV-1 negative contacts (OR = 4.1 95% CI 0.7-17). Tuberculin skin test positivity rates were the same among the HIV-1 negative contacts of HIV-1 positive and negative index cases (OR = 1.1 CI 0.7-1.6). CONCLUSIONS: HIV-1 associated pulmonary tuberculosis is not more infectious than tuberculosis alone. The presence of HIV-1 in a community does not mandate a change in the management of contacts of patients with pulmonary tuberculosis.

PIP: Using data on tuberculosis (TB) index cases over age 15 years seen at the Infectious Diseases Hospital in Nairobi and the Ngaira Avenue Chest Clinic over September 1, 1989 and October 10, 1990, and their contacts, the authors determined the infectiousness of culture-confirmed pulmonary TB in patients infected with HIV-1. Comparing the incidence of TB and the prevalence of tuberculin skin test positivity among the household contacts of HIV-1 positive and negative cases with pulmonary TB found HIV-1-associated pulmonary TB to be no more infectious than TB alone. The presence of HIV-1 in a community therefore does not require a change in the management of contacts of patients with pulmonary TB.

Cohort study of HIV-positive and HIV-negative tuberculosis, Nairobi, Kenya: comparison of bacteriological results.

We have set up a cohort of human immunodeficiency virus (HIV) positive and negative patients with tuberculosis in order to address the problems associated with HIV-related tuberculosis. We present here the results of sputum smear microscopy, culture, mycobacterial identification tests and drug susceptibility assays from specimens taken at presentation. In this selected population of largely pulmonary tuberculosis cases, HIV infection is not associated with significant differences in sputum smear positivity rate, culture positivity rate or initial drug resistance. No atypical mycobacteria were found. Direct sputum smear examination remains specific for the diagnosis of tuberculosis in Kenya in spite of the presence of HIV. HIV infection was not associated with an increase in the proportion of pulmonary cases still culture-positive at 6 months. However a significant increase in the proportion of cases still culture-positive at 6 months was seen in those with initially resistant strains and also in those treated with standard regimen (streptomycin, thiacetazone and isoniazid for 1 month followed by thiacetazone and isoniazid for 11 months, 1STH/11TH) rather than a short-course, rifampicin-containing regimen (rifampicin, pyrazinamide and isoniazid for 2 months, together with streptomycin for the first month and followed by 6 months of thiacetazone and isoniazid, SHRZ/6TH).

PIP: A study of HIV-related tuberculosis (TB) in Kenya was conducted by analyzing all cases of new suspected TB presenting from April 1989 through May 1990 at the Infectious Disease Hospital and the Ngaira Avenue Chest Clinic. There were 355 cases, 117 of whom were HIV+. No atypical mycobacteria were isolated. There were no significant differences between HIV+ and HIV-patients as to colony counts, grading of sputum smears or prevalence of drug-resistant strains initially. HIV infection was not associated with a significantly increased proportion of pulmonary TB cases still culture positive at 6 months. However, there was a significant increase in the proportion of cases still culture-positive at 6 months among those who initially had drug resistant strains and who were treated with the standard drug regimen (streptomycin, thiacetazone and isoniazid for 1 month, then thiacetazone and isoniazid for 11 months). The discussion enumerated several factors potentially effecting selection of the high proportion of pulmonary TB patients in this series. Direct sputum smear remains specific for diagnosis of TB in Kenya in spite of HIV. These results still suggest that HIV+ pulmonary TB responds well to standard anti-TB therapy.

Cross-sectional survey of HIV infection among patients with tuberculosis in Nairobi, Kenya.

Evidence from many countries suggests an association of human immunodeficiency virus (HIV) infection and tuberculosis of major public health significance. In order to begin assessing the impact of HIV on tuberculosis in Kenya, we have determined the HIV-1 seroprevalence among tuberculosis patients and compared the clinical characteristics of tuberculosis in HIV-positive and HIV-negative patients in two cross-sectional studies at the Infectious Disease Hospital (IDH) and the Ngaira Avenue Chest Clinic (NACC), Nairobi, Kenya. The diagnosis in 92% of all patients with pulmonary tuberculosis was confirmed by culture. The remainder were diagnosed on histological, clinical or radiological grounds. HIV seroprevalence among tuberculosis patients at IDH was 26.5% (52/196) compared to 9.2% (18/195) at NACC (P less than 0.001). There was no association between numbers of streptomycin injections in the previous 5 years and HIV infection. Positive sputum smear rates in HIV-positive patients were slightly lower than in HIV-negative patients at both study sites (71% vs 83% at IDH and 73% vs 82% at NACC) but the difference was not significant. Only Mycobacterium tuberculosis was isolated. Miliary disease was not associated with HIV infection. Persistent diarrhoea, oral candidiasis, generalized itchy rash, herpes zoster and generalized lymphadenopathy were all associated with HIV infection, but 46% (95% CI:38-54%) of all HIV-positive patients had none of the clinical features listed in the WHO Clinical Criteria for the Diagnosis of AIDS, apart from fever, cough and weight loss. Stevens-Johnson Syndrome was reported in 7/52 (13%) patients with HIV infection, and in 4/144 (3%) patients without (RR 4.85, 95% CI: 1.45-15.88).(ABSTRACT TRUNCATED AT 250 WORDS)