What capacity exists to provide essential inpatient care to small and sick newborns in a high mortality urban setting? - A cross-sectional study in Nairobi City County, Kenya.

INTRODUCTION: Appropriate demand for, and supply of, high quality essential neonatal care is key to improving newborn survival but evaluating such provision has received limited attention in low- and middle-income countries. Moreover, specific local data are needed to support healthcare planning for this vulnerable population. METHODS: We conducted health facility assessments between July 2015-April 2016, with retrospective review of admission events between 1st July 2014 and 30th June 2015, and used estimates of population-based incidence of neonatal conditions in Nairobi to explore access and evaluate readiness of public, private not-for-profit (mission), and private-for-profit (private) sector facilities providing 24/7 inpatient neonatal care in Nairobi City County. RESULTS: In total, 33 (4 public, 6 mission, and 23 private) facilities providing 24/7 inpatient neonatal care in Nairobi City County were identified, 31 were studied in detail. Four public sector facilities, including the only three facilities in which services were free, accounted for 71% (8,630/12,202) of all neonatal admissions. Large facilities (>900 annual admissions) with adequate infrastructure tended to have high bed occupancy (over 100% in two facilities), high mortality (15%), and high patient to nurse ratios (7-15 patients per nurse). Twenty-one smaller, predominantly private, facilities were judged insufficiently resourced to provide adequate care. In many of these, nurses provided newborn and maternity care simultaneously using resources shared across settings, newborn care experience was likely to be limited (<50 cases per year), there was often no resident clinician, and sick babies were often referred onwards. Results suggest 44% (9,764/21,966) of Nairobi's small and sick newborns may not access any of the identified facilities and a further 9% (2,026/21,966) access facilities judged to be inadequately equipped. CONCLUSION: Over 50% of Nairobi's sick newborns may not access a facility with adequate resources to provide essential care. A very high proportion of care accessed is provided by four public and one low cost mission facility; these face major challenges of high patient acuity (high mortality), high patient to nurse ratios, and often overcrowding. Reducing high neonatal mortality in this urban, predominantly poor, population will require effective long-term, multi-sectoral planning and investment.

The clinical burden of malaria in Nairobi: a historical review and contemporary audit.

BACKGROUND: Widespread urbanization over the next 20 years has the potential to drastically change the risk of malaria within Africa. The burden of the disease, its management, risk factors and appropriateness of targeted intervention across varied urban environments in Africa remain largely undefined. This paper presents a combined historical and contemporary review of the clinical burden of malaria within one of Africa's largest urban settlements, Nairobi, Kenya. METHODS: A review of historical reported malaria case burdens since 1911 within Nairobi was undertaken using archived government and city council reports. Contemporary information on out-patient case burdens due to malaria were assembled from the National Health Management and Information System (HMIS). Finally, an audit of 22 randomly selected health facilities within Nairobi was undertaken covering 12 months 2009-2010. The audit included interviews with health workers, and a checklist of commodities and guidelines necessary to diagnose, treat and record malaria. RESULTS: From the 1930's through to the mid-1960's malaria incidence declined coincidental with rapid population growth. During this period malaria notification and prevention were a priority for the city council. From 2001-2008 reporting systems for malaria were inadequate to define the extent or distribution of malaria risk within Nairobi. A more detailed facility review suggests, however that malaria remains a common diagnosis (11% of all paediatric diagnoses made) and where laboratories (n = 15) exist slide positivity rates are on average 15%. Information on the quality of diagnosis, slide reading and whether those reported as positive were imported infections was not established. The facilities and health workers included in this study were not universally prepared to treat malaria according to national guidelines or identify foci of risks due to shortages of national first-line drugs, inadequate record keeping and a view among some health workers (17%) that slide negative patients could still have malaria. CONCLUSION: Combined with historical evidence there is a strong suggestion that very low risks of locally acquired malaria exist today within Nairobi's city limits and this requires further investigation. To be prepared for effective prevention and case-management of malaria among a diverse, mobile population in Nairobi requires a major paradigm shift and investment in improved quality of malaria diagnosis and case management, health system strengthening and case reporting.

Factors influencing implementation of the Ministry of Health-led private medicine retailer programmes on malaria in Kenya.

BACKGROUND: Kenya has experienced a number of retail sector initiatives aimed at improving access to antimalarial medicines. This study explored stakeholders' perceptions of the role of private medicine retailers (PMRs), the value and feasibility of programme goals, perceived programme impact, factors influencing implementation and recommendations in three districts of Kenya. METHODS: This study was part of a larger evaluation of PMR programmes, including quantitative and qualitative components. The qualitative research was conducted to assess implementation processes and actors' experiences in the programmes, through focus group discussions with trained PMRs and mothers of children under five years, and in-depth interviews with programme managers, trainers and co-trainers. RESULTS: PMRs were perceived to provide rapid cheap treatment for non-serious conditions and used as a deliberate and continuously evaluated choice between different treatment sources. All stakeholders supported programme goals and most PMRs described increased customer satisfaction, more rational purchasing of medicine stock and increased medicine sales after participation. Factors undermining programme implementation included a lack of MoH resources to train and monitor large numbers of PMRs, the relative instability of outlets, medicines stocked and retail personnel, the large number of proprietary brands and financial challenges to retailers in stocking antimalarial medicines, and their customers in buying them. Unambiguous national support and a broad range of strategies are important to strengthen the feasibility of change in OTC antimalarial use. CONCLUSIONS: Understanding the context and implementation processes of PMR programmes and the perspectives of key actors are critical to identifying measures to support their effective implementation. Financial barriers underlie many described challenges, with important implications for policies on subsidies in this sector. In spite of barriers to implementation, increased exposure to programme activities promoted trust and improved relationships between PMRs and their clients and trainers, strengthening feasibility of such interventions. Public information can strengthen PMR training programmes by engaging local communities and may facilitate performance monitoring of PMRs by their clients.

Fever treatment in the absence of malaria transmission in an urban informal settlement in Nairobi, Kenya.

BACKGROUND: In sub-Saharan Africa, knowledge of malaria transmission across rapidly proliferating urban centres and recommendations for its prevention or management remain poorly defined. This paper presents the results of an investigation into infection prevalence and treatment of recent febrile events among a slum population in Nairobi, Kenya. METHODS: In July 2008, a community-based malaria parasite prevalence survey was conducted in Korogocho slum, which forms part of the Nairobi Urban Health and Demographic Surveillance system. Interviewers visited 1,069 participants at home and collected data on reported fevers experienced over the preceding 14 days and details on the treatment of these episodes. Each participant was tested for malaria parasite presence with Rapid Diagnostic Test (RDT) and microscopy. Descriptive analyses were performed to assess the period prevalence of reported fever episodes and treatment behaviour. RESULTS: Of the 1,069 participants visited, 983 (92%) consented to be tested. Three were positive for Plasmodium falciparum using RDT; however, all were confirmed negative on microscopy. Microscopic examination of all 953 readable slides showed zero prevalence. Overall, from the 1,004 participants who have data on fever, 170 fever episodes were reported giving a relatively high period prevalence (16.9%, 95% CI:13.9%-20.5%) and higher among children below five years (20.1%, 95%CI:13.8%-27.8%). Of the fever episodes with treatment information 54.3% (95%CI:46.3%-62.2%) were treated as malaria using mainly sulphadoxine-pyrimethamine or amodiaquine, including those managed at a formal health facility. Only four episodes were managed using the nationally recommended first-line treatment, artemether-lumefantrine. CONCLUSION: The study could not demonstrate any evidence of malaria in Korogocho, a slum in the centre of Nairobi. Fever was a common complaint and often treated as malaria with anti-malarial drugs. Strategies, including testing for malaria parasites to reduce the inappropriate exposure of poor communities to expensive anti-malarial drugs provided by clinical services and drug vendors, should be a priority for district planners.

Impact of ministry of health interventions on private medicine retailer knowledge and practices on anti-malarial treatment in Kenya.

Small-scale interventions on training medicine retailers on malaria treatment improve over-the-counter medicine use, but there is little evidence on effectiveness when scaled up. This study evaluated the impact of Ministry of Health (MoH) training programs on the knowledge and practices of medicine retailers in three districts in Kenya. A cluster randomized trial was planned across 10 administrative divisions. Findings indicated that 30.7% (95% confidence interval [CI]: 23.3, 39.0) and 5.2% (95% CI: 2.1, 10.3) of program and control retailers, respectively, sold MoH amodiaquine with correct advice on use to surrogate clients (OR = 8.8; 95% CI: 2.9, 26.9; P < 0.001). Similarly, 61.8% (95% CI: 54.2, 69.1) and 6.3% (95% CI: 2.7, 12.1) of program and control retailers, respectively, reported correct knowledge on dosing with amodiaquine (OR = 29.8; 95% CI: 8.2, 108.8). Large-scale retailer training programs within the national malaria control framework led to significant improvements in retailers' practices across three districts.

Use of over-the-counter malaria medicines in children and adults in three districts in Kenya: implications for private medicine retailer interventions.

BACKGROUND: Global malaria control strategies highlight the need to increase early uptake of effective antimalarials for childhood fevers in endemic settings, based on a presumptive diagnosis of malaria in this age group. Many control programmes identify private medicine sellers as important targets to promote effective early treatment, based on reported widespread inadequate childhood fever treatment practices involving the retail sector. Data on adult use of over-the-counter (OTC) medicines is limited. This study aimed to assess childhood and adult patterns of OTC medicine use to inform national medicine retailer programmes in Kenya and other similar settings. METHODS: Large-scale cluster randomized surveys of treatment seeking practices and malaria parasite prevalence were conducted for recent fevers in children under five years and recent acute illnesses in adults in three districts in Kenya with differing malaria endemicity. RESULTS: A total of 12, 445 households were visited and data collected on recent illnesses in 11, 505 children and 19, 914 adults. OTC medicines were the most popular first response to fever in children with fever (47.0%; 95% CI 45.5, 48.5) and adults with acute illnesses (56.8%; 95% CI 55.2, 58.3). 36.9% (95% CI 34.7, 39.2) adults and 22.7% (95% CI 20.9, 24.6) children using OTC medicines purchased antimalarials, with similar proportions in low and high endemicity districts. 1.9% (95% CI 0.8, 4.2) adults and 12.1% (95% CI 16.3,34.2) children used multidose antimalarials appropriately. Although the majority of children and adults sought no further treatment, self-referral to a health facility within 72 hours of illness onset was the commonest pattern amongst those seeking further help. CONCLUSION: In these surveys, OTC medicines were popular first treatments for fever in children or acute illnesses in adults. The proportions using OTC antimalarials were similar in areas of high and low malaria endemicity. In all districts, adults were more likely to self-treat with OTC antimalarial medicines than febrile children were to receive them, and less likely to use them in recommended ways. Government health centres were the most common second resort for treatment and were often used within 72 hours. In view of these practices, more research is needed to assess the impact on the popularity of private medicine sellers of strengthened public sector policies on access to malaria treatment and insecticide-treated bed nets. Improved targeting of OTC antimalarials to high risk groups, better communication strategies regarding adult as well as children's dosages, and facilitating more rapid referral to trained health workers where needed are important challenges to private medicine seller programmes.

The difference between effectiveness and efficacy of antimalarial drugs in Kenya.

OBJECTIVE: To demonstrate the difference between effectiveness and efficacy of antimalarial (AM) drugs in Kenya. METHODS: We undertook a series of linked surveys in four districts of Kenya between 2001 and 2002 on (i) community usage of nationally recommended first- and second-line AM drugs; (ii) commonly stocked AM products in the retail and wholesale sectors; and (iii) quality of the most commonly available first- and second-line AM products. These were combined with estimates of adherence and clinical efficacy to derive overall drug effectiveness. RESULTS: The overall modelled effectiveness for sulphadoxine-pyrimethamine (SP) was estimated to be 62% compared with 85% for reported SP clinical efficacy. For amodiaquine the modelled effectiveness was 48% compared with 99% reported efficacy during the same time period. CONCLUSIONS: The quality of AM products and patient adherence to dosage regimens are important determinants of drug effectiveness, and should be measured alongside clinical efficacy. Post-registration measures to regulate drug quality and improve patient adherence would contribute significantly to AM drug performance.

Averting a malaria disaster in Africa--where does the buck stop?

The serious threat posed by the spread of drug-resistant malaria in Africa has been widely acknowledged. Chloroquine resistance is now almost universal, and resistance to the successor drug, sulfadoxine-pyrimethamine (SP), is growing rapidly. Combination therapy has been suggested as being an available and potentially lasting solution to this impending crisis. However, the current cost of combination therapy, and especially that of artemisinin combination therapy (ACT), is potentially a serious drawback, even if a significant part of its cost is passed on to the end-user. If the question of cost is not successfully addressed this could lead to adverse results from the deployment of combination therapy as first-line treatment. These adverse effects range from an increase in potentially fatal delays in infected individuals presenting to medical services, to exclusion of the poorest malaria sufferers from receiving treatment altogether. Urgent steps are needed to reduce the cost of combination therapy to the end-user in a sustainable way if it is to be usable, and some possible approaches are discussed.

The use of formal and informal curative services in the management of paediatric fevers in four districts in Kenya.

OBJECTIVE: To assess the sources, costs, timing and types of treatment for fevers among children under 5 years of age in four ecologically distinct districts of Kenya. METHODS: Structured questionnaires were administered to caretakers of one randomly selected child aged <5 years per homestead to establish whether the child had had a fever within the last 14 days and the types, sources, costs, and timing of treatment. Drug charts of common proprietary anti-malarial and antipyretic drugs in Kenya were used as visual aids. RESULTS: A total of 2655 fevers were reported among 6287 (42.2%) children with significant differences between the four districts (P<0.01). A substantial number of fevers remained untreated (28.1%) across all districts and more fevers were treated in Greater Kisii than any other district (P<0.01). The median delay to any treatment was 2 days [inter-quartile range (IQR): 2, 4]. The informal retail sector had no transport costs associated with it and charged less for drugs than all the other sectors. Most antimalarial treated fevers occurred in the formal public sector (52.6%). Only 2.3% of fevers were treated within 24 h of onset with a sulphur-pyrimethamine drug, the nationally recommended first-line drug for the management of uncomplicated malaria. CONCLUSIONS: The Abuja target of ensuring that 60% of childhood fevers are treated with appropriate antimalarial drugs within 24 h of onset by 2010 is largely unmet and a major investment in improving prompt access to antimalarial drugs will be required to achieve this.

Use of bednets given free to pregnant women in Kenya.

In 2001, Unicef procured 70000 bednets and insecticide treatments to be distributed free to pregnant women attending antenatal clinics in 35 (of 69) districts in Kenya. 1 year later, we interviewed 294 pregnant women who had received a free net. 267 (91%) nets had remained in the target homesteads, and only one of the nets had been sold. In a district with high malarial transmission, 93 (84%) of 111 women who had not previously been sleeping under a bednet had used the net while pregnant, and 97 (91%) of the 107 surviving babies were also protected; in another district, which had low transmission, 73 (58%) of 126 women used the nets during pregnancy and 91 (80%) of 114 infants were protected by the nets. These data suggest that bednets given free to pregnant women are used by recipients and their newborn children, and should be regarded as an important delivery system in increasing access to and use of insecticide-treated bednets in vulnerable groups.

Performance of forecasting, warning and detection of malaria epidemics in the highlands of western Kenya.

On the 4th July 2002 a leading national newspaper in Kenya, the Daily Nation, ran the headline 'Minister sounds alert on malaria' in an article declaring the onset of epidemics in the highlands of western Kenya. There followed frequent media coverage with quotes from district leaders on the numbers of deaths, and editorials on the failure of the national malaria control strategy. The Ministry of Health made immediate and radical changes to national policy on treatment costs in the highlands by suspending cost-sharing. Development partners and non-governmental organisations also responded with a large increase in the distribution of commodities (approximately 500,000 US dollars) to support preventative strategies across the western highland region. What was conspicuous by its absence was any obvious effort to predict the epidemics in advance of press coverage.

Forecasting, warning, and detection of malaria epidemics: a case study.

Our aim was to assess whether a combination of seasonal climate forecasts, monitoring of meteorological conditions, and early detection of cases could have helped to prevent the 2002 malaria emergency in the highlands of western Kenya. Seasonal climate forecasts did not anticipate the heavy rainfall. Rainfall data gave timely and reliable early warnings; but monthly surveillance of malaria out-patients gave no effective alarm, though it did help to confirm that normal rainfall conditions in Kisii Central and Gucha led to typical resurgent outbreaks whereas exceptional rainfall in Nandi and Kericho led to true malaria epidemics. Management of malaria in the highlands, including improved planning for the annual resurgent outbreak, augmented by simple central nationwide early warning, represents a feasible strategy for increasing epidemic preparedness in Kenya.

Scaling-up coverage with insecticide-treated nets against malaria in Africa: who should pay?

Insecticide-treated nets (ITNs) have been shown to reduce the burden of malaria in African villages by providing personal protection and, if coverage of a community is comprehensive, by reducing the infective mosquito population. We do not accept the view that scaling-up this method should be by making villagers pay for nets and insecticide, with subsidies limited so as not to discourage the private sector. We consider that ITNs should be viewed as a public good, like vaccines, and should be provided via the public sector with generous assistance from donors. Our experience is that teams distributing free ITNs, replacing them after about 4 years when they are torn and retreating them annually, have high productivity and provide more comprehensive and equitable coverage than has been reported for marketing systems. Very few of the free nets are misused or sold. The estimated cost would be an annual expenditure of about US$295 million to provide for all of rural tropical Africa where most of the world's malaria exists. This expenditure is affordable by the world community as a whole, but not by its poorest members. Recently, funding of this order of magnitude has been committed by donor agencies for malaria control.

Too poor to pay: charging for insecticide-treated bednets in highland Kenya.

WHO has proposed malaria control as a means to alleviate poverty. One of its targets includes a 30-fold increase in insecticide-treated nets (ITNs) in the next 5 years. How this service will be financed remains unclear. In July 2000, 390 homesteads in rural highland Kenya were interviewed on their willingness to pay for ITNs. The costs to a household of protecting themselves with ITNs were compared with current household expenditure. Homesteads expressed a willingness to pay for ITNs, but the amounts offered were not sufficient to cover the costs of providing this service without donor support to meet the difference. Furthermore, as most household expenditure was allocated to basic needs these interventions were 'unaffordable'. The cost of protecting a household with ITNs would be equivalent to sending three children to primary school for a year. The aspiration by poor rural homesteads to protect themselves with ITNs is not compatible with their ability to pay. One option to have an immediate equitable impact on ITN coverage and break the cycle between malaria and poverty is to provide this service free of charge.

Clinical epidemiology of malaria in the highlands of western Kenya.

Malaria in the highlands of Kenya is traditionally regarded as unstable and limited by low temperature. Brief warm periods may facilitate malaria transmission and are therefore able to generate epidemic conditions in immunologically naive human populations living at high altitudes. The adult:child ratio (ACR) of malaria admissions is a simple tool we have used to assess the degree of functional immunity in the catchment population of a health facility. Examples of ACR are collected from inpatient admission data at facilities with a range of malaria endemicities in Kenya. Two decades of inpatient malaria admission data from three health facilities in a high-altitude area of western Kenya do not support the canonical view of unstable transmission. The malaria of the region is best described as seasonal and meso-endemic. We discuss the implications for malaria control options in the Kenyan highlands.

Defining and detecting malaria epidemics in the highlands of western Kenya.

Epidemic detection algorithms are being increasingly recommended for malaria surveillance in sub-Saharan Africa. We present the results of applying three simple epidemic detection techniques to routinely collected longitudinal pediatric malaria admissions data from three health facilities in the highlands of western Kenya in the late 1980s and 1990s. The algorithms tested were chosen because they could be feasibly implemented at the health facility level in sub-Saharan Africa. Assumptions of these techniques about the normal distribution of admissions data and the confidence intervals used to define normal years were also investigated. All techniques identified two "epidemic" years in one of the sites. The untransformed Cullen method with standard confidence intervals detected the two "epidemic" years in the remaining two sites but also triggered many false alarms. The performance of these methods is discussed and comments made about their appropriateness for the highlands of western Kenya.

Free bednets to pregnant women through antenatal clinics in Kenya: a cheap, simple and equitable approach to delivery.

Kenya's National Malaria Strategy states that insecticide-treated nets (ITNs) would be considered as a free service to pregnant women assuming sufficient financial commitment from donors. In 2001, United Nation's Children's Fund (UNICEF) and the Government of Kenya brokered support to procure and distribute nets and K-O TABs (deltamethrin) to 70 000 pregnant women in 35 districts throughout Kenya around Africa Malaria Day. This intervention represented the single largest operational distribution of ITN services in Kenya to date, and this study evaluates its success, limitations and costs. The tracking process from the central level through to antenatal clinic (ANC) facilities suggests that of the 70 000 nets procured, 37 206 nets (53%) had been distributed to pregnant women throughout the country within 12 weeks. One-fifth of the nets procured (14 117) had gone out to individuals other than pregnant women, most of these at the request of the district teams, with only 2870 nets estimated to have gone astray at the ANC facilities. At 12 weeks, the remaining 18 677 nets were still in storage awaiting distribution, with more than two-thirds having reached the district, and nearly half already being held at ANC facilities. The cost of getting a net and K-O TAB to an ANC facility ready for distribution to a pregnant woman was US$ 3.81. Accounting for the 14 117 nets that had gone to other users, the cost for an ITN received by a pregnant woman was US$ 5.26. Delivering ITNs free to pregnant women through ANCs uses an existing system (with positive spin-offs of low delivery cost and simple logistics), is equitable (as it not only targets those who can afford it) and can have the added benefits of strengthening ANC service, delivery and use.

Malaria prevention in highland Kenya: indoor residual house-spraying vs. insecticide-treated bednets.

This study compares the effectiveness and cost-effectiveness of indoor residual house-spraying (IRS) and insecticide-treated bednets (ITNs) against infection with Plasmodium falciparum as part of malaria control in the highlands of western Kenya. Homesteads operationally targeted for IRS and ITNs during a district-based emergency response undertaken by an international relief agency were selected at random for evaluation. Five hundred and ninety homesteads were selected (200 with no vector control, 200 with IRS and 190 with ITNs). In July 2000, residents in these homesteads were randomly sampled according to three age-groups: 6 months-4 years, 5-15 years, and > 15 years for the presence of P. falciparum antigen (Pf HRP-2) using the rapid whole blood immunochromatographic test (ICT). The prevalence of P. falciparum infection amongst household members not protected by either IRS or ITN was 13%. Sleeping under a treated bednet reduced the risk of infection by 63% (58-68%) and sleeping in a room sprayed with insecticide reduced the risk by 75% (73-76%). The economic cost per infection case prevented by IRS was US$ 9 compared to US$ 29 for ITNs. This study suggests that IRS may be both more effective and cheaper than ITNs in communities subjected to low, seasonal risks of infection and as such should be considered as part of the control armamentarium for malaria prevention.