Distinct pattern of class and subclass antibodies in immune complexes of children with cerebral malaria and severe malarial anaemia.

Plasmodium falciparum infection can lead to deadly complications such as severe malaria-associated anaemia (SMA) and cerebral malaria (CM). Children with severe malaria have elevated levels of circulating immune complexes (ICs). To further investigate the quantitative differences in antibody class/subclass components of ICs in SMA and CM, we enrolled 75 children with SMA and 32 children with CM from hospitals in western Kenya and matched them to 74 and 52 control children, respectively, with uncomplicated symptomatic malaria. Total IgG IC levels were always elevated in children with malaria upon enrollment, but children with CM had the highest levels of any group. Conditional logistic regression showed a borderline association between IgG4-containing IC levels and increased risk of SMA (OR = 3.11, 95% CI 1.01-9.56, P = 0.05). Total IgG ICs (OR = 2.84, 95% CI 1.08-7.46, P = 0.03) and IgE-containing ICs (OR = 6.82, OR 1.88-24.73, P < or = 0.01) were associated with increased risk of CM. These results point to differences in the contribution of the different antibody class and subclass components of ICs to the pathogenesis of SMA and CM and give insight into potential mechanisms of disease.

Determinants of under nutrition among school age children in a Nairobi peri-urban slum.

BACKGROUND: Malnutrition is a major public health concern affecting a significant number of school age children influencing their health, growth and development, and school academic performance. OBJECTIVE: To establish the determinants of under nutrition among school age children between 6-12 years in a low-income urban community. DESIGN: A cross-sectional descriptive study. SETTING: Kawangware peri-urban slum, Nairobi, Kenya. SUBJECTS: Three hundred and eighty four school children aged 6-12 years. RESULTS: A total of 4.5% were wasted, 14.9% underweight and 30.2% stunted. The children who were over nine years of age were more underweight (72.4%, p = 0.000) and stunted (77.2%, p = 0.000) than those below eight years. The girls were more wasted (29.1%, p = 0.013) than the boys (18.2%), whereas the boys were more stunted (65.7%, p = 0.003) than the girls (50.7%). The other variables found to have had significant association with the nutritional status of the children were: monthly household income (p = 0.008), food prices (p = 0.012), morbidity trends (p = 0.045), mode of treatment (p = 0.036) and school attendance (p = 0.044). CONCLUSION: The findings of this study show evidently that there is under nutrition among school age children, with stunting being the most prevalent. The Ministry of Education and Ministry of Health therefore need to develop policies which can alleviate under nutrition among school age children. We also recommend that awareness be created among the school age children, parents and teachers, on the dietary requirements of both boys and girls.

Home Management of Diarrhea among Underfives in a Rural Community in Kenya: Household Perceptions and Practices

Introduction: Diarrheal disease is a major cause of morbidity and mortality among under-fives especially in rural and peri-urbancommunities in developing countries. Home management of diarrhea is one of the key household practices targeted for enhancement in the Community Integrated Management of Childhood Illness (C-IMCI) strategy. Objective: The aim of this study was to determine the perceptions of mothers/caregivers regarding the causes of diarrhea among under-fives and how it was managed in the home before seeking help from Community Health Workers or health facilities. Design: A household longitudinal study was conducted in Nyando district; Kenya in 2004-2006 adopting both qualitative and quantitative approaches. Subjects: A total of 927 mothers/caregivers of under-fives participated in the study. Main outcome measures: Perceived causes of childhood diarrhoea; action taken during diarrhea; fluid intake; recognition of signs of dehydration; feeding during convalescence; adherence to treatment and advice. Results: Majority of the respondents 807(87.1) reported that their children had suffered from diarrhea within the last 2 weeks before commencement of the study. Diarrhea was found to contribute to 48of child mortality in the study area. Perceived causes of diarrhea were: unclean water 524(55.6); contaminated food 508(54.9); bad eye 464 (50.0); false teeth 423(45.6) and breast milk 331(35.8). More than 70of mothers decreased fluid intake during diarrhea episodes. The mothers perceived wheat flour; rice water and selected herbs as anti-diarrheal agents. During illness; 239(27.8) of the children were reported not to have drunk any fluids at all; 487(52.5) drunk much less and only 93(10.0) were reported to have drunk more than usual. A significant 831(89.6) withheld milk including breast milk with the notion that it enhanced diarrhea. Conclusion: Based on these findings; there is need to develop and implement interactive communication strategies for the health workers and mothers to address perceptions and miscon- ceptions and facilitate positive change in the household practice on management of diarrhea among under-fives

Role of child health clinics in promoting use of insecticide-treated nets among children under five years in Nyamira district, Kenya.

BACKGROUND: Maternal child health clinics are the ideal places to meet and sensitise all the mothers with children under five years on the use of insecticide-treated nets in the prevention of malaria. OBJECTIVE: To determine whether child health clinics are promoting the use of insecticide-treated nets in malaria prevention among children. DESIGN: Cross-sectional, descriptive study. SETTING: Eight health centres in Nyamira District. SUBJECTS: Four hundred mothers bringing their children aged five years and below to the child health clinics between August and October 2003. RESULTS: Two hundred and eighty four mothers (71%) had not received any information on the use of insecticide-treated nets while at the MCH clinics. Only 50% of the clinics had bed nets/ITNs posters mounted on their premises. Out of those clinics with posters, only in 50% of them had bed net posters seen. Very few mothers (36.2%) had seen the bed net/ITNs posters. None of the healthcare providers used bed net/ITNs posters to educate the mothers. None of the insecticide-treated net leaflets were issued. CONCLUSION: Despite the fact that maternal child health clinics were well placed in promoting the use of insecticide-treated nets to the mothers who brought their under five year children, very little was being done to this effect. MCH clinics need to be more aggressive in motivating mothers to use insecticide-treated nets.

Mothers' knowledge on malaria and vector management strategies in Nyamira District, Kenya.

BACKGROUND: Maternal knowledge on malaria and vector control measures are important because they enable mothers make an informed choice on the method of malaria control to use for their children under five years. OBJECTIVE: To determine the mothers' knowledge on malaria and vector control measures particularly use of insecticide treated nets. DESIGN: Cross sectional, descriptive study. SETTING: Eight health centres in Nyamira District, Kenya. SUBJECTS: Four hundred mothers bringing their children aged five years and below to the child health clinics. RESULTS: Mothers had a problem of defining malaria. Majority of them (91.8%) recognised mosquitoes as causing malaria. About 30% associated malaria with dirt, dirty compounds, dirty food/utensils, unboiled water and uncooked food. Many mothers identified basic malaria symptoms such as headache (70%), fever (68.8%), cold (65%), body or joint pain (65.5%) and abdominal pain/ vomiting (0.5%). Mothers (40.8%)were less knowledgeable on most vulnerable groups to malaria. A large number of mothers (55.5%) used nothing to protect themselves and their children under five years from mosquito bites. The radio (69%) tuned in the local language, played a very important role in the mothers' knowledge about the use of mosquito nets and insecticide treated nets. CONCLUSION: By virtue of the fact that majority of mothers (91.8%) recognised that mosquitoes caused malaria, it was an indicator that they were knowledgeable of its existence. Mothers were also informed of most of the malaria vector control measures particularly use of bed nets and insecticide treated nets. However, the general usage of those measures was very low.

Maternal use of insecticide-treated nets in the prevention of malaria among children under five years in Nyamira district, Kenya.

BACKGROUND: Insecticide treated nets (ITNs) have been proved as one of the most effective ways of reducing malaria morbidity and mortality in children and pregnant women. Proper use and care of insecticide treated nets reduce malaria health risk to children. OBJECTIVE: To determine maternal use of insecticide treated nets in the prevention of malaria among children under five years in Nyamira district. DESIGN: Cross-sectional, descriptive study. SETTING: Eight health centres in Nyamira district. SUBJECTS: Four hundred mothers bringing their children aged five years and below to the child health clinics between August and October 2003. RESULTS: There was very low usage of mosquito nets (33.8%) with the proportion of under five using bed nets and insecticide treated nets being 33.3% and 23.8% respectively. The possibility of a mother having an insecticide treated net was significantly related with the level of education of the mother (p = 0.003), occupation (p = 0.001) and knowledge (p = 0.000). Among the reasons given by mothers regarding non usage of insecticide treated nets included lack of money, they were expensive, ignorance and carelessness. CONCLUSION: There was low use of ITNs (23.8%) among children. There is need for health information, education and communication campaigns to sensitise the mothers on most risk groups from malaria so as to create awareness of who needed more protection through use of ITNs. There is need for ITNs intervention projects for malaria prevention in the area.

Anti-plasmodial activity of some Kenyan medicinal plant extracts singly and in combination with chloroquine.

Sixty organic and aqueous extracts of eleven plants used for the control of malaria by local communities in Kisii District, Kenya were screened for in vitro anti-plasmodial activity. The plants selection was based on existing ethnobotanical information and interviews with local communities. The extracts were tested against chloroquine sensitive and resistant laboratory adapted strains of Plasmodium falciparum. The study revealed that 63.6% of the plants were active (IC50 < or = 100 microg/mL). Extracts of four plants, Ekebergia capensis, Stephania abyssinica, Ajuga remota and Clerodendrum myricoides gave IC50 values below 30 microg/mL against both chloroquine sensitive and resistant P. falciparum strains. Combination of extracts of E. capensis and C. myricoides with chloroquine against the multi-drug resistant P. falciparum isolate (V1/S) revealed synergistic effect. The plants which showed activity may be useful as sources for novel anti-plasmodial compounds.

Quality of care provided to febrile children presenting in rural private clinics on the Kenyan coast.

BACKGROUND: Private sector health facilities are diverse in nature, and offer widely varying quality of care (QOC). OBJECTIVES: The study aimed to describe the QOC provided to febrile children at rural private clinics on the Kenyan coast and stakeholder perspectives on standards of practice and opportunities for change. METHODS: Data collection methods were structured observations of consultations; interviews with users on exit from clinic and at home and in depth interviews with private practitioners (PP) and district health managers. FINDINGS: Private clinics have basic structural features for health care delivery. The majority of the clinics in this study were owned and run by single-handed trained medical practitioners. Amongst 92 observed consultations, 62% of diagnoses made were consistent with the history, examinations and tests performed. 74% of childhood fevers were diagnosed as malaria, and 88% of all prescriptions contained an antimalarial drug. Blood slides for malaria parasites were performed in 55 children (60%). Of those whose blood slide was positive (n=27), 52% and 48% were treated with a nationally recommended first or second line antimalarial drug, respectively. Where no blood slide was done (n=37), 73% were prescribed a nationally recommended first line and 27% received a second line antimalarial drug. Overall, 68 % of antimalarial drugs were prescribed in an appropriate dose and regime. Both private practitioners and district health managers expressed the view that existing linkages between the public and private health sectors within the district are haphazard and inadequate. CONCLUSIONS: Although rural PPs are potentially well placed for treatment of febrile cases in remote settings, they exhibit varying QOC. Practitioners, users and district managers supported the need to develop interventions to improve QOC. The study identifies the need to consider involvement of the for-profit providers in the implementation of the IMCI guidelines in Kenya.

In vitro antiplasmodial activity of some plants used in Kisii, Kenya against malaria and their chloroquine potentiation effects.

Fifty-five organic and aqueous extracts of 11 plants used in malaria therapy in Kisii District, Kenya were tested in vitro against chloroquine (CQ)-sensitive and resistant strains of Plasmodium falciparum. Of the plants tested, 73% were active (IC(50) < 100 microg/ml). Three plants, Vernonia lasiopus, Rhamnus prinoides and Ficus sur afforded extracts with IC(50) values ranging less than 30 microg/ml against both CQ-sensitive and resistant strains. Combination of some extracts with CQ against the multi-drug resistant P. falciparum isolate V1/S revealed some synergistic effect. The plant extracts with low IC(50) values may be used as sources for novel antimalarial compounds to be used alone or in combination with CQ.

CD4T lymphocyte subsets and disease manifestation in children with and without HIV born to HIV-1 infected mothers.

OBJECTIVE: To understand the natural history of HIV-1 infection in children in terms of evolution of childhood clinical manifestations versus the immune status, we prospectively studied children with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 for two years between March 1998 and March 2000. DESIGN: A prospective cohort study. SETTING: An institutional children's home. SUBJECTS: Fifty nine children (26 males and 33 females) with and without maternally transmitted HIV-1 infection born to mothers infected with HIV-1 and adopted in institutional children home. METHODS: HIV-1 status of children under nine months was confirmed by polymerase chain reaction(PCR). ELISA for HIV-1 antibody in serum/plasma was used to confirm HIV-infection status for children aged < or = 18 months. Children were visited every three months between March and June 2000. At every visit blood was collected for total white cell count, haemoglobin and CD4+ and CD8+ T cell counts. The institutional doctor routinely examined children and treated all ailments. Clinical data were recorded. MEASURES: HIV-DNA, anti-HIV antibodies, total white blood count, total T cell counts, CD4 and CD8 T cell subset counts, frequency of childhood manifestations of infection. RESULTS: The children were aged between 4.5 and 13 years. The baseline haematological and immunological profiles (mean, mode) were: HIV-1 sero-converters (WBC 7151,7150; HB 11.6, 12.0; CD4+ 686, 795; CD8+ 2168, 1507) and HIV-1 de-seroconverters (mean, mode) were: (WBC 8386, 7150; HB 11.7, 12.8; CD4+ 735, 795; CD8+ 2168, 1507). The commonest causes of illnesses among the HIV-1 children were URTI (85.3%), TB(56.1 %), pneumonia (56.2%), tonsillitis (34.1%), parotiditis (28%) and acute otitis media (25%). The distribution of clinical manifestations was similar between the two categories of children, except URTI, whose prevalence was significantly increased among HIV-1 infected children (p-value=0.006). Among the HIV-1 infected children, only TB, parotiditis, and acute otitis media (AOM) were significantly associated with decreased CD4+ T cell count (p<0.05) resulting from HIV infection. CONCLUSIONS: HIV infection in children predisposes them to common childhood infections that can be used as markers of immune decline. TB, AOM, URTI may be early indicators of suspicion that would enable selective screening for HIV infection in children.