Factors associated with typical enteropathogenic Escherichia coli infection among children <5 years old with moderate-to-severe diarrhoea in rural western Kenya, 2008-2012.

Typical enteropathogenic Escherichia coli (tEPEC) infection is a major cause of diarrhoea and contributor to mortality in children <5 years old in developing countries. Data were analysed from the Global Enteric Multicenter Study examining children <5 years old seeking care for moderate-to-severe diarrhoea (MSD) in Kenya. Stool specimens were tested for enteric pathogens, including by multiplex polymerase chain reaction for gene targets of tEPEC. Demographic, clinical and anthropometric data were collected at enrolment and ~60-days later; multivariable logistic regressions were constructed. Of 1778 MSD cases enrolled from 2008 to 2012, 135 (7.6%) children tested positive for tEPEC. In a case-to-case comparison among MSD cases, tEPEC was independently associated with presentation at enrolment with a loss of skin turgor (adjusted odds ratio (aOR) 2.08, 95% confidence interval (CI) 1.37-3.17), and convulsions (aOR 2.83, 95% CI 1.12-7.14). At follow-up, infants with tEPEC compared to those without were associated with being underweight (OR 2.2, 95% CI 1.3-3.6) and wasted (OR 2.5, 95% CI 1.3-4.6). Among MSD cases, tEPEC was associated with mortality (aOR 2.85, 95% CI 1.47-5.55). This study suggests that tEPEC contributes to morbidity and mortality in children. Interventions aimed at defining and reducing the burden of tEPEC and its sequelae should be urgently investigated, prioritised and implemented.

Diarrhoea, enteric pathogen detection and nutritional indicators among controls in the Global Enteric Multicenter Study, Kenya site: an opportunity to understand reference populations in case-control studies of diarrhoea.

Given the challenges in accurately identifying unexposed controls in case-control studies of diarrhoea, we examined diarrhoea incidence, subclinical enteric infections and growth stunting within a reference population in the Global Enteric Multicenter Study, Kenya site. Within 'control' children (0-59 months old without diarrhoea in the 7 days before enrolment, n = 2384), we examined surveys at enrolment and 60-day follow-up, stool at enrolment and a 14-day post-enrolment memory aid for diarrhoea incidence. At enrolment, 19% of controls had ⩾1 enteric pathogen associated with moderate-to-severe diarrhoea ('MSD pathogens') in stool; following enrolment, many reported diarrhoea (27% in 7 days, 39% in 14 days). Controls with and without reported diarrhoea had similar carriage of MSD pathogens at enrolment; however, controls reporting diarrhoea were more likely to report visiting a health facility for diarrhoea (27% vs. 7%) or fever (23% vs. 16%) at follow-up than controls without diarrhoea. Odds of stunting differed by both MSD and 'any' (including non-MSD pathogens) enteric pathogen carriage, but not diarrhoea, suggesting control classification may warrant modification when assessing long-term outcomes. High diarrhoea incidence following enrolment and prevalent carriage of enteric pathogens have implications for sequelae associated with subclinical enteric infections and for design and interpretation of case-control studies examining diarrhoea.

Do clients receiving Home based testing and counselling (HBTC) utilize the HIV prevention messages delivered? A study among residents in an urban informal settlement in Kenya who previously received HBTC.

BACKGROUND: Home based HIV testing and counseling (HBTC) increases access to services and is associated with high testing uptake. Alongside testing, individuals are offered HIV prevention messages with an aim of helping them reduce HIV high risk sexual behaviors. This study explored the level of provision and subsequent utilization of HIV prevention messages and associated change in behavior among individuals who had received HBTC previously in an informal settlement. METHODS: In a mixed method cross sectional study, we interviewed 1257 individuals and conducted 6 focus group discussions (FGD). Multiple correspondence analysis (MCA) was used to construct provision of prevention messages and behavior change indices using STATA 3.0. Pearson's chi-square statistics was used to test for bivariate association between the outcomes and logistic regression analysis was carried out with the behavior change index as the outcome of interest and the predictors considered significant (p<0.1). Thematic content analysis for qualitative data was done using Atlas 3.0. RESULTS: Out of the 1257participants, 1078 (85.8%) had ever tested for HIV, with 74.2% having tested in the Kibera HBTC program. Nearly all (97.4%) rated HBTC experience as either excellent (62.4%) or good (37%) and would recommend it to a friend. Provision of prevention messages was high among HBTC clients compared to clients from other testing sites; partner reduction counselling (64% versus 52%) and faithfulness (78.3% versus 67%); p=0.001. Self-reported behavior change after HBTC was generally low with condom use at 10.7% and men more likely to practice safer sex (p = 0.002). Trust of the sexual partners and fear of suspicion were the main reasons given for not using condoms. Clients testing HIV positive after previous negative result were 3.4%. The focus group discussions reported multiple sexual partnerships among both HIV negative and positive residents alike. CONCLUSION: Although prevention messages delivered during HBTC are accepted and appreciated in this community, their utilization is low in both HIV negative and positive individuals. Innovative strategies for change of normative beliefs about sexual behavior are urgently needed.

BRUCELLOSIS IN TEREKEKA COUNTY, CENTRAL EQUATORIA STATE, SOUTHERN SUDAN.

OBJECTIVES: To identify factors associated with Brucellosis in patients attending Terekeka Health Facility, Terekeka County, Central Equatoria State, Southern Sudan and to evaluate the utility of the rapid test kit Euracil®. DESIGN: A facility based case-control study. SETTING: Terekeka Health Facility, Terekeka County, Central Equatoria State, Southern Sudan. SUBJECTS: Cases were patients presenting at the Terekeka Health Facility with clinical symptoms suggestive of Brucellosis and tested positive for Brucellosis by rapid antigen test while controls were selected from individuals attending Terekeka Health facility with health problems unrelated to brucellosis or febrile illness. RESULTS: A total of fifty eight cases with clinical symptoms suggestive of and tested positive for Brucellosis by rapid antigen test presented. A total of 116 consented controls were recruited into the study. Males accounted for 52% of the cases and 53% of the controls. The mean age was 31 years for both groups. Cases without formal education were 84% while 40% had no source of income, 20% of the cases and 14% of the controls were cattle keepers while 5% of the cases and 13% of the controls were students. In multivariate analysis there were many factors associated with Brucellosis like consumption of raw meat, living with animals at the same place, raising of goats, farm cleaning contact, eating of aborted and wild animals. Logistic regression revealed two factors associated with the disease; consumption of raw milk (OR=3.9, P-value 0.001, 95% CI 1.6666-9.0700) was a risk factor while drinking boiled milk was protective (OR = 0.09, p-value 0.000, 95% CI, 0.1-0.2). CONCLUSIONS: The main age-groups affected were 20-30 years with males being affected more than females. Drinking of raw milk was significantly associated with Brucellosis while drinking boiled milk was protective. There should be active public health education on the benefits of boiling milk before consumption. Further studies to elucidate the extent and epidemiology of brucellosis in humans and animals in Southern Sudan are recommended.

Syphilis among pregnant women in Juba, Southern Sudan.

OBJECTIVE: Determine factors associated with syphilis among pregnant women. DESIGN: Cross-sectional study. SETTING: Antenatal clinics of Juba Teaching Hospital, Malakia National Health Insurance Centre and Munuki Primary Health Care Centre in Juba, Southern Sudan. SUBJECTS: Consenting pregnant women not on syphilis treatment. MAIN OUTCOME MEASURES: Socio-demographic and clinical data, knowledge and behavioural characteristics. RESULTS: Of the 231 pregnant women participants, 51 (22.1%) were positive for syphilis with the rapid plasma reagin test and 79 (34.2%) were positive with the treponema pallidum Haemagglutination assay. Risk factors for syphilis were: housewife (OR 2.808; P= 0.0116), abortion (OR 2.654; P= 0.0116) and partner travel (OR 2.149; P= 0.028). Attending antenatal clinic for previous pregnancy was protective (OR 0.281; P= 0.0004) for syphilis. CONCLUSIONS: This is the first study to determine the prevalence and associated factors in the three clinics in Juba, South Sudan. There is a high prevalence of syphilis in pregnant women attending the selected health facilities. Treponema Pallindum Haemagglulination Assay can be used as a field test for syphilis due to its high sensitivity and specificity. Health education, screening and treating positive expectant mothers can reduce the prevalence of syphilis.

Molecular typing and antibiotic susceptibility patterns of enteropathogenic and shigatoxin producing Escherichia coli isolated from food handlers in three areas of Kenya.

OBJECTIVES: To determine the aetiology, epidemiology and sanitary factors of carriage of enteropathogenic Escherichia coli (EPEC) and Shiga-toxin producing E. coli (STEC) in food-handlers working in tourist hotels in three popular tourist destinations in Kenya. DESIGN: Cross sectional laboratory based study. SETTING: Three tourist destinations of Nairobi, Malindi and Diani in Kenya. SUBJECTS: Food handlers who were working in hotels frequented by tourists in the three study sites. RESULTS: Overall, during the period of April 2003 to May 2004, a total of 1399 food handlers stool samples were collected and analysed. EPEC expressing the eaeA gene and STEC expressing the stx2 gene were detected in 11/1399 (0.8%) and 2/1399 (0.1%) of the study subjects respectively. The mean age of the subjects from whom EPEC and STEC were isolated was similar (32.6 years) to those from whom no EPEC and STEC were isolated (32.5 years). Prior use of antibiotics, water source and toilet types were not significantly associated with the isolation of EPEC and STEC (p>0.05). There were 11 resistance patterns with six isolates (6/13, 46.2%) showing multidrug resistance. High prevalence of resistance was observed to co-trimoxazole (55.6%), chloramphenicol (33.3%), ampicillin (22.2%) and tetracycline (22.2%). High concentrations of antibiotics were required to achieve MIC90 for tetracycline, (>64 mg ml(-1)) and ampicillin (>256 mg ml(-1)). Cluster analysis of the Pulse Field Gel Electrophoresis profiles revealed that the EPEC and STEC isolates belonged to two main genotypes with 11 distinct DNA fragment profiles. CONCLUSION: This is the first report in Africa on the isolation of STEC from food handlers working in tourist hotels. These food handlers who carry the STEC and EPEC could potentially infect tourists and other people through food or water contamination in the hotel settings and thus our findings are of great public health importance.

Non-typhi salmonella in children with severe malaria.

OBJECTIVE: To determine the association between Plasmodium falciparum malaria and non-typhi Salmonella in children. DESIGN: Cross-sectional hospital based study. SETTING: Kilifi District Hospital (KDH) between January 1997 and June 2001. SUBJECTS: Children aged between three months to 123 months (mean age 28.28 months) and who had been admitted to the paediatric or High Dependency Research Ward (HDRW) of the KDH. METHODS: A total of 19, 118 blood cultures routinely obtained for all admissions and 1,820 clinically indicated stools samples were obtained from 9,147 children admitted with malaria. The specimens were cultured and antibiotic sensitivity done using standard laboratory procedures with stringent internal and external quality control in place. RESULTS: The total bacterial pathogens isolated from blood and stool were 1,395/19,118 (7.3%) and 342/1,820 (19%) respectively. Non-typhi salmonella consisted of 260/1,395 (18.6%) of the positive blood cultures and 92/324 (28.4%) of the stool cultures out of which a total of 101 NTS occurred in children with severe malaria. Out of the 9,147 malaria cases admitted, 101/9,147 (1.10%) had concomitant NTS infection. NTS with severe malaria as a proportion of all malaria admissions for the period varied between 0.8% and 1.5%. There was a significant association (p-value=0.032) between clinical outcome of death and female sex of the patient. The NTS isolates which occurred with severe malaria showed various levels of antibiotic resistance. They were resistant to ampicillin (35%), chloramphenicol (18%), gentamicin (22%), cefuroxime (29%), sulphamethoxazole-trimethoprim (39%), ciprofloxacin (3%), cefotaxime (14%), amoxycillin-clavulanic acid (26%) and tobramycin (18.0%). Multidrug resistance (MDR) was seen in 34 (33.6%) of the isolates. CONCLUSIONS: NTS and severe malaria occurring together are a problem in this area and that a large number of the isolates are MDR. An elaborate case-controlled study is required to elucidate the chain of events of both NTS and malaria parasite co-existence.

Prevention of bacterial diarrhea by pasteurization of drinking water in Kenya.

Diarrheal disease is one of the major causes of morbidity and mortality in developing countries. Drinking water is a primary transmission route of infectious diarrheagenic bacteria in a rural area of Kenya (Microbiol. Immunol. 41: 773-778, 1997). We tried to prevent diarrhea at villages with approximately 1,500 households in Kenya by pasteurizing drinking water. A durable simple thermoindicator which changes color at 70 C was used as an indicator of pasteurization. The number of households in which drinking water was coliform bacteria-free increased from 10.7% to 43.1% after adoption of a pasteurization practice. Consequently, the incidence of severe diarrhea among people drinking pasteurized water was significantly lower than in people taking raw water (odds ratio=0.55, P=0.0016). The reduction ratio of the incidence after pasteurization was nearly equivalent with that after the adoption of a boiling method. Employment of women leaders as fieldworkers and demonstration of bacterial colony disappearance on agar plates by pasteurization also affected reduction of the diarrheal incidence.

Genotypes of multidrug-resistant Salmonella enterica serotype typhimurium from two regions of Kenya.

A combination of phage typing and pulsed-field gel electrophoresis of Xbal-digested chromosomal DNA has been used to study the epidemiological relationships of multidrug-resistant Salmonella enterica serotype typhimurium from Nairobi (64 isolates) and Kilifi (40 isolates) collected over the period 1994-1997. Isolates from Nairobi belonged to 11 definitive phage types (DTs) encompassing eight different PFGE patterns. In contrast, isolates from Kilifi were mainly DT 56 (60%) and all fell into a single PFGE pattern. The remaining isolates did not conform to a recognisable phage type. We conclude that multidrug-resistant S. typhimurium infections from Nairobi were caused by multiple strains while those from Kilifi were likely to be from a microepidemic caused by a single clone.

Antibiotic susceptibility and genotypes of non-typhi Salmonella isolates from children in Kilifi on the Kenya coast.

A 4-year retrospective study was undertaken at the Kilifi District Hospital on the coast of Kenya to determine the antibiotic-susceptibility patterns and genotypes of non-typhi Salmonella (NTS) isolates from children. Overall, during the period 1994-97, positive cultures were obtained from 543 (14%) of 3885 blood samples, 364 (30%) of 1210 stool samples and 143 (11%) of 1283 cerebrospinal fluid (CSF) samples. NTS were isolated from 151 (27.8%), 72 (19.8%), and 11 (7.7%) of these positive cultures, respectively. The total 234 NTS isolates were serotyped: the most frequent were Salmonella enterica serotype Enteritidis (41%) and S. enterica serotype Typhimurium (38%). Antibiotic sensitivity testing was done using ampicillin (amp), chloramphenicol (chl), gentamicin (cn), co-trimoxazole (s-t), cefuroxime (cxm), ciprofloxacin (cip), cefotaxime (ctx), amoxicillin-clavulanic acid 20 micrograms-10 micrograms (amc), and tobramycin (tob). Of the 234 isolates, 43 were sensitive to all antibiotics tested and 133 were multiple drug resistant (MDR). The most common resistance type seen was amp, cn, cxm, s-t, ctx, amc, tob (36/234). Our results indicate a high proportion of MDR amongst the isolates from Kilifi. We conclude that 2 major serotypes of salmonella, i.e., S. enterica serotype Typhimurium and S. enterica serotype Enteritidis, of micro-epidemic nature that have been previously unrecognized in Kilifi are responsible for infection in Kilifi district on the coast of Kenya and that over half (56.8%) of total NTS isolates are MDR.

Multidrug-resistant enteroaggregative Escherichia coli associated with persistent diarrhea in Kenyan children.

To study the association of multidrug-resistant enteroaggregative Escherichia coli with persistent diarrhea in Kenyan children, stool specimens were obtained from 862 outpatients under 5 years of age from July 1991 to June 1993. E. coli O44 was identified as the sole bacterial pathogen in four patients experiencing at least 14 days of fever, vomiting, and diarrhea. Disk diffusion testing showed E. coli O44 resistance to tetracycline, ampicillin, erythromycin, trimethoprim-sulphamethoxazole, and amoxicillin/clavulanate and sensitivity to chloramphenicol, nalidixic acid, azithromycin, and cefuroxime. Further studies are needed to clarify the epidemiology, clinical spectrum, and pathogenesis of enteroaggregative E. coli infection.

Epidemiological study on infectious diarrheal diseases in children in a coastal rural area of Kenya.

Diarrheal diseases are major causes of morbidity and mortality among children in developing countries. We have analyzed the causative agents of diarrhea in children under five years of age who resided in rural environments but attended a hospital in Malindi, a coastal town in Kenya. Bacterial diarrhea was found in 239 (27.7%) of 862 patients with diarrhea. Diarrheagenic Escherichia coli, including enteropathogenic, enterotoxigenic, and enterohaemorrhagic strains, was isolated from 119 (13.8%) patients, followed by Salmonella spp. (63 cases, 7.3%) and Shigella spp. (56 cases, 6.5%). Intestinal parasites were found in 109 (12.6%) of the patients. Entamoeba histolytica and Giardia lamblia were found in 67 (7.8%) and 42 (4.9%) of the cases, respectively. Rotavirus was found in 69 (16.1%) of 428 cases, a part of the 862 cases. Significant differences in age distribution were seen in diarrheal cases due to Campylobacter spp., G. lamblia, and rotavirus. No significant seasonal incidence of specific pathogens was found, but the number of diarrheal patients was significantly correlated to rainfall. Drinking water was contaminated with bacteria at concentrations ranging from 10(3) to 10(6) CFU/ml in 98% of the households and by coliform bacteria at concentrations of 10(2) to 10(5) CFU/ml in 72% of the households. These results suggest that the main routes of infection may be contaminated drinking water and fecal-oral transmission of enteric pathogens. Consequently, we propose that the enhancement of hygienic practice through health education is a feasible control measure of diarrhea in the study area.

Outbreak of dysentery Is Kenya due to multi-resistant polyclonal strain of Shigella dysenteriae type 1.

Sixty-eight strains of multi-drug resistant Shigella dysenteriae type 1 were isolated from outbreaks of severe dysentery in three areas of Kenya, namely, Kisumu, Mombassa and Nairobi. The strains were tested for their susceptibility to seven antibiotics. Plasmids were extracted to study their variety and conjugated with Escherichia coli K12 to identify the plasmid coding for the resistance gese. All the strains were resistant to ampicillin, trimethoprim-sulfamethoxazole (S-T), tetracyciine and chloramphenicol. They were sensitive to gentamicin, kanamycin and nalidixic acid. Part of the resistance was found to be plasmid mediated and the sizes of plasmids coding resistance gene wereSMDaand 19MDa. These piasmids coded resistance for ampicillin, trimethoprim-sulfamethoxazole, tetracyciine and chloramphenicol. Verotoxin (VT) production was demonstrated in 80% of the strains by oligonucleotide DNA-DNA gybridization of whole cells with the VT-probe. In view of the extent of drug resistance exhibited by Shigella dysenteriae Type 1 in this study, we recommend the use of nalidixic acid as a first choice of treatment in multiresistant S. dysenteriae Type 1 dysentery outbreaks. Compared to the other two agents that the pathogen was sensitive to, nalidixic acid is relatively cheap with the cost of 7 days treatment for an adult being approximately five US dollars. Resistance to nalidixic acid has to be, however, closely monitored as S. dysenteriae Type 1 has been reported to develop resistance to this drug over time.

Plasmid profiles of E. coli, Salmonella and shigella organisms isolated in Kenya.

A number of serotypable E. coli, Salmonella and Shigella strains isolated from three districts in Kenya were investigated for carriage of plasmids. This was done through extraction of plasmids and separating them by electrophoresis on agarose. Most of the strains investigated showed presence of plasmids. The E. coli isolates had plasmids ranging in number from 1 to 5, the most common number was 2. The plasmid sizes ranged from 80 to 30 megadalton, the commonest of the heavy plasmids were 70 megadalton. The Shigella isolates had plasmids ranging in number from 1 to 3, the most common number was 1. The plasmid sizes ranged from 80 to 3.5 megadalton, the commonest of the heavy plasmids were 70 megadalton. Various plasmid-sizes have been published as being responsible for pathogenicity.

Resistance of E. coli strains, recovered from chickens to antibiotics with particular reference to trimethoprim-sulfamethoxazole (septrin).

Thirty-seven strains of E. coli recovered from cases of septicaemia in chicken were tested for sensitivity to 6 antibiotics. Minimum inhibitory concentration (MIC) determinations done on the strains showed resistance to trimethoprim-sulfamethoxazole (septrin) (100%), ampicillin (62.2%), tetracycline (51.4%), kanamycin (13.5%) and gentamicin (2.7%). All were sensitive to chloramphenicol. Conjugation studies showed easy transfer of the resistance factor for septrin to the recipient sensitive strain, K12F-, a 60 megadalton plasmid was transferred in most of the cases (a number of plasmids moved across to K12F- strains). Septrin was chosen as a referral antibiotic because it is used extensively for treating diarrhoeal cases in children in Kenya. The results expressed the possibility of the chicken being the possible source of the septrin resistance gene (plasmid) for humans, and vice versa.

Aetiogical agents of diarrhea in children living in a malaria epidemic area of Kenya

One hundred and four fecal specimen of children under five years reporting to Malindi Hospital were analysed for diarrhoegenic agents. These included bacterial; viral and parasitic agents which may cause diarrhoea. Conventional methods were employed in this study. The children were also examined for malaria parasites. consistency of the stool samples was loose 49; watery 26; formed 16; mucoid 9 and 3 of the specimen had traces of blood. 29 of the children were positive for malaria. Detection of diarrhoegenic agents was as follows;- 1. Bacteria 34; the highest of these being pathogenic Escherichia coli 39; Salmonella 28; Shigella 28 and Vibrio parahaemolyticus 3; 2. Rotaviruses 28; 3. Parasites 10 which included Ascaris lumbricoides 44; Trichuris trichura 33; Giardia lamblia 22 and Entamoeba coli 11. Mixed infections were observed in 7 of the subjects. Aetiological agents of diarrhoea could not be detected in 30 of the specimen

Minimum inhibitory concentration of antibiotics against bacteria associated with childhood diarrhoea in children attending a district hospital in Kenya

A study to determine the in vitro activity of antibiotics to bacterial pathogens isolated from diarrhoea stools of 125 patients reporting to the Paediatric Filter Clinic at Malindi District Hospital with acute diarrhoea was done. The ages of the patients ranged from one to five years. Samples of diarrhoea stools were collected before drug administration. 33 strains of Enterobacteriacea comprising 12 strains of pathogenic Escherichia coli; 13 strains of Salmonella SPP and 8 strains of Shigella SPP were isolated and minimum inhibitory concentration of five antibiotics determined. 5 pure antibiotic powders; namely; ampicillin; tetracycline; kanamycin; trimethoprim-sulfamethoxazole and nalidixic acid were tested using the agar dilution method (Muellerinton agar). The minimum inhibitory concentration (MIC) of the 5 antibiotics used ranged between 8#gml-1 and 128#gml-1 excep for t trimethoprin-sulfamethoxazole which had a MIC range of 0.25#gml-1 to 16#gml-1. Hyper resistance of the isolates was observed for ampicillin; tetracycline; kanamycin and nalidixic acid. The results of this work suggest that there is circulation of resistant strains of bacteria causing diarrhoea within the community around Malindi