What women want: A mixed-methods study of women's health priorities, preferences, and experiences in care in three Rwandan rural districts.

OBJECTIVE: To explore Rwandan women's experiences, priorities, and preferences in accessing health care for non-pregnancy-related conditions and inform development of healthcare services related to these conditions among women of reproductive age at district hospitals and health centers in Rwanda. METHODS: We used a mixed-methods, exploratory sequential design. Semi-structured qualitative interviews were conducted with Rwandan women and coded thematically. A cross-sectional quantitative survey based on the qualitative data was administered to women attending health centers. RESULTS: Seventeen interviews and 150 surveys were conducted. Women identified conditions including back pain, gynecologic cancers, and abnormal vaginal bleeding as concerns. They generally reported positive experiences while accessing health care and knowledge of accessing health care. Barriers to care were identified, including transportation costs and inability to miss work. Women expressed a desire for more control over their care and the importance of maintaining their dignity while accessing health care. CONCLUSION: These findings provide useful insights to inform development of non-pregnancy-related healthcare services for women in Rwanda according to their priorities and preferences. The reported end-user health concerns, barriers to care, and diminished control over their care point to a need to evolve health systems around user-tailored needs and design interventions optimizing access whilst promoting dignified care.

Trends in TB and HIV care and treatment cascade, Kenya, 2008-2018.

BACKGROUND: HIV infection is associated with high mortality among people with TB. Antiretroviral therapy (ART) reduces TB incidence and mortality among people living with HIV (PLHIV). Since 2005, Kenya has scaled up TB and HIV prevention, diagnosis and treatment. We evaluated the impact of these services on trends and TB treatment outcomes.METHODS: Using Microsoft Excel (2016) and Epi-Info 7, we analysed Kenya Ministry of Health TB surveillance data from 2008 to 2018 to determine trends in TB notifications, TB classification, HIV and ART status, and TB treatment outcomes.RESULTS: Among the 1,047,406 people reported with TB, 93% knew their HIV status, and 37% of these were HIV-positive. Among persons with TB and HIV, 69% received ART. Between 2008 and 2018, annual TB notifications declined from 110,252 to 96,562, and HIV-coinfection declined from 45% to 27%. HIV testing and ART uptake increased from 83% to 98% and from 30% to 97%, respectively. TB case fatality rose from 3.5% to 3.9% (P <0.018) among HIV-negative people and from 5.1% to 11.2% (P <0.001) among PLHIV on ART.CONCLUSION: TB notifications decreased in settings with suboptimal case detection. Although HIV-TB services were scaled-up, HIV-TB case fatality rose significantly. Concerted efforts are needed to address case detection and gaps in quality of TB care.

Can isoniazid preventive therapy be scaled up rapidly? Lessons learned in Kenya, 2014-2018.

BACKGROUND: TB is the leading cause of mortality among people living with HIV (PLHIV), for whom isoniazid preventive therapy (IPT) has a proven mortality benefit. Despite WHO recommendations, countries have been slow in scaling up IPT. This study describes processes, challenges, solutions, outcomes and lessons learned during IPT scale-up in Kenya.METHODS: We conducted a desk review and analyzed aggregated Ministry of Health (MOH) IPT enrollment data from 2014 to 2018 to determine trends and impact of program activities. We further analyzed IPT completion reports for patients initiated from 2015 to 2017 in 745 MOH sites in Nairobi, Central, Eastern and Western Kenya.RESULTS: IPT was scaled up 75-fold from 2014 to 2018: the number of PLHIV covered increased from 9,981 to 749,890. The highest percentage increases in the cumulative number of PLHIV on IPT were seen in the quarters following IPT pilot projects in 2014 (49%), national launch in 2015 (54%), and HIV treatment acceleration in 2016 (158%). Among 250,069 patients initiating IPT from 2015 to 2017, 97.5% completed treatment, 0.2% died, 0.8% were lost to follow-up, 1.0% were not evaluated, and 0.6% discontinued treatment.CONCLUSIONS: IPT can be scaled up rapidly and effectively among PLHIV. Deliberate MOH efforts, strong leadership, service delivery integration, continuous mentorship, stakeholder involvement, and accountability are critical to program success.

Prevalence of symptoms of asthma, rhinitis and eczema in 13- to 14-year-old children in Africa: the International Study of Asthma and Allergies in Childhood Phase III.

Phase I of the International Study of Asthma and Allergies in Childhood has provided valuable information regarding international prevalence patterns and potential risk factors in the development of asthma, allergic rhinoconjunctivitis and eczema. However, in Phase I, only six African countries were involved (Algeria, Tunisia, Morocco, Kenya, South Africa and Ethiopia). Phase III, conducted 5-6 years later, enrolled 22 centres in 16 countries including the majority of the centres involved in Phase I and new centres in Morocco, Tunisia, Democratic Republic of Congo, Togo, Sudan, Cameroon, Gabon, Reunion Island and South Africa. There were considerable variations between the various centres of Africa in the prevalence of the main symptoms of the three conditions: wheeze (4.0-21.5%), allergic rhinoconjunctivitis (7.2-27.3%) and eczema (4.7-23.0%). There was a large variation both between countries and between centres in the same country. Several centres, including Cape Town (20.3%), Polokwane (18.0%), Reunion Island (21.5%), Brazzaville (19.9%), Nairobi (18.0%), Urban Ivory Coast (19.3%) and Conakry (18.6%) showed relatively high asthma symptom prevalences, similar to those in western Europe. There were also a number of centres showing high symptom prevalences for allergic rhinoconjunctivitis (Cape Town, Reunion Island, Brazzaville, Eldoret, Urban Ivory Coast, Conakry, Casablanca, Wilays of Algiers, Sousse and Eldoret) and eczema (Brazzaville, Eldoret, Addis Ababa, Urban Ivory Coast, Conakry, Marrakech and Casablanca).

Cost-effectiveness of polymerase chain reaction versus Ziehl-Neelsen smear microscopy for diagnosis of tuberculosis in Kenya.

BACKGROUND: Laboratory services, particularly in large sub-Saharan cities, are overstretched, and it is becoming difficult both for patients and health staff to adhere to the diagnostic procedures for tuberculosis. Alternative techniques would be welcome. The polymerase chain reaction (PCR) has the potential to be cost-effective. We compared the cost-effectiveness of two diagnostic strategies, Ziehl-Neelsen (ZN) on three specimens followed by chest X-ray (CXR), and AMPLICOR MTB PCR on the first specimen only. METHODS: Three sputum samples were collected from tuberculosis (TB) suspects attending the Rhodes Chest Clinic, Nairobi. All samples were subjected to ZN, PCR and Löwenstein-Jensen culture used as gold standard. CXR was used to diagnose smear-negative TB. Cost analysis included health service and patient costs. RESULTS: Costs per correctly diagnosed case were US dollar 41 and dollar 67 for ZN and PCR, respectively. When treatment costs were included, including treatment of culture-negative cases, PCR was more cost-effective: dollar 382 vs. dollar 412. CONCLUSION: PCR may be an alternative in settings with many patients. PCR is patient friendly, CXR is not necessary and, unlike ZN, its performance is hardly affected by the human immunodeficiency virus. PCR can handle large numbers of specimens, with results becoming available on the same day.

Sex-specific performance of routine TB diagnostic tests.

SETTING: City Council Chest Clinic, Nairobi, Kenya. OBJECTIVE: To determine to what extent the performance of smear microscopy is responsible for sex differences in notification rates. METHODOLOGY: Three sputum samples from TB suspects were subjected to smear microscopy with Ziehl-Neelsen (ZN) and auramine (FM) staining. Lowenstein-Jensen culture was used as the gold standard. RESULTS: Of 998 suspects, 600 (60%) were men and 398 (40%) women. The odds of detecting culture-positive patients with ZN was lower for women (OR 0.67). By examining the first spot specimen, ZN detected 35% of culture-positive males and 26% of culture-positive females. These proportions increased to respectively 63% and 53% when examining three specimens, and to 79% and 74% when using FM. The sex difference reduced and became non-significant (P = 0.19) when adjusted for HIV; however, the numbers involved for HIV stratification were low. CONCLUSION: The performance of a diagnostic tool contributes to sex differences in notification rates and influences male/female ratios. Women were less likely to be diagnosed (P = 0.08), and when ZN was used they were less likely to be labelled as smear-positive TB (P < 0.01). The application of more sensitive diagnostic tools such as FM is to the advantage of women.

Quality of glycaemic control in ambulatory diabetics at the out-patient clinic of Kenyatta National Hospital, Nairobi.

BACKGROUND: Treatment of diabetes mellitus is based on the evidence that lowering blood glucose as close to normal range as possible is a primary strategy for reducing or preventing complications or early mortality from diabetes. This suggests poorer glycaemic control would be associated with excess of diabetes-related morbidity and mortality. This presumption is suspected to reach high proportions in developing countries where endemic poverty abets poor glycaemic control. There is no study published on Kenyan patients with diabetes mellitus about their glycaemic control as an audit of diabetes care. OBJECTIVE: To determine the glycaemic control of ambulatory diabetic patients. DESIGN: Cross-sectional study on each clinic day of a randomly selected sample of both type 1 and 2 diabetic patients. SETTING: Kenyatta National Hospital. METHODS: Over a period of six months, January 1998 to June 1998. During routine diabetes care in the clinic, mid morning random blood sugar and glycated haemoglobin (HbA1c) were obtained. RESULTS: A total of 305 diabetic patients were included, 52.8% were females and 47.2% were males. 58.3% were on Oral Hypoglycaemic Agent (OHA) only, 22.3% on insulin only; 9.2% on OHA and insulin and 4.6% on diet only. 39.5% had mean HbA1c < or = 8% while 60.5% had HbA1c > or = 8%. Patients on diet-only therapy had the best mean HbA1c = 7.04% while patients on OHA-only had the worst mean HbA1c = 9.06%. This difference was significant (p=0.01). The former group, likely, had better endogenous insulin production. The influence of age, gender and duration of diabetes on the level of glycaemic control observed did not attain statistically significant proportions. CONCLUSION: The majority of ambulatory diabetic patients attending the out-patient diabetic clinic had poor glycaemic control. The group with the poorest level of glycaemic control were on OHA-only, while best control was observed amongst patients on diet-only, because of possible fair endogenous insulin production. Poor glycaemic control was presumed to be due to sub-optimal medication and deteriorating diabetes. There is need to empower patients with knowledge and resources to enhance their individual participation in diabetes self-care. Diabetes care providers and facilities also need capacity building to improve care of patients with diabetes.

Pneumocystis carinii pneumonia in HIV/AIDS patients at an urban district hospital in Kenya.

BACKGROUND: Pneumocystis carinii pneumonia has generally been regarded to be an uncommon opportunistic infection in HIV infected individuals in sub-Saharan Africa. The reason for this has not been clear but postulates included a lack of suitable pathogenic types in the African environment, diagnostic difficulties and the more commonly held belief that African HIV infected individuals were dying early from common non-opportunistic pathogens before severe degrees of immunosuppression occured. Recently a trend has emerged at the Mbagathi district hospital whereby an increasing number of HIV infected patients are empirically treated for Pneumocystis carinii pneumonia (PCP) based on clinical and radiological features. OBJECTIVE: To determine the prevalence of PCP and clinical outcomes of HIV infected patients presenting at the Mbagathi District Hospital, Nairobi with the presumptive diagnosis of PCP. SETTING: Mbagathi District Hospital, a 169-bed public hospital in Nairobi, Kenya. METHODS: Patients presenting with a sub-acute onset of cough and dyspnoea were eligible for the study if they were found to have bilateral pulmonary shadows and had negative sputum smears for AFBS. Consenting patients who had no contraindication to fiberoptic bronchoscopy had a clinical evaluation which was followed with a fiberoptic bronchoscopy procedure where bronchoalveolar lavage fluid (BALF) was obtained. BALF was examined for cysts of P. carinii using toluidine blue stain and immunofluorescent antibody test (IFAT). BALF was also processed for fungi, bacteria and mycobacteria using routine procedures. Standard treatment with high dose cotrimoxazole was offered to all patients who were then followed up until discharge from hospital or death whichever came first. RESULTS: Between June 1999 and August 2000 a total of 63 patients were referred for bronchoscopy. Of these four declined to undergo the fiberoptic bronchoscopy procedure, four died before the procedure could be done, one was judged too sick to undergo the procedure and three had been on cotrimoxazole for longer than five days. Thus 51 patients underwent bronchoscopy. Pneumocystis carinii stain was positive in 19 (37.2%) while death occured in 16 (31.4%) of the 51 patients. There were more deaths in those without PCP but this difference was not statistically significant (odds ratio 0.68 (95% CI 0.35-1.32; P=0.2). CONCLUSION: PCP was found to be common in HIV infected patients presenting with clinical and radiological features of the disease. The mortality rate for patients with a presumptive diagnosis of PCP is high. This study suggests that cotrimoxazole preventive therapy may be a useful intervention in symptomatic HIV infected patients in Kenya for the prevention of PCP and may avert deaths from this disease.

Tuberculosis re-treatment outcomes within the public service in Nairobi, Kenya.

OBJECTIVES: This study was undertaken to describe treatment outcomes in patients started on a re-treatment drug regimen, assess the quality of follow up procedures and the adequacy of the currently advocated re-treatment drug regimen in Nairobi, Kenya. DESIGN: A retrospective study. SETTING: Mbagathi District Hospital (MDH), Nairobi, a public hospital that serves as the Tuberculosis (Tb) referral centre for Nairobi. MATERIALS AND METHODS: The Tb register at the MDH was used to identify patients who were on the re-treatment regimen for Tb. Case records for these patients were then retrieved. From these sources, information on age, sex, HIV status, previous and current tuberculosis disease and drug regimens, adherence to treatment and treatment outcomes, was obtained. Descriptive statistics was used to analyse the data. RESULTS: Of the total of 4702 patients registered at the MDH between 1996 and 1997, 593 (12.6%) were patients with either recurrent Tb, returning to treatment after default or had failed initial treatment. Of the 593 patients, case records were unavailable for 168 and 17 were children below the age of ten in whom the diagnosis of Tb was uncertain making a total of 185 patients who were excluded from the study. Of the remaining 408 patients, 77 (18.9%) were cured, 61 (15.0%) completed treatment without confirmation of cure, two (0.5%) defaulted, six (1.5%) died and 262 (64.2%) had no outcome information. There were no treatment failures. Treatment success defined as cure or treatment completion was achieved in 94.5% of the 146 patients in whom outcome data were available. HIV positive patients had a statistically significant poorer success rate (34/40, 85%) when compared with HIV negative patients (104/106, 94%), p=0.004. Mycobacterium tuberculosis culture and drug susceptibility testing, was not done. CONCLUSION: The high number of patients with no treatment outcome information at the MDH is worrying, as these patients may harbour drug resistant bacilli and reflects an inadequate follow up service for Tb re-treatment in Nairobi. However, where treatment outcomes could be assessed, the currently advocated re-treatment regimen achieved a high success rate. These observations point to an urgent need to improve Tb documentation and follow up procedures within the public service in Nairobi in order to forestall the emergence and spread of drug resistant Tb.

Part time female sex workers in a suburban community in Kenya: a vulnerable hidden population.

BACKGROUND: In sub-Saharan Africa, female sex workers (FSWs) are a vulnerable high risk group for the acquisition and transmission of sexually transmitted infections (STI) and HIV. OBJECTIVES: To study parameters of sexual behaviour and knowledge of STI and HIV, to describe health seeking behaviour related to STI, and to measure the prevalence of gonorrhoea, chlamydia, syphilis, and HIV-1, to provide baseline data for targeted STI and HIV prevention interventions. METHODS: In a cross sectional survey with snowballing recruitment, between February and March 2000, 503 self identified FSWs in a suburb in Mombasa, Kenya, were interviewed with a structured questionnaire and screened for gonorrhoea, chlamydia, syphilis, and HIV-1. RESULTS: The mean number of sexual partners in the previous week was 2.8 (SD 1.6). The mean number of non-regular clients and regular clients in the previous week was 1.5 (1.0) and 1.0 (0.9) respectively. The median weekly income from sex work was $US15. A total of 337 (67%) women had an alternative income in the informal sector. 146 (29%) and 145 (45%) never used a condom with a client and non-paying partner respectively. The prevalence of gonorrhoea, chlamydia, and syphilis was 1.8%, 4.2%, and 2.0% respectively. The overall HIV-1 seroprevalence was 30.6%. CONCLUSIONS: There is a large need for intensive STI and HIV prevention interventions in part time FSW.

Validity of random blood glucose as a predictor of the quality of glycaemic control by glycated haemoglobin in out-patient diabetic patients at Kenyatta National Hospital.

BACKGROUND: Patients with diabetes mellitus in Kenya come to the hospital for follow-up visits very infrequently. For most of these patients their blood glucose monitoring is done only on the day of visit to the doctor. OBJECTIVE: To determine how well the physician-based morning random blood level determines or reflects the quality of glycaemic control. DESIGN: Cross-sectional study (morning, random blood glucose taken between 8.00 a.m. and 12.00 noon). SETTING: Out-patient diabetic clinic of Kenyatta National Hospital. SUBJECTS: Patients with diabetes mellitus either type 1 or type 2 attending the out-patient clinic. MAIN OUTCOME MEASURES: Random blood glucose (morning) and glycated haemoglobin (HbA1c). RESULTS: The morning random glucose level had a linear relationship with glycated haemoglobin levels taken simultaneously. A blood glucose level of 7 mmol/l had 92.7% sensitivity for good control (HbA1c < or = 7.8%) on a blood sample which was taken simultaneously and 59.8% specific for the same. When blood glucose cut-off level was raised to 10 mmol/l sensitivity fell to 66.3% for HbA1c < or = 7.8%, and 83.2% specificity for poor glycaemic control (HbA1c > 7.8%). There was marked fall in sensitivity of rising random blood glucose level in predicting good glycaemic control in our study, with concomitant rise in specificity of those high cut-off levels of blood glucose in predicting poor glycaemic control. CONCLUSION: Morning random blood glucose in the ambulatory diabetic patients related well to simultaneously assayed HbA1c. Blood glucose within usual therapeutic targets of 4-8 mmol/l predicted good glycaemic control (HbA1c < or = 7.8%) with high sensitivity at the range of 86.3-98.4%. In resource-poor settings, the morning random blood glucose assay, which is done in patients who may attend the diabetic clinic in the morning hours, may be used to predict the quality of their diabetic control. However caution should be exercised in its widespread use because its overall applicability may be clinic-specific depending largely on the average metabolic control of the diabetic population using that clinic. Further studies need to be done to relate HbA1c to blood glucose levels obtained at different times of the day in this population to determine the best predictor of good glycaemic control.

Under-diagnosis of smear-positive pulmonary tuberculosis in Nairobi, Kenya.

SETTING: Nairobi City Council Chest Clinic, Nairobi, Kenya. OBJECTIVE: To determine if under-reading of sputum smears is a contributing factor in the disproportionate increase in smear-negative tuberculosis in Nairobi, Kenya. METHODOLOGY: Between October 1997 and November 1998, patients fulfilling the local programme definition of smear-negative presumed pulmonary tuberculosis were enrolled in the study. Two further sputum specimens were collected for examination in a research laboratory by fluorescence microscopy. RESULTS: Of 163 adult subjects enrolled, 55% were seropositive for the human immunodeficiency virus type 1 (HIV-1). One hundred subjects had had two pre-study sputum smears assessed before recruitment and produced two further sputum specimens for re-examination in the research laboratory; of these 19 (19%) were sputum smear-positive on re-examination and a further seven (7%) became smear-positive on second re-examination. CONCLUSIONS: Of those patients with smear-negative presumed pulmonary tuberculosis by the local programme definition, 26% were smear-positive when reexamined carefully with two repeat sputum smears. This suggests that the high rates of smear-negative tuberculosis being seen may in part be due to under-reading. This is probably as a result of the overwhelming burden of tuberculosis leading to over rapid and inaccurate sputum examination. Retraining of existing technicians and training of more technicians is likely to reduce underreading and increase the yield of smear-positive tuberculosis. This finding also stresses the need for regular quality assurance.

Autopsy study of HIV-1-positive and HIV-1-negative adult medical patients in Nairobi, Kenya.

HIV infection has now been consistently identified as the major cause of death in young Africans in both urban and rural areas. In Africa, several studies have defined the clinical presentation of HIV disease but there have only been a limited number of autopsy studies. Because of the scarcity of autopsy data and the possibility of differing type and frequency of opportunistic infections between different geographic locations we set out to study consecutive new adult medical admissions to a tertiary referral hospital in Nairobi and perform autopsies on a sample of HIV-1-positive and HIV-1-negative patients who died in the hospital ward. Basic demographic data were collected on all patients admitted to two acute medical wards over an 11-month period. Final outcome and final clinical diagnoses were recorded at discharge or death. An autopsy examination was requested if the patient died in the ward. Autopsy examination was performed in 75 HIV-1-positive (40 men, 35 women) and 47 HIV-1-negative (28 men, 19 women) adults who died in the hospital. This represented 48.4% of all HIV-1-positive deaths and 33.3% of all HIV-1-negative deaths. Tuberculosis (TB) and bacterial and interstitial bronchopneumonia accounted for 96% of the major pathology in patients found to be HIV-1-positive at autopsy. TB was present in half the HIV-1-positive autopsy patients and was disseminated in over 80% of cases. Meningeal involvement was present in 26% of those with disseminated TB. By contrast, TB was much less common in the HIV-1-negative patients at autopsy in whom bacterial bronchopneumonia and malignancies were the most common pathologies. The type pathology found in the HIV-1-positive autopsy patients was not different than that found in other areas in Africa so far studied.

Tuberculosis and the HIV epidemic: increasing annual risk of tuberculous infection in Kenya, 1986-1996.

OBJECTIVES: The purpose of this study was to assess the impact of the increased incidence of tuberculosis (TB) due to HIV infection on the risk of TB infection in schoolchildren. METHODS: Tuberculin surveys were carried out in randomly selected primary schools in 12 districts in Kenya during 1986 through 1990 and 1994 through 1996. Districts were grouped according to the year in which TB notification rates started to increase. HIV prevalence in TB patients and changes in TB infection prevalence were compared between districts. RESULTS: Tuberculous infection prevalence rates increased strongly in districts where TB notification rates had increased before 1994 (odds ratio = 3.1, 95% confidence interval = 2.3, 4.1) but did not increase in districts where notification rates had increased more recently or not at all. HIV prevalence rates in TB patients were 50% in districts with an early increase in notification rates and 28% in the other study districts. CONCLUSIONS: Countries with an increasing prevalence of HIV infection will need additional resources for TB control, not only for current patients but also for the patients in additional cases arising from the increased risk of TB infection.

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.

Home environment and asthma in Kenyan schoolchildren: a case-control study.

BACKGROUND: There is increasing evidence that environmental factors contribute to the development of asthma, so the relationship was studied between home environment factors and asthma among school children of varying socioeconomic backgrounds living in a developing country. METHODS: A case-control study was performed in participants of a prevalence survey which included 77 schoolchildren with asthma (defined by a history of wheeze, doctor diagnosis, or a decline in FEV1 of > or = 10% at five or 10 minutes after exercise) and 77 age and gender matched controls. Subjects were selected from 402 school children aged 9-11 years attending five primary schools in the city of Nairobi who participated in a prevalence survey of asthma. Visits were made to the homes of cases and controls and visual inspection of the home environment was made using a checklist. A questionnaire regarding supplemental salt intake, parental occupation, cooking fuels, and health of all children in the family was administered by an interviewer. RESULTS: In multivariate analysis the following factors were associated with asthma: damage caused by dampness in the child's sleeping area (adjusted odds ratio (OR) 4.9; 95% confidence interval (CI) 2.0 to 11.7), air pollution in the home (OR 2.5; 95% CI 2.0 to 6.4), presence of rugs or carpets in child's bedroom (OR 3.6; 95% CI 1.5 to 8.5). Children with asthma reported a supplemental mean daily salt intake of 817 mg compared with 483 mg in controls. CONCLUSIONS: Home environmental factors appear to be strongly associated with asthma in schoolchildren in a developing nation. These findings suggest a number of hypotheses for further studies.

Spirometric lung function. Distribution and determinants of test failure in a young adult population.

Spirometric test failure has been defined as failure by a subject to meet the acceptability and/or reproducibility criteria laid down by the American Thoracic Society for measurements derived from forced expiratory maneuvers. The prevalence and determinants of spirometric test failure were examined in 416 men and women aged 20 to 45 yr working in an office environment. In this study population, 11.5% (28 men and 20 women) exhibited test failure for forced expiratory volume in one second (FEV1). The main determinant of test failure in men was bronchial hyperresponsiveness to methacholine challenge (odds ratio 6.7; confidence interval 1.7, 27.1) and in women being a current smoker (odds ratio 4.02; confidence interval 1.13, 14.33). There was also a relationship to eczema in both men and women, but not at a statistically significant level. When FEV1 variability was defined as the difference (in milliliters) between the two best FEV1 values and the results of men and women combined for analysis, significant predictors were a history of eczema, recurrent chest illness in the past 3 yr, and level of bronchial responsiveness to inhaled methacholine. These findings contribute to the gathering evidence that test failure may be of itself an indicator of impaired respiratory health, and its association with bronchial hyperresponsiveness to methacholine in men suggests that in them test failure is related to airway lability, but in women the relationship to smoking suggests an irritative mechanism.