Roles of health system leadership under emergency in drought-affected districts in northeast Uganda: a mixed-method study.

OBJECTIVE: Health system leadership plays a critical role in sustaining healthcare delivery during emergencies. Thus, we aimed to assess the contribution of health system leadership in sustaining healthcare delivery under emergency conditions based on adaptive leadership theoretical framework. DESIGN: We employed a concurrent mixed-methods study approach to assess health system leadership roles during emergency. This involved a quantitative survey administered to 150 health facilities managers/service focal persons selected via multistage sampling method from 15 districts, and qualitative interviews with 48 key informants who purposively selected. PARTICIPANTS: We interviewed health facility managers, services focal persons, district health officers and residential district commissioners. We also reviewed weekly emergency situation reports and other relevant documents related to the emergency response. We used structured questionnaire, observation checklist and semistructured questionnaire to collect data. We employed descriptive statistics to analyse quantitative data and thematic analysis for qualitative data. MAIN OUTCOME: Health system leadership contributions in sustaining healthcare delivery during emergencies. RESULTS: Health system leadership was effective in leading emergency response and ensuring the continuity of health service during emergencies. Community engagement, partners coordination and intersectoral collaboration were effectively used in the emergency response and ensuring continuity of healthcare delivery. Deployment of experienced personnel and essential medical and non-medical supplies played a critical role in the continuity of health service. Availability of incidence management teams across health system significantly contributed to health system leadership. Participation of village health teams in community engagement and information communication helped in the success of health system leadership under emergency. CONCLUSION: Adaptive health system leadership played a crucial role in managing health services delivery under emergency conditions. Effective partnership coordination and collaboration across sectors, frequent information communication, building local actor capacity and implementing scheduled supportive supervisions emerged as key strategies for sustaining health services during emergencies.

Perceived barriers of access to health and nutrition services under drought and food insecurity emergency in north-east Uganda: a qualitative study.

BACKGROUND: In the face of drought and food insecurity emergency, evidence on access to health and nutrition services is important. Karamoja is one of the regions that have experienced extreme drought and food insecurity emergency in Uganda. As a part of the drought and food insecurity emergency response, World Health Organization (WHO) with Ministry of Health (MoH) has designed and implemented a qualitative study in 15 districts that have experienced drought and food insecurity emergency in north-east Uganda. Thus, we aimed to explore the barriers of access to health and nutrition services in drought and food insecurity emergency affected districts in north-east Uganda. METHODS: We employed a descriptive qualitative study design. We interviewed 30 patients and 20 Village Health Teams (VHT) from 15 districts. We employed an in-depth interview with semi-structured questions to collect data until information saturation reached. We used thematic data analysis approach by ATLAS.ti version 7.5.1.8 software. RESULTS: Of the 30 interviewed subjects, 15 were female, and the median age of the subjects was 29 years with interquartile range (IQR) of 23 to 37 years. Majority (68.8%) of subjects reported that access to health and nutrition services was harder to them. Four themes: sociocultural and economic; environmental; health system, and individual related factors were identified as the barriers of access to health and nutrition services. CONCLUSION: The present study identified several modifiable barriers that hinder access to health and nutrition services in drought and food insecurity affected districts. Comprehensive interventions aimed at addressing sociocultural, economic, environmental, health system and subject related challenges are required to improve access to health and nutrition services in drought and food insecurity affected setups.

Essential health services delivery and quality improvement actions under drought and food insecurity emergency in north-east Uganda.

BACKGROUND: Essential health services can be disrupted due to several naturally occurring public health emergencies such as drought, flood, earthquake and outbreak of infectious diseases. However, little evidence exists on the status of essential health services delivery under the effect of drought and food insecurity. North-east Uganda is severely affected by prolonged drought that significantly affected the livelihood of the residents. Therefore, we aimed to determine the current status of essential health services and quality improvement (QI) actions in health facilities in north-east Uganda. METHODS: We used a descriptive cross-sectional study design to assess the availability of essential health service and quality improvement activities in drought and food insecurity affected districts of north-east Uganda. We included a total of 150 health facilities from 15 districts with proportionated multistage sampling method. We interviewed health facilities' managers and services focal persons using structured questionnaire and observation checklist. We used a descriptive statistic to analyze the data with SPSS version 22. RESULTS: A few health facilities (8.7%) had mental health specialist. There was also lack of capacity building training on essential health services. Considerable proportion of health facilities had no non-communicable diseases (38.3%), mental health (47.0%), and basic emergency obstetric care (40.3%) services. Stock out of essential medicines were observed in 20% of health facilities. There was lack of supportive supervision, and poor documentation of QI activities. CONCLUSION: Essential health service and QI were suboptimal in drought and food insecure emergency affected districts. Human resource deployment (especially mental health specialist), provision of capacity building training, improving non-communicable diseases, mental health and basic emergency obstetric care services are required to improve availability of essential health services. Supporting supply chain management to minimize stock out of medicines, and promoting QI activities are also vital to assure quality of health service in drought and food insecurity affected districts in north-Eastern Uganda.

Improving global health security through implementation of the National Action Plan for Health Security in Sierra Leone, 2018-2021: lessons from the field.

BACKGROUND: All countries are required to implement International Health Regulations (IHR) through development and implementation of multi-year National Action Plans for Health Security (NAPHS). IHR implementation requires annual operational planning which involves several tools such as NAPHS, State Party Annual Report (SPAR), Joint External Evaluation (JEE) and WHO IHR Benchmarks tool. Sierra Leone has successfully improved IHR capacities across the years through successful annual operational planning using the above tools. We conducted a study to document and share the country's unique approach to implementation of NAPHS. METHODS: This was an observational study where the process of implementing and monitoring NAPHS in Sierra Leone was observed at the national level from 2018 to 2021. Data was obtained through review and analysis of NAPHS annual operational plans, quarterly review reports and annual IHR assessment reports. Available data was supplemented by information from key informants. Qualitative data was captured as notes and analysed for various themes while quantitative data was analyzed mainly for means and proportions. RESULTS: The overall national IHR Joint External Evaluation self-assessment score for human health improved from 44% in 2018 to 51% in 2019 and 57% in 2020. The score for the animal sector improved from 32% in 2018 to 43% in 2019 and 52% in 2020. A new JEE tool with new indicators was used in 2021 and the score for both human and animal sectors declined slightly to 51%. Key enablers of success included strong political commitment, whole-of-government approach, annual assessments using JEE tool, annual operational planning using WHO IHR Benchmarks tool and real time online monitoring of progress. Key challenges included disruption created by COVID-19 response, poor health infrastructure, low funding and inadequate health workforce. CONCLUSION: IHR annual operational planning and implementation using evidence-based data and tools can facilitate strengthening of IHR capacity and should be encouraged.

Implementing Joint External Evaluations of the International Health Regulations (2005) capacities in all countries in the WHO African region: process challenges, lessons learnt and perspectives for the future.

Following the West Africa Ebola virus disease outbreak (2013-2016), the Joint External Evaluation (JEE) is one of the three voluntary components recommended by the WHO for evaluating the International Health Regulations (2005) capacities in countries. Here, we share experience implementing JEEs in all 47 countries in the WHO African region. In February 2016, the United Republic of Tanzania (Mainland) was the first country globally to conduct a JEE. By April 2022, JEEs had been conducted in all 47 countries plus in the island of Zanzibar. A total of 360 subject matter experts (SMEs) from 88 organisations were deployed 607 times. Despite availability of guidelines, the process had to be contextualised while avoiding jeopardising the quality and integrity of the findings. Key challenges were: inadequate understanding of the process by in-country counterparts; competing country priorities; limited time for validating subnational capacities; insufficient availability of SMEs for biosafety and biosecurity, antimicrobial resistance, points of entry, chemical events and radio-nuclear emergencies; and inadequate financing to fill gaps identified. Key points learnt were: importance of country leadership and ownership; conducting orientation workshops before the self-assessment; availability of an external JEE expert to support the self-assessment; the skills, attitudes and leadership competencies of the team lead; identifying national experts as SMEs for future JEEs to promote capacity building and experience sharing; the centrality of involving One Health stakeholders from the beginning to the end of the process; and the need for dedicated staff for planning, coordination, implementation and timely report writing. Moving forward, it is essential to draw from this learning to plan future JEEs. Finally, predictable financing is needed immediately to fill gaps identified.

Innovative approach to monitor performance of integrated disease surveillance and response after the Ebola outbreak in Sierra Leone: lessons from the field.

BACKGROUND: Supervision of healthcare workers improves performance if done in a supportive and objective manner. Regular supervision is a support function of Integrated Disease Surveillance and Response (IDSR) strategy and allows systematic monitoring of IDSR implementation. Starting 2015, WHO and other development partners supported the Ministry of Health and Sanitation (MoHS) to revitalize IDSR in Sierra Leone and to monitor progress through supportive supervision assessments. We report on the findings of these assessments. METHODS: This was a cross-sectional study where six longitudinal assessments were conducted in randomly selected health facilities. Health facilities assessed were 71 in February 2016, 99 in July 2016, 101 in May 2017, 126 in August 2018, 139 in February 2019 and 156 in August 2021. An electronic checklist based on selected core functions of IDSR was developed and uploaded onto tablets using the Open Data Kit (ODK) platform. Supervision teams interviewed health care workers, reviewed documents and made observations in health facilities. Supervision books were used to record feedback and corrective actions. Data from the supervisory visits was downloaded from ODK platform, cleaned and analysed. Categorical data was summarized using frequencies and proportions while means and medians were used for continuous variables. Z test was used to test for differences in proportions. RESULTS: Completeness of IDSR reporting improved from 84.5% in 2016 to 96% in 2021 (11.5% points; 95% CI 3.6, 21.9; P-value 0.003). Timeliness of IDSR reports improved from 80.3 to 92% (11.7% points; 95% CI 2.4, 22.9; P-value 0.01). There was significant improvement in health worker knowledge of IDSR concepts and tools, in availability of IDSR standard case definition posters and reporting tools and in data analysis practices. Availability of vaccines and temperature monitoring tools in health facilities also improved significantly but some indicators dropped such as availability of IDSR technical guidelines and malaria testing kits and drugs. CONCLUSION: Supervision using electronic tool contributed to health systems strengthening through longitudinal tracking of core IDSR indicators and other program indicators such as essential malaria commodities and availability and status of routine vaccines. Supervision using electronic tools should be extended to other programs.

After action review of the response to an outbreak of Lassa fever in Sierra Leone, 2019: Best practices and lessons learnt.

BACKGROUND: In November 2019, an outbreak of Lassa Fever occurred among health workers in a non-endemic district in Sierra Leone. The outbreak resulted in five cases, including two that were exported to the Netherlands. The outbreak tested multiple technical capacities in the International Health Regulations (2005) in a real-life setting. As such, an after action review (AAR) was undertaken as recommended by World Health Organization. We report on the findings of the AAR including best practices and lessons learnt. METHODS: A two stage review process was employed. The first stage involved national pillar level reviews for each technical pillar and one review of the district level response. The second stage brought together all pillars, including participants from the national and sub-national level as well as health sector partners. National guidelines were used as references during the deliberations. A standardized template was used to report on the key findings on what happened, what was supposed to happen, what went well and lessons learnt. RESULTS: This was a hospital associated outbreak that likely occurred due to a breach in infection prevention and control (IPC) practices resulting in three health workers being infected during a surgical operation. There was a delay in detecting the outbreak on time due to low index of suspicion among clinicians. Once detected, the outbreak response contained the outbreak within one incubation period. Areas that worked well included coordination, contact tracing, active case search and ring IPC. Notable gaps included delays in accessing local emergency funding and late distribution of IPC and laboratory supplies. CONCLUSIONS: The incident management system worked optimally to contain this outbreak. The core technical gaps identified in surveillance, IPC and delay in deployment of resources should be addressed through systemic changes that can mitigate future outbreaks.

Achieving Minimum Standards for Infection Prevention and Control in Sierra Leone: Urgent Need for a Quantum Leap in Progress in the COVID-19 Era!

INTRODUCTION: Good Infection prevention and control (IPC) is vital for tackling antimicrobial resistance and limiting health care-associated infections. We compared IPC performance before (2019) and during the COVID-19 (2021) era at the national IPC unit and all regional (4) and district hospitals (8) in Sierra Leone. METHODS: Cross-sectional assessments using standardized World Health Organizations IPC checklists. IPC performance scores were graded as inadequate = 0-25%, basic = 25.1-50%, intermediate = 50.1-75%, and advanced = 75.1-100%. RESULTS: Overall performance improved from 'basic' to 'intermediate' at the national IPC unit (41% in 2019 to 58% in 2021) and at regional hospitals (37% in 2019 to 54% in 2021) but remained 'basic' at district hospitals (37% in 2019 to 50% in 2021). Priority gaps at the national IPC unit included lack of: a dedicated IPC budget, monitoring the effectiveness of IPC trainings and health care-associated infection surveillance. Gaps at hospitals included no assessment of hospital staffing needs, inadequate infrastructure for IPC and lack of a well-defined monitoring plan with clear goals, targets and activities. CONCLUSION: Although there is encouraging progress in IPC performance, it is slower than desired in light of the COVID-19 pandemic. There is urgent need to mobilize political will, leadership and resources and make a quantum leap forward.

Infection Prevention and Control in Three Tertiary Healthcare Facilities in Freetown, Sierra Leone during the COVID-19 Pandemic: More Needs to Be Done!

Infection Prevention and Control (IPC) measures are critical to the reduction in healthcare-associated infections, especially during pandemics, such as that of COVID-19. We conducted a hospital-based cross-sectional study in August 2021 at Connaught Hospital, Princess Christian Maternity Hospital and Ola During Children's Hospital located in Freetown, Sierra Leone. We used the World Health Organization's Infection Prevention and Control Assessment Framework Tool to assess the level of IPC compliance at these healthcare facilities. The overall IPC compliance score at Connaught Hospital was 323.5 of 800 points, 313.5 of 800 at Ola During Children's Hospital, 281 of 800 at Princess Christian Maternity Hospital, implying a 'Basic' IPC compliance grade. These facilities had an IPC program, IPC committees and dedicated IPC focal persons. However, there were several challenges, including access to safe and clean water and insufficient quantities of face masks, examination gloves and aprons. Furthermore, there was no dedicated budget or no healthcare-associated infection (HAI) surveillance, and monitoring/audit of IPC practices were weak. These findings are of concern during the COVID-19 era, and there is an urgent need for both financial and technical support to address the gaps and challenges identified.

Antibiotic Use in Suspected and Confirmed COVID-19 Patients Admitted to Health Facilities in Sierra Leone in 2020-2021: Practice Does Not Follow Policy.

Inappropriate use of antibiotics during the COVID-19 pandemic has the potential to increase the burden of antimicrobial resistance. In this study, we report on the prevalence of antibiotic use and its associated factors among suspected and confirmed COVID-19 patients admitted to 35 health facilities in Sierra Leone from March 2020-March 2021. This was a cross-sectional study using routinely collected patient data. Of 700 confirmed COVID-19 patients, 47% received antibiotics. The majority (73%) of the antibiotics belonged to the 'WATCH' group of antibiotics, which are highly toxic and prone to resistance. The most frequently prescribed antibiotics were azithromycin, ceftriaxone, amoxicillin, metronidazole, and amoxicillin-clavulanic acid. Antibiotic use was significantly higher in patients aged 25-34 years than in those with severe disease. Of 755 suspected COVID-19 patients, 61% received antibiotics, of which the majority (58%) belonged to the 'WATCH' category. The most frequently prescribed antibiotics were ceftriaxone, metronidazole, azithromycin, ciprofloxacin, and amoxycillin. The prevalence of antibiotic use among suspected and confirmed COVID-19 patients admitted to healthcare facilities in Sierra Leone was high and not in line with national and WHO case management guidelines. Training of health care providers, strengthening of antimicrobial stewardship programs, and microbiological laboratory capacity are urgently needed.

A challenging response to a Lassa fever outbreak in a non endemic area of Sierra Leone in 2019 with export of cases to The Netherlands.

INTRODUCTION: On November 20, 2019, the Sierra Leone International Health Regulations (IHR) National Focal Point was notified of an exported case of Lassa fever in The Netherlands, by a Dutch doctor who previously practiced in a rural hospital in Sierra Leone. This report describes the extent of the outbreak, possible sources of infection, and the outbreak response measures taken. METHODS: Response measures implemented to control the outbreak included coordination across multiple countries and cities, outbreak investigation, active case finding, contact tracing and monitoring, laboratory investigation, and isolation and treatment of cases. RESULTS: We report a hospital-associated outbreak that resulted in 3 confirmed cases (health workers) and 2 probable cases (patients). The case fatality rate was 60%, whereas the secondary attack rate was 14%. Two cases involved exportations to The Netherlands. Failure to detect the index case and poor adherence to infection prevention and control (IPC) protocols contributed to disease spread. Pregnancy status and nonspecific signs and symptoms of the index case contributed to failure in early case detection. CONCLUSIONS: Rapid activation of national and subnational incident management systems resulted in rapid outbreak control. We recommend regular training for clinicians on surveillance and IPC protocols and strengthening in-country Lassa virus diagnostic capacity.

Institutionalized data quality assessments: a critical pathway to improving the accuracy of integrated disease surveillance data in Sierra Leone.

BACKGROUND: Public health agencies require valid, timely and complete health information for early detection of outbreaks. Towards the end of the Ebola Virus Disease (EVD) outbreak in 2015, the Ministry of Health and Sanitation (MoHS), Sierra Leone revitalized the Integrated Disease Surveillance and Response System (IDSR). Data quality assessments were conducted to monitor accuracy of IDSR data. METHODS: Starting 2016, data quality assessments (DQA) were conducted in randomly selected health facilities. Structured electronic checklist was used to interview district health management teams (DHMT) and health facility staff. We used malaria data, to assess data accuracy, as malaria was endemic in Sierra Leone. Verification factors (VF) calculated as the ratio of confirmed malaria cases recorded in health facility registers to the number of malaria cases in the national health information database, were used to assess data accuracy. Allowing a 5% margin of error, VF < 95% were considered over reporting while VF > 105 was underreporting. Differences in the proportion of accurate reports at baseline and subsequent assessments were compared using Z-test for two proportions. RESULTS: Between 2016 and 2018, four DQA were conducted in 444 health facilities where 1729 IDSR reports were reviewed. Registers and IDSR technical guidelines were available in health facilities and health care workers were conversant with reporting requirements. Overall data accuracy improved from over- reporting of 4.7% (VF 95.3%) in 2016 to under-reporting of 0.2% (VF 100.2%) in 2018. Compared to 2016, proportion of accurate IDSR reports increased by 14.8% (95% CI 7.2, 22.3%) in May 2017 and 19.5% (95% CI 12.5-26.5%) by 2018. Over reporting was more common in private clinics and not- for profit facilities while under-reporting was more common in lower level government health facilities. Leading reasons for data discrepancies included counting errors in 358 (80.6%) health facilities and missing source documents in 47 (10.6%) health facilities. CONCLUSION: This is the first attempt to institutionalize routine monitoring of IDSR data quality in Sierra Leone. Regular data quality assessments may have contributed to improved data accuracy over time. Data compilation errors accounted for most discrepancies and should be minimized to improve accuracy of IDSR data.

Implementing Nationwide Facility-based Electronic Disease Surveillance in Sierra Leone: Lessons Learned.

The Global Health Security Agenda aims to improve countries' ability to prevent, detect, and respond to infectious disease threats by building or strengthening core capacities required by the International Health Regulations (2005). One of those capacities is the development of surveillance systems to rapidly detect and respond to occurrences of diseases with epidemic potential. Since 2015, the US Centers for Disease Control and Prevention (CDC) has worked with partners in Sierra Leone to assist the Ministry of Health and Sanitation in developing an Integrated Disease Surveillance and Response (IDSR) system. Beginning in 2016, CDC, in collaboration with the World Health Organization and eHealth Africa, has supported the ministry in the development of Android device mobile data entry at the health facility for electronic IDSR (eIDSR), also known as health facility-based eIDSR. Health facility-based eIDSR was introduced via a pilot program in 1 district, and national rollout began in 2018. With more than 1,100 health facilities now reporting, the Sierra Leone eIDSR system is substantially larger than most mobile-device health (mHealth) projects found in the literature. Several technical innovations contributed to the success of health facility-based eIDSR in Sierra Leone. Among them were data compression and dual-mode (internet and text) message transmission to mitigate connectivity issues, user interface design tailored to local needs, and a continuous-feedback process to iteratively detect user or system issues and remediate challenges identified. The resultant system achieved high user acceptance and demonstrated the feasibility of an mHealth-based surveillance system implemented on a national scale.

A Public Health Response to a Mudslide in Freetown, Sierra Leone, 2017: Lessons Learnt.

On August 14, 2017, a 6-kilometer mudslide occurred in Regent Area, Western Area District of Sierra Leone following a torrential downpour that lasted 3 days. More than 300 houses along River Juba were submerged; 1141 people were reported dead or missing and 5905 displaced. In response to the mudslide, the World Health Organization (WHO) Country Office in Sierra Leone moved swiftly to verify the emergency and constitute an incident management team to coordinate the response. Early contact was made with the Ministry of Health and Sanitation and health sector partners. A Public Health Emergency Operations Center was set up to coordinate the response. Joint assessments, planning, and response among health sector partners ensured effectiveness and efficiency. Oral cholera vaccination was administered to high-risk populations to prevent a cholera outbreak. Surveillance for 4 waterborne diseases was enhanced through daily reporting from 9 health facilities serving the affected population. Performance standards from the WHO Emergency Response Framework were used to monitor the emergency response. An assessment of the country's performance showed that the country's response was well executed. To improve future response, we recommend enhanced district level preparedness, update of disaster response protocols, and pre-disaster mapping of health sector partners.

Integrated Disease Surveillance and Response (IDSR) strategy: current status, challenges and perspectives for the future in Africa.

In 1998, the WHO African region adopted a strategy called Integrated Disease Surveillance and Response (IDSR). Here, we present the current status of IDSR implementation; and provide some future perspectives for enhancing the IDSR strategy in Africa. In 2017, we used two data sources to compile information on the status of IDSR implementation: a pretested rapid assessment questionnaire sent out biannually to all countries and quarterly compilation of data for two IDSR key performance indicators (KPI). The first KPI measures country IDSR performance and the second KPI tracks the number of countries that the WHO secretariat supports to scale up IDSR. The KPI data for 2017 were compared with a retrospective baseline for 2014. By December 2017, 44 of 47 African countries (94%) were implementing IDSR. Of the 44 countries implementing IDSR, 40 (85%) had initiated IDSR training at subnational level; 32 (68%) had commenced community-based surveillance; 35 (74%) had event-based surveillance; 33 (70%) had electronic IDSR; and 32 (68%) had a weekly/monthly bulletin for sharing IDSR data. Thirty-two countries (68%) had achieved the timeliness and completeness threshold of at least 80% of the reporting units. However, only 12 countries (26%) had the desired target of at least 90% IDSR implementation coverage at the peripheral level. After 20 years of implementing IDSR, there are major achievements in the indicator-based surveillance systems. However, major gaps were identified in event-based surveillance. All African countries should enhance IDSR everywhere.

Revitalization of integrated disease surveillance and response in Sierra Leone post Ebola virus disease outbreak.

BACKGROUND: The Ministry of Health and Sanitation (MOHS) in Sierra Leone partially rolled out the implementation of Integrated Disease Surveillance and Response (IDSR) in 2003. After the Ebola virus disease outbreak in 2014-2015, there was need to strengthen IDSR to ensure prompt detection and response to epidemic-prone diseases. We describe the processes, successes and challenges of revitalizing public health surveillance in a country recovering from a protracted Ebola virus disease outbreak. METHODS: The revitalization process began with adaptation of the revised IDSR guidelines and development of customized guidelines to suit the health care systems in Sierra Leone. Public health experts defined data flow, system operations, case definitions, frequency and channels of reporting and dissemination. Next, phased training of IDSR focal persons in each health facility and the distribution of data collection and reporting tools was done. Monitoring activities included periodic supportive supervision and data quality assessments. Rapid response teams were formed to investigate and respond to disease outbreak alerts in all districts. RESULTS: Submission of reports through the IDSR system began in mid-2015 and by the 35th epidemiologic week, all district health teams were submitting reports. The key performance indicators measuring the functionality of the IDSR system in 2016 and 2017 were achieved (WHO Africa Region target ≥80%); the annual average proportion of timely weekly health facility reports submitted to the next level was 93% in 2016 and 97% in 2017; the proportion of suspected outbreaks and public health events detected through the IDSR system was 96% (n = 87) in 2016 and 100% (n = 85) in 2017. CONCLUSION: With proper planning, phased implementation and adequate investment of resources, it is possible to establish a functional IDSR system in a country recovering from a public health crisis. A functional IDSR system requires well trained workforce, provision of the necessary tools and guidelines, information, communication and technology infrastructure to support data transmission, provision of timely feedback as well as logistical support.

Enteric pathogens and factors associated with acute bloody diarrhoea, Kenya.

BACKGROUND: Shigellosis is the major cause of bloody diarrhoea worldwide and is endemic in most developing countries. In Kenya, bloody diarrhoea is reported weekly as part of priority diseases under Integrated Disease Surveillance and Response System (IDSR) in the Ministry of Health. METHODS: We conducted a case control study with 805 participants (284 cases and 521 controls) between January and December 2012 in Kilifi and Nairobi Counties. Kilifi County is largely a rural population whereas Nairobi County is largely urban. A case was defined as a person of any age who presented to outpatient clinic with acute diarrhoea with visible blood in the stool in six selected health facilities in the two counties within the study period. A control was defined as a healthy person of similar age group and sex with the case and lived in the neighbourhood of the case. RESULTS: The main presenting clinical features for bloody diarrhoea cases were; abdominal pain (69 %), mucous in stool (61 %), abdominal discomfort (54 %) and anorexia (50 %). Pathogen isolation rate was 40.5 % with bacterial and protozoal pathogens accounting for 28.2 % and 12.3 % respectively. Shigella was the most prevalent bacterial pathogen isolated in 23.6 % of the cases while Entamoeba histolytica was the most prevalent protozoal pathogen isolated in 10.2 % of the cases. On binary logistic regression, three variables were found to be independently and significantly associated with acute bloody diarrhoea at 5 % significance level; storage of drinking water separate from water for other use (OR = 0.41, 95 % CI 0.20-0.87, p = 0.021), washing hands after last defecation (OR = 0.24, 95 % CI 0.08-.076, p = 0.015) and presence of coliforms in main source water (OR = 2.56, CI 1.21-5.4, p = 0.014). Rainfall and temperature had strong positive correlation with bloody diarrhoea. CONCLUSION: The main etiologic agents for bloody diarrhoea were Shigella and E. histolytica. Good personal hygiene practices such as washing hands after defecation and storing drinking water separate from water for other use were found to be the key protective factors for the disease while presence of coliform in main water source was found to be a risk factor. Implementation of water, sanitation and hygiene (WASH) interventions is therefore key in prevention and control of bloody diarrhoea.

Challenges of establishing the correct diagnosis of outbreaks of acute febrile illnesses in Africa: the case of a likely Brucella outbreak among nomadic pastoralists, northeast Kenya, March-July 2005.

An outbreak of acute febrile illness was reported among Somali pastoralists in remote, arid Northeast Kenya, where drinking raw milk is common. Blood specimens from 12 patients, collected mostly in the late convalescent phase, were tested for viral, bacterial, and parasitic pathogens. All were negative for viral and typhoid serology. Nine patients had Brucella antibodies present by at least one of the tests, four of whom had evidence suggestive of acute infection by the reference serologic microscopic agglutination test. Three patients were positive for leptospiral antibody by immunoglobulin M enzyme-linked immunosorbent assay, and two were positive for malaria. Although sensitive and specific point-of-care testing methods will improve diagnosis of acute febrile illness in developing countries, challenges of interpretation still remain when the outbreaks are remote, specimens collected too late, and positive results for multiple diseases are obtained. Better diagnostics and tools that can decipher overlapping signs and symptoms in such settings are needed.

Rapid spread of Vibrio cholerae O1 throughout Kenya, 2005.

Between January and June 2005, 5 distinct cholera outbreaks occurred in Kenya. Overall, 990 cases and 25 deaths (2.5%) were reported. Four outbreaks occurred in towns along major highways, and 1 occurred in a refugee camp near the Sudanese border, accessible to Nairobi by daily flights. Matched case-control studies from 2 outbreaks showed that failure to treat drinking water and storing drinking water in wide-mouthed containers were significantly associated with disease. Isolates from all 5 outbreaks were Vibrio cholerae O1, Inaba serotype, and had genetically similar PFGE patterns of SfiI-digested chromosomal DNA. Linkage of the outbreak locations by major transportation routes, their temporal proximity, and similar PFGE patterns of isolates suggests the outbreaks might have been linked epidemiologically, showing the speed and distance of cholera spread in countries like Kenya with pockets of susceptible populations connected by modern transportation. Prevention measures remain implementation of point-of-use safe water systems and case finding and referral.

Seroprevalence of Chikungunya virus (CHIKV) infection on Lamu Island, Kenya, October 2004.

An outbreak of Chikungunya virus (CHIKV) disease associated with high fever and severe protracted arthralgias was detected in Lamu, Kenya, peaking in July 2004. At least 1,300 cases were documented. We conducted a seroprevalence study to define the magnitude of transmission on Lamu Island. We conducted a systematic cross-sectional survey. We administered questionnaires and tested 288 sera from Lamu residents for IgM and IgG antibodies to CHIKV. Chikungunya virus infection (seropositivity) was defined as a person with IgG and/or IgM antibodies to CHIKV. IgM antibodies to CHIKV were detected in 18% (53/288) and IgG antibodies in 72% (206/288); IgM and/or IgG antibodies were present in 75% (215/288). The seroprevalence findings suggested that the outbreak was widespread, affecting 75% of the Lamu population; extrapolating the findings to the entire population, 13,500 (95% CI, 12,458-14328) were affected. Vector control strategies are needed to control the spread of this mosquito-borne infection.