Association of haemoglobin levels in the first trimester and at 26-30 weeks with fetal and neonatal outcomes: a secondary analysis of the Global Network for Women's and Children's Health's ASPIRIN Trial.

OBJECTIVE: Limited data are available from low- and middle-income countries (LMICs) on the relationship of haemoglobin levels to adverse outcomes at different times during pregnancy. We evaluated the association of haemoglobin levels in nulliparous women at two times in pregnancy with pregnancy outcomes. DESIGN: ASPIRIN Trial data were used to study the association between haemoglobin levels measured at 6+0 -13+6  weeks and 26+0 -30+0  weeks of gestation with fetal and neonatal outcomes. SETTING: Obstetric care facilities in Pakistan, India, Kenya, Zambia, The Democratic Republic of the Congo and Guatemala. POPULATION: A total of 11 976 pregnant women. METHODS: Generalised linear models were used to obtain adjusted relative risks and 95% CI for adverse outcomes. MAIN OUTCOME MEASURES: Preterm birth, stillbirth, neonatal death, small for gestational age (SGA) and birthweight <2500 g. RESULTS: The mean haemoglobin levels at 6+0 -13+6  weeks and at 26-30 weeks of gestation were 116 g/l (SD 17) and 107 g/l (SD 15), respectively. In general, pregnancy outcomes were better with increasing haemoglobin. At 6+0 -13+6  weeks of gestation, stillbirth, SGA and birthweight <2500 g, were significantly associated with haemoglobin of 70-89 g/l compared with haemoglobin of 110-129 g/l The relationships of adverse pregnancy outcomes with various haemoglobin levels were more marked at 26-30 weeks of gestation. CONCLUSIONS: Both lower and some higher haemoglobin concentrations are associated with adverse fetal and neonatal outcomes at 6+0 -13+6  weeks and at 26-30 weeks of gestation, although the relationship with low haemoglobin levels appears more consistent and generally stronger. TWEETABLE ABSTRACT: Both lower and some higher haemoglobin concentrations were associated with adverse fetal and neonatal outcomes at 6-13 weeks and 26-30 weeks of gestation.

Cost estimation alongside a multi-regional, multi-country randomized trial of antenatal ultrasound in five low-and-middle-income countries.

BACKGROUND: Improving maternal health has been a primary goal of international health agencies for many years, with the aim of reducing maternal and child deaths and improving access to antenatal care (ANC) services, particularly in low-and-middle-income countries (LMICs). Health interventions with these aims have received more attention from a clinical effectiveness perspective than for cost impact and economic efficiency. METHODS: We collected data on resource use and costs as part of a large, multi-country study assessing the use of routine antenatal screening ultrasound (US) with the aim of considering the implications for economic efficiency. We assessed typical antenatal outpatient and hospital-based (facility) care for pregnant women, in general, with selective complication-related data collection in women participating in a large maternal health registry and clinical trial in five LMICs. We estimated average costs from a facility/health system perspective for outpatient and inpatient services. We converted all country-level currency cost estimates to 2015 United States dollars (USD). We compared average costs across countries for ANC visits, deliveries, higher-risk pregnancies, and complications, and conducted sensitivity analyses. RESULTS: Our study included sites in five countries representing different regions. Overall, the relative cost of individual ANC and delivery-related healthcare use was consistent among countries, generally corresponding to country-specific income levels. ANC outpatient visit cost estimates per patient among countries ranged from 15 to 30 USD, based on average counts for visits with and without US. Estimates for antenatal screening US visits were more costly than non-US visits. Costs associated with higher-risk pregnancies were influenced by rates of hospital delivery by cesarean section (mean per person delivery cost estimate range: 25-65 USD). CONCLUSIONS: Despite substantial differences among countries in infrastructures and health system capacity, there were similarities in resource allocation, delivery location, and country-level challenges. Overall, there was no clear suggestion that adding antenatal screening US would result in either major cost savings or major cost increases. However, antenatal screening US would have higher training and maintenance costs. Given the lack of clinical effectiveness evidence and greater resource constraints of LMICs, it is unlikely that introducing antenatal screening US would be economically efficient in these settings--on the demand side (i.e., patients) or supply side (i.e., healthcare providers). TRIAL REGISTRATION: Trial number: NCT01990625 (First posted: November 21, 2013 on https://clinicaltrials.gov ).

A prospective cause of death classification system for maternal deaths in low and middle-income countries: results from the Global Network Maternal Newborn Health Registry.

OBJECTIVE: To describe the causes of maternal death in a population-based cohort in six low- and middle-income countries using a standardised, hierarchical, algorithmic cause of death (COD) methodology. DESIGN: A population-based, prospective observational study. SETTING: Seven sites in six low- to middle-income countries including the Democratic Republic of the Congo (DRC), Guatemala, India (two sites), Kenya, Pakistan and Zambia. POPULATION: All deaths among pregnant women resident in the study sites from 2014 to December 2016. METHODS: For women who died, we used a standardised questionnaire to collect clinical data regarding maternal conditions present during pregnancy and delivery. These data were analysed using a computer-based algorithm to assign cause of maternal death based on the International Classification of Disease-Maternal Mortality system (trauma, termination of pregnancy-related, eclampsia, haemorrhage, pregnancy-related infection and medical conditions). We also compared the COD results to healthcare-provider-assigned maternal COD. MAIN OUTCOME MEASURES: Assigned causes of maternal mortality. RESULTS: Among 158 205 women, there were 221 maternal deaths. The most common algorithm-assigned maternal COD were obstetric haemorrhage (38.6%), pregnancy-related infection (26.4%) and pre-eclampsia/eclampsia (18.2%). Agreement between algorithm-assigned COD and COD assigned by healthcare providers ranged from 75% for haemorrhage to 25% for medical causes coincident to pregnancy. CONCLUSIONS: The major maternal COD in the Global Network sites were haemorrhage, pregnancy-related infection and pre-eclampsia/eclampsia. This system could allow public health programmes in low- and middle-income countries to generate transparent and comparable data for maternal COD across time or regions. TWEETABLE ABSTRACT: An algorithmic system for determining maternal cause of death in low-resource settings is described.

Global Network for Women's and Children's Health Research: probable causes of stillbirth in low- and middle-income countries using a prospectively defined classification system.

OBJECTIVE: We sought to classify causes of stillbirth for six low-middle-income countries using a prospectively defined algorithm. DESIGN: Prospective, observational study. SETTING: Communities in India, Pakistan, Guatemala, Democratic Republic of Congo, Zambia and Kenya. POPULATION: Pregnant women residing in defined study regions. METHODS: Basic data regarding conditions present during pregnancy and delivery were collected. Using these data, a computer-based hierarchal algorithm assigned cause of stillbirth. Causes included birth trauma, congenital anomaly, infection, asphyxia, and preterm birth, based on existing cause of death classifications and included contributing maternal conditions. MAIN OUTCOME MEASURES: Primary cause of stillbirth. RESULTS: Of 109 911 women who were enrolled and delivered (99% of those screened in pregnancy), 2847 had a stillbirth (a rate of 27.2 per 1000 births). Asphyxia was the cause of 46.6% of the stillbirths, followed by infection (20.8%), congenital anomalies (8.4%) and prematurity (6.6%). Among those caused by asphyxia, 38% had prolonged or obstructed labour, 19% antepartum haemorrhage and 18% pre-eclampsia/eclampsia. About two-thirds (67.4%) of the stillbirths did not have signs of maceration. CONCLUSIONS: Our algorithm determined cause of stillbirth from basic data obtained from lay-health providers. The major cause of stillbirth was fetal asphyxia associated with prolonged or obstructed labour, pre-eclampsia and antepartum haemorrhage. In the African sites, infection also was an important contributor to stillbirth. Using this algorithm, we documented cause of stillbirth and its trends to inform public health programs, using consistency, transparency, and comparability across time or regions with minimal burden on the healthcare system. TWEETABLE ABSTRACT: Major causes of stillbirth are asphyxia, pre-eclampsia and haemorrhage. Infections are important in Africa.

Routine antenatal ultrasound in low- and middle-income countries: first look - a cluster randomised trial.

OBJECTIVE: Ultrasound is widely regarded as an important adjunct to antenatal care (ANC) to guide practice and reduce perinatal mortality. We assessed the impact of ANC ultrasound use at health centres in resource-limited countries. DESIGN: Cluster randomised trial. SETTING: Clusters within five countries (Democratic Republic of Congo, Guatemala, Kenya, Pakistan, and Zambia) METHODS: Clusters were randomised to standard ANC or standard care plus two ultrasounds and referral for complications. The study trained providers in intervention clusters to perform basic obstetric ultrasounds. MAIN OUTCOME MEASURES: The primary outcome was a composite of maternal mortality, maternal near-miss mortality, stillbirth, and neonatal mortality. RESULTS: During the 24-month trial, 28 intervention and 28 control clusters had 24 263 and 23 160 births, respectively; 78% in the intervention clusters received at least one study ultrasound; 60% received two. The prevalence of conditions noted including twins, placenta previa, and abnormal lie was within expected ranges. 9% were referred for an ultrasound-diagnosed condition, and 71% attended the referral. The ANC (RR 1.0 95% CI 1.00, 1.01) and hospital delivery rates for complicated pregnancies (RR 1.03 95% CI 0.89, 1.20) did not differ between intervention and control clusters nor did the composite outcome (RR 1.09 95% CI 0.97, 1.23) or its individual components. CONCLUSIONS: Despite availability of ultrasound at ANC in the intervention clusters, neither ANC nor hospital delivery for complicated pregnancies increased. The composite outcome and the individual components were not reduced. TWEETABLE ABSTRACT: Antenatal care ultrasound did not improve a composite outcome that included maternal, fetal, and neonatal mortality.

MALARIA PARASITAEMIA AMONG FEBRILE CHILDREN INFECTED WITH HUMAN IMMUNODEFICIENCY VIRUS IN THE CONTEXT OF PROPHYLACTIC COTRIMOXAZOLE AS STANDARD OF CARE: A CROSS- SECTIONAL SURVEY IN WESTERN KENYA.

OBJECTIVE: To document the prevalence of malaria parasitaemia among the HIV infected febrile children in a malaria endemic area. DESIGN: A cross-sectional study. SETTING: An ambulatory paediatric HIV clinic in Western Kenya, between November 2011 and December 2012. SUBJECTS: A total of 245 febrile HIV infected children aged less than 14 years attending the HIV clinic in the Webuye level IV hospital were included in the study. A systematic sampling method was used. MAIN OUTCOMES: A blood sample was taken for malaria parasite testing. Presence or absence of malaria parasites was documented. Clinical and socio-demographic characteristics of the participants were also recorded. RESULTS: A total of 245 participants were recruited mean age being 5.53 years. Malaria prevalence was 81.9%. Most participants (97%) were on cotrimoxazole prophylaxis. Some of the factors found to be positively associated with malaria parasitaemia were; male sex, care taker category (parent), WHO stage 3 and 4 of HIV disease, and a high absolute CD4 count. However, only the caretaker association was statistically significant. CONCLUSION: The frequency of malaria parasitaemia among febrile HIV infected children is still high regardless of the high cotrimoxazole prophylaxis uptake. It is also noted that there is a shift in the age group of fever among children toward the older age group. This implies that policies may need to be relooked at to include the older age group in the aggressive malaria prevention measures to avoid losing on the already made gains.

NUTRITIONAL STATUS OF CHILDREN ADMITTED FOR DIARRHOEAL DISEASES IN A REFERRAL HOSPITAL IN WESTERN KENYA.

OBJECTIVES: To determine the prevalence of malnutrition among children admitted with acute diarrhoea disease at Moi Teaching and Referral Hospital and to establish the effect of malnutrition on duration of hospital stay. DESIGN: Prospective observational study. SETTING: Paediatric wards of Moi Teaching and Referral Hospital, Eldoret, Kenya. SUBJECTS: A total of 191 children aged 6 and 59 months admitted with acute diarrhoea disease, without chronic co-morbidities or visible severe malnutrition, were systematically enrolled into the study between November 2011 and March 2012. OUTCOME MEASURES: Nutritional status based on WHO WHZ scores taken at admission and duration of hospital stay. RESULTS: The mean age was 13.2 months with a male to female sex ratio of 1.16:1. Of all the children seen with acute diarrhoeal diseases, 43.9% had acute malnutrition (<-2 WHZ score), with 12% being severely malnourished (<-3 Z score). Average duration of hospital stay was 3.36 (SD=1.54) days. Among those with malnutrition the average duration of stay was 3.39 (SD=1.48) days while for those without malnutrition it was 3.21(SD=1.20) days, which was not statistically different. No death was reported. WHO weight for Height Z scores picked 12% of severe form of malnutrition missed out by Welcome Trust classification (weight for age). CONCLUSION: Routine anthrometry including weight for height identifies more children with malnutrition in acute diarrhoeal diseases. Presence of malnutrition did not affect duration of hospital stay.

Training needs for mid-level managers and immunisation coverage in Western Kenya.

OBJECTIVES: To determine the current status of immunisation coverage in Western Kenya before intervention, to identify strengths and weaknesses of the existing programme in order to design educational interventions that could improve the services provided and find out the training needs of the mid-level managers of Kenya Expanded Programme of Immunisation. DESIGN: Cross-sectional descriptive study. SETTING: All thirty nine districts in Rift Valley, Western and Nyanza provinces. SUBJECTS: Mid-level managers of Kenya Expanded Programme on Immunisation in the 39 districts and the provinces. These included Provincial Logisticians, Provincial Medical Officers of Health, District Medical Officers of Health, District Public Health Nurses, District Records and Health Information Officers, District Disease Surveillance Officers, and District Public Health Officers. MAIN OUTCOME MEASURES: Number of staff trained on EPI, coverage rates and perceived training needs of the mid-level managers. RESULTS: A total of eighty eight mid-level managers participated in the interviews. Most of these were District Public Health Nurses (40.9%) and District Health Information and Records Officers (23.9%). Only 49 (25%) of the District Health Management Team members had undergone training at the supervisory level. Eighteen districts (43.6%) had no member of the District Health Management Team that had ever been trained at the supervisory level. Using rates of Pentavalent 1 and measles coverage, Nyanza Province had the highest immunisation dropout rate (Pentavalent 1--measles) whereas Rift Valley Province had the lowest. The annual cumulative coverage for all the provinces by antigen was 80% for Pentavalent 1 and 2 and 60% for measles. The most requested need for inclusion in the training curriculum was maintenance of the cold chain equipment. CONCLUSIONS: Most of the members in the study area have not been trained on Expanded Programme on Immunisation and may be ill-equipped to manage the complicated programmes needed to maximise delivery of services. The immunisation coverage in this area is low while the dropout rates are high. We therefore recommend that all the mid-level managers of Expanded Programme on Immunisation in this area be trained comprehensively through the Merck Vaccine Network--Africa programme using the World Health Organisation approved mid-level managers course.

Seroprevalence of hepatitis B markers in pregnant women in Kenya.

OBJECTIVE: To evaluate hepatitis B serological markers in pregnant women from various geographical sites in Kenya. DESIGN: A cross-sectional observational study of women attending antenatal clinics. SETTING: The Kenyatta National Hospital and eight hospitals from five provinces in Kenya. SUBJECTS: All women in their third trimester of pregnancy attending the antenatal clinic over the period June 2001 to June 2002. MAIN OUTCOME MEASURES: For each pregnant woman age and gestation were documented. Hepatitis serological markers were evaluated. RESULTS: A total of 2241 pregnant women were enrolled. Among them 205 women (9.3%) were positive for HbsAg and from these 18 (8.8%) were found to have HbeAg. Protective antibodies (anti-HbsAg) were detected in 669 (30.2%) of the women. There were notable significant regional differences for HbsAg rates. CONCLUSIONS: These results confirm the presence of high disease carrier rate and the corresponding previously reported low level of HbeAg suggesting questionable low rate of perinatal transmission but high rate of horizontal transmission.

The Mosoriot medical record system: design and initial implementation of an outpatient electronic record system in rural Kenya.

Mosoriot Health Center is a rural primary care facility situated on the outskirts of Eldoret, Kenya in sub-Saharan Africa. The region is characterised by widespread poverty and a very poor technology infrastructure. Many houses do not have electricity, telephones or tap water. The health center does have electricity and tap water. In a collaborative project between Indiana University and the Moi University Faculty of Health Sciences (MUFHS), we designed a core electronic medical record system within the Mosoriot Health Center, with the intention of improving the quality of health data collection and, subsequently, patient care. The electronic medical record system will also be used to link clinical data from the health center to information collected from the public health surveys performed by medical students participating in the public health research programs of Moi University. This paper describes the processes involved in the development of the computer-based Mosoriot medical record system (MMRS) up to the point of implementation. It particularly focuses on the decisions and trade-offs that must be made when introducing this technology into an established health care system in a developing country.

Comparison of standard mercury thermometer and the liquid crystal device skin contact thermometer in febrile children at Eldoret District Hospital.

The purpose of this study was to compare the temperature readings obtained from febrile children using the conventional glass mercury thermometer and the liquid crystal device skin contact thermometer. 56 children with fever were studied irrespective of the cause. In 30 children, the mercury thermometer recorded higher readings than the LCD skin contact thermometer by an average of 0.67 degree C while in 12 children the LCD thermometer recorded higher readings than the mercury thermometer by an average of 0.34 degree C. There was no temperature reading difference in 14 children between the two methods. It is concluded that LCD thermometer is a useful, cost effective, safe and durable alternative to mercury thermometers especially in developing countries.

Health education on breast feeding in antenatal clinics in Eldoret District Hospital, Kenya.

One hundred and sixty three mothers who delivered at Eldoret District Hospital (EDH) during the months of June to October, 1992 were interviewed using a structured questionnaire with the aim of establishing knowledge attained from antenatal visits on breast feeding and lactation. The mothers were either in the postnatal ward or in the newborn unit. The interview was on various aspects of breast feeding but with the main goal of establishing whether they received health education on breast feeding during the visits to ANC. 53.06% had antenatal education on breastfeeding during these visits while 46.94% did not. 69.44% attended ANC at a hospital, 24.3% attended at health centre and 6.25% attended a dispensary. Most mothers had between 3 and 5 ANC visits with a range of one to eleven visits and with a parity of between one and three. 79% of the mothers commenced ANC attendance by 24 weeks gestation with 19% starting at 12 weeks. The hospital ANC attendants had slightly higher proportion of mothers health educated on breast feeding than the health centre and dispensary groups. Only 76 mothers had received satisfactory health education on breast feeding. One third of the mothers had breastfed their children for 2 years and similarly, one third stopped breast feeding by 12 months postnatally. 90% of the mothers started weaning their children by one month of age.

Relationship between exposure to tobacco smoke and bronchial asthma in children: a review.

Asthma is a common chronic childhood disease yet not much is known about factors that determine its outcome. Cigarette smoke has been associated with lung cancer in adults but its effects on children has hitherto been underestimated and not well studied. Cigarette smoke has been noted through various research studies to influence the development and or the exacerbation of asthma in childhood. Furthermore the prevalence of childhood asthma is higher among the children of smoking parents, more so when both parents are smokers as compared to those of non-smoking parents. Corroborative evidence indicates elevated urine cotinine levels amongst children of smoking parents than those of non-smoking parents. There is a corresponding increase in prevalence and exacerbation of asthma symptoms among children with raised urine cotinine levels than those with low levels. The presence of other risk factors increases the risk of development and exacerbation of bronchial asthma in children exposed to tobacco smoke than those not exposed. Cigarette smoking is on the increase, especially in developing countries due to aggressive advertising and exportation by the tobacco industry from developed countries. International legislation is needed to regulate the production and exportation of tobacco products. However, this may be resisted by the influential tobacco industry and may not get the support from the developing countries due to economic gains from the sale of tobacco products. This scenario poses major health problems for the developing countries in the future.

HIV seropositivity in children admitted with diarrhoea at Eldoret District Hospital, Kenya.

Fifty seven children aged 2 years and below admitted to Paediatric ward of Eldoret District Hospital with a diagnosis of diarrhoea were studied for HIV infection. A total of 29 (50.9%) cases were found to be positive with no gender difference. 17 (70.8%) of 24 cases with diarrhoea of over 14 days duration were positive for HIV compared to 12 (36.7%) cases out of 33 cases with diarrhoea of less than 14 days' duration. There was a high (80%) prevalence of HIV positivity rate in patients who presented with pneumonia and malnutrition in addition to diarrhoea when compared to children who presented with diarrhoea and vomiting alone (44.1%).

PIP: All children 2 years and younger with diagnosis of gastroenteritis (diarrhea and vomiting) admitted to the Eldoret District Hospital between the February and June 1992 were enrolled. ELISA test was performed for HIV for each of the 57 children. In addition, relevant tests were carried out in all cases, such as hemogram, stool for ova and cysts, blood slide for malaria parasites, and urinalysis. The ELISA results were confirmed by the Western blot for all positive cases. A total of 57 children, 32 (56.1%) males and 25 (43.9%) females were studied. All the children were 2 years or younger, with 61.4% under 9 months old. The difference with respect to distribution of HIV positivity and negativity in those under 9 months and those above 9 months was significant (p 0.001). 29 of the 57 infants (50.9%) were ELISA and Western blot positive. Of the positive cases, 23 (79.3%) were 9 months or younger, with 6 (20.7%) between 9 months and 24 months (p 0.001). Of the 33 (58.3%) patients with diarrhea of less than 14 days' duration, 12 (36.70%) were seropositive, and of the 24 (41.7%) with diarrhea of more than 14 days, 17 (70.8%) were HIV positive. The difference in the duration of diarrhea in both the positive and negative cases in the 2 groups was significant. There were 34 patients who presented with diarrhea and vomiting alone of whom 15 (44.1%) were positive for HIV, while there were 10 who presented with diarrhea and either malnutrition or pneumonia with 8 (80%) positive for HIV. Diarrhea lasting more than 14 days was a significant parameter, as 70.8% of the patients in this category were seropositive for HIV compared to 36.7% in those with diarrhea of less than 14 days' duration (p 0.02). In addition, children 0-9 months old had a higher incidence of HIV seropositivity than the older age group, especially the age group 5-9 months, 73.6% of whom were seropositive.

Health problems of street children in Eldoret, Kenya.

BACKGROUND: The street children phenomenon is an increasing problem in most cosmopolitan cities of the world including Eldoret, which is a fast growing town. With the growth of the town so is the increasing number of street children. It is therefore important to have baseline data on their health problems. OBJECTIVE: To determine the health problems of street children in Eldoret. DESIGN: A prospective and descriptive study. SETTING: Eldoret Town, Kenya. SUBJECTS: Eldoret street children aged 5-21 years. Type 1 street children were the "on" the street children who spent most of their time on the streets but went home in the evenings, type 2 were the "of" the street children who spent all their time in the streets and had severed their links with their families and did not have a home to go to, type 3 were abandoned children staying in a shelter and type 4 were normal primary school children. RESULTS: One hundred and ninety one children were studied. There were 38, 47, 56 and 50 types 1, 2, 3 and 4 children, respectively. The most common symptom was cough (28.9%) while frequent diagnosis was upper respiratory tract infection (URTI) (12.1%) followed by skin disease (50.9%) as the leading disease category. The common drug of addiction was cigarette (37.6%) and none of the school children was taking any drug of addiction. The prevalence of disease was 467 per 1000 children. Type 2 street children had the highest prevalence of disease (833 per 1000 children). Shelter children had the least disease prevalence (474 per 1000). Factors determining prevalence of disease were the same as in normal children. The malnutrition rate was high with 31.1% and 41.9% of the children being stunted and underweight, respectively. Type 3 children had the highest rate of malnutrition with 51.8% and 64.3% being stunted and underweight. CONCLUSION: Street children have a high incidence of childhood diseases. Factors determining occurrence of disease among street children are as in normal children. Respiratory and skin diseases were the leading causes of morbidity. Drug abuse was rampant among the street children but none of the school children abused any drug. Sexually transmitted infections were not prevalent. Most of the shelter children were malnourished. RECOMMENDATIONS: The government of Kenya should provide free health care for street children in public hospitals. Further studies should be carried out on the prevalence of sexually transmitted diseases based on laboratory testing and on the causes of the injuries suffered by the street children. The reasons for the poor nutritional status of the shelter children should be analysed and appropriate measures taken.

Determinants of immunisation coverage among children in Mathare Valley, Nairobi.

OBJECTIVE: To establish the factors that determine the levels of immunisation coverage among children under five years in Mathare Valley. DESIGN: A cross-sectional study describing the situation at a point in time. SETTING: Mathare Valley slum with a population of 50,000 people in the city of Nairobi. SUBJECTS: The study population was mothers with children under five years in Mathare Valley and had been resident there for a period not less than five years prior to the study. OUTCOME MEASURES: Level of immunisation coverage among children in the study population and the factors that contribute to the low immunisation coverage. RESULTS: Knowledge on immunisation was high with 90% of the respondents able to define immunisation. The attitude on immunisation was positive (74.4%) and immunisation coverage stood at 62.2%. Age, level of education, attitude and knowledge on immunisation among the residents were significant determinants of immunisation coverage. CONCLUSION: Immunisation coverage was lower than the national average in Mathare Valley. Advanced mother's age, low level of education and relative lack of knowledge on immunisation were responsible for the low coverage.

Prevalence of asthma, allergic rhinitis and dermatitis in primary school children in Uasin Gishu district, Kenya.

OBJECTIVE: To establish the relative increase in the prevalence of asthma, allergic rhinitis and eczema in primary school children aged 13-14 years over a six year interval. DESIGN: Cross sectional comparative study. SETTING: Primary schools in three rural divisions at Uasin Gishu district in the Rift Valley Province of Kenya. METHODS: Three thousand two hundred and fifty eight children aged 13-14 years from seventy two primary schools in Uasin Gishu district were studied using the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. All children in the selected schools in this age range whose parents gave consent were included. RESULTS: There were 47.4% males and 52.6% females as compared to 48.7% and 51.3% respectively in 1995. The cumulative prevalence for wheezing, rhinitis, itchy eyes and dermatitis was 23.6%, 43%, 24.1% and 28.5% respectively which were higher than for 1995 which were 21.2%, 32.4%, 11.8% and 13.8% respectively (p = 0.001). The period prevalence rates for wheezing, rhinitis and eczema were 13.8%, 31.4% and 21.3% respectively as compared to 10.2%, 25.3% and 14.4% respectively for 1995 (p = 0.001). The prevalence of asthma, allergic rhinitis and eczema was 12.6%, 38.6% and 28.5% respectively in 2001 compared to 6.6%, 14.9% and 13.9% respectively in 1995 (p = 0.001). CONCLUSION: There was a significant increase in the prevalence of asthma, allergic rhinitis and eczema in children in the study population over the last six years.

Prevalence of asthma, allergic rhinitis and dermatitis in primary school children in Uasin Gishu district, Kenya.

Three thousand and eighteen children aged 13-14 years were studied using a standard questionnaire developed and field tested by the International Study of Asthma and Allergies in Children(ISAAC) steering committee between January and April 1995 to establish the prevalence and severity of asthma, rhinitis and eczema. 58 rural primary schools were randomly selected from which 3018 children filled out the written (WQ) and the video (VQ)questionnaires. There were 1471 (48.7%) males and 1547 (51.3%) females. On the written questionnaire the cumulative prevalence for wheezing, rhinitis, itchy eyes and skin rashes was 21.2%, 32.4%, 11.8% and 23.8% respectively, with respective 12 month period prevalence rates of 10.2%, 25.3% and 14.4% for wheezing, rhinitis and itchy rashes. On the video questionnaire the cumulative prevalence rates were 11.4%, 12.3%, 5.0%, 16.3% and 3.6% for wheezing, exercise induced wheezing, nocturnal wheezing, nocturnal cough and difficulty in breathing associated with wheezing respectively. The video questionnaire prevalence rates are lower than those of the written questionnaire possibly due to difficulties the children encountered in correlating the symptoms and the disease. The prevalence of severe symptoms for rhinitis, eczema and wheezing of 10.1%, 6.8% and 5.8% respectively are lower than those reported for developed countries. These results compare with those of a previous study in Estonia using the same ISAAC questionnaire and support the hypothesis that although the prevalence of asthma and allergic diseases are on the increase worldwide, it is more so in the developed than the developing countries.

Perinatal mortality in the Special Care Nursery of Moi Teaching and Referral Hospital, Eldoret, Kenya.

OBJECTIVES: To determine the mortality rate and causes of death of all infants admitted to the Special Care Nursery (SCN) of a tertiary referral hospital in rural Kenya. DESIGN: Prospective and Cross-sectional study SETTING: Special Care Nursery, Moi Teaching and Referral Hospital, Eldoret, Kenya. SUBJECTS: All infants admitted to the Special Care Nursing (SCN). MAIN OUTCOME MEASURES: Survival status at seven postnatal days; major causes of mortality and morbidity. RESULTS: Three hundred and thirty five babies were studied between February and September 1999. Out of these 167 (49.9%) were male. There were 50 (15%) preterm and 124 (37.3%) low birth weight babies. There were 198 (76.2%) appropriate for gestational age (AGA), 46 (17.7%) small for gestational age and 16 (6.2%) large for gestational age babies. The seven day mortality rate of infants admitted to the Special Care Nursery was 66 (19.7%). Birth asphyxia and respiratory distress accounted for most deaths. Infants who were admitted primarily because the mother remained under general anesthesia generally did well. Logistic factors, including inadequate training for neonatal resuscitation in ward cadre of staff, unavailability of trained paediatricians and obstetricians, and inadequate operating theatre supplies were all found to delay treatment and likely to increase mortality. CONCLUSION: Morbidity and mortality of infants born at the MTRH remain high. The most common cause of mortality remains birth asphyxia. Some causative factors, such as lack of resources or personnel, are logistic and could be rectified. Antenatal care had a significant positive impact on both morbidity and mortality.

Paediatric morbidity and mortality at the Eldoret District Hospital, Kenya.

Over an 18 month period, there were 4,720 paediatric admissions at the Eldoret District Hospital in Western Kenya. The most frequent 20 diseases were identified and their respective case fatality rates calculated. Malaria was the most common cause for admission (33.0%) but the fourth most common cause of death with a case fatality rate of 2.2%. The overall mortality rate on the paediatric wards was 8.2% with 64.9% of the deaths occurring within the first 24 hours of hospitalization. Three-fourth of all admissions were due to four diseases: malaria, pneumonia, gastroenteritis and measles. Targeted interventional programmes aimed at these 4 diseases, coupled with a comprehensive primary health care system, would most likely result in much less morbidity and mortality for the children in the district. The systems for routinely collecting and storing medical records were found to be substandard, making it very difficult to accurately monitor morbidity and mortality.

PIP: Over an 18-month period, from October 1991 through early 1993, a study was carried out in two phases in the pediatric wards of the Eldoret District Hospital to document infant and child morbidity and mortality in the Uasin Gishu district and parts of several surrounding districts in western Kenya. Patient discharge summaries and ward registers were analyzed for age, sex, diagnosis, length of hospitalization, and outcome. There were a total 4720 pediatric admissions over the period. The most frequent 20 diseases were identified and their respective case fatalities were calculated. 74.5% of the admissions were due to only four diseases: malaria (33.0%), pneumonia (26.8%), gastroenteritis (10%), and measles (7.6%). Malaria was responsible for only 9 (9.1%) of all deaths. The disease specific mortality rate for malaria was 2.2%, 11th among the top 15 diseases. 20 (20.4%) out of a total of 98 deaths were due to pneumonia. Measles was becoming less important as a cause of morbidity because of immunization: in 1991, over 20 cases/per month were admitted, but by 1993 only 6.5 cases/month were admitted, a decrease of 68%. Neonatal tetanus was responsible for 43.2% of neonatal mortality during the 18 months. In addition, 47 infants and children had severe anemia (hemoglobin 4.0 gm%); 8 (17%) of these children died despite emergency blood transfusions. The overall mortality rate in the hospital during the study was 8.2%, which compares with 9.6% reported in Tanzania in 1987. 61 (64.9%) deaths occurred within 24 hours of hospitalization owing to delay in seeking medical care. In a 1988 study in Harare, 201 (43.7%) of 460 deaths occurred within the first 24 hours of admission. Furthermore, during February through June 1992, 29 of 57 children under 2 years of age admitted for gastroenteritis tested positive for HIV antibodies. A retrospective review of the ward register also showed that in 20% of the admissions the outcome was not recorded, in 25% the length of stay could not be determined, and for 8.3% the age of the patient was not recorded.