Whole transcriptomic analysis reveals overexpression of salivary gland and cuticular proteins genes in insecticide-resistant Anopheles arabiensis from Western Kenya.

BACKGROUND: Effective vector control is key to malaria prevention. However, this is now compromised by increased insecticide resistance due to continued reliance on insecticide-based control interventions. In Kenya, we have observed heterogenous resistance to pyrethroids and organophosphates in Anopheles arabiensis which is one of the most widespread malaria vectors in the country. We investigated the gene expression profiles of insecticide resistant An. arabiensis populations from Migori and Siaya counties in Western Kenya using RNA-Sequencing. Centers for Disease Control and Prevention (CDC) bottle assays were conducted using deltamethrin (DELTA), alphacypermethrin (ACYP) and pirimiphos-methyl (PMM) to determine the resistance status in both sites. RESULTS: Mosquitoes from Migori had average mortalities of 91%, 92% and 58% while those from Siaya had 85%, 86%, and 30% when exposed to DELTA, ACYP and PMM, respectively. RNA-Seq analysis was done on pools of mosquitoes which survived exposure ('resistant'), mosquitoes that were not exposed, and the insecticide-susceptible An. arabiensis Dongola strain. Gene expression profiles of resistant mosquitoes from both Migori and Siaya showed an overexpression mainly of salivary gland proteins belonging to both the short and long form D7 genes, and cuticular proteins (including CPR9, CPR10, CPR15, CPR16). Additionally, the overexpression of detoxification genes including cytochrome P450s (CYP9M1, CYP325H1, CYP4C27, CYP9L1 and CYP307A1), 2 carboxylesterases and a glutathione-S-transferase (GSTE4) were also shared between DELTA, ACYP, and PMM survivors, pointing to potential contribution to cross resistance to both pyrethroid and organophosphate insecticides. CONCLUSION: This study provides novel insights into the molecular basis of insecticide resistance in An. arabiensis in Western Kenya and suggests that salivary gland proteins and cuticular proteins are associated with resistance to multiple classes of insecticides.

Transcriptomic analysis of Anopheles gambiae from Benin reveals overexpression of salivary and cuticular proteins associated with cross-resistance to pyrethroids and organophosphates.

BACKGROUND: Insecticide resistance (IR) is one of the major threats to malaria vector control programs in endemic countries. However, the mechanisms underlying IR are poorly understood. Thus, investigating gene expression patterns related to IR can offer important insights into the molecular basis of IR in mosquitoes. In this study, RNA-Seq was used to characterize gene expression in Anopheles gambiae surviving exposure to pyrethroids (deltamethrin, alphacypermethrin) and an organophosphate (pirimiphos-methyl). RESULTS: Larvae of An. gambiae s.s. collected from Bassila and Djougou in Benin were reared to adulthood and phenotyped for IR using a modified CDC intensity bottle bioassay. The results showed that mosquitoes from Djougou were more resistant to pyrethroids (5X deltamethrin: 51.7% mortality; 2X alphacypermethrin: 47.4%) than Bassila (1X deltamethrin: 70.7%; 1X alphacypermethrin: 77.7%), while the latter were more resistant to pirimiphos-methyl (1.5X: 48.3% in Bassila and 1X: 21.5% in Djougou). RNA-seq was then conducted on resistant mosquitoes, non-exposed mosquitoes from the same locations and the laboratory-susceptible An. gambiae s.s. Kisumu strain. The results showed overexpression of detoxification genes, including cytochrome P450s (CYP12F2, CYP12F3, CYP4H15, CYP4H17, CYP6Z3, CYP9K1, CYP4G16, and CYP4D17), carboxylesterase genes (COEJHE5E, COE22933) and glutathione S-transferases (GSTE2 and GSTMS3) in all three resistant mosquito groups analyzed. Genes encoding cuticular proteins (CPR130, CPR10, CPR15, CPR16, CPR127, CPAP3-C, CPAP3-B, and CPR76) were also overexpressed in all the resistant groups, indicating their potential role in cross resistance in An. gambiae. Salivary gland protein genes related to 'salivary cysteine-rich peptide' and 'salivary secreted mucin 3' were also over-expressed and shared across all resistant groups. CONCLUSION: Our results suggest that in addition to metabolic enzymes, cuticular and salivary gland proteins could play an important role in cross-resistance to multiple classes of insecticides in Benin. These genes warrant further investigation to validate their functional role in An. gambiae resistance to insecticides.

Key gene modules and hub genes associated with pyrethroid and organophosphate resistance in Anopheles mosquitoes: a systems biology approach.

Indoor residual spraying (IRS) and insecticide-treated nets (ITNs) are the main methods used to control mosquito populations for malaria prevention. The efficacy of these strategies is threatened by the spread of insecticide resistance (IR), limiting the success of malaria control. Studies of the genetic evolution leading to insecticide resistance could enable the identification of molecular markers that can be used for IR surveillance and an improved understanding of the molecular mechanisms associated with IR. This study used a weighted gene co-expression network analysis (WGCNA) algorithm, a systems biology approach, to identify genes with similar co-expression patterns (modules) and hub genes that are potential molecular markers for insecticide resistance surveillance in Kenya and Benin. A total of 20 and 26 gene co-expression modules were identified via average linkage hierarchical clustering from Anopheles arabiensis and An. gambiae, respectively, and hub genes (highly connected genes) were identified within each module. Three specific genes stood out: serine protease, E3 ubiquitin-protein ligase, and cuticular proteins, which were top hub genes in both species and could serve as potential markers and targets for monitoring IR in these malaria vectors. In addition to the identified markers, we explored molecular mechanisms using enrichment maps that revealed a complex process involving multiple steps, from odorant binding and neuronal signaling to cellular responses, immune modulation, cellular metabolism, and gene regulation. Incorporation of these dynamics into the development of new insecticides and the tracking of insecticide resistance could improve the sustainable and cost-effective deployment of interventions.

A new methodology for assessing health policy and systems research and analysis capacity in African universities.

BACKGROUND: The importance of health policy and systems research and analysis (HPSR+A) has been increasingly recognised, but it is still unclear how most effectively to strengthen the capacity of the different organisations involved in this field. Universities are particularly crucial but the expansive literature on capacity development has little to offer the unique needs of HPSR+A activity within universities, and often overlooks the pivotal contribution of capacity assessments to capacity strengthening. METHODS: The Consortium for Health Policy and Systems Analysis in Africa 2011-2015 designed and implemented a new framework for capacity assessment for HPSR+A within universities. The methodology is reported in detail. RESULTS: Our reflections on developing and conducting the assessment generated four lessons for colleagues in the field. Notably, there are currently no published capacity assessment methodologies for HPSR+A that focus solely on universities - we report a first for the field to initiate the dialogue and exchange of experiences with others. Second, in HPSR+A, the unit of assessment can be a challenge, because HPSR+A groups within universities tend to overlap between academic departments and are embedded in different networks. Third, capacity assessment experience can itself be capacity strengthening, even when taking into account that doing such assessments require capacity. CONCLUSIONS: From our experience, we propose that future systematic assessments of HPSR+A capacity need to focus on both capacity assets and needs and assess capacity at individual, organisational, and systems levels, whilst taking into account the networked nature of HPSR+A activity. A genuine partnership process between evaluators and those participating in an assessment can improve the quality of assessment and uptake of results in capacity strengthening.

Health system challenges to integration of mental health delivery in primary care in Kenya--perspectives of primary care health workers.

BACKGROUND: Health system weaknesses in Africa are broadly well known, constraining progress on reducing the burden of both communicable and non-communicable disease (Afr Health Monitor, Special issue, 2011, 14-24), and the key challenges in leadership, governance, health workforce, medical products, vaccines and technologies, information, finance and service delivery have been well described (Int Arch Med, 2008, 1:27). This paper uses focus group methodology to explore health worker perspectives on the challenges posed to integration of mental health into primary care by generic health system weakness. METHODS: Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 20 health workers drawn from a randomised controlled trial to evaluate the impact of a mental health training programme for primary care, 10 from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training). RESULTS: These focus group discussions suggested that there are a number of generic health system weaknesses in Kenya which impact on the ability of health workers to care for clients with mental health problems and to implement new skills acquired during a mental health continuing professional development training programmes. These weaknesses include the medicine supply, health management information system, district level supervision to primary care clinics, the lack of attention to mental health in the national health sector targets, and especially its absence in district level targets, which results in the exclusion of mental health from such district level supervision as exists, and the lack of awareness in the district management team about mental health. The lack of mental health coverage included in HIV training courses experienced by the health workers was also striking, as was the intensive focus during district supervision on HIV to the detriment of other health issues. CONCLUSION: Generic health system weaknesses in Kenya impact on efforts for horizontal integration of mental health into routine primary care practice, and greatly frustrate health worker efforts.Improvement of medicine supplies, information systems, explicit inclusion of mental health in district level targets, management and supervision to primary care are likely to greatly improve primary care health worker effectiveness, and enable training programmes to be followed by better use in the field of newly acquired skills. A major lever for horizontal integration of mental health into the health system would be the inclusion of mental health in the national health sector reform strategy at community, primary care and district levels rather than just at the higher provincial and national levels, so that supportive supervision from the district level to primary care would become routine practice rather than very scarce activity. TRIAL REGISTRATION: Trial registration ISRCTN 53515024.

Kenya's response to the COVID-19 pandemic: a balance between minimising morbidity and adverse economic impact.

Coronavirus disease 2019 (COVID-19) has ravaged the world's socioeconomic systems forcing many governments across the globe to implement unprecedented stringent mitigation measures to restrain its rapid spread and adverse effects. A disproportionate number of COVID-19 related morbidities and mortalities were predicted to occur in Africa. However, Africa still has a lower than predicted number of cases, 4% of the global pandemic burden. In this open letter, we highlight some of the early stringent countermeasures implemented in Kenya, a sub-Saharan African country, to avert the severe effects of the COVID-19 pandemic. These mitigation measures strike a balance between minimising COVID-19 associated morbidity and fatalities and its adverse economic impact, and taken together have significantly dampened the pandemic's impact on Kenya's populace.

The Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage.

OBJECTIVE: To evaluate the Bakri tamponade balloon as an adjunct treatment for refractory postpartum hemorrhage (PPH). METHODS: A prospective observational intervention study was conducted between January 1, 2013, and May 31, 2015, at Great Lakes Hospital and Moi Teaching and Referral Hospital in Kenya. Eligible participants were diagnosed with PPH (blood loss >500mL after vaginal or >1000mL after cesarean delivery, and/or hemodynamic changes suggestive of excessive blood loss) unresponsive to standard intervention and were treated using the Bakri balloon. Case report forms were completed for all participants. The primary endpoint was the frequency of surgery after use of the Bakri balloon. RESULTS: Among 58 patients, postpartum bleeding was controlled without further surgical intervention in 55 (95%). Among the 55 women with uterine atony, the Bakri balloon successful controlled PPH in 52 (95%). Two of the three hysterectomies performed were for continued bleeding after placement of the Bakri tamponade balloon. Four maternal deaths occurred. CONCLUSION: The Bakri tamponade balloon proved an effective adjunct in the management of refractory PPH.

Perspectives and concerns of clients at primary health care facilities involved in evaluation of a national mental health training programme for primary care in Kenya.

BACKGROUND: A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact on the health, disability and quality of life of clients, despite a severe shortage of medicines in the clinics (Jenkins et al. Submitted 2012). As focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems (Sharfritz and Roberts. Health Transit Rev 4:81-85, 1994), the experiences of the participating clients were explored through qualitative focus group discussions in order to better understand the potential reasons for the improved outcomes in the intervention group. METHODS: Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 clients from the intervention group clinics where staff had received the training programme, and 10 clients from the control group where staff had not received the training during the earlier randomised controlled trial. RESULTS: These focus group discussions suggest that the clients in the intervention group noticed and appreciated enhanced communication, diagnostic and counselling skills in their respective health workers, whereas clients in the control group were aware of the lack of these skills. Confidentiality emerged from the discussions as a significant client concern in relation to the volunteer cadre of community health workers, whose only training comes from their respective primary care health workers. CONCLUSION: Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcomes for clients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed. TRIAL REGISTRATION: ISRCTN 53515024.

Exploring the perspectives and experiences of health workers at primary health facilities in Kenya following training.

BACKGROUND: A cluster randomised controlled trial (RCT) of a national Kenyan mental health primary care training programme demonstrated a significant impact for health workers on the health, disability and quality of life of their clients, despite a severe shortage of medicines in the clinics. In order to better understand the potential reasons for the improved outcomes in the intervention group, the experiences of the participating health workers were explored through qualitative focus group discussions, as focus group methodology has been found to be a useful method of obtaining a detailed understanding of client and health worker perspectives within health systems. METHODS: Two ninety minute focus groups were conducted in Nyanza province, a poor agricultural region of Kenya, with 10 health workers from the intervention group clinics where staff had received the training programme, and 10 health workers from the control group where staff had not received the training during the earlier randomised controlled trial. RESULTS: These focus group discussions suggest that the health workers in the intervention group perceived an increase in their communication, diagnostic and counselling skills, and that the clients in the intervention group noticed and appreciated these enhanced skills, while health workers and clients in the control group were both aware of the lack of these skills. CONCLUSION: Enhanced health worker skills conferred by the mental health training programme may be responsible for the significant improvement in outcome of patients in the intervention clinics found in the randomised controlled trial, despite the general shortage of medicines and other health system weaknesses. These findings suggest that strengthening mental health training for primary care staff is worthwhile even where health systems are not strong and where the medicine supply cannot be guaranteed. TRIAL REGISTRATION: ISRCTN 53515024.

Short structured general mental health in service training programme in Kenya improves patient health and social outcomes but not detection of mental health problems - a pragmatic cluster randomised controlled trial.

TRIAL DESIGN: A pragmatic cluster randomised controlled trial. PARTICIPANTS: Clusters were primary health care clinics on the Ministry of Health list. Clients were eligible if they were aged 18 and over. INTERVENTIONS: Two members of staff from each intervention clinic received the training programme. Clients in both intervention and control clinics subsequently received normal routine care from their health workers. OBJECTIVE: To examine the impact of a mental health inservice training on routine detection of mental disorder in the clinics and on client outcomes. OUTCOMES: The primary outcome was the rate of accurate routine clinic detection of mental disorder and the secondary outcome was client recovery over a twelve week follow up period. Randomisation: clinics were randomised to intervention and control groups using a table of random numbers. Blinding: researchers and clients were blind to group assignment. RESULTS: Numbers randomised: 49 and 50 clinics were assigned to intervention and control groups respectively. 12 GHQ positive clients per clinic were identified for follow up. Numbers analysed: 468 and 478 clients were followed up for three months in intervention and control groups respectively. OUTCOME: At twelve weeks after training of the intervention group, the rate of accurate routine clinic detection of mental disorder was greater than 0 in 5% versus 0% of the intervention and control groups respectively, in both the intention to treat analysis (p = 0.50) and the per protocol analysis (p =0.50). Standardised effect sizes for client improvement were 0.34 (95% CI = (0.01,0.68)) for the General Health Questionnaire, 0.39 ((95% CI = (0.22, 0.61)) for the EQ and 0.49 (95% CI = (0.11,0.87)) for WHODAS (using ITT analysis); and 0.43 (95% CI = (0.09,0.76)) for the GHQ, 0.44 (95% CI = (0.22,0.65)) for the EQ and 0.58 (95% CI = (0.18,0.97)) for WHODAS (using per protocol analysis). HARMS: None identified. CONCLUSION: The training programme did not result in significantly improved recorded diagnostic rates of mental disorders in the routine clinic consultation register, but did have significant effects on patient outcomes in routine clinical practice. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number Register ISRCTN53515024.