Malaria Transmission Dynamics in a High-Transmission Setting of Western Kenya and the Inadequate Treatment Response to Artemether-Lumefantrine in an Asymptomatic Population.

BACKGROUND: Assessing the infectious reservoir is critical in malaria control and elimination strategies. We conducted a longitudinal epidemiological study in a high-malaria-burden region in Kenya to characterize transmission in an asymptomatic population. METHODS: 488 study participants encompassing all ages in 120 households within 30 clusters were followed for 1 year with monthly sampling. Malaria was diagnosed by microscopy and molecular methods. Transmission potential in gametocytemic participants was assessed using direct skin and/or membrane mosquito feeding assays, then treated with artemether-lumefantrine. Study variables were assessed using mixed-effects generalized linear models. RESULTS: Asexual and sexual parasite data were collected from 3792 participant visits, with 903 linked with feeding assays. Univariate analysis revealed that the 6-11-year-old age group was at higher risk of harboring asexual and sexual infections than those <6 years old (odds ratio [OR] 1.68, P < .001; and OR 1.81, P < .001), respectively. Participants with submicroscopic parasitemia were at a lower risk of gametocytemia compared with microscopic parasitemia (OR 0.04, P < .001), but they transmitted at a significantly higher rate (OR 2.00, P = .002). A large proportion of the study population who were infected at least once remained infected (despite treatment) with asexual (71.7%, 291/406) or sexual (37.4%, 152/406) parasites. 88.6% (365/412) of feeding assays conducted in individuals who failed treatment the previous month resulted in transmissions. CONCLUSIONS: Individuals with asymptomatic infection sustain the transmission cycle, with the 6-11-year age group serving as an important reservoir. The high rates of artemether-lumefantrine treatment failures suggest surveillance programs using molecular methods need to be expanded for accurate monitoring and evaluation of treatment outcomes.

Community suicide rates and related factors within a surveillance platform in Western Kenya.

BACKGROUND: Suicide is an important contributor to the burden of mental health disorders, but community-based suicide data are scarce in many low- and middle-income countries (LMIC) including Kenya. Available data on suicide underestimates the true burden due to underreporting related to stigma and legal restrictions, and under-representation of those not utilizing health facilities. METHODS: We estimated the cumulative incidence of suicide via verbal autopsies from the Health and Demographic Surveillance System (HDSS) in Kisumu County, Kenya. We then used content analysis of open history forms among deaths coded as accidents to identify those who likely died by suicide but were not coded as suicide deaths. We finally conducted a case-control study of suicides (both verbal autopsy confirmed and likely suicides) compared to accident-caused deaths to assess factors associated with suicide in this HDSS. RESULTS: A total of 33 out of 4306 verbal autopsies confirmed suicide as the cause of death. Content analysis of a further 228 deaths originally attributed to accidents identified 39 additional likely suicides. The best estimate of suicide-specific mortality rate was 14.7 per 100,000 population per year (credibility window = 11.3 - 18.0). The most common reported method of death was self-poisoning (54%). From the case-control study interpersonal difficulties and stressful life events were associated with increased odds of suicide in both confirmed suicides and confirmed combined with suspected suicides. Other pertinent factors such as age and being male differed depending upon which outcome was used. CONCLUSION: Suicide is common in this area, and interventions are needed to address drivers. The twofold increase in the suicide-specific mortality rate following incorporation of misattributed suicide deaths exemplify underreporting and misclassification of suicide cases at community level. Further, verbal autopsies may underreport suicide specifically among older and female populations.

Prevalence of malaria parasites in adults and its determinants in malaria endemic area of Kisumu County, Kenya.

BACKGROUND: The prevalence of malaria parasites in adults in Africa is less well researched than in children. Therefore, a demographic surveillance site was used to conduct a household survey of adults in the malaria endemic area of Maseno division in Kisumu County near Lake Victoria. METHODS: A random survey of 1,190 adults living in a demographic health surveillance site in a malaria endemic area of 70,805 population size was conducted, measuring presence of malaria parasites by slide microscopy. Data were analysed using STATA to calculate the prevalence of malaria and associated risk factors. RESULTS: The adult prevalence of presence of malaria parasites in Maseno was 28% (95% CI: 25.4-31.0%). Gender was a significant sociodemographic risk factor in both univariate (OR 1.5, p = 0.005) and multivariate (OR 1.4, p = 0.019) analyses. Females were 50% more likely to have malaria than men. CONCLUSIONS: Presence of malaria parasites is common in the adult population of this endemic area, and the rate is greatly increased in women. The presence of such an adult pool of malaria parasites represents a key reservoir factor in transmission of parasites to children, and is relevant for plans to eradicate malaria.

Common mental disorder in Nyanza province, Kenya in 2013 and its associated risk factors--an assessment of change since 2004, using a repeat household survey in a demographic surveillance site.

BACKGROUND: Repeat household surveys are useful to assess change in prevalence over time, but there have been no repeat surveys of common mental disorder (CMD) in Kenya, or indeed sub-Saharan Africa. Therefore a repeat household survey of CMD and its associated risk factors was conducted in Maseno area, Kisumu county in Kenya, using a demographic surveillance site as the sample frame, in order to test the hypotheses that (a) the prevalence of CMD would increase between 2004 and 2013 due to the intervening political, social and economic pressures; (b) as in 2004, there would be no gender difference in prevalence of CMD. METHODS: One thousand one hundred ninety households were selected, and 1158 adult participants consented to be interviewed with a structured epidemiological assessment while 32 refused to participate in the study interviews, giving a response rate of 97.3%. RESULTS: The study found that the overall prevalence of CMD in 2013 was 10.3%. However, there were significantly higher rates of having any CMD in 2013 if one was female (OR 6.2, p < 0.001), divorced/widowed (OR 2.5, p < 0.003), aged over 60 (OR 2.3, p = 0.052), either self-employed (OR 3.3 p < 0.001) or employed (OR 3.3, p < 0.001), or belonged to the lowest asset quintile (OR 2.5, p = .0.004) after adjusting for other variables significant at the bivariate level. The overall prevalence in 2013 was consistent with that found in 2004, despite intervening political and community turbulence. However, this apparent consistency masks the development of a striking difference in prevalence between the genders. Over the decade 2004-13, the prevalence for men dropped from 10.9 to 3.8% (P = 0.001) and the prevalence for women increased from 10.8 to 17.5% (p = 0.001). CONCLUSION: Common mental disorders continue to pose a significant public health burden in Kenya, and gender related vulnerability merits further research and is relevant for health worker training.

Alcohol consumption and hazardous drinking in western Kenya--a household survey in a health and demographic surveillance site.

BACKGROUND: Alcohol use and hazardous drinking have been studied in school children and in urban areas of Kenya, but there has been no adult survey of these issues in a rural household population. METHODS: This study reports the prevalence of alcohol consumption and hazardous drinking in a household survey of a demographic surveillance site in rural Kenya. Information collected included demographic characteristics, socio-economic factors, recent life events and perceived social support. Alcohol consumption was assessed by questions about quantity and frequency. The Alcohol Use Disorders Identification Test (AUDIT) measured hazardous alcohol use. The Clinical Interview Schedule- Revised assessed common mental disorder, and the Psychosis Screening Questionnaire indicated the presence of psychotic symptoms. RESULTS: The study found that lifetime and current alcohol consumption were 10.8% and 9.2% respectively. Current alcohol consumption was significantly higher in men (OR 0.4, p < 0.001 for women) and in the self-employed (OR 1.8, p = 0.013), after adjustment for factors significant at the bivariate level. Hazardous drinking was significantly higher in men (OR 0.3, p < 0.001 for women), people living in larger households (OR 1.8, p = 0.021), people who were single (OR 1.7, p = 0.093), and in those who are self-employed (OR 1.8, p = 0.036), after adjustment for factors significant at the bivariate level. CONCLUSION: This study suggests that alcohol consumption and hazardous drinking in the general population in a poor rural area in Nyanza Province is still relatively low. This represents an important public health educational opportunity to keep such rates low before increasing income and employment opportunities enable higher access to alcohol and other substances, and before the higher consumption found by studies on urban youth, especially neighbouring Kisumu town, spreads to the rural areas.

Tedium vitae, death wishes, suicidal ideation and attempts in Kenya-prevalence and risk factors.

BACKGROUND: There has been no previous household population study of suicidal ideation and attempts in Kenya. Therefore this study aimed to establish the prevalence of suicidal ideation and attempts in a rural population in Kenya, and to assess risk factors. METHODS: An epidemiological survey of a household population, using standardised structured interviews. We examined the prevalence of suicidal ideation and suicide attempts and the predictors of suicidal thoughts and attempts, using STATA to calculate unadjusted and adjusted odds ratios. RESULTS: A quarter of the sample (24.1 %) had thought that life was not worth living (tedium vitae) at some point in their lives, while a fifth had experienced death wishes at some stage. About 7.9 % reported suicidal thoughts and 1.9 % had made actual suicide attempts at some point in their lives. It can be seen that the prevalence of suicidal thoughts was 0.7 %, 4.2 %, 3.7 % and 7.9 % for last week, last year, at some other time, and lifetime respectively, while the prevalence of suicidal attempts was 0.5 %, 1.2 %, 0.7 and 1.9 % respectively. In the adjusted analysis of factors associated with suicidal thoughts, being female (OR 1.8, p = 0.017), having CMD (OR 2.7, p = 0.001), having a number of recent life events (OR 2.3, p = 0.001 for 2-3 life events and OR 2.6, p = 0.004 for 4 or more life events), and having a large social group size (OR 7.7, p = 0.006 for social group size of 4-8 and OR 9.1, p = 0.003 for social group size of 9 or more) were all associated with increased rates of life time suicidal thoughts, but psychotic symptoms were no longer significant after adjustment for the other variables. In the adjusted analysis of suicide attempts, having any psychotic symptoms (OR 5.1, p = 0.001) was the only factor associated with suicide attempts after adjustment for other factors significant at the bivariate level. CONCLUSION: Suicidal ideation and attempts pose a significant public health burden in this poor rural area of Kenya. The findings are relevant for mental health promotion and prevention programmes, public education and professional training programmes in relevant sectors, especially in front line health workers and social workers.

The Walter Reed Project, Kisumu Field Station: Impact of Research on Malaria Policy, Management, and Prevention.

The Walter Reed Project is a collaboration between the Walter Reed Army Institute of Research of the United States Department of Defense and the Kenya Medical Research Institute. The Kisumu field station, comprising four campuses, has until recently been devoted primarily to research on malaria countermeasures. The Kombewa Clinical Research Center is dedicated to conducting regulated clinical trials of therapeutic and vaccine candidates in development. The center's robust population-based surveillance platform, along with an active community engagement strategy, guarantees consistent recruitment and retention of participants in clinical trials. The Malaria Diagnostic Center, backed by WHO-certified microscopists and a large malaria blood film collection, champions high-quality malaria diagnosis and strict quality assurance through standardized microscopy trainings. The Malaria Drug Resistance Laboratory leverages cutting-edge technology such as real-time Polymerase Chain Reaction (qPCR) to conduct comprehensive research on resistance markers and obtain information on drug efficacy. The laboratory has been working on validating artemisinin resistance markers and improving tracking methods for current and future antimalarial compounds. Finally, the Basic Science Laboratory employs advanced genomic technology to examine endpoints such as immunogenicity and genomic fingerprinting for candidate drugs and vaccine efficacy. Herein, we examine the site's significant contributions to malaria policy, management, and prevention practices in Kenya and around the world.

Deployment of Rotavirus Vaccine in Western Kenya Coincides with a Reduction in All-Cause Child Mortality: A Retrospective Cohort Study.

Rotavirus is an important cause of fatal pediatric diarrhea worldwide. Many national immunization programs began adding rotavirus vaccine following a 2009 World Health Organization recommendation. Kenya added rotavirus vaccine to their immunization program at the end of 2014. From a cohort of 38,463 children in the Kisumu health and demographic surveillance site in western Kenya, we assessed how the implementation of the rotavirus vaccine affected mortality in children under 3 years of age. Following its introduction in late 2014, the span of rotavirus vaccine coverage for children increased to 75% by 2017. Receiving the rotavirus vaccine was associated with a 44% reduction in all-cause child mortality (95% confidence interval = 28-68%, p < 0.0001), but not diarrhea-specific mortality (p = 0.401). All-cause child mortality declined 2% per month following the implementation of the rotavirus vaccine (p = 0.002) among both vaccinated and unvaccinated children, but diarrhea-specific mortality was not associated with the implementation of the rotavirus vaccine independent of individual vaccine status (p = 0.125). The incidence of acute diarrhea decreased over the study period, and the introduction of the rotavirus vaccine was not associated with population-wide trends (p = 0.452). The receipt of the rotavirus vaccine was associated with a 34% reduction in the incidence of diarrhea (95% confidence interval = 24-43% reduction). These results suggest that rotavirus vaccine may have had an impact on all-cause child mortality. The analyses of diarrhea-specific mortality were limited by relatively few deaths (n = 57), as others have found a strong reduction in diarrhea-specific mortality. Selection bias may have played a part in these results-children receiving rotavirus vaccine were more likely to be fully immunized than children not receiving the rotavirus vaccine.

Preferences of Patients and Providers in High-Burden Malaria Settings for Long-Acting Malaria Chemoprevention.

Antimalarial medications are recommended for chemoprevention as part of malaria control programs to decrease the morbidity and mortality related to more than 200 million infections each year. We sought to evaluate patient and provider acceptability of malaria chemoprevention in a long-acting formulation. We administered questionnaires to patients and providers in malaria endemic districts in Kenya and Zambia. Questions explored preferences and concerns around long-acting antimalarial formulations compared with oral formulations. We recruited 202 patient respondents (Kenya, n = 102; Zambia, n = 100) and 215 provider respondents (Kenya, n = 105; Zambia, n = 110). Long-acting injection was preferred to oral pills, whereas oral pills were preferred to implant or transdermal administration by patient respondents. Of 202 patient respondents, 80% indicated that they 'definitely would try' malaria chemoprevention offered by injection instead of oral pills. Of parents or guardians, 84% of 113 responded that they 'definitely would' have their child age < 12 years and 90% of 88 'definitely would' have their child ≥12 years receive an injection for malaria prevention. Provider respondents indicated that they would be more likely to prescribe a long-acting injectable product compared with an oral product for malaria chemoprevention in adults (70%), adolescents ages 12 years and older (67%), and children <12 years (81%). Potential for prolonged adverse effects with long-acting products was the highest concern for patient respondents, while higher medication-related cost was cited as the most concerning barrier to implementation by providers. Overall, these findings indicate enthusiasm for the development of long-acting injectable antimalarials to provide individual delivery method options across age groups.

Clinical laboratory hematology reference values among infants aged 1month to 17 months in Kombewa Sub-County, Kisumu: A cross sectional study of rural population in Western Kenya.

There is an urgent need for reliable region-specific hematological reference values for clinical monitoring. Laboratory reference ranges are important for assessing study participant eligibility, toxicity grading and management of adverse events in clinical trials and clinical diagnosis. Most clinical laboratories in Kenya rely on hematological reference values provided by instrument manufacturers and/or textbooks, which are based on population from Europe or North America. The use of such values in medical practice could result in improper patient management, selection bias in selection of appropriate participants for clinical trials and flawed classification of the clinical adverse events when applied to African populations. The aim of this study was to establish local laboratory hematological reference values in infants aged 1 month to 17 months from Kombewa Sub-county that could be true representative of the existing rural population. The study participants in the current study were those who had previously been recruited from GSK-sponsored study. This study was a phase III, Double Blind, Randomized, GSK-sponsored, Malaria Vaccine Clinical Trial that was conducted in infants aged 1month to 17months. 1,509 participants were included in the study analysis. Data were partitioned into 3 different age groups (1-6 months[m], 6-12 m and 12-17 m) and differences between gender were compared within each group. Data were analyzed using Graphpad prism V5 to generate 95% reference ranges (2.5th-97.5th percentile). There was evidence of gender differences in hemoglobin values (p = 0.0189) and platelet counts (p = 0.0005) in the 1 to 6m group. For the 12-17m group, there were differences in MCV (p<0.0001) and MCH (p = 0.0003). Comparing gender differences for all age groups, differences were noted in percent lymphocytes (p = 0.0396), percent monocytes (p = 0.0479), percent granulocytes (p = 0.0044), hemoglobin (p = 0.0204), hematocrit (p = 0.0448), MCV (p = 0.0092), MCH (p = 0.0089), MCHC (p = 0.0336) and absolute granulocytes (p = 0.0237). In 1 to 6m age group and all age groups assessed, for WBCs, hemoglobin, hematocrit, MCV and lymphocytes absolute counts, both 2.5th and 97.5th percentiles for Kisumu infants were higher than those from Kilifi. Platelet ranges for Kisumu children were narrower compared to Kilifi ranges. Kisumu hematology reference ranges were observed to be higher than the ranges of Tanzanian children for the WBCs, absolute lymphocyte and monocyte counts, hemoglobin, hematocrit and MCV. Higher ranges of WBCs, absolute lymphocyte and monocyte counts were observed compared to the values in US/Europe. Wider ranges were observed in hemoglobin, hematocrit, and MCV. Wider ranges were observed in platelet counts in Kisumu infants compared to the US/Europe ranges. Compared to Harriet Lane Handbook reference values that are used in the area, higher counts were observed in WBC counts, both absolute and percent lymphocyte counts, as well as monocyte counts for current study. Wider ranges were observed in RBC, platelets and RDW, while lower ranges noted in the current study for hemoglobin, hematocrit and granulocyte counts. This study underscores the importance of using locally established hematology reference ranges of different age groups in support of proper patient management and for clinical trials.

Malaria, mental disorders, immunity and their inter-relationships - A cross sectional study in a household population in a health and demographic surveillance site in Kenya.

BACKGROUND: Both malaria and mental disorders are associated with immune changes. We have previously reported the associations between malaria and mental disorders. We now report associations between malaria, mental disorders and immunity. METHODS: A household survey of malaria, mental disorders and immunity was conducted in a health and demographic surveillance system's site of 70,000 population in an area endemic for malaria in western Kenya. A random sample of 1190 adults was selected and approached for consent, blood samples and structured interview. FINDINGS: We found marginally raised CD4/CD3 ratios of participants with malaria parasites, but no difference in CD4/CD3 ratios for participants with common mental disorder (CMD) or psychotic symptoms. People with psychotic symptoms had increased levels of IL-6, IL-8, and IL-10, and lower levels of IL-1beta. People with CMD had higher levels of IL-8 and IL-10. People with malaria had higher levels of IL-10 and lower levels of TNF-alpha. At the bivariate level, CMD was associated with log TNF-α levels using unadjusted odds ratios, but not after adjusting for malaria. Psychotic symptoms were associated with log IL-10 and log TNF-α levels at the bivariate level while in the adjusted analysis, log TNF-α levels remained highly significant.. INTERPRETATION: This is the first population based study of immune markers in CMD and psychotic symptoms, and the first to examine the 3 way relationship with malaria. Our findings suggest that TNF-α may mediate the relationship between malaria and CMD. FUND: The study was funded by UK Aid, Department for International Development, Kenya office.

A comparison of all-cause and cause-specific mortality by household socioeconomic status across seven INDEPTH network health and demographic surveillance systems in sub-Saharan Africa.

BACKGROUND: Understanding socioeconomic disparities in all-cause and cause-specific mortality can help inform prevention and treatment strategies. OBJECTIVES: To quantify cause-specific mortality rates by socioeconomic status across seven health and demographic surveillance systems (HDSS) in five countries (Ethiopia, Kenya, Malawi, Mozambique, and Nigeria) in the INDEPTH Network in sub-Saharan Africa. METHODS: We linked demographic residence data with household survey data containing living standards and education information we used to create a poverty index. Person-years lived and deaths between 2003 and 2016 (periods varied by HDSS) were stratified in each HDSS by age, sex, year, and number of deprivations on the poverty index (0-8). Causes of death were assigned to each death using the InterVA-4 model based on responses to verbal autopsy questionnaires. We estimated rate ratios between socioeconomic groups (2-4 and 5-8 deprivations on our poverty index compared to 0-2 deprivations) for specific causes of death and calculated life expectancy for the deprivation groups. RESULTS: Our pooled data contained almost 3.5 million person-years of observation and 25,038 deaths. All-cause mortality rates were higher among people in households with 5-8 deprivations on our poverty index compared to 0-2 deprivations, controlling for age, sex, and year (rate ratios ranged 1.42 to 2.06 across HDSS sites). The poorest group had consistently higher death rates in communicable, maternal, neonatal, and nutritional conditions (rate ratios ranged 1.34-4.05) and for non-communicable diseases in several sites (1.14-1.93). The disparities in mortality between 5-8 deprivation groups and 0-2 deprivation groups led to lower life expectancy in the higher-deprivation groups by six years in all sites and more than 10 years in five sites. CONCLUSIONS: We show large disparities in mortality on the basis of socioeconomic status across seven HDSS in sub-Saharan Africa due to disparities in communicable disease mortality and from non-communicable diseases in some sites. Life expectancy gaps between socioeconomic groups within sites were similar to the gaps between high-income and lower-middle-income countries. Prevention and treatment efforts can benefit from understanding subpopulations facing higher mortality from specific conditions.

Cause-specific mortality in the Kombewa health and demographic surveillance systems site, rural Western Kenya from 2011-2015.

BACKGROUND: The vast majority of deaths in the health and Kombewa demographic surveillance system (HDSS) study area are not registered and reported through official systems of vital registration. As a result, few data are available regarding causes of death in this population. OBJECTIVES: To describe causes of death among residents of all ages in the Kombewa HDSS, located in rural Western Kenya. METHODS: Verbal autopsy (VA) interviews at the site were conducted using the modified 2007 and later 2012 standardized WHO questionnaires. Assignment of causes of death was made using the InterVA-4 model version 4.02. Cox regression model, adjusted for sex, was built to evaluate the influence of age on mortality. RESULTS: There were a total of 5196 deaths recorded between 2011 and 2015 at the site. VA interviews were successfully completed for 3903 of these deaths (75.1%). Mortality rates were highest among neonates HR = 38.54 (<0.001) and among Infants HR = 2.07 (<0.006) in the Kombewa HDSS. Among those deaths in which VA was performed, the top causes of death were HIV/AIDS (12.6%), Malaria (10.3%), Pneumonia (10.1%), Acute abdomen (7.0%), Stroke (5.2%) and TB (4.9%) for the whole population in general. Stroke, acute abdomen heart diseases and Pneumonia were common causes of death (CODs) among the elderly over the age of 65. CONCLUSIONS: The analysis established the main CODs among people of all ages within the area served by the Kombewa HDSS. We hope that information generated from this study will help better address preventable deaths in the surveyed community as well as help mitigate negative health impacts in other rural communities throughout the Western Kenya region.

A Spatiotemporal Analysis of HIV-Associated Mortality in Rural Western Kenya 2011-2015.

BACKGROUND: Reliable data on the HIV epidemic is critical for the measurement of the impact of HIV response and for the implementation of further interventions. METHODS: We used mortality data from the Kombewa health and demographic surveillance systems (HDSS) from January 1, 2011 to December 31, 2015 to examine the space-time pattern of HIV-associated mortality. HIV mortality rate was calculated per 1000 persons living with HIV (for comparison with regional and national averages) and per 1000 person-years (p-y) for comparison with data from other HDSS sites. We used the Optimized Hot Spot Analysis to examine whether HIV-associated deaths would form statistically significant local aggregation in the 5-year period. P-value of <0.05 and <0.01 was considered significant. RESULTS: The HIV-associated mortality rate over the 5-year period was 9.8 per 1000 persons living with HIV (PLHIV). Mortality declined from 11.6 per 1000 PLHIV in 2011 to 7.3 per 1000 PLHIV by the end of 2015. The rates of HIV were highest among infants [hazard ratio (HR) = 2.39 (<0.001)]. Tuberculosis mortality rates were highest in the age group 5-14 years [HR = 2.29 (0.002)] and the age group 50-64 years [HR = 1.18 (0.531)]. The overall trend in HIV-associated mortality showed a decline from 1.8 per 1000 p-y in 2011 to 1.3 per 1000 p-y by the end of 2015. The hotspot analysis showed that 20.0% of the study area (72 km) was detected as hotspots (Z = 2.382-3.143, P ≤ 0.001) and 4.2% of the study area as cold spots (15 km). CONCLUSIONS: HIV attributable death in the HDSS population is substantial, although it is lower than both the national and the regional estimates.

Probable Post Traumatic Stress Disorder in Kenya and Its Associated Risk Factors: A Cross-Sectional Household Survey.

This study aimed to assess the prevalence of probable post-traumatic stress disorder (PTSD), and its associated risk factors in a general household population in Kenya. Data were drawn from a cross-sectional household survey of mental disorders and their associated risk factors. The participants received a structured epidemiological assessment of common mental disorders, and symptoms of PTSD, accompanied by additional sections on socio-demographic data, life events, social networks, social supports, disability/activities of daily living, quality of life, use of health services, and service use. The study found that 48% had experienced a severe trauma, and an overall prevalence rate of 10.6% of probable PTSD, defined as a score of six or more on the trauma screening questionnaire (TSQ). The conditional probability of PTSD was 0.26. Risk factors include being female, single, self-employed, having experienced recent life events, having a common mental disorder (CMD)and living in an institution before age 16. The study indicates that probable PTSD is prevalent in this rural area of Kenya. The findings are relevant for the training of front line health workers, their support and supervision, for health management information systems, and for mental health promotion in state boarding schools.

Adult psychotic symptoms, their associated risk factors and changes in prevalence in men and women over a decade in a poor rural district of Kenya.

There have been no repeat surveys of psychotic symptoms in Kenya or indeed subSaharan Africa. A mental health epidemiological survey was therefore conducted in a demographic surveillance site of a Kenyan household population in 2013 to test the hypothesis that the prevalence of psychotic symptoms would be similar to that found in an earlier sample drawn from the same sample frame in 2004, using the same overall methodology and instruments. This 2013 study found that the prevalence of one or more psychotic symptoms was 13.9% with one or more symptoms and 3.8% with two or more symptoms, while the 2004 study had found that the prevalence of single psychotic symptoms in rural Kenya was 8% of the adult population, but only 0.6% had two symptoms and none had three or more psychotic symptoms. This change was accounted for by a striking increase in psychotic symptoms in women (17.8% in 2013 compared with 6.9% in 2004, p < 0.001), whereas there was no significant change in men (10.6% in 2013 compared with 9.4% in 2004, p = 0.582). Potential reasons for this increase in rate of psychotic symptoms in women are explored.

Health & demographic surveillance system profile: The Kombewa health and demographic surveillance system (Kombewa HDSS).

The Kombewa Health and Demographic Surveillance System (HDSS) grew out of the Kombewa Clinical Research Centre in 2007 and has since established itself as a platform for the conduct of regulated clinical trials, nested studies and local disease surveillance. The HDSS is located in a rural part of Kisumu County, Western Kenya, and covers an area of about 369 km(2) along the north-eastern shores of Lake Victoria. A dynamic cohort of 141 956 individuals drawn from 34 718 households forms the HDSS surveillance population. Following a baseline survey in 2011, the HDSS continues to monitor key population changes through routine biannual household surveys. The intervening period between set-up and baseline census was used for preparatory work, in particular Global Positioning System (GPS) mapping. Routine surveys capture information on individual and households including residency, household relationships, births, deaths, migrations (in and out) and causes of morbidity (syndromic incidence and prevalence) as well as causes of death (verbal autopsy). The Kombewa HDSS platform is used to support health research activities, that is clinical trials and epidemiological studies evaluating diseases of public health importance including malaria, HIV and global emerging infectious diseases such as dengue fever.