CAREGIVERS' KNOWLEDGE AND HOME MANAGEMENT OF FEVER IN CHILDREN.

BACKGROUND: Fever is one of the most common complaints presented to the Paediatric Emergency Unit (PEU). It is a sign that there is an underlying pathologic process, the most common being infection. Many childhood illnesses are accompanied by fever, many of which are treated at home prior to presentation to hospital. Most febrile episodes are benign. Caregivers are the primary contacts to children with fever. Adequate caregivers' knowledge and proper management of fever at home leads to better management of febrile illnesses and reduces complications. OBJECTIVE: To determine the caregivers' knowledge and practices regarding fever in children. DESIGN: A cross-sectional study. SETTING: Peadiatric Emergency Unit at Kenyatta National Hospital (KNH) SUBJECTS: Two hundred and fifty caregivers of children under 12 years presenting with fever in August to October 2011 to the PEU. RESULTS: Three quarters of the caregivers' defined fever correctly. Their knowledge on the normal body was at 47.6%. Infection was cited as the leading cause of fever (95.2%). Brain damage (77.6%) and dehydration (65.6%) were viewed as the most common complication. Fever was treated at home by 97.2% of caregivers, most of them used medication. CONCLUSIONS: Fever was defined correctly by 75.2% of the study participants and a majority of them used touch to detect fever. Fever was managed at home with medications. Public Health Education should be implemented in order to enlighten caregivers on fever and advocate for the use of a clinical thermometer to monitor fever at home.

ADHERENCE TO PNEUMONIA GUIDELINES FOR CHILDREN 2 - 59 MONTHS AT GARRISA PROVINCIAL GENERAL HOSPITAL.

BACKGROUND: Clinical Practice Guidelines for childhood illnesses including pneumonia in Kenya are contained in the Ministry of Health Basic Paediatric Protocols. In the presence of a cough and/ or difficulty in breathing and increased respiratory rate for age, pneumonia is diagnosed. In addition to these the presence of lower chest wall indrawing denotes severe pneumonia; The presence of cyanosis, inability to drink/ breastfeed, grunting, level of consciousness using the AVPU scale less than A in addition to the aforementioned is classified as very severe pneumonia. Recommended management is intravascular Crystalline penicillin, gentamycin and oxygen for severe pneumonia, intravascular crystalline penicillin for severe pneumonia and oral amoxyl or cotrimaxole for pneumonia. These guidelines have been disseminated through the Emergency Triage And Treatment Plus (ETAT +) coursesheld since 2007. Implementation of guidelines into care has been shown to reduce case fatality from pneumonia by 36%. OBJECTIVES: To evaluate the level of adherence and factors affecting adherence to the National guidelines on management of pneumonia in children aged two to fifty nine months at Garissa provincial General Hospital, Kenya. DESIGN: Retrospective hospital based cross sectional study. SETTING: Paediatric Department of Garissa Provincial General Hospital (PGH) in Kenya. SUBJECTS: Hospital medical records of children aged two to fifty nine months diagnosed with pneumonia between January and June 2012 were reviewed. Data abstracted from the records included demographic information, recorded clinical signs and symptoms, disease classification and treatment. RESULTS: Records of 91 childrenwere reviewed. Theirmedian age was 12 months (IQR 6 - 18 months). There were more boys than girls with a male to female ratio of 1.25:1. Forty-eight of the participants (52.8%) had severe pneumonia. Guideline adherence was assessed at three levels; assessment of clinical signs and symptoms reflected by their recording, correct disease severity classification and correct treatment prescribed. There were a minimum of two and a maximum of six clinical sign and symptoms recorded. The average level of adherence was 42.9% (SD ± 17.3).Documented correct classification of disease severity was 56.6% and recommended treatment of pneumonia was 27.7%. The presence of a co-morbidity and severe disease was associated with better adherence to the assessment tasks (p = 0.033 and p = 0.021 respectively). Disease severity was associated with better adherence to the disease classification task (p = < 0.001) and treatment task (p = 0.02). CONCLUSION: Adherence to guidelines was low at all assessed levels. Overall, disease severity was associated with better guideline adherence. Presence of co-morbidities improved disease assessment.

Multifocal pheochromocytoma in early childhood: case report.

A three and a half year old male with multifocal phaeochromocytoma involving the right adrenal gland and an intrathoracic mass is presented. Twenty four hour vanillylmandelic acid (VMA) was negative despite suggestive symptomatology. The diagnosis was made on serial CT scans of the head, thoracic inlet and pelvis. He underwent right adrenalectomy and thoracotomy to remove the abdominal and intrathoracic mass. The diagnosis was confirmed by histology. He remained hypertensive on hefty antihypertensive doses throughout his lifespan and finally succumbed to status epilepticus at the age of ten, six years from the time of diagnosis.

Identification of malaria species by ELISA in sporozoite and oocyst infected Anopheles from western Kenya.

Enzyme-linked immunosorbent assays (ELISAs) for the circumsporozoite (CS) antigens of Plasmodium falciparum, P. malariae, and P. ovale were used to identify species of sporozoite and oocyst infections detected by dissection in Anopheles gambiae s.1. and An. funestus collected in western Kenya. ELISAs identified 92.5% of 1,113 salivary gland infections; Plasmodium species infections included 79.4% P. falciparum, 3.2% P. malariae, 1.7% P. ovale, and 2 or more Plasmodium species were detected in 15.7% of the Anopheles in which the species of parasite was identified. Identification was more likely with greater numbers of sporozoites observed in dissections, increasing from 65% ELISA positivity in mosquitoes with 1-10 sporozoites in their salivary glands to 96% in mosquitoes with over 1,000 sporozoites. ELISAs detected CS antigen in 66% of 294 Anopheles that by dissection had oocysts but uninfected salivary glands. Of 112 Anopheles with a single species of Plasmodium detected in the salivary glands, 29 (25.9%) had 1 or more additional species detected in the midgut, indicating a high potential for multiple infections. Similar proportions of Plasmodium species were found in An. gambiae s.1. and An. funestus.

Plasmodium falciparum gametocytemia in Kenyan children: associations among age, intensity of exposure to transmission, and prevalence and density of subsequent gametocytemia.

Recently, an association was described between the density of Plasmodium falciparum asexual parasitemia in Kenyan children and the entomologic inoculation rate (EIR) measured prior to measurement of asexual parasitemia. This study examined whether transmission pressure, as represented by the EIR, was associated with the prevalence or density of gametocytemia in Kenyan children. Each month for 19 months, a cohort of approximately 50 children was given a radical cure and enrolled in the study. Blood films were taken on days 0, 7, and 14. The EIR was calculated for the 28-day period ending 14 days prior to enrollment: the relationship between blood film data from day 7 and exposure variables was explored. We found that younger children were more likely to be gametocytemic than older children and, if gametocytemic, were more likely to have a dense gametocytemia. There was an inverse relationship between the number of infective bites per night received and prevalence but not density of gametocytemia, even after age adjustment. Concordance of gametocytemia prevalence on days 0 (64%), 7 (66%), and 14 (52%) was poor; 84% of the children were positive on at least one day. This indicates that in many subjects the detectable gametocytemia varied over the 14 days. Under these holoendemic transmission conditions, the EIR is inversely correlated with prevalence of gametocytemia, and point measurements of gametocytemia by conventional microscopy underestimate the number of infective donor hosts.

Plasmodium falciparum incidence relative to entomologic inoculation rates at a site proposed for testing malaria vaccines in western Kenya.

Relationships between Plasmodium falciparum incidence and entomologic inoculation rates (EIRs) were determined for a 21-month period in Saradidi, western Kenya, in preparation for malaria vaccine field trials. Children, ranging in age from six months to six years and treated to clear malaria parasites, were monitored daily for up to 12 weeks to detect new malaria infections. Overall, new P. falciparum infections were detected in 77% of 809 children. The percentage of children that developed infections per two-week period averaged 34.7%, ranging from 7.3% to 90.9%. Transmission by vector populations was detected in 86.4% (38 of 44) of the two-week periods, with daily EIRs averaging 0.75 infective bites per person. Periods of intense transmission during April to August, and from November to January, coincided with seasonal rains. Relationships between daily malaria attack rates and EIRs indicated that an average of only 7.5% (1 in 13) of the sporozoite inoculations produced new infections in children. Regression analysis demonstrated that EIRs accounted for 74% of the variation in attack rates. One of the components of the EIR, the human-biting rate, alone accounted for 68% of the variation in attack rates. Thus, measurements of either the EIR or the human-biting rate can be used to predict corresponding attack rates in children. These baseline epidemiologic studies indicate that the intense transmission patterns of P. falciparum in Saradidi will provide excellent conditions for evaluating malaria vaccine efficacy.

Plasmodium species identification by ELISA for sporozoites removed from dried dissection slides.

This study tested the feasibility of identifying salavary gland sporozoites to species by Plasmodium falciparum ELISA by drying them on slides or in vials. The glands were dissected from Anopheles gambiae Giles s.l. and An. funestus Giles collected in western Kenya. In 119 gland infections containing a geometric mean of 1,222 sporozoites, a mean of 72.5% of sporozoites were removed in 60 microliters saline from slides at the time of dissection. Each of the 119 samples was divided into three 18 microliters aliquots. Subsamples were stored at -70 degrees C, dried in vials, or dried on a microslide. When tested by Plasmodium falciparum ELISA, positive reactions were observed in 86.6% of frozen samples, 70.6% of samples held dry in vials, and 50.4% of samples held dry on microslides for 1 mo. Of 90 gland infections where coverslips were removed and slides were left to dry for 1 mo before adding blocking buffer, 81.1% were positive for P. falciparum. This was not significantly different from either frozen gland samples (where 85.5% of 392 infections were identified or frozen gland plus corresponding thorax samples where 86.2% of 160 samples were identified). In malaria field studies, where it is not always practical to freeze samples, sporozoites from dissected mosquitoes can be preserved adequately for ELISA identification by simply removing coverslips and drying dissection slides.

Species composition of the Anopheles gambiae complex (diptera: Culicidae) at two sites in western Kenya.

At two sites in the Kisumu area of western Kenya, the species composition of the Anopheles gambiae complex was determined by analysis of ovarian polytene chromosomes. Of 1,915 females, 26.1% were An. arabiensis Patton and 73.9% were An. gambiae Giles; one arabiensis x gambiae hybrid was identified. No major differences in the proportions of An. arabiensis and An. gambiae were observed between sites or between years. The ratio of An. arabiensis/An. gambiae was 6.7:1 (n = 231) in cow-baited traps, 0.2:1 (n = 1,525) in indoor resting samples, and 0.5:1 (n = 145) in all-night human bait catches. The proportion of An. arabiensis decreased progressively from 50.0% to 8.3% (n = 1,129) during 11 wk from September to November 1987; this change was correlated negatively with night temperature and positively with temperature range. In cow-baited traps, 97.4% (n = 194) of An. arabiensis were cow-fed and 95.8% (n = 1,054) of An. gambiae from indoor resting collections were human-fed. In indoor collections, 37.2% (n = 215) of An. arabiensis were cow-fed and 23.1% (n = 26) of An. gambiae from cow traps were human-fed. This demonstrates post-blood-feeding endophily by An. arabiensis and suggests post-blood-feeding exophily by An. gambiae. Malaria infection rates were higher for An. gambiae than for An. arabiensis by a ratio of 3:1 in 1986 (by Plasmodium falciparum ELISA) and 2.3:1 in 1987 (by dissection). Despite the higher proportion of infective An. gambiae, both species in this area serve as efficient vectors through their remarkably stable contact with the human population as demonstrated by their blood feeding and resting behavior.

Malaria sporozoite detection by dissection and ELISA to assess infectivity of afrotropical Anopheles (Diptera: Culicidae).

Malaria infection rates determined by dissection and Plasmodium falciparum enzyme-linked immunosorbent assay (ELISA) were compared for 26,935 Anopheles gambiae Giles sensu lato and 17,739 Anopheles funestus Giles collected during 20 mo in western Kenya. ELISA infection rates were about 43% higher than dissection sporozoite rates. In dissection-negative Anopheles, circumsporozoite (CS) protein was detected by ELISA in 5.2% of 10,017 salivary gland samples and in 12.2% of 237 thorax samples. The accuracy of dissection and ELISA techniques was compared by the following tests on a group of 352 field-collected Anopheles (held 10 d to ensure sporogonic development): salivary gland dissection, examination of Giemsa-stained dissection slides, ELISA tests on salivary gland and thorax body parts, and microscopic techniques for determining sporozoite loads. Respective infection rates were 9.9%, 10.8%, and 15.6% for dissection, stained slides, and ELISA. Sporozoite loads were associated significantly with ELISA absorbance values (r = 0.76). Compared with Giemsa-stained dissection slide results, the sensitivity of sporozoite detection was 92.1% for dissection compared with 78.9% for ELISA; specificity was 100.0% for dissection versus 92.0% for ELISA. Immunological detection of CS protein in head-thorax samples of Afrotropical vectors overestimated the proportion of infective Anopheles because the comparison of techniques indicated that 45.4% of the ELISA positive Anopheles did not contain salivary gland sporozoites.

Characterization of malaria transmission by Anopheles (Diptera: Culicidae) in western Kenya in preparation for malaria vaccine trials.

Malaria transmission was studied for 33 mo in the villages of Kisian and Saradidi in western Kenya in preparation for field trials of malaria vaccines. Abundance estimates of Anopheles gambiae Giles sensu lato and Anopheles funestus Giles, which constituted over 99% of 26,645 anophelines collected, were compared for all-night biting collections inside houses, outdoors, and in tents. The overall numbers of Anopheles per man-night were 2.3 times greater in Kisian than in Saradidi. For the three types of collections, mean sporozoite rates by dissection ranged from 2.2 to 5.4% for 13,072 Anopheles in Kisian and from 9.9 to 13.6% for 7,058 Anopheles in Saradidi; greater than 90% of the infections were Plasmodium falciparum, either alone or mixed with P. malariae or P. ovale. Heaviest transmission from April to July coincided with the end of the long rainy season. Entomological inoculation rates (EIR) averaged 0.82 infective bites per man per night inside houses in Kisian and 0.65 in Saradidi. Outdoors, EIRs averaged 0.09 in Kisian and 0.52 in Saradidi. In tents, which were evaluated to identify methods for exposing nonindigenous volunteers during vaccine efficacy trials, EIRs were 3.3 and 2.5 times less than inside houses for Kisian (EIR = 0.25) and Saradidi (EIR = 0.26), respectively. Exposure in tents averaged one infective bite every 4.0 d in Kisian and every 3.8 d in Saradidi. The use of tents in vaccine efficacy trials should provide adequate exposure for nonindigenous volunteers. Malaria vaccine trials could be conducted efficiently in western Kenya, with timing dependent upon the intensity of transmission required by vaccine trial objectives.

Effect of human circumsporozoite antibodies in Plasmodium-infected Anopheles (Diptera: Culicidae).

Human circumsporozoite (CS) antibodies to Plasmodium falciparum were detected in blood meals from 45.0% of 1,547 field-collected Anopheles gambiae Giles sensu lato and Anopheles funestus Giles from western Kenya. Possible effects on malaria infections within the Anopheles host were investigated. Circumsporozoite antibodies were detected in blood meals up to 36 h after feeding. Antibodies crossing the midgut were detected experimentally in hemolymph from 4 to 36 h after feeding; human IgG also was present in hemolymph from fully gravid field-collected Anopheles. Ingestion of high-titer human CS antibodies or 2A10 monoclonal antibody to P. falciparum sporozoites by P. falciparum-infected An. gambiae, 10 d after feeding on an infected human, had no effect on oöcyst maturation, sporozoite rates, or sporozoite loads. Contact between CS antibodies and sporozoites in the hemocoel did not block sporozoite invasion of salivary glands. Human IgG antibodies were detected by an indirect fluorescent antibody technique on salivary gland sporozoites from 83.3% of 114 field-collected Anopheles. In 65.4% of 26 infections, antibodies persisted on sporozoites for at least three days. Thus, a high proportion of naturally infected An. gambiae s.l. and An. funestus in western Kenya transmit sporozoites that are bound with human IgG acquired during previous blood meals. The infectivity of such sporozoites needs to be determined in relation to natural transmission and to the potential use of malaria sporozoite vaccines.

Relative abundance and blood feeding behavior of nocturnally active culicine mosquitoes in western Kenya.

At 2 sites in western Kenya targeted for future malaria vaccine trials, adult culicine mosquitoes were sampled over one year by 5 collection techniques to assess human exposure to potential vectors of pathogens other than malaria. Collections included 20,910 females representing 19 species in Kisian and 4,312 females of 11 species in Saradidi. Common species in Kisian included Culex quinquefasciatus (71.4%), Mansonia uniformis (15.8%), Ma. africana (6.2%), Aedes mcintoshi (2.0%), Coquillettidia fuscopennata (1.9%) and Ae. ochraceus (1.8%). Common species in Saradidi included Cx. quinquefasciatus (92.7%), Cx. nebulosus (4.5%) and Ma. uniformis (1.0%). Human-bait collections identified 16 man-biting culicine species in Kisian and 9 in Saradidi. Man-biting rates at Kisian for the 5 most common species were 1.8, 14.6 and 13.5 times higher than at Saradidi for indoor, outdoor and tent collections, respectively. Exposure indoors was estimated to be 1,277 bites/man/year at Kisian and 720 at Saradidi. Blood meal identification for 1,083 mosquitoes confirmed that the common culicine species feed primarily on humans and cows.

The diagnostic value of various features for acute lower respiratory infection among under fives.

One hundred and fifty children aged between 5 months and 5 years with cough of less than 2 weeks duration, and presenting at the paediatric filter clinic and paediatric observation ward of the Kenyatta National Hospital between July and December 1985 were each evaluated by a complete history, physical examination, and a chest X-ray. Ninety of them (or 60%) had radiological evidence of pneumonia. Respiratory rate of over 50 per minute, chest indrawing, flaring of alae nasae, and a history of rapid breathing were found to be valuable indicators of pneumonia.

Bacteriology of unheated expressed breast milk stored at room temperature.

Thirty samples of unheated expressed breast milk (EBM) from thirty lactating mothers, stored at room temperature (RT) and in the refrigerator (at +4 degrees C), were examined for the degree of bacterial contamination at two hourly intervals upto eight hours. All the EBM samples contained bacteria, mostly of normal skin flora; Staphylococcus albus 76.7%; Streptococcus viridans 40%. Potential pathogens were isolated in small numbers: Escherichia coli 26%, Streptococcus faecalis 13.6% and Staphylococcus aureus 6.7%. The bacterial colony counts (BCC) were consistently low; Mean initially 5.438 x 10(3) cfu/mm3 with a range of 0.15-23.1 x 10(3) cfu/mm3 and showed a significant reduction on storage in both EBM samples stored at RT and at +4 degrees C. The study proved that it is safe for mothers to keep unheated EBM at RT for at least eight hours before bacteria can multiply beyond unacceptable levels.

Effects of passive smoking and breastfeeding on childhood bronchial asthma.

OBJECTIVE: To evaluate the effect of passive smoking and breastfeeding on the severity and age of onset of bronchial asthma. DESIGN: Cross-sectional study. SETTING: Paediatric observation ward and paediatric chest clinic, Kenyatta National Hospital. PATIENTS: Children aged between one and 120 months. RESULTS: More than fifty per cent of the children had their first wheeze at less than 12 months of age and 68% were categorised as having moderate to severe asthma. Passive smoking was positively significantly associated with early onset of wheezing (chi 2 = 6.22, p = 0.012, Odds ratio = 2.44, 95% CI 1.2,5.0), and also, at a non significant level, to severity of asthma (chi 2 = 2.8, p = 0.09, Odds ratio = 2.1, 95% CI 0.9,4.7). On the other hand, exclusive breastfeeding was significantly negatively associated with severity of bronchial asthma (chi 2 = 4.02, p = 0.045, Odds ratio = 0.4, 95% CI 0.14,0.98), but did not seen to have effect on age of onset of the disease (chi 2 = 0.0006, p = 0.94, Odds ratio = 0.9, 95% CI 0.4,2.2). CONCLUSION: Passive smoking is associated with early onset of asthma and possibly with development of severe asthma while exclusive breastfeeding is protective against development of severe asthma but does not seem to affect the age of onset of this disease.

Verbal autopsy: a tool for determining cause of death in a community.

Verbal autopsy was used to determine causes of death in 239 children under the age of 5 years. The diagnosis derived from verbal autopsy was corroborated with hospital diagnosis in 39 cases. There was concurrence of diagnosis in 72% of the cases. Using the diagnosis of bronchopneumonia to validate the method, verbal autopsy was found to have a sensitivity of 71%, specificity of 92%, a positive predictive value of 85%. Reliability index of agreement was 0.654. Recall period up to 29 months after death was found to be reliable.

Mortality patterns in a rural Kenyan community.

Causes of death of 239 children below the age of 5 years in a rural community were determined using structured questionnaires. It was found that mortality was highest in infancy, accounting for 63% of all deaths with a trend of decreasing mortality with increasing age. The commonest cause of death was ARI (pneumonia and measles) accounting for 49% of the deaths, followed by diarrhoeal illnesses (8.8%). Only half of the deaths (51.5%) occurred at some health facility, though 77% of all children had been taken to a health facility for treatment during the fatal illness.

Childhood asthma at Kenyatta National Hospital, Nairobi.

Between January 1986 and July 1988, 356 children with bronchial asthma below 14 years of age were evaluated at the Kenyatta National Hospital. 21.3% experienced initial asthmatic attacks before the age of six months and 55.1% before 2 years. Only 8% of the study patients were below the age of 2 years at recruitment. The male:female ratio was 1:1. Physical exercise led to precipitation or worsening of attacks in 43.4% while 71.6% of the patients experienced attacks in the evening or at night. 18.5% and 42.9% had personal history of atopic dermatitis and allergic rhinitis respectively. The study shows that a substantial number of patients experience initial asthmatic attacks before the age of 6 months contrary to what has been previously believed.

X-ray diagnosable pneumonia in children with severe malnutrition at Kenyatta National Hospital.

OBJECTIVES: To estimate the prevalence of radiologically evident pneumonia among children with severe malnutrition and to evaluate the diagnostic utility of commonly used clinical indicators of pneumonia among children with severe malnutrition. METHODS: All children with severe malnutrition and admitted at the then Paediatric Observation Ward without congestive cardiac failure, severe anaemia, or severe dehydration, were clinically evaluated and a posteroanterior chest X-ray taken for each child. Pneumonia was diagnosed on the basis of radiological changes consistent with pneumonia as reported by an experienced radiologist. The performance of the various clinical parameters as diagnostic tests for pneumonia were also evaluated. SETTING: Kenyatta National Hospital, a tertiary level teaching institution for the University of Nairobi. RESULTS: One hundred and seven children comprising 68 males and 39 females were recruited into the study. Of these children, 38 had kwashiorkor, 40 had marasmus, while 29 had marasmic kwashiorkor. Radiological evidence of pneumonia was found in 58% of children with kwashiorkor, 75% with marasmic kwashiorkor, and 82% with marasmus. All the commonly used clinical parameters performed poorly as diagnostic tests for pneumonia among children with severe malnutrition. CONCLUSION: Prevalence of pneumonia was very high among children with severe malnutrition. Available clinical parameters, singly or in combination, are poor diagnostic tools for pneumonia in children with severe malnutrition. It is advisable to treat children with severe malnutrition as if they had pneumonia, even in the absence of suggestive clinical signs.

Prevalence of persistent diarrhoea in children aged 3-36 months at the Kenyatta National Hospital, Nairobi, Kenya.

Three hundred and eighty four children aged 3-36 months admitted to the Infectious Diseases Hospital (IDH) with diarrhoea were studied for persistent diarrhoea (PD), defined as diarrhoea lasting more than 14 days. To establish the duration of diarrhoea, the children were evaluated daily while in hospital and on days seven, fourteen, twenty one and twenty eight of the diarrhoea episode, if discharged. Of these children, 268 (69.8%) were less than 12 months. There was a slight male preponderance with a male to female ratio of 1.2:1. Twenty (5.4%) children presented with diarrhoea of more than 14 days at admission while of the 364 who presented with diarrhoea of less than 14 days at admission, 40 (11%) developed persistent diarrhoea, giving a total PD rate of 16.5%. The peak age for PD was nine months with no sex difference. Some possible risk factors for PD were identified as blood in stools, pneumonia, malnutrition, not breastfeeding, severe dehydration and antibiotic treatment. The total number of deaths in the study cases was 50, giving a case fatality rate of 13.6%. Of the children with PD, 19(31.7%) died. The children with PD were at a four times greater risk of dying (P<0.001, OR = 4.16). This study indicates that prevalence of PD among children admitted to IDH is high; and carries a high case fatality.