Kawasaki disease in Kenya and review of the African literature.

BACKGROUND: Kawasaki disease has been described across the globe, although publications from Africa are limited. To our knowledge, there are no publications on Kawasaki disease from Kenya, which triggered this report. METHODS: A retrospective cross-sectional study was undertaken to identify in-patients with a discharge diagnosis of Kawasaki disease, over 2 different 5-year periods, at two pediatric hospitals in Nairobi, Kenya. We reviewed the medical records of all patients and report their clinical findings, diagnostic workup and treatment. In addition, we undertook a detailed review of the literature. RESULTS: Twenty-three patients with Kawasaki disease were identified, of those 12 (52.2%) had incomplete disease. The mean age was 2.3 years (SD+/-2.2) (range 0.3-10.3) with a male to female ratio of 1:1. The mean duration of fever at diagnosis was 8.3 days (SD+/-4.7) (range 2-20). Oral changes were the most common clinical feature and conjunctivitis the least common. Thrombocytosis at diagnosis was seen in 52% (12/23). Twenty-one patients (91.3%) were treated with intravenous immunoglobulin and all except 1 received aspirin. Baseline echocardiograms were performed in 95.7% (22/23) and found to be abnormal in 3 (13.6%). Follow-up data was limited. Our literature review identified 79 publications with documented cases of Kawasaki disease in children from 22 countries across the African continent with a total of 1115 patients including those from this report. Only 153 reported cases, or 13.7%, are from sub-Saharan Africa. CONCLUSIONS: This is the first publication on Kawasaki disease from Kenya and one of the largest reports from sub-Saharan Africa. It is the first to have a complete review of the number of published cases from the African continent. Challenges in the diagnosis and management of Kawasaki disease in many African countries include disease awareness, infectious confounders, access and cost of intravenous immunoglobulin, access to pediatric echocardiography and follow-up. Increasing awareness and health care resources are important for improving outcomes of Kawasaki disease in Africa.

Acyclovir and transmission of HIV-1 from persons infected with HIV-1 and HSV-2.

BACKGROUND: Most persons who are infected with human immunodeficiency virus type 1 (HIV-1) are also infected with herpes simplex virus type 2 (HSV-2), which is frequently reactivated and is associated with increased plasma and genital levels of HIV-1. Therapy to suppress HSV-2 reduces the frequency of reactivation of HSV-2 as well as HIV-1 levels, suggesting that suppression of HSV-2 may reduce the risk of transmission of HIV-1. METHODS: We conducted a randomized, placebo-controlled trial of suppressive therapy for HSV-2 (acyclovir at a dose of 400 mg orally twice daily) in couples in which only one of the partners was seropositive for HIV-1 (CD4 count, > or = 250 cells per cubic millimeter) and that partner was also infected with HSV-2 and was not taking antiretroviral therapy at the time of enrollment. The primary end point was transmission of HIV-1 to the partner who was not initially infected with HIV-1; linkage of transmissions was assessed by means of genetic sequencing of viruses. RESULTS: A total of 3408 couples were enrolled at 14 sites in Africa. Of the partners who were infected with HIV-1, 68% were women, and the baseline median CD4 count was 462 cells per cubic millimeter. Of 132 HIV-1 seroconversions that occurred after randomization (an incidence of 2.7 per 100 person-years), 84 were linked within couples by viral sequencing: 41 in the acyclovir group and 43 in the placebo group (hazard ratio with acyclovir, 0.92, 95% confidence interval [CI], 0.60 to 1.41; P=0.69). Suppression with acyclovir reduced the mean plasma concentration of HIV-1 by 0.25 log(10) copies per milliliter (95% CI, 0.22 to 0.29; P<0.001) and the occurrence of HSV-2-positive genital ulcers by 73% (risk ratio, 0.27; 95% CI, 0.20 to 0.36; P<0.001). A total of 92% of the partners infected with HIV-1 and 84% of the partners not infected with HIV-1 remained in the study for 24 months. The level of adherence to the dispensed study drug was 96%. No serious adverse events related to acyclovir were observed. CONCLUSIONS: Daily acyclovir therapy did not reduce the risk of transmission of HIV-1, despite a reduction in plasma HIV-1 RNA of 0.25 log(10) copies per milliliter and a 73% reduction in the occurrence of genital ulcers due to HSV-2. (ClinicalTrials.gov number, NCT00194519.)

NUTRIENT INTAKE AMONG PREGNANT TEENAGE GIRLS ATTENDING ANTE-NATAL CLINICS IN TWO HEALTH FACILITIES IN BUNGOMA SOUTH DISTRICT, WESTERN KENYA.

OBJECTIVE: To assess the adequacy of nutrientintake including proteins, energy, calcium, iron, folate and vitamin C and identify the factors associated with nutrient intake. DESIGN: Cross sectional study. SETTING: Healthy facility based. Bungoma District Hospital and Bumula Health centre. SUBJECTS: Teenage pregnant girls attending Antenatal Clinic participated after providing written consent, with girls under 18 years being considered as emancipated minors. A standardised interviewer administered Food Frequency Questionnaire was used to asses the dietary intake. Nutrient calculator was used to determine the nutrient intake of the study participant. RESULTS: The intakes of all selected nutrients were significantly lower than the RDA. Protein intake was significantly associated with Education (OR: 0.537; 95% CI: 0.318-0.907), income (OR: 0.049; 95% CI: 0.919-0.128) and perceived food shortage (OR: 0.617; 95% CI: 0.389-0.890). Energy intake was significantly associated with income (p = 0.007, OR: 2.103; 95%CI: 1.225-3.608). Iron intake was significantly associated with perceived food shortage (OR: 2.548; 95% CI: 1.632-3.980). Hookworm affected calcium intake (OR: 3.074; 95% CI: 1.089-8.698) and malaria parasites affected folate intake (OR: 0.355; 95% CI: 0.226-0.557). Those with hookworm were 3 times more likely to have inadequate calcium intake as compared to those without. CONCLUSION: All the nutrients selected were lower than the Required Dietary Allowance. Level of education, income, Hookworm and malaria affected intake of various nutrients.

Distribution of Pseudocercospora species causing Sigatoka leaf diseases of banana in Uganda and Tanzania.

Sigatoka leaf diseases are a major constraint to banana production. A survey was conducted in Tanzania and Uganda to assess the distribution of Pseudocercospora species and severity of Sigatoka leaf diseases. Pseudocercospora species were identified using species-specific primers. Sigatoka-like leaf diseases were observed in all farms and on all cultivars, but disease severity varied significantly (P < 0.001) between countries, districts/regions within countries, altitudinal ranges and banana cultivars. In all regions except Kilimanjaro, P. fijiensis, the causal agent of black Sigatoka, was the only pathogen associated with Sigatoka disease. Mycosphaerella musae was associated with Sigatoka-like symptoms in Kilimanjaro region. Black Sigatoka disease was more severe in Uganda, with a mean disease severity index (DSI) of 37.5%, than in Tanzania (DSI = 19.9%). In Uganda, black Sigatoka disease was equally severe in Luwero district (mean DSI = 40.4%) and Mbarara district (mean DSI = 37.9%). In Tanzania, black Sigatoka was most severe in Kagera region (mean DSI = 29.2%) and least in Mbeya region (mean DSI = 11.5%). Pseudocercospora fijiensis, the most devastating sigatoka pathogen, was detected at altitudes of up to 1877 m a.s.l. This range expansion of P. fijiensis, previously confined to altitudes lower than 1350 m a.s.l. in East Africa, is of concern, especially for smallholder banana farmers growing the susceptible East African Highland bananas (EAHB). Among the banana varieties sampled, the EAHB, FHIA hybrids and Mchare were the most susceptible. Here, the loss of resistance in Yangambi KM5, a banana variety previously resistant to P. fijiensis, is reported for the first time.

Determinants in HIV counselling and testing in couples in North Rift Kenya.

BACKGROUND: Voluntary HIV counselling and testing (VCT) has been shown to be an acceptable and effective tool in the fight against HIV/AIDS. Couple HIV Counselling and Testing (CHCT) however, is a relatively new concept whose acceptance and efficacy is yet to be determined. OBJECTIVE: To describe factors that motivate couples to attend VCT as a couple. DESIGN: A cross sectional qualitative study. SETTING: Moi Teaching and Referral Hospital and Moi University, School of Medicine, Eldoret, Kenya SUBJECTS: Seventy one individuals were interviewed during KII (9) and dyad interviews (31 couples). Ten FGDs involving a total of 109 individuals were held. RESULTS: Cultural practices, lack of CHCT awareness, stigma and fear of results deter CHCT utilisation. Location of centre where it is unlikely to be associated with HIV testing, qualified professional staff and minimal waiting times would enhance CHCT utilisation. CONCLUSIONS: CHCT as a tool in the fight against HIV/AIDS in this region of Kenya is feasible as the factors that would deter couples are not insurmountable.

Stakeholders perception of HIV sero-discordant couples in western Kenya.

OBJECTIVE: To describe the perceptions of key stakeholders regarding the counselling needs of HIV sero-discordant couples as part of preparation for a clinical trial involving HIV sero-discordant couples. DESIGN: Qualitative study using key informant and couple interviews. SETTING: Moi Teaching and Referral Hospital (MTRH). SUBJECTS: A purposive sample of nine key informants and 31 couple interviews totaling 71 participants. The couple interviews consisted of HIV untested, HIV concordant (positive and negative) and discordant couples. RESULTS: Seventy one individuals participated in nine key informant and 31 couple interviews. The responses identified the following as key issues in counselling HIV discordant couples: The need for education on the meaning of HIV sero-discordancy including potential sources of infection; assistance in disclosing HIV test results to one's partner; discussion of the stigma surrounding formula feeding. Overall, the participants supported safer sexual practices in discordant partnerships. CONCLUSIONS: Psychosocial support of HIV sero-discordant couples should include messages about the meaning, mechanisms and implications of sero-discordancy. Culturally appropriate HIV-disclosure and safer sex messages are also needed to support these partnerships.

Stillbirths at Eldoret District Hospital: a retrospective study.

The result of a one year retrospective study on stillbirths (SBs) occurring at Eldoret District Hospital labour unit between 1st November and 31st October, 1992 is presented. The stillbirth rate (SBR) was 30.5 per 1000 births. 72.2% were fresh stillbirths (FSB). Intrapartum foetal asphyxia was the commonest probable cause of death accounting for 45.8% of all SBs while 26.4% of the SBs were unexplained. 43.9% of the SBs were low birth weight deliveries with mean gestational age for all SBs being 35.4 weeks. Spontaneous vaginal delivery was the commonest mode of delivery. 24.5% of the mothers were teenagers and 37.7% primigravidae. It is suggested that proper antenatal and intrapartum care can significantly reduce the SBR in this unit.

Attitudes of males to contraception in a Kenyan rural population.

The results of a contraceptive attitudes survey on 355 men carried out between January and March 1987 in Machakos District of Kenya are presented. 93.2% indicated that they approved of Family Planning. Although 63.9% of the respondents felt that family size decision making should be a couple's responsibility and 78.6% of respondents preferred a husband and wife approach to family planning counselling, 56.9% said that the women should be the one to actually use the contraceptive. 88.7% approved of female sterilization while 64.5% disapproved of vasectomy. There is need to re-evaluate the current integrated maternal child health-family planning services to actively and effectively accommodate men.

PIP: Results from the 1977-78 Kenya fertility survey revealed that, although 88% were aware of at least one family planning method, use was only 17% among currently married women of reproductive age. In 1987, a survey was conducted in the northern part of Machakos District of Kenya among 400 men in order to obtain information on male attitudes toward contraception. Of the 355 completed questionnaires, there were 94.6% currently married men with a mean age of 38.1. 31.8% were in polygamous unions and 68.2% were monogamous. Catholic Christians comprised 51.8% and 42 were nonCatholic Christians. 95.5% had some formal education. Family planning was approved of by 93.2% of the men and 86.1% thought their wives approved. 88.4% thought the wife should take the responsibility for actually using contraception. 33.6% thought the male should be the sole decision maker about family size; 1.4% thought the woman should be and 65.3% thought a joint decision was appropriate. 67.6% of the men had discussed family planning with others, of which 79.2% had with friends, 12.1% with family planning field educators, and 6.3% with relatives. 78.6% thought family planning should be presented to couples together. 41.6% thought the man alone or jointly had a role to play in family planning. 45.9% agreed that family planning should be used after the family size was completed, and 45.6% suggested after the first child. When family size had been achieved, 88.7% thought the wife should be sterilized. 64.5% disagreed with vasectomy use ever. 53.5% considered that the right choice of contraceptive would eliminate problems. 32.1% expressed the greatest fear of contraceptive being women falling ill from contraceptive use. Effect on future fertility was the greatest fear men had about vasectomies (59.2%). 23.5% thought male sterilization led to impotence.

Low birth weight deliveries at the Nyanza General Hospital Kisumu, Kenya.

The results of a four month descriptive study on low Birth weight (LBW) deliveries in Nyanza Provincial General Hospital, Kisumu from 15th March to 30th July 1987 are presented. The incidence of LBW was 15.0%. Premature labour accounted for 55.3% while term small for gestational age contributes 44.7% of all LBW babies. 4.8% of the mothers of LBW babies were teenagers. The mean gravidity of the mother's was 2.5 with 46.8% being primigravidae. Of the multiparae who delivered LBW babies: 26.6%, 25%, 12.9% and 12.1% gave history of previous abortion, premature delivery, neonatal death and stillbirth respectively. The most common antenatal complications associated with LBW delivery were pyrexia (20.2%), premature rupture of membranes before term (16.7%) and multiple pregnancy (14.6%). 82.4% of LBW deliveries were spontaneous vertex delivery, 12.5% vaginal breech delivery and 2.9% caesarean section. The worst perinatal outcome was associated with caesarean section while spontaneous vertex delivery had the best outcome. Other factors associated with good perinatal outcome were increasing birth weight; first stage of labour lasting less than 18 hours and small for gestational age babies.

Presentation and health care seeking behaviour of patients with cervical cancer seen at Moi Teaching and Referral Hospital, Eldoret, Kenya.

OBJECTIVE: To determine the clinicopathological characteristics and health care seeking behaviour of cervical cancer patients seen at Moi Teaching and Referral Hospital (MTRH). DESIGN: Prospective cross-sectional study. SETTING: Gynaecology Unit, Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya. SUBJECTS: Forty-two consecutive cervical cancer patients seen at MTRH gynaecology unit between May 1998 and November 1999. RESULTS: The mean age of the patients was 49.4 years (95% CI 45.4 to 53.3 years) range 24 to 80 years. All had been married and 42.9% had been in polygamous unions. Slightly more than seventy six per cent had had five or more confirmed pregnancies. Contraceptive everuse was 22%. The mean duration of clinical symptoms on presentation at MTRH was 8.2 months (95% CI 6.5 to 9.8 months) range 1 to 24 months. Female relatives and husbands were the first to be told about the symptoms by 90.3% of the patients and husbands alone by 48.8% of the patients. More than ninety per cent of patients sought health for the first time at a facility manned by trained health worker, with 39% visiting a dispensary or health centre first. More than 95% of patients had tumour stage 2 and above. Histopathologically, 80.9% of the tumours were squamous cell carcinoma, 11.9% were adenocarcinoma while the rest were anaplastic. CONCLUSION: Patients with cervical cancer present late for treatment at MTRH. They are most likely to have discussed their illness with their female relatives and husbands and to have first visited peripheral facilities manned by trained healthcare workers. Interventions to improve health care seeking behaviour among cervical cancer patients need to include education of husbands in addition to increasing awareness of the disease among private medical practitioners and health workers at dispensary and health centre level.

Randomised clinical trial to determine optimum initiation time of norgestrel-progestin only contraception in Eldoret Teaching Hospital, Kenya.

In a randomised controlled trial to determine the optimum time of initiation of Ovrette, a progestin only oral contraceptive among postpartum women, who fully or nearly fully breast-fed their infants in the first six months, no difference was found between group 1 (initiating at six weeks postpartum) and group 2 (initiating the pill at return of menses or 6 months postpartum). There were no pregnancies in either group during the 18 month follow-up. There were no significant differences in the continuation rates between the two group.

PIP: The optimal time for initiation of progestin-only oral contraception (POC) among fully or nearly fully breast-feeding women was investigated in a comparative study conducted among 200 women delivering at Kenya's Eldoret Teaching Hospital in a 2-year period during 1992-94. 100 women were randomly assigned to initiate POC use at 6 weeks' postpartum (group 1), while the remaining 100 women deferred POC initiation until the onset of menses or 6 postpartum months (whichever event occurred first) (group 2). At 12 months postpartum, 53.57% of mothers in group 1 and 56.67% in group 2 were still taking Ovrette; at 18 months, these rates were 46.10% and 43.59%, respectively. The mean duration of use was 7.6 months in group 1 and 7.5 months in group 2. There were 178 episodes of adverse experiences with Ovrette, 16.9% of which involved menstrual disturbances. Adverse experiences were more likely to be perceived as serious and related to Ovrette in group 1 than in group 2. There were no pregnancies recorded, suggesting that initiation of Ovrette use at 6 months postpartum or when menses reappears is a feasible strategy. However, postpartum women should be provided with counseling on the efficacy of the lactational amenorrhea method.

Perceptions of risk and barriers to cervical cancer screening at Moi Teaching and Referral Hospital (MTRH), Eldoret, Kenya.

BACKGROUND: Affordable screening cervical cancer methods using visual inspection with acetic acid (VIA) and with Lugol's iodine (VILI) are being developed. Scaling up of screening services requires an understanding of the user perceptions about screening. OBJECTIVES: Determine the perceptions of risk and barriers to previous cervical cancer screening by women attending MCH-FP clinic of MTRH, Eldoret, Kenya. METHODS: Cross-sectional questionnaire survey involving a consecutive sample of 219 consenting non-pregnant women about perceptions on cervical cancer risk, barriers to screening and previous screening. RESULTS: Of 219 women interviewed, 12.3% of participants had screened before. Women of over 30 years were more likely to have screened before (p=0.012). While 22.8% felt that they were at risk of the cervical cancer, 65% of all participants, nevertheless, wished to be screened. Perception of being at risk was significantly associated with a felt need for screening (p=0.002), an association that persisted only for women reporting multiple lifetime sex partners (p=0.005). Fear of abnormal results and lack of finances were the commonest barriers to screening reported by 22.4% and 11.4% of respondents, respectively. CONCLUSIONS: Previous screening was uncommon. Cheaper screening methods are needed. Messages about screening should clarify the meaning and consequences of possible results.

Integrating cervical cancer and genital tract infection screening into mother, child health and family planning clinics in Eldoret, Kenya.

BACKGROUND: Visual inspection, with acetic acid (VIA) and with Lugol's iodine (VILI), has been demonstrated to have test characteristics comparable to those of Pap smear but are more affordable and easier implement. It also presents an opportunity for management of female genital tract infection. OBJECTIVES: Pilot test integration of cervical cancer screening using visual inspection with genital tract infection identification into an existing MCH-FP in MTRH. METHODS: Cross sectional, descriptive study in which consecutive women were screened for genital tract inflammatory morbidity and cervical cancer through visual inspection. RESULTS: Two hundred and nineteen women with a mean age of 31-3 years, parity of 3.1 were screened. About 54% of study participants had multiple sex partners, 62% had sexual debut earlier than 20 years, while use of tobacco was reported by 4%. The test positivity rate was 13.9% and 16.9% for VIA and VILI respectively. Positive test finding was significantly related to contraceptive never-use after controlling for previous screening (p=0.006).Symptoms of genital tract infections were reported by 38% of the participants with features of cervicitis being reported by nearly 24%. CONCLUSION: Integration of cervical cancer screening and genital tract infection identification and treatment into the existing MCH-FP appears feasible.

Are bedside features of shock reproducible between different observers?

Shock is often under-reported in children attending hospitals in developing countries. Readily obtainable features of shock (capillary refill time, temperature gradient, pulse volume, and signs of dehydration) are widely used to help prioritise management in the emergency assessment of critically ill or injured children. However, data are lacking on their validity, including, importantly, reproducibility between observers. Agreement of these signs was examined in 100 consecutive children admitted to a paediatric ward on the coast of Kenya. After an initial training of clinical sign recognition, there was moderate agreement for most features of cardiovascular compromise (delayed capillary refill > or =4 s, kappa = 0.49; and weak pulse volume, kappa = 0.4) and only substantial agreement for temperature gradient (kappa = 0.62). For hydration status, only in the assessment of skin turgor was there a moderate level of agreement (kappa = 0.55). Capillary refill times and assessment of pulse volume recommended by the recent American consensus guidelines achieved only a "low" moderate to poor interrater agreement, questioning the reliability of such parameters.