The effect of delivery mechanisms on the uptake of bed net re-impregnation in Kilifi District, Kenya.

The results of recently completed trials in Africa of insecticide-treated bed nets (ITBN) offer new possibilities for malaria control. These experimental trials aimed for high ITBN coverage combined with high re-treatment rates. Whilst necessary to understand protective efficacy, the approaches used to deliver the intervention provide few indications of what coverage of net re-treatment would be under operational conditions. Varied delivery and financing strategies have been proposed for the sustainable delivery of ITBNs and re-treatment programmes. Following the completion of a randomized, controlled trial on the Kenyan coast, a series of suitable delivery strategies were used to continue net re-treatment in the area. The trial adopted a bi-annual, house-to-house re-treatment schedule free of charge using research project staff and resulted in over 95% coverage of nets issued to children. During the year following the trial, sentinel dipping stations were situated throughout the community and household members informed of their position and opening times. This free re-treatment service achieved between 61-67% coverage of nets used by children for three years. In 1997 a social marketing approach, that introduced cost-retrieval, was used to deliver the net re-treatment services. The immediate result of this transition was that significantly fewer of the mothers who had used the previous re-treatment services adopted this revised approach and coverage declined to 7%. The future of new delivery services and their financing are discussed in the context of their likely impact upon previously defined protective efficacy and cost-effectiveness estimates.

PIP: Recent trials of insecticide-treated bednets (ITBN) in Africa sought to achieve high ITBN coverage together with high net retreatment rates. Following the completion of a randomized, controlled trial on the coast of Kenya, a series of delivery strategies were used to continue net retreatment in the area. Adherence to a free bi-annual, house-to-house retreatment schedule resulted in a more than 95% coverage of nets issued to children. During the year following the trial, sentinel dipping stations were situated throughout the community and household members informed of their locations and opening times. More than 85% of bednets were re-impregnated between October 1993 and October 1995, and 61-67% coverage of nets used by children for 3 years after the free retreatment service was launched beginning in 1996. The introduction of a social marketing approach at sentinel sites in 1997 to retrieve some of the costs of the net retreatment services caused coverage to drop to 7.1% among children still resident in the study area who had had nets since 1993. The future of new delivery services and their financing are discussed with regard to their likely impact upon previously defined protective efficacy and cost-effectiveness estimates.

Insecticide-treated bednets reduce mortality and severe morbidity from malaria among children on the Kenyan coast.

New tools to prevent malaria morbidity and mortality are needed to improve child survival in sub-Saharan Africa. Insecticide treated bednets (ITBN) have been shown, in one setting (The Gambia, West Africa), to reduce childhood mortality. To assess the impact of ITBN on child survival under different epidemiological and cultural conditions we conducted a community randomized, controlled trial of permethrin treated bednets (0.5 g/m2) among a rural population on the Kenyan Coast. Between 1991 and 1993 continuous community-based demographic surveillance linked to hospital-based in-patient surveillance identified all mortality and severe malaria morbidity events during a 2-year period among a population of over 11000 children under 5 years of age. In July 1993, 28 randomly selected communities were issued ITBN, instructed in their use and the nets re-impregnated every 6 months. The remaining 28 communities served as contemporaneous controls for the following 2 years, during which continuous demographic and hospital surveillance was maintained until the end of July 1995. The introduction of ITBN led to significant reductions in childhood mortality (PE 33%, CI 7-51%) and severe, life-threatening malaria among children aged 1-59 months (PE 44%, CI 19-62). These findings confirm the value of ITBN in improving child survival and provide the first evidence of their specific role in reducing severe morbidity from malaria.

Death registration on the Kenyan Coast.

District level statistics provide health care planners necessary information for both identifying priority areas and evaluating existing health care programmes. Since 1986 an upgraded civil registration system has been in operation in Kilifi district on the Kenyan Coast. For a one-year period (1992-1993) an independent, prospective surveillance for mortality events in a defined population of approximately 51,000 people was conducted as part of intensive demographic studies. Comparisons between the active surveillance and the civil registration system revealed marked under-reporting of deaths, particularly childhood deaths, to the civil authorities. Consideration needs to be given to methods of increasing the coverage of civil registration or of developing supplementary alternative methods of collecting the same information.

Factors influencing admission to hospital during terminal childhood illnesses in Kenya.

BACKGROUND: Access to essential clinical services offered by district hospitals or health centres forms an important component of primary health care activities in the developing world. Utilization of hospital facilities during life-threatening childhood illnesses will affect survivorship. METHODS: We have examined clinical, geographical, social, economic and demographic features of families of 49 children who consulted a hospital facility during a terminal illness and 88 who did not during a 1-year prospective demographic and hospital-based surveillance of a rural community on the Kenyan Coast. RESULTS: Of children who died without admission, 15% had symptoms which lasted only 1 day compared to no children who were admitted (P = 0.004). Furthermore, those who died without admission tended to live further away from the nearest bus stage (P = 0.01) and had made greater use of traditional healers (P = 0.08). Mothers' education or household socioeconomic status did not influence admission to hospital. CONCLUSION: Health education is required to improve early recognition of clinical signs warranting hospital care and traditional healers should be included in any community-based education programmes.

The role of the district hospital in child survival at the Kenyan Coast.

Strategies for improving child survivorship in sub-Saharan Africa by the year 2000 have focused on low-cost, peripheral preventative and curative activities often with little reference to essential clinical services offered by hospitals at the district level. However, the recent World Bank World Development Report has re-emphasised the potential of district hospitals within selective PHC activities. We have estimated the likely impact of in-patient care offered by a rural district hospital on the Kenyan coast on under 5's mortality through comprehensive demographic and hospital surveillance. Within this population, childhood mortality may have been reduced by 44% as a result of hospital in-patient care. Strengthened referral systems, improvements in hospital accessibility, and better hospital care should be an integral part of PHC and other health promotion activities in sub-Saharan Africa.

The prevalence of epilepsy among a rural Kenyan population. Its association with premature mortality.

During a two year community-based investigation of mortality 3.5% of the deaths to individuals over the age of 5 years were reported by bereaved relatives to have occurred to epileptics and 77% of these deaths were thought to have occurred whilst the patient was in status epilepticus. This prompted us to determine the prevalence of epilepsy in this rural population by interviewing 7,450 residents of a pre-defined study area. The prevalence of 'Kifafa' or 'Vitsala', two local words used to describe epilepsy, but later confirmed through detailed interviews, was 0.4%. This prevalence is clearly an underestimate of the true prevalence of epilepsy in this population but is probably higher than prevalences reported in developed countries. Anti-convulsant prophylaxis is available at the district hospital but this service is only sporadically used by epileptics in this population. Uncontrolled and poorly managed epilepsy may result in an increased risk of premature mortality among epileptics living in this community.