Implementation of community case management of malaria in malaria endemic counties of western Kenya: are community health volunteers up to the task in diagnosing malaria?

BACKGROUND: Community case management of malaria (CCMm) is an equity-focused strategy that complements and extends the reach of health services by providing timely and effective management of malaria to populations with limited access to facility-based healthcare. In Kenya, CCMm involves the use of malaria rapid diagnostic tests (RDT) and treatment of confirmed uncomplicated malaria cases with artemether lumefantrine (AL) by community health volunteers (CHVs). The test positivity rate (TPR) from CCMm reports collected by the Ministry of Health in 2018 was two-fold compared to facility-based reports for the same period. This necessitated the need to evaluate the performance of CHVs in conducting malaria RDTs. METHODS: The study was conducted in four counties within the malaria-endemic lake zone in Kenya with a malaria prevalence in 2018 of 27%; the national prevalence of malaria was 8%. Multi-stage cluster sampling and random selection were used. Results from 200 malaria RDTs performed by CHVs were compared with test results obtained by experienced medical laboratory technicians (MLT) performing the same test under the same conditions. Blood slides prepared by the MLTs were examined microscopically as a back-up check of the results. A Kappa score was calculated to assess level of agreement. Sensitivity, specificity, and positive and negative predictive values were calculated to determine diagnostic accuracy. RESULTS: The median age of CHVs was 46 (IQR: 38, 52) with a range (26-73) years. Females were 72% of the CHVs. Test positivity rates were 42% and 41% for MLTs and CHVs respectively. The kappa score was 0.89, indicating an almost perfect agreement in RDT results between CHVs and MLTs. The overall sensitivity and specificity between the CHVs and MLTs were 95.0% (95% CI 87.7, 98.6) and 94.0% (95% CI 88.0, 97.5), respectively. CONCLUSION: Engaging CHVs to diagnose malaria cases under the CCMm strategy yielded results which compared well with the results of qualified experienced laboratory personnel. CHVs can reliably continue to offer malaria diagnosis using RDTs in the community setting.

Increasing access to the MDR-TB surveillance programme through a collaborative model in western Kenya.

OBJECTIVE: Kenya, like many resource-constrained countries, has a single mycobacterial laboratory, centrally located in Nairobi, with capacity for drug-susceptibility testing (DST) - the gold standard in diagnosing drug-resistant tuberculosis. We describe and evaluate a novel operational design that attempts to overcome diagnostic delivery barriers. METHODS: Review of the public DST programme identified several barriers limiting access: lack of programme awareness amongst physicians, limited supplies, unreliable transport and no specimen tracking methods. Staff visited 19 clinic sites in western Kenya and trained healthcare providers in regard to the novel diagnostics model. Provincial laboratory registries were reviewed to assess utilization of DST services prior to and after programme modification. RESULTS: Onsite training consisted of the inclusion criteria for re-treatment patients - the high-priority group for DST. Additionally, infrastructural support established a stable supply chain. An existing transport system was adapted to deliver sputum specimens. Task shifting created an accession and tracking system of specimens. During the 24 months post-implementation, the number of re-treatment specimens from the catchment area increased from 9.1 to 23.5 specimens per month. In comparing annual data pre- and post-implementation, the proportion of re-treatment cases receiving DST increased from 24.7% (n = 403) to 32.5% (n = 574) (P < 0.001), and the number of multidrug-resistant (MDR) TB cases increased from 5 to 10 cases. CONCLUSION: The delivery model significantly increased the proportion of re-treatment cases receiving DST. Barriers to accessing the national MDR-TB surveillance programme can be overcome through an operational model based on pragmatic use of existing services from multiple partners.

Prevalence of intestinal parasitic infections in certified food-handlers working in food establishments in the City of Nairobi, Kenya.

Most intestinal parasites are cosmopolitan with the highest prevalence in the tropics and subtopics. Rural-to-urban migration rapidly increases the number of food eating places in towns and their environs. Some of these eating estabishments have poor sanitation and are overcrowded, facilitating disease transmission, especially through food-handling. Our investigations in Nairobi, therefore, were set to determine the presence of intestinal parasites in food-handlers with valid medical certificates. Direct and concentrated stool processing techniques were used. Chisquare test and ANOVA were used for data analysis. The parasites Ascaris lumbricoides, Entamoeba histolytica and Giardia lamblia were observed in certified food-handlers. Significant difference was found in parasite frequency by eating classes and gender (χ(2) = 9.49, P = 0.73), (F = 1.495, P = 0.297), but not in parasite occurrence between age brackets (χ(2) = 6.99, P = 0.039). The six-month medical certificate validity period may contribute significantly to the presence of intestinal parasites in certified food-handlers.

The potential of the extracts of Tagetes minuta Linnaeus (Asteraceae), Acalypha fruticosa Forssk (Euphorbiaceae) and Tarchonanthus camphoratus L. (Compositae) against Phlebotomus duboscqi Neveu Lemaire (Diptera: Psychodidae), the vector for Leishmania major Yakimoff and Schokhor.

BACKGROUND & OBJECTIVES: Harmful effects of synthetic chemical insecticides including vector resistance, environmental pollution and health hazards have necessitated the current significance in the search for plant-based insecticide products that are environmentally safe and effective to leishmaniases control. The insecticidal activity of Tagetes minuta Linnaeus (Asteraceae), Acalypha fruticosa Forssk (Euphorbiaceae) and Tarchonanthus camphoratus L. (Compositae) extracts were investigated against Phlebotomus duboscqi Neveu Lemaire (Diptera: Psychodidae). METHODS: The extracts were prepared from dried aerial parts soaked in methanol and ethyl acetate twice until the filtrates became clear, filtered and dried out by rotary evaporation at 30-35 degrees C. The solid extracts obtained were later prepared into 2.5, 5 and 10 mg/ml. Two millilitres of the solutions were blotted on filter papers, which were dried overnight and placed into jars where adult sandflies were aspirated. Males and females were assayed separately. RESULTS & CONCLUSION: The extracts had significant mortality (p<0.05) in both males and females bioassays but were not significantly different between sexes. The extracts of Acalypha fruticosa and Tagetes minuta had significantly higher mortality rates than those of Tarchonanthus camphoratus and the different concentrations used showed significantly different mortality rates and 10 mg/ml was the most effective concentration. Cent percent mortality was obtained at 96 h of exposure to 5 and 10 mg/ml concentrations except for Tarchonanthus camphoratus which had a mortality of only 46.7% in 10 mg/ml bioassay. These extracts were found to be insecticidal to adult sandflies.

Methotrexate and aminopterin lack in vivo antimalarial activity against murine malaria species.

The antifolate anticancer drug methotrexate (MTX) has potent activity against Plasmodium falciparum in vitro. Experience of its use in the treatment of rheumatoid arthritis indicates that it could be safe and efficacious for treating malaria. We sought to establish a murine malaria model to study the mechanism of action and resistance of MTX and its analogue aminopterin (AMP). We used Plasmodium berghei, Plasmodium yoelii yoelii, Plasmodium chabaudi and Plasmodium vinckei. None of these species were susceptible to either drug. We have also tested the efficacy of pyrimethamine in combination with folic acid in P. berghei, and data indicate that folic acid does not influence pyrimethamine efficacy, which suggests that P. berghei may not transport folate. Since MTX and AMP utilise folate receptor/transport to gain access to cells, their lack of efficacy against the four tested murine malaria species may be the result of inefficiency of drug transport.