[Determinants of low birth weight among newborns to HIV-infected mothers not eligible for antiretroviral treatment in Africa]. / Déterminants du faible poids de naissance chez des enfants nés de mères séropositives pour le VIH, non éligibles au traitement antirétroviral, en Afrique.

BACKGROUND: Low birth weight (LBW) increases the risk of infant death, but little is known about its rate and determinants among babies born to HIV-infected mothers in sub-Saharan Africa. METHODS: This study was conducted in South Africa, Burkina Faso, Uganda and Zambia, during the recruitment process of the PROMISE-PEP (ANRS 12174) clinical trial. The study sample included 1196 subjects screened between August 2009 and December 2011, respectively 254 in South Africa, 221 in Burkina Faso, 197 in Uganda and 524 in Zambia, all ineligible for antiretroviral therapy. Data were collected during ANRS12174 clinical trial antenatal and postnatal screening visits, and during an inclusion visit for completion of an electronic case report form (eCRF). RESULTS: The mean (±SD) age of mothers was 27±5years and their mean CD4 count was 576±195cells/µL. Most mothers lived in a couple (78.7%), had no employment (72.3%) and had a good level of education (74% had gone to school). Male newborns predominated (51.7%). The mean birth weight was 3043g±435g, and 7.8% ([95%CI: 6.3%-9.3%]) of newborns weighed less than 2500g. In univariate analyses, being married or cohabiting, body mass index, WHO HIV disease stage II, female newborn and low gestational age were associated with risk of LBW. In multivariate regression model, low gestational age (aOR=3.74, P<0.0001) and female newborn (aOR=1.63, P=0.04) were significantly associated with LBW. CONCLUSION: The risk factors for LBW found in HIV-infected women ineligible for antiretroviral therapy were the same as in the general population. There was no evidence of additional risk factors associated with HIV infection.

Outcome and predictive factors of mortality in hospitalized HIV-patients in Burkina Faso.

BACKGROUND: The aim of this study was to describe the clinical presentation and predictors of death in a HIV population hospitalized in Ouagadougou, Burkina Faso. MATERIALS AND METHODS: Baseline demographics, viro-immunological status, clinical presentations, and outcome have been analyzed by univariate analysis and a multivariate model. RESULTS: A total of 1,071 hospitalizations of HIV-positive patients was recorded between 1 January, 2004 and 31 August, 2006, the majority of whom were female (64.1%). The baseline CD4 cell count/microl was higher in the female patients than in the male ones (166.1 vs 110.9). Gastroenteric symptoms were the first cause of hospitalization (61.7%). The crude mortality rate was higher in males than females (38% vs 25.3%). Baseline World Health Organization clinical stage IV (OR 9.22), neurological syndrome (OR 3.04) or wasting syndrome at admission (OR 2.9), positive malaria film (OR 2.17), and an older age independently predicted death. Weight at admission > 40 kg and a higher platelet count at admission were independently associated with a better outcome. CONCLUSIONS: Females are admitted to hospital earlier than males, probably as an indirect result of the Prevention of Mother-to-Child Transmission (PMTCT) public health initiative. An active search of HIV status in other members of the family (PMTCT-plus) may result in the detection of asymptomatic HIV-infected patients as well. A Plasmodium falciparum-positive smear during admission significantly impacted on outcome as well as low platelet count.

Health status and health seeking behaviour of the elderly persons in Dagoretti division, Nairobi.

OBJECTIVE: To determine the health status and the health seeking behaviour of the elderly people aged 65 years and above. DESIGN: A descriptive cross sectional study of individuals interviewed through questionnaires and focus groups discussions. SETTING: Dagoretti Division, Nairobi Province, Kenya. SUBJECTS: Four hundred non-institutionalised elderly persons. RESULTS: Four hundred people including 276(69%) women and 124(31%) males were interviewed; 44% had no independent source of livelihood and 51% were widowed. The majority 376(92.5%) of the respondents had been sick within the last three months, preceding the study with 111(27.8%) being sick all the time. The prevalent diseases included musculoskeletal (80%), respiratory (68%), sight (44%) and dental conditions(40%). Three hundred and sixteen (79%) of the respondents were functionally independent in activities of daily living. One hundred and sixty one (40.3%) were satisfied with their current way of life while (63%) perceived themselves as healthy, 24.8% of the respondents lived alone. The reported social problems included:- economic dependency (96%), poor housing (76%), loneliness (60%) and feeling not needed (42%) of the respondents. Only 26% were on treatment, lack of money hindered health care access to 73% of the respondents (p<0.001). Sixty two per cent of the respondents were buying over-the-counter drugs. Walking was under taken by 217(67%) as a physical exercise, and (26%) of the respondents consumed addictive drugs. The focus groups criticised the lack of health facilities for the elderly in the community. CONCLUSION: The effects of ageing, low economic status and inadequate access to health care contributed to the elderly poor health status. The use of over-the-counter drugs was indicative of the inefficient health facilities in meeting the health needs of the elderly. The study points out the need to formulate policies that will target on the health needs of the elderly.

Amodiaquine-artesunate versus amodiaquine for uncomplicated Plasmodium falciparum malaria in African children: a randomised, multicentre trial.

BACKGROUND: Increasing drug resistance limits the choice of efficacious chemotherapy against Plasmodium falciparum malaria in Africa. Amodiaquine still retains efficacy against P falciparum in many African countries. We assessed the safety, treatment efficacy, and effect on gametocyte carriage of adding artesunate to amodiaquine in three randomised trials in Kenya, Sénégal, and Gabon. METHODS: We enrolled 941 children (400 in Kenya, 321 in Sénégal, and 220 in Gabon) who were 10 years or older and who had uncomplicated P falciparum malaria. Patients were randomly assigned amodiaquine (10 mg/kg per day for 3 days) plus artesunate (4 mg/kg per day for 3 days) or amodiaquine (as above) and placebo (for 3 days). The primary endpoints were parasitological cure rates at days 14 and 28. Analysis was by intention to treat and by an evaluability method. FINDINGS: Both regimens were well tolerated. Six patients in the amodiaquine-artesunate group and five in the amodiaquine group developed early, drug-induced vomiting, necessitating alternative treatment. By intention-to-treat analysis, the day-14 cure rates for amodiaquine-artesunate versus amodiaquine were: 175/192 (91%) versus 140/188 (74%) in Kenya (D=16.7% [95% CI 9.3-24.1], p<0.0001), 148/160 (93%) versus 147/157 (94%) in Sénégal (-1.1% [-6.7 to 4.5], p=0.7), and 92/94 (98%) versus 86/96 (90%) in Gabon (8.3% [1.5-15.1], p=0.02). The corresponding rates for day 28 were: 123/180 (68%) versus 75/183 (41%) in Kenya (27.3% [17.5-37.2], p<0.0001), 130/159 (82%) versus 123/156 (79%) in Sénégal (2.9% [-5.9 to 11.7], p=0.5), and 80/94 (85%) versus 70/98 (71%) in Gabon (13.7% [2.2-25.2], p=0.02). Similar rates were obtained by evaluability analysis. INTERPRETATION: The combination of artesunate and amodiaquine improved treatment efficacy in Gabon and Kenya, and was equivalent in Sénégal. Amodiaquine-artesunate is a potential combination for use in Africa. Further investigations to assess the potential effect on the evolution of drug resistance, disease transmission, and safety of amodiaquine-artesunate are warranted.

Evidence for a mass community effect of insecticide-treated bednets on the incidence of malaria on the Kenyan coast.

The use of insecticide-treated bednets (ITBNs) has been shown to be effective in reducing mortality and morbidity from malaria. However, there is mixed evidence as to whether or not community-wide use of ITBNs engenders a 'mass effect', such that those not sleeping under bednets are offered protection from widespread ITBN use in the area in which they live. We have analysed data collected in Kilifi, Kenya, from a cohort of children followed from birth to investigate how the degree of net usage in the locality of a child affects the risk of developing malaria. This effect was explored using a Cox proportional hazards model. For those not using ITBNs, we found that an increasing level of ITBN usage within the area surrounding each child was associated with a decreasing risk of developing malaria, thus providing evidence in support of a mass community effect. The size and significance of this effect were found to decrease as non-overlapping areas of increasing distance away from a child's home were considered. The effect was significant for areas at distances of up to 1.5 km away from each child.

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.

An evaluation of surveillance of malaria at primary health care level in Kenya.

As less than twenty five per cent of persons suffering from malaria seek formal treatment in most of sub-Saharan Africa, Facility-based morbidity statistics are inadequate for monitoring malaria control programmes. This explorative study assessed whether a health centre equipped with a microscope and trained personnel could monitor malaria transmission within its catchment area. The study was conducted at Chemase Health Centre in Nandi District in Kenya, an area holoendemic for malaria with Anopheles gambiae as the main vector and Plasmodium falciparum as the commonest cause of malaria. From first August to 31 October 1991, first seven children under five years of age on each working day accompanied by their mothers to the maternal and child health clinic were studied. A general examination was performed by a Registered Clinical Officer (Medical Assistant) and thin and thick blood smears made, stained with Giemsa stain and examined for malaria parasites by a Medical Laboratory Technologist. Mothers were interviewed by enrolled community nurses on antimalarial measures they were using in their homes. Four hundred and fifty five children mostly under five years of age, consisting of 48.1% males and 51.9% females, were studied. Malaria parasites were present in 209 (45.9%) blood smears of the children. The percentage of blood smears positive for malaria parasites was high in children below 36 months of age. There was a tendency for low percentage of blood smears positive for malaria in children whose mothers reported using mosquito nets or insecticide sprays. The study did not interrupt the routine of the health centre. Periodic monitoring of new malaria illnesses. and percentage of blood smears positive for malaria parasites in children aged 0 to 35 months should be introduced into health centre practice in Kenya. This catchment area approach could be used to monitor malaria control programmes as well as predicting malaria epidemics.

PIP: Traditionally, new cases are used to assess the presence and level of transmission of malaria. In sub-Saharan Africa, where only 8-25% of persons suffering from malaria use formal health services for treatment, facility-based morbidity statistics are inadequate for monitoring malaria control programs. The present study investigated whether children and mothers attending a primary health care center equipped with a microscope and trained personnel could serve as a basis for such monitoring. The first 7 children under 5 years of age presenting to Chemase Health Center in Kenya's Nandi District each day in a 3-month period in 1991 were enrolled, yielding a cohort of 455 children mostly under 5 years of age. A general examination was performed by a Registered Clinical Officer and thin and thick blood smears were prepared and examined for malaria parasites. Parasites were detected in 209 blood smears (45.9%), with the highest prevalence among children under 36 months of age. Mothers who reported use of mosquito nets or insecticide sprays were less likely to have children with malarial infection. Periodic monitoring of new malaria illnesses and the percentage of blood smears positive for malaria parasites in children 0-35 months of age should be introduced into health centers in Kenya in order to monitor malaria control programs and predict epidemics. Personnel reported that the study did not interrupt normal health center routines.

Evaluating the community education programme of an insecticide-treated bed net trial on the Kenyan coast.

Increased interest in the potential contribution of insecticide-impregnated bed nets (ITBN) to malaria control has led to research efforts to determine the impact and sustainability of ITBN programmes in differing environments. There is a need to develop effective, feasible educational strategies that will both inform and motivate community members, and thus maximize the correct usage of ITBN. This is especially true in communities where indigenous usage of bed nets is low. This paper describes the educational component of a randomized controlled community intervention trial of ITBN, with childhood malaria morbidity as an outcome. The educational approach and messages for the ITBN trial were developed from anthropological survey data collected 4 years before the trial, and from community surveys conducted by project researchers. Low levels of understanding amongst mothers of the aetiological link between mosquitos and malaria led to the exclusion of the term 'malaria' from the initial educational messages promoting the use of ITBN. Appropriate individuals within the existing district health care structure were trained as community educators in the project. These educators conducted intensive teaching in the community through public meetings and group teaching in the first 6 months of the trial. The impact of these initial activities was assessed through interviews with a random sample of 100 mothers and 50 household heads. This allowed the identification of messages which had not been well understood and further educational methods were chosen to address the areas pinpointed. The community assessment also demonstrated that, in 1994, over 90% of mothers understood a protective role for bed nets against malaria and the ITBN education messages were changed to take account of this. The school programme was evaluated through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge and discussions with parent-teacher associations. It was shown that 40% of intervention homes with children in the target group were accessed, participant children learned the educational messages well (scores increased from a pre-teaching mean of 59% to a post-teaching mean of 92%) and a high level of awareness of the ITBN trial was achieved in these homes (75%). However, specific messages of the education programmed were not well transferred to the home (30%). The discussion emphasises the need for allocation of adequate resources for education in programmes dependent on achieving a change in community practices. We also describe the value of ongoing communication between programme planners and a target population in maximizing the effectiveness of messages and methods used.

PIP: In Kenya, public health officers, public health technicians, and field staff implemented the education component of the insecticide-treated bed net (ITBN) trial in Kilifi District along the coast. The education strategy was based on anthropological survey data collected 4 years before the trial and from community surveys. It included teaching about the intervention to household heads at public meetings (June 1993), individual instruction at the time of bed net delivery (June-July 1993), follow-up education with bed net contacts in a small group format after net delivery (June-August 1993), follow-up education with mothers in a small group format after net delivery (September 1993), house-to-house education at the time of ITBN redipping (April-May 1994), and a teaching program in primary schools (June-July 1994). In September 1993, 98% of mothers understood the important of using bed nets year-round but 29% would not use them when it was too hot. Educators changed ITBN education messages to account for the high level of understanding about the importance of bed net use. Since mothers had low levels of understanding of the etiological link between mosquitoes and malaria, the educators excluded the term malaria from the initial educational messages promoting ITBN use. The researchers evaluated the school program through determining outreach (the number of households accessed), changes in participant children's knowledge, post-teaching assessment of mothers' knowledge, and discussions with parent-teacher associations. 40% of the intervention homes were accessed. Learning the educational messages progressed well with the participant children (mean score, 59% at pre-test and 92% at post-test). At the end of the school program, members of 75% of intervention homes were aware of the ITBN trial. Yet, only 30% of homes understood specific messages of the school program. In conclusion, there is a need for allocation of adequate resources for education to achieve a change in community practices and for ongoing communication to maximize the effectiveness of messages and methods used.

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.

Misuse of drugs: perceptions of household heads in Kisumu district, Kenya.

A cross-sectional survey involving 15,324 household heads, reporting on a population of 68,487 people in Kisumu district in Kenya, revealed that there was at least one person who regularly used a drug in 6,793 (44.3%) of the households. Out of these 4,497 (66.2%) were concerned with the practice. This gave a reported rate of drug use of 6.4 for alcohol, 2.7 for cigarette smoking, 0.6 for bhang (Cannabis sativa) smoking, and 0.2 for unprescribed medicines per 100 study population. The main reasons for concern consisted of financial problems cited by 49.1% of the household heads; family violence by 19.7%; loss of jobs by 15.1%; chronic coughs by 10.7%; and other reasons that included imprisonment, decline in school performance, and abnormal behaviour. Out of those concerned about half (47.9%) had taken some actions to control the drug use with 26.7% of these reporting the actions having worked. This study points out a need for further research to identify the unprescribed medicines and quantify other drugs used in order to advice on an appropriate local and national drug policy.

Effects and control of highland malaria epidemic in Uasin Gishu District, Kenya.

This report documents the effects of malaria epidemic and how it was controlled in one highland district of Kenya. The effects of the epidemic are presented in terms of mortality, morbidity and school absenteeism; information is from routine and verbal reports. Treatment with chloroquine, amodiaquine and sulphonamide pyrimethamine combinations, limited vector control, and health education were used to control the epidemic. Hospital mortality per month increased by 8.6 times during the epidemic while morbidity went up by 3.7 times. Of the 103 deaths attributed to malaria, 64 (62.1%) occurred in hospital and 39 (37.9%) at home. Most of the home deaths (92.3%), occurred in areas that border the malaria endemic Lake Victoria Basin. The rate of pupil absenteeism ranged from 17.6% to 54.4% in primary schools. The policy implications of the report are discussed.

PIP: In Kenya, a physician conducted a study during the May-June 1990 malaria epidemic in the highlands of Uasin Gishu district to find areas for improvement in the surveillance and control of malaria epidemics. Deaths attributed to all causes and malaria-specific deaths per month rose by 2.2 and 8.6 times, respectively, during the epidemic. Malaria proportionate deaths peaked at 75%. Case fatality rates were not different from those of the periods before and after the epidemic. Most malaria-related deaths (62.1%) occurred in Eldoret District Hospital. Most mortality cases (92.3%) were from near the Turbo Rural Demonstration Health Centre. There were 3.7 times the number of patients with a primary clinical diagnosis of malaria in the hospital at the peak of the epidemic than there generally are. The proportion of primary school pupils absent ranged from 17.6% at Davis School to 54.4% at Kapkwis School. Children in the lower classes had a higher absenteeism rate than those in the higher classes (35-40% vs. 10-23%). One hospital, 8 health centers, and 33 dispensaries provided malaria treatment (chloroquine, amodiaquine, or sulfonamide combinations). During the 1st 7 days, 8 mobile teams treated 13,820 patients. They had to refer only 39 severe malaria cases to the hospital. 72.8% of the 674 blood smears examined in the field were positive for malaria parasites. Larvicides and insecticides were applied to manholes, septic tanks, cesspits, pit latrines, gully traps, water closets, soak pits, drinking water, and indoors at a university, college, prisons, and secondary boarding schools. Health education messages were delivered through all clinic sessions, schools, Barazas, and radio. The intervention team covered the affected areas in 14 days. The additional cost of controlling the epidemic totaled 1,833,609 KSHS.

Seasonality and community's satisfaction with sources of domestic water in the Lake Victoria basin.

A cross-sectional study was conducted to describe the changes in, and the satisfaction with, sources of domestic water made by the community in response to seasons in Kisumu district in July 1990. Out of 15,324 household heads interviewed, 42.8% got their water from taps throughout the year and during the dry season the remaining 58.2% got their water from rivers, streams, boreholes, ponds, roof catchments and one or two other sources. In the wet season three times as many households use roof catchment and fewer households use rivers and streams and boreholes. Only 21.9% were dissatisfied with their supply in the dry season the main reason being dirty water and insufficient quantity. These findings indicate a need to expand the provision of piped water into the rural communities and promote roof water harvesting in the lake basin. Roof catchment would provide safe water in areas without piped water, and as reserve water in those with piped. The safety of water from roofs made of natural and traditional materials, such as grass and palm leaves (makuti) need to be assessed.

Household sanitation in Uasin Gishu district in Kenya.

In rural Uasin Gishu District in 1990, 78.2% of the households had pit latrines, 11.3% ventilated improved pit latrines, 0.8% water-borne and 9.7% with no toilet facilities. On inspection, 97% of the toilet facilities were in use. Compost pits were present in 52.3% of the households. Utensil drying racks were found in 56.0% of the households. Compared to previous estimates, these levels represent a tremendous improvement in sanitation service coverage. It is recommended that the impact of water and sanitation programmes on health status needs to be evaluated. There is a need for studies to be done on the value of utensil drying racks in disease control.

The pattern of morbidity and its effects on productivity of factory workers in Kenya.

A retrospective study was carried out from January to September 1990 in a factory that manufactures textiles in Eldoret, Kenya. Over the study period, 1400 factory workers had 303 episodes of illness resulting in a loss of 720 productive man-days. This is an incidence of 289 episodes of illness per 1000 workers per year. On average, each episode of illness resulted in 2.4 man-days loss. Of all the episodes of illness, 58.8% were attributable to infective and parasitic diseases, 10.9% to respiratory system disorders and 21.7% to other conditions. Malaria constituted 53.1% of all episodes of illness, acute respiratory infection (ARI) 10.9%, physical injuries 5.6%, gastro-enteric illnesses 3.4% and other conditions 21.7%. For the productive man-days lost, 53.2% were attributable to malaria, 12.8% to ARI, 5.7% to physical injuries and 28.3% to other conditions. Abortions and worm infections resulted in loss of 7.0 man-days per episode of illness, diarrhoea 3.2, myalgia 3.0, ARI 2.8, eye diseases 2.7 and the rest below the average of 2.4 days. Apart from the physical injuries, there were no other occupational illnesses in the textile factory workers. Episodes of illness that occur during the last and the first week of the month constitute 61.0% of all illnesses. Mondays had 24.4% of the episodes of illness, Sundays 7.9% with the other days of the week constituting an average 13.5%.