Frankline M. Onchiri

High-risk enteric pathogens associated with HIV infection and HIV exposure in Kenyan children with acute diarrhoea.

Objective:HIV infection is an established risk for diarrhoeal severity, less is known about specific enteric pathogens associated with HIV status. We determined associations of selected enteric pathogens with HIV infection and HIV exposure among Kenyan children. Design:A cross-sectional study among 6 months to 15 year olds presenting to two Western Kenya District hospitals with acute diarrhoea between 2011 and 2013. Methods:Stool was tested using standard bacterial culture and microscopy for ova and parasites. HIV status was obtained from children and mothers. Enteric pathogen prevalence was compared between HIV-infected and HIV-uninfected children and between HIV-exposed uninfected (HEU) and HIV-unexposed. Unadjusted and adjusted prevalence ratios for selected pathogens by HIV status were estimated using relative risk (RR) regression. Age, site, income, household crowding, water source/treatment, anthropometrics, cotrimoxazole use and breastfeeding history were accounted for in multivariable models. Results:Among 1076 children, median age was 22 months (interquartile range: 11–42 months), 56 (5.2%) were HIV-infected and 105 (11.3%) of 926 HIV-uninfected children in whom maternal HIV status was obtained were HIV-exposed. The following organisms were most frequently isolated from stool: enteroaggregative Escherichia coli (13.3%), Giardia species (spp.) (11.1%), Campylobacter spp. (6.3%), enteropathogenic E. coli (EPEC) (6.1%) and Cryptosporidium spp. (3.7%). Accounting for age, HIV-infection was associated with typical EPEC infection (prevalence ratio 3.70, P = 0.002) while HIV-exposure was associated with Cryptosporidium among HIV-uninfected children (prevalence ratio 2.81, P = 0.005). Conclusion:EPEC and Cryptosporidium infections were more common in HIV-infected and HIV-exposed children, respectively. This could explain the increased mortality attributed to these pathogens in other studies. Interventions targeting EPEC and Cryptosporidium may reduce morbidity and mortality in high HIV-prevalence settings.

Seizure frequency and patient‐centered outcome assessment in epilepsy

Seizure frequency represents a commonly assessed epilepsy status, but in the context of the growing trend toward patient‐centered care, we examined the adequacy of seizure frequency as a measure of epilepsy status as perceived by the patient.

Evaluation of impact of long-lasting insecticide-treated bed nets and point-of-use water filters on HIV-1 disease progression in Kenya.

Objectives:Among HIV-1-infected individuals in Africa, coinfection with malaria and diarrhoeal disease may be associated with more rapid HIV-1 disease progression. We sought to determine whether the use of long-lasting insecticide-treated bed nets and simple point-of-use water filters can delay HIV-1 disease progression. Design:A prospective cohort study. Setting:Two HIV care sites in Kenya. Participants:HIV-1-infected adults not yet meeting criteria for antiretroviral therapy. Interventions:One group received the standard of care, whereas the other received long-lasting insecticide-treated bed nets and water filters. Individuals were followed for up to 24 months. Main outcome measures:The primary outcome measures were time to CD4 cell count less than 350 cells/&mgr;l and a composite endpoint of time to CD4 cell count less than 350 cells/&mgr;l and nontraumatic death. Time to disease progression was compared using Cox proportional hazards regression. Results:Of 589 individuals included, 361 received the intervention and 228 served as controls. Median baseline CD4 cell counts were similar (P = 0.36). After controlling for baseline CD4 cell count, individuals receiving the intervention were 27% less likely to reach the endpoint of a CD4 cell count less than 350 cells/&mgr;l (hazard ratio 0.73; 95% confidence interval 0.57–0.95). CD4 cell count decline was also significantly less in the intervention group (−54 vs. −70 cells/&mgr;l per year, P = 0.03). In addition, the incidence of malaria and diarrhoea were significantly lower in the intervention group. Conclusion:Provision of a long-lasting insecticide-treated bed net and water filter was associated with a delay in CD4 cell count decline and may be a simple, practical and cost-effective strategy to delay HIV-1 progression in many resource-limited settings.

Water availability at hospitals in low- and middle-income countries: implications for improving access to safe surgical care

INTRODUCTION Although two billion people now have access to clean water, many hospitals in low- and middle-income countries (LMICs) do not. Lack of water availability at hospitals hinders safe surgical care. We aimed to review the surgical capacity literature and document the availability of water at health facilities and develop a predictive model of water availability at health facilities globally to inform targeted capacity improvements. METHODS Using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a systematic search for surgical capacity assessments in LMICs in MEDLINE, PubMed, and World Health Organization Global Health Library was performed. Data regarding water availability were extracted. Data from these assessments and national indicator data from the World Bank (e.g., gross domestic product, total health expenditure, and percent of population with improved access to water) were used to create a predictive model for water availability in LMICs globally. RESULTS Of the 72 records identified, 19 reported water availability representing 430 hospitals. A total of 66% of hospitals assessed had water availability (283 of 430 hospitals). Using these data, estimated percent of water availability in LMICs more broadly ranged from under 20% (Liberia) to over 90% (Bangladesh, Ghana). CONCLUSIONS Less than two-thirds of hospitals providing surgical care in 19 LMICs had a reliable water source. Governments and nongovernmental organizations should increase efforts to improve water infrastructure at hospitals, which might aid in the provision of safe essential surgical care. Future research is needed to measure the effect of water availability on surgical care and patient outcomes.

Frequency and correlates of malaria over-treatment in areas of differing malaria transmission: a cross-sectional study in rural Western Kenya

BackgroundIn 2010, the World Health Organization shifted its malaria guidelines from recommending the empiric treatment of all febrile children to treating only those with laboratory-confirmed malaria. This study evaluated the frequency and predictors of malaria over-treatment among febrile malaria-negative children in Kenya.MethodsBetween 2012 and 2013, 1,362 children presenting consecutively with temperature ≥37.5°C to Kisii and Homa Bay hospitals were enrolled in a cross-sectional study evaluating causes of fever. Children were screened for malaria using smear microscopy and rapid diagnostic tests and managed according to standard of care at the hospitals. The frequency of anti-malarial prescriptions among children with laboratory-confirmed malaria negative children (malaria over-treatment) was determined; and clinical and demographic correlates of overtreatment evaluated using logistic regression. Because of differences in malaria endemicity, analyses were stratified and compared by site.ResultsAmong 1,362 children enrolled, 46 (7%) of 685 children in Kisii, and 310 (45.8%) of 677 in Homa Bay had laboratory-confirmed malaria; p < 0.001. Among malaria-negative children; 210 (57.2%) in Homa Bay and 45 (7.0%) in Kisii received anti-malarials; p < 0.001. Predictors of over-treatment in Homa Bay included ≥ one integrated management of childhood illness (IMCI) danger sign (aOR = 8.47; 95% CI: 4.81-14.89), fever lasting ≥ seven days (aOR = 4.94; 95% CI: 1.90-12.86), and fever ≥39°C (aOR = 3.07; 95% CI: 1.58-5.96). In Kisii, only fever ≥39°C predicted over-treatment (aOR = 2.13; 95% CI: 1.02-4.45).ConclusionsMalaria over-treatment was common, particularly in Homa Bay, where the prevalence of malaria was extremely high. Severe illness and high or prolonged fever were associated with overtreatment. Overtreatment may result in failure to treat other serious causes of fever, drug resistance, and unnecessarily treatment costs.

Predictors of incident epilepsy in older adults The Cardiovascular Health Study

Objective: To determine the prevalence, incidence, and predictors of epilepsy among older adults in the Cardiovascular Health Study (CHS). Methods: We analyzed data prospectively collected in CHS and merged with data from outpatient Medicare administrative claims. We identified cases with epilepsy using self-report, antiepileptic medication, hospitalization discharge ICD-9 codes, and outpatient Medicare ICD-9 codes. We used Cox proportional hazards regression to identify factors independently associated with incident epilepsy. Results: At baseline, 42% of the 5,888 participants were men and 84% were white. At enrollment, 3.7% (215 of 5,888) met the criteria for prevalent epilepsy. During 14 years of follow-up totaling 48,651 person-years, 120 participants met the criteria for incident epilepsy, yielding an incidence rate of 2.47 per 1,000 person-years. The period prevalence of epilepsy by the end of follow-up was 5.7% (335 of 5,888). Epilepsy incidence rates were significantly higher among blacks than nonblacks: 4.44 vs 2.17 per 1,000 person-years (p < 0.001). In multivariable analyses, risk of incident epilepsy was significantly higher among blacks compared to nonblacks (hazard ratio [HR] 4.04, 95% confidence interval [CI] 1.99–8.17), those 75 to 79 compared to those 65 to 69 years of age (HR 2.07, 95% CI 1.21–3.55), and those with history of stroke (HR 3.49, 95% CI 1.37–8.88). Conclusions: Epilepsy in older adults in the United States was common. Blacks, the very old, and those with history of stroke have a higher risk of incident epilepsy. The association with race remains unexplained.

Mycobacterium tuberculosis Bacteremia Among Acutely Febrile Children in Western Kenya.

In children, Mycobacterium tuberculosis (M. tuberculosis) frequently disseminates systemically, presenting with nonspecific signs including fever. We determined prevalence of M. tuberculosis bacteremia among febrile children presenting to hospitals in Nyanza, Kenya (a region with high human immunodeficiency virus (HIV) and M. tuberculosis prevalence). Between March 2013 and February 2014, we enrolled children aged 6 months to 5 years presenting with fever (axillary temperature ≥ 37.5°C) and no recent antibiotic use. Blood samples were collected for bacterial and mycobacterial culture using standard methods. Among 148 children enrolled, median age was 3.1 years (interquartile range: 1.8-4.1 years); 10.3% of children were living with a household member diagnosed with M. tuberculosis in the last year. Seventeen percent of children were stunted (height-for-age z-score < -2), 18.6% wasted (weight-for-height z-score < -2), 2.7% were HIV-infected, and 14.2% were HIV-exposed uninfected. Seventeen children (11.5%) had one or more signs of tuberculosis (TB). All children had a Bacille Calmette-Guerin vaccination scar. Among 134 viable blood cultures, none (95% confidence interval: 0-2.7%) had Mycobacterium isolated. Despite exposure to household TB contacts, HIV exposure, and malnutrition, M. tuberculosis bacteremia was not detected in this pediatric febrile cohort, a finding consistent with other pediatric studies.

Frequency and correlates of malaria overdiagnosis and treatment in western Kenya

Abstract Background Despite decreasing malaria burden in sub-Saharan Africa, fever in children is frequently attributed to malaria and empirically treated with antimalarial drugs. The 2010 WHO guidelines recommend laboratory confirmation of malaria before initiating therapy, but the uptake of these guidelines is slow. We determined frequency and predictors of malaria overtreatment in febrile children at two western Kenya rural hospitals in regions with varied malaria endemicity. Methods We enrolled consecutive febrile children aged 6 months to 15 years presenting to Kisii Provincial (malaria endemicity: hypoendemic) or Homa Bay District (malaria endemicity: holoendemic) hospitals between March, 2012, and November, 2013. Detailed demographic, clinical, and laboratory data were collected, including physician diagnosis at admission and corresponding treatments. All children were screened for HIV with antibody or PCR testing, for malaria using smear microscopy and Paracheck Pf rapid diagnostic tests, and for invasive bacterial infections using blood culture. We determined the frequency of clinician-prescribed antimalarial treatment among those with negative smear and rapid diagnostic test results and evaluated independent predictors of overtreatment using multivariate logistic regression. Because the sites had marked differences in underlying malaria endemicities that might impact clinician suspicion of parasitaemia, analyses were stratified and compared by site. Findings Among the 1362 children enrolled (685 in Kisii and 677 in Homa Bay), 46 (6·7%) and 310 (45·8%) had laboratory-confirmed malaria in Kisii and Homa Bay, respectively (p vs gold-standard laboratory-based diagnosis) was lower in Kisii than in Homa Bay (73·0% vs 95·3%, p vs 33·7%, p Interpretation Malaria was treated, despite negative laboratory testing, more frequently in Homa Bay than in Kisii, probably owing to underlying higher malaria prevalence. Despite availability of diagnostic testing, malaria prevalence appears to influence the clinical management of children in Kenya and may result in missed opportunities to accurately diagnose alternative causes of fever. Strengthening health system use and adherence to existing treatment guidelines appears necessary, particularly in areas of high malaria endemicity. Funding US National Institutes of Health.

World Health Organization's stage 4 conditions among adults accessing outpatient HIV care: a retrospective cohort study in Kisumu, Kenya.

Opportunistic infections (OIs) are the main cause of morbidity and mortality in patients with HIV-1 infection throughout the world, particularly among patients who have not had access to anti-retroviral therapy (ART) and other HIV care services. 1, 2, 3 Among patients taking ART, OIs can present when the immune system starts to recover aka immune reconstitution inflammatory syndrome (IRIS). 4, 5 Also, some patients do not have a sustained response to ART due to lack of adherence to medications, development of drug resistance, or suboptimal therapeutic regimens. 1 Therefore, OIs continue to cause substantial morbidity and mortality even after initiation of ART. The World Health Organization (WHO) developed HIV clinical staging criteria based on OIs to standardize disease severity classification in the absence of virologic or immunologic measurements. 6, 7 Diagnosis of WHO stage 4 conditions remains important in the ART era in order to: 1) help determine timing of ART initiation, and 2) treat OIs to reduce morbidity and mortality. There are no published data from Kenya that quantify the burden of WHO stage 4 conditions that persist in the ART era and continue to negatively impact patient survival. We therefore set out to determine the prevalence and gender distribution of WHO stage 4 conditions among patients enrolled in a large peri-urban HIV clinic in western Kenya.

WHO stage 4 conditions among adults accessing outpatient HIV care: A retrospective cohort study in Kisumu, Kenya

Opportunistic infections (OIs) are the main cause of morbidity and mortality in patients with HIV-1 infection throughout the world, particularly among patients who have not had access to anti-retroviral therapy (ART) and other HIV care services. 1, 2, 3 Among patients taking ART, OIs can present when the immune system starts to recover aka immune reconstitution inflammatory syndrome (IRIS). 4, 5 Also, some patients do not have a sustained response to ART due to lack of adherence to medications, development of drug resistance, or suboptimal therapeutic regimens. 1 Therefore, OIs continue to cause substantial morbidity and mortality even after initiation of ART. The World Health Organization (WHO) developed HIV clinical staging criteria based on OIs to standardize disease severity classification in the absence of virologic or immunologic measurements. 6, 7 Diagnosis of WHO stage 4 conditions remains important in the ART era in order to: 1) help determine timing of ART initiation, and 2) treat OIs to reduce morbidity and mortality. There are no published data from Kenya that quantify the burden of WHO stage 4 conditions that persist in the ART era and continue to negatively impact patient survival. We therefore set out to determine the prevalence and gender distribution of WHO stage 4 conditions among patients enrolled in a large peri-urban HIV clinic in western Kenya.