Stephanie M. Davis

Soil-Transmitted Helminth Infection and Nutritional Status Among Urban Slum Children in Kenya

To evaluate the nutritional impact of soil-transmitted helminth (STH) infection, we conducted a cross-sectional survey of 205 pre-school (PSC) and 487 school-aged children (SAC) randomly selected from the surveillance registry of the Centers for Disease Control and Prevention of the Kibera slum in Kenya. Hemoglobin, iron deficiency (ID), vitamin A deficiency (VAD), inflammation, malaria, anthropometry, and STH ova were measured. Poisson regression models evaluated associations between STH and malnutrition outcomes and controlled for confounders. Approximately 40% of PSC and SAC had STH infection, primarily Ascaris and Trichuris; 2.9% of PSC and 1.1% of SAC had high-intensity infection. Malnutrition prevalence among PSC and SAC was anemia (38.3% and 14.0%, respectively), ID (23.0% and 5.0%, respectively), VAD (16.9% and 4.5%, respectively), and stunting (29.7% and 16.9%, respectively). In multivariate analysis, STH in PSC was associated with VAD (prevalence ratio [PR] = 2.2, 95% confidence interval = 1.1-4.6) and ID (PR = 3.3, 95% confidence interval = 1.6-6.6) but not anemia or stunting. No associations were significant in SAC. Integrated deworming and micronutrient supplementation strategies should be evaluated in this population.

Soil-Transmitted Helminths in Pre-School-Aged and School-Aged Children in an Urban Slum: A Cross-Sectional Study of Prevalence, Distribution, and Associated Exposures

Soil-transmitted helminths (STHs) are controlled by regular mass drug administration. Current practice targets school-age children (SAC) preferentially over pre-school age children (PSAC) and treats large areas as having uniform prevalence. We assessed infection prevalence in SAC and PSAC and spatial infection heterogeneity, using a cross-sectional study in two slum villages in Kibera, Nairobi. Nairobi has low reported STH prevalence. The SAC and PSAC were randomly selected from the International Emerging Infections Programs surveillance platform. Data included residence location and three stools tested by Kato-Katz for STHs. Prevalences among 692 analyzable children were any STH: PSAC 40.5%, SAC 40.7%; Ascaris: PSAC 24.1%, SAC 22.7%; Trichuris: PSAC 24.0%, SAC 28.8%; hookworm < 0.1%. The STH infection prevalence ranged from 22% to 71% between sub-village sectors. The PSAC have similar STH prevalences to SAC and should receive deworming. Small areas can contain heterogeneous prevalences; determinants of STH infection should be characterized and slums should be assessed separately in STH mapping.

Prevalence of Strongyloides stercoralis Antibodies among a Rural Appalachian Population—Kentucky, 2013

We investigated whether Strongyloides infection remains endemic in rural Kentuckys Appalachian regions; 7 of 378 (1.9%) participants tested positive for Strongyloides antibodies. We identified no statistically significant association between a positive test and travel to a known endemic country (P = 0.58), indicating that transmission in rural Kentucky might be ongoing.We investigated whether Strongyloides infection remains endemic in rural Kentucky’s Appalachian regions; 7 of 378 (1.9%) participants tested positive for Strongyloides antibodies. We identified no statistically significant association between a positive test and travel to a known endemic country (P = 0.58), indicating that transmission in rural Kentucky might be ongoing.

A Cross-Sectional Study of Water, Sanitation, and Hygiene-Related Risk Factors for Soil-Transmitted Helminth Infection in Urban School- and Preschool-Aged Children in Kibera, Nairobi.

Soil-transmitted helminth (STH) infections affect persons living in areas with poor water, sanitation, and hygiene (WASH). Preschool-aged children (PSAC) and school-aged children (SAC) are disproportionately affected by STH infections. We aimed to identify WASH factors associated with STH infection among PSAC and SAC in Kibera, Kenya. In 2012, households containing a PSAC or SAC were randomly selected from those enrolled in the International Emerging Infections Program, a population-based surveillance system. We administered a household questionnaire, conducted environmental assessments for WASH, and tested three stools from each child for STH eggs using the Kato-Katz method. WASH factors were evaluated for associations with STH infection using univariable and multivariable Poisson regression. Any-STH prevalence was 40.8% among 201 PSAC and 40.0% among 475 SAC enrolled. Using the Joint Monitoring Programme water and sanitation classifications, 1.5% of households reported piped water on premises versus 98.5% another improved water source; 1.3% reported improved sanitation facilities, while 81.7% used shared sanitation facilities, 13.9% had unimproved facilities, and 3.1% reported no facilities (open defecation). On univariable analysis, STH infection was significantly associated with a household toilet located off-premises (prevalence ratio (PR) = 1.33; p = 0.047), while always treating water (PR = 0.81; p = 0.04), covering drinking water containers (PR = 0.75; p = 0.02), using clean towels during hand drying (PR = 0.58; p<0.01), having finished household floor material (PR = 0.76; p<0.01), having electricity (PR = 0.70; p<0.01), and increasing household elevation in 10-meter increments (PR = 0.89; p<0.01) were protective against STH infection. On multivariable analysis, usually versus always treating water was associated with increased STH prevalence (adjusted prevalence ratio (aPR) = 1.52; p<0.01), while having finished household floor material (aPR = 0.76; p = 0.03), reported child deworming in the last year (aPR = 0.76; p<0.01), and 10-meter household elevation increases (aPR = 0.89; p<0.01) were protective against infection. The intersection between WASH and STH infection is complex; site-specific WASH interventions should be considered to sustain the gains made by deworming activities.

Unprogrammed Deworming in the Kibera Slum, Nairobi: Implications for Control of Soil-Transmitted Helminthiases

Background Programs for control of soil-transmitted helminth (STH) infections are increasingly evaluating national mass drug administration (MDA) interventions. However, “unprogrammed deworming” (receipt of deworming drugs outside of nationally-run STH control programs) occurs frequently. Failure to account for these activities may compromise evaluations of MDA effectiveness. Methods We used a cross-sectional study design to evaluate STH infection and unprogrammed deworming among infants (aged 6–11 months), preschool-aged children (PSAC, aged 1–4 years), and school-aged children (SAC, aged 5–14 years) in Kibera, Kenya, an informal settlement not currently receiving nationally-run MDA for STH. STH infection was assessed by triplicate Kato-Katz. We asked heads of households with randomly-selected children about past-year receipt and source(s) of deworming drugs. Local non-governmental organizations (NGOs) and school staff participating in school-based deworming were interviewed to collect information on drug coverage. Results Of 679 children (18 infants, 184 PSAC, and 477 SAC) evaluated, 377 (55%) reported receiving at least one unprogrammed deworming treatment during the past year. PSAC primarily received treatments from chemists (48.3%) or healthcare centers (37.7%); SAC most commonly received treatments at school (55.0%). Four NGOs reported past-year deworming activities at 47 of >150 schools attended by children in our study area. Past-year deworming was negatively associated with any-STH infection (34.8% vs 45.4%, p = 0.005). SAC whose most recent deworming medication was sourced from a chemist were more often infected with Trichuris (38.0%) than those who received their most recent treatment from a health center (17.3%) or school (23.1%) (p = 0.05). Conclusion Unprogrammed deworming was received by more than half of children in our study area, from multiple sources. Both individual-level treatment and unprogrammed preventive chemotherapy may serve an important public health function, particularly in the absence of programmed deworming; however, they may also lead to an overestimation of programmed MDA effectiveness. A standardized, validated tool is needed to assess unprogrammed deworming.

Association between male circumcision and women's biomedical health outcomes: a systematic review

Summary Background Male circumcision reduces men’s risk of acquiring HIV and some sexually transmitted infections from heterosexual exposure, and is essential for HIV prevention in sub-Saharan Africa. Studies have also investigated associations between male circumcision and risk of acquisition of HIV and sexually transmitted infections in women. We aimed to review all evidence on associations between male circumcision and women’s health outcomes to benefit women’s health programmes. Methods In this systematic review we searched for peer-reviewed and grey literature publications reporting associations between male circumcision and women’s health outcomes up to April 11, 2016. All biomedical (not psychological or social) outcomes in all study types were included. Searches were not restricted by year of publication, or to sub-Saharan Africa. Publications without primary data and not in English were excluded. We extracted data and assessed evidence on each outcome as high, medium, or low consistency on the basis of agreement between publications; outcomes found in fewer than three publications were indeterminate consistency. Findings 60 publications were included in our assessment. High-consistency evidence was found for five outcomes, with male circumcision protecting against cervical cancer, cervical dysplasia, herpes simplex virus type 2, chlamydia, and syphilis. Medium-consistency evidence was found for male circumcision protecting against human papillomavirus and low-risk human papillomavirus. Although the evidence shows a protective association with HIV, it was categorised as low consistency, because one trial showed an increased risk to female partners of HIV-infected men resuming sex early after male circumcision. Seven outcomes including HIV had low-consistency evidence and six were indeterminate. Interpretation Scale-up of male circumcision in sub-Saharan Africa has public health implications for several outcomes in women. Evidence that female partners are at decreased risk of several diseases is highly consistent. Synergies between male circumcision and women’s health programmes should be explored. Funding US Centers for Disease Control and Prevention and Jhpiego

Notes from the Field: Tetanus Cases After Voluntary Medical Male Circumcision for HIV Prevention — Eastern and Southern Africa, 2012–2015

Voluntary medical male circumcision (VMMC) decreases the risk for female-to-male HIV transmission by approximately 60%, and the Presidents Emergency Plan for AIDS Relief (PEPFAR) is supporting the scale-up of VMMC for adolescent and adult males in countries with high prevalence of human immunodeficiency virus (HIV) and low coverage of male circumcision. As of September 2015, PEPFAR has supported approximately 8.9 million VMMCs.

Bleeding and Blood Disorders in Clients of Voluntary Medical Male Circumcision for HIV Prevention — Eastern and Southern Africa, 2015–2016

Male circumcision reduces the risk for female-to-male human immunodeficiency virus (HIV) transmission by approximately 60% (1) and has become a key component of global HIV prevention programs in countries in Eastern and Southern Africa where HIV prevalence is high and circumcision coverage is low. Through September 2017, the Presidents Emergency Plan for AIDS Relief (PEPFAR) had supported 15.2 million voluntary medical male circumcisions (VMMCs) in 14 priority countries in Eastern and Southern Africa (2). Like any surgical intervention, VMMC carries a risk for complications or adverse events. Adverse events during circumcision of males aged ≥10 years occur in 0.5% to 8% of procedures, though the majority of adverse events are mild (3,4). To monitor safety and service quality, PEPFAR tracks and reports qualifying notifiable adverse events. Data reported from eight country VMMC programs during 2015-2016 revealed that bleeding resulting in hospitalization for ≥3 days was the most commonly reported qualifying adverse event. In several cases, the bleeding adverse event revealed a previously undiagnosed or undisclosed bleeding disorder. Bleeding adverse events in men with potential bleeding disorders are serious and can be fatal. Strategies to improve precircumcision screening and performance of circumcisions on clients at risk in settings where blood products are available are recommended to reduce the occurrence of these adverse events or mitigate their effects (5).

Progress in voluntary medical male circumcision for HIV prevention supported by the US President’s Emergency Plan for AIDS Relief through 2017: longitudinal and recent cross-sectional programme data

Objective This article provides an overview and interpretation of the performance of the US President’s Emergency Plan for AIDS Relief’s (PEPFAR’s) male circumcision programme which has supported the majority of voluntary medical male circumcisions (VMMCs) performed for HIV prevention, from its 2007 inception to 2017, and client characteristics in 2017. Design Longitudinal collection of routine programme data and disaggregations. Setting 14 countries in sub-Saharan Africa with low baseline male circumcision coverage, high HIV prevalence and PEPFAR-supported VMMC programmes. Participants Clients of PEPFAR-supported VMMC programmes directed at males aged 10 years and above. Main outcome measures Numbers of circumcisions performed and disaggregations by age band, result of HIV test offer, procedure technique and follow-up visit attendance. Results PEPFAR supported a total of 15 269 720 circumcisions in 14 countries in Southern and Eastern Africa. In 2017, 45% of clients were under 15 years of age, 8% had unknown HIV status, 1% of those tested were HIV+ and 84% returned for a follow-up visit within 14 days of circumcision. Conclusions Over 15 million VMMCs have been supported by PEPFAR since 2007. VMMC continues to attract primarily young clients. The non-trivial proportion of clients not testing for HIV is expected, and may be reassuring that testing is not being presented as mandatory for access to circumcision, or in some cases reflect test kit stockouts or recent testing elsewhere. While VMMC is extremely safe, achieving the highest possible follow-up rates for early diagnosis and intervention on complications is crucial, and programmes continue to work to raise follow-up rates. The VMMC programme has achieved rapid scale-up but continues to face challenges, and new approaches may be needed to achieve the new Joint United Nations Programme on HIV/AIDS goal of 27 million additional circumcisions through 2020.

Morbidity Associated with Schistosomiasis Before and After Treatment in Young Children in Rusinga Island, Western Kenya

Schistosoma mansoni infection is a major cause of organomegaly and ultimately liver fibrosis in adults. Morbidity in pre-school-aged children is less defined, and they are currently not included in mass drug administration (MDA) programs for schistosomiasis control. We report results of a study of the association of schistosomiasis with organomegaly in a convenience sample of 201 children under 7 years old in Rusinga, Kenya on two cross-sectional visits, before and after praziquantel treatment. Data included stool examination and serology for schistosomiasis, the Niamey ultrasound protocol to stage hepatosplenic morbidity including organomegaly, and potential confounders including malaria. Unadjusted and adjusted Poisson regressions were performed. The baseline prevalence of schistosomiasis by antibody and/or stool was 80.3%. Schistomiasis was associated with hepatomegaly (adjusted prevalence ratio [aPR] = 1.4; 95% confidence interval [CI]: 1.0-2.1) and splenomegaly (aPR = 2.1; 95% CI: 1.2-3.7). The association with hepatomegaly persisted posttreatment (aPR = 1.4; 95% CI: 1.1-1.6). Schistosomiasis was associated with morbidity in this cohort. Efforts to include young children in mass treatment campaigns should intensify.