The Impact of COVID-19 on Survivors of Human Trafficking in Kenya: A Participatory Approach

Researchers and practitioners are increasingly calling for the involvement of survivors of human trafficking at all levels of, and in all areas of, anti-trafficking research, policy, work and legislation. Although it is now quite common for survivors to be called on to share their stories, if not done sensitively, this risks re-traumatising survivors, impeding or undoing progress in their recovery and side-lining them away from decision-making and the opportunity to exercise agency in the anti-trafficking sphere. Survivors may be used (a term we employ deliberately) by a third party to engage emotionally with policymakers, funders and members of the generalpublic, and their narratives are often shaped into expected contours – especially of innocence and victimhood – and sometimes even re-purposed without their consent. To counter this, NGOs and practitioners are increasingly engaging with participatory research methods in order to platform survivors. As an emerging field of research and practice, there are nonetheless power dynamics within these collaborations, as well as expectations from survivor narratives which impact how survivors are engaged with and the roles they are allowed to perform. More equitable, collaborative and inclusive methodologies have already been developed in the Arts, notably ethical storytelling and participatory photography. Our project makes a meaningful intervention in anti-trafficking work by combining these two methodologies: through a series of workshops, 16 survivors were invited to produce complementary stories and photographs that resonated with their lived experience. To our knowledge, this is the first time both methodologies have been employed together in anti trafficking work. Providing participants with a platform through which to produce both images and stories empowered them with multiple creative means to tell their own stories. We sought to employ these methodologies to help understand the experience of survivors of human trafficking in Kenya, engage them more meaningfully in anti-trafficking work and, ultimately, provide an evidence base for questions around whether ethically-sourced narratives which may or may not fit the expected arc or trope could engage the general public. This project can justifiably claim to be truly trauma-informed and survivor-led, as the project was suspended until survivors independently requested it resume. Our project started in October 2019, running until December 2020. Concerns about ethical practice were paramount, and exacerbated by the pressures of the COVID-19 pandemic. Delays to our project caused by COVID-19 mean we have not yet been able to form conclusions regarding the final aim of our research, but we have been able to address the first two. We found that using these approaches did empower survivors. One interesting finding is how these Arts-based methodologies, and engaging in research, gave survivors a way of escaping the pandemic and its effects on their lives, providing them with meaningful activity and a community. Our project shows that it is possible to conduct participatory, ethical work remotely, even during a pandemic, though this entails a considerable commitment of time from both participants and researchers.In this article, we first describe the context in which this research was conducted, define the methodological framework used, and outline the methods used within the project. We then explore the impact that COVID-19 had on both the project participants (through consideration of their stories, images and project evaluation feedback forms) and the project itself – as both the participants and practitioners adapted the intended project methodologies and methods. Lastly we share some reflections on what we learned about the use of these methodologies, and recommendations for future work, particularly working remotely in an equitable, ethical, and participatory way with survivors of human trafficking

Regional Variation of Extended-Spectrum Beta-Lactamase (ESBL)-Producing Enterobacterales, Fluoroquinolone-ResistantSalmonella entericaand Methicillin-ResistantStaphylococcus aureusAmong Febrile Patients in Sub-Saharan Africa

Background: Antimicrobial resistance (AMR) thwarts the curative power of drugs and is a present-time global problem. We present data on antimicrobial susceptibility and resistance determinants of bacteria the WHO has highlighted as being key antimicrobial resistance concerns in Africa, to strengthen knowledge of AMR patterns in the region. Methods: Blood, stool, and urine specimens of febrile patients, aged between ≥ 30 days and ≤ 15 years and hospitalized in Burkina Faso, Gabon, Ghana, and Tanzania were cultured from November 2013 to March 2017 (Patients > 15 years were included in Tanzania). Antimicrobial susceptibility testing was performed for all Enterobacterales and Staphylococcus aureus isolates using disk diffusion method. Extended-spectrum beta-lactamase (ESBL) production was confirmed by double-disk diffusion test and the detection of blaCTX–M, blaTEM and blaSHV. Multilocus sequence typing was conducted for ESBL-producing Escherichia coli and Klebsiella pneumoniae, ciprofloxacin-resistant Salmonella enterica and S. aureus. Ciprofloxacin-resistant Salmonella enterica were screened for plasmid-mediated resistance genes and mutations in gyrA, gyrB, parC, and parE. S. aureus isolates were tested for the presence of mecA and Panton-Valentine Leukocidin (PVL) and further genotyped by spa typing. Results: Among 4,052 specimens from 3,012 patients, 219 cultures were positive of which 88.1% (n = 193) were Enterobacterales and 7.3% (n = 16) S. aureus. The prevalence of ESBL-producing Enterobacterales (all CTX-M15 genotype) was 45.2% (14/31; 95% CI: 27.3, 64.0) in Burkina Faso, 25.8% (8/31; 95% CI: 11.9, 44.6) in Gabon, 15.1% (18/119; 95% CI: 9.2, 22.8) in Ghana and 0.0% (0/12; 95% CI: 0.0, 26.5) in Tanzania. ESBL positive non-typhoid Salmonella (n = 3) were detected in Burkina Faso only and methicillin-resistant S. aureus (n = 2) were detected in Ghana only. While sequence type (ST)131 predominated among ESBL E. coli (39.1%;9/23), STs among ESBL K. pneumoniae were highly heterogenous. Ciprofloxacin resistant nt Salmonella were commonest in Burkina Faso (50.0%; 6/12) and all harbored qnrB genes. PVL were found in 81.3% S. aureus. Conclusion: Our findings reveal a distinct susceptibility pattern across the various study regions in Africa, with notably high rates of ESBL-producing Enterobacterales and ciprofloxacin-resistant nt Salmonella in Burkina Faso. This highlights the need for local AMR surveillance and reporting of resistances to support appropriate action

A reduced-carbohydrate and lactose-free formulation for stabilization among hospitalized children with severe acute malnutrition: A double-blind, randomized controlled trial

BackgroundChildren with medically complicated severe acute malnutrition (SAM) have high risk of inpatient mortality. Diarrhea, carbohydrate malabsorption, and refeeding syndrome may contribute to early mortality and delayed recovery. We tested the hypothesis that a lactose-free, low-carbohydrate F75 milk would serve to limit these risks, thereby reducing the number of days in the stabilization phase.Methods and findingsIn a multicenter double-blind trial, hospitalized severely malnourished children were randomized to receive standard formula (F75) or isocaloric modified F75 (mF75) without lactose and with reduced carbohydrate. The primary endpoint was time to stabilization, as defined by the World Health Organization (WHO), with intention-to-treat analysis. Secondary outcomes included in-hospital mortality, diarrhea, and biochemical features of malabsorption and refeeding syndrome. The trial was registered at clinicaltrials.gov (NCT02246296). Four hundred eighteen and 425 severely malnourished children were randomized to F75 and mF75, respectively, with 516 (61%) enrolled in Kenya and 327 (39%) in Malawi. Children with a median age of 16 months were enrolled between 4 December 2014 and 24 December 2015. One hundred ninety-four (46%) children assigned to F75 and 188 (44%) to mF75 had diarrhea at admission. Median time to stabilization was 3 days (IQR 2–5 days), which was similar between randomized groups (0.23 [95% CI −0.13 to 0.60], P = 0.59). There was no evidence of effect modification by diarrhea at admission,age, edema, or HIV status. Thirty-six and 39 children died before stabilization in the F75 and in mF75 arm, respectively (P = 0.84). Cumulative days with diarrhea (P = 0.27), enteral (P = 0.42) or intravenous fluids (P = 0.19), other serious adverse events before stabilization, and serum and stool biochemistry at day 3 did not differ between groups. The main limitation was that the primary outcome of clinical stabilization was based on WHO guidelines, comprising clinical evidence of recovery from acute illness as well as metabolic stabilization evidenced by recovery of appetite. ConclusionsEmpirically treating hospitalized severely malnourished children during the stabilization phase with lactose-free, reduced-carbohydrate milk formula did not improve clinical outcomes. The biochemical analyses suggest that the lactose-free formulae may still exceed a carbohydrate load threshold for intestinal absorption, which may limit their usefulness in the context of complicated SAM

Changes in susceptibility to life-threatening infections after treatment for complicated severe malnutrition in Kenya

Background Goals of treating childhood Severe Acute Malnutrition (SAM), besides anthropometric recovery and preventing short-term mortality, include reducing risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation is unknown, but could inform improving design and scope of interventions. Objective To investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM. Design Secondary analysis of a clinical trial including 1,778 HIV-uninfected Kenyan children aged 2-59 months with complicated SAM, enrolled following the inpatient stabilization phase of treatment, and followed for 12 months. The main outcome was LTEs, defined as infections requiring re-hospitalization or causing death. We examined anthropometry measured at months one, three and six after enrolment in relation to LTEs occurring during the 6 months following each of these time points. Results During 12 months, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months one, three and six, 557(34%), 764(49%) and 842(56%) children had WHZ≥-2 respectively which, compared to WHZ Conclusion Anthropometric response was associated with rapid and substantial reduction risk of LTEs. However, reduction in susceptibility lagged behind anthropometric improvement. Disease events, alongside anthropometric assessment may provide a clearer picture of the effectiveness of interventions. Robust protocols for detecting and treating poor anthropometric recovery, and addressing broader vulnerabilities that complicated SAM indicates may save lives.</p

The evolving SARS-CoV-2 epidemic in Africa: Insights from rapidly expanding genomic surveillance

INTRODUCTION Investment in Africa over the past year with regard to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) sequencing has led to a massive increase in the number of sequences, which, to date, exceeds 100,000 sequences generated to track the pandemic on the continent. These sequences have profoundly affected how public health officials in Africa have navigated the COVID-19 pandemic. RATIONALE We demonstrate how the first 100,000 SARS-CoV-2 sequences from Africa have helped monitor the epidemic on the continent, how genomic surveillance expanded over the course of the pandemic, and how we adapted our sequencing methods to deal with an evolving virus. Finally, we also examine how viral lineages have spread across the continent in a phylogeographic framework to gain insights into the underlying temporal and spatial transmission dynamics for several variants of concern (VOCs). RESULTS Our results indicate that the number of countries in Africa that can sequence the virus within their own borders is growing and that this is coupled with a shorter turnaround time from the time of sampling to sequence submission. Ongoing evolution necessitated the continual updating of primer sets, and, as a result, eight primer sets were designed in tandem with viral evolution and used to ensure effective sequencing of the virus. The pandemic unfolded through multiple waves of infection that were each driven by distinct genetic lineages, with B.1-like ancestral strains associated with the first pandemic wave of infections in 2020. Successive waves on the continent were fueled by different VOCs, with Alpha and Beta cocirculating in distinct spatial patterns during the second wave and Delta and Omicron affecting the whole continent during the third and fourth waves, respectively. Phylogeographic reconstruction points toward distinct differences in viral importation and exportation patterns associated with the Alpha, Beta, Delta, and Omicron variants and subvariants, when considering both Africa versus the rest of the world and viral dissemination within the continent. Our epidemiological and phylogenetic inferences therefore underscore the heterogeneous nature of the pandemic on the continent and highlight key insights and challenges, for instance, recognizing the limitations of low testing proportions. We also highlight the early warning capacity that genomic surveillance in Africa has had for the rest of the world with the detection of new lineages and variants, the most recent being the characterization of various Omicron subvariants. CONCLUSION Sustained investment for diagnostics and genomic surveillance in Africa is needed as the virus continues to evolve. This is important not only to help combat SARS-CoV-2 on the continent but also because it can be used as a platform to help address the many emerging and reemerging infectious disease threats in Africa. In particular, capacity building for local sequencing within countries or within the continent should be prioritized because this is generally associated with shorter turnaround times, providing the most benefit to local public health authorities tasked with pandemic response and mitigation and allowing for the fastest reaction to localized outbreaks. These investments are crucial for pandemic preparedness and response and will serve the health of the continent well into the 21st century

What influences feeding decisions for HIV-exposed infants in rural Kenya?

Abstract Background Infant feeding in the context of human immunodeficiency virus (HIV) poses unique challenges to mothers and healthcare workers in balancing the perceived risks of HIV transmission and nutritional requirements. We aimed to describe the decision-making processes around infant feeding at a rural HIV clinic in Kenya. Methods We used a qualitative study design. Between March and August 2011, we conducted in-depth interviews (n = 9) and focus group discussions (n = 10) with purposively selected hospital and community respondents at Kilifi County Hospital, Kenya. These respondents had all experienced of infant feeding in the context of HIV. These interviews were informed by prior structured observations of health care worker interactions with carers during infant feeding counselling sessions. Results Overall, women living with HIV found it difficult to adhere to the HIV infant feeding guidance. There were three dominant factors that influenced decision making processes: 1) Exclusive breastfeeding was not the cultural norm, therefore practising it raised questions within the family and community about a mother’s parenting capabilities and HIV status. 2) Women living with HIV lacked autonomy in decision-making on infant feeding due to socio-cultural factors. 3) Non-disclosure of HIV status to close members due to the stigma. Conclusion Infant feeding decision-making by women living with HIV in rural Kenya is constrained by a lack of autonomy, stigma and poverty. There is an urgent need to address these challenges through scaling up psycho-social and gender empowerment strategies for women, and introducing initiatives that promote the integration of HIV infant feeding strategies into other child health services

Additional file 1: of What influences feeding decisions for HIV-exposed infants in rural Kenya?

Kiswahili version of observation tool. (DOCX 19 kb

Additional file 2: of What influences feeding decisions for HIV-exposed infants in rural Kenya?

Kiswahili version of focus group discussion guide. (DOC 49 kb

Ready-to-use therapeutic food with elevated n-3 polyunsaturated fatty acid content, with or without fish oil, to treat severe acute malnutrition; a randomized controlled trial

Background Ready-to-use therapeutic foods (RUTF) are lipid-based pastes widely used in the treatment of acute malnutrition. Current specifications for RUTF permit a high n-6 polyunsaturated fatty acid (PUFA) content and low n-3 PUFA, with no stipulated requirements for preformed long-chain n-3 PUFA. The objective of this study was to develop an RUTF with elevated short-chain n-3 PUFA and measure its impact, with and without fish oil supplementation, on children’s PUFA status during treatment of severe acute malnutrition. Methods This randomized controlled trial in children with severe acute malnutrition in rural Kenya included 60 children aged 6 to 50 months who were randomized to receive i) RUTF with standard composition; ii) RUTF with elevated short chain n-3 PUFA; or iii) RUTF with elevated short chain n-3 PUFA plus fish oil capsules. Participants were followed-up for 3 months. The primary outcome was erythrocyte PUFA composition. Results Erythrocyte docosahexaenoic acid (DHA) content declined from baseline in the two arms not receiving fish oil. Erythrocyte long-chain n-3 PUFA content following treatment was significantly higher for participants in the arm receiving fish oil than for those in the arms receiving RUTF with elevated short chain n-3 PUFA or standard RUTF alone: 3 months after enrolment, DHA content was 6.3% (interquartile range 6.0–7.3), 4.5% (3.9–4.9), and 3.9% (2.4–5.7) of total erythrocyte fatty acids (P <0.001), respectively, while eicosapentaenoic acid (EPA) content was 2.0% (1.5–2.6), 0.7% (0.6–0.8), and 0.4% (0.3–0.5) (P <0.001). RUTF with elevated short chain n-3 PUFA and fish oil capsules were acceptable to participants and carers, and there were no significant differences in safety outcomes. Conclusions PUFA requirements of children with SAM are not met by current formulations of RUTF, or by an RUTF with elevated short-chain n-3 PUFA without additional preformed long-chain n-3 PUFA. Clinical and growth implications of revised formulations need to be addressed in large clinical trials