Human metapneumovirus epidemiological and evolutionary patterns in Coastal Kenya, 2007-11

Background: Human metapneumovirus (HMPV) is an important global cause of severe acute respiratory infections in young children and the elderly. The epidemiology of HMPV in sub-Saharan Africa is poorly described and factors that allow its recurrent epidemics in communities not understood. Methods: We undertook paediatric inpatient surveillance for HMPV in Kilifi County Hospital (KCH) of Coastal Kenya between 2007 and 2011. Nasopharyngeal samples collected from children aged 1 day–59 months admitted with severe or very severe pneumonia, were tested for HMPV using real-time polymerase chain reaction (RT-PCR). Partial nucleotide sequences of the attachment (G) and fusion (F) surface proteins of positive samples were determined and phylogenetically analyzed. Results: HMPV was detected in 4.8 % (160/3320) of children [73.8 % (118/160) of these less than one year of age], ranging between 2.9 and 8.8 % each year over the 5 years of study. HMPV infections were seasonal in occurrence, with cases predominant in the months of November through April. These months frequently coincided with low rainfall, high temperature and low relative humidity in the location. Phylogenetic analysis of partial F and G sequences revealed three subgroups of HMPV, A2 (74 %, 91/123), B1 (3.2 %, 4/123) and B2 (22.8 %, 28/123) in circulation, with subgroup A2 predominant in majority of the epidemic seasons. Comparison of G sequences (local and global) provided a greater phylogenetic resolution over comparison of F sequences and indicated presence of probable multiple G antigenic variants within the subgroups due to differences in amino acid sequence, encoded protein length and glycosylation patterns. Conclusion: The present study reveals HMPV is an important seasonal contributor to respiratory disease hospitalization in coastal Kenya, with an evolutionary pattern closely relating to that of respiratory syncytial virus

Molecular characterization of rotavirus group A strains circulating prior to vaccine introduction in rural coastal Kenya, 2002-2013

Background Kenya introduced the monovalent Rotarix® rotavirus group A (RVA) vaccine nationally in mid-2014. Long-term surveillance data is important prior to wide-scale vaccine use to assess the impact on disease and to investigate the occurrence of heterotypic strains arising through immune selection. This report presents baseline data on RVA genotype circulation patterns and intra-genotype genetic diversity over a 7-year period in the pre-vaccine era in Kilifi, Kenya, from 2002 to 2004 and from 2010 to 2013. Methods A total of 745 RVA strains identified in children admitted with acute gastroenteritis to a referral hospital in Coastal Kenya, were sequenced using the di-deoxy sequencing method in the VP4 and VP7 genomic segments (encoding P and G proteins, respectively). Sequencing successfully generated 569 (76%) and 572 (77%) consensus sequences for the VP4 and VP7 genes respectively. G and P genotypes were determined by use of BLAST and the online RotaC v2 RVA classification tool. Results The most common GP combination was G1P[8] (51%), similar to the Rotarix® strain, followed by G9P[8] (15%) , G8P[4] (14%) and G2P[4] (5%). Unusual GP combinations—G1P[4], G2P[8], G3P[4,6], G8P[8,14], and G12P[4,6,8]—were observed at frequencies of <5%. Phylogenetic analysis showed that the infections were caused by both locally persistent strains as evidenced by divergence of local strains occurring over multiple seasons from the global ones, and newly introduced strains, which were closely related to global strains. The circulating RVA diversity showed temporal fluctuations both season by season and over the longer-term. None of the unusual strains increased in frequency over the observation period. Conclusions The circulating RVA diversity showed temporal fluctuations with several unusual strains recorded, which rarely caused major outbreaks. These data will be useful in interpreting genotype patterns observed in the region during the vaccine er

RANDOMISED DOUBLE BLIND STUDY TO COMPARE EFFECTIVENESS OF HONEY, SALBUTAMOL AND PLACEBO IN TREATMENT OF COUGH IN CHILDREN WITH COMMON COLD

Background: Acute upper respiratory infection is the most common childhood illness and presents with cough, coryza and fever. Available evidence suggests that cough medicines may be no more effective than honey-based cough remedies. Objective: To compare effectiveness of honey, salbutamol and placebo in the treatment of cough in children with acute onset cough. Design: Randomised control trial Setting: Aga Khan University Hospital Paediatric Casualty Subjects: Children between ages one to twelve years presenting with a common cold between December 2010 and February 2012 were enrolled. Outcome measures: Frequency, severity and extent to which cough bothered and disturbed child and parental sleep were assessed at baseline and over the subsequent five days through telephone interview using a validated scoring tool. Results: One hundred and forty five children were enrolled in the study (45- placebo, 57 –honey, 43 –salbutamol). Of the 145 children 51% were male. Honey significantly reduced the total mean symptom score by day three (p\u3c 0.001). Total mean difference in scores between day zero to five demonstrated a significant difference of honey’s efficacy over placebo (p\u3c 0.002) however no difference was noted when compared to salbutamol (p\u3c0.478). Significant differences in both total as well as each individual symptom score was detected with honey consistently scoring the best whilst placebo and salbutamol scored the worst. In paired comparisons honey was superior to placebo but not salbutamol, whilst salbutamol was not superior to placebo. Conclusion: Honey was most effective in symptomatic relief of symptoms associated with the common cold whilst salbutamol or placebo offered no benefit

Prevalence of Group a Rotavirus before and after Vaccine Introduction in Mukuru Informal Settlement in Kenya

Background: Rotavirus vaccines have been shown to be a lifesaving and cost-effective public health intervention in Africa and have resulted in reduced rotavirus mortality. In Kenya, rotavirus diarrhea causes 19% of hospitalizations and 16% of clinic visits among children &lt;5 years of age and causes 4471 deaths and 8,781 hospitalizations per year. Nationally, rotavirus disease costs the health care system $10.8 million annually. It is estimated that routine vaccination with a 2-dose rotavirus vaccination series would avert approximately 2,467 deaths (55%), 5,724 hospitalizations (65%), 852, 589 clinic visits (59%) and would save 58 disability-adjusted life-years (DALYs) per 1000 children annually. In July 2014, Kenya introduced rotavirus vaccine into its routine expanded programme  immunisation, with two doses given at 6 and 10ths week of age.WHO recommend having  surveillance studies before and after vaccine as baseline data and monitoring the possible effect after vaccine introductions. The aim of this study was to determine the prevalence of rotavirus in pre- and post-vaccine stool samples collected from children under five years, attending two selected clinics in Mukuru informal settlement in Nairobi, Kenya. Methods: Archived samples collected during a Salmonella surveillance study (SSC No. 2074) conducted between July 2013 and July 2015 were used for this study. A total of 270 samples (150 pre-vaccine and 120 post-vaccine) were tested for rotavirus using ELISA Prospect kit (Oxoid Ltd UK) and data analyzed using SPSS version 20. Results: Rotavirus prevalence was 10% (15/150) and 5% (6/120) in pre-vaccine and post-vaccine samples respectively. There was significant difference in prevalence pre and post vaccine samples for children less than 12 months (P=0.014), 13-24 months (P=0.002) and over 49 months (P=0.01). However, there was no difference in prevalence for age categories 25-36 and 37- 48 months. Conclusion: This study showed a reduction in prevalence of Group A rotavirus in Mukuru selected clinics one year after vaccine introduction into National immunization program in Kenya. Rotavirus prevalence differed significantly for cases less than 12 months, 13-24 months and over 49 months pre and post vaccine introduction. However, there was no difference in prevalence for age category 25-36 and 37- 48 months thus the vaccine proved to have a significant protection in the most vulnerable group of children. Keywords: Rotavirus, Kenya, vaccine, pre-vaccine, post-vaccine, prevalence, Kenya

Digital Signal Processing Research Program

Contains table of contents for Part III, table of contents for Section 1, an introduction and reports on seventeen research projects.U.S. Navy - Office of Naval Research Contract N00014-90-J-1544Charles S. Draper Laboratory Contract DL-H-404158Rockwell Corporation Doctoral FellowshipU.S. Navy - Office of Naval Research Grant N00014-89-J-1489U.S. Navy - Office of Naval Research Grant N00014-90-J-1109The Federative Republic of Brazil ScholarshipLockheed Sanders, Inc.National Science Foundation Grant MIP 87-14969AT&T Bell Laboratories Doctoral ProgramBell Northern Research Ltd.Defense Advanced Research Projects Agency Contract N00014-87-K-0825IBM CorporationSloan FoundationU.S. Air Force - Office of Scientific Research FellowshipU.S. Air Force - Office of Scientific Research Grant AFOSR-91-0034National Science Foundation Graduate FellowshipCanada, Natural Science and Engineering Research Council ScholarshipU.S. Air Force - Office of Scientific Research Grant AFOSR-91-0034Texas Instruments, Inc

Digital Signal Processing Research Program

Contains table of contents for Section 2, an introduction and reports on seventeen research projects.U.S. Navy - Office of Naval Research Grant N00014-91-J-1628Vertical Arrays for the Heard Island Experiment Award No. SC 48548Charles S. Draper Laboratories, Inc. Contract DL-H-418472Defense Advanced Research Projects Agency/U.S. Navy - Office of Naval Research Grant N00014-89-J-1489Rockwell Corporation Doctoral FellowshipMIT - Woods Hole Oceanographic Institution Joint ProgramDefense Advanced Research Projects Agency/U.S. Navy - Office of Naval Research Grant N00014-90-J-1109Lockheed Sanders, Inc./U.S. Navy - Office of Naval Research Contract N00014-91-C-0125U.S. Air Force - Office of Scientific Research Grant AFOSR-91-0034AT&T Laboratories Doctoral ProgramU.S. Navy - Office of Naval Research Grant N00014-91-J-1628General Electric Foundation Graduate Fellowship in Electrical EngineeringNational Science Foundation Grant MIP 87-14969National Science Foundation Graduate FellowshipCanada Natural Sciences and Engineering Research CouncilLockheed Sanders, Inc

What constitutes responsiveness of physicians: A qualitative study in rural Bangladesh

Responsiveness entails the social actions by health providers to meet the legitimate expectations of patients. It plays a critical role in ensuring continuity and effectiveness of care within people centered health systems. Given the lack of contextualized research on responsiveness, we qualitatively explored the perceptions of outpatient users and providers regarding what constitute responsiveness in rural Bangladesh. An exploratory study was undertaken in Chuadanga, a southwestern Bangladeshi District, involving in-depth interviews of physicians (n = 17) and users (n = 7), focus group discussions with users (n = 4), and observations of patient provider interactions (three weeks). Analysis was guided by a conceptual framework of responsiveness, which includes friendliness, respecting, informing and guiding, gaining trust and optimizing benefits. In terms of friendliness, patients expected physicians to greet them before starting consultations; even though physicians considered this unusual. Patients also expected physicians to hold social talks during consultations, which was uncommon. With regards to respect patients expected physicians to refrain from disrespecting them in various ways; but also by showing respect explicitly. Patients also had expectations related to informing and guiding: they desired explanation on at least the diagnosis, seriousness of illness, treatment and preventive steps. In gaining trust, patients expected that physicians would refrain from illegal or unethical activities related to patients, e.g., demanding money against free services, bringing patients in own private clinics by brokers (dalals), colluding with diagnostic centers, accepting gifts from pharmaceutical representatives. In terms of optimizing benefits: patients expected that physicians should be financially sensitive and consider individual need of patients. There were multiple dimensions of responsiveness- for some, stakeholders had a consensus; context was an important factor to understand them. This being an exploratory study, further research is recommended to validate the nuances of the findings. It can be a guideline for responsiveness practices, and a tipping point for future research

Treatment of shigella infections: why sulfamethoxazole-trimethoprim, tetracyclines and ampicillin should no longer be used

Background: Bloody diarrhoea results in high morbidity and mortality especially in developing countries with shigellosis being the main cause of acute bloody diarrhoea. The use of appropriate antimicrobial agents in the treatment of acute diarrheal disease shortens the duration of illness and bacterial shedding leading to a reduction in morbidity and mortality. Treatment options for many infections are becoming limited due to globally emerging antibiotic resistance. Globally, resistance of shigella species to trimethoprim-sulfamethoxazole (TMP-SMX), tetracyclines and ampicillin has been reported with subsequent recommendations of not using these antimicrobial drugs for empirical therapy of acute bloody diarrhoea.Objective: To establish the antimicrobial susceptibility patterns and antimicrobial drug use for treatment of shigella species in patients with acute bloody diarrhoea.Design: A hospital based case control study.Setting: Six health facilities, three in Kilifi County and three in Nairobi County.Subject: A total of 284 stool specimens were collected from patients who fitted the standard cases definition for acute bloody diarrhoea.Results: Eighty (28.2%) bacterial isolates were recovered from 284 stool samples collected from cases presenting with acute bloody diarrhoea of which 67 (83.8%) were Shigella species, nine (11.3%) were Enteroinvassive Escherichia coli isolates, three (3.8%) were Salmonella Typhi and one (1.3%) were Yersinia enterocolitica. Shigella isolates had high resistance to sulfamethoxazole-trimethoprim (97%), tetracycline (83.6%) ampicillin (58.2%) and chloramphenicol (20.9%). The isolates showed low resistance to nalidixic (4.5%) and ciprofloxacin (3.0%) while there was no resistance to ceftriaxone. The most common multidrug resistance pattern detected in Shigella strains combined sulfamethoxazole-trimethoprim, amoxicillin/ampicillin and tetracyclines.Antibiotic prescriptions were given to 243(85.6%) of the patients presenting with acute bloody diarrhoea. Among these, 94 (38.7%) were given prescriptions for ciprofloxacin, 53 (21.8%) for sulfamethaxazole-trimethiprin and 36(14.8%) for Tetracyclines. Chloramphenicol, amoxicillin/ampicillin, nalidixic acid and ceftriaxone were prescribed to 10.7 %, 3.7%, 2.9% and 0.4% of the patients respectively. A total of 123 (51%) received antibiotics which were ranked to have high resistance (sulfamethoxazole-trimethoprim, tetracyclines ampicillin and chloramphenicol).Conclusion: The high rates of antimicrobial resistance among the commonly prescribed antimicrobials such as sulfamethoxazole-trimethoprim, tetracycline, ampicillin and chloramphenicol is of major concern. Despite recommendations discouraging the empirical use of sulfamethoxazole-trimethoprim, tetracycline, ampicillin and chloramphenicol for treatment of acute bloody diarrhoea, more than half of the patients with acute bloody diarrhoea were still treated with these antibiotics.There is need to train health care workers on the proper management of acute bloody diarrhoea and the importance of adhering to the clinical guidelines