Violence, uncertainty, and resilience among refugee women and community workers: An evaluation of gender-based violence case management services in the Dadaab refugee camps.

Reports of gender-based violence (GBV) are common in camps for refugees and displaced populations. In the Dadaab refugee camps in north-eastern Kenya, the International Rescue Committee (IRC) and CARE International (CARE) implement programmes that aim to both respond to and prevent GBV. A cornerstone of this work has been to train refugees, known as refugee community workers, to deliver aspects of GBV prevention and response work in order to develop a broader implementation of traditional GBV outreach, community mobilisation, and case management. To date, there has been limited rigorous research on this broader GBV case management plus task sharing approach in the context of a refugee camp setting. To address this key gap in evidence, the London School of Hygiene and Tropical Medicine (LSHTM) and the African Population and Health Research Centre (APHRC), in collaboration with IRC and CARE, have sought to assess this model to understand its feasibility, acceptability, and influence among female survivors of GBV accessing care. Data for this study, funded by UK aid, were collected in the Dadaab refugee camps between 2014 and 2017, which coincided with a temporary decision to close the camp and repatriate Somali refugees. The research confirms the magnitude and complexity of the violence that women and girls experience in the camps in Dadaab. In the year leading up to this study, 47% of women accessing the GBV centres for case management reported experiencing intimate partner violence and 39% reported experiencing non-partner violence. In addition, the study highlights the specific risks, challenges, opportunities and rewards experienced by refugee community workers in their dual role of community members and GBV activists living side-by-side with survivors and perpetrators of violence. Solely related to their work as GBV caseworkers, one in three refugee community workers reported experiencing non-partner violence in the last 12 months. Despite this, 93% of refugee community workers stated their work was rewarding or extremely rewarding. The majority of women (82%) accessing services reported that their interactions with refugee community workers had a positive effect, and that working with them was useful. However, having refugees deliver services to their own community was not without its challenges, and survivors raised issues on confidentiality, mistranslations, and perceived biases on clan differences. The study also provides an insight into the importance of contextual factors in case management, and the impact of the announcement of the (now-delayed) camp closure in Dadaab. Priorities of both the camp population and service providers (GBV and referral services) shifted greatly during this time of uncertainty and affected when and how women were accessing services

Use of herbal medicines among pregnant women a attending antenatal clinic at Kiryandongo General Hospital, Uganda

Objective: To assess the knowledge and use of herbal medicines among pregnant women attending the antenatal clinic at Kiryandongo general hospital.Design: A descriptive cross-sectional studySetting: Kiryandongo general hospital in Masindi District, mid-western Uganda.Subjects: Four hundred (400) pregnant women attending antenatal care (ANC) were interviewed about their knowledge and use of herbal medicines during pregnancy using self-administered questionnaires, during the months of July and August 2013.Results: Of the 400 women who participated in the study, majority 246 (61.5%)was in the age range of 18 to 24 years old, married 379 (94.8%), stayed in a rural setting 293 (73.3%),had attained primary education 239(59.8%),peasant farmers 209 (52.3%), in monogamous marriage 247 (64.2%), of prime gravidae 117 (29.2%), and Banyoro by tribe 89 (22.3%). Three hundred and fifty (87.5%)of the respondents reported to have ever heard about the use of herbal medicines during pregnancy, with 169 (48.3%) reported having used herbal medicines during previous pregnancies or in the months prior to the study. One hundred and thirty two (37.7%) where found to be using herbal medicines at the time of the study, with the majority of them one hundred and eleven (84.1%) admitting that they will be using herbal medicines again in subsequent pregnancies. One hundred and fifty three (43.7%)considered herbal medicines to be safe during pregnancy and preferred them to conventional medicines because they have low side effects, are cheap and easy to access, and it is part of their tradition to use them during pregnancy.One hundred and ten (31.4%) believed that these herbs are neither dangerous to the mother nor the foetus.Conclusion: More efficient ways are required to educate the general population about the dangers of self-medication during pregnancy especially to advise pregnant mothers not to expose their unborn child to the risks of herbal medicines. Pharmacological and case control studies will be vital in assessing the efficacy and risks associated with herbal medicine use during pregnancy. Midwives, obstetricians and General Practitioners should facilitate women’s wishes without condemnation, but this must be tempered with accurate information

The Use of Interferon Gamma Inducible Protein 10 as a Potential Biomarker in the Diagnosis of Latent Tuberculosis Infection in Uganda.

BACKGROUND: In the absence of a gold standard for the diagnosis of latent tuberculosis (TB) infection (LTBI), the current tests available for the diagnosis of LTBI are limited by their inability to differentiate between LTBI and active TB disease. We investigated IP-10 as a potential biomarker for LTBI among household contacts exposed to sputum positive active TB cases. METHODS: Active TB cases and contacts were recruited into a cohort with six months' follow-up. Contacts were tested for LTBI using QuantiFERON®-TB Gold In-Tube (QFN) assay and the tuberculin skin test (TST). Baseline supernatants from the QFN assay of 237 contacts and 102 active TB cases were analysed for Mycobacterium tuberculosis (MTB) specific and mitogen specific IP-10 responses. RESULTS: Contacts with LTBI (QFN+TST+) had the highest MTB specific IP-10 responses at baseline, compared to uninfected contacts (QFN-TST-) p<0.0001; and active cases, p = 0.01. Using a cut-off of 8,239 pg/ml, MTB specific IP-10 was able to diagnose LTBI with a sensitivity of 87.1% (95% CI, 76.2-94.3) and specificity of 90.9% (95% CI, 81.3-96.6). MTB specific to mitogen specific IP-10 ratio was higher in HIV negative active TB cases, compared to HIV negative latently infected contacts, p = 0.0004. Concentrations of MTB specific IP-10 were higher in contacts with TST conversion (negative at baseline, positive at 6-months) than in those that were persistently TST negative, p = 0.001. CONCLUSION: IP-10 performed well in differentiating contacts with either latent or active TB from those who were uninfected but was not able to differentiate LTBI from active disease except when MTB specific to mitogen specific ratios were used in HIV negative adults. In addition, IP-10 had the potential to diagnose 'recent TB infection' in persons classified as having LTBI using the TST. Such individuals with strong IP-10 responses would likely benefit from chemoprophylaxis

Use of QuantiFERON®-TB Gold in-tube culture supernatants for measurement of antibody responses.

QuantiFERON®-TB Gold in-tube (QFT-GIT) supernatants may be important samples for use in assessment of anti-tuberculosis (TB) antibodies when only limited volumes of blood can be collected and when a combination of antibody and cytokine measurements are required. These analytes, when used together, may also have the potential to differentiate active pulmonary TB (APTB) from latent TB infection (LTBI). However, few studies have explored the use of QFT-GIT supernatants for investigations of antibody responses. This study determined the correlation and agreement between anti-CFP-10 and anti-ESAT-6 antibody concentrations in QFT-GIT nil supernatant and serum pairs from 68 TB household contacts. We also explored the ability of Mycobacterium tuberculosis (M.tb) specific antibodies, or ratios of antibody to interferon gamma (IFN-γ) in QFT-GIT supernatants, to differentiate 97 APTB cases from 58 individuals with LTBI. Sputum smear microscopy was used to define APTB, whereas the QFT-GIT and tuberculin skin test were used to define LTBI. There were strong and statistically significant correlations between anti-CFP-10 and anti-ESAT-6 antibodies in unstimulated QFT-GIT supernatants and sera (r = 0.89; p<0.0001 for both), and no significant differences in antibody concentration between them. Anti-CFP-10 & anti-ESAT-6 antibodies differentiated APTB from LTBI with sensitivities of 88.7% & 71.1% and specificities of 41.4% & 51.7% respectively. Anti-CFP-10 antibody/M.tb specific IFN-γ and anti-ESAT-6 antibody/M.tb specific IFN-γ ratios had sensitivities of 48.5% & 54.6% and specificities of 89.7% and 75.9% respectively. We conclude that QFT-GIT nil supernatants may be used in the place of sera when measuring antibody responses, reducing blood volumes needed for such investigations. Antibodies in QFT-GIT nil supernatants on their own discriminate APTB from LTBI with high sensitivity but have poor specificity, whereas the reverse is true when antibodies are used in combination with M.tb specific cytokines. Further antibody and antibody/cytokine combinations need to be explored to achieve better diagnostic accuracy

Effect of isoniazid preventive therapy on immune responses to mycobacterium tuberculosis: an open label randomised, controlled, exploratory study.

BACKGROUND: With the renewed emphasis to implement isoniazid preventive therapy (IPT) in Sub-Saharan Africa, we investigated the effect of IPT on immunological profiles among household contacts with latent tuberculosis. METHODS: Household contacts of confirmed tuberculosis patients were tested for latent tuberculosis using the QuantiFERON®-TB Gold In-Tube (QFN) assay and tuberculin skin test (TST). HIV negative contacts aged above 5 years, positive to both QFN and TST, were randomly assigned to IPT and monthly visits or monthly visits only. QFN culture supernatants from enrolment and six months' follow-up were analysed for M.tb-specific Th1, Th2, Th17, and regulatory cytokines by Luminex assay, and for M.tb-specific IgG antibody concentrations by ELISA. Effects of IPT were assessed as the net cytokine and antibody production at the end of six months. RESULTS: Sixteen percent of contacts investigated (47/291) were randomised to IPT (n = 24) or no IPT (n = 23). After adjusting for baseline cytokine or antibody responses, and for presence of a BCG scar, IPT (compared to no IPT) resulted in a relative decline in M.tb-specific production of IFN gamma (adjusted mean difference at the end of six months (bootstrap 95% confidence interval (CI), p-value) -1488.6 pg/ml ((-2682.5, -294.8), p = 0.01), and IL- 2 (-213.1 pg/ml (-419.2, -7.0), p = 0.04). A similar decline was found in anti-CFP-10 antibody levels (adjusted geometric mean ratio (bootstrap 95% CI), p-value) 0.58 ((0.35, 0.98), p = 0.04). We found no effect on M.tb-specific Th2 or regulatory or Th17 cytokine responses, or on antibody concentrations to PPD and ESAT-6. CONCLUSIONS: IPT led to a decrease in Th1 cytokine production, and also in the anti CFP-10 antibody concentration. This could be secondary to a reduction in mycobacterial burden or as a possible direct effect of isoniazid induced T cell apoptosis, and may have implications for protective immunity following IPT in tuberculosis-endemic countries. TRIAL REGISTRATION: ISRCTN registry, ISRCTN15705625. Registered on 30(th) September 2015

Marburg virus survivor immune responses are Th1 skewed with limited neutralizing antibody responses.

Until recently, immune responses in filovirus survivors remained poorly understood. Early studies revealed IgM and IgG responses to infection with various filoviruses, but recent outbreaks have greatly expanded our understanding of filovirus immune responses. Immune responses in survivors of Ebola virus (EBOV) and Sudan virus (SUDV) infections have provided the most insight, with T cell responses as well as detailed antibody responses having been characterized. Immune responses to Marburg virus (MARV), however, remain almost entirely uncharacterized. We report that immune responses in MARV survivors share characteristics with EBOV and SUDV infections but have some distinct differences. MARV survivors developed multivariate CD4(+) T cell responses but limited CD8(+) T cell responses, more in keeping with SUDV survivors than EBOV survivors. In stark contrast to SUDV survivors, rare neutralizing antibody responses in MARV survivors diminished rapidly after the outbreak. These results warrant serious consideration for any vaccine or therapeutic that seeks to be broadly protective, as different filoviruses may require different immune responses to achieve immunity

The impact of maternal infection with Mycobacterium tuberculosis on the infant response to bacille Calmette-Guérin immunization.

Bacille Calmette-Guérin (BCG) immunization provides variable protection against tuberculosis. Prenatal antigen exposure may have lifelong effects on responses to related antigens and pathogens. We therefore hypothesized that maternal latent Mycobacterium tuberculosis infection (LTBI) influences infant responses to BCG immunization at birth. We measured antibody (n = 53) and cellular (n = 31) responses to M. tuberculosis purified protein derivative (PPD) in infants of mothers with and without LTBI, in cord blood and at one and six weeks after BCG. The concentrations of PPD-specific antibodies declined between birth (median [interquartile range (IQR)]) 5600 ng ml(-1) [3300-11 050] in cord blood) and six weeks (0.00 ng ml(-1) [0-288]). Frequencies of PPD-specific IFN-γ-expressing CD4(+)T cells increased at one week and declined between one and six weeks (p = 0.031). Frequencies of IL-2- and TNF-α-expressing PPD-specific CD4(+)T cells increased between one and six weeks (p = 0.019, p = 0.009, respectively). At one week, the frequency of PPD-specific CD4(+)T cells expressing any of the three cytokines, combined, was lower among infants of mothers with LTBI, in crude analyses (p = 0.002) and after adjusting for confounders (mean difference, 95% CI -0.041% (-0.082, -0.001)). In conclusion, maternal LTBI was associated with lower infant anti-mycobacterial T-cell responses immediately following BCG immunization. These findings are being explored further in a larger study

Differences in seasons and rice varieties provide opportunities for improving nitrogen use efficiency and management in irrigated rice in Kenya

Open Access JournalApart from nitrogen (N) rates, N use efficiency (NUE) (yield N/total input N) is affected by seasons, crop developmental stages, and varieties. Knowledge of how these factors affect NUE in rice production in Kenya is limited. Therefore, field experiments were conducted with 'low rates' of N (simulating farmers' practices) of 0, 26, 52 and 78 kg N ha−1 with five varieties (MWUR1, MWUR4, IRAT109, NERICA4 and NERICA10) and higher rates of N (125, 175, and 225 kg N ha−1) simulating researchers' doses with two lowland varieties (Basmati 370 and BW 196) and IR 72. Another experiment on NUE responses to sites, N rates and dose (split or full dose) was undertaken with the IR97 variety. With the 'low rate', yields increased with incremental N rates up to 52 Kg N ha−1 and declined (during cold periods, for some varieties). In this scenario, the N agronomic efficiencies (AEN) declined with increasing N but depended on sites and seasons. However, most AEN values were above 100, implying nutrient mining. In most cases (except at the Mwea site), the N utilization efficiency (NUtE) ranged from 16 to 22kg kg−1 and were not significantly affected by sources and methods of N application. In all cases, an increase in N elicited declining trends in NUtE. Moreover, N uptake efficiency ranged between 22 and 90kg kg−1 without significant variation among varieties. For the 'high N rates', high biomass yield resulted in higher grain yields in BW 196 and IR 72 but yield declined beyond 75 kg ha−1 N rates due to poor grain filling, particularly when a cold period coincided with booting and grain filling. We conclude that N rates, doses and rice varieties are key determinants of AEN and NUtE in contrasting rice growing seasons in Kenya. Cropping seasons and rice varieties are therefore potential key determinants of sustainable rice productivity and improved NUE in rice-based systems in the studied regions of Kenya

‘They say our work is not halal’: experiences and challenges of refugee community workers involved in gender-based violence prevention and care in Dadaab, Kenya

Notwithstanding the growing centrality of refugee community workers (RCWs) in the current response to gender-based violence (GBV) in the Dadaab refugee camps, they remain poorly studied. Using interview data, we explored the work-related experiences and challenges as well as GBV-related beliefs of RCWs. Whilst they demonstrated elevated knowledge of the forms and drivers of GBV in their community, some of the RCWs did not deem early marriage, female genital mutilation and wife-beating to be GBV acts. In their work, RCWs were motivated by compassion for survivors as well as a sense of community service, but they faced challenges such as insecurity; poor pay; opposition and violence by community members; tense relationships with and suspicion by professional providers; and limited skills and preparation in GBV management. RCWs’ GBV-related beliefs and work experiences underscore the challenges of programming in a complex humanitarian space and offer insights for strengthening their contribution in GBV care and service delivery

Risk assessment for the implementation of controlled human Schistosoma mansoni infection trials in Uganda.

Schistosomiasis is a parasitic infection highly prevalent in sub-Saharan Africa, and a significant cause of morbidity; it is a priority for vaccine development. A controlled human infection model for Schistosoma mansoni (CHI-S) with potential to accelerate vaccine development has been developed among naïve volunteers in the Netherlands. Because responses both to infections and candidate vaccines are likely to differ between endemic and non-endemic settings, we propose to establish a CHI-S in Uganda where Schistosoma mansoni is endemic. As part of a "road-map" to this goal, we have undertaken a risk assessment. We identified risks related to importing of laboratory vector snails and schistosome strains from the Netherlands to Uganda; exposure to natural infection in endemic settings concurrently with CHI-S studies, and unfamiliarity of the community with the nature, risks and rationale for CHI. Mitigating strategies are proposed. With careful implementation of the latter, we believe that CHI-S can be implemented safely in Uganda. Our reflections are presented here to promote feedback and discussion