Outbreak of beriberi among African union troops in Mogadishu, Somalia

Context and Objectives: In July 2009, WHO and partners were notified of a large outbreak of unknown illness, including deaths, among African Union (AU) soldiers in Mogadishu. Illnesses were characterized by peripheral edema, dyspnea, palpitations, and fever. Our objectives were to determine the cause of the outbreak, and to design and recommend control strategies. Design, Setting, and Participants: The illness was defined as acute onset of lower limb edema, with dyspnea, chest pain, palpitations, nausea, vomiting, abdominal pain, or headache. Investigations in Nairobi and Mogadishu included clinical, epidemiologic, environmental, and laboratory studies. A case-control study was performed to identify risk factors for illness. Results: From April 26, 2009 to May 1, 2010, 241 AU soldiers had lower limb edema and at least one additional symptom; four patients died. At least 52 soldiers were airlifted to hospitals in Kenya and Uganda. Four of 31 hospitalized patients in Kenya had right-sided heart failure with pulmonary hypertension. Initial laboratory investigations did not reveal hematologic, metabolic, infectious or toxicological abnormalities. Illness was associated with exclusive consumption of food provided to troops (not eating locally acquired foods) and a high level of insecurity (e.g., being exposed to enemy fire on a daily basis). Because the syndrome was clinically compatible with wet beriberi, thiamine was administered to ill soldiers, resulting in rapid and dramatic resolution. Blood samples taken from 16 cases prior to treatment showed increased levels of erythrocyte transketolase activation coefficient, consistent with thiamine deficiency. With mass thiamine supplementation for healthy troops, the number of subsequent beriberi cases decreased with no further deaths reported. Conclusions: An outbreak of wet beriberi caused by thiamine deficiency due to restricted diet occurred among soldiers in a modern, well-equipped army. Vigilance to ensure adequate micronutrient intake must be a priority in populations completely dependent upon nutritional support from external sources

Captures d'écran : la photographie de presse et l'image télévisée

Influenza-associated disease burden among children in tropical sub-Saharan Africa is not well established, particularly outside of the 2009 pandemic period. We estimated the burden of influenza in children aged 0-4 years through population-based surveillance for influenza-like illness (ILI) and acute lower respiratory tract illness (ALRI). Household members meeting ILI or ALRI case definitions were referred to health facilities for evaluation and collection of nasopharyngeal and oropharyngeal swabs for influenza testing by real-time reverse transcription polymerase chain reaction. Estimates were adjusted for health-seeking behavior and those with ILI and ALRI who were not tested. During 2008-2012, there were 9,652 person-years of surveillance among children aged 0-4 years. The average adjusted rate of influenza-associated hospitalization was 4.3 (95% CI 3.0-6.0) per 1,000 person-years in children aged 0-4 years. Hospitalization rates were highest in the 0-5 month and 6-23 month age groups, at 7.6 (95% CI 3.2-18.2) and 8.4 (95% CI 5.4-13.0) per 1,000 person-years, respectively. The average adjusted rate of influenza-associated medically attended (inpatient or outpatient) ALRI in children aged 0-4 years was 17.4 (95% CI 14.2-19.7) per 1,000 person-years. Few children who had severe laboratory-confirmed influenza were clinically diagnosed with influenza by the treating clinician in the inpatient (0/33, 0%) or outpatient (1/109, 0.9%) settings. Influenza-associated hospitalization rates from 2008-2012 were 5-10 times higher than contemporaneous U.S. estimates. Many children with danger signs were not hospitalized; thus, influenza-associated severe disease rates in Kenyan children are likely higher than hospital-based estimates suggest

Estimation of the national disease burden of influenza-associated severe acute respiratory illness in Kenya and Guatemala : a novel methodology

Background: Knowing the national disease burden of severe influenza in low-income countries can inform policy decisions around influenza treatment and prevention. We present a novel methodology using locally generated data for estimating this burden. Methods and Findings: This method begins with calculating the hospitalized severe acute respiratory illness (SARI) incidence for children <5 years old and persons ≥5 years old from population-based surveillance in one province. This base rate of SARI is then adjusted for each province based on the prevalence of risk factors and healthcare-seeking behavior. The percentage of SARI with influenza virus detected is determined from provincial-level sentinel surveillance and applied to the adjusted provincial rates of hospitalized SARI. Healthcare-seeking data from healthcare utilization surveys is used to estimate non-hospitalized influenza-associated SARI. Rates of hospitalized and non-hospitalized influenza-associated SARI are applied to census data to calculate the national number of cases. The method was field-tested in Kenya, and validated in Guatemala, using data from August 2009–July 2011. In Kenya (2009 population 38.6 million persons), the annual number of hospitalized influenza-associated SARI cases ranged from 17,129–27,659 for children <5 years old (2.9–4.7 per 1,000 persons) and 6,882–7,836 for persons ≥5 years old (0.21–0.24 per 1,000 persons), depending on year and base rate used. In Guatemala (2011 population 14.7 million persons), the annual number of hospitalized cases of influenza-associated pneumonia ranged from 1,065–2,259 (0.5–1.0 per 1,000 persons) among children <5 years old and 779–2,252 cases (0.1–0.2 per 1,000 persons) for persons ≥5 years old, depending on year and base rate used. In both countries, the number of non-hospitalized influenza-associated cases was several-fold higher than the hospitalized cases. Conclusions: Influenza virus was associated with a substantial amount of severe disease in Kenya and Guatemala. This method can be performed in most low and lower-middle income countries

Satisfaction Rating of Coordination Mechanisms by Dairy Producers around Community Milk Cooling Plants in Western Kenya

A number of studies have used value chains approach to look at critical constraints that limit the growth of milk production and marketing. However, existing literature is limited on case studies that have first considered establishing the satisfaction levels of support services provision to individual producer households so as to inform accurate constraints identification for sustainable policy and technical intervention. This study undertook to identify and analyze coordination mechanisms that had been developed to support producer households around community milk cooling plants using factor analysis approach. Primary data from 273 households selected through simple random sampling method was collected using a semi structured interview schedule. From the results,  the overall satisfaction mean score  rating was 5.4 with feeds provision and clinical services had the highest satisfaction mean scores respectively. From factor analysis, three factors were generated, and were named as support for training, support for inputs and support for marketing respectively. Cronbach’s α test results confirmed reliability for support for input and training factors. It was concluded that though efforts had been made to provide support services to producers, service provision was inefficient and uptake still low in some services. It is recommended that in order to enhance the proportion of milk that entered the community milk cooling plants, pricing policies based on grade of milk should be put in place so as to attract more producers to join and supply regularly to the cooling plant at premium prices and also to make the producers benefit from the services being offered Key words: Community Milk Cooling Plant, Factor Analysis, Producers, Support Services

Concurrent sexual and substance-use risk behaviours among female sex workers in Kenya’s Coast Province: Findings from a behavioural monitoring survey

While many studies confirm the association between HIV, alcohol and injecting drug use by female sex workers (FSWs), little is known about their use of marijuana, khat and other substances and the association of these substances with HIV, risky sexual behaviour, and sexual violence. To better understand this association, data were analysed from a cross-sectional, behavioural survey of 297 FSWs in Mombasa, a well-known tourist destination and the second largest port in Africa and capital city of the Coast Province in Kenya. Among the FSWs, lifetime use of different substances was reported by 91% for alcohol, 71% for khat, 34% for marijuana, and 6% for heroin, cocaine, glue or petrol. The majority (79%) used more than one substance, and multiple-substance use was reported by all respondents who ever used marijuana, heroin, cocaine, glue and petrol. The risk of HIV acquisition was perceived as medium to highby 41% of respondents, 75% of whom attributed this risk to multiple partners. Sexual violence was reported by 48% of respondents,and 30% indicated that this happened several times. Despite HIV prevention programmes targeting FSWs in Mombasa, most of them continue to engage in risky sexual behaviours. This suggests that harm reduction strategies for substance use should be coupled with efforts to promote consistent condom use and partner reduction

Concurrent sexual and substance-use risk behaviours among female sex workers in Kenya\u27s Coast Province: findings from a behavioural monitoring survey

While many studies confirm the association between HIV, alcohol and injecting drug use by female sex workers (FSWs), little is known about their use of marijuana, khat and other substances and the association of these substances with HIV, risky sexual behaviour, and sexual violence. To better understand this association, data were analysed from a cross-sectional, behavioural survey of 297 FSWs in Mombasa, a well-known tourist destination and the second largest port in Africa and capital city of the Coast Province in Kenya. Among the FSWs, lifetime use of different substances was reported by 91% for alcohol, 71% for khat, 34% for marijuana, and 6% for heroin, cocaine, glue or petrol. The majority (79%) used more than one substance, and multiple-substance use was reported by all respondents who ever used marijuana, heroin, cocaine, glue and petrol. The risk of HIV acquisition was perceived as medium to high by 41% of respondents, 75% of whom attributed this risk to multiple partners. Sexual violence was reported by 48% of respondents, and 30% indicated that this happened several times. Despite HIV prevention programmes targeting FSWs in Mombasa, most of them continue to engage in risky sexual behaviours. This suggests that harm reduction strategies for substance use should be coupled with efforts to promote consistent condom use and partner reduction

RA92A recombinant protein as immunogen to protect cattle against tick challenge in Brazil and Uganda

In this study, the recombinant gut protein rRa92A produced in Pichia pastoris yeast cells was used to immunize cattle in two experiments, one in Brazil and the other in Uganda. In both experiments, the animals were intramuscularly (IM) injected with 200 µg of recombinant protein in Brazil on days 0, 30 and 51 and in Uganda on days 0, 30. Blood samples for sera separation were collected from different days in both experiments. These samples were analyzed by ELISAs. In Brazil, ticks collected from the animals during the experimental period were analyzed for biological parameters. At Uganda, blood was collected to assess blood parameters, clinical signs were recorded and adult tick (Rhipicephalus appendiculatus) counts were performed. All animals of the vaccinated groups were shown to produce antibodies, and it was not possible to detect an effect on Rhipicephalus microplus. All the clinical parameters were considered within the normal ranges for both the experimental and control groups in Uganda. Antibody absorbance was elevated after each immunization and remained high until the end of the experiments, remaining low in the control animals. The results of stall test carried out in Brazil using R. microplus tick showed efficacy of 21.95%. The rRa92A immunization trial experiments in Uganda showing a decrease of 55.2% in the number of engorged adult ticks, which was statistically significant (p&lt;0.05). Assessment of the immunogenicity of Ra92A produced in the P. pastoris expression system in bovines is reported for the first time, and the protein acted as a concealed antigen

Seasonal influenza vaccination in Kenya: an economic evaluation using dynamic transmission modelling.

BACKGROUND: There is substantial burden of seasonal influenza in Kenya, which led the government to consider introducing a national influenza vaccination programme. Given the cost implications of a nationwide programme, local economic evaluation data are needed to inform policy on the design and benefits of influenza vaccination. We set out to estimate the cost-effectiveness of seasonal influenza vaccination in Kenya. METHODS: We fitted an age-stratified dynamic transmission model to active surveillance data from patients with influenza from 2010 to 2018. Using a societal perspective, we developed a decision tree cost-effectiveness model and estimated the incremental cost-effectiveness ratio (ICER) per disability-adjusted life year (DALY) averted for three vaccine target groups: children 6-23 months (strategy I), 2-5 years (strategy II) and 6-14 years (strategy III) with either the Southern Hemisphere influenza vaccine (Strategy A) or Northern Hemisphere vaccine (Strategy B) or both (Strategy C: twice yearly vaccination campaigns, or Strategy D: year-round vaccination campaigns). We assessed cost-effectiveness by calculating incremental net monetary benefits (INMB) using a willingness-to-pay (WTP) threshold of 1-51% of the annual gross domestic product per capita ($17-$872). RESULTS: The mean number of infections across all ages was 2-15 million per year. When vaccination was well timed to influenza activity, the annual mean ICER per DALY averted for vaccinating children 6-23 months ranged between $749 and$1385 for strategy IA, $442 and$1877 for strategy IB, $678 and$4106 for strategy IC and $1147 and$7933 for strategy ID. For children 2-5 years, it ranged between $945 and$1573 for strategy IIA, $563 and$1869 for strategy IIB, $662 and$4085 for strategy IIC, and $1169 and$7897 for strategy IID. For children 6-14 years, it ranged between $923 and$3116 for strategy IIIA, $1005 and$2223 for strategy IIIB, $883 and$4727 for strategy IIIC and $1467 and$6813 for strategy IIID. Overall, no vaccination strategy was cost-effective at the minimum ($17) and median ($445) WTP thresholds. Vaccinating children 6-23 months once a year had the highest mean INMB value at $872 (WTP threshold upper limit); however, this strategy had very low probability of the highest net benefit. CONCLUSION: Vaccinating children 6-23 months once a year was the most favourable vaccination option; however, the strategy is unlikely to be cost-effective given the current WTP thresholds

Genetic and potential antigenic evolution of influenza A(H1N1)pdm09 viruses circulating in Kenya during 2009-2018 influenza seasons

Influenza viruses undergo rapid evolutionary changes, which requires continuous surveillance to monitor for genetic and potential antigenic changes in circulating viruses that can guide control and prevention decision making. We sequenced and phylogenetically analyzed A(H1N1)pdm09 virus genome sequences obtained from specimens collected from hospitalized patients of all ages with or without pneumonia between 2009 and 2018 from seven sentinel surveillance sites across Kenya. We compared these sequences with recommended vaccine strains during the study period to infer genetic and potential antigenic changes in circulating viruses and associations of clinical outcome. We generated and analyzed a total of 383 A(H1N1)pdm09 virus genome sequences. Phylogenetic analyses of HA protein revealed that multiple genetic groups (clades, subclades, and subgroups) of A(H1N1)pdm09 virus circulated in Kenya over the study period; these evolved away from their vaccine strain, forming clades 7 and 6, subclades 6C, 6B, and 6B.1, and subgroups 6B.1A and 6B.1A1 through acquisition of additional substitutions. Several amino acid substitutions among circulating viruses were associated with continued evolution of the viruses, especially in antigenic epitopes and receptor binding sites (RBS) of circulating viruses. Disease severity declined with an increase in age among children aged < 5 years. Our study highlights the necessity of timely genomic surveillance to monitor the evolutionary changes of influenza viruses. Routine influenza surveillance with broad geographic representation and whole genome sequencing capacity to inform on prioritization of antigenic analysis and the severity of circulating strains are critical to improved selection of influenza strains for inclusion in vaccines

Epidemiology of Severe Acute Respiratory Illness and Risk Factors for Influenza Infection and Clinical Severity among Adults in Malawi, 2011-2013

Data on the epidemiology of severe acute respiratory illness (SARI) in adults from low-income, high human immunodeficiency virus (HIV) prevalence African settings are scarce. We conducted adult SARI surveillance in Blantyre, Malawi. From January 2011 to December 2013, individuals aged ≥ 15 years with SARI (both inpatients and outpatients) were enrolled at a large teaching hospital in Blantyre, Malawi. Nasopharyngeal aspirates were tested for influenza and other respiratory viruses by polymerase chain reaction. We estimated hospital-attended influenza-positive SARI incidence rates and assessed factors associated with influenza positivity and clinical severity (Modified Early Warning Score > 4). We enrolled 1,126 SARI cases; 163 (14.5%) were positive for influenza. Human immunodeficiency virus prevalence was 50.3%. Annual incidence of hospital-attended influenza-associated SARI was 9.7-16.8 cases per 100,000 population. Human immunodeficiency virus was associated with a 5-fold greater incidence (incidence rate ratio 4.91, 95% confidence interval [CI]: 3.83-6.32). On multivariable analysis, female gender, as well as recruitment in hot, rainy season (December to March; adjusted odds ratios (aOR): 2.82, 95% CI: 1.57-5.06) and cool, dry season (April to August; aOR: 2.47, 95% CI: 1.35-4.15), was associated with influenza positivity, whereas influenza-positive patients were less likely to be HIV-infected (aOR: 0.59, 95% CI: 0.43-0.80) or have viral coinfection (aOR: 0.51, 95% CI: 0.36-0.73). Human immunodeficiency virus infection (aOR: 1.86; 95% CI: 1.35-2.56) and recruitment in hot, rainy season (aOR: 4.98, 95% CI: 3.17-7.81) were independently associated with clinical severity. In this high HIV prevalence population, influenza was associated with nearly 15% of hospital-attended SARI. Human immunodeficiency virus infection is an important risk factor for clinical severity in all-cause and influenza-associated SARI. Expanded access to HIV testing and antiretroviral treatment, as well as targeted influenza vaccination, may reduce the burden of SARI in Malawi and other high HIV prevalence settings