Maternal nutritional status in pastoral versus farming communities of West Pokot, Kenya: differences in iron and vitamin A status and body composition

BACKGROUND: Underweight and micronutrient deficiencies are sequelae of the prevailing harsh living and economic conditions of women in sub-Saharan Africa. There are few data describing maternal nutritional status in these resource-poor settings. Provision of more effective modes of intervention requires that public health and nutrition policy at both the national and the multisectoral levels be based on community-specific nutritional and behavioral practices. OBJECTIVE: This longitudinal study investigated maternal micronutrient status in two remote, semiarid, rural communities that are ethnically similar but have distinctly different pastoral and farming lifestyles. We looked at differences in iron stores, vitamin A levels, and body composition of women in the third trimester of pregnancy and again at 4 months postpartum. METHODS: Complete data were collected from 113 pastoral and 110 farming Pokot women. Anthropometric measurements were taken, and serum ferritin and retinol levels were measured. Infants were weighed within 7 days of birth. RESULTS: Women from the farming community had significantly (p < .05) lower hemoglobin concentrations than women from the pastoral community during the third trimester of pregnancy. Pastoral women had significantly higher serum ferritin concentrations than farming women during the third trimester of pregnancy (p <.05) and at 4 months postpartum. There were no significant differences between pastoral and farming women in the percentage of women with serum retinol levels < 0.70 micromol/L during the third trimester of pregnancy (27.9% [34/113] and 24.2% [31/110], respectively) and at 4 months postpartum (29.2% [33/113] and 30.9% [34/110]) In the farming community, mean infant birthweight was significantly lower (p <. 01) than in the pastoral community and a significantly higher (p < .05) proportion of newborns weighed less than 2.5 kg. At 4 months postpartum, the percentage of body fat was significantly lower in pastoral women than in farming women. CONCLUSIONS: Women from the farming community in West Pokot, Kenya, have lower iron stores during the third trimester of pregnancy than women in the pastoral community. In addition, the mean weight of their newborn infants is lower than that of infants in the pastoral community. These findings may be associated with differences in living conditions, which are usually harsher in farming than in pastoral communities. AD - Department of Epidemiology and Nutrition, School of Public Health, Moi University, Eldoret, Kenya. [email protected]

Nutritional status of children admitted for diarrhoeal diseases in a referral hospital in western Kenya

Objectives: To determine the prevalence of malnutrition among children admitted with acute diarrhoea disease at Moi Teaching and Referral Hospital and to establish the effect of malnutrition on duration of hospital stay. Design: Prospective observational study. Setting: Paediatric wards of Moi Teaching and Referral Hospital, Eldoret, Kenya Subjects: A total of 191 children aged 6 and 59 months admitted with acute diarrhoea disease, without chronic co-morbidities or visible severe malnutrition, were systematically enrolled into the study between November 2011 and March 2012. Outcome Measures: Nutritional status based on WHO WHZ scores taken at admission and duration of hospital stay. Results:The mean age was 13.2 months with a male to female sex ratio of 1.16:1. Of all the children seen with acute diarrhoeal diseases, 43.9% had acute malnutrition ( Conclusion: Routine anthrometry including weight for height identifies more children with malnutrition in acute diarrhoeal diseases. Presence of malnutrition did not affect duration of hospital stay

Malaria Parasitaemia among Febrile Children Infected with Human Immunodeficiency Virus in the Context of Prophylactic Cotrimoxazole as Standard of Care: A Cross- Sectional Survey in Western Kenya

Objective: To document the prevalence of malaria parasitaemia among the HIV infected febrile children in a malaria endemic area. Design: A cross-sectional study. Setting: An ambulatory paediatric HIV clinic in Western Kenya, between November 2011 and December 2012. Subjects: A total of 245 febrile HIV infected children aged less than 14 years attending the HIV clinic in the Webuye level IV hospital were included in the study. A systematic sampling method was used. Main outcomes: A blood sample was taken for malaria parasite testing. Presence or absence of malaria parasites was documented. Clinical and socio-demographic characteristics of the participants were also recorded. Results: A total of 245 participants were recruited mean age being 5.53 years. Malaria prevalence was 81.9%. Most participants (97%) were on cotrimoxazole prophylaxis. Some of the factors found to be positively associated with malaria parasitaemia were; male sex, care taker category (parent), WHO stage 3 and 4 of HIV disease, and a high absolute CD4 count. However, only the caretaker association was statistically significant. Conclusion: The frequency of malaria parasitaemia among febrile HIV infected children is still high regardless of the high cotrimoxazole prophylaxis uptake. It is also noted that there is a shift in the age group of fever among children toward the older age group. This implies that policies may need to be relooked at to include the older age group in the aggressive malaria prevention measures to avoid losing on the already made gains

Rectal dihydroartemisinin versus intravenous quinine in the treatment of severe malaria: A randomised clinical trial

Objective: To compare the clinical efficacy and safety of rectal dihydroartemisinin (DATM- Cotecxin) and intravenous quinine in the treatment of severe malaria in children and adults.Setting: Moi Teaching and Referral Hospital, Eldoret, Kenya between July and November1998.Patients: A total of sixty seven patients aged two to sixty years with severe malaria were studied.Design: This was an open randomised comparative clinical trial.Outcome measures: These were parasite clearance time, fever clearance time, efficacy and the side effect profile of the two drugs.Results: The two groups were comparable on admission on the clinical and laboratory parameters. The parasite clearance time was shorter in the rectal DATM group than quinine group. There was no statistical difference on the fever clearance time and cure rates in thetwo groups. The adverse reaction profile was better with rectal DATM than with quinine, tinnitus observed more in the quinine group.Conclusion: Rectal DATM is faster in parasite clearance than quinine and is a safe and convenient alternative to quinine in the treatment of severe malaria

Iron in Micronutrient Powder Promotes an Unfavorable Gut Microbiota in Kenyan Infants

Iron supplementation may have adverse health effects in infants, probably through manipulation of the gut microbiome. Previous research in low-resource settings have focused primarily on anemic infants. This was a double blind, randomized, controlled trial of home fortification comparing multiple micronutrient powder (MNP) with and without iron. Six-month-old, non- or mildly anemic, predominantly-breastfed Kenyan infants in a rural malaria-endemic area were randomized to consume: (1) MNP containing 12.5 mg iron (MNP+Fe, n = 13); (2) MNP containing no iron (MNP−Fe, n = 13); or (3) Placebo (CONTROL, n = 7), from 6–9 months of age. Fecal microbiota were profiled by high-throughput bacterial 16S rRNA gene sequencing. Markers of inflammation in serum and stool samples were also measured. At baseline, the most abundant phylum was Proteobacteria (37.6% of rRNA sequences). The proteobacterial genus Escherichia was the most abundant genus across all phyla (30.1% of sequences). At the end of the intervention, the relative abundance of Escherichia significantly decreased in MNP−Fe (−16.05 ± 6.9%, p = 0.05) and CONTROL (−19.75 ± 4.5%, p = 0.01), but not in the MNP+Fe group (−6.23 ± 9%, p = 0.41). The second most abundant genus at baseline was Bifidobacterium (17.3%), the relative abundance of which significantly decreased in MNP+Fe (−6.38 ± 2.5%, p = 0.02) and CONTROL (−8.05 ± 1.46%, p = 0.01), but not in MNP-Fe (−4.27 ± 5%, p = 0.4445). Clostridium increased in MNP-Fe only (1.9 ± 0.5%, p = 0.02). No significant differences were observed in inflammation markers, except for IL-8, which decreased in CONTROL. MNP fortification over three months in non- or mildly anemic Kenyan infants can potentially alter the gut microbiome. Consistent with previous research, addition of iron to the MNP may adversely affect the colonization of potential beneficial microbes and attenuate the decrease of potential pathogens

Assessment of body composition and breast milk volume in lactating mothers in pastoral communities in Pokot, Kenya, using deuterium oxide

BACKGROUND: In sub-Saharan Africa, the practice of breast-feeding infants is common. Records documenting the intake of breast milk amongst infants are limited. This study evaluated the association between maternal body composition and the intake of breast milk in infants from the pastoral communities within Pokot, Kenya. METHODS: The study was conducted in 10 lactating mothers who were participating in a longitudinal study aimed at determining maternal body composition, iron stores and vitamin A status during the third trimester pregnancy and four months after they had given birth. Maternal and infant anthropometric measurements were made, and maternal blood samples were taken to determine serum retinol and ferritin levels. Infant milk intake and maternal fat-free mass (FFM) and percent body fat (% BF) were measured using 'the dose to the mother method'. A measured deuterium oxide ((2)H(2)O) dose was given to the mother. Urine and breast milk from the mother, and saliva samples from the infant, were collected on days 1, 8 and 14 after dosing. RESULTS: The mean (+/- SD) maternal mid upper arm circumference (MUAC) and body mass index (BMI) were 21.8 (0.9) cm and 18.6 (1.0) kg/height (m(2)), respectively. Infant weight and weight/age Z score were 4.956 (0.874) kg and -1.750 (0.77), respectively. Throughout the study, the infants gained 20 (4) g/day in body weight and had a milk intake of 555 (22) ml/day. The energy intake of the infant was 1,602 (148) kJ/day and was lower (p < 0.05) than the 2,404 (423) kJ/day estimated requirement by the FAO/WHO/UNU. The maternal FFM, %BF, Hb, Hct, ferritin and retinol were 32.8 (3.1) kg, 17.24 (7.0), 11.5 (1.3) g/dl, 33.9 (4.9), 16.2 (0.1) microg/l and 0.894 (0.16) micromol/l, respectively. Infant milk intake was significantly and positively correlated to maternal pregnancy triceps (r = 0.679) p < 0.05) and pregnancy MUAC (r = 0.725) p < 0.05). Maternal pregnancy MUAC was an important predictor of infant breast milk intake. CONCLUSION: Data on volume of breast milk consumed by the infants suggests, at least for this group of infants, that adequate growth may not be achieved. There is a possibility that lactating mothers practicing exclusive breast-feeding and living under harsh conditions may experience periods of low breast milk volume. Body composition and biochemical findings among this group of Pokot mothers indicate dietary inadequacies that require nutritional intervention

Commonly cited incentives in the community implementation of the emergency maternal and newborn care study in western Kenya

Background: Mortality of mothers and newborns is an important public health problem in low-income countries. In the rural setting, implementation of community based education and mobilization are strategies that have sought to reduce these mortalities. Frequently such approaches rely on volunteers within each community. Objective: To assess the perceptions of the community volunteers in rural Kenya as they implemented the EmONC program and to identify the incentives that could result in their sustained engagement in the project. Method: A community-based cross sectional survey was administered to all volunteers involved in the study. Data were collected using a self-administered supervision tool from all the 881 volunteers. Results: 881 surveys were completed. 769 respondents requested some form of incentive; 200 (26%) were for monetary allowance, 149 (19.4%) were for a bicycle to be used for transportation, 119 (15.5%) were for uniforms for identification, 88 (11.4%) were for provision of training materials, 81(10.5%) were for training in Home based Life Saving Skills (HBLSS), 57(7.4%) were for provision of first AID kits, and 39(5%) were for provision of training more facilitators, 36(4.7%) were for provision of free medication. Conclusion: Monetary allowances, improved transportation and some sort of identification are the main incentives cited by the respondents in this context

Data quality monitoring and performance metrics of a prospective, population-based observational study of maternal and newborn health in low resource settings

BACKGROUND: To describe quantitative data quality monitoring and performance metrics adopted by the Global Network´s (GN) Maternal Newborn Health Registry (MNHR), a maternal and perinatal population-based registry (MPPBR) based in low and middle income countries (LMICs). METHODS: Ongoing prospective, population-based data on all pregnancy outcomes within defined geographical locations participating in the GN have been collected since 2008. Data quality metrics were defined and are implemented at the cluster, site and the central level to ensure data quality. Quantitative performance metrics are described for data collected between 2010 and 2013. RESULTS: Delivery outcome rates over 95% illustrate that all sites are successful in following patients from pregnancy through delivery. Examples of specific performance metric reports illustrate how both the metrics and reporting process are used to identify cluster-level and site-level quality issues and illustrate how those metrics track over time. Other summary reports (e.g. the increasing proportion of measured birth weight compared to estimated and missing birth weight) illustrate how a site has improved quality over time. CONCLUSION: High quality MPPBRs such as the MNHR provide key information on pregnancy outcomes to local and international health officials where civil registration systems are lacking. The MNHR has measures in place to monitor data collection procedures and improve the quality of data collected. Sites have increasingly achieved acceptable values of performance metrics over time, indicating improvements in data quality, but the quality control program must continue to evolve to optimize the use of the MNHR to assess the impact of community interventions in research protocols in pregnancy and perinatal health.Fil: Goudar, Shivaprasad S.. KLE University. Jawaharlal Nehru Medical College; IndiaFil: Stolka, Kristen B.. Research Triangle Institute International; Estados UnidosFil: Koso Thomas, Marion. Eunice Kennedy Shriver National Institute of Child Health and Human Development; Estados UnidosFil: Honnungar, Narayan V.. KLE University. Jawaharlal Nehru Medical College; IndiaFil: Mastiholi, Shivanand C.. KLE University. Jawaharlal Nehru Medical College; IndiaFil: Ramadurg, Umesh Y.. S. Nijalingappa Medical College; IndiaFil: Dhaded, Sangappa M.. KLE University. Jawaharlal Nehru Medical College; IndiaFil: Pasha, Omrana. Aga Khan University; PakistánFil: Patel, Archana. Indira Gandhi Government Medical College and Lata Medical Research Foundation; IndiaFil: Esamai, Fabian. University School of Medicine; KeniaFil: Chomba, Elwyn. University of Zambia; ZambiaFil: Garces, Ana. Universidad de San Carlos; GuatemalaFil: Althabe, Fernando. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Instituto de Efectividad Clínica y Sanitaria; ArgentinaFil: Carlo, Waldemar A.. University of Alabama at Birmingahm; Estados UnidosFil: Goldenberg, Robert L.. Columbia University; Estados UnidosFil: Hibberd, Patricia L.. Massachusetts General Hospital for Children; Estados UnidosFil: Liechty, Edward A.. Indiana University; Estados UnidosFil: Krebs, Nancy F.. University of Colorado School of Medicine; Estados UnidosFil: Hambidge, Michael K.. University of Colorado School of Medicine; Estados UnidosFil: Moore, Janet L.. Research Triangle Institute International; Estados UnidosFil: Wallace, Dennis D.. Research Triangle Institute International; Estados UnidosFil: Derman, Richard J. Christiana Care Health Services; Estados UnidosFil: Bhalachandra, Kodkany S.. KLE University. Jawaharlal Nehru Medical College; IndiaFil: Bose, Carl L.. University of North Carolina; Estados Unido

Stage progression and neurological symptoms in Trypanosoma brucei rhodesiense sleeping sickness: role of the CNS inflammatory response

Background: Human African trypanosomiasis progresses from an early (hemolymphatic) stage, through CNS invasion to the late (meningoencephalitic) stage. In experimental infections disease progression is associated with neuroinflammatory responses and neurological symptoms, but this concept requires evaluation in African trypanosomiasis patients, where correct diagnosis of the disease stage is of critical therapeutic importance. Methodology/Principal Findings: This was a retrospective study on a cohort of 115 T.b.rhodesiense HAT patients recruited in Eastern Uganda. Paired plasma and CSF samples allowed the measurement of peripheral and CNS immunoglobulin and of CSF cytokine synthesis. Cytokine and immunoglobulin expression were evaluated in relation to disease duration, stage progression and neurological symptoms. Neurological symptoms were not related to stage progression (with the exception of moderate coma). Increases in CNS immunoglobulin, IL-10 and TNF-α synthesis were associated with stage progression and were mirrored by a reduction in TGF-β levels in the CSF. There were no significant associations between CNS immunoglobulin and cytokine production and neurological signs of disease with the exception of moderate coma cases. Within the study group we identified diagnostically early stage cases with no CSF pleocytosis but intrathecal immunoglobulin synthesis and diagnostically late stage cases with marginal CSF pleocytosis and no detectable trypanosomes in the CSF. Conclusions: Our results demonstrate that there is not a direct linkage between stage progression, neurological signs of infection and neuroinflammatory responses in rhodesiense HAT. Neurological signs are observed in both early and late stages, and while intrathecal immunoglobulin synthesis is associated with neurological signs, these are also observed in cases lacking a CNS inflammatory response. While there is an increase in inflammatory cytokine production with stage progression, this is paralleled by increases in CSF IL-10. As stage diagnostics, the CSF immunoglobulins and cytokines studied do not have sufficient sensitivity to be of clinical value

Low-dose aspirin for the prevention of preterm delivery in nulliparous women with a singleton pregnancy (ASPIRIN): a randomised, double-blind, placebo-controlled trial.

BACKGROUND: Preterm birth remains a common cause of neonatal mortality, with a disproportionately high burden in low-income and middle-income countries. Meta-analyses of low-dose aspirin to prevent pre-eclampsia suggest that the incidence of preterm birth might also be decreased, particularly if initiated before 16 weeks of gestation. METHODS: ASPIRIN was a randomised, multicountry, double-masked, placebo-controlled trial of low-dose aspirin (81 mg daily) initiated between 6 weeks and 0 days of pregnancy, and 13 weeks and 6 days of pregnancy, in nulliparous women with an ultrasound confirming gestational age and a singleton viable pregnancy. Participants were enrolled at seven community sites in six countries (two sites in India and one site each in the Democratic Republic of the Congo, Guatemala, Kenya, Pakistan, and Zambia). Participants were randomly assigned (1:1, stratified by site) to receive aspirin or placebo tablets of identical appearance, via a sequence generated centrally by the data coordinating centre at Research Triangle Institute International (Research Triangle Park, NC, USA). Treatment was masked to research staff, health providers, and patients, and continued until 36 weeks and 7 days of gestation or delivery. The primary outcome of incidence of preterm birth, defined as the number of deliveries before 37 weeks\u27 gestational age, was analysed in randomly assigned women with pregnancy outcomes at or after 20 weeks, according to a modified intention-to-treat (mITT) protocol. Analyses of our binary primary outcome involved a Cochran-Mantel-Haenszel test stratified by site, and generalised linear models to obtain relative risk (RR) estimates and associated confidence intervals. Serious adverse events were assessed in all women who received at least one dose of drug or placebo. This study is registered with ClinicalTrials.gov, NCT02409680, and the Clinical Trial Registry-India, CTRI/2016/05/006970. FINDINGS: From March 23, 2016 to June 30, 2018, 14 361 women were screened for inclusion and 11 976 women aged 14-40 years were randomly assigned to receive low-dose aspirin (5990 women) or placebo (5986 women). 5780 women in the aspirin group and 5764 in the placebo group were evaluable for the primary outcome. Preterm birth before 37 weeks occurred in 668 (11·6%) of the women who took aspirin and 754 (13·1%) of those who took placebo (RR 0·89 [95% CI 0·81 to 0·98], p=0·012). In women taking aspirin, we also observed significant reductions in perinatal mortality (0·86 [0·73-1·00], p=0·048), fetal loss (infant death after 16 weeks\u27 gestation and before 7 days post partum; 0·86 [0·74-1·00], p=0·039), early preterm delivery (\u3c34 \u3eweeks; 0·75 [0·61-0·93], p=0·039), and the incidence of women who delivered before 34 weeks with hypertensive disorders of pregnancy (0·38 [0·17-0·85], p=0·015). Other adverse maternal and neonatal events were similar between the two groups. INTERPRETATION: In populations of nulliparous women with singleton pregnancies from low-income and middle-income countries, low-dose aspirin initiated between 6 weeks and 0 days of gestation and 13 weeks and 6 days of gestation resulted in a reduced incidence of preterm delivery before 37 weeks, and reduced perinatal mortality. FUNDING: Eunice Kennedy Shriver National Institute of Child Health and Human Development