Cost-efficient evaluation of ambulance services for community critical care transport needs in Machakos County, Kenya

Background: Machakos County is one of the 47 counties in Kenya. In the current study performance of ambulance services were measured using indicators such as response time, on-scene time, clients’ satisfaction and cost-efficiency (technical).Objectives: To determine the cost-efficient ambulance services appropriate for community critical care transport needs in Machakos County.Design: Descriptive cross sectional study.Setting: Machakos County (Emergencies Services Department)Subjects: Publically financed ambulancesResults: Machakos has seventy Basic Life Support (BLS) ambulances distributed among the 69 administrative locations (wards). A total of 12,674 victims were transported to different tares of hospital and referrals between March 2014 to May 2015. Victims requiring emergency obstetric care (EMOC) accounted for 24.7% of victims transported, road traffic accidents victims10.3% and the least were rape victims at 0.03%. The annual operational cost was Kshs. 70,328,627 (USD 717,639.05). Expenditure profiles indicated that staff wages accounted for 49% of total operational cost,overheads costs accounted for 33.5%, while office rent accounted for 1.36%. The mean unit cost per kilometer was Kshs. 30.9 (USD 0.32) and cost per victim transported by an ambulance was Kshs. 6,504 (USD 66.37). Key demand factors were social cultural and health seeking behaviours of residents. The supply barriers were transport costs, operational costs and in-efficient signage on roads for direction. The mean cost-efficiency (technical) of Machakos ambulance transport services was 90.6% (C.I 82.7% - 98.2%).Conclusion: Machakos County Government ambulance services was technically efficient operating

A comparative analysis of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopy biopsy histology as gold standard in women undergoing colposcopy in Kenyatta National Hospital

Background: Cervical cancer is one of the most common female malignancies worldwide. Since the introduction of conventional Papanicolaou smear mortality from cervical cancer has reduced considerably. Despite its success, it has sensitivity of only 51% and false negative rate of 5-10%. Approved liquid based cytology (LBC) products by FDA claim a 65-percent increased detection rate of high grade squamous intraepithelial lesions (HGSIL) compared with conventional smears, as well as decreased unsatisfactory sample rates. Evidence shows that liquid based preparation is more sensitive and accurate for the detection of both squamous and glandular lesions of the cervix. Studies of the accuracy of liquid based preparations reports sensitivity of 61-66% and specificity of 82-91%. Objective of current study is to compare the performance of conventional Pap smear cytology, liquid based cytology and colposcopy clinical impression with colposcopic biopsy as the gold standard among women eligible for colposcopy in Kenyatta National Hospital, Kenya.Methods: This was a hospital-based comparative cross-sectional study. Convenient sampling over a period of 4 months was used to recruit clients referred to colposcopy clinic with abnormal Pap smear results.Results: A total of 73 patients referred with abnormal pap smears were recruited into the study. The mean age of the patients was 38 yrs (SD ±10). About 45% of the patients interviewed did not have knowledge of Pap smear testing. Both the results of referral Pap smear and repeat Pap smear were predominantly low grade squamous intraepithelial lesions (LGSIL) or HGSIL. With biopsy results being the gold standard, Liquid based cytology had a higher specificity of 75% when compared with conventional pap smears’ 11%.Conclusions: Even though colposcopy clinical impression has the highest agreement with colposcopy biopsy it’s a diagnostic and not a screening test, hence Liquid based cytology showed better performance as a screening test compared to conventional Pap smear. In general, there was good agreement for cytological results of repeat CPAP and LBC. We therefore recommend that for patients referred with abnormal pap smears requiring a repeat pap smear, liquid based cytology is used due to its higher specificity compared to conventional Pap smear

Cryotherapy Following Visual Inspection with Acetic Acid and Lugol's Iodine (Via/Vili) in Khwisero, Western Kenya: Lesson from the Field Affecting Policy and Practice

Background: Cervical cancer can be prevented and mortality/morbidity reduced by early detection and referral. Developing countries are likely to benefit from more cost effective methods of screening and treatment. Visual inspection with acetic acid and Lugol`s iodine (VIA/VILI) offers a see and treat solution thus an affordable and efficient way to identify pre-malignant lesions. Immediate treatment with cryotherapy can be offered if pre-malignant lesions are found on visual inspection. Cryotherapy is a simple procedure that is curative for dysplasia; it is likely to benefit cervical dysplasia cases picked early in resource poor settings, however there are several factors that hinder patients’ access to this noble technique.Objective: Determine hindrances to cryotherapy for patients following  positive results of VIA/VILI after referral.Design: Cross sectional StudySetting: Khwisero, Western Kenya.Subjects: Women attending a medical camp, willing to get screened for cervical cancer.Results: One hundred and nine patients were screened; seventy three (66.97%) were negative for VIA/VILI, twenty one (19.26%) were positive and referred for cryotherapy. Reasons for lack of follow up were financial constraints, lack of medical personnel at referral centres and poor access to the referral facilities.19.26% of women identified with positive lesions required intervention. No patient received cryotherapy following referral.Conclusion: There is urgent need for availability of cryotherapy machines and training of personnel who can perform cryotherapy at the primary care level. Regional studies on knowledge attitudes and practices about  VIA/VILI and cryotherapy are required to provide reasons for the poor uptake of this procedure

Impact of Drought on the Spatial Pattern of Transmission of Sehistosoma haematobium in Coastal Kenya

We analyzed temporal changes in spatial patterns of active Schistosoma haematobium infection in different age groups and associated them with ponds infested with Bulinus snails. A major drought between 2001 and 2009 resulted in drying of ponds that were known sources of infection, and we detected very few or no snails in ponds that were infested in the past. The household-level spatial pattern of infection for children of various age groups in 2009 was contrasted with historical data from 2000. The significant local clustering of high- and low-infection levels among school-aged children that occurred in 2000 was absent in 2009. We attribute the disappearance of significant clustering around historical transmission hot spots to a decade-long drought in our study area. The implications of extreme weather and climate conditions on risk and transmission of S. haematobium and their relevance to control strategies are discussed. Copyright © 2011 by The American Society of Tropical Medicine and Hygiene

Anemia among Children Exposed to Polyparasitism in Coastal Kenya

Anemia represents a substantial problem for children living in areas with limited resources and significant parasite burden. We performed a cross-sectional study of 254 Kenyan preschool-and early school-age children in a setting endemic for multiple chronic parasitic infections to explore mechanisms of their anemia. Complete venous blood cell counts revealed a high prevalence of local childhood anemia (79%). Evaluating the potential links between low hemoglobin and socioeconomic factors, nutritional status, hemoglobinopathy, and/or parasite infection, we identified age < 9 years (odds ratio [OR]: 12.0, 95% confidence interval [CI]: 4.4, 33) and the presence of asymptomatic malaria infection (OR: 6.8, 95% CI: 2.1, 22) as the strongest independent correlates of having anemia. A total of 130/155 (84%) of anemic children with iron studies had evidence of iron-deficiency anemia (IDA), 16% had non-IDA; 50/52 of additionally tested anemic children met soluble transferrin-receptor (sTfR) criteria for combined anemia of inflammation (AI) with IDA. Children in the youngest age group had the greatest odds of iron deficiency (OR: 10.0, 95% CI: 3.9, 26). Although older children aged 9-11 years had less anemia, they had more detectable malaria, Schistosoma infection, hookworm, and proportionately more non-IDA. Anemia in this setting appears multifactorial such that chronic inflammation and iron deficiency need to be addressed together as part of integrated management of childhood anemia

Can Prenatal Malaria Exposure Produce an Immune Tolerant Phenotype?: A Prospective Birth Cohort Study in Kenya

In a prospective cohort study of newborns residing in a malaria holoendemic area of Kenya, Christopher King and colleagues find a subset of children born to malaria-infected women who acquire a tolerant phenotype, which persists into childhood and is associated with increased susceptibility to malarial infection and anemia

Comparison of pap smear, visual inspection with acetic acid, human papillomavirus DNA-PCR testing and cervicography

Objective: To assess the test qualities of four screening methods to detect cervical intra-epithelial neoplasia in an urban African setting. Method: Six hundred fiftythree women, attending a family planning clinic in Nairobi (Kenya), underwent four concurrent screening methods: pap smear, visual inspection with acetic acid (VIA), PCR for high risk human papillomavirus (HR HPV) and cervicography. The presence of cervical intra-epithelial neoplasia (CIN) was verified by colposcopy or biopsy. Result: Sensitivity (for CIN2 or higher) and specificity (to exclude any CIN or cancer) were 83.3% (95% CI [73.6, 93.0]) and 94.6% (95% CI [92.6, 96.5]), respectively, for pap smear; 73.3% (95% CI [61.8, 84.9]) and 80.0% (95% CI [76.6, 83.4]) for VIA; 94.4% (95% CI [84.6, 98.8]) and 73.9% (95% CI [69.7, 78.2]) for HR HPV; and 72.3% (95% CI [59.1, 85.6]) and 93.2% (95% CI [90.8, 95.7]) for cervicography. Conclusion: The pap smear had the highest specificity (94.6%) and HPV testing the highest sensitivity (94.4%). The visual methods, VIA and cervicography, were similar and showed an accuracy in between the former two tests

Age-Stratified Profiles of Serum IL-6, IL-10, and TNF-α Cytokines Among Kenyan Children with Schistosoma haematobium, Plasmodium falciparum, and Other Chronic Parasitic Co-Infections.

In a study of children having polyparasitic infections in a Schistosoma haematobium-endemic area, we examined the hypothesis that S. haematobium-positive children, compared with S. haematobium-negative children (anti-soluble worm antigen preparation [SWAP] negative and egg negative) have increased systemic production of pro-inflammatory cytokines (interleukin [IL]-6, tumor necrosis factor [TNF]-α) and decreased down-regulatory IL-10. A total of 804 children, 2-19 years of age, were surveyed between July and December 2009 and tested for S. haematobium, Plasmodium falciparum, filariasis, and soil-transmitted helminth infections. Plasma levels of IL-6, TNF-α, and IL-10 were compared for S. haematobium-positive and S. haematobium-negative children, adjusting for malaria, filaria, and hookworm co-infections, and for nutritional status, age group, sex, and geographic location. IL-10 was significantly elevated among children infected with S. haematobium, showing bimodal peaks in 7-8 and 13-14 years age groups. IL-10 was also higher among children who were acutely malnourished, whereas IL-10 levels were lower in the presence of S. haematobium-filaria co-infection. After adjustment for co-factors, IL-6 was significantly elevated among children of 5-6 years and among those with P. falciparum infection. Lower levels of IL-6 were found in malaria-hookworm co-infection. High levels of TNF-α were found in children aged 11-12 years regardless of infection status. In addition, village of residence was a strong predictor of IL-6 and IL-10 plasma levels. In adolescent children infected with S. haematobium, there is an associated elevation in circulating IL-10 that may reduce the risk of later morbidity. Although we did not find a direct link between S. haematobium infection and circulating pro-inflammatory IL-6 and TNF-α levels, future T-cell stimulation studies may provide more conclusive linkages between infection and cytokine responses in settings that are endemic for multiple parasites and multiple co-infections

Making the Most of What We Already Know: A Three-Stage Approach to Systematic Reviewing

BACKGROUND: Conducting a systematic review in social policy is a resource-intensive process in terms of time and funds. It is thus important to understand the scope of the evidence base of a topic area prior to conducting a synthesis of primary research in order to maximize these resources. One approach to conserving resources is to map out the available evidence prior to undertaking a traditional synthesis. A few examples of this approach exist in the form of gap maps, overviews of reviews, and systematic maps supported by social policy and systematic review agencies alike. Despite this growing call for alternative approaches to systematic reviews, it is still common for systematic review teams to embark on a traditional in-depth review only. OBJECTIVES: This article describes a three-stage approach to systematic reviewing that was applied to a systematic review focusing in interventions for smallholder farmers in Africa. We argue that this approach proved useful in helping us to understand the evidence base. RESULTS: By applying preliminary steps as part of a three-stage approach, we were able to maximize the resources needed to conduct a traditional systematic review on a more focused research question. This enabled us to identify and fill real knowledge gaps, build on work that had already been done, and avoid wasting resources on areas of work that would have no useful outcome. It also facilitated meaningful engagement between the review team and our key policy stakeholders