Epidemiology and Antimicrobial Resistance Patterns in Enteric Fever among patients in Garissa County, a Semi-Arid Region of North Eastern Kenya

Typhoid and paratyphoid fever continue to be important causes of illness and death, particularly among children and adolescents in developing countries where enteric fever is associated with poor sanitation and unsafe food and water. Quantification of disease burden is crucial for policy making about the deployment of enteric fever prevention measures and vaccines. This cross-sectional study was undertaken to determine the epidemiology and antimicrobial resistance pattern in bacterial aetiologies of enteric fever among patients attending Garissa County Referral Hospital, (GCRH) located in a semi-arid region of North Eastern Kenya. Blood and stool samples were obtained from 379 consenting patients and a detailed sociodemographic questionnaire was administered. Isolation and identification of Salmonella Typhi, S. Paratyphi A and S. Paratyphi B were obtained by convectional culture, PCR and Vitek-2 compact detection method. Antimicrobial susceptibility testing was done using Kirby-Bauer’s disc diffusion method. Multidrug resistance was defined as co-resistance to ampicillin, chloramphenicol and co- trimoxazole. Eight of the 379 (2.1%) participants were positive for Salmonella spp. Of the 8 Salmonella isolates were S. Typhi (n=2; 25%), S. Paratyphi A (n=2; 25%) and S. Paratyphi B (n=4; 50%). Resistance to ampicillin, tetracycline, gentamycin, chloramphenicol, nalidixic acid and trimethoprim-sulfamethoxazole was 100%, 87.5%, 75%, 50%, 25% and 25% respectively. No isolate showed resistance to ciprofloxacin. Half of all S. typhi, S. paratyphi A and B were multidrug-resistant. Risk factors including water and food (such as often eating outside homestead, family eating from a common plate, taking locally prepared cold drinks, family wash hands in common basin), low socio-economic status and availability of a previous laboratory confirmation of typhoid fever were associated with S. Typhi and S. Paratyphi infection. The isolation of a large proportion of MDR S. Typhi, S. Paratyphi A and B is worrying. Although these isolates were susceptible to fluoroquinolones, there is need for routine surveillance to monitor susceptibility to the initial first line antibiotics in clinical settings since the MDR strains have lately shown increased resistance. Addressing issues of contaminated food, water, sanitation and hygiene and low socio-economic status is likely to prevent and reduce the burden on enteric fever in this region. Keywords: Enteric Fever, Molecular Epidemiology, Antimicrobial Resistance Pattern, Semi-Arid Region of North Eastern Kenya DOI: 10.7176/JHMN/60-14 Publication date:March 31st 201

Risk of HIV Infection among Men Aged 50 to 75 Years using Erectile Dysfunction Drugs Attending at Kenyatta National Hospital: A Case Control Study, Kenya

Background: Erectile dysfunction drug (EDD) use has gained popularity among older men for enhancement and treatment of erectile dysfunction in recent years. Increased number of sexual partners and sexual activity due to EDD use concerns about the rising rate of HIV infection among older men. Men who use EDD for erectile dysfunction are found to be two to three times more likely to have sexually transmitted diseases (STDs), particularly human immunodeficiency virus (HIV) or chlamydia, than those who did not use the drugs. In Kenya, the prevalence of HIV among men of age 50 to 54 years has increased from 5.7% in 2003 to 9.1% in 2008. Objectives: This study was aimed at determining the association between EDD use and risk of HIV infection among men aged 50 to 75 years. Patients and Methods: A hospital based case-control study was conducted among men aged 50 to 75 years. A total of 274 men (137 cases confirmed as HIV positive and same number of controls confirmed as HIV negative), consented to participate in the study. Pearson’s chi-square test and odds ratio with corresponding 95% confidence interval were computed to establish the association between the dependent variable (HIV status) and independent variables (Key independent variable being EDD use). The level of statistical significance was set at p-value <0.05. Binary logistic regression analyses were performed to adjust for confounding factors in the relationship between HIV status and EDD use. Results: Out of 137 cases, 18(13.1%) used EDD before they found out that they were HIV +ve compared to 8(5.8%) of the controls. Even though the use of erectile dysfunction drugs was found to be significantly associated with serum HIV positivity in bivariate analysis (OR= 2.44; 95%CI: 1.04-5.93; p=0.039), it was not significant after adjustment for other factors at the multivariate analysis (AOR= 1.52; 95%CI: 0.43- 5.34; p=0.519). Multiple logistic regression revealed the following factors as independent predictors of HIV: having had sexually transmitted diseases (AOR=5.96; 95%CI: 2.43 – 14.63; p<0.001), taking alcohol/drunkenness (AOR=6.84; 95%CI: 3.22 – 14.56; p<0.001) and having multiple sexual partners (AOR=21.69; 95%CI: 8.82 – 53.33; p<0.001).Conclusion: This study shows that there is an increased risk of HIV infection among older men using EDD. However, this observation is not sustained after controlling for other associated factors. It is therefore recommended that a more robust study design (prospective cohort) with a large sample size to be undertaken to shed more light on this pressing topic. Keywords: Erectile Dysfunction Drugs, HIV infection, Older Men, Ris

Prevalence and factors associated with percutaneous injuries and splash exposures among health-care workers in a provincial hospital, Kenya, 2010

Introduction: Accidental occupational exposure of healthcare workers to blood and body fluids after skin injury or mucous membrane contact constitutes a risk for transmission of blood-borne pathogens. Such pathogens include Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV) and Hepatitis C virus (HCV). We conducted a study to determine the prevalence and associated factors for percutaneous injuries and splash exposures among health-care workers in Rift Valley provincial hospital. Methods: A cross-sectional study was carried out from October to November 2010. Self reported incidents, circumstances surrounding occupational exposure and post-exposure management were sought by use of interviewer administered questionnaire. Descriptive, bivariate and multiple logistic regression (forward stepwise procedure) analyses were performed. The level of significance was set at 0.05. Results: Twenty five percent of health-care workers interviewed (N=305) reported having been exposed to blood and body fluids in the preceding 12 months. Percutaneous injuries were reported by 19% (n=305) and splash to mucous membrane by 7.2%. Higher rates of percutaneous injuries were observed among nurses (50%), during stitching (30%), and in obstetric and gynecologic department (22%). Health workers aged below 40 years were more likely to experience percutaneous injuries (OR= 3.7; 95% CI=1.08-9.13) while previous training in infection prevention was protective (OR= 0.52; 95% CI=0.03-0.90). Forty eight percent (n=83) reported the incidents with 20% (n=83) taking PEP against HIV. Conclusion: Percutaneous injuries and splashes are common in Rift Valley Provincial hospital. Preventive measures remain inadequate. Health institutions should have policies, institute surveillance for occupational risks and enhance training of health care workers.Pan African Medical Journal 2013; 14:1

Resistance patterns of Mycobacterium tuberculosis isolates from pulmonary tuberculosis patients in Nairobi

Introduction: In Kenya, which ranks thirteenth of 27 high tuberculosis burden countries, diagnosis is based on Ziehl-Neelsen staining alone and patients are treated without information on sensitivity patterns. This study aimed to determine resistance patterns of Mycobacterium tuberculosis isolated from pulmonary samples. Methodology: Pulmonary tuberculosis patients in Nairobi were randomly sampled after informed consent and recruited into the study using a structured questionnaire. Specimens were cultured in liquid and solid media, and drug susceptibility tests were performed for first-line drugs including (isoniazid, rifampin, streptomycin, ethambutol and pyrazinamide). Results: Eighty-six (30%) of 286 isolates were resistant to at least one of five antibiotics tested. Thirty-seven (30.2%) isolates were resistant to isoniazid; 15 (11.6%) to streptomycin; 13 (4.5%) to ethambutol; four (1.4%) to rifampin ; and 30 (10.4%) to pyrazinamide. Double resistance was seen as follows: four (1.4%) isolates were resistant to both isoniazid and pyrazinamide; four (1.4%) to streptomycin and isoniazid; and one (0.3%) to rifampin and streptomycin. Two isolates (0.7%) were multidrug resistant, and one was triple resistant with an additional resistance to ethambutol. Results also showed 88.7% of patients were below the age of 40 years, while 26.3% were HIV positive. The majority of the patients (66.5%) were unemployed or self-employed in small businesses, with 79.4% earning less than 100 USD per month. Conclusion: The high resistance observed in isoniazid, which is a first-line drug, could result in an increase in multidrug resistance unless control programs are strengthened. Poverty should be addressed to reduce infection rates

An in vitro evaluation of drugs used in the Kenyan ART program

The majority of anti-HIV drug susceptibility tests have been performed on subtype B HIV-1 strains, since these are the most prevalent in countries designing, testing, and manufacturing the current anti-HIV agents. The increasing global spread of HIV subtype highlights the need to determine the activity of anti-HIV drugs against subtypes of HIV other than subtype B. Furthermore an increasing number of individuals infected with many of the non subtype B virus strains now receive antiretroviral therapy because of rollout programs in developing countries as well as increasing migration to the developed world. The phenotypic susceptibility of two laboratory strains HIV-1JFRL and HIV-1IIIB (representing subtype B) and two clinical isolates HIV-104RTA and HIV-1025RTA (representing subtypes A and D respectively) was determined. The in vitro drug susceptibility testing of the isolates was carried out in C8166 cell line and in peripheral blood mononuclear cells (PBMCs). The study revealed that the drugs used in the Kenyan national ART program inhibited HIV-1 replication in-vitro as their inhibitory concentrations (IC50) compared well with the standard Inhibitory concentration values. The results also suggest a biochemical similarity of the reverse transcriptase (RT) and protease enzymes from these subtypes despite the divergence at the genetic level. The findings suggest that similar clinical benefits of antiviral therapy obtain in persons infected with other subtypes of HIV-1other than subtype B and that the generic drugs used in the national ART program in Kenya are as efficacious as branded drugs in inhibiting HIV replication in vitro despite the limited number of the viruses studied.Pan African Medical Journal 2016; 2

Factors associated with adequate weekly reporting for disease surveillance data among health facilities in Nairobi County, Kenya, 2013

Introduction: Kenya adopted the Integrated Disease Surveillance and Response (IDSR) strategy in 1998 to strengthen disease surveillance and epidemic response. However, the goal of weekly surveillance reporting among health facilities has not been achieved. We conducted a crosssectional study to determine the prevalence of adequate reporting and factors associated with IDSR reporting among health facilities in one Kenyan County. Methods: Health facilities (public and private) were enrolled using stratified random sampling from 348 facilities prioritized for routine surveillance reporting. Adequately-reporting facilities were defined as those which submitted >10 weekly reports during a twelve-week period and a poor reporting facilities were those which submitted <10 weekly reports. Multivariate logistic regression with backward selection was used to identify risk factors associated with adequate reporting. Results: From September 2 through November 30, 2013, we enrolled 175 health facilities; 130(74%) were private and 45(26%) were public. Of the 175 health facilities, 77 (44%) facilities classified as adequate reporting and 98 (56%) were reporting poorly. Multivariate analysis identified three factors to be independently associated with weekly adequate reporting: having weekly reporting forms at visit (AOR19, 95% CI: 6-65], having posters showing IDSR functions (AOR8, 95% CI: 2-12) and having a designated surveillance focal person (AOR7, 95% CI: 2-20). Conclusion: The majority of health facilities in Nairobi County were reporting poorly to IDSR and we recommend that the Ministry of Health provide all health facilities in Nairobi County with weekly reporting tools and offer specific trainings on IDSR which will help designate a focal surveillance person.Pan African Medical Journal 2016; 2

Correlates of contraceptive use among HIV discordant couples in Kenya

Despite risks of HIV transmission to infants born of the HIV positive women, contraceptive use is uncommon among women in HIV discordant partnerships. The aim of this study was to determine the factors associated with contraceptive use in a clinical trial cohort of HIV serodiscordant couples based in Thika and Eldoret, Kenya. Data were analyzed from 481 HIV discordant couples enrolled in the Partners in Prevention HSV/HIV Transmission Study at the Thika and Eldoret sites. The primary study outcome was self-reported use of contraception other than condoms. Using a marginal longitudinal logistic model based on generalized estimating equations (GEE) approach we assessed the association of various demographic and behavioral factors with contraceptive use. At baseline the prevalence of non barrier contraceptive use among HIV positive and negative women was 24.3% and 25.7%, respectively. At month 12 of follow-up, the prevalence of contraceptive use was 44.4% among the HIV positive and 26% among the HIV negative women while at month 24, the prevalence of contraceptive use was 38.6% among the HIV positive and 18.2% among the HIV negative women. HIV positive women were more likely to report using contraception than HIV negative women (odds ratio (OR) 1.61 95% confidence interval (CI) 1.04-2.47). Additionally, being married (OR 2.4, 95% CI 1.2-5.0), attending Thika site clinic (OR 6.1, 95% CI 4.2-9.0), and having two or more children (OR 1.9, 95% CI 1.3-2.8) were significantly associated with use of non barrier contraceptives. Future programs should focus on interventions to increase contraceptive use among HIV serodiscordant couples, with a special emphasis on HIV negative women, unmarried women and women with few children

Development of immunoassays for detection of Human Immunodeficiency Virus based on Consensus env gp41 Immunodominant Region Peptide from HIV-1 infections in Kenya

Background: Human Immunodeficiency Virus (HIV) is characterized by high rates of genetic variability in vivo that could affect the performance of the HIV antibody-based detection kits. Objective: This study aimed at developing immunoassays for HIV based on Consensus env gp41 Immunodominant region (IDR) from HIV infections in Kenya. Methods: HIV RNA was extracted from 91 samples collected from 5 regional blood transfusion centers in Kenya. The RNA was reverse transcribed, sequenced in the env gp41-Immunodominant Region (IDR) and the Consensus sequence generated used to synthesize corresponding peptide. The Global HIV envgp41-IDR Consensus peptide was obtained from the literature and also synthesized. The two peptides were used to separately develop HIV immunoassays based on Enzyme-linked Immunosorbent Assay (ELISA) and Lateral Flow Assay (LFA) platforms and the performance of developed assays was evaluated. The same HIV env gp41 IDR peptides were used to develop ELISA-based immunoassays for determination HIV Incidence / Recency. Results: The study did not find significant difference between the performance of the immunoassays that were developed with Consensus env gp41-IDR peptide (Kenya) and those developed using Consensus env gp41-IDR peptide (Global). However, the study found a significant difference between the performance of HIV ELISA for HIV Incidence testing that was developed with Consensus envgp41-IDR peptide (Kenya) and that which was developed using Consensus envgp41-IDR peptide (Global) with the former displaying superior performance. Conclusions: The developed immunoassays demonstrated that both Consensus env gp41-IDR peptides (Kenya and Global) could be used to develop HIV immunoassays but Consensus env gp41-IDR peptide (Kenya) could be more suitable for development of HIV Incidence assays in Kenya. Keywords: HIV, Consensus sequence, env gp41-Immunodominant Region, Immunoassay

Factors influencing community participation in control and related operational research for urogenital schistosomiasis and soil-transmitted helminths in rural villages of Kwale County, coastal Kenya

Introduction: helminthic infections caused by soil-transmitted helminths (STH) and schistosomes are among the most prevalent afflictions of humans who live in areas of poverty. An operational research was undertaken in 5 villages of Kwale County during a pilot control programme which included both the adults and school going children. Willingness of community members to participate in the treatment as well as in the research is critical. A cross sectional study sought to determine factors influencing community participation in control and related operational research and assess the treatment coverage for urogenital schistosomiasis and hookworms in rural villages of Kwale County. Methods: crosssectional survey utilized quantitative and qualitative methods of data collection. A total of 220 households were recruited and household heads interviewed. Bivariate analysis was used to test association between different independent and dependent factors. Multivariate analysis was done using binary logistic regression to control for confounders and effect modification. Qualitative data was transcribed, coded and analyzed thematically. Results: religion and levels of income were significantly (P =0.04 and P=0.026 respectively) associated with participation in the research and control programme, history of ever suffering from schistosomiasis and intestinal worms was found to be significantly (P=0.008) associated with participation in the research. The study established that 82% (178) of the respondents received treatment for urogenital schistosomiasis and hookworms and 67% (146) of the respondents had participated in the research. Conclusion: this information will be useful in promoting health, enhancing learning and behaviour changes which will lead to increased community participation in similar disease control.Pan African Medical Journal 2016; 2