Drivers and subseasonal predictability of heavy rainfall in equatorial East Africa and relationship with flood risk

Equatorial East Africa (EEA) suffers from significant flood risks. These can be mitigated with pre-emptive action, however currently available early warnings are limited to a few days lead time. Extending warnings using subseasonal climate forecasts could open a window for more extensive preparedness activity. However before these forecasts can be used, the basis of their skill and relevance for flood risk must be established. Here we demonstrate that subseasonal forecasts are particularly skillful over EEA. Forecasts can skillfully anticipate weekly upper quintile rainfall within a season, at lead times of two weeks and beyond. We demonstrate the link between the Madden-Julian Oscillation (MJO) and extreme rainfall events in the region, and confirm that leading forecast models accurately represent the EEA teleconnection to the MJO. The relevance of weekly rainfall totals for fluvial flood risk in the region is investigated using a long record of streamflow from the Nzoia river in Western Kenya. Both heavy rainfall and high antecedent rainfall conditions are identified as key drivers of flood risk, with upper quintile weekly rainfall shown to skillfully discriminate flood events. We additionally evaluate GloFAS global flood forecasts for the Nzoia basin. Though these are able to anticipate some flooding events with several weeks lead time, analysis suggests action based on these would result in a false alarm more than 50% of the time. Overall, these results build on the scientific evidence base that supports the use of subseasonal forecasts in EEA, and activities to advance their use are discussed

Advancing operational flood forecasting, early warning and risk management with new emerging science: Gaps, opportunities and barriers in Kenya

Kenya and the wider East African region suffer from significant flood risk, as illustrated by major losses of lives, livelihoods and assets in the most recent years. This is likely to increase in future as exposure rises and rainfall intensifies under climate change. Accordingly, flood risk management is a priority action area in Kenya's national climate change adaptation planning. Here, we outline the opportunities and challenges to improve end-to-end flood early warning systems, considering the scientific, technical and institutional/governance dimensions. We demonstrate improvements in rainfall forecasts, river flow, inundation and baseline flood risk information. Notably, East Africa is a ‘sweetspot’ for rainfall predictability at sub-seasonal to seasonal timescales for extending forecast lead times beyond a few days and for ensemble flood forecasting. Further, we demonstrate coupled ensemble flow forecasting, new flood inundation simulation, vulnerability and exposure data to support Impact based Forecasting (IbF). We illustrate these advances in the case of fluvial and urban flooding and reflect on the potential for improved flood preparedness action. However, we note that, unlike for drought, there remains no national flood risk management framework in Kenya and there is need to enhance institutional capacities and arrangements to take full advantage of these scientific advances

The Impact of Retail-Sector Delivery of Artemether–Lumefantrine on Malaria Treatment of Children under Five in Kenya: A Cluster Randomized Controlled Trial

In a cluster randomized trial, Beth Kangwana and colleagues find that provision of subsidized packs of the malaria therapy artemether-lumefantrine to shops more than doubled the proportion of children with fever who received drugs promptly

Late Presentation With HIV in Africa: Phenotypes, Risk, and Risk Stratification in the REALITY Trial.

This article has been accepted for publication in Clinical Infectious Diseases Published by Oxford University PressBackground: Severely immunocompromised human immunodeficiency virus (HIV)-infected individuals have high mortality shortly after starting antiretroviral therapy (ART). We investigated predictors of early mortality and "late presenter" phenotypes. Methods: The Reduction of EArly MortaLITY (REALITY) trial enrolled ART-naive adults and children ≥5 years of age with CD4 counts .1). Results: Among 1711 included participants, 203 (12%) died. Mortality was independently higher with older age; lower CD4 count, albumin, hemoglobin, and grip strength; presence of World Health Organization stage 3/4 weight loss, fever, or vomiting; and problems with mobility or self-care at baseline (all P < .04). Receiving enhanced antimicrobial prophylaxis independently reduced mortality (P = .02). Of five late-presenter phenotypes, Group 1 (n = 355) had highest mortality (25%; median CD4 count, 28 cells/µL), with high symptom burden, weight loss, poor mobility, and low albumin and hemoglobin. Group 2 (n = 394; 11% mortality; 43 cells/µL) also had weight loss, with high white cell, platelet, and neutrophil counts suggesting underlying inflammation/infection. Group 3 (n = 218; 10% mortality) had low CD4 counts (27 cells/µL), but low symptom burden and maintained fat mass. The remaining groups had 4%-6% mortality. Conclusions: Clinical and laboratory features identified groups with highest mortality following ART initiation. A screening tool could identify patients with low CD4 counts for prioritizing same-day ART initiation, enhanced prophylaxis, and intensive follow-up. Clinical Trials Registration: ISRCTN43622374.REALITY was funded by the Joint Global Health Trials Scheme (JGHTS) of the UK Department for International Development, the Wellcome Trust, and Medical Research Council (MRC) (grant number G1100693). Additional funding support was provided by the PENTA Foundation and core support to the MRC Clinical Trials Unit at University College London (grant numbers MC_UU_12023/23 and MC_UU_12023/26). Cipla Ltd, Gilead Sciences, ViiV Healthcare/GlaxoSmithKline, and Merck Sharp & Dohme donated drugs for REALITY, and ready-to-use supplementary food was purchased from Valid International. A. J. P. is funded by the Wellcome Trust (grant number 108065/Z/15/Z). J. A. B. is funded by the JGHTS (grant number MR/M007367/1). The Malawi-Liverpool–Wellcome Trust Clinical Research Programme, University of Malawi College of Medicine (grant number 101113/Z/13/Z) and the Kenya Medical Research Institute (KEMRI)/Wellcome Trust Research Programme, Kilifi (grant number 203077/Z/16/Z) are supported by strategic awards from the Wellcome Trust, United Kingdom. Permission to publish was granted by the Director of KEMRI. This supplement was supported by funds from the Bill & Melinda Gates Foundation

Advancing operational flood forecasting, early warning and risk management with new emerging science: Gaps, opportunities and barriers in Kenya

Kenya and the wider East African region suffer from significant flood risk, as illustrated by major losses of lives, livelihoods and assets in the most recent years. This is likely to increase in future as exposure rises and rainfall intensifies under climate change. Accordingly, flood risk management is a priority action area in Kenya's national climate change adaptation planning. Here, we outline the opportunities and challenges to improve end-to-end flood early warning systems, considering the scientific, technical and institutional/governance dimensions. We demonstrate improvements in rainfall forecasts, river flow, inundation and baseline flood risk information. Notably, East Africa is a ‘sweetspot’ for rainfall predictability at sub-seasonal to seasonal timescales for extending forecast lead times beyond a few days and for ensemble flood forecasting. Further, we demonstrate coupled ensemble flow forecasting, new flood inundation simulation, vulnerability and exposure data to support Impact based Forecasting (IbF). We illustrate these advances in the case of fluvial and urban flooding and reflect on the potential for improved flood preparedness action. However, we note that, unlike for drought, there remains no national flood risk management framework in Kenya and there is need to enhance institutional capacities and arrangements to take full advantage of these scientific advances