Evaluation of treatment outcomes and associated factors among patients managed for tuberculosis in Vihiga County, 2012‐ 2015

Background: Tuberculosis (TB) treatment outcomes are used to evaluate program and patient success. Despite this, factors driving and sustaining high rates of poor TB treatment outcomes in Vihiga County are not well understood.Objective: To evaluate treatment outcomes and associated factors among patients managed for TB in Vihiga County between 2012 and 2015.Design: Descriptive cohort study.Setting: Vihiga County.Subjects: Notified TB patients >15years who were on drug susceptible TB treatment.Results: Of the 3288 eligible patients more than half were male 1961 (60%), 85% were from the public sector while 23% were over 45years. Among the TB patients, 2865 (87%) were successfully treated, 299 (9%) died and 124 (4%) had other poor treatment outcomes. On multivariate analysis, advancing age (Adjusted Odds Ratio (AOR) 3.3, 95% CI2.03‐5.38, P<0.001), HIV positive (AOR1.78, 95% CI1.27‐2.49, P0.001), previously treated (AOR1.78, 95% CI1.2‐2.49, P<0.001) and unknown HIV status (AOR 2.11, 95% CI 1.21‐3.68, P 0.008) increased the risk of death. TB patients with positive sputum results during initiation of treatment (AOR=0.68, CI=0.50‐0.94, P‐value 0.018) and those with normal body mass index (BMI) (AOR 0.37, 95% CI 0.24‐0.58, P<0.001), were less likely to die.Conclusion: While higher BMI and bacteriological confirmation reduced the risk of death, advancing age, unknown HIV status, HIV positive, being a previously treated TB case increased the risk of death. We recommend early and accurate diagnosis of TB cases, TB/HIV integration and active involvement of community health volunteers in TB management

Treatment outcomes for drug resistant tuberculosis among children below 15 years in Kenya, 2010‐2016

Background: Tuberculosis is a common cause of morbidity and mortality in children. Children are less likely to acquire resistance during the treatment of tuberculosis (TB). Most of the drug resistant TB infection in children is transmitted from adults.Objective: To determine the characteristics and treatment outcomes among children below 15 years managed for drug resistant TB in Kenya, 2010 – 2016.Design: Retrospective descriptive study.Setting: All health facilities managing drug resistant TB in KenyaSubjects: Children below 15 years treated for drug resistant TB between 2010 and 2016.Results: Sixty three children were notified with DR TB between 2010 and 2016. The median (IQR) age was11 (10‐13) years with a female to male ratio of 1:1. With 32 (52%) and 31 (51%) with smear and culture positive laboratory results respectively. Primary drug resistance was present in 25 (40%) of the children All the sputum and culture converted negative at month three of treatment. HIV testing uptake was 100% with a positivity rate of 26 (41%) and 100% anti‐retroviral therapy uptake. The treatment success rate for the cases was 31(91%) with a mortality rate of 2(5%) and lost‐to‐follow up 1 (3%).Conclusion: Drug‐resistant tuberculosis can be successfully treated and therapy well tolerated among children. There  is need for contact tracing and screening for all at risk including paediatric population

A clinician-nurse model to reduce early mortality and increase clinic retention among high-risk HIV-infected patients initiating combination antiretroviral treatment

<p>Abstract</p> <p>Background</p> <p>In resource-poor settings, mortality is at its highest during the first 3 months after combination antiretroviral treatment (cART) initiation. A clear predictor of mortality during this period is having a low CD4 count at the time of treatment initiation. The objective of this study was to evaluate the effect on survival and clinic retention of a nurse-based rapid assessment clinic for high-risk individuals initiating cART in a resource-constrained setting.</p> <p>Methods</p> <p>The USAID-AMPATH Partnership has enrolled more than 140,000 patients at 25 clinics throughout western Kenya. High Risk Express Care (HREC) provides weekly or bi-weekly rapid contacts with nurses for individuals initiating cART with CD4 counts of ≤100 cells/mm³. All HIV-infected individuals aged 14 years or older initiating cART with CD4 counts of ≤100 cells/mm³were eligible for enrolment into HREC and for analysis. Adjusted hazard ratios (AHRs) control for potential confounding using propensity score methods.</p> <p>Results</p> <p>Between March 2007 and March 2009, 4,958 patients initiated cART with CD4 counts of ≤100 cells/mm³. After adjusting for age, sex, CD4 count, use of cotrimoxazole, treatment for tuberculosis, travel time to clinic and type of clinic, individuals in HREC had reduced mortality (AHR: 0.59; 95% confidence interval: 0.45-0.77), and reduced loss to follow up (AHR: 0.62; 95% CI: 0.55-0.70) compared with individuals in routine care. Overall, patients in HREC were much more likely to be alive and in care after a median of nearly 11 months of follow up (AHR: 0.62; 95% CI: 0.57-0.67).</p> <p>Conclusions</p> <p>Frequent monitoring by dedicated nurses in the early months of cART can significantly reduce mortality and loss to follow up among high-risk patients initiating treatment in resource-constrained settings.</p

Assessment of neonatal care in clinical training facilities in Kenya.

OBJECTIVE: An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya. DESIGN: Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data. SETTING: Neonatal units of 22 public hospitals. PATIENTS: Neonates aged 20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively. CONCLUSIONS: Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training

Gender difference in mortality among pulmonary tuberculosis HIV co-infected adults aged 15-49 years in Kenya

Setting: Kenya, 2012–2015 Objective: To explore whether there is a gender difference in all-cause mortality among smear positive pulmonary tuberculosis (PTB)/ HIV co-infected patients treated for tuberculosis (TB) between 2012 and 2015 in Kenya. Design: Retrospective cohort of 9,026 smear-positive patients aged 15–49 years. All-cause mortality during TB treatment was the outcome of interest. Time to start of antiretroviral therapy (ART) initiation was considered as a proxy for CD4 cell count. Those who took long to start of ART were assumed to have high CD4 cell count. Results: Of the 9,026 observations analysed, 4,567(51%) and 4,459(49%) were women and men, respectively. Overall, out of the 9,026 patients, 8,154 (90%) had their treatment outcome as cured, the mean age in years (SD) was 33.3(7.5) and the mean body mass index (SD) was 18.2(3.4). Men were older (30% men’ vs 17% women in those ≥40 years, p = \u3c0.001) and had a lower BMI \u3c18.5 (55.3% men vs 50.6% women, p = \u3c0.001). Men tested later for HIV: 29% (1,317/4,567) of women HIV tested more than 3 months prior to TB treatment, as compared to 20% (912/4,459) men (p\u3c0.001). Mortality was higher in men 11% (471/4,459) compared to women 9% (401/4,567, p = 0.004). There was a 17% reduction in the risk of death among women (adjusted HR 0.83; 95% CI 0.72–0.96; p = 0.013). Survival varied by age-groups, with women having significantly better survival than men, in the age-groups 40 years and over (log-rank p = 0.006). Conclusion: Women with sputum positive PTB/HIV co-infection have a significantly lower risk of all-cause mortality during TB treatment compared to men. Men were older, had lower BMI and tested later for HIV than women

Herbal remedies and other risk factors for preterm birth in rural Kenya

Background: Premature infants contribute substantially to infant morbidity and mortality especially in low resource settings.  Information on herbal remedy use, previous preterm birth and low social-economic status and their association with incidence of preterm birth in Kenya is scanty. Objectives: To determine the use of herbal remedy use in pregnancy, previous preterm birth and low socio-economic status as risk factors for Preterm Birth in Kitui County among the immediate post-partum mothers. Methods: Unmatched case control study with a 1:4 ratio of cases to controls. The study was done in Kitui and Mwingi District Hospitals.  A total of 107 mothers with preterm birth (cases) and 453 mothers with term births (controls) were eligible and administered structured interviews. Results: Of the sample, 98% of cases resided in rural areas compared to 90% of controls.  The cases had a higher parity and were more likely to belong to the lowest three and four levels of socio-economic status. On multivariate logistic regression analysis, predictors of preterm birth were: preeclampsia (OR=9.06 [2.60-31.63], p=0.001), previous preterm, (OR=9.31 [2.82-30.68], p&lt;0.001), low socioeconomic status (OR=1.51 [1.05-2.16], p=0.03), herbal use in first trimester for 2-5 days (OR=11.10 [4.34-28.41], p&lt;0.001), herbal use in first trimester for 6-10 days (OR=44.87,[4.99-403.87] p=0.001), and herbal use in second trimester for 6-10 days (OR=16.43 [4.53-59.57], p&lt;0.001). Use of prescribed folic acid in second trimester for more than 31 days was associated with lower risk of preterm birth (OR=0.20 [0.12-0.34], p&lt;0.001). Conclusion: Herbal use in pregnancy regardless of gestation, previous preterm birth and low socio-economic status and are risk factors for preterm birth in Kitui County Kenya.  Interventions targeted to reduction of these risk factors will be an important additional prong in the reduction of preterm birth. Key words: Preterm birth, herbal remedy, risk factor

Factors Associated with Virological Failure and Suppression after Enhanced Adherence Counselling, in Children, Adolescents and Adults on Antiretroviral Therapy for HIV in Swaziland

This study explores factors associated with virological detectability, and viral re-suppression after enhanced adherence counselling, in adults and children on antiretroviral therapy (ART) in Swaziland

Addressing intimate partner violence and power in relationships in HIV testing services: Results of an intervention piloted in Nairobi, Kenya

The overarching goal of this study was to pilot an approach to HIV testing services (HTS) that addresses intimate partner violence (IPV) and sexual relationship power (SRP) inequalities, and explores the intervention’s potential for improving uptake and retention of antiretroviral therapy and prevention of mother-to-child transmission services. The project was implemented in Kenyatta National Hospital’s (KNH) antenatal care (ANC) clinic, and examined intermediate indicators of effect, as well as operational issues around incorporating attention to IPV in hospital procedures, especially in high-volume, high-need settings like KNH’s. The findings from this study suggest that providing some minimal IPV/SRP counseling to all women—not just IPV screening, and not just to those who disclose violence—is warranted in settings such as HTS and ANC. This intervention—using simple tools and provider training and support—demonstrated that addressing these issues in HTS and during ANC can lead to some significant effects

An Insight Into Cervical Cancer Screening and Treatment Capacity in Sub Saharan Africa.

OBJECTIVE Approximately 85% of cervical cancer cases and deaths occur in resource-constrained countries where best practices for prevention, particularly for women with HIV infection, still need to be developed. The aim of this study was to assess cervical cancer prevention capacity in select HIV clinics located in resource-constrained countries. MATERIALS AND METHODS A cross-sectional survey of sub-Saharan African sites of 4 National Institutes of Health-funded HIV/AIDS networks was conducted. Sites were surveyed on the availability of cervical cancer screening and treatment among women with HIV infection and without HIV infection. Descriptive statistics and χ or Fisher exact test were used as appropriate. RESULTS Fifty-one (65%) of 78 sites responded. Access to cervical cancer screening was reported by 49 sites (96%). Of these sites, 39 (80%) performed screening on-site. Central African sites were less likely to have screening on-site (p = .02) versus other areas. Visual inspection with acetic acid and Pap testing were the most commonly available on-site screening methods at 31 (79%) and 26 (67%) sites, respectively. High-risk HPV testing was available at 29% of sites with visual inspection with acetic acid and 50% of sites with Pap testing. Cryotherapy and radical hysterectomy were the most commonly available on-site treatment methods for premalignant and malignant lesions at 29 (74%) and 18 (46%) sites, respectively. CONCLUSIONS Despite limited resources, most sites surveyed had the capacity to perform cervical cancer screening and treatment. The existing infrastructure of HIV clinical and research sites may provide the ideal framework for scale-up of cervical cancer prevention in resource-constrained countries with a high burden of cervical dysplasia

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men