Environmental determinants of access to shared sanitation in informal settlements: a cross-sectional study in Abidjan and Nairobi

BACKGROUND: Universal access to basic sanitation remains a global challenge, particularly in low- and middle-income countries. Efforts are underway to improve access to sanitation in informal settlements, often through shared facilities. However, access to these facilities and their potential health gains-notably, the prevention of diarrheal diseases-may be hampered by contextual aspects related to the physical environment. This study explored associations between the built environment and perceived safety to access toilets, and associations between the latter and diarrheal infections. METHODS: A cross-sectional study was carried out between July 2021 and February 2022, including 1714 households in two informal settlements in Abidjan (Cote d'Ivoire) and two in Nairobi (Kenya). We employed adjusted odds ratios (aORs) obtained from multiple logistic regressions (MLRs) to test whether the location of the most frequently used toilet was associated with a perceived lack of safety to use the facility at any time, and whether this perceived insecurity was associated with a higher risk of diarrhea. The MLRs included several exposure and control variables, being stratified by city and age groups. We employed bivariate logistic regressions to test whether the perceived insecurity was associated with settlement morphology indicators derived from the built environment. RESULTS: Using a toilet outside the premises was associated with a perceived insecurity both in Abidjan [aOR = 3.14, 95% confidence interval (CI): 1.13-8.70] and in Nairobi (aOR = 57.97, 95% CI: 35.93-93.53). Perceived insecurity to access toilets was associated with diarrheal infections in the general population (aOR = 1.90, 95% CI: 1.29-2.79 in Abidjan, aOR = 1.69, 95% CI: 1.22-2.34 in Nairobi), but not in children below the age of 5 years. Several settlement morphology features were associated with perceived insecurity, namely, buildings' compactness, the proportion of occupied land, and angular deviation between neighboring structures. CONCLUSIONS: Toilet location was a critical determinant of perceived security, and hence, must be adequately addressed when building new facilities. The sole availability of facilities may be insufficient to prevent diarrheal infections. People must also be safe to use them. Further attention should be directed toward how the built environment affects safety

Operational Research Project Management, Experiences, Challenges and Lessons Learnt

Introduction: Effective project management revolves around Strategic Management. Logistics seem simple and straight forward but, often the role  it plays in scientific undertakings is overlooked. It is usually assumed that research starts and ends in the laboratory. It is a fact that, for research activities to be successful, it requires exceptional planning to ensure that, resources are available as per the approved work-plan. This entails  determination of what, when, who, why and how it is to be done. Recent studies indicate that, logistics-related activities' impact on research  undertakings significantly. Objective: To document the project management experiences and lessons learnt in coordinating and implementation of East Africa Public Health Laboratories Networking Project –Operational Research (EAPHLNP-OR) activities in five East African countries, namely: Kenya, Rwanda, Burundi, Uganda and Tanzania. Methodology: The operational research component of the EAPHLNP, KEMRI established an OR Secretariat to coordinate the project activities in  Kenya and provide leadership to regional principal investigators. In consultation with the project Secretariat, the role of the administrator involved Work plan and budget preparation, planning, organizing, communicating, coordinating local and regional meetings, linking KEMRI research team with the study site (Hospital Administration) and Research Teams in the various counties. The site Teams obtained informed consent, recruited respondents, collected specimens, analyzed the specimens and shipped a portion of the same together with the results to KEMRI. Key Activities Of The Project: Managing financial aspects (budget and financial report preparations), logistical coordination, and procurement of training materials, organizing for meeting venues, taking minutes, travel arrangements and participation in scientific report writing. Control mechanism such as dairies, ledger books, work plan charts and schedules, managing and monitoring the progress of the project activities. Lesson Learnt & Challenges: Interpersonal skills were essential at all stages of the project. The critical stage was the forming, storming, and  norming stages. Here, group dynamics and conflicts took center stage. This threatened to stall the OR Project. Timely and constant communication with the study site coordinators, prioritization of scheduled project activities, was essential. Ensuring all parties are kept informed on the progress of the OR activities. The information in user-friendly format dairies and schedules provided the necessary feedback at administrative level, on project performance and at research findings. Key challenges included fluctuating funding, group dynamic conflicts and staff transfers. Discussion: EAPHLNP-OR was a Seven (7) years project undertaking, which for effective management involved understanding of the operating environment, strategic planning for short and long term goals, constant communication, review of priorities, documentation and practise of goodinterpersonal skills. Conclusion: Successful project management in OR required an administrator to coordinate the utilization of the available resources both capital and human. This is the second supplement in this issue only aspects on findings from TB and Enteric studies done in Kenya have been addressed.Three regional policy briefs on TB Enteric and malaria have been included

Experience and Lessons Learnt on Health Care Personnel Participating In the Implementation of TB Operational Research at (EAPHLNP -OR) Malindi, Kenya

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Unlocking the health system barriers to maximise the uptake and utilisation of molecular diagnostics in low- and middle- income country setting

The study was funded by the European and Developing Countries Clinical Trials Partnership (EDCTP), grant TWENDE-EDCTP-CSA-2014-283.Background : Early access to diagnosis is crucial for effective management of any disease including tuberculosis (TB). We investigated the barriers and opportunities to maximise uptake and utilisation of molecular diagnostics in routine healthcare settings. Methods : Using the implementation of World Health Organisation approved TB diagnostics, Xpert MTB/RIF and Line Probe Assay (LPA) as a benchmark we evaluated the barriers and how they could be unlocked to maximise uptake and utilisation of molecular diagnostics. Results : Health officers representing 190 districts/counties participated in the survey across Kenya, Tanzania and Uganda. The survey findings were corroborated by 145 healthcare facility (HCF) audits and 11 policymaker engagement workshops. Xpert MTB/RIF coverage was 66%, falling behind microscopy and clinical diagnosis by 33% and 1% respectively. Stratified by HCF type, Xpert MTB/RIF implementation was 56%, 96% and 95% at district-, regional- and national referral- hospital levels. LPA coverage was 4%, 3% below culture across the three countries. Out of 111 HCFs with Xpert MTB/RIF, 37 (33%) utilised it to full capacity, performing ≥8 tests per day of which 51% of these were level five (zonal consultant and national referral) HCFs. Likewise, 75% of LPA was available at level five HCFs. Underutilisation of Xpert MTB/RIF and LPA was mainly attributed to inadequate- utilities, 26% and human resource, 22%. Underfinancing was the main reason underlying failure to acquire molecular diagnostics. Second to underfinancing was lack of awareness with 33% healthcare administrators and 49% practitioners were unaware of LPA as TB diagnostic. Creation of a health tax and decentralising its management was proposed by policymakers as a booster of domestic financing needed to increase access to diagnostics. Conclusion : Our findings suggest higher uptake and utilisation of molecular diagnostics at tertiary level HCFs contrary to the WHO recommendation. Country-led solutions are crucial for unlocking barriers to increase access to diagnostics.Publisher PDFPeer reviewe

Household carbon monoxide (CO) concentrations in a large African city: An unquantified public health burden?

Carbon monoxide (CO) is a poisonous gas produced by incomplete combustion of carbon-based fuels that is linked to mortality and morbidity. Household air pollution from burning fuels on poorly ventilated stoves can lead to high concentrations of CO in homes. There are few datasets available on household concentrations of CO in urban areas of sub-Saharan African countries. CO was measured every minute over 24 h in a sample of homes in Nairobi, Kenya. Data on household characteristics were gathered by questionnaire. Metrics of exposure were summarised and analysis of temporal changes in concentration was performed. Continuous 24-h data were available from 138 homes. The mean (SD), median (IQR) and maximum 24-h CO concentration was 4.9 (6.4), 2.8 (1.0–6.3) and 44 ppm, respectively. 50% of homes had detectable CO concentrations for 847 min (14h07m) or longer during the 24-h period, and 9% of homes would have activated a CO-alarm operating to European specifications. An association between a metric of total CO exposure and self-reported exposure to vapours >15 h per week was identified, however this were not statistically significant after adjustment for the multiple comparisons performed. Mean concentrations were broadly similar in homes from a more affluent area and an informal settlement. A model of typical exposure suggests that cooking is likely to be responsible for approximately 60% of the CO exposure of Nairobi schoolchildren. Household CO concentrations are substantial in Nairobi, Kenya, despite most homes using gas or liquid fuels. Concentrations tend to be highest during the evening, probably associated with periods of cooking. Household air pollution from cooking is the main source of CO exposure of Nairobi schoolchildren. The public health impacts of long-term CO exposure in cities in sub-Saharan Africa may be considerable and should be studied further

Abnormal Brain Iron Homeostasis in Human and Animal Prion Disorders

Neurotoxicity in all prion disorders is believed to result from the accumulation of PrP-scrapie (PrPSc), a β-sheet rich isoform of a normal cell-surface glycoprotein, the prion protein (PrPC). Limited reports suggest imbalance of brain iron homeostasis as a significant associated cause of neurotoxicity in prion-infected cell and mouse models. However, systematic studies on the generality of this phenomenon and the underlying mechanism(s) leading to iron dyshomeostasis in diseased brains are lacking. In this report, we demonstrate that prion disease–affected human, hamster, and mouse brains show increased total and redox-active Fe (II) iron, and a paradoxical increase in major iron uptake proteins transferrin (Tf) and transferrin receptor (TfR) at the end stage of disease. Furthermore, examination of scrapie-inoculated hamster brains at different timepoints following infection shows increased levels of Tf with time, suggesting increasing iron deficiency with disease progression. Sporadic Creutzfeldt-Jakob disease (sCJD)–affected human brains show a similar increase in total iron and a direct correlation between PrP and Tf levels, implicating PrPSc as the underlying cause of iron deficiency. Increased binding of Tf to the cerebellar Purkinje cell neurons of sCJD brains further indicates upregulation of TfR and a phenotype of neuronal iron deficiency in diseased brains despite increased iron levels. The likely cause of this phenotype is sequestration of iron in brain ferritin that becomes detergent-insoluble in PrPSc-infected cell lines and sCJD brain homogenates. These results suggest that sequestration of iron in PrPSc–ferritin complexes induces a state of iron bio-insufficiency in prion disease–affected brains, resulting in increased uptake and a state of iron dyshomeostasis. An additional unexpected observation is the resistance of Tf to digestion by proteinase-K, providing a reliable marker for iron levels in postmortem human brains. These data implicate redox-iron in prion disease–associated neurotoxicity, a novel observation with significant implications for prion disease pathogenesis

Household carbon monoxide (CO) concentrations in a large African city: An unquantified public health burden?

Carbon monoxide (CO) is a poisonous gas produced by incomplete combustion of carbon-based fuels that is linked to mortality and morbidity. Household air pollution from burning fuels on poorly ventilated stoves can lead to high concentrations of CO in homes. There are few datasets available on household concentrations of CO in urban areas of sub-Saharan African countries. CO was measured every minute over 24 h in a sample of homes in Nairobi, Kenya. Data on household characteristics were gathered by questionnaire. Metrics of exposure were summarised and analysis of temporal changes in concentration was performed. Continuous 24-h data were available from 138 homes. The mean (SD), median (IQR) and maximum 24-h CO concentration was 4.9 (6.4), 2.8 (1.0–6.3) and 44 ppm, respectively. 50% of homes had detectable CO concentrations for 847 min (14h07m) or longer during the 24-h period, and 9% of homes would have activated a CO-alarm operating to European specifications. An association between a metric of total CO exposure and self-reported exposure to vapours >15 h per week was identified, however this were not statistically significant after adjustment for the multiple comparisons performed. Mean concentrations were broadly similar in homes from a more affluent area and an informal settlement. A model of typical exposure suggests that cooking is likely to be responsible for approximately 60% of the CO exposure of Nairobi schoolchildren. Household CO concentrations are substantial in Nairobi, Kenya, despite most homes using gas or liquid fuels. Concentrations tend to be highest during the evening, probably associated with periods of cooking. Household air pollution from cooking is the main source of CO exposure of Nairobi schoolchildren. The public health impacts of long-term CO exposure in cities in sub-Saharan Africa may be considerable and should be studied further

Spatial patterns of slums : comparing African and Asian cities

Spatial data on slums are commonly either generalized, outdated or not available. Thus, very limited knowledge exists on spatial and locational factors of slums across cities in the Global South. Therefore, this study compares slum characteristics of six cities (three Asian and three African). These characteristics were analyzed at landscape, settlement and object level using available datasets (e.g. Open Street Map) and a set of indicators that are able to describe spatial commonalities and differences at these three spatial levels. The results indicate that slums show at environ level commonalities across six selected cities, while object and settlement level characteristics display more variations between African and Asian cities. Yet, slums are dominated by small buildings, high densities and good locations in terms of accessibility but poor in terms of land suitability

Follow-Up of HIV Positive-Sputum Smear Negative Presumptive Tuberculosis Patients in The EAPHLNP Study Site in Kenya

Tuberculosis (TB) is a global health problem that causes ill-health among millions of people each year. The most common method for diagnosing TB worldwide was sputum smear microscopy. However the advent of HIV/AIDS has complicated the diagnosis and  management of TB with associated emergence of multidrug resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB). Studies that evaluate methods for diagnosing TB and follow-up of Presumptive TB patients to verify the presence or absence of active TB are crucial for prompt diagnosis and treatment. Objective: The study aimed to assess adherence to attend follow up clinical and sputum reexamination clinics for symptomatic HIV positive presumptive TB patients initially assumed to be TB negative. To find out at what stage HIV positive smear negative presumptive TB patients would become positive for TB with which diagnostic method within a 6 month follow up. Methodology: This was cohort study conducted in nine East African Public Health Laboratory Networking Project study sites in Kenya.  Eligible new and previously treated presumptive TB patients i.e. a patient presenting with symptoms and signs suggestive of TB who tested positive for HIV and had sputum smear negative on initial sputum smear examination were enrolled in to the study. Study participants were expected to be followed up for repeat sputum smear examination at 2 weeks, 2, 4, and 6 months. Results: Out of the 1323 presumptive TB patients enrolled between February 2013 and February 2014, only 201 (15.2%) were eligible for follow up and 164 (81.6%) did not return at 2 weeks for a follow up. Out of the 37 (18.4%) who returned for a follow up at 2 weeks, none was either sputum smear positive or Gene-Xpert positive. Initial sputum samples from all the 201 participants were subjected to culture. Culture results were available for only 156 patients of whom 15/156, (9.6%) were culture positive. Follow up adherence at 2 weeks was significantly associated with history of previous treatment (p-value = 0.010) but not associated with gender (p-value =0.268). Conclusion: The high level of non-adherence to follow up among HIV positive presumptive TB patients is a cause for concern to the  national TB program. We recommend active follow up of this group who has initial sputum smear negative results using the new  diagnostic tools that are available and can diagnosis TB early. Future studies should evaluate strategies that should be put in place to ensure enhanced follow up of the presumptive TB patients as part of the protocol. Key Words: Presumptive tuberculosis, HIV positive smear negative, Follow up&nbsp