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Background: Road traffic accidents (RTAs) are a significant contributor to morbidity and mortality in East Africa. Lower extremity (LE) injuries are especially debilitating, negatively impacting quality of life and employment prospects. This systematic review characterizes the proportion of LE injuries due to RTAs in four members of the East African Community: Kenya, Rwanda, Tanzania, and Uganda. Methods: Embase, Medline, Web of Science, and PubMed were queried for studies from 2010 to 2022 providing information on lower extremity injuries caused by RTAs in the countries of interest. Proportions of RTA-related LE injuries were extracted from eligible papers. Study quality and bias were assessed using the framework for systematic reviews established by Zaza et al.1 Results: Seven studies met the eligibility criteria--four for Kenya, two for Uganda, and one for Tanzania; however, no eligible studies were found for Rwanda. The proportion of RTA-related injuries affecting the lower extremities ranged from 0.39 to 0.49. In patients presenting with LE injuries, RTAs were the most frequent cause, representing more than 70% of cases in the examined studies. Motorcycle accidents were not more likely to cause LE injuries, but they were the most significant contributor to the overall LE injury burden due to their prevalence. Conclusions: With urbanization and the increased adoption of low-cost motorcycles, RTAs will continue to pose a public health challenge. Investments in traffic enforcement and physical infrastructure will alleviate the risks to both motorists and pedestrians. In addition to primary prevention, there is a significant need for improvements in emergency care and surgical capacity. [ABSTRACT FROM AUTHOR]

Background: Routine Data Quality Assessments (RDQAs) were developed to measure and improve facility-level electronic medical record (EMR) data quality. We assessed if RDQAs were associated with improvements in data quality in KenyaEMR, an HIV care and treatment EMR used at 341 facilities in Kenya. Methods: RDQAs assess data quality by comparing information recorded in paper records to KenyaEMR. RDQAs are conducted during a one-day site visit, where approximately 100 records are randomly selected and 24 data elements are reviewed to assess data completeness and concordance. Results are immediately provided to facility staff and action plans are developed for data quality improvement. For facilities that had received more than one RDQA (baseline and follow-up), we used generalized estimating equation models to determine if data completeness or concordance improved from the baseline to the follow-up RDQAs. Results: 27 facilities received two RDQAs and were included in the analysis, with 2369 and 2355 records reviewed from baseline and follow-up RDQAs, respectively. The frequency of missing data in KenyaEMR declined from the baseline (31% missing) to the follow-up (13% missing) RDQAs. After adjusting for facility characteristics, records from follow-up RDQAs had 0.43-times the risk (95% CI: 0.32–0.58) of having at least one missing value among nine required data elements compared to records from baseline RDQAs. Using a scale with one point awarded for each of 20 data elements with concordant values in paper records and KenyaEMR, we found that data concordance improved from baseline (11.9/20) to follow-up (13.6/20) RDQAs, with the mean concordance score increasing by 1.79 (95% CI: 0.25–3.33). Conclusions: This manuscript demonstrates that RDQAs can be implemented on a large scale and used to identify EMR data quality problems. RDQAs were associated with meaningful improvements in data quality and could be adapted for implementation in other settings. [ABSTRACT FROM AUTHOR]

Introduction: The growing impact of non-communicable diseases in low- to middle-income countries makes epilepsy a key research priority. We evaluated peer-reviewed published literature on childhood epilepsy specific to Kenya to identify knowledge gaps and inform future priorities. Methodology: A literature search utilizing the terms "epilepsy" OR "seizure" as exploded subject headings AND "Kenya" was conducted. Relevant databases were searched, generating 908 articles. After initial screening to remove duplications, irrelevant articles, and publications older than 15 years, 154 papers remained for full-article review, which identified 35 publications containing relevant information. Data were extracted from these reports on epidemiology, etiology, clinical features, management, and outcomes. Results: The estimated prevalence of lifetime epilepsy in children was 21–41 per 1,000, while the incidence of active convulsive epilepsy was 39–187 cases per 100,000 children per year. The incidence of acute seizures was 312–879 per 100,000 children per year and neonatal seizures 3,950 per 100,000 live births per year. Common risk factors for both epilepsy and acute seizures included adverse perinatal events, meningitis, malaria, febrile seizures, and family history of epilepsy. Electroencephalography abnormalities were documented in 20%–41% and neurocognitive comorbidities in more than half. Mortality in children admitted with acute seizures was 3%–6%, and neurological sequelae were identified in 31% following convulsive status epilepticus. Only 7%–29% children with epilepsy were on antiseizure medication. Conclusion: Active convulsive epilepsy is a common condition among Kenyan children, remains largely untreated, and leads to extremely poor outcomes. The high proportion of epilepsy attributable to preventable causes, in particular neonatal morbidity, contributes significantly to the lifetime burden of the condition. This review reaffirms the ongoing need for better public awareness of epilepsy as a treatable disease and for national-level action that targets both prevention and management. [ABSTRACT FROM AUTHOR]

Rapid detection and response to infectious disease outbreaks requires a robust surveillance system with a sufficient number of trained public health workforce personnel. The Frontline Field Epidemiology Training Program (Frontline) is a focused 3-month program targeting local ministries of health to strengthen local disease surveillance and reporting capacities. Limited literature exists on the impact of Frontline graduates on disease surveillance completeness and timeliness reporting. Using routinely collected Ministry of Health data, we mapped the distribution of graduates between 2014 and 2017 across 47 Kenyan counties. Completeness was defined as the proportion of complete reports received from health facilities in a county compared with the total number of health facilities in that county. Timeliness was defined as the proportion of health facilities submitting surveillance reports on time to the county. Using a panel analysis and controlling for county-fixed effects, we evaluated the relationship between the number of Frontline graduates and priority disease reporting of measles. We found that Frontline training was correlated with improved completeness and timeliness of weekly reporting for priority diseases. The number of Frontline graduates increased by 700%, from 57 graduates in 2014 to 456 graduates in 2017. The annual average rates of reporting completeness increased from 0.8% in 2014 to 55.1% in 2017. The annual average timeliness reporting rates increased from 0.1% in 2014 to 40.5% in 2017. These findings demonstrate how global health security implementation progress in workforce development may influence surveillance and disease reporting.

The logistical and operational challenges to improve public health practice capacity across Africa are well documented. This report describes Kenya's Field Epidemiology and Laboratory Training Program's (KFELTP) experience in implementing frontline public health worker training to transfer knowledge and practical skills that help strengthen their abilities to detect, document, respond to, and report unusual health events. Between May 2014 and May 2015, KFELTP hosted five training courses across the country to address practice gaps among local public health workers. Participants completed a 10-week process: two 1-week didactic courses, a 7-week field project, and a final 1-week course to present and defend the findings of their field project. The first year was a pilot period to determine whether the program could fit into the existing 2-year KFELTP model and whether this frontline-level training would have an impact on local practice. At the end of the first year, KFELTP certified 167 frontline health workers in field epidemiology and data management. This paper concludes that local, national, and international partnerships are critical for improving local public health response capacity and workforce development training in an African setting. [ABSTRACT FROM AUTHOR]

A primary use of malaria parasite genomics is identifying highly related infections to quantify epidemiological, spatial, or temporal factors associated with patterns of transmission. For example, spatial clustering of highly related parasites can indicate foci of transmission and temporal differences in relatedness can serve as evidence for changes in transmission over time. However, for infections in settings of moderate to high endemicity, understanding patterns of relatedness is compromised by complex infections, overall high forces of infection, and a highly diverse parasite population. It is not clear how much these factors limit the utility of using genomic data to better understand transmission in these settings. In particular, further investigation is required to determine which patterns of relatedness we expect to see with high quality, densely sampled genomic data in a high transmission setting and how these observations change under different study designs, missingness, and biases in sample collection. Here we investigate two identity-by-state measures of relatedness and apply them to amplicon deep sequencing data collected as part of a longitudinal cohort in Western Kenya that has previously been analysed to identify individual-factors associated with sharing parasites with infected mosquitoes. With these data we use permutation tests, to evaluate several hypotheses about spatiotemporal patterns of relatedness compared to a null distribution. We observe evidence of temporal structure, but not of finescale spatial structure in the cohort data. To explore factors associated with the lack of spatial structure in these data, we construct a series of simplified simulation scenarios using an agent based model calibrated to entomological, epidemiological and genomic data from this cohort study to investigate whether the lack of spatial structure observed in the cohort could be due to inherent power limitations of this analytical method. We further investigate how our hypothesis testing behaves under different sampling schemes, levels of completely random and systematic missingness, and different transmission intensities. [ABSTRACT FROM AUTHOR]

Background Although Shigella is an important cause of diarrhea in Kenyan children, robust research platforms capable of conducting incidence-based Shigella estimates and eventual Shigella- targeted clinical trials are needed to improve Shigella -related outcomes in children. Here, we describe characteristics of a disease surveillance platform whose goal is to support incidence and consequences of Shigella diarrhea as part of multicounty surveillance aimed at preparing sites and assembling expertise for future Shigella vaccine trials. Methods We mobilized our preexisting expertise in shigellosis, vaccinology, and diarrheal disease epidemiology, which we combined with our experience conducting population-based sampling, clinical trials with high (97%–98%) retention rates, and healthcare utilization surveys. We leveraged our established demographic surveillance system (DSS), our network of healthcare centers serving the DSS, and our laboratory facilities with staff experienced in performing microbiologic and molecular diagnostics to identify enteric infections. We joined these resources with an international network of sites with similar capabilities and infrastructure to form a cohesive scientific network, designated Enterics for Global Health (EFGH), with the aim of expanding and updating our knowledge of the epidemiology and adverse consequences of shigellosis and enriching local research and career development priorities. Conclusions Shigella surveillance data from this platform could help inform Shigella vaccine trials. [ABSTRACT FROM AUTHOR]

Background: More than two-thirds of the world's HIV-positive individuals live in sub-Saharan Africa, where genetic susceptibility to kidney disease is high and resources for kidney disease screening and antiretroviral therapy (ART) toxicity monitoring are limited. Equations to estimate glomerular filtration rate (GFR) from serum creatinine were derived in Western populations and may be less accurate in this population. Methods: We compared results from published GFR estimating equations with a direct measure of GFR by iohexol clearance in 99 HIV-infected, ART-naïve Kenyan adults. Iohexol concentration was measured from dried blood spots on filter paper. The bias ratio (mean of the ratio of estimated to measured GFR) and accuracy (percentage of estimates within 30% of the measured GFR) were calculated. Results: The median age was 35 years, and 60% were women. The majority had asymptomatic HIV, with median CD4+ cell count of 355 cells/mm3. Median measured GFR was 115 mL/min/1.73 m2. Overall accuracy was highest for the Chronic Kidney Disease Epidemiology Consortium (CKD-EPI) equation. Consistent with a prior report, bias and accuracy were improved by eliminating the coefficient for black race (85% of estimates within 30% of measured GFR). Accuracy of all equations was poor in participants with GFR 60–90 mL/min/1.73 m2 (<65% of estimates within 30% of measured GFR), although this subgroup was too small to reach definitive conclusions. Conclusions: Overall accuracy was highest for the CKD-EPI equation. Eliminating the coefficient for race further improved performance. Future studies are needed to determine the most accurate GFR estimate for use in individuals with GFR <90 mL/min/1.73 m2, in whom accurate estimation of kidney function is important to guide drug dosing. Direct measurement of GFR by iohexol clearance using a filter paper based assay is feasible for research purposes in resource-limited settings, and could be used to develop more accurate GFR estimates in African populations. [ABSTRACT FROM AUTHOR]

We conducted a randomized, controlled trial to test the effectiveness of a text-messaging system used for notification of disease outbreaks in Kenya. Health facilities that used the system had more timely notifications than those that did not (19.2% vs. 2.6%), indicating that technology can enhance disease surveillance in resource-limited settings. [ABSTRACT FROM AUTHOR]

Background: Monitoring and evaluation of malaria programmes may require a combination of approaches to detect any effects of control. This is particularly true at lower transmission levels where detecting both infection and exposure to infection will provide additional evidence of any change. This paper describes use of three transmission metrics to explore the malaria epidemiology in the highlands of western Kenya. Methods: A malariometric survey was conducted in June 2009 in two highland districts, Kisii and Rachuonyo South, Nyanza Province, Kenya using a cluster design. Enumeration areas were used to sample 46 clusters from which 12 compounds were randomly sampled. Individuals provided a finger-blood sample to assess malaria infection (rapid diagnostic test, PCR) and exposure (anti-Plasmodium falciparum MSP-1 antibodies) and a questionnaire was administered to record household factors and assess use of vector control interventions. Results: Malaria prevalence infection rates were 3.0 % (95 % CI 2.2–4.2 %) by rapid diagnostic test (RDT) and 8.5 % (95 % CI 7.0–10.4 %) by PCR and these ranged from 0–13.1 to 0–14.8 % between clusters for RDT and PCR, respectively. Seroprevalence was 36.8 % (95 % CI 33.9–39.8) ranging from 18.6 to 65.8 %. Both RDT and PCR prevalences were highest in children aged 5–10 years but the proportion of infections that were sub-patent was highest in those between 15 and 20 years of age (78.1 %, 95 % CI 63.0–93.3 %) and those greater than 20 years (73.3 %, 95 % CI 64.5– 81.9 %). Those reporting both indoor residual spraying (IRS) in their home and use of bed nets had lower exposure to malaria compared to those who reported using IRS or bed nets alone. Conclusions: In this highland site in western Kenya malaria transmission was low, but highly heterogeneous. To accurately characterize the true extent of malaria transmission, more sensitive and complementary metrics such as PCR or serology are required in addition to the standard microscopy and/or RDTs that are routinely used. This is likely to be the case in other low endemicity settings. [ABSTRACT FROM AUTHOR]

Background: Improved understanding and quantification of social contact patterns that govern the transmission dynamics of respiratory viral infections has utility in the design of preventative and control measures such as vaccination and social distancing. The objective of this study was to quantify an age-specific matrix of contact rates for a predominantly rural low-income population that would support transmission dynamic modeling of respiratory viruses. Methods and Findings: From the population register of the Kilifi Health and Demographic Surveillance System, coastal Kenya, 150 individuals per age group (<1, 1–5, 6–15, 16–19, 20–49, 50 and above, in years) were selected by stratified random sampling and requested to complete a day long paper diary of physical contacts (e.g. touch or embrace). The sample was stratified by residence (rural-to-semiurban), month (August 2011 to January 2012, spanning seasonal changes in socio-cultural activities), and day of week. Usable diary responses were obtained from 568 individuals (∼50% of expected). The mean number of contacts per person per day was 17.7 (95% CI 16.7–18.7). Infants reported the lowest contact rates (mean 13.9, 95% CI 12.1–15.7), while primary school students (6–15 years) reported the highest (mean 20.1, 95% CI 18.0–22.2). Rates of contact were higher within groups of similar age (assortative), particularly within the primary school students and adults (20–49 years). Adults and older participants (>50 years) exhibited the highest inter-generational contacts. Rural contact rates were higher than semiurban (18.8 vs 15.6, p = 0.002), with rural primary school students having twice as many assortative contacts as their semiurban peers. Conclusions and Significance: This is the first age-specific contact matrix to be defined for tropical Sub-Saharan Africa and has utility in age-structured models to assess the potential impact of interventions for directly transmitted respiratory infections. [ABSTRACT FROM AUTHOR]

As populations move to urban centres across East Africa, lifestyle habits that affect cardiovascular disease have changed, affecting non-communicable disease risk. In particular, the prevalence of hypertension, and associated awareness of this life-threatening condition, has not been studied in Mombasa, Kenya. This paper assesses the rates of prevalence, awareness, treatment and control of hypertension in Old Town, an urban district of the coastal city. We surveyed 469 subjects, gathered via a clustered sampling technique. Age-adjusted prevalence of hypertension was measured at 32.6% (±2.2) for adults over 18 and was linearly related to age. Results indicate that hypertension awareness was associated with age and sex, as women were substantially more likely to be aware of and to control their hypertension. Only 23.2% (±2.0) of subjects had knowledge of both the causes of and practical solutions to hypertension, and practical hypertension knowledge was associated with hypertension awareness and gender (women had higher rates of knowledge than men). These results indicate that hypertension is a real public health concern in Old Town, and that younger individuals, particularly males, are least likely to be aware of the dangers of hypertension. Public health measures should focus on this population. [ABSTRACT FROM AUTHOR]

Background: The current shortage of human resources for health threatens the attainment of the Millennium Development Goals. There is currently limited published evidence of health-related training programmes in Africa that have produced graduates, who remain and work in their countries after graduation. However, anecdotal evidence suggests that the majority of graduates of field epidemiology training programmes (FETPs) in Africa stay on to work in their home countries--many as valuable resources to overstretched health systems.Methods: Alumni data from African FETPs were reviewed in order to establish graduate retention. Retention was defined as a graduate staying and working in their home country for at least 3 years after graduation. African FETPs are located in Burkina Faso, Ethiopia, Ghana, Kenya, Nigeria, Rwanda, South Africa, the United Republic of Tanzania, Uganda and Zimbabwe. However, this paper only includes the Uganda and Zimbabwe FETPs, as all the others are recent programmes.Results: This review shows that enrolment increased over the years, and that there is high graduate retention, with 85.1% (223/261) of graduates working within country of training; most working with Ministries of Health (46.2%; 105/261) and non-governmental organizations (17.5%; 40/261). Retention of graduates with a medical undergraduate degree was higher (Zimbabwe 80% [36/83]; Uganda 90.6% [125/178]) than for those with other undergraduate qualifications (Zimbabwe 71.1% [27/83]; Uganda 87.5% [35/178]).Conclusions: African FETPs have unique features which may explain their high retention of graduates. These include: programme ownership by ministries of health and local universities; well defined career paths; competence-based training coupled with a focus on field practice during training; awarding degrees upon completion; extensive training and research opportunities made available to graduates; and the social capital acquired during training. [ABSTRACT FROM AUTHOR]

Background: Trials in Africa indicate that medical adult male circumcision (MAMC) reduces the risk of HIV by 60%. MAMC may avert 2 to 8 million HIV infections over 20 years in sub-Saharan Africa and cost less than treating those who would have been infected. This paper estimates the financial and human resources required to roll out MAMC and the net savings due to reduced infections. Methods: We developed a model which included costing, demography and HIV epidemiology. We used it to investigate 14 countries in sub-Saharan Africa where the prevalence of male circumcision was lower than 80% and HIV prevalence among adults was higher than 5%, in addition to Uganda and the Nyanza province in Kenya. We assumed that the roll-out would take 5 years and lead to an MC prevalence among adult males of 85%. We also assumed that surgery would be done as it was in the trials. We calculated public program cost, number of full-time circumcisers and net costs or savings when adjusting for averted HIV treatments. Costs were in USD, discounted to 2007. 95% percentile intervals (95% PI) were estimated by Monte Carlo simulations. Results: In the first 5 years the number of circumcisers needed was 2 282 (95% PI: 2 018 to 2 959), or 0.24 (95% PI: 0.21 to 0.31) per 10 000 adults. In years 6-10, the number of circumcisers needed fell to 513 (95% PI: 452 to 664). The estimated 5-year cost of rolling out MAMC in the public sector was $919 million (95%PI: 726 to 1 245). The cumulative net cost over the first 10 years was $672 million (95% PI: 437 to 1 021) and over 20 years there were net savings of $2.3 billion (95% PI: 1.4 to 3.4). Conclusion: A rapid roll-out of MAMC in sub-Saharan Africa requires substantial funding and a high number of circumcisers for the first five years. These investments are justified by MAMC's substantial health benefits and the savings accrued by averting future HIV infections. Lower ongoing costs and continued care savings suggest long-term sustainability. [ABSTRACT FROM AUTHOR]

This paper describes the development of a pilot project to test the implementation of an epidemiological surveillance system for intentional (violent) and non-intentional injuries, at emergency departments in selected hospitals in five African countries applying the World Health Organization's guidelines. We outline obstacles and opportunities encountered during the process. By definition, a surveillance system systematically collects, reviews, and evaluates information to understand the context in which specific injuries occur. Implementation in diverse sociocultural environments in Zambia, Uganda, Democratic Republic of the Congo, Nigeria, and Kenya has provided an opportunity to gather reliable data on injuries for comparisons between these countries. Analysis of the detailed information may permit researchers to generate evidence-based recommendations. Addressed to public authorities, and health authorities in particular, they can help address injury incidence in their communities from a public health perspective.Journal of Public Health Policy (2007) 28, 432–441. doi:10.1057/palgrave.jphp.3200154 [ABSTRACT FROM AUTHOR]

Road traffic injury (RTI) is a major public health concern in Kenya with more than 13,000 deaths estimated annually. The primary objective of this study was to design and implement an injury surveillance tool for the collection of injury data, and assess the tool's feasibility for the development of a hospital-based trauma registry in a leading Kenyan referral hospital. Secondarily, an epidemiologic profile was created to characterize RTI in the region. An injury surveillance tool was developed and implemented, on a pilot basis, in a level 5 trauma hospital, Jaramogi Oginga Odinga Teaching and Referral Hospital (JOOTRH), in Kisumu City, Western Kenya, for a 4-week period from 2019-07-15 to 2019-08-11. A descriptive statistical analysis summarized injury frequency counts and percentages. Over the pilot phase, 371 patients had forms completed, but 488 official injury-related hospital registrations, indicating that 117 injury patients (24%) were missed. A process evaluation of the tool implementation revealed issues in the collection protocol that required revisions, resulting in improved data form completeness rates. For the 368 cases with cause documented, the most common mechanisms of injury were RTI (46.5%; n = 171), assaults (23.9%; n = 88), and falls (14.9%; n = 55). For RTI patients, the median age was 28 years (IQR = 16) and 77% (n = 132) were males, with motorbike collision injuries (n = 91; 53.2%) the leading RTI mechanism. There were 348 injuries for 171 patients. The most common anatomical regions for RTI were the lower limb 32.8% (n = 114), upper limb (15.2%; n = 53), followed by head lacerations 8.6% (n = 30) and concussions 7.2% (n = 25). Two-thirds of patients (n = 113; 66.1%) were discharged from ED, just over a quarter (n = 46; 26.9%) were admitted to hospital and 9 patients succumbed to RTI (5.3%). This injury surveillance pilot study produced the first injury dataset in Kisumu City, demonstrating the significant magnitude of RTI in Western Kenya, the leading cause of injury for the region. This dataset can be replicated in other hospitals to create an injury surveillance system for the collection of trauma data, needed for the development of countermeasures for the reduction of trauma, as well as for quality initiatives to improve patient outcomes. [ABSTRACT FROM AUTHOR]

Background: Kenya introduced Rotarix® (GlaxoSmithKline Biologicals, Rixensart, Belgium) vaccination into its national immunization programme beginning July 2014. The impact of this vaccination program on the local epidemiology of various known enteropathogens is not fully understood. Methods: We used a custom TaqMan Array Card (TAC) to screen for 28 different enteropathogens in 718 stools from children aged less than 13 years admitted to Kilifi County Hospital, coastal Kenya, following presentation with diarrhea in 2013 (before vaccine introduction) and in 2016–2018 (after vaccine introduction). Pathogen positivity rate differences between pre- and post-Rotarix® vaccination introduction were examined using both univariate and multivariable logistic regression models. Results: In 665 specimens (92.6%), one or more enteropathogen was detected, while in 323 specimens (48.6%) three or more enteropathogens were detected. The top six detected enteropathogens were: enteroaggregative Escherichia coli (EAggEC; 42.1%), enteropathogenic Escherichia coli (EPEC; 30.2%), enterovirus (26.9%), rotavirus group A (RVA; 24.8%), parechovirus (16.6%) and norovirus GI/GII (14.4%). Post-rotavirus vaccine introduction, there was a significant increase in the proportion of samples testing positive for EAggEC (35.7% vs. 45.3%, p = 0.014), cytomegalovirus (4.2% vs. 9.9%, p = 0.008), Vibrio cholerae (0.0% vs. 2.3%, p = 0.019), Strongyloides species (0.8% vs. 3.6%, p = 0.048) and Dientamoeba fragilis (2.1% vs. 7.8%, p = 0.004). Although not reaching statistical significance, the positivity rate of adenovirus 40/41 (5.8% vs. 7.3%, p = 0.444), norovirus GI/GII (11.2% vs. 15.9%, p = 0.089), Shigella species (8.7% vs. 13.0%, p = 0.092) and Cryptosporidium spp. (11.6% vs. 14.7%, p = 0.261) appeared to increase post-vaccine introduction. Conversely, the positivity rate of sapovirus decreased significantly post-vaccine introduction (7.8% vs. 4.0%, p = 0.030) while that of RVA appeared not to change (27.4% vs. 23.5%, p = 0.253). More enteropathogen coinfections were detected per child post-vaccine introduction compared to before (mean: 2.7 vs. 2.3; p = 0.0025). Conclusions: In this rural Coastal Kenya setting, childhood enteropathogen infection burden was high both pre- and post-rotavirus vaccination introduction. Children who had diarrheal admissions post-vaccination showed an increase in coinfections and changes in specific enteropathogen positivity rates. This study highlights the utility of multipathogen detection platforms such as TAC in understanding etiology of childhood acute gastroenteritis in resource-limited regions. [ABSTRACT FROM AUTHOR]

Caprine besnoitiosis, caused by the cyst-forming protozoal apicomplexan Besnoitia caprae appears to be endemic in Kenya, Nigeria and Iran, but has yet to be detected in other parts of the world. The infection causes an important parasitic disease of goats in affected developing countries. Bovine besnoitiosis, is a widespread disease of cattle in Africa, Asia (but not Iran) and southern Europe. Recent epidemiological data confirm that the incidence and geographical range of bovine besnoitiosis in Europe is increasing, which is why growing attention has been given to the condition during the past decade. This paper reviews pertinent information on the biology, epidemiology, pathology, clinical signs, diagnosis and control of caprine besnoitiosis, together with its similarities to, and differences from, bovine besnoitiosis. The serious economic consequences of besnoitiosis on goat breeding and local meat and hide industries is also considered [ABSTRACT FROM AUTHOR]

Abstract: Although available evidence indicates that vouchers improve service utilization among the target populations, we do not know whether increased utilization results from improved access (new clients who would not have used services without the voucher) or from shifting clients from non-accredited to contracted service providers. This paper examines whether the safe motherhood voucher program in Kenya is associated with improved access to health facility delivery using information on births within two years preceding the survey in voucher and comparison sites. Data were collected in 2010–2011 and in 2012 among 2933 and 3094 women aged 15–49 years reporting 962 and 1494 births within two years before the respective surveys. Analysis entails cross-tabulations and estimation of multilevel random-intercept logit models. The results show that the proportion of births occurring at home declined by more than 10 percentage points while the proportion of births delivered in health facilities increased by a similar margin over time in voucher sites. The increase in facility-based births occurred in both public and private health facilities. There was also a significant increase in the likelihood of facility-based delivery (odds ratios [OR]: 2.04; 95% confidence interval [CI]: 1.40–2.98 in the 2006 voucher arm; OR: 1.72; 95% CI: 1.22–2.43 in the 2010–2011 voucher arm) in voucher sites over time. In contrast, there were no significant changes in the likelihood of facility-based delivery in the comparison arm over time. These findings suggest that the voucher program contributed to improved access to institutional delivery by shifting births from home to health facilities. However, available evidence from qualitative data shows that some women who purchased the vouchers did not use them because of high transportation costs to accredited facilities. The implication is that substantial improvements in service uptake could be achieved if the program subsidized transportation costs as well. [Copyright &y& Elsevier]

Background: Program Science is an iterative, multi-phase research and program framework where programs drive the scientific inquiry, and both program and science are aligned towards a collective goal of improving population health. Discussion: To achieve this, Program Science involves the systematic application of theoretical and empirical knowledge to optimize the scale, quality and impact of public health programs. Program Science tools and approaches developed for strategic planning, program implementation, and program management and evaluation have been incorporated into HIV and sexually transmitted infection prevention programs in Kenya, Nigeria, India, and the United States. Conclusion: In this paper, we highlight key scientific contributions that emerged from the growing application of Program Science in the field of HIV and STI prevention, and conclude by proposing future directions for Program Science. [ABSTRACT FROM AUTHOR]

Background: Falciparum and endemic Burkitt lymphoma (eBL) are co-endemic in Africa, but the malaria experience in eBL patients is unknown. A lower prevalence of falciparum has been reported in eBL patients, but those results are anecdotally attributed to pre-enrollment anti-malaria treatment. Methods: We studied 677 eBL patients and 2920 community controls aged 0–15 years enrolled in six regions in Uganda, Tanzania, and Kenya during 2010–2016. Falciparum was diagnosed using thick blood film microscopy (TFM) and antigen-capture rapid diagnostic tests (RDTs). Guardians of the children answered a 40-item structured questionnaire about their child's pre-enrollment lifetime malaria history and treatment, demographics, socioeconomics, animal exposures, fevers, and hospitalizations. We utilized exploratory factor analysis to reduce the 40 questionnaire variables into six factors, including Inpatient malaria and Outpatient malaria factors that were surrogates of pre-enrollment anti-malaria treatment. The six factors accounted for 83–90% of the variance in the questionnaire data. We calculated odds ratios and 95% confidence intervals (OR 95% CI) of association of eBL with falciparum positivity, defined as positive both on TFM or RDTs, or only RDTs (indicative of recent infection) or TFM (indicative of current falciparum infection) versus no infection, using multivariable logistic regression, controlling for group of age (0–2, 3–5, 6–8, 9–11 and 12–15 years), sex, and study site and the afore-mentioned pre-enrollment factors. Results: The prevalence of falciparum infection was 25.6% in the eBL cases and 45.7% in community controls (aOR = 0.43, 95% CI: 0.40, 0.47; P < 0.0001). The results were similar for recent falciparum infection (6.9% versus 13.5%, aOR = 0.44, 95% CI: 0.38, 0.50; P < 0.0001) and current falciparum infection (18.7% versus 32.1%, aOR = 0.47, 95% CI: 0.43, 0.51; P < 0.0001). These aORs for any, recent and current falciparum infection did not change when we adjusted for pre-enrollment factors (aORs = 0.46, =0.44, and = 0.51, respectively) were significantly lower in stratified analysis for any infection in children < 5 years (aOR = 0.46; 95% CI: 0.29, 0.75) or ≥ 10 years (aOR = 0.47; 95% CI: 0.32, 0.71). Conclusion: Our study results reduce support for pre-enrollment antimalaria treatment as a sole explanation for the observed lower falciparum prevalence in eBL cases and open a space to consider alternative immunology-based hypotheses. [ABSTRACT FROM AUTHOR]

Schistosomiasis is among the most common parasitic diseases in the world, with over 142 million people infected in low- and middle-income countries. Measuring population-level transmission is centrally important in guiding schistosomiasis control programs. Traditionally, human Schistosoma mansoni infections have been detected using stool microscopy, which is logistically difficult at program scale and has low sensitivity when people have low infection burdens. We compared serological measures of transmission based on antibody response to S. mansoni soluble egg antigen (SEA) with stool-based measures of infection among 3,663 preschool-age children in an area endemic for S. mansoni in western Kenya. We estimated force of infection among children using the seroconversion rate and examined how it varied geographically and by age. At the community level, serological measures of transmission aligned with stool-based measures of infection (ρ = 0.94), and serologicalmeasures provided more resolution for between-community differences at lower levels of infection. Force of infection showed a clear gradient of transmission with distance from Lake Victoria, with 94% of infections and 93% of seropositive children in communities <1.5 km from the lake. Force of infection increased through age 3 y, by which time 65% (95% CI: 53%, 75%) of children were SEA positive in hightransmission communities'2 y before they would be reached by school-based deworming programs. Our results show that serologic surveillance platforms represent an important opportunity to guide and monitor schistosomiasis control programs, and that in hightransmission settings preschool-age children represent a key population missed by school-based deworming programs. [ABSTRACT FROM AUTHOR]

Summary: Platelet counts are decreased in Plasmodium falciparum malaria, which is aetiologically linked with endemic Burkitt lymphoma (eBL). However, the pattern of platelet counts in eBL cases is unknown. We studied platelet counts in 582 eBL cases and 2 248 controls enrolled in a case‐control study in Uganda, Tanzania and Kenya (2010–2016). Mean platelet counts in controls or eBL cases with or without malaria‐infection in controls versus eBLcases were compared using Student's t‐test. Odds ratios (ORs) and two‐sided 95% confidence intervals (95% CIs) were estimated using multiple logistic regression, controlling for age, sex, haemoglobin and white blood cell counts. Platelets were decreased with malaria infection in the controls [263 vs. 339 × 109 platelets/l, P < 0·0001; adjusted OR (aOR) = 3·42, 95% CI: 2·79–4·18] and eBL cases (314 vs. 367 × 109 platelets/l, P‐value = 0·002; aOR = 2·36, 95% CI: 1·49–3·73). Unexpectedly, platelets were elevated in eBL cases versus controls in overall analyses (mean: 353 vs. 307 × 109 platelets/l, P < 0·0001; aOR = 1·41; 95% CI: 1·12–1·77), and when restricted to malaria‐positive (mean 314 vs. 263 × 109 platelets/l, P < 0·0001; OR = 2·26; 95% CI: 1·56–3·27) or malaria‐negative (mean 367 vs. 339 × 109 platelets/l, P < 0·001; OR = 1·46; 95% CI: 1·17–1·83) subjects. Platelets were decreased with malaria infection in controls and eBL cases but elevated with eBL. [ABSTRACT FROM AUTHOR]

This study aimed to examine the association between breastfeeding and childhood obesity. A multinational cross‐sectional study of 4,740 children aged 9–11 years was conducted from 12 countries. Infant breastfeeding was recalled by parents or legal guardians. Height, weight, waist circumference, and body fat were obtained using standardized methods. The overall prevalence of obesity, central obesity, and high body fat were 12.3%, 9.9%, and 8.1%, respectively. After adjustment for maternal age at delivery, body mass index (BMI), highest maternal education, history of gestational diabetes, gestational age, and child's age, sex, birth weight, unhealthy diet pattern scores, moderate‐to‐vigorous physical activity, sleeping, and sedentary time, exclusive breastfeeding was associated with lower odds of obesity (odds ratio [OR] 0.76, 95% confidence interval, CI [0.57, 1.00]) and high body fat (OR 0.60, 95% CI [0.43, 0.84]) compared with exclusive formula feeding. The multivariable‐adjusted ORs based on different breastfeeding durations (none, 1–6, 6–12, and > 12 months) were 1.00, 0.74, 0.70, and 0.60 for obesity (Ptrend =.020) and 1.00, 0.64, 047, and 0.64 for high body fat (Ptrend =.012), respectively. These associations were no longer significant after adjustment for maternal BMI. Breastfeeding may be a protective factor for obesity and high body fat in 9‐ to 11‐year‐old children from 12 countries. [ABSTRACT FROM AUTHOR]

Background: African animal trypanosomosis (AAT) is a major livestock disease in Kenya. Even though, over the years various organizations have collected a vast amount of field data on tsetse and AAT in different parts of the country, recent national-level maps are lacking. To address this gap, a national atlas of tsetse and AAT distribution is being developed by the Kenya Tsetse and Trypanosomosis Eradication Council (KENTTEC) and partners. Methods: All data collected by KENTTEC from 2006 to 2019 were systematically assembled, georeferenced and harmonized. A comprehensive data repository and a spatially-explicit database were created. Input data were collected mainly in the context of control activities, and include both baseline surveys (i.e. pre-intervention) and the subsequent monitoring during and after interventions. Surveys were carried out in four regions (i.e. Western, Rift Valley, Central and Coast), and in 21 of the 47 counties in Kenya. Various devices were used for entomological data collection (i.e. biconical, NGU and H traps, and sticky panels), while the buffy-coat technique was the method used to detect AAT. Results: Tsetse trapping was carried out in approximately 5000 locations, and flies (> 71,000) were caught in all four investigated regions. Six species of Glossina were detected: G. pallidipes (87% of the catches); G. brevipalpis (8%); G. fuscipes fuscipes (4%); G. longipennis (< 1%); G. austeni (< 1%); and G. swynnertoni (< 1%). A total of 49,785 animals (98% of which cattle) were tested for AAT in approximately 500 locations. Of these, 914 animals were found to be infected. AAT was confirmed in all study regions, in particular caused by Trypanosoma vivax (48% of infections) and T. congolense (42%). Fewer cases of T. brucei were found. Conclusions: The development and regular update of a comprehensive national database of tsetse and AAT is crucial to guide decision making for the progressive control of the disease. This first version of the atlas based on KENTTEC data has achieved a remarkable level of geographical coverage, but temporal and spatial gaps still exist. Other stakeholders at the national and international level will contribute to the initiative, thus improving the completeness of the atlas. [ABSTRACT FROM AUTHOR]

Malaria drug resistance is a global public health concern. Though parasite mutations have been associated with resistance, other factors could influence the resistance. A robust surveillance system is required to monitor and help contain the resistance. This study established the role of travel and gender in dispersion of chloroquine resistant genotypes in malaria epidemic zones in Kenya. A total of 1,776 individuals presenting with uncomplicated malaria at hospitals selected from four malaria transmission zones in Kenya between 2008 and 2014 were enrolled in a prospective surveillance study assessing the epidemiology of malaria drug resistance patterns. Demographic and clinical information per individual was obtained using a structured questionnaire. Further, 2 mL of blood was collected for malaria diagnosis, parasitemia quantification and molecular analysis. DNA extracted from dried blood spots collected from each of the individuals was genotyped for polymorphisms in Plasmodium falciparum chloroquine transporter gene (Pfcrt 76), Plasmodium falciparum multidrug resistant gene 1 (Pfmdr1 86 and Pfmdr1 184) regions that are putative drug resistance genes using both conventional polymerase chain reaction (PCR) and real-time PCR. The molecular and demographic data was analyzed using Stata version 13 (College Station, TX: StataCorp LP) while mapping of cases at the selected geographic zones was done in QGIS version 2.18. Chloroquine resistant (CQR) genotypes across gender revealed an association with chloroquine resistance by both univariate model (pD0:027) and by multivariate model (p D 0:025), female as reference group in both models. Prior treatment with antimalarial drugs within the last 6 weeks before enrollment was associated with carriage of CQR genotype by multivariate model (pD0:034). Further, a significant relationship was observed between travel and CQR carriage both by univariate model (pD0:001) and multivariate model (p D 0:002). These findings suggest that gender and travel are significantly associated with chloroquine resistance. From a gender perspective, males are more likely to harbor resistant strains than females hence involved in strain dispersion. On the other hand, travel underscores the role of transport network in introducing spread of resistant genotypes, bringing in to focus the need to monitor gene flow and establish strategies to minimize the introduction of resistance strains by controlling malaria among frequent transporters. [ABSTRACT FROM AUTHOR]

Avocado production has increased exponentially over the years worldwide. This has been necessitated by the various uses of avocado fruits other than as a source of nutrients which includes pharmaceutical, cosmetic and oil industries. These various uses of avocado have resulted to improved livelihood in terms of income generation. Increased avocado production worldwide has been at the expense of other tree and food crops. In Kenya, it is attributed to decreased acreage of key cash crops such as coffee and tea as well as staple food crops such as maize and beans. Avocado production, however, has been faced by several constraints such as poor rootstalks, diseases, pests, abiotic factors, poor harvesting technology, poor handling of harvested fruits and post-harvest diseases. All these challenges lead to poor fruit quality at the market both local and export market leading to losses economically. Of major concern is anthracnose disease caused by Colletotrichum gloeosporioides, Colletotrichum boninense, Pestalotiopsis microspora both in the field and after harvest. The disease is associated with 60% losses as a result of abortion of fruits in the field and post-harvest rots. Limited studies on the the interaction of the causal agents, the disease cycle and its epidemiology in Kenya, has rendered disease management impractical. Control of this disease has been through pruning and sorting of the diseased fruits. However, majority of the farmers do not apply any control measures. Furthermore, the use of chemical control has been limited due to a lack of available fungicides registered for use in Kenya. Fruit rots and quality issues due to black spots has affected the marketability of avocado fruits in the export market mainly EU market. Due to this, the avocado farmer in Kenya has been receiving low returns from their avocado export. Further understanding of the anthracnose disease epidemiology, virulence and genetic variation of the causal agent and the sensitivity of the causal agent to available fungicides will enhance the effectiveness of the anthracnose disease management, resulting in improved avocado productivity. [ABSTRACT FROM AUTHOR]

Rotavirus gastroenteritis still remains a major cause of morbidity and mortality among young children in developing countries, with ∼150 000–200 000 deaths occurring annually in sub-Saharan Africa. We reviewed papers published over the last 30 years on the epidemiology of rotavirus diarrhoea among the hospitalized and out-patient children in Kenya. The analysis shows rotavirus prevalence of 6–56% with diarrhoea occurring throughout the year and generally exhibiting distinct peaks during the dry months. Among the common genotype, G1 was the most predominant up to the year 2002 but more recently there has been an emergence of genotype G9 as the most predominant genotype and to a less extent G8. It is important to continue rotavirus surveillance in Kenya to determine accurately the burden of rotavirus disease and the emerging new genotypes. This will assist policy makers in decision making on rotavirus vaccine introduction and determining the impact of the vaccine. [ABSTRACT FROM AUTHOR]

Objective: Voluntary Counseling and Testing for HIV (VCT) and increasing access to male condoms are common strategies to respond to the HIV/AIDS pandemic. Using biological and behavioral outcomes, we compared programs to increase access to VCT, male condoms or both among youth in Western Kenya with the standard available HIV prevention services within this setting. Design: A four arm, unblinded randomized controlled trial. Methods: The sample includes 10,245 youth aged 17 to 24 randomly assigned to receive community-based VCT, 150 male condoms, both VCT and condoms, or neither program. All had access to standard HIV services available within their communities. Surveys and blood samples for HSV-2 testing were collected at baseline (2009–2010) and at follow up (2011–2013). VCT was offered to all participants at follow up. HSV-2 prevalence, the primary outcome, was assessed using weighted logistic regressions in an intention-to-treat analysis. Results: For the 7,565 respondents surveyed at follow up, (effective tracking rate = 91%), the weighted HSV-2 prevalence was similar across groups (control group = 10.8%, condoms only group = 9.1%, VCT only group = 10.2%, VCT and condoms group = 11.5%). None of the interventions significantly reduced HSV-2 prevalence; the adjusted odds ratios were 0.87 (95% CI: 0.61–1.25) for condoms only, 0.94 (95% CI: 0.64–1.38) for VCT only, and 1.12 (95% CI: 0.79–1.58) for both interventions. The VCT intervention significantly increased HIV testing (adj OR: 3.54, 95% CI: 2.32–5.41 for VCT only, and adj OR: 5.52, 95% CI: 3.90–7.81 for condoms and VCT group). There were no statistically significant effects on risk of HIV, or on other behavioral or knowledge outcomes including self-reported pregnancy rates. Conclusion: This study suggests that systematic community-based VCT campaigns (in addition to VCT availability at local health clinics) and condom distribution are unlikely on their own to significantly reduce the prevalence of HSV-2 among youth. [ABSTRACT FROM AUTHOR]

Background: Globally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation. Method: A 5-year (2012–2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for ‘lost-to-follow-up’ we used competing risk analysis method to examine risk factors for all-cause mortality. Results: 10,717 patients receiving TB treatment, median (IQR) age 33 (24–45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3–13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4–9.5) in 2012 to 17.7 (95% CI 14.9–21.1) in 2016 per 100PY (Ptrend<0.0001). 449/585 (77%) of the deaths occurred within the first three months after starting TB treatment. The median time to death (IQR) declined from 87 (40–100) days in 2012 to 46 (18–83) days in 2016 (Ptrend = 0·04). Mortality rate per 100PY was 7.3 (95% CI 6.5–7.8) and 23.1 (95% CI 20.8–25.7) among HIV-uninfected and HIV-infected patients respectively. Age, being a female, extrapulmonary TB, being undernourished, HIV infected and year of diagnosis were significantly associated with mortality. Conclusions: We found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend. [ABSTRACT FROM AUTHOR]

Purpose: To date, there has been insufficient focus on age and sex differences in studies of violence amongst adolescents and young adults in low- and middle-income countries. As adolescence is a formative period during which experiencing violence can have both short- and long-term consequences, we aim to investigate experiences of violence by age and sex across five countries. Methods: Incidences of past-year violence victimization were estimated by sex across two-year age bands (13–24 years) using Violence Against Children Survey datasets from Cambodia, Haiti, Kenya, Malawi, and Tanzania. Analyses were conducted separately for each country. The presence of an association with age and each type of violence was identified using logistic regressions separately by sex. Sex was then added to the models as an interaction term and adjusted Wald tests were used to assess differences between males and females in age effects. Results: Risk of physical violence by both an adult caregiver and a community member decreased with age for both sexes in all countries. In contrast, risk of IPV increased with age for both sexes in all countries. Although some countries displayed a steeper increase in risk of IPV and sexual violence with age for males, females face higher overall levels of risk for these forms of violence. Conclusion: Findings highlight how adolescents’ and young adults’ risk of violence changes with age and type of violence. The analysis underscores the importance of collecting violence data disaggregated by age and sex to best inform policies and programming. Implications and contributions: We analyzed five Violence Against Children Surveys (VACS) and found age effects for physical, sexual, and intimate partner violence for adolescents 13–24 years old. Age effects for sexual violence are stronger among females than males. Future policies targeting adolescents should consider how age and gender influence risk of violence. [ABSTRACT FROM AUTHOR]

Background: Expanded HIV prevention options are needed to increase uptake of HIV prevention among women, especially in generalized epidemics. As the dapivirine vaginal ring moves forward through regulatory review and open-label extension studies, the potential public health impact and cost-effectiveness of this new prevention method are not fully known. We used mathematical modeling to explore the impact and cost-effectiveness of the ring in different implementation scenarios alongside scale-up of other HIV prevention interventions. Given the knowledge gaps about key factors influencing the ring’s implementation, including potential uptake and delivery costs, we engaged in a stakeholder consultation process to elicit plausible parameter ranges and explored scenarios to identify the possible range of impact, cost, and cost-effectiveness. Methods and findings: We used the Goals model to simulate scenarios of oral and ring pre-exposure prophylaxis (PrEP) implementation among female sex workers and among other women ≤21 years or >21 years with multiple male partners, in Kenya, South Africa, Uganda, and Zimbabwe. In these scenarios, we varied antiretroviral therapy (ART) coverage, dapivirine ring coverage and ring effectiveness (encompassing efficacy and adherence) by risk group. Following discussions with stakeholders, the maximum level of PrEP coverage (oral and/or ring) considered in each country was equal to modern contraception use minus condom use in the two age groups. We assessed results for 18 years, from 2018 to 2035. In South Africa, for example, the HIV infections averted by PrEP (ring plus oral PrEP) ranged from 310,000 under the highest-impact scenario (including ART held constant at 2017 levels, high ring coverage, and 85% ring effectiveness) to 55,000 under the lowest-impact scenario (including ART reaching the UNAIDS 90-90-90 targets by 2020, low ring coverage, and 30% ring effectiveness). This represented a range of 6.4% to 2.2% of new HIV infections averted. Given our assumptions, the addition of the ring results in 11% to 132% more impact than oral PrEP alone. The cost per HIV infection averted for the ring ranged from US$13,000 to US$121,000. Conclusions: This analysis offers a wide range of scenarios given the considerable uncertainty over ring uptake, consistency of use, and effectiveness, as well as HIV testing, prevention, and treatment use over the next two decades. This could help inform donors and implementers as they decide where to allocate resources in order to maximize the impact of the dapivirine ring in light of funding and implementation constraints. Better understanding of the cost and potential uptake of the intervention would improve our ability to estimate its cost-effectiveness and assess where it can have the most impact. [ABSTRACT FROM AUTHOR]

Objectives: Female sex workers (FSWs) in sub-Saharan Africa are a key population for HIV prevention and treatment interventions, but less attention is given to their family planning needs. We evaluated the prevalence and predictors of unmet contraceptive need in HIV-positive FSWs. Study design: This cross-sectional analysis used data from an existing longitudinal study of FSWs in Mombasa, Kenya. This analysis included women who were HIV positive, age ≥18 years, pre-menopausal, not currently pregnant or desiring pregnancy, and reported exchanging sex for cash or in-kind payment at the time of enrollment. Unmet contraceptive need was defined as non-use of modern non-barrier contraceptives and not currently trying to become pregnant. Poisson regression was used to identify factors independently associated with unmet contraceptive need. Results: Among 346 HIV-positive FSWs, 125 (36.1%) reported modern non-barrier contraceptive use, leaving 221 (63.9%, 95%CI 58.8–68.9%) with unmet contraceptive need. Condom use was the only form of contraception for 129 (37.3%) participants. In unadjusted analyses, unmet contraceptive need was associated with physical abuse in the past year by someone other than a regular partner (PR 1.2, 95%CI 1.0–1.5), desire for (more) children (PR 1.3, 95%CI 1.1–1.5), and having 2–3 previous pregnancies compared to 0–1 prior pregnancies (PR 0.8, 95%CI 0.6–0.9). In adjusted analyses, lower number of previous pregnancies and having desire for future children remained significantly associated with a higher prevalence of unmet contraceptive need. Conclusions: Unmet need for modern non-barrier contraception was found in two-thirds of HIV-positive FSWs who reported that they were not currently trying to become pregnant, and was higher in women with the lowest number of prior pregnancies (0–1 prior pregnancies) and in those reporting desire for (more) children in the future. These findings highlight the need for concerted efforts to identify and eliminate barriers to contraceptive use in FSWs living with HIV. [ABSTRACT FROM AUTHOR]

Introduction: Global efforts to end HIV by 2030 focus on reducing and eventually eliminating new infections in priority populations. Identifying these populations and characterizing their vulnerability factors helps in guiding investment of scarce HIV prevention resources to achieve maximum impact. We sought to establish HIV prevalence, spatial distribution and risk factors for HIV infection in the Kenyan fishing communities of Lake Victoria. Methods: We conducted a cross-sectional survey of 2637 people from all the 308 fish-landing beaches on the Kenyan shore of Lake Victoria. The number of participants enrolled at each beach were weighted based on the size of the beach, determined by the number of functional registered boats. We used simple random sampling to select those to be approached for study participation. Consenting participants were privately interviewed about their socio-economic and demographic characteristics and sexual behavior, and were invited for HIV test using the Kenya rapid HIV testing protocol. We used descriptive statistics and multivariate logistic and linear regression for analysis. Results: We found high HIV prevalence of 32% with significant differences between men (29%) and women (38%). Among men, having an HIV negative sexual partner, being circumcised, increasing number of condom protected sex acts in the preceding month, being younger and being a resident of Homa Bay, Kisumu, Siaya and Busia counties compared to Migori County reduced the risk of HIV infection. For women, being married, having more children with the current spouse, having an HIV negative sexual partner and being a resident of Busia compared to Migori County reduced the risk of HIV infection. We also found that longer distance from the beaches to the nearest public health facilities was associated with increasing cumulative HIV prevalence at the beaches. Conclusion: Fishing communities have high HIV prevalence and may greatly benefit from interventions such as wider ART coverage, couple HIV risk reduction counseling, PrEP use for HIV negative partner at substantial continuous risk, alongside other HIV prevention services that the Kenyan government is currently rolling out. This will additionally require adequate plans to synchronize the provision of these services with the population’s routine schedules for all these options to be reasonably accessible to them. [ABSTRACT FROM AUTHOR]

Background: Kenya is 1 of 14 priority countries in Africa scaling up voluntary medical male circumcision (VMMC) for HIV prevention following the recommendations of the World Health Organization and the Joint United Nations Programme on HIV/AIDS. To inform VMMC target setting, we modeled the impact of circumcising specific client age groups across several Kenyan geographic areas. Methods: The Decision Makers’ Program Planning Tool, Version 2 (DMPPT 2) was applied in Kisumu, Siaya, Homa Bay, and Migori counties. Initial modeling done in mid-2016 showed coverage estimates above 100% in age groups and geographic areas where demand for VMMC continued to be high. On the basis of information obtained from country policy makers and VMMC program implementers, we adjusted circumcision coverage for duplicate reporting, county-level population estimates, migration across county boundaries for VMMC services, and replacement of traditional circumcision with circumcisions in the VMMC program. To address residual inflated coverage following these adjustments we applied county-specific correction factors computed by triangulating model results with coverage estimates from population surveys. Results: A program record review identified duplicate reporting in Homa Bay, Kisumu, and Siaya. Using county population estimates from the Kenya National Bureau of Statistics, we found that adjusting for migration and correcting for replacement of traditional circumcision with VMMC led to lower estimates of 2016 male circumcision coverage especially for Kisumu, Migori, and Siaya. Even after addressing these issues, overestimation of 2016 male circumcision coverage persisted, especially in Homa Bay. We estimated male circumcision coverage in 2016 by applying correction factors. Modeled estimates for 2016 circumcision coverage for the 10- to 14-year age group ranged from 50% in Homa Bay to approximately 90% in Kisumu. Results for the 15- to 19-year age group suggest almost complete coverage in Kisumu, Migori, and Siaya. Coverage for the 20- to 24-year age group ranged from about 80% in Siaya to about 90% in Homa Bay, coverage for those aged 25–29 years ranged from about 60% in Siaya to 80% in Migori, and coverage in those aged 30–34 years ranged from about 50% in Siaya to about 70% in Migori. Conclusions: Our analysis points to solutions for some of the data issues encountered in Kenya. Kenya is the first country in which these data issues have been encountered because baseline circumcision rates were high. We anticipate that some of the modeling methods we developed for Kenya will be applicable in other countries. [ABSTRACT FROM AUTHOR]

Peer education with micro-planning has been integral to scaling up key population (KP) HIV/STI programmes in Kenya since 2013. Micro-planning reinforces community cohesion within peer networks and standardizes programme inputs, processes and targets for outreach, including peer educator (PE) workloads. We assessed programme performance for outreach–in relation to the mean number of KPs for which one PE is responsible (KP:PE ratio)–and effects on HIV/STI service utilisation. Quarterly programmatic monitoring data were analysed from October 2013 to September 2016 from implementing partners working with female sex workers (FSWs) and men who have sex with men (MSM) across the country. All implementing partners are expected to follow national guidelines and receive micro-planning training for PEs with support from a Technical Support Unit for KP programmes. We examined correlations between KP:PE ratios and regular outreach contacts, condom distribution, risk reduction counselling, STI screening, HIV testing and violence reporting by KPs. Kenya conducted population size estimates (PSEs) of KPs in 2012. From 2013 to 2016, KP programmes were scaled up to reach 85% of FSWs (PSE 133,675) and 90% of MSM (PSE 18,460). Overall, mean KP:PE ratios decreased from 147 to 91 for FSWs, and from 79 to 58 for MSM. Lower KP:PE ratios, up to 90:1 for FSW and 60:1 for MSM, were significantly associated with more regular outreach contacts (p<0.001), as well as more frequent risk reduction counselling (p<0.001), STI screening (p<0.001) and HIV testing (p<0.001). Condom distribution and reporting of violence by KPs did not differ significantly between the two groups over all time periods. Micro-planning with adequate KP:PE ratios is an effective approach to scaling up HIV prevention programmes among KPs, resulting in high levels of programme uptake and service utilisation. [ABSTRACT FROM AUTHOR]

The Kenya National AIDS and STI Control Programme (NASCOP) conducted annual polling booth surveys (PBS) in 2014 and 2015 to measure outcomes from the national HIV prevention programme for key populations (KPs), comprising behavioural, biomedical and structural interventions. KPs included female sex workers (FSWs), men who have sex with men (MSM) and people who inject drugs (PWID). We compared survey results from the first and second rounds. Comparing the second to the first round, significantly more FSWs (93% vs. 88%, p<0.001) and MSM (77% vs. 58%, p<0.001) reported condom use at last sex with a paying client, and at last anal sex among MSM (80% vs. 77%, p<0.05) and PWID (48% vs. 27%, p<0.01). However, condom use with regular partners remained low, at less than 53% for FSWs and 69% for MSM. Among PWID, there was a significant increase in use of new needles and syringes at last injection (93% vs. 88%, p<0.001), and a significant decrease in reported non-availability of clean needles (23% vs. 36%, p<0.001). The number of overdoses in the past six months reduced significantly but remained high (40% vs. 51%, p<0.001). FSWs and MSM reported significantly higher HIV testing, and in all KP groups, over 93% reported ever having been tested for HIV. Among the respondents self-reporting to have tested HIV positive (24% of FSW, 22% of MSM and 19% of PWID), 80% of FSWs, 70% of MSM, and 73% of PWID reported currently taking antiretroviral therapy (ART). While the experience of forced intercourse by partners declined among FSWs (18% vs. 22%, p<0.01) and MSM (13% vs. 17%, p<0.01), more FSWs reported violence by law enforcement personnel (49% vs. 44%, p<0.001). These findings provide valuable information on the programme’s progress, and a signpost for the integrated behavioural, biomedical and structural interventions to achieve their HIV prevention targets. [ABSTRACT FROM AUTHOR]

Until recently, HIV in Africa was presumed to be driven by poverty, gender inequality and poor governance. The last decade has seen a shift in global and national public health discourses, especially in eastern Africa where new statistical evidence is used to justify prevention efforts to target Key Populations, i.e. men who have sex with men (MSM), injecting drug users, and sex workers. In this article, we focus on Kenya to examine state, NGO and community HIV treatment and prevention efforts targeting MSM, specifically male sex workers. We combine ethnographic fieldwork with a critical analysis of policy(making) and implementation practices to sketch the contours of the global, national and local forces that have combined to (re)make male homosexual sex to be understood as a practice that contributes to HIV incidence in Kenya. We also show that HIV-related MSM programmes in Kenya primarily enrol male sex workers in HIV treatment programmes, which focus on mainly on treatment adherence and pay insufficient attention to the economic and psycho-social problems experienced by male sex workers. Although upper and middle class MSM are involved in running LGTBI rights-based interventions and in mobilising male sex workers for HIV interventions, they are rarely targeted by those interventions. [ABSTRACT FROM AUTHOR]

Vector-borne diseases (VBDs) of humans and domestic animals are a significant component of the global burden of disease and a key driver of poverty. The transmission cycles of VBDs are often strongly mediated by the ecological requirements of the vectors, resulting in complex transmission dynamics, including intermittent epidemics and an unclear link between environmental conditions and disease persistence. An important broader concern is the extent to which theoretical models are reliable at forecasting VBDs; infection dynamics can be complex, and the resulting systems are highly unstable. Here, we examine these problems in detail using a case study of Rift Valley fever (RVF), a high-burden disease endemic to Africa. We develop an ecoepidemiological, compartmental, mathematical model coupled to the dynamics of ambient temperature and water availability and apply it to a realistic setting using empirical environmental data from Kenya. Importantly, we identify the range of seasonally varying ambient temperatures and water-body availability that leads to either the extinction of mosquito populations and/or RVF (nonpersistent regimens) or the establishment of long-term mosquito populations and consequently, the endemicity of the RVF infection (persistent regimens). Instabilities arise when the range of the environmental variables overlaps with the threshold of persistence. The model captures the intermittent nature of RVF occurrence, which is explained as low-level circulation under the threshold of detection, with intermittent emergence sometimes after long periods. Using the approach developed here opens up the ability to improve predictions of the emergence and behaviors of epidemics of many other important VBDs. [ABSTRACT FROM AUTHOR]

Background: Influenza‐associated respiratory illness was substantial during the emergence of the 2009 influenza pandemic. Estimates of influenza burden in the post‐pandemic period are unavailable to guide Kenyan vaccine policy. Objectives: To update estimates of hospitalized and non‐hospitalized influenza‐associated severe acute respiratory illness (SARI) during a post‐pandemic period (2012‐2014) and describe the incidence of disease by narrow age categories. Methods: We used data from Siaya County Referral Hospital to estimate age‐specific base rates of SARI. We extrapolated these base rates to other regions within the country by adjusting for regional risk factors for acute respiratory illness (ARI), regional healthcare utilization for acute respiratory illness, and the proportion of influenza‐positive SARI cases in each region, so as to obtain region‐specific rates. Results: The mean annual rate of hospitalized influenza‐associated SARI among all ages was 21 (95% CI 19‐23) per 100 000 persons. Rates of non‐hospitalized influenza‐associated SARI were approximately 4 times higher at 82 (95% CI 74‐90) per 100 000 persons. Mean annual rates of influenza‐associated SARI were highest in children <2 years of age with annual hospitalization rates of 147 (95% CI of 134‐160) per 100 000 persons and non‐hospitalization rates of 469 (95% CI 426‐517) per 100 000 persons. For the period 2012‐2014, there were between 8153 and 9751 cases of hospitalized influenza‐associated SARI and 31 785‐38 546 cases of non‐hospitalized influenza‐associated SARI per year. Conclusions: The highest burden of disease was observed among children <2 years of age. This highlights the need for strategies to prevent influenza infections in this age group. [ABSTRACT FROM AUTHOR]

Objective: We compared the impact and costs of HIV prevention strategies focusing on youth (15–24 year-old persons) versus on adults (15+ year-old persons), in a high-HIV burden context of a large generalized epidemic. Design: Compartmental age-structured mathematical model of HIV transmission in Nyanza, Kenya. Interventions: The interventions focused on youth were high coverage HIV testing (80% of youth), treatment at diagnosis (TasP, i.e., immediate start of antiretroviral therapy [ART]) and 10% increased condom usage for HIV-positive diagnosed youth, male circumcision for HIV-negative young men, pre-exposure prophylaxis (PrEP) for high-risk HIV-negative females (ages 20–24 years), and cash transfer for in-school HIV-negative girls (ages 15–19 years). Permutations of these were compared to adult-focused HIV testing coverage with condoms and TasP. Results: The youth-focused strategy with ART treatment at diagnosis and condom use without adding interventions for HIV-negative youth performed better than the adult-focused strategy with adult testing reaching 50–60% coverage and TasP/condoms. Over the long term, the youth-focused strategy approached the performance of 70% adult testing and TasP/condoms. When high coverage male circumcision also is added to the youth-focused strategy, the combined intervention outperformed the adult-focused strategy with 70% testing, for at least 35 years by averting 94,000 more infections, averting 5.0 million more disability-adjusted life years (DALYs), and saving US$46.0 million over this period. The addition of prevention interventions beyond circumcision to the youth-focused strategy would be more beneficial if HIV care costs are high, or when program delivery costs are relatively high for programs encompassing HIV testing coverage exceeding 70%, TasP and condoms to HIV-infected adults compared to combination prevention programs among youth. Conclusion: For at least the next three decades, focusing in high burden settings on high coverage HIV testing, ART treatment upon diagnosis, condoms and male circumcision among youth may outperform adult-focused ART treatment upon diagnosis programs, unless the adult testing coverage in these programs reaches very high levels (>70% of all adults reached) at similar program costs. Our results indicate the potential importance of age-targeting for HIV prevention in the current era of ‘test and start, ending AIDS’ goals to ameliorate the HIV epidemic globally. [ABSTRACT FROM AUTHOR]

Background: Pediatric rheumatic diseases are chronic illnesses that can cause considerable disease burden to children and their families. There is limited epidemiologic data on these diseases in East Africa. The aim of this study was to assess the spectrum of pediatric rheumatic diagnoses in an in-patient setting and determine the accuracy of ICD-10 codes in identifying these conditions. Methods: Medical records from Gertrude's Children's Hospital in Kenya were reviewed for patients diagnosed with "diseases of the musculoskeletal system and connective tissue" as per ICD-10 diagnostic codes assigned at discharge between January and December 2011. Cases were classified as "rheumatic" or "non-rheumatic". Accuracy of the assigned ICD-10 code was ascertained. Death records were reviewed. Longitudinal follow-up of "rheumatic" cases was done by chart review up to March 2014. Results: Twenty six patients were classified as having a "rheumatic" condition accounting for 0.32% of patients admitted. Of these, 11 (42.3%) had an acute inflammatory arthropathy, 6 (23.1%) had septic arthritis, 4 (15.4%) had Kawasaki disease, 2 (7.7%) had pyomyositis, and there was one case each of septic bursitis, rheumatic fever, and a non-specific soft tissue disorder. No cases of juvenile idiopathic arthritis (JIA) were identified. One case of systemic lupus erythematosus was documented by death records. The agreement between the treating physician's discharge diagnosis and medical records ICD-10 code assignment was good (Kappa: 0.769). On follow-up, one child had recurrent knee swelling that was suspicious for JIA. Conclusions: Pediatric rheumatic conditions represented 0.32% of admissions at a pediatric hospital in Kenya. Acute inflammatory arthropathies, septic arthritis and Kawasaki disease were the most frequent in-patient rheumatic diagnoses. Chronic pediatric rheumatic diseases were rare amongst this in-patient population. Despite limitations associated with the use of administrative diagnostic codes, they can be a first step in evaluating the spectrum of pediatric rheumatic conditions in Kenya and other countries in East Africa. [ABSTRACT FROM AUTHOR]

Purpose: The objective of the study was to estimate the prevalence, comorbidity and socio-demographic correlates of common mental disorders among orphan and vulnerable children (OVCs) in residential care.Methods: The Youth Self Report (YSR) instrument was adapted for use and administered to 630 OVCs aged 10-18 years in four institutions operating within the Eastern province of Kenya. We estimated the prevalence of YSR syndromes and used logistic regression analyses to examine socio-demographic factors associated with each disorder.Results: The prevalence of any mental disorder according to YSR syndrome scale was 30.8% (95% CI 27.1-34.6). Female gender and older children were less likely to be associated with risk of scoring in the clinical range of the mental disorders. The presence of multiple mental problems was seen among 16.7% of the children. Of the 16.7%, 5.6% had one comorbid mental disorder and 11.1% had three to eight mental disorders.Conclusion: We found a high prevalence of mental disorders and co-occurring disorders among the OVCs in residential institutions in Kenya. There is need for an alternative approach that can reach out to critical numbers of children for screening and public health, rather than purely clinical approach. The capacity for these institutions should also be regulated and more efforts focusing on improving the quality of care in the facilities taken into account at all times. [ABSTRACT FROM AUTHOR]

The last decade has witnessed a steady reduction of the malaria burden worldwide. With various countries targeting disease elimination in the near future, the popular parasite infection or entomological inoculation rates are becoming less and less informative of the underlying malaria burden due to a reduced number of infected individuals or mosquitoes at the time of sampling. To overcome such problem, alternative measures based on antibodies against specific malaria antigens have gained recent interest in malaria epidemiology due to the possibility of estimating past disease exposure in absence of infected individuals. This paper aims then to review current mathematical models and corresponding statistical approaches used in antibody data analysis. The application of these models is illustrated with three data sets from Equatorial Guinea, Brazilian Amazonia region, and western Kenyan highlands. A brief discussion is also carried out on the future challenges of using these models in the context of malaria elimination. [ABSTRACT FROM AUTHOR]

Background: Brucellosis is a debilitating zoonotic disease affecting humans and animals. A comprehensive, evidence-based assessment of literature and officially available data on animal and human brucellosis for Kenya are missing. The aim of the current review is to provide frequency estimates of brucellosis in humans, animals and risk factors for human infection, and help to understand the current situation in Kenya.Methods: A total of accessible 36 national and international publications on brucellosis from 1916 to 2016 were reviewed to estimate the frequency of brucellosis in humans and animals, and strength of associations between potential risk factors and seropositivity in humans in Kenya.Results: The conducted studies revealed only few and fragmented evidence of the disease spatial and temporal distribution in an epidemiological context. Bacteriological evidence revealed the presence of Brucella (B.) abortus and B. melitensis in cattle and human patients, whilst B. suis was isolated from wild rodents only. Similar evidence for Brucella spp infection in small ruminants and other animal species is unavailable. The early and most recent serological studies revealed that animal brucellosis is widespread in all animal production systems. The animal infection pressure in these systems has remained strong due to mixing of large numbers of animals from different geographical regions, movement of livestock in search of pasture, communal sharing of grazing land, and the concentration of animals around water points. Human cases are more likely seen in groups occupationally or domestically exposed to livestock or practicing risky social-cultural activities such as consumption of raw blood and dairy products, and slaughtering of animals within the homesteads. Many brucellosis patients are misdiagnosed and probably mistreated due to lack of reliable laboratory diagnostic support resulting to adverse health outcomes of the patients and routine disease underreporting. We found no studies of disease incidence estimates or disease control efforts.Conclusion: The risk for re-emergence and transmission of brucellosis is evident as a result of the co-existence of animal husbandry activities and social-cultural activities that promote brucellosis transmission. Well-designed countrywide, evidence-based, and multidisciplinary studies of brucellosis at the human/livestock/wildlife interface are needed. These could help to generate reliable frequency and potential impact estimates, to identify Brucella reservoirs, and to propose control strategies of proven efficacy. [ABSTRACT FROM AUTHOR]

Background: Q fever in Kenya is poorly reported and its surveillance is highly neglected. Standard empiric treatment for febrile patients admitted to hospitals is antimalarials or penicillin-based antibiotics, which have no activity against Coxiella burnetii. This study aimed to assess the seroprevalence and the predisposing risk factors for Q fever infection in febrile patients from a pastoralist population, and derive a model for clinical prediction of febrile patients with acute Q fever.Methods: Epidemiological and clinical data were obtained from 1067 patients from Northeastern Kenya and their sera tested for IgG antibodies against Coxiella burnetii antigens by enzyme-linked-immunosorbent assay (ELISA), indirect immunofluorescence assay (IFA) and quantitative real-time PCR (qPCR). Logit models were built for risk factor analysis, and diagnostic prediction score generated and validated in two separate cohorts of patients.Results: Overall 204 (19.1 %, 95 % CI: 16.8-21.6) sera were positive for IgG antibodies against phase I and/or phase II antigens or Coxiella burnetii IS1111 by qPCR. Acute Q fever was established in 173 (16.2 %, 95 % CI: 14.1-18.7) patients. Q fever was not suspected by the treating clinicians in any of those patients, instead working diagnosis was fever of unknown origin or common tropical fevers. Exposure to cattle (adjusted odds ratio [aOR]: 2.09, 95 % CI: 1.73-5.98), goats (aOR: 3.74, 95 % CI: 2.52-9.40), and animal slaughter (aOR: 1.78, 95 % CI: 1.09-2.91) were significant risk factors. Consumption of unpasteurized cattle milk (aOR: 2.49, 95 % CI: 1.48-4.21) and locally fermented milk products (aOR: 1.66, 95 % CI: 1.19-4.37) were dietary factors associated with seropositivity. Based on regression coefficients, we calculated a diagnostic score with a sensitivity 93.1 % and specificity 76.1 % at cut off value of 2.90: fever >14 days (+3.6), abdominal pain (+0.8), respiratory tract infection (+1.0) and diarrhoea (-1.1).Conclusion: Q fever is common in febrile Kenyan patients but underappreciated as a cause of community-acquired febrile illness. The utility of Q fever score and screening patients for the risky social-economic and dietary practices can provide a valuable tool to clinicians in identifying patients to strongly consider for detailed Q fever investigation and follow up on admission, and making therapeutic decisions. [ABSTRACT FROM AUTHOR]

Background: Malaria transmission is highly heterogeneous, generating malaria hotspots that can fuel malaria transmission across a wider area. Targeting hotspots may represent an efficacious strategy for reducing malaria transmission. We determined the impact of interventions targeted to serologically defined malaria hotspots on malaria transmission both inside hotspots and in surrounding communities.Methods and Findings: Twenty-seven serologically defined malaria hotspots were detected in a survey conducted from 24 June to 31 July 2011 that included 17,503 individuals from 3,213 compounds in a 100-km2 area in Rachuonyo South District, Kenya. In a cluster-randomized trial from 22 March to 15 April 2012, we randomly allocated five clusters to hotspot-targeted interventions with larviciding, distribution of long-lasting insecticide-treated nets, indoor residual spraying, and focal mass drug administration (2,082 individuals in 432 compounds); five control clusters received malaria control following Kenyan national policy (2,468 individuals in 512 compounds). Our primary outcome measure was parasite prevalence in evaluation zones up to 500 m outside hotspots, determined by nested PCR (nPCR) at baseline and 8 wk (16 June-6 July 2012) and 16 wk (21 August-10 September 2012) post-intervention by technicians blinded to the intervention arm. Secondary outcome measures were parasite prevalence inside hotpots, parasite prevalence in the evaluation zone as a function of distance from the hotspot boundary, Anopheles mosquito density, mosquito breeding site productivity, malaria incidence by passive case detection, and the safety and acceptability of the interventions. Intervention coverage exceeded 87% for all interventions. Hotspot-targeted interventions did not result in a change in nPCR parasite prevalence outside hotspot boundaries (p ≥ 0.187). We observed an average reduction in nPCR parasite prevalence of 10.2% (95% CI -1.3 to 21.7%) inside hotspots 8 wk post-intervention that was statistically significant after adjustment for covariates (p = 0.024), but not 16 wk post-intervention (p = 0.265). We observed no statistically significant trend in the effect of the intervention on nPCR parasite prevalence in the evaluation zone in relation to distance from the hotspot boundary 8 wk (p = 0.27) or 16 wk post-intervention (p = 0.75). Thirty-six patients with clinical malaria confirmed by rapid diagnostic test could be located to intervention or control clusters, with no apparent difference between the study arms. In intervention clusters we caught an average of 1.14 female anophelines inside hotspots and 0.47 in evaluation zones; in control clusters we caught an average of 0.90 female anophelines inside hotspots and 0.50 in evaluation zones, with no apparent difference between study arms. Our trial was not powered to detect subtle effects of hotspot-targeted interventions nor designed to detect effects of interventions over multiple transmission seasons.Conclusions: Despite high coverage, the impact of interventions targeting malaria vectors and human infections on nPCR parasite prevalence was modest, transient, and restricted to the targeted hotspot areas. Our findings suggest that transmission may not primarily occur from hotspots to the surrounding areas and that areas with highly heterogeneous but widespread malaria transmission may currently benefit most from an untargeted community-wide approach. Hotspot-targeted approaches may have more validity in settings where human settlement is more nuclear.Trial Registration: ClinicalTrials.gov NCT01575613. [ABSTRACT FROM AUTHOR]

Background: The MSM population in Kenya contributes to 15% of HIV incidence. This calls for innovative HIV prevention interventions. Pre-exposure prophylaxis (PrEP) has been efficacious in preventing HIV among MSM in trials. There is limited data on the willingness to take daily oral PrEP in sub-Sahara Africa. PrEP has not been approved for routine use in most countries globally. This study aimed to document the willingness to take PrEP and barriers to uptake and adherence to PrEP in Kenya. The findings will inform the design of a PrEP delivery program as part of the routine HIV combination prevention. Methods: Eighty MSM were recruited in 2 Counties in December 2013. Quantitative data on sexual behaviour and willingness to take PrEP were collected using semi-structured interviews and analysed using SPSS. Qualitative data on knowledge of PrEP, motivators and barriers to uptake and adherence to PrEP were collected using in-depth interviews and FGDs and analysed using Nvivo. Analysis of data in willingness to take PrEP was conducted on the HIV negative participants (n = 55). Results: 83% of MSM were willing to take daily oral HIV PrEP. Willingness to take PrEP was higher among the bi-sexual and younger men. Motivators for taking PrEP were the need to stay HIV negative and to protect their partners. History of poor medication adherence, fear of side effects and HIV stigma were identified as potential barriers to adherence. Participants were willing to buy PrEP at a subsidized price. Conclusions: There is willingness to take PrEP among MSM in Kenya and there is need to invest in targeted education and messaging on PrEP to enhance adherence, proper use and reduce stigma in the general population and among policy makers. [ABSTRACT FROM AUTHOR]