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BackgroundMore than 49,000 cases of infection and 900 deaths from COVID-19 have been recorded in the Kenya. However, the characteristics and risk factors for severe outcomes among hospitalized COVID-19 patients in this setting have not been described.MethodsWe extracted demographic, laboratory, clinical and outcome data from medical records of RT-PCR confirmed SARS-CoV2 patients admitted in six hospitals in Kenya between March and September, 2020. We used Cox proportional hazards regressions to determine factors related to in-hospital mortality.ResultsData from 787 COVID-19 patients was available. The median age was 43 years (IQR 30-53), with 505 (64%) males. At admission, 455 (58%) were symptomatic. The commonest symptoms were cough (337, 43%), loss of taste or smell (279, 35%), and fever (126, 16%). Co-morbidities were reported in 340 (43%), with cardiovascular disease, diabetes and HIV documented in 130 (17%), 116 (15%), 53 (7%) respectively. 90 (11%) were admitted to ICU for a mean of 11 days, 52 (7%) were ventilated with a mean of 10 days, 107 (14%) died. The risk of death increased with age [hazard ratio (HR) 1.57 (95% CI 1.13 – 2.19)] for persons >60 years compared to those ConclusionsWe identify the risk factors for mortality that may guide stratification of high risk patients.

Asthma prevalence in children varies substantially around the world, but the contribution of known risk factors to this international variation is uncertain. The International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two studied 8-12 year old children in 30 centres worldwide with parent-completed symptom and risk factor questionnaires and aeroallergen skin prick testing. We used multilevel logistic regression modelling to investigate the effect of adjustment for individual and ecological risk factors on the between-centre variation in prevalence of recent wheeze. Adjustment for single individual-level risk factors changed the centre-level variation from a reduction of up to 8.4% (and 8.5% for atopy) to an increase of up to 6.8%. Modelling the 11 most influential environmental factors among all children simultaneously, the centre-level variation changed little overall (2.4% increase). Modelling only factors that decreased the variance, the 6 most influential factors (synthetic and feather quilt, mother's smoking, heating stoves, dampness and foam pillows) in combination resulted in a 21% reduction in variance. Ecological (centre-level) risk factors generally explained higher proportions of the variation than did individual risk factors. Single environmental factors and aeroallergen sensitisation measured at the individual (child) level did not explain much of the between-centre variation in wheeze prevalence.

Background In low‐ and middle‐income countries, the majority of patients lack access to surgical care due to limited personnel and infrastructure. The Lancet Commission on Global Surgery recommended laparotomy for district hospitals. However, little is known about the cost of laparotomy and associated clinical care in these settings. Methods This costing study included patients with acute abdominal conditions at three rural district hospitals in 2015 in Rwanda, and used a time‐driven activity‐based costing methodology. Capacity cost rates were calculated for personnel, location and hospital indirect costs, and multiplied by time estimates to obtain allocated costs. Costs of medications and supplies were based on purchase prices. Results Of 51 patients with an acute abdominal condition, 19 (37 per cent) had a laparotomy; full costing data were available for 17 of these patients, who were included in the costing analysis. The total cost of an entire care cycle for laparotomy was US$1023·40, which included intraoperative costs of US$427·15 (41·7 per cent) and preoperative and postoperative costs of US$596·25 (58·3 per cent). The cost of medicines was US$358·78 (35·1 per cent), supplies US$342·15 (33·4 per cent), personnel US$150·39 (14·7 per cent), location US$89·20 (8·7 per cent) and hospital indirect cost US$82·88 (8·1 per cent). Conclusion The intraoperative cost of laparotomy was similar to previous estimates, but any plan to scale‐up laparotomy capacity at district hospitals should consider the sizeable preoperative and postoperative costs. Although lack of personnel and limited infrastructure are commonly cited surgical barriers at district hospitals, personnel and location costs were among the lowest cost contributors; similar location‐related expenses at tertiary hospitals might be higher than at district hospitals, providing further support for decentralization of these services.

Some previously described environmental associations for atopic eczema may be due to reverse causation. We explored the role of reverse causation by comparing individual-and school-level results for multiple atopic eczema risk factors. The International Study of Asthma and Allergies in Childhood (i.e, ISAAC) Phase Three surveyed children in schools (the sampling unit) regarding atopic eczema symptoms and potential risk factors. We assessed the effect of these risk factors on atopic eczema symptoms using mixed-effect logistic regression models, first with individual-level exposure data and second with school-level exposure prevalence. Overall, 546,348 children from 53 countries were included. At ages 6-7 years, the strongest individual-level associations were with current paracetamol use (odds ratio [OR] = 1.45, 95% confidence interval [CI] = 1.37-1.54), which persisted at school-level (OR = 1.55, 95% CI = 1.10-2.21), early-life antibiotics (OR = 1.41, 95% CI = 1.34-1.48), and early-life paracetamol use (OR = 1.28, 95% CI = 1.21-1.36), with the former persisting at the school level, whereas the latter was no longer observed (OR = 1.35, 95% CI = 1.00-1.82 and OR = 0.94, 95% CI = 0.69-1.28, respectively). At ages 13-14 years, the strongest associations at the individual level were with current paracetamol use (OR = 1.57, 95% CI = 1.51-1.63) and open-fire cooking (OR = 1.46, 95% CI = 1.33-1.62); both were stronger at the school level (OR = 2.57, 95% CI = 1.84-3.59 and OR = 2.38, 95% CI = 1.52-3.73, respectively). Association with exposure to heavy traffic (OR = 1.31, 95% CI = 1.27-1.36) also persisted at the school level (OR = 1.40, 95% CI = 1.07-1.82). Most individual-and school-level effects were consistent, tending to exclude reverse causation.

Background: Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC) measured the global prevalence of symptoms of asthma in children. We undertook comprehensive analyses addressing risk factors for asthma symptoms in combination, at both the individual and the school level, to explore the potential role of reverse causation due to selective avoidance or confounding by indication. Objective: To explore the role of reverse causation in risk factors of asthma symptoms. Methods: We compared two sets of multilevel logistic regression analyses, using (a) individual level exposure data and (b) school level average exposure (ie prevalence), in two different age groups. In individual level analyses, reverse causation is a possible concern if individual level exposure statuses were changed as a result of asthma symptoms or diagnosis. School level analyses may suffer from ecologic confounding, but reverse causation is less of a concern because individual changes in exposure status as a result of asthma symptoms would only have a small effect on overall school exposure levels. Results: There were 131 924 children aged 6-7 years (2428 schools, 25 countries) with complete exposure, outcome and confounder data. The strongest associations in individual level analyses (fully adjusted) were for current paracetamol use (odds ratio = 2.06; 95% confidence interval 1.97-2.16), early life antibiotic use (1.65; 1.58-1.73) and open fire cooking (1.44; 1.26-1.65). In school level analyses, these risk factors again showed increased risks. There were 238 586 adolescents aged 13-14 years (2072 schools, 42 countries) with complete exposure, outcome and confounder data. The strongest associations in individual level analyses (fully adjusted) were for current paracetamol use (1.80; 1.75-1.86), cooking on an open fire (1.32; 1.22-1.43) and maternal tobacco use (1.23; 1.18-1.27). In school level analyses, these risk factors again showed increased risks. Conclusions & clinical relevance: These analyses strengthen the potentially causal interpretation of previously reported individual level findings, by providing evidence against reverse causation.

Objectives: This study aims to recommend Arthrheuma Society of Kenya (ARSK) proposed Rheumatoid Arthritis (RA) management and to compose a national expert opinion management of RA under guidance of current guidelines and implantation and dissemination of these international guidelines into our clinical practice.Materials and methods: A scientific committee of nineteen experts consisting of nine rheumatologists, three rheumatology nurses and seven physicians was formed. The recommendations, systemic reviews, and meta-analysis including pharmacologic and non-pharmacologic treatment were scrutinized paying special attention with convenient key words. The draft ARSK recommendations for management of RA opinion whose roof consisted of international treatment recommendations, particularly the assessment of American College of Rheumatology (ACR)/ European League Against Rheumatism was composed. Assessment of level of agreement with opinions by task force members was established through the Delphi technique. Voting using a numerical rating scale assessed the strength of each recommendation.Results: Panel comprised of six basic principles and recommendations including pharmacological and nonpharmacological methods. All of the recommendations had adequate strength.Conclusion: ARSK expert opinion for the management of RA was developed based on scientifi c evidence. These recommendations will be updated regularly in accordance with current developments.Keywords: Arthrheuma Society of Kenya, Rheumatoid Arthritis, Management guidelines

Fever of Unknown Origin (FUO) is a syndrome defined by persistent fevers above 38.30C that lasts for longer than 3 weeks with no obvious source. It usually poses a diagnostic challenge to the clinician.We describe a case of FUO in a young male adult who was treated several times with antibiotics and anti-malarial with no resolution of symptoms. A diagnosis of Adult Onset Still’s Disease (AOSD) was made after thorough investigation. A methylprednisolone pulse therapy relieved the fevers and maintenance therapy continued with methotrexate.Adult Onset Still’s Disease is a multi-systemic inflammatory disorder that can manifest as FUO and should be suspected if the fever does not respond to therapy.Keywords: Adult Onset Still’s Disease, Fever of unknown origin

Background: Systemic lupus erythematosus (SLE), a chronic multisystem autoimmune disease with a wide spectrum of manifestations, shows considerable variation across the globe, although there is data from Africa is limited. Quantifying the burden of SLE across Africa can help raise awareness and knowledge about the disease. It will also clarify the role of genetic, environmental and other causative factors in the natural history of the disease, and to understand its clinical and societal consequences in African set up.Objective: To determine the clinical profile of SLE patients at a tertiary care centre in Nairobi, Kenya.Methods: Case records of patients who were attending the Nairobi Arthritis Clinic seen between January 2002 and January 2013 were reviewed. This was a cross-sectional study done on 100 patients fulfilling the 2012 Systemic Lupus Collaborating Clinics (SLICC) criteria for SLE attending the Nairobi Arthritis Clinic, Kenya. The patients were evaluated for sociodemographic, clinical and immunological manifestations and drugs used to manage SLE.Results: Hundred patients diagnosed with SLE were recruited into the study. Ninety seven per cent of the study participants were female with a mean age of 36.6 years. Thirty three years was the mean age of diagnosis. The mean time duration of disease was 3 years with a range of 0-13 years. There was extensive disease as many had multi-organ involvement. Majority (83%) of the study participants met between 4 and 6 manifestations for the diagnosis criteria for SLE. Non erosive arthritis and cutaneous disease were the commonest initial manifestation. The patients had varied cutaneous, haematological, pulmonary, cardiac, renal and neuropsychiatric manifestations. Antinuclear antibody (ANA) assay and anti-dsDNA was positive in 82% and 52%. Patients on steroids, non-steroidal drugs and synthetic disease modifying anti-rheumatic drugs were 84%, 49% and 43% respectively. None of the patients were on biologic disease modifying antirheumatic drugs.Conclusions: In Nairobi, SLE is a multisystem disorder affecting predominantly young females. Polyarthritis and cutaneous disease were the most common clinical features. This is comparable to other studies done in black African population. We found a higher prevalence of haematological and lower rate of renal disease as compared to other studies done in black Africans. The ANA assay and anti-dsDNA positivity was lower than those in other studies on black Africans. Majority of the patients were on steroids.Keywords: SLE, Nairobi, Kenya

Extensive planning will be necessary to integrate HIV pre-exposure prophylaxis (PrEP) into public health systems. In Bondo and Kisumu, Kenya, we conducted interviews with 16 district and provincial public health stakeholders and held consultations with 18 provincial and 23 national public health stakeholders on topics related to PrEP rollout. We coded interview transcripts and created memos summarizing responses. We documented consultation discussions through note taking. Human resource challenges identified included increased workload and insufficient personnel, the need for task shifting/sharing, training needs, infrastructural requirements, discrimination and stigma by staff towards at-risk clients, and providers’ personal priorities about offering PrEP. These challenges paralleled current challenges related to integration of antiretroviral therapy (ART) and could be partially addressed prior to PrEP rollout. The recommendations for training staff are likewise grounded in lessons from ART and have practical application for program planners developing training curricula for PrEP delivery. Keywords: Human resources; pre-exposure prophylaxis; PrEP integration

The International Study of Asthma and Allergies in Childhood (ISAAC) Phase One showed large worldwide variations in the prevalence of symptoms of asthma, rhinoconjunctivitis and eczema, up to 10 to 20 fold between countries. Ecological analyses were undertaken with ISAAC Phase One data to explore factors that may have contributed to these variations, and are summarised and reviewed here.In ISAAC Phase One the prevalence of symptoms in the past 12 months of asthma, rhinoconjunctivitis and eczema were estimated from studies in 463,801 children aged 13 - 14 years in 155 centres in 56 countries, and in 257,800 children aged 6-7 years in 91 centres in 38 countries. Ecological analyses were undertaken between symptom prevalence and the following: Gross National Product per capita (GNP), food intake, immunisation rates, tuberculosis notifications, climatic factors, tobacco consumption, pollen, antibiotic sales, paracetamol sales, and outdoor air pollution.Symptom prevalence of all three conditions was positively associated with GNP, trans fatty acids, paracetamol, and women smoking, and inversely associated with food of plant origin, pollen, immunisations, tuberculosis notifications, air pollution, and men smoking. The magnitude of these associations was small, but consistent in direction between conditions. There were mixed associations of climate and antibiotic sales with symptom prevalence.The potential causality of these associations warrant further investigation. Factors which prevent the development of these conditions, or where there is an absence of a positive correlation at a population level may be as important from the policy viewpoint as a focus on the positive risk factors. Interventions based on small associations may have the potential for a large public health benefit.

BACKGROUND: Associations of larger families with lower prevalences of hay fever, eczema and objective markers of allergic sensitization have been found fairly consistently in affluent countries, but little is known about these relationships in less affluent countries.\ud \ud METHODS: Questionnaire data for 210,200 children aged 6-7 years from 31 countries, and 337,226 children aged 13-14 years from 52 countries, were collected by Phase Three of the International Study of Asthma and Allergies in Childhood (ISAAC). Associations of disease symptoms and labels of asthma, rhinoconjunctivitis and eczema were analysed by numbers of total, older and younger siblings, using mixed (multi-level) logistic regression models to adjust for individual covariates and at the centre level for region, language and national affluence.\ud \ud RESULTS: In both age groups, inverse trends (P < 0.0001) were observed for reported 'hay fever ever' and 'eczema ever' with increasing numbers of total siblings, and more specifically older siblings. These inverse associations were significantly (P < 0.005) stronger in more affluent countries. In contrast, symptoms of severe asthma and severe eczema were positively associated (P < 0.0001) with total sibship size in both age groups. These associations with disease severity were largely independent of position within the sibship and national GNI per capita.\ud \ud CONCLUSIONS: These global findings on sibship size and childhood asthma, rhinoconjunctivitis and eczema suggest at least two distinct trends. Inverse associations with older siblings (observations which prompted the 'hygiene hypothesis' for allergic disease) are mainly a phenomenon of more affluent countries, whereas greater severity of symptoms in larger families is globally more widespread.

Background: Systemic Lupus Erythematosus (SLE) is a chronic autoimmune disease that affects all organs of the body. It is becoming increasingly clear that SLE is not as rare in Kenya as was previously thought. Due to its chronicity SLE has been known to affect the quality of life of those affected by it. There is minimal data on SLE in East Africa and especially in Kenya. The quality of life of SLE patients in this country has never been assessed. Objectives: To document the quality of life of patients with SLE in Kenyatta National Hospital using LUPUS QOL questionnaire. We also sought to correlate HRQOL with duration of illness, drugs used and age of the patient. Design: This was a cross sectional study done on patients attending Rheumatology Clinic in Kenyatta National Hospital. Methods: Patients who satisfy the ACR criteria were consecutively recruited. All patients with SLE attending the clinic were included in the study. Consent was obtained from the patients after which their demographic data was obtained. Patients were examined for the presence of malar rash, discoid rash, arthritis/athralgia, photosensitivity, CNS symptoms, serositis and oral ulcers. The patients then filled the LUPUS QOL questionnaire. The information acquired was then analysed using SPSS version 17.0 using student t test and regression analysis. The quality of life was calculated and then correlated with age, duration of illness and drug management. Results: Sixty two patients were analysed (60 females 2 males). Mean age of the population was 37.3 years (range 14-71 years). All patients had some level of education with 61.3% of the population having some form of secondary education. Most patients 54.8% were married. Mean age of diagnosis was 34.5 years with mean duration of illness 1.5 years. Majority (88.7%) had arthritis/ athralgia, oral ulcers (62.9%), malar rash (59.7%), photosensitivity (58.1%), serositis (32.3%), CNS symptoms (27.4%) and discoid rash (17.7%). Patients scored globally low in all domains of LUPUS QOL. Highest domain was planning 63.7 (29.3), emotional health 61.3 (26.5), burden to others 58.9 (31.2), fatigue 57.5 (30.0), pain 56.6 (29.6), physical health 54.0 (23.3), body image 47.1 (24.2) intimate relations 41.1 (38.4).The most common drug in use in our population was prednisone at 74.2%. This was followed by HCQ at 69.4%, NSAIDS 54.8%, azathioprine 37.1%, methotrexate 22.6%, mycofenolate mofetil 8.1%, CCB 11.3%, cyclosporine 3.2%. HRQOL correlated positively with advance in age for the domains. Physical health, burden to others, emotional health and fatigue. There was no correlation between HRQOL and duration of illness or drugs used by the population. Conclusion: The HRQOL of our SLE patients was found to be low in all domains and to correlate with advance in age in the domains of physical health, burden to others, emotional health and fatigue. However there was no correlation with duration of illness or the drugs used by the patients.

Background: Childhood obesity and asthma are increasing worldwide. A possible link between the two conditions has been postulated. Methods: Cross-sectional studies of stratified random samples of 8-12-year-old children (n=10 652) (16 centres in affluent and 8 centres in non-affluent countries) used the standardized methodology of ISAAC Phase Two. Respiratory and allergic symptoms were ascertained by parental questionnaires. Tests for allergic disease were performed. Height and weight were measured, and overweight and obesity were defined according to international definitions. Prevalence rates and prevalence odds ratios were calculated. Results: Overweight (odds ratio=1.14, 95%-confidence interval: 0.98; 1.33) and obesity (odds ratio=1.67, 95%-confidence interval: 1.25; 2.21) were related to wheeze. The relationship was stronger in affluent than in non-affluent centres. Similar results were found for cough and phlegm, rhinitis and eczema but the associations were mostly driven by children with wheeze. There was a clear association of overweight and obesity with airways obstruction (change in FEV1/FVC, 20.90, 95%-confidence interval: 21.33%; 20.47%, for overweight and 22.46%, 95%-confidence interval: 23.84%; 21.07%, for obesity) whereas the results for the other objective markers, including atopy, were null. Conclusions: Our data from a large international child population confirm that there is a strong relation of body mass index with wheeze especially in affluent countries. Moreover, body mass index is associated with an objective marker of airways obstruction (FEV1/FVC) but no other objective markers of respiratory and allergic disorders. © 2014 Weinmayr et al.

This paper presents research to identify and assess soil and plant parameters during transition to selected conservation agriculture practices identified by smallholder farmers in western Kenya.

Low nitrogen use efficiency and fertilizer recovery by crops in sub-Saharan Africa suggests high rates of nitrogen and carbon leaching, resulting in greenhouse gas emissions. The objective of this study was to inventory seasonal GHG emissions from continuous maize/bean intercropping grown under unimodal (one growing season) and bi-modal (two growing seasons) conditions. Soils from the bimodal area of Bungoma had very high N2O emissions during crop growth and greater though still very low CH4 assimilation compared to Trans-Nzoia. LTRA-10 (CAPS for smallholder farms in eastern Uganda and western Kenya)

Metadata only record Soil quality and crop yield parameters resulting from conservation agriculture practices were evaluated in on-station and on-farm studies established in two highland sites and two lowland sites in the Mount Elgon region of western Kenya and eastern Uganda. Each of the four study areas consists of an on-station and four on-farm sites, each with of three tillage practices (conventional moldboard, no-till, and minimum till); two levels of nitrogen fertilizer (60 Kg N Ha-1 and none); and three cropping systems (traditional maize-beans intercropping, maize intercropped with a bean-Mucuna [Mucuna pruriens] relay, and strip intercropping with maize, beans, and Mucuna in rotation planted in four-row strips) in a factorial design with nine treatments. First and second year results of soil organic matter analyses and crop yields indicate that reduced tillage combined with adding the cover crop to the rotation has begun to improve soil quality and has not negatively impacted yields. Some cooperating farmers have noted improved maize yields following Mucuna and are eager to scale up reduced-tillage and cover crop treatments. LTRA-10 (CAPS for smallholder farms in eastern Uganda and western Kenya)

Bulb extracts of Gladiolus dalenii reportedly used in the treatment of fungal infections in HIV/AIDS patients in the Lake Victoria region were tested for antifungal activity using the disc diffusion assay technique. Commercially used antifungal drugs, Ketaconazole and Griseofulvin (Cosmos Pharmaceuticals) were used as standards. Dichloromethane (CH2CL2)/Methanol (MeOH) in the ratio 1:1. Soluble extracts showed antifungal activity against Aspergillus niger. Direct bioautography on silica gel Thin Layer Chromatography (TLC) and appropriate spraying agents were used to identify the active component in the extract. The activities of both the extracts were higher than that of Griseofulvin. CH2CL2 soluble extract in addition showed ability to delay sporulation in A.niger. The active group of compounds in the extracts was identified as alkaloids, which offer immense potential for development of new and valuable pharmaceutical products.Key words: G. dalenii, Aspergillus niger, Antifungal activity

Laboratory services, particularly in large sub-Saharan cities, are overstretched, and it is becoming difficult both for patients and health staff to adhere to the diagnostic procedures for tuberculosis. Alternative techniques would be welcome. The polymerase chain reaction (PCR) has the potential to be cost-effective. We compared the cost-effectiveness of two diagnostic strategies, Ziehl-Neelsen (ZN) on three specimens followed by chest X-ray (CXR), and AMPLICOR MTB PCR on the first specimen only. Three sputum samples were collected from tuberculosis (TB) suspects attending the Rhodes Chest Clinic, Nairobi. All samples were subjected to ZN, PCR and Löwenstein-Jensen culture used as gold standard. CXR was used to diagnose smear-negative TB. Cost analysis included health service and patient costs. Costs per correctly diagnosed case were US dollar 41 and dollar 67 for ZN and PCR, respectively. When treatment costs were included, including treatment of culture-negative cases, PCR was more cost-effective: dollar 382 vs. dollar 412. PCR may be an alternative in settings with many patients. PCR is patient friendly, CXR is not necessary and, unlike ZN, its performance is hardly affected by the human immunodeficiency virus. PCR can handle large numbers of specimens, with results becoming available on the same day

City Council Chest Clinic, Nairobi, Kenya. To determine to what extent the performance of smear microscopy is responsible for sex differences in notification rates. Three sputum samples from TB suspects were subjected to smear microscopy with Ziehl-Neelsen (ZN) and auramine (FM) staining. Lowenstein-Jensen culture was used as the gold standard. Of 998 suspects, 600 (60%) were men and 398 (40%) women. The odds of detecting culture-positive patients with ZN was lower for women (OR 0.67). By examining the first spot specimen, ZN detected 35% of culture-positive males and 26% of culture-positive females. These proportions increased to respectively 63% and 53% when examining three specimens, and to 79% and 74% when using FM. The sex difference reduced and became non-significant (P = 0.19) when adjusted for HIV; however, the numbers involved for HIV stratification were low. The performance of a diagnostic tool contributes to sex differences in notification rates and influences male/female ratios. Women were less likely to be diagnosed (P = 0.08), and when ZN was used they were less likely to be labelled as smear-positive TB (P