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Background: Many studies show that working mothers are unable to exclusively breastfeed successfully. Expression and storage of breastmilk is a strategy that ensures continued breastmilk consumption in the event of temporary separation of an infant from the mother. The 2017 Kenyan Health Act mandates employers to provide lactation rooms with guidance for appropriate utilization.Methodology: The study objective was to assess knowledge attitude and practice of breastmilk expression and storage among working women with infants below six months of age in Public Well Baby Clinics. This was a cross sectional study among 395 working women attending two large public hospitals in Nairobi Kenya. A structured questionnaire with open and closed ended questions was used to establish the knowledge and practice while a Likert scale was used to explore attitudes of the mothers towards expression and storage of breast milk. Results: Only 161(41%) were expressing breast milk. Those with tertiary education and those working in the public sector had significantly higher odds of having satisfactory knowledge OR4.47(95%CI 2.01-11.07) and OR2.26(95%CI 1.33-3.85) respectively. Attaining tertiary education was significantly associated with a possibility of expressing and storing breastmilk OR3.6(95% CI 1.81-7.95). The workplace did not provide adequate equipment to facilitate breastmilk expression. Challenges experienced were breast pain and cumbersome nature of expressing milk.Conclusion: The study revealed knowledge gaps in expression and storage of breastmilk that need to be addressed to enable the mothers fully utilize the lactation rooms when they become available at the workplace.

Background: Health care-associated infection (HCAI) is a significant cause of morbidity and mortality among hospitalised patients, particularly neonates. Compliance with hand hygiene (HH) recommendations is the simplest and most effective measure in preventing this infection. Objectives: To determine the HH practices among healthcare workers (HCWs) in the newborn unit of a tertiary referral hospital in Kenya, their knowledge and perceptions regarding HCAI and importance of HH, and barriers to the recommended HH practices. Methods: A descriptive cross-sectional study was conducted to evaluate the HCWs’ compliance with the World Health Organization (WHO) ‘5 Moments for Hand Hygiene’ and a structured self-administered questionnaire adopted from the WHO knowledge and perception of HCW questionnaires was used to answer the secondary objectives. Results: The overall HH compliance rate was 15%. HCWs were twice more likely to take a HH action ‘after’ than ‘before’ a patient care procedure (odds ratio [OR] = 2.05; 95% confidence interval [CI] = 1.02–4.19; P = 0.03). Nurses and nursing students had statistically significant lower compliance (OR 0.41; 95% CI = 0.18-0.91; p=0.016) and (OR 0.21; 95% CI = 0.06-0.70; p = 0.004) respectively, compared to the doctors. More than half (52%) of the HCWs were unaware of the five moments/indication for HH. Lack of supplies, forgetfulness and use of gloves were the commonly cited barriers to HH compliance. Discussion: HH compliance rate among HCWs in the newborn unit of the tertiary referral hospital was very low. The observed and reported barriers to optimal HH compliance demonstrate a necessity for the adoption of the WHO recommended multimodal HH improvement strategy in this unit.

Background: Exclusive breastfeeding (EBF) improves infant health and survival. We tested the effectiveness of a homebased\ud intervention using Community Health Workers (CHWs) on EBF for six months in urban poor settings in Kenya.\ud Methods: We conducted a cluster-randomized controlled trial in Korogocho and Viwandani slums in Nairobi.\ud We recruited pregnant women and followed them until the infant’s first birthday. Fourteen community clusters\ud were randomized to intervention or control arm. The intervention arm received home-based nutritional\ud counselling during scheduled visits by CHWs trained to provide specific maternal infant and young child\ud nutrition (MIYCN) messages and standard care. The control arm was visited by CHWs who were not trained in\ud MIYCN and they provided standard care (which included aspects of ante-natal and post-natal care, family\ud planning, water, sanitation and hygiene, delivery with skilled attendance, immunization and community\ud nutrition). CHWs in both groups distributed similar information materials on MIYCN. Differences in EBF by\ud intervention status were tested using chi square and logistic regression, employing intention-to-treat analysis.\ud Results: A total of 1110 mother-child pairs were involved, about half in each arm. At baseline, demographic\ud and socioeconomic factors were similar between the two arms. The rates of EBF for 6 months increased from\ud 2% pre-intervention to 55.2% (95% CI 50.4–59.9) in the intervention group and 54.6% (95% CI 50.0–59.1) in the\ud control group. The adjusted odds of EBF (after adjusting for baseline characteristics) were slightly higher in the\ud intervention arm compared to the control arm but not significantly different: for 0–2 months (OR 1.27, 95% CI\ud 0.55 to 2.96; p = 0.550); 0–4 months (OR 1.15; 95% CI 0.54 to 2.42; p = 0.696), and 0–6 months (OR 1.11, 95% CI\ud 0.61 to 2.02; p = 0.718).\ud Conclusions: EBF for six months significantly increased in both arms indicating potential effectiveness of using\ud CHWs to provide home-based counselling to mothers. The lack of any difference in EBF rates in the two groups\ud suggests potential contamination of the control arm by information reserved for the intervention arm.\ud Nevertheless, this study indicates a great potential for use of CHWs when they are incentivized and monitored\ud as an effective model of promotion of EBF, particularly in urban poor settings. Given the equivalence of the\ud results in both arms, the study suggests that the basic nutritional training given to CHWs in the basic primary\ud health care training, and/or provision of information materials may be adequate in improving EBF rates in\ud communities. However, further investigations on this may be needed. One contribution of these findings to\ud implementation science is the difficulty in finding an appropriate counterfactual for community-based\ud educational interventions.\ud Trial registration: ISRCTN ISRCTN83692672. Registered 11 November 2012. Retrospectively registered.

Background. Paediatric septic shock is a subset of sepsis associated with high mortality. Implementing the existing international Surviving Sepsis Campaign Guidelines 2012 (SSCG) have contributed to reduction of mortality in many places but these have not been adopted in our setting. The current study aimed at documenting the practice at a national referral hospital. Methods. A hospital based longitudinal survey carried out among 325 children from September to October 2016. Children aged 0 days (≥37 weeks gestation) to12 years were included. The aim was to determine the prevalence, audit the management and determine the outcome at 72 hours of septic shock among children admitted at the Kenyatta National Hospital (KNH). A standard questionnaire was used for data collection and Surviving Sepsis Guideline 2012 was used as a reference for auditing the management of septic shock. Data was stored in MS-EXCEL and analysed in STATA 12. Results. The prevalence of septic shock was 50 (15.4%), with a median age of 4 months. Septic shock was recognized by the attending clinician in 28 (56%). The level of care to children with septic shock was not to the level recommended by the SSCG 2012. Odds of being diagnosed with septic shock reduced with age (odds ratio 4.38 (1.7–11.0), p=0.002) and no child aged above 60 months age was diagnosed with septic shock. The mortality was 35 (70%) at 72 hours of admission, with a median of 14 hours. Infants had the highest case fatality of 82.6%. It was found that lack of mechanical ventilation, and presence of hypotension at admission were associated with greater mortality (p values of 0.03 and 0.01 respectively). Conclusion. The prevalence rate of septic shock is 15.4% among children admitted at the KNH and is associated with high mortality. The advanced degree of shock contributed to mortality. The level of care at KNH was not to the level of SSCG 2012, and hence the need to include septic shock management guidelines/protocols in our local Kenyan paediatric guideline.

Donor human milk (DHM) is recomended as the best alternative when use of mothers' own milk is not a feasible option. Kenya has not yet established human milk banks (HMBs) for provision of safe DHM, which is free from any physical, chemical, microbiological contaminants or pathogens. This study aimed to establish the perceptions on donating and using DHM, and establishing HMBs in Kenya. Qualitative data were collected through 17 focus group discussions, 29 key informant interviews, and 25 in‐depth interviews, with women of childbearing age, community members, health workers, and policy makers. Quantitative interviews were conducted with 868 mothers of children younger than 3 years. Descriptive analysis of quantitative data was performed in STATA software, whereas qualitative interviews were coded using NVIVO and analysed thematically. Majority of them had a positive attitude towards donating breast milk to a HMB (80%) and feeding children on DHM (87%). At a personal level, participants were more willing to donate their milk to HMBs (78%) than using DHM for their own children (59%). The main concerns on donation and use of DHM were personal dislikes, fear of transmission of diseases including HIV, and hygiene concerns. Ensuring safety of DHM was considered important in enhancing acceptability of DHM and successful establishment of the HMBs. When establishing HMBs, Kenya must take into consideration communication strategies to address the main concerns raised regarding the quality and safety of the DHM. The findings will contribute to the development of HMB guidelines in Kenya and other African contexts.

Background. Neonatal sepsis is a leading cause of morbidity and mortality globally. A high index of suspicion is required since features of sepsis are nonspecific. Auditing of antibiotic use is necessary to reduce misuse and minimise development of antibiotic resistance. Objectives. To assess the antibiotic prescribing practices in NBU at KNH against recommended Kenyan guidelines for neonatal sepsis. In addition, outcome within 7 days was described. Methods. This was a prospective audit of 320 neonates over a 2-month period at NBU of KNH. Data were collected using a structured questionnaire, stored in MS-EXCEL, and analysed using STATA. Results. Documentation of perinatal risk factors and clinical features at admission and at the time of change of antibiotics was very poor. The rate of investigations to confirm infection was very low. Blood cultures were done only in 13 (4%) neonates on admission, while complete blood count and C reactive protein were done in 224 (70%) and 198 (62%), respectively. Appropriate antibiotics as per the Kenyan guidelines were prescribed in 313 (97.8%) of neonates on admission. However, these were not stopped at 48-72 hours for the 148 (53.62%) who had improved. Overall mortality was high in neonates at 80 (25%). Majority (55%) died within 48 hours. Mortality was high among preterm neonates; 70 (43.8%) died out of 160. Conclusion. Overall documentation and investigations to confirm infection was poor. The continuation of antibiotics was inappropriate. Overall mortality was high especially in the first 48 hours of admission. To improve documentation, availability of a checklist on admission is recommended.

Introduction Early empiric broad spectrum antibiotic administration in children with septic shock improves outcome. Knowledge on possible bacterial aetiology, drug resistance pattern and rational choice of antibiotics is crucial in management of septic shock. Methods This was an audit carried out among 50 (0- 5 years age) children admitted with septic shock at the Kenyatta National Hospital between October to December 2016. A standard questionnaire was used for data collection as per the Surviving Sepsis Guideline. Data were stored in Excel and analyzed in Strata 12. Results Of the 50 admitted children with septic shock 86% were less than one-year age. Samples for blood cultures were removed from 12(24%) prior to administration of antibiotics. Blood culture bottles were unavailable in 80%. All children received antibiotics. Antibiotics were initiated in 44(88%) in the golden hour of diagnosis of septic shock. Monotherapy with cephalosporins 30 (60%) was the commonest choice of initial antibiotic. Antibiotics were changed in 7(22.6%) and 1(5.3%) at 24 and 48 hours respectively due to clinical deterioration. Over mortality at 72 hours was 35 (70%). All the 9 children initiated on meropenem monotherapy on admission died. Conclusion The majority of patients with septic shock were under one-year age. All patients were initiated on antibiotics. Blood cultures were done in a quarter of the patients. Monotherapy with cephalosporin was the commonest choice of antibiotic. De-escalation was not well accomplished due to microbiological culture limitation. There was no standard antibiotic choice hence antibiotic use in septic shock needs to be included in the paediatric local guidelines.

Objective We conducted a retrospective cohort study to evaluate the efficacy of the World Health Organization (WHO) “Universal Test and Treat” (UTT) policy, initiated in Kenya in September 2016. Under this policy, every human immunodeficiency virus (HIV)-infected person should be initiated on antiretroviral therapy (ART). We compared intra- and inter-group viral suppression and ART adherence rates for pre-UTT (initiated on ART in March–August 2016) and UTT groups (initiated in September 2016). The study was conducted in a community outreach Program in Nairobi with 3500 HIV-infected children enrolled. Results 122 children and adolescents were initiated on first-line ART pre-UTT, and 197 during the UTT period. The 6 month viral suppression rate was 79.7% pre-UTT versus 76.6% UTT (P

In Kenya, human immunodeficiency virus (HIV) prevalence ranks among the highest in the world. Approximately 60 000 infections yearly are attributed to vertical transmission including the process of labour and breast-feeding. The vast of the population affected is in the developing world. Clinical officers and nurses play an important role in provision of primary health care to antenatal and postnatal mothers. There are a few studies that have explored the clinicians’ knowledge on breast-feeding in the face of HIV and in relation to vertical transmission this being a vital component in prevention of maternal-to-child transmission. The aim of this study was to evaluate clinicians’ knowledge on HIV in relation to breast-feeding in Kenya. A cross-sectional survey was conducted to assess knowledge of 161 clinical officers and nurses serving in the maternity and children’ wards in various hospitals in Kenya. The participants were derived from all district and provincial referral facilities in Kenya. A preformatted questionnaire containing a series of questions on HIV and breast-feeding was administered to clinicians who were then scored and analyzed. All the 161 participants responded. Majority of clinicians (92%) were knowledgeable regarding prevention of mother-to-child transmission. Regarding HIV and breast-feeding, 49.7% thought expressed breast milk from HIV-positive mothers should be heated before being given. Majority (78.3%) thought breast milk should be given regardless of availability of alternatives. According to 74.5% of the participants, exclusive breast-feeding increased chances of HIV transmission. Two-thirds (66.5%) would recommend breast-feeding for mothers who do not know their HIV status (66.5%). This study observes that a majority of the clinicians have inadequate knowledge on breast-feeding in the face of HIV. There is need to promote training programmes on breast-feeding and transmission of HIV from mother to child. This can be done as in-service training, continuous medical education and as part of the formal training within medical institutions.

The human caliciviruses (HuCVs) are important causes of gastroenteritis worldwide. Norovirus (NoV) and sapovirus (SaV) have been detected in HIV-seropositive children but the genetic diversity of HuCVs circulating in these individuals is largely unknown. In this study the prevalence and genotype diversity of HuCVs circulating in Kenyan HIV-positive children, with or without diarrhea, from the year 1999 to 2000 was investigated. The overall prevalence of HuCVs was 19% with NoV predominating at 17% (18/105) and SaV present in 5.7% (6/105) of specimens. Human CVs were detected in both symptomatic (24%) and asymptomatic (16%) children. Co-infections with other enteric viruses were detected in 21.6% of children with diarrhea but only in 4.4% of children without diarrhea. Remarkable genetic diversity was observed with 12 genotypes (7 NoV, 5 SaV) being identified in 20 HuCV-infected children. NoV genogroup II (GII) strains predominated with GII.2 and GII.4 each representing 27% of the NoV-positive strains. The GII.4 strain was most closely related to the nonepidemic GII.4 Kaiso 2003 variant. Other NoV genotypes detected were GI.3, GII.6, GII.12, GII.14, and GII.17. Five different SaV genotypes (GI.2, GI.6, GII.1, GII.2, and GII.4) were characterized from six specimens. Diarrheal symptoms were not associated with any specific HuCV genotype. Overall the HuCV genotype distribution detected in this study reflects those in other studies worldwide. The strains detected are closely related to genotypes that have circulated on several continents since the year 2000.

BACKGROUND: Despite numerous interventions promoting optimal breastfeeding practices in Kenya, pockets of suboptimal breastfeeding practices are documented in Kenya's urban slums. This paper describes cultural and social beliefs and practices that influence breastfeeding in two urban slums in Nairobi, Kenya.METHODS: Qualitative data were collected in Korogocho and Viwandani slums through 10 focus group discussions and 19 in-depth interviews with pregnant, breastfeeding women and community health volunteers and 11 key-informant interviews with community leaders. Interviews were audiotaped, transcribed verbatim, coded in NVIVO and analyzed thematically.RESULTS: Social and cultural beliefs and practices that result to suboptimal breastfeeding practices were highlighted including; considering colostrum as 'dirty' or 'curdled milk', a curse 'bad omen' associated with breastfeeding while engaging in extra marital affairs, a fear of the 'evil eye' (malevolent glare which is believed to be a curse associated with witchcraft) when breastfeeding in public and breastfeeding being associated with sagging breasts. Positive social and cultural beliefs were also identified including the association of breast milk with intellectual development and good child health. The beliefs and practices were learnt mainly from spouses, close relatives and peers.CONCLUSION: Interventions promoting behavior change with regards to breastfeeding should focus on dispelling the beliefs and practices that result to suboptimal breastfeeding practices and to build on the positive ones, while involving spouses and other family members as they are important sources of information on breastfeeding.TRIAL REGISTRATION: ISRCTN83692672: December 2013 (retrospectively registered).

Background: Worldwide access to antiretroviral therapy (ART) in low- and middle-income countries has significantly increased. Although this presents better treatment options for HIV-infected individuals, the challenge of monitoring ART in these settings still remains. Objective: To investigate efficient and cost-effective criteria for assessing ART failure among HIV-1-infected children on first-line ART in resource-limited settings. Study design: Retrospective analysis of 75 HIV-1 vertically infected Kenyan children with a follow-up period of 24 months after initiating ART. Plasma viral load, peripheral CD4+T-cell counts and HIV-1 drug-resistance mutations were monitored biannually. Results: Plasma viral load (VL) was suppressed to undetectable level or more than 1.5 log10 from baseline levels in 53 (70.7%) children within 24 months. VL in the remaining 22 (29.3%) children was not suppressed significantly. Of the 22 children, 21 were infected with HIV-1 strains that developed drug-resistance mutations; 9 within 12 months and 12 between 12 and 24 months. Among the 53 who were successfully treated, VL was suppressed in 33 within 12 months and in 20 between 12 and 24 months. There was no significant difference in VL at baseline and the change of CD4+T-cell counts after initiating ART between those treated successfully and the failure groups. Conclusion: After initiating ART, children may require longer times to achieve complete viral suppression. Plasma viral load testing 24 months after initiating ART could be used to differentiate ART failures among HIV-1 vertically infected children in resource-limited settings. Additionally, drug resistance testing, if affordable, would be helpful in identifying those failing therapy and in choosing second-line regimens. © 2011 Elsevier B.V. All rights reserved.

Summary We conducted a prospective audit of 101 children aged 6 to 59 months, admitted to Kenyatta National Hospital (KNH) with severe malnutrition, from February-April 2008. Forty-seven per cent (47/101) of children were younger than one year old. Overall, 58% (59/101) of children had marasmus, 70.3% (71/101) had diarrhoea and 51.5% (52/101) had pneumonia on admission. A structured tool was prepared to capture data to allow assessment of implementation of WHO guidelines steps 1–8. The highest degree of implementation (91/101, 90%) was observed for Step 5: treatment of potentially severe infections, although only 55% (56/101) of patients had F75 prescribed even though this starter formula was available. There was modest implementation of Step 2: ensuring warmth (47/101, 46.5%), Step 3: treatment of dehydration (39/71, 54.9%) and Step 4: correction of electrolyte imbalance (46/101, 45.5%). There was least implementation of Step 8: transition to catch-up feeding (16/67, 23.8%). There was a delay in initiating feeds with a median time of 14.7 hours from the time of admission. We conclude that quality of care for children admitted with severe malnutrition at KNH, Kenya's largest tertiary level health facility, is inadequate and often does not follow WHO guidelines. Improving care will require a holistic and not simply medical approach.

A switch of coreceptor usage from CCR5 to CXCR4 occurs in about half of HIV-1-infected individuals in the natural course of infection. To investigate whether antiretroviral therapy (ART) enhances the coreceptor switch of HIV-1, we genotypically analyzed the env-V3 amino acid sequences from 81 HIV-1-infected children in Kenya whose plasma samples were obtained between 2000 and 2007. Of 41 children on ART, 35 had HIV-1 using CCR5 as a coreceptor at baseline. In 7 (20%) of them HIV-1 switched the coreceptor usage during the follow-up period. The mean duration of ART to the time of coreceptor switch was 2.6 years (range: 0.5-5.2). Of the remaining 40 children without ART, 32 had HIV-1 using CCR5 as a coreceptor at baseline and in 3 (9.4%) HIV-1 switched the coreceptor usage. The mean age of the children with HIV-1 coreceptor switch with and without ART was 7.3 and 9.7 years, respectively. The difference in the rate and age of coreceptor switch between treated and untreated children was not significant (p = 0.38 and 0.31, respectively). Of the HIV-1-infected children, 10 started ART by the age of 5 years (rapid progressors) and 23 did not need ART by the age of 10 years (slow progressors). The rate of coreceptor switch was strongly higher in rapid progressors (40%) than slow progressors (8.7%) (p = 0.053). These results suggest that switching of coreceptor usage from CCR5 to CXCR4 among HIV-1-infected children is not influenced by ART, but by factors responsible for rapid disease progression.

Early nutrition is critical for later health and sustainable development. We determined potential effectiveness of the Kenyan Community Health Strategy in promoting exclusive breastfeeding (EBF) in urban poor settings in Nairobi, Kenya. We used a quasi-experimental study design, based on three studies [Pre-intervention (2007–2011; n=5824), Intervention (2012–2015; n=1110) and Comparison (2012–2014; n=487)], which followed mother–child pairs longitudinally to establish EBF rates from 0 to 6 months. The Maternal, Infant and Young Child Nutrition (MIYCN) study was a cluster randomized trial; the control arm (MIYCN-Control) received standard care involving community health workers (CHWs) visits for counselling on antenatal and postnatal care. The intervention arm (MIYCN-Intervention) received standard care and regular MIYCN counselling by trained CHWs. Both groups received MIYCN information materials. We tested differences in EBF rates from 0 to 6 months among four study groups (Pre-intervention, MIYCN-Intervention, MIYCN-Control and Comparison) using a χ2 test and logistic regression. At 6 months, the prevalence of EBF was 2% in the Pre-intervention group compared with 55% in the MIYCN-Intervention group, 55% in the MIYCN-Control group and 3% in the Comparison group (P

Poor breastfeeding practices are widely documented in Kenya, where only a third of children are exclusively breastfed for 6 months and only 2% in urban poor settings. This study aimed to better understand the factors that contribute to poor breastfeeding practices in two urban slums in Nairobi, Kenya. In‐depth interviews (IDIs), focus group discussions (FGDs) and key informant interviews (KIIs) were conducted with women of childbearing age, community health workers, village elders and community leaders and other knowledgeable people in the community. A total of 19 IDIs, 10 FGDs and 11 KIIs were conducted, and were recorded and transcribed verbatim. Data were coded in NVIVO and analysed thematically. We found that there was general awareness regarding optimal breastfeeding practices, but the knowledge was not translated into practice, leading to suboptimal breastfeeding practices. A number of social and structural barriers to optimal breastfeeding were identified: (1) poverty, livelihood and living arrangements; (2) early and single motherhood; (3) poor social and professional support; (4) poor knowledge, myths and misconceptions; (5) HIV; and (6) unintended pregnancies. The most salient of the factors emerged as livelihoods, whereby women have to resume work shortly after delivery and work for long hours, leaving them unable to breastfeed optimally. Women in urban poor settings face an extremely complex situation with regard to breastfeeding due to multiple challenges and risk behaviours often dictated to them by their circumstances. Macro‐level policies and interventions that consider the ecological setting are needed.

Background: The kidney is the most damaged organ in asphyxiated full-term infants. The severity of its damage is correlated with the severity of neurological damage. We determined the prevalence of perinatal asphyxia-associated acute kidney injury (AKI).Methods: We conducted a prospective cohort study including 60 full-term neonates admitted at the Kenyatta National Hospital newborn unit (NBU) in Nairobi with hypoxic ischaemic encephalopathy (HIE) from June 2012 to November 2012. Renal function was assessed by measuring serum creatinine on day 3 of life. AKI was defined by a level of creatinine above 133 μmol/l. The degree of neurological impairment was determined daily until patient discharge, death or day 7 of life.Results: Of the 60 infants 36.6% had HIE I, 51.6% HIE II and 11.8% HIE III. The prevalence of AKI was 11.7 %. There was a 15 fold increase risk of developing AKI in HIE III versus HIE I, p=0.034. Mortality rate in perinatal asphyxia associated AKI was 71.4 % with a 24 fold increase risk of death in neonates with AKI, p=0.001.Conclusions: AKI is common and associated with poorer outcomes in perinatal asphyxia. Larger studies need to be done to correlate maternal factors and perinatal asphyxia-associated AKI.Key words: moderate perinatal asphyxia, severe perinatal asphyxia, hypoxic ischaemic encephalopathy, neonatal kidney dysfunction, neonatal neurological dysfunction.

Multidrug-resistant organisms are increasing worldwide. Over the years we have noted increasing resistance of organisms isolated in our neonatal unit. There is a need therefore to scrutinize the problem so as to be able to plan for the future. Over a 5-month period, 716 infants were admitted of which 192 were screened for sepsis. Overall, 121 (16.7 per cent) had positive blood cultures. The predominant organisms were Gram negative (73.6 per cent of isolates) with Klebsiella species topping the list at 31 per cent. Case fatality for infants infected with Gram negative organisms was 41 per cent. Resistance to gentamicin was 20 per cent chloramphenicol 23.6 per cent, and amoxicillin/ampicillin 66.3 per cent. Of worry is the resistance to ceftazidime 19.1 per cent, and cefuroxime 21.3 per cent, with the figures rising to 27 per cent when more specialized tests are done (disc approximation and potentiation tests). If these drugs cannot be used in 20-27 per cent of cases then the situation is serious. The contributory factors to increased resistance include: non-investigation of infants put on antibiotics (50 per cent of cases); prolonged (73 per cent) and sometimes unjustified (41.7 per cent) use of antibiotics; and non-utilization of investigations when these are done (52 per cent) together with the delay in getting results back in the ward (6 days).

The human caliciviruses (HuCVs) are important causes of gastroenteritis worldwide. Norovirus (NoV) and sapovirus (SaV) have been detected in HIV-seropositive children but the genetic diversity of HuCVs circulating in these individuals is largely unknown. In this study the prevalence and genotype diversity of HuCVs circulating in Kenyan HIV-positive children, with or without diarrhea, from the year 1999 to 2000 was investigated. The overall prevalence of HuCVs was 19% with NoV predominating at 17% (18/105) and SaV present in 5.7% (6/105) of specimens. Human CVs were detected in both symptomatic (24%) and asymptomatic (16%) children. Co-infections with other enteric viruses were detected in 21.6% of children with diarrhea but only in 4.4% of children without diarrhea. Remarkable genetic diversity was observed with 12 genotypes (7 NoV, 5 SaV) being identified in 20 HuCV-infected children. NoV genogroup II (GII) strains predominated with GII.2 and GII.4 each representing 27% of the NoV-positive strains. The GII.4 strain was most closely related to the nonepidemic GII.4 Kaiso 2003 variant. Other NoV genotypes detected were GI.3, GII.6, GII.12, GII.14, and GII.17. Five different SaV genotypes (GI.2, GI.6, GII.1, GII.2, and GII.4) were characterized from six specimens. Diarrheal symptoms were not associated with any specific HuCV genotype. Overall the HuCV genotype distribution detected in this study reflects those in other studies worldwide. The strains detected are closely related to genotypes that have circulated on several continents since the year 2000.

Without an effective therapeutic human immunodeficiency virus (HIV)-1 vaccine, providing cost-effective, minimally toxic antiretroviral therapy to the many individuals already infected with HIV-1 is a global priority. Implementation of a structured treatment interruption (STI) regimen may be a promising intervention for HIV-1 infection. We adopted this approach out of necessity for 3 severely immunocompromised African children naive to therapy, and increases in the T lymphocyte count and improved quality and sustainability of life 2 years after initiation of the STI regimen were noted.

Objective: To evaluate utility of C-reactive protein (CRP) in the early diagnosis of neonatal sepsis in a tertiary care Newborn Unit in Kenya. Design: Cross-sectional study. Setting: Newborn Unit, Kenyatta National Hospital. Subjects: All neonates admitted to Newborn Unit, Kenyatta National Hospital during the study period with suspected sepsis based on specified clinical criteria. Results: Of the 310 infants, there were 83 episodes of proven sepsis and 94 episodes of probable sepsis. Using the standard CRP cut-off value of 5 mg/dl, a sensitivity of 95.2% in proven sepsis and 98.9% for probable septic episodes were noted. In proven sepsis, a specificity of 85.3%, positive predictive value of 80.6%, and a negative predictive value of 96.5% were noted. In probable sepsis, a specificity of 83.3%, positive predictive value of 80.9% and a negative predictive value of 99.1% were noted. The overall accuracy in proven sepsis was 96.5%, and in probable sepsis was noted to be 99.1%. Sub-analysis showed a lower positive predictive value (61.5%) for early onset sepsis compared to 93% for late onset sepsis. Repeat CRP tests were done in 33 babies. Twenty two of the 29 with proven/probable infection had a ten-fold increase in CRP levels, but levels were noted to be low or reducing in seven (24.1%) babies showing signs of improvement clinically. Using a receiver operator characteristic curve, the optimal cut-off point for CRP was found to be 5 mg/dl. Conclusions: Serum CRP is an accurate indicator of neonatal sepsis, with high sensitivity, specificity and predictive values, at the standard cut-off of 5. CRP is a better screening test for late-onset than early-onset neonatal sepsis. The standard recommended CRP cut -off point of 5 is appropriate for local use.

Human rotaviruses have emerged as a leading cause of acute diarrhea in children

金沢大学大学院医学系研究科感染症制御学, Recently increased availability of antiretroviral therapy (ART) has mitigated HIV-1/AIDS prognoses especially in resource poor settings. The emergence of ART resistance-associated mutations from non-suppressive ART has been implicated as a major cause of ART failure. Reverse transcriptase inhibitor (RTI)-resistance mutations among 12 non-subtype B HIV-1-infected children with treatment failure were evaluated by genotypically analyzing HIV-1 strains isolated from plasma obtained between 2001 and 2004. A region of pol-RT gene was amplified and at least five clones per sample were analyzed. Phylogenetic analysis revealed HIV-1 subtype A1 (n = 7), subtype C (n = 1), subtype D (n = 3), and CRF02_AG (n = 1). Before treatment, 4 of 12 (33.3%) children had primary RTI-resistance mutations, K103N (n = 3, ages 5-7 years) and Y181C (n = 1, age 1 year). In one child, K103N was found as a minor population (1/5 clones) before treatment and became major (7/7 clones) 8 months after RTI treatment. In 7 of 12 children, M184V appeared with one thymidine-analogue-associated mutation (TAM) as the first mutation, while the remaining 5 children had only TAMs appearing either individually (n = 2), or as TAMs 1 (M41L, L210W, and T215Y) and 2 (D67N, K70R, and K219Q/E/R) appearing together (n = 3). These results suggest that "vertically transmitted" primary RTI-resistance mutations, K103N and Y181C, can persist over the years even in the absence of drug pressure and impact RTI treatment negatively, and that appearing patterns of RTI-resistance mutations among non-subtype B HIV-1-infected children could possibly be different from those reported in subtype B-infected children. © 2007 Wiley-Liss, Inc.

Objectives: Disease progression varies among HIV-1-infected individuals. The present study aimed to explore possible viral and host factors affecting disease progression in HIV-1-infected children. Methods: Since 2000, 102 HIV-1 vertically-infected children have been followed-up in Kenya. Here we studied 29 children (15 male/14 female) who started antiretroviral treatment at 10 years of age (slow progressors; SP). Sequence variations in the HIV-1 gag and nef genes and the HLA class I-related epitopes were compared between the two groups. Results: Based on nef sequences, HIV-1 subtypes A1/D were detected in 62.5%/12.5% of RP and 66.7%/20%of SP, with no significant difference in subtype distribution between groups (p = 0.8). In the ten Nef functional domains, only the PxxP3 region showed significantly greater variation in RP (33.3%) than SP (7.7%, p = 0.048). Gag sequences did not significantly differ between groups. The reportedly protective HLA-A alleles, A∗74:01, A∗32:01 and A∗26, were more commonly observed in SP (50.0%) than RP (11.1%, p = 0.010), whereas the reportedly disease-susceptible HLA-B∗45:01 was more common in RP (33.3%) than SP (7.4%, p = 0.045). Compared to RP, SP showed a significantly higher median number of predicted HLA-B-related 12-mer epitopes in Nef (3 vs. 2, p = 0.037), HLA-B-related 11-mer epitopes in Gag (2 vs. 1, p = 0.029), and HLA-A-related 9-mer epitopes in Gag (4 vs. 1, p = 0.051). SP also had fewer HLA-C-related epitopes in Nef (median 4 vs. 5, p = 0.046) and HLA-C-related 11-mer epitopes in Gag (median 1 vs. 1.5, p = 0.044) than RP. Conclusions: Compared to rapid progressors, slow progressors had more protective HLA-A alleles and more HLA-B-related epitopes in both the Nef and Gag proteins. These results suggest that the host factor HLA plays a stronger role in disease progression than the Nef and Gag sequence variations in HIV-1-infected Kenyan children. © 2015 Saina et al.

Background There are few data on African children infected with nonclade B HIV-1 in endemic settings, which limits generalizations about pathogenesis and progression. Genotypic and phenotypic variations in host immunogenetics and HIV-1 negative factor (nef) accessory protein may influence disease progression and have frequently been characterized in subjects infected with clade B HIV-1. Methods In this descriptive study, we report nef gene sequence variation and host genetic polymorphisms in 32 Kenyan children, including 12 slow progressors. Results Phylogenetic analysis identified HIV-1 clades A, C and D and a recombinant A/D subtype. Grossly defective nef genes or significant changes from relevant clade reference sequences were not identified in children with delayed disease progression. Conclusions nef sequence variations may not be common in perinatally infected African children. Further studies are warranted in HIV-1-infected subjects in settings where infection is endemic.

Without treatment most HIV-1-infected children in Africa die before their third birthday (>89%) and long-term nonprogressors are rare. The mechanisms underlying nonprogression in HIV-1-infected children are not well understood. In the present study, we examined potential correlates of delayed HIV disease progression in 51 HIV-1-infected African children. Children were assigned to progression subgroups based on clinical characterization. HIV-1-specific immune responses were studied using a combination of ELISPOT assays, tetramer staining, and FACS analysis to characterize the magnitude, specificity, and functional phenotype of HIV-1-specific CD8+ and CD4+ T cells. Host genetic factors were examined by genotyping with sequence-specific primers. HIV-1 nef gene sequences from infecting isolates from the children were examined for potential attenuating deletions. Thymic output was measured by T cell rearrangement excision circle assays. HIV-1-specific CD8+ T cell responses were detected in all progression groups. The most striking attribute of long-term survivor nonprogressors was the detection of HIV-1-specific CD4+ Th responses in this group at a magnitude substantially greater than previously observed in adult long-term nonprogressors. Although long-term survivor nonprogressors had a significantly higher percentage of CD45RA+CD4+ T cells, nonprogression was not associated with higher thymic output. No protective genotypes for known coreceptor polymorphisms or large sequence deletions in the nef gene associated with delayed disease progression were identified. In the absence of host genotypes and attenuating mutations in HIV-1 nef, long-term surviving children generated strong CD4+ T cell responses to HIV-1. As HIV-1-specific helper cells support anti-HIV-1 effector responses in active disease, their presence may be important in delaying disease progression.

Background: Meningitis occurs in up to one third of neonates with septicaemia. Diagnosis is difficult due to its non-specificity of signs and symptoms. While neonatal septicaemia is a common problem at Kenyatta National Hospital (KNH), there are no recent data on the incidence and clinical characteristics of neonatal meningitis at the hospital. Objective: To evaluate the prevalence and the bacterial aetiology of meningitis in neonates at the Newborn Unit (NBU) of KNH. Design: Descriptive cross-sectional study. Setting: Newborn Unit of Kenyatta National Hospital, Nairobi, Kenya. Subjects and methods: Lumbar punctures were performed on eighty-four neonates with suspected sepsis based on specified clinical criteria. Cases were defined as meningitis if the cerebrospinal fluid (CSF) was positive for bacteria by Gram stain, aerobic bacterial culture or latex particle agglutination assay. Results: The prevalence of meningitis amongst cases of suspected sepsis was 17.9%. The male:female ratio was l.5:1 mean birth weight 2116.7 grams (1682.2-2551.2) mean gestational age 35.7 weeks (32.6-38.8) and the mean postnatal age was 4.1 days (2.7- 5.4) with none of the parameters being significantly different from those without meningitis. Feed intolerance and lethargy were the most common clinical features, present in 73.3% and 60% of patients with meningitis respectively. Neonates with meningitis had a higher mean CSF protein value (2.67 g/L vs 1.97 g/L, p=0.367) and a significantly higher mean CSF white cell count (21 cells/mL vs 7 cells/mL, p=0.001). The most common aetiological agents were Escherichia coli (46.7%). Group B. Streptococci (26.7%) and Klebsiella pneumonia (13.3%). Most blood and CSF isolates were resistant to ampicillin and gentamicin but showed good in-vitro sensitivities to amikacin, ceturoxime and the third generation cephalosporins (ceftriaxone, ceftazidime and cefotaxime). Blood cultures were positive in only 53.3% of neonates with meningitis. Conclusion: Neonatal bacterial meningitis is an important clinical problem at KNH with a prevalence of 17.9% and amongst cases of suspected sepsis. E. coli and Group B Streptococci were the most common aetiological pathogens. Blood cultures were negative in almost half of the patients with meningitis. Resistance to the commonly employed first-line antibiotics (penicillin and gentamicin) is high and a chance of empirical antibiotic use for neonates with suspected sepsis is recommended.

Objective: As a result of the HIV epidemic in Africa much debate exists on whether institutionalized compared with community-based care provides optimum management of infected children. Previous reports calculated 89% mortality by age 3 years among outpatients in Malawi. No similar data are available for infected children in institutionalized care. We characterized patterns of morbidity and mortality among HIV-1–infected children residing at an orphanage in Nairobi. Methods: Medical records for 174 children followed over 5 years were reviewed. Mortality was analyzed by Kaplan–Meier methods with adjustment to account for survival in the community before admission. Anthropometric indices were calculated to include mean z scores for weight for length and length for age. Low indices reflected wasting and stunting. Opportunistic infections were documented. Results: Of 174 children 64 had died. Survival was 70% at age 3 years. Morbidity included recurrent respiratory tract infections gastroenteritis parotitis and lymphoid interstitial pneumonitis. No new cases of tuberculosis disease were noted after admission. Mean z scores for length for age suggested overall stunting (z = -1.65). Wasting was not observed (z = -0.39). Conclusion: The optimal form of care for HIV-infected children in resource-poor settings may be the development of similar homes. Absence of tuberculosis disease in long-standing residents may have contributed to improved survival. Stunting in the absence of wasting implied that growth was compromised by opportunistic infections and other cofactors. (authors)

Background : Infants less than 1500 grams at birth have been demonstrated to be particularly prone to development of low levels of serum sodium often leading to increased early neonatal morbidity and mortality. No local study has been done to quantify this problem among sick newborns. Studies elsewhere demonstrate a high incidence of hyponatraemia among such preterms. Objective : To evaluate the influence of infant early neonatal morbidity on serum sodium levels and justify regular monitoring and supplementation. Design : Comparative cohort study. Setting : Newborn Unit, Kenyatta National Hospital, Nairobi. Subjects : Fifty six very low birth weight (1000-1500 grams at birth) infants during their first week of life. Half of them were designated as cases in view of having various early neonatal illnesses. The remaining 28 being clinically stable were taken as controls. These two groups had comparable birthweights, sex distribution and gestational ages. Their sodium intakes were also similar during the first week of life. Results : The sick infants (cases) had persistently low serum sodium (mean of 120 mmols/L) throughout the first week while among the healthy infants (controls) a sequential increase from 127 to 133 mmol/l, (mean values) was observed during the same period. The difference registered on day seven (133 versus 120) was statistically significant (p= 0.02). Using a cut off point of 130 mmol/L to define hyponatraemia the proportion of infants with hyponatraemia, which was similar at the beginning became higher among the cases for the rest of the week with the largest disparity observed on the seventh day (75% versus 23%, p=0.007). Urinary sodium losses as measured by Fractional Sodium Excretion were also initially similar between the two groups but later became higher among the cases (4.96 versus 3.5 p=0.08). Conclusion : Very low birth weight infants who are ill have lower serum sodium and are more likely to develop significant hyponatraemia than their healthy counterparts during the first week of life. Standard care of these sick infants must therefore routinely include regular monitoring of serum sodium and its correction if found to be low. (East African Medical Journal: 2002 79(3): 120-123)

City-dwelling children from Kenya who were infected with human immunodeficiency virus type 1 (HIV-1) were tested for coinfection with cytomegalovirus (CMV), human T cell lymphotropic viruses 1 and 2, Kaposi sarcoma-associated herpesvirus (KSHV), or hepatitis B, C, and G viruses. All children were found to be coinfected with CMV, whereas 5% had hepatitis G virus coinfection and 15% had KSHV coinfection. A protective role for hepatitis G virus cannot be excluded but likely affects only a minority of HIV-1-infected African children.

Background : Survival of patients is regularly used as a measure of the level and appropriateness of medical care provided by institutions. Newborn services have been evaluated in this manner since the 1960s. Though Kenyatta National Hospital has provided neonatal services for over 25 years, no survival data for the low birth weight infants has been published since 1978. Objective : To determine the birthweight specific neonatal survival of infants born weighing less than 2000 grams at Kenyatta National Hospital. Design : A cross sectional survey. Setting : Newborn Unit, Kenyatta National Hospital, Nairobi. Main outcome measures : The proportion of infants surviving the first 28 days of life grouped in the following birthweight categories; below 1000 grams (extremely low birthweight), 1000 - 1499 grams (very low birthweight) and 1500 - 1999 grams (low birthweight). Results : The overall neonatal survival of 163 infants born below 2000 grams was 62.6%. None of the 23 infants born less than 1000 grams survived the neonatal period. Bigger infants fared much better with 68% (n=73) of the 1000 - 1499 and 78% (n=67) of the 1500-1999 gram groups surviving. Survival based on gestational age was also determined. Sixty nine per cent of infants born between 32 and 35 weeks survived while only 27% and 9% of the 28 - 31 weeks and those less than 28 weeks survived respectively. When the patients were analysed for age at death, it was found that over 28% of the deaths occurred within the first day and by the seventh day, more than 70% had died. Less than 30% of the deaths occurred after the first week. The commonest clinical syndromes seen were infection (41%) and respiratory distress (43%). Conclusion : Neonatal survival rates of low birthweight infants are still much lower than those observed in developed countries as far back as the early 1970's. The big proportion of deaths occurring during the first week, and in particular the first day, is due to lack of neonatal intensive care facilities and inadequate obstetric services. (East African Medical Journal: 2002 79(2): 77-79)

Sodium and potassium levels were measured weekly in mothers’ milk and in serum and urine of 41 supplemented and 25 unsupplemented very-low-birth-weight infants whose mean birth weights were 1390 g and 1332 g, respectively (mean gestational age, 31 weeks). Sodium intake was 5.95 mmol/kg/day for the supplemented group and 2.75 mmol/kg/day for controls. None of the infants in either group was hyponatremic during the 6-week period of study. Urinary sodium in the supplemented group was 15.7 mmol/L as compared with 7 5 mmol/L in controls. Human milk sodium was significantly lower than reported elsewhere. Growth in the supplemented group was greater than in the unsupplemented group. Since no episode of hyponatremia occurred, it was concluded that routine sodium supplementation was unnecessary.

Background Nutrition in the first 1,000 days of life (during pregnancy and the first two years) is critical for child growth and survival. Poor maternal, infant and young child nutrition (MIYCN) practices are widely documented in Kenya, with potential detrimental effects on child growth and survival. This is particularly a problem in slums, where most urban residents live. For example, exclusive breastfeeding for the first six months is only about two per cent. Innovative strategies to reach slum residents are therefore needed. Strategies like the Baby Friendly Hospital Initiative have proven effective in some settings but their effectiveness in resource-limited settings, including slums where many women do not deliver in hospital, is questionable. We propose to test the effectiveness of a home-based intervention on infant feeding practices, nutrition and health outcomes of infants born in two slums in Nairobi, Kenya. Methods/Design The study, employing a cluster-randomised study design, will be conducted in two slums in Nairobi: Korogocho and Viwandani where 14 community units (defined by the Government’s health care system) will form the unit of randomization. A total of 780 pregnant women and their respective child will be recruited into the study. The mother-child pair will be followed up until the child is one year old. Recruitment will last approximately one year and three months from September 2012 to December 2013. The mothers will receive regular, personalised, home-based counselling by trained Community Health Workers on MIYCN. Regular assessment of knowledge, attitudes and practices on MIYCN will be done, coupled with assessments of nutritional status of the mother-child pairs and diarrhea morbidity for the children. Statistical methods will include analysis of covariance and multinomial logistic regression. Additionally, cost-effectiveness analysis will be done. The study is funded by the Wellcome Trust and will run from March 2012 to February 2015. Discussion Interventions aimed at promoting optimal breastfeeding and complementary feeding practices are considered to have high impact and could prevent a fifth of the under-five deaths in countries with high mortality rates. This study will inform policy and practice in Kenya and similar settings regarding delivery mechanisms for such high-impact interventions, particularly among urban poor populations. Trial registration ISRCTN83692672

Though there is still some reluctance to use human milk for low birth weight infants, we have shown that it is possible exclusively to feed these infants on milk from their own mothers. The infants have adequate weight gain and are less likely to get infections, especially gastrointestinal and respiratory. It is possible to sustain lactation through manual expression during the period that the mother is not nursing her infant directly on the breast. A cup rather than a bottle can be used to feed these small infants. The mothers are thus encouraged because the infant does not suffer nipple confusion with a bottle and they continue breastfeeding after discharge from the hospital.

In Kenya hepatitis B virus (HBV) infection and its sequelae are common. We followed up 49 hepatitis B surface antigen (HBsAg)- positive mothers and their newborn infants for 9 months to determine the importance of perinatal transmission in the African and to relate this to the HBe and HBV-DNA status of the mother. Our study shows that perinatal transmission is relatively unimportant in Kenya and that this may be a consequence of the low levels of circulating HBV-DNA in the maternal plasma. These results imply that vaccination without hyperimmune globulin may be adequate to control HBV infection in Kenya.

The weight of 64 preterm appropriate for gestational age infants were followed closely during the period of stay in the newborn unit. They were subdivided into three groups: A (1001-1250 g), B (1250-1500 g), and C (1501-1750 g). The mean gestation for these groups were 28.7, 30.5, and 31 weeks, respectively, while mean birth weights were 1132 +/- 81.7 g, 1377 +/- 85.6 g, and 1641 +/- 88.6 g. All were fed their own mothers breast milk during the period of study with no supplements. During the first week, there was significant weight loss in all groups as follows: A (12.0 per cent), B (7.7 per cent), and C (4.4 per cent). Thereafter, only group A lost weight in the second week, but the loss was not significant. Birth weights were regained at 23, 16, and 15 days, respectively. The weight gain after the initial loss was A (20.0 g), B (20.4 g), and C (20.2 g) per day. Group A had the fastest growth rate.