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This paper reports the detailed results of a study of the impact of the Health Workers for Change (HWFC) workshop series on clients' perceptions of health services, relationships within the health centre and relations between the health facility and the district health system. The study was carried out in three stages: baseline, intervention and evaluation over a period of 20 months. Data, both qualitative and quantitative, were collected at three levels: client, facility and system. Results indicate that relations between health workers and clients improved a great deal after the intervention while those between the facility and the system remained to a large extent unchanged. The paper concludes that, with external support and help, especially from the health system level, health workers can work towards improving health services and their job satisfaction, which can lead to better health worker-client relations. [ABSTRACT FROM AUTHOR]

Presents the results of microgeographical studies of human water contact behavior and Schistosoma mansoni transmission levels and intensity of infection in four rural areas in Machakos District, Kenya. Utilization of linear regression and mapping techniques; Parameters considered; Factors responsible for the development of a transmission pattern.

Two populations with differing histories of Schistosoma mansoni and hepatitis C infection were compared directly for severity of disease and extent of comorbidity. Demographic, parasitologic, and ultrasound surveys were conducted on 2038 Egyptians and on 2120 Kenyans. Hepatitis B and C serologies and transaminase levels were obtained from a subset at each site. Despite significantly lower prevalence and intensity of infection, Egyptians had a higher prevalence of severe schistosomal fibrosis than Kenyans (36.8% vs. 4.6%). Hepatitis C infection was 3 times more prevalent among Egyptians, and evidence of hepatocellular damage was significantly greater among Egyptians. There was no interaction between S. mansoni infection or disease and the prevalence or severity of hepatitis C. For both infections, the intensity or prevalence of infection was a poor predictor of morbidity. The prevalence of disease in the Egyptian population from different pathogens suggests a generalized susceptibility to inflammatory liver disease.

Severe periportal fibrosis is not an inevitable consequence of infection with Schistosoma mansoni. Genetic predisposition may be a deciding factor in the development of disease. To assess the contribution of genetic factors in the severity of hepatic fibrosis, the degree of familial aggregation was determined in a Kenyan population. Schistosomal fibrosis was identified with hepatic ultrasound and newly proposed World Health Organization criteria, which include both qualitative and quantitative observations. These 2 aspects of the criteria correlated well with one another. The peak prevalence of ultrasound proven fibrosis trailed 5-10 years behind peak prevalence of infection and declined sharply after age 50 years. This pattern was consistent with either resolution of severe fibrosis over 10-20 years or early death of those severely affected. Genetic predisposition appears to be a weak factor in the development of severe disease in this population, since no household or familial aggregation could be identified.

A total of 19 annual or biannual audits were performed over a 12-year period by an independent microscopist on randomized subsamples of Kato slides examined for Schistosoma mansoni eggs by Kenyan microscopists from the Division of Vector-borne Diseases (DVBD). The recounts were invariably lower than the originals owing to some deterioration of the preparations between counts, but the two were strongly correlated: significant regressions of recounts on counts taking up 80-90% of the observed variance. Observer bias differed significantly between microscopists but remained stable over time, whereas repeatability of recounts on counts dropped slightly in periods of maximum work load but did not vary systematically with time. Approximately 7% of the counts and recounts disagreed on the presence or absence of eggs, but less than a third of these were negatives that were found positive on recount. False negatives dropped to 1.3% if duplicate counts were considered. The performance of the Kenyan microscopists was remarkably high and consistent throughout the 12-year period. This form of quality control is suitable for projects where limited funds preclude full-time supervisors using more sophisticated systems.

Haematological surveys were carried out in 3 schools in 2 areas where Schistosoma mansoni is endemic in Machakos District, Kenya, before and after a treatment campaign using praziquantel. Earlier clinical impressions of differences in the levels of anaemia between the 2 areas were not confirmed. Although individual haemoglobin levels and haematocrits often fell below international norms, significant anaemia with abnormal red blood cell morphology was rare (< 5%), but varied between schools. Altitude could have accounted for some of these differences, but other factors, including diet and parasitism, were involved. Anaemia was associated with splenomegaly and, to a lesser extent, hepatosplenomegaly. Epidemic malaria (mainly Plasmodium falciparum) appeared to be the main cause of parasite-induced anaemia. There was no significant association with the scarce hookworm infections (mainly Necator americanus); nor did the much commoner S. mansoni cause severe anaemia at the community level, but haemoglobin levels dropped as its intensity increased. Treatment with praziquantel eliminated this trend except in a few subjects with splenomegaly alone (probably due to malaria) or with schistosomal hepatosplenic disease. Possible pathogenic mechanisms are reviewed, including the consumption of red blood cells by adult schistosomes as a possible cause of anaemia.

Formol-ether concentration supplemented by fresh saline smears was used to study intestinal parasites in two communities, Miu and Kitengei, in Machakos District, Kenya. These communities differed markedly in schistosome associated morbidity, in spite of similar prevalence and intensities of infection as revealed by Kato examination, Seven helminth and nine protozoan species were detected among 1011 samples examined. More than 60% of the subjects were infected with more than one parasite: one had nine. Age-prevalence curves were typical for the different species, and overall prevalence of some protozoa, including Entamoeba spp. and Blastocystis hominis, exceeded that of the commonest helminth, Schistosoma mansoni. However, the observed prevalence of S. mansoni was barely 40% of that detected by Kato examinations. Strong associations were found between some pairs of protozoan species, but not with or among the helminths. The differences in the abundance and age-specific distribution of the other intestinal parasites at Miu and Kitengei were so small that it is unlikely that interactions between them and S. mansoni would account for the differences in schistosomal morbidity.

Fifty local medicinal, agricultural and wild growing deciduous plants, representing 49 species, 46 genera and 22 families, were screened as water extracts at 1:1000 concentration for molluscicidal activity against Biomphalaria pfeifferi in Machakos District, Kenya. Forty-seven of the 50 (94%) plants and 106 of the 134 (79%) plant materials (roots, stems, leaves, fruits, flowers and seeds) were molluscicidal. The leaves of Pappea capensis (Sapindaceae), Steganotaenia araliacea (Umbelliferae), Zornia setosa subsp. obvata (Papilionaceae) and Terminalia kilimandscharica (Combretaceae), the flower pods of Hyptis pectinata (Labiatae), the seeds of Acacia nilotica (Mimosaceae) and the fruits and roots of Solanum nigrum (Solanaceae) gave 100% kill. Another 15 species produced mortality rates between 53% and 87%. Plants were evaluated for possible use in local snail control programmes by considering their growing characteristics, habitat requirements, toxicity in non-target organisms, abundance in the study area and competing uses.

From June 1982 to May 1986 in a small village in Kwale, Kenya, we studied seasonal fluctuations in populations of Bulinus globosus, prevalence of Schistosoma haematobium infection in this snail, and effects of chemotherapy and piped water supply on infection rate of snails. In the perennially-flowing Pemba River, relatively small numbers of snails were collected; they were found only during the hot dry season (December to March). In a tributary stream, the Kadingo River, whose flow ceased at the end of both the cool and hot dry seasons, snail numbers peaked at the end of the cool dry season (October to November) and at the beginning of the hot dry season (January). Large numbers of infected snails were found in the Kadingo River from November to January (short rainy season and beginning of dry season). Selective mass chemotherapy with metrifonate and provision of piped water were begun in February and March 1984. These control measures achieved a significant reduction in the infection rate of snails (P less than 0.001); the annual infection rate for the 2 years before treatment was 9.3% and 13.1%, and for the 2 years after treatment was 3.5% and 3.4%.