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Summary: Background: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2–2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3–0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2–18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46–13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99–17·34]) or anaesthesia complications (11·47 (1·20–109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7–5·0). Interpretation: Maternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. Funding: Medical Research Council of South Africa.

Coffee is an important commodity for Kenya, where production is steadily declining, despite a global rise in demand. Of the various constraints affecting production, plant-parasitic nematodes are a significant, but often overlooked, threat. As a perennial crop, treating plantations once infected with nematodes becomes difficult. The current study evaluated the drenching application of two biocontrol agents, Trichoderma asperellum and Purpureocillium lilacinum , for their nematode control efficacy, as well as their impact on the soil nematode community structure on mature, established coffee trees in Kenya. Seven Arabica coffee field trials were conducted over two years on trees of various ages. All the fields were heavily infested with Meloidogyne hapla , the first report of the species on coffee in Kenya. Both fungal biocontrol agents were detected endophytically infecting roots and recovered from soil but not until six months after initial applications. The population densities of M. hapla had significantly declined in roots of treated trees 12 months after the initial application, although soil nematode density data were similar across treatments. Based upon the maturity index and the Shannon index, treatment with T. asperellum led to improved soil health conditions and enrichment of diversity in the microbial community. Application of P. lilacinum , in particular, led to an increased abundance of fungivorous nematodes, especially Aphelenchus spp., for which P. lilacinum would appear to be a preferred food source. The soils in the trials were all stressed and denuded, however, which likely delayed the impact of such treatments or detection of any differences between treatments using indices, such as the functional metabolic footprint, over the period of study. A longer period of study would therefore likely provide a better indication of treatment benefits. The current study positively demonstrates, however, the potential for using biologically based options for the environmentally and climate-smart management of nematode threats in a sustainable manner on established, mature coffee plantations., Competing Interests: Authors SN and RM are employed by the company RealIPM. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. JWK and DWM supervised CO at University of Nairobi for her MSc and contributed to the experimental design and helped revise the original thesis., (Copyright © 2023 Saikai, Oduori, Situma, Njoroge, Murunde, Kimenju, Miano, Haukeland and Coyne.)

Persistent food insecurity in the global south has triggered calls for sustainable development worldwide. Moreover, more than a quarter of the world's population suffers from micronutrient deficiencies or hidden hunger. The population bulge, declining soil fertility and inadequate/inappropriate use of farm inputs in Sub-Saharan Africa place it in a precarious position. Multi-nutrient fertilizer blends have been mooted as a key innovation in closing yield gaps and boosting food and nutrition security. This study assessed the extent of multi-nutrient fertilizer blends utilization and yield response across agroecological zones and their on-farm profitability under Kenyan smallholder farmer conditions. We collected data through a detailed household survey conducted in eight counties in Kenya representative of high, medium, and low productivity zones using a sample of 1094 smallholder farmers. Multi-nutrient fertilizers increased maize yields significantly ( P < 0.05 ), eliciting a 400% yield increase compared to the control and 108% greater maize yield than conventional fertilizers in the high potential zone. Conversely, at 3.7 t/ha conventional fertilizers elicited a significant ( P < 0.05 ) yield response in Irish potatoes in the high potential areas. Multi-nutrient fertilizers increased on-farm profitability of crops, specifically for potato production systems where a benefit: cost ratio (BCR) of more than 2 was observed. Farmers may break even when they use multi-nutrient fertilizers on maize particularly in the low potential areas. Therefore, there is considerable potential for multi-nutrient fertilizers to increase crop productivity while being economically viable across agroecological zones and cropping systems. However, the uptake of multi-nutrient fertilizers among farmers is quite low across the country, except for small pockets where limited interventions have been carried out. This calls for sustained efforts to scale multi-nutrient fertilizers with a focus on clear messaging that stresses the need to apply appropriate rates of various nutrients including the secondary nutrients and micro-nutrients., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2023 The Authors.)

Live bird markets (LBMs) provide integral hubs for 95% of poultry produced for food. Surveillance systems in LBMs serving smallholder farmers in sub-saharan Africa are often non-functional, and data about public health risks and emerging pathogens are lacking. Studies in Kenya have reported 29-44% Campylobacter prevalence in poultry. We analysed such LBMs in Kenya for likely transmission of Campylobacter from poultry to humans. We conducted a cross-sectional survey among 186 live poultry traders (LPTs) in 14 LBMs in a region with widespread backyard poultry systems. A pretested structured questionnaire was administered to all LPTs having regular contacts with poultry to gather market data and risk information on campylobacteriosis. Campylobacter was detected in individual cloacal cultures and identified through PCR. The median score obtained from the outcome of risk assessment dichotomized respondents into high and low risk categories. We performed logistic regression at 95% confidence interval (CI) to compare market characteristics and Campylobacter positivity to risk categories to identify LBM-associated public health risks. Markets had a median of 13 traders, and mean age of 46.3 ± 13.7 years. Majority 162/186 (87.1%) were males. Market behavioural processes by LPTs varied: Only 58.6% LPTs held bird species separate; onsite slaughter (38.7%); encountered sick-bird (93%) and dead-bird (83%) amidst limited health inspection (31.2%). Campylobacter positivity in live birds was 43/112 (38.4%, 95% CI: 29.4-48.1). Risk information on campylobacteriosis was low 41/114 (36%, 95% CI: 27.2-45.5). Sanitary risks were related to accumulation of litter (adjusted prevalence odds ratio [aPOR]: 19.67, 95% CI: 3.01-128.52). Accessing hand-wash facilities (aPOR: .32, 95% CI: .13-.78) and access to information (aPOR: .24, 95% CI: .09-.61) were protective. Sanitary risks were related to poor hygiene. LBMs could be central surveillance sites for Campylobacter. Public health authorities/actors should consider appropriate targeting to improve sanitary measures and Campylobacter control strategies., (© 2022 The Authors. Transboundary and Emerging Diseases published by Wiley-VCH GmbH.)

Increasing fertilizer access and use is an essential component for improving crop production and food security in sub-Saharan Africa (SSA). However, given the heterogeneous nature of smallholder farms, fertilizer application needs to be tailored to specific farming conditions to increase yield, profitability, and nutrient use efficiency. The site-specific nutrient management (SSNM) approach initially developed in the 1990 s for generating field-specific fertilizer recommendations for rice in Asia, has also been introduced to rice, maize and cassava cropping systems in SSA. The SSNM approach has been shown to increase yield, profitability, and nutrient use efficiency. Yield gains of rice and maize with SSNM in SSA were on average 24% and 69% when compared to the farmer practice, respectively, or 11% and 4% when compared to local blanket fertilizer recommendations. However, there is need for more extensive field evaluation to quantify the broader benefits of the SSNM approach in diverse farming systems and environments. Especially for rice, the SSNM approach should be expanded to rainfed systems, which are dominant in SSA and further developed to take into account soil texture and soil water availability. Digital decision support tools such as RiceAdvice and Nutrient Expert can enable wider dissemination of locally relevant SSNM recommendations to reach large numbers of farmers at scale. One of the major limitations of the currently available SSNM decision support tools is the requirement of acquiring a significant amount of farm-specific information needed to formulate SSNM recommendations. The scaling potential of SSNM will be greatly enhanced by integration with other agronomic advisory platforms and seamless integration of digital soil, climate and crop information to improve predictions of SSNM recommendations with reduced need for on-farm data collection. Uncertainty should also be included in future solutions, primarily to also better account for varying prices and economic outcomes., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Authors.)

Introduction: Women with a history of preeclampsia have a higher risk of recurrent preeclampsia. This study sought to ascertain the relationship between the interbirth interval and the risk of recurrent preeclampsia and difference in angiogenic markers between the two groups., Methods: Data was collected from an ongoing cohort study of women with hypertensive disorders of pregnancy (HDP) enrolled at the admission to the labor and delivery floor. From this dataset, multigravida women with a prior diagnosis of preeclampsia were identified and compared to women with no prior history of preeclampsia., Results: Of the 375 women with HDP who were predominantly African American, 245 were multigravida and 44 (18.0%) had a prior history of preeclampsia. Women with prior preeclampsia had an earlier gestational age of delivery, higher rates of preterm delivery and a higher incidence of preeclampsia with severe features (56.8% vs 29.8%) in the index pregnancy (p-values ≤ 0.001) than those without. The median number of years between history of preeclampsia in previous pregnancy and current pregnancy was 6 years (IQR 3, 8). Among patients with a prior history of preeclampsia, the interbirth interval was not associated with severe preeclampsia (p = 0.60) and there was no difference in angiogenic factors between patients with a prior history of preeclampsia compared to those without., Conclusions: In this study, the duration of the interbirth interval was not identified as a risk factor of developing severe preeclampsia in a subsequent pregnancy and angiogenic factors are not a reflection of maternal predisposition to recurrent preeclampsia., (Copyright © 2021 International Society for the Study of Hypertension in Pregnancy. Published by Elsevier B.V. All rights reserved.)

Helicobacter pylori ( H.pylori ) infection is etiologically associated with severe diseases including gastric cancer; but its pathogenicity is deeply shaped by the exceptional genomic diversification and geographic variation of the species. The clinical relevance of strains colonizing Africa is still debated. This study aimed to explore genomic features and virulence potentials of H. pylori KE21, a typical African strain isolated from a native Kenyan patient diagnosed with a gastric cancer. A high-quality circular genome assembly of 1,648,327 bp (1590 genes) obtained as a hybrid of Illumina Miseq short reads and Oxford Nanopore MinION long reads, clustered within hpAfrica1 population. This genome revealed a virulome and a mobilome encoding more than hundred features potentiating a successful colonization, persistent infection, and enhanced disease pathogenesis. Furthermore, through an experimental infection of gastric epithelial cell lines, strain KE21 showed the ability to promote interleukin-8 production and to induce cellular alterations resulting from the injection of a functional CagA oncogene protein into the cells. This study shows that strain KE21 is potentially virulent and can trigger oncogenic pathways in gastric epithelial cells. Expended genomic and clinical explorations are required to evaluate the epidemiological importance of H. pylori infection and its putative complications in the study population.

Aflatoxins are secondary metabolites produced by soilborne saprophytic fungus Aspergillus flavus and closely related species that infect several agricultural commodities including groundnut and maize. The consumption of contaminated commodities adversely affects the health of humans and livestock. Aflatoxin contamination also causes significant economic and financial losses to producers. Research efforts and significant progress have been made in the past three decades to understand the genetic behavior, molecular mechanisms, as well as the detailed biology of host-pathogen interactions. A range of omics approaches have facilitated better understanding of the resistance mechanisms and identified pathways involved during host-pathogen interactions. Most of such studies were however undertaken in groundnut and maize. Current efforts are geared toward harnessing knowledge on host-pathogen interactions and crop resistant factors that control aflatoxin contamination. This study provides a summary of the recent progress made in enhancing the understanding of the functional biology and molecular mechanisms associated with host-pathogen interactions during aflatoxin contamination in groundnut and maize., (Copyright © 2020 Soni, Gangurde, Ortega-Beltran, Kumar, Parmar, Sudini, Lei, Ni, Huai, Fountain, Njoroge, Mahuku, Radhakrishnan, Zhuang, Guo, Liao, Singam, Pandey, Bandyopadhyay and Varshney.)

In this work, we present an experimental study on the acoustic vibrations of ZnO nanoparticles array with different concentration of Ga dopings by using femtosecond pump-probe technique. The Ga-doped ZnO (GZO) nano-triangle particles with the sizes of 190, 232 and 348 nm are fabricated by nanosphere lithography and pulsed laser deposition method. The result indicates that the frequency of acoustic vibrations of GZO nanoparticles decrease as the Ga-concentration is increased. Importantly, the vibration period of the GZO nanoparticles at the same Ga doping concentration show a nonlinear increase as the nanoparticle size is increased, which is different from the common linear dependency in undoped ZnO nanoparticles. It may be attributed to the crystal structure distortion and elastic characteristics variation due to Ga doping, and the elastic modulus at 7.3% Ga doping is decreased by 30%-60% for GZO nanoparticles with different sizes. The study can be very helpful for evaluating the crystal structure distortion and elastic characteristics of doped nano-materials with optical methods. Besides, it can offer a complementary method of thermal management in ZnO based optoelectronic devices.

Aflatoxin is considered a "hidden poison" due to its slow and adverse effect on various biological pathways in humans, particularly among children, in whom it leads to delayed development, stunted growth, liver damage, and liver cancer. Unfortunately, the unpredictable behavior of the fungus as well as climatic conditions pose serious challenges in precise phenotyping, genetic prediction and genetic improvement, leaving the complete onus of preventing aflatoxin contamination in crops on post-harvest management. Equipping popular crop varieties with genetic resistance to aflatoxin is key to effective lowering of infection in farmer's fields. A combination of genetic resistance for in vitro seed colonization (IVSC), pre-harvest aflatoxin contamination (PAC) and aflatoxin production together with pre- and post-harvest management may provide a sustainable solution to aflatoxin contamination. In this context, modern "omics" approaches, including next-generation genomics technologies, can provide improved and decisive information and genetic solutions. Preventing contamination will not only drastically boost the consumption and trade of the crops and products across nations/regions, but more importantly, stave off deleterious health problems among consumers across the globe.

Water quality assessment was conducted on the Ruiru River, a tributary of an important tropical river system in Kenya, to determine baseline river conditions for studies on the aquatic fate of N-methyl carbamate (NMC) pesticides. Measurements were taken at the end of the long rainy season in early June 2013. Concentrations of copper (0.21-1.51 ppm), nitrates (2.28-4.89 ppm) and phosphates (0.01-0.50 ppm) were detected at higher values than in uncontaminated waters, and attributed to surface runoff from agricultural activity in the surrounding area. Concentrations of dissolved oxygen (8-10 ppm), ammonia (0.02-0.22 ppm) and phenols (0.19-0.83 ppm) were found to lie within normal ranges. The Ruiru River was found to be slightly basic (pH 7.08-7.70) with a temperature of 17.8-21.2°C. The half-life values for hydrolysis of three NMC pesticides (carbofuran, carbaryl and propoxur) used in the area were measured under laboratory conditions, revealing that rates of decay were influenced by the electronic nature of the NMCs. The hydrolysis half-lives at pH 9 and 18°C decreased in the order carbofuran (57.8 h) > propoxur (38.5 h) > carbaryl (19.3 h). In general, a decrease in the electron density of the NMC aromatic ring increases the acidity of the N-bound proton removed in the rate-limiting step of the hydrolysis mechanism. Our results are consistent with this prediction, and the most electron-poor NMC (carbaryl) hydrolyzed fastest, while the most electron-rich NMC (carbofuran) hydrolyzed slowest. Results from this study should provide baseline data for future studies on NMC pesticide chemical fate in the Ruiru River and similar tropical water systems.

Introduction: In 2010, WHO recommended a new first-line treatment for visceral leishmaniasis (VL) in Eastern Africa. The new treatment, a combination of intravenous (IV) or intramuscular (IM) sodium stibogluconate (SSG) and IM paromomycin (PM) was an improvement over SSG monotherapy, the previous first-line VL treatment in the region. To monitor the new treatment's safety and effectiveness in routine clinical practice a pharmacovigilance (PV) programme was developed., Methods: A prospective PV cohort was developed. Regulatory approval was obtained in Sudan, Kenya, Uganda and Ethiopia. Twelve sentinel sites sponsored by the Ministries of Health, Médecins Sans Frontières (MSF) and Drugs for Neglected Diseases initiative (DNDi) participated. VL patients treated using the new treatment were consented and included in a common registry that collected demographics, baseline clinical characteristics, adverse events, serious adverse events and treatment outcomes. Six-monthly periodic safety update reports (PSUR) were prepared and reviewed by a PV steering committee., Results: Overall 3126 patients were enrolled: 1962 (62.7%) from Sudan, 652 (20.9%) from Kenya, 322 (10.3%) from Ethiopia and 190 (6.1%) from Uganda. Patients were mostly male children (68.1%, median age 11 years) with primary VL (97.8%). SSG-PM initial cure rate was 95.1%; no geographical differences were noted. HIV/VL co-infected patients and patients older than 50 years had initial cure rates of 56 and 81.4%, respectively, while 1063 (34%) patients had at least one adverse event (AE) during treatment and 1.92% (n = 60) had a serious adverse event (SAE) with a mortality of 1.0% (n = 32). There were no serious unexpected adverse drug reactions., Conclusions: This first regional PV programme in VL supports SSG-PM combination as first-line treatment for primary VL in Eastern Africa. SSG-PM was effective and safe except in HIV/VL co-infected or older patients. Active PV surveillance of targeted safety, effectiveness and key VL outcomes such us VL relapse, PKDL and HIV/VL co-infection should continue and PV data integrated to national and WHO PV databases.

Improved understanding of soil fertility factors limiting crop productivity is important to develop appropriate soil and nutrient management recommendations in sub-Saharan Africa. Diagnostic trials were implemented in Kenya, Malawi, Mali, Nigeria and Tanzania, as part of the African Soils Information Service (AfSIS) project, to identify soil fertility constraints to crop production across various cropping systems and soil fertility conditions. In each country, one to three sites of 10 km × 10 km were included with each site having 12-31 field trials. The treatments tested included a control, an NPK treatment, three treatments in which the N, P and K nutrients were omitted one at a time from the NPK treatment, and three treatments in which secondary and micronutrients (Ca, Mg, S, Zn and B) simply referred here as multi-nutrients, manure and lime were added to the NPK. The field trials were conducted for 1-2 seasons; the test crop was maize except in Mali where sorghum was used. Nitrogen was limiting in all sites and generally the most limiting nutrient except in Sidindi (Kenya) and Kontela (Mali) where P was the most limiting. The general pattern in Kiberashi (Tanzania) shows none of the nutrients were limiting. K is mainly limiting in only one site (Mbinga) although incidences of K limitation were seen in almost all sites. Addition of multi-nutrients and manure further improved the yields of NPK in most sites. Cluster analyses revealed that maize crop in 11% of fields were highly responsive to nitrogen application, 25% (i.e., 21% poor and 4% fertile) 'non-responsive' to any nutrient or soil amendment, 28% being 'low responsive' and 36% of 'intermediate response'. This study indicates that constraints to crop production vary considerably even within a site, and that addressing limitations in secondary and micronutrients, and increasing soil carbon can improve response to fertilizers. For sustainable crop production intensification in smallholder farming systems in SSA, there is need to develop management strategies to improve efficiency of fertilizer use and of other inputs, recognizing the site-specific nutrient response patterns at various spatial scales.

Multidrug-resistant bacteria pose a major challenge to the clinical management of infections in resource-poor settings. Although nontyphoidal Salmonella (NTS) bacteria cause predominantly enteric self-limiting illness in developed countries, NTS is responsible for a huge burden of life-threatening bloodstream infections in sub-Saharan Africa. Here, we characterized nine S. Typhimurium isolates from an outbreak involving patients who initially failed to respond to ceftriaxone treatment at a referral hospital in Kenya. These Salmonella enterica serotype Typhimurium isolates were resistant to ampicillin, chloramphenicol, cefuroxime, ceftriaxone, aztreonam, cefepime, sulfamethoxazole-trimethoprim, and cefpodoxime. Resistance to β-lactams, including to ceftriaxone, was associated with carriage of a combination of blaCTX-M-15, blaOXA-1, and blaTEM-1 genes. The genes encoding resistance to heavy-metal ions were borne on the novel IncHI2 plasmid pKST313, which also carried a pair of class 1 integrons. All nine isolates formed a single clade within S. Typhimurium ST313, the major clone of an ongoing invasive NTS epidemic in the region. This emerging ceftriaxone-resistant clone may pose a major challenge in the management of invasive NTS in sub-Saharan Africa., (Copyright © 2015, Kariuki et al.)

Objective: To determine the antibiotic resistance patterns of pathogenic Escherichia coli on goat meat carcass at Huruma and Kiserian abattoirs in Kenya., Design: Laboratory based study., Setting: Huruma and Kiserian abattoirs in Kenya,, Subjects: 400 slaughtered goats inspected by veterinary health officers and approved for human consumption., Methods: A Total of 400 slaughtered goats which were inspected by veterinary health officers and approved for human consumption were sampled from Huruma and Kiserian abattoir. Goat carcass swabs were collected by passing each swab tissue on four parts of the carcass mainly neck, right and left forelimbs, right and left hind limbs, and brisket., Results: A total of 54 E. coli isolates were isolated and confirmed to be pathogenic. The percentage of isolates resistant to various microbial agents was recorded as follows: ampicillin (26 %), amoxycillin-clavulanic acid (17%), tetracycline (15%), chroramphenicol (4%), and ceftrixone (2% each). All Escherichia coli isolates were susceptible to gentamicin sulphamethaxazole-trimethomprin, kanamycin, cetriazididine (CAZ, 30pg), ciproxacin, nalidixic acid and chloramphenicol. Isolates were resistant to one or more of the antibiotics tested. Among the drugs tested, resistance was more frequently observed against ampicillin, amoxycillin-clavulanic acid, tetracycline, ceftrixone and chroramphenicol antibiotics. Among the isolates 26(48%) were positive for the stx1 gene, 19(35%) had the eae gene, 10(19%) possessed est gene,while 8(15%) harboured elt gene. Overall five isolates (10%) possessed aspu gene and two (4%) had aggR gene. No isolate possessed ipah gene., Conclusion: This study demonstrated that there is a significant level of antimicrobial resistance in pathogenic E. coli isolated from goat meat from Huruma and Kiserian abattoir. This indicates that goat meat from abattoirs could pose a risk of transmission of pathogenic antibiotic resistant strains to human. Poor hygienic standards and indiscriminate use of antimicrobials are the two main reasons for the presence of resistant pathogens in goat carcasses., Recommendations: Implemention of appropriate hygiene measures to control contamination of meat with pathogenic E. coli.

Background: Alternative treatments for visceral leishmaniasis (VL) are required in East Africa. Paromomycin sulphate (PM) has been shown to be efficacious for VL treatment in India., Methods: A multi-centre randomized-controlled trial (RCT) to compare efficacy and safety of PM (20 mg/kg/day for 21 days) and PM plus sodium stibogluconate (SSG) combination (PM, 15 mg/kg/day and SSG, 20 mg/kg/day for 17 days) with SSG (20 mg/kg/day for 30 days) for treatment of VL in East Africa. Patients aged 4-60 years with parasitologically confirmed VL were enrolled, excluding patients with contraindications. Primary and secondary efficacy outcomes were parasite clearance at 6-months follow-up and end of treatment, respectively. Safety was assessed mainly using adverse event (AE) data., Findings: The PM versus SSG comparison enrolled 205 patients per arm with primary efficacy data available for 198 and 200 patients respectively. The SSG & PM versus SSG comparison enrolled 381 and 386 patients per arm respectively, with primary efficacy data available for 359 patients per arm. In Intention-to-Treat complete-case analyses, the efficacy of PM was significantly lower than SSG (84.3% versus 94.1%, difference = 9.7%, 95% confidence interval, CI: 3.6 to 15.7%, p = 0.002). The efficacy of SSG & PM was comparable to SSG (91.4% versus 93.9%, difference = 2.5%, 95% CI: -1.3 to 6.3%, p = 0.198). End of treatment efficacy results were very similar. There were no apparent differences in the safety profile of the three treatment regimens., Conclusion: The 17 day SSG & PM combination treatment had a good safety profile and was similar in efficacy to the standard 30 day SSG treatment, suggesting suitability for VL treatment in East Africa., Clinical Trials Registration: www.clinicaltrials.govNCT00255567.

Background: Visceral leishmaniasis (VL) is a major health problem in developing countries. The untreated disease is fatal, available treatment is expensive and often toxic, and drug resistance is increasing. Improved treatment options are needed. Paromomycin was shown to be an efficacious first-line treatment with low toxicity in India., Methods: This was a 3-arm multicentre, open-label, randomized, controlled clinical trial to compare three treatment regimens for VL in East Africa: paromomycin sulphate (PM) at 15 mg/kg/day for 21 days versus sodium stibogluconate (SSG) at 20 mg/kg/day for 30 days; and the combination of both dose regimens for 17 days. The primary efficacy endpoint was cure based on parasite-free tissue aspirates taken 6 months after treatment., Findings: Overall, 135 patients per arm were enrolled at five centres in Sudan (2 sites), Kenya (1) and Ethiopia (2), when the PM arm had to be discontinued due to poor efficacy. The trial has continued with the higher dose of PM as well as the combination of PM and SSG arms. These results will be reported later. Baseline patient characteristics were similar among treatment arms. The overall cure with PM was significantly inferior to that with SSG (63.8% versus 92.2%; difference 28.5%, 95%CI 18.8% to 38.8%, p<0.001). The efficacy of PM varied among centres and was significantly lower in Sudan (14.3% and 46.7%) than in Kenya (80.0%) and Ethiopia (75.0% and 96.6%). No major safety issues with PM were identified., Conclusion: The efficacy of PM at 15 mg/kg/day for 21 days was inadequate, particularly in Sudan. The efficacy of higher doses and the combination treatment warrant further studies.

In a case of poisoning involving 70 cattle analysis of specimens obtained during post mortem examination showed that the toxic substances were arsenic and toxaphene. This was consistent with both the clinical and post mortem findings. Arsenic was detected in water from an abandoned cattle dip in the farm. Soil samples collected in the vicinity of the dip contained both arsenic and toxaphene.