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Introduction Tuberculosis (TB) remains a major cause of morbidity and mortality, especially in sub-Saharan Africa. We qualitatively evaluated the implementation of an Evidence-Based Multiple Focus Integrated Intensified TB Screening package (EXIT-TB) in the East African region, aimed at increasing TB case detection and number of patients receiving care. Objective We present the accounts of participants from Tanzania, Kenya, Uganda, and Ethiopia regarding the implementation of EXIT-TB, and suggestions for scaling up. Methods A qualitative descriptive design was used to gather insights from purposefully selected healthcare workers, community health workers, and other stakeholders. A total of 27, 13, 14, and 19 in-depth interviews were conducted in Tanzania, Kenya, Uganda, and Ethiopia respectively. Data were transcribed and translated simultaneously and then thematically analysed. Results The EXIT-TB project was described to contribute to increased TB case detection, improved detection of Multidrug-resistant TB patients, reduced delays and waiting time for diagnosis, raised the index of TB suspicion, and improved decision-making among HCWs. The attributes of TB case detection were: (i) free X-ray screening services; (ii) integrating TB case-finding activities in other clinics such as Reproductive and Child Health clinics (RCH), and diabetic clinics; (iii), engagement of CHWs, policymakers, and ministry level program managers; (iv) enhanced community awareness and linkage of clients; (v) cooperation between HCWs and CHWs, (vi) improved screening infrastructure, (vii) the adoption of the new simplified screening criteria and (viii) training of implementers. The supply-side challenges encountered ranged from disorganized care, limited space, the COVID-19 pandemic, inadequate human resources, inadequate knowledge and expertise, stock out of supplies, delayed maintenance of equipment, to absence of X-ray and GeneXpert machines in some facilities. The demand side challenges ranged from delayed care seeking, inadequate awareness, negative beliefs, fears towards screening, to financial challenges. Suggestions for scaling up ranged from improving service delivery, access to diagnostic equipment and supplies, and infrastructure, to addressing client fears and stigma. Conclusion The EXIT-TB package appears to have contributed towards increasing TB case detection and reducing delays in TB treatment in the study settings. Addressing the challenges identified is needed to maximize the impact of the EXIT-TB intervention.

The World Health Organization (WHO) criteria for diagnosing and treating Tuberculosis (TB) includes clinical signs, therefore not requiring bacteriological laboratory confirmation. In resource-limited settings, including Kenya, this empirical TB treatment is routine practice however limited data exist on patient clinical outcomes when comparing the method of diagnosis. We evaluated TB treatment outcomes comparing clinically diagnosed and bacteriologically confirmed TB, 6 months after starting treatment of TB in a rural county in Kenya. Our analysis compared patients with a clinical versus a bacteriologically confirmed TB diagnosis. In this retrospective analysis, we included all adults (≥ 18 years) starting treatment of TB and followed up for 6 months, within the County TB surveillance database from 2012 to 2018. Patients included from both public and private facilities. The TB treatment outcomes assessed included treatment success, treatment failure, death, defaulted and transferred out. We used survival regression models to assess effect of type of diagnosis on TB treatment outcome defining time at risk from date of starting treatment to experiencing one of the treatment outcomes or completing 6-months of treatment. A total of 12,856 patients; median age 37 [IQR 28 − 50] years were included. 7639 (59%) were male while 11,339 (88%) were pulmonary TB cases. Overall, 11,633 (90%) were given first-line TB treatment and 3791 (29%) were HIV infected. 6472 (50%) of the patients were clinically diagnosed of whom 4521/6472 (70%) had a negative sputum/GeneXpert test. During the study 5565 person-years (PYs) observed, treatment success was 82% and 83% amongst clinically and bacteriologically diagnosed patients (P = 0.05). There were no significant differences in defaulting (P = 0.70) or transfer out (P = 0.19) between clinically and bacteriologically diagnosed patients. Mortality was significantly higher among clinically diagnosed patients: 639 (9.9%) deaths compared to 285 (4.5%) amongst the bacteriologically diagnosed patients; aHR 5.16 (95%CI 2.17 − 12.3) P

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

BackgroundDiagnosing bacterial meningitis is essential to optimise the type and duration of antimicrobial therapy to limit mortality and sequelae. In sub-Saharan Africa, many public hospitals lack laboratory capacity, relying on clinical features to empirically treat or not treat meningitis. We investigated whether clinical features of bacterial meningitis identified prior to the introduction of conjugate vaccines still discriminate meningitis in children aged ≥60 days.MethodsWe conducted a retrospective cohort study to validate seven clinical features identified in 2002 (KCH-2002): bulging fontanel, neck stiffness, cyanosis, seizures outside the febrile convulsion age range, focal seizures, impaired consciousness, or fever without malaria parasitaemia and Integrated Management of Childhood Illness (IMCI) signs: neck stiffness, lethargy, impaired consciousness or seizures, and assessed at admission in discriminating bacterial meningitis after the introduction of conjugate vaccines. Children aged ≥60 days hospitalised between 2012 and 2016 at Kilifi County Hospital were included in this analysis. Meningitis was defined as positive cerebrospinal fluid (CSF) culture, organism observed on CSF microscopy, positive CSF antigen test, leukocytes ≥50/μL, or CSF to blood glucose ratio ResultsAmong 12,837 admissions, 98 (0.8%) had meningitis. The presence ofKCH-2002signs had a sensitivity of 86% (95% CI 77–92) and specificity of 38% (95% CI 37–38). Exclusion of ‘fever without malaria parasitaemia’ reduced sensitivity to 58% (95% CI 48–68) and increased specificity to 80% (95% CI 79–80). IMCI signs had a sensitivity of 80% (95% CI 70–87) and specificity of 62% (95% CI 61–63).ConclusionsA lower prevalence of bacterial meningitis and less typical signs than in 2002 meant the lower performance ofKCH-2002signs. Clinicians and policymakers should be aware of the number of lumbar punctures (LPs) or empirical treatments needed for each case of meningitis. Establishing basic capacity for CSF analysis is essential to exclude bacterial meningitis in children with potential signs.

The performance of projects in the Kenyan land development industry has of late been tempestuous. The study was particularly centered on the impact of task planning, venture correspondence, asset accessibility and partner's association on usage of land ventures actualized by SACCOS. The investigation was guided by the following specific objectives: to analyze the influence of project planning on performance of real estate projects financed by registered SACCOS in Nairobi City County; to establish the influence of project communication management on performance of real estate projects financed by registered SACCOS in Nairobi City County; to assess the influence of stakeholder involvement on performance of real estate projects financed by registered SACCOS in Nairobi City County; and to assess the influence of resource availability on performance of real estate projects financed by registered SACCOS in Nairobi City County. The study utilized descriptive examination outline. The target population of this study comprised of all the 153 land development ventures being actualized by the 38 SACCOS enrolled by SASRA in Nairobi County. It was established that most of the project implementation indicators had positive impact on performance of the real estate projects. The study further adopted a regression analysis to determine the relationship between the variables. The study findings showed that the four variables had a significant influence on performance of the real estate projects. The study recommended that a similar research should be conducted with an aim at investigating the determinates of project implementation on the performance of real estate projects financed by registered SACCOS in Nairobi with other variables or of other firms in other sectors, including the other counties in the Kenya. The findings showed that 69.4 % of the performance is explained by the four variables while 30.6 can be accounted by other factors captured by the standard error. Key words: Project Implementation, Project Planning, Project Communication Management, Stakeholder Involvement, Resource Availability, Performance of Real Estate Projects CITATION: Masasabi, H. W., & Ngari, C. (2019). Determinants of project implementation on performance of real estate projects financed by registered Saccos in Nairobi City County, Kenya. The Strategic Journal of Business & Change Management, 6 (2), 1542 –1555.

Objectives To determine the factors associated with poor outcomes among people living with HIV (PLHIV) started on anti- retroviral therapy before and after implementation of “Test and treat” program in 18 facilities in Coastal Kenya. Methods A retrospective cohort study design was used to study PLHIV aged > 15 years and started on ART in the periods of April to August 2016, and April to August 2017, then followed up for 24 months. Primary outcome was retention defined as being alive and on ARVs after 24 months. Death and loss to follow-up were considered as poor outcomes. Kaplan–Meier survival methods were used to describe time to primary outcome. Cox proportional regression analysis was used to determine factors associated with poor outcomes. Results 86 patients (470 before test and treat, and 316 after test and treat cohorts) were enrolled. Overall, the median [IQR] age was 39.3 [32.5–47.5] years and 539 (69%) were female. After 24 months, retention rates for the before (68%) and after (64%) test and start groups were similar (absolute difference: -4.0%, 95%CI: -11-3.1, P = 0.27). There were 240(31%, 95%CI 27 to 34%) PLHIV with poor outcomes, 102 (32%) and 138 (29%) occurred among the test and treat group, and delayed treatment patients respectively. In multivariable regression model, test and treat had no significant effect on risk of poor outcomes (aHR = 1.17, 95%CI 0.89–1.54). Increasing age (aHR = 0.98, 95%CI 0.97–0.99), formal employment (aHR = 0.42, 95%CI 0.23–0.76) and not being employed (aHR = 0.53, 95%CI 0.34–0.81) were negatively associated with poor outcomes. The risk of poor outcomes was higher among males compared to female patients (aHR = 1.37, 95%CI 1.03–1.82) and among divorced/separated patients compared to the married (aHR = 1.44, 95%CI 1.04–1.99). Conclusion Retention patterns for the “test and treat” cohort were comparable to those who started ART before “test and treat”. Patients who are males, young, divorced/separated, with poor socio-economic status had higher risks for poor clinical outcomes. Interventions targeting PLHIV who are young, male and economically disadvantaged provide an opportunity to improve the long-term outcomes.

Introduction Human-snake interactions are common in tropical regions where subsistence-farming and livestock-herding activities predominate alongside proliferation of snakes. Local beliefs and perceptions about snakes and snakebites influence human behaviour. Understanding these beliefs and perceptions can inform the development of resources to drive behaviour change and to minimise the risk of injury to both humans and snakes. This qualitative study, conducted between May and July 2019, sought to explore the beliefs and perceptions regarding snakes and snakebites, and methods of prevention and management among members of the community in Kitui County, Kenya. Methods Semi-structured interviews were used to collect qualitative data from 23 participants, recruited using a stratified purposeful sampling strategy in four selected sub-counties of Kitui county. Interview data was anonymised and coded and a thematic analysis was conducted using NVivo 12. Results People from Kitui county mostly had negative perceptions about snakes. There was a generalised awareness of the need to prevent snakebite, predominantly through keeping snakes away from homes/compounds. However, implementation was limited by financial constraints. Participants also identified logistic and financial obstacles to early hospital presentation following a snakebite, and they expressed a strong preference of having their snakebites treated in a hospital over consulting traditional healers. There was a universal recognition of the benefit of early intervention with a specific appreciation of the utility of the black stone. Furthermore, the removal of a snake’s “teeth” was an expected treatment outcome for some community members, with the failure to do so perceived as causing poor wound healing or persistence of symptoms. Some religious groups held views which differed from most participants. Conclusion There is a need to explore and clarify common misconceptions about snakes and first aid treatment of snakebites, encourage learning about the true nature of snakes, and highlight beneficial uses of snakes. A change in the epistemological conception of community education material by enhancing the value and use of local forms of knowledge, and the employment of art techniques to transmit this knowledge, could improve community perception and methods of snakebite prevention. Patient expectations should be appropriately managed by discussing possible outcomes, incorporating follow-up visits and addressing long-term complications of snakebites.

BackgroundDetection of meningitis is essential to optimise the duration and choice of antimicrobial agents to limit mortality and sequelae. In low and middle-income countries most health facilities lack laboratory capacity and rely on clinical features to empirically treat meningitis.ObjectiveWe conducted a diagnostic validation study to investigate the performance of clinical features (fever, convulsions, irritability, bulging fontanel and temperature ≥39°C) and WHO-recommended signs (drowsiness, lethargy, unconsciousness, convulsions, bulging fontanel, irritability or a high-pitched cry) in discriminating meningitis in young infants.DesignRetrospective cohort study.SettingKilifi County Hospital.PatientsInfants aged Main outcome measureDefinite meningitis defined as positive cerebrospinal fluid (CSF) culture, microscopy or antigen test, or leucocytes ≥0.05 x 10∧9/L.ResultsOf 4809 infants aged ConclusionsDespite a lower prevalence of definite meningitis, the performance of previously identified signs at admission in predicting meningitis was unchanged. Presence of history of fever improves the sensitivity of WHO-recommended signs but loses specificity. Careful evaluation, repeated assessment and capacity for lumbar puncture and CSF microscopy to exclude meningitis in most young infants with potential signs are essential to management in this age group.

Culicine mosquitoes are vectors of human disease-causing pathogens like filarial worms and several arthropod-borne viruses (arboviruses). Currently, there has been an increase in emerging and re-emerging vector-borne diseases along coastal Kenya, which has been of major concern in public health. This study aimed at determining culicine mosquito species abundance, diversity and their host feeding preferences in Taita-Taveta County, Coastal Kenya. Entomological sampling was done during the long-wet season (March and May) and long dry season (June to October) 2016–2018. Mosquito sampling was done using CDC light traps and Backpack aspiration for indoor and outdoor environments. All culicine mosquitoes collected were identified morphologically and categorized according to their physiological status. Blood fed culicine mosquitoes were tested for bloodmeal sources using ELISA. In total, 3,278 culicine mosquitoes were collected, of which 738 (22.5 %) were found indoors and 2,540, (77.5 %) outdoors. The mosquitoes consisted of 18 species belonging to four genera: Aedes (7), Culex (8), Mansonia (2), and Coquillettidia (1). Overall, there was high mosquito species diversity (H) in outdoors (H = 2.4339) than in indoors (H = 2.2523), whereas even distribution (EH) was higher in indoors (EH = 0.9064) than outdoors (EH = 0.8266). Majorly the bloodmeals identified were from multiple host sources with (51.6%), single hosts (41.3%), and unidentified (7.2%). This study has demonstrated a high diversity of culicine mosquitoes with relaxed feeding tendencies. These mosquitoes are contributing to mosquito biting nuisance and the likelihood of exposure of populations to diseases of public health.

Introduction Isoniazid preventive therapy (IPT) taken by People Living with HIV (PLHIV) protects against active tuberculosis (TB). Despite its recommendation, data is scarce on the uptake of IPT among PLHIV and factors associated with treatment outcomes. We aimed at determining the proportion of PLHIV initiated on IPT, assessed TB screening practices during and after IPT and IPT treatment outcomes. Methods A retrospective cohort study of a representative sample of PLHIV initiated on IPT between July 2015 and June 2018 in Kenya. For PLHIV initiated on IPT during the study period, we abstracted patient IPT uptake data from the National data warehouse. In contrast, we obtained information on socio-demographic, TB screening practices, IPT initiation, follow up, and outcomes from health facilities' patient record cards, IPT cards, and IPT registers. Further, we assessed baseline characteristics as potential correlates of developing active TB during and after treatment and IPT completion using multivariable logistic regression. Results From the data warehouse, 138,442 PLHIV were enrolled into ART during the study period and initiated 95,431 (68.9%) into IPT. We abstracted 4708 patients’ files initiated on IPT, out of which 3891(82.6%) had IPT treatment outcomes documented, 4356(92.5%) had ever screened for TB at every clinic visit, and 4,243(90.1%) had documentation of TB screening on the IPT tool before IPT initiation. 3712(95.4%) of patients with documented IPT treatment outcomes completed their treatment. 42(0.89%) of the abstracted patients developed active TB,16(38.1%) during, and 26(61.9%) after completing IPT. Follow up for active TB at 6-month post-IPT completion was done for 2729(73.5%) of patients with IPT treatment outcomes. Sex, Viral load suppression, and clinic type were associated with TB development (p Conclusion IPT initiation stands at two-thirds of the PLHIV, with a high completion rate. TB screening practices were better during IPT than after completion. Development of active TB during and after IPT emphasizes the need for a keen follow up.

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

IntroductionAntimicrobial resistance (AMR) is a growing problem globally especially in Sub-Saharan Africa including Kenya. Without any intervention, lower/middle-income countries (LMICs) will be most affected due to already higher AMR levels compared with higher income countries and due to the far higher burden of diseases in the LMICs. Studies have consistently shown that inappropriate use of antimicrobials is the major driver of AMR. To address this challenge, hospitals are now implementing antibiotic stewardship programmes (ASPs), which have been shown to achieve reduced antibiotic usage, to decrease the prevalence of resistance and lead to significant economic benefits. However, the implementation of the guideline is highly dependent on the settings in which they are rolled out. This study, employing an implementation science approach, aims to address the knowledge gap in this area and provide critical data as well as practical experiences when using antibiotic guidelines and stewardship programmes in the public health sector. This will provide evidence of ASP performance and potentially contribute to the county, national and regional policies on antibiotics use.Methods and analysisThe study will be conducted in three geographically diverse regions, each represented by two hospitals. A baseline study on antibiotic usage, resistance and de-escalation, duration of hospital stay, rates of readmission and costs will be carried out in the preimplementation phase. The intervention, that is, the use of antibiotic guidelines and ASPs will be instituted for 18 months using a stepwise implementation strategy that will facilitate learning and continuous improvement of stewardship activities and updating of guidelines to reflect the evolving antibiotic needs.Ethics and disseminationApprovals to carry out the study have been obtained from the National Commission for Science, Technology and Innovation and the Mount Kenya University Ethics Review Committee. The approvals from the two institutions were used to obtain permission to conduct the study at each of the participating hospitals. Study findings will be presented to policy stakeholders and published in peer-reviewed scientific journals. It is anticipated that the findings will inform the appropriate antibiotic use guidelines within our local context.

Background: There is an increasing recognition of malnutrition among infants under 6 mo of age (U6M). Current diagnosis criteria use weight-for-length z scores (WLZs), but the 2006 WHO standards exclude infants shorter than 45 cm. In older children, midupper arm circumference (MUAC) predicts mortality better than does WLZ. Outcomes may also be influenced by exposure to HIV and size or gestational age at birth. Diagnostic thresholds for WLZ, MUAC, and other indexes have not been fully evaluated against mortality risk among U6M infants. Objective: The aim was to determine the association of anthropometric indexes with risks of inpatient and postdischarge mortality among U6M infants recruited at the time of hospitalization. Design: We analyzed data from a cohort of U6M infants admitted to Kilifi County Hospital (2007–2013), Kenya. The primary outcomes were inpatient death and death during follow-up over 1 y after discharge. We calculated adjusted RRs for inpatient mortality and HRs for postdischarge mortality for different anthropometric measures and thresholds. Discriminatory value was assessed by using receiver operating characteristic curves. Results: A total of 2882 infants were admitted: 140 (4.9%) died in the hospital and 1405 infants were followed up after discharge. Of these, 75 (5.3%) died within 1 y during 1318 child-years of observation. MUAC and weight-for-age z score (WAZ) predicted inpatient and postdischarge mortality better than did WLZ (P < 0.0001). A single MUAC threshold of 0.05) and performed better than WLZ

Background The emergence and re-emergence of arboviral infections particularly Chikungunya, dengue hemorrhagic fever, Rift Valley fever, and yellow fever in humans around the world threatens global health. The purpose of this study was to determine the urban ecology of the common arboviral mosquito vectors in urban Coastal Kenya areas.Materials and Methods The current study was conducted in urban settings of Kilifi and Mombasa counties in coastal Kenya in 2016 to 2017. Adult mosquitoes were collected both indoors and outdoors by CDC light traps and BG-Sentinel traps respectively. All blood fed mosquitoes were tested for blood meal sources by an Enzyme Linked Immunosorbent Assay (ELISA). Mosquito larvae were collected using standard dippers and pipettes. Egg survivorship in dry soil was evaluated by collecting of soil samples from dry potential breeding habitats, watering them for hatching and rearing of the eventual larvae to adults. Mosquitoes were screened for Flavivirus, Alphavirus and Phlebovirus arboviruses using Reverse Transcriptase Quantitative Polymerase Chain Reaction (RT qPCR).Results A total of 3,264 adult mosquitoes belonging to ten species of Culex (Cx.), Aedes (Ae) and Anopheles (An.) were collected. Overall, the predominant species were Cx. quinquefasciatus 72.4% (n=2,364) and Ae. aegypti, 25.7%, (n=838). A total of 415 breeding habitat types were identified indoors (n=317) and outdoors (n=98). The most productive habitat types in both indoors and outdoors were: assorted small containers, water tanks, drainages, drums and jericans. Overall, 62% (n=18) of the soil samples collected from the two sites (Kilifi and Malindi) were positive for larvae which were used as proxy to measure the presence of eggs. The mosquitoes had high preference for human blood (29.81%) and chicken (3.73%) but none had fed on either goat or bovine. Of 259 mosquitoes tested for viral infection, 11.6% were positive for Flavivirus only.Conclusion Peri-domestic containers were identified to be the key breeding areas of arboviral vectors.

BackgroundGlobally in 2016, 1.7 million people died of Tuberculosis (TB). This study aimed to estimate all-cause mortality rate, identify features associated with mortality and describe trend in mortality rate from treatment initiation.MethodA 5-year (2012-2016) retrospective analysis of electronic TB surveillance data from Kilifi County, Kenya. The outcome was all-cause mortality within 180 days after starting TB treatment. The risk factors examined were demographic and clinical features at the time of starting anti-TB treatment. We performed survival analysis with time at risk defined from day of starting TB treatment to time of death, lost-to-follow-up or completing treatment. To account for 'lost-to-follow-up' we used competing risk analysis method to examine risk factors for all-cause mortality.Results10,717 patients receiving TB treatment, median (IQR) age 33 (24-45) years were analyzed; 3,163 (30%) were HIV infected. Overall, 585 (5.5%) patients died; mortality rate of 12.2 (95% CI 11.3-13.3) deaths per 100 person-years (PY). Mortality rate increased from 7.8 (95% CI 6.4-9.5) in 2012 to 17.7 (95% CI 14.9-21.1) in 2016 per 100PY (PtrendConclusionsWe found most deaths occurred within three months and an increasing mortality rate during the time under review among patients on TB treatment. Our results therefore warrant further investigation to explore host, disease or health system factors that may explain this trend.

BACKGROUND: Although an estimated three million tuberculosis (TB) cases worldwide are missed by national TB programs annually, the level of under-reporting of diagnosed cases in high TB burden settings is largely unknown. OBJECTIVE: To quantify and describe under-reporting of sputum smear-positive TB cases in Kenya. DESIGN: A national-level retrospective TB inventory study was conducted. All sputum smear-positive TB cases diagnosed by public or private laboratories during 1 April–30 June 2013 were extracted from laboratory registers in 73 randomly sampled subcounties and matched to TB cases in the national TB surveillance system (TIBU). Bivariate and multivariate analyses were conducted. RESULTS: In the subcounties sampled, 715 of 3409 smear-positive TB cases in laboratory registers were not found in TIBU. The estimated level of under-reporting of smear-positive TB cases in Kenya was 20.7% (95%CI 18.4–23.0). Under-reporting was greatest in subcounties with a high TB burden. Unreported cases were more likely to be patients aged ≥55 years, have scanty smear results, and be diagnosed at large facilities, private facilities, and facilities in high TB burden regions. CONCLUSION: In Kenya, one fifth of smear-positive TB cases diagnosed during the study period went unreported, suggesting that the true TB burden is higher than reported. TB surveillance in Kenya should be strengthened to ensure all diagnosed TB cases are reported.

Background Leprosy elimination defined as a registered prevalence rate of less than 1 case per 10,000 persons was achieved in Kenya at the national level in 1989. However, there are still pockets of leprosy in some counties where late diagnosis and consequent physical disability persist. The epidemiology of leprosy in Kenya for the period 2012 through to 2015 was defined using spatial methods. Methods This was a retrospective ecological correlational study that utilized leprosy case based data extracted from the National Leprosy Control Program database. Geographic information system and demographic data were obtained from Kenya National Bureau of Statistics (KNBS). Chi square tests were carried out to check for association between sociodemographic factors and disease indicators. Two Spatial Poisson Conditional Autoregressive (CAR) models were fitted in WinBUGS 1.4 software. The first model included all leprosy cases (new, retreatment, transfers from another health facility) and the second one included only new leprosy cases. These models were used to estimate leprosy relative risks per county as compared to the whole country i.e. the risk of presenting with leprosy given the geographical location. Principal findings Children aged less than 15 years accounted for 7.5% of all leprosy cases indicating active leprosy transmission in Kenya. The risk of leprosy notification increased by about 5% for every 1 year increase in age, whereas a 1% increase in the proportion of MB cases increased the chances of new leprosy case notification by 4%. When compared to the whole country, counties with the highest risk of leprosy include Kwale (relative risk of 15), Kilifi (RR;8.9) and Homabay (RR;4.1), whereas Turkana had the lowest relative risk of 0.005. Conclusion Leprosy incidence exhibits geographical variation and there is need to institute tailored local control measures in these areas to reduce the burden of disability., Author summary Leprosy is a chronic bacterial disease that mainly affects the nerves. If untreated, it may cause progressive and permanent damage to the skin, nerves, limbs, and eyes leading to physical disability. Through use of a combination of drugs, Kenya was able to declare the disease as eliminated in the year 1989. However, there are still pockets of leprosy in some Kenyan counties where physical disability persists, mainly due to late diagnosis. To be able to curb this disease, control measures must be intensified, especially in the counties reporting more cases. We used data of the leprosy cases reported in Kenya for the period 2012 through to 2015 in order to describe geographical variation and factors influencing this variation. More than half of the registered cases had visible physical disability. The risk of leprosy notification increased with an increase in age as well as the severity of disease. We estimated that people living in Kwale, Kilifi and Homabay counties are 15, 9, and 5 times respectively more at risk of leprosy as compared to the whole country. Given the limited resources, it’s therefore paramount that high risk counties be initially targeted for control, with a focus on early diagnosis.

BackgroundStunting is the most common manifestation of childhood undernutrition worldwide. Children presenting with severe acute malnutrition (SAM) are often also severely stunted. We evaluated linear growth and its determinants after medically complicated SAM.MethodsWe performed secondary analysis of clinical trial data (NCT00934492) from HIV-uninfected Kenyan children aged 2–59 months hospitalised with SAM. Outcome was change in height/length-for-age z-score (HAZ) between enrolment and 12 months later. Exposures were demographic, clinical, anthropometric characteristics and illness episodes during follow-up.ResultsAmong 1169 children with HAZ values at month 12 (66% of those in original trial), median (IQR) age 11 (7–17) months and mean (SD) HAZ −2.87 (1.6) at enrolment, there was no change in mean HAZ between enrolment and month 12: −0.006Z (95% CI −0.07 to 0.05Z). While 262 (23%) children experienced minimal HAZ change (within ±0.25 HAZ), 472 (40%) lost >0.25 and 435 (37%) gained >0.25 HAZ. After adjusting for regression to the mean, inpatient or outpatient episodes of diarrhoea and inpatient severe pneumonia during follow-up were associated with HAZ loss. Premature birth and not being cared by the biological parent were associated with HAZ gain. Increases in mid-upper arm circumference and weight-for-age were associated with HAZ gain and protected against HAZ loss. Increase in weight-for-height was not associated with HAZ gain but protected against HAZ loss. No threshold of weight gain preceding linear catch-up growth was observed.ConclusionsInterventions to improve dietary quality and prevent illness over a longer period may provide opportunities to improve linear growth.

The primary degradation of benzene derivatives in aquatic environments occurs via microbial and chemical processes. This study investigated the kinetic degradation of o-ethyltoluene and 1,3,5-trimethylbenzene in the wetland of Lake Naivasha. Sediment samples were collected from 6:00 AM to 6:00 PM at intervals of 3 h during the dry season of December 2017. The sediment samples were air dried, ground into powder, followed by soxhlet extraction in a binary mixture of methanol and hexane in the ratio of 1:1. The extract was analyzed using gas chromatograph with mass selective detector. Variation in the concentrations of o-ethyltoluene and 1,3,5-trimethylbenzene with time was monitored kinetically. Accordingly, the half-lives for the degradation of o-ethyltoluene and 1,3,5-trimethylbenzene were 4.9 and 5.4 h, respectively, and their corresponding decay rate constants were 3.93 × 10−5 and 3.56 × 10−5 S−1. 1,3,5-Trimethylbenzene was the most persistent contaminants in the wetland.

Background Goals of treating childhood severe acute malnutrition (SAM), in addition to anthropometric recovery and preventing short-term mortality, include reducing the risks of subsequent serious infections. How quickly and how much the risk of serious illness changes during rehabilitation are unknown but could inform improving the design and scope of interventions. Objective The aim of this study was to investigate changes in the risk of life-threatening events (LTEs) in relation to anthropometric recovery from SAM. Design This was a secondary analysis of a clinical trial including 1778 HIV-uninfected Kenyan children aged 2–59 mo with complicated SAM, enrolled after the inpatient stabilization phase of treatment, and followed for 12 mo. The main outcome was LTEs, defined as infections requiring rehospitalization or causing death. We examined anthropometric variables measured at months 1, 3, and 6 after enrollment in relation to LTEs occurring during the 6 mo after each of these time points. Results Over 12 mo, there were 823 LTEs (257 fatal), predominantly severe pneumonia and diarrhea. At months 1, 3, and 6, 557 (34%), 764 (49%), and 842 (56%) children had a weight-for-height or -length z score (WHZ) ≥−2, respectively, which, compared with a WHZ

Supplemental Digital Content is available in the text., Background: Neonatal mortality remains high in sub-Saharan Africa, and a third of deaths are estimated to result from infection. While coagulase-negative staphylococci (CoNS) are leading neonatal pathogens in resource-rich settings, their role, and the need for early anti-Staphylococcal treatment in empiric antibiotic guidelines, is unknown in sub-Saharan Africa. Methods: We examined systematic clinical and microbiologic surveillance data from all neonatal admissions to Kilifi County Hospital (1998–2013) to determine associated case fatality and/or prolonged duration of admission associated with CoNS in neonates treated according to standard World Health Organization guidelines. Results: CoNS was isolated from blood culture in 995 of 9552 (10%) neonates. Case fatality among neonates with CoNS isolated from blood did not differ from other neonatal admissions (P = 0.2), and duration of admission was not prolonged [odds ratio (OR) = 0.9 (0.7–1.0), P = 0.040]. Neonates with CoNS were more likely to have convulsions [OR = 1.4 (1.0–1.8), P = 0.031] but less likely to have impaired consciousness or severe indrawing [OR = 0.8 (0.7–0.9), P = 0.025; OR = 0.9 (0.7–1.0), P = 0.065]. Conclusions: CoNS isolation in blood cultures at admission was not associated with adverse clinical outcomes in neonates treated according to standard World Health Organization guidelines for hospital care in this setting. There is no evidence that first-line antimicrobial treatment guidelines should be altered to increase cover for CoNS infections in neonates in this setting.

Background: The effects of rickets on children recovery from severe acute malnutrition (SAM) is unknown. Rickets may affect growth and susceptibility to infectious diseases. We investigated the associations of clinically diagnosed rickets with life-threatening events and anthropometric recovery during one year following inpatient treatment for complicated SAM. Methods: Secondary analysis of clinical trial data amongst non-HIV infected Kenyan children with complicated SAM (2-59 months) followed for one year post-hospital discharge (ClinicalTrials.gov ID NCT00934492). The outcomes were mortality, hospital re-admissions and growth during 12 months. The main exposure was clinically diagnosed rickets at baseline. Results: Of 1,778 children recruited, 230 (12.9% (95% CI 11.4 to 14 .6%) had clinical signs of rickets at baseline. Enrolment at an urban site, height-for-age and head circumference-for-age z scores were associated with rickets. Rickets was associated with increased mortality; adjusted Hazard Ratio (aHR) 1.61 (95% CI 1.14-2.27), any re-admission to hospital; aHR 1.37 (95% CI 1.09-1.72); re-admission for severe pneumonia; aHR 1.37 (95% CI 1.05-1.79), but not with diarrhoea; aHR 1.05 (95% CI 0.73-1.51). Rickets was associated with increased height gain; adjusted regression co-efficient 0.19 (95% CI 0.10-0.28), but not changes in head circumference, mid-upper arm circumference (MUAC) or weight. Conclusion: Rickets was common among children with SAM at urban sites and associated with increased risks of severe pneumonia and death. Increased height gain may have resulted from vitamin D and calcium treatment. Future work should explore the possibility of other concurrent micronutrient deficiencies and optimal treatment of rickets in this high-risk population.

BACKGROUND: Bloodstream infection is a common cause of morbidity in children aged METHODS: Systematically collected clinical and microbiological surveillance data from children aged 6-59 months admitted to Kilifi County Hospital (2007-2013) were analysed. Multivariable regression was used to test associations between CoNS isolation from blood cultures and SAM (MUAC RESULTS: CoNS were isolated from blood culture in 906/13,315 (6.8%) children, of whom 135/906 (14.9%) had SAM and 54/906 (6.0%) were HIV antibody positive. CoNS isolation was not associated with SAM (MUACCONCLUSION: In a large, systematic study, there was no evidence that antimicrobial therapy should specifically target CoNS amongst children with SAM or HIV-infection or exposure.

Reference intervals for clinical laboratory parameters are important for assessing eligibility, toxicity grading and management of adverse events in clinical trials. Nonetheless, haematological and biochemical parameters used for clinical trials in sub-Saharan Africa are typically derived from industrialized countries, or from WHO references that are not region-specific. We set out to establish community reference values for haematological and biochemical parameters amongst children aged 4 weeks to 17 months in Kilifi, Kenya. We conducted a cross sectional study nested within phase II and III trials of RTS, S malaria vaccine candidate. We analysed 10 haematological and 2 biochemical parameters from 1,070 and 423 community children without illness prior to experimental vaccine administration. Statistical analysis followed Clinical and Laboratory Standards Institute EP28-A3c guidelines. 95% reference ranges and their respective 90% confidence intervals were determined using non-parametric methods. Findings were compared with published ranges from Tanzania, Europe and The United States. We determined the reference ranges within the following age partitions: 4 weeks to

Background Pneumonia is the leading cause of childhood mortality. Deaths may occur after discharge from hospital, but prior studies have been small, in selected groups or not fully evaluated potential risk factors, including malnutrition and HIV. We aimed to determine one year post-discharge mortality and its risk factors amongst children consecutively admitted to a rural Kenyan hospital with severe pneumonia. Methods A cohort study of children aged 1-59 months admitted to Kilifi County Hospital with severe pneumonia (2007-2012). The primary outcome was death within one year after discharge, determined through Kilifi Health and Demographic Surveillance System (KHDSS) quarterly census rounds. Results Of 4,184 children (median age 9 months) admitted with severe pneumonia, 1,041(25%) had severe acute malnutrition (SAM), 267(6.4%) had a positive HIV antibody test, and 364(8.7%) died in hospital. After discharge, 2,279 KHDSS-resident children were followed up; 70(3.1%) died during 2,163 child-years of observation (cyo): 32 [95%CI 26, 41] deaths per 1000 cyo. Post-discharge mortality was greater after admission for severe pneumonia than for other diagnoses, hazard ratio 2.50 [95%CI 1.17, 5.32]. Malnutrition, HIV status, age and prolonged hospitalization, but not signs of pneumonia severity, were associated with post-discharge mortality. 52% [95%CI 37%, 63%] of post-discharge deaths were attributable to low mid-upper arm circumference and 11% [95%CI 3.3%, 18%] to a positive HIV test. Conclusions Admission with severe pneumonia is an important marker of vulnerability. Risk stratification and better understanding of the mechanisms underlying post-discharge mortality, especially for undernourished children, are needed to reduce mortality after treatment for pneumonia.

Background Ready-to-use therapeutic foods (RUTF) are lipid-based pastes widely used in the treatment of acute malnutrition. Current specifications for RUTF permit a high n-6 polyunsaturated fatty acid (PUFA) content and low n-3 PUFA, with no stipulated requirements for preformed long-chain n-3 PUFA. The objective of this study was to develop an RUTF with elevated short-chain n-3 PUFA and measure its impact, with and without fish oil supplementation, on children’s PUFA status during treatment of severe acute malnutrition. Methods This randomized controlled trial in children with severe acute malnutrition in rural Kenya included 60 children aged 6 to 50 months who were randomized to receive i) RUTF with standard composition; ii) RUTF with elevated short chain n-3 PUFA; or iii) RUTF with elevated short chain n-3 PUFA plus fish oil capsules. Participants were followed-up for 3 months. The primary outcome was erythrocyte PUFA composition. Results Erythrocyte docosahexaenoic acid (DHA) content declined from baseline in the two arms not receiving fish oil. Erythrocyte long-chain n-3 PUFA content following treatment was significantly higher for participants in the arm receiving fish oil than for those in the arms receiving RUTF with elevated short chain n-3 PUFA or standard RUTF alone: 3 months after enrolment, DHA content was 6.3% (interquartile range 6.0–7.3), 4.5% (3.9–4.9), and 3.9% (2.4–5.7) of total erythrocyte fatty acids (P Conclusions PUFA requirements of children with SAM are not met by current formulations of RUTF, or by an RUTF with elevated short-chain n-3 PUFA without additional preformed long-chain n-3 PUFA. Clinical and growth implications of revised formulations need to be addressed in large clinical trials.

OBJECTIVE: To determine the diagnostic value of visible severe wasting in identifying severe acute malnutrition at two public hospitals in Kenya. METHODS: This was a cross-sectional study of children aged 6 to 59.9 months admitted to one rural and one urban hospital. On admission, mid-upper arm circumference (MUAC), weight and height were measured and the presence of visible severe wasting was assessed. The diagnostic performance of visible severe wasting was evaluated against anthropometric criteria. FINDINGS: Of 11,166 children admitted, 563 (5%) had kwashiorkor and 1406 (12.5%) were severely wasted (MUAC

BackgroundWe aimed to determine the prevalence of pulmonary TB amongst the adult population (≥15 years) in 2016 in Kenya.MethodA nationwide cross-sectional survey where participants first underwent TB symptom screening and chest x-ray. Subsequently, participants who reported cough >2weeks and/or had a chest x-ray suggestive of TB, submitted sputum specimen for laboratory examination by smear microscopy, culture and Xpert MTB/RIF.ResultThe survey identified 305 prevalent TB cases translating to a prevalence of 558 [95%CI 455-662] per 100,000 adult population. The highest disease burden was reported among people aged 25-34 years (716 [95% CI 526-906]), males (809 [(95% CI 656-962]) and those who live in urban areas (760 [95% CI 539-981]). Compared to the reported TB notification rate for Kenya in 2016, the prevalence to notification ratio was 2.5:1. The gap between the survey prevalence and notification rates was highest among males, age groups 25-34, and the older age group of 65 years and above. Only 48% of the of the survey prevalent cases reported cough >2weeks. In addition, only 59% of the identified cases had the four cardinal symptoms for TB (cough ≥2 weeks, fever, night sweat and weight loss. However, 88.2% had an abnormal chest x-ray suggestive of TB. The use of Xpert MTB/RIF identified 77.7% of the cases compared to smear microscopy's 46%. Twenty-one percent of the survey participants with respiratory symptoms reported to have sought prior health care at private clinics and chemists. Among the survey prevalent cases who reported TB related symptoms, 64.9% had not sought any health care prior to the survey.ConclusionThis survey established that TB prevalence in Kenya is higher than had been estimated, and about half of the those who fall ill with the disease each year are missed.

Background Maternal mortality has declined by 43 % globally between 1990 and 2013, a reduction that was insufficient to achieve the 75 % reduction target by millennium development goal (MDG) five. Kenya recorded a decline of 18 % from 490 deaths in 1990 to 400 deaths per 100,000 live births in 2013. Delivering at home, is associated with higher risk of maternal deaths, therefore reducing number of home deliveries is important to improve maternal health. In this study, we aimed at establishing the proportion of home deliveries and evaluating factors associated with home deliveries in Kilifi County. Methods The study was conducted among mothers seeking immunization services in selected health facilities within Kilifi County using Semi-structured questionnaires administered through face to face oral interviews to collect both quantitative and qualitative data. Six Focus Group Discussion (FGD) and ten in-depth interviews (IDIs) were used to collect qualitative data. A random sample of 379 mothers was sufficient to answer the study question. Log-binomial regression model was used to identify factors associated with childbirth at home. Results A total of 103 (26 %) mothers delivered at home. From the univariate analysis, both mother and the partners old age, being in a polygamy marriage, being a mother of at least two children and staying ≥5 Kms radius from the nearest health facility were associated with higher risk of delivering at home (crude P

Summary Background Children with complicated severe acute malnutrition (SAM) have a greatly increased risk of mortality from infections while in hospital and after discharge. In HIV-infected children, mortality and admission to hospital are prevented by daily co-trimoxazole prophylaxis, despite locally reported bacterial resistance to co-trimoxazole. We aimed to assess the efficacy of daily co-trimoxazole prophylaxis on survival in children without HIV being treated for complicated SAM. Methods We did a multicentre, double-blind, randomised, placebo-controlled study in four hospitals in Kenya (two rural hospitals in Kilifi and Malindi, and two urban hospitals in Mombasa and Nairobi) with children aged 60 days to 59 months without HIV admitted to hospital and diagnosed with SAM. We randomly assigned eligible participants (1:1) to 6 months of either daily oral co-trimoxazole prophylaxis (given as water-dispersible tablets; 120 mg per day for age

Kenya recently transitioned from a paper to an electronic system for recording and reporting of tuberculosis (TB) data. During September–October 2013, the data quality of the new system was evaluated through an audit of data in paper source documents and in the national electronic system, and an analysis of all 99,281 cases reported in 2012. While the new electronic system overall is robust, this assessment demonstrated limitations in the concordance and completeness of data reaching the national level. Additional oversight and training in data entry are needed to strengthen TB surveillance data quality in Kenya.

Objective: The purpose of this study was to evaluate differences in the relationship between asthma and immune responses to allergens in children living in rural and urban areas of Kenya. Study design: Children (mean age, 11 years) from Kabati (n = 136), a rural village, and Thika (n = 129), a small town, were studied by skin testing and serum immunoglobulin E (IgE) and immunoglobuluin G (IgG) antibody measurement. Asthma was evaluated by symptoms, as well as spirometry before and after vigorous exercise to test for exercised-induced bronchospasm (EIB). School children from a study performed in Atlanta, Georgia, were used for comparison of anthropometric and immunologic results. Results: Compared with the urban area of Kenya, children living in the rural area had a lower percentage of body fat, smaller and fewer skin test responses to allergens, a higher prevalence of IgE antibodies to Ascaris (67% vs 26%) and 10-fold higher total IgE. In the urban area of Kenya, there was a strong correlation between EIB and atopy determined both by IgE antibodies (P =.02) and skin tests (P =.002). By contrast, in the rural area, none of the 13 children with EIB were skin-test positive (vs 13/109 of children without EIB). Conclusions: Among the rural children, there was no association between immune responses to allergens and airway-related symptoms or reactivity. The association between asthma and atopy seen in the town of Thika may represent an important step in the increase in asthma seen both in urban Africa and in the West. (J Pediatr 2002;140:582-8)

Background Mortality from TB continues to be a global public health challenge. TB ranks alongside Human Immunodeficiency Virus (HIV) as the leading infectious causes of death globally. HIV is a major driver of TB related morbidity and mortality while TB is the leading cause of mortality among people living with HIV/AIDS. We sought to determine excess mortality associated with HIV and the effect of antiretroviral therapy on reducing mortality among tuberculosis patients in Kenya. Methods We conducted a retrospective analysis of Kenya national tuberculosis program data of patients enrolled from 2013 through 2014. We used direct standardization to obtain standardized mortality ratios for tuberculosis patients compared with the general population. We calculated the population attributable fraction of tuberculosis deaths due to HIV based on the standardized mortality ratio for deaths among TB patients with HIV compared to TB patients without HIV. We used Cox proportional hazards regression for assessing risk factors for mortality. Results Of 162,014 patients included in the analysis, 6% died. Mortality was 10.6 (95% CI: 10.4–10.8) times higher among TB patients than the general population; 42% of deaths were attributable to HIV infection. Patients with HIV who were not receiving ART had an over four-fold risk of death compared to patients without HIV (aHR = 4.2, 95% CI 3.9–4.6). In contrast, patients with HIV who were receiving ART had only 2.6 times the risk of death (aHR = 2.6, 95% CI 2.5–2.7). Conclusion HIV was a significant contributor to TB-associated deaths in Kenya. Mortality among HIV-infected individuals was higher among those not on ART than those on ART. Early initiation of ART among HIV infected people (a “test and treat” approach) should further reduce TB-associated deaths.

Objectives Worldwide, school age children and adolescents are vulnerable to conflict and food insecurity and HIV-infected children are increasingly surviving into adolescence. WHO recommends assessing acute malnutrition in this age group using body mass index-for-age Z scores (BMIz). For under-fives, mid upper arm circumference (MUAC) is the mainstay of community diagnosis of acute malnutrition, is simple to perform and predicts survival better than weight-for-height Z scores. MUAC is little-used in older children and adolescents because there is no accepted international reference. This study aimed to construct growth curves for MUAC-for-age Z score (MUACz) for 5-19 year olds that accord with WHO Growth Standards, and evaluate their discriminatory performance for subsequent mortality. Design The HES/NHANES US population datasets (age 5-25 years), which were used to construct the 2007 WHO Growth Reference for BMI in this age group, were merged with an imputed dataset matching the distribution of the WHO 2006 Growth Standards age 2-6 years. To construct standardised growth curves, we used Generalized Additive Models for Location, Scale and Shape with Box-Cox Cole Green transformation and penalized B-spline smoothing. Validation for subsequent mortality in two cohorts was done using Cox proportional hazards models for pre-defined MUACz and BMIz thresholds, with age, gender and HIV status as covariates; and estimation of the area under receiver-operating characteristic curves (AUC). Participants Validation data were from 685 HIV-infected children age 5¬–17 years participating in the ARROW trial in Uganda and Zimbabwe; and 1,741 children age 5–13 years discharged from a rural Kenyan hospital (3.8% HIV-infected). Both cohorts were followed up for survival during one year. Main outcome measures Concordance with WHO 2006 Growth Standards at age 60 months and survival during one year according to MUACz and BMIz. Results The new growth curves transitioned smoothly with WHO Growth Standards at age 5 years. MUACz of -2 to -3 and Conclusions MUACz is at least as effective as BMIz for assessing mortality risks associated with undernutrition among African school-aged children and adolescents. MUAC can provide simplified screening and diagnosis within nutrition and HIV programmes, and in research.

Background Clinical trials data management (CTDM) remains one of the many challenges in running state of the art trials in resource-poor settings since most trials do not allocate, or have available, sufficient resources for CTDM and because of poor internet connectivity. Open-source software like OpenClinica could be a solution in such scenarios. Findings In 2007, the KEMRI-Wellcome Trust Research Programme (KWTRP) adopted OpenClinica (OC) community edition, an open-source software system and we share our experience and lessons learnt since its adoption. We have used OC in three different modes; direct remote data entry from sites through Global System for Mobile Communications (GSM) modems, a centralized data centre approach where all data from paper records were entered at a central location and an off-line approach where data entry was done from a copy of database hosted on a field-site server laptop, then data uploaded to a centralized server later. We have used OC in eleven trials/studies with a cumulative number of participants in excess of 6000. These include large and complex trials, with multiple sites recruiting in different regions of East Africa. In the process, we have developed substantial local capacity through hands-on training and mentorship, which we have now begun to share with other institutions in the region. Conclusions Our experience demonstrates that an open source data management system to manage trials’ data can be utilized to international industry standards in resource-poor countries.