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Given the challenges in accurately identifying unexposed controls in case-control studies of diarrhoea, we examined diarrhoea incidence, subclinical enteric infections and growth stunting within a reference population in the Global Enteric Multicenter Study, Kenya site. Within 'control' children (0-59 months old without diarrhoea in the 7 days before enrolment, n = 2384), we examined surveys at enrolment and 60-day follow-up, stool at enrolment and a 14-day post-enrolment memory aid for diarrhoea incidence. At enrolment, 19% of controls had ⩾1 enteric pathogen associated with moderate-to-severe diarrhoea ('MSD pathogens') in stool; following enrolment, many reported diarrhoea (27% in 7 days, 39% in 14 days). Controls with and without reported diarrhoea had similar carriage of MSD pathogens at enrolment; however, controls reporting diarrhoea were more likely to report visiting a health facility for diarrhoea (27% vs. 7%) or fever (23% vs. 16%) at follow-up than controls without diarrhoea. Odds of stunting differed by both MSD and 'any' (including non-MSD pathogens) enteric pathogen carriage, but not diarrhoea, suggesting control classification may warrant modification when assessing long-term outcomes. High diarrhoea incidence following enrolment and prevalent carriage of enteric pathogens have implications for sequelae associated with subclinical enteric infections and for design and interpretation of case-control studies examining diarrhoea. [ABSTRACT FROM AUTHOR]

INTRODUCTION: Cholera, a disease caused by Vibrio cholera O1 and O139 remains an important public health problem globally. In the last decade, Kenya has experienced a steady increase of cholera cases. In 2009 alone, 11,769 cases were reported to the Ministry of Public Health and Sanitation. This study sought to describe the phenotypic characteristics of the isolated V. cholera isolates. METHODS: This was a laboratory based cross-sectional study that involved isolates from different cholera outbreaks. Seventy six Vibrio cholera O1 strains from different geographical areas were used to represent 2007 to 2010 cholera epidemics in Kenya, and were characterized by serotyping, biotyping, polymerase chain r(PCR), pulsed-field gel electrophoresis (PFGE) and ribotyping along with antimicrobial susceptibility testing. RESULTS: Seventy six Vibrio cholera O1 strains from different geographical areas were used to represent 2007 to 2010 cholera epidemics in Kenya. Serotype Inaba was dominant (88.2%) compared to Ogawa. The isolates showed varying levels of antibiotic resistance ranging from 100% susceptible to tetracycline, doxycycline, ofloxacin, azithromycin, norfloxacin and ceftriaxone to 100% resistant to furazolidone, trimethoprim-sulfamethoxazole, polymyxin-B and streptomycin. The isolates were positive for ctxA, tcpA (El Tor), rtxC genes and were biotype El Tor variant harboring classical ctxB gene. All the isolates were classified as cholera toxin (CT) genotype 1 as they had mutation in the ctxB at positions 39 and 68. All the isolates had genetically similar NotI PFGE and BglI ribotype patterns. The absence of any observed variation is consistent with a clonal origin for all of the isolates. CONCLUSION: Kenya experienced cholera numerous outbreak from 2007-2010. The clinical Vibrio cholera O1 isolates from the recent cholera epidemic were serotypes Inaba and Ogawa, Inaba being the predominant serotype. The Vibrio cholera O1 strains were biotype El Tor variants that produce cholera toxin B (ctx B) of the classical type and were positive for ctxA, tcpA El Tor and rtxC genes.

Abstract Background Although causing substantial morbidity, the burden of pneumococcal disease among older children and adults in Africa, particularly in rural settings, is not well-characterized. We evaluated pneumococcal bacteremia among 21,000 persons ≥5 years old in a prospective cohort as part of population-based infectious disease surveillance in rural western Kenya from October 2006-September 2008. Methods Blood cultures were done on patients meeting pre-defined criteria - severe acute respiratory illness (SARI), fever, and admission for any reason at a referral health facility within 5 kilometers of all 33 villages where surveillance took place. Serotyping of Streptococcus pneumoniae was done by latex agglutination and quellung reaction and antibiotic susceptibility testing was done using broth microdilution. We extrapolated incidence rates based on persons with compatible illnesses in the surveillance population who were not cultured. We estimated rates among HIV-infected persons based on community HIV prevalence. We projected the national burden of pneumococcal bacteremia cases based on these rates. Results Among 1,301 blood cultures among persons ≥5 years, 52 (4%) yielded pneumococcus, which was the most common bacteria isolated. The yield was higher among those ≥18 years than 5-17 years (6.9% versus 1.6%, p < 0.001). The highest yield was for inpatients with SARI (10%), compared with SARI outpatients (3%) and acute febrile outpatients (1%). Serotype 1 pneumococcus was most common (42% isolates) and 71% were serotypes included in the 10-valent pneumococcal conjugate vaccine (PCV10). Non-susceptibility to beta-lactam antibiotics was low (95%). The crude rate of pneumococcal bacteremia was 129/100,000 person-years, and the adjusted rate was 419/100,000 person-years. Nineteen (61%) of 31 patients with HIV results were HIV-positive. The adjusted rate among HIV-infected persons was 2,399/100,000 person-years (Rate ratio versus HIV-negative adults, 19.7, 95% CI 12.4-31.1). We project 58,483 cases of pneumococcal bacteremia will occur in Kenyan adults in 2010. Conclusions Pneumococcal bacteremia rates were high among persons ≥5 years old, particularly among HIV-infected persons. Ongoing surveillance will document if expanded use of highly-active antiretroviral treatment for HIV and introduction of PCV10 for Kenyan children (anticipated in late 2010) result in substantial secondary benefits by reducing pneumococcal disease in adults.

Presents a study which compared the effectiveness of a single dose of azithromycin and a three-day course of ciprofloxacin in the treatment of epidemic dysentery. Characteristics of the study participants; Data and methods used; Findings.

Background: Child mortality is high in Ethiopia, but reliable data on the causes of death are scarce. We aimed to gather data for the contributory causes of stillbirth and child deaths in eastern Ethiopia., Methods: In this population-based post-mortem study, we established a death-notification system in health facilities and in the community in Kersa (rural), Haramaya (rural) and Harar (urban) in eastern Ethiopia, at a new site of the Child Health and Mortality Prevention Surveillance (CHAMPS) network. We collected ante-mortem data, did verbal autopsies, and collected post-mortem samples via minimally invasive tissue sampling from stillbirths (weighing at least 1000 g or with an estimated gestational age of at least 28 weeks) and children who died younger than 5 years. Children-or their mothers, in the case of stillbirths and deaths in children younger than 6 months-had to have lived in the catchment area for the past 6 months to be included. Molecular, microbiological, and histopathological analyses were done in collected samples. Cause of death was established by an expert panel on the basis of these data and classified as underlying, comorbid, or immediate separately for stillbirths, neonatal deaths (deaths aged 0-27 days), and child deaths (aged 28 days to <5 years)., Findings: Between Feb 4, 2019, and Feb 3, 2021, 312 deaths were eligible for inclusion, and the families gave consent in 195 (63%) cases. Cause of death was established in 193 (99%) cases. Among 114 stillbirths, the underlying cause of death was perinatal asphyxia or hypoxia in 60 (53%) and birth defects in 24 (21%). Among 59 neonatal deaths, the most common underlying cause was perinatal asphyxia or hypoxia (17 [29%]) and the most common immediate cause of death was neonatal sepsis, which occurred in 27 (60%). Among 20 deaths in children aged 28 days to 59 months, malnutrition was the leading underlying cause (15 [75%]) and infections were common immediate and comorbid causes. Pathogens were identified in 19 (95%) child deaths, most commonly Klebsiella pneumoniae and Streptococcus pneumoniae., Interpretation: Perinatal asphyxia or hypoxia, infections, and birth defects accounted for most stillbirths and child deaths. Most deaths could have been prevented with feasible interventions, such as improved maternity services, folate supplementation, and improved vaccine uptake., Funding: Bill & Melinda Gates Foundation., Competing Interests: Declaration of interests ACS has been affiliated with the Bill & Melinda Gates Foundation (the study funder) since October, 2023 (after this manuscript was first submitted). This affiliation is not directly related to the submitted work. All other authors declare no competing interests., (The Author(s). Published by Elsevier Ltd. This is an open access article under the CC BY 4.0 license.)

Objective: We conducted serosurveillance of anti-SARS-CoV-2 antibodies among pregnant women attending their first antenatal care., Setting: The surveillance was set in one referral hospital in Harar, one district hospital and one health centre located in Haramaya district in rural eastern Ethiopia., Participants: We collected questionnaire data and a blood sample from 3312 pregnant women between 1 April 2020 and 31 March 2021. We selected 1447 blood samples at random and assayed these for anti-SARS-CoV-2 antibodies at Hararghe Health Research laboratory using WANTAI SARS-CoV-2 Rapid Test for total immunoglobulin., Outcome: We assayed for anti-SARS-CoV-2 antibodies and temporal trends in seroprevalence were analysed with a χ 2 test for trend and multivariable binomial regression., Results: Among 1447 sera tested, 83 were positive for anti-SARS-CoV-2 antibodies giving a crude seroprevalence of 5.7% (95% CI 4.6% to 7.0%). Of 160 samples tested in April-May 2020, none was seropositive; the first seropositive sample was identified in June and seroprevalence rose steadily thereafter (χ 2 test for trend, p=0.003) reaching a peak of 11.8% in February 2021. In the multivariable model, seroprevalence was approximately 3% higher in first-trimester mothers compared with later presentations, and rose by 0.75% (95% CI 0.31% to 1.20%) per month of calendar time., Conclusions: This clinical convenience sample illustrates the dynamic of the SARS-CoV-2 epidemic in pregnant women in eastern Ethiopia; infection was rare before June 2020 but it spread in a linear fashion thereafter, rather than following intermittent waves, and reached 10% by the beginning of 2021. After 1 year of surveillance, most pregnant mothers remained susceptible., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Coronavirus disease 2019 (COVID-19) is a public health emergency with little testing and treatment experiences at its occurrence. Diagnostic and treatment rapidly changed in the world including Ethiopia. Haramaya University has strived to change its diagnostic capacity using existing facilities in response to the national call to the pandemic. Objective: This summary aims to detail experiences of setting up COVID-19 testing in Haramaya University laboratories, Eastern Ethiopia. Methods: Desktop exercise was conducted to understand the start-up and implementations of COVID-19 testing in two Haramaya University laboratories, Hararghe Health Research Partnership and Campylobacter Genomics and Environmental Enteric Dysfunction laboratories. Communication, formats, guidelines, and standards were reviewed and summarized. Discussion with those involved in the start-up and implementation of the testing were also held. Ideas were summarized to learn the experiences the COVID-19 testing exercises. Lesson Learned: This is a huge experience for Haramaya University to participate in the national call to increase the testing platform in the management of COVID19. Close work relationship with the public health authorities at all levels demonstrated the university's commitment to public service. The university has used the opportunity to advance its molecular testing capability by training its staff and students. The University has also contributed to the capacity development for laboratories in the surrounding areas of Harar, Somali, Oromia, and Dire Dawa. The pandemic has been an opportunity in harnessing existing resource for the benefit of the public during such times of dire needs to provide critical public health laboratory interventions., Competing Interests: The 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., (Copyright © 2021 Assefa, Hassen, Admassu, Brhane, Deressa, Marami, Teklemariam, Dessie and Oundo.)

Brucellosis is an important zoonotic disease globally, with particularly high burdens in pastoral settings. While the zoonotic transmission routes for Brucella spp. are well known, the relative importance of animal contact, food-handling and consumption practices can vary. Understanding the local epidemiology of human brucellosis is important for directing veterinary and public health interventions, as well as for informing clinical diagnostic decision making. We conducted a cross-sectional study in Ijara District Hospital, north-eastern Kenya. A total of 386 individuals seeking care and reporting symptoms of febrile illness were recruited in 2011. Samples were tested for the presence of Brucella spp. using a real-time PCR (RT-PCR) and results compared to those from the test for brucellosis used at Ijara District Hospital, the febrile Brucella plate agglutination test (FBAT). A questionnaire was administered to all participants and risk factors for brucellosis identified using logistic regression with an information theoretic (IT) approach and least absolute shrinkage and selection (LASSO). Sixty individuals were RT-PCR positive, resulting in a prevalence of probable brucellosis of 15.4% (95% CI 12.0-19.5). The IT and LASSO approaches both identified consuming purchased milk as strongly associated with elevated risk and boiling milk before consumption strongly associated with reduced risk. There was no evidence that livestock keepers were at different risk of brucellosis than non-livestock keepers. The FBAT had poor diagnostic performance when compared to RT-PCR, with an estimated sensitivity of 36.6% (95% CI 24.6-50.1) and specificity of 69.3% (95% CI 64.0-74.3). Brucellosis is an important cause of febrile illness in north-eastern Kenya. Promotion of pasteurisation of milk in the marketing chain and health messages encouraging the boiling of raw milk before consumption could be expected to lead to large reductions in the incidence of brucellosis in Ijara. This study supports the growing evidence that the FBAT performs very poorly in the diagnosis of brucellosis., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Unsafe transfusion practices can put millions of people at risk of Transfusion Transmissible Infections (TTIs). In Kenya the current blood transfusion scheme involves screening of blood for HIV, Hepatitis B virus (HBV), Hepatitis C virus (HCV) and syphilis. Malaria is also a blood-borne disease which is not currently screened for. In Kenya blood donor selection criteria were reviewed in 2009. Regular review of effectiveness of donor selection criteria can help reduce TTIs prevalence amongst donors and thus make the blood supply safer., Methods: A cross sectional study was conducted between November 2011 to January 2012 among 594 blood donors in the Regional Blood Transfusion Center Nakuru and Tenwek Mission Hospital. Socio-demographic characteristics and associated risk factors were collected using a standard blood transfusion service questionnaire. Donors were obtained through systematic sampling. Each donor sample was screened, for HIV-1 and HIV-2, HBV, HCV, syphilis and malaria parasites., Results: The overall prevalence of TTIs was 14.1%, which ranged from 0.7% for malaria to 5.6% for HBsAg. Blood donors who were married (P=0.0057), had non-formal or just primary education (P=0.0262), had multiple sexual partners (P=0.0144) and in informal occupation (P=0.0176) were at higher risk of HIV positivity. History of blood transfusion/blood products (P=0.0055), being married (P=0.0053) were high risk factors associated with positive syphilis. Being male (P=0.0479) was a high risk factor to HBV infection., Conclusion: The prevalence of TTIs indicates a need to review the questionnaire and apply it strictly for donor selection. The 0.7% prevalence of malaria, poses a serious health risk to non-immune recipients of transfusion. Malaria should be included among mandatory TTI tests in Kenya., Competing Interests: The authors declare no competing interests., (© Grace Bartonjo et al.)

Background: Cryptosporidium is a leading cause of moderate-to-severe diarrhea (MSD) in young children in Africa. We examined factors associated with Cryptosporidium infection in MSD cases enrolled at the rural western Kenya Global Enteric Multicenter Study (GEMS) site from 2008-2012., Methodology/principal Findings: At health facility enrollment, stool samples were tested for enteric pathogens and data on clinical, environmental, and behavioral characteristics collected. Each child's health status was recorded at 60-day follow-up. Data were analyzed using logistic regression. Of the 1,778 children with MSD enrolled as cases in the GEMS-Kenya case-control study, 11% had Cryptosporidium detected in stool by enzyme immunoassay; in a genotyped subset, 81% were C. hominis. Among MSD cases, being an infant, having mucus in stool, and having prolonged/persistent duration diarrhea were associated with being Cryptosporidium-positive. Both boiling drinking water and using rainwater as the main drinking water source were protective factors for being Cryptosporidium-positive. At follow-up, Cryptosporidium-positive cases had increased odds of being stunted (adjusted odds ratio [aOR] = 1.65, 95% CI: 1.06-2.57), underweight (aOR = 2.08, 95% CI: 1.34-3.22), or wasted (aOR = 2.04, 95% CI: 1.21-3.43), and had significantly larger negative changes in height- and weight-for-age z-scores from enrollment., Conclusions/significance: Cryptosporidium contributes significantly to diarrheal illness in young children in western Kenya. Advances in point of care detection, prevention/control approaches, effective water treatment technologies, and clinical management options for children with cryptosporidiosis are needed., Competing Interests: The authors have declared that no competing interests exist.

Introduction: Rotavirus is a leading cause of morbidity and mortality among children under five years worldwide. This study aimed to characterize the circulating genotypes of rotavirus and to determine risk factors of rotavirus infection in North Eastern, Kenya before the introduction of rotavirus vaccines., Methods: we conducted a cross sectional study among children < 5 years old hospitalized for acute gastroenteritis at the study hospital. Rotavirus was detected in stool specimens and further characterized using PAGE and RT-PCR. Socio-demographic and risk factor information was collected using a standard questionnaire., Results: we enrolled 237 children into the study hospitalized with acute gastroenteritis. Of these, 41 (17%) tested positive for group A rotavirus in stool specimens. Age < 2 years, unboiled tap water, underweight and low birth weight were identified as independent risk factors of rotavirus infection. Majority 8 (57%) of the detected rotavirus RNA profiles were long electropherotypes. G3, G9 and P4 were the predominant genotypes identified., Conclusion: Rotavirus is an important aetiology of acute gastroenteritis among children under five years in this region. Risk factors common in other regions and rotavirus vaccine preventable genotypes are responsible for infection. We recommend the introduction of rotavirus vaccines, coupled with good infant nutrition, safe water supply and maternal hygienic practices during infant feeding.

Introduction: Home Based Testing and Counselling (HBTC) aims at reaching individuals who have low HIV risk perception and experience barriers which prevent them from seeking HIV testing and counseling (HTC) services. Saturating the community with HTC is needed to achieve the ambitious 90-90-90 targets of knowledge of HIV status, ARV treatment and viral suppression. This paper describes the use of health belief model and community participation principles in HBTC to achieve increased household coverage and HTC uptake., Methods: This cross sectional survey was done between August 2009 and April 2011 in Kibera slums, Nairobi city. Using three community participation principles; defining and mobilizing the community, involving the community, overcoming barriers and respect to cultural differences and four constructs of the health belief model; risk perception, perceived severity, perceived benefits of changed behavior and perceived barriers; we offered HTC services to the participants. Descriptive statistics were used to describe socio-demographic characteristics, calculate uptake and HIV prevalence., Results: There were 72,577 individuals enumerated at the start of the program; 75,141 residents were found during service delivery. Of those, 71,925 (95.7%) consented to participate, out of which 71,720 (99.7%) took the HIV test. First time testers were (39%). The HIV prevalence was higher (6.4%) among repeat testers than first time testers (4.0%) with more women (7.4%) testing positive than men (3.6%) and an overall 5.5% slum prevalence., Conclusion: This methodology demonstrates that the use of community participation principles combined with a psychosocial model achieved high HTC uptake, coverage and diagnosed HIV in individuals who believed they are HIV free. This novel approach provides baseline for measuring HTC coverage in a community.

The Hologic Aptima HIV-1 Qualitative RNA assay was used in a rigorous screening approach designed to identify individuals at the earliest stage of HIV-1 infection for enrollment into subsequent studies of cellular and viral events in early infection (RV 217/Early Capture HIV Cohort [ECHO] study). Volunteers at high risk for HIV-1 infection were recruited from study sites in Thailand, Tanzania, Uganda, and Kenya with high HIV-1 prevalence rates among the populations examined. Small-volume blood samples were collected by finger stick at twice-weekly intervals and tested with the Aptima assay. Participants with reactive Aptima test results were contacted immediately for entry into a more comprehensive follow-up schedule with frequent blood draws. Evaluation of the Aptima test prior to use in this study showed a detection sensitivity of 5.5 copies/ml (50%), with all major HIV-1 subtypes detected. A total of 54,306 specimens from 1,112 volunteers were examined during the initial study period (August 2009 to November 2010); 27 individuals were identified as converting from uninfected to infected status. A sporadic reactive Aptima signal was observed in HIV-1-infected individuals under antiretroviral therapy. Occasional false-reactive Aptima results in uninfected individuals, or nonreactive results in HIV-1-infected individuals not on therapy, were observed and used to calculate assay sensitivity and specificity. The sensitivity and specificity of the Aptima assay were 99.03% and 99.23%, respectively; positive and negative predictive values were 92.01% and 99.91%, respectively. Conversion from HIV-1-uninfected to -infected status was rapid, with no evidence of a prolonged period of intermittent low-level viremia., (Copyright © 2017 Manak et al.)

Diarrheal disease is a leading cause of death among young children worldwide. As rates of acute diarrhea (AD; 1-6 days duration) have decreased, persistent diarrhea (PD; > 14 days duration) accounts for a greater proportion of the diarrheal disease burden. We describe factors associated with the duration of moderate-to-severe diarrhea in Kenyan children < 5 years old enrolled in the Global Enteric Multicenter Study. We found 587 (58%) children experienced AD, 360 (35%) had prolonged acute diarrhea (ProAD; 7-13 days duration), and 73 (7%) had PD. We constructed a Cox proportional hazards model to identify factors associated with diarrheal duration. Risk factors independently associated with longer diarrheal duration included infection with Cryptosporidium (hazard ratio [HR]: 0.868, P = 0.035), using an unimproved drinking water source (HR: 0.87, P = 0.035), and being stunted at enrollment (HR: 0.026, P < 0.0001). Diarrheal illness of extended duration appears to be multifactorial; given its association with adverse health and development outcomes, effective strategies should be implemented to reduce the duration and severity of diarrheal illness. Effective treatments for Cryptosporidium should be identified, interventions to improve drinking water are imperative, and nutrition should be improved through exclusive breastfeeding in infants ≤ 6 months and appropriate continued feeding practices for ill children.

Background: Home based HIV testing and counseling (HBTC) increases access to services and is associated with high testing uptake. Alongside testing, individuals are offered HIV prevention messages with an aim of helping them reduce HIV high risk sexual behaviors. This study explored the level of provision and subsequent utilization of HIV prevention messages and associated change in behavior among individuals who had received HBTC previously in an informal settlement., Methods: In a mixed method cross sectional study, we interviewed 1257 individuals and conducted 6 focus group discussions (FGD). Multiple correspondence analysis (MCA) was used to construct provision of prevention messages and behavior change indices using STATA 3.0. Pearson's chi-square statistics was used to test for bivariate association between the outcomes and logistic regression analysis was carried out with the behavior change index as the outcome of interest and the predictors considered significant (p<0.1). Thematic content analysis for qualitative data was done using Atlas 3.0., Results: Out of the 1257participants, 1078 (85.8%) had ever tested for HIV, with 74.2% having tested in the Kibera HBTC program. Nearly all (97.4%) rated HBTC experience as either excellent (62.4%) or good (37%) and would recommend it to a friend. Provision of prevention messages was high among HBTC clients compared to clients from other testing sites; partner reduction counselling (64% versus 52%) and faithfulness (78.3% versus 67%); p=0.001. Self-reported behavior change after HBTC was generally low with condom use at 10.7% and men more likely to practice safer sex (p = 0.002). Trust of the sexual partners and fear of suspicion were the main reasons given for not using condoms. Clients testing HIV positive after previous negative result were 3.4%. The focus group discussions reported multiple sexual partnerships among both HIV negative and positive residents alike., Conclusion: Although prevention messages delivered during HBTC are accepted and appreciated in this community, their utilization is low in both HIV negative and positive individuals. Innovative strategies for change of normative beliefs about sexual behavior are urgently needed., Competing Interests: Competing interests The authors declare that they have no competing interests.

Objective: To evaluate factors associated with rotavirus diarrhea and to describe severity of illness among children <5 years old with non-dysenteric, moderate-to-severe diarrhea (MSD) in rural western Kenya., Methods: We analyzed data from children <5 years old with non-dysenteric MSD enrolled as cases in the Global Enteric Multicenter Study (GEMS) in Kenya. A non-dysenteric MSD case was defined as a child with ≥3 loose stools in 24 hrs. and one or more of the following: sunken eyes, skin tenting, intravenous rehydration, or hospitalization, who sought care at a sentinel health center within 7 days of illness onset. Rotavirus antigens in stool samples were detected by ELISA. Demographic and clinical information was collected at enrollment and during a single follow-up home visit at approximately 60 days. We analyzed diarrhea severity using a GEMS 17 point numerical scoring system adapted from the Vesikari score. We used logistic regression to evaluate factors associated with rotavirus infection., Results: From January 31, 2008 to September 30, 2012, among 1,637 (92%) non-dysenteric MSD cases, rotavirus was detected in stools of 245 (15.0%). Rotavirus-positive compared with negative cases were: younger (median age, 8 vs. 13 months; p<0.0001), had more severe illness (median severity score, 9 vs 8; p<0.0001) and had to be hospitalized more frequently (37/245 [15.1%] vs. 134/1,392 [9.6%]), p <0.013). Independent factors associated with rotavirus infection included age 0-11 months old (aOR = 5.29, 95% CI 3.14-8.89) and presenting with vomiting ≥3 times/24hrs (aOR = 2.58, 95% CI [1.91-3.48]). Rotavirus was detected more commonly in warm and dry months than in the cool and rainy months (142/691 [20%] vs 70/673 [10%]) p<0.0001)., Conclusions: Diarrhea caused by rotavirus is associated with severe symptoms leading to hospitalization. Consistent with other settings, infants had the greatest burden of disease.

Introduction: Safe water for human consumption is important, but there is a limited supply. Mombasa County has water shortages making residences rely on other sources of water including boreholes and wells. Microbiological evaluation of drinking water is important to reduce exposure to water borne enteric diseases. This cross sectional study aimed at determining the frequency and characterization of Escherichia coli (E. coli) pathotypes from water samples collected from wells and boreholes in Mombasa County., Methods: One hundred and fifty seven (157) water samples were collected from four divisions of the county and a questionnaire administered. The samples were inoculated to double strength MacConkey broth and incubated at 370C for up to 48 hours. Positive results were compared to the 3 tube McCrady MPN table. The E. coli were confirmed by Eijkman's test and antibiotic susceptibility carried out. Using polymerase chain reaction (PCR), the E. coli were characterized to establish pathotypes., Results: One hundred and thirty one (n = 131; 83.4%) samples had coliform bacteria with only 79 (60.3%) samples having E. coli. Significant values (<0.05) were noted when coliforms were compared to variables with E. Coli showing no significance when compared to similar variables. E. coli (n = 77; 100%) tested were sensitive to Gentamicin, while all (n = 77; 100%) isolates were resistant to Ampicillin. PCR typed isolates as enteroinvasive E. Coli (EIEC)., Conclusion: Findings suggest that coliforms and E. coli are major contaminants of wells and boreholes in Mombasa County. The isolates have a variety of resistant and sensitivity patterns to commonly used antibiotics.

Atypical enteropathogenic Escherichia coli (aEPEC) is an umbrella term given to E. coli that possess a type III secretion system encoded in the locus of enterocyte effacement (LEE), but lack the virulence factors (stx, bfpA) that characterize enterohaemorrhagic E. coli and typical EPEC, respectively. The burden of disease caused by aEPEC has recently increased in industrialized and developing nations, yet the population structure and virulence profile of this emerging pathogen are poorly understood. Here, we generated whole-genome sequences of 185 aEPEC isolates collected during the Global Enteric Multicenter Study from seven study sites in Asia and Africa, and compared them with publicly available E. coli genomes. Phylogenomic analysis revealed ten distinct widely distributed aEPEC clones. Analysis of genetic variation in the LEE pathogenicity island identified 30 distinct LEE subtypes divided into three major lineages. Each LEE lineage demonstrated a preferred chromosomal insertion site and different complements of non-LEE encoded effector genes, indicating distinct patterns of evolution of these lineages. This study provides the first detailed genomic framework for aEPEC in the context of the EPEC pathotype and will facilitate further studies into the epidemiology and pathogenicity of EPEC by enabling the detection and tracking of specific clones and LEE variants.

Molecular identification of the invasion plasmid antigen-H (ipaH) gene has been established as a useful detection mechanism for Shigella spp. The Global Enteric Multicenter Study (GEMS) identified the etiology and burden of moderate-to-severe diarrhea (MSD) in sub-Saharan Africa and south Asia using a case-control study and traditional culture techniques. Here, we used quantitative polymerase chain reaction (qPCR) to identify Shigella spp. in 2,611 stool specimens from GEMS and compared these results to those using culture. Demographic and nutritional characteristics were assessed as possible risk factors. The qPCR identified more cases of shigellosis than culture; however, the distribution of demographic characteristics was similar by both methods. In regression models adjusting for Shigella quantity, age, and site, children who were exclusively breast-fed had significantly lower odds of MSD compared with children who were not breast-fed (odds ratio [OR] = 0.47, 95% confidence interval (CI) = 0.28-0.81). The association between Shigella quantity and MSD increased with age, with a peak in children of 24-35 months of age (OR = 8.2, 95% CI = 4.3-15.7) and the relationship between Shigella quantity and disease was greatest in Bangladesh (OR = 13.2, 95% CI = 7.3-23.8). This study found that qPCR identified more cases of Shigella and age, site, and breast-feeding status were significant risk factors for MSD., (© The American Society of Tropical Medicine and Hygiene.)

Populations living in informal settlements with inadequate water and sanitation infrastructure are at risk of epidemic disease. In 2010, we conducted 398 household surveys in two informal settlements in Nairobi, Kenya with isolated cholera cases. We tested source and household water for free chlorine residual (FCR) and Escherichia coli in approximately 200 households. International guidelines are ≥0.5 mg/L FCR at source, ≥0.2 mg/L at household, and <1 E. coli/100 mL. In these two settlements, 82% and 38% of water sources met FCR guidelines; and 7% and 8% were contaminated with E. coli, respectively. In household stored water, 82% and 35% met FCR guidelines and 11% and 32% were contaminated with E. coli, respectively. Source water FCR≥0.5 mg/L (p=0.003) and reported purchase of a household water treatment product (p=0.002) were associated with increases in likelihood that household stored water had ≥0.2 mg/L FCR, which was associated with a lower likelihood of E. coli contamination (p<0.001). These results challenge the assumption that water quality in informal settlements is universally poor and the route of disease transmission, and highlight that providing centralized water with ≥0.5 mg/L FCR or (if not feasible) household water treatment technologies reduces the risk of waterborne cholera transmission in informal settlements.

Pathogens in the gastrointestinal tract exist within a vast population of microbes. We examined associations between pathogens and composition of gut microbiota as they relate to Shigella spp./enteroinvasive Escherichia coli infection. We analyzed 3,035 stool specimens (1,735 nondiarrheal and 1,300 moderate-to-severe diarrheal) from the Global Enteric Multicenter Study for 9 enteropathogens. Diarrheal specimens had a higher number of enteropathogens (diarrheal mean 1.4, nondiarrheal mean 0.95; p<0.0001). Rotavirus showed a negative association with Shigella spp. in cases of diarrhea (odds ratio 0.31, 95% CI 0.17-0.55) and had a large combined effect on moderate-to-severe diarrhea (odds ratio 29, 95% CI 3.8-220). In 4 Lactobacillus taxa identified by 16S rRNA gene sequencing, the association between pathogen and disease was decreased, which is consistent with the possibility that Lactobacillus spp. are protective against Shigella spp.-induced diarrhea. Bacterial diversity of gut microbiota was associated with diarrhea status, not high levels of the Shigella spp. ipaH gene.

Background: Diarrheal diseases continue to contribute significantly to morbidity and mortality in infants and young children in developing countries. There is an urgent need to better understand the contributions of novel, potentially uncultured, diarrheal pathogens to severe diarrheal disease, as well as distortions in normal gut microbiota composition that might facilitate severe disease., Results: We use high throughput 16S rRNA gene sequencing to compare fecal microbiota composition in children under five years of age who have been diagnosed with moderate to severe diarrhea (MSD) with the microbiota from diarrhea-free controls. Our study includes 992 children from four low-income countries in West and East Africa, and Southeast Asia. Known pathogens, as well as bacteria currently not considered as important diarrhea-causing pathogens, are positively associated with MSD, and these include Escherichia/Shigella, and Granulicatella species, and Streptococcus mitis/pneumoniae groups. In both cases and controls, there tend to be distinct negative correlations between facultative anaerobic lineages and obligate anaerobic lineages. Overall genus-level microbiota composition exhibit a shift in controls from low to high levels of Prevotella and in MSD cases from high to low levels of Escherichia/Shigella in younger versus older children; however, there was significant variation among many genera by both site and age., Conclusions: Our findings expand the current understanding of microbiota-associated diarrhea pathogenicity in young children from developing countries. Our findings are necessarily based on correlative analyses and must be further validated through epidemiological and molecular techniques.

Introduction: Diarrhoea remains a major public health problem in East African nations such as Kenya. Surveillance for a broad range of enteric pathogens is necessary to accurately predict the frequency of pathogens and potential changes in antibiotic resistance patterns., Methods: A cross sectional study was conducted in Igembe District Hospital in Meru County to determine the burden and factors associated enteric bacterial infection among children aged five years and below. Stool samples were collected between March and July 2012. Bacterial pathogens were identified and antibiotic susceptibility of bacterial isolates was ascertained. Questionnaire was administered to the 308 study participants to identify the modifiable risk factors. Data was entered and analyzed using Epi Info version 3.5.3., Results: The study recruited 308 children. The mean age was 27.25 months, median of 26.0 months and age range between 2-60 months. The bacterial isolation rates were ETEC 9.1%, EPEC 6.8% and EAEC 12.3%, Salmonella paratyphoid (10.4%), Shigella flexineri (1.9%) and Shigella dysentriae (0.9%). Over 95%, of the isolates were resistance to amoxicillin, sulphinatozole, cotrimoxazole. Six factors were independently associated with diarrhoeal diseases, occupation of the parent/ guardian (miraa business) (OR=1.8, CI:1.44-4.99),care taker not washing hands after changing napkins (OR= 1.6, CI:1.2-19.7), child drank untreated water from the river (OR= 2.7, CI:2.4-9.9) child not exclusively breastfed (OR= 2.4, CI:2.1-10.5),child did not Wash hands before eating (OR=2.2, CI:1.91-16.3) and after visiting toilet (OR=3.7,CI:2.8-39.4). Eating of mangoes was found to be protective against diarrhoea (OR=0.5, CI:0.03-0.89)., Conclusion: The bacterial pathogens were found to be a significant cause of diarrhoea in the study participants. We established higher resistance to several commonly prescribed antibiotics. Several factors were significantly association with diarrhoea illness. We recommend multifaceted approach that acknowledges the public health aspects that would reduce the burden of diarrhoea infections as identified in this study.

Cultivation-based assays combined with PCR or enzyme-linked immunosorbent assay (ELISA)-based methods for finding virulence factors are standard methods for detecting bacterial pathogens in stools; however, with emerging molecular technologies, new methods have become available. The aim of this study was to compare four distinct detection technologies for the identification of pathogens in stools from children under 5 years of age in The Gambia, Mali, Kenya, and Bangladesh. The children were identified, using currently accepted clinical protocols, as either controls or cases with moderate to severe diarrhea. A total of 3,610 stool samples were tested by established clinical culture techniques: 3,179 DNA samples by the Universal Biosensor assay (Ibis Biosciences, Inc.), 1,466 DNA samples by the GoldenGate assay (Illumina), and 1,006 DNA samples by sequencing of 16S rRNA genes. Each method detected different proportions of samples testing positive for each of seven enteric pathogens, enteroaggregative Escherichia coli (EAEC), enterotoxigenic E. coli (ETEC), enteropathogenic E. coli (EPEC), Shigella spp., Campylobacter jejuni, Salmonella enterica, and Aeromonas spp. The comparisons among detection methods included the frequency of positive stool samples and kappa values for making pairwise comparisons. Overall, the standard culture methods detected Shigella spp., EPEC, ETEC, and EAEC in smaller proportions of the samples than either of the methods based on detection of the virulence genes from DNA in whole stools. The GoldenGate method revealed the greatest agreement with the other methods. The agreement among methods was higher in cases than in controls. The new molecular technologies have a high potential for highly sensitive identification of bacterial diarrheal pathogens.

Introduction: Kenya is home to over 400 000 refugees from neighbouring countries. There is scanty information about diarrhoea amongst urban refugees in Kenya., Objectives: We investigated the enteric bacteria causing diarrhoea amongst urban refugee children and described the associated factors., Method: During the period of August-December 2010, urban refugee children between the ages of two and five who attended Eastleigh County Council Health Centre were enrolled into the study. Diarrhoeal cases were compared with age-matched children with no diarrhoea (controls). Stool specimens were collected and enteric bacteria isolated. A questionnaire was administered to identify risk factors., Results: A total of 41 cases and 41 controls were enrolled in the study. The age and country of origin were similar for cases and controls. The bacterial isolation rates amongst the cases were: non-pathogenic Escherichia coli 71%, Shigella dysenteriae 2.4%, Shigella flexneri 2.4%, Salmonella paratyphi 5%. For the controls, non-pathogenic E. coli 90% and enterotoxigenic E. coli (ETEC) 2.4% were amongst the organisms isolated. All isolates were resistant to amoxicillin; resistance to other antibiotics varied by isolate type. Factors associated independently with diarrhoea included children not washing their hands with soap (aOR 5.9, p < 0.05), neighbour(s) having diarrhoea (aOR 39.8, p < 0.05), children not exclusively breastfed for their first 6 months (aOR 7.6, p < 0.05) and children eating food cooked the previous day (aOR 23.8, p = 0.002)., Conclusions: Shigella species, Salmonella species and ETEC were found to be responsible for diarrhoea amongst the urban refugee children. Measures to control and guide the use of antibiotics are critical for the prevention of antibiotic resistance. Efforts to improve personal and domestic hygiene, including educational campaigns to promote appropriate handwashing, should be encouraged., Competing Interests: The authors declare that they have no financial or personal relationship(s) that may have inappropriately influenced them in writing this article.

Background: As the threat of zoonoses and the emergence of pandemic-prone respiratory viruses increases, there is a need to establish baseline information on the incidence of endemic pathogens in countries worldwide., Objectives: To investigate the presence of viruses associated with influenza-like illnesses (ILI) in Uganda., Methods: A cross-sectional study was conducted in which nasopharyngeal swab specimens were collected from patients diagnosed with ILI in Kampala and Entebbe between 14 August 2008 - 15 December 2008. A multiplex polymerase chain reaction assay for detecting 12 respiratory viruses was used., Results: A total of 369 patients (52.3% females) was enrolled; the median age was 6 years (range 1-70). One or more respiratory viruses were detected in 172 (46.6%) cases and their prevalence were influenza A virus (19.2%), adenovirus (8.7%), human rhinovirus A (7.9%), coronavirus OC43 (4.3%), parainfluenza virus 1 (2.7%), parainfluenza virus 3 (2.7%), influenza B virus (2.2%), respiratory syncytial virus B (2.2%), human metapneumovirus (1.4%), respiratory syncytial virus A (1.1%), parainfluenza virus 2 (0.5%) and coronavirus 229E (0.5%). There were 24 (14.0%) mixed infections., Conclusions: This study identified some of the respiratory viruses associated with ILI in Uganda. The circulation of some of the viruses was previously unknown in the study population. These results are useful in order to guide future surveillance and case management strategies involving respiratory illnesses in Uganda., Competing Interests: The authors declare that they have no financial or personal relationship(s) which may have inappropriately influenced them in writing this article.

Estimates of the prevalence of Shigella spp. are limited by the suboptimal sensitivity of current diagnostic and surveillance methods. We used a quantitative PCR (qPCR) assay to detect Shigella in the stool samples of 3,533 children aged <59 months from the Gambia, Mali, Kenya, and Bangladesh, with or without moderate-to-severe diarrhea (MSD). We compared the results from conventional culture to those from qPCR for the Shigella ipaH gene. Using MSD as the reference standard, we determined the optimal cutpoint to be 2.9 × 10(4) ipaH copies per 100 ng of stool DNA for set 1 (n = 877). One hundred fifty-eight (18%) specimens yielded >2.9 × 10(4) ipaH copies. Ninety (10%) specimens were positive by traditional culture for Shigella. Individuals with ≥ 2.9 × 10(4) ipaH copies have 5.6-times-higher odds of having diarrhea than those with <2.9 × 10(4) ipaH copies (95% confidence interval, 3.7 to 8.5; P < 0.0001). Nearly identical results were found using an independent set of samples. qPCR detected 155 additional MSD cases with high copy numbers of ipaH, a 90% increase from the 172 cases detected by culture in both samples. Among a subset (n = 2,874) comprising MSD cases and their age-, gender-, and location-matched controls, the fraction of MSD cases that were attributable to Shigella infection increased from 9.6% (n = 129) for culture to 17.6% (n = 262) for qPCR when employing our cutpoint. We suggest that qPCR with a cutpoint of approximately 1.4 × 10(4) ipaH copies be the new reference standard for the detection and diagnosis of shigellosis in children in low-income countries. The acceptance of this new standard would substantially increase the fraction of MSD cases that are attributable to Shigella.

To understand the etiology of moderate-to-severe diarrhea among children in high mortality areas of sub-Saharan Africa and South Asia, we performed a comprehensive case/control study of children aged <5 years at 7 sites. Each site employed an identical case/control study design and each utilized a uniform comprehensive set of microbiological assays to identify the likely bacterial, viral and protozoal etiologies. The selected assays effected a balanced consideration of cost, robustness and performance, and all assays were performed at the study sites. Identification of bacterial pathogens employed streamlined conventional bacteriologic biochemical and serological algorithms. Diarrheagenic Escherichia coli were identified by application of a multiplex polymerase chain reaction assay for enterotoxigenic, enteroaggregative, and enteropathogenic E. coli. Rotavirus, adenovirus, Entamoeba histolytica, Giardia enterica, and Cryptosporidium species were detected by commercially available enzyme immunoassays on stool samples. Samples positive for adenovirus were further evaluated for adenovirus serotypes 40 and 41. We developed a novel multiplex assay to detect norovirus (types 1 and 2), astrovirus, and sapovirus. The portfolio of diagnostic assays used in the GEMS study can be broadly applied in developing countries seeking robust cost-effective methods for enteric pathogen detection.

Numerous outbreaks of cholera have occurred in Kenya since 1971. To more fully understand the epidemiology of cholera in Kenya, we analyzed the genetic relationships among 170 Vibrio cholerae O1 isolates at 5 loci containing variable tandem repeats. The isolates were collected during January 2009-May 2010 from various geographic areas throughout the country. The isolates grouped genetically into 5 clonal complexes, each comprising a series of genotypes that differed by an allelic change at a single locus. No obvious correlation between the geographic locations of the isolates and their genotypes was observed. Nevertheless, geographic differentiation of the clonal complexes occurred. Our analyses showed that multiple genetic lineages of V. cholerae were simultaneously infecting persons in Kenya. This finding is consistent with the simultaneous emergence of multiple distinct genetic lineages of V. cholerae from endemic environmental reservoirs rather than recent introduction and spread by travelers.

Objectives: To identify factors associated with Brucellosis in patients attending Terekeka Health Facility, Terekeka County, Central Equatoria State, Southern Sudan and to evaluate the utility of the rapid test kit Euracil®., Design: A facility based case-control study., Setting: Terekeka Health Facility, Terekeka County, Central Equatoria State, Southern Sudan., Subjects: Cases were patients presenting at the Terekeka Health Facility with clinical symptoms suggestive of Brucellosis and tested positive for Brucellosis by rapid antigen test while controls were selected from individuals attending Terekeka Health facility with health problems unrelated to brucellosis or febrile illness., Results: A total of fifty eight cases with clinical symptoms suggestive of and tested positive for Brucellosis by rapid antigen test presented. A total of 116 consented controls were recruited into the study. Males accounted for 52% of the cases and 53% of the controls. The mean age was 31 years for both groups. Cases without formal education were 84% while 40% had no source of income, 20% of the cases and 14% of the controls were cattle keepers while 5% of the cases and 13% of the controls were students. In multivariate analysis there were many factors associated with Brucellosis like consumption of raw meat, living with animals at the same place, raising of goats, farm cleaning contact, eating of aborted and wild animals. Logistic regression revealed two factors associated with the disease; consumption of raw milk (OR=3.9, P-value 0.001, 95% CI 1.6666-9.0700) was a risk factor while drinking boiled milk was protective (OR = 0.09, p-value 0.000, 95% CI, 0.1-0.2)., Conclusions: The main age-groups affected were 20-30 years with males being affected more than females. Drinking of raw milk was significantly associated with Brucellosis while drinking boiled milk was protective. There should be active public health education on the benefits of boiling milk before consumption. Further studies to elucidate the extent and epidemiology of brucellosis in humans and animals in Southern Sudan are recommended.

Background: The epidemiology of non-Typhi Salmonella (NTS) bacteremia in Africa will likely evolve as potential co-factors, such as HIV, malaria, and urbanization, also change., Methods: As part of population-based surveillance among 55,000 persons in malaria-endemic, rural and malaria-nonendemic, urban Kenya from 2006-2009, blood cultures were obtained from patients presenting to referral clinics with fever ≥38.0°C or severe acute respiratory infection. Incidence rates were adjusted based on persons with compatible illnesses, but whose blood was not cultured., Results: NTS accounted for 60/155 (39%) of blood culture isolates in the rural and 7/230 (3%) in the urban sites. The adjusted incidence in the rural site was 568/100,000 person-years, and the urban site was 51/100,000 person-years. In both sites, the incidence was highest in children <5 years old. The NTS-to-typhoid bacteremia ratio in the rural site was 4.6 and in the urban site was 0.05. S. Typhimurium represented >85% of blood NTS isolates in both sites, but only 21% (urban) and 64% (rural) of stool NTS isolates. Overall, 76% of S. Typhimurium blood isolates were multi-drug resistant, most of which had an identical profile in Pulse Field Gel Electrophoresis. In the rural site, the incidence of NTS bacteremia increased during the study period, concomitant with rising malaria prevalence (monthly correlation of malaria positive blood smears and NTS bacteremia cases, Spearman's correlation, p = 0.018 for children, p = 0.16 adults). In the rural site, 80% of adults with NTS bacteremia were HIV-infected. Six of 7 deaths within 90 days of NTS bacteremia had HIV/AIDS as the primary cause of death assigned on verbal autopsy., Conclusions: NTS caused the majority of bacteremias in rural Kenya, but typhoid predominated in urban Kenya, which most likely reflects differences in malaria endemicity. Control measures for malaria, as well as HIV, will likely decrease the burden of NTS bacteremia in Africa.

In October 2010, the US Centers for Disease Control and Prevention received reports of cases of severe watery diarrhea in Haiti. The cause was confirmed to be toxigenic Vibrio cholerae, serogroup O1, serotype Ogawa, biotype El Tor. We characterized 122 isolates from Haiti and compared them with isolates from other countries. Antimicrobial drug susceptibility was tested by disk diffusion and broth microdilution. Analyses included identification of rstR and VC2346 genes, sequencing of ctxAB and tcpA genes, and pulsed-field gel electrophoresis with SfiI and NotI enzymes. All isolates were susceptible to doxycycline and azithromycin. One pulsed-field gel electrophoresis pattern predominated, and ctxB sequence of all isolates matched the B-7 allele. We identified the tcpETCIRS allele, which is also present in Bangladesh strain CIRS 101. These data show that the isolates from Haiti are clonally and genetically similar to isolates originating in Africa and southern Asia and that ctxB-7 and tcpET(CIRS) alleles are undergoing global dissemination.

Laboratories are integral to the delivery of quality health care and for public health functions; however laboratory systems and services are often neglected in resource-poor settings such as the East African region. In order to sustainably strengthen national laboratory systems in resource-poor countries, there is a need to train laboratory personnel to work in clinical as well as public health laboratories. In 2004,Kenya, Uganda, Tanzania, and South Sudan began training public health laboratory workers jointly with field epidemiologists in the Kenya Field Epidemiology and Laboratory Training Program (FELTP), and later through the Tanzania FELTP, as a strategy to strengthen public health laboratories. These programs train laboratory epidemiologists through a two-year public health leadership development course, and also offer various types of short course training for frontline staff. The FELTP laboratory graduates in Kenya, Tanzania, Uganda, and South Sudan are working in their respective countries to strengthen public health laboratory systems while the short course participants provide a pool of frontline implementers with the capacity to support the lower tiers of health systems, as well as serve as surge capacity for the regions and the national level. Through training competent public health laboratory workers, the East African ministries of health, in collaboration with other regional partners and stakeholders are now engaged in developing and implementing a holistic approach that will guarantee an overall strengthening of the health system by using well-trained public health laboratory leaders to drive the process. Strengthening public health laboratory medicine in East Africa is critical to improve health-care systems. The experience with the FELTP model in East Africa is a step in the right direction towards ensuring a stronger role for the laboratory in public health.

Background: Road traffic injuries continue to exert a huge burden on the health care system in Kenya. Few studies on the severity of road traffic injuries have been conducted in Kenya. We carried out a cross-sectional study to determine factors associated with severity of road traffic injuries in a public hospital in Thika district, Kenya., Methods: Road crash victims attending the Thika district hospital, a 265-bed public hospital, emergency room were recruited consecutively between 10th August 2009 and 15th November 2009. Epidemiologic and clinical information was collected from medical charts and through interview with the victims or surrogates using a semi-structured questionnaire. Injuries were graded as severe or non-severe based on the Injury Severity Score (ISS). Independent factors associated with injury severity were assessed using multivariate logistic regression., Results: The mean age of participants was 32.4 years, three quarters were between 20-49 years-old and 73% (219) were male. Nineteen percent (56/300) of the victims had severe injury. Five percent (15) had head injury while 38% (115) had fractures. Vulnerable road users (pedestrians and two-wheel users) comprised 33% (99/300) of the victims. Vulnerable road users (OR=2.0, 95%CI=1.0-3.9), road crashes in rainy weather (OR=2.9, 95%CI=1.3-6.5) and night time crashes (OR=2.0, 95%CI=-1.1-3.9) were independent risk factors for sustaining severe injury., Conclusion: Severe injury was associated with vulnerable road users, rainy weather and night time crashes. Interventions and measures such as use of reflective jackets and helmets by two wheel users and enhanced road visibility could help reduce the severity of road traffic injuries.

Background: Although causing substantial morbidity, the burden of pneumococcal disease among older children and adults in Africa, particularly in rural settings, is not well-characterized. We evaluated pneumococcal bacteremia among 21,000 persons > or =5 years old in a prospective cohort as part of population-based infectious disease surveillance in rural western Kenya from October 2006-September 2008., Methods: Blood cultures were done on patients meeting pre-defined criteria--severe acute respiratory illness (SARI), fever, and admission for any reason at a referral health facility within 5 kilometers of all 33 villages where surveillance took place. Serotyping of Streptococcus pneumoniae was done by latex agglutination and quellung reaction and antibiotic susceptibility testing was done using broth microdilution. We extrapolated incidence rates based on persons with compatible illnesses in the surveillance population who were not cultured. We estimated rates among HIV-infected persons based on community HIV prevalence. We projected the national burden of pneumococcal bacteremia cases based on these rates., Results: Among 1,301 blood cultures among persons > or =5 years, 52 (4%) yielded pneumococcus, which was the most common bacteria isolated. The yield was higher among those > or =18 years than 5-17 years (6.9% versus 1.6%, p < 0.001). The highest yield was for inpatients with SARI (10%), compared with SARI outpatients (3%) and acute febrile outpatients (1%). Serotype 1 pneumococcus was most common (42% isolates) and 71% were serotypes included in the 10-valent pneumococcal conjugate vaccine (PCV10). Non-susceptibility to beta-lactam antibiotics was low (<5%), but to trimethoprim-sulfamethoxazole was high (>95%). The crude rate of pneumococcal bacteremia was 129/100,000 person-years, and the adjusted rate was 419/100,000 person-years. Nineteen (61%) of 31 patients with HIV results were HIV-positive. The adjusted rate among HIV-infected persons was 2,399/100,000 person-years (Rate ratio versus HIV-negative adults, 19.7, 95% CI 12.4-31.1). We project 58,483 cases of pneumococcal bacteremia will occur in Kenyan adults in 2010., Conclusions: Pneumococcal bacteremia rates were high among persons > or =5 years old, particularly among HIV-infected persons. Ongoing surveillance will document if expanded use of highly-active antiretroviral treatment for HIV and introduction of PCV10 for Kenyan children (anticipated in late 2010) result in substantial secondary benefits by reducing pneumococcal disease in adults.

Objective: Determine factors associated with syphilis among pregnant women., Design: Cross-sectional study., Setting: Antenatal clinics of Juba Teaching Hospital, Malakia National Health Insurance Centre and Munuki Primary Health Care Centre in Juba, Southern Sudan., Subjects: Consenting pregnant women not on syphilis treatment., Main Outcome Measures: Socio-demographic and clinical data, knowledge and behavioural characteristics., Results: Of the 231 pregnant women participants, 51 (22.1%) were positive for syphilis with the rapid plasma reagin test and 79 (34.2%) were positive with the treponema pallidum Haemagglutination assay. Risk factors for syphilis were: housewife (OR 2.808; P= 0.0116), abortion (OR 2.654; P= 0.0116) and partner travel (OR 2.149; P= 0.028). Attending antenatal clinic for previous pregnancy was protective (OR 0.281; P= 0.0004) for syphilis., Conclusions: This is the first study to determine the prevalence and associated factors in the three clinics in Juba, South Sudan. There is a high prevalence of syphilis in pregnant women attending the selected health facilities. Treponema Pallindum Haemagglulination Assay can be used as a field test for syphilis due to its high sensitivity and specificity. Health education, screening and treating positive expectant mothers can reduce the prevalence of syphilis.

Objectives: To determine the aetiology, epidemiology and sanitary factors of carriage of enteropathogenic Escherichia coli (EPEC) and Shiga-toxin producing E. coli (STEC) in food-handlers working in tourist hotels in three popular tourist destinations in Kenya., Design: Cross sectional laboratory based study., Setting: Three tourist destinations of Nairobi, Malindi and Diani in Kenya., Subjects: Food handlers who were working in hotels frequented by tourists in the three study sites., Results: Overall, during the period of April 2003 to May 2004, a total of 1399 food handlers stool samples were collected and analysed. EPEC expressing the eaeA gene and STEC expressing the stx2 gene were detected in 11/1399 (0.8%) and 2/1399 (0.1%) of the study subjects respectively. The mean age of the subjects from whom EPEC and STEC were isolated was similar (32.6 years) to those from whom no EPEC and STEC were isolated (32.5 years). Prior use of antibiotics, water source and toilet types were not significantly associated with the isolation of EPEC and STEC (p>0.05). There were 11 resistance patterns with six isolates (6/13, 46.2%) showing multidrug resistance. High prevalence of resistance was observed to co-trimoxazole (55.6%), chloramphenicol (33.3%), ampicillin (22.2%) and tetracycline (22.2%). High concentrations of antibiotics were required to achieve MIC90 for tetracycline, (>64 mg ml(-1)) and ampicillin (>256 mg ml(-1)). Cluster analysis of the Pulse Field Gel Electrophoresis profiles revealed that the EPEC and STEC isolates belonged to two main genotypes with 11 distinct DNA fragment profiles., Conclusion: This is the first report in Africa on the isolation of STEC from food handlers working in tourist hotels. These food handlers who carry the STEC and EPEC could potentially infect tourists and other people through food or water contamination in the hotel settings and thus our findings are of great public health importance.