Hospital In Nairobi Research Articles

Molecular Identification of Co-Existence of Carbapenemase and Extended-Spectrum <i>β</i>-Lactamase Genes in <i>Klebsiella pneumoniae</i> Clinical Isolates, and Their Phylogenetic Patterns in Kenya

The increasing incidence of multidrug-resistant Klebsiella pneumoniae strains has become a serious global healthcare problem. Additionally, the carriage of both extended-spectrum ß-lactamase and carbapenemase genes on plasmid and genomic DNA in K. pneumoniae clinical isolates has not been documented in Kenya. This study aimed to assess the presence of extended spectrum β-lactamase (ESBL) and carbapenemase genes on genomic and plasmid DNA in K. pneumoniae, and classify these super-bug clinical isolates based on their phylogenetic patterns. The identification of Klebsiella-like clinical isolates (n = 20) collected from Kenyatta National Hospital in Nairobi was performed using API 20E Kit. Screening and confirmation for ESBL and carbapenemase phenotypes were conducted using Kirby-Bauer disk diffusion susceptibility test protocol. Conventional PCR technique was used to characterize ESBL and carbapenemase resistant genes on both genomic and plasmid DNA. Subsequently, 16S rRNA gene amplification and sequencing were performed. The 16S rRNA gene contiguous sequences of the bacterial isolates were analyzed using the ChromasPro. The gene sequence was compared with the sequences in GenBank database, using the BLAST program of NCBI to obtain the nearest phylogenetic neighbours from the databases. Then, the sequences of MDR K. pneumoniae and its relatives were aligned using ClustalW. The evolutionary history was inferred by using the maximum likelihood algorithm in MEGA MX. The phenotypic data of antibiotic susceptibility testing revealed that 2/20 (10%) clinical isolates were resistant both to imipenem and meropenem and producers of carbapenemase. These isolates were carbapenemase producers but not extended β-lactamases. However, 3/20 (15%) isolates that co-harboured blaNDM-1, blaIMP, blaTEM, and bla-OXA were identified during genotypic analysis. The positive control used separately yielded the expected band sizes for blaIMP (275 bp), blaOXA-48 (438 bp), and BlaKPC (798). The phylogenetic analysis showed the dual ESBL and carbapenemase producing Klebsiella pneumoniae could be classified as K. pneumoniae strain DSM 30104 and K. pneumonia subsp. pneumoniae strain GMH1080. This study confirmed the co-existence of ESBL and carbapenemase genes in Klebsiella pneumoniae on both bacterial genomic and Plasmid DNA, and demonstrated that the isolates are evolutionarily distinct. These findings raise a concern about the genotypic diversity of antibiotic resistance genes in bacterial isolates and their location. We, therefore, recommend an alternative management approach to combat these MDR bacterial isolates as well as frequent molecular surveillance programs to support antimicrobial stewardship.

Tuberculosis in an urban hospital setting: Descriptive epidemiology among patients at Kenyatta National Hospital TB clinic, Nairobi, Kenya

BackgroundThe prevalence of tuberculosis (TB) in low-to-middle-income countries is larger than that observed in developed countries. This study aimed to characterize TB disease among patients diagnosed at Kenyatta National Hospital (KNH) in Nairobi, Kenya, for public health action. MethodsWe conducted a descriptive cross-sectional study at KNH TB clinic from January to December 2015. Data were extracted from TB clinic in- and out-patient registers, entered into MS-Excel, and descriptive and associative statistics were calculated with Open-Epi software. ResultsA total of 1,551 TB cases were identified, with mean age of 31.5 ± 16.5 years, and 771 (49.7%) were < 32 years old. Bivariate analyses showed significant associations between younger age (<32 years) and being hospitalized for the infection (OR 8.18, 95% CI 6.47–10.38, p < 0.0001) and being diagnosed by sputum microscopy (OR 2.12, 95% CI 1.39–3.25, p = 0.0005). ConclusionYounger patients were more likely to be diagnosed at a sicker stage of disease than their older counterparts and to be hospitalized as a result. This calls for intensified TB case finding among younger patients by use of more rapid TB tests to diagnose TB earlier.

Cost Analysis of Treatment of Road Traffic Injuries among Victims at the Kenyatta National Hospital Nairobi City County, Kenya

Background; Many studies have reported Road traffic injuries (RTIs) leading to fatalities of over one million victims annually and negatively impacting on health, economy and development of the society as a whole, furthermore, young men and women at their most economic age group, are highly affected by RTIs and in most cases it causing mortality and very severe morbidity due disability. With projection by the year 2030, RTIs will be ranked as the fifth cause of disability adjusted life years (DALYs) lost. There is little or no any published Evidence on healthcare resource utilization and allocations after RTIs, especially in developing countries. Africa included. Locally in Kenya road accident remains a major public health concern, with high mortality and morbidity rates reported annually. Aim: The Main objective of this study was to analyze the total hospital Expenditure/cost related to RTI (Road traffic injury) admitted at the Kenyatta National Hospital for a period of 3 months from the start of the study. Methods: This was a cross sectional study design; the study location was the Kenyatta National Hospital Nairobi, surgical wards and Accident &amp; Emergency. A sample (n=124) comprising of victims admitted to the Hospital due to RTI from January 25th 2019 to 30 th May 2019. Systematic sampling was used. The independent variable was the cost of treatment while the dependent variable was direct medical treatment cost, non-medical treatment cost, productivity loss and length of stay. Primary Data collections was done through interviews of all victims admitted at the KNH through A&amp;E and qualify as per the inclusion criteria, the victims were admitted at the surgical unit level 4,5, and 6. The data collection of direct and direct non-medical cost, was by data extraction tool, testing of the tools was done at the surgical ward. Productivity loss of the victims was calculated by use of Work Productivity and Activity Impairment Questionnaire (WPAIQ). Data was analyzed by SSPS version 22. Results: From the study 76.6% of the road users were male, while female was 23.4%. Most of injuries were lower limbs, head and upper limbs in that order. Leading injuries by mode of transport was Motorcycle at 43.5%, pedestrian and public transport at 23.4 % and 17.7%. Daily bed charges and Surgery were the leading cost component followed by pharmacy. Average length of stay was 24.1 days, average medical cost was at (KSH 66,482, 642 USD), productivity loss at (KSH19, 061, USD 184) and indirect cost at KSH10, 745 USD 107). There was significance correlation between total bed charges, medical cost and productivity loss at P=0.01. (Cl 95%) chi square showed linear by linear association of P value of .000 Conclusion: Road traffic accident is an economic burden to individual, family and country at large, males more affected at their most economic age groups. Findings will aid policy makers in review on resource allocation. Further Motion studies on cost analysis of RTIs, over a longer period to be conducted to provide more insight on the subject.

Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya

Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation. Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.

LINC-32. REPORT OF AN INITIAL SITE VISIT TO DETERMINE FEASIBILITY AND IMPLEMENTATION OF A COMPREHENSIVE NEURO-ONCOLOGY PROGRAM IN KENYA

BACKGROUNDPediatric central nervous system (CNS) tumors are the leading solid tumors in the United States, but vastly under-reported in the African population. There’s limited data on childhood brain tumors as well as the histopathological distribution in Kenya. This report surveys as an initial site visit to determine the feasibility of a comprehensive neuro-oncology program at Kenyatta National Hospital (KNH) in Nairobi, Kenya. DESIGN: This collaboration began with a visit from the director of neuropathology at KNH to our neuro-Oncology program at Riley Hospital for Children at Indiana University Health in May 2019. This report includes recommendations from the May 2019 trip, as well as a reciprocal site visit to Kenya in January 2020.RESULTSBuilding off the May 2019 trip, a brain tumor registry has been initiated and maintained. Additionally, the KNH program has many necessary components to forming a comprehensive neuro-oncology program, including capable neurosurgeons with a neurosurgical training program, radiology, intensive care unit, oncology ward, rehab, skilled nursing, and radiation oncology services. Currently, neurosurgery, radiology, and pathology meet weekly to review challenging cases.CONCLUSIONKenyatta National Hospital has the expertise to build a comprehensive neuro-oncology program. The program currently lacks a dedicated nurse coordinator and “specialist” in neuro-oncology. Ongoing discussions with local stakeholders are aimed to galvanize national support to improve awareness for children with brain tumors and to plan a multidisciplinary neuro-oncology symposium in 2021. In the meantime, telemedicine efforts can support nursing education and reiterate the multidisciplinary needs for children with brain tumors.

Derivation and internal validation of a data-driven prediction model to guide frontline health workers in triaging children under-five in Nairobi, Kenya

Background: Many hospitalized children in developing countries die from infectious diseases. Early recognition of those who are critically ill coupled with timely treatment can prevent many deaths. A data-driven, electronic triage system to assist frontline health workers in categorizing illness severity is lacking. This study aimed to develop a data-driven parsimonious triage algorithm for children under five years of age. Methods: This was a prospective observational study of children under-five years of age presenting to the outpatient department of Mbagathi Hospital in Nairobi, Kenya between January and June 2018. A study nurse examined participants and recorded history and clinical signs and symptoms using a mobile device with an attached low-cost pulse oximeter sensor. The need for hospital admission was determined independently by the facility clinician and used as the primary outcome in a logistic predictive model. We focused on the selection of variables that could be quickly and easily assessed by low skilled health workers. Results: The admission rate (for more than 24 hours) was 12% (N=138/1,132). We identified an eight-predictor logistic regression model including continuous variables of weight, mid-upper arm circumference, temperature, pulse rate, and transformed oxygen saturation, combined with dichotomous signs of difficulty breathing, lethargy, and inability to drink or breastfeed. This model predicts overnight hospital admission with an area under the receiver operating characteristic curve of 0.88 (95% CI 0.82 to 0.94). Low- and high-risk thresholds of 5% and 25%, respectively were selected to categorize participants into three triage groups for implementation. Conclusion: A logistic regression model comprised of eight easily understood variables may be useful for triage of children under the age of five based on the probability of need for admission. This model could be used by frontline workers with limited skills in assessing children. External validation is needed before adoption in clinical practice.

Social stigma and cultural beliefs associated with cleft lip and/or palate: parental perceptions of their experience in Kenya

Cleft lip with or without cleft palate (CL/P)—a condition associated with speech, hearing, feeding, and dental problems, as well as anomalies of the bone and soft tissue around the mouth—is a common birth defect around the globe. The prevalence of this condition varies widely across different countries and regions, and is apparently highest among Asians and lowest among Africans. A review of literature reveals that there exists a dearth of information on experiences of parents of children with CL/P and stigma communication, as well as cultural beliefs associated with CL/P in Africa. To fill this gap, we conducted a descriptive qualitative study examining the experiences of parents of children with CL/P, stigma communication, and cultural beliefs associated with CL/P in Kenya. Twenty four in-depth interviews were done involving purposefully sampled parents of children born with CL/P at AIC CURE International Hospital in Nairobi, Kenya. Five overarching themes emerged under the lived experiences of parents of children with CL/P: Emotional experiences; relational experiences; burden of care and concerns; reaction by the public and friends; and source of social support. The stigma messages and beliefs associated with CL/P further exacerbated the stigma. The study revealed that stigma communication associated with CL/P remains a significant source of social and psychological anguish to parents and guardians of children with CL/P. These findings have critical implications for the management of stigma communication associated with CL/P. They point to the need for public awareness campaigns on CL/P to demystify the condition, its causes and treatment. The study shows that raising public awareness of CL/P would go a long way towards addressing the stigma associated with the condition. It underscores the need for open communication and engagement with all stakeholders to manage stigma communication associated with CL/P through culturally appropriate anti-stigma campaigns.

The Impact of COVID-19 on Health Care, Education, and Persons With Disabilities in Kenya

The Impact of COVID-19 on Health Care, Education, and Persons With Disabilities in Kenya

Candida auris Outbreak Control in Critical Care Units in a Tertiary-Care Hospital in Nairobi, Kenya

Background:Candida auris is an emerging pathogen associated with nosocomial outbreaks. During January to May 2019, 11 invasive cases of C. auris were identified in the intensive care unit (ICU) and high-dependency unit (HDU) at a hospital in Nairobi, Kenya. We report on the interventions implemented to control the outbreak. Methods: Intensified infection prevention and control (IPC) interventions were implemented. All patients infected or colonized with C. auris were placed in single-patient rooms with strict contact precautions. Cleaning of the patient care environment was enhanced by instituting a 3-step procedure of cleaning with soap and water, disinfecting with 0.5% chlorine, and rinsing with water. Glo-Germ gel was used to evaluate the cleaning processes, and percentage of missed surfaces was calculated. Hand hygiene training and compliance observations were conducted to enforce adherence to hand hygiene. The IPC team provided training and observational feedback of IPC to staff, patients, and their families. The IPC interventions were guided by screening activities. To monitor ongoing transmission, a biweekly point-prevalence survey (PPS) was performed to screen all previously negative ICU and HDU patients for C. auris. Furthermore, admission and contact screening were added to guide patient placement. Screening was conducted by collecting a composite swab from the bilateral axilla and groin. Samples were incubated in salt dulcitol broth for 5 days at 40°C then subcultured onto Sabouraud dextrose agar. Colony identification was performed using a Vitek 2 system (bioMérieux). Results: In total, 177 patients were placed in single-patient rooms under contact precautions during May–August 2019. We conducted 123 environmental cleaning observations, and the percentage of missed surfaces decreased from 71% (10 of 14) in June to 7% (1 of 16) in August. Hand hygiene compliance among ICU and HDU staff was 79% (204 of 257) in May, 71% (159 of 223) in June, 73% (170 of 233) in July, and 81% (534 of 657) in August. In total, 283 screening swabs from 234 patients were processed during May–August 2019. Overall, 18 of 88 PPS swabs (20%), 13 of 180 admission screening swabs (7%), and 0 of 15 contact screening swabs (0%) were positive for C. auris. The PPS results showed a rapid decrease in colonization: 6 of 14 (43%) in May, 12 of 54 (22%) in June, 9 of 98 (9%) in July, and 1 of 70 (2%) in August. No new C. auris infections were identified from June to October 2019. Conclusions: The control of C. auris in a hospital outbreak requires multimodal interventions, including enhanced IPC interventions, PPS, admission and contact screening for colonization, rigorous monitoring, and team effort.Funding: NoneDisclosures: None

Feasibility of using an Early Warning Score for preterm or low birthweight infants in a low-resource setting: results of a mixed-methods study at a national referral hospital in Kenya

IntroductionFifteen million babies are born prematurely, before 37 weeks gestational age, globally. More than 80% of these are in sub-Saharan Africa and Asia. 35% of all deaths in the first...

Point-Prevalence Surveys of Antibiotic Use at Three Large Public Hospitals in Kenya

Background: Antibiotics are the most prescribed medicines worldwide, accounting for 20%–30% of total drug expenditures in most settings. Antimicrobial stewardship activities can provide guidance for the most appropriate antibiotic use. Objective: In an effort to generate baseline data to guide antimicrobial stewardship recommendations, we conducted point-prevalence surveys at 3 hospitals in Kenya. Methods: Sites included referral hospitals located in Nairobi (2,000 beds), Eldoret (900 beds) and Mombasa (700 beds). [Results are presented in this order.] Hospital administrators, heads of infection prevention and control units, and laboratory department heads were interviewed about ongoing antimicrobial stewardship activities, existing infection prevention and control programs, and microbiology diagnostic capacities. Patient-level data were collected by a clinical or medical officer and a pharmacist. A subset of randomly selected, consenting hospital patients was enrolled, and data were abstracted from their medical records, treatment sheets, and nursing notes using a modified WHO point-prevalence survey form. Results: Overall, 1,071 consenting patients were surveyed from the 3 hospitals (n = 579, n = 263, and n = 229, respectively) of whom &gt;60% were aged &gt;18 years and 53% were female. Overall, 489 of 1,071 of patients (46%) received ≥1 antibiotic, of whom 254 of 489 (52%) received 1 antibiotic, 201 of 489 (41%) received 2 antibiotics, 31 of 489 (6%) received 3 antibiotics, and 3 of 489 (1%) received 4 antibiotics. Antibiotic use was higher among those aged &lt;5 years: 150 of 244 (62%) compared with older individuals (337 of 822, 41%). Amoxicillin/clavulanate was the most commonly used antibiotic (66 of 387, 17%) at the largest hospital (in Nairobi) whereas ceftriaxone was the most common at the other 2 facilities: 57 of 184 (31%) in Eldoret and 55 of 190 (29%) in Mombasa. Metronidazole was the next most commonly prescribed antibiotic (15%–19%). Meropenem was the only carbapenem reported: 22 of 387 patients (6%) in Nairobi, 2 of 190 patients (1%) in Eldoret, and 8 of 184 patients (4%) in Mombasa. Stop dates or review dates were not indicated for 106 of 390 patients (27%) in Nairobi, 75 of 190 patients (40%) in Eldoret, and 113 of 184 patients (72%) in Mombasa receiving antibiotics. Of 761 antibiotic prescriptions, 45% had a least 1 missed dose. Culture and antibiotic susceptibility tests were limited to 50 of 246 patients (20%) in Nairobi, 17 of 124 patients (14%) in Eldoret, and 23 of 119 patients (19%) in Mombasa who received antibiotics. The largest hospital had an administratively recognized antimicrobial stewardship committee. Conclusions: The prevalence of antibiotic use found by our study was 46%, generally lower than the rates reported in 3 similar studies from other African countries, which ranged from 56% to 65%. However, these survey findings indicate that ample opportunities exist for improving antimicrobial stewardship efforts in Kenya considering the high usage of empiric therapy and low microbiologic diagnostic utilization.Funding: NoneDisclosures: None

Prevalence of vitamin D deficiency in exclusively breastfed infants at a tertiary healthcare facility in Nairobi, Kenya.

To determine the prevalence of vitamin D deficiency (VDD) in exclusively breastfed infants at the Aga Khan University Hospital Nairobi, Kenya (AKUHN). The relationships between 25-hydroxyvitamin D; 25OHD, parathyroid hormone (PTH), maternal vitamin D supplementation, and sunlight exposure were also determined. Blood from 98 infants was assayed for 25OHD, calcium, phosphate, and PTH. Socio-demographic and clinical characteristics were analyzed using descriptive statistics and inferential analysis (p < 0.05). The prevalence of VDD (25OHD <12 ng/mL), vitamin D insufficiency (VDI, 25OHD 12-20 ng/mL) and vitamin D sufficiency (VDS, 25OHD >20 ng/mL) was 11.2% (95% CI 8.0%-14.4%), 12.2% (95% CI 8.9%-15.5%), and 76.5% (95% CI 72.3%-80.8%) respectively. There was no difference in the mean age, head circumference, length, or weight of infants in VDD, VDI, and VDS groups. PTH was elevated when 25OHD was <12 ng/mL and normal when 25OHD was between 12-20 ng/mL. 25OHD and PTH were normal in infants whose mothers received vitamin D supplements. Infants who received <30 minutes/day of exposure to sunlight were 5 times more likely to have VDI than infants who received ≥30 minutes/day (p = 0.042). The prevalence of VDD in exclusively breastfed infants at AKUHN is low. The current national policy that recommends exclusive breastfeeding of infants in the first 6 months of life appears to be effective in staving off vitamin D deficiency but those infants with < 30 minutes sunlight exposure may benefit from low dose supplemental vitamin D during times of low sunlight exposure.

INVESTIGATION OF RISPERIDONE; CASE OF SELECTED PATIENTS FROM KENYA

Risperidone is considered as an atypical antipsychotic. It is considered as an effective treatment of psychotic disorders in adults. However, our understanding of its usage among young individuals is limited. In this study, the objective was to identify the safety profile of Risperidone among young children. Methodology wise, the study was conducted among children of less than 5 years old who were treating behavioral problems associated with various childhood disorders. The study was conducted in a hospital in Nairobi, Kenya. Common childhood disorders were diagnosed using the Diagnostic and Statistical Manual (DSM IV) and those associated with disruptive behavioral problems. We used Clinical Global Impression- Severity (CGI-S) and Improvement (CGI-I) scales for symptoms severity and improvement respectively. We took informed consents from parents of the children and initiated Risperidone. The total of 12 patients were included in the study consist of PDD (n=4), PDD plus ADHD (n=2), PDD plus ADHD plus Intellectual disability (n=2), Cerebral Palsy with Epilepsy (n=2) and Global developmental delay (n=2). Baseline and end point CGI scores were 5-6 and 1-2 respectively. Baseline investigations such as lipid profile, fasting blood sugar levels, Electro cardiogram (ECG) were recorded and compared before and after initiation of risperidone. Dose range of risperidone was 0.5-2mg per day. Common side effects were sedation and weight gain in a few patients only. No life-threatening side effects were noted. Our conclusion is that risperidone is well tolerated even in children below 5 years of age over a period of 1 year with improvement in target symptoms.

Staphylococcus aureus bacteremia at a referral medical center in Kenya: A retrospective review of cases from 2010 to 2018.

BackgroundMany studies have shown that Staphylococcus aureus is a leading cause of both community onset and hospital onset bloodstream infections. However, relatively little is known about the occurrence and outcome of S. aureus bacteremia in sub-Saharan Africa. A previous report indicated that S. aureus accounts for 16% of community onset and 6% of hospital onset bloodstream infections at Aga Khan University Hospital Nairobi (AKUHN). Data about the etiology of S. aureus bacteremia in sub-Saharan Africa will help optimize recognition and treatment. This study was performed in order to understand the etiologies and risk factors for S. aureus bacteremia in a sub-Saharan location.Materials and methodsA review of the electronic record of laboratory results from September 2010 through December 2018 identified 201 patients seen at AKUHN with S. aureus bacteremia. The source and/or focus of infection was identified and in-hospital mortality was determined. Cases with bacteremia after three days of hospitalization were considered hospital acquired. Community onset cases were divided into community acquired and health care associated.ResultsMost cases (71%; 143/201) were community onset, but only 41% (83/201) of these cases were community acquired. The most commonly identified foci of infection for community acquired bacteremia were musculoskeletal (25%; 21/83) and skin and soft tissue (24%; 20/83). The majority of health care associated (70%; 40/57) and hospital acquired cases (74%; 43/58) were associated with invasive vascular devices, with peripheral IVs being the most common for hospital acquired and dialysis catheters being the most common for health care associated infections. In-hospital mortality rates were 23% (19/83) for community acquired, 19% (11/57) for health care associated and 33% (19/58) for hospital acquired infections.ConclusionInvasive vascular devices were associated with a substantial portion of cases of S. aureus bacteremia and provide an important target for infection control efforts.

Building focused cardiac ultrasound capacity in a lower middle-income country: A single centre study to assess training impact.

BackgroundIn low- and middle-income countries (LMICs) where echocardiography experts are in short supply, training non-cardiologists to perform Focused Cardiac Ultrasound (FoCUS) could minimise diagnostic delays in time-critical emergencies. Despite advocacy for FoCUS training however, opportunities in LMICs are limited, and the impact of existing curricula uncertain. The aim of this study was to assess the impact of FoCUS training based on the Focus Assessed Transthoracic Echocardiography (FATE) curriculum. Our primary objective was to assess knowledge gain. Secondary objectives were to evaluate novice FoCUS image quality, assess inter-rater agreement between expert and novice FoCUS and identify barriers to the establishment of a FoCUS training programme locally.MethodsThis was a pre-post quasi-experimental study at a tertiary hospital in Nairobi, Kenya. Twelve novices without prior echocardiography training underwent FATE training, and their knowledge and skills were assessed. Pre- and post-test scores were compared using the Wilcoxon signed-rank test to establish whether the median of the difference was different than zero. Inter-rater agreement between expert and novice scans was assessed, with a Cohen's kappa >0.6 indicative of good inter-rater agreement.ResultsKnowledge gain was 37.7%, with a statistically significant difference between pre-and post-test scores (z = 2.934, p = 0.001). Specificity of novice FoCUS was higher than sensitivity, with substantial agreement between novice and expert scans for most FoCUS target conditions. Overall, 65.4% of novice images were of poor quality. Post-workshop supervised practice was limited due to scheduling difficulties.ConclusionsAlthough knowledge gain is high following a brief training in FoCUS, image quality is poor and sensitivity low without adequate supervised practice. Substantial agreement between novice and expert scans occurs even with insufficient practice when the prevalence of pathology is low. Supervised FoCUS practice is challenging to achieve in a real-world setting in LMICs, undermining the effectiveness of training initiatives.

Cervical Dysplasia, Infection, and Phylogeny of Human Papillomavirus in HIV-Infected and HIV-Uninfected Women at a Reproductive Health Clinic in Nairobi, Kenya.

High risk human Papillomavirus (HPV) infections ultimately cause cervical cancer. Human Immunodeficiency Virus (HIV) infected women often present with multiple high-risk HPV infections and are thus at a higher risk of developing cervical cancer. However, information on the circulating high-risk HPV genotypes in Kenya in both HIV-infected and HIV-uninfected women is still scanty. This study is aimed at determining the phylogeny and the HPV genotypes in women with respect to their HIV status and at correlating this with cytology results. This study was carried out among women attending the Reproductive Health Clinic at Kenyatta National Hospital, a referral hospital in Nairobi, Kenya. A cross-sectional study recruited a total of 217 women aged 18 to 50 years. Paired blood and cervical samples were obtained from consenting participants. Blood was used for serological HIV screening while cervical smears were used for cytology followed by HPV DNA extraction, HPV DNA PCR amplification, and phylogenetic analysis. Out of 217 participants, 29 (13.4%) were HIV seropositive, while 68 (31.3%) were positive for HPV DNA. Eight (3.7%) of the participants had abnormal cervical cytology. High-risk HPV 16 was the most prevalent followed by HPV 81, 73, 35, and 52. One participant had cervical cancer, was HIV infected, and had multiple high-risk infections with HPV 26, 35, and 58. HPV 16, 6, and 81 had two variants each. HPV 16 in this study clustered with HPV from Iran and Africa. This study shows the circulation of other HPV 35, 52, 73, 81, 31, 51, 45, 58, and 26 in the Kenyan population that play important roles in cancer etiology but are not included in the HPV vaccine. Data from this study could inform vaccination strategies. Additionally, this data will be useful in future epidemiological studies of HPV in Nairobi as the introduction or development of new variants can be detected.

Types and prevalence of HIV-related opportunistic infections/conditions among HIV-positive patients attending Kenyatta National Hospital in Nairobi, Kenya.

Although antiretroviral therapy (ART) has resulted in significant decrease in opportunistic infections (OIs), OIs continue to cause significant morbidity and mortality among HIV patients. To determine the prevalence and types of HIV/AIDS-related OIs among patients attending Kenyatta National Hospital (KNH) in Nairobi, Kenya. A cross-sectional study was conducted from May to August 2010 among patients ≥19 years. An interviewer-administered questionnaire was used to collect data on socio-demographic factors, HIV and OIs. CD4 data were extracted from clinical records. Most patients (72%) had lived with HIV for ≤ 5 years and 78.8% had an OI. The 3 most common OIs were TB (35%), Herpes Zoster (HZ; 15.4%) and oral thrush (OT; 8%). Years of HIV infection significantly predicted TB (p=0.01). Patients with CD4 ≤ 349 were almost twice as likely to have TB, than those with CD4 ≥500. Type of occupation predicted OT (p=0.04) with skilled workers less likely to have OT. Patients with primary/vocational/technical education were >3 times more likely to have HZ than those with tertiary education. Due to the complex management of HIV and its associated OIs, appropriate implementation of the recommended guidelines for care and prevention among patients at KNH is important.

Factors other than sheer numbers of blood cells in circulation may be responsible for clinical presentations in chronic myeloid leukaemia.

e19527 Background: CML commonly presents with abdominal pain and swelling, and in up to about 50% of cases it is discovered incidentally due to abnormally elevated white blood cell (wbc) counts in circulation. Some present with bleeding tendency, others nusual presentations including hearing and visual loss whose pathogenesis is poorly understood also occur. Priapism presents rarely, attributed to hyperviscosity complicating wbc counts ≥ 250x109/litre. Nonspecific symptoms also present. We wanted to interrogate the link between baseline myeloid elements in circulation, bone marrow blasts, and BCR-ABL values with clinical manifestations. Methods: Patients attending the Glivec International Patient Assistance Clinic at the Nairobi Hospital had records prospectively collected, and analyzed. These included demographic profiles, physical examination, and laboratory values. Absolute, range, median and mean counts for wbcs, absolute neutrophil counts (ANC), platelets, haemoglobin and BCR-ABL values, were tested against each of the clinical presentations. Results: There were 583 patients, males 322 (55.2%) and females 261 (44.8); mean age 39.8 years. Commonest symptom was abdominal swelling in 235 cases (40.3%); 70 (12%) experienced abdominal pain. Priapism occurred in 4 males (1.2%), blindness and deafness in 8 patients (1.4%). Splenomegaly was more common among males than females; [Pearson Chi2 (1) = 5.9545, ( Pr = 0.015)]. Patients aged ≤ 20 years were more likely to be in heart failure, [Pearson Chi2 (3) = 8.8255,( Pr = 0.032)], leg swelling more in those with high platelet counts; [Ranksum test, (p = 0.023)]. Unclear presentation was more common in those with high wbc counts; [Ranksum test, (p = 0.015)]. Total wbc counts and BCR-ABL levels were higher among younger patients; [Kruskal-Wallis test (p = 0.036, and 0.025 respectively)]. Patients with leg swelling had lower BCR-ABL levels; [Ranksum test (p = 0.005)], those in heart failure had significantly higher BCR-ABL levels at baseline compared with the rest; [Ranksum test (p = 0.037)]. Patients with lymphadenopathy were more likely to have lower ANCs; [Ranksum test (p = 0.035)]. Conclusions: Clinical manifestations of CML cannot be explained merely by haematologic values. Complex biologic factors should be interrogated further.

Cytopenia among CML Patients on Imatinib in Kenya: Types, Grades, and Time Course.

Background Imatinib mesylate is the gold standard for the treatment of all phases of Philadelphia-positive chronic myeloid leukemia. Patients on imatinib treatment may develop cytopenia due to drug toxicity. This study aimed to determine the types, grades, and time course of cytopenia in CML patients on imatinib at a Nairobi hospital. Methods This was a cross-sectional descriptive study of adult patients aged ≥18 years followed up at the Glivec International Patient Access Program (GIPAP) clinic from 2007 to 2015. Patients who developed cytopenia within 12 months of initiating imatinib were eligible. Clinical and hematologic data were retrieved from the patients' charts and entered into a study proforma. Measures of central tendency such as mean, median, mode, standard deviation, and variance were used for analysis. Results Sixty three percent (63.6%) of the 94 patients developed a monocytopenia, with anemia seen in 34%, neutropenia in 27.6%, and thrombocytopenia in 8% of the 94 patients. Anemia plus neutropenia was the most common bicytopenia at 12.7%. Pancytopenia was seen in only 5 of the 94 patients. Most of the cytopenia was grades 2 and 3. Anemia was present at baseline while neutropenia and thrombocytopenia developed within 12 months of imatinib initiation. Anemia resolved during the first 12 months of therapy while neutropenia and thrombocytopenia resolved within 24–36 months of treatment. Conclusion Monocytopenia, especially anemia, was the most common type of cytopenia. The cytopenia was predominantly grade 2, developed in majority of the patients within 6 months after imatinib initiation, and had resolved by 24–36 months after imatinib initiation.

Evaluation of non-invasive continuous physiological monitoring devices for neonates in Nairobi, Kenya: a research protocol

IntroductionContinuous physiological monitoring devices are often not available for monitoring high-risk neonates in low-resource settings. Easy-to-use, non-invasive, multiparameter, continuous physiological monitoring devices could be instrumental in providing appropriate care and...