Kenya Land Alliance

Abstract Rationale: We explored the impact of a multicenter, randomized controlled trial (RCT) on clinical care in five hospitals in Sub-Saharan Africa from the perspective of study staff and hospital clinicians. Describing these impacts will facilitate improved research design and increased equity in clinical research. Methods: We conducted a qualitative analysis of the Building Respiratory Support in East Africa Through High-Flow versus Standard Flow Oxygen Evaluation (BREATHE) trial, an RCT comparing high-flow oxygen with usual care across four public and one faith-based hospital in Kenya, Malawi, and Rwanda (ClinicalTrials.gov, NCT05754034). Guided by the Consolidated Framework for Implementation Research (CFIR), we performed a rapid inductive analysis of 50 staff meetings and 9 clinician interviews to identify trial-related facilitators of and barriers to quality care. Results: We identified several facilitators of improved clinical practice from the perspective of trial staff and clinicians. Patients in both arms received increased monitoring, diagnostics (lung ultrasound), and emotional support from study staff, a significant benefit in settings with low clinician-to-patient ratios. Trial-related monitoring helped identify existing clinical gaps. Leadership at some sites were eager to incorporate aspects of trial protocols, such as oxygen titration guidelines, into hospital-wide practice. Trial staff conducted educational sessions for clinical staff, which were well-attended and appreciated. Many felt the trial fostered a culture of academic inquiry and cross-site networking for future clinical trials, for which planning is already underway. One clinician suggested further locally-driven research “would be very good because we can use the effective data which is local..the real population and the real conditions.” Negative impacts (barriers) were also identified. Early in enrollment, adapting to trial activities was burdensome for busy clinicians. Patients were worried about randomization and parallel care pathways. Later, clinicians expressed concern about a vacuum of knowledge and resources that may occur when the trial concludes-"If they left them [HFO devices] without training they cannot benefit us.” These are preliminary results pending further interviews with clinical staff, patients, and caregivers. Conclusion: CFIR-guided analysis of a multicenter RCT in sub-Saharan Africa uncovered impacts of RCT implementation at participating hospitals including increased monitoring and support for patients, identification of care gaps, education for clinical staff, and fostering a culture of inquiry, but also extra clinician burden, patient concerns around randomization, and worries about reduced resources after trial completion. Future researchers should consider these factors during study design and implementation to account for the impact of research on clinical practice.

Abstract Rationale: Although most critical care and pulmonary research is conducted in high-income countries, the barriers and facilitators of randomized controlled trials (RCTs) in resource-constrained settings are poorly characterized. Understanding RCT implementation in these settings can facilitate future studies and ultimately improve equity and generalizability of research. Methods: We analyzed qualitative data from Building Respiratory support in East Africa Through High flow versus standard flow oxygen Evaluation (BREATHE), an RCT comparing clinical outcomes of high-flow oxygen therapy to standard care at resource-constrained, predominantly RCT-inexperienced hospitals in Rwanda, Malawi, and Kenya (ClinicalTrials.govNCT05754034). Employing the Consolidated Framework for Implementation Research (CFIR) and Proctor's Implementation Outcomes Framework, we conducted rapid CFIR-based inductive analysis on 34 weekly staff meetings and 8 clinician interviews to identify barriers, facilitators, and other features of trial implementation. Results: Trial acceptance was facilitated by preexisting trust in local leaders, attentiveness of research assistants, appreciation of increased patient monitoring, education sessions for clinical and study staff, and perception of intervention benefit. Clinicians appreciated receiving the results of diagnostic testing performed by the study, and hospital leadership at one site requested study protocols to adapt for clinical care. Concerns about harm for the intervention were rare. Consent processes were adapted to cultural preferences for extensive family participation, particularly at two sites. Consent was facilitated by language and/or tribe concordance between patient and study staff at three sites. Suspicion of the study intervention occasionally arose surrounding the formal consent process and the switch from hospital device to study device. A government-employed doctors’ strike halted enrollment at one (government) site when few patients were presenting for care, while another (non-government) site was overwhelmed by an influx of critically ill patients, making study enrollment difficult. A public health emergency halted enrollment at two sites when study devices were needed for patients with Marburg virus. Infrastructure challenges included delays in replacing and repairing equipment, as well as adaptations around variable internet connectivity. Both oxygen and electricity interruptions occurred at some sites. Regulatory, data-sharing, and patient protection requirements were substantial, varied by country and over time, and required significant resources to anticipate and manage. These findings are preliminary, pending analysis of additional meetings and interviews. Conclusions: CFIR-guided analysis of BREATHE revealed unique barriers and facilitators to implementation relating to acceptability, environment, consent, communication, critical incidents, infrastructure, and regulatory oversight. These insights could streamline future RCTs in East Africa and other resource-constrained contexts.

There is a knowledge gap on the epidemiology of inflammatory bowel disease in Africa. To begin to address this issue, we formed a case reporting network of practitioners with an interest in inflammatory bowel disease across sub-Saharan Africa. Here, we report a series of 175 cases from 12 countries over 2 years.

Bilateral spontaneous lumbar colocutaneous fistulae are rare. They are associated with high costs of care, morbidity, and mortality. We present the case of a 50- year-old male patient who presented with a 10-year history of two low-output spontaneous colocutaneous fistulae from both the left and right lower lumbar regions with no identifiable risk factors. He was managed operatively with segmental left colon resection and a temporary loop ileostomy with uneventful recovery after reversal of the ileostomy 2 months later. Whether the etiology of the fistulae is clinically apparent or not, the management should follow commonly known principles. This report highlights a case of bilateral lumbar region spontaneous colocutaneous fistulae of unknown cause that was managed operatively with satisfactory short-term outcomes.

Introduction Hand injuries are a recognized occupational hazard from the use of chaff cutters. With increasing mechanization of farming in our region, the burden of hand injuries is poised to increase. Methods We conducted a descriptive study of 47 patients presenting with chaff cutter hand injuries at our center in one year. Results They were predominantly male (98%) and the majority (70%) were aged between 21 and 40 years. The majority of patients who had not resumed work were those with severe injuries and those who had had an amputation. There was a positive correlation between age category and severity of injury. Discussion Chaff cutter injuries contribute considerably to hand amputations at our center. The majority of patients with severe injuries and those undergoing amputations do not return to gainful activities one year after sustaining the injury, suggesting increased dependency. Further research is paramount to identify safety features of chaff cutters in this region.

We introduce the iDARE methodology and present the results of iDARE implementation in Uganda, Kenya, and Tanzania during the coronavirus disease (COVID-19) pandemic. IDARE METHODOLOGY: iDARE drives locally led solutions that address barriers to achieving improved health outcomes. WI-HER supported the governments of Uganda, Kenya, and Tanzania, to design and implement solutions to improve (1) HIV health outcomes, (2) gender-based violence identification and response, and (3) mass drug administration coverage, respectively. In Uganda, the iDARE team at Nagongera Health Center IV increased viral load suppression (VLS) among actively enrolled men in care from 65% to 95% and increased VLS among actively enrolled children in care from 60% to 96% in 12 months. In 11 months, the Mulanda Health Center IV iDARE team increased VLS among actively enrolled men in care from 85% to 93% and actively enrolled children in care from 73% to 96%. In Kenya, 8 facility iDARE teams improved identification, management, and response for gender-based violence survivors by a monthly average of 642% in 10 months. Additionally, the identification, management, and response for male survivors of gender-based violence increased from an average of 8 to 188 men per month and from an average of 81 to 364 women per month. In Tanzania, the government applied iDARE to improve mass drug administration (MDA) access and uptake among school-age children. Eighteen percent of the children (equal male and female) had missed or refused treatment during school-based MDA. After 1 month of application of iDARE, the 4 schools achieved 99% MDA uptake among registered children (enrolled and nonenrolled). Due to the various lockdowns, restrictions, and safety implications during the COVID-19 pandemic, iDARE was used to rapidly adjust from planned in-person to sometimes virtual engagements. Despite these challenges, iDARE demonstrated improvements in Uganda, Kenya, and Tanzania.

Autonomous replication and segregation of mitochondrial DNA (mtDNA) creates the potential for evolutionary conflict driven by emergence of haplotypes under positive selection for ‘selfish’ traits, such as replicative advantage. However, few cases of this phenomenon arising within natural populations have been described. Here, we survey the frequency of mtDNA horizontal transfer within the canine transmissible venereal tumour (CTVT), a contagious cancer clone that occasionally acquires mtDNA from its hosts. Remarkably, one canine mtDNA haplotype, A1d1a, has repeatedly and recently colonised CTVT cells, recurrently replacing incumbent CTVT haplotypes. An A1d1a control region polymorphism predicted to influence transcription is fixed in the products of an A1d1a recombination event and occurs somatically on other CTVT mtDNA backgrounds. We present a model whereby ‘selfish’ positive selection acting on a regulatory variant drives repeated fixation of A1d1a within CTVT cells.

Objective:Antibiotics are essential with inappropriate use leading to antimicrobial resistance (AMR). Currently, little is known about antibiotic use among hospitals in Kenya, which is essential to tackle as part of the recent national action plan addressing rising AMR rates. Consequently, the objective was to overcome this gap in a leading referral hospital in Kenya. The findings will subsequently be used to develop quality improvement programs for this and other hospitals in Kenya.Methods:This was a point prevalence survey. Data on antibiotic use were abstracted from patient medical records by a pharmacy team.Findings:The prevalence of antibiotic prescribing was 54.7%, highest in the intensive care unit and isolation wards. Most antibiotics were for treatment (75.4%) rather than prophylaxis (29.0%). The majority of patients on surgical prophylaxis were on prolonged duration (>1 day), with only 9.6% on a single dose as per current guidelines. Penicillins (46.9%) followed by cephalosporins (44.7%) were the most prescribed antibiotic classes. The indication for antibiotic use was documented in only 37.3% of encounters. Generic prescribing was 62.5% and empiric prescribing was seen in 82.6% of encounters. Guideline compliance was 45.8%.Conclusion:Several areas for improvement were identified including addressing prolonged duration for prophylaxis, extensive prescribing of broad-spectrum antibiotics, high rates of empiric prescribing, and lack of documenting the indication for antimicrobials. Initiatives are ongoing to address this with pharmacists playing a key role.

Purpose: Cataract is the leading cause of blindness in the world, and is particularly common in low-income countries. Cataract is asserted to increase poverty through reduced productivity; however there is a lack of empirical data supporting this claim. The aim of this study was to examine the relationship between visual impairment from cataract with time-use in adults (aged ≥ 50 years) in Kenya, Bangladesh, and The Philippines. Methods: A population-based case-control study was conducted in three countries. Detailed time-use data were collected through interview from 139, 216 and 238 cases with visually impairing cataract and 124, 280 and 163 controls with normal vision in Kenya, Bangladesh and Philippines, respectively during 2005–2006. Results: Cases were substantially less likely than controls to participate in productive activities, including paid work and non-market activities (odds ratio [OR] across three countries is 0.2 95% confidence interval (CI): 0.1–0.3) and in leisure outside of the household (OR 0.7, 95% CI: 0.5, 0.9). Among cases, those with more severe visual impairment spent significantly less time on productive activities and leisure outside of the home, and more time on “no particular activity” (Kenya and Bangladesh) or leisure in the home (The Philippines). Cases were substantially more likely to require assistance in any activity than controls in Kenya (OR 9.8, 95% CI: 3.3, 29.8), Bangladesh (OR 8.6, 95% CI: 5.1–14.4) and the Philippines (OR 2.7, 95% CI: 1.4–5.1). Conclusions: Cataract visual impairment restricts engagement in productive and leisure activities in this population of older adults in three different low income settings.

The prevalence of Helicobacter pylori infection was studied in 138 patients with dyspepsia in a hospital in Nakuru, Kenya, and in 138 asymptomatic sex- and age-matched controls from the same population. Anti–H. pylori immunoglobulin (Ig) G was more prevalent in dyspeptic than asymptomatic persons (71% vs. 51%), particularly those <30 years old (71% vs. 38%). H. pylori seropositivity was associated with dyspepsia after adjusting for age, sex, and residence (urban or rural). Among adults, the association between H. pylori infection and dyspepsia remained after adjusting for the above factors and for educational attainment, family size, and manual occupation. H. pylori infection in asymptomatic residents of Nakuru, Kenya, was more prevalent in older persons, with a rate of 68%, than in those 31–40 years of age. However, young persons with dyspepsia had an unexpectedly high prevalence of H. pylori infection. H. pylori test-and-treat strategy should be considered in Kenyan patients with dyspepsia, particularly in persons <30 years of age.