Moving the GoalPosts

Globally 36.7 million people have HIV, and in Kenya it is estimated that 1.5 million are infected. The HCV burden is estimated to be 32 million in sub Saharan Africa with Kenya having a prevalence of less <1%. In Kenya Injection Drug Users [IDU’s] are estimated to be 50,000. There is increased public concern on the rising cases of injection substance users, which has also led to increased HIV prevalence in Mombasa County, which stands at 8.6%. This is above Kenya’s prevalence rate, which is at 6.3%. Lymphopaenias among the HIV and HCV co-infected IDU’s has also not been explored and therefore this study was aimed to address this gap. Through this study significant fibrosis and lymphopaenias among HIV- and HCV-co-infected injection substance users were determined. While HIV promotes acceleration of HCV infections towards fibrotic liver disease, HCV increases immunosuppression in HIV infections, leading to early acquired immunodeficiency syndrome (AIDS) and death in untreated cases. Liver disease related to hepatitis C virus (HCV) and human immunodeficiency virus (HIV) infection may affect the immune status of the injection substance users. Limited data exists on significant fibrosis and lymphopaenia among human immunodeficiency virus and hepatitis C virus co-infected injection drug users. This was a cross-sectional study involving consenting adult (≥18 years) IDUs at Bomu Hospital, Mombasa, Kenya. The study groups were HCV-/HIV- IDUs (n=114); HCV-/HIV+ IDUs (n=73); HCV+/HIV- IDUs (n=19); and HCV+/HIV+ co-infected (n=17). A total of 223 participants were recruited. Socio-demographic and clinical characteristics data were collected using a pre-tested structured participant questionnaire. Consenting participants were serologically screened for the hepatitis C virus and also screened for the human immunodeficiency virus using the national algorithm of testing. Immunological status was tested by the BD FACS Calibur flow cytometer. Immunologic staging was based on the CD4 count, where lymphopaenia was a count of <500 cells/µl. Platelets alongside aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were also determined. The aspartate aminotransferase to platelet ratio index (APRI), fibrosis 4 index (FIB 4) and non-alcoholic fatty liver score (NAFLD) were used to determine significant fibrosis. APRI approached significant difference (P=0.054) across the groups. Age showed significance P 0.001 and gender P<0.0001. The AST levels across the groups are P=0.001. In immunological staging, lymphopaenia was more profound in HIV mono-infected injection drug users (65.8%), HCV/HIV co-infected injection substance users (41.2%), HCV/HIV uninfected (21.1%) and lastly HCV mono-infected injection substance users (15.8%). From the results it can be concluded that HCV/HIV co-infection among IDU’s, is associated with high burden of significant fibrosis and lymphopaenia. Significant fibrosis was more pronounced across groups with HCV mono-infected IDUs leading, while lymphopaenia was most severe in HIV mono-infected IDUs (65.8%). The HCV/HIV co-infected burden of both significant fibrosis and lymphopaenia (41.2%) is progressively high. These findings highlight the profound impact of HIV and HCV on liver disease progression and immune suppression. This emphasises the urgent need for early screening, monitoring and integrated management of co-infected individuals to reduce morbidity and mortality in this vulnerable population.

Brainstem ependymomas (EPNs) are rare and aggressive central nervous system tumors with unique anatomical challenges and poor prognosis. Traditional survival estimates offer limited clinical guidance due to their static nature. This study aimed to investigate the dynamic survival patterns of brainstem EPNs using conditional survival (CS) analysis and to develop a web-based nomogram model for individualized, real-time prognostication. Patients diagnosed with primary brainstem EPNs between 2000 and 2021 were identified from the SEER database. CS analysis was performed to assess changes in survival probability over time. Annual hazard rates were calculated to identify high-risk periods. Prognostic variables were selected using best subset regression (BSR) and least absolute shrinkage and selection operator (LASSO) methods. A CS-based nomogram was constructed using multivariable Cox regression and validated through calibration plots, ROC curves, and decision curve analysis (DCA). A risk stratification system and an interactive web calculator were also developed. A total of 697 patients were included and randomly assigned to training (n = 487) and validation (n = 210) cohorts. CS analysis showed that as patients survive longer after diagnosis, their probability of surviving additional years increases steadily. And six variables (age, sex, race, histology, surgery, and radiotherapy) were identified via the LASSO model for nomogram construction. The CS-nomogram demonstrated good calibration and acceptable discrimination, with 1-, 3-, and 5-year AUCs of 0.626, 0.649, and 0.656 in the training cohort, and 0.688, 0.692, and 0.687 in the validation cohort, respectively. DCA confirmed the clinical utility of the model. A risk classification system effectively stratified patients into high- and low-risk groups with significantly different survival outcomes. A web-based calculator was created to facilitate real-world application. This study presents a novel CS-based nomogram that dynamically predicts survival in patients with brainstem EPNs. By capturing time-dependent survival probabilities and integrating key clinical factors, the model offers a practical tool to support individualized prognosis, patient counseling, and follow-up planning in clinical practice. While it offers individualized prognostic insights, its clinical use requires further external validation.

Mortality among adults admitted to hospital with community acquired pneumonia in resource-limited settings is high. Recent studies conducted in high-income settings have demonstrated beneficial effects of low-dose corticosteroids in reducing mortality in patients with severe community acquired pneumonia. It is unknown whether these findings apply to low-income settings such as sub-Saharan Africa.This pragmatic randomized-controlled open-label trial will determine the effect of adjunctive low-dose corticosteroids in the management of adults admitted to hospital with community acquired pneumonia on mortality 30-days post-randomization. We will enroll and randomize 2180 patients admitted with a diagnosis of community acquired pneumonia into two arms: the control and intervention arm. Those in the control arm will receive standard care for the treatment of community acquired pneumonia i.e., combination therapy with a beta-lactam and macrolide antibiotic. Those in the intervention arm will receive up to 10-days treatment with low-dose oral corticosteroids in addition to standard care. All participants will be followed up to 30- days post randomization and their final status recorded (alive or dead). If adjunctive low-dose oral corticosteroids are found to be beneficial, this easily scalable intervention would significantly reduce the currently high mortality associated with community acquired pneumonia.Pan-African Clinical Trials Registry: PACTR202111481740832; ISRCTRN registry: ISRCTN36138594.

Food insecurity disproportionately affects smallholder farming households and within them women, who bear primary caregiving responsibilities and contend with time and resource constraints that heighten their vulnerability to adverse nutrition-related health outcomes. This study cross-sectionally investigates the association between food production practices, household consumer behaviour, and the experience of food insecurity with women's waist-hip ratio (WHR), a key indicator of abdominal obesity, in a coastal community in Kenya. In total, 394 households were randomly selected from a list of farming households in Kaloleni and Rabai sub-counties of Kilifi. Trained enumerators administered questionnaires to adult female family members who play a pivotal role in household management. Household dietary diversity scores (HDDS) were computed from 16 food groups consumed in the 7 days preceding the survey. Waist-hip measurements focused on these females, representing vulnerable populations. Pathway-based regression models were constructed using STATA version 13 (p < 0.05). Most households practised mixed farming (59.9%) and monocropping (73.2%) and most female respondents were widowed (75.1%) with limited education (73.1% had no formal education) and over 20 years of farming experience. Food insecurity was prevalent, affecting 80.7% of households. Limited dietary diversity was noted with an average HDDS of 9. The most commonly consumed foods were cereals, spices, condiments and beverages, while meat, eggs and fruits were infrequently eaten. An inverse association was observed between HDDS and WHR (standardised regression coefficient = -0.1328; p = 0.026) but while food insecurity was inversely associated with both HDD and WHR, these associations did not reach statistical significance (HDDS-standardised regression coefficient -0.0294; p = 0.592: WHR-standardised regression coefficient -0.0155; p = 0.791). Existing research has primarily addressed the undernutrition and hunger-related impacts of food insecurity. The findings underscore the need to better understand the complex interplay between food insecurity and nutritional health, including markers of adiposity, to effectively promote health.

BackgroundTungiasis is a highly neglected tropical skin disease caused by the sand flea, Tunga penetrans, the female of which burrows into the skin, causing pain and itching. The disease occurs throughout South America and sub-Saharan Africa but there are few systematic data on national disease burdens. The tungiasis research community is keen to develop survey methods to fill this gap. Here we used a school-based, thorough examination method to determine the prevalence and risk factors for tungiasis in Kenya.MethodsWe conducted the first nationally representative survey of tungiasis, including nine counties covering the major ecological zones of Kenya. A stratified multistage random sampling was used to select 22 primary schools from each of the nine counties and to select up to 114 pupils aged 8 to 14 years in each school. Pupils were examined thoroughly for tungiasis. Two surveys were conducted, the first between May and July 2021 and the second between October 2021 and April 2023 when pupils were also interviewed for risk factors. Mixed effect logistic regression models were used to test associations of independent variables with tungiasis using the school as a random effect.ResultsThe overall prevalence of tungiasis in the first survey was 1.35% [95% confidence interval (CI): 1.15–1.59%], and 0.89% in the second survey. The prevalence ranged from 0.08% (95% CI: 0.01–0.59%) in Taita Taveta county to 3.24% (95% CI: 2.35–4.44%) in Kajiado county. Tungiasis infection was associated with county of residence, male sex [adjusted odds ratio (aOR) = 2.01, 95% CI: 1.52–2.67], and lower age (aOR = 0.81, 95% CI: 0.75–0.88). For the first time we demonstrate an association with attending public schools rather than private schools (aOR = 5.62, 95% CI: 1.20–26.22) and lower socioeconomic status (aOR = 0.10, 95% CI: 0.03–0.33). Using a rapid screening method of the top of feet only, would have missed 62.9% of all cases, 78.9% of mild cases and 20.0% of severe cases.ConclusionsTungiasis is widely but heterogeneously distributed across Kenya. School-based surveys offer an efficient strategy for mapping tungiasis distribution.Graphical

We sought to estimate SARS-CoV-2 antibody seroprevalence within representative samples of the Kenyan population during the third year of the COVID-19 pandemic and the second year of COVID-19 vaccine use. We conducted cross-sectional serosurveys among randomly selected, age-stratified samples of Health and Demographic Surveillance System (HDSS) residents in Kilifi and Nairobi. Anti-spike (anti-S) immunoglobulin G (IgG) serostatus was measured using a validated in-house ELISA and antibody concentrations estimated with reference to the WHO International Standard for anti-SARS-CoV-2 immunoglobulin. HDSS residents were sampled in February-June 2022 (Kilifi HDSS N= 852; Nairobi Urban HDSS N= 851) and in August-December 2022 (N= 850 for both sites). Population-weighted coverage for ≥1 doses of COVID-19 vaccine were 11.1% (9.1-13.2%) among Kilifi HDSS residents by November 2022 and 34.2% (30.7-37.6%) among Nairobi Urban HDSS residents by December 2022. Population-weighted anti-S IgG seroprevalence among Kilifi HDSS residents increased from 69.1% (65.8-72.3%) by May 2022 to 77.4% (74.4-80.2%) by November 2022. Within the Nairobi Urban HDSS, seroprevalence by June 2022 was 88.5% (86.1-90.6%), comparable with seroprevalence by December 2022 (92.2%; 90.2-93.9%). For both surveys, seroprevalence was significantly lower among Kilifi HDSS residents than among Nairobi Urban HDSS residents, as were antibody concentrations (p< 0.001). More than 70% of Kilifi residents and 90% of Nairobi residents were seropositive for anti-S IgG by the end of 2022. There is a potential immunity gap in rural Kenya; implementation of interventions to improve COVID-19 vaccine uptake among sub-groups at increased risk of severe COVID-19 in rural settings is recommended.

The aim of this study was to characterize an unusual case of spontaneous, community-acquired Escherichia coli meningitis in an adult presenting to a general hospital in Kenya, where initial clinical recovery was followed by reinfection with an MDR, hospital-acquired strain. An adult presented to a hospital in Kenya with meningitis symptoms. E. coli was cultured from CSF. Treatment with ceftriaxone was successful; however, the patient relapsed a few days later. E. coli was cultured from CSF and blood during the reinfection episode, though the patient died during admission. We sequenced the isolates using Illumina MiSeq and performed antimicrobial susceptibility testing, fitness and virulence assays on the bacteria. The E. coli isolates from the two episodes were found to be distinct: the initial strain was ST88, serotype O8 H17 while the subsequent episode was caused by an ST167, serotype O101 H5 MDR strain. The ST88 strain was susceptible to all drugs except ampicillin and amoxicillin/clavulanate while the ST167 strain was MDR, including to all β-lactam drugs due to the presence of the carbapenemase gene bla NDM-5. The hospital-acquired ST167 strain was also resistant to newer drugs such as cefiderocol and eravacycline, which are currently not available locally, and had overall lower fitness and virulence in vitro compared with the initial infecting strain. Though less fit and virulent in vitro, the MDR strain was fatal, suggesting that host factors, rather than bacterial virulence, may have been of greater importance in this patient's outcome.

Background: To prevent poor long-term outcomes (deaths and readmissions) the integrated global action plan for pneumonia and diarrhoea recommends under the 'Treat' element of Protect, Prevent and Treat interventions the importance of continued feeding but gives no specific recommendations for nutritional support. Early nutritional support has been practiced in a wide variety of critically ill patients to provide vital cell substrates, antioxidants, vitamins, and minerals essential for normal cell function and decreasing hypermetabolism. We hypothesise that the excess post-discharge mortality associated with pneumonia may relate to the catabolic response and muscle wasting induced by severe infection and inadequacy of the diet to aid recovery. We suggest that providing additional energy-rich, protein, fat and micronutrient ready-to-use therapeutic feeds (RUTF) to help meet additional nutritional requirements may improve outcome. Methods: COAST-Nutrition is an open, multicentre, Phase II randomised controlled trial in children aged 6 months to 12 years hospitalised with suspected severe pneumonia (and hypoxaemia, SpO 2 <92%) to establish whether supplementary feeds with RUTF given in addition to usual diet for 56-days (experimental) improves outcomes at 90-days compared to usual diet alone (control). Primary endpoint is change in mid-upper arm circumference (MUAC) at 90 days and/or as a composite with 90-day mortality. Secondary outcomes include anthropometric status, mortality, readmission at days 28 and 180. The trial will be conducted in four sites in two countries (Uganda and Kenya) enrolling 840 children followed up to 180 days. Ancillary studies include cost-economic analysis, molecular characterisation of bacterial and viral pathogens, evaluation of putative biomarkers of pneumonia, assessment of muscle and fat mass and host genetic studies. Discussion: This study is the first step in providing an option for nutritional support following severe pneumonia and will help in the design of a large Phase III trial. Registration: ISRCTN10829073 (6 th June 2018) PACTR202106635355751 (2 nd June 2021).

ABSTRACTBackgroundFew studies have assessed the seroprevalence of antibodies against SARS-CoV-2 among Health Care Workers (HCWs) in Africa. We report findings from a survey among HCWs in three counties in Kenya.MethodsWe recruited 684 HCWs from Kilifi (rural), Busia (rural) and Nairobi (urban) counties. The serosurvey was conducted between 30thJuly 2020 and 4thDecember 2020. We tested for IgG antibodies to SARS-CoV-2 spike protein using ELISA. Assay sensitivity and specificity were 93% (95% CI 88-96%) and 99% (95% CI 98-99.5%), respectively. We adjusted prevalence estimates using Bayesian modeling to account for assay performance.ResultsCrude overall seroprevalence was 19.7% (135/684). After adjustment for assay performance seroprevalence was 20.8% (95% CI 17.5-24.4%). Seroprevalence varied significantly (p&lt;0.001) by site: 43.8% (CI 35.8-52.2%) in Nairobi, 12.6% (CI 8.8-17.1%) in Busia and 11.5% (CI 7.2-17.6%) in Kilifi. In a multivariable model controlling for age, sex and site, professional cadre was not associated with differences in seroprevalence.ConclusionThese initial data demonstrate a high seroprevalence of antibodies to SARS-CoV-2 among HCWs in Kenya. There was significant variation in seroprevalence by region, but not by cadre.