Risk Factors for Inadequate TB Case Finding in Rural Western Kenya: A Comparison of Actively and Passively Identified TB Patients

Background

The findings of a prevalence survey conducted in western Kenya, in a population with 14.9% HIV prevalence suggested inadequate case finding. We found a high burden of infectious and largely undiagnosed pulmonary tuberculosis (PTB), that a quarter of the prevalent cases had not yet sought care, and a low case detection rate.

Objective and methods

We aimed to identify factors associated with inadequate case finding among adults with PTB in this population by comparing characteristics of 194 PTB patients diagnosed in a health facility after self-report, i.e., through passive case detection, with 88 patients identified through active case detection during the prevalence survey. We examined associations between method of case detection and patient characteristics, including HIV-status, socio-demographic variables and disease severity in univariable and multivariable logistic regression analyses.

Findings

HIV-infection was associated with faster passive case detection in univariable analysis (crude OR 3.5, 95% confidence interval (CI) 2.0–5.9), but in multivariable logistic regression this was largely explained by the presence of cough, illness and clinically diagnosed smear-negative TB (adjusted OR (aOR) HIV 1.8, 95% CI 0.85–3.7). Among the HIV-uninfected passive case detection was less successful in older patients aOR 0.76, 95%CI 0.60–0.97 per 10 years increase), and women (aOR 0.27, 95%CI 0.10–0.73). Reported current or past alcohol use reduced passive case detection in both groups (0.42, 95% CI 0.23–0.79). Among smear-positive patients median durations of cough were 4.0 and 6.9 months in HIV-infected and uninfected patients, respectively.

Conclusion

HIV-uninfected patients with infectious TB who were older, female, relatively less ill, or had a cough of a shorter duration were less likely found through passive case detection. In addition to intensified case finding in HIV-infected persons, increasing the suspicion of TB among HIV-uninfected women and the elderly are needed to improve TB case detection in Kenya.     

The Sero-epidemiology of Coxiella burnetii in Humans and Cattle,Western Kenya: Evidence from a Cross-Sectional Study

Evidence suggests that the intracellular bacterial pathogen Coxiella burnetii (which causes Q fever) is widespread, with a near global distribution. While there has been increasing attention to Q fever epidemiology in high-income settings, a recent systematic review highlighted significant gaps in our understanding of the prevalence, spatial distribution and risk factors for Q fever infection across Africa. This research aimed to provide a One Health assessment of Q fever epidemiology in parts of Western and Nyanza Provinces, Western Kenya, in cattle and humans. A cross-sectional survey was conducted: serum samples from 2049 humans and 955 cattle in 416 homesteads were analysed for C. burnetii antibodies. Questionnaires covering demographic, socio-economic and husbandry information were also administered. These data were linked to environmental datasets based on geographical locations (e.g., land cover). Correlation and spatial-cross correlation analyses were applied to assess the potential link between cattle and human seroprevalence. Multilevel regression analysis was used to assess the relationships between a range of socio-economic, demographic and environmental factors and sero-positivity in both humans and animals. The overall sero-prevalence of C. burnetii was 2.5% in humans and 10.5% in cattle, but we found no evidence of correlation between cattle and human seroprevalence either within households, or when incorporating spatial proximity to other households in the survey. Multilevel modelling indicated the importance of several factors for exposure to the organism. Cattle obtained from market (as opposed to those bred in their homestead) and those residing in areas with lower precipitation levels had the highest sero-prevalence. For humans, the youngest age group had the highest odds of seropositivity, variations were observed between ethnic groups, and frequent livestock contact (specifically grazing and dealing with abortion material) was also a risk factor. These results illustrate endemicity of C. burnetii in western Kenya, although prevalence is relatively low. The analysis indicates that while environmental factors may play a role in cattle exposure patterns, human exposure patterns are likely to be driven more strongly by livestock contacts. The implication of livestock markets in cattle exposure risks suggests these may be a suitable target for interventions.     

Geohelminth Infections among Pregnant Women in Rural Western Kenya; a Cross-Sectional Study

Background

Geohelminth infections are common in rural western Kenya, but risk factors and effects among pregnant women are not clear.

Methodology

During a community-based cross-sectional survey, pregnant women were interviewed and asked to provide a blood sample and a single fecal sample. Hemoglobin was measured and a blood slide examined for malaria. Geohelminth infections were identified using the concentration and Kato-Katz method.

Results

Among 390 participants who provided a stool sample, 76.2% were infected with at least one geohelminth: 52.3% with Ascaris lumbricoides, 39.5% with hookworm, and 29.0% with Trichuris trichiura. Infection with at least one geohelminth species was associated with the use of an unprotected water source (adjusted odds ratio [AOR] 1.8, 95% confidence interval [CI] 1.1–3.0) and the lack of treatment of drinking water (AOR 1.8, 95% CI 1.1–3.1). Geohelminth infections were not associated with clinical symptoms, or low body mass index. A hookworm infection was associated with a lower mid upper arm circumference (adjusted mean decrease 0.7 cm, 95% CI 0.3–1.2 cm). Hookworm infections with an egg count ≥1000/gram feces (11 women) were associated with lower hemoglobin (adjusted mean decrease 1.5 g/dl, 95% CI 0.3–2.7). Among gravidae 2 and 3, women with A. lumbricoides were less likely to have malaria parasitemia (OR 0.4, 95% CI 0.2–0.8) compared to women without A. lumbricoides, unlike other gravidity groups.

Conclusion

Geohelminth infections are common in this pregnant population; however, there were few observed detrimental effects. Routine provision of antihelminth treatment during an antenatal clinic visit is recommended, but in this area an evaluation of the impact on pregnancy, malaria, and birth outcome is useful.     

An Imported Case of Echinococcosis of the Liver in a Korean Who Traveled to Western and Central Europe

Echinococcus granulosus, an intestinal tapeworm of dogs and other canids, infects humans in its larval stage and causes human echinococcosis or hydatid disease. In the Republic of Korea, 31 parasite-proven human echinococcosis cases have been reported, most of which were imported from the Middle East. We recently examined a 61-year-old Korean man who had a large cystic mass in his liver. ELISA was negative for tissue parasitic infections, including echinococcosis, cysticercosis, paragonimiasis, and sparganosis. The patient underwent surgery to remove the cyst, and the resected cyst was processed histopathologically for microscopic examinations. In sectioned cyst tissue, necrotizing protoscolices with disintegrated hooklets of E. granulosus were found. In some areas, only freed, fragmented hooklets were detected. The patient had traveled to western and central Europe in 1996, and had no other history of overseas travel. We report our patient as a hepatic echinococcosis case which was probably imported from Europe.     

一例母及其亲子DNA指纹与血清蛋白、酯酶遗传的研究

采用ＤＮＡ指纹分析和聚丙烯酰胺凝胶电泳法,对一例与公驴交配生育了后代的母后代进行了亲缘鉴定和血清蛋白、酯酶遗传的分析。结果可以认定其亲子关系并证实母骡生育的事实。虽然本例母的后代在Ｐｒ、Ａｌ、Ｐａ和Ｈｂ、Ｅｓ等基因座位上的基因表达倾向于驴,但其外貌仍明显地带有种间杂种的特征。因此,尚不能简单地认为其已“回归”为纯种的驴。     

Dragonfly Assemblages in Arid Tropical Environments: A Case Study from Western Namibia

Dragonflies have been proposed as indicators for the ecosystem health of freshwater wetlands. For their useful functioning as indicators it is, however, necessary to identify species compositions in specific habitats and species-habitat associations, particularly in the tropics, where such knowledge is still weak. We examined the dragonfly species composition of 133 localities in the arid environment of western Namibia. An analysis of nestedness indicated that distinct, and predictable patterns of species associations can be expected. Discriminant analyses revealed that most of the nine habitat types separated by structural and hydrological parameters are well discriminated by their dragonfly assemblages. Spring brooks in particular host a specific assemblage, which is threatened due to the habitat restriction of several species, as well as by recent habitat loss and degradation. Using a hierarchical method of several criteria we demonstrated the selection of a set of potential indicator species from the species set, most of these being useful indicators for spring brook assemblages. The conservation status of certain habitats and species is discussed. We propose that dragonflies will have a high indicator potential for threatened freshwater wetlands in such areas and may also serve as an indication of the sustainable use of water resources including evaluating measures to rehabilitate environments.     

Past Climate Change and Plant Evolution in Western North America: A Case Study in Rosaceae

Species in the ivesioid clade of Potentilla (Rosaceae) are endemic to western North America, an area that underwent widespread aridification during the global temperature decrease following the Mid-Miocene Climatic Optimum. Several morphological features interpreted as adaptations to drought are found in the clade, and many species occupy extremely dry habitats. Recent phylogenetic analyses have shown that the sister group of this clade is Potentilla section Rivales, a group with distinct moist habitat preferences. This has led to the hypothesis that the ivesioids (genera Ivesia, Horkelia and Horkeliella) diversified in response to the late Tertiary aridification of western North America. We used phyloclimatic modeling and a fossil-calibrated dated phylogeny of the family Rosaceae to investigate the evolution of the ivesioid clade. We have combined occurrence- and climate data from extant species, and used ancestral state reconstruction to model past climate preferences. These models have been projected into paleo-climatic scenarios in order to identify areas where the ivesioids may have occurred. Our analysis suggests a split between the ivesioids and Potentilla sect. Rivales around Late Oligocene/Early Miocene (∼23 million years ago, Ma), and that the ivesioids then diversified at a time when summer drought started to appear in the region. The clade is inferred to have originated on the western slopes of the Rocky Mountains from where a westward range expansion to the Sierra Nevada and the coast of California took place between ∼12-2 Ma. Our results support the idea that climatic changes in southwestern North America have played an important role in the evolution of the local flora, by means of in situ adaptation followed by diversification.     

Seasonal Effects on Great Ape Health: A Case Study of Wild Chimpanzees and Western Gorillas

Among factors affecting animal health, environmental influences may directly or indirectly impact host nutritional condition, fecundity, and their degree of parasitism. Our closest relatives, the great apes, are all endangered and particularly sensitive to infectious diseases. Both chimpanzees and western gorillas experience large seasonal variations in fruit availability but only western gorillas accordingly show large changes in their degree of frugivory. The aim of this study is to investigate and compare factors affecting health (through records of clinical signs, urine, and faecal samples) of habituated wild ape populations: a community (N = 46 individuals) of chimpanzees (Pan troglodytes) in Kanyawara, Kibale National Park (Uganda), and a western gorilla (G. gorilla) group (N = 13) in Bai Hokou in the Dzanga-Ndoki National Park (Central African Republic). Ape health monitoring was carried out in the wet and dry seasons (chimpanzees: July–December 2006; gorillas: April–July 2008 and December 2008–February 2009). Compared to chimpanzees, western gorillas were shown to have marginally greater parasite diversity, higher prevalence and intensity of both parasite and urine infections, and lower occurrence of diarrhea and wounds. Parasite infections (prevalence and load), but not abnormal urine parameters, were significantly higher during the dry season of the study period for western gorillas, who thus appeared more affected by the large temporal changes in the environment in comparison to chimpanzees. Infant gorillas were the most susceptible among all the age/sex classes (of both apes) having much more intense infections and urine blood concentrations, again during the dry season. Long term studies are needed to confirm the influence of seasonal factors on health and parasitism of these great apes. However, this study suggest climate change and forest fragmentation leading to potentially larger seasonal fluctuations of the environment may affect patterns of ape parasitism and further exacerbate health impacts on great ape populations that live in highly seasonal habitats.     

Biodiversity and Ecosystem Multi-Functionality: Observed Relationships in Smallholder Fallows in Western Kenya

Recent studies indicate that species richness can enhance the ability of plant assemblages to support multiple ecosystem functions. To understand how and when ecosystem services depend on biodiversity, it is valuable to expand beyond experimental grasslands. We examined whether plant diversity improves the capacity of agroecosystems to sustain multiple ecosystem services—production of wood and forage, and two elements of soil formation—in two types of smallholder fallows in western Kenya. In 18 grazed and 21 improved fallows, we estimated biomass and quantified soil organic carbon, soil base cations, sand content, and soil infiltration capacity. For four ecosystem functions (wood biomass, forage biomass, soil base cations, steady infiltration rates) linked to the focal ecosystem services, we quantified ecosystem service multi-functionality as (1) the proportion of functions above half-maximum, and (2) mean percentage excess above mean function values, and assessed whether plant diversity or environmental favorability better predicted multi-functionality. In grazed fallows, positive effects of plant diversity best explained the proportion above half-maximum and mean percentage excess, the former also declining with grazing intensity. In improved fallows, the proportion above half-maximum was not associated with soil carbon or plant diversity, while soil carbon predicted mean percentage excess better than diversity. Grazed fallows yielded stronger evidence for diversity effects on multi-functionality, while environmental conditions appeared more influential in improved fallows. The contrast in diversity-multi-functionality relationships among fallow types appears related to differences in management and associated factors including disturbance and species composition. Complementary effects of species with contrasting functional traits on different functions and multi-functional species may have contributed to diversity effects in grazed fallows. Biodiversity and environmental favorability may enhance the capacity of smallholder fallows to simultaneously provide multiple ecosystem services, yet their effects are likely to vary with fallow management.     

Livestock Acquisitions Dynamics in Nomadic Pastoralist Herd Demography: A Case Study Among Ngisonyoka Herders of South Turkana, Kenya

Despite the attention given to social relations in the pastoral literature, the role of livestock acquisitions—additions of livestock to herds through bridewealth, exchanges, gifts, payments, and begging (requests)—in herd build up has usually been assumed to be relatively minor compared to births and relevant mostly when the need for rebuilding arises after major losses. This study is based on an unusual set of data—the reproductive histories of the female cattle, camels, and goats and sheep of 13 Ngisonyoka Turkana nomadic herders in northwestern Kenya, collected in 1987. The article reports on the means by which mothers were added to the herd and how these changed through time. The results suggest that for this population in the late 1970s and 1980s, acquisitions were not merely relevant when disaster struck, but instead were a continuously important component of herd management. The results demonstrate the crucial role of social networks in the survival of Ngisonyoka pastoralists in their non-equilibrial ecosystem. Social exchanges, such as bridewealth, provide a resource security well suited to the challenges of coping with such unpredictable environments. Researchers and policymakers are urged to make efforts to support such indigenous networks if they want nomadic pastoralists to continue their effective use of arid, marginal lands.

Multiple Methods in the Study of Driving Forces of Land Use and Land Cover Change: A Case Study of SE Kajiado District,Kenya

This landscape-scale study combines analysis of multitemporal satellite imagery spanning 30 years and information from field studies extending over 25 years to assess the extent and causes of land use and land cover change in the Loitokitok area, southeast Kajiado District, Kenya. Rain fed and irrigated agriculture, livestock herding, and wildlife and tourism have all experienced rapid change in their structure, extent, and interactions over the past 30 years in response to a variety of economic, cultural, political, institutional, and demographic processes. Land use patterns and processes are explored through a complementary application of interpretation of satellite imagery and case study analysis that explicitly addresses the local–national spatial scale over a time frame appropriate to the identification of fundamental causal processes. The results illustrate that this combination provides an effective basis for describing and explaining patterns of land use and land cover change and their root causes.     

Ethnicity and Shared Meanings: A Case Study of the "Orphaned Bones" Ritual in Mainland China and Overseas

ABSTRACT   Several theories of ethnicity emphasize the analysis of intergroup relations. They neglect, however, the conflation of ideas and values structuring these relations—notably the cross-cultural aggregates of shared cultural meanings that underlie forms of cooperation and competition between interacting groups. In this article, I explore this kind of process through a multisite ethnography of the Xiu gugu ("refining of orphaned bones"), a ritual that the Chaozhou people of northeast Guangdong province, an ethnic subgroup of the Han, perform periodically. The celebration of this rite in Chaozhou is compared to versions resulting of the ritual in Malay Muslim and Thai Buddhist contexts. In the latter case, close conceptions of malevolent death underlie a fascinating interethnic cooperation, with most of the unfortunate dead whose bones are "refined" during the Chaozhou ritual being Thai.     

Tree Diversity in Western Kenya: Using Profiles to Characterise Richness and Evenness

Species diversity is a function of the number of species and the evenness in the abundance of the component species. We calculated diversity and evenness profiles, which allowed comparing the diversity and evenness of communities. We applied the methodology to investigate differences in diversity among the main functions of trees on western Kenyan farms. Many use-groups (all trees and species that provide a specific use) could not be ranked in diversity or evenness. No use-group had perfectly even distributions. Evenness could especially be enhanced for construction materials, fruit, ornamental, firewood, timber and medicine, which included some of the most species-rich groups of the investigated landscape. When considering only the evenness in the distribution of the dominant species, timber, medicine, fruit and beverage ranked lowest (> 60% of trees belonged to the dominant species of these groups). These are also use-groups that are mainly grown by farmers to provide cash through sales. Since not all communities can be ranked in diversity, studies that attempt to order communities in diversity should not base the ordering on a single index, or even a combination of several indices, but use techniques developed for diversity ordering such as the Rényi diversity profile. The rarefaction of diversity profiles described in this article could be used in studies that compare results from surveys with different sample sizes.     

Uncertainty Estimation in a Remediation Process: A Case Study

A case study concerning the reclamation of a brownfield for residential purposes is presented. Because a high contamination of Polycyclic Aromatic Hydrocarbons (PAHs) was detected in soil, a remediation process is necessary. Bench-scale treat-ability tests were carried out in order to evaluate performances of some remediation technologies on this specific matrix, and particularly for the removal of high-molecular-weight PAHs. Biodegradation studies allowed the evaluation of PAH abatement in a slurry phase treatment, the amount of abiotic losses and the effect of macronutri-ents and bioaugmentation on the removal efficiency. The experimental study was performed in compliance with a Quality System, based on ISO 9001:2000 and ISO/ EC 17025:1999; validation of the analytical method provided the expanded uncertainty of the removal efficiency, varying from nearly 13 to 21%, depending on the compound considered. Experimental results showed a high removal efficiency for all PAHs; the addition of nitrogen and phosphorous increased the removal rate and the efficiency for high-molecular-weight PAHs, whereas no remarkable differences were observed in total (abiotic + biotic) removal of light compounds.     

Determinants of Primary School Non-Enrollment and Absenteeism: Results from a Retrospective,Convergent Mixed Methods,Cohort Study in Rural Western Kenya

Background

Education is a key element in the socioeconomic development required to improve quality of life in Kenya. Despite the introduction of free primary education, primary school enrollment and attendance levels remain low. Drawing on qualitative and quantitative data, this study explores the determinants of non-enrollment and absenteeism in rural western Kenya and potential mitigation strategies to address these issues.

Methods

The study was conducted in Bwaliro village in rural western Kenya. A random sample of 64 students was obtained by blocking the village primary school’s student population according to grade level, gender, and orphan status. Qualitative and quantitative data were collected through interviews with parents, guardians, and key informants, and focus group discussions with students. Quantitative data were compared using chi-square tests, Student’s T-test, and Poisson regressions. Qualitative data were analyzed using thematic content analysis.

Results

Malaria, menstruation, and lack of money were among the most notable determinants of primary school dropout and absenteeism, and these factors disproportionately impacted orphans and female students. Potential mitigation strategies suggested by the community included provision of malaria treatment or prevention, reduction in education costs, expansion of the established school-feeding program, and provision of sanitary pads.

Conclusion

Despite free primary education, numerous factors continue to prevent children in rural western Kenya from attending primary school. The findings suggest that interventions should primarily target orphaned and female students. Prior to implementation, suggested mitigation strategies should be assessed for cost-effectiveness.     

Treatment of Tungiasis with Dimeticone: A Proof-of-Principle Study in Rural Kenya

Tungiasis (sand flea disease) is a neglected tropical disease, prevalent in resource-poor communities in South America and sub-Saharan Africa. It is caused by an inflammatory response against penetrated female sand fleas (Tunga penetrans) embedded in the skin of the host. Although associated with debilitating acute and chronic morbidity, there is no proven effective drug treatment. By consequence patients attempt to remove embedded sand fleas with non-sterile sharp instruments, such as safety pins, a procedure that represents a health threat by itself. In this proof-of-principle study we compared the topical application of a mixture of two dimeticones of low viscosity (NYDA) to the topical application of a 0.05% solution of KMnO4 in 47 school children in an endemic area in rural Kenya. The efficacy of the treatment was assessed during a follow up period of seven days using viability signs of the embedded parasites, alterations in the natural development of lesion morphology and the degree of local inflammation as outcome measures. Seven days after treatment, in the dimeticone group 78% (95% CI 67–86%) of the parasites had lost all signs of viability as compared to 39% (95% CI 28–52%) in the KMnO4 group (p<0.001). In the dimeticone group 90% (95% CI 80–95%) of the penetrated sand fleas showed an abnormal development already after 5 days, compared to 53% (95% CI 40–66%; p<0.001) in the KMnO4 group. Seven days after treatment, signs of local skin inflammation had significantly decreased in the dimeticone group (p<0.001). This study identified the topical application of dimeticones of low viscosity (NYDA) as an effective means to kill embedded sand fleas. In view of the efficacy and safety of the topical treatment with dimeticone, the mechanical extraction of embedded sand fleas using hazardous instruments is no longer warranted.