Levels of childhood vaccination coverage and the impact of maternal HIV status on child vaccination status in rural KwaZulu‐Natal,South Africa*

Objectives To analyse coverage of childhood vaccinations in a rural South African population and investigate whether maternal HIV status is associated with children’s vaccination status. Methods 2 431 children with complete information, 12–23 months of age at some point during the period January 2005 through December 2006 and resident in the Africa Centre Demographic Surveillance Area at the time of their birth were investigated. We examined the relationship between maternal HIV status and child vaccination status for five vaccinations [Bacillus Calmette‐Guérin (BCG), diphtheria‐tetanus‐pertussis (DTP3), poliomyelitis (polio3), hepatitis B (HepB3), and measles] in multiple logistic regressions, controlling for household wealth, maternal age, maternal education and distances to roads, fixed and mobile clinics. Results Coverage of the five vaccinations ranged from 89.3% (95% CI 81.7–93.9) for BCG to 77.3% (67.1–83.6) for measles. Multivariably, maternal HIV‐positive status was significantly associated with lower adjusted odds ratios (AOR) of child vaccination for all vaccines [(AOR) 0.60–0.74, all P ≤ 0.036] except measles (0.75, P = 0.073), distance to mobile clinic was negatively associated with vaccination status (all P ≤ 0.029), household wealth was positively (all P ≤ 0.013) and distance to nearest road negatively (all P ≤ 0.004) associated with vaccination status. Conclusion Positive maternal HIV status independently reduces children’s probability to receive child vaccinations, which likely contributes to the morbidity and mortality differential between children of HIV‐positive and HIV‐negative mothers. As a means of increasing vaccination coverage, policy makers should consider increasing the number of mobile clinics in this and similar communities in rural Africa.     

A randomised, controlled trial of once daily and multi-dose daily gentamicin in young Kenyan infants

Aims: To test the suitability of a simple once daily (OD) gentamicin regimen for use in young infants where routine therapeutic drug monitoring is not possible. Methods: In an open, randomised, controlled trial, infants with suspected severe sepsis admitted to a Kenyan, rural district hospital received a novel, OD gentamicin regimen or routine multi-dose (MD) regimens. Results: A total of 297 infants (over 40% ⩽7 days) were randomised per protocol; 292 contributed at least some data for analysis of pharmacological endpoints. One hour after the first dose, 5% (7/136) and 28% (35/123) of infants in OD and MD arms respectively had plasma gentamicin concentrations <4 µg/ml (a surrogate of treatment inadequacy). Geometric mean gentamicin concentrations at this time were 9.0 µg/ml (95% CI 8.3 to 9.9) and 4.7 µg/ml (95% CI 4.2 to 5.3) respectively. By the fourth day, pre-dose concentrations ⩾2 µg/ml (a surrogate of potential treatment toxicity) were found in 6% (5/89) and 24% (21/86) of infants respectively. Mortality was similar in both groups and clinically insignificant, although potential gentamicin induced renal toxicity was observed in <2% infants. Conclusions: A "two, four, six, eight" OD gentamicin regime, appropriate for premature infants and those in the first days and weeks of life, seems a suitable, safe prescribing guide in resource poor settings.     

An outbreak of poliomyelitis caused by poliovirus type I in captive black and white colobus monkeys (Colobus abyssinicus kikuyuensis) in Kenya

In the latter part of 1982, three black and white colobus monkeys, Colobus abyssinicus kikuyuensis, from a small breeding group maintained at the Institute of Primate Research in Kenya, became paralysed within one month. Two of these cases were fatal and the third animal survived. The clinical and pathological findings suggested a poliomyelitis-like disease. This was confirmed by the isolation of wild strains of poliomyelitis virus type I from faeces, spleen, kidney, lung and central nervous system from affected animals.     

Implementing routine provider-initiated HIV testing in public health care facilities in Kenya: a qualitative descriptive study of nurses' experiences

Routine "provider-initiated testing and counselling" (PITC) for HIV has been implemented amidst concern over how consent, confidentiality and counselling (the 3Cs) can be maintained in under-resourced health care settings. In Kenya, PITC has been rolled out since 2005, HIV prevalence is 7.1% and more than 86% of adults have not been tested. Kenyan nurses are the main cadre implementing PITC, but little is known about their experiences of incorporating HIV testing into everyday practice and the challenges faced in maintaining the 3Cs within their work environments. This study aimed to explore these issues and adopted a qualitative multi-method design using a convenience sampling approach. Two focus group discussions (total n=12) and 13 in-depth individual interviews were undertaken with nurses from 11 different public health care facilities in Nairobi and its surrounding areas (including in-patient and outpatient settings). Data were analysed thematically. Nurses identified a range of personal, client and health system challenges in the everyday application of PITC. These included (i) the contradictions of normalising a highly stigmatised disease and the difficulty in providing client-centred care within a routinised and target-oriented work culture; (ii) the challenge of dealing with ethically complex client situations in which the principles of the 3Cs could be difficult to uphold; and (iii) lack of time, resources, space and recognition within workplace environments (especially in-patient settings) that, likewise, led to problems with maintaining the 3Cs. In-patient nurses in particular identified problems associated with testing in a multi-disciplinary context, suggesting that other health professionals appeared to routinely flout the PITC guidelines. In conclusion, this study shows that the process of translating policy into practice is invariably complex and that more research is needed to explore PITC practices, particularly in in-patient settings. Nurses require supervision and support to negotiate the challenges and to fulfil their roles effectively.     

Prevalence of human papillomavirus in women with invasive cervical carcinoma by HIV status in Kenya and South Africa

Data on the prevalence of human papillomavirus (HPV) types in cervical carcinoma in women with HIV are scarce but are essential to elucidate the influence of immunity on the carcinogenicity of different HPV types, and the potential impact of prophylactic HPV vaccines in populations with high HIV prevalence. We conducted a multicentre case-case study in Kenya and South Africa. During 2007-2009, frozen tissue biopsies from women with cervical carcinoma were tested for HPV DNA using GP5+/6+-PCR assay. One hundred and six HIV-positive (mean age 40.8 years) and 129 HIV-negative women (mean age 45.7) with squamous cell carcinoma were included. Among HIV-positive women, the mean CD4 count was 334 cells/μL and 48.1% were on combined antiretroviral therapy. HIV-positive women had many more multiple HPV infections (21.6% of HPV-positive carcinomas) compared with HIV-negative women (3.3%) (p < 0.001) and the proportion of multiple infections was inversely related to CD4 level. An excess of HPV18 of borderline statistical significance was found in HIV-positive compared with HIV-negative cases (Prevalence ratio (PR) = 1.9, 95% confidence interval (CI): 1.0-3.7, adjusted for study centre, age and multiplicity of infection). HPV16 and/or 18 prevalence combined, however, was similar in HIV-positive (66.7%) and HIV-negative cases (69.1%) (PR = 1.0, 95% CI: 0.9-1.2). No significant difference was found for other HPV types. Our data suggest that current prophylactic HPV vaccines against HPV16 and 18 may prevent similar proportions of cervical SCC in HIV-positive as in HIV-negative women provided that vaccine-related protection is sustained after HIV infection.     

A randomised, controlled trial of once daily and multi-dose daily gentamicin in young Kenyan infants.

AIMS: To test the suitability of a simple once daily (OD) gentamicin regimen for use in young infants where routine therapeutic drug monitoring is not possible. METHODS: In an open, randomised, controlled trial, infants with suspected severe sepsis admitted to a Kenyan, rural district hospital received a novel, OD gentamicin regimen or routine multi-dose (MD) regimens. RESULTS: A total of 297 infants (over 40% < or =7 days) were randomised per protocol; 292 contributed at least some data for analysis of pharmacological endpoints. One hour after the first dose, 5% (7/136) and 28% (35/123) of infants in OD and MD arms respectively had plasma gentamicin concentrations <4 microg/ml (a surrogate of treatment inadequacy). Geometric mean gentamicin concentrations at this time were 9.0 microg/ml (95% CI 8.3 to 9.9) and 4.7 microg/ml (95% CI 4.2 to 5.3) respectively. By the fourth day, pre-dose concentrations > or =2 microg/ml (a surrogate of potential treatment toxicity) were found in 6% (5/89) and 24% (21/86) of infants respectively. Mortality was similar in both groups and clinically insignificant, although potential gentamicin induced renal toxicity was observed in <2% infants. CONCLUSIONS: A "two, four, six, eight" OD gentamicin regime, appropriate for premature infants and those in the first days and weeks of life, seems a suitable, safe prescribing guide in resource poor settings.