Risk factors for symptoms of gastrointestinal illness in rural town Isiolo, Kenya

Factors associated with total coliform and total viable bacterial count in camel milk from Isiolo County, Kenya

Background and Aim:

Camels have adaptive features to harsh climatic conditions, which make them a valued stable source of livelihood in arid lands. This study estimated the total bacterial and coliform counts (CCs), their associated factors in raw camel milk from the pastoral camel keepers, and the entire milk value chain in Isiolo County and Nairobi, Kenya. This study elucidates the bacterial load in camel milk and its potential risk. Moreover, this study provides recommendations on how to avert a human health hazard.

Materials and Methods:

This cross-sectional study targeted the camel pastoralists in Isiolo County, in the northern central part of Kenya. The study was conducted in July and August 2021. In addition, camel milk samples were collected along the value chain key points, including the producers, transporters, one bulker, and small traders in Isiolo town, and other retailers in Nairobi City. Eight camel herds were purposively selected and visited for a sample collection from pooled milking containers (10 mL each). In addition, milk was collected from pooled milk through the transporters, two milk bulkers, and several milk retailers in Isiolo town. Milk was further collected from retailers in Eastleigh town, Nairobi City. At each sampling point, 20 mL of milk sample was collected aseptically. The milk samples were assessed for total viable bacterial counts (TVBC) and CCs using the plate count and digital colony count, respectively.

Results:

A total of 76 respondents were selected and 213 milk samples were collected in this study. The respondents included the 1 (1.3%) bulker, 32 (42.1%) producers, 26 (34.2%) traders, and 17 (22.4%) transporters. Most respondents were male (62%), with most being over 40 years old. Overall, the TVBC had a mean of 2436835 ± 9276636 and a median of 3600. Furthermore, the multivariable multilevel mixed-effects linear regression model indicated that gender and practice of smoking milk-handling containers were positively and negatively associated with high counts of the natural logarithm of total viable bacteria, respectively. Of the milk samples evaluated for the CC, 10.3% (22/213) had counts greater than or equal to (≥) 100,000, where some also indicated extreme outliers of about 9.3 million.

Conclusion:

This study reports a low proportion of camel milk samples with high total viable bacterial and CCs. The material of the milk container and level of education interactively affected the total viable bacteria.

Brucellosis risk factors and milk hygiene handling practices in pastoral communities in Isiolo county, Kenya

The study was conducted from June to August 2014 in Isiolo Central division of Isiolo Sub‐County and Sericho division of Garbatulla Sub‐County and comprised two components: (i) a cross‐sectional study on the milk‐handling hygiene practices, where milk traders’ households were the study units and (ii) a case‐control study on the risk factors for Brucella spp. infection in humans. Results of the cross‐sectional study showed that 26.74% of the respondents never washed their hands before milking, 60.47% never washed the udder before milking and 54.65% never withhold consumption of milk from animals under treatment with antibiotics. The case–control study included household units with previous cases of brucellosis (53.33%) and those without (46.67%) over the previous 5 years and identified drinking of raw milk as the main risk factor for infection (OR = 26.44; 95% CI: 8.04–86.99). Pastoralists’ unhygienic handling of milk from production to market is suboptimal and this is due to poor knowledge on hygienic practices, poor knowledge on the risks associated with poor milk hygiene and lack of sufficient and potable water for cleaning of milk containers. Many pastoralists still consume milk raw and this is a major public health risk for milk‐borne diseases.

Detection of Brucella spp. in raw milk from various livestock species raised under pastoral production systems in Isiolo and Marsabit Counties, northern Kenya

Introduction

Brucellosis is an important zoonotic disease in Kenya, and identifying the bacteria in milk is important in assessing the risk of exposure in people.

Methods

A cross-sectional study that involved 175 households was implemented in the pastoral counties of Marsabit and Isiolo in Kenya. Pooled milk samples (n = 164) were collected at the household level, and another 372 were collected from domesticated lactating animals (312 goats, 7 sheep, 50 cattle and 3 camels). Real-time polymerase chain reaction (qPCR) testing of the milk samples was performed to identify Brucella species. Brucella anti-LPS IgG antibodies were also detected in bovine milk samples using an indirect enzyme-linked immunosorbent assay (ELISA).

Results

Based on the qPCR, the prevalence of the pathogen at the animal level (considering samples from individual animals) was 2.4% (95% confidence interval (CI) 1.1–4.5) and 3.0% (CI: 1.0–7.0) in pooled samples. All 14 samples found positive by qPCR were from goats, with 10 contaminated with B. abortus and 4 with B. melitensis. The Brucella spp. antibody prevalence in bovine milk using the milk ELISA was 26.0% (95% CI: 14.6–40.3) in individual animal samples and 46.3% (95% CI: 30.7–62.6) in pooled samples.

Conclusion

The study is the first in Kenya to test for Brucella spp. directly from milk using qPCR without culturing for the bacteria. It also detected B. abortus in goats, suggesting transmission of brucellosis between cattle and goats. The high prevalence of Brucella spp. is a significant public health risk, and there is a need for intervention strategies necessary in the study area.

Electronic supplementary material

The online version of this article (10.1007/s11250-020-02389-1) contains supplementary material, which is available to authorized users.

Zoonotic Pathogens of Dromedary Camels in Kenya: A Systematised Review

Kenya is home to Africa’s third largest population of dromedary camels, and production at commercial and local levels are increasingly important. In pastoral and nomadic communities in the arid and semi-arid lands (ASALs), camels play a vital role in food security, while commercial milk production and formalized export markets are rapidly emerging as camel populations expand into non-traditional areas. Until recently, little focus was placed on camels as hosts of zoonotic disease, but the emergence of Middle Eastern respiratory coronavirus (MERS-CoV) in 2012, and the discovery of exposure to the virus in Kenyan camels, highlighted the need for further understanding of this area. This systematised review utilised a robust search strategy to assess the occurrence of camel-associated zoonoses in Kenya and to evaluate the quality of the published literature. Seventy-four studies were identified, covering sixteen pathogens, with an increasing number of good quality studies in recent years. Despite this, the area remains under-researched and there is a lack of robust, high-quality research. Trypanosome spp., Echinococcus granulosus and Brucella spp. appeared most frequently in the literature. Pathogens with the highest reported prevalence were MERS-CoV (0–100%), Echinococcus granulosa (7–60%) and Rift Valley fever virus (7–57%). Exposure to Brucella spp., Coxiella burnetii and Crimean-Congo haemorrhagic fever virus showed higher levels in camel or camel-associated vectors than other livestock species, although brucellosis was the only disease for which there was robust evidence linking camel and human exposure. Zoonotic agents with less severe human health outcomes, such as Dermatophilosus congolensis and contagious ecthyma, were also represented in the literature. This review provides an important summary of the scope and quality of current knowledge. It demonstrates that further research, and improved adherence to robust study design and reporting are essential if the zoonotic risk from camels in Kenya, and elsewhere, is to be better understood.

Detection of Brucella antibodies in domestic animals of southern Cameroon: Implications for the control of brucellosis

Brucellosis is one of the world's most widespread bacterial zoonoses caused by Brucella. It leads to considerable economic losses as a result of low productivity of infected animals and the long debilitating illness in humans. Despite its impact on human and animal health, little attention has been paid on Brucella infections in domestic animals. It is in this light that the prevalence of Brucella antibodies was determined in domestic animals with the overarching goal of improving our knowledge on brucellosis in southern Cameroon. During cross-sectional studies conducted from December 2016 to August 2018 in five sites of southern Cameroon, blood samples were collected in cattle, sheep, goat, pig and dog. Plasma was obtained from each blood sample and Brucella antibodies were detected using the Rose Bengal test and the enzyme-linked immunosorbent assay (ELISA). From 1873 animals that were sampled, the overall prevalence of Brucella antibodies using Indirect enzyme-linked immunosorbent assay (i-ELISA) was 6.35% (118/1873): 9.12% (78/855) in cattle; 8.04% (30/373) in sheep; 6.06% (2/33) in dog, 1.87% (3/160) in pig and 1.1% (5/452) in goat. Between animal species (p-value < .0001, x2  = 33.63) as well as sampling sites (p-value = .0001, x2  = 18.97), significant differences were observed in the prevalence of Brucella antibodies. Yoko and Noun localities have shown the highest prevalence of 8.6% (30/348) and 7.2% (78/1070), respectively. This prevalence was significantly higher (p = .03, x2  = 1.25) in female than male cattle. Between adult (16.923%) and young cattle (7.8%), significant difference (p = .04, x2  = 6.42) was observed in the prevalence of Brucella antibodies. This study shows that the prevalence of Brucella antibodies varies between animal species and localities. It also shows several domestic animals of southern Cameroon that have been in contact with Brucella. It enabled to identify villages where investigations on the transmission dynamic must be focused for the final goal of developing control measures for this neglected zoonotic disease.

Common Gastrointestinal Symptoms and Associated Factors Among Under-5 Children in Rural Dembiya, Northwest Ethiopia: A Community-Based Cross-Sectional Study

BACKGROUND

Gastrointestinal (GI) symptoms such as abdominal discomfort, abdominal cramp, nausea, vomiting, gas in the GI tract, changes in bowel habits (e.g. diarrhea), or heartburn are common in the community. However, these symptoms may be misinterpreted and their impact and significance misunderstood, especially in the rural communities. This study was, therefore, conducted to assess common GI symptoms among children in rural Dembiya, northwest Ethiopia.

METHODS

A community-based cross-sectional study was conducted in May 2017 among 225 randomly selected under-5 children. We primarily used mothers' report to assess GI symptoms. Health professionals also diagnosed for some symptoms. Direct stool examination technique was used to identify parasitic infections. Bacteriological analysis of drinking water was done to determine the quality of drinking water. Food safety, environmental sanitation, and hygiene condition of children were assessed using observation checklists. Multivariable binary logistic regression analysis was employed to identify factors associated with GI symptoms on the basis of adjusted odds ratio (OR) with 95% confidence interval (CI) and P < .05.

RESULTS

The current study depicted that 139 of 225(61.8%) of the children had GI symptoms. Abdominal discomfort (137 of 139 [98.7%]), abdominal cramp (125 of 139 [89.9%]), and diarrhea (118 of 139 [84.9%]) were the highest GI symptoms reported. GI symptoms were significantly associated with childhood intestinal parasitic infections (OR = 13.69, 95% CI = 3.31-56.59), unclipped and unclean finger nails (OR = 2.28, 95% CI = 1.02-5.10), inadequate living environment sanitation (OR = 2.37, 95% CI = 1.08-5.18), unclean living houses (OR = 9.06, 95% CI = 2.60-31.54), and owning livestock (OR = 4.68, 95% CI = 1.82, 12.03).

CONCLUSION

The prevalence of GI symptoms among under-5 children in rural Dembiya, northwest Ethiopia, was found to be high. GI symptoms were significantly associated with childhood intestinal parasitic infections, hand hygiene condition of children, and sanitation condition of the living environment. Therefore, preventing intestinal parasitic infections, improving hand hygiene condition, and promoting environmental sanitation will have overriding contributions to prevent symptoms among children in rural Dembiya.

Subclinical mastitis in pastoralist dairy camel herds in Isiolo, Kenya: Prevalence, risk factors, and antimicrobial susceptibility

Mastitis is an important constraint to milk production in pastoralist camel (Camelus dromedarius) herds in Kenya. The objective of this study was to investigate the prevalence, risk factors, and bacterial panorama of subclinical mastitis (SCM) in pastoralist camel herds in Isiolo County, Kenya. Furthermore, antimicrobial susceptibility in udder pathogens was studied. A cross-sectional sample of 206 camels from 20 milking herds was screened using the California Mastitis Test (CMT), and quarter milk was subjected to bacterial culturing. Isolates were confirmed using MALDI-TOF mass spectrometry analysis, and antimicrobial susceptibility was determined using the broth microdilution method. Interviews focusing on herd management were conducted with camel owners. Subclinical mastitis, defined as a CMT score ≥ 3 (scale 1 to 5) and absence of clinical symptoms in the udder, were present in all visited herds. On the individual level, 46% of the camels had at least 1 quarter affected with SCM, and on the quarter level the prevalence was 26%. Intramammary infections (IMI) were common; out of 798 quarter milk samples, 33% yielded conclusive bacterial growth. The sensitivity and specificity of CMT for correctly identifying quarters with IMI were 82% and 92%, respectively. The most prevalent pathogen was Streptococcus agalactiae (72% of IMI-positive quarters), followed by non-aureus staphylococci (19%) and Staphylococcus aureus (13%). Antimicrobial susceptibility testing revealed that only a low proportion (4.9%) of Strep. agalactiae isolates was sensitive to tetracycline. For Staph. aureus, 59.1% of isolates exhibited sensitivity to penicillin. Skin lesions on the teats or udder were a risk factor for SCM. Increased age, parity, and stage of lactation were associated with increased risk of both SCM and IMI. Older camels with a blind teat or a previous history of mastitis were more likely to be infected with Strep. agalactiae. Hygiene routines for milking were largely absent in the observed herds, and knowledge of adequate milk handling was limited. The poor udder health is likely to depend on multiple factors, most prominently the within-herd maintenance of contagious udder pathogens, in combination with difficult sanitary conditions and lack of awareness among camel keepers. This study showed that in pastoralist camel herds around Isiolo town, SCM and IMI specifically caused by Strep. agalactiae are common udder health problems and are associated with increasing age, parity, and stage of lactation, and skin lesions on the teats and udder. Resistance to tetracycline in Strep. agalactiae was common. Control strategies specifically targeting SCM and adapted to pastorally managed camel herds need to be developed to reduce disease, combat antimicrobial resistance, and improve the livelihoods of pastoralists.

A Review of Zoonotic Pathogens of Dromedary Camels

Dromedary, or one-humped, camels Camelus dromedarius are an almost exclusively domesticated species that are common in arid areas as both beasts of burden and production animals for meat and milk. Currently, there are approximately 30 million dromedary camels, with highest numbers in Africa and the Middle East. The hardiness of camels in arid regions has made humans more dependent on them, especially as a stable protein source. Camels also carry and may transmit disease-causing agents to humans and other animals. The ability for camels to act as a point source or vector for disease is a concern due to increasing human demands for meat, lack of biosafety and biosecurity protocols in many regions, and a growth in the interface with wildlife as camel herds become sympatric with non-domestic species. We conducted a literature review of camel-borne zoonotic diseases and found that the majority of publications (65%) focused on Middle East respiratory syndrome (MERS), brucellosis, Echinococcus granulosus, and Rift Valley fever. The high fatality from MERS outbreaks during 2012-2016 elicited an immediate response from the research community as demonstrated by a surge of MERS-related publications. However, we contend that other camel-borne diseases such as Yersinia pestis, Coxiella burnetii, and Crimean-Congo hemorrhagic fever are just as important to include in surveillance efforts. Camel populations, particularly in sub-Saharan Africa, are increasing exponentially in response to prolonged droughts, and thus, the risk of zoonoses increases as well. In this review, we provide an overview of the major zoonotic diseases present in dromedary camels, their risk to humans, and recommendations to minimize spillover events.

Milk handling practices and consumption behavior among Borana pastoralists in southern Ethiopia

BACKGROUND

Safety and wholesomeness of milk intended for human consumption are influenced by various interlinked factors. However, information on what these factors are, especially in the pastoral traditional communities of Ethiopia, is largely lacking. The objective of this study is to assess the hygienic milk production, processing and consumption practices, and behaviors of Borana pastoralists.

METHODS

The study used qualitative participatory research methods. Individual semi-structured interviews, focus group discussions, informal discussions, and observations were carried out on (1) milk handling practices, (2) perceptions of quality and safety of milk, including perceived criteria for good milk, (3) awareness of milk-borne diseases, and (4) perception towards milk boiling practices. The interviews and discussions were audio recorded, transcribed, and analyzed by identifying themes.

RESULTS

Some risky behaviors related to milk handling and consumption were identified. These include unhygienic conditions in handling milk and milk products, consumption behaviors such as consuming raw milk purchased from markets, and children directly consuming milk from the udder of animals (e.g., goats). There was a very strong reluctance to boil milk before consumption mainly because of the misconception that nutrients in the milk are destroyed when milk is boiled and "boiled milk is dead". On the other hand, potential risk mitigation practices were identified such as smoking of milk containers (which may help reduce microbial growth), processing milk through fermentation, consuming milk in boiled tea, and a recent trend towards boiling milk for babies. However, the latter was not motivated by concern over microbial hazards but the belief that raw milk could form curds in children's stomach which might then suffocate them.

CONCLUSION

The findings highlight the need to promote hygienic handling practices of milk and closely engage with local communities to improve their understanding of milk safety to facilitate change in practices. Educating pastoralists on good milk production practices should be given priority. One of the ways to do this could be by strengthening the integration of milk hygiene in research and development programs as an entry point for behavioral change towards the safe handling and consumption of milk and milk products.

Identification of Biological Hazards in Produce Consumed in Industrialized Countries: A Review

Microbial contamination of fresh produce (fresh fruits and vegetables) poses serious public health concerns worldwide. This study was conducted as a comprehensive analysis of biological hazards in the global fresh produce chain. Data about produce-related outbreaks and illness were collected from the annual reports and databases of foodborne outbreak surveillance systems in different regions and countries from 2010 to 2015. The global patterns of and regional differences in documented outbreaks and cases were analyzed, and produce commodities and pathogens of greatest concern were identified. Data on sporadic illnesses were also collected through a comprehensive literature review of case-control studies. We found 988 produce-related outbreaks (with known agents) and 45,723 cases in all regions and countries. The numbers of produce-related outbreaks per million person-years were approximately 0.76, 0.26, 0.25, 0.13, 0.12, and 0.05 in New Zealand, Australia, the United States, the European Union, Canada, and Japan, respectively. The top three food categories and pathogens contributing to produce-related outbreaks were vegetables and nonfruits (i.e., food other than fruits; 27.0%), unspecified vegetables (12.2%), and vegetable row crops (11.7%) and norovirus (42.4%), Salmonella enterica (19.9%), and Staphylococcus aureus (7.9%), respectively. Produce consumption was identified as a protective factor, a risk factor, and either a protective or risk factor for sporadic illnesses in 11, 5, and 5 studies, respectively, among 21 case-control studies. Risks associated with produce consumption in the United States and the European Union have been linked to various factors such as irrigation water, cross-contamination, storage time and temperature abuse, infected food handlers, and unprocessed contaminated ingredients. The results of the current study indicate the complexity of produce products consumed across the globe and the difficulty in tracing illnesses back to specific food ingredients.

Serosurvey of Coxiella burnetii (Q fever) in Dromedary Camels (Camelus dromedarius) in Laikipia County, Kenya

Dromedary camels (Camelus dromedarius) are an important protein source for people in semi-arid and arid regions of Africa. In Kenya, camel populations have grown dramatically in the past few decades resulting in the potential for increased disease transmission between humans and camels. An estimated four million Kenyans drink unpasteurized camel milk, which poses a disease risk. We evaluated the seroprevalence of a significant zoonotic pathogen, Coxiella burnetii (Q fever), among 334 camels from nine herds in Laikipia County, Kenya. Serum testing revealed 18.6% positive seroprevalence of Coxiella burnetii (n = 344). Increasing camel age was positively associated with C. burnetii seroprevalence (OR = 5.36). Our study confirmed that camels living in Laikipia County, Kenya, have been exposed to the zoonotic pathogen, C. burnetii. Further research to evaluate the role of camels in disease transmission to other livestock, wildlife and humans in Kenya should be conducted.

Animal-related factors associated with moderate-to-severe diarrhea in children younger than five years in western Kenya: A matched case-control study

BACKGROUND

Diarrheal disease remains among the leading causes of global mortality in children younger than 5 years. Exposure to domestic animals may be a risk factor for diarrheal disease. The objectives of this study were to identify animal-related exposures associated with cases of moderate-to-severe diarrhea (MSD) in children in rural western Kenya, and to identify the major zoonotic enteric pathogens present in domestic animals residing in the homesteads of case and control children.

METHODOLOGY/PRINCIPAL FINDINGS

We characterized animal-related exposures in a subset of case and control children (n = 73 pairs matched on age, sex and location) with reported animal presence at home enrolled in the Global Enteric Multicenter Study in western Kenya, and analysed these for an association with MSD. We identified potentially zoonotic enteric pathogens in pooled fecal specimens collected from domestic animals resident at children's homesteads. Variables that were associated with decreased risk of MSD were washing hands after animal contact (matched odds ratio [MOR] = 0.2; 95% CI 0.08-0.7), and presence of adult sheep that were not confined in a pen overnight (MOR = 0.1; 0.02-0.5). Variables that were associated with increased risk of MSD were increasing number of sheep owned (MOR = 1.2; 1.0-1.5), frequent observation of fresh rodent excreta (feces/urine) outside the house (MOR = 7.5; 1.5-37.2), and participation of the child in providing water to chickens (MOR = 3.8; 1.2-12.2). Of 691 pooled specimens collected from 2,174 domestic animals, 159 pools (23%) tested positive for one or more potentially zoonotic enteric pathogens (Campylobacter jejuni, C. coli, non-typhoidal Salmonella, diarrheagenic E. coli, Giardia, Cryptosporidium, or rotavirus). We did not find any association between the presence of particular pathogens in household animals, and MSD in children.

CONCLUSIONS AND SIGNIFICANCE

Public health agencies should continue to promote frequent hand washing, including after animal contact, to reduce the risk of MSD. Future studies should address specific causal relations of MSD with sheep and chicken husbandry practices, and with the presence of rodents.

East and West African milk products are reservoirs for human and livestock-associated Staphylococcus aureus

Staphylococcus aureus frequently isolated from milk products in sub-Saharan Africa (SSA) is a major pathogen responsible for food intoxication, human and animal diseases. SSA hospital-derived strains are well studied but data on the population structure of foodborne S. aureus required to identify possible staphylococcal food poisoning sources is lacking. Therefore, the aim was to assess the population genetic structure, virulence and antibiotic resistance genes associated with milk-derived S. aureus isolates from Côte d'Ivoire, Kenya and Somalia through spa-typing, MLST, and DNA microarray analysis. Seventy milk S. aureus isolates from the three countries were assigned to 27 spa (7 new) and 23 (12 new) MLST sequence types. Milk-associated S. aureus of the three countries is genetically diverse comprising human and livestock-associated clonal complexes (CCs) predominated by the CC5 (n = 10) and CC30 (n = 9) isolates. Panton-Valentine leukocidin, toxic shock syndrome toxin and enterotoxin encoding genes were predominantly observed among human-associated CCs. Penicillin, fosfomycin and tetracycline, but not methicillin resistance genes were frequently detected. Our findings indicate that milk-associated S. aureus in SSA originates from human and animal sources alike highlighting the need for an overarching One Health approach to reduce S. aureus disease burdens through improving production processes, animal care and hygienic measures.

Systematic review of brucellosis in Kenya: disease frequency in humans and animals and risk factors for human infection

BACKGROUND

Brucellosis is a debilitating zoonotic disease affecting humans and animals. A comprehensive, evidence-based assessment of literature and officially available data on animal and human brucellosis for Kenya are missing. The aim of the current review is to provide frequency estimates of brucellosis in humans, animals and risk factors for human infection, and help to understand the current situation in Kenya.

METHODS

A total of accessible 36 national and international publications on brucellosis from 1916 to 2016 were reviewed to estimate the frequency of brucellosis in humans and animals, and strength of associations between potential risk factors and seropositivity in humans in Kenya.

RESULTS

The conducted studies revealed only few and fragmented evidence of the disease spatial and temporal distribution in an epidemiological context. Bacteriological evidence revealed the presence of Brucella (B.) abortus and B. melitensis in cattle and human patients, whilst B. suis was isolated from wild rodents only. Similar evidence for Brucella spp infection in small ruminants and other animal species is unavailable. The early and most recent serological studies revealed that animal brucellosis is widespread in all animal production systems. The animal infection pressure in these systems has remained strong due to mixing of large numbers of animals from different geographical regions, movement of livestock in search of pasture, communal sharing of grazing land, and the concentration of animals around water points. Human cases are more likely seen in groups occupationally or domestically exposed to livestock or practicing risky social-cultural activities such as consumption of raw blood and dairy products, and slaughtering of animals within the homesteads. Many brucellosis patients are misdiagnosed and probably mistreated due to lack of reliable laboratory diagnostic support resulting to adverse health outcomes of the patients and routine disease underreporting. We found no studies of disease incidence estimates or disease control efforts.

CONCLUSION

The risk for re-emergence and transmission of brucellosis is evident as a result of the co-existence of animal husbandry activities and social-cultural activities that promote brucellosis transmission. Well-designed countrywide, evidence-based, and multidisciplinary studies of brucellosis at the human/livestock/wildlife interface are needed. These could help to generate reliable frequency and potential impact estimates, to identify Brucella reservoirs, and to propose control strategies of proven efficacy.

Febrile patients admitted to remote hospitals in Northeastern Kenya: seroprevalence, risk factors and a clinical prediction tool for Q-Fever

BACKGROUND

Q fever in Kenya is poorly reported and its surveillance is highly neglected. Standard empiric treatment for febrile patients admitted to hospitals is antimalarials or penicillin-based antibiotics, which have no activity against Coxiella burnetii. This study aimed to assess the seroprevalence and the predisposing risk factors for Q fever infection in febrile patients from a pastoralist population, and derive a model for clinical prediction of febrile patients with acute Q fever.

METHODS

Epidemiological and clinical data were obtained from 1067 patients from Northeastern Kenya and their sera tested for IgG antibodies against Coxiella burnetii antigens by enzyme-linked-immunosorbent assay (ELISA), indirect immunofluorescence assay (IFA) and quantitative real-time PCR (qPCR). Logit models were built for risk factor analysis, and diagnostic prediction score generated and validated in two separate cohorts of patients.

RESULTS

Overall 204 (19.1 %, 95 % CI: 16.8-21.6) sera were positive for IgG antibodies against phase I and/or phase II antigens or Coxiella burnetii IS1111 by qPCR. Acute Q fever was established in 173 (16.2 %, 95 % CI: 14.1-18.7) patients. Q fever was not suspected by the treating clinicians in any of those patients, instead working diagnosis was fever of unknown origin or common tropical fevers. Exposure to cattle (adjusted odds ratio [aOR]: 2.09, 95 % CI: 1.73-5.98), goats (aOR: 3.74, 95 % CI: 2.52-9.40), and animal slaughter (aOR: 1.78, 95 % CI: 1.09-2.91) were significant risk factors. Consumption of unpasteurized cattle milk (aOR: 2.49, 95 % CI: 1.48-4.21) and locally fermented milk products (aOR: 1.66, 95 % CI: 1.19-4.37) were dietary factors associated with seropositivity. Based on regression coefficients, we calculated a diagnostic score with a sensitivity 93.1 % and specificity 76.1 % at cut off value of 2.90: fever >14 days (+3.6), abdominal pain (+0.8), respiratory tract infection (+1.0) and diarrhoea (-1.1).

CONCLUSION

Q fever is common in febrile Kenyan patients but underappreciated as a cause of community-acquired febrile illness. The utility of Q fever score and screening patients for the risky social-economic and dietary practices can provide a valuable tool to clinicians in identifying patients to strongly consider for detailed Q fever investigation and follow up on admission, and making therapeutic decisions.

Diarrhoeal diseases among adult population in an agricultural community Hanam province, Vietnam, with high wastewater and excreta re-use

BACKGROUND

Despite the potential health risks of wastewater and excreta use as fertiliser in agriculture, it is still widespread in Vietnam. However, the importance of diarrheal risk in adults' associated with the combined exposures to both excreta and wastewater use in agriculture is largely unknown. This study was carried out to determine diarrhoeal incidence and associated risk factors among the adult population exposed to wastewater and excreta used in agriculture in Hanam province, Vietnam.

METHODS

An open cohort of 867 adults, aged 16-65 years, was followed weekly for 12 months to determine the incidence of diarrhoea. A nested case-control study was used to assess the risk factors of diarrhoeal episodes. Two hundred and thirty-two pairs of cases and controls were identified and exposure information related to wastewater, human and animal excreta, personal hygiene practices, and food and water consumption was collected.

RESULTS

The incidence rate of reported diarrhoea was 0.28 episodes per person-years at risk. The risk factors for diarrhoeal diseases included direct contact with the Nhue River water (odds ratio [OR] = 2.4, attributable fraction [AF] 27%), local pond water (OR = 2.3, AF 14%), composting of human excreta for a duration less than 3 months (OR = 2.4, AF 51%), handling human excreta in field work (OR = 5.4, AF 7%), handling animal excreta in field work (OR = 3.3, AF 36%), lack of protective measures while working (OR = 6.9, AF 78%), never or rarely washing hands with soap (OR = 3.3, AF 51%), use of rainwater for drinking (OR = 5.4, AF 77%) and eating raw vegetables the day before (OR = 2.4, AF 12%).

CONCLUSIONS

Our study shows that professional exposure to wastewater and excreta during agricultural activities are significantly contributing to the risk of diarrhoea in adults. The highest attributable fractions were obtained for direct contact with Nhue River and local ponds, handling practices of human and animal excreta as fertilisers, lack of protective measures while working and poor personal hygiene practices, and unsafe food and water consumption were associated with the risk of diarrhoeal episodes in adults. Improve personal hygiene practices and use of relevant treated wastewater and excreta as the public health measures to reduce these exposures will be most effective and are urgently warranted.

Prevalence and comparison of Streptococcus infantarius subsp. infantarius and Streptococcus gallolyticus subsp. macedonicus in raw and fermented dairy products from East and West Africa

Streptococcus infantarius subsp. infantarius (Sii) and Streptococcus gallolyticus subsp. macedonicus are members of the Streptococcus bovis/Streptococcus equinus complex (SBSEC) associated with human infections. SBSEC-related endocarditis was furthermore associated with rural residency in Southern Europe. SBSEC members are increasingly isolated as predominant species from fermented dairy products in Europe, Asia and Africa. African variants of Sii displayed dairy adaptations to lactose metabolism paralleling those of Streptococcus thermophilus including genome decay. In this study, the aim was to assess the prevalence of Sii and possibly other SBSEC members in dairy products of East and West Africa in order to identify their habitat, estimate their importance in dairy fermentation processes and determine geographic areas affected by this potential health risk. Presumptive SBSEC members were isolated on semi-selective M17 and SM agar media. Subsequent genotypic identification of isolates was based on rep-PCR fingerprinting and SBSEC-specific16S rRNA gene PCR assay. Detailed identification was achieved through application of novel primers enhancing the binding stringency in partial groES/groEL gene amplification and subsequent DNA sequencing. The presence of S. thermophilus-like lacS and lacZ genes in the SBSEC isolates was determined to elucidate the prevalence of this dairy adaptation. Isolates (n = 754) were obtained from 72 raw and 95 fermented milk samples from Côte d'Ivoire and Kenya on semi-selective agar media. Colonies of Sii were not detected from raw milk despite high microbial titers of approximately 10(6)CFU/mL on M17 agar medium. However, after spontaneous milk fermentation Sii was genotypically identified in 94.1% of Kenyan samples and 60.8% of Kenyan isolates. Sii prevalence in Côte d'Ivoire displayed seasonal variations in samples from 32.3% (June) to 40.0% (Dec/Jan) and isolates from 20.5% (June) to 27.7% (Dec/Jan) present at titers of 10(6)-10(8)CFU/mL. lacS and lacZ genes were detected in all Kenyan and 25.8% (June) to 65.4% (Dec/Jan) of Ivorian Sii isolates. Regional differences in prevalence of Sii and dairy adaptations were observed, but no clear effect of dairy animal, fermentation procedure and climate was revealed. Conclusively, the high prevalence of Sii in Kenya, Côte d'Ivoire in addition to Somalia, Sudan and Mali strongly indicates a pivotal role of Sii in traditional African dairy fermentations potentially paralleling that of typical western dairy species S. thermophilus. Putative health risks associated with the consumption of high amounts of live Sii and potential different degrees of evolutionary adaptation or ecological colonization require further epidemiologic and genomic investigations, particularly in Africa.