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Craig J, Sriram A, Sadoff R, Bennett S, Bahati F, Beauvais W. Correction: Behavior-change interventions to improve antimicrobial stewardship in human health, animal health, and livestock agriculture: A systematic review. PLOS Glob Public Health 2024; 4:e0002930. [PMID: 38315672 PMCID: PMC10843131 DOI: 10.1371/journal.pgph.0002930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
[This corrects the article DOI: 10.1371/journal.pgph.0001526.].
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Craig J, Sriram A, Sadoff R, Bennett S, Bahati F, Beauvais W. Behavior-change interventions to improve antimicrobial stewardship in human health, animal health, and livestock agriculture: A systematic review. PLOS Glob Public Health 2023; 3:e0001526. [PMID: 37155592 PMCID: PMC10166487 DOI: 10.1371/journal.pgph.0001526] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/22/2023] [Accepted: 04/16/2023] [Indexed: 05/10/2023]
Abstract
Antimicrobial resistance (AMR) is an economic, food security, and global health threat accelerated by a multitude of factors including the overuse and misuse of antimicrobials in the human health, animal health, and agriculture sectors. Given the rapid emergence and spread of AMR and the relative lack of development of new antimicrobials or alternative therapies, there is a need to develop and implement non-pharmaceutical AMR mitigation policies and interventions that improve antimicrobial stewardship (AMS) practices across all sectors where antimicrobials are used. We conducted a systematic literature review per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines to identify peer-reviewed studies that described behavior-change interventions that aimed to improve AMS and/or reduce inappropriate antimicrobial use (AMU) among human health, animal health, and livestock agriculture stakeholders. We identified 301 total publications- 11 in the animal health sector and 290 in the human health sector-and assessed described interventions using metrics across five thematic areas- (1) AMU, (2) adherence to clinical guidelines, (3) AMS, (4) AMR, and (5) clinical outcomes. The lack of studies describing the animal health sector precluded a meta-analysis. Variation across intervention type, study type, and outcome precluded a meta-analysis for studies describing the human health sector; however, a summary descriptive analysis was conducted. Among studies in the human health sector, 35.7% reported significant (p<0.05) pre- to post-intervention decreases in AMU, 73.7% reported significant improvements in adherence of antimicrobial therapies to clinical guidelines, 45% demonstrated significant improvements in AMS practices, 45.5% reported significant decreases in the proportion of isolates that were resistant to antibiotics or the proportion of patients with drug-resistant infections across 17 antimicrobial-organism combinations. Few studies reported significant changes in clinical outcomes. We did not identify any overarching intervention type nor characteristics associated with successful improvement in AMS, AMR, AMU, adherence, nor clinical outcomes.
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Affiliation(s)
- Jessica Craig
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, United States of America
| | | | - Rachel Sadoff
- Mailman School of Public Health, Columbia University, New York, NY, United States of America
| | | | - Felix Bahati
- King’s College London, London, United Kingdom
- KEMRI Wellcome Trust Research Programme, Health Services Research Unit, Nairobi, Kenya
- Department of Environmental Health and Disease Control, College of Health Sciences, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya
| | - Wendy Beauvais
- Department of Comparative Pathobiology, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, United States of America
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Moturi AK, Robert BN, Bahati F, Macharia PM, Okiro EA. Investigating rapid diagnostic testing in Kenya's health system, 2018-2020: validating non-reporting in routine data using a health facility service assessment survey. BMC Health Serv Res 2023; 23:306. [PMID: 36997953 PMCID: PMC10061357 DOI: 10.1186/s12913-023-09296-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 03/16/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND Understanding the availability of rapid diagnostic tests (RDTs) is essential for attaining universal health care and reducing health inequalities. Although routine data helps measure RDT coverage and health access gaps, many healthcare facilities fail to report their monthly diagnostic test data to routine health systems, impacting routine data quality. This study sought to understand whether non-reporting by facilities is due to a lack of diagnostic and/or service provision capacity by triangulating routine and health service assessment survey data in Kenya. METHODS Routine facility-level data on RDT administration were sourced from the Kenya health information system for the years 2018-2020. Data on diagnostic capacity (RDT availability) and service provision (screening, diagnosis, and treatment) were obtained from a national health facility assessment conducted in 2018. The two sources were linked and compared obtaining information on 10 RDTs from both sources. The study then assessed reporting in the routine system among facilities with (i) diagnostic capacity only, (ii) both confirmed diagnostic capacity and service provision and (iii) without diagnostic capacity. Analyses were conducted nationally, disaggregated by RDT, facility level and ownership. RESULTS Twenty-one per cent (2821) of all facilities expected to report routine diagnostic data in Kenya were included in the triangulation. Most (86%) were primary-level facilities under public ownership (70%). Overall, survey response rates on diagnostic capacity were high (> 70%). Malaria and HIV had the highest response rate (> 96%) and the broadest coverage in diagnostic capacity across facilities (> 76%). Reporting among facilities with diagnostic capacity varied by test, with HIV and malaria having the lowest reporting rates, 58% and 52%, respectively, while the rest ranged between 69% and 85%. Among facilities with both service provision and diagnostic capacity, reporting ranged between 52% and 83% across tests. Public and secondary facilities had the highest reporting rates across all tests. A small proportion of health facilities without diagnostic capacity submitted testing reports in 2018, most of which were primary facilities. CONCLUSION Non-reporting in routine health systems is not always due to a lack of capacity. Further analyses are required to inform other drivers of non-reporting to ensure reliable routine health data.
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Affiliation(s)
- Angela K Moturi
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Bibian N Robert
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Felix Bahati
- Health Services Research Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter M Macharia
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
| | - Emelda A Okiro
- Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
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Akech S, Nyamwaya B, Gachoki J, Ogero M, Kigo J, Maina M, Mutua E, Ooko E, Bejon P, Mwarumba S, Bahati F, Mvera B, Musyimi R, Onsare R, Hutter J, Tanui E, Wesangula E, Turner P, Dunachie S, Lucey O, McKnight J. The CINAMR (Clinical Information Network-Antimicrobial Resistance) Project: A pilot microbial surveillance using hospitals linked to regional laboratories in Kenya: Study Protocol. Wellcome Open Res 2022; 7:256. [PMID: 37786881 PMCID: PMC10541537 DOI: 10.12688/wellcomeopenres.18289.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/03/2022] [Indexed: 10/04/2023] Open
Abstract
Background: Antimicrobial resistance (AMR) is a global threat and is thought to be acute in low-and middle-income country (LMIC) settings, including in Kenya, but there is limited unbiased surveillance that can provide reliable estimates of its burden. Current efforts to build capacity for microbiology testing in Kenya are unlikely to result in systematic routine microbiological testing in the near term. Therefore, there is little prospect for microbiological support to inform clinical diagnoses nor for indicating the burden of AMR and for guiding empirical choice of antibiotics. Objective: We aim to build on an existing collaboration, the Clinical Information Network (CIN), to pilot microbiological surveillance using a 'hub-and-spoke' model where selected hospitals are linked to high quality microbiology research laboratories. Methods: Children admitted to paediatric wards of 12 participating hospitals will have a sample taken for blood culture at admission before antibiotics are started. Indication for blood culture will be a clinician's prescription of antibiotics. Samples will then be transported daily to the research laboratories for culture and antibiotic susceptibility testing and results relayed back to clinicians for patient management. The surveillance will take place for 6 months in each hospital. Separately, we shall conduct semi-structured interviews with frontline health workers to explore the feasibility and utility of this approach. We will also seek to understand how the availability of microbiology results might inform antibiotic stewardship, and as an interim step to the development of better national or regional laboratories linked to routine surveillance. Conclusions: If feasible, this approach is less costly and periodic 'hub-and-spoke' surveillance can be used to track AMR trends and to broadly guide empirical antibiotic guidance meaning it is likely to be more sustainable than establishing functional microbiological facilities in each hospital in a LMIC setting.
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Affiliation(s)
- Samuel Akech
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Brian Nyamwaya
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Jackline Gachoki
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Morris Ogero
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Joyce Kigo
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Michuki Maina
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Edna Mutua
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Ednah Ooko
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Philip Bejon
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Salim Mwarumba
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Felix Bahati
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Benedict Mvera
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Robert Musyimi
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
| | - Robert Onsare
- Kenya Medical Research Institute-Centre for Microbiology Research, Nairobi, Kenya
| | - Jack Hutter
- United States Army Medical Research Directorate-Africa/Kenya (USAMRD-A/K), Kombewa, Kenya
| | - Emmanuel Tanui
- Kenya Ministry of Health - AMR National Secretariat, Nairobi, Kenya
| | - Evelyn Wesangula
- Kenya Ministry of Health - AMR National Secretariat, Nairobi, Kenya
| | - Paul Turner
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Cambodia Oxford Medical Research Unit (COMRU), Angkor Hospital for Children, Siem Reap, Cambodia
| | - Susanna Dunachie
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Mahidol-Oxford Tropical Medicine Research Unit, University of Mahidol, Bangkok, Thailand
| | | | - Jacob McKnight
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - CINAMR Investigators
- Kenya Medical Research Institute-Wellcome Trust Research Programme, Kilifi, Kenya
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Kenya Medical Research Institute-Centre for Microbiology Research, Nairobi, Kenya
- United States Army Medical Research Directorate-Africa/Kenya (USAMRD-A/K), Kombewa, Kenya
- Kenya Ministry of Health - AMR National Secretariat, Nairobi, Kenya
- Cambodia Oxford Medical Research Unit (COMRU), Angkor Hospital for Children, Siem Reap, Cambodia
- Mahidol-Oxford Tropical Medicine Research Unit, University of Mahidol, Bangkok, Thailand
- Imperial College London, London, UK
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Bahati F, Mcknight J, Swaleh F, Malaba R, Karimi L, Ramadhan M, Kiptim PK, Okiro EA, English M. Reporting of diagnostic and laboratory tests by general hospitals as an indication of access to diagnostic laboratory services in Kenya. PLoS One 2022; 17:e0266667. [PMID: 35395040 PMCID: PMC8992978 DOI: 10.1371/journal.pone.0266667] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 03/24/2022] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Information on laboratory test availability and current testing scope among general hospitals in Kenya is not readily available. We sought to explore the reporting trends and test availability within clinical laboratories in Kenya over a 24-months period through analysis of the laboratory data reported in the District Health Information System (DHIS2). METHODS Monthly hospital laboratory testing data were extracted from the Kenyan DHIS2 between January 2018 and December 2019. We used the national laboratory testing summary tool (MoH 706) to identify the tests of interest among 204 general hospitals in Kenya. A local practitioner panel consisting of individuals with laboratory expertise was used to classify the tests as common and uncommon. We compared the tests on the MoH 706 template with the Essential Diagnostic List (EDL) of the World Health Organisation and further reclassified them into test categories based on the EDL for generalisability of our findings. Evaluation of the number of monthly test types reported in each facility and the largest number of tests ever reported in any of the 24 months were used to assess test availability and testing scope, respectively. RESULTS Out of the 204 general hospitals assessed, 179 (179/204) reported at least one of the 80 tests of interest in any of the 24 months. Only 41% (74/179) of the reporting hospitals submitted all their monthly DHIS2 laboratory reports for the entire 24 months. The median testing capacity across the hospitals was 40% with a wide variation in testing scope from one hospital laboratory to another (% IQR: 33.8-51.9). Testing scope was inconsistent within facilities as indicated by often large monthly fluctuations in the total number of recommended and EDL tests reported. Tests of anatomical pathology and cancer were the least reported with 4 counties' hospitals not reporting any cancer or anatomical pathology tests for the entire 24 months. CONCLUSION The current reporting of laboratory testing information in DHIS2 is poor. Monitoring access and utilisation of laboratory testing across the country would require significant improvements in consistency and coverage of routine laboratory test reporting in DHIS2. Nonetheless, the available data suggest unequal and intermittent population access to laboratory testing provided by general hospitals in Kenya.
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Affiliation(s)
- Felix Bahati
- Health Services Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Jacob Mcknight
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Fatihiya Swaleh
- Ministry of Health, Mama Lucy Kibaki Hospital, Nairobi, Kenya
| | - Rose Malaba
- Ministry of Health, Kakamega County Referral Hospital, Kakamega, Kenya
| | | | - Musa Ramadhan
- Ministry of Health, Nakuru Provincial General Hospital, Nakuru, Kenya
| | | | - Emelda A. Okiro
- Population Health Unit, KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Oxford Centre for Global Health Research, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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Bahati F, Kairu-Wanyoike S, Nzioki JM. Adherence to iron and folic acid supplementation during pregnancy among postnatal mothers seeking maternal and child healthcare at Kakamega level 5 hospital in Kenya: a cross-sectional study. Wellcome Open Res 2021; 6:80. [PMID: 34405117 PMCID: PMC8366300 DOI: 10.12688/wellcomeopenres.16699.2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 11/20/2022] Open
Abstract
Background: Maternal anaemia is a public health problem worldwide, and its aetiology is linked to iron deficiency. The high nutrient demand during pregnancy exacerbates the condition. To meet the increased nutritional demand, supplementation of iron and folic acid (IFA) is key. The supplements are provided freely to pregnant women during antenatal visits at public health facilities, however, their uptake and adherence in Kenya remain unacceptably low. Methods: A hospital-based cross-sectional study involving 241 postnatal mothers seeking maternal and child healthcare (MCH) care at Kakamega level 5 hospital was conducted. Both quantitative and qualitative data were collected. Quantitative data were collected from 241 eligible postnatal mothers, while qualitative data were obtained through key informant interviews with community health volunteers and healthcare providers. Results: There was a moderate adherence to IFA supplementation (60.6%) during pregnancy among postnatal mothers seeking MCH care at Kakamega level 5 hospital. Some of the reasons for non-adherence stated by the respondents included; IFA related side effects (41.3%), forgetfulness (37.3%) and bad smell of the IFA supplements (10.3%). Higher IFA adherence was noted among the primigravida participants (OR=2.704; 95% CI: 1.262, 5.793; p=0.010) compared to multigravida participants, and those with a higher knowledge level of anaemia (OR=3.215; 95% CI: 1.346, 7.68; p=0.009) compared to their counterparts with low anaemia knowledge. Other factors that showed correlation with IFA adherence were: IFA education, pregnancy counselling before conception and the number of antenatal care visits attained. Conclusion: There is a moderate adherence to IFA supplementation during pregnancy among mothers seeking MCH at Kakamega level 5 hospital. The greatest impediments of IFA compliance during pregnancy are IFA side effects, forgetfulness and the bad smell of the IFA tablets. Therefore, providing IFA education to pregnant mothers incorporated with probable ways of managing the IFA side effects would contribute to IFA supplementation adherence.
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Affiliation(s)
- Felix Bahati
- Health Services Research Unit, KEMRI Wellcome Trust, Nairobi, Nairobi, 43640-00100, Kenya
- Environmental Health and Disease Control, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Nairobi, 62 000 – 00200, Kenya
| | - Salome Kairu-Wanyoike
- Directorate of Veterinary Services, Ministry of Agriculture, Livestock, Fisheries and Cooperatives, Nairobi, Nairobi, Kangemi 00605, Kenya
| | - Japheth Mativo Nzioki
- Environmental Health and Disease Control, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Nairobi, 62 000 – 00200, Kenya
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Bahati F, Kairu-Wanyoike S, Nzioki JM. Adherence to iron and folic acid supplementation during pregnancy among postnatal mothers seeking maternal and child healthcare at Kakamega level 5 hospital in Kenya: a cross-sectional study. Wellcome Open Res 2021; 6:80. [PMID: 34405117 PMCID: PMC8366300 DOI: 10.12688/wellcomeopenres.16699.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/31/2021] [Indexed: 04/04/2024] Open
Abstract
Background: Maternal anaemia is a public health problem worldwide, and its aetiology is linked to iron deficiency. The high nutrient demand during pregnancy exacerbates the condition. To meet the increased nutritional demand, supplementation of iron and folic acid (IFA) is key. The supplements are provided freely to pregnant women during antenatal visits at public health facilities, however, their uptake and adherence in Kenya remain unacceptably low. Methods: A hospital-based cross-sectional study involving 241 postnatal mothers seeking maternal and child healthcare (MCH) care at Kakamega level 5 hospital was conducted. Both quantitative and qualitative data were collected. Quantitative data were collected from 241 eligible postnatal mothers, while qualitative data were obtained through key informant interviews with community health volunteers and healthcare providers. Results: There was a moderate adherence to IFA supplementation (60.6%) during pregnancy among postnatal mothers seeking MCH care at Kakamega level 5 hospital. Some of the reasons for non-adherence stated by the respondents included; IFA related side effects (41.3%), forgetfulness (37.3%) and bad smell of the IFA supplements (10.3%). Higher IFA adherence was noted among the primigravida participants (OR=2.704; 95% CI: 1.262, 5.793; p=0.010) compared to multigravida participants, and those with a higher knowledge level of anaemia (OR=3.215; 95% CI: 1.346, 7.68; p=0.009) compared to their counterparts with low anaemia knowledge. Other factors that showed correlation with IFA adherence were: IFA education, pregnancy counselling before conception and the number of antenatal care visits attained. Conclusion: There is a moderate adherence to IFA supplementation during pregnancy among mothers seeking MCH at Kakamega level 5 hospital. The greatest impediments of IFA compliance during pregnancy are IFA side effects, forgetfulness and the bad smell of the IFA tablets. Therefore, providing IFA education to pregnant mothers incorporated with probable ways of managing the IFA side effects would contribute to IFA supplementation adherence.
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Affiliation(s)
- Felix Bahati
- Health Services Research Unit, KEMRI Wellcome Trust, Nairobi, Nairobi, 43640-00100, Kenya
- Environmental Health and Disease Control, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Nairobi, 62 000 – 00200, Kenya
| | - Salome Kairu-Wanyoike
- Directorate of Veterinary Services, Ministry of Agriculture, Livestock, Fisheries and Cooperatives, Nairobi, Nairobi, Kangemi 00605, Kenya
| | - Japheth Mativo Nzioki
- Environmental Health and Disease Control, Jomo Kenyatta University of Agriculture and Technology, Nairobi, Nairobi, 62 000 – 00200, Kenya
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McKnight J, Wilson ML, Banning P, Paton C, Bahati F, English M, Fleming K. Effective coding is key to the development and use of the WHO Essential Diagnostics List. Lancet Digit Health 2021; 1:e387-e388. [PMID: 33323218 PMCID: PMC7613503 DOI: 10.1016/s2589-7500(19)30196-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/18/2019] [Accepted: 10/28/2019] [Indexed: 12/03/2022]
Affiliation(s)
- Jacob McKnight
- Oxford Health System Collaboration, University of Oxford, Oxford OX1 3SY, UK.
| | | | - Pamela Banning
- 3M Health Information Systems, Salt Lake City, UT, USA; LOINC, Regenstrief Institute, Indianapolis, IN, USA
| | - Chris Paton
- Oxford Health System Collaboration, University of Oxford, Oxford OX1 3SY, UK
| | - Felix Bahati
- KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Oxford Health System Collaboration, University of Oxford, Oxford OX1 3SY, UK; KEMRI-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Ken Fleming
- Oxford Health System Collaboration, University of Oxford, Oxford OX1 3SY, UK
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Bahati F, English M, Sayed S, Horton S, Odhiambo OA, Samatar AA, McKnight J. Information asymmetry in the Kenyan medical laboratory sector. Glob Health Action 2021; 14:1964172. [PMID: 34445946 PMCID: PMC8405108 DOI: 10.1080/16549716.2021.1964172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 07/30/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Important information about medical laboratory providers is not readily available to all patients, clinicians nor regulators in Kenya. This study was conducted as part of a wider project aiming to improve access to high quality diagnostics by addressing information asymmetries in the Kenyan market for laboratory services. OBJECTIVES The purpose of this study was to: 1) Gather pricing information for 49 common laboratory tests from medical laboratories in Nairobi, Kenya, noting where these prices were publicly available or withheld. 2) Assess patients' knowledge of testing information including: turnaround time, price, and test availability. METHOD This was a cross-sectional study where a mystery caller approach was used to survey 49 tests for turnaround time, price, and availability across 13 laboratories selected purposively. The mystery shopper survey was complemented by 251 patient exit interviews at two Kenyan hospitals to understand whether patients seeking laboratory tests in Nairobi had access to such information. All 251 patients were selected by convenience sampling. RESULTS We noted that 85% of the private laboratories did not disclose test prices and turnaround times to their patients. There was a wide range of prices on several key tests, with private in-facility laboratories charging an average test price of 468% of the average test price in public laboratories across all the 49 tests. We also found that many patients lacked key information regarding the tests they needed: 65% did not know the purpose of the test while 41% did not know the test price at all. CONCLUSION Under the current system, patients have limited access to information regarding the key criteria required to make a rational decision. This has a significant impact on the quality, price, and turnaround time (TAT) offered by the medical laboratories that operate in this dysfunctional market.
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Affiliation(s)
- Felix Bahati
- Health Services Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
| | - Mike English
- Health Services Research Unit, KEMRI Wellcome Trust Research Programme, Nairobi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - Shahin Sayed
- Department of Pathology, Aga Khan University Hospital, Nairobi, Kenya
| | - Susan Horton
- School of Public Health and Health Systems, University of Waterloo, Waterloo, Canada
| | - Onyango Abel Odhiambo
- Department of Regulatory Affairs, Kenya Medical Laboratory Technicians & Technologists Board, Nairobi, Kenya
| | - Abdulatif A Samatar
- Department of Regulatory Affairs, Kenya Medical Laboratory Technicians & Technologists Board, Nairobi, Kenya
| | - Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
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McKnight J, Wilson ML, Banning P, Paton C, Bahati F, English M, Fleming K. Use of LOINC for interoperability between organisations poses a risk to safety - Authors' reply. Lancet Digit Health 2020; 2:e570. [PMID: 33328085 PMCID: PMC7613542 DOI: 10.1016/s2589-7500(20)30247-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 09/02/2020] [Accepted: 09/21/2020] [Indexed: 12/03/2022]
Affiliation(s)
- Jacob McKnight
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK.
| | | | - Pamela Banning
- 3M Health Information Systems, Salt Lake City, UT, USA; LOINC, Regenstrief Institute, Indianapolis, IN, USA
| | - Chris Paton
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK
| | | | - Mike English
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK
| | - Ken Fleming
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 3SY, UK
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Chadeka EA, Nagi S, Cheruiyot NB, Bahati F, Sunahara T, Njenga SM, Hamano S. A high-intensity cluster of Schistosoma mansoni infection around Mbita causeway, western Kenya: a confirmatory cross-sectional survey. Trop Med Health 2019; 47:26. [PMID: 31015786 PMCID: PMC6463626 DOI: 10.1186/s41182-019-0152-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 03/21/2019] [Indexed: 08/19/2023] Open
Abstract
In Kenya, communities residing along the shores and islands of Lake Victoria bear a substantial burden of schistosomiasis. Although there is a school-based deworming program in place, the transmission of Schistosoma mansoni varies even at a fine scale. Given the focal nature of schistosomes’ transmission, we aim to identify areas with high intensity of S. mansoni infection in Mbita, Homabay County, western Kenya, for prioritized integrated control measures. Our findings confirm a high intensity of S. mansoni infection cluster around Mbita causeway. While the current efforts to curtail morbidity due to schistosomiasis through preventive chemotherapy in schools are crucial, fine-scale mapping of risk areas is necessary for specific integrated control measures.
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Affiliation(s)
- Evans Asena Chadeka
- 1Leading program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.,2Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.,3The Joint Usage/Research Center on Tropical Diseases, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Sachiyo Nagi
- 2Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.,3The Joint Usage/Research Center on Tropical Diseases, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Ngetich B Cheruiyot
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Felix Bahati
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Toshihiko Sunahara
- 3The Joint Usage/Research Center on Tropical Diseases, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.,5Department of Vector Ecology and Environment, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Sammy M Njenga
- 6Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Shinjiro Hamano
- 1Leading program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan.,2Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.,3The Joint Usage/Research Center on Tropical Diseases, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan.,Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
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Kijogi C, Kimura D, Bao LQ, Nakamura R, Chadeka EA, Cheruiyot NB, Bahati F, Yahata K, Kaneko O, Njenga SM, Ichinose Y, Hamano S, Yui K. Modulation of immune responses by Plasmodium falciparum infection in asymptomatic children living in the endemic region of Mbita, western Kenya. Parasitol Int 2018; 67:284-293. [PMID: 29353010 DOI: 10.1016/j.parint.2018.01.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Revised: 01/06/2018] [Accepted: 01/14/2018] [Indexed: 11/24/2022]
Abstract
Individuals living in malaria endemic areas become clinically immune after multiple re-infections over time and remain infected without apparent symptoms. However, it is unclear why a long period is required to gain clinical immunity to malaria, and how such immunity is maintained. Although malaria infection is reported to induce inhibition of immune responses, studies on asymptomatic individuals living in endemic regions of malaria are relatively scarce. We conducted a cross-sectional study of immune responses in asymptomatic school children aged 4-16years living in an area where Plasmodium falciparum and Schistosoma mansoni infections are co-endemic in Kenya. Peripheral blood mononuclear cells were subjected to flow cytometric analysis and cultured to determine proliferative responses and cytokine production. The proportions of cellular subsets in children positive for P. falciparum infection at the level of microscopy were comparable to the negative children, except for a reduction in central memory-phenotype CD8+ T cells and natural killer cells. In functional studies, the production of cytokines by peripheral blood mononuclear cells in response to P. falciparum crude antigens exhibited strong heterogeneity among children. In addition, production of IL-2 in response to anti-CD3 and anti-CD28 monoclonal antibodies was significantly reduced in P. falciparum-positive children as compared to -negative children, suggesting a state of unresponsiveness. These data suggest that the quality of T cell immune responses is heterogeneous among asymptomatic children living in the endemic region of P. falciparum, and that the responses are generally suppressed by active infection with Plasmodium parasites.
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Affiliation(s)
- Caroline Kijogi
- Division of Immunology, Department of Molecular Microbiology and Immunology, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Daisuke Kimura
- Division of Immunology, Department of Molecular Microbiology and Immunology, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Lam Quoc Bao
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University
| | - Risa Nakamura
- Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University
| | - Evans Asena Chadeka
- Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Nagasaki University Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Ngetich Benard Cheruiyot
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Nagasaki University Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Felix Bahati
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Nagasaki University Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Kazuhide Yahata
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Department of Protozoology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Osamu Kaneko
- Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Department of Protozoology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan
| | - Sammy M Njenga
- Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Yoshio Ichinose
- Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Nagasaki University Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Shinjiro Hamano
- Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University; Nagasaki University Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Katsuyuki Yui
- Division of Immunology, Department of Molecular Microbiology and Immunology, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan; Program for Nurturing Global Leaders in Tropical and Emerging Infectious Diseases, Graduate School of Biomedical Sciences, Nagasaki University, 1-12-4 Sakamoto, Nagasaki 852-8523, Japan.
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13
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Chadeka EA, Nagi S, Sunahara T, Cheruiyot NB, Bahati F, Ozeki Y, Inoue M, Osada-Oka M, Okabe M, Hirayama Y, Changoma M, Adachi K, Mwende F, Kikuchi M, Nakamura R, Kalenda YDJ, Kaneko S, Hirayama K, Shimada M, Ichinose Y, Njenga SM, Matsumoto S, Hamano S. Spatial distribution and risk factors of Schistosoma haematobium and hookworm infections among schoolchildren in Kwale, Kenya. PLoS Negl Trop Dis 2017; 11:e0005872. [PMID: 28863133 PMCID: PMC5599053 DOI: 10.1371/journal.pntd.0005872] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Revised: 09/14/2017] [Accepted: 08/14/2017] [Indexed: 11/19/2022] Open
Abstract
Background Large-scale schistosomiasis control programs are implemented in regions with diverse social and economic environments. A key epidemiological feature of schistosomiasis is its small-scale heterogeneity. Locally profiling disease dynamics including risk factors associated with its transmission is essential for designing appropriate control programs. To determine spatial distribution of schistosomiasis and its drivers, we examined schoolchildren in Kwale, Kenya. Methodology/Principal findings We conducted a cross-sectional study of 368 schoolchildren from six primary schools. Soil-transmitted helminths and Schistosoma mansoni eggs in stool were evaluated by the Kato-Katz method. We measured the intensity of Schistosoma haematobium infection by urine filtration. The geometrical mean intensity of S. haematobium was 3.1 eggs/10 ml urine (school range, 1.4–9.2). The hookworm geometric mean intensity was 3.2 eggs/g feces (school range, 0–17.4). Heterogeneity in the intensity of S. haematobium and hookworm infections was evident in the study area. To identify factors associated with the intensity of helminth infections, we utilized negative binomial generalized linear mixed models. The intensity of S. haematobium infection was associated with religion and socioeconomic status (SES), while that of hookworm infection was related to SES, sex, distance to river and history of anthelmintic treatment. Conclusions/Significance Both S. haematobium and hookworm infections showed micro-geographical heterogeneities in this Kwale community. To confirm and explain our observation of high S. haematobium risk among Muslims, further extensive investigations are necessary. The observed small scale clustering of the S. haematobium and hookworm infections might imply less uniform strategies even at finer scale for efficient utilization of limited resources. The World Health Organization is spearheading the war on neglected tropical diseases, including helminth infections, by encouraging its member states to intensify control efforts. This call has recently been answered in most endemic regions of helminthiasis and governments are scaling up chemotherapy-based control programs in collaboration with private and public partners. However, it is necessary to clearly understand factors driving local transmission dynamics of helminth infections to design effective control programs. Here, we conducted a cross-sectional survey of 368 primary schoolchildren in Kwale, Kenya, and identified factors associated with the intensity of Schistosoma haematobium and hookworm infections. The negative binomial generalized linear mixed model showed the intensity of S. haematobium infection was much higher among Muslims and schoolchildren from low socioeconomic status households. High intensity of hookworm infection was associated with sex, SES, distance to river and history of anthelmintic treatment. Our findings demonstrate considering social and cultural drivers of NTDs could be beneficial in designing of efficient control programs and expediting NTDs control.
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Affiliation(s)
- Evans Asena Chadeka
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Sachiyo Nagi
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Toshihiko Sunahara
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Department of Vector Ecology and Environment, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | | | - Felix Bahati
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Yuriko Ozeki
- Department of Bacteriology, Niigata University School of Medicine, Niigata, Japan
| | - Manabu Inoue
- Department of Bacteriology and Virology, Osaka-City University Graduate School of Medicine, Osaka, Japan
| | - Mayuko Osada-Oka
- Food Hygiene and Environmental Health Division of Applied Life Science, Graduate School of Life and Environmental Sciences, Kyoto Prefectural University, Kyoto, Japan
| | - Mayuko Okabe
- Department of Immunology, National Institute of Infectious Diseases, Tokyo, Japan
| | - Yukio Hirayama
- Department of Bacteriology, Niigata University School of Medicine, Niigata, Japan
| | - Mwatasa Changoma
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Keishi Adachi
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Department of Immunology, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Faith Mwende
- Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Mihoko Kikuchi
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Risa Nakamura
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Yombo Dan Justin Kalenda
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Department of Eco-Epidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Satoshi Kaneko
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
- Department of Eco-Epidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Kenji Hirayama
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Department of Immunogenetics, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Masaaki Shimada
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
- Department of Eco-Epidemiology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
| | - Yoshio Ichinose
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
| | - Sammy M. Njenga
- Eastern and Southern Africa Centre of International Parasite Control (ESACIPAC), Kenya Medical Research Institute (KEMRI), Nairobi, Kenya
| | - Sohkichi Matsumoto
- Department of Bacteriology, Niigata University School of Medicine, Niigata, Japan
| | - Shinjiro Hamano
- Leading Program, Graduate School of Biomedical Sciences, Nagasaki University, Nagasaki, Japan
- Department of Parasitology, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- The Joint Usage/Research Center on Tropical Disease, Institute of Tropical Medicine (NEKKEN), Nagasaki University, Nagasaki, Japan
- Nagasaki University, Kenya Research Station, NUITM-KEMRI Project, Nairobi, Kenya
- * E-mail:
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