COMMUNITY PERCEPTIONS OF SCHISTOSOMIASIS TRANSMISSION, PREVALENCE AND CONTROL IN RELATION TO AQUATIC HABITATS IN THE LAKE VICTORIA BASIN OF KENYA

BACKGROUND

Intestinal schistosomiasis caused by Schistosoma mansoni and urinary schistosomiasis caused by Schistosoma haematobium are widely distributed parasites in several localities of the Lake Victoria basin of Kenya, the former being more prevalent. In Kenya, transmission of the intestinal form of bilharzia (S. mansoni) tends to be closely confined to narrow zones along the shores of large bodies of water such as Lake Victoria where it is endemic and the intermediate host is found. The prevalence of S. mansoni along the Kenyan Lake Victoria basin ranges between 40% and 80%.

OBJECTIVE

To assess the community's knowledge and perceptions of schistosomiasis prevalence, transmission and control in relation to aquatic habitats in the Lake Victoria basin of Kenya.

DESIGN

Community-based cross-sectional study.

SETTING

The Kenyan Lake Victoria basin.

SUBJECTS

Two hundred and forty three individuals (both women and men residing in the beaches and surrounding areas) were interviewed about their knowledge and perceptions regarding schistosomiasis.

RESULTS

The community regarded schistosomiasis as a naturalistic disease not caused by supernatural forces but by an agent of contamination in water. Knowledge on schistosomiasis transmission and control was low, with 42% of the respondents having no idea on how schistosomiasis is contracted, while 22% and 18% of the respondents mentioned contact with contaminated water and drinking / eating dirty water / food, respectively. Most respondents were familiar with the snails' habitats, but had poor knowledge on aquatic plants harbouring snails, as 57% of the respondents did not know about aquatic plants being associated with schistosomiasis snails. Only 3% of the respondents associated snails with schistosomiasis transmission. Sixty percent (60%) of the respondents mentioned use of tablets and injections as means of treating schistosomiasis, while 38% had no idea how it is treated and 2% mentioned use of local herbs and services of medicine men.

CONCLUSION

Majority of Kenyan Lake Victoria basin inhabitants had little awareness about schistosomiasis despite high prevalence of the disease in the region. There is need to adapt prevention and control strategies to the people's livelihoods. There is also need to target the less advantaged members of the community such as women, uneducated and subsistence farmers for intense health education strategies aimed at increasing participation in the control of schistosomiasis. Study to elicit divergence between biomedical and local understandings of schistosomiasis/bilharzia is suggested.

Pyrethroid resistance in Anopheles gambiae s.s. and Anopheles arabiensis in western Kenya: phenotypic, metabolic and target site characterizations of three populations

Field and laboratory investigations revealed phenotypic, target site and metabolic resistance to permethrin in an Anopheles gambiae s.s. (Diptera: Culicidae) population in Bungoma District, a region in western Kenya in which malaria is endemic and rates of ownership of insecticide-treated bednets are high. The sensitivity of individual An. gambiae s.l. females as indicated in assays using World Health Organization (WHO) test kits demonstrated reduced mortality in response to permethrin, deltamethrin and bendiocarb. Estimated time to knock-down of 50% (KDT50 ) of the test population in Centers for Disease Control (CDC) bottle bioassays was significantly lengthened for the three insecticides compared with that in a susceptible control strain. Anopheles arabiensis from all three sites showed higher mortality to all three insecticides in the WHO susceptibility assays compared with the CDC bottle assays, in which they showed less sensitivity and longer KDT50 than the reference strain for permethrin and deltamethrin. Microplate assays revealed elevated activity of β-esterases and oxidases, but not glutathione-S-transferase, in An. gambiae s.s. survivors exposed to permethrin in bottle bioassays compared with knocked down and unexposed individuals. No An. arabiensis showed elevated enzyme activity. The 1014S kdr allele was fixed in the Bungoma An. gambiae s.s. population and absent from An. arabiensis, whereas the 1014F kdr allele was absent from all samples of both species. Insecticide resistance could compromise vector control in Bungoma and could spread to other areas as coverage with longlasting insecticide-treated bednets increases.

Bacteremia in Kenyan children presenting with malaria

Since the etiologies and clinical outcomes of bacteremia in children with Plasmodium falciparum infections, particularly in areas of holoendemic malaria transmission, are largely unexplored, blood cultures and comprehensive clinical, laboratory, hematological, and nutritional parameters for malaria-infected children (aged 1 to 36 months, n = 585 patients) were investigated at a rural hospital in western Kenya. After the exclusion of contaminant microorganisms, the prevalence of bacteremia was 11.7% in the cohort (n = 506), with nontyphoidal Salmonella spp. being the most common isolates (42.4%). Bacteremia was found to occur in a significantly higher proportion of females than males and was associated with elevated blood glucose concentrations and lowered malaria parasite and hemoglobin (Hb) levels compared to those in abacteremic participants. In addition, the incidences of respiratory distress and severe malarial anemia (SMA; Hb level of <6.0 g/dl) were nonsignificantly greater in children with bacteremia. Mortality was 8.5-fold higher in children with bacteremia. Multivariate logistic regression analyses revealed that bacteremia was significantly associated with reduced incidences of high-density parasitemia (HDP; ≥ 10,000/μl) and increased incidences of malnutrition (i.e., underweight; weight-for-age Z score of <-2 using the NCHS system). Since previous studies showed that bacteremia caused by Gram-negative organisms is associated with enhanced anemia and mortality, multivariate logistic regression was also performed separately for randomly age- and gender-matched children with bacteremia caused by Gram-negative organisms (n = 37) and for children found to be abacteremic (n = 74). These results revealed that the presence of bacteremia caused by Gram-negative organisms was significantly associated with reduced HDP, enhanced susceptibility to respiratory distress, SMA (Hb level of <6.0 g/dl), and being underweight (Z score, <-2). Data presented here from a region of holoendemic P. falciparum transmission demonstrate that although bacteremia is associated with reduced malaria parasitemia, a number of unfavorable clinical outcomes, including malnutrition, respiratory distress, anemia, and mortality, are elevated in children with bacteremia, particularly in cases of Gram-negative origin.

A supervised land cover classification of a western Kenya lowland endemic for human malaria: associations of land cover with larval Anopheles habitats

BACKGROUND

A supervised land cover classification was developed from very high resolution IKONOS satellite data and extensive ground truth sampling of a ca. 10 sq km malaria-endemic lowland in western Kenya. The classification was then applied to an investigation of distribution of larval Anopheles habitats. The hypothesis was that the distribution and abundance of aquatic habitats of larvae of various species of mosquitoes in the genus Anopheles is associated with identifiable landscape features.

RESULTS AND DISCUSSION

The classification resulted in 7 distinguishable land cover types, each with a distinguishable vegetation pattern, was highly accurate (89%, Kappa statistic = 0.86), and had a low rate of omission and commission errors. A total of 1,198 habitats and 19,776 Anopheles larvae of 9 species were quantified in samples from a rainy season, and 184 habitats and 582 larvae from a dry season. Anopheles gambiae s.l. was the dominant species complex (51% of total) and A. arabiensis the dominant species. Agricultural land covers (mature maize fields, newly cultivated fields, and pastured grasslands) were positively associated with presence of larval habitats, and were located relatively close to stream channels; whilst nonagricultural land covers (short shrubs, medium shrubs, tall shrubs, and bare soil around residences) were negatively associated with presence of larval habitats and were more distant from stream channels. Number of larval habitats declined exponentially with distance from streams. IKONOS imagery was not useful in direct detection of larval habitats because they were small and turbid (resembling bare soil), but was useful in localization of them through statistical associations with specific land covers.

CONCLUSION

A supervised classification of land cover types in rural, lowland, western Kenya revealed a largely human-modified and fragmented landscape consisting of agricultural and domestic land uses. Within it, larval habitats of Anopheles vectors of human malaria were associated with certain land cover types, of largely agricultural origin, and close to streams. Knowledge of these associations can inform malaria control to gather information on potential larval habitats more efficiently than by field survey and can do so over large areas.

Impact of sustained use of insecticide-treated bednets on malaria vector species distribution and culicine mosquitoes

Insecticide-treated bednets (ITNs) significantly reduce malaria vector populations. Susceptibility to ITNs differs by vector species, and culicine mosquitoes have not been shown to be significantly affected by the use of ITNs. We examined the impact of 2-4 yr of ITN use on malaria vector species distribution and culicine mosquitoes. Routine entomological surveillance was conducted in adjacent areas with and without ITNs from November 1999 to January 2002. Use of ITNs reduced the proportion of Anopheles gambiae Giles relative to Anopheles arabiensis Giles. The number of culicines per house was significantly lower in the ITN area than in the neighboring area. Changes in the An. gambiae sibling species distribution may help to explain apparent mosquito behavioral changes attributed to ITNs. Reductions in culicines by ITNs may have implications for community perceptions of ITN effectiveness and for control of other diseases such as lymphatic filariasis.

Progression of stunting and its predictors among school-aged children in western Kenya

OBJECTIVE

The objectives of this study were (1) to assess whether a cohort of school-aged children experiences progression of stunting over a 2-y-period of observation and (2) to identify baseline nutritional and body composition risk factors for the progression of stunting.

METHODS

As part of a large-scale, randomized controlled trial assessing the impact of insecticide-treated bednets (ITNs) on nutritional status, we longitudinally followed a cohort of school-aged children over a 2-y-period in western Kenya. Anthropometric measurements were made at four time points from which Z-scores for height-for-age (HAZ), weight-for-age (WAZ), and body mass index (BMIZ) were calculated. Two measures of body composition, upper arm fat area and upper arm muscle area, were derived from mid-upper arm circumference (MUAC) and triceps skinfold thickness.

RESULTS

Subjects experienced a mean change in HAZ from baseline to 9 months of -0.16 [-0.19, -0.13], from baseline to 16 months of -0.18 [-0.22, -0.15], and from baseline to 24 months of -0.36 [-0.41, -0.31]. Thus, the average individual's change in HAZ at the three follow-up time points is significantly less than zero, meaning that, on average, the cohort is deviating further from NCHS reference medians over time. The baseline nutritional measure that explained the greatest amount of variance in the progression of stunting was the upper arm muscle area Z-score (F=8.1; P=0.005).

CONCLUSIONS

This longitudinal study provides further evidence from a distinct ecological setting regarding the progression of undernutrition during middle childhood in the developing world. It suggests that school-aged children in the developing world do not experience catch-up growth or remain stable. Rather, they continue to deviate from NCHS standards, accruing greater height deficits with age. In addition, absolute lean body mass explained the most variability in the progression of stunting, which supports cross-sectional findings from other studies.

Maternal immune responses and risk of infant infection with HIV-1 after a short course Zidovudine in a cohort of HIV-1 infected pregnant women in rural Kenya

OBJECTIVE

To investigate the effects of short-course nucleoside reverse transcriptase inhibitor (Zidovudine, ZDW/AZT) on maternal immune responses and risk of infant infection with HIV-1 among rural-based mothers in western Kenya.

DESIGN

A prospective cohort study involving HIV-1 seropositive pregnant mothers and their infants.

SUBJECTS

One hundred and seven HIV-1 seropositive asymptomatic pregnant women and their infants.

METHODS

After informed consent, the women were enrolled at gestation age between 16-24 weeks. For cultural and economic reasons, all mothers were allowed to breast feed their infants. Short-course antepartum regime of AZT was administered to all mothers starting at 36 weeks gestation until start of labour. Maternal absolute CD4+ T cell subset assays were performed before 3rd trimester (about 36 weeks gestation) and after a 4-week therapy of AZT (at least one month post-nuptially). Infant HIV-1 status was determined by HIV-1 DNA polymerase chain reaction (PCR) on samples sequentially taken at 1, 2, 3, 4, 6 and 9 months and confirmed by serology at 18 months of age.

INTERVENTIONS

Antepartum short-course orally administered AZT: 300mg twice-daily starting at 36 weeks gestation until start of labour, 300mg at labour onset and 300mg every three hours during labour until delivery.

MAIN OUTCOME MEASURES

Maternal CD4+ T cell counts before and after AZT treatment. Determination of infant HIV-1 infection status.

RESULTS

Among 107 women sampled, only 59 received full dose of AZT and thus qualified for present analysis. Of these, 12 infected their children with HIV, while 47 did not. Comparison of CD4+ T cells before and after AZT treatment scored a significant rise in all mothers (P = 0.01). This increase in CD4+ T cells was not significant among mothers who infected their infants with HIV-1 (P = 0.474). However, a significant rise in CD4+ T cells following AZT therapy was observed only in mothers who did not transmit HIV-1 to their infants (P=0.014).

CONCLUSION

These data suggest that a rise in the CD4+ T cell counts following short AZT regimen, now widely in use in resource-weak countries, may be evidence of the active suppression of the replication of HIV. However, further studies to examine the multi-factorial effect of CD4+ lymphocytes and pregnancy on MTCT of HIV need to be carried out to help fully explain the effect of AZT on immune response and whether the CD4+T cell count can be used as a true test of immunological normalisation during antiretroviral therapy.

Identification of a point mutation in the voltage-gated sodium channel gene of Kenyan Anopheles gambiae associated with resistance to DDT and pyrethroids

A field trial of permethrin-impregnated bednets and curtains was initiated in Western Kenya in 1990, and a strain of Anopheles gambiae showing reduced susceptibility to permethrin was colonized from this site in 1992. A leucine-phenylalanine substitution at position 1014 of the voltage-gated sodium channel is associated with resistance to permethrin and DDT in many insect species, including Anopheles gambiae from West Africa. We cloned and sequenced a partial sodium channel cDNA from the Kenyan permethrin-resistant strain and we identified an alternative substitution (leucine to serine) at the same position, which is linked to the inheritance of permethrin resistance in the F(2) progeny of genetic crosses between susceptible and resistant individuals. The diagnostic polymerase chain reaction (PCR) developed by Martinez-Torres et al. [(1998) Insect Mol Biol 7: 179-184] to detect kdr alleles in field populations of An. gambiae will not detect the Kenyan allele and hence reliance on this assay may lead to an underestimate of the prevalence of pyrethroid resistance in this species. We adapted the diagnostic PCR to detect the leucine-serine mutation and with this diagnostic we were able to demonstrate that this kdr allele was present in individuals collected from the Kenyan trial site in 1986, prior to the introduction of pyrethroid-impregnated bednets. The An. gambiae sodium channel was physically mapped to chromosome 2L, division 20C. This position corresponds to the location of a major quantitative trait locus determining resistance to permethrin in the Kenyan strain of An. gambiae.

Molecular entomology and prospects for malaria control

During the past decade, the techniques of molecular and cell biology have been embraced by many scientists doing research on anopheline vectors of malaria parasites. Some of the most important research advances in molecular entomology have concerned the development of sophisticated molecular tools for procedures such as genetic and physical mapping and germ line transformation. Major advances have also been made in the study of specific biological processes such as insect defence against pathogens and the manner in which malaria parasites and their anopheline hosts interact during sporogony. One of the most important highlights of this research trend has been the emergence during the past year of a formal international Anopheles gambiae genome project, which at present includes investigators in several laboratories in Europe and the USA. Although much of this molecular research is directed towards the development of malaria control strategies that are probably many years from implementation, there are some important areas of molecular entomology that may have a more near-term impact on malaria control. We highlight developments over the past decade in three such areas that we believe can make important contributions to the development of near-term malaria control strategies. These areas are anopheline species identification, the detection and monitoring of insecticide susceptibility/resistance in wild anopheline populations and the determination of the genetic structure of anopheline populations.

Elevated oxidase and esterase levels associated with permethrin tolerance in Anopheles gambiae from Kenyan villages using permethrin-impregnated nets

The permethrin tolerance (PT) of a population of the mosquito Anopheles gambiae (Diptera: Culicidae) increased following the introduction of permethrin-impregnated nets for malaria control in certain villages near Kisumu, western Kenya. Using a biochemical test that indirectly measures oxidases associated with permethrin resistance, we found that this population had higher oxidase levels than a comparison population from villages without impregnated nets. Mosquitoes from a colony of An. gambiae selected for PT, the RSP (reduced susceptibility to permethrin) strain, were exposed to permethrin with or without the oxidase inhibitor piperonyl butoxide (PB). Significantly higher mortality rates occurred when permethrin was synergized by PB, presumably by suppression of oxidases responsible for PT. An unselected (UNS) colony of An. gambiae that was more susceptible than RSP in a permethrin-susceptibility bioassay (i.e. LT50 22 min for UNS, vs. 42min for RSP) was compared with the RSP colony for levels of oxidases and esterases. The levels of both enzymes were very significantly higher in the RSP strain (P<0.0001). We speculate that use of impregnated nets selected for higher oxidase and esterase levels in An. gambiae to metabolize permethrin acquired from the nets. Both oxidase and esterase mechanisms could confer cross-resistance to other pyrethroids.

Knowledge and attitudes to malaria control and acceptability of permethrin impregnated sisal curtains

OBJECTIVES

The objectives of this study were to conduct a survey on the knowledge and practices relating to malaria prevention and treatment in two rural communities in Western Kenya, and to determine the acceptability of specially designed permethrin impregnated sisal strands curtains previously introduced into one of the study communities as barriers to mosquito biting.

DESIGN

A knowledge, attitudes and practices (KAP) survey was conducted by pre-trained interviewers using a pre-tested questionnaire.

SETTING

The study was conducted in two communities located 15 km northwest of Kisumu town, and next to the swamps bordering Lake Victoria in Kisumu District, Western Kenya.

PARTICIPANTS

Adult individuals from 50 houses selected from the intervention, and 50 houses from the control sites were included in the study.

RESULTS

Both communities had a clear conception of malaria and its symptoms, and of the mosquito as its vector. Malaria was recognised as a potential cause of death by 44% and 72% of the participants in the intervention and control sites respectively. Sixty two per cent to 74% of the people interviewed in both sites named mosquitoes as the causative agents of malaria. Chloroquine was still the drug of choice for malaria treatment, with over 70% usage among the study population. Mention of pyrimethamine/sulfadoxine and pyrimethamine/sulfalene as alternative therapy was below five per cent. Despite a high level (86%) of awareness of bednets as effective barriers to mosquito biting, they were reported in use by less than 35% in both communities. Sisal strand curtains were considered effective and acceptable to more than 80% of the community.

CONCLUSIONS

The results of this study underscore the existing need for affordable means of mosquito control, such as sisal strand curtains, for such rural communities which may be acutely aware of the problems associated with malaria, but are constrained from taking any action by lack of resources.

Some observations on the biting behavior of Anopheles gambiae s.s., Anopheles arabiensis, and Anopheles funestus and their implications for malaria control

Studies were carried out in three villages in western Kenya on the biting behavior of Anopheles gambiae s.s., Anopheles arabiensis, and Anopheles funestus. Blood feeding behavior and departure from houses were studied under the impact of permethrin-impregnated eaves-sisal curtains. Only 2-13% of the female vector population was collected biting before 2200 hr. Over 90% of the villagers went to bed by 2100 hr. An. funestus was 6.6-8.2 times more likely to bite people indoors than outdoors, while An. gambiae s.l. females were only 2 times as likely. Under the influence of permethrin-impregnated sisal curtains placed under the eaves of village houses, there was a marked egress of blood-fed An. funestus and An. gambiae s.s. Permethrin seems to have induced exophily of half-gravid female An. gambiae s.s. While An. gambiae s.s. remained highly anthropophagic under the impact of permethrin, An. funestus shifted to feeding more on cattle. An arabiensis were largely zoophilic. Our results underline the difficulties of controlling An. gambiae s.s., the principal African malaria vector. New strategies must be found to control this vector.

Some emerging issues on the malaria problem in Kenya

Malaria in Kenya has been characterised by marked variability in its epidemiology, partly reflecting the obstacles and progress made in the control strategies. The impact of anti-vector activities in the 1970s and before have been observed for variable lengths of time afterwards. Malaria has re-emerged in areas previously with little or no transmission. The recovery of infective Anopheles gambiae vector in higher altitudes affirms the potential for transmission in areas where epidemics have been known to occur. Morbidity and mortality patterns in the otherwise endemic lowlands have become increasingly severe, an observation which would be attributed to the increasing inefficacy of chloroquine. Efforts to promote personal protection suffer substantial setbacks in sustainability inspite of apparent acceptability. There are indications that the mosquito vector susceptibility to permethrin and other insecticides will now require continual monitoring in order to detect development of significant resistance. In this communication, we review some emergent issues in malaria transmission in Kenya and the potential for control as adduced from historical and contemporary perspectives.

Long-term use of permethrin-impregnated nets does not increase Anopheles gambiae permethrin tolerance

Previous use of permethrin-impregnated bednets (mosquito nets) and curtains in four Kenyan villages for one year, 1990-91, raised the permethrin LT50 of Anopheles gambiae to 2.4-fold above its baseline value, designated permethrin tolerance (PT), as measured by exposure to 0.25% permethrin-impregnated papers in W.H.O. test-kits. During 1992-93, with ongoing use of permethrin-impregnated nets and curtains, PT regressed slightly compared with the contemporary susceptibility level of An.gambiae from non-intervention villages, to 1.8-fold in 1992 and only 1.6-fold in 1993. Thus the selection pressure of impregnated nets for PT in An.gambiae appears to be minimal in our study villages, although the impact of permethrin was demonstrated by a significantly lower parous-rate of An.gambiae females in the intervention (63-66%) than in non-intervention (79%) villages, and by reduced malaria transmission (reported elsewhere). In a selected stock of An.gambiae from the study area, PT did not affect the susceptibility to deltamethrin, fenitrothion, propoxur or DDT. Bioassays described herein provide easy procedures for field-monitoring of mosquito susceptibility/tolerance/resistance to insecticides used for net impregnation in operational programmes.

Small-scale field evaluation of the monomolecular surface film 'Arosurf MSF' against Anopheles arabiensis Patton

A field trial was conducted to test the insecticidal action of the monolayer surface film 'Arosurf MSF' applied by knapsack sprayers, against larvae and pupae of Anopheles arabiensis Patton in a rice irrigation scheme in Western Kenya. Larval and pupal densities and the number of emerging adults were determined by dipping and emergence cages respectively. Application of the monolayer by knapsack sprayers provided good coverage. There were high daily mortalities of the fourth instar larvae, with no adult emergence from 'Arosurf MSF' treated plots compared to lower fourth instar mortalities and continuous adult emergence from untreated control plots, indicating the potential of the monolayer for control of An. arabiensis mosquitoes in rice fields.

Reduced susceptibility of Anopheles gambiae to permethrin associated with the use of permethrin-impregnated bednets and curtains in Kenya

Susceptibility of the malaria vector Anopheles gambiae to permethrin decreased following the installation of mosquito nets impregnated with 0.5 g permethrin per square metre in four villages near Kisumu, Kenya. During the first year that permethrin-impregnated bednets and curtains were in place, the exposure time to 50% mortality (LT50) increased 2.5-fold from 13 to 33 min, while the LT50 for An.gambiae was unchanged in two other villages where no intervention measures were used. Two years after permethrin-impregnated mosquito nets were distributed the LT50s for An.gambiae were 28, 28 and 16 min, respectively, in the villages with bednets, curtains and with no such intervention. Using a colony of An.gambiae derived from females collected in the villages using permethrin-impregnated mosquito nets, we lengthened the LT50 from 28 to 41 min in two generations by exposing all females to permethrin-treated papers for 60 min and rearing offspring of the survivors. Permethrin-impregnated bednets and curtains are intended to reduce vectorial capacity. Reduced susceptibility to permethrin could counter this beneficial effect.