New Vibrio cholerae sequences from Eastern and Southern Africa alter our understanding of regional cholera transmission

Despite ongoing containment and vaccination efforts, cholera remains prevalent in many countries in sub-Saharan Africa. Part of the difficulty in containing cholera comes from our lack of understanding of how it circulates throughout the region. To better characterize regional transmission, we generated and analyzed 118 Vibrio cholerae genomes collected between 2007-2019 from five different countries in Southern and Eastern Africa. We showed that V. cholerae sequencing can be successful from a variety of sample types and filled in spatial and temporal gaps in our understanding of circulating lineages, including providing some of the first sequences from the 2018-2019 outbreaks in Uganda, Kenya, Tanzania, Zambia, and Malawi. Our results present a complex picture of cholera transmission in the region, with multiple lineages found to be co-circulating within several countries. We also find evidence that previously identified sporadic cases may be from larger, undersampled outbreaks, highlighting the need for careful examination of sampling biases and underscoring the need for continued and expanded cholera surveillance across the African continent.

Prioritizing interventions for cholera control in Kenya, 2015-2020

Kenya has experienced cholera outbreaks since 1971, with the most recent wave beginning in late 2014. Between 2015-2020, 32 of 47 counties reported 30,431 suspected cholera cases. The Global Task Force for Cholera Control (GTFCC) developed a Global Roadmap for Ending Cholera by 2030, which emphasizes the need to target multi-sectoral interventions in priority cholera burden hotspots. This study utilizes the GTFCC's hotspot method to identify hotspots in Kenya at the county and sub-county administrative levels from 2015 through 2020. 32 of 47 (68.1%) counties reported cholera cases during this time while only 149 of 301 (49.5%) sub-counties reported cholera cases. The analysis identifies hotspots based on the mean annual incidence (MAI) over the past five-year period and cholera's persistence in the area. Applying a MAI threshold of 90th percentile and the median persistence at both the county and sub-county levels, we identified 13 high risk sub-counties from 8 counties, including the 3 high risk counties of Garissa, Tana River and Wajir. This demonstrates that several sub-counties are high level hotspots while their counties are not. In addition, when cases reported by county versus sub-county hotspot risk are compared, 1.4 million people overlapped in the areas identified as both high-risk county and high-risk sub-county. However, assuming that finer scale data is more accurate, 1.6 million high risk sub-county people would have been misclassified as medium risk with a county-level analysis. Furthermore, an additional 1.6 million people would have been classified as living in high-risk in a county-level analysis when at the sub-county level, they were medium, low or no-risk sub-counties. This results in 3.2 million people being misclassified when county level analysis is utilized rather than a more-focused sub-county level analysis. This analysis highlights the need for more localized risk analyses to target cholera intervention and prevention efforts towards the populations most vulnerable.

Characterization of COVID-19 cases in the early phase (March to July 2020) of the pandemic in Kenya

Background

Kenya detected the first case of COVID-19 on March 13, 2020, and as of July 30, 2020, 17 975 cases with 285 deaths (case fatality rate (CFR) = 1.6%) had been reported. This study described the cases during the early phase of the pandemic to provide information for monitoring and response planning in the local context.

Methods

We reviewed COVID-19 case records from isolation centres while considering national representation and the WHO sampling guideline for clinical characterization of the COVID-19 pandemic within a country. Socio-demographic, clinical, and exposure data were summarized using median and mean for continuous variables and proportions for categorical variables. We assigned exposure variables to socio-demographics, exposure, and contact data, while the clinical spectrum was assigned outcome variables and their associations were assessed.

Results

A total of 2796 case records were reviewed including 2049 (73.3%) male, 852 (30.5%) aged 30-39 years, 2730 (97.6%) Kenyans, 636 (22.7%) transporters, and 743 (26.6%) residents of Nairobi City County. Up to 609 (21.8%) cases had underlying medical conditions, including hypertension (n = 285 (46.8%)), diabetes (n = 211 (34.6%)), and multiple conditions (n = 129 (21.2%)). Out of 1893 (67.7%) cases with likely sources of exposure, 601 (31.8%) were due to international travel. There were 2340 contacts listed for 577 (20.6%) cases, with 632 contacts (27.0%) being traced. The odds of developing COVID-19 symptoms were higher among case who were aged above 60 years (odds ratio (OR) = 1.99, P = 0.007) or had underlying conditions (OR = 2.73, P < 0.001) and lower among transport sector employees (OR = 0.31, P < 0.001). The odds of developing severe COVID-19 disease were higher among cases who had underlying medical conditions (OR = 1.56, P < 0.001) and lower among cases exposed through community gatherings (OR = 0.27, P < 0.001). The odds of survival of cases from COVID-19 disease were higher among transport sector employees (OR = 3.35, P = 0.004); but lower among cases who were aged ≥60 years (OR = 0.58, P = 0.034) and those with underlying conditions (OR = 0.58, P = 0.025).

Conclusion

The early phase of the COVID-19 pandemic demonstrated a need to target the elderly and comorbid cases with prevention and control strategies while closely monitoring asymptomatic cases.

Reduction in malaria burden following the introduction of indoor residual spraying in areas protected by long-lasting insecticidal nets in Western Kenya, 2016-2018

Background

Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the main malaria vector control measures deployed in Kenya. Widespread pyrethroid resistance among the primary vectors in Western Kenya has necessitated the re-introduction of IRS using an organophosphate insecticide, pirimiphos-methyl (Actellic® 300CS), as a pyrethroid resistance management strategy. Evaluation of the effectiveness of the combined use of non-pyrethroid IRS and LLINs has yielded varied results. We aimed to evaluate the effect of non-pyrethroid IRS and LLINs on malaria indicators in a high malaria transmission area.

Methods

We reviewed records and tallied monthly aggregate of outpatient department (OPD) attendance, suspected malaria cases, those tested for malaria and those testing positive for malaria at two health facilities, one from Nyatike, an intervention sub-county, and one from Suba, a comparison sub-county, both located in Western Kenya, from February 1, 2016, through March 31, 2018. The first round of IRS was conducted in February–March 2017 in Nyatike sub-county and the second round one year later in both Nyatike and Suba sub-counties. The mass distribution of LLINs has been conducted in both locations. We performed descriptive analysis and estimated the effect of the interventions and temporal changes of malaria indicators using Poisson regression for a period before and after the first round of IRS.

Results

A higher reduction in the intervention area in total OPD, the proportion of OPD visits due to suspected malaria, testing positivity rate and annual malaria incidences were observed except for the total OPD visits among the under 5 children (59% decrease observed in the comparison area vs 33% decrease in the intervention area, net change -27%, P <0.001). The percentage decline in annual malaria incidence observed in the intervention area was more than twice the observed percentage decline in the comparison area across all the age groups. A marked decline in the monthly testing positivity rate (TPR) was noticed in the intervention area, while no major changes were observed in the comparison area. The monthly TPR reduced from 46% in February 2016 to 11% in February 2018, representing a 76% absolute decrease in TPR among all ages (RR = 0.24, 95% CI 0.12–0.46). In the comparison area, TPR was 16% in both February 2016 and February 2018 (RR = 1.0, 95% CI 0.52–2.09). A month-by-month comparison revealed lower TPR in Year 2 compared to Year 1 in the intervention area for most of the one year after the introduction of the IRS.

Conclusions

Our findings demonstrated a reduced malaria burden among populations protected by both non-pyrethroid IRS and LLINs implying a possible additional benefit afforded by the combined intervention in the malaria-endemic zone.

Contrasting Epidemiology of Cholera in Bangladesh and Africa

In Bangladesh and West Bengal cholera is seasonal, transmission occurs consistently annually. By contrast, in most African countries, cholera has inconsistent seasonal patterns and long periods without obvious transmission. Transmission patterns in Africa occur during intermittent outbreaks followed by elimination of that genetic lineage. Later another outbreak may occur because of reintroduction of new or evolved lineages from adjacent areas, often by human travelers. These then subsequently undergo subsequent elimination. The frequent elimination and reintroduction has several implications when planning for cholera's elimination including: a) reconsidering concepts of definition of elimination, b) stress on rapid detection and response to outbreaks, c) more effective use of oral cholera vaccine and WASH, d) need to readjust estimates of disease burden for Africa, e) re-examination of water as a reservoir for maintaining endemicity in Africa. This paper reviews major features of cholera's epidemiology in African countries which appear different from the Ganges Delta.

Laboratory and Field Evaluation of the Crystal VC-O1 Cholera Rapid Diagnostic Test

Cholera is a severe acute, highly transmissible diarrheal disease which affects many low- and middle-income countries. Outbreaks of cholera are confirmed using microbiological culture, and additional cases during the outbreak are generally identified based on clinical case definitions, rather than laboratory confirmation. Many low-resource areas where cholera occurs lack the capacity to perform culture in an expeditious manner. A simple, reliable, and low-cost rapid diagnostic test (RDT) would improve identification of cases allowing rapid response to outbreaks. Several commercial RDTs are available for cholera testing with two lines to detect either serotypes O1 and O139; however, issues with sensitivity and specificity have not been optimal with these bivalent tests. Here, we report an evaluation of a new commercially available cholera dipstick test which detects only serotype O1. In both laboratory and field studies in Kenya, we demonstrate high sensitivity (97.5%), specificity (100%), and positive predictive value (100%) of this new RDT targeting only serogroup O1. This is the first field evaluation for the new Crystal VC-O1 RDT; however, with these high-performance metrics, this RDT could significantly improve cholera outbreak detection and improve surveillance for better understanding of cholera disease burden.

A protracted cholera outbreak among residents in an urban setting, Nairobi county, Kenya, 2015

Introduction

in 2015, a cholera outbreak was confirmed in Nairobi county, Kenya, which we investigated to identify risk factors for infection and recommend control measures.

Methods

we analyzed national cholera surveillance data to describe epidemiological patterns and carried out a case-control study to find reasons for the Nairobi county outbreak. Suspected cholera cases were Nairobi residents aged >2 years with acute watery diarrhea (>4 stools/≤12 hours) and illness onset 1-14 May 2015. Confirmed cases had Vibrio cholerae isolated from stool. Case-patients were frequency-matched to persons without diarrhea (1:2 by age group, residence), interviewed using standardized questionaires. Logistic regression identified factors associated with case status. Household water was analyzed for fecal coliforms and Escherichia coli.

Results

during December 2014-June 2015, 4,218 cholera cases including 282 (6.7%) confirmed cases and 79 deaths (case-fatality rate [CFR] 1.9%) were reported from 14 of 47 Kenyan counties. Nairobi county reported 781 (19.0 %) cases (attack rate, 18/100,000 persons), including 607 (78%) hospitalisations, 20 deaths (CFR 2.6%) and 55 laboratory-confirmed cases (7.0%). Seven (70%) of 10 water samples from communal water points had coliforms; one had Escherichia coli. Factors associated with cholera in Nairobi were drinking untreated water (adjusted odds ratio [aOR] 6.5, 95% confidence interval [CI] 2.3-18.8), lacking health education (aOR 2.4, CI 1.1-7.9) and eating food outside home (aOR 2.4, 95% CI 1.2-5.7).

Conclusion

we recommend safe water, health education, avoiding eating foods prepared outside home and improved sanitation in Nairobi county. Adherence to these practices could have prevented this protacted cholera outbreak.

An outbreak of cholera in western Kenya, 2015: a case control study

Introduction

in February 2015, an outbreak of acute watery diarrhea was reported in two sub counties in western Kenya. Vibrio cholerae 01 serotype Ogawa was isolated from 26 cases and from water samples collected from a river mainly used by residents of the two sub-counties for domestic purposes. We carried out an investigation to determine factors associated with the outbreak.

Methods

we conducted a frequency matched case control study in the community. We defined cases as episodes of watery diarrhea (at least three motions in 24 hours) in persons ≥ 2 years who were residents of Rongo or Ndhiwa sub-counties from January 23-February 25, 2015. Cases were systematically recruited from a cholera line list and matched to two controls (persons without diarrhea since January 23, 2015) by age category and residence. A structured questionnaire was administered to evaluate exposures in cases and controls and multivariable logistic regression done to determine independent factors associated with the outbreak.

Results

we recruited 52 cases and 104 controls. Females constituted 61% (95/156) of all participants. Overall latrine coverage was 58% (90/156). Latrine coverage was 44% (23/52) for cases and 64% (67/104) for controls. Having no latrine at home (aOR = 10.9; 95% CI: 3.02-39.21), practicing communal hand washing in a basin (aOR = 6.5; 95% CI: 2.30-18.11) and vending of food as an occupation (aOR = 3.4; 95% CI: 1.06-10.74) were independently associated with the outbreak.

Conclusion

poor latrine coverage and personal hygiene practices were identified as the main drivers of the outbreak. We recommended improved public health education on latrine usage and promotion of hand washing with soap and water in the community.

Cholera Outbreak in Dadaab Refugee Camp, Kenya - November 2015-June 2016

Dadaab Refugee camp in Garissa County, Kenya, hosts nearly 340,000 refugees in five subcamps (Dagahaley, Hagadera, Ifo, Ifo2, and Kambioos) (1). On November 18 and 19, 2015, during an ongoing national cholera outbreak (2), two camp residents were evaluated for acute watery diarrhea (three or more stools in ≤24 hours); Vibrio cholerae serogroup O1 serotype Ogawa was isolated from stool specimens collected from both patients. Within 1 week of the report of index cases, an additional 45 cases of acute watery diarrhea were reported. The United Nations High Commissioner for Refugees and their health-sector partners coordinated the cholera response, community outreach and water, sanitation, and hygiene (WASH) activities; Médecins Sans Frontiéres and the International Rescue Committee were involved in management of cholera treatment centers; CDC performed laboratory confirmation of cases and undertook GIS mapping and postoutbreak response assessment; and the Garissa County Government and the Kenya Ministry of Health conducted a case-control study. To prevent future cholera outbreaks, improvements to WASH and enhanced disease surveillance systems in Dadaab camp and the surrounding area are needed.

Systems, supplies, and staff: a mixed-methods study of health care workers' experiences and health facility preparedness during a large national cholera outbreak, Kenya 2015

Background

From December 2014 to September 2016, a cholera outbreak in Kenya, the largest since 2010, caused 16,840 reported cases and 256 deaths. The outbreak affected 30 of Kenya’s 47 counties and occurred shortly after the decentralization of many healthcare services to the county level. This mixed-methods study, conducted June–July 2015, assessed cholera preparedness in Homa Bay, Nairobi, and Mombasa counties and explored clinic- and community-based health care workers’ (HCW) experiences during outbreak response.

Methods

Counties were selected based on cumulative cholera burden and geographic characteristics. We conducted 44 health facility cholera preparedness checklists (according to national guidelines) and 8 focus group discussions (FGDs). Frequencies from preparedness checklists were generated. To determine key themes from FGDs, inductive and deductive codes were applied; MAX software for qualitative data analysis (MAXQDA) was used to identify patterns.

Results

Some facilities lacked key materials for treating cholera patients, diagnosing cases, and maintaining infection control. Overall, 82% (36/44) of health facilities had oral rehydration salts, 65% (28/43) had IV fluids, 27% (12/44) had rectal swabs, 11% (5/44) had Cary-Blair transport media, and 86% (38/44) had gloves. A considerable number of facilities lacked disease reporting forms (34%, 14/41) and cholera treatment guidelines (37%, 16/43). In FDGs, HCWs described confusion regarding roles and reporting during the outbreak, which highlighted issues in coordination and management structures within the health system. Similar to checklist findings, FGD participants described supply challenges affecting laboratory preparedness and infection prevention and control. Perceived successes included community engagement, health education, strong collaboration between clinic and community HCWs, and HCWs’ personal passion to help others.

Conclusions

The confusion over roles, reporting, and management found in this evaluation highlights a need to adapt, implement, and communicate health strategies at the county level, in order to inform and train HCWs during health system transformations. International, national, and county stakeholders could strengthen preparedness and response for cholera and other public health emergencies in Kenya, and thereby strengthen global health security, through further investment in the existing Integrated Disease Surveillance and Response structure and national cholera prevention and control plan, and the adoption of county-specific cholera control plans.

Late entry to HIV and AIDS care and treatment, Juba Teaching Hospital, Juba, South Sudan, 2013-2016

Late diagnosis of HIV and enrolment to care are global public health challenges. This study aimed to characterise late HIV diagnoses and initiation of treatment among patients at Juba Teaching Hospital (JTH) in South Sudan. We conducted a retrospective review of lab-confirmed HIV patients at JTH, 2013-2016. Demographic, clinical, and laboratory data were entered into and descriptive statistics were calculated using Microsoft Excel. We identified 401 patients, with mean age 33.71±4.54 years, 235 (59%) were female, 307 (77%) were late entry, 64 (16%) were lost to follow-up, and 57 (14%) died within 12 months of diagnosis. Among patients who presented late, 122 (57%) were female, and 112 (53%) were <34 years old. Among patients who died, 33 (58%) were male, and 52 (91%) had CD4 counts <350 cells/mm3 and World Health Organization (WHO) stage >2 at diagnosis. Late diagnosis of HIV infection is a significant public health problem in South Sudan, particularly for younger and female patients.

Etiology of bacterial meningitis: a cross-sectional study among patients admitted in a semi-urban hospital in Nairobi, Kenya

Introduction

bacterial meningitis, responsible for childhood morbidity and mortality, can also lead to permanent neurological disability among survivors. This study conducted from January to December, 2015 used standard bacteriological and molecular methods to investigate the etiology of three common causes of bacterial meningitis among hospitalized patients admitted at a semi-urban hospital in Nairobi, Kenya.

Methods

a total of 196 patients admitted at Mama Lucy Kibaki with clinically diagnosed meningitis were recruited into this cross-sectional study. Participants’ information was collected through patient interviews and abstraction of health records. Bacterial culture, gram stains and multiplex polymerase chain reaction (PCR) were used to investigate causes of bacterial meningitis from cerebrospinal fluid (CSF) samples. Characteristics such as age, gender, occupation, underlying conditions of patients with laboratory confirmed bacterial meningitis infection are described.

Results

among the 196 patients diagnosed with bacterial meningitis, the median age was 1 year (range 1 to 36 years) with 87.2% aged 1 to 4 years; 54.6% were males. Using PCR, 22 out of 196 (11.2%) samples had evidence suggesting a bacterial infection. These included 12/22 (54.5%) S. pneumonia, 7/22 (31.8%) N. meningitides and 3/22 (13.6%) H. influenza. From bacterial culture, four of 196 (2.1%) samples grew S. pneumonia. All three samples found positive for H. influenza were from male patients aged between 1 to 4 years.

Conclusion

of the three common causes evaluated, S. pneumonia was the most common cause of bacterial meningitis among patients from this region, particularly among infants. One older patient was diabetic, thereby highlighting the importance of pre-existing conditions. Although serotyping of bacteria was not done, under-vaccination might have played a role in the cases identified and ensuring complete and timely vaccination may prevent further cases of bacterial meningitis.

Male partner involvement in efforts to eliminate mother-to-child transmission of HIV in Kisumu County, Western Kenya, 2015

INTRODUCTION

male partner involvement in elimination of mother-to-child transmission (eMTCT) of HIV activities remains low in Western Kenya, despite its importance in reducing rates of child HIV transmission. We sought to identify factors associated with male partner involvement in eMTCT in Kisumu East sub-County, Western Kenya.

METHODS

we conducted a cross-sectional study among women aged ≥ 18 years who had children aged ≤ 12 months and were attending a child health clinic for immunization services in one of four Western Kenya health centers between February and April, 2015. We assessed male involvement using an "involvement index" of five factors of equal weight: partner antenatal care (ANC) attendance, partner HIV testing, partner financial support to the woman during ANC, partner awareness of ANC services and partner participation in decision making on contraception including condom use. Male involvement was classified as high or low based on their index score. We calculated odds ratios (OR) and 95% confidence intervals (CI) to identify factors associated with high male partner involvement.

RESULTS

we recruited 216 female participants. Mean age was 26.1 years (± 5.5 years), 189 (87.5%) were married. The majority (94.4%) had attended ANC in public health facilities. Nineteen percent of women had high male involvement. Having > 8 years of formal education (AOR 3.9, CI = 1.51-10.08), having male partner who was employed, history of previous couple testing (AOR = 3.2, CI = 1.42-7.22) and reports of partner having read the mother-child booklet during ANC (AOR = 2.9, CI = 1.30-6.49), were associated with high male involvement.

CONCLUSION

based on our findings, we recommend targeted strategies to actively sensitize men and encourage their involvement in eMTCT, particularly among partners of women with fewer years of education and among partners who are not employed.

Strengthening health systems in Africa: a case study of the Kenya field epidemiology training program for local frontline health workers

The logistical and operational challenges to improve public health practice capacity across Africa are well documented. This report describes Kenya's Field Epidemiology and Laboratory Training Program's (KFELTP) experience in implementing frontline public health worker training to transfer knowledge and practical skills that help strengthen their abilities to detect, document, respond to, and report unusual health events. Between May 2014 and May 2015, KFELTP hosted five training courses across the country to address practice gaps among local public health workers. Participants completed a 10-week process: two 1-week didactic courses, a 7-week field project, and a final 1-week course to present and defend the findings of their field project. The first year was a pilot period to determine whether the program could fit into the existing 2-year KFELTP model and whether this frontline-level training would have an impact on local practice. At the end of the first year, KFELTP certified 167 frontline health workers in field epidemiology and data management. This paper concludes that local, national, and international partnerships are critical for improving local public health response capacity and workforce development training in an African setting.

Factors associated with malaria microscopy diagnostic performance following a pilot quality-assurance programme in health facilities in malaria low-transmission areas of Kenya, 2014

BACKGROUND

Malaria accounts for ~21% of outpatient visits annually in Kenya; prompt and accurate malaria diagnosis is critical to ensure proper treatment. In 2013, formal malaria microscopy refresher training for microscopists and a pilot quality-assurance (QA) programme for malaria diagnostics were independently implemented to improve malaria microscopy diagnosis in malaria low-transmission areas of Kenya. A study was conducted to identify factors associated with malaria microscopy performance in the same areas.

METHODS

From March to April 2014, a cross-sectional survey was conducted in 42 public health facilities; 21 were QA-pilot facilities. In each facility, 18 malaria thick blood slides archived during January-February 2014 were selected by simple random sampling. Each malaria slide was re-examined by two expert microscopists masked to health-facility results. Expert results were used as the reference for microscopy performance measures. Logistic regression with specific random effects modelling was performed to identify factors associated with accurate malaria microscopy diagnosis.

RESULTS

Of 756 malaria slides collected, 204 (27%) were read as positive by health-facility microscopists and 103 (14%) as positive by experts. Overall, 93% of slide results from QA-pilot facilities were concordant with expert reference compared to 77% in non-QA pilot facilities (p < 0.001). Recently trained microscopists in QA-pilot facilities performed better on microscopy performance measures with 97% sensitivity and 100% specificity compared to those in non-QA pilot facilities (69% sensitivity; 93% specificity; p < 0.01). The overall inter-reader agreement between QA-pilot facilities and experts was κ = 0.80 (95% CI 0.74-0.88) compared to κ = 0.35 (95% CI 0.24-0.46) between non-QA pilot facilities and experts (p < 0.001). In adjusted multivariable logistic regression analysis, recent microscopy refresher training (prevalence ratio [PR] = 13.8; 95% CI 4.6-41.4), ≥5 years of work experience (PR = 3.8; 95% CI 1.5-9.9), and pilot QA programme participation (PR = 4.3; 95% CI 1.0-11.0) were significantly associated with accurate malaria diagnosis.

CONCLUSIONS

Microscopists who had recently completed refresher training and worked in a QA-pilot facility performed the best overall. The QA programme and formal microscopy refresher training should be systematically implemented together to improve parasitological diagnosis of malaria by microscopy in Kenya.

Antimicrobial resistance: capacity and practices among clinical laboratories in Kenya, 2013

Introduction

Antimicrobial resistance is neglected in developing countries; associated with limited surveillance and unregulated use of antimicrobials. Consequently, delayed patient recoveries, deaths and further antimicrobial resistance occur. Recent gastroenteritis outbreak at a children's home associated with multidrug resistant non-typhoidal Salmonella spp, raised concerns about the magnitude of the problem in Kenya, prompting antimicrobial resistance assessment preceding surveillance system establishment.

Methods

Eight public medical laboratories were conveniently selected. Questionnaires were administered to key informants to evaluate capacity, practice and utilization of antimicrobial susceptibility tests. Retrospective review of laboratory records determined antimicrobial resistance to isolates. Antimicrobial resistance was defined as resistance of a microorganism to an antimicrobial agent to which it was previously sensitive and multidrug resistance as non-susceptibility to at least one agent in three or more antimicrobial categories.

Results

The laboratories comprised; 2(25%) national, 4(50%) sub-national and 2(25%) district. Overall, antimicrobial susceptibility testing capacity was inadequate in all. Seven (88%) had basic capacity for stool cultures, 3(38%) had capacity for blood culture. Resistance to enteric organisms was observed with the following and other commonly prescribed antimicrobials, ampicillin: 40(91%) Salmonella spp isolates; Tetracycline: 16(84%) Shigella flexineri isolates; cotrimoxazole: 20(100%) Shigella spp isolates, 24(91%) Salmonella spp isolates. Comparable patterns of multidrug resistance were evident with Shigella flexineri and Salmonella typhimurium. Ten (100%) clinicians reported not using laboratory results for patient management, for various reasons.