Training needs for mid-level managers and immunisation coverage in Western Kenya

OBJECTIVES

To determine the current status of immunisation coverage in Western Kenya before intervention, to identify strengths and weaknesses of the existing programme in order to design educational interventions that could improve the services provided and find out the training needs of the mid-level managers of Kenya Expanded Programme of Immunisation.

DESIGN

Cross-sectional descriptive study.

SETTING

All thirty nine districts in Rift Valley, Western and Nyanza provinces.

SUBJECTS

Mid-level managers of Kenya Expanded Programme on Immunisation in the 39 districts and the provinces. These included Provincial Logisticians, Provincial Medical Officers of Health, District Medical Officers of Health, District Public Health Nurses, District Records and Health Information Officers, District Disease Surveillance Officers, and District Public Health Officers.

MAIN OUTCOME MEASURES

Number of staff trained on EPI, coverage rates and perceived training needs of the mid-level managers.

RESULTS

A total of eighty eight mid-level managers participated in the interviews. Most of these were District Public Health Nurses (40.9%) and District Health Information and Records Officers (23.9%). Only 49 (25%) of the District Health Management Team members had undergone training at the supervisory level. Eighteen districts (43.6%) had no member of the District Health Management Team that had ever been trained at the supervisory level. Using rates of Pentavalent 1 and measles coverage, Nyanza Province had the highest immunisation dropout rate (Pentavalent 1--measles) whereas Rift Valley Province had the lowest. The annual cumulative coverage for all the provinces by antigen was 80% for Pentavalent 1 and 2 and 60% for measles. The most requested need for inclusion in the training curriculum was maintenance of the cold chain equipment.

CONCLUSIONS

Most of the members in the study area have not been trained on Expanded Programme on Immunisation and may be ill-equipped to manage the complicated programmes needed to maximise delivery of services. The immunisation coverage in this area is low while the dropout rates are high. We therefore recommend that all the mid-level managers of Expanded Programme on Immunisation in this area be trained comprehensively through the Merck Vaccine Network--Africa programme using the World Health Organisation approved mid-level managers course.

High levels of TNF, soluble TNF receptors, soluble ICAM-1, and IFN-gamma, but low levels of IL-5, are associated with hepatosplenic disease in human schistosomiasis mansoni

In a case-control study based in two areas of Kenya, hepatosplenic schistosomiasis mansoni was shown to be linked with low levels of IL-5 and with correspondingly high IFN-gamma, TNF, and circulating soluble TNF receptor I (sTNFR-I), sTNFR-II, and sICAM-1. PBMC from the hepatosplenic cases responded to in vitro Ag stimulation with significantly higher levels of IFN-gamma and TNF, but lower levels of IL-5, compared with nonhepatosplenic controls matched for age and infection intensity. Most of these correlations were confounded by differences between geographical areas. However, principle component analysis identified a high IFN-gamma and TNF, and low IL-5 axis in the data as the first principle component; this was significantly associated with hepatosplenomegaly (p < 0.0005) even after controlling for area. High plasma levels of sTNFR-I (p < 0.001), sTNFR-II, (p < 0.0001), and sICAM-1 (p < 0.009) were also significantly associated with hepatosplenomegaly, independently of area, in the case of the soluble forms of both TNF receptors. These parameters were negatively related to IL-5. These results suggest that proinflammatory cytokines are involved in the hepatosplenic disease process in infected individuals who have low anti-inflammatory Th2 responses and that sTNFR may be a useful circulating marker for this disease process, perhaps reflecting the level of TNF activity in hepatic tissues.

Immunity after treatment of human schistosomiasis: association between cellular responses and resistance to reinfection

Previous studies have demonstrated the development of an age-dependent resistance to reinfection after chemotherapeutic cure of the helminthic parasite Schistosoma mansoni. Here we report on a longitudinal investigation of cell-mediated responses in infected individuals before and after treatment which was designed to outline those parameters important in mediating a protective response. A well-defined study group of 89 individuals with an age range of 9 to 35 years was selected from an area of high S. mansoni transmission in the Machakos district of Kenya. Peripheral blood mononuclear cell proliferation and cytokine production (interleukin-2 [IL-2], gamma interferon IL-5, IL-4, and tumor necrosis factor) in response to different crude life cycle-stage antigens of S. mansoni were assessed longitudinally in vitro before, 3 months after, and 1 year after treatment. Detailed statistical analyses of the results from this study have indicated a clear negative association between the proliferative responses to adult- and schistosomulum-stage antigens and subsequent reinfection intensity in older individuals (14 to 35 years) which was not present in the younger individuals (9 to 13 years). This association was significant even after the effects of age, sex, and exposure had been accounted for in multiple regression analyses. Cytokines were detected predominantly in response to adult worm and egg antigen extracts. An inverse association between the two cytokines gamma interferon and IL-5 was detected in response to all antigens at the three time points investigated, indicating cross-regulation in the production of these two mediators. Differences in antigen-specific cytokine levels between the two age groups were detected, with significantly higher IL-5 levels detected in the older (more resistant) age group. An inverse correlation between this cytokine and reinfection was detected but could not be dissociated from the effects of age and exposure in multiple regression analysis.

Enhancement of eosinophil-mediated cytotoxicity to schistosomula of Schistosoma mansoni by autologous mononuclear cells from patients

Adherent mononuclear cells (monolayer), when co-cultured with autologous peripheral blood eosinophils isolated from patients treated for Schistosoma mansoni infections, enhanced the eosinophil-mediated killing of antibody coated schistosomula. The monolayer increased the activity of the eosinophils by 225%, and was observed in 80% of the patients studied. Heat labile factors other than complement, present in immune serum, further enhanced the ability of eosinophils to kill schistosomula in the presence of the monolayer. On their own the adherent cells did not mediate obvious damage to the parasite. Eosinophils that had been pre-incubated with the monolayer (100 mins) and tested separately, killed equal numbers of schistosomula as in the co-culture assay; this excludes the possibility of concurrent schistosomula cytotoxicity by the two cell populations. The ability of the monolayer to activate eosinophils was not altered by inhibitors of protein synthesis. The monolayer was largely consistent of monocytes as demonstrated by an over 96% positive staining for non-specific esterases.

Immune responses after treatment for Schistosoma mansoni infections

The changes in the immune responses of patients before and at 3 weeks after treatment with anti-schistosomal drugs were investigated. Lymphocyte responses to Concanavalin A and to worm antigens were inhibited after treatment, whereas responses to cercarial and egg antigens remained unchanged. Eosinophil levels were significantly elevated after treatment and were positively correlated with the increase in anti-worm antibodies (r = 0.587), and negatively associated with anti-egg antibodies (r = -0.727). Although the eosinophil-dependent cytotoxicity to schistosomula was not significantly enhanced after treatment, some increased killing was evident of half the patients (7/15). On the other hand, the ability of adherent mononuclear cells to stimulate eosinophil functions was markedly enhanced by treatment (P less than 0.001). These studies suggest that treatment may enhance some of the potentially protective host's immune mechanisms.

Eosinophilia and eosinophil helminthotoxicity in patients treated for Schistosoma mansoni infections

The changes in eosinophil levels and in eosinophil-mediated antibody-dependent schistosomular cytotoxicity, following treatment for Schistosoma mansoni infections, have been investigated in 2 similar groups of patients aged 15-50 years. Patients in group 1 were treated with either hycanthone or oxamniquine, and those in group 2 with hycanthone or praziquantel. Eosinophil levels were significantly increased in both groups. In group 1 peripheral blood eosinophil counts rose from a mean of 175/microliters before treatment to 745/microliters 3 weeks after treatment, and in group 2 from 181/microliters to 1066/microliters. The increase in eosinophil levels was positively correlated with a rise in circulating anti-adult worm antibodies (r = -0.587, P less than 0.05), whereas a negative correlation was recorded with anti-egg antibodies (r = -0.727). Despite some enhanced eosinophil helminthotoxicity following treatment in some of the individuals in group 1 (7/15), the change overall was not significant. In group 2, in which a different standard anti-schistosomular antibody was used, the eosinophil killing capacity recorded at 3 weeks was lower than that before commencement of treatment (t = 2.89, P less than 0.01). The eosinophil stimulating activity, detected in cultured mononuclear cell supernatants (MCS) from individual patients, correlated with eosinophil levels (r = 0.582, P less than 0.02) but there was no association with eosinophil killing. MCS activity did not appear to be boosted by treatment. These studies showed that peripheral blood eosinophil counts were increased following treatment, but their ability to kill schistosome larvae is variable and may depend on the immune serum used as the source of anti-schistosomular antibody.

Molluscicidal activity of Solanum aculeatum (family: Solanaceae) berries against Biomphalaria pfeifferi, Bulinus globosus and Lymnaea natalensis

Aqueous suspensions of powder of sun- or freeze-dried berries of the plant Solanum aculeatum (Family Solanaceae), indigenous in Kenya, were tested for molluscicidal activity against Biomphalaria pfeifferi, Bulinus globosus and Lymnaea natalensis under laboratory conditions. One hundred or 50 mg powder L-1 of sun- or freeze-dried berries killed over 60% of the test B. pfeifferi, Bul. globosus and L. natalensis. Whereas 25 mg L-1 of the sun dried material killed less than 60% of the test snails, similar concentrations of the freeze dried molluscicide produced 60-80% mortality in the snails, under similar conditions. Using L. natalensis as the target snail, it was shown that the freeze dried material was more potent than the freeze-dried berries of S. incanum, S. nigrum or leaves of Polygonum senegalensis (Family Polygonaceae), all present in Kenya, and known to possess molluscicidal properties. The powdered material retained molluscicidal activity even after several months storage at room temperature. These findings suggest that S. aculeatum is a potent plant molluscicide, and has the potential for the control of vectors of schistosomiasis and fascioliasis in Kenya.