Bio

BRIEF PROFILE

I am Professor of Paediatrics and Child Health with specialization in Newborn Medicine. I presently hold several high level portfolios in several institutions.  At the University of  Nairobi (where I am full time employee) I am Dean School of Medicine supervising about 3000 students and over 500 members of staff alongside my teaching duties. I also support the Ministry of Health on several national committees in various areas of child health. I am also holding the office of Acting Principal, College of Health Sciences.

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Publications


2017

Gharial, J, Laving A, Were F.  2017.  Racecadotril for the treatment of severe acute watery diarrhoea in children admitted to a tertiary hospital in Kenya. BMJ Open Gastroenterol. 4(1) AbstractWebsite

Background

Diarrhoea is the second most common cause of death in children under 5 years of age in Kenya. It is usually treated with oral rehydration, zinc and continued feeding. Racecadotril has been in use for over 2 decades; however, there is a paucity of data regarding its efficacy from Africa.
Objectives

The objectives of this study were: to compare the number of stools in the first 48 hours in children with severe gastroenteritis requiring admission and treated with either racecadotril or placebo, to study the impact of racecadotril on duration of inpatient stay as well as duration of diarrhoea and to describe the side effect profile of racecadotril.
Methods

This was a randomised, double-blinded, placebo-controlled trial. It enrolled children between the age of 3 and 60 months who were admitted with severe acute gastroenteritis. They received either racecadotril or placebo in addition to oral rehydration solution (ORS) and zinc and were followed up daily.
Results

120 children were enrolled into the study. There were no differences in the demographics or outcomes between the 2 groups. Stools at 48 hours: median (IQR) of 5 (3–7) and 5 (2.5–7.5), respectively; p=0.63. The duration of inpatient stay: median (IQR): 4 days (1.5–6.5) and 4.5 (1.8–6.3); p=0.71. The duration of illness: 3 days (2–4) and 2 days (1–3); p=0.77. The relative risk of a severe adverse event was 3-fold higher in the drug group but was not statistically significant (95% CI 0.63 to 14.7); p=0.16.
Conclusions

Racecadotril has no impact on the number of stools at 48 hours, the duration of hospital stay or the duration of diarrhoea in children admitted with severe gastroenteritis and managed with ORS and zinc

English, M, Ayieko P, Nyamai R, Were F, Githanga D, Grace Irimu, R W Nduati.  2017.  What do we think we are doing? How might a clinical information network be promoting implementation of recommended paediatric care practices in Kenyan hospitals? Health Res Policy Syst.. 15(4) AbstractWebsite

Background

The creation of a clinical network was proposed as a means to promote implementation of a set of recommended clinical practices targeting inpatient paediatric care in Kenya. The rationale for selecting a network as a strategy has been previously described. Here, we aim to describe network activities actually conducted over its first 2.5 years, deconstruct its implementation into specific components and provide our ‘insider’ interpretation of how the network is functioning as an intervention.
Methods

We articulate key activities that together have constituted network processes over 2.5 years and then utilise a recently published typology of implementation components to give greater granularity to this description from the perspective of those delivering the intervention. Using the Behaviour Change Wheel we then suggest how the network may operate to achieve change and offer examples of change before making an effort to synthesise our understanding in the form of a realist context–mechanism–outcome configuration.
Results

We suggest our network is likely to comprise 22 from a total of 73 identifiable intervention components, of which 12 and 10 we consider major and minor components, respectively. At the policy level, we employed clinical guidelines, marketing and communication strategies with intervention characteristics operating through incentivisation, persuasion, education, enablement, modelling and environmental restructuring. These might influence behaviours by enhancing psychological capability, creating social opportunity and increasing motivation largely through a reflective pathway.
Conclusions

We previously proposed a clinical network as a solution to challenges implementing recommended practices in Kenyan hospitals based on our understanding of theory and context. Here, we report how we have enacted what was proposed and use a recent typology to deconstruct the intervention into its elements and articulate how we think the network may produce change. We offer a more generalised statement of our theory of change in a context–mechanism–outcome configuration. We hope this will complement a planned independent evaluation of ‘how things work’, will help others interpret results of change reported more formally in the future and encourage others to consider further examination of networks as means to scale up improvement practices in health in lower income countries.

Gathara, D, Malla L, Ayieko P, Karuri S, Nyamai R, Grace Irimu, R W Nduati.  2017.  Variation in and risk factors for paediatric inpatient all-cause mortality in a low income setting: data from an emerging clinical information network. BMC Pediatrics. AbstractWebsite

BACKGROUND Hospital mortality data can inform planning for health interventions and may help optimize resource allocation if they are reliable and appropriately interpreted. However such data are often not available in low income countries including Kenya. METHODS Data from the Clinical Information Network covering 12 county hospitals' paediatric admissions aged 2-59 months for the periods September 2013 to March 2015 were used to describe mortality across differing contexts and to explore whether simple clinical characteristics used to classify severity of illness in common treatment guidelines are consistently associated with inpatient mortality. Regression models accounting for hospital identity and malaria prevalence (low or high) were used. Multiple imputation for missing data was based on a missing at random assumption with sensitivity analyses based on pattern mixture missing not at random assumptions. RESULTS The overall cluster adjusted crude mortality rate across hospitals was 6 · 2% with an almost 5 fold variation across sites (95% CI 4 · 9 to 7 · 8; range 2 · 1% - 11 · 0%). Hospital identity was significantly associated with mortality. Clinical features included in guidelines for common diseases to assess severity of illness were consistently associated with mortality in multivariable analyses (AROC =0 · 86). CONCLUSION All-cause mortality is highly variable across hospitals and associated with clinical risk factors identified in disease specific guidelines. A panel of these clinical features may provide a basic common data framework as part of improved health information systems to support evaluations of quality and outcomes of care at scale and inform health system strengthening efforts.

English, MM, Irimu GG, Nyamai RR, Were FF, Garner PP, Opiyo NN, F W.  2017.  Developing guidelines in low-income and middle-income countries: lessons from Kenya. Arch Dis Child. 1(6) AbstractWebsite

There are few examples of sustained nationally organised, evidence-informed clinical guidelines development processes in Sub-Saharan Africa. We describe the evolution of efforts from 2005 to 2015 to support evidence-informed decision making to guide admission hospital care practices in Kenya. The approach to conduct reviews, present evidence, and structure and promote transparency of consensus-based procedures for making recommendations improved over four distinct rounds of policy making. Efforts to engage important voices extended from government and academia initially to include multiple professional associations, regulators and practitioners. More than 100 people have been engaged in the decision-making process; an increasing number outside the research team has contributed to the conduct of systematic reviews, and 31 clinical policy recommendations has been developed. Recommendations were incorporated into clinical guideline booklets that have been widely disseminated with a popular knowledge and skills training course. Both helped translate evidence into practice. We contend that these efforts have helped improve the use of evidence to inform policy. The systematic reviews, Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approaches and evidence to decision-making process are well understood by clinicians, and the process has helped create a broad community engaged in evidence translation together with a social or professional norm to use evidence in paediatric care in Kenya. Specific sustained efforts should be made to support capacity and evidence-based decision making in other African settings and clinical disciplines.

Osano, BO, Were F, Mathews S.  2017.  Mortality among 5-17 year old children in Kenya . PanAfrican Medical Journal. AbstractWebsite

Introduction: global mortality trends have changed over time and are expected to continue changing with a reduction in communicable diseases and an increase of non-communicable disease. Increased survival of children beyond five years may change mortality patterns for these children. There are few studies in Africa that explore the causes of mortality in children over five years. The objective of this study was to determine the mortality rate and clinical profiles of children aged 5-17 years who died in six Kenyan hospitals in 2013.
 
Methods: retrospective review of patients’ medical records to abstract data on diagnosis for those who died in year 2013. Data was analysed to provide descriptive statistics and explored differences in mortality rates between age groups and gender.
 
Results: we retrieved 4,520 patient records. The in-hospital mortality rate was 3.5% (95%CI 3.0-4.1) with variations in deaths between the ages and gender. Among the deaths, 60% suffered from communicable diseases, maternal and nutritional causes; 41.3% suffered from non-communicable diseases. A further 11.9% succumbed to traumatic injuries. The predominant clinical diagnoses among patients who died were HIV/AIDS, respiratory tract infections and malaria.
 
Conclusion: infectious causes had the highest proportion of diagnoses among children aged 5-17 years who died.

2016

Nshimirimana, DA, Uwurukundo JMC, Kokonya D, Biraboneye P, Were F, Baribwira C.  2016.  Pain Assessment among African Neonates. American Journal of Pediatrics. 2(2) AbstractWebsite

Neonates who require treatment and venous drawing of blood samples in the newborn units are subjected to acute and painfully invasive procedures. Several tools to assess pain among newborns have been developed and are widely used in developed countries, but in Africa, there is limited experience in the assessment pain among newborns. This study assessed physiological and behavioral responses to pain among neonates during invasive procedures performed in a newborn unit in Rwanda. A total of 60 neonates born at gestational age of 28-42 weeks at the National University of Rwanda Teaching and Referral Hospital in the year 2005 were enrolled into this study. Blood pressures, heart and respiratory rates, oxygen saturation levels, the Neonatal Facing Coding System (NFCS) and Neonatal Acute Pain (APN) pain tools were and scores recorded before, immediately and 5, 10, 15 and 20 minutes after procedures were recorded. Physiological parameters were compared using the Wilcoxon Signed Ranks Test while the NFCS and APN were compared using the McNemar Test. All (100%) neonates experienced acutely peak pain in the first 5 minutes of the invasive procedures with peak responses recorded at 2.5 minutes and no pain (resolution) after 15 minutes among 81% of the neonates and only 6% experienced pain after 20 minutes. The increases in systolic blood pressures immediately after inflicting pain, 5, 10, 15 and 20 minutes were statistically significant (p<0.001, p<0.001, p<0.005 and p<0.046) respectively compared to the diastolic blood pressures whose significant increases were at 5 and 10 minutes, (p<0.001 and p<0.001) respectively. Respiratory rates were significantly high at the onset (p<0.001), 5 minutes (p<0.001) and 10 minutes later (p<0.002). Heart rates significantly increased at the onset of the procedures (p<0.000), 5 minutes (p<0.001) and after 10 minutes (p<0.033). Decrease in oxygen saturation immediately after the procedures was significant (p<0.001). Oxygen saturation immediately after the procedures significantly increased up to 5 minutes (p<0.001) and 10 minutes (p<0.001). Invasive procedures caused acute pain among neonates in the African settings but to date, neonatal practice had not been given its due consideration with the aim of reducing pain among African neonates.

Keywords: Pain, Assessment, Neonates, Physiological, APN, NFCS, Africa

English, M, Grace Irimu, R W Nduati, Agweyu A, Gathara D, Oliwa J, Ayieko P, Were F, Paton C, Tunis S, Forrest CB.  2016.  Building Learning Health Systems to Accelerate Research and Improve Outcomes of Clinical Care in Low- and Middle-Income Countries. PLOS Medicine. 10(1371) Abstractbuilding_learning_health_systems_to_accelerate_research_and_improve_outcomes_of_clinical_care_in_low-_and_middle-income_countries.pdf

Achieving universal coverage that supports high-quality care will require that health systems are designed to integrate the delivery of health services with the generation of new knowledge about the effectiveness of these services.
System strengthening and research will need to be better integrated to achieve this in low- and middle-income countries (LMIC) so that changes in coverage, quality, and impact are measured, costs are contained, and health systems are responsive to users’ needs and concerns.
In high-income countries, learning health systems (LHS) are emerging to meet similar needs. The LHS vision aspires to engage policy makers, researchers, service providers, and patients in learning that uses and strengthens routinely collected data to conduct pragmatic, contextually appropriate research, promote rapid adoption of findings to improve quality and outcomes, and promote continuous learning.
Although there are significant challenges, we should begin to develop LHS in LMIC for their immediate and longer term benefits and to avoid having to retrofit health systems with the capability to promote learning at a later date and even greater cost.
A global coalition on how to build LHS effectively that shares accumulating learning could enable such a strategy.

Stokx, J, Dochez C, Ochieng P, Bahl J, Were F.  2016.  Evaluation of a Training DVD on Pneumococcal Conjugate Vaccine for Kenyan EPI Healthcare Workers. Education for Health. 29(1) Abstractevaluation_of_a_training_dvd_on_pneumococcal_conjugate_vaccine_for_kenyan_epi_healthcare_workers.pdf

Background: The Kenyan Ministry of Public Health and Sanitation was the first in Africa to introduce the new 10‑valent Pneumococcal Conjugate Vaccine, PCV‑10, in 2011. For successful implementation and to avoid adverse events following immunisation, specific training on handling and storage of the PCV‑10 vaccine was required. Therefore, a training DVD was recorded in English and partly in Kiswahili to be used in combination with in‑classroom training. Since the Kenyan Immunisation Programme was the first to use a DVD for training healthcare workers, an evaluation was done to obtain feedback on content, format and use, and propose suggestions to improve quality and uptake of the DVD. Methods: Feedback was obtained from nurses and vaccinology course participants through the completion of a questionnaire. Nurses also participated in focus group discussions and trainers in key informant interviews. Results: Twelve trainers, 72 nurses and 26 international vaccinology course participants provided feedback, with so e notable differences between the three study groups. The survey results confirmed the acceptability of the content and format, and the feasibility of using the DVD in combination with in‑classroom teaching. To improve the quality and adoption of the DVD, key suggestions were: Inclusion of all EPI vaccines and other important health issues; broad geographic distribution of the DVD; and bilingual English/Kiswahili use of languages or subtitles. Discussion: The Kenyan DVD is appreciated by a heterogeneous and international audience rendering the DVD suitable for other Anglophone African countries. Differences between feedback from nurses and vaccinology course participants can be explained by the practical approach of the DVD and the higher education and service level of the latter. A drawback is the use of DVD players and televisions due to lack of electricity, but it is a matter of time before all rural health facilities in Africa will have access to electricity and modern technology.

Aluvaala, J, Nyamai R, Were F, Wasunna A, Kosgei R, Karumbi J, Gathara D, English M.  2016.  Assessment of neonatal care in clinical training facilities in Kenya. Arch Dis Child. (100):42-47. Abstractassessment_of_neonatal_care_in_clinical_training_facilities_in_kenya.pdf

Objective: An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.
Design: Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data. Setting Neonatal units of 22 public hospitals. Patients Neonates aged <7 days.
Main outcome measures: Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.
Results: All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented. Maternal HIV status was documented in 674/1249 (54%, 95% CI 41.9% to 66.1%) cases. Drug doses exceeded recommendations by >20% in prescriptions for penicillin (11.6%, 95% CI 3.4% to 32.8%) and gentamicin (18.5%, 95% CI 13.4% to 25%), respectively.
Conclusions: Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.

Were, F, Ayieko P, English M, Githanga D.  2016.  Characteristics of admissions and variations in the use of basic investigations, treatments and outcomes in Kenyan hospitals within a new Clinical Information Network . Archives of Diseases of Childhood. 101:223-229. Abstractarch_dis_child-2016-ayieko-223-9.pdf

Background Lack of detailed information about hospital activities, processes and outcomes hampers planning, performance monitoring and improvement in low-income countries (LIC). Clinical networks offer one means to advance methods for data collection and use, informing wider health system development in time, but are rare in LIC. We report baseline data from a new Clinical Information Network (CIN) in Kenya seeking to promote data-informed improvement and learning. Methods Data from 13 hospitals engaged in the Kenyan CIN between April 2014 and March 2015 were captured from medical and laboratory records. We use these data to characterise clinical care and outcomes of hospital admission. Results Data were available for a total of 30 042 children aged between 2 months and 15 years. Malaria (in five hospitals), pneumonia and diarrhoea/dehydration (all hospitals) accounted for the majority of diagnoses and comorbidity was found in 17 710 (59%) patients. Overall, 1808 deaths (6%) occurred (range per hospital 2.5%–11.1%) with 1037 deaths (57.4%) occurring by day 2 of admission (range 41%–67.8%). While malaria investigations are commonly done, clinical health workers rarely investigate for other possible causes of fever, test for blood glucose in severe illness or ascertain HIV status of admissions. Adherence to clinical guideline-recommended treatment for malaria, pneumonia, meningitis and acute severe malnutrition varied widely across hospitals. Conclusion Developing clinical networks is feasible with appropriate support. Early data demonstrate that hospital mortality remains high in Kenya, that resources to investigate severe illness are limited, that care provided and outcomes vary widely and that adoption of effective interventions remains slow. Findings suggest considerable scope for improving care within and across sites.

2015

FN, O, JP O, F W.  2015.  The challenges fraughting isoniazid prophylaxis as a child tuberculosis prevention strategy in high burden settings in Nairobi, Kenya. East and Central Africa Medical Journal. 2(1):39-45. Abstractthe_challenges_fraughting_isoniazid_prophylaxis_as_a_child_tuberculosis_prevention.pdf

Background: Paediatric Tuberculosis (TB) is rapidly becoming a major public health concern among the urban poor. Though contacts' tracing and Isoniazid Prophylaxis Therapy (lPT) is an effective prevention strategy, its benefits have not been realized in many resource poor settings. Barriers to its uptake have not been fully elucidated.
Objectives: To evaluate the challenges that fraught the implementation of' contact tracing and IPT, as a TB prevention strategy in children in household contact with adults with TB from informal settlements in Nairobi, Kenya.
Metbodology: A prospective longitudinal multicenter cohort study was done, where 366 recently diagnosed TB smear positive source cases were asked to enroll their child contacts for IPT. Consent was sought. Structured standard questionnaire was used to get information on source case TB treatment, socio-demographics, TB knowledge and perceptions. Baseline screening was done to exclude those with TB and/or other chronic illnesses. Contacts were then put on daily isoniazid for 6 months and followed up monthly for one year for new TB disease. Adherence, safety and challenges were monitored. Focused group discussions and key informant interviews were used to provide secondary data.
Results: All the 366 source cases interviewed were on first line anti- TB treatment. IPT acceptability was 87.3%. A total of 428 child contacts were screened, but 14(3.2%) had TB disease hence excluded. Compliance rates were 93% (95% CI 90.1 - 96.2%) and 85% (95% CI 80.2%- 88%) after 1'1and 6th months respectively. Challenges reported included; side effects in 22%, programmatic concerns in 86%, drug related issues in 70.1 %, and various health system challenges. The leading programmatic challenge was too many hospital visits (65.2%) and the drug related challenge was difficulty in administering tablets to children (44.3%). IPT completion rate was 368 out of 414 (88.8%). By endpoint, IPT failure was documented in 6( 1.6%), hence the relative risk of new TB disease in contacts on IPT was 0.49 (95% CI 0.21 -0.86).
Conclusion: IPTwas an effective and safe child TB prevention strategy in informal settlements, but it's implementation had been hampered by relatively low acceptability, sub-optimal adherence, programmatic challenges, and high defaulting rates and by limited benefits realized.

Otieno, SB, Were F, EW K, Waza K.  2015.  GENDER RELATED EFFECTS OF YEAST SELENIUM ON WEIGHT FOR AGE Z SCORE OF ASYMPTOMATIC HIV TYPE 1 POSITIVE CHILDREN AT NYAMASARIA IN KISUMU KENYA. International Journal of Current Advanced. 4(7):194-199. Abstractgender_related_effects_of_yeast_selenium_on_weight_for_age_z_score_of.pdf

Background: Selenoprotein Iodothyronine 5’Deiodonases activates pro-T3 to 3,3’- 5T3(Tri-iodothyronine) which is involved in growth through a gene mediated protein metabolism. Oestradiol (E2) enhances activity of selenoproteins in adult pre-menopausal women taking selenium supliments, however the effect of selenium supplementation on weight change of different gender of asymptomatic HIV positive pre-puberty children is still unknown.
Methods: In this study of 25 Females and 25 Males randomly chosen asymptomatic HIV positive children 3 – 16 years old, 25 of the children were given, a fixed dose of 50μg yeast selenium while a matched control of 25 were put on placebo. Weight of children were taken at 3 months intervals up to 6 months, using electronic personal scale (model 10010), the resultant data was analyzed by Epi Info version 6,and SPSS version 16.
Results: No significant difference in mean weight of children was observed at baseline between the controls and children on test . Children on selenium had weight increase of 2.5Kg at six months .The weight for age Z score increased above -2SDs cut off point at six months amongst the children on selenium, in all age categories, 3-5 years 1.20 ± 2.45, 6-8years 0.19 ± 0.880, 9-15 years 0.97 ± 1.22, while there was a decrease in all the age categories in matched controls to below -2SDs at six months , 3-5 years -2.218 ± 1.46, 6-8 years -2.95. ± 3.10, 9-15 -2.30 ± 1.240. There was a significant WAZ difference between controls and selenium group at six months {F (5,12) = =5.758, P=0.006}. Prevalence of underweight in control was 48% compared to the test group at 9% at six months. Female children on selenium initially had a decrease and then sharp increase in WAZ (Tick Phenomenon), compared to the males who had a steady increase in WAZ.
Conclusion: It can be concluded that intake of yeast Selenium led to significant improvement in weight for age Z score at six months and further that there is gender related differences in weight change between HIV positive asymptomatic female and male children taking selenium as a supplement

Gathara, D, Nyamai R, Were F, Mogoa W, Karumbi J, Kihuba E, Mwinga S, Aluvaala J, Mulaku M, Kosgei R, Todd J, Allen E, English M.  2015.  Moving towards Routine Evaluation of Quality of Inpatient Pediatric Care in Kenya. PLOS ONE. Abstractmoving_towards_routine_evaluation_of_quality_of_inpatient_pediatric_care_in_kenya.pdf

Background: Regular assessment of quality of care allows monitoring of progress towards system goals and identifies gaps that need to be addressed to promote better outcomes.We report efforts to initiate routine assessments in a low-income country in partnership with government.
Methods: A cross-sectional survey undertaken in 22 ‘internship training’ hospitals across Kenya that examined availability of essential resources and process of care based on review of 60 case-records per site focusing on the common childhood illnesses (pneumonia, malaria, diarrhea/ dehydration, malnutrition and meningitis).
Results: Availability of essential resources was 75% (45/61 items) or more in 8/22 hospitals. A total of 1298 (range 54–61) case records were reviewed. HIV testing remained suboptimal at 12% (95% CI 7–19). A routinely introduced structured pediatric admission record form improved documentation of core admission symptoms and signs (median score for signs 22/ 22 and 8/22 when form used and not used respectively). Correctness of penicillin and gentamicin dosing was above 85% but correctness of prescribed intravenous fluid or oral feed volumes for severe dehydration and malnutrition were 54% and 25% respectively. Introduction of Zinc for diarrhea has been relatively successful (66% cases) but use of artesunate for malaria remained rare. Exploratory analysis suggests considerable variability of the quality of care across hospitals.

Aluvaala, J, Okello D, Murithi G, Wafula L, Wanjala L, Isika N, Wasunna A, Were F, Nyamai R, English M.  2015.  Delivery outcomes and patterns of morbidity and mortality for neonatal admissions in five Kenyan hospitals. Journal of Tropical Pediatrics. (61):255–259. Abstractdelivery_outcomes_and_patterns_of_morbidity_and_mortality_for_neonatal_admissions_in_five_kenyan_hospitals.pdf

A cross-sectional survey was conducted in neonatal and maternity units of five Kenyan district public hospitals. Data for 1 year were obtained: 3999 maternal and 1836 neonatal records plus tallies of maternal deaths, deliveries and stillbirths. There were 40 maternal deaths [maternal mortality ratio: 276 per 100 000 live births, 95% confidence interval (CI): 197–376]. Fresh stillbirths ranged from 11 to 43 per 1000 births. A fifth (19%, 263 of 1384, 95% CI: 11–30%) of the admitted neonates died. Compared with normal birth weight, odds of death were significantly higher in all of the low birth weight (LBW, <2500 g) categories, with the highest odds for the extremely LBW (<1000 g) category (odds ratio: 59, 95% CI: 21–158, p<0.01). The observed maternal mortality, stillbirths and neonatal mortality call for implementation of the continuum of care approach to intervention delivery with particular emphasis on LBW babies.

2014

Warfa, O, Njai D, Ahmed L, Admani B, Were F, Osano B, Mburugu P, Mohamed M.  2014.  Evaluating the level of adherence to Ministry of Health guidelines in the management of Severe Acute Malnutrition at Garissa Provincial General hospital, Garissa, Kenya. Pan African Medical Journal. 17(214) Abstractevaluating_the_level_of_adherence_to_ministry_of_health_guidelines_in_the_management_of_severe_acute_malnutrition_at_garissa_provincial_general_hospital_garissa_kenya.pdf

Introduction: Half of Kenya's high infant and under five mortality rates is due to malnutrition. Proper implementation of World Health Organization's (WHO) Evidence Based Guidelines (EBG) in management of severe acute malnutrition can reduce mortality rates to less than 5%. The objectives were to establish the level of adherence to WHO guideline and the proportion of children appropriately managed for severe acute malnutrition (steps 1-8) as per the WHO protocol in the management of severe acute malnutrition. This was a short longitudinal study of 96 children, aged 6-59 months admitted to the pediatric ward with diagnosis of severe acute malnutrition. Methods: Data was extracted from patients' medical files and recorded into an audit tool to compare care provided in this hospital with WHO guidelines. Results: Non-edematous malnutrition was the commonest presentation (93.8%). A higher proportion (63.5%) of patients was male. Most (85.4%) of patients were younger than 2 years. Patients with non-edematous malnutrition were younger (mean age for non-edematous malnutrition was 16 (± 10.6) months versus 25 (± 13.7) months in edematous malnutrition). The commonest co- morbid condition was diarrhea (52.1%). Overall, 13 children died giving an inpatient case fatality rate of 13.5%. Appropriate management was documented in only 14.6% for hypoglycemia (step1), 5.2% for hypothermia (step 2) and 31.3% for dehydration (step 3). Conclusion: The level of adherence to MOH guidelines was documented in 5 out of the 8 steps. Appropriate management of children with severe acute malnutrition was inadequate at Garissa hospital

Gisore, P, Kaseje D, Were F, Ayuku D.  2014.  Motivational Interviewing Intervention on Health-Seeking Behaviors of Pregnant Women in Western Kenya. Applied Biobehavioral Research. 19(2):144-156. Abstract

We studied the effect of using Motivational Interviewing Intervention (MII) on health facility delivery and newborn care practices among pregnant women receiving Care of the Mother and Newborn at Home (CNH) visits by Community Health Workers (CHWs). Near-Term women who had received at least oneCHWhome visit, were randomly assigned to one session of MII (intervention) or no MII (Control). Fifty five (55%) of intervention women, compared to 35% of control women delivered in health facilities. Intervention women also understood the need to breastfeed exclusively for 6 months better than controls (P = 0.000), and had a p-value of 0.07 for breastfeeding within one hour after birth. We concluded in the context of CHW Home visit program, adding may improve perinatal care.

English, M, Gathara D, Mwinga S, Ayieko P, Opondo C, Aluvaala J, Kihuba E, Mwaniki P, Were F, Grace Irimu, R W Nduati, Wasunna A, Mogoa W, Nyamai R.  2014.  Adoption of recommended practices and basic technologies in a low-income setting. Arch Dis Child. (99):452–456.adoption_of_recommended_practices_and_basic_technologies_in_a_low-income_setting.pdf
Bandika, VL, Were FN, Simiyu ED, Oyatsi DP.  2014.  Hypoglycaemia and hypocalcaemia as determinants of admission birth weight criteria for term stable low risk macrosomic neonates. African Health Sciences. 14(3) Abstracthypoglycaemia_and_hypocalcaemia_as_determinants_of_admission_birth_weight_criteria_for_term_stable_low_risk_macrosomic_neonates.pdf

Background: Large for gestational age (LGA) accounts for about 6.3% of admissions in kenyatta national hospital, newborn unit. As a policy all IGA’s, defined by birth weight of 4000g and above are admitted for 24hours to monitor blood glucose levels. The rational for this policy is questionable and contributes to unnecessary burden on resources needed for new born care.
Objective: To study birth weight related incidence of hypoglycemia and hypocalcaemia in stable low risk lgas in knh and use it to establish a new admission weight based criteria.
Patients and methods: prospective cohort study done in new born-unit, post natal and labour wards of knh. Term lga neonates (birth weight = 4000g) were recruited as subjects and controlled against term appropriate weight (aga) neonates.
Results: the incidence of hypoglycemia and hypocalcaemia in lgas was 21% and 9% respectively. Hypoglycemia was rarely encountered after 12 hours of life in lgas. Hypoglycemia and hypocalcaemia showed a direct upward relationship with weight beyond 4250g. No significant difference in incidence of hypoglycemia and hypocalcaemia between controls and 4000-4249g category to justify their routine admission to newborn unit.
Conclusion: the study identified 4275g as new admission birth weight criteria for stable term low risk IGA‘s admission.

Essajee, F, Were F, Admani B.  2014.  Urine neutrophil gelatinase-associated lipocalin in asphyxiated neonates: a prospective cohort study. Pediatr Nephrol. 30(14):1189–1196. Abstracturine_neutrophil_gelatinase-associated_lipocalin_in_asphyxiated_neonates_a_prospective_cohort_study.pdf

Background: Acute kidney injury (AKI) is the most common complication of perinatal asphyxia. Recent research indicates that urine neutrophil gelatinase-associated lipocalin (NGAL) is an early marker for AKI; yet, there is a paucity of data about its use in term neonates with perinatal asphyxia. Methods A prospective cohort study was conducted on 108 term babies in the new-born unit of Pumwani Maternity Hospital and Kenyatta National Hospital. Urine NGAL and serum creatinine were measured in 108 term asphyxiated neonates on days 1 and 3 of life.
Results: One-hundred and eight patients were recruited (male:female 1.4:1). At a cut-off of 250 ng/ml, urine NGAL had an acceptable discriminative capability of predicting AKI (area under the curve 0.724). The sensitivity, specificity, positive and negative predictive value and likelihood ratios were 88, 56, 30, 95 %, 2 and 0.2 respectively. Urine NGAL levels were significantly higher in patients with AKI compared with those without AKI. An NGAL level greater than 250 ng/ml on day 1 was significantly associated with severe hypoxic ischaemic encephalopathy (HIE); odds ratio=8.9 (95 % CI 1.78– 37.69) and mortality; odds ratio=8.9 (95 % CI 1.78–37.69).
Conclusion: Urine NGAL is a good screening test for the early diagnosis of AKI. It is also a predictor of mortality and severity of HIE in asphyxiated neonates.

Gisore, P, Kaseje D, Were F, Ayuku D.  2014.  Motivational Interviewing Intervention on Health-Seeking Behaviors of Pregnant Women in Western Kenya. 2(19):144-156. Abstractmotivational_interviewing_intervention_on.pdf

We studied the effect of using Motivational Interviewing Intervention (MII) on health facility delivery and newborn care practices among pregnant women receiving Care of the Mother and Newborn at Home (CNH) visits by Community Health Workers (CHWs). Near-Term women who had received at least one CHW home visit, were randomly assigned to one session of MII (intervention) or no MII (Control). Fifty five (55%) of intervention women, compared to 35% of control women delivered in health facilities. Intervention women also understood the need to breastfeed exclusively for 6 months better than controls (P = 0.000), and had a p-value of 0.07 for breastfeeding within one hour after birth. We concluded in the context of CHW Home visit program, adding may improve perinatal care.

Warfa, O, Njai D, Ahmed L, Admani B, Were F, Dalton Wamalwa, Mburugu P, Mohamed M.  2014.  Evaluating the level of adherence to Ministry of Health guidelines in the management of Severe Acute Malnutrition at Garissa Provincial General hospital, Garissa, Kenya. 10 Abstract

Introduction: Half of Kenya's high infant and under five mortality rates is due to malnutrition. Proper implementation of World Health Organization's (WHO) Evidence Based Guidelines (EBG) in management of severe acute malnutrition can reduce mortality rates to less than 5%. The objectives were to establish the level of adherence to WHO guideline and the proportion of children appropriately managed for severe acute malnutrition (steps 1-8) as per the WHO protocol in the management of severe acute malnutrition. This was a short longitudinal study of 96 children, aged 6-59 months admitted to the pediatric ward with diagnosis of severe acute malnutrition. Methods: Data was extracted from patients' medical files and recorded into an audit tool to compare care provided in this hospital with WHO guidelines. Results: Non-edematous malnutrition was the commonest presentation (93.8%). A higher proportion (63.5%) of patients was male. Most (85.4%) of patients were younger than 2 years. Patients with non-edematous malnutrition were younger (mean age for non-edematous malnutrition was 16 (± 10.6) months versus 25 (± 13.7) months in edematous malnutrition). The commonest co- morbid condition was diarrhea (52.1%). Overall, 13 children died giving an inpatient case fatality rate of 13.5%. Appropriate management was documented in only 14.6% for hypoglycemia (step1), 5.2% for hypothermia (step 2) and 31.3% for dehydration (step 3). Conclusion: The level of adherence to MOH guidelines was documented in 5 out of the 8 steps. Appropriate management of children with severe acute malnutrition was inadequate at Garissa hospital.

Aluvaala, J, Nyamai R, Were F, Wasunna A, Kosgei R, Karumbi J, Gathara D, English M.  2014.  Assessment of neonatal care in clinical training facilities in Kenya. 10(306423):42-47. Abstractassessment_of_neonatal_care_in_clinical_training_facilities_in_kenya..pdf

Objective
An audit of neonatal care services provided by clinical training centres was undertaken to identify areas requiring improvement as part of wider efforts to improve newborn survival in Kenya.
Design
Cross-sectional study using indicators based on prior work in Kenya. Statistical analyses were descriptive with adjustment for clustering of data.
Setting Neonatal units of 22 public hospitals.
Patients Neonates aged <7 days.
Main outcome measures
Quality of care was assessed in terms of availability of basic resources (principally equipment and drugs) and audit of case records for documentation of patient assessment and treatment at admission.
Results
All hospitals had oxygen, 19/22 had resuscitation and phototherapy equipment, but some key resources were missing—for example kangaroo care was available in 14/22. Out of 1249 records, 56.9% (95% CI 36.2% to 77.6%) had a standard neonatal admission form. A median score of 0 out of 3 for symptoms of severe illness (IQR 0–3) and a median score of 6 out of 8 for signs of severe illness (IQR 4–7) were documented.
Maternal HIV status was documented in 674/1249
(54%, 95% CI 41.9% to 66.1%) cases. Drug doses
exceeded recommendations by >20% in prescriptions for
penicillin (11.6%, 95% CI 3.4% to 32.8%) and
gentamicin (18.5%, 95% CI 13.4% to 25%),
respectively.
Conclusions
Basic resources are generally available, but there are deficiencies in key areas. Poor documentation limits the use of routine data for quality improvement. Significant opportunities exist for improvement in service delivery and adherence to guidelines in hospitals providing professional training.

English, M, Gathara D, Mwinga S, Ayieko P, Opondo C, Aluvaala J, Kihuba E, Mwaniki P, Were F, Grace Irimu, R W Nduati, Wasunna A, Mogoa W, Nyamai R.  2014.  Adoption of recommended practices and basic technologies in a low-income setting. 10(2013-305561):452-456. Abstractadoption_of_recommended_practices_and_basic_technologies_in_a_low-income_setting.pdf

Objective In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent. Design and setting We used data collected on a consistent panel of indicators during four separate cross sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002–2012). Main outcome measures Basic resource availability,use of diagnostics and uptake of recommended practices. Results There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines. Conclusions Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low income settings and to those developing novel therapeutic or diagnostic interventions.

2013

Otieno, SB, Were F, Afullo A, Waz K.  2013.  Selenium levels in foods in a high hiv prevalence community, A case of pala in Bondo district Kenya. East African Journal of Public Health. 10(3) Abstractselenium_levels_in_foods_in_a_high_hiv_prevalence_community_a_case_of_pala_in_bondo_district_kenya.pdf

Introduction: An investigation of dietary patterns and selenium levels in diets of smallholder farmers was carried out in Pala Sub-location between June and August 2008.
Methods: In this study a total of 386 respondents selected randomly were interviewed in the four villages in the sub-location and 17 foods commonly eaten sampled. The data was coded and analyzed by SPSS program while food selenium levels were analyzed by AAS.
Results: The foods eaten by 75.2% of the respondents were Oreochromis niloticus,Lates niloticus and Ugali-Sorghum bicolour spp , 64.1% eat vegetables and that both children and adults eat same types of food. It was further shown that traditional foods which have become extinct are mainly vegetables (46%). The study established that selenium levels in foods eaten in Pala sub-location varies, vegetables have higher levels of selenium,(,Laurnea cornuta (148.5mg/kg)Cleome gynandra(121.5mg/kg), Vignia unguculata (21.97 mg/kg), while Rastrineobola argentea (51mg/kg) Oreochromis niloticus( 0), Lates niloticus(0) Sorghum bicolour spp (red) 19.97 mg/kg, and Sorghum bicolour spp(white)(0).The study showed that there is inverse relationship between foods eaten and selenium levels with foods eaten by 75.2% of respondents (Oreochromis niloticus/Lates niloticus) having no detectable selenium .
Recommendation: To increase selenium levels in the diet, more production and consumption of traditional vegetables should be encouraged, this should be accompanied by nutrition education targeting women and possibly using mass media on short term, while long term intervention should include fortifying the foods commonly purchased and eaten in the community like sugar, table salt, and maize meal and accompanied by increased selenium in animal feeds and in fertilizer.

G, G, ZN Q, W K, F W.  2013.  Antenatal corticosteroid use in preterm birth at Kenyatta National Hospital. Journal of Obstetrics and Gynaecology of Eastern and Central Africa. 1(25):15-21. Abstractantenatal_corticosteroid_use_in_preterm_birth_at_kenyatta_national_hospital.pdf

Background:Preterm birth causes about 75% of neonatal deaths that are not attributable to congenital malfor-mations. Antenatal corticosteroids (ACS) given to mothers at risk of preterm birth reduce the incidence/severity of RDS, intraventricular haemmorhage, necrotizing enterocolitis and neonatal deaths. The WHO recommends use of antenatal steroids for all pregnant women 26-34 weeks gestation at risk of preterm delivery and after 34 weeks gestation only if there is evidence of fetal pulmonary immaturity. Despite this, ACS are widely used locally across all gestational periods.Objective: To determine the frequency of administration and impact of ACS in reducing the morbidity and mor-tality in preterm neonates born 28- 37 weeks gestation at Kenyatta National Hospital.Design: This was a hospital-based retrospective cohort study.Setting: Kenyattah National Hospital labour ward, antenatal wards, NBU, NICU.Methods: The study compared the neonatal outcomes of mothers with preterm birth who received antenatal steroids and those who did not receive. The study populations were mothers with preterm birth due to preterm labor, PPROM and severe pre eclampsia and their neonates. Mothers who met the inclusion criteria were recruit-ed immediately after delivery, interviewed, medical records scrutinized and information obtained entered into a questionnaire. Neonates were followed until discharge/death/ 7th day whichever came earlier. The outcome measures considered were the occurrence and severity of RDS, NBU admissions and neonatal deaths.Results: Two hundred and six mother/neonate pairs were recruited. Overall 35% of mothers/neonates were exposed to ACS. Forty six percent of those who delivered <34 weeks received ACS compared to 26% of those who delivered >34 weeks. Only 3% of mothers received a complete course of ACS. ACS significantly reduced the occurrence and severity of RDS in preterm neonates up to 34 weeks gestation. Sixty eight percent of neonates delivered before 34 weeks and not exposed to ACS developed RDS compared to 38% of those exposed (RR 0.6, 95% CI 0.4-0.9, P= 0.005). Exposure to ACS >34 weeks gestation did not reduce occurrence and severity of RDS. Forty percent of those exposed to ACS developed RDS compared to 37% of those not exposed (RR 1.2 95% CI 0.7-1.8, P =0.755). ACS reduced neonatal mortality across all gestational ages. The neonatal mortality within 7 days of life was 26% among those exposed to ACS <34 weeks compared to 38% among those not exposed (RR1.2, 95% CI 0.9-1.6, p=0.224). for those delivered after 34 weeks mortality was 3.3% in the exposed group compared to 9.2% in the non exposed group (RR 1.1 95%CI 1.0-1.2 p=0.443). ACS did not reduce NBU/NICU admissions across all gestational ages. Eighty five percent of neonates exposed to ACS before 34 weeks were admitted to NBU compared to 71% of those not exposed (RR1.2, 95% CI 1-2.1, p=0.113). Fifty percent of neonates exposed to ACS after 34 weeks were admitted to NBU compared to 32.2% of those not exposed (RR 1.3 95% CI 0.9-2.1, p=0.225). Conclusions: ACS are underutilized. ACS significantly reduce the incidence/severity of neonatal RDS and mortality <34 weeks gestation.Recommendations: There is need to upscale the utilization of ACS. The study provides local evidence to discourage routine use of ACS >34 weeks.

English, M, Gathara D, Mwinga S, Ayieko P, Opondo C, Aluvaala J, Kihuba E, Mwaniki P, Were F, Grace Irimu, R W Nduati.  2013.  Adoption of recommended practices and basic technologies in a low-income setting. (99):452-456. Abstract

Objective In global health considerable attention is focused on the search for innovations; however, reports tracking their adoption in routine hospital settings from low-income countries are absent.
Design and setting We used data collected on a consistent panel of indicators during four separate cross-sectional, hospital surveys in Kenya to track changes over a period of 11 years (2002–2012).
Main outcome measures Basic resource availability, use of diagnostics and uptake of recommended practices. Results There appeared little change in availability of a panel of 28 basic resources (median 71% in 2002 to 82% in 2012) although availability of specific feeds for severe malnutrition and vitamin K improved. Use of blood glucose and HIV testing increased but remained inappropriately low throughout. Commonly (malaria) and uncommonly (lumbar puncture) performed diagnostic tests frequently failed to inform practice while pulse oximetry, a simple and cheap technology, was rarely available even in 2012. However, increasing adherence to prescribing guidance occurred during a period from 2006 to 2012 in which efforts were made to disseminate guidelines.
Conclusions Findings suggest changes in clinical practices possibly linked to dissemination of guidelines at reasonable scale. However, full availability of basic resources was not attained and major gaps likely exist between the potential and actual impacts of simple diagnostics and technologies representing problems with availability, adoption and successful utilisation. These findings are relevant to debates on scaling up in low-income settings and to those developing novel therapeutic or diagnostic interventions.

2012

A, O, EC R, chindia ML, FG M, M N, Fred W.  2012.  Craniofacial anomalies amongst births at two hospitals in Nairobi, Kenya.. 41:596-603. Abstractcraniofacial_anomalies_amongst_births_at_two_hospitals_in_nairobi_kenya.pdf

The pattern of congenital oral and craniofacial anomalies (CFAs) in the Kenyan population remains unknown. The objective of this study was to describe the pattern of occurrence of CFAs at two hospitals in Nairobi. A descriptive cross-sectional study at the Kenyatta National Hospital and Pumwani Maternity Hospital was carried out from November 2006 to March 2007. Mothers who delivered at the hospitals consented to an interview and physical examination of their babies within 48 h of delivery. The anomalies were classified for type and magnitude. Data were analysed to determine the association of these anomalies with ages of the mothers, gender, weight, birth order, mode of delivery and birth status of the babies. During the study period, 7989 babies were born. The CFAs manifested in 1.8% of the total births and were more common in female (1.4%) than in male (1.0%) live births. 12.8% of stillbirths had CFAs, with lesions manifesting more in males (16.7%) than in females (6.9%). The commonest CFA was preauricular sinus (4.3/1000) followed by hydrocephalus (1.9/1000) then preauricular tags and cleft lip and palate (1.5/1000 and 1.3/1000 total births, respectively).

2011

Ayieko, P, Ntoburi S, Wagai J, Opondo C, Opiyo N, Migiro S, Wamae A, Mogoa W, Were F, Wasunna A, Fegan G, Grace Irimu, R W Nduati, English M.  2011.  A Multifaceted Intervention to Implement Guidelines and Improve Admission Paediatric Care in Kenyan District Hospitals: A Cluster Randomised Trial. 8(4):19. Abstract

Abstract
Background:In developing countries referral of severely ill children from primary care to district hospitals is common, but hospital care is often of poor quality. However, strategies to change multiple paediatric care practices in rural hospitals have rarely been evaluated.
MethodsandFindings:This cluster randomized trial was conducted in eight rural Kenyan district hospitals, four of which were randomly assigned to a full intervention aimed at improving quality of clinical care (evidence-based guidelines, training, job aides, local facilitation, supervision, and face-to-face feedback; n = 4) and the remaining four to control intervention (guidelines, didactic training, job aides, and written feedback; n = 4). Prespecified structure, process, and outcome indicators were measured at baseline and during three and five 6-monthly surveys in control and intervention hospitals, respectively. Primary outcomes were process of care measures, assessed at 18 months postbaseline. In both groups performance improved from baseline. Completion of admission assessment tasks was higher in intervention sites at 18 months (mean = 0.94 versus 0.65, adjusted difference 0.54 [95% confidence interval 0.05–0.29]). Uptake of guideline recommended therapeutic practices was also higher within intervention hospitals: adoption of once daily gentamicin (89.2% versus 74.4%; 17.1% [8.04%–26.1%]); loading dose quinine (91.9% versus 66.7%, 26.3% [23.66% to 56.3%]); and adequate prescriptions of intravenous fluids for severe dehydration (67.2% versus 40.6%; 29.9% [10.9%–48.9%]). The proportion of children receiving inappropriate doses of drugs in intervention hospitals was lower (quinine dose .40 mg/ kg/day; 1.0% versus 7.5%; 26.5% [212.9% to 0.20%]), and inadequate gentamicin dose (2.2% versus 9.0%; 26.8% [211.9% to 21.6%]).
Conclusions:Specific efforts are needed to improve hospital care in developing countries. A full, multifaceted intervention was associated with greater changes in practice spanning multiple, high mortality conditions in rural Kenyan hospitals than a partial intervention, providing one model for bridging the evidence to practice gap and improving admission care in similar settings.

2009

Grace Irimu, R W Nduati, Wamae A, Wasunna A, Were F, Ntoburi S, Opiyo N, Ayieko P, Peshu N, English M.  2009.  Developing and Introducing Evidence Based Clinical Practice Guidelines for Serious Illness in Kenya. 10(93):799-804. Abstractdeveloping_and_introducing_evidence_based_clinical_practice_guidelines_for_serious_illness_in_kenya..pdf

The under-5 mortality rate in most developing countries remains high yet many deaths could be averted if available knowledge was put into practice. For seriously ill children in hospital investigations in low-income countries commonly demonstrate incorrect diagnosis and treatment and frequent prescribing errors. To help improve hospital management of the major causes of inpatient childhood mortality we developed simple clinical guidelines for use in Kenya, a low-income setting. The participatory process we used to adapt existing WHO materials and further develop and build support for such guidelines is discussed. To facilitate use of the guidelines we also developed job-aides and a 5.5 days training programme for their dissemination and implementation. We attempted to base our training on modern theories around adult learning and deliberately attempted to train a ‘critical mass’ of health workers within each institution at low cost. Our experience suggests that with sustained effort it is possible to develop locally owned, appropriate clinical practice guidelines for emergency and initial hospital care for seriously ill children with involvement of pertinent stake holders throughout. Early experience suggests that the training developed to support the guidelines, despite the fact that it challenges many established practices, is well received, appropriate to the needs of front line health workers in Kenya and feasible. To our knowledge the process described in Kenya is among a handful of attempts globally to implement inpatient or referral care components of WHO / UNICEF’s Integrated Management of Childhood Illness approach. However, whether guideline dissemination and implementation result in improved quality of care in our environment remains to be seen.

Were, F, bwibo.  2009.  THE CONTRIBUTION OF VERY LOW BIRTH WEIGHT DEATHS TO INFANT MORTALITY. 8:374-377. Abstractcontribution_of_vlbw_infants.pdf

Background: Infant mortality remains high in many developing countries in which the contribution of deaths among infants born very low birth weight (VLBW) may be considerable. This contribution has however not been quantified in most such countries. This paper explores a model that can be used in this respect.
Objective: To determine the contribution of very low birth weight infants towards the overall infants deaths in Kenya.
Design: Prospective cohort study.
Setting: Kenyatta National Hospital, Pumwani Maternity Hospital and Kilifi District Hospital.
Subjects: Very low birth weight infants followed up for a period of one year.
Results: The neonatal, post-neonatal and infant mortalities for the cohort were 442, 139 and 581/1000 respectively. These were thirteen, three and seven times higher than the national averages respectively. Of the national birth cohort of 1,300,000 during that year, it was estimated that between 15,600 (1.2%) and 24,700 (1.9%) were born VLBW. Given this VLBW infant burden and extrapolating the infant mortality observed in this study to the general population, between 9,064 (8.9%) and 14,351(14.2%) of the 101,400 (78/1000) infants who die during infancy in the country are born VLBW.
Conclusion: The cohort reports very high infant mortality for VLBW infants when compared to the general population. Despite constituting less than 2% of the birth cohort, these infants contribute between 8.9% and 14.2% of all infant deaths.

Opondo, C, Ntoburi S, Wagai J, Wafula J, Wasunna A, Were F, Wamae A, Migiro S, Grace Irimu, R W Nduati, English M.  2009.  Are hospitals prepared to support newborn survival. 14(10):1165-1172. Abstractare_hospitals_prepared_to_support_newborn_survival.pdf

objective
To assess the availability of resources that support the provision of basic neonatal care in eight first referral level (district) hospitals in Kenya.
methods
We selected two hospitals each from four of Kenya’s eight provinces with the aim of representing the diversity of this part of the health system in Kenya. We created a checklist of 53 indicator items necessary for providing essential basic care to newborns and assessed their availability at each of the eight hospitals by direct observation, and then compared our observations with the opinions of health workers providing care to newborns on recent availability for some items, using a self administered structured questionnaire.
results
The hospitals surveyed were often unable to maintain a safe hygienic environment for patients and health care workers; staffing was insufficient and sometimes poorly organised to support the provision of care; some key equipment, laboratory tests, drugs and consumables were not available while patient management guidelines were missing in all sites.
conclusion
Hospitals appear relatively poorly prepared to fill their proposed role in ensuring newborn survival. More effective interventions are needed to improve them to meet the special needs of this at-risk group.

2008

English, M, Grace Irimu, R W Nduati, Wamae A, Were F, Wasunna A, Fegan G, Peshu N.  2008.  Health systems research in a low income country - easier said than done. 93(6):540-544. Abstract

Small hospitals sit at the apex of the pyramid of primary care in many low-income country health systems. If the Millennium Development Goal for child survival is to be achieved hospital care for severely ill, referred children will need to be improved considerably in parallel with primary care in many countries. Yet we know little about how to achieve this. We describe the evolution and final design of an intervention study attempting to improve hospital care for children in Kenyan district hospitals. We believe our experience illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system rather than an individual level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question - does it work? While there are increasing calls for more health systems research in low-income countries the importance of strong, broadly-based local partnerships and long term commitment even to initiate projects are not always appreciated.

Opiyo, N, Were F, Govedi F, Fegan G, Wasunna A, English M.  2008.  Effect of Newborn Resuscitation Training on Health Worker Practices in Pumwani Hospital, Kenya. 3(2):1-7. Abstract

Background: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya.

Methods/Principal Findings: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group, n = 55). The training was adapted locally from the approach of the UK Resuscitation Council. The primary outcome was the proportion of appropriate initial resuscitation steps with the frequency of inappropriate practices as a secondary outcome. Data were collected on 97 and 115 resuscitation episodes over 7 weeks after early training in the intervention and control groups respectively. Trained providers demonstrated a higher proportion of adequate initial resuscitation steps compared to the control group (trained 66% vs control 27%; risk ratio 2.45, [95% CI 1.75–3.42], p,0.001, adjusted for clustering). In addition, there was a statistically significant reduction in the frequency of inappropriate and potentially harmful practices per resuscitation in the trained group (trained 0.53 vs control 0.92; mean difference 0.40, [95% CI 0.13–0.66], p = 0.004).

Conclusions/Significance: Implementation of a simple, one day newborn resuscitation training can be followed immediately by significant improvement in health workers’ practices. However, evidence of the effects on long term performance or clinical outcomes can only be established by larger cluster randomised trials.

O, PROFWASUNNAAGGREY, W. DRIRIMUGRACE, N PROFWEREFREDRICK.  2008.  English M, Irimu G, Wamae A, Were F, Wasunna A, Fegan G, Peshu N.Health systems research in a low-income country: easier said than done.Arch Dis Child. 2008 Jun;93(6):540-4.. Arch Dis Child. 2008 Jun;93(6):540-4.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract
Small hospitals sit at the apex of the pyramid of primary care in the health systems of many low-income countries. If the Millennium Development Goal for child survival is to be achieved, hospital care for referred severely ill children will need to be improved considerably in parallel with primary care in many countries. Yet little is known about how to achieve this. This article describes the evolution and final design of an intervention study that is attempting to improve hospital care for children in Kenyan district hospitals. It illustrates many of the difficulties involved in reconciling epidemiological rigour and feasibility in studies at a health system, rather than an individual, level and the importance of the depth and breadth of analysis when trying to provide a plausible answer to the question: does it work? Although there are increasing calls for more health systems research in low-income countries, the importance of strong, broadly based local partnerships and long-term commitment even to initiate projects is not always appreciated.
O, PROFWASUNNAAGGREY, N PROFWEREFREDRICK.  2008.  Effect of newborn resuscitation training on health worker practices in Pumwani Hospital, Kenya. Opiyo N, Were F, Govedi F, Fegan G, Wasunna A, English M.PLoS ONE. 2008 Feb 13;3(2):e1599.. PLoS ONE. 2008 Feb 13;3(2):e1599.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract
{ BACKGROUND: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya. METHODS/PRINCIPAL FINDINGS: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group
O, PROFWASUNNAAGGREY, W. DRIRIMUGRACE, N PROFWEREFREDRICK.  2008.  Irimu G, Wamae A, Wasunna A, Were F, Ntoburi S, Opiyo N, Ayieko P, Peshu N, English M.Developing and introducing evidence based clinical practice guidelines for serious illness in Kenya.Arch Dis Child. 2008 Sep;93(9):799-804. Arch Dis Child. 2008 Sep;93(9):799-804. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract
{ BACKGROUND: Birth asphyxia kills 0.7 to 1.6 million newborns a year globally with 99% of deaths in developing countries. Effective newborn resuscitation could reduce this burden of disease but the training of health-care providers in low income settings is often outdated. Our aim was to determine if a simple one day newborn resuscitation training (NRT) alters health worker resuscitation practices in a public hospital setting in Kenya. METHODS/PRINCIPAL FINDINGS: We conducted a randomised, controlled trial with health workers receiving early training with NRT (n = 28) or late training (the control group
M., PROFMACHARIAW, N PROFWEREFREDRICK.  2008.  Admani B, Macharia W and Were F: Prevalence of Varicella Zoster in Immune-compromised children at Kenyatta National Hospital . E Afr Med. J. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract
Two male patients with diabetes mellitus and alcohol dependence syndrome are presented. Both were married and in middle age. MI stayed alone in the city while his spouse and two children lived in the rural home. He showed no obvious underlying psychiatric morbidity. FWK was living with his family in the city. He was an alcoholic receiving psychiatric care for alcoholism. They both presented separately at different hospitals with decompensated diabetes following heavy alcohol consumption. The history and clinico-laboratory picture of both patients are presented and brief management programme and outcome are also given. Review of literature on alcoholism and its potential impact on the course and management of diabetes is presented.

2007

O, PROFBWIBONIMROD, N PROFWEREFREDRICK.  2007.  Neonatal nutrition and later outcomes of very low birth weight infants at Kenyatta national hospital Afr Health Sci. 2007 June; 7 (2) : 108. Afr Health Sci. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

Extensive research in developed countries has established that very low birth weight (VLBW) infants are particularly vulnerable to the effects of early nutritional deficiencies. There is, however, little information from poor countries on the long-term effects of these deficiencies in such infants.

Determine the association between neonatal feeding regimens and post-discharge morbidity/ mortality and neurological abnormalities at the age of two years for a cohort of VLBW infants.

One hundred and seventy five VLBW infants were recruited over a consecutive period of one year and followed up to the age of two years corrected for gestation. With neonatal feeding regimes as the exposure variable, post-discharge re-hospitalization, mortality and Saigal and Rosenbaum's functional disability assessment scores were compared as the outcome variables.

2006

O, PROFBWIBONIMROD, N PROFWEREFREDRICK.  2006.  Early growth of very low birth weight infants. East Afr Med J. 2006 Mar;83(3):84-9. Were FN, Bwibo NO.. East Afr Med J. 2006 Mar;83(3):84-9.. : F.N. kamau, G. N Thothi and I.O Kibwage Abstract

Department of Paediatrics and Child Health, College of Health Sciences, University of Nairobi, P.O. Box 20956-00202, Nairobi, Kenya. BACKGROUND: Early growth in very low birth weight (VLBW) infants has been found predictive of their later outcomes. This has led to increased interest in establishing measures to optimise such growth. In facilities without the resources required to undertake long-term audits for all the high risk infants they graduate, these growth parameters may also be used as selection criteria for those meriting such follow up reducing costs. OBJECTIVES: To describe early growth patterns among a cohort of VLBW infants and determine some of the factors associated with poor growth among them. DESIGN: Cross section survey. SETTING: Kenyatta National Hospital, Nairobi, Kenya. SUBJECTS: One hundred and seventy five neonatal survivors. RESULTS: Of the 175 infants recruited, the male/female ratio was 4:6, sixty four (36.6%) were intrauterine growth retarded while significant illnesses during the neonatal period were reported in 109 (62.3%). Forty seven percent of the infants had been fed on exclusive breast milk, 33% on mixed feeds while 20% received exclusive preterm formula. The mean neonatal weight gain for the whole cohort was 13.5 (3.9) g/kg/day, length of 0.34 (0.11) cm/week and head circumference of 0.32 (0.71) cm/week. By term only 33 (18.9%), 37 (21.1%) and 48 (28%) had reached the expected (the 3rd percentile) weight, length and head circumference respectively. Sixty percent of the infants gained weight at <15 g/kg/day while 70% and 78% grew in head circumference and length at < 0.5 cm/week respectively. At term weight, head and linear growth faultering were recorded in 81%, 72% and 79% respectively. The factors that were associated with better growth at this stage included feeding on preterm formula (P < 0.001) and absence of neonatal morbidity (P < 0.001). Infants who were appropriate for gestational age at birth also had better catch up growth at term compared to those born small for gestation (P < 0.001) but their neonatal growth itself was not significantly better. CONCLUSION: The mean neonatal growth in all anthropometric measures was less than expected and by the time of their expected delivery, less than 30% of these infants had reached the 3rd percentile of the expected measurement in all the three growth parameters. Choice of milk and neonatal morbidity influenced these growth patterns. RECOMMENDATIONS: Routine fortification of mother's milk or addition of preterm formula and reorganised care of sick newborns is recommended to improve early growth. PMID: 16771104 [PubMed - indexed for MEDLINE]

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