research topics in public health in kenya

Volume 19 Supplement 3

10th anniversary of the Centers for Disease Control and Prevention - Global Disease Detection program

• Correspondence
• Open access
• Published: 10 May 2019

Successes and challenges of the One Health approach in Kenya over the last decade

• Peninah M. Munyua 1 ,
• M. Kariuki Njenga 2 ,
• Eric M. Osoro 3 ,
• Clayton O. Onyango 1 ,
• Austine O. Bitek 4 ,
• Athman Mwatondo 3 ,
• Mathew K. Muturi 4 ,
• Norah Musee 1 ,
• Godfrey Bigogo 5 ,
• Elkanah Otiang 5 ,
• Fredrick Ade 5 ,
• Sara A. Lowther 1 , 6 ,
• Robert F. Breiman 7 ,
• John Neatherlin 1 , 6 , 8 ,
• Joel Montgomery 6 &
• Marc-Alain Widdowson 1 , 6  

BMC Public Health volume  19 , Article number:  465 ( 2019 ) Cite this article

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More than 75% of emerging infectious diseases are zoonotic in origin and a transdisciplinary, multi-sectoral One Health approach is a key strategy for their effective prevention and control. In 2004, US Centers for Disease Control and Prevention office in Kenya (CDC Kenya) established the Global Disease Detection Division of which one core component was to support, with other partners, the One Health approach to public health science. After catalytic events such as the global expansion of highly pathogenic H5N1 and the 2006 East African multi-country outbreaks of Rift Valley Fever, CDC Kenya supported key Kenya government institutions including the Ministry of Health and the Ministry of Agriculture, Livestock, and Fisheries to establish a framework for multi-sectoral collaboration at national and county level and a coordination office referred to as the Zoonotic Disease Unit (ZDU). The ZDU has provided Kenya with an institutional framework to highlight the public health importance of endemic and epidemic zoonoses including RVF, rabies, brucellosis, Middle East Respiratory Syndrome Coronavirus, anthrax and other emerging issues such as anti-microbial resistance through capacity building programs, surveillance, workforce development, research, coordinated investigation and outbreak response. This has led to improved outbreak response, and generated data (including discovery of new pathogens) that has informed disease control programs to reduce burden of and enhance preparedness for endemic and epidemic zoonotic diseases, thereby enhancing global health security. Since 2014, the Global Health Security Agenda implemented through CDC Kenya and other partners in the country has provided additional impetus to maintain this effort and Kenya’s achievement now serves as a model for other countries in the region.

Significant gaps remain in implementation of the One Health approach at subnational administrative levels; there are sustainability concerns, competing priorities and funding deficiencies.

More than 75% of emerging and re-emerging infectious diseases are of zoonotic origin including Severe Acute Respiratory Syndrome (SARS), highly pathogenic avian influenza (HPAI), Middle East Respiratory Syndrome (MERS), and Rift Valley Fever (RVF). These can cause explosive global outbreaks resulting in substantial economic and public health burden [ 1 ]. Moreover, zoonotic pathogens may spill over to human hosts and in some cases result in a considerable endemic health burden. This is especially true in low resourced and rural settings, where livestock play a central role in daily life and people interact closely with their animals through shared housing and during routine husbandry practices including herding, milking, helping with birthing process and deworming. In addition, various cultural norms in some communities promote consumption of unprocessed livestock products such as unpasteurized milk and uninspected meat. As a result, this expanded and close human-animal interface in countries such as Kenya presents a threat for increased transmission of zoonotic pathogens between animals and humans along the livestock value chain, increasing the likelihood of novel zoonotic pathogens establishing themselves in human populations, the overall endemic burden of common zoonoses, and the threat of infectious disease outbreaks which can threaten global health security.

One Health approach has been defined by the American Veterinary Medical Association as the integrative effort of multiple disciplines working locally, nationally, and globally to attain optimal health for people, animals, and the environment [ 2 ]. Globally, the recognition of the threat of emerging and re-emerging zoonoses led to advocacy for the adoption of a One Health approach at country level aimed at strengthening monitoring and response to zoonotic disease risks via a multisectoral, transdisciplinary collaboration [ 3 , 4 ]. In practice, different countries have approached implementation the principle of One Health variously with varying successes and challenges [ 5 ]. In Kenya, creation of a coordination framework between public health and animal (domestic and wildlife) health sector to understand, prevent and control re-emerging and endemic zoonotic diseases has played a central role in the adoption and implementation of the One Health approach.

In Kenya, livestock contributes over 5.5% of the National Gross Domestic Product [ 6 ]. About 60% of all cattle, sheep and goats is found in arid and semi-arid areas, where approximately 10 million Kenyans derive their livelihood from livestock. Even in non-arid and semi-arid rural regions of Kenya, most farmers practice mixed farming that includes livestock ownership. For example, among 1500 households participating in a study in Western Kenya, within a non-arid and semi-arid area, 93% of households owned at least one type of livestock with 88% keeping chickens, 55% keeping cattle, 41% keeping goats, and 19% keeping sheep [ 7 ].

In 2004, the US CDC, in collaboration with the Kenya Medical Research Institute (KEMRI) and the Kenya Ministry of Health, established the Global Disease Detection Division (GDDD) at CDC Kenya to facilitate building diagnostic and epidemiologic capacity for epidemic prone diseases, conducting public health research of global importance, and contributing to development and use of effective interventions to reduce impact of diseases. Within the GDDD, zoonotic diseases research and a One Health approach were identified as key focus areas with dedicated funding and personnel to lead this effort within the One Health Program formally set up in 2010. The GDDD’s One Health program focused on enhancing collaboration between human and animal health sectors, improving surveillance and diagnostic capacity for the animal health sector and conducting research at the human-animal interface.

Here, we highlight the successes and challenges of the GDDD (now called the Division of Global Health Protection – DGHP) in the last decade, specifically in 1) developing institutional capacity for One Health implementation, 2) strengthening capacity for surveillance and reporting in animal health sector and 3) expanding the research capacity in Kenya and the East Africa region. In addition, we highlight implementation challenges and recommendations to achieve the full benefits of the One Health approach.

One health institutional capacity

A framework for collaboration.

Kenya adopted the One Health approach in 2006 by establishing a multi-sectoral committee aligned with global recommendation to coordinate preparedness efforts to prevent the spread HPAI in the wake of the global spread of H5N1. This framework was quickly tested by an outbreak of RVF in the Eastern Africa Region during 2006–2007. Previously, despite the endemicity of RVF and the relative predictability of epidemics, the 1996–1997 RVF outbreak in Kenya caught public health authorities unprepared. Delays in detection and response combined with the lack of local capacity for diagnostic testing (specimens were tested late in the outbreak’s course at the National Institute of Communicable Diseases in South Africa) likely contributed to the large 1996/7 outbreak resulting in 27,500 human infections and 170 deaths in Garissa in North Eastern Kenya. The outbreak was associated with large, but mostly undocumented socio-economic impacts resulting from animal deaths [ 8 , 9 ]. In contrast, the 2006/07 RVF outbreak in Kenya that was more geographically widespread was characterized by a more timely diagnosis and better coordinated response and resulted in 700 suspected human cases and 90 deaths. This enhanced response could in part be credited to the efforts to build capacity for coordinated outbreak response and communication pathways within the Ministry of Health (MoH) and Ministry of Agriculture, Livestock, and Fisheries (MALF), through increased human capacity, the presence of a multisectoral coordination structure arising from the HPAI preparedness effort and enhanced diagnostic capacity in local government, and improved research infrastructure including a BSL-3 laboratory at KEMRI supported by CDC Kenya [ 10 , 11 , 12 ]. The 2006/07 RVF outbreak played a key role in galvanizing collaboration in One Health approaches among government departments, researchers and international organizations to mitigate impacts of future outbreaks and catalyzed the need for clearer understanding and adoption of One Health approach with a focus on supporting animal health surveillance activities [ 10 ]. This success with RVF, demonstrated the need to expand and improve the approach for all potentially zoonotic outbreaks, but also to understand, prevent and control endemic zoonotic disease. In Particular a lack of a formal framework for systematic collaboration between government Ministries and among key stakeholders on management of zoonotic disease outbreaks was a critical gap.

DGHP’s One Health Program worked with other partners including the US Cooperative Biological Engagement Program of the Department of Defense and Biological Engagement Program of the Department of State, to continually advocate for and provide technical and financial assistance to the establishment of a formal collaborative framework between the public and animal health sectors. These efforts led to the formation of a national One Health coordinating office referred to as Zoonotic Disease Unit (ZDU) in 2012 and the process to do this has been laid out previously [ 13 ] (Fig. 1 ).

Major milestones on One Health implementation and publications on zoonoses by year, CDC-Kenya, 2004–2017. Global Disease Detection Division (GDDD) now called the Division of Global Health Protection (DGHP); Field Epidemiology and Laboratory Training program (FELTP); Ministry of Health (MOH)

The ZDU’s key mandate was to act as a focal point of collaboration between the MoH and the MALF with a goal to establish structures and partnerships that promote the One Health approach, to enhance or build zoonotic epidemic and endemic disease surveillance, and to coordinate implementation of control measure and to support public health research in Kenya [ 13 , 14 ].

In 2013, the governance system in Kenya changed from a centralized to a devolved government of 47 counties; where functions such as public health and animal were undertaken by county governments. This provided an opportunity and need to expand the One Health approach to the subnational (county) level. To cascade the benefits of One Health approach to the county level, the ZDU and its partners have embarked in training and setting up county One Health units supported mainly through CDC Kenya’s Global Health Security Agenda (GHSA) implementing partners. County One Health units focus on initiating or enhancing communication platforms between the health and livestock sectors to improve surveillance and reporting of zoonotic diseases, ensuring rapid joint investigation and response to zoonotic disease outbreaks to mitigate disease impact. As of April 2017, there were 31 of 47 Kenya counties with established county One Health units. Through collaborations with other international partners, there will be county One Health units in all 47 counties by 2019. Sharing of disease outbreak information across sectors and rapid joint outbreak response at county level should help reduce the burden of spillover to humans that acquire zoonotic disease infections as illustrated by an example of an anthrax outbreak in Nakuru County (Table 1 ).

In 2015, a multidisciplinary team of human, animal and wildlife health experts in surveillance, research and laboratory science drawn from the national and county levels conducted prioritization of zoonotic diseases in Kenya [ 15 ]. From a list of 35 zoonotic diseases, the top five were anthrax, trypanosomiasis, rabies, brucellosis and Rift Valley Fever. Based on these findings, development and implementation of disease prevention and control plans for these priority zoonoses with greatest public health impact is being undertaken while promoting collaborative research and surveillance for all the diseases to generate national data and for evaluating control strategies.

One Health workforce development

In 2004, the Kenya Ministry of Health, with support from CDC and other partners, launched Kenya’s Field Epidemiology and Laboratory Training Program (FELTP). This program provides training in applied epidemiology, resulting in a Master’s of Science (MSc), initially offered to medical doctors and laboratory scientists working within government ministries [ 16 ]. Since 2006, with increased recognition of the value of One Health, veterinarians have been admitted to the training [ 16 ]. By 2017, the Kenya FELTP had 169 medical and 19 veterinary epidemiologists complete the two-year training program. Of these trained veterinarians, all initially returned to government positions, and the majority stayed at national or country level, strengthening collaboration between the human and animal health sector with fellow FELTP graduates participating in joint outbreak response and other activities during their training (Fig. 2 ).

Map of Kenya showing trained County One Health Units, Veterinary Field Epidemiology and Laboratory Training Program (FELTP) graduates and research sites by county. County One Health Units (COHUs)

Surveillance

Surveillance for animal diseases in most developing countries is designed to detect notifiable and trade sensitive diseases (e.g. foot and mouth disease) and to report to the World Organization for Animal Health (OIE). However, these systems are established to detect animal syndromes and generally without consideration of zoonotic aspects of clusters of animal diseases and the risk that infections may spill-over to humans locally and further afield. This calls for establishment of surveillance platforms that can detect and report cases of these zoonotic diseases in a timely manner, coupled with enhanced collaboration and information sharing between human health and animal health sectors.

In September 2015, the United States’ Pandemic and Forecasting Science Technical Working Group and the Food and Agriculture Organization issued an alert predicting a high likelihood of El Niño-type rainfall and subsequent potential for an RVF epidemic in the Eastern Africa region, and covering the known high risk areas of RVF in Kenya [ 17 , 18 ]. In response to the alert, CDC Kenya, in collaboration with Kenya MALF (through GHSA funding), set up a mobile phone-based enhanced active surveillance system between November 2015 and February 2016 in 22 (of 47) RVF high-risk counties. The surveillance system collected environmental and livestock monitoring data from resident veterinary officers at county and sub-county level on weekly basis and provided for toll free telephone contact to headquarters in order to report any suspected RVF cases. The veterinary surveillance officers contacted a network of farmers spread out through the sub counties. Over 10,000 reports were submitted with 66 of the syndromic reports meeting the suspect case definition for RVF [ 19 ], however none was confirmed, and the conclusion was that no RVF in  livestock had actually occurred. Although an outbreak had not occurred, the potential of one provided an opportunity to test a coordinated, rapid and enhanced surveillance response, highlighting possibility of a more robust and real-time reporting tool in place of a variety of manual and electronic tools that have been used with varied success.

In Kenya, the current surveillance effort is focusing on development and deployment of syndromic surveillance system in domestic and wild animals, using a mobile phone based application that will incorporate reporting and a feedback function to the surveillance officers and has capabilities for routine data analysis and visualization to detect animal disease events of public health concern. The mobile application has adapted manual disease reporting forms currently in use for reporting. Nine syndromes are targeted for reporting: abortion, sudden death, hemorrhagic, neurologic, respiratory, animal bites and oral/foot lesions. Since this mobile phone based application can be downloaded onto any android-based mobile phone device, this reporting tool promises to greatly enhance real-time surveillance within Kenya’s animal health sector. This surveillance is part of institutional capacity building funded by GHSA and targeted to reach up to 10 counties by 2019.

Zoonotic disease research in Kenya

The burden and transmission dynamics of many zoonotic infections are poorly understood in developing countries, including Kenya, which can challenge the progress of disease control programs to reduce burden and impact. In 2005, KEMRI and the DGHP in Kenya established the Population Based Infectious Disease Surveillance (PBIDS) platforms in a rural site in Western Kenya and an urban site in Nairobi to define the burden, etiologies and risk factors of common infectious disease syndromes (fever, jaundice, diarrhea and respiratory illness) among others [ 20 , 21 ]. Additionally, in 2008 through collaborative partnerships with the Wellcome Trust, zoonotic disease research was started among farmers and animals within PBIDS. The zoonotic disease research in DGHP has catalyzed additional studies within the PBIDS platform with other partners such as Washington State University and developed further platforms in different sites in the country with the overall focus of generating disease data to inform public health actions (Fig. 1 ). Some examples of these are outlined below.

Coxiella burnetti is on the US Federal Select Agent list and was first reported in Kenya over half a century ago, but since the late 1970’s there had been no further study of this pathogen. In 2009, KEMRI and CDC Kenya carried out retrospective studies on archived human sera collected between 2007 and 2008 in the PBIDS platform and cross-sectional studies carried out in the same site in 2009 among cattle, sheep and goats and the vector ticks to determine the sero-prevalence of the disease [ 22 ]. These pivotal studies by CDC and KEMRI triggered a sustained interest among research groups who showed variable but high sero-prevalence in humans and the reservoir domestic animals in different eco-systems in Kenya and highlighted Coxiella burnetti as a key etiology for consideration for undifferentiated fever in communities keeping livestock [ 23 , 24 ]. In 2015, data from these studies were used during a One Health Zoonotic Disease Prioritization workshop in Kenya, where Q-fever was identified as one of the diseases that would benefit from integrated prevention and control programs using the One Health approach [ 15 ].

Brucellosis

CDC Kenya and the ZDU implemented a study in three counties among humans and their livestock and found a varying (2.4–46.4%) seroprevalence in humans and 1.2–13.5% in livestock among the counties, largely associated with cultural practices around livestock and their products particularly unpasteurized milk and low knowledge levels on brucellosis. This underscored the need for targeted public health messaging, effective diagnostic capacity in local hospitals and systematic control programs for brucellosis in animals [ 25 ].

Rift Valley fever

The momentum built around the 2006–2007 RVF outbreak in Kenya progressed to robust research projects by multisectoral collaborative research groups. A key output from learning the lessons on preparedness from the 2006–2007 outbreak is the RVF decision support tool kit for Chief Veterinary officers in the Horn of Africa region to support evidence-based actions to mitigate the impact of RVF outbreaks when they occur [ 26 ]. This tool has been adapted into the RVF integrated preparedness and response plan for Kenya and was applied in late 2015 when RVF was predicted in Kenya and the Eastern Africa region as described previously.

Other DGHP- Kenya research work on RVF described climatic, geographic, and geologic predictive factors associated with occurrence of RVF in Kenya [ 27 , 28 ]. These data taken together with a historical review of RVF outbreaks since 1912, were used to generate a risk map for RVF in Kenya [ 27 , 29 , 30 ]. A temporal spatial mapping of the RVF outbreaks in the Eastern Africa region followed by molecular analysis of viruses isolated from humans, animals and mosquitoes found foci-specific viral lineages suggesting de novo activation of viruses in specific outbreak sites rather than spatial spread from the initial outbreak site to another [ 31 ]. This knowledge was useful in defining the endemic nature of RVF in certain regions in Kenya and subsequent studies on factors associated with endemicity, outbreak flare-ups and factors associated with human morbidity and mortality [ 27 , 32 ]. To address safety concerns surrounding the locally available RVF vaccine, a field trial to evaluate the safety and efficacy of new RVF clone 13 vaccine was conducted in Kenya in collaboration with Kenya Ministry of Agriculture Livestock and Fisheries [ 33 , 34 , 35 ]. The results showed the vaccine as a promising tool, being safe and with high immunogenicity in sheep and goats and moderate immunogenicity in cattle under field conditions. This vaccine has been earmarked for registration locally.

Between 2006 and 2008 a hospital based study conducted by KEMRI and CDC Kenya in North Eastern Kenya identified for the first time, Rickettsia felis —an agent of flea-borne spotted fever in 3.7% of patients [ 36 ]. A second study (2007–2010) in the PBIDS Lwak health facility in Western Kenya reported 57% seroprevalence of antibodies versus Rickettsial species in archived human sera. Rickettsia were detected by PCR in 7.2% of febrile patients, which was 2-fold higher than in the afebrile patients suggesting that Rickettsial pathogens are an important differential diagnosis among patients with undifferentiated fever in this region [ 37 ]. Subsequently cross-sectional studies in PBIDS platforms found previous exposure to spotted fever group rickettsia in goats (43%), sheep (23%) and cattle (1%) and in majority (> 90%) of Amblyomma variegatum tick pools and in 66% of flea pools [ 38 ]. Further these studies identified, isolated and sequenced a novel (to the world) rickettsial pathogen, Rickettsia asemboensis in cat and dog fleas in western Kenya.

Middle East respiratory syndrome coronavirus

High seroprevalence of Middle East Respiratory Syndrome Corona Virus (MERS COV) among camels has been reported in Kenya and other countries in Africa [ 39 , 40 ]. Kenya has over three million camels reared in the arid northern part of the country. CDC Kenya in collaboration with KEMRI assessed whether persons exposed to seropositive camels (90% sero-prevalence) at household level had serological evidence of infection. None of the 760 persons tested with well-characterized exposure to camels and camel products (milk) showed evidence of previous exposure MERS COV [ 41 ]. To test the hypothesis that perhaps a different strain of MERS COV that is less transmissible from camels to humans is circulating in camels in Kenya we have set up a study to detect and isolate MERS virus strain circulating in camels in Kenya for comparison with strains circulating elsewhere and addition expanded an enhanced surveillance of respiratory illness to Marsabit where camel pastoralists reside to detect any cases in humans.

Potential zoonotic pathogens in small mammals

In 2008, KEMRI and CDC conducted a study in the urban (Nairobi) Kibera PBIDS platform with rodents captured in and around houses and reported a diversity of pathogenic leptospires [ 42 ]. Two studies carried out by KEMRI and CDC on Bartonella in rodents and bats captured in or around homesteads in Kibera PBIDS platform found Bartonella strains that are closely related to known human Bartonella species [ 43 ]. In addition, from a variety of bats captured in multiple sites across Kenya, a high prevalence and diversity of Bartonella species were identified [ 44 ]. Detection of these pathogens in these animal reservoirs suggests potential for exposure and transmission to humans in different settings. Future work is underway to understand the contribution of these pathogens as etiologies for undifferentiated fever in humans using multi-pathogen detection assay such as the AFI TaqMan array card in several sites including the PBIDs platform in Western Kenya.

Linking animal ownership and health status to human health outcomes

Since 2013, CDC and KEMRI in collaboration with Washington State University have conducted animal (cattle, sheep, goats, and poultry) syndromic surveillance in 1500 households in Western Kenya, a subset of the on-going PBIDS platform [ 7 ]. This integrated and unique study design allows for measuring of the impact of livestock diseases on human health and socio-economic status at household level. Preliminary data analysis reported at household level, showed strong association between cumulative human and animal illness though the mechanism for this association was not clear [ 7 ]. Further work looking at  the linkage of human health and owning livestock through the nutritional pathway as well as assessing the level of microbiome development among children at household level has yielded insights into the impact of animal ownership and animal source foods on growth and development of children under 5 years old as well as the factors associated with level of microbiome sharing [ 45 , 46 ]. There are on-going studies on impact of interventions to reduce diseases in animals on health and socio-economic status of households.

In summary, the CDC, KEMRI and collaborators investments in research on zoonotic diseases has generated credible and useful data on occurrence, identified new pathogens and etiologies of common syndromes, clarified the ecology of disease occurrence and overall contributed in the formulation of science-based interventions in endemic zoonotic diseases. In addition, the innovative and unique linked human-animal interface study designs have highlighted the benefits of adopting a One Health approach in research to study zoonoses and complex interlinked human and animal health relationships. Overall, 30 publications covering viral, bacterial and other (mainly reviews and topics on disease ecology) have been realized from this work (Fig. 1 ).

While zoonotic diseases spill-over to human populations and the concept of controlling infections at source is well appreciated, the animal health sector continues to be under-resourced in critical elements of surveillance and reporting of animal diseases and laboratory diagnosis. In addition, setting up surveillance programs is resource intensive with few partners providing support. Convincing policy makers of the benefit of planning and investing in animal surveillance for public health gain is often challenged where data on burden of zoonoses are scanty and when the threat is not immediately apparent zoonotic and/or not an existing emerging disease threat. On a positive note, in 2013 DGHP Kenya funded the development of a rabies elimination plan for Kenya [ 14 ] that has since attracted funding from various MALF and MOH development partners for rabies elimination activities including mass dog vaccination, enhanced rabies surveillance in humans and animals, enhanced management of dog bite cases and operational research. Finally, the Kenya ZDU has not fully incorporated the environment health sector to be fully compliant with the scope of One Health approach. This has in part been due to lack of clearly designated government ministry that represents the environment sector. Currently efforts have been made to include an ecologist as a core personnel to the ZDU to provide environmental health expertise. In addition, the strategic plan for the implementation of One Health is being reviewed to reflect the progress made and identify strategies for institutionalizing One Health at sub-national level.

The change of Kenya’s governance structure from a central to a devolved system in 2012 necessitated a different approach in the implementation of One Health. The extent of adoption of the One Health approach has been remarkable at the national level. However, at the sub-national (County and sub-county levels) where most disease management decisions are made, more progress is needed. With GHSA support, the ZDU has made concerted efforts to establish functional One Health units at county levels to enhance coordination and communication of key ministries and stakeholders for surveillance and disease outbreak response; however the benefits of these efforts are currently being evaluated. Finally, sustainability of the current progress and efforts are not guaranteed due to the reliance on donor funding to implement these One Health activities. This is a challenge that goes beyond One Health implementation and is largely appreciated for many donor-initiated efforts. Most governments have a host of competing interests including constant outbreaks of epidemic prone diseases such as cholera, other infectious diseases and non-communicable diseases within the health sector and focusing on promotion of international trade in animals and animal products that often make the importance of zoonotic diseases pale in comparison. Commendably, ZDU has initiated advocacy plans to lobby for government support through the line ministries to maintain One Health activities beyond the current GHSA initiative.

Conclusions

Since 2006, CDC Kenya has successfully supported and collaborated with Kenyan government institutions to establish a sustainable One Health program at national and county levels; a process catalyzed by emerging zoonotic threats such as RVF and H5N1. The results have been the establishment of an effective cross-sectoral coordinating government unit (ZDU), an enhanced surveillance system in domestic and wild animals that meets the needs of animal and human health, a workforce trained in the One Health approach, improved outbreak investigations and a robust and productive public health scientific program including the discovery of zoonotic pathogens new to the world. The adoption of the One Health program and approach in Kenya has led to rapid detection and control of zoonotic disease outbreaks at their source and thereby enhanced global health security. These achievements have allowed for advocacy and informed decisions to be made on the control and prevention of zoonotic pathogens and have identified gaps in diagnosis and surveillance. However, challenges remain in sustainability, veterinary laboratory diagnosis and resources to implement more comprehensive control and prevention measures.

Since zoonotic infections continue to  impose a health burden on population, and new zoonoses can emerge in any country and spread globally, the regional and global adoption of the One Health agenda is a key capacity of the global health security agenda. Lessons learnt from Counties in Kenya are applicable to establish One Health programs throughout Kenya, the African region, and beyond.

Abbreviations

Centers for Disease Control and Prevention

Division of Global Health Protection

Global Disease Detection Division

Highly pathogenic avian influenza

Kenya Medical Research Institute

Middle East Respiratory Syndrome Corona Virus

Rift Valley Fever

Zoonotic Disease Unit

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Acknowledgements

Establishment of ZDU and programs: We would like to acknowledge the Directors of Medical Services, Ministry of Health and Director of Veterinary Services, Ministry of Agriculture, Livestock and Fisheries and personnel from the respective ministries and Kenya Wildlife Service for their excellent collaboration and efforts in setting infrastructure and continued facilitation for ZDU operations. We would also like to acknowledge the technical and financial support from Biological Engagement Program of the US Department of State, Defense Threat Reduction Agency of the US Department of Defense, US Agency for International Development (USAID)-Kenya, World Health Organization (WHO), Food and Agriculture Organization of the United Nations – Emergency Center for Transboundary Animal Diseases (ECTAD) Kenya, International Livestock Research Institute (ILRI), Africa Field Epidemiology Network (AFENET) and Kenya Medical Research Institute among other stakeholders. We also would like to acknowledge excellent research collaboration with the Wellcome trust; Washington State University with funding from Paul Allen Foundation; The Global Alliance for Livestock Veterinary Medicines; Defense Threat Reduction Agency of the US Department of Defense; The One Health Office in the National Center for Emerging and Zoonotic Infectious Diseases, and the Center for Global Health, US CDC, Atlanta.

Publication of this article was funded by US Centers for Disease Control and Prevention, Global Detection Division, Division of Global Health Protection, Kenya.

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This article has been published as part of BMC Public Health Volume 19 Supplement 3, 2019: 10th anniversary of the Centers for Disease Control and Prevention - Global Disease Detection program. The full contents of the supplement are available online at https://bmcpublichealth.biomedcentral.com/articles/supplements/volume-19-supplement-3 .

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Munyua, P.M., Njenga, M.K., Osoro, E.M. et al. Successes and challenges of the One Health approach in Kenya over the last decade. BMC Public Health 19 (Suppl 3), 465 (2019). https://doi.org/10.1186/s12889-019-6772-7

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Research projects in kenya, innovations in hiv prevention and treatment heading link copy link.

HIV remains a global pandemic, with 37 million infected. An excess of new infections occur in sub-Saharan Africa.  Hearteningly, it is estimated that the scale-up of voluntary medical male circumcision (VMMC) has averted 2 million HIV infections and 300,000 deaths since the results of three randomized controlled trials in sub-Saharan Africa proved the efficacy of VMMC in reducing HIV transmission in 2006.

One of those trials, in Kisumu, Kenya, was led by Robert Bailey, PhD, professor emeritus of epidemiology. With support from the National Institutes of Health (NIH), Bailey conducted the trial from 2002-2006, demonstrating a 60 percent reduction in HIV incidence among men undergoing VMMC, with post-trial surveillance showing efficacy maintained through at least 6 years.

From 2010-2015, Bailey led country-wide scale-up with support from the Bill & Melinda Gates Foundation and Centers for Disease Control and Prevention.  Throughout that time, Bailey’s program in Kenya supported and graduated 5 MS and 7 PhD students. Results of this research have global reach, informing several of the World Health Organization guidelines for VMMC practice and scale up.

Over the years, 30 MPH students have completed their global health practicum through our Kenya program. Importantly, Bailey’s research in Kenya has provided a platform for other SPH faculty to conduct research successfully in Kenya.

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Experiences of violence among adolescent girls in rural Kenya Heading link Copy link

Violence against women is endemic across much of Sub-Saharan Africa. In Kenya, 47 percent of women aged 15-49 have experienced physical or sexual violence in their lives, with most violence among ever-married women occurring at the hands of a current or former partner. Among adolescent girls 15-19 years, 35 percent report having experienced physical or sexual violence. Physical and sexual violence that occurs in during youth is associated with a wide variety of adverse outcomes, including increased HIV/AIDS risks, physical harm, and decreased psychosocial wellbeing and educational attainment. Moreover, these harms and risks increase as the number or severity of violence increases.

Led by Alisa Velonis, PhD, assistant professor of maternal and child health, this study aims to characterize of types of violence and examine whether violence and/or forced sex is associated with educational or mental health outcomes, in particular school absence and quality of life.

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After serving as a co-investigator to the VMMC trial, SPH’s Supriya Mehta, PhD, interim associate dean of global health, was awarded NIH funding to study microbiome-related HIV and sexually transmitted infection risk in Kenya. Focusing on the microbiome (bacterial community) as a central driver of women’s risk of sexually transmitted infections, Mehta and colleagues from UIC collaborated with peers in Kenya to demonstrate that the male partner’s penile microbiome composition accurately predicts a woman’s risk of vagina infection up to one year later. These results have been featured in numerous news outlets, including CNN, Newsweek and Fox News, reflecting the importance of the study to the public.

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At the intersection of sanitation and clean water Heading link Copy link

People may choose fields, bushes or other open space for defecation if they do not have a toilet readily accessible. Open defecation causes diarrheal disease in children, which leads to malnutrition and increased mortality. As communities shift to ‘open defecation free (ODF)’ and construction of toilets, related diarrheal disease should decrease.

Courtney Babb, MS in Epidemiology ’15, partnered with the Ministry of Health in Nyando District, Kenya, to evaluate latrine intervention conditions in relation to diarrheal disease. Babb and community health workers visited individual households across 33 villages to take water samples for testing and assess latrine conditions. Unexpectedly, children in households without ODF zones had the same rate of diarrhea as children in ODF areas. Babb demonstrated that this was due to greater availability of safer water in the non-ODF areas compared to the ODF areas.

Shockingly, the prevalence of unsafe water by sub-location ranged from 43 percent to 87.5 percent by World Health Organization (WHO) classification of coliform bacteria and other water quality indicators. According to WHO, by 2025, half of the world’s population will be living in water-stressed areas.

Assisting tobacco farmers in finding viable economic alternatives Heading link Copy link

More than eight million people die each year from tobacco-related illnesses. With changing markets, more than 80 percent of the disease burden from tobacco use will fall on low to middle-income countries (LMICs) by 2030. Driving this shift, opponents of tobacco control have argued that tobacco control measures harm smallholder farmers in LMICs; as a result, many governments have been slow to adopt these policies.

Funded by the NIH and the Canadian Institute of Health Research, Jeff Drope, PhD, research professor in health policy and administration, and his colleagues are rigorously examining the economic lives of these farmers in six major tobacco-growing LMICs—Indonesia, Kenya, Malawi, Mozambique, Zambia and Zimbabwe.  The project aims to illuminate the broader structures, policies and other important contexts that frame farmers’ livelihoods.  Their findings show unequivocally that the tobacco industry’s narrative of farmer prosperity is mostly untrue. In reality, most tobacco farmers are struggling economically much more than their neighbors who do not grow tobacco.

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Building Mental Health Research Capacity in Kenya: A South - North Collaboration

Muthoni mathai.

Senior lecturer Department of Psychiatry, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Ann Vander Stoep

Associate professor, department of Psychiatry and Behavioural sciences, Epidemiology University of Washington. Seattle. Box 354920, Child Health Institute, 6200 NE 74th Street, Suite 210, Seattle, WA 98115 -1538 Tel: 206-543-1538

Manasi Kumar

Senior lecturer Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Associate Professor and head of Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Anne Obondo

Associate Professor Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Violet Kimani

Professor School of Public Health, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Beatrice Amugune

Senior lecturer, School of Pharmacy, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Margaret Makanyengo

Clinician Kenyatta National Hospital, Honorary Lecturer University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Anne Mbwayo

Lecturer Department of Psychiatry, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA Mara Child,

Jürgen Unützer

Professor and Chair department of Psychiatry and Behavioural Sciences, adjunct professor School of Public Health and Department of Global Health, University of Washington. Seattle. 1959 NE Pacific Street, Seattle, WA 98195, United States

James Kiarie

Associate Professor Department of Obstetrics and Gynaecology, University of Nairobi; World Health Organisation: Coordinator, Human Reproduction Team. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA

Associate Professor Department of Global Mental health, Psychiatry and Behavioural Sciences. University of Washington, Seattle. Department of Global Health; Harborview Medical Center, Box 359931, 325 9 th Ave, Seattle, WA 98104 USA

This paper describes a mental health capacity-building partnership between the University of Nairobi (UON) and the University of Washington (UW) that was built upon a foundational 30-year HIV/AIDS research training collaboration between the two institutions. With funding from the US National Institute of Mental Health Medical Education Program Initiative (MEPI), UW and UON faculty collaborated to develop and offer a series of workshops in research methods, grant writing, and manuscript publication for UON faculty and post-graduate students committed to mental health research. UON and UW scientists provided ongoing mentorship to UON trainees through Skype and email. Three active thematic research groups emerged that focused on maternal and child mental health, gender-based violence, and HIV-related substance abuse. Challenges to conducting mental health research in Kenya included limited resources to support research activities, heavy teaching responsibilities, clinical duties, and administrative demands on senior faculty, and stigmatization of mental health conditions, treatment, and research within Kenyan society. The partnership yielded a number of accomplishments: a body of published papers and presentations at national and international meetings on Kenyan mental health topics, the institution of systematic mental health data collection in rural clinics, funded research proposals, and a mental health research resource centre. We highlight lessons learned for future mental health research capacity-building initiatives.

The majority of Sub-Saharan countries suffer from a shortage of health workers in general ( Machayo & Keraro, 2013 ). This shortage becomes even more acute in specialties like mental health, with untreated mental disorders accounting for a large proportion of the disease burden that afflicts the continent ( Fryers, Melzer, & Jenkins, 2003 ; Global Burden of Disease Study 2013 Collaborators, 2015 ). Strong evidence demonstrates that addressing common mental disorders can help improve outcomes for people living with communicable and non-communicable diseases in a cost effective manner ( Katon et al., 2012 ). Many countries, however, do not have mental health budgets to implement public mental health programs. Of those countries with mental health budgets, the proportion of total health expenditures designated for mental health is under 1% ( Shekhar Saxena, Thornicroft, Knapp, & Whiteford, 2007 ).

Strengthening mental health research capacity in low resource contexts will contribute towards reducing disease burden globally ( Whiteford et al., 2013 ). The World Health Organization-Mental Health Global Action Programme asserts that well-grounded local research is critical for identifying mental health needs, prioritizing relevant mental health problems, and developing and evaluating appropriate interventions that can be integrated into community and clinical settings ( World Health Organization, 2016 ). Low resource settings, including Kenya, have very few health workers with specialized training in mental health care ( Vasquez, Hirsch, Giang, & Parker, 2013 ), and among those who have received such training, only a small proportion conducts research due to the high demand for clinical services and poor access to research mentorship, funding, and materials ( Pratap, Itzhak, Sylvie, Francisco, & Shekhar, 2007 ; S. Saxena, Paraje, Sharan, Karam, & Sadana, 2006 ). While low resource settings shoulder 75% of the burden of mental illness ( Patel, 2007 ), fewer than 10% of research trials on mental health interventions occur in these settings. Between 1992 and 2001 researchers in low resource settings authored fewer than 4% of mental health-related publications ( Saxena et al. 2006 ). The situation in Kenya is no different. A 2007 survey showed that Kenya was among 12 African countries that together contributed only 2% of the indexed mental health research articles from low and moderate resource contexts that were published from 1999–2003 ( Pratap et al., 2007 ).

To enhance the likelihood that research will have the desired public health impact, Collins and colleagues (2013) argue that researchers need a skill set that enables them to effectively “engage community stakeholders, journalists, decision-makers, and policymaking organizations before, during, and following the completion of research activities” ( Collins, 2013 ). Thus, an important consideration in building research capacity is to equip a workforce with methodological training that is suited to the setting and that prioritizes local health demands. While international collaboration can be a helpful resource for faculty and students to overcome impediments to the production of useful research findings, over-reliance on quantitative measures, diagnostic categories, and treatment paradigms based in western psychiatry have created cultural inappropriateness and neocolonialist frameworks that can yield uninterpretable research findings and irrelevant interventions ( Horton, 2013 ). Research training grants require writing skills and multidisciplinary teamwork to produce and execute, which can foster overreliance upon institutions in high resource settings.

Several initiatives have been undertaken worldwide to build research capacity in low resource settings (Council on Health Research and Development 2012). These initiatives typically provide funds to individual researchers or academic institutions and offer research training and opportunities for research collaboration ( Lansang & Dennis, 2004 ; Vasquez et al., 2013 ). This paper describes one such South-North collaborative mental health research capacity-building collaboration between Kenya and the U.S. We used a complementary approach that included: 1) training of individual researchers from masters to doctoral level with a small research seed grant; 2) learning by doing approach-requiring all trainees, academic or on the job mental health workers, to carry out a research project or write a grant proposal and thirdly built on a creation of a south-north partnership ( Lansang & Dennis, 2004 ). Our collaboration was initiated in 2011 and has built a foundation upon the National Institutes of Health (NIH) Medical Education Partnership Initiative (MEPI) funding mechanism (R25 MH099132) which required that low resource setting institutions submit proposals and become the recipients of the grants, thereby developing capacity for grant and subcontract administration.

Within the partnership model, the NIH provides a multiple Principal Investigator option that “encourages collaboration among equals when that is the most appropriate way to address a scientific problem.” The Multiple PI designation provided a project framework for promoting equity across institutions and disciplines. During project implementation, decision-making at the PI, grant administration, and co-investigator levels reflected this collaborative model ( NIH, 2011 ).

The Kenyan Context

University of nairobi (uon) and university of washington (uw) research collaboration.

For over thirty years, the University of Nairobi and University of Washington have been working together to build health research capacity and conduct research in the area of HIV/AIDS. The UON/UW collaboration ( Child et al., 2014 ) has built a significant research infrastructure within Kenya with the aid of United States government funding. Bilateral research teams have been working on infectious disease prevention and control, reproductive health, and psychosocial issues related to engagement in care in three regions: Nairobi, Kisumu, and Kilifi. During the past 25 years about 153 health workers have received training from the University of Washington through the AIDS International Training and Research Program (AITRP), funded by the Fogarty International Center at the National Institutes of Health (NIH). These are the researchers who have become the driving force in health research at the University of Nairobi ( Child et al., 2014 ). The collaboration hosts regular training programs and workshops that cover topics such as the responsible conduct of research, implementation science, grant writing, and manuscript preparation. In addition, the UW has worked to strengthen UON administrative capacity to take on foreign research grants. The “Partnership for Medical Education in Kenya” (PRIME-K) was a MEPI collaborative research program between the two institutions that approached medical education from a multidisciplinary and community-based perspective. The main objective was to expand clinical training opportunities at the UON and other Kenyan universities through innovative training methods and community integration as potential training sites ( Osanjo et al., 2015 ). The MEPI program also provided its participants training in rigorous research methodologies, as well as mentorship.

After the initial MEPI program was funded, the NIH announced opportunities for capacity-building in mental health research. Applications were limited to schools with a previous MEPI grant. In response to the call, the Departments of Psychiatry at UON and UW, as well as the UW Department of Global Health took advantage of the links that had been previously forged through PRIME-K.

Status of Mental Health Research in Kenya

Since 1971 the Department of Psychiatry at the University of Nairobi has been training psychiatrists, clinical psychologists, and other mental health workers. To complete their Master’s degrees in psychiatry or clinical psychology, trainees must complete a thesis based on original research. Between 1980 and 2013, 106 postgraduate theses and dissertations were completed, but only eight (7.5%) were published. In a 9 years period between 2002 and 2011 there were 49 peer reviewed publications authored by faculty within the Department of Psychiatry, compared with over 100 publications produced by the Department of Obstetrics and Gynecology at UON within a 5 year time period. Of the 49 publications from Psychiatry, one researcher served as first author for 37% of papers.

The department of Psychiatry has from the onset worked with some renowned researchers among the faculty, including being involved in international projects, few faculty however have had formal training in research methods and grant writing and those who had training were hampered in their research productivity by the real demands of their academic roles in two institutions which serve as teaching hospitals for the UON College of Health Sciences. Faculty take on heavy responsibilities for clinical teaching and supervision, clinical service, and academic program administration. Without time and resources the Department had made little progress towards developing or adapting culturally appropriate tools, intervention approaches and models for delivering mental health care in general health care facilities, schools, work and other community settings. Faculty needed grant writing skills to enable them to fund their research.

Other Barriers to Mental Health Research Capacity Building

Stigma associated with mental illness presents another significant barrier to mental health research in Kenya. This stigma discourages health care providers from entering mental health professions, people with mental illnesses from seeking treatment and disclosing their status to researchers, and researchers from focusing on mental health questions ( Rüsch et al., 2014 ). The stigma impedes interdisciplinary dialogue between mental health specialists, (e.g., psychiatrists, psychologists, social workers, and psychiatric nurses), and researchers from other disciplines, (e.g., public health, anthropology, nursing, general, pediatric, and gynecologic medicine, and pharmacy) ( Rao et al., 2012 ). Without interdisciplinary collaboration, the critical interplay between “physical” and “mental” health is not recognized, and mental health research and practice remain “siloed’. To expand expertise in relevant research methodologies, UON faculty needed training in both qualitative and quantitative methodologies to elucidate local mental health problems and to adapt and test culturally appropriate mental health assessment tools, interventions, and service delivery models.

Proposal Development and Project Initiation

In 2011 the UON and UW wrote a response to the NIH call for mental health research capacity-building proposals. The proposal was developed with joint input across institutions to ensure that it had local relevance for the Kenyan setting, while integrating the research and writing expertise of the multidisciplinary UW team that included co-investigators from Psychiatry, Psychology, Epidemiology, and Global Health. Two Principal Investigators from UON and UW were designated. UON was the primary grant recipient, and UW the subcontractor, with budget management onsite at UON. The objectives of the project were to train interdisciplinary groups of postgraduate trainees and faculty in mental health research methods and engage in collaborative efforts to disseminate knowledge about mental health in Kenya and conduct funded mental health research. The ultimate goal was to improve the health of Kenyans.

The project had three aims. AIM 1: Improve mental health research capacity at UON by training UON and KNH faculty in research methods, grant writing, and manuscript writing; AIM 2. Train postgraduates in mental health research through coursework and mentored research projects; and AIM 3. Establish a mental health research resource centre. A secondary aim was to train non-academic health workers in other decentralized sites in research methods and support them through a project.

Project Implementation

NIH funded the three-year MEPI-mental health research capacity-building project (R25 MH099132) with project kick-off held in August of 2012 in which the chairs of the UON and UW Departments of Psychiatry, the UW Department of Global Health participated. The project followed the process initiated by PRIME-K of an integrated approach involving multidisciplinary partners and key stakeholders from the beginning ( Child et al., 2014 ). The Director in charge of mental health at the Ministry of Health, Kenya, representatives from the Mathari Teaching and Referral Hospital for Psychiatry, heads of departments from the different schools and representatives from two other Universities were involved in the inaugural capacity-building activities in January 2013. Mental health research capacity-building was promoted through five activities: conducting annual research training workshops for faculty and trainees at the University of Nairobi; forming thematic groups to focus research efforts on four priority areas; engaging mental health professionals from decentralized sites in research training and collaborative projects; establishing a mental health research resource centre that was accessible to UON and KNH researchers and other health workers; and providing ongoing mentorship for post-graduate trainees at UON.

UW faculty members have been onsite at the UON for two, four, and five weeks across the three successive years of the project. Over the course of the project UON faculty made two week-long visits to UW. An official visit to UW by the UON principal investigator in May 2013 helped strengthen ties and develop mutual understanding of the academic environments and work responsibilities across institutions. In 2015, two UON faculty members traveled to the UW to participate in an intensive training workshop in Interpersonal Therapy (IPT) and to consult with experts who had implemented IPT research studies to address depression in Ugandan adults and adolescents ( Bass et al., 2006 ; Bolton et al., 2007 ; Verdeli et al., 2008 ). The face-to-face time that collaborators had at the two institutions was instrumental in fostering an understanding of differences and similarities in mental health resources and service delivery models and infrastructures for supporting research activities.

Research Methods and Writing Workshops

In each of the project years, UW and UON faculty led research methods workshops in Kenya for postgraduate trainees and faculty members with representation from six health disciplines: psychiatry, clinical psychology, public health, pharmacy, nursing, and obstetrics/gynecology. The first training workshop, held for two weeks in January 2013, was modeled after an AFYA BORA Consortium grant writing course and a UW graduate course in psychiatric epidemiology, (i.e., public mental health research methods). An extensive review of the literature yielded scientific articles about mental health conducted in Kenya and neighboring countries in East Africa. Workshops were augmented with e-learning modules available for download on the internet or cd-rom. The initial curriculum was based on a research needs assessment tool ( Table 1 ), that was given to eight faculty involved in the study, this was then revised jointly over email and Skype discussions, and further revision occurred in-person on a day-to-day basis as the workshops progressed. A post workshop evaluation with all participants was done at the end of each workshop and this was used to modify the next workshop.

Research needs assessment tool

In the month prior to each annual workshop, interested trainees applied to participate by submitting a research concept; 15 were selected annually by UON faculty. An important criterion for selection was that the research topics were mental health-related and focused on prioritized thematic areas of mental health issues of persons with HIV/AIDs, alcohol and substance use disorders, gender-based violence and PTSD, and maternal and child mental health.

In the workshops, instructors used problem-based and interactive pedagogical approaches with locally relevant examples from mental health studies conducted in Kenya and other sub-Saharan African countries. The workshops began with overview of why it is important to conduct research and the need for mental health research in Kenya. Subsequent sessions introduced basic quantitative and qualitative research topics of study design, sampling, mental health measurement, research ethics, sample size determination, data management and statistical analysis (See Table 2 ).

Outline of Year 1 and Year 2 Mental Health Research Methods Workshop Curriculum

Over the course of the three project years, responsibility for teaching topics in the workshops shifted from UW to UON faculty. In the initial year, UON faculty taught single sessions on the following topics: research ethics, sample size calculation, qualitative research methods, and literature review, while UW faculty taught multiple sessions on quantitative research methods and grant writing. In year 2, a UON faculty member was assigned to co-facilitate each of the quantitative research methods sessions with UW faculty. In year 3, UON faculty prepared for teaching by participating in coaching sessions with UW faculty and delivered all of the didactic portions of the workshop on their own. To help trainees solidify concepts, UON and UW faculty co-led discussions following didactic sessions. Table 2 also illustrates how the workshop curriculum was modified from Year 1 to Year 2 in response to UON faculty and trainee needs.

In the final project year UW faculty led two additional types of workshops: three grant-writing workshops for each of the thematic groups and a “thesis-to-publication” workshop for eight Year 1 trainees who had successfully completed their theses. The grant writing workshops included didactic content to familiarize UON thematic group members with typical grant formats and requirements. Group members selected a funding mechanism and a research topic and produced a draft of a grant proposal.

On successive days of the thesis-to-publication writing workshop, participants were introduced to techniques of writing each part of a scientific article: Introduction, Methods, Results and Discussion, and Abstract. Didactic sessions were followed by writing sessions where participants adapted parts of their theses to journal article format with consultation from UON and UW mentors. In both types of writing workshops, in the early evening, each group (grant-writing) or participant (manuscript-writing) made a brief presentation of their progress. In Years 2 and 3 trainees were encouraged to attend other manuscript writing workshops organized by PRIME-K in the UON College of Health Sciences.

Thematic Groups

The project investigators established priority areas and thematic work groups, taking into account areas of research interest and specialization at both the UON and UW. Pairs of local and UW mentors helped trainees to design and conduct their research and provided mentorship on the write-up of their results. At the end of the three-year award, all thematic groups had met separately at least once in retreats in Kenya with their respective UON/UW faculty to craft a proposal for submission for external funding of future work.

One thematic group focused on substance use disorders and HIV/AIDS. The chair of the UON Department of Psychiatry, a UW-based specialist in substance use disorders, and a local substance use disorder intervention specialist met with interested trainees individually and in groups to help them design their studies.

The second thematic group met with a UON psychiatrist and a UW-based trauma psychologist and supported trainees as they crafted projects centered around gender-based violence (GBV) research. The trainees and mentors then designed and implemented studies to identify socio-cultural reasons for delayed reporting of gender-based violence and examine the psychosocial and medical outcomes of survivors seen in a GBV clinic based in the Kenyan teaching hospital. Results of these studies are being used to improve services in the Kenyatta National Hospital’s GBV programme. In the second project year, a UW co-investigator provided a one-day training on Cognitive Processing Therapy (CPT), with case examples from CPT implementation in the Democratic Republic of Congo.

The thematic group focusing on maternal and child mental health (MCMH) convened with two clinical psychologists who were UON faculty and a UW child psychiatric epidemiologist. Members of the MCMH group were interested in the effects of pre- and post-partum depression on mothers and their infants. This important topic had received little research attention in Kenya. Trainees attached to this thematic group addressed a number of related topics, including depression screening in antenatal clinics, maternal depression and its impact on infant feeding and growth, depression in pregnant women with HIV, and parent-child attachment in Kenyan school children. The UON Department of Psychiatry has begun to collaborate with the UON Department of Obstetrics/Gynecology to broaden the scope and potential impact of antenatal depression research.

Ongoing Mentorship

Over the three-year funding period and up to the present, UON trainees have worked closely with UON faculty and UW to write collaborative manuscripts for publication based on their completed thesis research projects. Weekly consultation occurred amongst trainees at UON while field work was in process, and UW faculty members were consulted more frequently to mentor on data analysis and writing.

Engaging Mental Health Professionals from Decentralized Sites

In year 3 UON faculty recruited non-academic health workers from sites outside of Nairobi and from the Gender-Based Violence Recovery Centre at Kenyatta National Hospital to participate in mental health research capacity-building activities. Six ‘decentralized’ sites representing diversity in geographical regions were selected, and selected representatives to participate in the research methods workshop.

Establishing a Mental Health Resource Centre

To meet our third aim, the Kenyan national teaching hospital, Kenyatta National Hospital, refurbished a space to create a Mental Health Resource Centre. The Centre is stocked with relevant resource books on research methodology, training videos, computers with statistical and referencing software, and internet/e-learning materials provided by UW. The Centre is staffed by two researchers who help trainees through the process of submitting proposals for UON Ethics Committee review, managing field research stipends, reviewing literature, implementing research protocols, and conducting data entry and analysis. The resource centre has become a hub for student and faculty consultations. A second resource centre has been established at Mathari Hospital, the national psychiatric referral and teaching hospital in Nairobi.

Progress towards building mental health research capacity is reflected in the generation of research products, including theses completed, manuscripts developed for publication, research grant proposals submitted and funded, and research career pathways taken. This progress is summarized in a diagram below (see Figure 1 ).

Accomplishments of MEPI mental health trainees

Workshop Participation and Thesis Completion

Over the three-year project period, a total of 45 trainees, 15 faculty, and nine non-academic health workers from remote clinical sites participated in research capacity-building activities implemented through the MEPI mental health project. Benefits to the trainees of participation included learning research methods and skills through workshop attendance, mentorship from UON and UW faculty to design and carry out thesis research projects, seed funding for conducting field research, and membership in an ongoing collaborative multidisciplinary thematic research group of UON and UW faculty and UON trainees.

Responses on daily workshop evaluations conveyed that trainees gained an appreciation of the value of conducting research and enjoyed working with mentors and a team of scientists. They also gained useful skills for searching the research literature which provided them with a strong foundation from which to generate their research questions and write their proposals (See Table 3 ).

Student Feedback after First Mental Health Research Methods Workshop

Research Theses, Presentations and Papers

Twenty-eight trainees who participated in the mental health research capacity-building workshops have completed their master’s theses and one has completed a PhD thesis. Strong efforts have been made towards disseminating emerging research findings locally where they have their most relevance. To date, UON workshop participants have made presentations at three local, three regional, and two international conferences where they engaged in extensive networking with other African and global mental health researchers. In 2015 the MEPI-Mental Health research capacity-building project co-sponsored the Kenya Psychiatric Association (KPA) annual conference in Eldoret, Western Kenya and contributed to eleven presentations at the conference. In 2016, in keeping with the conference theme of “Depression, a Global Crisis,” our trainees made four presentations at the annual KPA conference in Nyeri, Central Kenya. In 2017 KPA hosted the 4th annual conference of the African Association of Psychiatrists and Allied Professionals (AAPAP), where our trainees and faculty made two presentations (see Table 4 ).

Presentations at the 2015, 2016 and 2017 annual conferences of the Kenya Psychiatric Association

In 2015, a trainee in the first workshop won a scholarship to present her dissertation findings at the biannual meeting of International Society for Research in Child and Adolescent Psychopathology held in the U.S. The UON Principal Investigator was invited to present accomplishments in Kenya research capacity-building at National Institute of Mental Health-sponsored Global Mental Health workshops held in Toronto (2016) and Washington, DC (2017). Significantly, over the past three years sixteen trainees have made a contribution to the mental health research literature by submitting eighteen manuscripts for publication in peer-reviewed journals. To date, thirteen have been accepted for publication ( Ambale CA, Sinei KA, Amugune BK, & Oluka MN, 2017 ; Jomo, Amugune, Sinei, & Oluka, 2016 ; Madeghe, Kimani, Vander Stoep, Nicodimos, & Kumar, 2016 ; Maina et al., 2015 ; Manasi, Linnet, Ongeri, Mathai, & Mbwayo, 2015 ; Mbwayo & Mathai, 2016 ; Musyoka, Obwenyi, Mathai, & Ndetei, 2016 ; Mutavi, Mathai, & Obondo, 2017 ; Mutavi, Obondo, Nganga, Kumar, & Mathai, 2016 ; Mutavi, Obondo, Nganga, Kumar & Mathai, 2016 ; Polkovnikova-Wamoto, Mathai, Vander Stoep, & Kumar, 2016 ; Waititu, Mwangangi, Amugune, Bosire, & Makanyengo, 2016 ; Yator, Mathai, Vander Stoep, Rao, & Kumar, 2016 ). Several other manuscripts are currently under review.

Development of Research Proposals

The substance abuse thematic group submitted one R21 proposal to the US National Institute of Alcohol and Drug Abuse. The aim of the proposed project was to conduct a pilot study to test the effectiveness of a community-based intervention program developed in Kenya that combines motivational interviewing, 12-step support, and cognitive behavioral coping skills. Based on pilot findings from a study conducted by a postgraduate trainee, the GBV thematic working group applied for foundation funding to test the feasibility of an intervention to address intergenerational effects of gender-based violence towards Kenyan women. The maternal and child mental health group has submitted three proposals for funding to generate information from community surveys and focus groups that will lay the groundwork for a future randomized clinical trial to test the effectiveness of group-based brief Interpersonal Therapy (IPT) for improving engagement in antenatal services of pregnant Kenyan adolescents and overall outcomes for these adolescents and their babies.

To date, none of the thematic groups have been awarded funding for their proposed research; however, signs of a growing capacity to conduct mental health research are in evidence. One of the UON faculty who received research training has a prominent role on an NIH-funded U-19 project entitled, “ African Regional Research Partnerships for Scaling Up Child Mental Health Evidence-Based Practices ” (M. McKay and K. Hoagwood, PIs, U19 {"type":"entrez-nucleotide","attrs":{"text":"MH110001","term_id":"1540586049","term_text":"MH110001"}} MH110001 –01-6883). And in autumn of 2017 UON and UW faculty submitted a collaborative R-21 grant proposal in response to the NIMH funding announcement, “ Mobile Health: Technology and Outcomes in Low and Middle Income Countries ” (M. Mathai and A. Vander Stoep, PIs).

UON and UW faculty also collaborated to write a multi-disciplinary proposal, entitled, “ Partnerships of Health Research Training in Kenya (P-HERT)” (D. Wamalwa and C. Farquhar, PIs, D43 {"type":"entrez-nucleotide","attrs":{"text":"DW010141","term_id":"89024524","term_text":"DW010141"}} DW010141 ) to provide additional research training opportunities for UON junior faculty. The five-year project was funded by the US National Institute of Health/Fogarty International in 2015. The P-HERT project is supporting junior faculty in the areas of mental health, HIV/AIDS, and maternal newborn and child health. Faculty from three Kenyan universities take epidemiology and biostatistics courses in the UW School of Public Health and link with a UW mentor to design and carry out a small PHERT grant-funded research project in Kenya that can lay the groundwork for future intervention development and research. To date three junior faculty members from UON and Kenyatta Universities who are in the mental health field have been selected as P-HERT fellows.

Research Initiated at Decentralized Sites.

In the third project year, we recruited six health workers from non-academic health facilities designated as “decentralized sites” for medical education in the PRIME-K project and three health workers from the Gender-based Violence Recovery Centre (GBVRC) at Kenyatta National hospital, for training in mental health research alongside postgraduate trainees. The health workers deliberated on priority mental health topics in their respective geographic settings and in the end pooled these together to come up with a multisite study design. They opted to conduct a multi-site prevalence study of depression and suicidality, alcohol use disorders and PTSD in patients seen at outpatient clinics in County Hospitals. The GBVRC group decided to evaluate barriers to successful treatment completion among child sexual abuse survivors (CSA). With support from UON faculty, four sites and the GBVRC team have gone on to write proposals that have passed ethical review. Data have been collected and are currently undergoing analysis.

Lessons Learned

Our collaborative activities yielded a number of lessons that we hope will be of value to institutions who engage in mental health research capacity-building efforts in the future. The first lesson was that the NIH Multiple PI model provided a strong platform for distributing responsibilities equitably among faculty from the two participating institutions. The Multiple PI model was extended to the shared leadership by UON and UW subject-matter experts of thematic groups and shared guidance of mentees. This model enabled trainees to draw optimally on combined strengths of local and US mentors.

While we envisioned that UON thematic groups members would meet altogether regularly with UW mentors via Skype, this turned out to be impossible. Ten hour differences in time zones, different work schedules, problems with equipment, and power outages were technical problems that made multiple member Skype calls impossible. In addition, having multiple trainees participate on a single one-hour call was ineffective, when each needed a stronger dose of individual mentorship. We developed a more constructive pattern that took a layered form of supervision, whereby the UON trainee consulted with the local thematic group leader, and who then had a 1:1 consultation with the UW leader to address questions raised in trainee consultations. A second lesson learned was that designating thematic groups was a very helpful mechanism to create a narrow, tangible perimeter for the selection of research ideas by trainees and provision of leadership by mentors.

Another lesson learned was about the pace and content of the workshop curriculum. In the first workshop, what the UW team had planned was found to be too ambitious, with didactic teaching taking up both morning and afternoon sessions. UON collaborators suggested a slower pace, more active learning and including sessions on qualitative research methods. In year 2, the curriculum was considerably leaner in content, with only morning sessions devoted to didactics. Each afternoon UON/UW thematic group leaders met with their constituent trainees and applied the research methodology skills they had learned to design their master’s thesis research projects. In the smaller groups, we could devote attention to each of 5–6 proposals, starting with determining the research question, reviewing the literature, designing the study, selecting the sample source and size, determining the measurement strategy, considering the ethical considerations, and formulating a detailed study protocol. At the end of the workshop, trainees had in hand a strong outline for their UON Ethics Committee application.

We learned other lessons about the value of being able to augment data analyses by deploying skilled UW graduate students. It is typical for the UON trainees, after executing the field work of their thesis research, to hand off their data to a statistician whom they hire and who has no familiarity with the topic they are studying. The statistical output they produced is often adequate for meeting requirements of the thesis, but inadequate for publication in peer reviewed journals. Graduate students in the UW Department of Epidemiology volunteered to give statistical support to move manuscripts from thesis to publication. The UON trainee would send their de-identified datasets with variable and value labels to the UW in excel or SPSS data files. UW mentors then supervised the graduate students through the process of re-analysis of the Kenyan data. UW graduate students were grateful to be added as co-authors.

Another generative process was when UW mentors set aside a block of time to collaborate on editing and polishing UON trainees’ manuscripts together with the UON faculty mentors, working together with the motto, “Many hands make light labor.”

Other Challenges

Heavy demands on a limited number of UON faculty made it difficult for them to set aside their teaching, clinical, and administrative responsibilities to participate in intensive research training workshops. Difficulties were overcome by ensuring that the workshops were organized during times when faculty were not responsible for monitoring student exams. The first workshop was organized on the UON College of Health Sciences campus, and there were frequent interruptions when workshop participants were called to attend to administrative, clinical, and family duties. Afternoons were characterized by anxiety from anticipating rush hour traffic jams in Nairobi. We learned that we could hold briefer, more intensive workshops outside of college settings, allowing UON faculty to get away from multiple demands on their time, carry out team-building activities in the early evening, participate in group work in the evenings, and socialize.

Building and maintaining collaborative relationships and supporting trainees to design, implement, and disseminate research findings requires major commitments of time. UW and UON faculty have both been challenged by low salary support relative to high mentorship demands from the MEPI activities. Faculty members from both academic institutions have capitalized on opportunities to meet in person at global mental health conferences to carry forward collaborative projects.

The most crucial ingredients to our successful South-North collaboration include the Multiple PI model that has promoted equitable South/North collaboration. Implementing this model generated a two-way transfer of skills and knowledge, as well as mutual trust, respect and even friendship. Other key ingredients include strong institutional support, multidisciplinary collaboration, a good relationship with the UON Ethics Review Committee, appropriate funding mechanisms, and good communication with and support from the funding organization.

Looking to the Future

UON faculty members have made considerable progress in moving beyond single-discipline research silos to acquire and utilize mental health research skills, to foster research team development, and to promote international and interdisciplinary research collaboration. Currently, the UON Department of Psychiatry faculty members are integrating the project research methods workshop curriculum into research training for the master’s program in Psychiatry. They are also in the process of building up this curriculum to form the core of course work for a PhD program. The research centre is still used as the hub for mental health researchers at the university, KNH and Mathari Hospital. In summary, the “Mental Health Research Training for Improved Health Outcomes in Kenya” project succeeded in setting the stage for an enduring and mutually beneficial partnership that we hope will yield future funded programs and sustain efforts to improve mental health and well-being for Kenyans.

Acknowledgments

Funding for this work came from the National Institute of Health/ National Institute of Mental Health (NIMH) through award number R25MH099132 and D43DW010141. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health or the National Institute of Mental Health. All research conducted in this project receives approval from the KNH-UON Ethics and Research Committee ( http://erc.uonbi.ac.ke )

Conflict of Interest statement

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Contributor Information

Muthoni Mathai, Senior lecturer Department of Psychiatry, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Ann Vander Stoep, Associate professor, department of Psychiatry and Behavioural sciences, Epidemiology University of Washington. Seattle. Box 354920, Child Health Institute, 6200 NE 74th Street, Suite 210, Seattle, WA 98115 -1538 Tel: 206-543-1538.

Manasi Kumar, Senior lecturer Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Mary Kuria, Associate Professor and head of Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Anne Obondo, Associate Professor Department of Psychiatry, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Violet Kimani, Professor School of Public Health, University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Beatrice Amugune, Senior lecturer, School of Pharmacy, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Margaret Makanyengo, Clinician Kenyatta National Hospital, Honorary Lecturer University of Nairobi, Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Anne Mbwayo, Lecturer Department of Psychiatry, University of Nairobi. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA Mara Child,

Jürgen Unützer, Professor and Chair department of Psychiatry and Behavioural Sciences, adjunct professor School of Public Health and Department of Global Health, University of Washington. Seattle. 1959 NE Pacific Street, Seattle, WA 98195, United States.

James Kiarie, Associate Professor Department of Obstetrics and Gynaecology, University of Nairobi; World Health Organisation: Coordinator, Human Reproduction Team. Kenyatta National Hospital, P O Box 19676 - 00202, NAIROBI, KENYA.

Deepa Rao, Associate Professor Department of Global Mental health, Psychiatry and Behavioural Sciences. University of Washington, Seattle. Department of Global Health; Harborview Medical Center, Box 359931, 325 9 th Ave, Seattle, WA 98104 USA.

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Research on nutrition-related policy and practices in Kenya identifies a pathway to reduce disease

March 1, 2021

Danielle Doughman

Danielle Doughman, MSPH , coauthored an article published in PLOS One that reports on research in Nairobi, Kenya, to assess government policies to support access to, knowledge about and consumption of healthy food in Kenya and suggest actions the government can take to improve them.

Noncommunicable diseases (NCDs), especially those related to diet and nutrition, are on the rise, and previous research shows that unhealthy food environments are an important driver of this increase.

A food environment is made up of the physical, economic, political and sociocultural surroundings and conditions that influence what people eat, and this study is one element of a three-part project to assess food consumption in Kenya, learn how the food environment drives consumption of unhealthy foods and identify policies to promote healthy eating.

The purpose of this study was to establish a baseline that researchers in subsequent phases will use to measure progress and identify priorities for future action. To do this, Doughman – who earned a Master of Science in Public Health degree at the UNC Gillings School of Global Public Health and is an adjunct professor at Gillings School’s online MPH@UNC degree program – worked with the African Population and Health Research Center and a team of researchers to rate the degree of implementation of current healthy food environment policies in Kenya.

“This benchmarking research is an excellent tool for policy action,” she said. “Instead of one-off programs or pilots, we hope to work towards lasting, context-appropriate and evidence-based policy change that will improve how people in Nairobi access and make choices about food. We hope that such changes will serve to counteract rising obesity and diet-related non-communicable diseases.”

The team adapted the Healthy Food Environment Policy Index (Food-EPI) developed by an international consortium of food policy experts that work to increase access to healthy food environments – the International Network for Food and Obesity / Noncommunicable Diseases Research, Monitoring and Action Support ( INFORMAS ).

Between 2017–2018, the researchers reviewed current government policies and programs related to the food environment and categorized them based on 13 indicators related to policy and infrastructure support and 43 indicators related to general good practice. A panel of policy and NCDs experts gauged progress on each of these indicators according to the policy development cycle and international best practices. Based on the implementation gaps they found, the research team identified priority actions to improve food environments in Kenya.

The researchers found that 37% of good practice indicators were in the “implementation” phase of the policy cycle and half were “in development.” The experts rated roughly 84% of policy indicators as “low” or “very little,” and the panel distilled 23 possible actions related to policy and infrastructure support. The research team facilitated a consensus-building process that allowed the panel to narrow these further, resulting in seven priority actions the Government of Kenya can take to improve the country’s food environment in the areas of leadership, food composition, labeling, promotion, prices and health-in-all policies. These priority actions include restricting advertisement of unhealthy foods, establishing food content guidelines and providing tax relief for producers of healthy foods.

“The results of the benchmarking study can be used to initially focus on the most feasible and most important policy actions in hope of some early wins,” said Doughman. “I think pursuing priorities through consensus decision-making makes perfect sense for this topic, on which there are many possible ways forward and many stakeholders.”

Though policies are being implemented in Kenya, most of these policies were found to be in development, and in some cases, progress lags established international good practices. These findings increase awareness of food environments in Kenya and suggest a path forward to address gaps and, over time, hopefully reduce the burden of NCDs in the country.

This study’s focus was limited to the Government of Kenya’s policy efforts, and it was designed as a first step in improving food environments in Kenya. The baseline it establishes will allow measurement of the effectiveness of future policy interventions.

Doughman also notes that this research contributes to a larger body of work to improve food environments, and that, because of the information it collects, the Food-EPI method will more broadly represent international policies on NCDs each time its implemented.

“As a part of the Food-EPI model, we also reviewed good practices from other countries with the expert panel, which is useful in their thinking about what might be adapted for Kenya,” she said. “As the number of participating countries increases, it is hoped that the pool of good practice policies will deepen and strengthen, and include policy innovations from Kenya.”

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24 Best Public Health schools in Kenya

Updated: February 29, 2024

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Below is a list of best universities in Kenya ranked based on their research performance in Public Health. A graph of 155K citations received by 14.3K academic papers made by 24 universities in Kenya was used to calculate publications' ratings, which then were adjusted for release dates and added to final scores.

We don't distinguish between undergraduate and graduate programs nor do we adjust for current majors offered. You can find information about granted degrees on a university page but always double-check with the university website.

1. University of Nairobi

For Public Health

2. Jomo Kenyatta University of Agriculture and Technology

3. Moi University

4. Kenyatta University

5. Egerton University

6. Maseno University

7. Mount Kenya University

8. Masinde Muliro University of Science and Technology

9. Strathmore University

10. University of Eldoret

11. Catholic University of Eastern Africa

12. Great Lakes University of Kisumu

13. Kenya Methodist University

14. Jaramogi Oginga Odinga University of Science and Technology

15. Technical University of Kenya

16. Pwani University

17. Technical University of Mombasa

18. Karatina University

19. South Eastern Kenya University

20. Machakos University

21. Africa International University

22. University of Kabianga

23. Daystar University

24. Dedan Kimathi University of Technology

The best cities to study Public Health in Kenya based on the number of universities and their ranks are Nairobi , Eldoret , Njoro , and Maseno .

Medicine subfields in Kenya

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AFRICAN JOURNAL OF HEALTH SCIENCES

Introduction.

The African Journal of Health Sciences (AJHS) provides a forum for communication of research outputs and policy issues in the health sciences and related disciplines. The Journal is dedicated to serving primarily scientists in Africa and those outside the continent wishing to contribute to global health on a variety of subjects including medicine, geo-medicine, dentistry, nursing, public health, nutrition, biostatistics, pharmacology, toxicology, pharmaceutical science, social science etc. The Editorial Board will give priority to articles that make significant contributions to the development and promotion of health in Africa. We publish original research papers, reviews, short communications, commentaries, case studies, surveys etc.

Frequency of Publication : We publish Bi-monthly (every two months).

Meet the Team

Dr. steve wandiga, dr hudson a. lodenyo, editorial advisory board, journal office.

Editor-In-Chief

[email protected]

Senior Editor

Dr. Lodenyo is a Specialist Physician, Gastroenterologist and Senior Research Officer with extensive experience in clinical research.  He has attracted several international research grants and awards with at least 25 publications in peer reviewed journals

[email protected]

AJHS EDITORS

• Dr. Stephen Munga
• Dr. Veronica Manduku
• Dr. Peter Mwitari
• Dr. Joel Lutomia
• Dr. Doris Njomo
• Prof. Matilu Mwau
• Dr. Videlis Nduba
• Dr. Willie Sang
• Dr. Benjamin Tsofa
• Dr. Ziporrah Bukania
• Dr. Luna Kamau
• Dr. Esther Matu
• Prof. Erick Omonge
• Abdala M S (Kenya)
• Kokotey – Ahulu (Ghana)
• Kilama W L (Tanzania)
• Tukei P M (Kenya)
• Salako L (Nigeria)
• Mkoji G (Kenya)
• Mwandawiro C (Kenya)
• Gikaru L K (Kenya)
• Watkins W M (Kenya)
• Githure J I (Kenya)
• Kokwaro G (Kenya)
• Thairu K (Kenya)
• Waiyaki P G (Kenya)
• Nancy K (Kenya)
• Kaimenyi J T (Kenya)
• Mengech J T (Kenya)
• Mwanzia J (Kenya)
• Shepard E (UK)
• Marsh K (UK)
• Esitambale (Kenya)

Ms. Tiner Ouma

Research scientist.

Tiner Ouma is a Research Scientist at the African Journal of Health Sciences. She holds a Bachelor’s degree in Environmental Health from the University of Eastern Africa, Baraton and is currently pursuing a Master’s degree in Epidemiology at the KEMRI Graduate School. She is a member of the Association of Public Health Officers of Kenya (APHOK)

[email protected]

Mr. Alexander Gitonga

Ict officer.

Mr Alexander is an ICT officer at the Centre for Microbiology Research and the web administrator for the African Journal of Health Sciences. He has more than 20 years of experience in ICT management in the institute.

Alexander holds a Bachelor’s degree in Education from Kenyatta University and a certificate of Computer Studies from University of Nairobi. He is a member of Computer Society of Kenya (CSK). Additionally, he has completed CCNA, MCSE, HP Networking as well as ITIL and PRINCE2 Project Management.

[email protected]

Publication process

When the AJHS receives manuscripts submitted for publication consideration, they are first screened by members of the scientific editorial team. Manuscripts are sent to peer reviewers if they meet our minimum standard. Each manuscript is assigned two scientific peer reviewers. A verdict for publication is made by the Editors considering the recommendations of reviewers. A verdict for publication or rejection is made based on the scientific soundness of the paper.

Issue Content Format

Each Issue will contain essentially the following sections, with variants where necessary:

• A short editorial statement on policy issues, of not more than two thousand words, placed not necessarily on the first page.
• A short review of not more than 5000 words titled ‘Perspective’ on a current topic in the health sciences.
• One or two review articles by invitation or on application
• Peer-reviewed articles by invitation or an application.
• Letters to the Editor
• News about and on African Health and related matters.

AJHS accepts submissions written in British English. The papers should have a maximum of 5000 words, including references. Because we appreciate clear and concise writing that highlights key concepts about the work. We encourage authors to structure the content using approaches such as headings, subheadings, tables and figures. Do number the pages but do not include line numbers.

Tables and figures

All tables and figures should be presented in APA style, numbered and given appropriate titles that briefly describe the information they carry. We encourage the authors to use no more than 5 tables and 8 figures in an article. These should be placed in the body of the manuscript (and not on a separate file). Any supplementary materials submitted that the authors wish to publish should be inserted in the manuscript as appendices after the references. Title pages should also not be submitted separately but rather presented in the upper section of the first page of the article. They should include the title, authors’ names and institutional affiliation.

Formatting of Research Papers

Research papers should be organized in this order:

• Title: Should be short (a maximum of 25 words) and specific.
• Byline: Full names of all authors, their qualifications, institutional affiliations and full address of each author. Qualification of authors is only required for purposes of the Editors’ reference and not for publication.
• Name and email address of corresponding author(s).
• Source of financial support, if any.
• Summary: Should be structured (background/introduction, materials and methods, results, conclusions and recommendations) with between 250 – 300 words.
• Background/ Introduction: Concise and clear, justifying the study rationale and stating the aim of the study.
• Materials and methods: Briefly outline important aspects of your methodology such as the study design, the sample size (with adequate justification), the sampling technique, methods and instruments of data collection, techniques to minimize bias/errors, ethical considerations (quote Ethical approval number for human studies) and data analysis. Laboratory procedures can be summarized and referenced if descriptions of the procedures are very lengthy.
• Results: Logically presented with appropriate displays.
• Discussion: Key findings of the study, giving comparisons with other literature (with proper citations).
• Limitations/ Strengths of the study
• Conclusions: Derived from the findings of the study.
• Acknowledgements
• Conflict of interest statement
• Availability of data statement
• Author Email contacts
• References: Arranged according to the Vancouver style. In-text citations should be numbered and placed in the text in parenthesis (2) or as superscripts without brackets 2 .

Formatting of Short Communications

They should possess all the elements of scientific communication as research papers, but without abstracts, subheadings and with not more than 500 words and 5 references

AJHS follows the Vancouver referencing style. We encourage authors to consider using reference management software, such as Zotero (free), Mendeley (free), EndNote, or RefWorks, which include built-in styles. This software is automated making it easier for authors to format citations and their reference lists as they revise. References should be numbered consecutively in the order in which they are first mentioned in the text. Include a list of all references cited at the end of the article, in the order in which they were mentioned in the text.

• Citation of Periodicals: Watkins WM, Howells RE, Brandling-Bennet AD and Koech DK . In vitro susceptibility of Plasmodium falciparum isolates from Jilore, Kenya to antimalarial drugs. American Journal of Tropical Medicine and Hygiene . 1987; 37: 445-451.
• Citation of Books: OleFijerskov, Firoze Manji and Vibeke Baellum, eds. Dental flouroris; Handbook for health workers. Copenhagen; Munksgaard , 1988 p.
• Citation of Chapters in Books: Same as B above.

The use of footnotes is generally discouraged. Any such statements should be incorporated into the body of the paper.

Submission Process

All submissions to the AJHS are sent online through our contact email address: africanjournal obfsctd @kemri.go.ke . Submitted articles should be a proofread final draft and submitted as a Microsoft Word attachment (DOC, DOCX). Submissions should include the following:

• A soft copy of the manuscript/ article
• A letter of submission
• Written permission from authors whose copyright material/ illustrations/photographs/figures have been used in the manuscript.
• Informed consent from participants whose photographs have been used.
• A signed ownership declaration statement.

Peer Review process

The AJHS operates a single-blind peer review system where the reviewers’ identity is concealed from the authors. Original research and reviews will first undergo peer review before publication. Each manuscript will be assigned two peer reviewers. The process takes 4-6 weeks of review and revision until the Editors are satisfied with the state of the paper. Peer reviewers are drawn from our pool of scientific peer reviewers although Authors may be asked to propose potential reviewers for their papers. If we make such a request, kindly propose reviewers with no conflict of interest.

Peer reviewers are selected considering their area of specialty and a review guideline provided. During the peer review process, the AJHS sets a time limit of 21 working days within which reviewers need to review manuscripts and submit their comments to the journal. The authors are then allotted 14 working days to send back their responses to the reviewers’ comments. If the authors or reviewers need more time, this turnaround time can be extended. Reviewers have the option to either recommend:

• ‘Publish as is’
• ‘Publish with minor revisions
• ‘Publish with major revision
• ‘Suitable for publication in another journal
• ‘Not suitable for publication in this journal

If the decision is for revision, authors are requested to respond to comments raised by reviewers. When the Editors confirm that the authors have satisfactorily responded to all comments raised by peer-reviewers a verdict is made and reviewers are informed of the status of the manuscripts they have reviewed.

Use of copyrighted material

When authors use photographs in their manuscripts, they will be responsible for ensuring that the images presented are at high enough resolution to produce good-quality reproduction in the published article. If the photographs presented have identifiable images of people or reproducing illustrations/figures from sources whose copyright ownership is not owned by the authors, you must also submit written evidence of permission to use the said material the paper goes to publication.

Conflict of Interest

All authors’ manuscripts submitted must include a statement on conflict of interest. Where there are no competing interests, please indicate, “None declared.”

The AJHS applies the Creative Commons Attribution License to all articles that we publish. Therefore, under this license, authors will retain ownership of the copyright for their articles or they can transfer copyright to their institution, but authors allow anyone to copy, distribute, transmit, and/or adapt articles without permission, so long as the original authors and source are cited.

We strictly discourage plagiarism. The authors are responsible for ensuring that all original works have been duly cited. Evidence of plagiarism will lead to the rejection of submissions. If evidence of plagiarism is discovered after publication, then the paper will be retracted from our publications. All authors will sign an ‘ ownership declaration form ’ for all manuscripts submitted to the AJHS.

Author Fees

AJHS charges an article processing fee of Kenya shillings of 4000 to Kenyan authors and USD 100 to non-Kenyan authors.  The fee is paid once during submission. However, fees will only be paid if the manuscript passes the initial screening and has been included for consideration in the AJHS. Fee payment details will be provided at this stage

Authors listed in the byline should all conform to ICMJE guidelines on authorship. All contributors who do not meet the criteria for authorship should be mentioned in the acknowledgement section. Contributions/support by authors in the byline should be briefly described. The corresponding author’s name and email contact should be provided. The journal will communicate to the authors through the corresponding author.

Source of Funding

Please declare the source of funding.

African Journal of Health Sciences,

Kenya Medical Research Institute Headquarters,

Off Raila Odinga Way, Nairobi, Kenya.

P.O. Box 54840-00200, Nairobi, Kenya.

Tel: +254 0202722541/4

Email: africanjournal obfsctd @kemri.go.ke

Website: www.ajhsjournal.org

Archives: https://www.ajol.info/index.php/ajhs

http://www.bioline.org.br/toc?id=jhWe

We are listed on AJOL

Frequently Asked Questions (FAQs)

What is your turnaround time?

• The turnaround time from acceptance to publication is 2-4 months, depending on the number of accepted papers awaiting publication.

Is your Journal peer-reviewed?

• Yes, the AJHS is peer-reviewed. The peer review process is described in the information to contributors.

When do I pay the Article Processing Fee?

• The APC is paid during submission, but after the paper has passed the first screening. Authors will be notified by email when their papers successfully go through the preliminary screening.

Where can I get the banking details for the fee payment?

• The AJHS secretariat will send the banking details to the authors by email.

Is publication guaranteed once I pay the article processing fee?

• Verdicts for publication/ rejection will be made solely based on the scientific soundness of the submitted manuscript.

Is there a prescribed format for manuscripts?

• The prescribed format for research papers is provided in the information to contributors. Authors are encouraged to follow the guidelines as closely as possible to ensure a faster turnaround time.

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Internship in Kenya enriches Global Health Epidemiology personal journey

Christopher floyd, bs ’21, mph ’24.

• Global Health Epidemiology

April 18, 2024

Christopher Floyd, BS ’21, MPH ’24, was well acquainted with the Uni versity of Michigan School of Public Health after he earned a Bachelor of Science degree in Public Health Sciences in 2021.

It was that familiarity that allowed him to zero in on a Master of Public Health degree in Global Health Epidemiology .

A blend of personal and academic experiences has cemented Floyd’s commitment to public health. The untimely death of relatives in his hometown of Southfield, Michigan, sparked his early interest in the health field, laying the foundation for his career.

An eight-month internship in Kenya proved pivotal, offering practical exposure to global health issues and cultural immersion, further enriching his academic perspectives.

Floyd will graduate in May with a Master of Public Health degree in Global Health Epidemiology from Michigan Public Health. He was supported through the Office of Global Public Health as a Gelman Global Scholar and through the Natalie and Jack Blumenthal Internship and Mechthild Medzihradsky Global Internship funds.

Personal experiences spark public health drive

Several of Floyd’s relatives, including aunts, uncles and even his grandfather died from health complications in their mid-to-late 60s, which planted a seed in for his interest in health and healthcare.

“When I was growing up, I had a lot of family members who unfortunately died at a relatively young age,” Floyd said. “So, part of my motivation for entering the health field was to gain an understanding of why certain health events occur.

“My father is nearing 60 and considering other family members who passed away at what I consider a young age is unsettling. It raises concerns and difficult thoughts about life expectancy, which moved me toward a deeper exploration of health issues to perhaps influence change in that area.”

I didn’t even know what public health was before I started my undergraduate studies, but COVID-19 really put public health in the spotlight. Now, even my parents, who first thought I was studying medicine, appreciate the breadth and significance of public health.”

His undergraduate journey began with the intent of studying medicine but shifted toward public health after exposure to courses that highlighted the multidimensional nature of health and the influence of social determinants.

This passion for understanding health beyond the clinician-patient dynamic led him to pursue a graduate degree. Floyd’s appreciation for interdisciplinary studies resonated with epidemiology, where he values the scope ranging from infectious diseases to environmental impacts and systemic health issues such as food insecurity.

Being an undergraduate student during the COVID-19 pandemic solidified his newfound passion for public health.

“I didn’t even know what public health was before I started my undergraduate studies, but COVID-19 really put public health in the spotlight,” Floyd said. “Now, even my parents, who first thought I was studying medicine, appreciate the breadth and significance of public health.”

Interconnecting health’s social determinants

Learning about the social determinants of health, the conditions in environments where people are born, live, learn, work, play, worship and age, and how they affect a wide range of health, functioning, and quality-of-life outcomes and risks, had a profound impact on Floyd.

“One of the most interesting parts about it was just realizing how interconnected everything is,” he said. “Learning about how one aspect of public health has direct or indirect effects on another system or institution is fascinating, especially when addressing issues such as food insecurity.”

The food system, for instance, is deeply tied to people’s living conditions and broader societal structures.

I appreciate epidemiology’s interdisciplinary nature, allowing exploration into various areas from infectious diseases to environmental health and beyond.”

“At Michigan Public Health, I learned to critically evaluate these intricate networks and appreciate the complexity of creating effective interventions,” Floyd said.

He saw firsthand the thoroughness involved in not just proposing solutions but in planning their sustainable implementation and the community impact. His classroom experiences, especially in the Community, Culture and Social Justice in Public Health course, challenged him to consider the full lifecycle of public health initiatives, from conception through to the long-term effects on the communities involved.

Floyd regards epidemiology as a cornerstone of the public health field—the discipline through which risks are assessed and health data is extrapolated. His intrigue in epidemiology stems from its analytical role in deciphering the relationships between activities such as smoking and health consequences such as cancer.  

“I appreciate epidemiology’s interdisciplinary nature, allowing exploration into various areas from infectious diseases to environmental health and beyond,” said Floyd, whose current interest lies in how food insecurity impacts long-term health outcomes, reflecting the breadth that epidemiology encompasses.

Kenya internship shapes global health perspective

He chose Michigan Public Health for his graduate studies because of its strong Global Health Epidemiology program, which aligns with his interests in international health concerns.

His commitment to global health was further cemented by an opportunity to intern in Kenya, where he contributed to a project evaluating climate change risks. As a research intern with Eco2Librium, Floyd designed surveys to capture perceptions of climate impact among residents in western Kenya, exploring the relation between local weather patterns and issues of food and water security.

Spending eight-months in Kenya provided an experiential experience, grounding his academic knowledge in real-world contexts. The experience of living internationally for an extended period was more than just an academic or professional excursion for Floyd. It was a broadening life experience that deeply influenced his perspective.

“I really enjoyed my experience,” he said. “It was a fantastic opportunity to go to Kenya. I had never been to Kenya or the African continent. Immersing myself in a foreign country for eight months will always be something to look back on with fondness as I continue my career.”

Residing in Kakamega—a smaller city compared to Kenya’s bustling capital of Nairobi—Floyd experienced a different pace of life.

“It was definitely a very different experience to how everything is in the United States,” he said. “We very much have this obsession with productivity and getting things done at a certain time. Going to Kenya taught me that it’s OK to slow down, and everything doesn’t have to be so time constrained. Even just that small difference in culture was very impactful.

“I lived in the forest, and it was so quiet—it was peaceful and a lot colder than I expected because it was the rainy season. I also really liked the food.”

This international experience has not only expanded Floyd's professional capabilities. It has also altered his worldview and deepened his appreciation for cultural diversity. As he continues along his career path, Floyd will carry with him the lessons learned and the relationships forged during his transformative time in Kenya—a defining chapter in his journey through the world of public health.

I like to think that public health gives people the opportunity to live their life to the fullest extent.”

Charting pathways in public health

Having gained experience outside the classroom while earning two degrees from Michigan Public Health during a pandemic also had a profound effect on Floyd.

Along with several classmates, he went to Grenada as a member of the Public Health Action Support Team (PHAST) in February. PHAST helped develop a voluntary, non-remunerated blood donation program. In collaboration with the Grenada Red Cross Society, the team completed eight key-informant interviews with stakeholders in education, health and disaster management as well as 77 surveys with local community members.

Floyd also was a research assistant for Abram Wagner , assistant professor of Epidemiology and Global Public Health, studying vaccination and mask-wearing behaviors in the United States.

Overall, he is open to what the future may hold, and he’s thankful he is well equipped for that journey because of his time at Michigan Public Health.

“I think public health is a good way to kind of ‘liberate people,’” Floyd said. “In the sense that when you are in a position where you’re worrying about if you’re going to have enough food or about hospital bills for you or your children or things like that, that can be very debilitating. It doesn’t allow you to live a fulfilling life; it doesn't allow you to really experience the world—you’re always in survival mode.

“I like to think that public health gives people the opportunity to live their life to the fullest extent.”

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Who Pays for Rising Health Care Prices? Evidence from Hospital Mergers

We analyze the economic consequences of rising health care prices in the US. Using exposure to price increases caused by horizontal hospital mergers as an instrument, we show that rising prices raise the cost of labor by increasing employer-sponsored health insurance premiums. A 1% increase in health care prices lowers both payroll and employment at firms outside the health sector by approximately 0.4%. At the county level, a 1% increase in health care prices reduces per capita labor income by 0.27%, increases flows into unemployment by approximately 0.1 percentage points (1%), lowers federal income tax receipts by 0.4%, and increases unemployment insurance payments by 2.5%. The increases in unemployment we observe are concentrated among workers earning between $20,000 and $100,000 annually. Finally, we estimate that a 1% increase in health care prices leads to a 1 per 100,000 population (2.7%) increase in deaths from suicides and overdoses. This implies that approximately 1 in 140 of the individuals who become fully separated from the labor market after health care prices increase die from a suicide or drug overdose.

We thank Joseph Altonji, Steven Berry, Zachary Bleemer, Anne Case, Angus Deaton, Amy Finkelstein, Joshua Gottlieb, Jason Hockenberry, Anders Humlum, Dmitri Koustas, Neale Mahoney, Alex Mas, Costas Meghir, Fiona Scott Morton, Chima Ndumele, Seth Zimmerman, and many seminar participants for extremely valuable feedback. We benefited enormously from excellent research assistance provided by Felix Aidala, Krista Duncan, James Han, Mirko De Maria, Kelly Qiu, Shambhavi Tiwari, and Mai-Anh Tran. This project received financial support from Arnold Ventures and the National Institute on Aging (Grant P01-AG019783). We acknowledge the assistance of the Health Care Cost Institute (HCCI) and its data contributors, Aetna, Humana, and UnitedHealthcare, in providing the claims data analyzed in this study. HCCI had a right to review this research to guarantee we adhered to reporting requirements for the data related to patient confidentiality and the ban on identifying individual providers. Neither HCCI nor the data contributors could limit publication for reasons other than the violation of confidentiality requirements around patients and providers, nor could they require edits to the manuscript as a condition of publication. The opinions expressed in this article and any errors are those of the authors alone. This research was conducted while some of the authors were employees at the U.S. Department of the Treasury. The findings, interpretations, and conclusions expressed in this paper are entirely those of the authors and do not necessarily reflect the views or the official positions of the U.S. Department of the Treasury. Any taxpayer data used in this research was kept in a secured Treasury or IRS data repository, and all results have been reviewed to ensure that no confidential information has been disclosed. The views expressed herein are those of the authors and do not necessarily reflect the views of the National Bureau of Economic Research.

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US Surgeon General Dr. Vivek Murthy declares gun violence 'public health crisis' in America

Murthy also called for an evidence-based approach to public health change.

WASHINGTON -- The U.S. Surgeon General, Dr. Vivek Murthy, issued a new advisory on Tuesday declaring gun violence a public health crisis.

In his announcement, Murthy also called for an evidence-based approach to public health change and a ban on assault weapons and large-capacity magazines for civilian use.

"Firearm violence is an urgent public health crisis that has led to loss of life, unimaginable pain, and profound grief for far too many Americans," Murthy said in a statement.

Ten national medical organizations, including the American Medical Association, American Academy of Pediatrics, American College of Surgeons, American Public Health Association and the YWCA, issued statements of support in a press release distributed by the Office of the Surgeon General.

"Across the country, physicians everywhere treat patients and families afflicted by firearm violence," said American Medical Association President Bruce A. Scott, MD, in a statement.

Gun violence is now the leading cause of death in the U.S. among kids and teens. Gun-related suicides have risen among all age groups from 2012 to 2022; the greatest rise has been among 10-14-year-olds, according to the advisory.

Rates of gun-related deaths among kids 1-19 years old in the U.S. are astronomically high and significantly higher than in other high-income countries.

"Pediatricians have long understood that gun violence is a public health threat to children and that its impact on families and communities can be devastating and long-lasting," said American Academy of Pediatrics President Ben Hoffman, MD, FAAP, in a statement.

Over 50% of Americans say they or their family have experienced a firearm-related incident in their lifetime, and about 60% of U.S. adults say that they worry "sometimes," "almost every day," or "every day" about a loved one being a victim of firearm violence, according to the advisory.

The advisory also shows how certain groups are disproportionally impacted by gun violence, including people who are Black, American Indian, Alaskan Natives and veterans.

The advisory says the impact of firearm violence goes beyond deaths and injuries; it leads to cascading harm and collective trauma across society and threatens the mental and physical health of young people's wellbeing, which warrants heightened attention and action.

"We don't have to continue down this path, and we don't have to subject our children to the ongoing horror of firearm violence in America. All Americans deserve to live their lives free from firearm violence, as well as from the fear and devastation that it brings. It will take the collective commitment of our nation to turn the tide on firearm violence," Murthy said.

The advisory outlines an evidence-informed public health approach with prevention strategies that public health leaders and policymakers can consider to reduce and prevent firearm-related death and injury, including by increasing research investments and data collection, implementing risk reduction strategies and engaging communities.

The report also calls for a ban on assault weapons and large-capacity magazines for civilian use and says firearms should be treated like other consumer products to enhance and standardize safety.

"Gun violence is a national tragedy. It's a serious public health problem that is highly preventable," said American Public Health Association Executive Director Georges C. Benjamin, MD in a statement.

Dr. Jade A Cobern, M.D., MPH, a licensed and practicing physician board-certified in pediatrics and preventive medicine, is a medical fellow of the ABC News Medical Unit.

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  Tanzania Journal of Health Research Journal / Tanzania Journal of Health Research / Vol. 25 No. 3 (2024): Tanzania Journal of Health Research / Articles (function() { function async_load(){ var s = document.createElement('script'); s.type = 'text/javascript'; s.async = true; var theUrl = 'https://www.journalquality.info/journalquality/ratings/2406-www-ajol-info-thrb'; s.src = theUrl + ( theUrl.indexOf("?") >= 0 ? "&" : "?") + 'ref=' + encodeURIComponent(window.location.href); var embedder = document.getElementById('jpps-embedder-ajol-thrb'); embedder.parentNode.insertBefore(s, embedder); } if (window.attachEvent) window.attachEvent('onload', async_load); else window.addEventListener('load', async_load, false); })();  

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Article Details

Edwin liheluka.

University of Dodoma, Department of Public Health and Community Nursing, Dodoma, Tanzania

Nyasiro Gibore

Samwel gesase.

National Institute for Medical Research, National Institute for Medical Research, Tanga Centre, Tanzania

National Institute for Medical Research,Tanga Centre, Tanzania

Daniel Minja

National Institute for Medical Research, NIMR, Tanga Centre, Tanzania

Theodora Bali

University of Dodoma, Department of Educational Psychology and Curriculum Studies,  Dodoma, Tanzania

Main Article Content

Traditional medicines that are used to treat witchcraft-related diarrhoea among under-five children in northern tanzania children in northern tanzania.

Introduction: Diarrhoea continues to be a severe public health concern, particularly in developing nations. The illness is responsible for various bacterial, viral, and other physiological changes. However, it has also been perceived by the community that diarrhoea among under-five children could be due to witchcraft. In principle, all forms of diarrhoea can be managed with well-established contemporary therapies; nonetheless, it has been suggested that perceived witchcraft-related diarrhoea among under-five children can only be managed by traditional medicines. In northern Tanzania, the use of conventional drugs in the management of perceived witchcraft-related diarrhoea among under-five children is substantial. Yet, there are limited studies on this subject. The present study explored traditional medicines that are used to treat perceived witchcraft-related diarrhoea among under-five children.

Methods: A cross-sectional study using a qualitative research approach was carried out in Korogwe and Handeni districts in northern Tanzania. The study population included paediatric health workers, caretakers of under-five children, and traditional healers. In-depth interviews and focus group discussions served as the data collection methods. Thematic analysis was employed for data analysis.

Results: A total of 247 participants were enrolled, which included 127 males and 120 females. Most participants, especially caretakers and traditional healers, preferred the use of conventional medicines in treating diarrhoea among under-five children and held the belief that a specific form of diarrhoea among under-five children is caused by witchcraft. It was also revealed that traditional medicines are the only types of medication that can treat this form of diarrhoea among under-five children. Plants were the primary source of many traditional remedies that were purported to be able to treat perceived witchcraft-related diarrhoea among under-five children.

Conclusion: Most participants believed that there is a specific form of diarrhoea among children that is caused by witchcraft, and they boldly stated that traditional medicines are the only treatment option for this form of diarrhoea. Thorough research on this topic is essential. If additional research confirms that conventional remedies effectively treat the illness, these treatments should be extended to other serious illnesses the community suffers from.

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CDC Public Health Science Agenda for Highly Pathogenic Avian Influenza A(H5N1) – June 2024

What to know.

• CDC has developed strategic priorities for improving global influenza control, prevention, preparedness, and response. These priorities guide research and surveillance activities around seasonal and pandemic influenza preparedness and response.
• CDC works to address these strategic priorities through ongoing collaboration with public and animal health partners at the local, state, and national level.
• CDC has identified the following primary HPAI A(H5N1) scientific response objectives for the current outbreak of HPAI A(H5N1) in dairy cattle, other animals, and people.

Beginning the week of March 25, 2024, the U.S. Department of Agriculture confirmed detections of highly pathogenic avian influenza HPAI A(H5N1) virus infection in dairy cows in the United States. On April 4, 2024, CDC initiated a center (National Center for Immunization and Respiratory Diseases)-led emergency response for the HPAI A(H5N1) outbreak in dairy cows with a One Health approach. Since April 2024, several human cases of H5N1 have been detected in association with the ongoing outbreak of HPAI A(H5N1) in dairy cows and other animals. Human infections have occurred in dairy workers who had direct exposure to cattle presumed to be infected with HPAI A(H5N1) virus ( H5N1 Bird Flu: Current Situation ).

The HPAI A(H5N1) viruses currently circulating in the United States have thus far not demonstrated the ability to efficiently bind to receptors that predominate in the human upper respiratory tract. This is a major reason why CDC assesses the current risk to the public from HPAI A(H5N1) viruses to be low. However, influenza viruses have potential to rapidly evolve and HPAI A(H5N1) viruses are widely prevalent globally in wild birds. Therefore, continued comprehensive and coordinated, multisectoral surveillance across public health and animal health for these viruses in wild birds, poultry, mammals, and people worldwide, are critical to determine the public health risk.

CDC has developed strategic priorities for improving global influenza control, prevention, preparedness, and response. These priorities guide research and surveillance activities around seasonal and pandemic influenza preparedness and response. CDC works to address these strategic priorities through ongoing collaboration with public and animal health partners at the local, state, and national level. Additionally, CDC has identified the following primary HPAI A(H5N1) scientific response objectives for the current outbreak of HPAI A(H5N1) in dairy cattle, other animals, and people.

Objective 1

Prevent infection and illness in people exposed to hpai a(h5n1) viruses..

Focus Area: Understanding the risk of infection among people exposed to infected dairy cattle, other animals, and their environment or contaminated animal products (e.g., raw milk).

Focus Area: Determining what measures most minimize the risk of infection among exposed persons. This includes personal protective equipment (PPE), and administrative and engineering controls.

Focus Area: Identifying host, pathogen, and exposure risk indicators for severe illness.

Focus Area: Monitoring and evaluating the effectiveness of influenza antiviral medications in preventing and attenuating illness, and public health interventions, including A(H5N1) vaccine (should it be employed).

Objective 2

Understand human infection and illness with hpai a(h5n1) virus (clinical, virologic, and epidemiologic characteristics)..

Focus Area: Monitoring for human infections using existing influenza surveillance platforms and developing strategies for enhanced surveillance and laboratory testing.

Focus Area: Determining how widespread human exposure and infection are. This includes estimating the prevalence and incidence of human infections.

Focus Area: Identifying the primary means of transmission for HPAI A(H5N1) human infections. This includes animal-to-human zoonotic transmission and transmission via fomites. It also includes assessment of how the virus gains entry and replicates in humans.

Focus Area: Describing the spectrum of human clinical illness, including prevalence of severe illness, illness resulting in hospitalization or death, and asymptomatic and pauci-symptomatic cases.

Focus Area: Describing parameters important to human infection and resolution of illness, including estimated incubation period and duration of infectiousness.

Focus Area: Employing animal models to help describe clinical presentation, virulence, and transmissibility of these HPAI A(H5N1) viruses compared to seasonal and other zoonotic influenza viruses.

Focus Area: Identifying virologic characteristics of HPAI A(H5N1) viruses. Identifying genetic markers associated with increased infectivity, transmissibility or reduced antiviral susceptibility. Tracking genetic changes that occur in the virus during animal and human infections.

Objective 3

Prepare for and mitigate the possibility of an hpai a(h5n1) virus pandemic..

Focus Area: Estimating the pandemic potential of this HPAI A(H5N1) virus with the Influenza Risk Assessment Tool (IRAT) .

Focus Area: Conducting comprehensive antigenic, phenotypic, genotypic, and evolutionary characterization of HPAI A(H5N1) viruses detected in humans and animals.

Focus Area: Identifying candidate vaccine viruses (CVVs) expected to provide protection against currently circulating HPAI A(H5N1) viruses in animals; evaluating antiviral drugs to assess emergence of drug resistant viruses; and developing diagnostic test methods and additional assays to rapidly and accurately identify HPAI A(H5N1) virus infections.

Focus Area: Estimating the impact of nonpharmaceutical interventions and medical counter measures, including pre-pandemic H5 vaccines and potential H5 vaccines made using existing candidate vaccine viruses in preventing infection and/or severe illness, should widespread person-to-person transmission occur.

Focus Area: Coordinating with the WHO's Global Influenza Programme and the Global Influenza Surveillance and Response System (GISRS) and the OFFLU animal health network (World Organisation for Animal Health, Food and Agriculture Organization, and reference laboratories) to support rapid information and resource sharing. As a WHO Influenza Collaborating Centre, the CDC Influenza Division actively supports global surveillance efforts and contributes materials, technical assistance, and data to global veterinary and public health partners to guide pandemic preparedness planning, including development/deployment of H5 diagnostic tests, monitoring for antiviral resistance, recommendations/development of vaccine candidates, and virus risk assessment.

Focus Area: Conducting immunologic and virologic pandemic risk assessment of novel influenza viruses in animal models and other model system.

Focus Area: Determining virus and host factors that impact virulence and transmission of novel influenza viruses, including conducting serology studies to determine the population immunity among the general population to HPAI A(H5N1) viruses.

Focus Area: Evaluating strategies to increase uptake of public health interventions such as vaccines.

Avian influenza or bird flu refers to the disease caused by infection with avian (bird) influenza (flu) Type A viruses.

JRC methods to help detect and quantify antibiotic residues in animal feed

Official National control laboratories across the EU have until 20 May 2025 to prepare for carrying out tests to detect and to quantify trace levels of antibiotics in compound feed.

Leveraging its expertise in food and feed analysis, the JRC developed and validated cutting-edge analytical methods capable of detecting trace amounts of 24 target antibiotics in compound feed. 

This boosts the EU fight against  antimicrobial resistance (AMR) – the ability of micro-organisms to survive or grow despite treatment with antimicrobial drugs. The methods make part of  Delegated Regulation (EU) 2024/1229   which limits the presence of antibiotics in  animal feed and empowers National control labs across the EU to detect and analyse 24 antibiotics in compound feed.

Compound feed contains a mix of nutritional raw materials for farmed animals. Antibiotics can be added to restore animal health, but misuse or excessive use can drive the development of antimicrobial resistance (AMR), i.e. drug-resistant pathogens that can potentially pass to humans. AMR is responsible for more than 35,000 deaths annually in EU/EEA (EU27 and Iceland, Lichtenstein and Norway). Furthermore, it is one of the top three priority health threats in the EU.

Applicable as of 20 May 2025, the regulation establishes specific maximum levels of cross-contamination of antimicrobial active substances in compound feed and lays down the reference methods for the analysis of residues of 24 antibiotics.

By enabling the detection of antibiotics across various types of compound feed at "as low as achievable" levels, these methods play a pivotal role in safeguarding animal welfare and public health. The findings served as a crucial criterion for establishing maximum acceptable levels of cross-contamination.

This legislation supplements  Regulation (EU) 2019/4 that established stringent guidelines for the manufacture, placement on the market and use of  medicated feed . 

Anti-microbial resistance is a serious threat today and will be for decades to come. Standing at the forefront, JRC upheld the highest standards of food safety as illustrated by this specific scientific work. The JRC-developed methods constitute a significant contribution and advancement in the concerted global effort to combat antimicrobial resistance and preserve the well-being of both animals and humans alike.

Regulation (EU) 2019/4 of the European Parliament and of the Council on medicated feed is one of the major initiatives that have contributed to further strengthening the EU’s response to AMR, together with the adoption of the 2017 AMR Action Plan and the adoption of the 2023 Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach. 

In particular, the  proposal for a Council Recommendation extends and complements the  2017 EU One Health Action Plan against AMR in all three dimensions of the One Health spectrum – people, animals and ecosystems – to maximise synergies and attain a strong and effective response against AMR across the EU.

One of the objectives of this proposal for a Council Recommendation is to reinforce surveillance and monitoring of AMR and antimicrobial consumption.

Related links

Delegated Regulation (EU) 2024/1229

Determination of 24 antibiotics at trace levels in animal feed by High Performance Liquid Chromatography - Tandem Mass Spectrometry (LC- MS/MS)

Antimicrobial resistance (AMR)  

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