Analytical methods to quantify pesticide biomarkers in human population studies are critical for exposure assessment given the widespread use of pesticides for pest and weed control and their potential for affecting human health. We developed a method to quantify, in 0.2 mL of urine, concentrations of 10 pesticide biomarkers: four organophosphate insecticide metabolites (3,5,6-trichloro-2-pyridinol (TCPy), 2-isopropyl-6-methyl-4-pyrimidinol, para-nitrophenol, malathion dicarboxylic acid); five synthetic pyrethroid insecticide metabolites (4-fluoro-3-phenoxybenzoic acid, 3-phenoxybenzoic acid, cis and trans-3-(2,2-dichlorovinyl)-2,2-dimethylcyclopropane carboxylic acid (DCCA), cis-3-(2,2-dibromovinyl)-2,2-dimethylcyclopropane-1-carboxylic acid); and the herbicide 2,4-dichlorophenoxyacetic acid. The method is based on enzymatic hydrolysis of conjugated urinary metabolites, extraction and pre-concentration of the deconjugated metabolites using automated online solid-phase extraction, and separation and quantification using liquid chromatography-isotope dilution tandem mass spectrometry. Depending on the analyte, method detection limits were 0.1-0.6 ng/mL; mean accuracy, calculated as spike recoveries, was 91-102%, and total precision, given as percent variation coefficient, was 5.9-11.5%. Percent differences associated with three freeze-thaw cycles, 24-h benchtop storage, and short-term processed sample stability were <14%. METHOD: suitability was assessed by recurring successful participation in external quality assessment schemes and by analyzing samples from subjects with suspected exposure to pesticides (n = 40) or who self-reported consuming an organic diet (n = 50). Interquartile ranges were considerably lower for people consuming an organic diet than for those potentially exposed for cis-DCCA (0.37 ng/mL vs 0.75 ng/mL), trans-DCCA (0.88 ng/mL vs 1.78 ng/mL) and TCPy (1.81 ng/mL vs 2.48 ng/mL). This method requires one-fifth of the sample used in our previous method and is suitable for assessing background exposures to select pesticides in large human populations and for studies with limited sample volumes.

INTRODUCTION: Kenya started implementing voluntary medical male circumcision (VMMC) for HIV prevention in 2008 and adopted the use of decision makers program planning tool version 2 (DMPPT2) in 2016, to model the impact of circumcisions performed annually on the population prevalence of male circumcision (MC) in the subsequent years. Results of initial DMPPT2 modeling included implausible MC prevalence estimates, of up to 100%, for age bands whose sustained high uptake of VMMC pointed to unmet needs. Therefore, we conducted a cross-sectional survey among adolescents and men aged 10-29 years to determine the population level MC prevalence, guide target setting for achieving the goal of 80% MC prevalence and for validating DMPPT2 modelled estimates. METHODS: Beginning July to September 2019, a total of 3,569 adolescents and men aged 10-29 years from households in Siaya, Kisumu, Homa Bay and Migori Counties were interviewed and examined to establish the proportion already circumcised medically or non-medically. We measured agreement between self-reported and physically verified circumcision status and computed circumcision prevalence by age band and County. All statistical were test done at 5% level of significance. RESULTS: The observed MC prevalence for 15-29-year-old men was above 75% in all four counties; Homa Bay 75.6% (95% CI [69.0-81.2]), Kisumu 77.9% (95% CI [73.1-82.1]), Siaya 80.3% (95% CI [73.7-85.5]), and Migori 85.3% (95% CI [75.3-91.7]) but were 0.9-12.4% lower than DMPPT2-modelled estimates. For young adolescents 10-14 years, the observed prevalence ranged from 55.3% (95% CI [40.2-69.5]) in Migori to 74.9% (95% CI [68.8-80.2]) in Siaya and were 25.1-32.9% lower than DMMPT 2 estimates. Nearly all respondents (95.5%) consented to physical verification of their circumcision status with an agreement rate of 99.2% between self-reported and physically verified MC status (kappa agreement p-value<0.0001). CONCLUSION: This survey revealed overestimation of MC prevalence from DMPPT2-model compared to the observed population MC prevalence and provided new reference data for setting realistic program targets and re-calibrating inputs into DMPPT2. Periodic population-based MC prevalence surveys, especially for established programs, can help reconcile inconsistencies between VMMC program uptake data and modeled MC prevalence estimates which are based on the number of procedures reported in the program annually.

Voluntary medical male circumcision is a crucial HIV prevention program for men in sub-Saharan Africa. Kenya is one of the first countries to achieve high population coverage and seek to transition the program to a more sustainable structure designed to maintain coverage while making all aspects of service provision domestically owned and implemented. Using pre-defined metrics, we created and evaluated three models of circumcision service delivery (static, mobile and mixed) to identify which had potential for sustaining high circumcision coverage among 10-14-year-olds group, a historically high-demand and accessible age group, at the lowest possible cost. We implemented each model in two distinct geographic areas, one in Siaya and the other in Migori county, and assessed multiple aspects of each model's sustainability. These included numerical achievements against targets designed to reach 80% coverage over two years; quantitative expenditure outcomes including unit expenditure plus its primary drivers; and qualitative community perception of program quality and sustainability based on Likert scale. Outcome values at baseline were compared with those for year one of model implementation using bivariate linear regression, unpaired t-tests and Wilcoxon rank tests as appropriate. Across models, numerical target achievement ranged from 45-140%, with the mixed models performing best in both counties. Unit expenditures varied from approximately $57 in both countries at baseline to $44-$124 in year 1, with the lowest values in the mixed and static models. Mean key informant perception scores generally rose significantly from baseline to year 1, with a notable drop in the area of community engagement. Consistently low scores were in the aspects of domestic financing for service provision. Sustainability-focused circumcision service delivery models can successfully achieve target volumes at lower unit expenditures than existing models, but strategies for domestic financing remain a crucial challenge to address for long-term maintenance of the program.

BACKGROUND: Given the global nursing shortage and investments to scale-up the workforce, this study evaluated trends in annual student nurse enrolment, pre-service attrition between enrolment and registration, and factors that influence nurse production in Kenya. METHODS: This study used a mixed methods approach with data from the Regulatory Human Resources Information System (tracks initial student enrolment through registration) and the Kenya Health Workforce Information System (tracks deployment and demographic information on licensed nurses) for the quantitative analyses and qualitative data from key informant interviews with nurse training institution educators and/or administrators. Trends in annual student nurse enrolment from 1999 to 2010 were analyzed using regulatory and demographic data. To assess pre-service attrition between training enrolment and registration with the nursing council, data for a cohort that enrolled in training from 1999 to 2004 and completed training by 2010 was analyzed. Multivariate logistic regression was used to test for factors that significantly affected attrition. To assess the capacity of nurse training institutions for scale-up, qualitative data was obtained through key informant interviews. RESULTS: From 1999 to 2010, 23,350 students enrolled in nurse training in Kenya. While annual new student enrolment doubled between 1999 (1,493) and 2010 (3,030), training institutions reported challenges in their capacity to accommodate the increased numbers. Key factors identified by the nursing faculty included congestion at clinical placement sites, limited clinical mentorship by qualified nurses, challenges with faculty recruitment and retention, and inadequate student housing, transportation and classroom space. Pre-service attrition among the cohort that enrolled between 1999 and 2004 and completed training by 2010 was found to be low (6%). CONCLUSION: To scale-up the nursing workforce in Kenya, concurrent investments in expanding the number of student nurse clinical placement sites, utilizing alternate forms of skills training, hiring more faculty and clinical instructors, and expanding the dormitory and classroom space to accommodate new students are needed to ensure that increases in student enrolment are not at the cost of quality nursing education. Student attrition does not appear to be a concern in Kenya compared to other African countries (10 to 40%).

BACKGROUND: Antiretroviral (ARV) prophylaxis effectively reduces mother-to-child transmission of human immunodeficiency virus type 1 (HIV). However, it is unclear whether stopping ARVs after breastfeeding cessation affects maternal HIV disease progression. We assessed 18-24-month postpartum disease progression risk among women in a randomized trial assessing efficacy and safety of prophylactic maternal ARVs. METHODS: From 2005 to 2008, HIV-infected pregnant women with CD4+ counts of 200-500/mm(3) were randomized to receive either triple ARV (zidovudine, lamivudine, and lopinavir/ritonavir during pregnancy and breastfeeding) or AZT/sdNVP (zidovudine until delivery with single-dose nevirapine without postpartum prophylaxis). Maternal disease progression was defined as the combined endpoint of death, World Health Organization clinical stage 4 disease, or CD4+ counts of <200/mm(3). RESULTS: Among 824 randomized women, 789 had at least 1 study visit after cessation of ARV prophylaxis. Following delivery, progression risk up to 24 months postpartum in the triple ARV arm was significantly lower than in the AZT/sdNVP arm (15.7 vs 28.3; P =. 001), but the risks of progression after cessation of ARV prophylaxis (rather than after delivery) were not different (15.0 vs 13.8 18 months after ARV cessation). Among women with CD4+ counts of 200-349/mm(3) at enrollment, 24.0 (95 confidence interval [CI], 15.7-35.5) progressed with triple ARV, and 23.0 (95 CI, 17.8-29.5) progressed with AZT/sdNVP, whereas few women in either arm (<5) with initial CD4+ counts of >=350/mm(3) progressed. CONCLUSIONS: Interrupting prolonged triple ARV prophylaxis had no effect on HIV progression following cessation (compared with AZT/sdNVP). However, women on triple ARV prophylaxis had lower progression risk during the time on triple ARV. Given the high rate of progression among women with CD4+ cells of <350/mm(3), ARVs should not be discontinued in this group. CLINICAL TRIALS REGISTRATION: ISRCTN71468410. (2012 The Author.)

OBJECTIVE: To examine the impact of out-migration on Kenya's nursing workforce. STUDY SETTING: This study analyzed deidentified nursing data from the Kenya Health Workforce Informatics System, collected by the Nursing Council of Kenya and the Department of Nursing in the Ministry of Medical Services. STUDY DESIGN: We analyzed trends in Kenya's nursing workforce from 1999 to 2007, including supply, deployment, and intent to out-migrate, measured by requests for verification of credentials from destination countries. PRINCIPLE FINDINGS: From 1999 to 2007, 6 percent of Kenya's nursing workforce of 41,367 nurses applied to out-migrate. Eighty-five percent of applicants were registered or B.Sc.N. prepared nurses, 49 percent applied within 10 years of their initial registration as a nurse, and 82 percent of first-time applications were for the United States or United Kingdom. For every 4.5 nurses that Kenya adds to its nursing workforce through training, 1 nurse from the workforce applies to out-migrate, potentially reducing by 22 percent Kenya's ability to increase its nursing workforce through training. CONCLUSIONS: Nurse out-migration depletes Kenya's nursing workforce of its most highly educated nurses, reduces the percentage of younger nurses in an aging nursing stock, decreases Kenya's ability to increase its nursing workforce through training, and represents a substantial economic loss to the country.

OBJECTIVE: To analyse the effect of Kenya’s Emergency Hiring Plan for nurses on their inequitable distribution in rural and underserved areas. | METHODS: We used data from the Kenya Health Workforce Informatics System on the nursing workforce to determine the effect of the Emergency Hiring Plan on nurse shortages and maldistribution. The total number of nurses, the number of nurses per 100,000 population and the opening of previously closed or new heath facilities were recorded. FINDINGS: Of the 18,181 nurses employed in Kenya’s public sector in 2009, 1836 (10%) had been recruited since 2005 through the Emergency Hiring Plan. Nursing staff increased by 7% in hospitals, 13% in health centres and 15% in dispensaries. North Eastern province, which includes some of the most remote areas, benefited most: the number of nurses per 100,000 population increased by 37%. The next greatest increase was in Nyanza province, which has the highest prevalence of HIV infection in Kenya. Emergency Hiring Plan nurses enabled the number of functioning public health facilities to increase by 29%. By February 2010, 94% of the nurses hired under pre-recruitment absorption agreements had entered the civil service. CONCLUSION: The Emergency Hiring Plan for nurses significantly increased health services in Kenya’s rural and underserved areas over the short term. Preliminary indicators of sustainability are promising, as most nurses hired are now civil servants. However, continued monitoring will be necessary over the long term to evaluate future nurse retention. The accurate workforce data provided by the Kenya Health Workforce Informatics System were essential for evaluating the effect of the Emergency Hiring Plan.

SETTING: Improved documentation of human immunodeficiency virus (HIV) testing and care among tuberculosis (TB) patients is needed to strengthen TB-HIV programs. In 2007, Kenya piloted the use of personal digital assistants (PDAs) instead of paper registers to collect TB-HIV surveillance data from TB clinics. OBJECTIVE: To evaluate the acceptability, data quality and usefulness of PDAs. DESIGN: We interviewed four of 31 district coordinators who collected data in PDAs for patients initiating TB treatment from April to June 2007. In 10 of 93 clinics, we randomly selected patient records for comparison with corresponding records in paper registers or PDAs. Using Cochran-Mantel-Haenszel tests, we compared missing data proportions in paper registers with PDAs. We evaluated PDA usefulness by analyzing PDA data from all 93 clinics. RESULTS: PDAs were well accepted. Patient records were more frequently missing (28/97 vs. 1/112, P < 0.001) and data fields more frequently incomplete (148/1449 vs. 167/2331, P = 0.03) in PDAs compared with paper registers. PDAs, however, facilitated clinic-level analyses: 48/93 (52%) clinics were not reaching the targets of testing ≥80% of TB patients for HIV, and 8 (9%) clinics were providing <80% of TB-HIV co-infected patients with cotrimoxazole (CTX). CONCLUSION: PDAs had high rates of missing data but helped identify clinics that were undertesting for HIV or underprescribing CTX.