TABLE OF CONTENTS
DECLARATION………………………………………………………………………………………. ii
DEDICATION…………………………………………………………………………………………. iii
ACKNOWLEDGEMENT…………………………………………………………………………. iv
ACRONYMS/ABBREVIATIONS…………………………………………………………… xii
TABLE OF CONTENTS……………………………………………………………………………. v
LIST OF TABLES………………………………………………………………………………….. viii
LIST OF FIGURES………………………………………………………………………………….. ix
LIST of APPENDICES……………………………………………………………………………… x
LIST OF PLATES…………………………………………………………………………………….. xi
ABSTRACT……………………………………………………………………………………………. xii
CHAPTER ONE: INTRODUCTION………………………………………………………….. 1
- Background to the study……………………………………………………………………….. 1
CHAPTER TWO: LITERATURE REVIEW………………………………………………… 7
- Rift Valley Fever (RVF) Virus……………………………………………………………….. 7
CHAPTER THREE: RESEARCH METHODOLOGY……………………………….. 23
- The Study Area…………………………………………………………………………………… 23
- Study Population………………………………………………………………………………… 24
- Ethical Consideration…………………………………………………………………………… 25
CHAPTER FOUR: RESULTS AND DISCUSSION…………………………………… 30
- : Types of Health Facilities in the Study Area………………………………………….. 30
CHAPTER FIVE…………………………………………………………………………………….. 56
CONCLUSION AND RECOMMENDATION………………………………………….. 56
5.1 Conclusions………………………………………………………………………………………… 56
5:2 Recommendations from the Study………………………………………………………… 56
5.3: Areas for Further Research………………………………………………………………….. 57
REFERENCES……………………………………………………………………………………….. 58
APPENDICES………………………………………………………………………………………… 64
Table 2.1: Negative Economic Impact of 2006/7RVF outbreak in Kenya……….. 13
Table 3.1: Population distribution in the study area………………………………………. 23
Table 3.2: Health Care providers in the study area………………………………………… 24
Table 3.3 Health Facilities and their level in the study area…………………………… 27
Table 4:1 Levels of the health facilities studied……………………………………………. 33
Table 4.2: Cadre of health care providers…………………………………………………….. 34
Table 4.3: Healthcare providers level of education by facility type………………….. 36
Table 4.4: Healthcare providers’ training on detection of RVF………………………. 37
Table 4.5: Responds response on the time cases of RVF are likely to be high…… 38
Table 4.6: Respondents’ knowledge on economic impoortance of RVF…………… 39
Table 4.7: Respondents’ knowledge of people likely to suffer from RVF………… 38
Table 4.8: Respondents’ knowledge on the clinical manifestation of RVF………. 39
Table 4.9: Respondents’ knowledge of the cause of RVF……………………………… 43
Table 4.10: Healthcare providers’ knowledge of RVF control………………………… 44
Table 4.11: Respondents’ knowledge of RVF diagnosis……………………………….. 45
Table 4.12: Staff training on RVF management……………………………………………. 46
Table 4.13:Where the staff have been trained for the past year………………………. 47
Table 4.14: Challenges Healthcare providers faced when managing RVF……….. 48
Table 4.15: Addressing challenges in RVF management……………………………….. 49
Table 4.16: Additional information shared by healthcare providers…………………. 50
Table 4.17 Types of health facilities for diagnosis of RVF…………………………….. 49
Table 4.18: Source of laboratory reagents…………………………………………………….. 50
Table 4.19: Facilities capacity for RVF detection…………………………………………. 54
Table 4.20: Availability ofRVF contaminated materials disposal……………………. 55
Table 4.21: Availability of backup power source…………………………………………… 54
Table 4.22: Availability of operational hazard waste disposal…………………………. 55
LIST OF FIGURES
Figure 2.1: Schematic cross-section of a Bunyaviridae virion (virus shape)………… 8
Figure 2.2: Replication cycles of viruses in the family Bunyaviridae (RVF)………. 9
Figure 2.3: Geographical Distribution of Rift Valley Fever (FAO)…………………. 11
Figure 2.4 Map of Kenya showing infected and confirmed Districts………………. 12
Figure 2.5: Model of Rift Valley Fever pathogenesis in primates……………………. 16
Figure3.1: Conceptual frame wor……………………………………………………………….. 26
Appendix 1: Map of the Study Area…………………………………………………………… 64
Appendix 2: List of health facilities visited in study area………………………………. 65
Appendix 3: Research Permit…………………………………………………………………….. 69
Appendix 4: Letter of Research Authorization…………………………………………….. 70
Appendix 5: Data Collection Tools…………………………………………………………….. 75
Plate 1: A route map of the study area………………………………………………………… 71
Plate 2: Medical waste disposal in a health facilities visited…………………………… 71
Plate 3: An Improvised Deep pit medical waste in a health facilities………………. 72
Plate 4: A waste Disposal at a back yard of a shopping centre……………………….. 72
Plate 5: Medical waste disposal system in a health facilities in the study area…… 73
Plate 6: Medical waste disposal by incineration in a health facilities……………….. 73
Plate 7: A modern diagnosis system at RVF testing laboratories in Nairobi……… 74
ACRONYMS/ABBREVIATIONS
| AMREF | African Medical Research Foundation |
| CDC | Centers for Disease Control and Prevention |
| CO | Clinical Officer |
| DALYs | Disability Adjusted Live Years |
| DPHN | District Public Health Nurse |
| ELISA | Enzyme Linked Immunoabsorbent Assay |
| FAO | Food and Agricultural Organization |
| FBO | Faith-Based Organizations |
| ILRI | International Livestock Research Institute |
| KEMRI | Kenya Medical Research Institute |
| RT-PCR | Reverse Transcriptase Polymerase Chain Reaction |
| RVF | Rift Valley Fever |
| RVFV | Rift Valley Fever Virus |
| SPSS | Statistical Package for Social Sciences |
| USD | United States of America Dollar |
| VEEU | Veterinary Epidemiology and Economics Unit |
| Vero Cells | African Green monkey Kidney Cells |
| WHO | World Health Organization |
ABSTRACT
Rift valley fever (RVF) is a zoonotic mosquito-borne viral disease found in Africa and other continents and is documented in Kenya since 1910. Mosquito and other insect bites, contact with body fluids during slaughter, milking, treatment and examination and consumption of under-cooked contaminated animal products transmit the disease. In epizootic areas, RVF causes abortion in majority of pregnant ewes and cows while high mortality occurs among newborn lambs making diagnosis easy. In humans the disease causes hemorrhagic fever, encephalitis, retinal vasculitis and death. Laboratory confirmation is necessary especially when RVF extends to new regions. The lack of capacity and ability to detect RVF infections early has resulted in massive economic losses in herds of sheep and cattle, and human fatalities. Outbreaks are associated with high population of vector insects as occurs following unusually high level rainfall with prolonged flooding. With the increasing trends of flooding in Kenya, it is apparent that there is need for more attention on the disease. Outbreaks in Kenya are in 5-15 years’ cycle, the most recent being December 2006 to June 2007. Since the first outbreak, Murang’a County has always been one of the high risk areas. The capacity of healthcare providers and healthcare facilities in Murang’a County to handle and diagnose RVF is not known. This study assessed the capacity of healthcare providers’ and healthcare facilities to diagnose Rift Valley Virus infections. Sixty-six (66) healthcare facilities, Government, Private and Faith-based were censured, data obtained and relevant data on Rift Valley Virus infections extracted for analysis. Data was collected by administering structured questionnaires to eighty-four purposely and conveniently selected healthcare providers in the healthcare facilities while the capacity of the healthcare facilities was determined by a checklist as per World Health Organization (WHO) standards for RVF diagnosis. The data was processed using Statistical Package for Social Sciences. This study found that the healthcare providers lacked the capacity to detect RVF while most facilities lacked equipment to detect and handle RVF. There was no significant difference in education and training levels of the health care providers in the health care facilities (P= 0.5132) and (P = 0.8124), respectfully. The tools, equipment and facilities available in the healthcare institutions were found to be below the WHO expectations. The study recommends carrying out of similar studies in other high-risk counties for better understanding and preparedness in case of an outbreak. The study also informs the Kenya Government on the priority areas of training, re-training and requirements of healthcare providers especially in high-risk locations.
CHAPTER ONE: INTRODUCTION
Background to the study
Rift Valley Fever is a disease of humans and animals. The disease is mainly transmitted by mosquitoes. The disease was first discovered in Kenya in 1930 in Rift Valley province of Kenya. The disease has been occurring in a cycle of 5-15 years since then. The last outbreak occurred in 2006/7 and affected 35 of the then 71 districts in 6 of the 8 provinces in Kenya (Bird et al., 2008). There were 717 reported human cases of which 216 were confirmed in the laboratory with 162 deaths. With respect to animals, 558,000 cattle, 1,107,910 sheep and goats and 400,000 camels were infected with 448 of the cases being confirmed in the laboratory. The mortalities were 145,080 cattle, 276,977 sheep and goats and 26,136 camels. The outbreak had a negative economic impact and caused losses of about Kshs 4 billion (Bird et al., 2008).
The public health burden of Rift Valley Fever outbreaks measured in disability adjusted live years (DALYs) – the first of its kind in Kenya – shows that the 2006 and 2007 outbreak resulted in 3.4 DALYs per 1000 people and household costs of about Ksh 10,000 United State of America Dollar 120 (USD) for every human case reported. In 2008, International Livestock Research Institute (ILRI) estimated the disease cost the Kenyan economy USD 30 million (Esther et al., 2012).
The key lesson learnt from the 2006/2007 outbreak was that the impact of the disease could have been avoided or minimized were it not for inadequate preparedness by
stakeholders; poor communication and delayed resource mobilization. The importance of prediction of such an outbreak was underlined with the most important activities identified as resource mobilization, stakeholders’ awareness and strategic vaccination, (Bird et al., 2008). In addition, it is important to understand and evaluate the competence of the health providers in the diagnosis of RVF in the high risk areas, and their preparedness in responding to situations when they occur. During the last out break four deaths were recorded in Murang’a County and foreign experts from America came in to bridge the gap in detection and confirmation of the disease (Bird et al., 2008).
Statement of the Problem
Outbreaks of Rift Valley Fever (RVF) have occurred in Kenya over the last 40 years and are often associated with heavy rainfall in the generally dry, bushy and woody grasslands. For example, there was an outbreak after the El Niño rains of 1998. The last outbreak occurred in 2006-2007. RVF is a rare disease and when it occurs, many institutions are not prepared to deal with it. At times the outbreak calls for international intervention in detection, confirmation, containment and control (Bird et al., 2008). The application of laboratory tests for diagnosis of infections caused by the Rift Valley Fever Virus by healthcare providers is limited; this is mainly due to lack of resources like well-trained personnel, equipment, reagents and laboratory facilities. There is no information on the knowledge and capacity to handle RVF infections in Murang’a County (Bird et al., 2008).
Lack of training in the management of RVF among health workers is partly due to the fact that most of the trainings and even refresher courses are directed to the management of other diseases like sexually transmitted infections, diarrhoeal diseases malaria, safe motherhood and nutrition just to mention a few.
Unlike other animal diseases like rabies and anthrax that have a compulsory vaccination program, there is no compulsory vaccination programme in place for RVF in Kenya or elsewhere where the disease has been reported and individual farmers vaccinate at will. Thus, there are no data available on the immunity history of people and animals. Vaccines for animal use are available, but are known to cause birth defects and abortions in sheep and provide only low-level protection in cattle (Kasiiti et al., 2014). No effective vaccine or antiviral medication is approved for use in humans (Vialat et al., 2000). The classical methods for the detection of infection by RVF virus include various forms of virus neutralization polymerase chain reaction, immuno assays, haemagglutination-inhibition tests and virus isolation. These tests require well-trained healthcare providers with up-to-date working equipment.
Detection of Rift Valley Fever is often delayed when the disease occurs. Laboratory confirmation is necessary even in the presence of clinical suspicious disease activity. The detection systems are rigorous in terms of skills and experience thus the need to assess the situations in one of the high risk areas (Digoutte et al., 1999). Maragua District was conveniently chosen because of persistence incidences since the first
outbreak including its proximity to Nairobi where the population has a high preference of roasted meat and cost implications as compared to other high prevalence areas such as Ijara, Garissa and Baringo districts where incidences of RVF have been reported (Jacqueline et al., 2014, Peter et al., 2012). During the last outbreak 4 (Four) people died in Maragua District and a lot of loss was incurred due death of animals lack of trade of animals and their products. People also suffered psychosocial distress for losing members of the family (Peninah et al., 2010, Bird et al., 2008 Sindato et al., 2011). The outbreak had a negative economic impact of about Kshs 4 billion excluding loss of human lives (Bird et al., 2008). If the outbreak recurs over 387,969 humans are at risk.
