Transcript The prevalence and yearly trends of adult pneumonia in Nairobi

The prevalence and yearly trends of adult
pneumonia in Nairobi
Apollo Maima
Presented at:
The PSK Annual Scientific Conference,
Whitesands Hotel, MOMBASA
2nd June, 2016
Part of a Thesis in partial fulfilment of the
requirements for the award of PhD in
Community Health and Development
Apollo Maima
In the supervision of:
Prof. Dan Kaseje, PhD
Professor of Public Health
& Vice-Chancellor, Great Lakes University of Kisumu.
Dr. Faith Okalebo, PhD
Senior Lecturer, Pharmacology & Health Economics,
School of Pharmacy, University of Nairobi.
BACKGROUND
About adult pneumonia:
» A common cause of hospitalization in Kenya
» Has major health, social and economic impacts
» Causes the death of about 11% of people with acute disease
» Very little epidemiological or cost-burden studies of the
disease in Kenya, Nairobi included
» No recorded prevalence of the disease in Nairobi
Study Objectives
Main Objective:
To establish the Prevalence and yearly Trends of adult
pneumonia in Nairobi County in 2011-2014
Epidemiology by causative agents
Over 90 causative pathogens:
 Viruses: influenza viruses, adenovirus, Respiratory Syncytial Virus,
Parainfluenza virus & coronavirus
 Bacteria: Streptococcus pneumoniae, Haemophilus influenzae (Hi)
serotypes (a–f), Enterobacteriaceae, Staphylococcus aureus,
Francisella tularensis, Burkholderia pseudomallei, Pasteurella
multocida, Bacillus anthracis, Actinomyces Israeli, Nocardia spp.
Gram negatives: Pseudomonas aeruginosa, Klebsiella
pneumoniae, Escherichia coli, Enterobacter spp, Serratia spp, Proteus
spp
 Mycoplasma: Mycoplasma pneumonia, Chlamydophila pneumonia,
Mycobacterium tuberculosis or Legionella pneumophila
 Pneumocystis jirovei
Risk factors for adult pneumonia
 Age (< 1, ˃65)
 Compromised or impaired immunity
 ICU admission or use of mechanical ventilators
 Reduction of stomach acid, incl. use of PPI’s
 Dormitory or barrack conditions
 Smoking (incl. exposure to second hand smoke)
 Air pollutants
 Poverty factors: lack of immunization, use of solid fuels
Health is “not merely the absence of disease or infirmity but a
state of complete physical, mental and social well-being that
enables one to lead a socially and economically productive life
(Anon., 1946; WHO, 1986; HEU, 2010).”
 Health thus has Clinical and Functional measures whose
outcomes include impairment, disability or handicap
(Clewer & Perkins, 1997).
 Components of morbidity and disability measured:
 Duration
 Severity
 Consequences
METHODOLOGY
» Study area
» Study design
» Study population
Pneumonia patients from the sampled facilities were surveyed as a
census. They were adults, of at least 18 years of age, diagnosed
with clinical pneumonia, residing in Nairobi County.
METHODOLOGY Cont’d
» Data collection
˃ Standard case definitions, standard case reports, investigation forms
and pre-designed survey questionnaires using ODK platform.
˃ Active surveillance using current facility data
˃ Passive surveillance using official records
» Data entry and monitoring
˃monitoring real‐time progress over the internet
˃ODK aggregate allocated unique phone ID’s
˃Monitoring of newly uploaded survey responses
˃Daily progress was observed and the enumerators contacted for any
comments or updates.
METHODOLOGY Cont’d
Data analysis:
» Data obtained was programmed and coded.
» Then entered, decoded and analysed in Windows EXCEL
and in SPSS.
» Statistical analysis, graphics and regression analysis
were done in SPSS and in STATA 10.
» Descriptive statistics was generated from the
quantitative data to enhance summary and
explanations
» Inferential statistics (chi-square and ANOVA) were used
to test the variables of interest.
METHODOLOGY Cont’d
Ethics and Human Subject Considerations:
Ethical approval was obtained from:
» Kenyatta National Hospital /University of Nairobi Ethics and
Research Committee (KNH-UON ERC)
» Great Lakes University of Kisumu Research and Ethics
Committee.
» Medical Superintendents /CEO’s through Facility ERC’s
Ethical principles of research on human subjects outlined by
the International Conference on Harmonization (World
Medical Association, 2013; Nwabueze, 2013) was adhered to.
RESULTS & SUMMARY DISCUSSION
Results are presented as:
1. Summary statistics: means, standard deviations, medians,
interquartile ranges, percentages and frequencies, reported for
some tested variables.
2. Tables and bar charts illustrate the frequency distributions for
each tested factor.
3. Diagnostic statistics test for regression model, including the
diagnostic procedures.
RESULTS: Facility Caseload & Trends
» Only 48.2% of facilities had in-patient services
» Ratios of male to female patients almost 1:1
» Only 13% of public records were computerized, compared
to 70% of faith based and 52% of private facilities records
» Mean age: all pneumonia patients 41.7 yrs (SD=15.47),
Median: 40 yrs (IQR: 29-51.5)
Males 43.5 (SD=15.14), females 40 (SD=15.6)
» 63% of patients aged 18-29 yrs were females
» 72% of pneumonia patients belonged to low to lower socioeconomic classes
» 75.5% of pneumonia deaths occurred in adults below 45 yrs
Deaths due to Pneumonia at Mbagathi Hospital in 2014 by age
Number of pneumonia deaths
Percentage of total
adult pneumonia
Age Cohort
Male
Female
Total
18—25
25
9
34
30.9
26—35
25
6
31
28.2
36—45
13
5
18
16.4
46—55
8
3
11
10
56—65
7
5
12
10.9
>=66
2
2
4
3.6
Total
80
30
110
100
deaths
Estimated Prevalence per 100,000
Outpatients
In-patients
Year
Males
Females
Males
Females
2014
5,175
5,746
445
528
2013
6,252
6,577
563
572
2012
3,013
3,250
232
234
2011
1,624
1,767
128
127
CONCLUSION: Facility caseload and trends
» Overall mean age: 41.7 years (SD=15.47), & Median age: 40
years (IQR: 29-51.5).
» Mean age, males (43.5, SD=15.14) was significantly higher
than that of females (40, SD=15.6), p = 0.011.
» Mean ages world over are higher, e.g. Enugu, Nigeria: 52.9 ±
18.98 years; Karachi, Pakistan: 60 ± 18.0 years.
» In 47 study facilities 2011-2014: Out of 393,973 outpatients,
21,885 (5.6%) had pneumonia.
» For 33,462 inpatients, 3,278 (9.8%) had pneumonia
» In 2014, Prevalence was 5,932 per 100,000.
CONCLUSION: Prevalence
» Gender difference in types of causative organisms (p=0.037):
˃ For H. influenza: (60.6% of males & 44.2% of females)
˃ For atypical bacteria: (6.5% of males & 23.7% of females)
˃ This difference has not been reported before
» In 2014, Prevalence was 5,932 per 100,000
» Prevalence higher among women
» Compare with:
˃ 500-1,100 per 100,000 in Pakistan and
˃ 288-442 per 100,000 in Denmark
CONCLUSION: Seasonal variation
» Pneumonia is endemic in Nairobi
» Incidences exhibited a seasonal pattern
˃ Highest no. of cases in August (mean = 475.6, SD = 181)
˃ During the dry cold period Jun.-Aug.
˃ Lowest no. of cases in January (mean = 368.5, SD = 143.75)
» Significant relationship between pneumonia morbidity and
Nairobi weather
˃ Daily temperatures
˃ Rainfall
» Time-series patterns of pneumonia morbidity shown
RECOMMENDATIONS:
» 100% Computerization of health records
» Increasing access to better treatment, including vaccinations
» Increasing support for household assets and savings; coping
strategies, and wider community responses and services that
enhance coping
» Replacing the paper-based data systems of cold chains with
ODK 2.0 to improve the speed and reliability of the inventory
update process
» Carrying out studies to find out whether illness diagnoses in
Kenya, especially in private facilities, are driven by profit