The prevalence and yearly trends of adult pneumonia in N airobi

1. 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

2. 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.

3. 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

4. Study Objectives Main Objective: Toestablish the Prevalence and yearly Trends of adult pneumonia in Nairobi County in 2011-2014

5. Epidemiology by causative agents Over 90 causative pathogens: • Viruses: influenza viruses, adenovirus, Respiratory Syncytial Virus, Parainfluenza virus & coronavirus • Bacteria: Streptococcus pneumoniae, Haemophilusinfluenzae(Hi) serotypes (a–f), Enterobacteriaceae, Staphylococcus aureus, Francisellatularensis, Burkholderiapseudomallei, Pasteurellamultocida, Bacillus anthracis,ActinomycesIsraeli, Nocardiaspp. Gram negatives: Pseudomonas aeruginosa, Klebsiellapneumoniae, Escherichia coli, Enterobacterspp, Serratiaspp, Proteus spp • Mycoplasma: Mycoplasma pneumonia, Chlamydophilapneumonia, Mycobacterium tuberculosis orLegionella pneumophila • Pneumocystis jirovei

6. 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

7. Approaches for measuring disease impact 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 ClinicalandFunctionalmeasures whose outcomes include impairment, disability or handicap (Clewer & Perkins, 1997). • Components of morbidity and disability measured: • Duration • Severity • Consequences

8. 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.

9. 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.

10. 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.

11. 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 KisumuResearch 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.

12. RESULTS & SUMMARY DISCUSSION Results are presented as: • Summary statistics: means, standard deviations, medians, interquartile ranges, percentages and frequencies, reported for some tested variables. • Tables and bar charts illustrate the frequency distributions for each tested factor. • Diagnostic statistics test for regression model, including the diagnostic procedures.

13. 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 socio-economic classes • 75.5% of pneumonia deaths occurred in adults below 45 yrs

14. Figure 4.1: Percentage of patients who had pneumonia

15. Deaths due to Pneumonia at Mbagathi Hospital in 2014 by age

16. Estimated Prevalence per 100,000

17. Annual Prevalence of outpatient adult pneumonia in Nairobi

18. Annual Prevalence of in-patient adult pneumonia in Nairobi

19. Four-year averages of monthly pneumonia morbidity in Nairobi (2011 – 2014)

20. Effect of weather on pneumonia morbidity in Nairobi

21. Four-year adult pneumonia morbidity trend in Nairobi

22. 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.

23. 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

24. 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

25. 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

26. Thank you for your attention!