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surveillance) would have made to preparedness activities for T Guttuso, J Roscoe, and J Griggs conceived and designed the study and the 2002 malaria emergency in western Kenya.
analysed and interpreted the data; T Guttuso acquired the data; T Guttuso The highlands of western Kenya have seasonal and J Roscoe drafted the manuscript; and J Roscoe and J Griggs undertookcritical revision of the manuscript for important intellectual content.
mesoendemic malaria transmission with resurgent outbreaks2in June and July after the long rains.3 The role of MEWS in these highland areas is often, therefore, to detect whether a seasonal resurgent outbreak is usual or has the potential to become a true epidemic.2 A joint UNICEF and Division of This work was funded by an Experimental Therapeutics in Neurological Malaria Control team was sent to four districts (Kisii Central, Disease (NIH 5 T32 NS07338-12) and by University of Rochesterinstitutional research funds. The sponsors of the study had no role in study Gucha, Nandi, and Kericho) to examine the true extent of the design, data collection, data analysis, data interpretation, or writing of the media publicised emergency and to ascertain how existing report. There was no industry support or industry influence of any kind surveillance mechanisms and available data could have assisted provided for this study. The University of Rochester has a patent for the use of gabapentin for the treatment of hot flushes, on which T Guttuso is listed as theinventor. No licensing fees associated with this patent have been negotiated or A seasonal climate forecast for the March–May period was received by the University. Neither the University of Rochester nor any of the published in February, 2002, by the Greater Horn of Africa authors have a patent or a patent application for the use of gabapentin for the Climate Forum ( treatment of any nausea-related condition, including chemotherapy-induced african_desk). The outlook for the Kenyan western highlands nausea. This new-use patent is owned by a separate organisation.
was for the highest likelihood (40%) of normal conditions, a Pater JL, Lofters WS, Zee B, et al. The role of the 5-HT3 antagonistsondansetron and dolasetron in the control of delayed onset nausea and 35% chance of higher than average rainfall, and a 25% chance vomiting in patients receiving moderately emetogenic chemotherapy. of drier than average conditions. Although the long lead-time Ann Oncol 1997; 8: 181–85.
of a seasonal climate forecast can be useful for planning, in this The Italian Group for Antiemetic Research. Dexamethasone alone or in case the information provided was inaccurate; exceptional combination with ondansetron for the prevention of delayed nausea and
vomiting induced by chemotherapy. N Engl J Med 2000; 342: 1554–59.
rainfall occurred in May, 2002 (table). This skill, coupled with Kris MG, Gralla RJ, Clark RA, et al. Incidence, course, and severity of the limited temporal and spatial specificity of the information delayed nausea and vomiting following the administration of high-dose provided, compromises the usefulness of long-range weather cisplatin. J Clin Oncol 1985; 3: 1379–84.
Guttuso T Jr, Kurlan R, McDermott M, Kieburtz K. Gabapentin’s effectson hot flushes in postmenopausal women: a randomised controlled trial.
Satellite and meteorological station data are combined to Obstet Gynecol 2003; 101: 337–45.
provide on-line rainfall estimates (RFE) for Africa in Navari RM, Reinhardt RR, Gralla RJ, et al. Reduction of cisplatin- near-real time at an 8ϫ8 km spatial resolution induced emesis by a selective neurokinin-1-receptor antagonist. L-754,030 ( We retrieved these data Antiemetic Trials Group. N Engl J Med 1999; 340: 190–95.
for the duration of the archive and extracted district total Department of Neurology, Box 673 (T Guttuso, Jr MD), Cancer Center rainfall estimates for the four districts. In Kisii Central and (J Griggs MD, J Roscoe PhD), University of Rochester, Rochester, Gucha, the estimates for the months of April and May were not very different from average (table), suggesting a resurgent outbreak of normal proportions. By contrast, (e-mail: Nandi and Kericho received over a third more rain than isusual in May (table), indicating suitable conditions for trueepidemics. Details for all the districts in the western highlands can be found in the UNICEF report cited in theAcknowledgments section. No equivalent sources of public- domain temperature data are available.
Simon I Hay, Eric C Were, Melanie Renshaw, Abdisalan M Noor, District Health Management Teams were visited in the Sam A Ochola, Iyabode Olusanmi, Nicholas Alipui, Robert W Snow four districts to collect information on malaria outpatients Our aim was to assess whether a combination of seasonal until the end of August, 2002, and for the preceding 5 years.
climate forecasts, monitoring of meteorological conditions, and We then used the WHO quartile, Cullen, and cumulative early detection of cases could have helped to prevent the 2002 sum (C-SUM) epidemic detection techniques3 for objective malaria emergency in the highlands of western Kenya. Seasonal quantification of the scale of the emergency. Resurgent climate forecasts did not anticipate the heavy rainfall. Rainfall outbreaks arose in Kisii Central and Gucha, compared with data gave timely and reliable early warnings; but monthly surveil- true epidemics in Nandi and Kericho (figure) in the months lance of malaria out-patients gave no effective alarm, though it of June and July, as had been predicted on the basis of the did help to confirm that normal rainfall conditions in Kisii Central rainfall estimates. The monthly temporal resolution of and Gucha led to typical resurgent outbreaks whereas malaria outpatient reporting was not sufficient for the early exceptional rainfall in Nandi and Kericho led to true malaria detection of epidemics, since none of the techniques epidemics. Management of malaria in the highlands, including indicated unusual conditions in May. The routine health improved planning for the annual resurgent outbreak, augmented information and management systems were weak and did by simple central nationwide early warning, represents a feasible not provide timely information during the 2002 emergency.
strategy for increasing epidemic preparedness in Kenya.
The highland populations are typical of those of the rest of Kenya, with poor access to, and use of, insecticide treated nets, emerging antimalarial drug resistance, supply of A strategic aim advocated by Roll Back Malaria—a partnership antimalarial products from the informal sector—which fail founded by WHO, the United Nations Development internationally acceptable quality assurance standards—poor Programme, the United Nations Children’s Fund (UNICEF),and the World Bank to help reduce the burden of malaria in Africa—is the implementation of malaria early warning systems (MEWS) to facilitate timely responses to prevent and contain malaria epidemics.1 Our goal was to examine what contribution the proposed methods for seasonal climate forecasting, early warning through the monitoring of Rainfall estimates for 2002 expressed as a proportion of meteorological conditions, and early detection (case THE LANCET • Vol 361 • May 17, 2003 • For personal use. Only reproduce with permission from The Lancet Publishing Group.
2002 2002, 2002, 2002y, 2002 2002 2002, 2002 2002 2002v, 2002 2002 2002 2002, 2002, 2002y, 2002 2002 2002, 2002 2002 2002v, 2002 2002 Jan, Feb, Mar Apr Ma Jun, Jul, Aug Sep, Oct, No Jan, Feb, Mar Apr Ma Jun, Jul, Aug Sep, Oct, No Epidemic detection in Kisii Central (A), Gucha (B), Nandi (C), and Kericho (D)In each graph, the blue bars represent the number of cases of malaria in 2002. If a bar exceeds the thin blue line the outbreak is a WHO definedepidemic, the green line a Cullen defined epidemic, and the red line a C-SUM defined epidemic.3 case management, and inadequate prescription practices by ContributorsS I Hay, E C Were, M Renshaw, A M Noor, S A Ochola, I Olusanmi, formal health-service providers. The highlands of Kenya N Alipui, and R W Snow contributed to data collection and analyses, and the should, therefore, not be viewed as a distinct case, demanding great revisions to national policy. Increasing access to affordable, effective, preventative and curative strategies are as relevant in the highlands as they are in the more intense transmission areas of the country. We would, We thank Prof Sarah E Randolph and Prof David J Rogers for their however, argue that emphasis should be given to improved comments. Funds were provided by UNICEF Kenya Country Office (SpecialService Agreement 059—SSA/KENA/2002/00001290-0). The full report of planning cognisant of the seasonal epidemiology of risk, in this work, distributed to all relevant partners, can be requested for further view of the fact that every year about 25% of the annual case details: Hay SI. The inter-sectoral response to the 2002 malaria outbreak in burden occurs in June and July. This planning should the highlands of western Kenya. Nairobi: UNICEF, Kenya Country Office concentrate central, provincial, and particularly district level (KCO), 2002. The opinions and assertions contained herein are private viewsof the authors and are not to be construed as official or as reflecting the views efforts at preparedness (indoor residual spraying, advocacy of UNICEF. SIH is supported as an Advanced Training Fellow by the for the use of mosquito nets and re-treatment, community Wellcome Trust (#056642) and affiliated to the Kenya Medical Research mobilisation and education, audits of drug stock, efficacy, Institute/Wellcome Trust Collaborative Programme, PO Box 43640, Nairobi, Kenya. In respect of the term and conditions of this and resistance, medical staff audits, retraining, etc) in the award, the consultancy for UNICEF was operated on an expenses only basis.
months of April and May before the predictable seasonal RWS is a Senior Wellcome Trust Fellow (#058992) and acknowledges the resurgence. Further considerations for the highlands might support of the Kenya Medical Research Institute. This report is publishedwith the permission of the director of the Kenyan Medical Research Institute include modifications of national policies for malaria to allow (KEMRI). The sponsors of the study had no role in study design, data for: proportionately more advocacy for indoor residual house collection, data analysis, data interpretation, or writing of the report.
spraying;4 routine suspension of cost sharing for malaria 1 WHO. Malaria early warning systems, a framework for field research in treatment in May, June, and July to encourage more Africa: concepts, indicators and partners. Geneva: World Health prompt treatment of disease as a midway to mass drug administration, which has historically been shown to be very 2 Nájera JA, Kouznetsov RL, Delacollete C. Malaria epidemics: detection and control, forecasting and prevention. Geneva: World Health effective;5 the strict management of leave during the months of May, June, and July for key medical and administrative 3 Hay SI, Simba M, Busolo M, et al. Defining and detecting malaria staff at the relevant districts, provinces, and central levels; epidemics in the highlands of Western Kenya. Emerg Infect Dis 2002; 8:
and embracing the role of the media as an important 4 Guyatt HL, Corlett SK, Robinson TP, Ochola SA, Snow RW. Malaria component of the wider dissemination of public-health prevention in highland Kenya: indoor residual house-spraying vs.
information through appointment of a press representative to insecticide-treated bednets. Trop Med Int Health 2002; 7: 298–303.
assist in quality control of information reported.
5 Roberts JMD. The control of epidemic malaria in the highlands of western Kenya, 3: after the campaign. J Trop Med Hyg 1964; 67: 230–37.
Ironically, the national and international attention paid to the highland malaria emergency in western Kenya in 2002 TALA Research Group, Department of Zoology, University of Oxford, ignored the fact that malaria is a leading cause of death in South Parks Road, Oxford OX1 3PS, UK (S Hay DPhil); Division of MalariaControl, Ministry of Health, Nairobi, Kenya (E Were BSc, S Ochola MBChB); 65 of the 70 Kenyan administrative districts. In these UNICEF ESARO (M Renshaw PhD), UNICEF KCO (I Olusanmi MBBS, districts those who die are generally voiceless, politically inert N Alipui MD), UN Complex Gigiri, Nairobi; Kenya Medical Research children. Although some aspects of MEWS are of potential Institute/Wellcome Trust Collaborative Programme, Nairobi (S Hay, benefit to the western highland districts, better utilisation of A Noor BSc, Prof R Snow PhD); and Centre for Tropical Medicine, early warning potential within and beyond the highlands University of Oxford, John Radcliffe Hospital, Oxford (Prof R Snow) would help ensure equitable implementation of the national THE LANCET • Vol 361 • May 17, 2003 • For personal use. Only reproduce with permission from The Lancet Publishing Group.


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