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ASSESSMENT OF THE HEALTHCARE PROVIDERS KNOWLEDGE AND CAPACITY TO DETECT RIFT VALLEY FEVER INFECTIONS IN MARAGUA SUB-COUNTY OF MURANG’A COUNTY OF

GACHERU STEPHEN GITAU (HND) I57/6472/03

A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE DEGREE OF MASTER OF PUBLIC HEALTH (EPIDEMIOLOGY AND DISEASE CONTROL) IN THE SCHOOL OF PUBLIC HEALTH OF KENYATTA UNIVERSITY

APRIL 2016 ii

DECLARATION

This thesis is my original work and has not been presented for a degree or other awards in any other university.

Signature …………………………………… Date …………………………. Stephen G. Gacheru (I57/6472/2003) Department of Community Health

SUPERVISORS

We confirm that the work reported in this thesis was carried out by the candidate under our supervision

Signature …………………………………… Date …………………………. Prof. Joseph N. Ngeranwa Department of Biochemistry and Biotechnology Kenyatta University

Signature …………………………………… Date …………………………. Dr. Anne W. Kamau Department of Sociology Kenyatta University

Signature …………………………………… Date …………………………. Dr. Yatinde S. Binepal

Biotechnology Centre Kenya Agriculture and Livestock Research Organization (KALRO) iii

DEDICATION

To my family; Elvis, Joel, Hannah and Knollecah.

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ACKNOWLEDGEMENTS

My gratitude goes to my supervisors, Prof. Joseph. J. N. Ngeranwa, Dr.

Yetinde S. Binepal and Dr. Anne W. Kamau for their inspiration and scientific guidance. Dr. Isaac Mwanzo is appreciated for his guidance in choosing the topic of study and also encouragement throughout the entire course. I sincerely thank, The Kenya Veterinary Service Department who facilitated funding support for this study. Thanks to the Murang’a South Public health staff for their support, not forgetting the District Public Health Nurses for ,

Murang’a South and , namely; Esther Wahome, Catherine Gachanja and Njeri Kande respectfully for their dedication and tireless effort in assisting me during the visit to the health facilities during the study. The dedication of the drivers Daniel Irungu, Stephen Muturi and Joseph Okong’o all of Kabete who worked beyond the normal working hours and at times driving tirelessly in the rains on unfamiliar routes is highly appreciated. Thanks also go to Mrs.

Bilha Muna of epidemiology unit Kabete for providing the map of the study area. Thank to Timothy Kinoti of African Medical Research Foundation for guidance and support in data analysis work and the use of the Statistical

Package for Social Sciences. I am grateful to Mr. Antony D. Bojana and Mr.

David Mainge both of Kenyatta University who assisted in the final editorial work of the thesis. v

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 1.1 Background to the study ...... 1 1.2 Statement of the Problem ...... 2 1.3 Research Questions ...... 5 1.4 Hypotheses...... 5 1.5 Objective...... 5 1.5.1 General ...... 5 1.5.2 Specific Objectives ...... 5 1.6 Significance of the study ...... 5 CHAPTER TWO: LITERATURE REVIEW ...... 7 2.1 Rift Valley Fever (RVF) Virus ...... 7 2.1.1 Structure of Rift Valley Fever Virus...... 8 2.1.2 Replication of Rift Valley Fever Virus ...... 9 2.2 History of Rift Valley Fever Outbreaks ...... 10 2.3 Distribution of Rift Valley Fever in Africa and Middle East ...... 11 2.4 Rift Valley Fever in Kenya ...... 12 2.5 Socio- Economic Impact of Rift Valley Fever Infection ...... 13 2.6 Transmission of Rift Valley Fever...... 14 2.6.1 Rift Valley Fever Vectors ...... 14 vi

2.7 Pathogenesis of Rift Valley Fever in Primates ...... 15 2.8 Clinical features of Rift Valley Fever Infections ...... 17 2.9 Detection and Diagnosis of the RVF Agent ...... 18 2.10 Control of RVF ...... 19 2.10.1 Controlling RVF in Animals ...... 19 2.10.2 Controlling RVF in Humans ...... 19 2.10.3 Vector control ...... 20 2.10.4 RVF forecasting and climate models ...... 21 2.11 Treatment and Vaccination...... 21 CHAPTER THREE: RESEARCH METHODOLOGY ...... 23 3.1 The Study Area ...... 23 3.2 Research Design and Study Location Description ...... 24 3.3 Sites Selection and Study Design ...... 26 3.4 Study Population ...... 24 3.5 Sample size and sampling procedures ...... 27 3.6 Research Instruments and Data Collection ...... 28 3.7 Data Analysis ...... 28 3.8 Ethical Consideration ...... 25 CHAPTER FOUR: RESULTS AND DISCUSSION ...... 30 4.1: Types of Health Facilities in the Study Area ...... 30 4.2 Healthcare Providers in the Study Area ...... 31 4.2.1 Healthcare Providers Level of Education ...... 32 4.2.2 Healthcare Providers Training on RVF Detection ...... 33 4.2.3 Healthcare Providers’ Knowledge on When to Expect Cases of RVF ...... 35 4.2.4 Healthcare Providers’ Knowledge on Economic Importance of RVF ...... 36 4.2.5 Healthcare Providers Knowledge on People Likely to Suffer from RVF .... 37 4.2.6 Healthcare Providers’ Knowledge on Clinical Manifestation of RVF ...... 38 4.2.7 Healthcare Providers’ Knowledge on the Cause of RVF ...... 40 4.2.8 Healthcare Providers’ Knowledge on Control of RVF ...... 40 4.2.9 Healthcare Providers’ Knowledge on Diagnosis of RVF ...... 42 vii

4.2.10 Healthcare Providers’ Training on Management of RVF ...... 43 4.2.11 Healthcare Providers Training in the Past Year ...... 44 4.2.12 Challenges Healthcare Providers Face When Managing RVF ...... 45 4.2.13 Addressing Challenges Healthcare Providers Face in Diagnosis of RVF .. 47 4.2.14 Additional Information Shared by Healthcare Providers ...... 48 4.3: Laboratory Facilities in the Healthcare Institutions ...... 48 4.3.1 Source of Laboratory Reagents ...... 50 4.3.2 Facilities Capacity for RVF Detection ...... 51 4.3.3 Medical Waste Disposal ...... 53 4.3.4 Availability of Power and Backups in the Health Facilities ...... 52 4.3.5 Availability of Operational Hazardous Medical Waste Disposal System.... 54 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

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LIST OF TABLES 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 ix

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

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LIST OFAPPENDICES 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 xi

LIST OF PLATES 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

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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

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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.

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CHAPTER ONE: INTRODUCTION

1.1 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 2

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).

1.2 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).

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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 4

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, 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 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.

Health care providers are in the first line in suspecting, detecting and reporting infections in the community for early response. The health care providers need be a highly trained and skilled health workforce to respond to RVF out breaks. This study examined the capacity of the healthcare providers in diagnosis of RVF in Maragua.

The study sought to make recommendations for improving the situation, especially of the health workers capacity and their preparedness in dealing with the epidemic and sought the Kenyan capacity of its own local experts who can effectively handle the disease instead of relying on foreign experts as it happened during the 2007 outbreak where Americans came in to help detect and confirm the disease.

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1.3 Research Questions

(i). What is the capacity of the healthcare providers in Murang’a County to

detect and diagnose Rift Valley Fever?

(ii). Are the healthcare facilities in Murang’a County equipped to diagnose

Rift Valley Fever?

1.4 Hypotheses

(i). Murang’a County does not have qualified healthcare providers to detect

Rift Valley Fever.

(ii). Healthcare facilities in Murang’a County do not have capacity to

diagnose Rift Valley Fever.

1.5 Objectives of the study

1.5.1 General objective

To determine the status of the healthcare providers knowledge and capacity to correctly detect and diagnose Rift Valley Fever in Murang’a County.

1.5.2 Specific Objectives

(i). To determine the status Rift Valley Fever knowledge of among healthcare

providers in Murang’a County, Kenya.

(ii). To determine the status of healthcare facilities capacity to diagnose Rift

Valley Fever in Murang’a County, Kenya.

1.6 Significance of the study

(i). The study was carried out as a requirement for partial fulfillment for the

award of masters’ degree in public health. 6

(ii). To identify the gaps in the study area in terms of knowledge and facilities

to detect Rift Valley Fever by the health care providers

(iii). To communicate the finding to the authorities for policy development

aimed at improvement of preparedness of dealing with future out breaks

of RVF thus reducing the losses related to the disease. 7

CHAPTER TWO: LITERATURE REVIEW

2.1 Rift Valley Fever (RVF) Virus

Rift Valley Fever (RVF) is a disease of humans and animals (Zoonotic). It is a viral disease transmitted by mosquitoes in Africa, Yemen, Saudi Arabia and Madagascar.

Clinical diagnosis of Rift Valley Fever in affected areas is relatively easy because a high proportion of infected pregnant ewes and cows abort, and high mortality usually occur among newborn lambs (Swanepoel et al., 1994). Diagnosis is often delayed when Rift Valley Fever extends to new regions, and laboratory confirmation is necessary even in the presence of suspicious disease activity. Example is the first confirmed outbreak of Rift Valley Fever in humans and livestock in the Kingdom of

Saudi Arabia and Yemen (Jupp et al., 2002; Shoemaker et al., 2002).

RVFV is a Group V virus consisting of a single serotype of the family Bunyaviridae of the genus Phlebovirus. It has morphological and physicochemical properties typical of Bunyaviruses. The virus is segmented thrice, single-stranded, negative- sense RNA genome and consists of the three segments: L (large), M (medium) and S

(small), each of which is contained in a separate nucleocapsid within the virion. The

S segment is ambience RNA, that is, has bi-directional coding (Gentsch et al., 1979).

The L segment codes for the L protein which is the polymerase. The M segment codes for glycoproteins G1 and G2 and two others proteins of 78 and 14 K. The S segment codes for the nucleoprotein N and the non structural (NSs) protein using an ambience strategy (Sall et al., 1986). The envelop proteins Gn and Gc are concerned 8

with pathogenicity of the virus and are found in the M segment of the Rift Valley

Fever Virus. (Vialat et al., 2000). Infected subjects develop specific antibodies that may become demonstrable by Viral Neutralization (VN) as early as 3 days following infection and after 6–7 days by enzyme-linked immunosorbent assay, haemagglutination inhibition. Serological tests used less often include immunofluorescence, complement fixation and immunodiffusion.

2.1.1 Structure of Rift Valley Fever Virus

The three RNA genome segments (S, M, and L) are complexed with nucleocapsid protein to form ribonucleocapsid structures. The nucleocapsids and RNA-dependent

RNA polymerase are packaged within a lipid envelope that contains the viral glycoproteins, G1 and G2 (also referred to as Gn and Gc, respectively) (Whitehouse,

2004). Figure 2.1 shows the structure of RVF virus.

Figure 2.1: Schematic cross-section of a Bunyaviridae virion (virus shape) (Whitehouse, 2004).

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2.1.2 Replication of Rift Valley Fever Virus

Replication cycle of viruses are numbered as follows: (1) attachment of virions to cell-surface receptors; (2) entry via endocytosis followed by membrane fusion, allowing viral ribonucleocapsids and RNA-dependent RNA polymerase access to the cytoplasm; (3) primary transcription; (4) translation of viral proteins; (5) replication of vRNA via a cRNA intermediate; (6) assembly of virions at the Golgi or plasma membrane; (7) egress by budding into the Golgi followed by exocytosis, or budding through the plasma membrane (Whitehouse, 2004). Figure 2.2 gives a virus replication cycle.

Figure 2.2: Replication cycles of viruses in the family Bunyaviridae

(Whitehouse, 2004). 10

2.2 History of Rift Valley Fever Outbreaks

The virus which causes the Rift Valley Fever was isolated for the first time in 1931 near Lake in the region of the Rift Valley, in Kenya (Daubney et al., 1931).

The disease was later reported in regions of high altitude South Africa in 1951,

Zimbabwe in 1958, Nigeria in 1958, Chad and Cameroon in 1967, before getting over the Saharan barrier and affecting river valleys of Sudan in 1973, Egypt in 1977 and Mauritania in 1987 (Digoutte et al., 1999). The agent was able to infect breeders in contact with affected or dead animals, but the human infection remained minor until the 70's; when it was known as a feverish affection of harmless evolution (Eisa et al., 1980). This situation suddenly changed in 1973. After a first source of infection which appeared in the district of the White Nile in Sudan, an epidemic triggered off in Egypt (Eisa et al., 1980; Meegan et al., 1980).

During the summer of 1977, the first cases were reported in Egypt, where according to the estimations, one million human beings were contaminated, clinic cases amounted to eighteen thousand people and six hundred deaths were reported

(Meegan et al., 1979). In Senegal, the RVF virus, initially described under the name of Zinga, was isolated for the first time in 1974. Serologic studies performed between 1981 and 1986 highlighted an important circulation of the RVF virus in

Southern Mauritania: 17.8% of the small ruminants had antibodies against the RVF virus and 13.3% of the breeders proved to be positive. Two new sources of infection were observed in 1993 in flocks of small ruminants, in the area of St Luis in Senegal and of Guidimaka in Mauritania. One year later, in October-December 1994, two 11

other sources of infection were detected in the Senegal valley and in the Ferlo valley

(Thiongane et al., 1995).

2.3 Geographical Distribution of Rift Valley Fever in Africa and Middle East Below is a figure showing the outbreaks which have been reported and confirmed in different parts of Africa and Middle East: Blue, countries with endemic disease and substantial outbreaks of RVF; green, countries known to have some cases, periodic isolation of virus, or serologic evidence of RVF (Figure 2.3).

Figure 2.3: Geographical Distribution of Rift Valley Fever (FAO 1998).

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2.4 Rift Valley Fever in Kenya

Outbreaks of Rift Valley Fever in Kenya have been reported since 1912, 1930-31,

1968, 1997-98 and the last one, 2007 (Bird et al., 2008). The provinces which have reported the disease in all outbreaks includes; Rift valley, Nairobi, Central, Coast,

Western, Eastern and North Eastern. In , the disease has been reported in , , Maragua, , and . Signs of the disease tend to be non-specific, rendering it difficult to recognise individual cases (Weiss, 1957;

Easterday, 1965; Coackley et al., 1967; Coetzer, 1977; Barnard, 1977; Coetzer,

1982; Meegan, 1989; Bird et al., 2008). Figure 2.4 shows the districts where RVF infections have been reported and confirmed.

Figure 2.4 Map of Kenya showing infected and confirmed Districts (Bird et al.,

2008) 13

2.5 Socio- Economic Impact of Rift Valley Fever Infection

Infected subjects develop specific antibodies that may become demonstrable by VN as early as 3 days following infection and after 6–7 days by enzyme-linked immunosorbent assay, and by haemagglutination inhibition. Serological tests used less often include immunofluorescence, complement fixation and immunodiffusion. These are the prescribed tests both by WHO and OIE; the tests are carried out by well-trained specialists and take a lot of man hours and money. The 2006/7 outbreak affected 35 of the then 71 districts in 6 of the 8 provinces. The outbreak had a negative economic impact of about Kshs 4 billion with the following breakdown as shown in (Table 2.1).

Table 2.1: Negative Economic Impact of RVF during 2006/7 outbreak in Kenya

Parameter Value (Ksh)

Total herd meat loss due to RVF (20,237,829 KG) 1,251,909,117

Total milk loss due to RVF (21,134,520 liters) 221,912,460

Net losses to business actors 2,320,000,000

Government expenditure in control measures 200,000,000

Total cost of outbreak (excluding value of human lives lost) 3,993,821,577

Sources: Socioeconomic studies by Veterinary Epidemiology and Economics Unit (VEEU) and ILRI 2008 Department of Veterinary Services Records.

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 the stakeholders; poor risk communication and delayed resource mobilization (Bird et al.,

2008). The importance of prediction was underlined with the most important activity 14

during the lead period being resource mobilization, stakeholders’ awareness and strategic vaccination (Bird et al., 2008). It is within this respect that the evaluation of the competence of the health providers in the diagnosis of RVF in the high risk areas is proposed to activate emergency response plan (Bird et al., 2008).

2.6 Transmission of Rift Valley Fever

RVF is able to infect many species of animals causing severe disease in domesticated animals including cattle, sheep, camels and goats. Sheep appear to be more susceptible than cattle or camels (Bird et al., 2008). Age has also been shown, by

Meegan to be a significant factor in the animal's susceptibility to the severe form of the disease, in his studies on the antibodies to RVF virus in ovine and bovine sera: over 90% of lambs infected with RVF die, whereas mortality among adult sheep can be as low as 10% (Meegan, 1989). The rate of abortion among pregnant infected ewes is almost 100% (Meegan, 1989). An outbreak of RVF in animals frequently manifests itself as a wave of unexplained abortions in livestock and may signal the start of an epidemic (Meegan, 1989; Bird et al., 2008).

2.6.1 Rift Valley Fever Vectors

Several different species of mosquito are able to act as vectors for transmission of the RVF virus. (Shabani et al., 2015). The dominant vector species varies between different regions and different species. They also play different roles in sustaining the transmission of the virus (Meegan, 1989; Bird et al., 2008).

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There is also a potential for epizootics and associated human epidemics to spread to areas that were previously unaffected. This has occurred when infected animals have introduced the virus into areas where vectors were present and is a particular concern

(Coetzer, 1982). When uninfected Aedes and other species of mosquitoes feed on infected animals, a small outbreak can quickly be amplified through the transmission of the virus to other animals on which they subsequently feed (Coetzer, 1982).

Among animals, the RVF virus is spread primarily by the bite of infected mosquitoes, mainly the Aedes species, which can acquire the virus from feeding on infected animals (Coetzer, 1982). The female mosquito is also capable of transmitting the virus directly to her offspring via eggs leading to new generations of infected mosquitoes hatching from eggs. This accounts for the continued presence of the RVF virus in enzootic foci and provides the virus with a sustainable mechanism of existence as the eggs of these mosquitoes can survive for several years in dry conditions. During periods of heavy rainfall, larval habitats frequently become flooded enabling the eggs to hatch and the mosquito population to rapidly increase, spreading the virus to the animals on which they feed (Coackley et al., 1967; Bird et al., 2008).

2.7 Pathogenesis of Rift Valley Fever in Primates

Virus spreads from the initial infection site to regional lymph nodes, liver and spleen.

At these sites, the virus infects tissue macrophages (including Kupffer cells) and dendritic cells. Soluble factors released from virus-infected monocytes and macrophages act locally and systemically. Release of chemokines from these virus- 16

infected cells recruits’ additional macrophages to sites of infection, making more target cells available for viral exploitation and further amplifying the dysregulated host response (Geisbert and Jahrling, 2004).

The hemodynamic and coagulation disorders common among all of the Rift Valley

Fevers are exacerbated by infection of hepatocytes and adrenal cortical cells.

Infection of hepatocytes impairs synthesis of important clotting factors. At the same time, reduced synthesis of albumin by hepatocytes results in a reduced plasma osmotic pressure and contributes to edema. Impaired secretion of steroid- synthesizing enzymes by hemorrhagic fever virus-infected adrenal cortical cells leads to hypotension and sodium loss with hypovolemia. Macular rashes are often seen in RVFs. This is shown in Figure 2.5 (Geisbert and Jahrling, 2004).

Figure 2.5: Model of current understanding of Rift Valley Fever pathogenesis in primates (Geisbert and Jahrling, 2004). 17

2.8 Clinical Features of Rift Valley Fever Infections in Humans

The clinical presentation of the disease in humans features in different forms of which their names are derived from. These clinical presentations are; mild form, severe form, ocular form, meningoencephalitis form and haemorrhagic fever form.

These forms have clinical features characterized by; incubation period of 2-6 days with no detectable symptoms experienced by the infected, feverish syndrome, sudden onset of flu-like fever, muscle pain, joint pain and headache. Others develop neck stiffness, sensitivity to light, loss of appetite and vomiting; in these patients the disease, in its early stages, may be mistaken for meningitis. The symptoms of RVF usually last from four to seven days, after which time the immune response becomes detectable with the appearance of antibodies and the virus gradually disappears from the blood (Geisbert and Jahrling, 2004).

In the severe form, the patient develops much more severe form of the disease. This could be ocular characterized by retinal lesions with blurred or decreased vision to permanent loss of vision or death, meningoencephalitis characterized by intense headache, loss of memory, hallucinations, confusion, disorientation, vertigo, convulsions, lethargy and coma (Geisbert and Jahrling, 2004).

Neurological complications and death or haemorrhagic fever characterized by evidence of severe liver impairment, such as jaundice, with subsequently signs of haemorrhage such as vomiting blood, passing blood in the faeces, a purpuric rash or ecchymoses (caused by bleeding in the skin), bleeding from the nose or gums, menorrhagia and bleeding from venepuncture sites. Death usually occurs three to six 18

days after the onset of symptoms. The virus may be detectable in the blood for up to

10 days, in patients with the hemorrhagic icterus form of RVF (Swanepoel et al.,

1986; Stuthers et al., 1986).

2.9 Detection and Diagnosis of the RVF Agent

RVF virus consists of a single serotype and has morphological and physicochemical properties typical of bunyaviruses. The virus can be isolated from blood, preferably collected in an anticoagulant, during the febrile stage of the disease, or from liver, spleen and brain tissues of patients that have died and from the organs of aborted fetuses on cell cultures of various types, such as African green monkey kidney (Vero) cells, baby hamster kidney cells, chicken embryo reticulum cells or primary cells of sheep or cattle origin. Alternatively, hamsters, adult or suckling mice, embryonated chicken eggs or 2-day-old lambs may be used for virus isolation (Coackley et al., 1967).

A rapid diagnosis can be achieved by using the supernatant of homogenized samples as antigen in virus neutralization (VN) tests; immunofluorescent staining of impression smears of liver, spleen, brain or infected cell cultures; or by the demonstration of virus in serum, taken during the febrile stage of the disease, by enzyme immunoassay or immunodiffusion (Coackley et al., 1967). Acute RVF can be diagnosed using several different methods. Serological tests such as enzyme- linked immunoassay (the "ELISA" or "EIA" methods) may confirm the presence of specific IgM antibodies to the virus. The virus itself may be detected in blood during the early phase of illness or in post-mortem tissue using a variety of techniques 19

including virus propagation (in cell cultures or inoculated animals), antigen detection tests and RT-PCR (Coackley et al., 1967; Bird et al., 2008).

2.10 Control of RVF

2.10.1 Controlling RVF in Animals

Outbreaks of RVF in animals can be prevented by a sustained programme of animal vaccination. Animal immunization must be implemented prior to an outbreak if an epizootic is to be prevented. During mass animal vaccination campaigns, animal health workers may, inadvertently, transmit the virus through the use of multi-dose vials and the re-use of needles and syringes. If some of the animals in the herd are already infected and viraemic (although not yet displaying obvious signs of illness), the virus can be transmitted among the herd, and the outbreak amplified (Bird et al.,

2008). Restricting or banning the movement of livestock may be effective in slowing the expansion of the virus from infected to uninfected areas. As outbreaks of RVF in animals precede human cases, the establishment of an active animal health surveillance system to detect new cases is essential in providing early warning for veterinary and human public health authorities (Coackley et al., 1967; Bird et al.,

2008).

2.10.2 Controlling RVF in Humans

During an outbreak of RVF, close contact with animals, particularly with their body fluids, either directly or via aerosols, has been identified as the most significant risk factor for RVF virus infection. In the absence of specific treatment and an effective 20

human vaccine, raising awareness of the risk factors of RVF infection as well as the protective measures individuals can take to prevent mosquito bites, is the only way to reduce human infection and deaths (Coackley et al., 1967).

Public health messages for risk reduction should focus on reducing the risk of animal-to-human transmission as a result of unsafe animal husbandry and slaughtering practices. Gloves and other appropriate protective clothing should be worn and care taken when handling sick animals or their tissues or when slaughtering animals and reducing the risk of animal-to-human transmission arising from the unsafe consumption of fresh blood, raw milk or animal tissue. In the infected regions, all animal products (blood, meat and milk) should be thoroughly cooked before eating (Bird et al., 2008; Peter et al., 2012).

Although no human-to-human transmission of RVF has been demonstrated, there is still a theoretical risk of transmission of the virus from infected patients to healthcare provider through contact with infected blood or tissues. Healthcare providers caring for patients with suspected or confirmed RVF should implement standard precautions when handling specimens from patients (Bird et al., 2008; Peninah et al.,

2010).

2.10.3 Vector control

Other ways in which to control the spread of RVF involve control of the vector and protection against their bites. Larvicidal measures at mosquito breeding sites are the 21

most effective form of vector control if breeding sites can be clearly identified and are limited in size and extent. During periods of flooding, however, the number and extent of breeding sites is usually too high for larvicidal measures to be feasible

(Bird et al., 2008, WHO 2010).

2.10.4 RVF forecasting and climate models

Forecasting can predict climatic conditions that are frequently associated with an increased risk of outbreaks, and may improve disease control. In Africa, Saudi

Arabia and Yemen, RVF outbreaks are closely associated with periods of above- average rainfall. The response of vegetation to increased levels of rainfall can be easily measured and monitored by Remote Sensing Satellite Imagery. In addition,

RVF outbreaks in East Africa are closely associated with the heavy rainfall that occurs during the warm phase of the El Niño/Southern Oscillation (ENSO) phenomenon (Linthicum et al., 1985; Ropelewski et al., 1987).

2.11 Treatment and Vaccination

As most human cases of RVF are relatively mild and of short duration, no specific treatment is required for these patients. For the more severe cases, the predominant treatment is general supportive therapy. An inactivated vaccine has been developed for human use. However, this vaccine is not licensed and is not commercially available. It has been used experimentally to protect veterinary and laboratory personnel at high risk of infection (Linthicum et al., 1985).

22

There is no established course of treatment for patients infected with RVF virus.

However, studies in monkeys and other animals have shown promise for ribavirin, an antiviral drug, for future use in humans. Additional studies suggest that interferon, immune modulators, and convalescent phase plasma may also help in the treatment of patients with RVF. No vaccines are currently available for human vaccination, although several candidates are available for veterinary use. Among the vaccines available for animal use are, killed, live and live attenuated vaccines. The killed vaccines are not practical in routine animal field vaccination because of the need of multiple injections.

On the other hand live vaccines require a single injection but are known to cause birth defects and abortions in sheep and induce only low level protection in cattle. The live attenuated vaccine, MP-12, has demonstrated promising results in laboratory trials in domesticated animals, but more research is needed before the vaccine can be used in the field. The live attenuated clone 13 vaccine was recently registered and used in South

Africa. Alternative vaccines using molecular recombinant constructs are in development stages and show promising results. In addition, surveillance (close monitoring for RVF infection in animal and human populations) is essential to learning more about how

RVF virus infection is transmitted and to formulate effective measures for reducing the number of infections (RVF Facts sheet, 2010).

23

CHAPTER THREE: MATERIALS AND METHODS

3.1 The Study Area and Study Location Description

The study was done in Maragua Sub County of Murang’a County, located in the Central

Province. Murang’a County is one of the Forty- seven Counties in Kenya; it has a population 942,000, of which 387,969 are in Maragua Sub County (1999 census) in an area of 868km². Maragua Sub County was created in September 1996, when it was split from Murang’a District. The study area was the former Maragua District now subdivided into three Sub Counties of Kandara Kigumo and Murang’a south districts.

Murang’a South comprises Makuyu and Maragua Divisions (Appendix 1). The names of their headquarters form the three constituencies of the study area, i.e. Kigumo

Kandara and Maragua. The population is distributed as shown in Table 3.1 below. The study area has 210 health care providers who are distributed in 66 health facilities as shown in table 3.2 and Table 3.3 respectively.

Table 3.1: Population distribution in the study area

New Districts

Division Population*

Kandara 157,454 (41%)

Kigumo 78,678 (20%)

Murang’a South (Maragua) 151,837 (39%)

Total 387,969 (100%) http://www.cck.go.ke/html/final_annex1_cover_status.pdf (1999 census). 24

3.2 Study Population

Healthcare providers involved in detection of diseases in the study area health facilities were mainly nurses and clinical officers The distribution of the health care providers in the study area are as shown in Table 3.2.

Table 3.2: Health Care providers in the study area

Area Nurses Clinical Officers Laboratory Technicians Totals

Kigumo 48 3 (1%) 12 (6%) 63 (30%)

(23%)

Kandara 57 3 (1%) 17 (8%) 77 (37%)

(27%)

Murang’a 58 3 (1%) 9 (4%) 70 (33%)

South (28%)

Totals 163 9 (4%) 38 (18%) 210 (100%)

(78%)

District Public Health Nurse Office Maragua (2009).

3.2.1 Inclusion Criteria

Health care providers who were attending or would be attending to the patients and consented during the visit to the health care facility. Health care facilities providing curative or preventive services in Maragua Sub County. 25

3.2.2 Exclusion Criteria

Health care providers, who did not consent, were not involved in attending to patients and not on duty during the visits to the healthcare facility. Health care facilities not providing curative or preventive services in Maragua Sub County.

3.3 Study Design

The research design was a descriptive cross-sectional study targeting healthcare providers and the facilities operating and offering curative and preventive services in

Maragua Sub County of Murang’a County. The County has 66 health facilities as shown in appendix 2. All 66 facilities in the County were censored during the study.

Healthcare providers working in the study area, who consented and were attending to patients during the visits to the healthcare facility, were conveniently and purposefully interviewed in the study.

3.3.1 Theoretical Presentation

Health care providers and health facilities were evaluated on the status of knowledge and capacity to detect RVF. Knowledge was evaluated in terms of formal training,

Knowledge on causative agent, who is likely to contract, when to expect, clinical signs, diagnosis prevention and control of RVF. The facilities were evaluated in terms of equipment, reagents, protective gears and medical waste disposal systems.

The summary is as shown in Figure 3.1.

26

Schematic presentation of dependent and independent variables in relationship to detection of RVF

RVF DETECTION

Knowledge of Health Care Capacity of Health Facility Provider

•Dependent variable •Dependent variable •Knowledge of RVF •Equipment •Training Independent variable •Protective gears •Cause Intervening Variables •Reagents •Who is likely to suffer •Staff motivation •Waste disposal •When to expect •Political will system •Community •Clinical signs awareness •Diagnosis •Prevention/control

Figure 3.1 Conceptual Frame Work

3.4 Sites Selection

Murang’a County was selected for the study due to the fact that the disease has been reported in the County and confirmed in the laboratory in all the five outbreaks that have occurred in the Country and convenience in terms of cost of the study for the student (Bird et al., 2008; Peter et al., 2012). Healthcare facilities in Maragua Sub

County were censored to determine the status of preparedness in terms of recognition of Rift Valley Fever infections. A total of sixty-six (66) health facilities were visited

(Appendix 2). The facilities included public, private and faith-based organizations.

The healthcare facilities were visited and questionnaires administered to the 27

healthcare providers present and attending to patients during the visits. This was

carried out with

authorities and permissions granted by concerned bodies of the Government as

shown in Appendix 3 and 4. A check list of equipment and reagents in the health

facilities and their state of operation was completed (Appendix 5). The facilities

ranged from dispensaries to the district hospitals. The distribution of the health

facilities is as shown in Table 3.3 below.

Table 3.3: Health facilities and their level in the study area

Health Facilities in the study are

Level/Category n (%)

Private 18 (27%)

District hospital 1 (1%)

Health center 8 (12%)

Dispensary 30 (45%)

Faith Based Organizations (FBO) 8 (12%)

Total 66 (100%)

A total of 66 health facilities were censured.45% (30/66) were dispensaries.

3.5 Sample size and sampling procedures

The target population of the study was health care providers and health care facilities in

Maragua Sub County. Sixty-six health facilities located in Maragua Sub County were

censored and 84 out of 210 healthcare providers were conveniently and purposefully 28

interviewed. Researchers such as Mugenda and Mugenda (1999) suggest that one may use a sample size of at least 10 per cent, but for better, more representative results, a higher percentage is better. Thus eight-four (40%) healthcare providers were interviewed for the study by filling in the structured questionnaires on knowledge of

RVF as a disease.

10/100X210=21% Thus 21% of 210=44.1 Therefore any number from 44 of health care providers was sufficient for the study, Mugenda and Mugenda (1999).

3.6 Research Instruments and Data Collection

The study used questionnaires, interviews and checklist. Structured questionnaires were administered to healthcare providers. The questionnaires aimed at finding out the status of knowledge of the health care providers in terms of causative agent, transmission, clinical signs prevention and control in relation to RVF according to

RVF facts sheet and WHO recommendations and guidelines. A checklist was used to get information of what was available in the healthcare facility and physical inspection of equipment status and facilities in relation with RVF detection as recommended by CDC, RVF fact sheet and WHO guidelines for diagnosis of RVF infections, RVF Fact sheet (2010).

3.7 Data Analysis

The collected data was processed using a Statistical Package for Social Sciences,

Data Editor and Analysis; chi-square, version 16 (SPSS). Data collection and analysis were in regard to overall function of disease detection systems in the health 29

facility in the area of study. WHO/CDC health facility assessment tool and format

2000 was used.

3.8 Ethical Consideration

Clearance was obtained from Kenyatta University Graduate School, Research permit from Ministry of Higher Education and National Council for Science and

Technology (Permit No NCST/RRI/12/1/MED011/131 dated 7th September, 2011) as shown in Appendix 3. Authority to conduct the study was given by Maragua District

Commissioner, the Office of the President, Provincial administration and Internal

Security (Reference No MAR/CORR.3.3. (86) Dated 21st September, 2011) as shown in Appendix 4. Confidentiality and anonymity in data collection and recording were practiced throughout the study. Verbal consent for participation from the respondents was sought before any information and data were collected from them. 30

CHAPTER FOUR: RESULTS AND DISCUSSION

4.1: Types of Health Facilities in the Study Area

A total of sixty-six (66) health facilities were assessed for their preparedness to deal with Rift Valley Fever (RVF) infections. Of these forty (40) were government, eighteen

(18) private and eight (8) faith-based. Of the 40 government facilities one, (1) was a district hospital (level 4), one (1) sub-district (level 3) eight (8) health centers (level 2) and thirty (30) dispensaries (level 1). For the private the facilities they were one (1) hospital and seventeen (17) medical clinics while for the faith-based, they were two hospitals (2), one (1) health centre and five (5) dispensaries (Table 4.1).

Table 4.1 Levels of the health facilities studied

Level of Health Facility in the Study

Facility type Level n (%)

Government District hospital 1 (1.5%)

Sub district hospital 1 (1.5%)

Health Center 30 (45.5%)

Dispensary 8 (12.1%)

Private Hospital 1 (1.5%)

Medical Clinics 17 (25.8%)

Hospital 2 (3%) Faith Based Organizations (FBO) Health Centre 1 (1.5%)

Dispensary 5 (7.6%)

Total 66 (100%)

In this study the levels were not applied and the researcher used the categories as Government, Private or Faith based. 31

4.2 Healthcare Providers in the Study Area A total of 84 Healthcare providers were involved in the study. The study included only the healthcare providers found on duty in the aforementioned healthcare facilities at the time of visit during the study period. In large facilities more health care providers were interviewed like in District, sub-District hospitals and private and faith based hospitals as there were more attending to the patients. They were distributed as follows; doctors

(2), nurses (62), medical officers (18), laboratory Technologists (1), and healthcare facility administrator (1) (Table 4.2), District Public Health Nurse Office Maragua

(2009).

Table 4.2 Cadre of health care provider

Cadre of Health Care Providers

Cadre n (%)

Doctor 2 (2.4%)

Clinical Officer 18 (21.4%)

Nurse 62 (73.8%)

Lab technologist 1 (1.2%)

Others 1 (1.2%)

Total 84 (100%)

Nurses formed the majority (74%) of the health care providers in the study population

32

4.2.1 Healthcare Providers Level of Education

The healthcare providers interviewed were those handling the patients at the time of the visit and by extension the ones most likely to come into contact with the RVF in case of outbreak. From the government sponsored facilities, two (2) of the respondents were university graduates while the rest were college graduates. In the private facilities, one

(1) respondent was a university graduate, twenty (20) college trained while one (1) was not trained formally. In the Faith-based facilities, all the eleven (11) personnel were college graduates (Table 4.3). There was no significant difference in the training levels of the healthcare providers and the category of the health facility (X2=3.2728; df=4; p=

0.5132). This means that there was no difference in the level of training between health workers in public or public health facilities. Their capacity to respond to RVF was therefore the same. WHO medical professionals’ critical shortage findings place

Africa’s shortage at 817,992 in 46 member countries. Kenya is placed in group four with a ratio of 1:7100 (medical professional: patient), WHO (2014) Global atlas of health work force. The trend on the level of training of healthcare providers in

Murang’a County concurs with WHO findings for African continent. The health facilities were manned by college graduates whose cost of training, deployment and retention is lower than that of university graduates. This could be attributed by low gross domestic income and few colleges to train health care providers. It cost up to 41,

272 pounds (5.8 million) to train a general practitioner in UK and over 1million

Shillings in Kenya (University of Kentucky, 2009). Cuba is the best in the world and is in category one with the ratio of 1:170. Cuba spends 10% of her income on health.

Malawi and Tanzania are rated last at 1:50,000 (WHO 2014). 33

Table 4:3 Healthcare providers level of education by facility type

Type of health facility Respondent Government Private Faith-based Total

Education Level n (%) n (%) n (%) n (%)

No response 1 (1%) 1 (1%) 0 (0%) 2 (2%)

University 2 (2%) 1 (1%) 0 (0%) 3 (4%)

College/Tertiary education 47 (56%) 20 (24%) 11 (13%) 78 (93%)

At least secondary 0 (0%) 1 (1%) 0 (0%) 1 (1%)

Total 50 (60%) 23 (27%) 11 (13%) 84 (100%)

Majority (93%) of the health care providers in this study were college graduates

4.2.2 Healthcare Providers Training on RVF Detection

In this study, among the 84 respondents, only 76 gave information on training on RVF.

Of these, 58 (76%) did not have any training while 18 (24%) had training on RVF detection in the past one year prior to anticipated RVF outbreak. Among those trained, six (6) (33%) were from private institutions, nine (9) (50%) government and 3 (17%) from faith-based institutions. There was no significant difference between the training of the healthcare providers and the category of the health facility (X2=0.4155; df= 2; p =

0.8124).

The low proportion of those trained on RVF could be due to the level of priority the majority of the health facilities visited gave to any training in general and RVF in particular. The majority of the healthcare providers in the study area were nurses and clinical officers and these results hence indicate that nurses and clinical officers were 34

not trained in the past one year ahead of a predicted outbreak (Table 4.4). This is not unique to Kenya as the same trend is observed in other parts of the world and in Africa like Tanzania and Malawi are rated last by WHO (WHO 2014). The other cause of minimum training recorded in the study area could be attributed to the priority level

RVF is placed by the Ministry of Health among other diseases in the country, District public office (2009)

World Health Organization recommends that the healthcare provider be trained and curriculum is demand-driven on what services are expected in the region. The current study found that healthcare providers are not very conversant with RVF which occurs in the area. This could lead to RVF related losses being unnoticed or reported in the study area. Similar situation is observed in temperate regions where malaria is not commonly en countered and healthcare providers lack any training on the same. This calls for adaption of WHO guidelines all over the world, WHO (2014).

Table 4.4: Healthcare providers training on detection of RVF

Type of Health Facility No n(%) Yes n(%) Total n(%)

Private 16 (21%) 6 (8%) 22 (29%)

Public/government 34 (45%) 9 (12%) 43 (57%)

Faith-based 8 (11%) 3 (4%) 11 (15%)

Total 58 (76%) 18 (24%) 76 (100%)

Majority of the health care providers58/76 (76%) did not have training on RVF detection in the study area. 35

4.2.3 Healthcare Providers’ Knowledge on When to Expect Cases of RVF

In this study, 34/44 (77%) of the respondents from the government, facilities while

13/18 (72%) from the private and 7/10 (70%) from faith-based facilities knew well when the cases of Rift Valley Fever are likely to be high. This reflects well with the national standards and WHO expected standards whereby the healthcare providers are expected to know when and which diseases are likely to occur in their geographical region. There is no significant difference between the knowledge on when to expect cases of RVF by the healthcare providers and the category of the health facility

(X2=1.6310; df=6; p = 0.9503; Table 4.5). There is no significant difference between the institutions on the knowledge on when to expect high number of cases of RVF. The question aimed at finding out whether the healthcare providers were aware of when to look for the signs and symptoms of RVF in patients attending the health facilities. This agrees with the WHO RVF fact sheet No. 207 (revised 2010) about healthcare providers being knowledgeable of the disease prevalence in their geographical region and how to detect them. The fact is, Rift Valley Fever infections are likely to be high after unusual heavy rains and occur in cycle of 5-15 years (Bird et al., 2009).

36

Table 4.5: Respondents responses on the time cases of RVF are likely to be high

Type of health facility Respondent Government Private Faith-based Total

When high cases of RVF occurs n (%) n (%) n (%) n (%)

January March 3 (7%) 1 (6%) 1 (10%) 5 (7%)

April June 5 (11%) 3 (17%) 2 (20%) 10 (14%)

October December 1 (2%) 1 (6%) 0 (0%) 2 (3%)

After unusual heavy rains 34 (77%) 13 (72%) 7 (70%) 54 (75%)

No response 1 (2%) 0 (0%) 0 (0%) 1 (1%)

Total 44 (100%) 18 (100%) 10 (100%) 72 (100%)

A total of 54 out of 72 (75%) of health care providers were able to associate Rift valley Fever outbreak with unusual heavy rains.

4.2.4 Healthcare Providers’ Knowledge on Economic Importance of RVF

On the question on how the disease affect the economy of the country, this study found that 7/45 (16%) of the respondents could not see any economic impact of the disease from the government and 1/15 (6%) from private institutions and none from the faith- based institutions. The difference in knowledge on the economic importance of the disease by the healthcare providers is not significant between the healthcare facilities in the study area (X2=5.3181, df=6; p = 0.5037; Table 4.6).

The respondents although they are not economist like Esther Schelling and Tabitha

Kimani 62/70 (89%) were able to point out that the disease causes some sort of economical impact to the country, Esther Schelling, et al (2012). 37

Table 4.6: Healthcare providers’ knowledge on the economical importance of RVF

Type of health facility Respondent Government Private Faith-based Total

Economical importance of RVF n (%) n (%) n (%) n (%)

Human death 27 (60%) 9 (60%) 9 (90%) 45 (64%)

Abortion in animals 10 (22%) 5 (33%) 1 (10%) 16 (23%)

Death of new born lambs 1 (2%) 0 (0%) 0 (0%) 1 (1%)

None of the above 7 (15%) 1 (7%) 0 (0%) 8 (11%)

Total 45 (100%) 15 (100%) 10 (100%) 70 (100%)

Economical losses involve human deaths, abortion in animals and deaths.

4.2.5 Healthcare providers knowledge on people most likely to suffer from RVF

On the knowledge about who are likely to suffer from RVF, this study found that animal handlers and butchers are the people most likely to contract and suffer from

RVF (Table 4.7). 4/50 (8%) of healthcare providers from the government facility, 1/23

(4%) from private institutions and 2/11 (18%) had knowledge that they are likely to contract the disease in the course of their duty. These percentages indicate a gap in the knowledge among healthcare providers on who are likely to suffer from RVF. There is no significant difference between the health facilities in the knowledge on who is most likely to suffer from RVF in the study area, (X2=7.7584, df=8; p = 0.4574; Table 4.7).

38

The study found that 70/84 (83%) of the respondents knew who is likely to suffer from

RVF. This compares well with the study carried out by Peter Musyoka Kioko., et al

(2012) in the same area, though his study was on actors in beef industry and food safety.

Table 4.7: Responds knowledge on people most likely to suffer from RVF

People likely to suffer from RVF?

Type of health No Animal Healthcare Forest honey

facility response handlers Butchers providers gatherers Total

n (%) n (%) n (%) n (%) n (%) n (%)

Government 5 (40%) 29 (69%) 10 (45%) 4 (57%) 2 (67%) 50 (93%)

Private 5 (50%) 10 (24%) 7 (32%) 1 (14%) 0 (0%) 23 (27%)

Faith-based 0 (0%) 3 (7%) 5 (23%) 2 (29%) 1 (33%) 11 (13%)

Total 10 (100%) 42 (100%) 22 (100%) 7 (100%) 3(100%) 84 (100%)

Due to the nature of the disease transmission; animal handlers including veterinarians and laboratory staff, butchers, health care providers and forest honey gather are all at risk of RVF infections during an outbreak. 50% (42/84) considered RVF as a disease of animal handlers and 8% (7/84) health care providers knew they were also at risk of contracting the disease.

4.2.6 Healthcare Providers’ Knowledge on Clinical Manifestation of RVF

On the knowledge of clinical manifestation of RVF infection, 43 out of 79 respondents

(54.4%) answered that fever is the main clinical sign. Others cited photosensitivity jaundice, bloody stool, headache and stiffness of neck. Only 16 (20%) who mentioned all of the clinical manifestations had correct knowledge. This means that there is low understanding and knowledge of the RVF disease manifestation. This implies that a lot 39

more needs to be done to raise knowledge among the health workers on detection of

RVF. This is particularly important because it can, to a certain extent, be unrecognized and misdiagnosed for timely management. Only 9 out of 16 were from government, 6 out of 16 private and 1 out of 16 faith-based institutions stated correctly RVF manifestation.

There was no significant difference between the knowledge on clinical manifestation of

RVF by the healthcare providers and the category of the health facility (X2=12.0475, df=12; p = 0.4419; Table 4.8). The low scores could be due to the cadre of the healthcare providers covered in the study, nurses and clinical officers, and maybe RVF is not covered in their training at the college, WHO recommends that health care providers be conversant with health conditions prevalent in their region (WHO 2014).

Table 4.8: Respondents’ knowledge on the clinical manifestation of RVF

Type of health facility Respondent Government Private Faith-based Total

Clinical manifestation of RVF n (%) n (%) n (%) n (%)

Fever 30 (63%) 8 (40%) 5 (45%) 43 (54%)

Photosensitivity 1 (2%) 2 (10%) 2 (18%) 5 (6%)

Jaundice 4 (8%) 2 (10%) 2 (18%) 8 (10%)

Bloody stool 3 (6%) 1 (5%) 1 (9%) 5 (6%)

Headache 1 (2%) 0 (0%) 0 (0%) 1 (1%)

Stiffness of neck 0 (0%) 1 (5%) 0 (0%) 1 (1%)

All of them 9 (19%) 6 (30%) 1 (9%) 16 (20%)

Total 48 (100%) 20 (100%) 11 (100%) 79 (100%) 40

4.2.7 Healthcare Providers’ Knowledge on the Cause of RVF

On the knowledge on the causes of RVF, the healthcare providers were asked a question on the cause of RVF and this study found that 33 out of 80 (41%) knew what causes

RVF. Of these thirty –three who knew the cause of RVF, 23(70%) were from the government, nine (27%) from private and one (3%) from faith-based institutions. There was no significant difference between the knowledge of the cause of RVF by the healthcare providers and the category of the health facility (X2=9.5665, df=6; p=

0.1441; Table 4.9). This compiles well with the study carried out by Shabani., et al

(2015), in Tanzania whereby the study reported that the majority of respondents had heard of RVF. However, only 8.8 % knew that mosquitoes were transmitting vectors.

The gap in the knowledge could be attributed to the nature of the training of the healthcare providers and their lack of refresher courses on zoonotic diseases such as

RVF.

4.2.8 Healthcare Providers’ Knowledge on Control of RVF

On the knowledge on control of RVF this study found that 36/79(46%) respondents mentioned vaccination as a means of control. Of these 20/47 (43%) were from government institutions, 12/21 (57%) private institutions and 4/11 (36%) from Faith- based institutions. Other method included vector control and bush clearing. There was no significant difference between the knowledge on the control of RVF by the healthcare providers and the category of the health facility (X2=6.2810, df=6; p=

0.3925; Table 4.10). There is no proven vaccine for humans thus no mass vaccination of 41

the human population is carried out in the country and farmers vaccinate their animals at free will. (Bird et al., 2009 and CDC RVF Facts sheet 2010).

Table 4.9: Respondents’ knowledge on the cause of RVF

Type of Health facility Government Private Faith-based Total

Cause of RVF n (%) n (%) n (%) n (%)

Virus 23 (47%) 9 (45%) 1 (9%) 33 (41%

Mosquitoes 20 (41%) 10 (50%) 10 (91%) 40 (50%)

Air 3 (6%) 1 (5%) 0 (0%) 4 (5%)

None of above 2 (4%) 0 (0%) 0 (0%) 2 (3%)

No response 1 (2%) 0 (0%) 0 (0%) 1 (1%)

Total 49 (100%) 20 (100%) 11 (100%) 80 (100%)

On what causes RVF; the health care providers appeared to confuse between the mosquitoes and the virus. The fact is; the virus is the cause and it is transmitted by mosquitoes.

Table 4.10: Healthcare providers’ knowledge on control of RVF

Type of health facility Respondent Government Private Faith-based Total

How to control RVF n (%) n (%) n (%) n (%)

Through vaccination 20 (43%) 12 (57%) 4 (36%) 36 (46%)

Vector control 22 (47%) 9 (43%) 6 (55%) 37 (47%)

Bush clearing 4 (9%) 0 (0%) 0 (0%) 4 (5%)

None of the above 1 (2%) 0 (0%) 1 (9%) 2 (3%)

Total 47 (100) 21 (100%) 11 (100%) 79 (100%)

The best method to control RVF is by vector control and quarantine as there is no proven vaccine for humans and animals. 42

4.2.9 Healthcare Providers’ Knowledge on Diagnosis of RVF

On the knowledge on how diagnosis of RVF is carried out, 26/76 (34%) answered

Enzyme Linked Immunobsorbent assay (ELISA), 25/76 (33%) polymerase chain reaction (PCR) and 12/76 (16%) virus neutralization assay, 13 out 76 could not answer to any of the questions provided in the questionnaire. The gold standard test for diagnosis of RVF is viral neutralization test although with advance in technologies,

WHO also recommends ELISA and for those laboratories which can afford molecular tests, PCR. There was no significant difference in the knowledge of healthcare providers and the category of the health facility (X2=9.1928, df=6; p = 0.1630; Table

4.11). The knowledge on diagnosis could be attributed to the lack of training on RVF that was found to be generally low among the health workers interviewed. It could also be attributed to the cadre of the healthcare provider involved in the study given that most of those who were interviewed were nurses and clinical officers who may not have had training on RVF diagnosis.

Acute RVF can be diagnosed using several different methods. Serological tests such as enzyme-linked immunoassay (the "ELISA" or "EIA" methods) may confirm the presence of specific IgM antibodies to the virus. The virus itself may be detected in blood during the early phase of illness or in post-mortem tissue using a variety of techniques including virus propagation (in cell cultures or laboratory animal inoculation), antigen detection tests like viral neutralization and RT-PCR. (WHO;

2010).

43

Table 4.11: Respondents’ knowledge on diagnosis of RVF

Type of health facility Government Private Faith-based Total

How RVF can be diagnosed n (%) n (%) n (%) n (%)

PCR 13 (29%) 6 (30%) 6 (55%) 25 (33%)

ELISA 12 (27%) 9 (45%) 5 (45%) 26 (34%)

Neutralization assay 10 (22%) 2 (4%) 0 (0%) 12 (16%)

None of the above 9 (20%) 3 (7%) 0 (0%) 12 (16%)

No response 1 (2%) 0 (0%) 0 (0%) 1 (13%)

Total 45 (100%) 20 (100%) 11 (100%) 76 (100%)

RVF can be diagnosed in the laboratory by PCR, ELISA or viral neutralization test.

4.2.10 Healthcare Providers’ Training on Management of RVF

This study found that 2/84 (2%) of health care providers in the government institutions and one health care provider in the private had trained on management of RVF. There was no significant difference between the untrained healthcare providers and the category of the healthcare facility (X2=0.5361, df=2; p = 0.7649; Table 4.12). Well- trained personnel is one of the requirements for the facility to be considered to be capable of detection of RVF. The low number of the trained healthcare providers could be due to the levels of the healthcare facilities involved in the study and the priority of the of the disease in the ministry of health listing. There is no much work done on the 44

levels of training of the health profesionals and especily in relation to RVF in the regions where RVF occurs.

Table 4.12: Staff training on RVF management

Type of health facility Response

No response

n (%) Yes n (%) No n (%) Total n (%)

Government 4 (57%) 2 (67%) 44 (59%) 50 (60%)

Private 3 (43%) 1 (33%) 19 (26%) 23 (27%)

Faith-based 0 (0%) 0 (0%) 11 (15%) 11 (13%)

Total 7 (100%) 3 (100%) 74 (100%) 84 (100%)

4.2.11 Healthcare Providers Training in the Past Year

This study found that 29/50 (58%) government facility, 13/23 (57%) Private institution and 6/11 (55%) faith-based institutions had not been trained in the past year prior to anticipated out break. There was no significant difference between the training of the healthcare providers for the past year and the category of health facility (X2=2.9780, df=4; p = 0.5615; Table 4.13) . Continuous training is one of the ways to keep the healthcare providers informed with the current knowledge concerning disease situation in the working region. The study tried to assess whether and where the staff have been trained in the past year.The study found that very few health care providers had been trained in the past one year. The high numbers of the untrained healthcare providers could be due to lack of funds or the trainings are not budgeted for. Seventy six out of 45

eighty four (90%) of the healthcare providers indicated that they wished to understand more about RVF and that they needed training on diagnosis of RVF. Forty six out of fifty (92%) in the public institutions, 22/23 (96%) Private and 8/11 (73%) from Faith- based institutions identified more training on RVF as a priority in their health institutions (Table 4 16). Regular training is required as sited by Bird et al., 2008.

Table 4.13: Where the staff have been trained for the past year

Type of health facility Respondent Government Private Faith- Total

Staff training for the past year based n (%) n (%) n (%)

n (%)

Formal training at national facility 17 (20%) 6 (7%) 5 (6%) 28 (33%)

International Training 1 (1%) 2 (2%) 0 (0%) 3 (4%)

Formal training on-site 3 (4%) 2 (2%) 0 (0%) 5 (6%)

None of the above 29 (36%) 13 (15%) 6 (7%) 48 (57%)

Total 50 (60% 23 (27%) 11 (13%) 84 (100%)

Continuous health education is a very important tool in disease control and eradication.

4.2.12 Challenges Healthcare Providers Face When Managing RVF

On the challenges the healthcare providers face in management of the RVF this study found; lack of skills and knowledge, drugs, protective garments, laboratory equipments and late diagnosis (Table 4.14).

46

Managing RVF at times is challenging since it does not always occur throughout the year and its clinical manifestation can be confused with other infections. WHO recommends that healthcare providers be provided with the right skills, equipment and garments to

handle RVF but due to financial constrains the healthcare providers were lacking specialized skills and equipments for detection of RVF in the study area, during the

2007/08 Bird had to travel to Kenya with equipments and personnel, Bird et al., 2008.

Table 4.14: Challenges healthcare providers faced when managing RVF

Type of health facility Respondent Government Private Faith-based Total

Challenges cited n (%) n (%) n (%) n (%)

No response 14 (28%) 10 (43%) 2 (18%) 26 (31%)

Not come across any case 4 (8%) 1 (4%) 2 (18%) 7 (8%)

No skills/knowledge 18 (36%) 7 (30%) 2 (18%) 27 (32%)

No drugs 5 (10%) 1 (4%) 2 (18%) 8 (10%)

No protective garments 0 (0%) 3 (13%) 2 (18%) 5 (6%)

No management guidelines 5 (10%) 0 (0%) 1 (9%) 6 (7%)

Lack of Lab. Equipments 2 (4%) 1 (4%) 0 (0%) 3 (4%)

Late Diagnosis 2 (4%) 0 (0%) 0 (0%) 2 (2%)

Total 50 (100%) 23 (100%) 11 (100%) 84 (100%)

Health care providers are met with challenges in the course of their duty and when handling RVF outbreak the challenges range from lack of skills and protective clothing to lack of laboratory diagnostic systems. 47

4.2.13 Addressing Challenges Healthcare Providers Face in Diagnosis of RVF

This study found that referrals to higher level health facilities, on job training, cost sharing, improving available resources and facilities, educating the community, others do not attempt to make diagnosis for fear of contracting the disease. As the ways of addressing the challenges they face in diagnosis of RVF (Table 4.15). According to

WHO (2010), community education is one of the strategies in the containment and control of RVF infections.

Table 4.15: Addressing challenges healthcare providers face in Management of

RVF

Type of health facility Respondent Government Private Faith- Total

Addressing challenges in RVF based n (%) n (%) n (%)

n (%)

Referrals 13 (50%) 5 (50%) 6 (86%) 24 (56%)

On job training 10 (38%) 2 (20%) 1 (14%) 13 (30%)

Cost sharing 1 (4%) 1 (10%) 0 (0%) 2 (5%)

Improving available materials 1 (4%) 1 (10%) 0 (0%) 2 (5%)

Others * 1 (4%) 1 (10%) 0 (0%) 2 (5%)

Total 26 (100%) 10 (100%) 7 (100%) 43

(100%)

24/43 (56%) considered referrals as the best alternative to addressing the challenges related to RVF. Others* =No attempt to make diagnosis and Educate the community)

48

4.2.14 Additional Information Shared by Healthcare Providers

On additional information 76/84 (90%) of the healthcare providers indicated that they wished to understand more about RVF and that they needed training on diagnosis of

RVF. 46/50 (92%) in the public institutions, 22/23 (96%) Private and 8/11 (73%) from

Faith-based institutions identified more training on RVF as a priority in their health institutions (Table 4 16).

Table 4.16: Additional information shared by healthcare provider

Type of health facility Respondent Government Private Faith-based Total

Additional information shared n (%) n (%) n (%) n (%)

understand more on RVF 33 (66%) 17 (74%) 5 (46%) 55 (65%)

Training on diagnosis 13 (26%) 5 (22%) 3 (27%) 21 (25%)

Nothing 4 (8%) 1 (4%) 3 (27%) 8 (10%)

Total 50 (100%) 23 (100%) 11 (100%) 84 (100%)

Training was singled out as a gap by the health care providers.

4.3: Laboratory Facilities in the Healthcare Institutions

During this study, health institutions were visited to find out the types of facilities that were available in the study area in relation to RVF diagnosis. The health care providers were asked what they considered as an ideal facility for diagnosis of RVF. The response among the choices of hospital, laboratory and well trained staff were 44/79 (58%) from the government facilities, 22/79 (29%) from private institutions and 10/79 (13%) from 49

faith-based institutions. There was no significant difference between what the health care providers considered ideal for RVF diagnosis and the category of health facility.

(X2=3.5069, df=6; p = 0.7430; Table 4.17).

For diagnosis of RVF to take place several things have to be in place. These include hospitals and health centers laboratories and skilled health care providers with working equipment. The prescribed test for RVF by WHO and CDC includes immuno assays, viral isolation and identification and molecular assays (WHO 2010). For the purpose of the study, the items and materials for carrying out prescribed tests for RVF laboratory confirmation were evaluated using a checklist (Table 4 16).

Table 4.17: Types of health facilities for diagnosis of RVF

Type of health facility Government Private Faith-based Total

Health facilities for RVF n (%) n (%) n (%) n (%) diagnosis

Hospital 13 (28%) 9 (41%) 4 (40%) 26 (33%)

Laboratory 24 (51%) 7 (32%) 4 (40%) 35 (44%)

Well-trained staff 7 (15%) 5 (23%) 2 (20%) 14 (18%)

None of the above 3 (6%) 1 (5%) 0 (0%) 4 (5%)

Total 47/79(59%) 22/79(28%) 10/79 (13%) 79/79 (100%)

Findings Inadequate Inadequate Inadequate Adequate

50

4.3.1 Source of Laboratory Reagents

Commercial supplies was reported in 34/38 (89%) in the government facilities as the main source of the laboratory reagents 56/64 (88%) in all health facilities in the study area (Table 4.18). There was no significant deference between the procurement processes and the category of the healthcare facility (X2=4.1092, df=4; p = 0.3914;

Table 4.16). The sources of diagnostic reagents are of paramount importance in correct and reliable diagnosis of infections in the laboratory. Different reagents and protocols usually lead to variation in the results obtained in the different laboratories. The high preference of commercial supplies indicates that there is usually money set aside for sourcing of laboratory reagents and may be if the reagents for RVF could be include in the procurement plan then RVF could be done in the available laboratories. WHO recommends sourcing laboratory reagents from reputable institutions (WHO 2014).

Table 4.18: Source of laboratory Reagents

Type of health facility Government Private Faith-based Total

Sourcing of laboratory n (%) n (%) n (%) n (%) reagents

Commercial suppliers 34 (89%) 13 (86%) 9 (82%) 56 (88%)

From another lab 4 (11%) 1 (7%) 2 (18%) 7 (11%)

Prepared in house 0 (0%) 1 (7%) 0 (0%) 1 (1%)

Total 38/64 (59%) 15/64 (23%) 11/64 (17%) 64/64 (100%)

Findings Inadequate Inadequate Inadequate Inadequate

51

4.3.2 Facilities Capacity for RVF Detection

This study finding was calculated in percentages and the percentages were used to determine the capacity as adequate or inadequate and the scores were; (37%) Public,

(32%) private and (37%) faith-based. The cutoff used for categorization was 70%. All the three categories did not have adequate facilities to detect RVF infection as per the

WHO RVF facts Sheet No 207 of 2005 in the study area (Table 4.19).

The health facility capacity to detect RVF infections was summarized in terms of whether the facility carries out virological tests; has a space set aside for laboratory analytical work, source laboratory reagents; availability of equipment like autoclave, cold storage facility, centrifuge, warm air incubator and biosafety cabinet.

Fifty-one percent of the government facilities have a laboratory space in place and 89% source their laboratory reagents commercially; this translate that there is funds set aside for the purchase of laboratory reagents and its possible to source reagents for RVF detection (Bird et al., 2008).

4.3.3 Medical Waste Disposal

The study found that; 29/43 (67%) of government facilities had incinerators and answered that incineration was the method of choice for disposing off RVF contaminated materials. Out of 20 respondents from the private facilities, none considered burial as a way of disposal yet it’s a fact that dead people are buried in the study area. There was no significant difference between the availability of medical 52

waste system and the category of the healthcare facility (X2=5.9409; df=4; p= 0.2036;

Table 4.20). Proper and recommended disposal of medical waste capacity is one of the requirements for a healthcare provider facility. Medical waste is disposed off through autoclaving, incineration and burying in deep pits. Private and faith-based institutions did not have adequate medical waste disposal system. Public health Act Chapter 242

Revised Edition 2012 [1986] and Published by the National Council for Law Reporting with the Authority of the Attorney recommends containment of and appropriate disposal of all waste generated by the health facilities.

4.3.4 Availability of Power and Backups in the Health Facilities

This study found that 8% of Government, 22% of private and 36% of faith-based institutions had power backup (Table 4.21). The overall power backup in the study area was 13/49 (26%) The availability of electricity in the health facility is one of the requirements in a health facility carrying out laboratory procedures to confirm the presence or absence of pathological agents in samples. The power backup maintains constant power especially when running laboratory tests and storage of laboratory reagents and standards for consistence reproducible and reliable laboratory results. The low percentage in the government institutions could be due to the distribution and establishments of the facilities deep in rural areas while the private and faith-based facilities were e more in towns where the population density is high and can afford to pay for the services.

53

Table 4.19 Facilities capacity for RVF detection

Type of health facility Government Private Faith-based Findings

Facilities capacity for n (%) n (%) n (%) RVF detection Performing 4/50(8%) 3/23(13%) 3/11(27%) Inadequate Virological tests Inadequate Inadequate Inadequate Laboratory 24/47(51%) 7/22(32%) 4/10(40%) Inadequate Availability Inadequate Inadequate Inadequate Autoclave 15/50(30%) 7/23(30%) 3/11(27%) Inadequate Availability Inadequate Inadequate Inadequate Commercial Reagent 34/38(89%) 13/15(86%) 9/11(81%) Adequate Procurement Adequate Adequate Adequate Coldstorage 26/50(52%) 11/23(48%) 7/11(63%) Inadequate Availability Inadequate Inadequate Inadequate Centrifuge 29/50(58%) 8/23(35%) 4/11(36%) Inadequate Availability Adequate Inadequate Inadequate Availability of warm 1/50(2%) 2/23(8%) 0/11(0%) Inadequate air incubator Inadequate Inadequate Inadequate Availability of 2/50(4%) 0/23(0%) 2/11(18%) Inadequate biosafety cabinet Inadequate Inadequate Inadequate Findings 294/8(36.75%) 252/8(31.5%) 292/8(36.5%) Inadequate

Inadequate Inadequate Inadequate

Health facilities just like health professionals have to score over 70% to be considered capable of carrying out health related services. Most of the health facilities lacked in one way or the other, thus considered as inadequate.

54

Table 4.20: Availability of RVF contaminated materials disposal system

Type of health facility Government Private Faith-based Totals

Method of Medical n (%) n (%) n (%) n (%) Waste Disposal

Autoclaving 5 (12%) 4 (20%) 1 (9%) 10 (14%)

Incineration 29 (67%) 16 (80%) 9 (82%) 54 (73%)

Burial 9 (21%) 0 (0%) 1 (9%) 10 (14%)

Total 43/74 (58%) 20/74 (27%) 11/74 (15% 74/74 (100)

Findings Inadequate Inadequate Inadequate Adequate

Table 4.21: Availability of backup power source in case of power failure

Emergency generator availability

Yes No Total Adequate or Inadequate Type of health

facility n (%) n (%) n (%) n(%)

Government 4 (31%) 26 (72%) 30 (61%) 4/30(13.3%) Inadequate

Private 5 (38%) 7 (19%) 12 (24%) 5/12(41.7%) Inadequate

Faith-based 4 (31%) 3 (8%) 7 (14%) 4/7 (57.1%) Inadequate

Total 13 (100%) 36 (100%) 49 (100%) 13/49 (26%) Inadequate

4.3.5 Availability of Operational Hazardous Medical Waste Disposal System

This study found that (45/66) 68% hazardous waste disposal systems were not operational in the study area over all. In the government institutions, there were (23/40) 55

58%, private (15/18) 83% and faith-based (7/8) 88% of the facilities were non operational (Table 4.22). Medical waste disposal is one of the measures the health facilities undertake to save guard the environment against contamination with infectious or toxic waste. The difference in the private and faith-based institutions could be some of the facilities were affiliated to government institutions for medical waste disposal; however the waste disposal systems were far below average.

Table 4.22: Availability of Operational hazardous Medical waste disposal system

Operational hazardous waste disposal system

Type of health No Yes Total Adequate/Inadequate

facility n (%) n (%) n (%) n(%)

Government 23 (34%) 17 (26%0 40 (60%0 17/40 (43%) Inadequate

Private 15 (23%) 3 (5%) 18 (28%) 3/18(17%) Inadequate

Faith-based 7 (11%) 1 (2%) 8 (13%) 1/8 (13%) Inadequate

Total 45 (100%) 11 (100%) 66 (100%) 11/66 (17%) Inadequate

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CHAPTER FIVE: CONCLUSIONS AND RECOMMENDATIONS

5.1 Conclusions

From the findings of this study the following conclusions have been arrived at according to the study objectives.

(i). The healthcare providers in Maragua, Murang’a County are lacking in

the knowledge, equipment and garments to handle RVF. There was low

level of training on RVF detection in all the healthcare facilities

evaluated in study area. The government facilities had the lowest at 21%

whiles the private and faith-based had 27% each.

(ii). All the healthcare institutions evaluated in this study did not have

adequate facilities to diagnose RVF applying recommended tests for the

disease; government 35%, private 31% and faith-based 24%, these

scores are all below average of 50% and even far below the 70%

recommendation by WHO. Thus, the capacity is not in place to detect

RVF infections in Maragua, Murang’a County

(iii). The resultant of poor knowledge and capacity to detect RVF can lead to

undetected out breaks, loss of lives and livelihoods to the community of

the affected area.

5:2 Recommendations

(i). There is need to train and equip the healthcare providers with knowledge

and equipment to handle all aspects of RVF infections in the county. 57

This should be accompanied by follow-ups to build on the skills and

information impacted with the aim of developing local experts on RVF.

(ii). The Ministry of Health should improve and equip health facilities with

laboratories, test kits and power back-ups for RVF diagnosis with the

aim of serving local communities within reach.

(iii). It is recommended that Medical Training Institutes in Kenya adopt

training on RVF detection and diagnosis in the training curricula

5.3: Areas for Further Research

Studies should be undertaken in other high-risk counties to find out the status and

increase understanding and the level of preparedness of RVF in case outbreak.

58

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Veterinary Epidemiology and Economics Unit (VEEU) and ILRI (2008) Socioeconomic studies on RVF, Department of Veterinary Services Records.

Vialat, P., Billecocq, A., Kohl, A. and Bouloy, M. (2000). Attenuated Rift Valley Fever Virus: human and veterinary vaccine applications A licensing opportunity D1 99/75. Journal of Virology, 74(3):1538-1543.

Weiss, K.E. (1957). Rift Valley Fever – a review. Bulleting of Epizootic. Diseases in Africa, 5: 431–458.

Whitehouse, (2004). Replication cycles of viruses in the family Bunyaviridae.

WHO (2000). Development of a plan of action to strengthen laboratory capacity for surveillance. Laboratory Assessment Tool.

WHO (2014) Global atlas of health work force.

WHO RVF facts sheet (2010). RVF facts sheet No 207. 64

APPENDICES Appendix 1: Map of the Study Area

Map of Kenya showing the study area, old Maragua District which has now been divided into Kigumo, Kandara and Murang’a south Divisions (Source: Veterinary Epidemiology Unit, Kenya, 2008, Peter et al 2012).

65

Appendix 2: List of health facilities visited in study area

(Kigumo Kandara and Murang’a South Districts) Health

No of Healthcare Provider Presence of facility

Health Facility Name Respondents Category Laboratory Affiliation

1. Ichagaki Mission Health Clinical officer and

Centre 2 Administrator Yes FBO

2. Ruchu Catholic Dispensary 1 Nurse Yes FBO

3. AIC Githumu Mission

Hospital 3 Clinical Officer Yes FBO

4. Gaichanjiru Mission 2Nurses 1 Clinical

Hospital 3 officer Yes FBO

5. ACC and C Gituru

Dispensary 2 Nurse Yes FBO

6. Mariira Catholic

Dispensary 1 Clinical Officer Yes FBO

7. ACC and C Tata Hannah

Dispensary 1 Nurse Yes FBO

8. P.C.E.A. Muthithi

Dispensary 1 Clinical Officer Yes FBO

3Clinical officer 1

9. Maragua District Hospital 4 doctor Yes GoK 66

10. Kianjugu Dispensary 1 Nurse Yes GoK

11. Kamahuha Dispensary 1 Nurse Yes GoK

12. Gitathi Dispensary 1 Nurse No GoK

13. Kaharo Dispensary 1 Nurse No GoK

14. Maragua Ridge Health

Centre 1 Nurse Yes GoK

15. Makuyu Health Centre 1 Nurse No GoK

16. Maranjau Prison

Dispensary 1 Nurse No GoK

17. Katipanga Dispensary 1 Nurse Yes GoK

18. Mihango Dispensary 1 Nurse Yes GoK

19. Kambiti Dispensary 1 Nurse Yes GoK

20. Gikono Dispensary 1 Nurse Yes GoK

21. Muruka Dispensary 2 Nurse No GoK

22. Naaro Dispensary 1 Nurse Yes GoK

23. Ngararia Dispensary 1 Nurse Yes GoK

24. Kandara Health Centre 3 Nurse Yes GoK

25. Gacharage Dispensary 1 Nurse Yes GoK

26. Kaguthi Dispensary 1 Nurse Yes GoK

27. Gichagi-ini Dispensary 1 Nurse No GoK

28. Maria-ini Dispensary 1 Nurse Yes GoK

29. Nguthuru Dispensary 1 Nurse No GoK 67

30. Kagumo -ini Dispensary 1 Nurse Yes GoK

31. Githunguri Dispensary 1 Nurse Yes GoK

32. Muthithi Dispensary 1 Nurse Yes GoK

2Clinical officers 1

33. Kigumo Health Centre 3 nurse Yes GoK

34. Gatia-ini Dispensary 1 Nurse No GoK

35. Mairi Dispensary 1 Nurse Yes GoK

2Nurses1Clinical

36. Kangari Health Centre 3 officer Yes GoK

37. Kanderedu Dispensary 1 Nurse Yes GoK

38. Mununga Health clinic 1 Nurse No GoK

39. Gikoe Dispensary 1 Nurse Yes GoK

40. Mugumo-ini Dispensary 1 Nurse Yes GoK

41. Turuturu Dispensary 1 Nurse Yes GoK

42. Irigiro Health centre 1 Nurse Yes GoK

Nurse Clinical

43. Sabasaba Health Centre 2 officer Yes GoK

44. Kagundu-ini Dispensary 1 Nurse Yes GoK

45. Kariti Dispensary 1 Nurse Yes GoK

46. Kariua Dispensary 1 Nurse Yes GoK

47. Mutheru Dispensary 1 Nurse Yes GoK

48. Mukoe Dispensary 1 Nurse No GoK 68

49. Neema Medical Clinic 1 Nurse No Private

50. Kwa Ng'ang'a Medical

Clinic 1 Nurse No Private

51. Kenol Hospital 2 Nurse and doctor Yes Private

52. St. Pauline Medical Service 1 Nurse Yes Private

53. Sarmer Medical Clinic 1 Nurse No Private

54. Watony Private Clinic 1 Nurse No Private

55. Woodpark Medical clinic 1 Nurse Yes Private

56. Roadside Medical Clinic 1 Nurse No Private

57. Rose Medical clinic 1 Nurse Yes Private

58. Solea Medical 1 Nurse yes Private

59. Provide Medical Centre 1 Nurse Yes Private

60. Tewas Medical Clinic 1 Clinical Officer No Private

61. Njambu Medical Clinic 1 Nurse No Private

62. Kamukabi Medical Centre 1 Nurse No Private

63. Emmaus Clinic 1 Nurse Yes Private

64. Sannka Medical clinic 1 Nurse Yes Private

65. Kamunyaka Medical Clinic 1 Nurse Yes Private

66. ACC and C Kariua

Dispensary 1 Nurse Yes Private

69

Appendix 3: Research Permit

Research Permit from the National Council for Science and Technology in the

Ministry of Higher Education 70

Appendix 4: Letter of Research Authorization

Research Authorization Letter from Office of the President Murang’a South

71

PLATES

Plate 1: A route map of the study area: Kigumo, Kandara and Murang’a South Districts.

Kigumo, Kandara and Murang’a south by road.

Plate 2: Medical waste disposal in one of the health facilities visited.

The inside of a medical waste disposal incenerator with a rised platform to ensure complete burning of the waste. 72

Plate 3: An Improvised Deep pit medical waste in one of the health facilities.

Plate 4: A waste Disposal at a back yard of a shopping centre where one of the health facilities was located.

The disposed medical waste is not properly done and can be a source of infection to the public. 73

Plate 5: Medical waste disposal system in one of the health facilities in the study area.

Plate 6: Medical waste disposal by incineration found in one of the health facilities.

A proper waste disposal system where all the waste is burned and the smoke dispersed high in the sky. 74

Plate 7: A modern and molecular diagnosis system at one of the RVF testing laboratories in Nairobi.

A simple and morden equipment like this one can be used in the health facilities for quick diagnosis of RVF. 75

Appendix 5; DATA COLLECTION TOOLS

Data collection instrument DATA COLLECTION TOOLS QUESTIONNAIRE FOR HEALTH CARE PROVIDERS; Maragua Stephen Gacheru [email protected]

I will ask you some questions to assess your level of knowledge on Clinical Diagnosis of RVF. Please note that this is not in any way aimed at assessing your competence but just to give an understanding of the awareness levels about RVF among health care providers.

PART I: BACKGROUND INFORMATION 1. Name of the Health facility ………………………………………………………………. 2. Address of the Health facility ……………………………………………………………… 3. Telephone/fax/e-mail…………………………………………………………………………. 4. Contact Person ……….……………………………………………………………………………… 5. Level of the Health facility (tick as appropriate) 1. District hospital 2. Sub-district hospital 3. Health center 4. Dispensary 5. Health facility (tick as appropriate) 1. Public/government institution 2. Private institution 3. Academic institution 4. Non-governmental organization (NGO) 5. Religious institution

RESPONDENT CHARACTERISTICS

6. Name of health care provider …………………………………………………………………….……… 7. Contact………………………………………………………………………………………………….

7. Gender of health care provider …………………………………………………………………

8. Position held in the 1. In-charge of facility e.g. MoH (please specify)…………….…………………. health facility 2. In-charge of a unit e.g. Lab etc (please specify)…………….………….……… 3. Other (specify)………….……..……………………………………………….. 9. Cadre of the health 1. Doctor provider (tick as 2. Clinical officer appropriate) 3. Nurse 4. Lab technologist/technician 5. Other (specify)………………………………………………………………… 10. Education level 1. University 2. College/tertiary education 3. At least secondary 4. Other (specify)…………………………………………………………… 76

PART II: HEALTH CARE PROVIDERS’ TRAINING & KNOWLEDGE ON RVF 11. Have you received training on how to detect/diagnose Rift Valley Fever? 1. Yes 2. No

12. What kind of training do you have? 1. Up to degree level (Please specify) 2. Diploma 3. Certificate 4. On-job training 5. Other (specify)………………………………………… 13. When are the cases of Rift Valley 1. April June Fever likely to be in high? 2. January March (tick as appropriate) 3. October December 4. After unusually heavy rains 5. Others (specify)………………… 14. What is the economical importance of 1. Human deaths Rift Valley Fever (RVF)? 2. Abortion in animals (tick as appropriate) 3. Deaths of new born lambs 4. None of the above 15. Who are likely to suffer from RFV? 1. Animal handlers (tick as appropriate) 2. Butchers 3. Health care providers 4. Forest honey gatherers 5. Others (specify)…………………………… 16. What is the clinical manifestation of 1. Fever RVF? (tick as appropriate) 2. Photosensitivity 3. Jaundice 4. Bloody stool 5. Headache 6. Stiffness of neck 7. All of them 8. Other (specify)……………………….. 17. RVF is transmitted by (tick as 1. Virus appropriate) 2. Mosquitoes 3. Air 4. None of the above 5. Others (specify)………………………… 18. How can RVF be controlled? 1. Through vaccination 2. Vector control 3. Bush clearing 4. None of the above 5. Others (specify)……………………… 19. How can RFV be Diagnosed 1. Polymerase Chain Reaction (PCR) (tick as appropriate) 2. Enzyme Linked Immunobsorbent Assay (ELISA) 3. Neutralization assay 4. None of the above 5. Others (specify)………………………………. 20. Where is the world reference 1. South Africa laboratory for RVF? 2. USA (tick as appropriate) 3. Germany 4. Kenya 5. Others (specify)…………………………….………..

77

PART III: HEALTH CARE PROVIDERS’ CAPACITY TO DETECT, DIAGNOSE AND MANAGE RVF 21. What health facilities are in place for diagnosis of 1. Hospital RVF? 2. Laboratory (You can tick more than one) 3. Well trained staff 4. Working equipments 5. None of the above 6. Others (specify)………………………………… 22. How do you recruit your staff? 1. Through interviews (tick as appropriate) 2. Direct employment from colleges and universities 3. Direct from school then on job training 4. Others (specify)……………..………………….. 23. How do you procure your laboratory Reagents? 1. Commercial supplier (tick as appropriate) 2. From anther laboratory 3. Prepared in-house 4. Others (specify)……………………………… 24. What is the source of water for diagnosis work? 1. Deionized (tick as appropriate) 2. Distilled 3. Tap water 4. All of the above 5. Others (specify)………………………… 25. What is the source of power for the facility? 1. Generator (tick as appropriate) 2. Solar 3. KPLC 4. Others (specify)…………… …………………… 26. How are the samples and materials contaminated 1. Autoclaving with RVF disposed? 2. Incineration (tick as appropriate) 3. Burial 4. Send to another facility 27. Has any staff been trained on RVF management? 1. Yes 2. No 3. If Yes How many……………………………………………….. 28. Where has the staff been trained for the past year? 1. 1Formal training at national facility (tick as appropriate) 2. 2Formal training on-site 3. 3International training 78

4. 4None of the above.

29. What other diseases are diagnosed in the facility? 5. Malaria (tick as appropriate) 6. Yellow fever 7. Typhoid 8. Others (specify)… …………………………. 30. What protective clothing is in place? 1. Gloves (tick as appropriate) 2. Lab coats 3. Safety glasses 4. Others (specify) ………………………………

PART IV: CHALLENGES FACED BY HEALTH CARE PROVIDERS IN DIAGNOSING AND MANAGING RVF 31. What challenges do you face in …………………………………………………………………………… diagnosing RVF? …………………………………………………………………………… Please Explain ……………………………… 32. What challenges do you face in ……………………………………………………………………… the management of RVF? Please explain 33. Are there any other challenges? …………………………………………………………………………… Please explain ……………………………………………………………………………

PART V: HOW HEALTH CARE PROVIDERS DEAL WITH THE CHALLENGES 34. How do you address the …………………………………………………………………………………… challenges faced in …………………………………………………………………………………… diagnosing RVF? …………………………………………………………………………………… Please explain ……………………………………………………………………………..… 35. How do you address the …………………………………………………………………………………… challenges faced in the …………………………………………………………………………………… management of RVF? …………………………………………………………………………………… Please explain ………………………………………………………………………………… 36. How do you address …………………………………………………………………………………… these other challenges? …………………………………………………………………………………… Please explain ……………………………………………………………………………………. 37. Is there any additional information that you would like to add or share with me? …………… THANK YOU FOR YOUR TIME 79

Assessment Tool for Health Facility General Information

 11Name of the Health facility ……………………………………………………………….  2Address of the Health facility …………………………………………………………….

 3Telephone/fax/e-mail………………………………………contact person…………………………

 4 Level of the Health facility (i). District hospital (tick as appropriate) (ii). Sub-district hospital (iii). Health center (iv). Dispensary  5Health facility 1. Public/government institution (tick as appropriate) 2. Private institution 3. Academic institution 4. Non-governmental organization (NGO) 5. Religious institution

Building facilities and utility services

 6Does the laboratory perform tests for:

(i). Virology Yes No

(ii). Cell culture facility? Yes No

 7What percent of the working day are the following facilities available?

(i). Electricity <50% 50-95%

95-100% (ii). Running water <50%

50-95% 95-100% (iii). Gas (including bottled) <50%

80

50-95%

95-100%

 8 Is there a back-up power source in case of power failure

(e.g. emergency generator)?

 9 If yes, what systems are protected? (tick Yes or No)

(i). Refrigerators/freezers ………………… Yes No

(ii). Ventilation/AC ……………………… Yes No

(iii). Computers…………………………… Yes No

(iv). Other ………………………………... Yes No N/A

 10What ventilation is provided? …………………………………………

(i)Windows Yes No

(ii)Electrically-powered ventilation (exhaust, not fans) system or Yes No air-conditioning

(iii)Others (Specify)………………………………………………..

Laboratory equipment Check list

11Type and number of items available in the Present Number laboratory

1. Refrigerator Yes No 2. Freezing at –20°C Yes No

3. Freezing at –70°C Yes No

4. Microscope with oil-immersion objective Yes No

5. Scale or balance Yes No

6. Adequate glassware for media preparation Yes No

(flasks, graduated cylinders, etc.)

7. Wash bottles Yes No

81

8. pH paper Yes No

9. pH meter Yes No

10. Manual pipettes (e.g. Eppendorf) Yes No

11. Water distillation system Yes No 12. Low-speed centrifuge (hand or electrically Yes No

powered)

13. Autoclave - manually controlled Yes No

14. Autoclave - electrically controlled Yes No

15. Hot air oven Yes No

16. Inverted microscope Yes No

17. Fluorescent microscope Yes No

18. Electron microscope Yes No

19. ELISA plate reader Yes No

20. Electrically-powered water bath Yes No

21. Warm air incubator Yes No

22. CO2 incubator Yes No

23. CO2 tanks Yes No

24. Liquid nitrogen storage Yes No

25. ELISA washer Yes No

26. Safety cabinet- level 1 (operator protection. Yes No

Open-fronted, unrecirculated airflow away

from operator)

27. Safety cabinet- level 2 (protects operator Yes No

and material from contamination. Open

fronted, filtered supply and exhaust air)

28. Safety cabinet- level 3 (protects operator, Yes No

material and environment from 82

contamination-enclosed, negative pressure,

HEPA filtered air supply and exhaust)

29. Is all equipment functioning? (Ask this Yes No

question after each equipment item, if

response is NO, record below)

If no, what items of equipment are not functioning?

Health facility Inspection check List

The health facility will be inspected and the following form completed. One will be courteous by first

asking permission to open refrigerators, freezers, media storage closets and incubators to examine items

contained therein. Some of the information collected during a walk-through will be used to verify

information provided on the questionnaire. Additional notes will be made as required, e.g. general

cleanliness and organization of the health facility, staff activity level, workload (specimens and assays

in process). Copies of standard forms where indicated will be obtained.

Equipment and reagents

37. Briefly look to see if reported number and type of equipment Yes No

items is consistent with those reported on the questionnaire.

Are findings generally consistent with responses above?

Inspect equipment to see if performance indicators (e.g., temperatures) are regularly recorded

38. Equipment Sheet present Temps. Recorded (per cent

item complete)

39. Refrigerators Yes No 0%

1-50%

>50% 40. Freezers Yes No 0%

1-50%

83

>50%

41. Incubators Yes No 0%

1-50%

>50% Inspect prepared reagents, dehydrated media, antibiotic susceptibility disks and prepared

media to see if dates are recorded for the date prepared or opened and to see if expiration dates

have passed.

42. Proportion of reagents labeled appropriately? None

<50%

>50%

43. Expiration dates found? None

<50%

>50% 44. For reagents with dates - percent outdated? None

<50%

>50%

Inspect media, both prepared and dehydrated, and reagents for signs of deterioration, e.g.

drying and discoloration

45. Deterioration noted in media None

< 50%

>50% Safety

46. If biosafety hood is present, is it operational? Yes No

No hood

47. Is a certification/inspection sticker present? Yes No

Not applicable

84

48. If yes, date of certification? < 1 year

>1 year

Not applicable

Inspect laboratory for presence of biosafety equipment (gloves, sharps containers, safety glasses)

49. Gloves present Yes No

50. Sharps containers Yes No

51. What proportion of staff are wearing gloves while performing <1-50%

procedures? >50%

None Unknown

52. Inspect equipment used for the disposal of biological wastes, Yes No

e.g. autoclaves, incinerator. Is the hazardous waste disposal

system operational?

THANK YOU FOR YOUR TIME