Gerard asked me
to write a brief description of what I do at work. This won’t be nearly as interesting as his travels, but I’ll give
it a go.
A bit of background first. I’m working for the US Centers for Disease Control and Prevention who are collaborating with the Kenya Medical Research Institute (KEMRI) here in Kenya. CDC’s been working in western Kenya for quite some time but it’s only in the last few years that the field station has really grown. We now have about 120 employees at the main office (mostly data entry clerks and lab people) and then an additional 100 employees in the “field”, along with over 350 casual staff. There are always numerous projects on-going at the field station, but the largest project right now is the one I’m working on.
In 1996, CDC got
some money from the US Agency for International Development to evaluate the
impact of insecticide-treated bednets on child mortality. Malaria is a huge problem in Africa,
infecting somewhere around 350 million people and killing between 1-2 million
each year, mostly children < 5 years old.
The battle against malaria has been waged for centuries now but not only
have we made very little progress, but the disease seems to be taking hold in
new areas these days (such as the African highlands, where I did my PhD
research). They’ve tried numerous
approaches to preventing malaria but without much success. Bednets have been used for some years now as
a personal protection measure, but it was only in the last decade or so when it
was found that the nets could be dipped in insecticide so they would not just
protect the sleepers but also kill mosquitoes and thereby protect others that
the idea of using insecticide-treated bednets (ITBNs) really took off.
To date, several
studies have shown ITBNs to have a strong protective effect against malarial
illness as well as all-cause child mortality.
These studies have shown a reduction in mortality of 30-60% in children
using nets. However, most of the
randomized studies, the ones best suited to answering the question of whether
ITBNs are an effective intervention, were done in areas of low or seasonal
transmission rather than areas with intense transmission year-round. This is important because of the immunity
factor.
Sorry – more
background. Kids die from malaria
mostly between the ages of 6 months and 1 year. This occurs because it’s the time when maternal protection is
waning and the children haven’t yet developed any immunity of their own. After surviving 1 or 2 bouts of malaria,
most children are protected from dying.
They get sick but they don’t usually die. By the time they’re adults, their immunity to malaria has
developed to such a degree that when they are infected with malaria it is
generally just a mild illness. However,
in areas of seasonal transmission, the mosquito bites that children receive are
generally concentrated during 2-3 months of the year. They can get a massive inoculation of parasites in those bites
but the bites are not spread out evenly throughout the year, which is more the
case in an area of perennial transmission.
Infections that occur all at one time may not result in the same level
of immunity as receiving those bites spread out at intervals. So ITBNs might work in an area of seasonal
transmission where people do not develop the same degree of immunity as in
areas of year-round transmission, whereas in areas where people develop
immunity fairly quickly, ITBNs may reduce their immune levels and thus put them
at greater risk of malaria.
So CDC got this
money and started the first randomized trial of ITBNs in an area of intense,
perennial transmission in 1996-97. This
study went on for 2 years and wrapped up in 1999. The findings are still being analyzed but it looks as if bednets
had a similar impact on mortality and morbidity in western Kenya as they did
elsewhere.
However, there
is still a question about the benefits of long-term use of bednets. The reason for these questions is related to
the discussion above. If you prevent
children from receiving infectious bites during their early years when they
would normally be developing immunity to malaria, perhaps over time you put
them at more risk for malaria. So we
are now continuing the original bednet study to look at the long-term impact of
bednets on child mortality and morbidity.
So what do
you really DO on a daily basis, Kim?
I was getting to
that! We have a lot of activities
on-going and I’m basically coordinating them, sometimes initiating them or
cleaning up after them. My first work
was with the passive surveillance system for malaria which we are running. We are trying to monitor malaria levels over
time to compare the groups that have had nets for at least 2 years and those
that received nets 1 year ago. So we
have staff (about 12) who sit at 7 health facilities in our study area and wait
for patients to come in. When mothers
bring their sick children, our staff interview them to find out what symptoms
they’ve been experiencing, whether they use a net and what the clinician
diagnoses them with. This system
doesn’t require that much maintenance as it’s been on-going for several years.
Then in May-June
I organized what we call a cross-sectional survey (i.e. we gather together a
large number of children at once and measure lots of things, like parasitemia
status, height, weight, hemoglobin, etc.).
We had to relocate about 1350 children who had been seen in a similar
survey the year before. It’s not always
easy to find people here: they move about a lot and tracing them can be
difficult. We managed to relocate all
but about 150 of them (who had moved outside of the study area). We had a crew of about 40 people working on
this survey. I had to make sure that we
had a good questionnaire(s), sufficient supplies and medicines (because we
treat all sick children), transportation, etc.
Logistically it was a pain in the butt but overall the whole thing went
really well. I can’t take any credit
for that, unfortunately. The staff we
have have participated in a similar study for the last 3 years so they have the
procedures down like clockwork.
Now I am
involved in helping out the bi-annual census we conduct. This census is an absolute nightmare. First, as I said, people move a lot. They move away and then they move back. They move from house to house within a
compound. The spelling of their names
changes frequently. And we have
inherited a terrible data entry system that has made data entry extremely slow
and full of errors. And most of our
field staff have had very limited education.
I’m involved in re-designing the forms to try and minimize the problems
we have in the past and I’m trying to develop a system to track people who move
between villages.
Okay, this is
getting boring. The other mundane
things I do are sign time cards, verify lunch allowances, design data entry
screens, develop forms and questionnaires, try to document our study protocols
in detail, plan redipping of nets, coordinate with the field supervisors,
oversee data entry, advise students on their thesis projects, order supplies,
blah blah blah. The really fun stuff
comes once the data have been entered and cleaned. Then I get to analyze the data and begin writing papers. I’m hoping that will happen in the next few
months but I’ll have to see how the power situation continues (currently, we
are without power every other day and have to generate our own, but the
generator doesn’t always work).
Any
questions? Anybody still out there?