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Gerard asked me to write a brief description of what I do at work. This wonít be nearly as interesting as his travels, but Iíll give it a go.


A bit of background first. Iím working for the US Centers for Disease Control and Prevention  who are collaborating with the Kenya Medical Research Institute (KEMRI) here in Kenya. CDCís been working in western Kenya for quite some time but itís 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 ďfieldĒ, 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 Iím 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). Theyíve 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 Ė more background. Kids die from malaria mostly between the ages of 6 months and 1 year. This occurs because itís the time when maternal protection is waning and the children havenít 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 donít usually die. By the time theyíre 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 Iím 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 theyíve been experiencing, whether they use a net and what the clinician diagnoses them with. This system doesnít require that much maintenance as itís 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. Itís 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 canít 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. Iím involved in re-designing the forms to try and minimize the problems we have in the past and Iím 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. Iím hoping that will happen in the next few months but Iíll 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 doesnít always work).


Any questions? Anybody still out there?