The purpose of this technical note is to provide health professionals in United Nations agencies, non-governmental organizations, donor agencies and local authorities working with populations affected by emergencies with up-to-date technical guidance on the major communicable disease threats faced by the emergency-affected population in Kenya.
The endemic and epidemic-prone diseases indicated have been selected on the basis of the burden of morbidity, mortality and epidemic potential in the area, as previously documented by WHO.
The prevention and control of communicable diseases represent a significant challenge to those providing health-care services in this evolving situation. It is hoped that this technical note will facilitate the coordination of activities to control communicable diseases between all agencies working among the populations currently affected by the crisis.
1. BACKGROUND AND RISK FACTORS
Kenya is a low-income, food-deficient country with a population of 34 million and a per capita yearly income of USD 1 037. In 2007, Kenya's position on the UNDP human development index was 148th of 177 countries. About 58% of the population lives below the poverty line. Kenya's economy is highly dependant on tourism. Economic productivity is unevenly distributed between the central areas, characterized by high population density, commercial agriculture, industries and improving standard of living, and the sparsely populated peripheral areas, characterized by pastoralism and subsistence agriculture. Vulnerability to drought and food shortages is widespread in the arid and semi-arid districts located in the northern, coastal and central provinces. Kenya is also home to an estimated 238 000 refugees, mainly from Sudan and Somalia, and 360 000 internally displaced persons(1).
Major health problems in Kenya, which could be exacerbated by this crisis, relate to communicable diseases and malnutrition, especially in children. As of 2005, 20% of children were assessed to be moderately to severely under-weight(2). Major causes of death in all ages are HIV/AIDS, respiratory infections and diarrhoeal diseases(3).
On 27 December 2007 Kenya held nationwide government elections. The results were widely disputed, leading to conflict between opposition and government supporters. Violence, which began in densely-packed urban areas, quickly spread to rural areas. The deteriorating security environment has led to targeted killings and reprisals, widespread looting and burning, massive population displacement, and numerous reports of rape and sexual violence. As of 31 January, more than 800 people were reported to have been killed and hundreds of thousands displaced by the violence(4).
Kenya is divided administratively into 8 provinces (mkoa), which are composed of 71 districts (wilaya'at) and subdivided into 262 divisions (tarafa). The countrywide post-election violence has significantly affected six of the eight provinces - Nairobi, Coast, Western, Central, Rift Valley, and Nyanza provinces - including the cities of Nairobi, Mombasa, and Kisumu.
The violence and insecurity has led to widespread closure of health clinics. WHO reports 30% of the health facilities in some areas closed, mainly due to staff displacements and insecurity, with burning, looting, and vandalism of some health facilities(5). Access to the public health system is therefore severely affected, adversely impacting all aspects of health-care delivery including the capacity of the surveillance system to detect and respond to epidemics. Displaced populations lack food, water, fuel and access to health care.
WHO is leading the health cluster and participating in initial rapid assessments and UN joint assessment teams in the most affected areas as security permits. WHO-Kenya has deployed a field team to Nakaru in Rift Valley province to assist local health authorities and assess the situation, but has been affected by the deteriorating security environment.
Risk factors for increased communicable disease burden
1. Interruption of access to safe water and sanitation facilities. The populations displaced by violence are at immediate and high risk of outbreaks of waterborne and foodborne diseases.
2. Population displacement with overcrowding. Populations in the affected areas and relief centres are at immediate and high risk from the transmission of measles and increased incidence of ARI. Increased risk of meningitis transmission is also associated with overcrowding in general.
3. Malnutrition and transmission of communicable diseases. The combination of malnutrition and communicable diseases is potentially a significant public health problem, particularly among infants and children. Malnutrition compromises natural immunity, leading to more frequent, severe and prolonged episodes of infections. Severe malnutrition often masks symptoms and signs of communicable diseases, making prompt clinical diagnosis and early treatment more difficult.
4. Increased exposure to disease vectors. Displacement of populations can result in greater exposure to disease-carrying vectors, increasing the risk of malaria, dengue, and chikungunya fever, as well as other less common illnesses such as Rift Valley fever, yellow fever, human African trypanosomiasis, and plague. Risk of malaria is increased for people moving from low malaria risk areas into endemic regions such as Western Kenya, Nyanza and Coast.
5. Poor access to health services is of immediate concern. The deterioration of security and the degradation of the health infrastructure prevent access to usual services, as well as to emergency medical and surgical services put in place in response to this crisis.
6. Gender-based violence. Disruption of families and communities due to displacement can leave women and children vulnerable to rape and sexual violence, lead to commercial sex work, and increase the risk of HIV and sexually transmitted infections (STI).
(1) WHO. Kenya country profile, 2006. Available at: http://www.who.int/hac/crises/ken/en/index.html
(2) UNICEF. Country statistics Kenya. Available at: http://www.unicef.org/infobycountry/kenya_statistics.html
(3) WHO. Country health system fact sheet 2006, Kenya. Available at: http://www.afro.who.int/home/countries/fact_sheets/kenya.pdf
(4) OCHA Kenya Weekly Humanitarian Update vol 2, 21 - 28 Jan 2008
(5) WHO. Kenya situation report #7, 26 January 2008. Available at: http://www.who.int/hac/crises/ken/sitreps/en/index.html