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Kenyan Neonatal Morbidity and Mortality: Genetics or Not?
INTERNATIONAL CONNECTIONS
Kenyan Neonatal Morbidity and Mortality: Genetics or Not? Carole Kenner, DNS, RNC, FAAN Column Editor Florence Mubichi, MS, MPH, RN
Our world is shrinking because of computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review (NAINR) issue will feature a column that highlights care-related issues from a featured country or region of the world. This article focuses on Kenya. Newborn and infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe will be featured that addresses NAINR's theme-oriented topic. This month, Kenya will be featured. Our guest author is Florence Mubichi, MS, MPH, RN, faculty from the University of Oklahoma College of Nursing (Oklahoma City, OK) and regional network contact for the Council of International Neonatal Nurses for Kenya. This month's article focuses on genetics. © 2008 Elsevier Inc. All rights reserved. Keywords: Neonatal morbidity; Neonatal mortality; Genetics
Kenya, like many African countries, faces many challenges when it comes to maternal and child health. In 2000, the neonatal mortality rate was 29/1000 live births, whereas in 2005, the younger than 1 year infant mortality rate was 64/1000 live births.1 Most of the infant mortality rate is because of neonatal mortality. What is the underlying cause of these deaths? Is there a genetic linkage?
Causes of Neonatal Death Many causes are known to contribute to neonatal and ultimately infant mortality. The leading causes are malnutrition of mothers and infants, infections—perinatal and neonatal— including malaria, tuberculosis, human immunodeficiency virus (HIV), and other sexually transmitted diseases, measles, neonatal tetanus, and complications from low birth weight. From the University of Oklahoma College of Nursing, Oklahoma City, OK. Address correspondences to Florence Mubichi, MS, MPH, RN, University of Oklahoma College of Nursing, 1100 Stonewall, Room 441, PO Box 26901, Oklahoma City, OK 73117. Tel.: +1 405 271 1491x49100. E-mail: [email protected] (C. Kenner), [email protected] (F. Mubichi). URL: http://www.coinnurses.org (C. Kenner). © 2008 Elsevier Inc. All rights reserved. 1527-3369/08/0801-0229$10.00/0 doi:10.1053/j.nainr.2007.12.002
According to United Nations Children's Fund, 10% of all babies born in Kenya are considered of low birth weight.1
Genetic Linkages It is difficult to pinpoint if genetics plays a key role in these deaths as, like many countries, there is no national repository of birth defects or genetic conditions. Another issue is that there is no mandated genetic or newborn screening in this country. However, from my clinical experience in Kenya, it is not uncommon to identify children with hearing problems— congenital deafness, but the identification is not made until they fail to respond to sounds or they are delayed in their verbalizations. There is no mandatory hearing screen done. Another condition I observed with some regularity is hydrocephalus. Again, oftentimes the underlying problem was not readily identified. In southern coastal Kenya, the incidence of ectopic kidney is higher than expected. Whether this is genetic is unclear but is suspected.2 The normal incidence is 1/1000. A population-based survey of urinary tract disease was carried out in five rural villages, in a Schistosoma haematobium-endemic area of coastal Kenya in south Mombasa. There were 3118 subjects age 2 years and older (up to age 60) who participated in this study. Of these subjects, 11 had renal ectopia and 3 had renal agenesis.2 These children were not related, indicating that there was a possible exposure to one or more teratogens or a genetic expression of the condition that varied across the population.
Although there were some intertribal marriages, other factors such as famine, maternal malnutrition, low levels of vitamin A, and infectious agents were all considered as possible factors.2 Genetic linkages are possible and cannot be ruled out.
Genetic Breakthroughs In the last few years, there have been scientific breakthroughs in the area of HIV and mother-to-child transmission (MTCT). Yang and colleagues3 examined the genetic variations of HIV-1 group M subtypes on MTCT of HIV-1. The genetic subtype analysis was of the p24gag and gp41env in 414 women with HIV-1 and 1 of 4 subtypes A through D. The findings suggested that MTCT was greater for those women with subtype D.3 This knowledge helps to identify more appropriate treatment plans for the mothers and counseling regarding family planning. Malaria is also transmitted via MTCT. Researchers are looking for answers to combat this disease.4 It appears that immunologic responses vary in the mother and possibly, fetus. Other factors may be damage to the placenta itself or its effect on an antigen response to HIV replication; however, genetic influences are not specifically implicated. On the other hand, immune responses can be mediated by an individual's genetic makeup. Measles is another disease that is rampant in Kenya. Of the 3.9 million infants in Kenya,5 about 1.75 million have received no immunizations. These infants then pose a threat to the unimmunized pregnant woman. Measles is known for its contribution to congenital anomalies ranging from congenital cataracts to blindness and can lead to neonatal and infant death.
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Conclusion In Kenya, little emphasis has been placed on genetics and genetic testing. However, as more research focuses on the major causes of neonatal mortality, it is likely that more scientific evidence will be uncovered to link an individual's genotype (maternal and neonatal) with one's disposition to disease and even death.
References 1. Ayisi JG, van Eijk AM, Newman RD, terKuile FO, Shi YP, et al. Maternal malaria and perinatal HIV transmission, Western Kenya. Emerg Infect Dis. 2004;10:643-652. 2. International Federation of Red Cross and Red Crescent Societies (IFRC). Kenya: Measles Outbreak—Information Bulletin No. 1. Available at: http://www.reliefweb.int/rw/ rwb.nsf/db900SID/HMYT-6PDL54?OpenDocument; 2006 [Retrieved September 22, 2007]. 3. Magak P, Ireri E, Kadzo H, King CH, Ouma JH, et al. High prevalence of ectopic kidney in Coast Province, Kenya. Trop Med Int Health 2004;9:595-600. 4. UNICEF. Kenya Statistics. Available at: http://www.unicef. org/infobycountry/kenya_statistics.html; 2007 [Retrieved September 22, 2007]. 5. Yang C, Li M, Shi YP, Winter J, van Eijk AM, et al. Genetic diversity of HIV-1 in Western Kenya: subtype specific differences in mother-to-child transmission. AIDS. 2003; 17:1667-1674.
& INFANT NURSING REVIEWS
Kenyan Neonatal Morbidity and Mortality: Genetics or Not? Carole Kenner, DNS, RNC, FAAN Column Editor Florence Mubichi, MS, MPH, RN
Our world is shrinking because of computerized linkages and the mobility of society. Information is shared rapidly around the world. Issues surrounding newborn and infant nursing are global. In efforts to acknowledge the international community, each Newborn and Infant Nursing Review (NAINR) issue will feature a column that highlights care-related issues from a featured country or region of the world. This article focuses on Kenya. Newborn and infant health issues are global ones. To review issues occurring in different areas of the world, a different area of the globe will be featured that addresses NAINR's theme-oriented topic. This month, Kenya will be featured. Our guest author is Florence Mubichi, MS, MPH, RN, faculty from the University of Oklahoma College of Nursing (Oklahoma City, OK) and regional network contact for the Council of International Neonatal Nurses for Kenya. This month's article focuses on genetics. © 2008 Elsevier Inc. All rights reserved. Keywords: Neonatal morbidity; Neonatal mortality; Genetics
Kenya, like many African countries, faces many challenges when it comes to maternal and child health. In 2000, the neonatal mortality rate was 29/1000 live births, whereas in 2005, the younger than 1 year infant mortality rate was 64/1000 live births.1 Most of the infant mortality rate is because of neonatal mortality. What is the underlying cause of these deaths? Is there a genetic linkage?
Causes of Neonatal Death Many causes are known to contribute to neonatal and ultimately infant mortality. The leading causes are malnutrition of mothers and infants, infections—perinatal and neonatal— including malaria, tuberculosis, human immunodeficiency virus (HIV), and other sexually transmitted diseases, measles, neonatal tetanus, and complications from low birth weight. From the University of Oklahoma College of Nursing, Oklahoma City, OK. Address correspondences to Florence Mubichi, MS, MPH, RN, University of Oklahoma College of Nursing, 1100 Stonewall, Room 441, PO Box 26901, Oklahoma City, OK 73117. Tel.: +1 405 271 1491x49100. E-mail: [email protected] (C. Kenner), [email protected] (F. Mubichi). URL: http://www.coinnurses.org (C. Kenner). © 2008 Elsevier Inc. All rights reserved. 1527-3369/08/0801-0229$10.00/0 doi:10.1053/j.nainr.2007.12.002
According to United Nations Children's Fund, 10% of all babies born in Kenya are considered of low birth weight.1
Genetic Linkages It is difficult to pinpoint if genetics plays a key role in these deaths as, like many countries, there is no national repository of birth defects or genetic conditions. Another issue is that there is no mandated genetic or newborn screening in this country. However, from my clinical experience in Kenya, it is not uncommon to identify children with hearing problems— congenital deafness, but the identification is not made until they fail to respond to sounds or they are delayed in their verbalizations. There is no mandatory hearing screen done. Another condition I observed with some regularity is hydrocephalus. Again, oftentimes the underlying problem was not readily identified. In southern coastal Kenya, the incidence of ectopic kidney is higher than expected. Whether this is genetic is unclear but is suspected.2 The normal incidence is 1/1000. A population-based survey of urinary tract disease was carried out in five rural villages, in a Schistosoma haematobium-endemic area of coastal Kenya in south Mombasa. There were 3118 subjects age 2 years and older (up to age 60) who participated in this study. Of these subjects, 11 had renal ectopia and 3 had renal agenesis.2 These children were not related, indicating that there was a possible exposure to one or more teratogens or a genetic expression of the condition that varied across the population.
Although there were some intertribal marriages, other factors such as famine, maternal malnutrition, low levels of vitamin A, and infectious agents were all considered as possible factors.2 Genetic linkages are possible and cannot be ruled out.
Genetic Breakthroughs In the last few years, there have been scientific breakthroughs in the area of HIV and mother-to-child transmission (MTCT). Yang and colleagues3 examined the genetic variations of HIV-1 group M subtypes on MTCT of HIV-1. The genetic subtype analysis was of the p24gag and gp41env in 414 women with HIV-1 and 1 of 4 subtypes A through D. The findings suggested that MTCT was greater for those women with subtype D.3 This knowledge helps to identify more appropriate treatment plans for the mothers and counseling regarding family planning. Malaria is also transmitted via MTCT. Researchers are looking for answers to combat this disease.4 It appears that immunologic responses vary in the mother and possibly, fetus. Other factors may be damage to the placenta itself or its effect on an antigen response to HIV replication; however, genetic influences are not specifically implicated. On the other hand, immune responses can be mediated by an individual's genetic makeup. Measles is another disease that is rampant in Kenya. Of the 3.9 million infants in Kenya,5 about 1.75 million have received no immunizations. These infants then pose a threat to the unimmunized pregnant woman. Measles is known for its contribution to congenital anomalies ranging from congenital cataracts to blindness and can lead to neonatal and infant death.
e26
NEWBORN
Conclusion In Kenya, little emphasis has been placed on genetics and genetic testing. However, as more research focuses on the major causes of neonatal mortality, it is likely that more scientific evidence will be uncovered to link an individual's genotype (maternal and neonatal) with one's disposition to disease and even death.
References 1. Ayisi JG, van Eijk AM, Newman RD, terKuile FO, Shi YP, et al. Maternal malaria and perinatal HIV transmission, Western Kenya. Emerg Infect Dis. 2004;10:643-652. 2. International Federation of Red Cross and Red Crescent Societies (IFRC). Kenya: Measles Outbreak—Information Bulletin No. 1. Available at: http://www.reliefweb.int/rw/ rwb.nsf/db900SID/HMYT-6PDL54?OpenDocument; 2006 [Retrieved September 22, 2007]. 3. Magak P, Ireri E, Kadzo H, King CH, Ouma JH, et al. High prevalence of ectopic kidney in Coast Province, Kenya. Trop Med Int Health 2004;9:595-600. 4. UNICEF. Kenya Statistics. Available at: http://www.unicef. org/infobycountry/kenya_statistics.html; 2007 [Retrieved September 22, 2007]. 5. Yang C, Li M, Shi YP, Winter J, van Eijk AM, et al. Genetic diversity of HIV-1 in Western Kenya: subtype specific differences in mother-to-child transmission. AIDS. 2003; 17:1667-1674.
& INFANT NURSING REVIEWS