Preventable but neglected: rickets in an informal settlement

Nairobi, Kenya.

JK Edwards,1 A Thiongó,1 R Van den Bergh,2 W Kizito,1 RJ Kosgei,3 A Sobry,1 A Vandenbulcke,1 I Zuniga,2 T Reid2

1. Médecins Sans Frontières, Nairobi, Kenya. 2. Médecins Sans Frontières, Brussels, Belgium. 3. University of Nairobi, Nairobi, Kenya

Acknowledgements Parental permission was obtained for images.

This project would not have been possible without the support of the Kibera project staff and reflects their on going tireless commitment to those who live within Kibera. This research was supported by the Operational Research Unit (LUXOR), Médecins Sans Frontières, Brussels Operational Centre, Luxembourg; the Centre for Operational Research, International Union Against Tuberculosis and Lung Disease (The Union), Paris, France and The Union South-East Asia Regional Office, Delhi, India.

AimThe purpose of this study was to describe:

•demographic, social and clinical characteristics of children

•treatment outcomes

•challenges with loss to follow up in the informal settlement of Kibera

IntroductionNutritional rickets is a disease whose etiology is related to a lack of vitamin D, calcium and sunlight exposure. Globally, it is one of the most common non-communicable diseases afflicting children, especially in certain populations of developing countries.

Untreated, rickets can have chronic sequelae including developmental delays, skeletal abnormalities and painful pathological fractures.

Despite this burden and previous recommendations from many developed countries, there are no public health initiatives to address rickets prevention in resource-limited countries.

Médecins Sans Frontières (MSF) operates the only large scale primary care program for the informal settlement of Kibera in Nairobi, Kenya, which has an estimated population of 200,000. In 2011-2012, the program noted an increasing number of cases of rickets among children.

While recommended for all high risk children and usually a routine practice in developed countries, vitamin D supplementation was not provided by MSF or the Kenyan Ministry of Health.

Method cont.The study participants children from

September 2012 to October 2013.

Inclusion criteria: • < five years old • widening of the wrists or• rachitic rosary of the ribs

Predicted sensitivity of 89% and specificity of 59% based upon previous validation.

All patients were started on an age-based dosage of vitamin D and were prescribed calcium.

Data were recorded:

• Epi Info 7 database

• Statistical analysis with Epi Info 7 Analysis

Figures

MethodThis is a descriptive, retrospective case review using routinely collected program data.

MSF operates in Kibera:

•Kibera South Health Centero treating ~ 1330 < 5 yrs

old/month

• Silanga Dispensary o treating ~ 930 < 5 yrs old/month

ResultsKey findings:

•Total of 82 met inclusion criteria

•71% had ≤ 3 hours of sunlight exposure per week

•Rickets cases peaked during the rainy season of 2013 (29% of all cases in March-April)

•2 of 12 villages accounted for 44% of all cases of rickets

•39% were malnourished using MUAC scores

•67% presented with symptoms of weakness, wrist swelling and/or an enlarged head.

•44% were found to have some degree of gross motor developmental delay

•60% completed the full six week treatment course

•65% demonstrated clinical improvement with treatment

•40 % were lost to follow up

Figure 2. Rachitic rosary of the ribs. Figure 3. Widening of the wrists.

Conclusion•Rickets is not uncommon within the informal settlement of Kibera.

•Factors possibly associated:o dieto malnutritiono lack of sunlighto seasonal variationo village of residence

•Loss to follow up makes treatment challenging

•It is recommended that vitamin D be given preventively in similar contexts within Africa routinely.

Figure 1. Frequency of rickets by village within Kibera.

Selected Characteristics Male, N (%) Female, N (%)

Frequency of rickets: 47 (57) 35 (43)

by clinic: KSHC 11 (23) 6 (17)

Silanga Dispensary 36 (76) 29 (83)

Median age in months (IQR) 12 (10-15) 14 (11-17)

Median weight on intake in kilograms (IQR) 8 (7-9) 8 (7-8)

Median MUAC measurement in cm (IQR) 128 (120-138) 126 (1220136)

Exam findings: wrist swelling 40 (85) 32 (91)

rachitic rosary of ribs 25 (53) 19 (54)

frontal bossing of skull 34 (72) 21 (60)

developmental delay 20 (42) 12 (34)

Table 1. Selected characteristics from children diagnosed with rickets, Kibera, Nairobi, Kenya.