Kenya scientific programme 08/01/07. By the Wellcome Trust The KEMRI-Wellcome Trust Research Programme in Kenya is divided into three main sections: clinical, developmental and therapeutic studies; epidemiology and immunology; and social, behavioural and public health.

The KEMRI (Kenya Medical Research Institute)-Wellcome Trust Research Programme in Kenya is organised under three broad research themes:

• clinical, developmental and therapeutic studies
• epidemiology and immunology
• social, behavioural and public health.

Within these themes, there are a number of key research clusters driven by groups of scientists or individuals; these research clusters and groups have largely emerged from Wellcome Trust career support over the last five years. A high degree of interaction between these research areas has resulted in several unique opportunities to complete a cycle of basic, interventional and implementation research, forming the basis of informed health policy in Kenya, the region and internationally.

Clinical, developmental and therapeutic studies

The unit's location in a busy district hospital provides a unique opportunity to define and optimise management of major causes of morbidity and mortality in in-patients, as well as providing an excellent environment for postgraduate training in paediatrics and adult medicine, which is recognised by both Kenyan and UK professional bodies.

Data from numerous clinical studies have fed into National and WHO guidelines on the management of malaria and other common childhood illnesses. Careful clinical characterisation has provided the platform for studies on pathogenesis, genetics and immunity. Linkage to epidemiological surveillance of the surrounding community allows determination of population-based rates of disease, provides the sampling frame for case control studies and allows severe hospitalised disease to form an end point in intervention trials.

The clinical-epidemiological linkage provides a unique opportunity to examine long-term survival and disability following admission with a range of severe insults. Initial work detected cognitive impairment in children exposed to severe malaria. This led to a more concerted effort to develop tools and skills to address this neglected area of research in developing countries. Assessment techniques have incorporated the adaptation of more traditional neuropsychological tests, computerised assessment programmes and neurophysiological techniques. The programme has established strong links with the community to incorporate their perceptions into the definition of impairment and disability, and into the identification of priorities for the target, design and implementation of rehabilitation programmes.

A particularly important component of the programme is the link between clinical activities and pharmacology, which has established one of the highest quality bio-analytical capacities in sub-Saharan Africa and acts as a regional training facility through support from Multilateral Initiative in Malaria. The group plays a central role in supporting clinical studies at Kilifi in the form of drug analysis, including therapeutic drug monitoring, clinical pharmacokinetic studies, antimalarial drug sensitivity testing and monitoring of the emergence of malaria parasite resistance. It also carries out basic research on the mode of action of antimalarial drugs and drug discovery.

Epidemiology and immunology

A key theme of the Kilifi programme is an improvement in epidemiological and immunological understanding of a range of infectious diseases (e.g. S. pneumoniae, malaria, HIV, and RSV) and non-infectious diseases (e.g. disability, epilepsy, haemoglobinopathies and malnutrition).

Collectively, the work strives towards a quantitative understanding of infection transmission and disease through community and hospital-based studies, with associated immunological and molecular based investigations. The scale of the community-based research, its integration within an epidemiological-demographic surveillance system (EPI-DSS), attention to the underlying process of disease, and integrated investigation of parasite, host and environmental variability are important strengths of the research programme.

Between 1990 and 1993 a demographic surveillance system (DSS) was established north of the district hospital, covering 70 000 people. This was used to study a range of malaria epidemiological questions and a community randomised trial of insecticide-treated nets. In 2002 the EPI-DSS was re-established and extended to areas south of the hospital, now covering at total population of 220 000. Over 24 000 homesteads have been mapped using global positioning systems, and enumerated nine times between 2002 and 2005.

Nested within the EPI-DSS is an established recruitment programme for a longitudinal birth cohort – the Kilifi Birth Cohort – originally established as a platform to detect incident cases of invasive pneumococcal disease and now forming the basis for cohort surveillance for a number of infectious diseases, such as malaria and RSV.

Malaria remains a core interest of much of the research at Kilifi. The focus is on the understanding of the biology of the parasite in relation to pathogenesis and new approaches to disease prevention. The programme aims to:

• establish a comprehensive picture of the development of protective immunity in order to inform future vaccine design and facilitate monitoring of vaccine trials
• understand the interaction between immunity and virulence
• continue the work on the relationships between vector dynamics, transmissibility and disease susceptibility
• continue to study the effect of host-genetic factors on the risk and pattern of clinical malaria
• create a framework to test vaccine and non-vaccine based interventions.

Social, behavioural and public health

The social, behavioural and public health theme provides the framework for research beyond the basic science and phase III trial stages of the Kenyan unit's programme, and the platform to influence national, regional and international health policy agendas. It comprises two key clusters: the Social and Behavioral Research (SBR) cluster in Kilifi and the Nairobi Public Health (NPH) cluster.

The SBR is a grouping of researchers with a background in social science, health economics, and developing and evaluating community-based interventions and communication strategies. The SBR cluster has developed a strong methodological basis to study the social and behavioural aspects of access to health care at household, community and district levels, and the multi-level issues related to ethical principles of health research in low-income countries. This group works synergistically with the NPH cluster through formal and informal linkages ranging from research collaborations and joint PhD supervision to proposal development meetings.

The NPH cluster is a multidisciplinary team that combines approaches to explain the clinical, epidemiological, social and spatial determinants of childhood morbidity and mortality within a research framework that describes the operational effectiveness of systems, delivery partnerships and financing of child survival interventions. The NPH cluster has developed a national credibility through its support to the Ministry of Heath (Division of Malaria Control and Division of Child Health) and the Kenya Expanded Programme on Immunisations and technical advice to bilateral and multilateral donor partners (Department for International Development, United States Agency for International Development and UNICEF). Furthermore the group provides technical and institutional support to sub-regional monitoring networks for antimalarials (East African Network for Monitoring Antimalarial Treatment - EANMAT) and vaccines/antibiotics (Network for Surveillance of Pneumococcal Diseases in the East African Region - netSPEAR).

The combined SBR and NPH clusters aim to develop and evaluate appropriate health interventions in sub-Saharan Africa based on an understanding of social, cultural, economic and health system constraints of delivery.

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