Last data update: Nov 11, 2024. (Total: 48109 publications since 2009)
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Establishing an early warning event management system at Africa CDC
Mercy K , Salyer SJ , Mankga C , Hedberg C , Zondo P , Kebede Y . PLOS Digit Health 2024 3 (7) e0000546 Africa is home to hotspots of disease emergence and re-emergence. To adequately detect and respond to these health threats, early warning systems inclusive of event-based surveillance (EBS) are needed. However, data systems to manage these events are not readily available. In 2020, Africa Centres for Disease Control and Prevention developed an event management system (EMS) to meet this need. The district health information software (DHIS2), which is free and open-source software was identified as the platform for the EMS because it can support data capture and analysis and monitor and report events. The EMS was created through a collaborative and iterative prototyping process that included modifying key DHIS2 applications like Tracker Capture. Africa CDC started piloting the EMS with both signal and event data entry in June 2020. By December 2022, 416 events were captured and over 140 weekly reports, including 19 COVID-19 specific reports, were generated and distributed to inform continental awareness and response efforts. Most events detected directly impacted humans (69%), were considered moderate (50%) to high (29%) risk level and reflected both emerging and endemic infectious disease outbreaks. Highly pathogenic avian influenza, specifically H5N1, was the most frequently detected animal event and storms and flooding were most frequently detected environmental events. Both data completeness and timeliness improved over time. Country-level interest and utility resulted in four African countries adapting the EMS in 2022 and two more in 2023. This system demonstrates how integrating digital technology into health systems and utilising existing digital platforms like DHIS2 can improve early warning at the continental and country level by improving EBS workflow. |
Use of electronic quality monitoring tool and central dashboard to improve clinical and programmatic decisions
Eskinder B , Habte D , Molla M , Hailemeskel F , Tewldebirhan E , Kebede T , Assefa T , Kabtyimer D , Amidino W , Lulseged S . Stud Health Technol Inform 2024 310 1472-1473 The HIV service quality improvement tool is deployed in 123 health facilities in Ethiopia. The tool uses a central dashboard for visualization and decision making at the health facility and higher levels of the health systems. The dashboard is developed on excel with analytics about HIV testing, case finding, treatment linkage and quality indicators. The dashboard was developed based on the requirements requested during discussions with HIV clinicians and the program team. |
Tropical data: Approach and methodology as applied to trachoma prevalence surveys
Harding-Esch EM , Burgert-Brucker CR , Jimenez C , Bakhtiari A , Willis R , Bejiga MD , Mpyet C , Ngondi J , Boyd S , Abdala M , Abdou A , Adamu Y , Alemayehu A , Alemayehu W , Al-Khatib T , Apadinuwe SC , Awaca N , Awoussi MS , Baayendag G , Badiane MD , Bailey RL , Batcho W , Bay Z , Bella A , Beido N , Bol YY , Bougouma C , Brady CJ , Bucumi V , Butcher R , Cakacaka R , Cama A , Camara M , Cassama E , Chaora SG , Chebbi AC , Chisambi AB , Chu B , Conteh A , Coulibaly SM , Courtright P , Dalmar A , Dat TM , Davids T , Djaker MEA , de Fátima Costa Lopes M , Dézoumbé D , Dodson S , Downs P , Eckman S , Elshafie BE , Elmezoghi M , Elvis AA , Emerson P , Epée EE , Faktaufon D , Fall M , Fassinou A , Fleming F , Flueckiger R , Gamael KK , Garae M , Garap J , Gass K , Gebru G , Gichangi MM , Giorgi E , Goépogui A , Gómez DVF , Gómez Forero DP , Gower EW , Harte A , Henry R , Honorio-Morales HA , Ilako DR , Issifou AAB , Jones E , Kabona G , Kabore M , Kadri B , Kalua K , Kanyi SK , Kebede S , Kebede F , Keenan JD , Kello AB , Khan AA , Khelifi H , Kilangalanga J , Kim SH , Ko R , Lewallen S , Lietman T , Logora MSY , Lopez YA , MacArthur C , Macleod C , Makangila F , Mariko B , Martin DL , Masika M , Massae P , Massangaie M , Matendechero HS , Mathewos T , McCullagh S , Meite A , Mendes EP , Abdi HM , Miller H , Minnih A , Mishra SK , Molefi T , Mosher A , M'Po N , Mugume F , Mukwiza R , Mwale C , Mwatha S , Mwingira U , Nash SD , Nassa C , Negussu N , Nieba C , Noah Noah JC , Nwosu CO , Olobio N , Opon R , Pavluck A , Phiri I , Rainima-Qaniuci M , Renneker KK , Saboyá-Díaz MI , Sakho F , Sanha S , Sarah V , Sarr B , Szwarcwald CL , Shah Salam A , Sharma S , Seife F , Serrano Chavez GM , Sissoko M , Sitoe HM , Sokana O , Tadesse F , Taleo F , Talero SL , Tarfani Y , Tefera A , Tekeraoi R , Tesfazion A , Traina A , Traoré L , Trujillo-Trujillo J , Tukahebwa EM , Vashist P , Wanyama EB , Warusavithana SDP , Watitu TK , West S , Win Y , Woods G , Yajima A , Yaya G , Zecarias A , Zewengiel S , Zoumanigui A , Hooper PJ , Millar T , Rotondo L , Solomon AW . Ophthalmic Epidemiol 2023 30 (6) 544-560 PURPOSE: Population-based prevalence surveys are essential for decision-making on interventions to achieve trachoma elimination as a public health problem. This paper outlines the methodologies of Tropical Data, which supports work to undertake those surveys. METHODS: Tropical Data is a consortium of partners that supports health ministries worldwide to conduct globally standardised prevalence surveys that conform to World Health Organization recommendations. Founding principles are health ministry ownership, partnership and collaboration, and quality assurance and quality control at every step of the survey process. Support covers survey planning, survey design, training, electronic data collection and fieldwork, and data management, analysis and dissemination. Methods are adapted to meet local context and needs. Customisations, operational research and integration of other diseases into routine trachoma surveys have also been supported. RESULTS: Between 29(th) February 2016 and 24(th) April 2023, 3373 trachoma surveys across 50 countries have been supported, resulting in 10,818,502 people being examined for trachoma. CONCLUSION: This health ministry-led, standardised approach, with support from the start to the end of the survey process, has helped all trachoma elimination stakeholders to know where interventions are needed, where interventions can be stopped, and when elimination as a public health problem has been achieved. Flexibility to meet specific country contexts, adaptation to changes in global guidance and adjustments in response to user feedback have facilitated innovation in evidence-based methodologies, and supported health ministries to strive for global disease control targets. |
Evaluating event-based surveillance capacity in Africa: Use of the Africa CDC scorecard, 2022-2023
Tetuh KM , Salyer SJ , Aliddeki D , Tibebu B , Osman F , Amabo FC , Warren LK , Buba MI , Kebede Y . Prev Med Rep 2023 36 102398 INTRODUCTION: Event-based surveillance (EBS) is a critical component of Early Warning, Alert and Response (EWAR) capacity needed for outbreak prevention and control. To better understand existing EBS and monitor the progress of capacity-building efforts over time, Africa CDC developed an EBS scorecard as part of a revision to the EBS Framework. METHODS: We distributed the scorecard to African Union (AU) Member States (MSs). Survey responses from the MSs' human health sector were aggregated, cleaned, and analysed. MS, regional, and continental EBS capacity was assessed. RESULTS: Between 21 July 2022 and 4 April 2023, a total of 63 respondents representing 49 (89%) of 55 MSs completed the survey. Given Africa CDC's public health mandate, we acknowledged the importance of One Health collaboration in MSs but focused on and analysed only the human health sector responses. Thirty-four (71%) MSs stated having EBS in place; hotline was the most common type of EBS implemented (76%). Seventeen (50%) MSs reported multisectoral, One Health collaboration as part of EBS implementation. Scorecard outcomes showed a minimal (score of <60%) to average (score between 60-80%) level of EBS capacity in 29 and five (5) MSs respectively. DISCUSSION: Current EBS capacity levels need to be strengthened in Africa to ensure the continent remains prepared for future public health threats. The Africa CDC EBS scorecard provides a useful way to measure and track this capacity over time. Results can be used to advocate for and target resources for capacity building to foster public health emergency preparedness efforts. |
Notes from the field: Exposures to mpox among cases in children aged 12 years - United States, September 25-December 31, 2022
Nemechek K , Stefanos R , Miller EL , Riser A , Kebede B , Galang RR , Hufstetler K , Descamps D , Balenger A , Hennessee I , Neelam V , Hutchins HJ , Labuda SM , Davis KM , McCormick DW , Marx GE , Kimball A , Ruberto I , Williamson T , Rzucidlo P , Willut C , Harold RE , Mangla AT , English A , Brikshavana D , Blanding J , Kim M , Finn LE , Marutani A , Lockwood M , Johnson S , Ditto N , Wilton S , Edmond T , Stokich D , Shinall A , Alravez B , Crawley A , Nambiar A , Gateley EL , Schuman J , White SL , Davis K , Milleron R , Mendez M , Kawakami V , Segaloff HE , Bower WA , Ellington SR , McCollum AM , Pao LZ . MMWR Morb Mortal Wkly Rep 2023 72 (23) 633-635 During May 17–December 31, 2022, 125 probable or confirmed U.S. monkeypox (mpox)† cases were reported among patients aged <18 years, including 45 (36%) in children aged ≤12 years. Eighty-three cases in persons aged <18 years diagnosed during May 17–September 24, 2022 were previously described (1); 28 (34%) of these were in children aged ≤12 years, 29% of whom did not have reported information on exposure. Among 20 (71%) of 28 patients with documented information on exposure, most were exposed by a household contact. This report updates the previous report using data collected during September 25–December 31, 2022, proposes possible mpox exposure routes in children aged ≤12 years, and describes three U.S. mpox cases in neonates. Household members or caregivers with mpox, including pregnant women and their health care providers, should be informed of the risk of transmission to persons aged <18 years, and strategies to protect persons aged <18 years at risk for exposure, including isolating household contacts with mpox, should be implemented immediately. | | During September 25–December 31, 2022, 17 children aged ≤12 years with probable or confirmed mpox were identified through national surveillance. CDC provided a questionnaire to state and local health departments for collection of the child’s history of exposure to any person with mpox§ during the previous 3 weeks, exposure settings, types of contact (e.g., skin-to-skin, being held or cuddled, diaper change, or toilet use), and precautions taken by the person with mpox (e.g., practiced isolation or covered lesions). This activity was reviewed by CDC and was conducted consistent with applicable federal law and CDC policy.¶ |
Building integrated testing programs for infectious diseases
Alemnji G , Mosha F , Maggiore P , Alexander H , Ndlovu N , Kebede Y , Tiam A , Albert H , Edgil D , de Lussigny S , Peter T . J Infect Dis 2023 228 (10) 1314-1317 In the past two decades, testing services for diseases such as HIV, TB and malaria have expanded dramatically. Investments in testing capacity and supportive health systems have often been disease specific, resulting in siloed testing programs with suboptimal capacity, reduced efficiency, and limited ability to introduce additional tests or respond to new outbreaks. Emergency demand for SARS-CoV2 testing overcame these silos and demonstrated the feasibility of integrated testing. Moving forward, an integrated public laboratory infrastructure that services multiple diseases, including SARS-CoV-2, influenza, HIV, TB, hepatitis, malaria, sexually transmitted diseases, and other infections will help improve universal healthcare delivery and pandemic preparedness. However, integrated testing faces many barriers including poorly aligned health systems, funding and policies. Strategies to overcome these include greater implementation of policies that support multi-disease testing and treatment systems, diagnostic network optimization, bundled test procurement, and more rapid spread of innovation and best practices across disease programs. |
Child maltreatment reporting during the initial weeks of COVID-19 in the US: Findings from NCANDS.
Shusterman GR , Fluke JD , Nunez JJ , Fettig NB , Kebede BK . Child Abuse Negl 2022 134 105929 BACKGROUND: After the national COVID-19 emergency declaration in the U.S. in March 2020, child welfare agencies observed large reductions in maltreatment reporting. OBJECTIVE: To quantify the impact of the COVID-19 pandemic on child maltreatment reporting nationally to inform policy for future emergencies. PARTICIPANTS AND SETTING: Administrative data from the National Child Abuse and Neglect Data System (NCANDS) for 48 states for federal fiscal years (FFYs) 2017 through 2020. METHODS: Analyses focused on reports to child protective services (CPS) between weeks 12 and 24 of calendar years 2017 through 2020 (mid-March through mid-June). Report sources of screened in and substantiated reports were compared with those during the prior year. Likelihood of a report being substantiated in 2020 compared with 2019 based on report source was calculated using odds ratios. RESULTS: In 2020, CPS screened in 39% fewer reports than during the same period in 2019 and the proportion of reports substantiated increased from 18 to 22%. Reports from all report sources decreased, especially from education personnel (90% decrease) and child daycare providers (65% decrease). The odds for substantiation were significantly higher during 2020 than in 2019 for reports from all but three sources. CONCLUSION: During the initial weeks following the national COVID-19 emergency declaration, the number of reports to CPS declined sharply at the national level and across all states, primarily in association with a large reduction in referrals from education sentinels. Explanations for the increase in percent of substantiation in the context of reduction of reports are considered. |
High level of HIV drug resistance and virologic nonsuppression among female sex workers in Ethiopia: A nationwide cross-sectional study
Arimide DA , Amogne MD , Kebede Y , Balcha TT , Adugna F , Ramos A , DeVos J , Zeh C , Agardh A , Chih-Wei Chang J , Björkman P , Medstrand P . J Acquir Immune Defic Syndr 2022 89 (5) 566-574 OBJECTIVE: To determine viral load (VL) nonsuppression (VLN) rates, HIV drug resistance (HIVDR) prevalence, and associated factors among female sex workers (FSWs) in Ethiopia. METHODS: A cross-sectional biobehavioral survey was conducted among FSWs in 11 cities in Ethiopia in 2014. Whole blood was collected, and HIVDR genotyping was performed. Logistic regression analysis was performed to identify factors associated with VLN and HIVDR. RESULTS: Among 4900 participants, 1172 (23.9%) were HIV-positive and 1154 (98.5%) had a VL result. Participants were categorized into antiretroviral therapy (ART) (n = 239) and ART-naive (n = 915) groups based on self-report. From the 521 specimens (ART, 59; ART-naive, 462) with VL ≥1000 copies/mL, genotyping was successful for 420 (80.6%) and 92 (21.9%) had drug resistance mutations (DRMs). Pretreatment drug resistance (PDR) was detected in 16.5% (63/381) of the ART-naive participants. Nucleoside reverse transcriptase inhibitor (NRTI), non-NRTIs (NNRTIs), and dual-class DRMs were detected in 40 (10.5%), 55 (14.4%), and 35 (9.2%) of the participants, respectively. Among 239 participants on ART, 59 (24.7%) had VLN. Genotyping was successfully performed for 39 (66.1%). DRMs were detected in 29 (74.4%). All 29 had NNRTI, 23 (79.3%) had NRTI or dual-class DRMs. VLN was associated with age 35 years or older, CD4+ T-cell count <350 cells/mm3, and being forced into selling sex. PDR and acquired drug resistance were associated with CD4+ T-cell count <350 cells/mm3 (P < 0.001). CONCLUSIONS: The high VLN and HIVDR rates among FSWs underscore the need for targeted interventions to improve ART access and virologic monitoring to maximize the benefit of ART and limit the spread of HIV and HIVDR. |
Investigation of Plasmodium falciparum pfhrp2 and pfhrp3 gene deletions and performance of a rapid diagnostic test for identifying asymptomatic malaria infection in northern Ethiopia, 2015.
Leonard CM , Assefa A , McCaffery JN , Herman C , Plucinski M , Sime H , Mohammed H , Kebede A , Solomon H , Haile M , Murphy M , Hwang J , Rogier E . Malar J 2022 21 (1) 70 BACKGROUND: Rapid diagnostic tests (RDTs) are widely used for malaria diagnosis of both symptomatic and asymptomatic infections. Although RDTs are a reliable and practical diagnostic tool, the sensitivity of histidine-rich protein 2 (HRP2)-based RDTs can be reduced if pfhrp2 or pfhrp3 (pfhrp2/3) gene deletions exist in the Plasmodium falciparum parasite population. This study evaluated dried blood spot (DBS) samples collected from a national household survey to investigate the presence of pfhrp2/3 deletions and the performance of the RDT used in the cross-sectional survey in a low transmission setting. METHODS: The 2015 Ethiopia Malaria Indicator Survey tested household members by RDT and collected DBS samples. DBS (n = 2648) from three regions in northern Ethiopia were tested by multiplex bead-based antigen detection assay after completion of the survey. The multiplex assay detected pan-Plasmodium lactate dehydrogenase (LDH), pAldolase, and HRP2 antigens in samples. Samples suspected for pfhrp2/3 gene deletions (pLDH and/or pAldolase positive but low or absent HRP2) were further investigated by molecular assays for gene deletions. Antigen results were also compared to each individual's RDT results. Dose-response logistic regression models were fit to estimate RDT level of detection (LOD) antigen concentrations at which 50, 75, 90, and 95% of the RDTs returned a positive result during this survey. RESULTS: Out of 2,648 samples assayed, 29 were positive for pLDH or pAldolase antigens but low or absent for HRP2 signal, and 15 of these samples (51.7%) were successfully genotyped for pfhrp2/3. Of these 15 P. falciparum infections, eight showed single deletions in pfhrp3, one showed a single pfhrp2 deletion, and six were pfhrp2/3 double-deletions. Six pfhrp2 deletions were observed in Tigray and one in Amhara. Twenty-five were positive for HRP2 by the survey RDT while the more sensitive bead assay detected 30 HRP2-positive samples. A lower concentration of HRP2 antigen generated a positive test result by RDT compared to pLDH (95% LOD: 16.9 ng/mL vs. 319.2 ng/mL, respectively). CONCLUSIONS: There is evidence of dual pfhrp2/3 gene deletions in the Tigray and Amhara regions of Ethiopia in 2015. As the prevalence of malaria was very low (< 2%), it is difficult to make strong conclusions on RDT performance, but these results challenge the utility of biomarkers in household surveys in very low transmission settings. |
Spatial distribution of Plasmodium falciparum and P. vivax in northern Ethiopia by microscopy, rapid diagnostic test, laboratory antibody and antigen data
Leonard CM , Assefa A , Sime H , Mohammed H , Kebede A , Solomon H , Drakeley C , Murphy M , Hwang J , Rogier E . J Infect Dis 2021 225 (5) 881-890 BACKGROUND: Determining malaria transmission within regions of low, heterogenous prevalence is difficult. A variety of malaria tests exist and range from identification of diagnostic infection to testing for prior exposure. This study describes concordance of multiple malaria tests using data from a 2015 household survey conducted in Ethiopia. METHODS: Blood samples (n= 2,279) from three regions in northern Ethiopia were assessed for Plasmodium falciparum and P. vivax by microscopy, rapid diagnostic test (RDT), multiplex antigen assay, and multiplex assay for IgG antibodies. Geospatial analysis was conducted with spatial scan statistics and kernel density estimation to identify hotspots of malaria by different test results. RESULTS: Prevalence of malaria infection was low (1.4% by RDT, 1.0% by microscopy, and 1.8% by laboratory antigen assay). For P. falciparum, overlapping spatial clusters for all tests and an additional five unique IgG clusters were identified. For P. vivax, clusters identified for bead antigen assay, microscopy, and IgG with partial overlap. CONCLUSIONS: Assessing the spatial distribution of malaria exposure using multiple metrics can improve the understanding of malaria transmission dynamics in a region. The relative abundance of antibody clusters indicates that in areas of low-transmission, IgG antibodies are a more useful marker to assess malaria exposure. |
Seroprevalence and risk factors for SARS-CoV-2 Infection in selected urban areas in Ethiopia: a cross-sectional evaluation during July 2020.
Tadesse EB , Endris AA , Solomon H , Alayu M , Kebede A , Eshetu K , Teka G , Seid BE , Ahmed J , Abayneh SA , Moges B , Gerawork H , Sugerman D , Assefa Z , Abayneh A , Abate E , Taddese L . Int J Infect Dis 2021 111 179-185 BACKGROUND: Ethiopia reported the first case of COVID-19 on 13(th) March, 2020 with community transmission ensuing by mid-May. A national, population-based serosurvey against anti-SARS-CoV-2 IgG was conducted to measure the prevalence of prior COVID-19 infections and better approximate the burden across major towns in Ethiopia. METHODS: We conducted a cross-sectional, population-based serosurvey from June 24 to July 8, 2020 in 14 major urban areas. Two-stage cluster sampling was used to randomly select enumeration areas and households. All persons aged ≥15 years were enrolled. Serum samples were tested by Abbott™ ARCHITECT™ assay for SARS-CoV-2 IgG antibodies. National COVID-19 surveillance data on the median date of the serosurvey is analyzed for comparison. FINDINGS: Adjusted seroprevalence was 3.5% (95% CI: 3.2%-3.8%) after controlling for age, sex and test kit performance. Males (3.7%) and females (3.3%) were nearly equally infected, while middle-aged adults '40-65 years' had the highest (4.0%) prevalence. Gambella (7.5%), Dire Dawa (6.2%) and Jigjiga (6.1%) were the most affected towns. About 6.7% and 8.0% of seropositives had symptoms and chronic underlying illness, respectively. A surveillance system had identified 4,416 RT-PCR confirmed cases in Addis Ababa. INTERPRETATION: This serosurvey shows that a majority of urban Ethiopians remain uninfected with SARS-CoV-2. Most anti-SARS-CoV-2 IgG positive cases were asymptomatic with no underlying illness, keeping case detection to a minimum. |
The first and second waves of the COVID-19 pandemic in Africa: a cross-sectional study.
Salyer SJ , Maeda J , Sembuche S , Kebede Y , Tshangela A , Moussif M , Ihekweazu C , Mayet N , Abate E , Ouma AO , Nkengasong J . Lancet 2021 397 (10281) 1265-1275 BACKGROUND: Although the first wave of the COVID-19 pandemic progressed more slowly in Africa than the rest of the world, by December, 2020, the second wave appeared to be much more aggressive with many more cases. To date, the pandemic situation in all 55 African Union (AU) Member States has not been comprehensively reviewed. We aimed to evaluate reported COVID-19 epidemiology data to better understand the pandemic's progression in Africa. METHODS: We did a cross-sectional analysis between Feb 14 and Dec 31, 2020, using COVID-19 epidemiological, testing, and mitigation strategy data reported by AU Member States to assess trends and identify the response and mitigation efforts at the country, regional, and continent levels. We did descriptive analyses on the variables of interest including cumulative and weekly incidence rates, case fatality ratios (CFRs), tests per case ratios, growth rates, and public health and social measures in place. FINDINGS: As of Dec 31, 2020, African countries had reported 2 763 421 COVID-19 cases and 65 602 deaths, accounting for 3·4% of the 82 312 150 cases and 3·6% of the 1 798 994 deaths reported globally. Nine of the 55 countries accounted for more than 82·6% (2 283 613) of reported cases. 18 countries reported CFRs greater than the global CFR (2·2%). 17 countries reported test per case ratios less than the recommended ten to 30 tests per case ratio range. At the peak of the first wave in Africa in July, 2020, the mean daily number of new cases was 18 273. As of Dec 31, 2020, 40 (73%) countries had experienced or were experiencing their second wave of cases with the continent reporting a mean of 23 790 daily new cases for epidemiological week 53. 48 (96%) of 50 Member States had five or more stringent public health and social measures in place by April 15, 2020, but this number had decreased to 36 (72%) as of Dec 31, 2020, despite an increase in cases in the preceding month. INTERPRETATION: Our analysis showed that the African continent had a more severe second wave of the COVID-19 pandemic than the first, and highlights the importance of examining multiple epidemiological variables down to the regional and country levels over time. These country-specific and regional results informed the implementation of continent-wide initiatives and supported equitable distribution of supplies and technical assistance. Monitoring and analysis of these data over time are essential for continued situational awareness, especially as Member States attempt to balance controlling COVID-19 transmission with ensuring stable economies and livelihoods. FUNDING: None. |
Assessment of subpatent Plasmodium infection in northwestern Ethiopia
Assefa A , Ahmed AA , Deressa W , Wilson GG , Kebede A , Mohammed H , Sassine M , Haile M , Dilu D , Teka H , Murphy MW , Sergent S , Rogier E , Zhiyong Z , Wakeman BS , Drakeley C , Shi YP , Von Seidlein L , Hwang J . Malar J 2020 19 (1) 108 BACKGROUND: Ethiopia has set a goal for malaria elimination by 2030. Low parasite density infections may go undetected by conventional diagnostic methods (microscopy and rapid diagnostic tests) and their contribution to malaria transmission varies by transmission settings. This study quantified the burden of subpatent infections from samples collected from three regions of northwest Ethiopia. METHODS: Sub-samples of dried blood spots from the Ethiopian Malaria Indicator Survey 2015 (EMIS-2015) were tested and compared using microscopy, rapid diagnostic tests (RDTs), and nested polymerase chain reaction (nPCR) to determine the prevalence of subpatent infection. Paired seroprevalence results previously reported along with gender, age, and elevation of residence were explored as risk factors for Plasmodium infection. RESULTS: Of the 2608 samples collected, the highest positive rate for Plasmodium infection was found with nPCR 3.3% (95% CI 2.7-4.1) compared with RDT 2.8% (95% CI 2.2-3.5) and microscopy 1.2% (95% CI 0.8-1.7). Of the nPCR positive cases, Plasmodium falciparum accounted for 3.1% (95% CI 2.5-3.8), Plasmodium vivax 0.4% (95% CI 0.2-0.7), mixed P. falciparum and P. vivax 0.1% (95% CI 0.0-0.4), and mixed P. falciparum and Plasmodium malariae 0.1% (95% CI 0.0-0.3). nPCR detected an additional 30 samples that had not been detected by conventional methods. The majority of the nPCR positive cases (61% (53/87)) were from the Benishangul-Gumuz Region. Malaria seropositivity had significant association with nPCR positivity [adjusted OR 10.0 (95% CI 3.2-29.4), P < 0.001]. CONCLUSION: Using nPCR the detection rate of malaria parasites increased by nearly threefold over rates based on microscopy in samples collected during a national cross-sectional survey in 2015 in Ethiopia. Such subpatent infections might contribute to malaria transmission. In addition to strengthening routine surveillance systems, malaria programmes may need to consider low-density, subpatent infections in order to accelerate malaria elimination efforts. |
Multiplex serology demonstrate cumulative prevalence and spatial distribution of malaria in Ethiopia
Assefa A , Ali Ahmed A , Deressa W , Sime H , Mohammed H , Kebede A , Solomon H , Teka H , Gurrala K , Matei B , Wakeman B , Wilson GG , Sinha I , Maude RJ , Ashton R , Cook J , Shi YP , Drakeley C , von Seidlein L , Rogier E , Hwang J . Malar J 2019 18 (1) 246 BACKGROUND: Measures of malaria burden using microscopy and rapid diagnostic tests (RDTs) in cross-sectional household surveys may incompletely describe the burden of malaria in low-transmission settings. This study describes the pattern of malaria transmission in Ethiopia using serological antibody estimates derived from a nationwide household survey completed in 2015. METHODS: Dried blood spot (DBS) samples were collected during the Ethiopian Malaria Indicator Survey in 2015 from malarious areas across Ethiopia. Samples were analysed using bead-based multiplex assays for IgG antibodies for six Plasmodium antigens: four human malaria species-specific merozoite surface protein-1 19kD antigens (MSP-1) and Apical Membrane Antigen-1 (AMA-1) for Plasmodium falciparum and Plasmodium vivax. Seroprevalence was estimated by age, elevation and region. The seroconversion rate was estimated using a reversible catalytic model fitted with maximum likelihood methods. RESULTS: Of the 10,278 DBS samples available, 93.6% (9622/10,278) had valid serological results. The mean age of participants was 15.8 years and 53.3% were female. National seroprevalence for antibodies to P. falciparum was 32.1% (95% confidence interval (CI) 29.8-34.4) and 25.0% (95% CI 22.7-27.3) to P. vivax. Estimated seroprevalences for Plasmodium malariae and Plasmodium ovale were 8.6% (95% CI 7.6-9.7) and 3.1% (95% CI 2.5-3.8), respectively. For P. falciparum seroprevalence estimates were significantly higher at lower elevations (< 2000 m) compared to higher (2000-2500 m) (aOR 4.4; p < 0.01). Among regions, P. falciparum seroprevalence ranged from 11.0% (95% CI 8.8-13.7) in Somali to 65.0% (95% CI 58.0-71.4) in Gambela Region and for P. vivax from 4.0% (95% CI 2.6-6.2) in Somali to 36.7% (95% CI 30.0-44.1) in Amhara Region. Models fitted to measure seroconversion rates showed variation nationally and by elevation, region, antigen type, and within species. CONCLUSION: Using multiplex serology assays, this study explored the cumulative malaria burden and regional dynamics of the four human malarias in Ethiopia. High malaria burden was observed in the northwest compared to the east. High transmission in the Gambela and Benishangul-Gumuz Regions and the neglected presence of P. malariae and P. ovale may require programmatic attention. The use of a multiplex assay for antibody detection in low transmission settings has the potential to act as a more sensitive biomarker. |
Role of public-private partnerships in achieving UNAIDS HIV treatment targets
Shrivastava R , Fonjungo PN , Kebede Y , Bhimaraj R , Zavahir S , Mwangi C , Gadde R , Alexander H , Riley PL , Kim A , Nkengasong JN . BMC Health Serv Res 2019 19 (1) 46 BACKGROUND: Despite progress towards achieving UNAIDS 90-90-90 goals, barriers persist in laboratory systems in sub-Saharan Africa (SSA) restricting scale up of early infant diagnosis (EID) and viral load (VL) test monitoring of patients on antiretroviral therapy. If these facilities and system challenges persist, they may undermine recorded gains and appropriate management of patients. The aim of this review is to identify Public Private Partnerships (PPP) in SSA that have resolved systemic barriers within the VL and EID treatment cascade and demonstrated impact in the scale up of VL and EID. METHODS: We queried five HIV and TB laboratory databases from 2007 to 2017 for studies related to laboratory system strengthening and PPP. We identified, screened and included PPPs that demonstrated evidence in alleviating known system level barriers to scale up national VL and EID testing programs. PPPs that improved associated systems from the point of viral load test request to the use of the test result for patient management were deemed eligible. RESULTS: We identified six PPPs collaborations with multiple activities in select countries that are contributing to address challenges to scale up national viral load programs. One of the six PPPs reached 14.5 million patients in remote communities and transported up to 400,000 specimens in a year. Another PPP enabled an unprecedented 94% of specimens to reach national laboratory through improved sample referral network and enabled a cost savings of 62%. Also PPPs reduced cost of reagents and enabled 300,000 tested infants to be enrolled in care as well as reduced turnaround time of reporting results by 50%. CONCLUSIONS: Our review identified the benefits, enabling factors, and associated challenges for public and private sectors to engage in PPPs. PPP contributions to laboratory systems strengthening are a model and present opportunities that can be leveraged to strengthen systems to achieve the UNAIDS 90-90-90 treatment targets for HIV/AIDS. Despite growing emphasis on engaging the private sector as a critical partner to address global disease burden, PPPs that specifically strengthen laboratories, the cornerstone of public health programs, remain largely untapped. |
Glucose-6-phosphate dehydrogenase (G6PD) deficiency in Ethiopia: absence of common African and Mediterranean allelic variants in a nationwide study
Assefa A , Ali A , Deressa W , Tsegaye W , Abebe G , Sime H , Kebede A , Jima D , Kassa M , Abreha T , Teka H , Solomon H , Malone J , Shi YP , Zhou Z , Reithinger R , Hwang J . Malar J 2018 17 (1) 388 BACKGROUND: Building on the declining trend of malaria in Ethiopia, the Federal Ministry of Health aims to eliminate malaria by 2030. As Plasmodium falciparum and Plasmodium vivax are co-endemic in Ethiopia, the use of primaquine is indicated for both transmission interruption and radical cure, respectively. However, the limited knowledge of the local prevalence of glucose-6-phosphate dehydrogenase (G6PD) deficiency and its associated variants has hindered the use of primaquine. METHODS: Some 11,138 dried blood spot (DBS) samples were collected in 2011 as part of a national, household Malaria Indicator Survey, a multi-stage nationally representative survey of all malaria-endemic areas of Ethiopia. A randomly selected sub-set of 1414 DBS samples was successfully genotyped by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. Considering the geographical position and ethnic mix of the country, three common variants: G6PD*A (A376G), G6PD*A- (G202A) and Mediterranean (C563T) were investigated. RESULTS: Of the 1998 randomly selected individuals, 1429 (71.5%) DBS samples were genotyped and merged to the database, of which 53.5% were from females. G6PD*A (A376G) was the only genotype detected. No sample was positive for either G6PD*A- (G202A) or Mediterranean (C563T) variants. The prevalence of G6PD*A (A376G) was 8.9% [95% confidence interval (CI) 6.7-11.2] ranging from 12.2% in the Southern Nations, Nationalities and Peoples' (95% CI 5.7-18.7) to none in Dire Dawa/Harari Region. CONCLUSION: The common G6PD*A- (G202A) or Mediterranean (C563T) variants were not observed in this nationwide study. The observed G6PD*A (A376G) mutation has little or no clinical significance. These findings supported the adoption of primaquine for P. falciparum transmission interruption and radical cure of P. vivax in Ethiopia. As the presence of other clinically important, less common variants cannot be ruled out, the implementation of radical cure will be accompanied by active haematological and adverse events monitoring in Ethiopia. |
HIV-genetic diversity and drug resistance transmission clusters in Gondar, Northern Ethiopia, 2003-2013.
Arimide DA , Abebe A , Kebede Y , Adugna F , Tilahun T , Kassa D , Assefa Y , Balcha TT , Bjorkman P , Medstrand P . PLoS One 2018 13 (10) e0205446 BACKGROUND: The HIV-1 epidemic in Ethiopia has been shown to be dominated by two phylogenetically distinct subtype C clades, the Ethiopian (C'-ET) and East African (C-EA) clades, however, little is known about the temporal dynamics of the HIV epidemic with respect to subtypes and distinct clades. Moreover, there is only limited information concerning transmission of HIV-1 drug resistance (TDR) in the country. METHODS: A cross-sectional survey was conducted among young antiretroviral therapy (ART)-naive individuals recently diagnosed with HIV infection, in Gondar, Ethiopia, 2011-2013 using the WHO recommended threshold survey. A total of 84 study participants with a median age of 22 years were enrolled. HIV-1 genotyping was performed and investigated for drug resistance in 67 individuals. Phylogenetic analyses were performed on all available HIV sequences obtained from Gondar (n = 301) which were used to define subtype C clades, temporal trends and local transmission clusters. Dating of transmission clusters was performed using BEAST. RESULT: Four of 67 individuals (6.0%) carried a HIV drug resistance mutation strain, all associated with non-nucleoside reverse transcriptase inhibitors (NNRTI). Strains of the C-EA clade were most prevalent as we found no evidence of temporal changes during this time period. However, strains of the C-SA clade, prevalent in Southern Africa, have been introduced in Ethiopia, and became more abundant during the study period. The oldest Gondar transmission clusters dated back to 1980 (C-EA), 1983 (C-SA) and 1990 (C'-ET) indicating the presence of strains of different subtype C clades at about the same time point in Gondar. Moreover, some of the larger clusters dated back to the 1980s but transmissions within clusters have been ongoing up till end of the study period. Besides being associated with more sequences and larger clusters, the C-EA clade sequences were also associated with clustering of HIVDR sequences. One cluster was associated with the G190A mutation and showed onward transmissions at high rate. CONCLUSION: TDR was detected in 6.0% of the sequenced samples and confirmed pervious reports that the two subtype C clades, C-EA and C'-ET, are common in Ethiopia. Moreover, the findings indicated an increased diversity in the epidemic as well as differences in transmission clusters sizes of the different clades and association with resistance mutations. These findings provide epidemiological insights not directly available using standard surveillance and may inform the adjustment of public health strategies in HIV prevention in Ethiopia. |
Epidemiology of measles in the metropolitan setting, Addis Ababa, Ethiopia, 2005-2014: a retrospective descriptive surveillance data analysis
Hassen MN , Woyessa AB , Getahun M , Beyene B , Buluanger L , Ademe A , Bekele A , Addissie A , Kebede A , Jima D . BMC Infect Dis 2018 18 (1) 400 BACKGROUND: Measles is a highly infectious and serious respiratory viral disease which caused by a virus. It is a significant cause of illness and death worldwide. This data analysis was conducted to describe the trend and determine the reporting rate of measles cases in Addis Ababa to make recommendation for the government of the city to strengthening measles control interventions. METHODS: We obtained and extracted ten years (2005-2014) Addis Ababa city's measles surveillance data from national database. We carried out retrospective descriptive data analysis by time, place and person variables. We calculated cumulative and specific reporting rates by dividing measles cases (lab confirmed, epidemiologically linked and compatible cases) to respective population and multiplying by 100,000. We divided average of ten years measles cases to midyear population and multiplied by 100,000 to calculate annualized reporting rate. We analyzed non-measles febrile rash rate by dividing laboratory negative cases to total population and multiplying by 100,000. RESULTS: A total of 4203 suspected measles cases were identified. Among them 1154 (27.5%) were laboratory confirmed, 512 (12.2%) were clinically compatible, 52 (1.2%) were epidemiologically linked cases and the rest 2485 (59.1%) were IgM negative for measles which makes total measles cases 1718 (40.9%). Median age was 5 years with 2-18 years interquartile-range. The annualized measles reporting rate was 5.9, which was 40.2 among > 1 year, 11.5 among 1-4 years, 6.0 among 5-14 years, 4.1 among 15-44 years and 0.01 among >/= 45 years per 100,000 population. Among the total measles cases; 380 (22%) were received at least one dose of measles containing vaccine (MCV) while 415 (24%) cases were not vaccinated and the vaccination status of 923 (54%) cases were not known. CONCLUSION: Our analysis revealed that the reporting rate was higher among young children than older age group. Among all the patients 22% were received at least one dose of measles vaccine whereas 13% were not vaccinated against measles antigen. Routine immunization should be strengthened to reach all children through well monitored vaccine cold chain management. |
Sero-prevalence of yellow fever and related Flavi viruses in Ethiopia: a public health perspective
Mengesha Tsegaye M , Beyene B , Ayele W , Abebe A , Tareke I , Sall A , Yactayo S , Shibeshi ME , Staples E , Belay D , Lilay A , Alemu A , Alemu E , Kume A , HMariam A , Ronveaux O , Tefera M , Kassa W , Bekele Weyessa A , Jima D , Kebede A , Tayachew A . BMC Public Health 2018 18 (1) 1011 BACKGROUND: Yellow fever (YF) is a viral hemorrhagic fever, endemic in the tropical forests of Africa and Central and South America. The disease is transmitted by mosquitoes infected with the yellow fever virus (YFV). Ethiopia was affected by the largest YF outbreak since the vaccination era during 1960-1962. The recent YF outbreak occurred in 2013 in Southern part of the country. The current survey of was carried out to determine the YF seroprevalence so as to make recommendations from YF prevention and control in Ethiopia. METHODOLOGY: A multistage cluster design was utilized. Consequently, the country was divided into 5 ecological zones and two sampling towns were picked per zone randomly. A total of 1643 serum samples were collected from human participants. The serum samples were tested for IgG antibody against YFV using ELISA. Any serum sample testing positive by ELISA was confirmed by plaque reduction neutralization test (PRNT). In addition, differential testing was performed for other flaviviruses, namely dengue, Zika and West Nile viruses. RESULT: Of the total samples tested, 10 (0.61%) were confirmed to be IgG positive against YFV and confirmed with PRNT. Nine (0.5%) samples were antibody positive for dengue virus, 15(0.9%) forWest Nile virus and 7 (0.4%) for Zika virus by PRNT. Three out of the five ecological zones namely zones 1, 3 and 5 showed low levels (< 2%) of IgG positivity against YFV. A total of 41(2.5%) cases were confirmed to be positive for one of flaviviruses tested. CONCLUSION: Based on the seroprevalence data, the level of YFV activity and the risk of a YF epidemic in Ethiopia are low. However additional factors that could impact the likelihood of such an epidemic occurring should be considered before making final recommendations for YF prevention and control in Ethiopia. Based on the results of the serosurvey and other YF epidemic risk factors considered, a preventive mass vaccination campaign is not recommended, however the introduction of YF vaccine in routine EPI is proposed nationwide, along with strong laboratory based YF surveillance. |
Results of a confirmatory mapping tool for Lymphatic filariasis endemicity classification in areas where transmission was uncertain in Ethiopia
Sime H , Gass KM , Mekasha S , Assefa A , Woyessa A , Shafi O , Meribo K , Kebede B , Ogoussan K , Pelletreau S , Bockarie MJ , Kebede A , Rebollo MP . PLoS Negl Trop Dis 2018 12 (3) e0006325 BACKGROUND: The goal of the global lymphatic filariasis (LF) program is to eliminate the disease as a public health problem by the year 2020. The WHO mapping protocol that is used to identify endemic areas in need of mass drug administration (MDA) uses convenience-based sampling. This rapid mapping has allowed the global program to dramatically scale up treatment, but as the program approaches its elimination goal, it is important to ensure that all endemic areas have been identified and have received MDA. In low transmission settings, the WHO mapping protocol for LF mapping has several limitations. To correctly identify the LF endemicity of woredas, a new confirmatory mapping tool was developed to test older school children for circulating filarial antigen (CFA) in settings where it is uncertain. Ethiopia is the first country to implement this new tool. In this paper, we present the Ethiopian experience of implementing the new confirmatory mapping tool and discuss the implications of the results for the LF program in Ethiopia and globally. METHODS: Confirmatory LF mapping was conducted in 1,191 schools in 45 woredas, the implementation unit in Ethiopia, in the regions of Tigray, Amhara, Oromia, SNNP, Afar and Harari, where the results of previous mapping for LF using the current WHO protocol indicated that LF endemicity was uncertain. Within each woreda schools were selected using either cluster or systematic sampling. From selected schools, a total of 18,254 children were tested for circulating filarial antigen (CFA) using the immuno-chromatographic test (ICT). RESULTS: Of the 18,254 children in 45 woredas who participated in the survey, 28 (0.16%) in 9 woredas tested CFA positive. According to the confirmatory mapping threshold, which is >/=2% CFA in children 9-14 years of age, only 3 woredas out of the total 45 had more CFA positive results than the threshold and thus were confirmed to be endemic; the remaining 42 woredas were declared non-endemic. These results drastically decreased the estimated total population living in LF-endemic woredas in Ethiopia and in need of MDA by 49.1%, from 11,580,010 to 5,893,309. CONCLUSION: This study demonstrated that the new confirmatory mapping tool for LF can benefit national LF programs by generating information that not only can confirm where LF is endemic, but also can save time and resources by preventing MDA where there is no evidence of ongoing LF transmission. |
The role of national committees in eliminating onchocerciasis
Griswold E , Unnasch T , Eberhard M , Nwoke BEB , Morales Z , Muheki Tukahebwa E , Kebede B , Anagbogu I , Katabarwa M , Habomugisha P , Tadesse Z , Miri ES , Evans D , Cohn D , Elhassan E , Richards F . Int Health 2018 10 i60-i70 National onchocerciasis elimination committees (NOECs) serve to help ministries of health complete the pathway to successful verification of elimination of onchocerciasis (river blindness), as outlined in the 2016 World Health Organization guidelines. These guidelines, however, only take effect when the country believes it has reached a point that elimination can be demonstrated, and do not address the preceding milestones. Therefore, NOECs can be of great help with guiding and tailoring earlier planning, programming and assessments to empower national programs to aggressively move toward their countries' elimination goals. In this article, we provide suggestions for organizing NOECs and examples of four such committees that have successfully operated in Africa and the Americas. |
Insecticide resistance in Anopheles arabiensis from Ethiopia (2012-2016): a nationwide study for insecticide resistance monitoring
Messenger LA , Shililu J , Irish SR , Anshebo GY , Tesfaye AG , Ye-Ebiyo Y , Chibsa S , Dengela D , Dissanayake G , Kebede E , Zemene E , Asale A , Yohannes M , Taffese HS , George K , Fornadel C , Seyoum A , Wirtz RA , Yewhalaw D . Malar J 2017 16 (1) 469 BACKGROUND: Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) remain the cornerstones of malaria vector control. However, the development of insecticide resistance and its implications for operational failure of preventative strategies are of concern. The aim of this study was to characterize insecticide resistance among Anopheles arabiensis populations in Ethiopia and describe temporal and spatial patterns of resistance between 2012 and 2016. METHODS: Between 2012 and 2016, resistance status of An. arabiensis was assessed annually during the long rainy seasons in study sites from seven of the nine regions in Ethiopia. Insecticide resistance levels were measured with WHO susceptibility tests and CDC bottle bioassays using insecticides from four chemical classes (organochlorines, pyrethroids, organophosphates and carbamates), with minor variations in insecticides tested and assays conducted between years. In selected sites, CDC synergist assays were performed by pre-exposing mosquitoes to piperonyl butoxide (PBO). In 2015 and 2016, mosquitoes from DDT and deltamethrin bioassays were randomly selected, identified to species-level and screened for knockdown resistance (kdr) by PCR. RESULTS: Intense resistance to DDT and pyrethroids was pervasive across Ethiopia, consistent with historic use of DDT for IRS and concomitant increases in insecticide-treated net coverage over the last 15 years. Longitudinal resistance trends to malathion, bendiocarb, propoxur and pirimiphos-methyl corresponded to shifts in the national insecticide policy. By 2016, resistance to the latter two insecticides had emerged, with the potential to jeopardize future long-term effectiveness of vector control activities in these areas. Between 2015 and 2016, the West African (L1014F) kdr allele was detected in 74.1% (n = 686/926) of specimens, with frequencies ranging from 31 to 100% and 33 to 100% in survivors from DDT and deltamethrin bioassays, respectively. Restoration of mosquito susceptibility, following pre-exposure to PBO, along with a lack of association between kdr allele frequency and An. arabiensis mortality rate, both indicate metabolic and target-site mutation mechanisms are contributing to insecticide resistance. CONCLUSIONS: Data generated by this study will strengthen the National Malaria Control Programme's insecticide resistance management strategy to safeguard continued efficacy of IRS and other malaria control methods in Ethiopia. |
Knowledge and perception towards net care and repair practice in Ethiopia
Zewde A , Irish S , Woyessa A , Wuletaw Y , Nahusenay H , Abdelmenan S , Demissie M , Gulema H , Dissanayake G , Chibsa S , Solomon H , Yenehun MA , Kebede A , Lorenz LM , Ponce-de-Leon G , Keating J , Worku A , Berhane Y . Malar J 2017 16 (1) 396 BACKGROUND: Long-lasting insecticidal nets (LLINs) are a key malaria control intervention. Although LLINs are presumed to be effective for 3 years under field or programmatic conditions, net care and repair approaches by users influence the physical and chemical durability. Understanding how knowledge, perception and practices influence net care and repair practices could guide the development of targeted behavioural change communication interventions related to net care and repair in Ethiopia and elsewhere. METHODS: This population-based, household survey was conducted in four regions of Ethiopia [Amhara, Oromia, Tigray, Southern Nations Nationalities Peoples Region (SNNPR)] in June 2015. A total of 1839 households were selected using multi-stage sampling procedures. The household respondents were the heads of households. A questionnaire was administered and the data were captured electronically. STATA software version 12 was used to analyse the data. Survey commands were used to account for the multi-stage sampling approach. Household descriptive statistics related to characteristics and levels of knowledge and perception on net care and repair are presented. Ordinal logistic regression was used to identify factors associated with net care and repair perceptions. RESULTS: Less than a quarter of the respondents (22.3%: 95% CI 20.4-24.3%) reported adequate knowledge of net care and repair; 24.6% (95% CI 22.7-26.5%) of the respondents reported receiving information on net care and repair in the previous 6 months. Thirty-five per cent of the respondents (35.1%: 95% CI 32.9-37.4%) reported positive perceptions towards net care and repair. Respondents with adequate knowledge on net care and repair (AOR 1.58: 95% CI 1.2-2.02), and those who discussed net care and repair with their family (AOR 1.47: 95% CI 1.14-1.89) had higher odds of having positive perceptions towards net care and repair. CONCLUSIONS: The low level of reported knowledge on net care and repair, as well as the low level of reported positive perception towards net repair need to be addressed. Targeted behavioural change communication campaigns could be used to target specific groups; increased net care and repair would lead to longer lasting nets. |
Laboratory-based performance evaluation of PIMA CD4+ T-lymphocyte count point-of-care by lay-counselors in Kenya
Zeh C , Rose CE , Inzaule S , Desai MA , Otieno F , Humwa F , Akoth B , Omolo P , Chen RT , Kebede Y , Samandri T . J Immunol Methods 2017 448 44-50 BACKGROUND: CD4+ T-lymphocyte count testing at the point-of-care (POC) may improve linkage to care of persons diagnosed with HIV-1 infection, but the accuracy of POC devices when operated by lay-counselors in the era of task-shifting is unknown. We examined the accuracy of Alere's Pima POC device on both capillary and venous blood when performed by lay-counselors and laboratory technicians. METHODS: In Phase I, we compared the perfomance of POC against FACSCalibur for 280 venous specimens by laboratory technicians. In Phase II we compared POC performance by lay-counselors versus laboratory technicians using 147 paired capillary and venous specimens, and compared these to FACSCalibur. Statistical analyses included Bland-Altman analyses, concordance correlation coefficient, sensitivity, and specificity at treatment eligibility thresholds of 200, 350, and 500cells/mul. RESULTS: Phase I: POC sensitivity and specificity were 93.0% and 84.1% at 500cells/mul, respectively. Phase II: Good agreement was observed for venous POC results from both lay-counselors (concordance correlation coefficient (CCC)=0.873, bias -86.4cells/mul) and laboratory technicians (CCC=0.920, bias -65.7cells/mul). Capillary POC had good correlation: lay-counselors (CCC=0.902, bias -71.2cells/mul), laboratory technicians (CCC=0.918, bias -63.0cells/mul). Misclassification at the 500 cells/mul threshold for venous blood was 13.6% and 10.2% for lay-counselors and laboratory technicians and 12.2% for capillary blood in both groups. POC tended to under-classify the CD4 values with increasingly negative bias at higher CD4 values. CONCLUSIONS: Pima results were comparable to FACSCalibur for both venous and capillary specimens when operated by lay-counselors. POC CD4 testing has the potential to improve linkage to HIV care without burdening laboratory technicians in resource-limited settings. |
Comparison of artemether-lumefantrine and chloroquine with and without primaquine for the treatment of Plasmodium vivax infection in Ethiopia: A randomized controlled trial
Abreha T , Hwang J , Thriemer K , Tadesse Y , Girma S , Melaku Z , Assef A , Kassa M , Chatfield MD , Landman KZ , Chenet SM , Lucchi NW , Udhayakumar V , Zhou Z , Shi YP , Kachur SP , Jima D , Kebede A , Solomon H , Mekasha A , Alemayehu BH , Malone JL , Dissanayake G , Teka H , Auburn S , von Seidlein L , Price RN . PLoS Med 2017 14 (5) e1002299 BACKGROUND: Recent efforts in malaria control have resulted in great gains in reducing the burden of Plasmodium falciparum, but P. vivax has been more refractory. Its ability to form dormant liver stages confounds control and elimination efforts. To compare the efficacy and safety of primaquine regimens for radical cure, we undertook a randomized controlled trial in Ethiopia. METHODS AND FINDINGS: Patients with normal glucose-6-phosphate dehydrogenase status with symptomatic P. vivax mono-infection were enrolled and randomly assigned to receive either chloroquine (CQ) or artemether-lumefantrine (AL), alone or in combination with 14 d of semi-supervised primaquine (PQ) (3.5 mg/kg total). A total of 398 patients (n = 104 in the CQ arm, n = 100 in the AL arm, n = 102 in the CQ+PQ arm, and n = 92 in the AL+PQ arm) were followed for 1 y, and recurrent episodes were treated with the same treatment allocated at enrolment. The primary endpoints were the risk of P. vivax recurrence at day 28 and at day 42. The risk of recurrent P. vivax infection at day 28 was 4.0% (95% CI 1.5%-10.4%) after CQ treatment and 0% (95% CI 0%-4.0%) after CQ+PQ. The corresponding risks were 12.0% (95% CI 6.8%-20.6%) following AL alone and 2.3% (95% CI 0.6%-9.0%) following AL+PQ. On day 42, the risk was 18.7% (95% CI 12.2%-28.0%) after CQ, 1.2% (95% CI 0.2%-8.0%) after CQ+PQ, 29.9% (95% CI 21.6%-40.5%) after AL, and 5.9% (95% CI 2.4%-13.5%) after AL+PQ (overall p < 0.001). In those not prescribed PQ, the risk of recurrence by day 42 appeared greater following AL treatment than CQ treatment (HR = 1.8 [95% CI 1.0-3.2]; p = 0.059). At the end of follow-up, the incidence rate of P. vivax was 2.2 episodes/person-year for patients treated with CQ compared to 0.4 for patients treated with CQ+PQ (rate ratio: 5.1 [95% CI 2.9-9.1]; p < 0.001) and 2.3 episodes/person-year for AL compared to 0.5 for AL+PQ (rate ratio: 6.4 [95% CI 3.6-11.3]; p < 0.001). There was no difference in the occurrence of adverse events between treatment arms. The main limitations of the study were the early termination of the trial and the omission of haemoglobin measurement after day 42, resulting in an inability to estimate the cumulative risk of anaemia. CONCLUSIONS: Despite evidence of CQ-resistant P. vivax, the risk of recurrence in this study was greater following treatment with AL unless it was combined with a supervised course of PQ. PQ combined with either CQ or AL was well tolerated and reduced recurrence of vivax malaria by 5-fold at 1 y. TRIAL REGISTRATION: ClinicalTrials.gov NCT01680406. |
Predictors of survival among adult Ethiopian patients in the National ART Program at seven university teaching hospitals: A prospective cohort study
Fekade D , Weldegebreal T , Teklu AM , Damen M , Abdella S , Baraki N , Belayhun B , Berhan E , Kebede A , Assefa Y . Ethiop J Health Sci 2017 27 63-71 BACKGROUND: In Ethiopia, the publicly funded antiretroviral treatment (ART) program was started in 2005. Two hundred seventy-five thousand patients were enrolled in the national ART program by 2012. However, there is limited data on mortality and predictors of death among adult patients in the ART program. The study aimed to estimate mortality and risk factors for death among adult, ART-naive patients, started in the national ART program from January 2009 to July 2013. METHODS: Multi-site, prospective, observational cohort study of adult, age > 18 years, ART-naive patients, started in the national ART program at seven university-affiliated hospitals from January 2009 - July 2013. Kaplan-Meier and Cox regression analyses were used to estimate survival and determine risk factors for death. RESULTS: A total of 976 patients, 594 females (60.9 %), were enrolled into the study. Median age of the cohort was 33years. The median CD4 count at start of ART was 144 cells/microl (interquartile range (IQR) 78-205), and 34.2% (330/965) had CD4 < 100. Sixty-three percent (536/851) had viral load greater than 5 log copies/ml (IQR 4.7-5.7) at base line. One hundred and one deaths were recorded during follow-up period, all-cause mortality rate 10.3%; 5.4 deaths/100 person years of observation, 95% confidence interval 4.4-6.5. Seventy percent of the deaths occurred within six months of starting ART. Cox regression analyses showed that the following measures independently predicted mortality: age >51 years, (Adjusted Hazard Ratio (AHR) 4.01, P=0.003), WHO stages III&IV, (AHR 1.76, p = 0.025), CD4 count, <100, (AHR 2.36, p =0.006), and viral load >5 log copies /ml (CHR 1.71, p = 0.037). CONCLUSION: There is high early on- ART mortality in patients presenting with advanced immunodeficiency. Detecting cases and initiating ART before onset of advanced immunodeficiency might improve survival. |
Combatting global infectious diseases: A network effect of specimen referral systems
Fonjungo PN , Alemnji GA , Kebede Y , Opio A , Mwangi C , Spira TJ , Beard RS , Nkengasong JN . Clin Infect Dis 2017 64 (6) 796-803 The recent Ebola virus outbreak in West Africa clearly demonstrated the critical role of laboratory systems and networks in responding to epidemics. Because of the huge challenges in establishing functional laboratories at all tiers of health systems in developing countries, strengthening specimen referral networks is critical. In this review article, we propose a platform strategy for developing specimen referral networks based on 2 models: centralized and decentralized laboratory specimen referral networks. These models have been shown to be effective in patient management in programs in resource-limited settings. Both models lead to reduced turnaround time and retain flexibility for integrating different specimen types. In Haiti, decentralized specimen referral systems resulted in a 182% increase in patients enrolling in human immunodeficiency virus treatment programs within 6 months. In Uganda, cost savings of up to 62% were observed with a centralized model. A platform strategy will create a network effect that will benefit multiple disease programs. |
Improved specimen-referral system and increased access to quality laboratory services in Ethiopia: The role of the public-private partnership
Kebede Y , Fonjungo PN , Tibesso G , Shrivastava R , Nkengasong JN , Kenyon T , Kebede A , Gadde R , Ayana G . J Infect Dis 2016 213 Suppl 2 S59-64 BACKGROUND: Nonstandardized specimen-transport logistics, lack of laboratory personnel to transport specimens, lack of standard specimen containers, and long turnaround time (TAT) hindered access to quality laboratory services. The objective of the Becton, Dickinson, and Company (BD)-US President's Emergency Plan for AIDS Relief (PEPFAR) Public-Private Partnership (PPP) was to support country-specific programs to develop integrated laboratory systems, services, and quality improvement strategies, with an emphasis on strengthening the specimen-referral system (SRS). METHODS: In 2007, through the Centers for Disease Control and Prevention (CDC), the Ethiopian Public Health Institute (EPHI) joined with the BD-PEPFAR PPP to strengthen laboratory systems. A joint planning and assessment committee identified gaps in the SRS for prioritization and intervention and piloted the system in Addis Ababa and Amhara Region. RESULTS: The PPP established standardized, streamlined specimen logistics, using the Ethiopian Postal Service Enterprise to support a laboratory network in which 554 facilities referred specimens to 160 laboratories. The PPP supported procuring 400 standard specimen containers and the training of 586 laboratory personnel and 81 postal workers. The average TAT was reduced from 7 days (range, 2-14 days) to 2 days (range, 1-3 days) in Addis Ababa and from 10 days (range, 6-21 days) to 5 days (range, 2-6 days) in Amhara Region. CONCLUSIONS: This study highlights the feasibility and untapped potential of PPPs to strengthen laboratory systems. This planned and structured approach to improving specimen referral enhanced access to quality laboratory services. |
Detection of Onchocerca volvulus in Skin Snips by Microscopy and Real-Time Polymerase Chain Reaction: Implications for Monitoring and Evaluation Activities.
Thiele EA , Cama VA , Lakwo T , Mekasha S , Abanyie F , Sleshi M , Kebede A , Cantey PT . Am J Trop Med Hyg 2016 94 (4) 906-11 Microscopic evaluation of skin biopsies is the monitoring and evaluation (M and E) method currently used by multiple onchocerciasis elimination programs in Africa. However, as repeated mass drug administration suppresses microfilarial loads, the sensitivity and programmatic utility of skin snip microscopy is expected to decrease. Using a pan-filarial real-time polymerase chain reaction with melt curve analysis (qPCR-MCA), we evaluated 1) the use of a single-step molecular assay for detecting and identifying Onchocerca volvulus microfilariae in residual skin snips and 2) the sensitivity of skin snip microscopy relative to qPCR-MCA. Skin snips were collected and examined with routine microscopy in hyperendemic regions of Uganda and Ethiopia (N = 500 each) and "residual" skin snips (tissue remaining after induced microfilarial emergence) were tested with qPCR-MCA. qPCR-MCA detected Onchocerca DNA in 223 residual snips: 139 of 147 microscopy(+) and 84 among microscopy(-) snips, suggesting overall sensitivity of microscopy was 62.3% (139/223) relative to qPCR-MCA (75.6% in Uganda and 28.6% in Ethiopia). These findings demonstrate the insufficient sensitivity of skin snip microscopy for reliable programmatic monitoring. Molecular tools such as qPCR-MCA can augment sensitivity and provide diagnostic confirmation of skin biopsies and will be useful for evaluation or validation of new onchocerciasis M and E tools. |
Metals exposures of residents living near the Akaki river in Addis Ababa, Ethiopia: A cross-sectional study
Yard E , Bayleyegn T , Abebe A , Mekonnen A , Murphy M , Caldwell KL , Luce R , Hunt DR , Tesfaye K , Abate M , Assefa T , Abera F , Habte K , Chala F , Lewis L , Kebede A . J Environ Public Health 2015 2015 935297 BACKGROUND: The Akaki River in Ethiopia has been found to contain elevated levels of several metals. Our objectives were to characterize metals exposures of residents living near the Akaki River and to assess metal levels in their drinking water. METHODS: In 2011, we conducted a cross-sectional study of 101 households in Akaki-Kality subcity (near the Akaki River) and 50 households in Yeka subcity (distant to the Akaki River). One willing adult in each household provided urine, blood, and drinking water sample. RESULTS: Urinary molybdenum (p < 0.001), tungsten (p < 0.001), lead (p < 0.001), uranium (p < 0.001), and mercury (p = 0.049) were higher in Akaki-Kality participants compared to Yeka participants. Participants in both subcities had low urinary iodine; 45% met the World Health Organization (WHO) classification for being at risk of moderate iodine deficiency. In Yeka, 47% of households exceeded the WHO aesthetic-based reference value for manganese; in Akaki-Kality, only 2% of households exceeded this value (p < 0.001). There was no correlation between metals levels in water samples and clinical specimens. CONCLUSIONS: Most of the exposures found during this investigation seem unlikely to cause acute health effects based on known toxic thresholds. However, toxicity data for many of these metals are very limited. |
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