Escherichia coli isolates from vegetable farms in Addis Ababa, Ethiopia: Antimicrobial susceptibility profile and associated resistance genetic markers.

The use of animal manure to fertilize soil is an emerging concern contributing to the transfer of antimicrobial-resistant pathogens to vegetables. Hence, assessing antimicrobial susceptibility profile of Escherichia coli in vegetable farms is essential to design appropriate interventions against antimicrobial resistance (AMR) in the food chain. This study assessed antimicrobial resistance profile and associated genetic markers among E. coli isolated from vegetable farms fertilized with animal manure in Addis Ababa, Ethiopia. A total of 1044 samples were collected using convenience sampling: soil (n = 271), manure (n = 375), and vegetables (n = 398) from 81 vegetable farms in Addis Ababa, Ethiopia. Antimicrobial susceptibility test was conducted for 100 E. coli isolates and antimicrobial resistance genes (ARGs) were tested by polymerase chain reaction (PCR). Of the 1044 collected samples, 25.3% were positive for E. coli, with significantly higher prevalence in the manure sample and samples collected from Akaki Kality sub-city (p < .05). The highest resistance rate was recorded for tetracycline (72%), followed by streptomycin (63%), and sulfamethoxazole +trimethoprim (56%). Multidrug resistance was detected in 61% of the E. coli isolates. The aac(3)-IV (76.9%), bla TEM (65.4%), aadA (60.3%), tet(A) (58.3%), and sulI (51.7%) were the commonly detected resistance genes. The current study showed a high burden of antimicrobial resistance among E. coli isolated from manure-amended vegetable farms, with potential of playing a significant role in the dissemination of antimicrobial resistance in the food chain. Efforts should be made to reduce the burden of resistant organisms and ARGs through prudent use of antimicrobials in livestock and application of appropriate composting techniques before using manure as fertilizer.

Barriers and enablers to improving integrated primary healthcare for non-communicable diseases and mental health conditions in Ethiopia: a mixed methods study.

BACKGROUND: The Ethiopian Primary Healthcare Clinical Guidelines (EPHCG) seek to improve quality of primary health care, while also expanding access to care for people with Non-Communicable Diseases and Mental Health Conditions (NCDs/MHCs). The aim of this study was to identify barriers and enablers to implementation of the EPHCG with a particular focus on NCDs/MHCs. METHODS: A mixed-methods convergent-parallel design was employed after EPHCG implementation in 18 health facilities in southern Ethiopia. Semi-structured interviews were conducted with 10 primary healthcare clinicians and one healthcare administrator. Organisational Readiness for Implementing Change (ORIC) questionnaire was self-completed by 124 health workers and analysed using Kruskal Wallis ranked test to investigate median score differences. Qualitative data were mapped to the Consolidated Framework for Implementation Science (CFIR) and the Theoretical Domains Framework (TDF). Expert Recommendations for Implementing Change (ERIC) were employed to select implementation strategies to address barriers. RESULTS: Four domains were identified: EPHCG training and implementation, awareness and meeting patient needs (demand side), resource constraints/barriers (supply side) and care pathway bottlenecks. The innovative facility-based training to implement EPHCG had a mixed response, especially in busy facilities where teams reported struggling to find protected time to meet. Key barriers to implementation of EPHCG were non-availability of resources (CFIR inner setting), such as laboratory reagents and medications that undermined efforts to follow guideline-based care, the way care was structured and lack of familiarity with providing care for people with NCDs-MHCs. Substantial barriers arose because of socio-economic problems that were interlinked with health but not addressable within the health system (CFIR outer setting). Other factors influencing effective implementation of EPHCG (TDF) included low population awareness about NCDs/MHCs and unaffordable diagnostic and treatment services (TDF). Implementation strategies were identified. ORIC findings indicated high scores of organisational readiness to implement the desired change with likely social desirability bias. CONCLUSION: Although perceived as necessary, practical implementation of EPHCG was constrained by challenges across domains of internal/external determinants. This was especially marked in relation to expansion of care responsibilities to include NCDs/MHCs. Attention to social determinants of health outcomes, community engagement and awareness-raising are needed to maximize population impact.

The importance of self-management for better treatment outcomes for HIV patients in a low-income setting: perspectives of HIV experts and service providers.

BACKGROUND: Self-management is the most important strategy to improve quality of life in patients with a chronic disease. Despite the increasing number of people living with HIV (PLWH) in low-income countries, very little research on self-management is conducted in this setting. The aim of this research is to understand the perspectives of service providers and experts on the importance of self-management for PLWH. METHODS: A systematizing expert interview type of qualitative methodology was used to gain the perspectives of experts and service providers. The study participants had experience in researching, managing, or providing HIV service in east and southern African (ESA) countries. All the interviews were audio recorded, transcribed, and translated to English. The quality of the transcripts was ensured by randomly checking the texts against the audio record. A thematic analysis approach supported by Atlas TI version 9 software. RESULT: PLWH face a variety of multi-dimensional problems thematized under contextual and process dimensions. The problems identified under the contextual dimension include disease-specific, facility-related, and social environment-related. Problems with individual origin, such as ignorance, outweighing beliefs over scientific issues, low self-esteem, and a lack of social support, were mostly highlighted under the process dimensions. Those problems have a deleterious impact on self-management, treatment outcomes, and the quality of life of PLWH. Low self-management is also a result of professional-centered service delivery in healthcare facilities and health service providers' incapacity to comprehend a patient's need beyond the medical concerns. Participants in the study asserted that patients have a significant stake in enhancing treatment results and quality of life through enhancing self-management. CONCLUSION AND RECOMMENDATION: HIV patients face multifaceted problems beyond their medical issues. The success of medical treatment for HIV is strongly contingent upon patients' self-management practices and the supportive roles of their family, society, and health service providers. The development and integration of self-management practices into clinical care will benefit patients, their families, and the health system.

Prevalence and Antimicrobial Susceptibility Profile of Salmonella from Poultry Farms and In-Contact Humans and Associated Risk Factors in Addis Ababa, Ethiopia.

Poultry and poultry products are the common sources of Salmonella,which is one of the serious food-borne bacterial diseases in humans. Little is known about the status of Salmonella and their antimicrobial susceptibility in poultry farms in Addis Ababa. This study was conducted to estimate the prevalence and antimicrobial susceptibility of Salmonella isolates and to investigate possible risk factors for the occurrence of Salmonella in poultry farms in Addis Ababa. We recruited 58 poultry farms, from which 471 poultry-related samples and 44 stool samples from in-contact humans were collected. The isolates were tested for their susceptibility to 11 antimicrobials using the Kirby-Bauer disk diffusion assay. The farm-level prevalence of Salmonella was 36.2% and the sample-level prevalence was 6.4% for samples taken from poultry farms and 4.5% in human stool samples who have contact with poultry. On-farm waste disposal practices and chicken being purchased from different multiplication farms were significantly associated with Salmonella positivity of the farms (p < 0.05). Eleven (34.4%) Salmonella isolates were resistant to streptomycin, and nine (28.1%) were resistant to tetracycline. Thirteen (40.6%) Salmonella isolates were resistant to two or more antimicrobials tested in this study, whereas resistance to 3 or more antimicrobials was detected in seven (21.9%) isolates. In conclusion, a high prevalence of Salmonella and a high rate of resistance to multiple antimicrobials were detected in poultry farms in Addis Ababa. Hence, implementation of strong biosecurity measures and rational use of antimicrobials are recommended.

Childhood Intestinal Parasitic Reinfection, Sanitation and Hygiene Practice in Eastern Ethiopia: Case Control Study.

Background: The recurrence of intestinal parasitic infections (IPIs) can lead to different problems that can be transferred from generation to generation. Sanitation and hygienic practices have vital role in the parasitic reinfection. In poor hygienic and sanitation condition children may live in a continuous cycle of infection and reinfection. Objective: To assess childhood IP reinfection and its association with sanitation and hygienic practice in eastern Ethiopia. Methods: A population-based case-control design was used in this study. Data were collected from 75 reinfected cases and 147 unmatched controls. Fecal specimens were observed for parasites using direct smear and formol ether techniques. Epi-Info and SPSS (the statistical package for social science) were used for data entry and analysis, respectively. Logistic regression analysis was conducted to identify significant associations (P<0.05) between variables. Results: The overall IP reinfection rate within 24 weeks after treatment was 33.8% (75/222), with a 95% CI=27.7%-40.5%. The frequency of intestinal protozoa was 18%, and for helminths was 15.8%. Children who swam in a polluted water had 3.7 times greater odds of IP reinfection than children who did not swim (P =0.01, 95% CI: 1.4-10.0). Children who regularly bathed in streams and children who bathed both at home and in streams were found to have 12.6 times and 5.8 times higher odds of IP reinfection than children who bathed regularly at home (P=0.002, 95% CI:2.5-64.8) and (P = 0.042, 95% CI:1.1-31.3), respectively. Children in households that owned domestic animals had 4.5 times higher odds of IP reinfection than the reference group (P = 0.013, 95% CI: 1.3-12.5). Conclusion: IP reinfection rates were significantly associated with habits of swimming in a polluted water, places of bathing, and ownership of domestic animals. Therefore, efforts should be made considering such factors to minimize IP reinfection in the area.

Impact of depression on self-efficacy, illness perceptions and self-management among people with type 2 diabetes: A systematic review of longitudinal studies.

BACKGROUND: Treating comorbid depression does not always improve outcomes for people with type 2 diabetes. Evidence is lacking on potential psychological and behavioural intermediaries of the impact of depression on diabetes outcomes. OBJECTIVE: To synthesise evidence on the impact of comorbid depression on self-efficacy, illness perceptions, and self-management in people with type 2 diabetes. DATA SOURCES: We searched PubMed, Embase, PsycINFO, and Global Health databases from inception up to 29th March 2023. STUDY ELIGIBILITY CRITERIA: Only prospective studies (cohort or intervention studies) were included, with no restrictions on language. The outcomes were self-efficacy, illness perceptions, and self-management. PARTICIPANTS: People with type 2 diabetes in community or health settings. EXPOSURE: Comorbid depression or depressive symptoms in people with type 2 diabetes. SYNTHESIS OF RESULTS: A narrative review of heterogeneous studies. RISK OF BIAS: The risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) quality assessment tool for quantitative studies. RESULTS: Twenty-five studies were included, all from high-income countries. Depression was associated with lower self-efficacy (2 studies), poor illness perception (1 study), and poor self-management practices (17 studies) in people with type 2 diabetes. In 6/7 studies, depressive symptoms predicted less adherence to dietary recommendations, 8/10 studies found depressive symptoms were associated with poor medication adherence, 1/3 study found that depressive symptoms were associated with poor weight control, 3/4 with less physical exercise, and 2/3 with general self-care practices. LIMITATIONS: There were no studies from low- and middle-income countries and non-Western settings, and we cannot assume the mechanisms linking comorbid depression with diabetes outcomes are similar. CONCLUSIONS: Comorbid depression was associated with lower self-efficacy, poorer self-management, and less adaptive illness perceptions among people with diabetes.

Antibiogram of Escherichia coli Isolated from Dairy Cattle and in-Contact Humans in Selected Areas of Central Ethiopia.

Background: Antimicrobial resistance (AMR) is a global threat to public and animal health. Escherichia coli is considered an indicator organism for monitoring AMR among gram-negative Enterobacteriaceae in humans and animals. The current study aims to assess the antibiogram profile of E. coli isolated from dairy cattle and in-contact humans in central Ethiopia and to identify risk factors associated with multidrug resistance (MDR). Methods: A cross-sectional study was conducted in which 58 farms were recruited from selected districts of central Ethiopia. E. coli was isolated using standard bacteriological techniques. A total of 200 representative isolates (140 from cattle and 60 from humans in contact) were randomly selected and tested for susceptibility to a panel of 13 antimicrobials using the Kirby-Bauer disc diffusion assay. Results: The highest rate of resistance was observed for sulfamethoxazole+trimethoprim (58.6%, 82/140) and amoxicillin+clavulanic acid (70.0%, 42/60) among E. coli isolates from cattle and hmans, respectively. In contrast, resistance rates in isolates from in contact humans with the cattle were 30%, 33.3%, and 66.7%, respectively. Resistance to tetracycline (p=0.02), streptomycin (p=0.03), and sulfamethoxazole+trimethoprim (p=0.007) was significantly high in E. coli isolated from cattle on commercial dairy farms than in those isolated from cattle on smallholder farms. There was no significant difference (p>0.05) in the rate of resistance between E. coli isolated from in contact humans with smallholder and commercial dairy farms. Antimicrobial use for treatment purpose (p=0.04) and non-compliance with the drug withdrawal period (p=0.03) were significantly associated with the farm-level occurrence of MDR. Conclusion: A high rate of resistance was detected in E. coli isolated from the feces of dairy cattle and in-contact humans. This necessitates an effective intervention through a one-health approach and further molecular studies are required to establish source attribution.

Food insecurity and perinatal depression among pregnant women in BUNMAP cohort in Ethiopia: a structural equation modelling.

OBJECTIVE: To assess the effect of food insecurity on perinatal depression in rural Ethiopia. DESIGN: We used a prospective cohort in which food insecurity was considered as primary exposure and perinatal depression as an outcome. Food insecurity at baseline (in the period of 8-24 weeks of pregnancy) was measured using the Household Food Insecurity Access Scale (HFIAS), and perinatal depression at follow-up (in 32-36 weeks of pregnancy) was measured using a Patient Health Questionnaire (PHQ-9). We used multivariable regression to assess the effect of food insecurity on the prevalence of perinatal depression. We explored food insecurity's direct and indirect impacts on perinatal depression using structural equation modelling (SEM). SETTING: This paper used data from the Butajira Nutrition, Mental Health and Pregnancy (BUNMAP) cohort established under the Butajira Health and Demographic Surveillance Site (BHDSS). PARTICIPANTS: Seven hundred and fifty-five pregnant women. RESULTS: Among the study participants, 50 % were food-insecure, and about one-third were depressed at 32-36 follow-up. In SEM, higher values of baseline food insecurity, depressive symptoms and state-trait anxiety (STA) were positively and significantly associated with perinatal depression. The direct impact of food insecurity on perinatal depression accounts for 42 % of the total effect, and the rest accounted for the indirect effect through baseline depression (42 %) and STA (16 %). CONCLUSION: The significant effect of food insecurity at baseline on perinatal depression and the indirect effect of baseline food insecurity through baseline anxiety and depression in the current study implies the importance of tailored interventions for pregnant women that consider food insecurity and psychosocial problems.

Compliance with infection prevention and control standard precautions and factors associated with noncompliance among healthcare workers working in public hospitals in Addis Ababa, Ethiopia.

BACKGROUND: Standard Precautions (SPs) are the minimal infection prevention and control (IPC) measures that apply to all patient care activities at all times, regardless of whether the patient has a suspected or proven disease, in any place where healthcare service is provided. These evidence-based practices protect healthcare workers (HCWs) from infection while preventing the spread of infectious agents among patients, visitors, and the environment. OBJECTIVES: Assessed compliance of HCWs working in public hospitals in Addis Ababa to infection prevention and control SPs, and factors associated with noncompliance. METHODS: In a hospital-based cross-sectional study, 422 HCWs were recruited from nine public hospitals in Addis Ababa using a stratified random sampling technique. Data were collected using self-administered questionnaires, entered into a computer using Epi data, and analyzed using SPSS version 25. The association between the independent and the outcome variables was investigated using logistic regression. Odd ratios with corresponding 95% confidence intervals (CI) were used as measures of the strength of the association between the outcome and the explanatory variables. A p-value below 5% was considered an indicator of statistical significance. RESULTS: The level of knowledge of HCWs about IPC and SPs was 51.9% and 36.49% of the respondents were compliant with SPs. Receiving IPC Training [Adjusted Odds Ratio (AOR) = 1.81, 95% CI 1.06, 3.09], knowing SPs [AOR = 3.46, 95% CI = 1.83, 6.54], presence of a mechanism in the hospital to enforce the IPC practices [AOR = 1.71 95% CI = 1.01, 2.89], and availability of cleaning and disinfection chemicals in the hospital [AOR = 2.18, 95%CI = 1.15, 4.13] were significantly associated with the HCWs' compliance with SPs. CONCLUSION: Compliance with IPC standard precautions of HCWs in public hospitals of Addis Ababa is suboptimal. Working in medical units, less work experience, lack of training, poor knowledge, absence of a mechanism to enforce adherence, and inadequate resources are independent predictors for non-compliance of the HCWs.

Delays to treatment initiation and emergence of drug resistance among new adult tuberculosis patients in Tigray, Northern Ethiopia.

Introduction. Studies in Ethiopia have indicated that tuberculosis (TB) patient's elapsed a long time before initiating treatment.Gap Statement. However, there is very limited evidence on the association of treatment initiation delay with drug resistance.Research Aim. To investigate the association of delayed treatment initiation with drug resistance among newly diagnosed TB patients in Tigray, Ethiopia.Methods. We conducted a follow-up study from October 2018 to June 2020 by recruiting 875 pulmonary tuberculosis (PTB) patients from 21 randomly selected health facilities. Delays to initiate treatment and drug resistance were collected using a standardized questionnaire and standard laboratory investigation. The association of delay to initiate treatment with acquired drug resistance was modelled using penalized maximum-likelihood (PML) regression models. Data were analysed using stata software version 15. Statistical significance was reported whenever the P-value was less than 0.05.Result. The median total delay to treatment initiation was 62 days with an inter-quartile range of 16-221 days. A unit change in time to initiate treatment reduced the risk of acquired drug resistance by 3 %. Being smear-positive at the end of treatment and after 2 months of treatment initiation were significantly associated with a higher risk of acquired drug resistance. Whereas, having a mild clinical condition was associated with a lower risk of drug resistance.Conclusion. Time to treatment initiation delay is associated with an increased risk of the emergence of drug resistance. Efforts targeted towards reducing the negative effects of PTB should focus on reducing the length of delay to initiate treatment.

Developing interventions to improve detection of depression in primary healthcare settings in rural Ethiopia.

BACKGROUND: The poor detection of depression in primary healthcare (PHC) in low- and middle-income countries continues to threaten the plan to scale up mental healthcare coverage. AIMS: To describe the process followed to develop an intervention package to improve detection of depression in PHC settings in rural Ethiopia. METHOD: The study was conducted in Sodo, a rural district in south Ethiopia. The Medical Research Council's framework for the development of complex interventions was followed. Qualitative interviews, observations of provider-patient communication, intervention development workshops and pre-testing of the screening component of the intervention were conducted to develop the intervention. RESULTS: A multicomponent intervention package was developed, which included (a) manual-based training of PHC workers for 10 days, adapted from the World Health Organization's Mental Health Gap Action Programme Intervention Guide, with emphasis on depression, locally identified depressive symptoms, communication skills, training by people with lived experience and active learning methods; (b) screening for culturally salient manifestations of depression, using a four-item tool; (c) raising awareness among people attending out-patient clinics about depression, using information leaflets and health education; and (d) system-level interventions, such as supportive supervision, use of posters at health facilities and a decision support mobile app. CONCLUSIONS: This contextualised, multicomponent intervention package may lead to meaningful impact on the detection of depression in PHC in rural Ethiopia and similar settings. The intervention will be pilot tested for feasibility, acceptability and effectiveness before its wider implementation.

Antimicrobial Susceptibility and Characterization of Extended-Spectrum ß-Lactamase-Producing Escherichia coli Isolated from Stools of Primary Healthcare Patients in Ethiopia.

Antimicrobial resistance of Escherichia coli is a growing problem in both developed and developing countries. This study aimed to investigate the phenotypic antimicrobial resistance of E. coli isolates (n = 260) isolated from the stool specimen of patients attending public health facilities in Addis Ababa and Hossana. This study also aimed to characterize phenotypically confirmed extended-spectrum beta-lactamase (ESBL)-producing E. coli isolates (n = 22) using whole-genome sequencing. Resistance to 18 different antimicrobials was assessed using the disc diffusion method according to the European Committee on Antimicrobial Susceptibility Testing (EUCAST) guidelines. The highest resistance rate among the E. coli isolates was found for ampicillin (52.7%), followed by trimethoprim-sulfamethoxazole (29.6%). Of all isolates, 50 (19.2%) were multidrug-resistant and 22 (8.5%) were ESBL producers. ESBL genes were detected in 94.7% of the sequenced E. coli isolates, and multiple ß-lactamase genes were detected in 57.9% of the isolates. The predominant ESBL gene identified was blaCTX-M-15 (78.9%). The blaTEM-1B gene was detected in combination with other ESBL genes in 57.9% of the isolates, while only one of the sequenced isolates contained the blaTEM-1B gene alone. The blaCTX-M-3 gene was detected in three isolates. The genes blaCTX-M-15 and blaTEM-1B as well as blaCTX-M-15 and blaTEM-169 were confirmed to coexist in 52.6% and 10.5% of the sequenced E. coli isolates, respectively. In addition, blaOXA-1 was identified together with blaCTX-M-15 and blaTEM-1B in one isolate, and in one isolate, blaTEM-169 together with blaCTX-M-15 and blaTEM-1B was found. The results obtained show that measures need to be taken to reduce the spread of drug resistance and ensure the long-term use of available antimicrobials.

Experiences of people living with HIV in low- and middle-income countries and their perspectives in self-management: a meta-synthesis.

INTRODUCTION: Availability of anti-retroviral treatment has changed HIV in to a manageable chronic disease, making effective self-management essential. However, only a few studies in low- and middle-income countries (LMICs) reported experiences of people living with HIV (PLWH) on self-management. METHODS: This meta-synthesis of qualitative studies investigated perspectives of PLWH in LMICs on self-management. Various databases, including PubMed, EMBASE, EBSCO, and CINHAL, were searched through June 2022. Relevant additional articles were also included using cross-referencing of the identified papers. We used a thematic synthesis guided by the "Model of the Individual and Family Self-Management Theory" (IFSMT). RESULT: PLWH in LIMICs experience a variety of challenges that restrict their options for effective self-management and compromises their quality of life. The main ones include: misconceptions about the disease, poor self-efficacy and self-management skills, negative social perceptions, and a non-patient-centered model of care that reduces the role of patients. The experiences that influenced the ability to practice self-management are summarized in context (the condition itself, physical and environmental factors, individual and family factors) and process factors (knowledge and beliefs, relationship with the health care worker, self-regulation skills and abilities, and social facilitation). Context and process greatly impacted quality of life through the self-management practices of the patients. CONCLUSION AND RECOMMENDATION: PLWH encounter multiple challenges, are not empowered enough to manage their own chronic condition, and their needs beyond medical care are not addressed by service providers. Self-management practice of these patients is poor, and service providers do not follow service delivery approaches that empower patients to be at the center of their own care and to achieve an effective and sustainable outcome from treatment. These findings call for a comprehensive well thought self-management interventions.

Impact of quality improvement interventions on facility readiness, quality and uptake of maternal and child health services in developing regions of Ethiopia: a secondary analysis of programme data.

BACKGROUND: Quality improvement intervention (QI) was implemented from 2018 to 2021 in health facilities of developing regional states of Ethiopia. The main objective of this study was to examine the impact of QI interventions on facility readiness, service availability, quality and usage of health services in these regions. METHODS: We used district health information system data of 56 health facilities (HFs). We also used baseline and endline QI monitoring data from 28 HFs. Data were summarised using descriptive statistics and various tests. Regression analysis was employed to examine the impact of QI interventions on various outcomes. RESULT: The QI intervention improved readiness of HFs, service availability and quality of maternal and child health service delivery. The mean availability of basic amenities increased from 1.89 to 2.89; HF cleanliness score increased from 4.43 to 5.96; family planning method availability increased from 4 to 5.75; score for emergency drugs at labour ward increased from 5.32 to 7.00; and the mean score for basic emergency obstetric and newborn care service availability increased from 5.68 to 6.75; intrauterine contraceptive devices removal service increased from 39.3% to 82.1%; and partograph use increased from 53.6% to 92.9%. HFs that use partograph for labour management increased by 39.3%. The QI intervention increased the quality of antenatal care by 29.3%, correct partograph use by 51.7% and correct active third-stage labour management, a 19.6% improvement from the baseline. The interventions also increased the service uptake of maternal health services, but not significantly associated with improvement in contraceptive service uptake. CONCLUSION: The integrated QI interventions in HFs could have an impact on facility readiness for service delivery, service accessibility and quality of service delivery. The effectiveness of the QI intervention should be evaluated using robust methods, and efforts to enhance contraceptive services through a QI approach requires further study.

Genomic transmission clusters and circulating lineages of Mycobacterium tuberculosis among refugees residing in refugee camps in Ethiopia.

BACKGROUND: Understanding the transmission dynamics of Mycobacterium tuberculosis (Mtb) could benefit the design of tuberculosis (TB) prevention and control strategies for refugee populations. Whole Genome Sequencing (WGS) has not yet been used to document the Mtb transmission dynamics among refugees in Ethiopia. We applied WGS to accurately identify transmission clusters and Mtb lineages among TB cases in refugee camps in Ethiopia. METHOD AND DESIGN: We conducted a cross-sectional study of 610 refugees in refugee camps in Ethiopia presenting with symptoms of TB. WGS data of 67 isolates was analyzed using the Maximum Accessible Genome for Mtb Analysis (MAGMA) pipeline; iTol and FigTree were used to visualize phylogenetic trees, lineages, and the presence of transmission clusters. RESULTS: Mtb culture-positive refugees originated from South Sudan (52/67, 77.6%), Somalia (9/67, 13.4%). Eritrea (4/67, 6%), and Sudan (2/67, 3%). The majority (52, 77.6%) of the isolates belonged to Mtb lineage (L) 3, and one L9 was identified from a Somalian refugee. The vast majority (82%) of the isolates were pan-susceptible Mtb, and none were multi-drug-resistant (MDR)-TB. Based on the 5-single nucleotide polymorphisms cutoff, we identified eight potential transmission clusters containing 23.9% of the isolates. Contact investigation confirmed epidemiological links with either family or social interaction within the refugee camps or with neighboring refugee camps. CONCLUSION: Four lineages (L1, L3, L4, and L9) were identified, with the majority of strains being L3, reflecting the Mtb L3 dominance in South Sudan, where the majority of refugees originated from. Recent transmission among refugees was relatively low (24%), likely due to the short study period. The improved understanding of the Mtb transmission dynamics using WGS in refugee camps could assist in designing effective TB control programs for refugees.

Community-based rehabilitation intervention for people with schizophrenia in Ethiopia (RISE) cluster-randomised controlled trial: An exploratory analysis of impact on food insecurity, underweight, alcohol use disorder and depressive symptoms.

We evaluated the effectiveness of community-based rehabilitation (CBR) in reducing depressive symptoms, alcohol use disorder, food insecurity and underweight in people with schizophrenia. This cluster-randomised controlled trial was conducted in a rural district of Ethiopia. Fifty-four sub-districts were allocated in a 1:1 ratio to the facility-based care [FBC] plus CBR arm and the FBC alone arm. Lay workers delivered CBR over 12 months. We assessed food insecurity (self-reported hunger), underweight (BMI< 18.5 kg/m2), depressive symptoms (PHQ-9) and alcohol use disorder (AUDIT ≥ 8) at 6 and 12 months. Seventy-nine participants with schizophrenia in 24 sub-districts were assigned to CBR plus FBC and 87 participants in 24 sub-districts were assigned to FBC only. There was no evidence of an intervention effect on food insecurity (aOR 0.52, 95% CI 0.16-1.67; p = 0.27), underweight (aOR 0.44, 95% CI 0.17-1.12; p = 0.08), alcohol use disorder (aOR 0.82, 95% CI 0.24-2.74; p = 0.74) or depressive symptoms (adjusted mean difference - 0.06, 95% CI -1.35, 1.22; p = 0.92). Psychosocial interventions in low-resource settings should support access to treatment amongst people with schizophrenia, and further research should explore how impacts on economic, physical and mental health outcomes can be achieved.

Problem-solving therapy for pregnant women experiencing depressive symptoms and intimate partner violence: A randomised, controlled feasibility trial in rural Ethiopia.

Evidence for the feasibility of brief psychological interventions for pregnant women experiencing intimate partner violence (IPV) in rural, low-income country settings is scarce. In rural Ethiopia, the prevalence of antenatal depressive symptoms and lifetime IPV are 29% and 61%, respectively. We aimed to assess the feasibility and related implementation outcomes of brief problem-solving therapy (PST) adapted for pregnant women experiencing IPV (PST-IPV) in rural Ethiopia, and of a randomised, controlled feasibility study design. We recruited 52 pregnant women experiencing depressive symptoms and past-year IPV from two antenatal care (ANC) services. Consenting women were randomised to PST-IPV (n = 25), 'standard' PST (not adapted for women experiencing IPV; n = 12) or enhanced usual care (information about sources of support; n = 15). Masked data collectors conducted outcome assessments nine weeks post-enrolment. Addis Ababa University (#032/19/CDT) and King's College London (#HR-18/19-9230) approved the study. Fidelity to randomisation was impeded by strong cultural norms about what constituted IPV. However, recruitment was feasible (recruitment rate: 1.5 per day; 37% of women screened were eligible). The intervention and trial were acceptable to women (4% declined initial screening, none declined to participate, and 76% attended all four sessions of either active intervention). PST-IPV was acceptable to ANC providers: none dropped out. Sessions lasting up to a mean 52 minutes raised questions about the appropriateness of the model to this context. Competence assessments recommended supplementary communication skills training. Fidelity assessments indicated high adherence, quality, and responsiveness but assessing risks and social networks, and discussing confidentiality needed improvement. Adjustments to optimise a future, fully powered, randomised controlled trial include staggering recruitment in line with therapist availability, more training on the types of IPV and how to discuss them, automating randomisation, a supervision cascade model, and conducting post-intervention outcome assessments immediately and three months postpartum. Registration: Pan African Clinical Trials Registry #PACTR202002513482084 (13/12/2019): https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=9601.

The effect of a health extension program on improving water, sanitation, and hygiene practices in rural Ethiopia.

BACKGROUND: To make basic primary health care services accessible, especially to the rural community, the government of Ethiopia launched the Health Extension Program (HEP) in 2004. Most of components of HEP are dedicated to hygiene and sanitation. Few studies have assessed the role of the Health Extension Program in improving water, hygiene, and sanitation (WASH) practices in Ethiopia. This study explored the role of health extension workers (HEWs) in influencing household water treatment practices, latrine ownership, latrine use and ownership, and the use of hand-washing facilities on the incidence of diarrheal diseases among the children under five years of age in rural Ethiopia. METHODS: Using a cross sectional design, we conducted a national assessment that covered all nine regions of Ethiopia. We conducted face-to-face interviews among a sample of 6430 rural households using a structured questionnaire and an observation checklist to collect data from March 2018 to May 2019. Multilevel logistic regressions models were used to determine the relationships between the exposure of households to HEWs and WASH practice outcomes such as the use of water from an improved water source, household water treatment practices, availability of hand-washing and hand-washing with soap and water, availability of latrines, and use of latrines as well as the incidence of diarrheal diseases among children age 5 and younger. Our models were adjusted for covariates and confounders and P-values less than 5% were set to determine statistical significance. RESULTS: We found that 72.7% of rural households had some type of latrine and 27.3% reported practicing open defecation. A total of 71.5% of rural households had access to drinking water from improved water sources, but only 9.4% reported practicing household water treatment. Exposure to HEWs was positively associated with household water treatment practices (AOR: 1.46; 95% CI = 1.01-2.10) and latrine availability (AOR: 1.44; 95% CI = 1.15-1.80). Among the households who were either visited by HEWs at their home or the that visited health posts to meet with the HEWs, being exposed to WASH health education by HEWs was significantly associated with the availability of a hand-washing facility (AOR: 5.14; 95% CI = 4.11-6.42) and latrine availability (AOR: 1.48; 95% CI = 1.10-2.01). However, we did not find a relationship between the incidence of diarrhea among children age 5 and under and exposure to HEWs (AOR: 2.09; 95% CI = 0.73- 6.62). CONCLUSION: Our results show a significant association between exposure to the Health Extension Program/ HEWs and improved household water treatment practices, latrine construction, and the availability of hand-washing facilities in rural Ethiopia, suggesting the need to strengthen efforts to change WASH behavior through the Heath Extension Program. On the other hand, further investigation is needed regarding the spillover effect of latrine use practices and the reduction of the incidence of diarrheal diseases.

Trend analysis of malaria in urban settings in Ethiopia from 2014 to 2019.

BACKGROUND: Urbanization generally improves health outcomes of residents and is one of the potential factors that might contribute to reducing malaria transmission. However, the expansion of Anopheles stephensi, an urban malaria vector, poses a threat for malaria control and elimination efforts in Africa. In this paper, malaria trends in urban settings in Ethiopia from 2014 to 2019 are reported with a focus on towns and cities where An. stephensi surveys were conducted. METHODS: A retrospective study was conducted to determine malaria trends in urban districts using passive surveillance data collected at health facilities from 2014 to 2019. Data from 25 towns surveyed for An. stephensi were used in malaria trend analysis. Robust linear models were used to identify outliers and impute missing and anomalous data. The seasonal Mann-Kendal test was used to test for monotonic increasing or decreasing trends. RESULTS: A total of 9,468,970 malaria cases were reported between 2014 and 2019 through the Public Health Emergency Management (PHEM) system. Of these, 1.45 million (15.3%) cases were reported from urban settings. The incidence of malaria declined by 62% between 2014 and 2018. In 2019, the incidence increased to 15 per 1000 population from 11 to 1000 in 2018. Both confirmed (microscopy or RDT) Plasmodium falciparum (67%) and Plasmodium vivax (28%) were reported with a higher proportion of P. vivax infections in urban areas. In 2019, An. stephensi was detected in 17 towns where more than 19,804 malaria cases were reported, with most of the cases (56%) being P. falciparum. Trend analysis revealed that malaria cases increased in five towns in Afar and Somali administrative regions, decreased in nine towns, and had no obvious trend in the remaining three towns. CONCLUSION: The contribution of malaria in urban settings is not negligible in Ethiopia. With the rapid expansion of An. stephensi in the country, the receptivity is likely to be higher for malaria. Although the evidence presented in this study does not demonstrate a direct linkage between An. stephensi detection and an increase in urban malaria throughout the country, An. stephensi might contribute to an increase in malaria unless control measures are implemented as soon as possible. Targeted surveillance and effective response are needed to assess the contribution of this vector to malaria transmission and curb potential outbreaks.