Training on the Silverman and Andersen score improved how special care unit nurses assessed neonatal respiratory distress in a low-resource setting.

AIM: Identifying the severity of neonatal respiratory distress (RD) is essential, so that resources can be appropriately allocated. We assessed the ability of nurses to grade neonatal RD in a low-resource setting before and after they were trained to use a dedicated scoring tool. METHODS: The study was conducted in the Special Care Unit of St Luke Wolisso Hospital, Ethiopia. Ten nurses reviewed nine local video recordings and graded neonatal RD without a standardised method, which was current practice, and then after they were trained to use the Silverman and Andersen score. The data were analysed using the McNemar test and Cohen's kappa. RESULTS: Training increased the identification of mild RD from 63% to 93% (p = 0.008) and moderate RD from 40% to 73% (p = 0.03). Severe RD was 93% before and 90% after training (p = 0.99). Overall, the agreement improved from kappa 0.59 to 0.84, mainly by reducing the overestimation of milder degrees of RD. CONCLUSION: Being trained on how to use the Silverman and Andersen score improved the ability of nurses to identify mild and moderate neonatal RD. This improvement has the potential to optimise the use of equipment, staff and time.

Treating iPSC-Derived ß Cells with an Anti-CD30 Antibody-Drug Conjugate Eliminates the Risk of Teratoma Development upon Transplantation.

Insulin-producing cells derived from induced pluripotent stem cells (iPSCs) are promising candidates for ß cell replacement in type 1 diabetes. However, the risk of teratoma formation due to residual undifferentiated iPSCs contaminating the differentiated cells is still a critical concern for clinical application. Here, we hypothesized that pretreatment of iPSC-derived insulin-producing cells with an anti-CD30 antibody−drug conjugate could prevent in vivo teratoma formation by selectively killing residual undifferentiated cells. CD30 is expressed in all human iPSCs clones tested by flow cytometry (n = 7) but not in iPSC-derived ß cells (ißs). Concordantly, anti-CD30 treatment in vitro for 24 h induced a dose-dependent cell death (up to 90%) in human iPSCs while it did not kill ißs nor had an impact on iß identity and function, including capacity to secrete insulin in response to stimuli. In a model of teratoma assay associated with iß transplantation, the pretreatment of cells with anti-CD30 for 24 h before the implantation into NOD-SCID mice completely eliminated teratoma development (0/10 vs. 8/8, p < 0.01). These findings suggest that short-term in vitro treatment with clinical-grade anti-CD30, targeting residual undifferentiated cells, eliminates the tumorigenicity of iPSC-derived ß cells, potentially providing enhanced safety for iPSC-based ß cell replacement therapy in clinical scenarios.

Modeling the interplay between demography, social contact patterns, and SARS-CoV-2 transmission in the South West Shewa Zone of Oromia Region, Ethiopia.

BACKGROUND: COVID-19 spread may have a dramatic impact in countries with vulnerable economies and limited availability of, and access to, healthcare resources and infrastructures. However, in sub-Saharan Africa, a low prevalence and mortality have been observed so far. METHODS: We collected data on individuals' social contacts in the South West Shewa Zone (SWSZ) of Ethiopia across geographical contexts characterized by heterogeneous population density, work and travel opportunities, and access to primary care. We assessed how socio-demographic factors and observed mixing patterns can influence the COVID-19 disease burden, by simulating SARS-CoV-2 transmission in remote settlements, rural villages, and urban neighborhoods, under school closure mandate. RESULTS: From national surveillance data, we estimated a net reproduction number of 1.62 (95% CI 1.55-1.70). We found that, at the end of an epidemic mitigated by school closure alone, 10-15% of the population residing in the SWSZ would have been symptomatic and 0.3-0.4% of the population would require mechanical ventilation and/or possibly result in a fatal outcome. Higher infection attack rates are expected in more urbanized areas, but the highest incidence of critical disease is expected in remote subsistence farming settlements. School closure contributed to reduce the reproduction number by 49% and the attack rate of infections by 28-34%. CONCLUSIONS: Our results suggest that the relatively low burden of COVID-19 in Ethiopia observed so far may depend on social mixing patterns, underlying demography, and the enacted school closures. Our findings highlight that socio-demographic factors can also determine marked heterogeneities across different geographical contexts within the same region, and they contribute to understand why sub-Saharan Africa is experiencing a relatively lower attack rate of severe cases compared to high-income countries.

Transcriptional dynamics of induced pluripotent stem cell differentiation into ß cells reveals full endodermal commitment and homology with human islets.

BACKGROUND AIMS: Induced pluripotent stem cells (iPSCs) have the capacity to generate ß cells in vitro, but the differentiation is incomplete and generates a variable percentage of off-target cells. Single-cell RNA sequencing offers the possibility of characterizing the transcriptional dynamics throughout differentiation and determining the identity of the final differentiation product. METHODS: Single-cell transcriptomics data were obtained from four stages across differentiation of iPSCs into ß cells and from human donor islets. RESULTS: Clustering analysis revealed that iPSCs undertake a full endoderm commitment, and the obtained endocrine pancreatic cells have high homology with mature islets. The iPSC-derived ß cells were devoid of pluripotent residual cells, and the differentiation was pancreas-specific, as it did not generate ectodermal or mesodermal cells. Pseudotime trajectory identified a dichotomic endocrine/non-endocrine cell fate and distinct subgroups in the endocrine branch. CONCLUSIONS: Future efforts to produce ß cells from iPSCs must aim not only to improve the resulting endocrine cell but also to avoid differentiation into non-pancreatic endoderm cells.

Limited agreement between clinical assessment of infant colour at birth and oxygen saturation in a hospital in Ethiopia.

AIM: To evaluate the relationship between clinical assessment of infant colour and oxygen saturation at birth in a low-resource setting. METHODS: Classification of infant colour (cyanotic, pink or unclear) by midwives was compared to pulse-oximeter data at 60-90-120-300 seconds after birth in 60 neonates. RESULTS: Overall, oxygen saturation increased over time (P < .0001) and was different according to infant colour (P < .0001). Median oxygen saturation in pink infants was 87% at 60 seconds (n = 1), 90% (IQR 83-91) at 90 seconds (n = 5), 86% (IQR 81-94) at 120 seconds (n = 11) and 93% (IQR 90-96) at 300 seconds (n = 20). Median oxygen saturation in cyanotic infants was 60% (IQR 45-70) at 60 seconds (n = 52), 64% (IQR 52-69) at 90 seconds (n = 42), 63% (IQR 56-68) at 120 seconds (n = 35) and 66% (IQR 62-74) at 300 seconds (n = 22). Median oxygen saturation in unclear-coloured infants was 57% (IQR 56-60) at 60 seconds (n = 7), 78% (IQR 71-81) at 90 seconds (n = 13), 81% (IQR 79-88) at 120 seconds (n = 14) and 80% (IQR 76-84) at 300 seconds (n = 18). The proportion of infants with unclear colour ranged from 12% to 30%. CONCLUSION: The variability of oxygen saturation among pink and cyanotic infants, and the substantial proportion of unclear infant colour, suggest the possible benefit of the availability of pulse oximetry in low-resource settings.

Risk factors for mortality among neonates admitted to a special care unit in a low-resource setting.

BACKGROUND: Although under-5 mortality has decreased in the last two decades, neonatal mortality remains a global health challenge. Despite achieving notable progress, Ethiopia has still one of the highest neonatal mortality rates worldwide. We aimed to assess the risk factors for mortality among neonates admitted to a special care unit in a referral hospital in rural Ethiopia. METHODS: This was a retrospective observational study including all 4182 neonates admitted to the special care unit of the St. Luke Wolisso Hospital (Ethiopia) from January 2014 to December 2017. Data were retrieved from hospital charts and entered in an anonymized dataset. A logistic regression model was applied to identify predictors of mortality and effect sizes were expressed as odds ratios with 95% confidence intervals. RESULTS: Proportion of deaths was 17% (709/4182 neonates). Neonates referred from other health facilities or home (odds ratio 1.52, 95% confidence interval 1.21 to 1.91), moderate hypothermia at admission (odds ratio 1.53, 95% confidence interval 1.09 to 2.15) and diagnosis of late-onset sepsis (odds ratio 1.63, 95% confidence interval 1.12 to 2.36), low birthweight (odds ratio 2.48, 95% confidence interval 2.00 to 3.09), very low birthweight (odds ratio 11.71, 95% confidence interval 8.63 to 15.94), extremely low birthweight (odds ratio 76.04, 95% confidence interval 28.54 to 263.82), intrapartum-related complications (odds ratio 4.69, 95% confidence interval 3.55 to 6.20), meconium aspiration syndrome (odds ratio 2.34, 95% confidence interval 1.15 to 4.43), respiratory distress (odds ratio 2.25, 95% confidence interval 1.72 to 2.95), other infections (odds ratio 1.92, 95% confidence interval 1.31 to 2.81) or malformations (odds ratio 2.32, 95% confidence interval 1.49 to 3.57) were associated with increased mortality. Being admitted in 2017 vs. 2014 (odds ratio 0.71, 95% confidence interval 0.52 to 0.97), and older age at admission (odds ratio 0.95, 95% confidence interval 0.93 to 0.97) were associated with decreased likelihood of mortality. CONCLUSIONS: The majority of neonatal deaths was associated with preventable and treatable conditions. Education on neonatal resuscitation and postnatal management, and the introduction of an on-call doctor for high-risk deliveries might have contributed to the reduction in neonatal mortality over time.

A simplified diagnostic work-up for the detection of gestational diabetes mellitus in low resources settings: achievements and challenges.

PURPOSE: Modern strategies for the screening and diagnosis of Gestational Diabetes Mellitus (GDM) rely on universal Oral Glucose Tolerance Test (OGTT). However, they are unsustainable in low-income countries. In this study, we aimed at assessing the feasibility of a simplified diagnostic policy. METHODS: The study took place in an urban referral hospital in Freetown, Sierra Leone. During an 11-month period, pregnant women were offered capillary blood test for glucose assessment. They could be screened at any time during pregnancy. GDM was diagnosed if fasting glucose was ≥ 92 mg/dl or if the OGTT was positive. The latter was prescribed only to women presenting after 24 weeks' gestation with at least one risk factor for GDM and fasting capillary glucose between 85 and 91 mg/dl. A definitive diagnosis required confirmation to this aim, women with values above the thresholds were invited to refer the next working day for repeating the test after fasting overnight. RESULTS: Overall, 7827 women were referred for screening, of whom 6872 (87%) underwent at least one capillary glucose assessment. However, 895 of those who had a positive test did not return for confirmation. Overall, a definite assessment could be done in 5799 subjects corresponding to 76% (95% CI 75-77%) of those eligible. GDM was diagnosed in 128 women (1.9%, 95% CI 1.6-2.2%). Based on an expected confirmation rate of 22% (calculated from those who referred for confirmation) in the 895 women who did not come back, one could infer that GDM would have been diagnosed in additional 197 women, raising the prevalence to 4.7% (95% CI 4.2-5.3%). CONCLUSION: Three quarters of subjects could be assessed with our approach. Data also suggest that GDM is not rare even if identification of affected cases remains challenging.

The hidden burden of measles in Ethiopia: how distance to hospital shapes the disease mortality rate.

BACKGROUND: A sequence of annual measles epidemics has been observed from January 2013 to April 2017 in the South West Shoa Zone of the Oromia Region, Ethiopia. We aimed at estimating the burden of disease in the affected area, taking into account inequalities in access to health care due to travel distances from the nearest hospital. METHODS: We developed a dynamic transmission model calibrated on the time series of hospitalized measles cases. The model provided estimates of disease transmissibility and incidence at a population level. Model estimates were combined with a spatial analysis to quantify the hidden burden of disease and to identify spatial heterogeneities characterizing the effectiveness of the public health system in detecting severe measles infections and preventing deaths. RESULTS: A total of 1819 case patients and 36 deaths were recorded at the hospital. The mean age was 6.0 years (range, 0-65). The estimated reproduction number was 16.5 (95% credible interval (CI) 14.5-18.3) with a cumulative disease incidence of 2.34% (95% CI 2.06-2.66). Three thousand eight hundred twenty-one (95% CI 1969-5671) severe cases, including 2337 (95% CI 716-4009) measles-related deaths, were estimated in the Woliso hospital's catchment area (521,771 inhabitants). The case fatality rate was found to remarkably increase with travel distance from the nearest hospital: ranging from 0.6% to more than 19% at 20 km. Accordingly, hospital treatment prevented 1049 (95% CI 757-1342) deaths in the area. CONCLUSIONS: Spatial heterogeneity in the access to health care can dramatically affect the burden of measles disease in low-income settings. In sub-Saharan Africa, passive surveillance based on hospital admitted cases might miss up to 60% of severe cases and 98% of related deaths.

Cost-effectiveness of an ambulance-based referral system for emergency obstetrical and neonatal care in rural Ethiopia.

BACKGROUND: To estimate the cost-effectiveness of an ambulance-based referral system an dedicated to emergency obstetrics and neonatal care (EmONC) in remote sub-Saharan settings. METHODS: In this prospective study performed in Oromiya Region (Ethiopia), all obstetrical cases referred to the hospital with the ambulance were consecutively evaluated during a three-months period. The health professionals who managed the referred cases were requested to identify those that could be considered as undoubtedly effective. Pre and post-referral costs included those required to run the ambulance service and the additional costs necessary for the assistance in the hospital. Local life expectancy tables were used to calculate the number of year saved. RESULTS: A total of 111 ambulance referrals were recorded. The ambulance was undoubtedly effective for 9 women and 4 newborns, corresponding to 336 years saved. The total cost of the intervention was 8299 US dollars. The cost per year life saved was 24.7 US dollars which is below the benchmarks of 150 and 30 US dollars that define attractive and very attractive interventions. Sensitivity analyses on the rate of effective referrals, on the costs of the ambulance and on the discount rate confirmed the robustness of the result. CONCLUSIONS: An ambulance-based referral system for EmONC in remote sub-Saharan areas appears highly cost-effective.

Gender Inequalities in Remote Settings: Analysis of 105,025 Medical Records of a Rural Hospital in Ethiopia (2005-2015).

Gender inequalities in Sub-Saharan Africa are deemed relevant but data to support this view are scanty. Retrospective analysis of a large dataset of 105,025 patients admitted to an Ethiopian rural private, non-for-profit hospital over a 11 years period (2005-2015). Since 2001, the hospital and the local community are involved in a long-term, comprehensive and externally-supported health care intervention. The total number of admissions was higher for females (61.9% of the total) mainly because of the high frequency of admissions for obstetrics conditions. The total male-to-female ratio (M:F) was 0.6. Except for malaria, men had more admissions for the other leading causes, with the highest M:F being found for injuries (2.7) and musculoskeletal diseases (1.7). Overall, excluding admissions for pregnancy-related issues, the M:F was 1.4. The frequency of admissions changed with age and gender. Female admissions prevailed in the reproductive age period (from 15 to 44 years of age) while males admissions prevailed in the younger and older age groups. The case fatality rate was higher for men (M:F = 2.0). The total M:F and the M:F excluding pregnancy-related admissions did not change during the study period. Gender inequalities do exist in rural remote setting but tend to affect women differently during their lifespan. Even if gender inequalities generally favor males, the substantial proportion of admissions for pregnancy-related situations is encouraging.

Determinants of utilisation of antenatal care and skilled birth attendant at delivery in South West Shoa Zone, Ethiopia: a cross sectional study.

BACKGROUND: Ethiopia has high maternal mortality ratio and poor access to maternal health services. Attendance of at least four antenatal care (ANC) visits and delivery by a skilled birth attendant (SBA) are important in preventing maternal deaths. Understanding the reasons behind the poor use of these services is important in designing strategies to address the problem. This study aimed to determine the coverage of at least four ANC visits and delivery by a SBA and to identify determinants of utilisation of these services in three districts in South West Shoa Zone, Ethiopia. METHODS: A cross-sectional survey of 500 women aged 15-49 years with a delivery in two years prior to the survey was conducted in Wolisso, Wonchi and Goro districts in February 2013. Data were collected using an interviewer administered questionnaire. Logistic regression models were used to explore determinants of ANC attendance and SBA at delivery. RESULTS: Coverage of at least four ANC visits and SBA at delivery were 45.5 and 28.6 %, respectively. Most institutional deliveries (69 %) occurred at the single hospital that serves the study districts. Attendance of at least four ANC visits was positively associated with wealth status, knowledge of the recommended number of ANC visits, and attitude towards maternal health care, but was negatively associated with woman's age. SBA at delivery was negatively associated with parity and time to the health facility, but was positively associated with urban residence, wealth, knowledge of the recommended number of ANC visits, perceived good quality of maternal health services, experience of a pregnancy/delivery related problem, involvement of the partner/family in decision making on delivery place, and birth preparedness. CONCLUSIONS: Raising awareness about the minimum recommended number of ANC visits, tackling geographical inaccessibility, improving the quality of care, encouraging pregnant women to have a birth and complication readiness plan and community mobilisation targeting women, husbands, and families for their involvement in maternal health care have the potential to increase use of maternal health services in this setting. Furthermore, supporting health centres to increase uptake of institutional delivery services may rapidly increase coverage of delivery by SBA and reduce inequity.

Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey.

BACKGROUND: Maternal mortality is persistently high in Uganda. Access to quality emergency obstetrics care (EmOC) is fundamental to reducing maternal and newborn deaths and is a possible way of achieving the target of the fifth millennium development goal. Karamoja region in north-eastern Uganda has consistently demonstrated the nation's lowest scores on key development and health indicators and presents a substantial challenge to Uganda's stability and poverty eradication ambitions. The objectives of this study were: to establish the availability of maternal and neonatal healthcare services at different levels of health units; to assess their utilisation; and to determine the quality of services provided. METHODS: A cross sectional study of all health facilities in Napak and Moroto districts was conducted in 2010. Data were collected by reviewing clinical records and registers, interviewing staff and women attending antenatal and postnatal clinics, and by observation. Data were summarized using frequencies and percentages and EmOC indicators were calculated. RESULTS: There were gaps in the availability of essential infrastructure, equipment, supplies, drugs and staff for maternal and neonatal care particularly at health centres (HCs). Utilisation of the available antenatal, intrapartum, and postnatal care services was low. In addition, there were gaps in the quality of care received across these services. Two hospitals, each located in the study districts, qualified as comprehensive EmOC facilities. The number of EmOC facilities per 500,000 population was 3.7. None of the HCs met the criteria for basic EmOC. Assisted vaginal delivery and removal of retained products were the most frequently missing signal functions. Direct obstetric case fatality rate was 3%, the met need for EmOC was 9.9%, and 1.7% of expected deliveries were carried out by caesarean section. CONCLUSIONS: To reduce maternal and newborn morbidity and mortality in Karamoja region, there is a need to increase the availability and the accessibility of skilled birth care, address the low utilisation of maternity services and improve the quality of care rendered. There is also a need to improve the availability and accessibility of EmOC services, with particular attention to basic EmOC.

A qualitative study on barriers to utilisation of institutional delivery services in Moroto and Napak districts, Uganda: implications for programming.

BACKGROUND: Skilled attendance at delivery is critical in prevention of maternal deaths. However, many women in low- and middle-income countries still deliver without skilled assistance. This study was carried out to identify perceived barriers to utilisation of institutional delivery in two districts in Karamoja, Uganda. METHODS: Data were collected through participatory rural appraisal (PRA) with 887 participants (459 women and 428 men) in 20 villages in Moroto and Napak districts. Data were analysed using deductive content analysis. Notes taken during PRA session were edited, triangulated and coded according to recurring issues. Additionally, participants used matrix ranking to express their perceived relative significance of the barriers identified. RESULTS: The main barriers to utilisation of maternal health services were perceived to be: insecurity, poverty, socio-cultural factors, long distances to health facilities, lack of food at home and at health facilities, lack of supplies, drugs and basic infrastructure at health facilities, poor quality of care at health facilities, lack of participation in planning for health services and the ready availability of traditional birth attendants (TBAs). Factors related to economic and physical inaccessibility and lack of infrastructure, drugs and supplies at health facilities were highly ranked barriers to utilisation of institutional delivery. CONCLUSION: A comprehensive approach to increasing the utilisation of maternal health care services in Karamoja is needed. This should tackle both demand and supply side barriers using a multi-sectorial approach since the main barriers are outside the scope of the health sector. TBAs are still active in Karamoja and their role and influence on maternal health in this region cannot be ignored. A model for collaboration between skilled health workers and TBAs in order to increase institutional deliveries is needed.

Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data.

INTRODUCTION: Sierra Leone is among the top countries with the highest maternal mortality rates. Although progress has been made in reducing maternal mortality, challenges remain, including limited access to skilled care and regional disparities in accessing quality care. This paper presents the first comprehensive analysis of the burden of different causes of maternal deaths reported in the Maternal Death Surveillance and Response (MDSR) system at the district level from 2016 to 2019. METHODS: The MDSR data are accessed from the Ministry of Health and Sanitation, and the secondary data analysis was done to determine the causes of maternal death in Sierra Leone. The proportions of each leading cause of maternal deaths were estimated by districts. A subgroup analysis of the selected causes of death was also performed. RESULTS: Overall, obstetric haemorrhage was the leading cause of maternal death (39.4%), followed by hypertensive disorders (15.8%) and pregnancy-related infections (10.1%). Within obstetric haemorrhage, postpartum haemorrhage was the leading cause in each district. The burden of death due to obstetric haemorrhage slightly increased over the study period, while hypertensive disorders showed a slightly decreasing trend. Disparities were found among districts for all causes of maternal death, but no clear geographical pattern emerged. Non-obstetric complications were reported in 11.5% of cases. CONCLUSION: The MDSR database provides an opportunity for shared learning and can be used to improve the quality of maternal health services. To improve the accuracy and availability of data, under-reporting must be addressed, and frontline community staff must be trained to accurately capture and report death events.

Cardiac Tuberculosis: A Case Series from Ethiopia, Italy, and Uganda and a Literature Review.

Extrapulmonary tuberculosis (TB) is estimated to account for up to 20% of active cases of TB disease, but its prevalence is difficult to ascertain because of the difficulty of diagnosis. Involvement of the heart is uncommon, with constrictive pericarditis being the most common cardiac manifestation. Diagnostic research for cardiac disease is frequently lacking, resulting in a high mortality rate. In addition to direct cardiac involvement, instances of cardiac events during antitubercular therapy are described. This case series describes five cases of TB affecting the heart (cardiac TB) from Italy and high-burden, low-income countries (Ethiopia and Uganda), including a case of Loeffler syndrome manifesting as myocarditis in a patient receiving antitubercular therapy. Our study emphasizes how cardiac TB, rare but important in high-burden areas, is a leading cause of pericardial effusion or pericarditis. Timely diagnosis and a comprehensive approach, including imaging and microbiological tools, are crucial. Implementing high-sensitivity methods and investigating alternative samples, such as detection of tuberculosis lipoarabinomannan or use of the GeneXpert assay with stool, is recommended in TB control programs.

Protocol for an evaluation of the initiation of an integrated longitudinal outpatient care model for severe chronic non-communicable diseases (PEN-Plus) at secondary care facilities (district hospitals) in 10 lower-income countries.

INTRODUCTION: The Package of Essential Noncommunicable Disease Interventions-Plus (PEN-Plus) is a strategy decentralising care for severe non-communicable diseases (NCDs) including type 1 diabetes, rheumatic heart disease and sickle cell disease, to increase access to care. In the PEN-Plus model, mid-level clinicians in intermediary facilities in low and lower middle income countries are trained to provide integrated care for conditions where services traditionally were only available at tertiary referral facilities. For the upcoming phase of activities, 18 first-level hospitals in 9 countries and 1 state in India were selected for PEN-Plus expansion and will treat a variety of severe NCDs. Over 3 years, the countries and state are expected to: (1) establish PEN-Plus clinics in one or two district hospitals, (2) support these clinics to mature into training sites in preparation for national or state-level scale-up, and (3) work with the national or state-level stakeholders to describe, measure and advocate for PEN-Plus to support development of a national operational plan for scale-up. METHODS AND ANALYSIS: Guided by Proctor outcomes for implementation research, we are conducting a mixed-method evaluation consisting of 10 components to understand outcomes in clinical implementation, training and policy development. Data will be collected through a mix of quantitative surveys, routine reporting, routine clinical data and qualitative interviews. ETHICS AND DISSEMINATION: This protocol has been considered exempt or covered by central and local institutional review boards. Findings will be disseminated throughout the project's course, including through quarterly M&E discussions, semiannual formative assessments, dashboard mapping of progress, quarterly newsletters, regular feedback loops with national stakeholders and publication in peer-reviewed journals.

Factors associated with patient and health care system delay in diagnosis for tuberculosis in the province of Luanda, Angola.

BACKGROUND: Tuberculosis (TB) is still a great challenge to public health in sub-Saharan Africa. Most transmissions occur between the onset of coughing and initiation of treatment. Delay in diagnosis is significant to disease prognosis, thus early diagnosis and prompt effective therapy represent the key elements in controlling the disease. The objective of this study was to investigate the factors influencing the patient delay and the health system delay in TB diagnosis in Angola. METHODS: On a cross-sectional study, 385 TB patients who visited 21 DOTS clinics in Luanda were included consecutively. The time from the onset of symptoms to the first consultation of health providers (patients' delay) and the time from the first consultation to the date of diagnosis (health system's delay) were analysed. Bivariate and logistics regression were applied to analyse the risk factors of delays. RESULTS: The median total time elapsed from the onset of symptoms to diagnosis was 45 days (interquartile range [IQR]: 21-97 days). The median patient delay was 30 days (IQR: 14-60 days), and the median health care system delay was 7 days (IQR: 5-15 days). Primary education (AOR = 1.75; CI [95%] 1.06-2.88; p <0.029) and the health centre of the first contact differing from the DOTS centre (AOR = 1.66; CI [95%] 1.01-2.75; p <0.046) were independent risk factors for patient delay >4 weeks. Living in a suburban area (AOR = 2,32; CI [95%] 1.21-4.46; p = 0.011), having a waiting time in the centre >1 hour (AOR = 4.37; CI [95%] 1.72-11.14; p = 0.002) and the health centre of the first contact differening from the DOTS centre (AOR = 5.68; CI [95%] 2.72-11,83; p < 0,00001) were factors influencing the system delay. CONCLUSIONS: The results indicate that the delay is principally due to the time elapsed between the onset of symptoms and the first consultation. More efforts should be placed in ensuring the availability of essential resources and skills in all healthcare facilities other than the DOTS centres, especially those located in suburban areas.

Measuring equity in utilization of emergency obstetric care at Wolisso Hospital in Oromiya, Ethiopia: a cross sectional study.

INTRODUCTION: Improving equity in access to services for the treatment of complications that arise during pregnancy and childbirth, namely Emergency Obstetric Care (EmOC), is fundamental if maternal and neonatal mortality are to be reduced. Consequently, there is a growing need to monitor equity in access to EmOC. The objective of this study was to develop a simple questionnaire to measure equity in utilization of EmOC at Wolisso Hospital, Ethiopia and compare the wealth status of EmOC users with women in the general population. METHODS: Women in the Ethiopia 2005 Demographic and Health Survey (DHS) constituted our reference population. We cross-tabulated DHS wealth variables against wealth quintiles. Five variables that differentiated well across quintiles were selected to create a questionnaire that was administered to women at discharge from the maternity from January to August 2010. This was used to identify inequities in utilization of EmOC by comparison with the reference population. RESULTS: 760 women were surveyed. An a posteriori comparison of these 2010 data to the 2011 DHS dataset, indicated that women using EmOC were wealthier and more likely to be urban dwellers. On a scale from 0 (poorest) to 15 (wealthiest), 31% of women in the 2011 DHS sample scored less than 1 compared with 0.7% in the study population. 70% of women accessing EmOC belonged to the richest quintile with only 4% belonging to the poorest two quintiles. Transportation costs seem to play an important role. CONCLUSIONS: We found inequity in utilization of EmOC in favour of the wealthiest. Assessing and monitoring equitable utilization of maternity services is feasible using this simple tool.

Priority age targets for COVID-19 vaccination in Ethiopia under limited vaccine supply.

The worldwide inequitable access to vaccination claims for a re-assessment of policies that could minimize the COVID-19 burden in low-income countries. Nine months after the launch of the national vaccination program in March 2021, only 3.4% of the Ethiopian population received two doses of COVID-19 vaccine. We used a SARS-CoV-2 transmission model to estimate the level of immunity accrued before the launch of vaccination in the Southwest Shewa Zone (SWSZ) and to evaluate the impact of alternative age priority vaccination targets in a context of limited vaccine supply. The model was informed with available epidemiological evidence and detailed contact data collected across different geographical settings (urban, rural, or remote). We found that, during the first year of the pandemic, the mean proportion of critical cases occurred in SWSZ attributable to infectors under 30 years of age would range between 24.9 and 48.0%, depending on the geographical setting. During the Delta wave, the contribution of this age group in causing critical cases was estimated to increase on average to 66.7-70.6%. Our findings suggest that, when considering the vaccine product available at the time (ChAdOx1 nCoV-19; 65% efficacy against infection after 2 doses), prioritizing the elderly for vaccination remained the best strategy to minimize the disease burden caused by Delta, irrespectively of the number of available doses. Vaccination of all individuals aged ≥ 50 years would have averted 40 (95%PI: 18-60), 90 (95%PI: 61-111), and 62 (95%PI: 21-108) critical cases per 100,000 residents in urban, rural, and remote areas, respectively. Vaccination of all individuals aged ≥ 30 years would have averted an average of 86-152 critical cases per 100,000 individuals, depending on the setting considered. Despite infections among children and young adults likely caused 70% of critical cases during the Delta wave in SWSZ, most vulnerable ages should remain a key priority target for vaccination against COVID-19.

Adherence to WHO guidelines on severe pneumonia management in children and its impact on outcome: an observational study at Jinka General Hospital in Ethiopia.

Introduction: Poor adherence to guidelines during empirical antibiotic prescription in low-income countries could increase antimicrobial resistance without improving outcomes. Revised World Health Organization (WHO) guidelines published in 2014 on childhood (2-59 months) pneumonia re-defined the classification of severe pneumonia and changed the first-line treatment. The adherence to WHO guidelines in southern Ethiopia at the hospital level is unknown. We sought to determine the adherence to WHO guidelines on severe pneumonia first-line treatment in children in an Ethiopian referral hospital and assess the impact of non-adherence on patient outcomes. Methods: An observational study was conducted on all children (2-59 months) clinically diagnosed with severe pneumonia and admitted to the Pediatric Ward of Jinka Hospital from 1 June 2021 to 31 May 2022. Exclusion criteria included a known HIV infection, ongoing antibiotic treatment before the event not related to acute pneumonia, or any other severe bacterial infection, confirmed or suspected. Adherence to guidelines was defined as first-line treatment with ampicillin or benzylpenicillin and gentamicin at the recommended dose. We compared the patients treated adherently vs. non-adherently. For categorical variables, the chi-square or Fisher's exact test was used, while for continuous variables, the Mann-Whitney U-test was used. Multivariate logistic regression was used to evaluate the association between adherence and demographic and clinical characteristics. Results: During the observational period, 266 patients were registered as having severe pneumonia with an age between 2 and 59 months. After excluding 114 patients due to missing charts or other exclusion criteria, a total of 152 patients were included in the analysis. Of these, 78 (51%) were girls with a median age of 10 months (IQR 7-14). Overall, 75 (49%) patients received therapy according to the WHO guidelines. Compared to patients treated adherently to the guidelines, patients not treated adherently had similar outcomes [median length of stay of 3 (IQR 3-5) and 4 (IQR 3-6) days], median duration of oxygen therapy of 2 (IQR 1-3) for both the groups, and self-discharge rates of 5% and 6.5%, respectively). Conclusion: Adherence to the revised WHO guideline was limited and not associated with outcomes. Efforts should focus on reducing the gap between theory and practice.