Epidemiology and Outcomes of Critical Illness and Novel Predictors of Mortality in an Ethiopian Medical Intensive Care Unit.

Low- and middle-income countries (LMICs) bear most of the global burden of critical illness. Managing this burden requires improved understanding of epidemiology and outcomes in LMIC intensive care units (ICUs), including LMIC-specific mortality prediction scores. This study was a retrospective observational study at Tikur Anbessa Specialized Hospital in Addis Ababa, Ethiopia, examining all consecutive medical ICU admissions from June 2014 to April 2015. The primary outcome was ICU mortality; secondary outcomes were prolonged ICU stay and prolonged mechanical ventilation. ICU mortality prediction models were created using multivariable logistic regression and compared with the Mortality Probability Model-II (MPM-II). Associations with secondary outcomes were examined with multivariable logistic regression. There were 198 admissions during the study period; mortality was 35%. Age, shock on admission, mechanical ventilation, human immunodeficiency virus, and Glasgow Coma Scale ≤8 were associated with ICU mortality. The receiver operating characteristic curve for this 5-factor model had an AUC of 0.8205 versus 0.7468 for MPM-II, favoring the simplified new model. Mechanical ventilation and lack of shock were associated with prolonged ICU stays. Mortality in an LMIC medical ICU was high. This study examines an LMIC medical ICU population, showing a simplified prediction model may predict mortality as well as complex models.

Risk factors and determinants of pulmonary function impairments in chronic respiratory diseases in Ethiopia: A hospital-based cross-sectional study

Introduction: Chronic respiratory diseases (CRDs) are diseases of the lung airways and parenchyma. Globally, they are the leading causes of morbidity and mortality. This study aimed to characterize the common CRDs, along with their lung function and possible determinants in symptomatic patients attending Bishoftu General Hospital, Ethiopia. Methods: A cross-sessional study was conducted at the outpatient of Bishoftu Hospital, Ethiopia from June 2019 to March 2020. Consecutive adult patients aged 18 and above with CRDs (≥8 weeks) were recruited. Questionnaires were used to collect data on demographics, symptoms, diagnoses, and putative risk factors. Lung function was measured by spirometry. Result: A total of 170 participants were recruited, the majority 102(60.0%) were female. The mean age was 49 years (SD=16). The most common symptoms were wheezing in the last twelve months 156 (91.8%), cough 138 (81.2%), and severe exertional breathlessness 137 (80.6%). Thirty-nine (22.9%) were either active or passive smokers. Half of the patients (50.3%) were exposed daily to vapors, dust, gases, or fumes and 58 (34.3%) were exposed to biomass smoke. In total, 138 (81.2%) had a positive allergen skin prick test. Chronic bronchitis (49.1%) and asthma (36.1%) were the most common clinical diagnoses. Classification of lung function revealed 23 (15%) normal, 29 (19%) obstructive, 36(23.5%) restrictive and 61(39.9%) mixed patterns. Airflow obstruction was independently associated with increasing age (p<0.05), exertional breathlessness (p<0.001), previous history of asthma (p<0.05), BMI (p<0.05), and doctor-diagnosed chronic obstructive pulmonary disease (p<0.001) and asthma (p<0.05). Conclusion: This study shows a high burden of abnormal lung function in patients attending clinics because of CRDs symptoms. These findings support the critical need for spirometry services to determine lung abnormality in patients with chronic respiratory symptoms.

Alternative epidemic indicators for COVID-19 in three settings with incomplete death registration systems.

Not all COVID-19 deaths are officially reported, and particularly in low-income and humanitarian settings, the magnitude of reporting gaps remains sparsely characterized. Alternative data sources, including burial site worker reports, satellite imagery of cemeteries, and social media-conducted surveys of infection may offer solutions. By merging these data with independently conducted, representative serological studies within a mathematical modeling framework, we aim to better understand the range of underreporting using examples from three major cities: Addis Ababa (Ethiopia), Aden (Yemen), and Khartoum (Sudan) during 2020. We estimate that 69 to 100%, 0.8 to 8.0%, and 3.0 to 6.0% of COVID-19 deaths were reported in each setting, respectively. In future epidemics, and in settings where vital registration systems are limited, using multiple alternative data sources could provide critically needed, improved estimates of epidemic impact. However, ultimately, these systems are needed to ensure that, in contrast to COVID-19, the impact of future pandemics or other drivers of mortality is reported and understood worldwide.

Prognostic factors and outcomes of COVID-19 cases in Ethiopia: multi-center cohort study protocol.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus (SARS-CoV-2) and became pandemic after emerging in Wuhan, China, in December 2019. Several studies have been conducted to understand the key features of COVID-19 and its public health impact. However, the prognostic factors of COVID-19 are not well studied in the African setting. In this study, we aim to determine the epidemiological and clinical features of COVID-19 cases, immunological and virological courses, interaction with nutritional status, and response to treatment for COVID-19 patients in Ethiopia. METHODS: A multi-center cohort study design will be performed. Patients with confirmed COVID-19 infection admitted to selected treatment centers will be enrolled irrespective of their symptoms and followed-up for 12 months. Baseline epidemiological, clinical, laboratory and imaging data will be collected from treatment records, interviews, physical measurements, and biological samples. Follow-up data collection involves treatment and prognostic outcomes to be measured using different biomarkers and clinical parameters. Data collection will be done electronically using the Open Data Kit (ODK) software package and then exported to STATA/SPSS for analysis. Both descriptive and multivariable analyses will be performed to assess the independent determinants of the treatment outcome and prognosis to generate relevant information for informed prevention and case management. The primary outcomes of this study are death/survival and viral shedding. Secondary outcomes include epidemiological characteristics, clinical features, genetic frequency shifts (genotypic variations), and nutritional status. DISCUSSION: This is the first large prospective cohort study of patients in hospitals with COVID-19 in Ethiopia. The results will enable us to better understand the epidemiology of SARS-CoV-2 in Africa. This study will also provide useful information for effective public health measures and future pandemic preparedness and in response to outbreaks. It will also support policymakers in managing the epidemic based on scientific evidence. TRIAL REGISTRATION: The Protocol prospectively registered in ClinicalTrials.gov (NCT04584424) on 30 October, 2020.

Clinical Characteristics and Molecular Profiles of Lung Cancer in Ethiopia.

INTRODUCTION: Lung cancer is the most common cause of cancer deaths worldwide, accounting for 1.8 million deaths each year. Only 20% of lung cancer cases are reported to occur in low- and middle-income countries. An estimated 1.5% of all Ethiopian cancers involved the lung; however, no nationwide cancer registry exists in Ethiopia. Thus, accurate data on clinical history, histopathology, molecular characteristics, and risk factors for lung cancer are not available. The aim of this study was to describe the clinical, radiologic, and pathologic characteristics, including available molecular profiles, for lung cancer at Tikur Anbessa Specialized Hospital (TASH), the main tertiary referral center in Addis Ababa, Ethiopia. METHODS: A cross-sectional study was conducted at TASH among 146 patients with pathologically confirmed primary lung cancer, diagnosed from 2015 to 2019 and recorded in the Addis Ababa Cancer Registry at TASH. Clinical data were extracted from patient medical records, entered into a Research Electronic Data Capture database, and analyzed using Statistical Package for the Social Sciences statistical software. Variables collected included sociodemographics, personal exposures, comorbidities, clinical manifestations at presentation, chest imaging results, diagnostic procedures performed, histopathological classification, cancer staging, and type of treatment (if any). A subset of lung biopsies fixed in formalin for 2 to 7 days, which could be retrieved from the files of the Pathology Department of TASH, were reviewed, and molecular analysis was performed using next-generation sequencing to identify the tumor-oncogenic drivers. RESULTS: Among the 146 patients studied, the mean (SD) age was 54 plus or minus 13 years; 61.6% (n = 90) were male and 25.3% (n = 37) had a history of tobacco use. The most common clinical manifestations included cough (88.4%, n = 129), chest pain (60.3%, n = 88), and dyspnea (53.4%, n = 78). The median duration of any symptoms was 6 months (interquartile range: 3-12 mo). The most common radiologic features were lung mass (84.9%, n = 129) and pleural effusion (52.7%, n = 77). Adenocarcinoma accounted for 35.7% of lung cancers (n = 52) and squamous cell carcinoma 19.2% (n = 28) from those specimens was reported. Among patients on whom staging of lung cancer was documented, 92.2% (n = 95) of the subjects presented at advanced stages (stages III and IV). EGFR mutation, exons 19 and 20, was found in 7 of 14 tissue blocks analyzed. No specific risk factors were identified, possibly reflecting the relatively small sample size and limited exposures. CONCLUSIONS: There are marked differences in the presentation, risk factors, and molecular characteristics of lung cancer in Ethiopia as compared with other African and non-African countries. Adenocarcinoma was the most common histologic type of lung cancer detected in our study, similar to findings from other international studies. Nevertheless, compared with high-income countries, lung cancer in Ethiopia presents at a younger age, a later stage, and without considerable personal tobacco use. The relatively higher prevalence of EGFR mutation, from the limited molecular analyses, suggests that factors other than smoking history, such as exposure to biomass fuel, may be a more important risk factor. Country-specific screening guidelines and treatment protocols, in addition to a national tumor registry and greater molecular mutation analyses, are needed to improve prevention and management of lung cancer in Ethiopia.

Clinical Characteristics of COVID-19 Related Deaths in Ethiopia.

BACKGROUND: Since the occurrence of COVID-19 in the world, it has claimed nearly 1.39 million human lives in the world and more than 1500 lives in Ethiopia. The number of deaths is increasing with variable distribution in the world. Despite its increasing fatality, the clinical characteristics of the deceased patients are not yet fully known. Analyzing the clinical characteristics of deceased patients will help to improve the outcome of infected patients. Hence, this study aimed to determine the clinical characteristics of patients who died due to COVID-19 in Ethiopia. METHODS: Hospital based multi-center cross-sectional study was conducted using chart review of deceased patients. Since the number of COVID-19 related deaths was limited, all consecutive COVID-19 related hospital deaths were analyzed. The data was entered into and analyzed using SPSS version 25.0. Descriptive statistics was used to explain the data collected from the survey. RESULT: A total of 92 deceased patient charts were analyzed. Of these patients, 65(71%) were males. Age ranged from 17 to 92 years (mean age being 59 years). On arrival vital signs, 60.5% of them had hypoxia, 49% had tachycardia and only 32% of patients had fever. Three fourth of the patients 64/85 had at least one comorbidity. Diabetes mellitus (DM) was the commonest comorbidity accounting for 445.9%, followed by hypertension, 23/85(27%), and HIV/ AIDS, 15/85 (17.5%). CONCLUSION: The results of this study showed that COVID-19 deceased patients presented with respiratory failure and hypoxia. However, less than a third of these patients had fever. In addition, the presence of comorbid illnesses and non-COVID-19 diseases like AIDS defining illness in significant amount needs further study to identify their level of contribution to the increasing burden of COVID-19 deaths in Ethiopia.

Clinical and Socio-demographic Profile of the First 33 COVID-19 Cases Treated at Dedicated Treatment Center in Ethiopia.

BACKGROUND: Severe respiratory tract infection caused by family of Corona viruses has become world pandemic. The purpose of this study was to describe the first few COVID 19 cases in Ethiopia. METHOD: Descriptive study was conducted on the first 33 consecutive RT-PCR confirmed COVID 19 cases diagnosed and managed at Ekka-Kotebe COVID Treatment Center in Addis Ababa, Ethiopia. RESULT: The median age of the cases was 36 years. Cough, headache and fever were the most frequent symptoms. Diarrhea, sore throats, loss of taste and/or smell sensation were among the rare symptoms. Most (84.8%) had mild to moderate disease, and 15.2%(n=5) were critical at the time of admission. Among the five ICU admissions, four patients required invasive mechanical ventilation. Thirty cases were discharged after two pairs of nasopharyngeal and oropharyngeal samples turned negative for SARS CoV2. Three cases from the ICU died while on mechanical ventilator. The age of the two deaths was 65 years, and one was 60 years. With the exception of three, all cases were either imported from abroad or had contact with confirmed cases. CONCLUSION: Most of our patients were in the younger age group with male predominance and few with comorbidities. Cough was the commonest symptom followed by headache and fever. As it was in the early stage of the pandemic, observation of more cases in the future will reveal further clinical and demographic profiles of COVID-19 cases in Ethiopia.

Clinical and socio-demographic profile of the first 33 COVID-19 cases treated at dedicated treatment center in Ethiopia

BACKGROUND:Severe respiratory tract infection caused by family of Corona viruses has become world pandemic. The purpose of this study was to describe the first few COVID 19 cases in Ethiopia. METHOD: Descriptive study was conducted on the first 33 consecutive RT-PCR confirmed COVID 19 cases diagnosed and managed at Ekka-Kotebe COVID Treatment Center in Addis Ababa, Ethiopia. RESULT: The median age of the cases was 36 years. Cough, headache and fever were the most frequent symptoms. Diarrhea, sore throats, loss of taste and/or smell sensation were among the rare symptoms. Most (84.8%) had mild to moderate disease, and 15.2%(n=5) were critical at the time of admission. Among the five ICU admissions, four patients required invasive mechanical ventilation. Thirty cases were discharged after two pairs of nasopharyngeal and oropharyngeal samples turned negative for SARS CoV2. Three cases from the ICU died while on mechanical ventilator. The age of the two deaths was 65 years, and one was 60 years. With the exception of three, all cases were either imported from abroad or had contact with confirmed cases. CONCLUSION: Most of our patients were in the younger age group with male predominance and few with comorbidities. Cough was the commonest symptom followed by headache and fever. As it was in the early stage of the pandemic, observation of more cases in the future will reveal further clinical and demographic profiles of COVID-19 cases in Ethiopia

Creating a specialist physician workforce in low-resource settings: reflections and lessons learnt from the East African Training Initiative.

Many African countries have extremely low ratios of physicians to population, and there are very, very few specialists. This leaves most patients without access to specialised care, and importantly also leaves many countries with insufficient expertise to properly evaluate the burden of illness and the needs of the population overall. The challenges to training a specialised physician workforce in resource-limited settings are many, and they go far beyond the (relatively simple) task of transmission of clinical skills. We initiated a capacity-building programme to train pulmonary physicians in Ethiopia, a country of 105 million persons with a high burden of lung disease that had no prior existing training programme in pulmonary medicine. Using volunteer faculty from the USA and Europe, we have provided high-quality training and established a cohort of pulmonary specialists there. We have identified several components of training that go beyond clinical skills development but which we feel are crucial to sustainability. These components include the delineation of viable career pathways that allow professional growth for subspecialist physicians and that support the permanent establishment of a local faculty; the development of important non-clinical skills, including leadership and pedagogical techniques; training in clinical research methodologies; and the development of mechanisms to amplify the impact of a still relatively small number of specialised physicians to address the needs of the population generally. Our programme, the East African Training Initiative, has successfully addressed many of these challenges and we hope that it can be replicated elsewhere.