Associations of Plasmodium and Intestinal Helminth Infections with Maternal Anemia and Adverse Pregnancy Outcomes in Northwest Ethiopia.

Malaria and intestinal helminth infections are significant public health challenges in Ethiopia. However, little is known about the relationship of Plasmodium and intestinal helminth infections in pregnancy with maternal anemia and adverse pregnancy outcomes. A health-facility-based cross-sectional study was conducted among 526 parturients in northwest Ethiopia to investigate the associations of these parasitic infections with anemia and adverse pregnancy outcomes. Maternal and newborn profiles were collected using questionnaires and checklists. Maternal hematocrit was determined using the micro-hematocrit method. Malaria was diagnosed by microscopy, rapid diagnostic tests, and quantitative polymerase chain reaction, whereas intestinal parasites were detected microscopically using stool wet mount and Kato-Katz preparations. Among the women, 38.6% were anemic, and 36.5% had adverse pregnancy outcomes. Single infections of hookworm (adjusted odds ratio [aOR] = 3.11, 95% CI: 1.64-5.87) in pregnancy were associated with anemia at parturiency, whereas malaria single infections were associated with anemia (aOR = 4.28, 95% CI: 2.17-8.23) and adverse pregnancy outcomes (aOR = 2.94, 95% CI: 1.47-5.91). Moreover, intestinal helminth coinfections in pregnancy were associated with anemia (aOR = 13.3, 95% CI: 4.8-36.8), whereas malaria-helminth coinfections were associated with anemia (aOR = 7.47, 95% CI: 3.71-15.04) and adverse pregnancies (aOR = 4.75, 95% CI: 2.36-9.57). Overall, the study showed that Plasmodium and intestinal helminth infections in pregnancy are associated with anemia and adverse pregnancy outcomes. Thus, strengthening malaria and intestinal parasite infection prevention and control practices in pregnancy is warranted to alleviate the burden of anemia and adverse pregnancy outcomes.

SARS-CoV-2 variant typing using real-time reverse transcription-polymerase chain reaction-based assays in Addis Ababa, Ethiopia.

Objectives: This study aimed to determine the SARS-CoV-2 variants in the first four COVID-19 waves using polymerase chain reaction (PCR)-based variant detection in Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted using repository nasopharyngeal samples stored at the Ethiopian Public Health Institute COVID-19 testing laboratory. Stored positive samples were randomly selected from the first four waves based on their sample collection date. A total of 641 nasopharyngeal samples were selected and re-tested for SARS-CoV-2. RNA was extracted using nucleic acid purification instrument. Then, SARS-CoV-2 detection was carried out using 10 µl RNA and 20 µl reverse transcription-PCR fluorescent mix. Cycle threshold values <38 were considered positive. Results: A total of 374 samples qualified for B.1.617 Lineage and six spike gene mutation variant typing kits. The variant typing kits identified 267 (71.4%) from the total qualifying samples. Alpha, Beta, Delta, and Omicron were dominantly identified variants from waves I, II, III, and IV, respectively. From the total identified positive study samples, 243 of 267 (91%) of variants identified from samples had cycle threshold values <30. Conclusions: The study data demonstrated that reverse transcription-PCR-based variant typing can provide additional screening opportunities where sequencing opportunity is inaccessible. The assays could be implemented in laboratories performing SARS-CoV-2 molecular testing.

Molecular detection of waterborne pathogens in infants' drinking water and their relationship with water quality determinants in eastern Ethiopia: loop-mediated isothermal amplification (LAMP)-based study.

Cryptosporidium, Shigella, toxin-producing Escherichia coli, and rotavirus were reported to be the most responsible for severe and fatal diarrhea among infants. This study aimed to investigate the presence of these pathogens in infants' drinking water samples and analyzing using water quality determinants in eastern Ethiopia. A molecular (LAMP)-based cross-sectional study design was employed. A total of 410 and 37 water samples were tested from infant point-of-use at household and corresponding water source, respectively, from June 2020 to May, 2021. Cryptosporidium, Shigella, toxin-producing E. coli, and rotavirus were detected in 28.5, 30.0, 26.3, and 32.2%, of water samples tested from infant point-of-use, respectively. About 13.2% of the water samples were positive for all (four) pathogens together. Cryptosporidium, Shigella, toxin-producing E. coli, and rotavirus were detected in 27.0, 32.4, 29.7, and 37.8%, of water samples tested from water sources, respectively. Positive significant correlation was observed between infant point-of-consumption and water sources from which it is drawn toward the presence of each targeted pathogen. Unimproved water source showed a strong significant association with the presence of Cryptosporidium, Shigella and toxin-producing E. coli. Therefore, efforts should be made in development of improved water sources, source protection safety and health education to caretakers of infants.

Reemergence of Human African Trypanosomiasis Caused by Trypanosoma brucei rhodesiense, Ethiopia.

We report 4 cases of human African trypanosomiasis that occurred in Ethiopia in 2022, thirty years after the last previously reported case in the country. Two of 4 patients died before medicine became available. We identified the infecting parasite as Trypanosoma brucei rhodesiense. Those cases imply human African trypanosomiasis has reemerged.

Plasmodium infections and associated risk factors among parturients in Jawi district, northwest Ethiopia: a cross-sectional study.

BACKGROUND: Pregnant women have an increased risk of Plasmodium infections and disease. Malaria in pregnancy is a major public health problem in endemic areas. Assessment of the burden and risk factors of malaria in pregnancy across different malaria transmission settings is required to guide control strategies and for malaria elimination. Thus, the current study is generating such evidence from parturient women in northwest Ethiopia. METHODS: A cross-sectional study was conducted among 526 pregnant women admitted to the delivery rooms of selected health facilities in Jawi district, northwest Ethiopia, between November 2021 and July 2022. Data on the socio-demographic, clinical, obstetric, and malaria prevention practices of pregnant women were collected using interviewer-administered questionnaires and from women's treatment cards. Malaria was diagnosed by light microscopy, rapid diagnostic test, and multiplex real-time polymerase chain reaction. Risk factors for malaria were evaluated using bivariable and multivariable logistic regression models. A P-value of < 0.05 was considered statistically significant. RESULTS: Among the examined parturient women, 14.3% (95% CI 11.4-17.5%) had Plasmodium infections. The prevalence of peripheral, placental, and congenital malaria was 12.2% (95% CI 9.5-15.3%), 10.9% (95% CI 8.2-14.1%), and 3.7% (95% CI 2.3-6.1%), respectively. About 90.6% of peripheral and 92% of placental Plasmodium infections were asymptomatic. Plasmodium infection at parturiency was independently predicted by maternal illiteracy (AOR = 2.03, 95% CI 1.11-3.74), primigravidity (AOR = 1.88, 95% CI 1.01-3.49), lack of antenatal care follow-up (AOR = 2.28, 95% CI 1.04-5.03), and history of symptomatic malaria during pregnancy (AOR = 4.2, 95% CI 2.32-7.59). Moreover, the blood group O phenotype was significantly associated with placental malaria among the primiparae. CONCLUSIONS: Overall, asymptomatic Plasmodium infections were prevalent among parturients in northwest Ethiopia. Maternal illiteracy, primigravidity, lack of antenatal care follow-up, and history of symptomatic malaria during pregnancy were the risk factors for malaria during parturiency. Thus, promotion of a healthy pregnancy through ANC follow-up, strengthening malaria prevention and control practices, and screening of malaria in asymptomatic pregnant women are suggested to reduce its burden in pregnancy.

First report of cutaneous leishmaniasis caused by Leishmania donovani in Ethiopia.

BACKGROUND: Leishmaniasis is a common neglected tropical disease in Ethiopia. Visceral leishmaniasis (VL) caused by Leishmania donovani presents in the lowlands, while cutaneous leishmaniasis (CL) affects people living in the highlands. Although CL is described as being caused by Leishmania aethiopica, there is also evidence of L. tropica and L. major isolated from a patient, sand flies and potential reservoirs. Information on species causing CL in Ethiopia is patchy, and no nation-wide study has ever been done. Understanding which species are causing CL in Ethiopia can have important implications for patient management and disease prevention. METHODS: We analyzed stored routine samples and biobanked DNA isolates from previously conducted studies of CL patients from different centers in the north, center and south of Ethiopia. Species typing was performed using ITS-1 PCR with high-resolution melt (HRM) analysis, followed by HSP70 amplicon sequencing on a selection of the samples. Additionally, sociodemographic, clinical and laboratory data of patients were analyzed. RESULTS: Of the 226 CL samples collected, the Leishmania species could be determined for 105 (45.5%). Leishmania aethiopica was identified in 101 (96.2%) samples from across the country. In four samples originating from Amhara region, northwestern Ethiopia, L. donovani was identified by ITS-1 HRM PCR, of which two were confirmed with HSP70 sequences. While none of these four patients had symptoms of VL, two originated from known VL endemic areas. CONCLUSIONS: The majority of CL was caused by L. aethiopica, but CL due to L. tropica and L. major cannot be ruled out. Our study is the first to our knowledge to demonstrate CL patients caused by L. donovani in Ethiopia. This should spark future research to investigate where, how and to which extent such transmission takes place, how it differs genetically from L. donovani causing VL and whether such patients can be diagnosed and treated successfully with the currently available tools and drugs.

Sero-prevalence of visceral leishmaniasis and its associated factors among asymptomatic individuals visiting Denan health center, southeastern Ethiopia.

BACKGROUND: In the Somali region of Ethiopia, visceral leishmaniasis (VL) is a public health concern. However, VL epidemiology and sand fly vectors have not been well studied in various areas of the regional state, including Denan district. Therefore, this study was conducted to determine the sero-prevalence, associated factors, and distribution of sand fly vectors of VL in Denan district, south-eastern Ethiopia. METHODS: A facility-based cross-sectional study was conducted from April to September 2021 among VL patients with classic signs and symptoms visiting Denan Health Center in south-eastern Ethiopia. Using a convenience sampling method, 187 blood samples were collected from individuals who visited Denan Health Center during the study period. Blood samples were subjected to Direct Agglutination Test for the detection of antibodies to VL. A pre-tested structured questionnaire was also used to gather information on risk factors and other characteristics of knowledge and attitude assessment. Sand flies were also collected from indoor, peri-domestic, mixed forest, and termite mounds using light and sticky traps to determine the fauna and abundance. RESULTS: The overall sero-prevalence rate was 9.63% (18/187). The sero-prevalence was significantly associated with outdoor sleeping (OR = 2.82), the presence of damp floors (OR = 7.76), and sleeping outdoor near animals (OR = 3.22). Around 53.48% of the study participants had previously heard about VL. Study participants practiced different VL control methods, including bed nets (42%), insecticide spraying (32%), smoking plant parts (14%), and environmental cleaning (8%). In total, 823 sand fly specimens, comprising 12 species in two genera (Phlebotomus and Sergentomyia), were trapped and identified. The most abundant species was Sergentomyia clydei (50.18%), followed by Phlebotomus orientalis (11.42%). Also, a higher proportion of P. orientalis was found in termite mounds (65.43%), followed by mixed forest (37.8%) and peri-domestic (20.83%) habitats. CONCLUSION: The study demonstrated a 9.63% sero-positivity of VL and a remarkable gap in knowledge, attitude, and practices towards VL. P. orientalis was also detected, which could be a probable vector in this area. Thus, public education should be prioritized to improve the community's awareness of VL and its public health impact. In addition, detailed epidemiological and entomological studies are recommended.

Drug Resistance in Tuberculous Lymphadenitis: Molecular Characterization.

Background: Drug-resistant tuberculosis (TB) epidemic in high-TB-incidence countries, particularly Ethiopia, remains a significant challenge. As a result, we investigated the drug resistance, common gene mutation, and molecular characterization of mycobacterial isolates from patients with suspected tuberculous lymphadenitis (TBLN). Methodology. A cross-sectional study of 218 FNA samples from TBLN patients inoculated on Lowenstein-Jensen media was carried out. The culture isolates were identified as MTB by polymerase chain reaction (PCR) and the difference-9 (RD9) test region. In addition, the GenoType MTBDRplus assay tested the first and second-line MTB drugs, and the spoligotyping strain-dependent polymorphism test was determined. Results: Among the 50 culture-positive isolates, 14% (7/50) had drug resistance caused by a gene mutation. Out of these, 4 (8%) isolates were mono-resistant to isoniazid drug, which is caused by a gene mutation in katG in the region of interrogated at codon 315 in the amino acid sequence of S315T1, and 3 (6%) isolates were resistant to both rifampicin and isoniazid drugs. The mutation was observed for katG (at codon 315 with a change in the sequence of amino acid S315T) and rpoB (at codon 530-533 with a change in the sequence of amino acid S531L (S450L)) genes. The most prevalent spoligotypes were orphan and SIT53 strains. Conclusion: The predominance of INH mono-resistance poses a critical risk for the potential development of MDR-TB, as INH mono-resistance is a typical pathway to the occurrence of MDR-TB. The orphan and SIT53 (T) strains were the most common in the study area, and a drug-resistant strain caused by a common gene mutation could indicate the transmission of clonal-resistant strains in the community.

Therapeutic efficacies of artemether-lumefantrine and dihydroartemisinin-piperaquine for the treatment of uncomplicated Plasmodium falciparum and chloroquine and dihydroartemisinin-piperaquine for uncomplicated Plasmodium vivax infection in Ethiopia.

BACKGROUND: Routine monitoring of anti-malarial drugs is recommended for early detection of drug resistance and to inform national malaria treatment guidelines. In Ethiopia, the national treatment guidelines employ a species-specific approach. Artemether-lumefantrine (AL) and chloroquine (CQ) are the first-line schizonticidal treatments for Plasmodium falciparum and Plasmodium vivax, respectively. The National Malaria Control and Elimination Programme in Ethiopia is considering dihydroartemisinin-piperaquine (DHA/PPQ) as an alternative regimen for P. falciparum and P. vivax. METHODS: The study assessed the clinical and parasitological efficacy of AL, CQ, and DHA/PPQ in four arms. Patients over 6 months and less than 18 years of age with uncomplicated malaria mono-infection were recruited and allocated to AL against P. falciparum and CQ against P. vivax. Patients 18 years or older with uncomplicated malaria mono-infection were recruited and randomized to AL or dihydroartemisinin-piperaquine (DHA/PPQ) against P. falciparum and CQ or DHA/PPQ for P. vivax. Patients were followed up for 28 (for CQ and AL) or 42 days (for DHA/PPQ) according to the WHO recommendations. Polymerase chain reaction (PCR)-corrected and uncorrected estimates were analysed by Kaplan Meier survival analysis and per protocol methods. RESULTS: A total of 379 patients were enroled in four arms (n = 106, AL-P. falciparum; n = 75, DHA/PPQ- P. falciparum; n = 142, CQ-P. vivax; n = 56, DHA/PPQ-P. vivax). High PCR-corrected adequate clinical and parasitological response (ACPR) rates were observed at the primary end points of 28 days for AL and CQ and 42 days for DHA/PPQ. ACPR rates were 100% in AL-Pf (95% CI: 96-100), 98% in CQ-P. vivax (95% CI: 95-100) at 28 days, and 100% in the DHA/PPQ arms for both P. falciparum and P. vivax at 42 days. For secondary endpoints, by day three 99% of AL-P. falciparum patients (n = 101) cleared parasites and 100% were afebrile. For all other arms, 100% of patients cleared parasites and were afebrile by day three. No serious adverse events were reported. CONCLUSION: This study demonstrated high therapeutic efficacy for the anti-malarial drugs currently used by the malaria control programme in Ethiopia and provides information on the efficacy of DHA/PPQ for the treatment of P. falciparum and P. vivax as an alternative option.

Cost-analysis of COVID-19 sample collection, diagnosis, and contact tracing in low resource setting: The case of Addis Ababa, Ethiopia.

BACKGROUND: Ethiopia has been responding to the COVID-19 pandemic through a combination of interventions, including non-pharmaceutical interventions, quarantine, testing, isolation, contact tracing, and clinical management. Estimating the resources consumed for COVID-19 prevention and control could inform efficient decision-making for epidemic/pandemic-prone diseases in the future. This study aims to estimate the unit cost of COVID-19 sample collection, laboratory diagnosis, and contact tracing in Addis Ababa, Ethiopia. METHODS: Primary and secondary data were collected to estimate the costs of COVID-19 sample collection, diagnosis, and contact tracing. A healthcare system perspective was used. We used a combination of micro-costing (bottom-up) and top-down approaches to estimate resources consumed and the unit costs of the interventions. We used available cost and outcome data between May and December 2020. The costs were classified into capital and recurrent inputs to estimate unit and total costs. We identified the cost drivers of the interventions. We reported the cost for the following outcome measures: (1) cost per sample collected, (2) cost per laboratory diagnosis, (3) cost per sample collected and laboratory diagnosis, (4) cost per contact traced, and (5) cost per COVID-19 positive test identified. We conducted one-way sensitivity analysis by varying the input parameters. All costs were reported in US dollars (USD). RESULTS: The unit cost per sample collected was USD 1.33. The unit cost of tracing a contact of an index case was USD 0.66. The unit cost of COVID-19 diagnosis, excluding the cost for sample collection was USD 3.91. The unit cost of sample collection per COVID-19 positive individual was USD 11.63. The unit cost for COVID-19 positive test through contact tracing was USD 54.00. The unit cost COVID-19 DNA PCR diagnosis for identifying COVID-19 positive individuals, excluding the sample collection and transport cost, was USD 37.70. The cost per COVID-19 positive case identified was USD 49.33 including both sample collection and laboratory diagnosis costs. Among the cost drivers, personnel cost (salary and food cost) takes the highest share for all interventions, ranging from 51-76% of the total cost. CONCLUSION: The costs of sample collection, diagnosis, and contact tracing for COVID-19 were high given the low per capita health expenditure in Ethiopia and other low-income settings. Since the personnel cost accounts for the highest cost, decision-makers should focus on minimizing this cost when faced with pandemic-prone diseases by strengthening the health system and using digital platforms. The findings of this study can help decision-makers prioritize and allocate resources for effective public health emergency response.

Aflatoxin exposure among children of age 12-59 Months in Butajira District, South-Central Ethiopia: a community based cross-sectional study.

BACKGROUND: The continued provision of safe food, free of aflatoxin remains a huge challenge in developing countries. Despite several favourable climatic conditions that facilitate aflatoxin contamination in Ethiopia, there is little information showing aflatoxin exposure in children. Therefore, this study assessed aflatoxin exposure among young children in Butajira district, South-Central Ethiopia. METHODS: Community based cross-sectional study stratified by agro-ecology was employed in Health and Demographic Surveillance Site (HDSS) of Butajira. The study included 332 children aged 12-59 months and were selected by simple random sampling technique using the HDSS registration number as a sampling frame. We collected data on dietary practice and aflatoxin exposure. Aflatoxin M1 concentration in urine was measured by Enzyme-Linked Immunosorbent assay (ELISA). The data analysis was carried out using STATA. RESULTS: Detectable urinary Aflatoxin M1 was found in 62.4% (95% CI: 56.9 - 67.5%) of the children at a level ranging from 0.15 to 0.4 ng/ml. Children living in lowland agro-ecological zone had [AOR = 2.11 (95% CI; 1.15, 3.88] odds of being exposed to aflatoxin as compared to children living in highland agro-ecological zone. Children at lower socio-economic status [AOR = 0.27 (95% CI; 0.14, 0.50] and medium socio-economic status [AOR = 0.47 (95% CI; 0.25, 0.87] had 73% and 53% lower odds of being exposed to aflatoxin as compared to children in the higher socio-economic status, respectively. CONCLUSIONS: Aflatoxin exposure among young children was very high in South-Central Ethiopia. This high aflatoxin exposure might emphasize the need for aflatoxin exposure mitigation strategies in Ethiopia. Especially, raising awareness of the community towards aflatoxin exposure is very crucial. In addition, further research is required to assess long-term aflatoxin exposure and its association with child growth and development.

Case Report: Disseminated Strongloides stercoralis Presenting as an Ulcerated Gastric Mass in an HIV-1-infected Patient.

Disseminated Strongloides stercoralis is a common phenomenon among patients with immunosuppression. In this report, we present a case of disseminated Strongloides stercoralis presenting as a gastric mass in a 42-year-old male patient with a known history of HIV-1 infection and type 2 diabetes mellitus (T2DM). The patient presented with symptoms and signs suggestive of acute on chronic erosive gastritis, which included persistent vomiting. Endoscopic examination revealed a gastric mass with no signs of malignancy or dysplasia. There was noted to be chronic inflammation along with morphologic features consistent with the larvae and eggs of Strongloides nematodes in a biopsied gastric mass tissue and duodenum. The disease subsequently resulted in death despite the administration of ivermectin.

Diagnostic accuracy of three commercially available one step RT-PCR assays for the detection of SARS-CoV-2 in resource limited settings.

BACKGROUND: COVID-19 is an ongoing public health pandemic regardless of the countless efforts made by various actors. Quality diagnostic tests are important for early detection and control. Notably, several commercially available one step RT-PCR based assays have been recommended by the WHO. Yet, their analytic and diagnostic performances have not been well documented in resource-limited settings. Hence, this study aimed to evaluate the diagnostic sensitivities and specificities of three commercially available one step reverse transcriptase-polymerase chain reaction (RT-PCR) assays in Ethiopia in clinical setting. METHODS: A cross-sectional study was conducted from April to June, 2021 on 279 respiratory swabs originating from community surveillance, contact cases and suspect cases. RNA was extracted using manual extraction method. Master-mix preparation, amplification and result interpretation was done as per the respective manufacturer. Agreements between RT-PCRs were analyzed using kappa values. Bayesian latent class models (BLCM) were fitted to obtain reliable estimates of diagnostic sensitivities, specificities of the three assays and prevalence in the absence of a true gold standard. RESULTS: Among the 279 respiratory samples, 50(18%), 59(21.2%), and 69(24.7%) were tested positive by TIB, Da An, and BGI assays, respectively. Moderate to substantial level of agreement was reported among the three assays with kappa value between 0 .55 and 0.72. Based on the BLCM relatively high specificities (95% CI) of 0.991(0.973-1.000), 0.961(0.930-0.991) and 0.916(0.875-0.952) and considerably lower sensitivities with 0.813(0.658-0.938), 0.836(0.712-0.940) and 0.810(0.687-0.920) for TIB MOLBIOL, Da An and BGI respectively were found. CONCLUSIONS: While all the three RT-PCR assays displayed comparable sensitivities, the specificities of TIB MOLBIOL and Da An were considerably higher than BGI. These results help adjust the apparent prevalence determined by the three RT-PCRs and thus support public health decisions in resource limited settings and consider alternatives as per their prioritization matrix.

Evaluating performance of multiplex real time PCR for the diagnosis of malaria at elimination targeted low transmission settings of Ethiopia.

BACKGROUND: Malaria incidence has declined in Ethiopia in the past 10 years. Current malaria diagnostic tests, including light microscopy and rapid antigen-detecting diagnostic tests (RDTs) cannot reliably detect low-density infections. Studies have shown that nucleic acid amplification tests are highly sensitive and specific in detecting malaria infection. This study took place with the aim of evaluating the performance of multiplex real time PCR for the diagnosis of malaria using patient samples collected from health facilities located at malaria elimination targeted low transmission settings in Ethiopia. METHODS: A health facility-based, cross-sectional survey was conducted in selected malaria sentinel sites. Malaria-suspected febrile outpatients referred to laboratory for malaria testing between December 2019 and March 2020 was enrolled into this study. Sociodemographic information and capillary blood samples were collected from the study participants and tested at spot with RDTs. Additionally, five circles of dry blood spot (DBS) samples on Whatman filter paper and thick and thin smear were prepared for molecular testing and microscopic examination, respectively. Multiplex real time PCR assay was performed at Ethiopian Public Health Institute (EPHI) malaria laboratory. The performance of multiplex real time PCR assay, microscopy and RDT for the diagnosis of malaria was compared and evaluated against each other. RESULTS: Out of 271 blood samples, multiplex real time PCR identified 69 malaria cases as Plasmodium falciparum infection, 16 as Plasmodium vivax and 3 as mixed infections. Of the total samples, light microscopy detected 33 as P. falciparum, 18 as P. vivax, and RDT detected 43 as P. falciparum, 17 as P. vivax, and one mixed infection. Using light microscopy as reference test, the sensitivity and specificity of multiplex real time PCR were 100% (95% CI (93-100)) and 83.2% (95% CI (77.6-87.9)), respectively. Using multiplex real time PCR as a reference, light microscopy and RDT had sensitivity of 58% (95% CI 46.9-68.4) and 67% (95% CI 56.2-76.7); and 100% (95% CI 98-100) and 98.9% (95% CI 96-99.9), respectively. Substantial level of agreement was reported between microscopy and multiplex real time PCR results with kappa value of 0.65. CONCLUSIONS: Multiplex real-time PCR had an advanced performance in parasite detection and species identification on febrile patients' samples than did microscopy and RDT in low malaria transmission settings. It is highly sensitive malaria diagnostic method that can be used in malaria elimination programme, particularly for community based epidemiological samples. Although microscopy and RDT had reduced performance when compared to multiplex real time PCR, still had an acceptable performance in diagnosis of malaria cases on patient samples at clinical facilities.

Baseline malaria prevalence at the targeted pre-elimination districts in Ethiopia.

BACKGROUND: Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country's malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings. METHODS: A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature. RESULT: Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age. CONCLUSION: The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

Diagnostic efficacy of Light-Emitting Diode (LED) Fluorescence based Microscope for the diagnosis of Tuberculous lymphadenitis.

BACKGROUND: The comparatively straightforward and cheaper light-emitting diode fluorescent microscope (LEDFM) was suggested by WHO to replace conventional microscope in tuberculosis (TB) laboratories. However, the comparable efficacy of each of those techniques differs from laboratory to laboratory. We investigated the efficacy of LEDFM for the diagnosis of tuberculous lymphadenitis (TBLN) patients. METHODS: A cross-sectional study was conducted on 211 samples from clinically suspected tuberculous lymphadenitis patients. Three smears were prepared from FNA on microscope slides for cytomorphology study, Auramine O (AO), and for Ziehl-Neelsen (ZN) staining. The left-over samples were inoculated onto Lowenstein-Jensen (LJ) media. Statistical analysis was done using STATA version 11. The sensitivity, specificity, positive and negative predictive values were calculated by considering the culture results as the gold standard using a 95% confidence interval. RESULTS: Among 211 samples 49.7% (105) were positive by cytomorphology, 32.7% (69) by LEDFM, 23.69% (50) by LJ culture, and 13.7% (29) by ZN. Compared to the gold standard sensitivity of ZN, LEDFM, and cytomorphology were 30% [95% CI: 17.9-44.6], 66% [95% CI: 51.2-78.8] 78% [95% CI: 64-88.5], respectively. The specificity of ZN, LEDFM, and cytomorphology was 91.3% [95% CI: 85.8-95.2], 77.6% [95% CI: 70.4-83.8], 58.8% [95% CI: 50.7-66.5], respectively. CONCLUSION: LED fluorescence microscopy gives a legitimate option in contrast to conventional ZN techniques in terms of its higher sensitivity, a bit lower specificity, time-saving, and minimal effort.

Prevalence of SARS-CoV-2 in urban and rural Ethiopia: Randomized household serosurveys reveal level of spread during the first wave of the pandemic.

BACKGROUND: The spread of SARS-CoV-2 in Sub-Saharan Africa is poorly understood and to date has generally been characterised by a lower number of declared cases and deaths as compared to other regions of the world. Paucity of reliable information, with insights largely derived from limited RT-PCR testing in high-risk and urban populations, has been one of the biggest barriers to understanding the course of the pandemic and informed policy-making. Here we estimate seroprevalence of anti-SARS-CoV-2 antibodies in Ethiopia during the first wave of the pandemic. METHODS: We undertook a population-based household seroprevalence serosurvey based on 1856 participants in Ethiopia, in the capital city Addis Ababa, and in Jimma, a middle-sized town in the Oromia region, and its rural surroundings (districts of Seka and Mana), between 22 July and 02 September 2020. We tested one random participant per household for anti-SARS-CoV-2 antibodies using a high specificity rapid diagnostic tests (RDTs) and evaluated population seroprevalence using a Bayesian logistic regression model taking into account test performance as well as age and sex of the participants. FINDINGS: In total, 2304 random households were visited, with 1856 individuals consenting to participate. This produced a sample of 956 participants in Addis Ababa and 900 participants in Jimma. IgG prevalence was estimated at 1.9% (95% CI 0.4-3.7%), and combined IgM/IgG prevalence at 3.5% (95% CI 1.7-5.4%) for Addis Ababa in early August 2020, with higher prevalence in central sub-cities. Prevalence in Jimma town was lower at 0.5% (95% CI 0-1.8%) for IgG and 1.6% (95%CI 0-4.1%) for IgM/IgG, while in rural Jimma IgG prevalence was 0.2% and IgM/IgG 0.4% in early September. INTERPRETATION: More than four months after the first cases were detected in Ethiopia, Addis Ababa displayed a prevalence under 5% and likely as low as 2%, while rural Jimma displayed a prevalence of 0.2%. A 2% seroprevalence figure for the capital translated to a number of cases at least five times larger than those reported for the country as a whole. At the same time, it contrasts with significantly higher seroprevalence figures in large cities in Europe and America only two to three months after the first cases. This population-based seroepidemiological study thus provides evidence of a slower spread of SARS-CoV-2 in the Ethiopian population during the first wave of the pandemic and does not appear to support the notion that lower case numbers were simply a reflection of limited testing and surveillance. FUNDING: Schmidt Family Foundation, Joachim Hertz Foundation, Nespresso, Peet's and Smuckers.

Mentorship on malaria microscopy diagnostic service in Ethiopia: baseline competency of microscopists and performance of health facilities.

BACKGROUND: In Ethiopia, malaria cases are declining as a result of proven interventions, and in 2017 the country launched a malaria elimination strategy in targeted settings. Accurate malaria diagnosis and prompt treatment are the key components of the strategy to prevent morbidity and stop the continuation of transmission. However, the quality of microscopic diagnosis in general is deteriorating as malaria burden declines. This study was carried out to evaluate the competency of microscopists and the performance of health facilities on malaria microscopic diagnosis. METHODS: A cross-sectional study was conducted from 1 August to 30 September, 2019 in 9 regional states and one city administration. A standard checklist was used for on-site evaluation, archived patient slides were re-checked and proficiency of microscopists was tested using a WHO-certified set of slides from the national slide bank at the Ethiopian Public Health Institute (EPHI). The strength of agreement, sensitivity, specificity, and positive and negative predictive values were calculated. RESULTS: In this study, 102 health facilities (84 health centres and 18 hospitals) were included, from which 202 laboratory professionals participated. In slide re-checking, moderate agreement (agreement (A): 76.0%; Kappa (K): 0.41) was observed between experts and microscopists on malaria detection in all health facilities. The sensitivity and specificity of routine slide reading and the re-checking results were 78.1 and 80.7%, respectively. Likewise, positive predictive value of 65.1% and negative predictive value of 88.8% were scored in the routine diagnosis. By panel testing, a substantial overall agreement (A: 91.8%; K: 0.79) was observed between microscopists and experts in detecting malaria parasites. The sensitivity and specificity in the detection of malaria parasites was 92.7 and 89.1%, respectively. In identifying species, a slight agreement (A: 57%; K: 0.18) was observed between microscopists and experts. CONCLUSION: The study found significant false positive and false negative results in routine microscopy on slide re-checking of Plasmodium parasites. Moreover, reduced grade in parasite species identification was reported on the panel tests. Implementing comprehensive malaria microscopy mentorship, in-service training and supportive supervision are key strategies to improve the overall performance of health facilities in malaria microscopy.

Whole blood-based in vitro culture reveals diminished secretion of pro-inflammatory cytokines and chemokines in visceral leishmaniasis.

The likelihood of being bitten by sand flies infected with Leishmania (L.) donovani is considered to be high for all inhabitants living in the endemic areas, but only a small ratio of the population develop symptomatic visceral leishmanisis (VL). Since adequate activation of antimicrobial immune response plays a key role in control of pathogens early after infection we hypothesized that a dysfunction of essential cells of the immune system is associated with disease development after infection with L. donovani. In order to obtain insights into the capacity of leukocytes to respond to L. donovani, a whole blood based assay was applied to evaluate the production of cytokines and chemokines in clinical VL versus Ethiopian endemic healthy control (EHC). In response to L. donovani, VL blood cultures showed significantly lower secretion of IL-12p70, IL-6, IL-17, IL-8 and IP-10 compared to EHC. On the contrary, there was a significantly higher secretion of IL-10 observed in VL compared to EHC. In response to LPS also a lower IL-1ß, IL-12p70 and IL-6 secretion was observed in VL as compared to EHC. The data clearly indicate a diminished ability of blood leukocytes in VL to respond to L. donovani and to the TLR ligand LPS. This compromised response in VL may contribute to the severe disease development and enhanced susceptibility to secondary infections in VL.