Implementation of a mentored professional development programme in laboratory leadership and management in the Middle East and North Africa.

Laboratories need leaders who can effectively utilize the laboratories' resources, maximize the laboratories'capacity to detect disease, and advocate for laboratories in a fluctuating health care environment. To address this need, the University of Washington, USA, created the Certificate Program in Laboratory Leadership and Management in partnership with WHO Regional Office for the Eastern Mediterranean, and implemented it with 17 participants and 11 mentors from clinical and public health laboratories in 10 countries (Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, and Yemen) in 2014. Designed to teach leadership and management skills to laboratory supervisors, the programme enabled participants to improve laboratory testing quality and operations. The programme was successful overall, with 80% of participants completing it and making impactful changes in their laboratories. This success is encouraging and could serve as a model to further strengthen laboratory capacity in the Region.

Implementation of a mentored professional development programme in laboratory leadership and management in the Middle East and North Africa

Laboratories need leaders who can effectively utilize the laboratories' resources, maximize the laboratories'capacity to detect disease, and advocate for laboratories in a fluctuating health care environment. To address this need, the University of Washington, USA, created the Certificate Program in Laboratory Leadership and Management in partnership with WHO Regional Office for the Eastern Mediterranean, and implemented it with 17 participants and 11 mentors from clinical and public health laboratories in 10 countries [Egypt, Iraq, Jordan, Lebanon, Morocco, Oman, Pakistan, Qatar, Saudi Arabia, and Yemen] in 2014. Designed to teach leadership and management skills to laboratory supervisors, the programme enabled participants to improve laboratory testing quality and operations. The programme was successful overall, with 80% of participants completing it and making impactful changes in their laboratories. This success is encouraging and could serve as a model to further strengthen laboratory capacity in the Region

Les laboratoires ont besoin de directeurs à même d'utiliser les ressources internes de façon efficace, de maximiser leurs capacités à dépister les maladies, et d'oeuvrer pour le bien de ces établissements dans un environment de soins de santé en perpétuel changement. Pour répondre à ces besoins, l'Université de Washington [Etats-Unis], en partenariat avec le Bureau régional de l'OMS pour la Méditerranée orientale, a mis au point le Programme de certification en direction et gestion de laboratoire qui a été suivi par 17 participants et 11 mentors issus de laboratoires de santé clinique et publique dans 10 pays [Arabie saoudite, Egypte, Iraq, Jordanie, Liban, Maroc, Oman, Pakistan, Qatar et Yémen] au cours de l'année 2014. Conçu pour former les responsables de laboratoire aux compétences de direction et de gestion, le programme a permis aux participants de renforcer la qualité du dépistage et des opérations de leurs laboratoires. Le programme a été une réussite dans l'ensemble puisqu'il a été suivi jusqu'à son terme par 80% des participants et que ceux-ci ont ensuite pu mettre en place des changements réels dans leurs laboratoires. Ce succès est encourageant et pourrait servir de modèle afin de renforcer davantage encore les capacités des laboratoires dans la Région

Prevalence of cdtABC genes encoding cytolethal distending toxin among Haemophilus ducreyi and Actinobacillus actinomycetemcomitans strains.

The aim of this study was to investigate the presence of the three cdtABC genes responsible for production of cytolethal distending toxin (CDT) in Haemophilus ducreyi and Actinobacillus actinomycetemcomitans strains. Of 100 H. ducreyi strains from the culture collection of the University of Göteborg (CCUG), 27 strains with low or intermediate cytotoxic titre (< 1 in 10(4)) and 23 of the remaining isolates with a high cytotoxic titre (> or = 1 in 10(4)) were selected. Twenty-nine strains of H. ducreyi were isolated recently from patients with chancroid and 50 A. actinomycetemcomitans strains from patients with periodontitis. The cytotoxic activity on HEp-2 cells and the presence of cdtABC genes were studied by cytotoxicity assay of bacterial sonicates and PCR with primers specific for individual cdtA, B, and C genes of H. ducreyi in bacterial DNA preparations, respectively. All strains that manifested a cytotoxic titre in sonicate > or = 1 in 100 possessed all the three cdt genes. Eighteen of the 50 strains selected from the culture collection were negative and 32 positive for cdt genes. As all strains with a high cytotoxic titre gave positive PCR results, it can be assumed that the remaining 50 strains, which have high cytotoxic titre, would have been positive as well. Thus, it can be estimated that 82% of the culture collection strains had cdtABC genes. Similarly, 24 (83%) of 29 recent H. ducreyi isolates expressed the CDT activity and displayed all cdtABC genes. Forty-three (86%) of 50 strains of the closely related A. actinomycetemcomitans, expressing a cytotoxic activity > or = 1 in 100, also possessed all three genes. Furthermore, the nucleotide sequence of the cdtABC genes was highly conserved among H. ducreyi strains from different geographic areas. These results indicate that the majority of pathogenic H. ducreyi and A. actinomycetemcomitans strains express a CDT activity encoded by all three cdtABC.

Antibodies specific to surface antigens are not effective in complement-mediated killing of Haemophilus ducreyi.

The bactericidal activity of serum is an important primary host defence against gram-negative bacteria. Little is known regarding such antibodies that are specific to outer membrane (OM) antigens as pili and lipooligosaccharides (LOS) in the bactericidal killing of Haemophilus ducreyi. Presence of serum antibodies with specificity to a 430 kDa protein (polymer of the 24 kDa protein, named fine-tangled pili) and LOS in serum from chancroid patients and healthy individuals were investigated by ELISA. Using a bactericidal assay, we investigated the role of human and rabbit antibodies with the aforementioned specificity. Accessibility of LOS and of OM antigens, as well as the deposition of components of the complement (C) system on the surface of the bacteria, was further investigated by whole-cell ELISA and immunoelectron microscopy. Immunoglobulin G (IgG) antibodies specific to the 430 kDa polymer and to LOS were demonstrated in the majority of sera from chancroid patients and healthy individuals. However, sera from chancroid patients did not significantly enhance the C-mediated killing of H. ducreyi compared with normal human serum (NHS). Similar results were demonstrated using rabbit sera to whole bacteria, specific to the 430 kDa protein and LOS of H. ducreyi. However, using the same assay noncapsulatedH. influenzae was totally killed, as were H. influenzae type b in presence of specific antibodies. This suggests a limited effectiveness of antibodies specific to surface antigens in C-mediated killing of H. ducreyi. LOS was detectable on the surface of H. ducreyi with a specific monoclonal antibody in white-cell ELISA. However, a significant enhancement of LOS detection was demonstrated on washed bacteria. OM antigens of 26, 40, 45 kDa and the major outer membrane protein (MOMP) of 43 kDa were not detectable on the surface of nonwashed and washed bacteria by specific monoclonal antibodies, indicating a lack of accessibility of these antigens on the bacterial surface. However, the C6 to C9 components of C were detected on the bacterial surface, suggesting capacity of forming the membrane attack complex. Altogether, these findings imply that antibodies specific to surface antigens, such as the 430 kDa protein and LOS, are not capable of enhancing killing of bacteria. The demonstrated relative resistance is probably due not to a lack of deposition of the membrane attack complex components, but rather to a blocking of LOS accessibility and OM proteins as potential targets of bactericidal antibodies and C action.

Structurally defined epitopes of Haemophilus ducreyi lipooligosaccharides recognized by monoclonal antibodies.

By use of enzyme-linked immunosorbent assay and immunoblotting techniques, the migration patterns and binding epitopes of lipooligosaccharides (LOS) from 10 Haemophilus ducreyi strains were investigated with two monoclonal antibodies (MAbs), MAHD6 and MAHD7, raised against LOS from H. ducreyi ITM 2665. Closely related LOS, with defined structures, from Haemophilus influenzae, Bordetella pertussis, Aeromonas spp., and synthetic glycoproteins were also included in the analyses. The MAbs bound to conserved epitopes of LOS exposed on the surface of H. ducreyi. The MAb MAHD6 reacted with 8 of the 10 LOS from H. ducreyi but with none of the other Haemophilus or Bordetella spp. with structurally defined LOS. It is suggested that MAb MAHD6 binds to a LOS epitope (-DD-Hepp-1-->6-beta-D-Glcp-). This LOS epitope is not present in the hexasaccharide structure of LOS from H. ducreyi ITM 4747 (E. K. H. Schweda, A. C. Sundström, L. M. Eriksson, J. A. Jonasson, and A. A. Lindberg, J. Biol. Chem. 269:12040-12048, 1994). Because MAb MAHD6 reacts with the epitope mentioned above, it also discriminates between the two LOS structures, the hexasaccharide group and the nonasaccharide group, of H. ducreyi strains. MAb MAHD7 recognizes the common conserved inner core region of the LOS because it reacts with all H. ducreyi strains and with LOS with minor components in the inner core epitope structure. Rabbit polyclonal sera raised against the LOS from strains CCUG 4438 and CCUG 7470 were tested with the 10 LOS from the H. ducreyi strains. The antiserum to CCUG 7470 reacted with all H. ducreyi strains as did MAb MAHD7, whereas the antiserum to CCUG 4438 reacted with only its homologous strain and strain ITM 4747. Also, the LOSs of our reference strains CCUG 4438 and CCUG 7470 were structurally analyzed by use of sugar analyses and electrospray ionization-mass spectrometry. The hexasaccharide and nonasaccharide structures obtained from LOS of strains CCUG 4438 and CCUG 7470 were identical to the described LOS structures from H. ducreyi ITM 4747 and ITM 2665, respectively. In conclusion, the MAb MAHD6 recognizes an epitope present in the nonasaccharide LOS group, whereas the MAb MAHD7 recognizes a conserved epitope on LOS of H. ducreyi, which is present in all strains of H. ducreyi tested. Two major groups of oligosaccharides were distinguished by their LOS structures and the reactivity of monoclonal as well as polyclonal antibodies. The majority of H. ducreyi strains possess a nonasaccharide structure of LOS.

Monoclonal antibodies against Haemophilus ducreyi lipooligosaccharide and their diagnostic usefulness.

Monoclonal antibodies against the lipooligosaccharide of Haemophilus ducreyi were produced. Two of them, MAHD6 and MAHD7, were found to be relatively, although not absolutely, specific and reacted with nearly all strains of Haemophilus ducreyi tested: 59 of 60 and 60 of 60, respectively. The diagnostic usefulness of MAHD7 was assessed. Clinical specimens collected in Zambia from patients with genital ulcers were tested using indirect immunofluorescence (IF), enzyme immunoassay (EIA), the polymerase chain reaction (PCR) and bacterial culture. Compared with culture, IF had a sensitivity of 100%; compared with PCR, sensitivity was 89%. The corresponding figures for the EIA were 83% and 74%, respectively. The sensitivity of culture compared with PCR was 63%. The results suggest that IF on genital smears using MAHD7 might be an excellent tool for the diagnosis of chancroid in high-prevalence populations. However, further evaluation of the specificity of this test is needed.

Monoclonal antibodies against Haemophilus lipopolysaccharides: clone DP8 specific for Haemophilus ducreyi and clone DH24 binding to lacto-N-neotetraose.

Mouse monoclonal antibodies (MAbs) DP8 [immunoglobulin G1(kappa)] and DH24 [immunoglobulin M(kappa)], which are specific for Haemophilus ducreyi lipopolysaccharide (LPS), were generated by fusing mouse myeloma NS0 cells with spleen cells of BALB/c mice immunized with a total membrane preparation of H. ducreyi. MAb DP8 reacted in whole-cell enzyme immunoassay (EIA) and colony dot immunoblotting with all 50 strains of H. ducreyi but not with any other bacteria tested, which suggests an exposed and species-specific epitope on the H. ducreyi cell surface. This conclusion was supported by the finding that DP8 bound to all six H. ducreyi LPSs tested but not to any of the Haemophilus influenzae or enterobacterial LPSs or synthetic glycoconjugates. The MAb DH24 bound to 43 of 50 strains of H. ducreyi and to few strains of H. influenzae, Neisseria gonorrhoeae, and Neisseria meningitidis, as evaluated by whole-cell EIA and colony dot immunoblotting. The MAb DH24 reacted with five of the six H. ducreyi LPSs tested and with the lacto-N-neotetraose (Gal beta 1-->4GlcNAc beta 1-->3Gal beta 1-->4Glc) series of synthetic glycoconjugates, as determined by EIA. By using polysaccharides obtained after both mild acidic hydrolysis and strong alkali treatment and dephosphorylated samples as inhibitors of the MAbs binding to H. ducreyi LPS antigens, it could be shown that phosphate groups were essential for the binding of DP8 to LPS but that they did not affect antigenic recognition by DH24. None of the MAbs bound to isolated lipid A, but aggregation caused by the fatty acids of lipid A was essential for epitope recognition.

An epidemic of Neisseria gonorrhoeae in a Somali orphanage.

Neisseria gonorrhoeae was isolated from 53 young females (6-14 years old) in a Somali orphanage. A male guardian was found to be the effective transmitter having sexually abused the children. All the bacterial isolates were of the same serogroup WI and the same serovar Aedih. This presents an unusual example of a tight geographic cluster of infected people which is often characteristic of gonorrhoea epidemics.

PIP: The physician of an orphanage in Afgoye, 30 km from Mogadishu, Somalia, noticed vaginal discharge in 95 of the 500 girls at the orphanage in September 1987. A Somali-Italian investigative team took vaginal specimens from the 95 girls. Laboratory personnel isolated Neisseria gonorrhoea in 56% of the 95 6-14 year old females (53) who all lived in 2 adjacent dormitories. They found that all the bacterial isolates were of the N. gonorrhoea WI serogroup and Aedih serovar. The physician prescribed penicillin treatment for all the girls. Contact tracing revealed that a male guardian was the source of gonorrhea. Some children had already accused him of sexually abusing them. Orphanage officials had transferred him 1 week before the arrival of the investigative team. His room had been very near to the 2 dormitories for only a few weeks before the investigative team arrived. In this short time, his sexual abuse effected this cluster of infections. This supports the present theory of gonorrhea epidemiology that a core group of infectious people are most likely responsible for most, if not all, of the continuing endemicity of gonorrhea. The infection rate was in range of the estimated probability of transmission (50-70%) during sexual intercourse from an infectious male to a female. The results showed that high resolution typing of gonococci has in addition to its scientific value a more practical value; forensic medicine and illustration that gonorrhea consists of smaller microepidemics.

Syphilis and human immunodeficiency virus seroconversion during a 6-month follow-up of female prostitutes in Mogadishu, Somalia.

A total of 155 prostitutes inhabiting 4 different districts in Mogadishu, Somalia, were enrolled in a 6 month prospective study of syphilis and HIV infection. Blood samples were taken on entry, at 3 months and at 6 months. Differences were seen between the prostitutes in the 4 districts regarding possible risk factors for the acquisition of STDs. Initially 107 (69%) were found to have syphilis serum markers and 47% had active syphilis as judged by positivity in both Treponema Pallidum Haemagglutination (TPHA) test and non-treponemal (VDRL and RPR) tests. TPHA positivity was correlated to the number of sexual partners. Sixty-nine prostitutes were followed for 6 months. Two of the 16 initially TPHA negative women seroconverted for syphilis during the follow-up. HIV antibodies were detected in one (0.6%) of the 155 prostitutes at the start of the study and one out of 68 seroconverted during the 6 months follow-up. To control the spread of HIV infection health education targeting the risk groups like prostitutes must be given a high priority.

Syphilis, gonorrhoea and genital chlamydial infection in a Somali village.

A total of 767 sera were collected from 187 men, 200 women and 380 children in a Somali village, Jambaluul. All sera were tested for syphilis serological markers by Venereal Diseases Research Laboratory (VDRL) and Treponema pallidum Haemagglutination Assay (TPHA). Sera positive for both or either of these tests were further analysed for the presence of specific IgM antibodies by Solid Phase Haemadsorption Assay (SPHA). A high and almost equal prevalence of TPHA positivity was found in men and women; 24% and 22.5%, respectively, and IgM antibodies were found in 3% and 4%, respectively. TPHA positivity significantly increased with age. Thus more than half of the villagers at the age of 45 years or more were TPHA positive. One percent of the children were TPHA positive. From all adults aged 15 years and above urogenital specimens were also taken for Chlamydia trachomatis antigen detection with an enzyme-amplified immunoassay (IDEIA) and Neisseria gonorrhoeae culture. Chlamydial genital infection was found in 6% of the men and 18% of the women. All gonococcal cultures were negative.

Sexually transmitted diseases in men in Mogadishu, Somalia.

The prevalence of viral and bacterial sexually transmitted diseases were studied in 101 men attending a dermatovenereal outpatient clinic in Mogadishu. A control group of 103 healthy adult men were included for the serological part of the study. Serological markers of hepatitis B virus (HBV), human immunodeficiency virus (HIV), cytomegalovirus (CMV) and herpes simplex virus (HSV) were studied. All sera were tested for syphilis markers. HBV serum markers were detected in 84% of the men in the study group and 66% of the healthy controls (P less than 0.005). Hepatitis B virus carriers were detected more frequently in the study group than among the controls. Also, 96% of the men in both groups had CMV antibodies and all of them had antibodies to HSV. No sera were found to contain HIV antibodies. The TPHA-positivity was 10% and 3% in the study and control groups respectively, and 5% of the patients had syphilis IgM antibodies. Sexual contact with prostitutes was recorded in 54% and 48% respectively of patients and controls, and such contact was correlated with TPHA-positivity in the study group. Chlamydia trachomatis antigen was detected in urogenital specimens of 14% of the men in the study group and gonococcal culture was positive in 53% of those with urethral discharge.

A two-year study of enteric infections associated with diarrhoeal diseases in children in urban Somalia.

A hospital-based systematic sample of 1667 children with severe diarrhoeal disease was studied in Mogadishu, Somalia, throughout 1983 and 1984. One or more enteric pathogens were found in 61% of the patients. Rotavirus (25%), enterotoxigenic Escherichia coli (11%), Shigella spp. (9%), Aeromonas hydrophila (9%), Giardia lamblia trophozoites (8%), Campylobacter jejuni (8%), and Vibrio cholerae non-O1 (6%) were the most frequently identified pathogens. Age-specific detection rates of enteric pathogens and helminths, seasonal patterns, and relationship of some specific infections with feeding status and main clinical features have been defined for all the sample examined.

Human toxoplasmosis in Somalia. Prevalence of Toxoplasma antibodies in a village in the lower Scebelli region and in Mogadishu.

The acquisition of Toxoplasma antibodies in various age groups was studied in 2 populations in Somalia, inhabitants of a village in the southern part of the country and residents in Mogadishu. The overall prevalence of antibodies was 56% in the village and 40% in Mogadishu. In both populations, antibodies were acquired early in life. At the age of 10 years, 44% of the villagers and 31% of the Mogadishu children were seropositive. In Europe and the USA the highest rate of antibody acquisition has been recorded in young adults. This difference may indicate different routes of transmission. In Europe and the USA Toxoplasma is transmitted mainly by the ingestion of undercooked pork or lamb. Undercooked meat is seldom consumed in Somalia, and pork not at all. However, the soil in Somalia is heavily contaminated with cat faeces and the humid climate in the southern part of the country may contribute to long survival of oocysts. In the villages all household activities are performed on the ground and in Mogadishu children play mainly outdoors on the ground. It therefore seems that conditions in Somalia favour transmission by oocysts rather than by infected meat. The early acquisition of antibodies in Somalia suggests that infection during pregnancy and, therefore, congenital toxoplasmosis are rare.