Efficacy and Safety of 'Fixed Dose' versus 'Loose' Drug Regimens for Treatment of Pulmonary Tuberculosis in Two High TB-Burden African Countries: A Randomized Controlled Trial.

BACKGROUND: There are limited data on the performance of the use of fixed-dose combination (FDC) TB drugs when used under programmatic settings in high TB-endemic countries. We evaluated the efficacy and safety of FDC versus loose formulation (LF) TB treatment regimens for treatment of pulmonary TB (PTB) in the context of actual medical practice in prevailing conditions within programmatic settings in five sites in two high TB-burden African countries. METHODS: A two-arm, single-blind, randomized clinical trial comparing FDCs with separate LFs involving 1000 adults newly diagnosed with culture positive PTB was conducted at five sites in two African countries between 2007 and 2011. Participants were randomized to receive daily treatment with anti-TB drugs given as either FDC or separate LFs for 24 weeks (intensive phase- 8 weeks of isoniazid, rifampicin, ethambutol and pyrazinamide; continuation phase- 16 weeks of rifampicin and isoniazid). Primary outcome measures were microbiological cure and safety at the end of six months' treatment; pre-specified non-inferiority margin for difference in cure rate was 4%. The primary efficacy analysis was based on the modified intent to treat (mITT) cohort comprising all randomized patients with a positive baseline culture result for TB and who received at least one dose of study treatment. Patients missing end of treatment culture results were considered failures. Further analyses were done in which mITT patients without an end of treatment (EOT) culture were excluded in a complete case analysis (mITTcc) and a per protocol cohort analysis defined as mITTcc patients who received at least 95% of their intended doses and had an EOT culture result. RESULTS: In the mITT analysis, the cure rate in the FDC group was 86.7% (398/459) and in the LF group 85.2% (396/465) (difference 1.5-% (90% confidence interval (CI) (-2.2%- 5.3%)). Per Protocol analysis showed similar results: FDC 98.9% (359/363) versus LF 96.9% (345/356), (difference 2.0% (90% CI: 0.1%- 3.8%)). The two arms showed no significant differences in terms of safety, early culture conversion and patient adherence to treatment. INTERPRETATION: The comparison of the two drug regimens satisfied the pre-specified non-inferiority criterion. Our results support the WHO recommendations for the use of FDC in the context of actual medical practice within health services in high TB-endemic countries. TRIAL REGISTRATION: ISRCTN Registry 95204603.

A Randomized Controlled Double Blind Trial of Ciclosporin versus Prednisolone in the Management of Leprosy Patients with New Type 1 Reaction, in Ethiopia.

BACKGROUND: Leprosy Type 1 (T1R) reactions are immune-mediated events leading to nerve damage and preventable disability affecting hands, feet and eyes. Type 1 Reactions are treated with oral corticosteroids. There is little evidence on alternative treatments for patients who do not respond to steroids or experience steroid adverse effects. We report the results of a randomized controlled trial testing the efficacy and adverse effect profile of ciclosporin and prednisolone (CnP) in comparison to prednisolone only (P) in patients with new T1R in Ethiopia. Ciclosporin is a potent immunosuppressant. Outcomes were measured using a clinical severity score, recurrence rate, adverse events and quality of life. RESULTS: Seventy three patients with new T1R were randomized to receive CnP or P for 20 weeks. Recovery rates in skin signs was similar in both groups (91% vs 88%). Improvements in nerve function both, new and old, sensory (66% vs 49%) and motor (75% vs 74%) loss were higher (but not significantly so) in the patients on CnP. Recurrences rates of T1R (85%) were high in both groups, and recurrences occurred significantly earlier (8 weeks) in patients CnP, who needed 10% more additional prednisolone. Serious major and minor adverse events rates were similar in patients in the two treatment arms of the study. Both groups had a significant improvement in their quality of life after the study, measured by the SF-36. CONCLUSIONS: This is the first double-blind RCT assessing ciclosporin, in the management of T1R in Africa. Ciclosporin could be a safe alternative second-line drug for patients with T1R who are not improving with prednisolone or are experiencing adverse events related to prednisolone. This study illustrates the difficulty in switching off leprosy inflammation. Better treatment agents for leprosy patients with reactions and nerve damage are needed.

Comparison of Efficacy and Safety of Ciclosporin to Prednisolone in the Treatment of Erythema Nodosum Leprosum: Two Randomised, Double Blind, Controlled Pilot Studies in Ethiopia.

BACKGROUND: Erythema Nodosum Leprosum (ENL) is a serious complication of leprosy. It is normally treated with high dose steroids, but its recurrent nature leads to prolonged steroid usage and associated side effects. There is little evidence on the efficacy of alternative treatments for ENL, especially for patients who have become steroid resistant or have steroid side effects. These two pilot studies compare the efficacy and side effect profile of ciclosporin plus prednisolone against prednisolone alone in the treatment of patients with either new ENL or chronic and recurrent ENL. METHODS AND RESULTS: Thirteen patients with new ENL and twenty patients with chronic ENL were recruited into two double-blinded randomised controlled trials. Patients were randomised to receive ciclosporin and prednisolone or prednisolone treatment only. Patients with acute ENL had a delay of 16 weeks in the occurrence of ENL flare-up episode, with less severe flare-ups and decreased requirements for additional prednisolone. Patients with chronic ENL on ciclosporin had the first episode of ENL flare-up 4 weeks earlier than those on prednisolone, as well as more severe ENL flare-ups requiring 2.5 times more additional prednisolone. Adverse events attributable to prednisolone were more common that those attributable to ciclosporin. CONCLUSIONS: This is the first clinical trial on ENL management set in the African context, and also the first trial in leprosy to use patients' assessment of outcomes. Patients on ciclosporin showed promising results in the management of acute ENL in this small pilot study. But ciclosporin, did not appear to have a significant steroid-sparing effects in patients with chronic ENL, which may have been due to the prolonged use of steroids in these patients in combination with a too rapid decrease of steroids in patients given ciclosporin. Further research is needed to determine whether the promising results of ciclosporin in acute ENL can be reproduced on a larger scale.

Characterization of the etiological agents of tuberculous lymphadenitis in Dera Woreda, North Showa, Ethiopia.

BACKGROUND: Tuberculous lymphadenitis (TBLN) is a common form of extra pulmonary tuberculosis where lymph nodes particularly from cervical, axillary and inguinal sites are mostly involved, however, its diagnosis poses a major challenge in resource limited settings. OBJECTIVE: To identify the etiological species of Mycobacteria responsible for TBLN in Derra area, a rural district in Ethiopia, where the status of TBLN is unknown. MATERIALS AND METHODS: A total of 153 patients who were clinically suspected for TBLN, between the periods of August 2004 and February 2005 were included in the study. Fine needle aspirates (FNA) were collected and processed from 145 participants and further analyzed using Ziehl Neelsen staining, culture, cytology and polymerase chain reaction (PCR) using sets of primers, targeting the IS6110 insertion sequence and the pncA gene allelic variation at position 169. RESULTS: Out of the 145 FNA samples, 66 (45.5%) demonstrated growth on Lowenstein-Jensen (LJ) medium and 115 (79.3%) cases were confirmed as TBLN by a combination of results from acid fast bacilli (AFB) smear examination, culture, cytology and PCR. From the 145 clinically suspected TBLN cases, 108 (75%) were identified by PCR at complex level of which 107/108 (99.1%) were positive for M. tuberculosis and 1/108 (0.9%) was positive for M. bovis using pncA primers. CONCLUSION: The study indicates that M. tuberculosis is the major cause of tuberculous lymphadenitis in Dera area.

Chronic meningitis in immunocompromised adult Ethiopians visiting Tikur Anbessa Teaching Hospital and Ye'huleshet Clinic from 2003-2004.

BACKGROUND: Chronic meningitis is inflammation of the meninges where signs and symptoms develop and last for at least four weeks without alleviation. Little is known about the current etiology and incidence of the disease in adults living in developing countries. OBJECTIVE: The objective of this study was to elucidate the most common etiologies of chronic meningitis in adult Ethiopian patients and give an aid in the empiric therapy. METHODOLOGY: A total of 53 adult patients (median age 32 years) having chronic meningitis and who were admitted at Tikur Anbessa Teaching Hospital and Ye'huleshet Clinic, Addis Ababa, Ethiopia were recruited between 2003 and 2004. Of the 53 patients, bacteriological, molecular and immunological investigations were done for 52 of the study participants to detect Cryptococcus neoformans, Mycobacterium tuberculosis, Toxoplasma gondii, Brucella and Neisseria meningitides infections. RESULTS: Forty eight of the participants were HIV positive and 15% (8/52) of the CSF were positive with Cryptococcal latex antigen detection test; in addition, M. tuberculosis DNA was detected using PCR from CSF ofpatients infew of the patients. Multiple infections were observed in studyparticipants with < 0.1 to 1 CD4 to CD8 ratio. CONCLUSION: Chronic meningitis mostly occurred in HIV infected patients, where most of the infections were attributed to Cryptococcus neoformans whereas M. tuberculosis appeared secondary.

A pilot study on detection and genotyping of humanpapilloma virus isolated from clinically diagnosed Ethiopian women having cervical intraepithelial neoplasia.

BACKGROUND: Human Papilloma virus associated cervical cancers are more prevalent in developing countries compared to developed countries. Cervical cancer is reported as the most frequent malignancy among women visiting hospitals in Ethiopia. This study is a pilot study designed to examine the prevalence and genotypes of HPV in twenty Ethiopian women, clinically diagnosed to have cervical neoplasia, while visiting gynecology unit of a tertiary level referral hospital in Addis Ababa. The objective of this study was to detect the presence of HPV L1 gene and respective genotypes among women clinically diagnosed with different grades of cervical neoplasia. METHODOLOGY: A total of 20 fresh biopsy samples were collected from clinically diagnosed cases, DNA extracted and further amplified using PCR for HPV L1 and beta globin genes. The PCR amplicons were denatured and allowed for hybridization onto a nitrocellulose strip containing the type-specific probes for 27 HPV genotypes representing both high and low risk groups as well as beta globin genes. Socio-demographic characteristics and clinical findings of the participants were recorded on structured questionnaires. RESULTS: Amplification of HPV L1 gene by PCR detected 17 cases out of 20. Based on reverse line blot hybridization assay, the most frequent genotype identified was HPV16 (13/20). Mixed infection of HPV 16 with HPV 33, HPV 35, HPV 45 and HPV 58 was detected from other four study participants. CONCLUSION: Human papilloma virus type 16 was the most prevalent genotype identified from the subjects screened. Further investigation with statistically sound sample size would help to clearly visualize the existing trend in Ethiopia regarding factors for high risk HPV positivity and multiple gravidity, young age at first coitus and cervical neoplasia.

Parasitic infection may be associated with discordant responses to QuantiFERON and tuberculin skin test in apparently healthy children and adolescents in a tuberculosis endemic setting, Ethiopia.

BACKGROUND: M. tuberculosis remains one of the world's deadliest pathogens in part because of its ability to establish persistent, latent infections, which can later reactivate to cause disease. In regions of the globe where disease is endemic, as much as 50% of the population is thought to be latently infected, complicating diagnosis and tuberculosis control. The tools most commonly used for diagnosis of latent M. tuberculosis infection are the tuberculin skin test and the newer interferon-gamma release assays, both of which rely on an antigen-specific memory response as an indicator of infection. It is clear that the two tests, do not always give concordant results, but the factors leading to this are only partially understood. METHODS: In this study we examined 245 healthy school children aged from 12 to 20 years from Addis Ababa, a tuberculosis-endemic region, characterised them with regard to response in the tuberculin skin test and QuantIFERON™ test and assessed factors that might contribute to discordant responses. RESULTS: Although concordance between the tests was generally fair (90% concordance), there was a subset of children who had a positive QuantIFERON™ result but a negative tuberculin skin test. After analysis of multiple parameters the data suggest that discordance was most strongly associated with the presence of parasites in the stool. CONCLUSIONS: Parasitic gut infections are frequent in most regions where M. tuberculosis is endemic. This study, while preliminary, suggests that the tuberculin skin test should be interpreted with caution where this may be the case.

Development of a proof of concept immunochromatographic lateral flow assay for point of care diagnosis of Mycobacterium tuberculosis.

BACKGROUND: Despite major public health initiatives and the existence of efficacious treatment regimes, tuberculosis (TB) remains a threat, particularly in resource-limited settings. A significant part of the problem is the difficulty of rapidly identifying infected individuals, and as a result, there has been renewed interest in developing better diagnostics for infection or disease caused by Mycobacterium tuberculosis. Many of the existing tools, however, have limitations such as poor sensitivity or specificity, or the need for well-equipped laboratories to function effectively. Serodiagnostic approaches in particular have long drawn attention, due to their potential utility in large field studies, particularly in resource-poor settings. Unfortunately none of the serodiagnostic approaches have so far proven useful under field conditions. RESULTS: We screened a large panel of antigens with serodiagnostic potential by ELISA and selected a subpanel that was strongly and broadly recognised by TB patients, but not by controls. These antigens were then formulated into a simple immuno-chromatographic lateral flow assay format, suitable for field use, and tested against panels of plasma and blood samples from individuals with different clinical status (confirmed TB patients, household contacts, and apparently healthy community controls), recruited from Ethiopia (a highly TB-endemic country) and Turkey (a TB meso-endemic country). While specificity was good (97-100% in non TB-endemic controls), the sensitivity was not as high as expected (46-54% in pulmonary TB, 25-29% in extra-pulmonary TB). CONCLUSIONS: Though below the level of sensitivity the consortium had set for commercial development, the assay specifically identified M. tuberculosis-infected individuals, and provides a valuable proof of concept.

Throat carriage rate and antimicrobial susceptibility pattern of group A Streptococci (GAS) in healthy Ethiopian school children.

BACKGROUND: Group A Streptococci (GAS) or Streptococcus pyogenes are the most frequent cause of pharyngitis and skin infection in children and lead to post infection complications including acute rheumatic fever and glomerulonephritis. Pharyngeal carriage rates of GAS among healthy school children vary with geographical location and seasons. There is not much information on the screening of children for carriage of GAS in Ethiopia. OBJECTIVES: The study aimed at assessing the carriage rate of Group A Streptococci and antimicrobial susceptibility of the isolates in healthy Ethiopian school children. METHODS: A total of 937 children residing in Addis Ababa (n=491), Gondar (n=265) and Dire-Dawa (n=181) were investigated during a period between November 2004 and January 2005. Throat specimens were collected and cultured using standard procedure. Beta haemolytic streptococci were serogrouped by agglutination tests using specific antisera. Antimicrobial susceptibility testing of the isolates was performed by diffusion method. RESULTS: The median and the mean ages of the study participants were 11 (range 6-14) years. Girls constituted 52% (486/937) of the study participants. A total of 167 (17.8%) beta haemolytic streptococci were recovered from 937 children investigated GAS accounted for 91/167 (54.5%) of beta hemolytic streptococcal isolates. The carrier rate for GAS was 9.7% (91/937) of the screened children followed by group G with 3.2% (30/937) and group C streptococci with 2.2% (21/937). All GAS isolates were sensitive to oxacillin, penicillin, erythromycin, clindamycin and trimethoprim-sulphamethoxazole. Lower frequency of resistance was observed against tetracycline and vanocmycin. CONCLUSION: The present study revealed that GAS was the most predominant beta-haemolytic streptococcus among healthy Ethiopian school children. Our results showed that pharyngeal carriage of GAS in school children should not be underestimated. Therefore it is recommended to conduct regular screening and GAS surveillance in schools, and maintain rational use of antibiotics to minimize GAS resistance.

Expression of apoptosis-related genes in an Ethiopian cohort study correlates with tuberculosis clinical status.

Mycobacterium tuberculosis remains one of the world's deadliest pathogens in part because of its ability to persist in the face of an active immune response. It has been suggested that apoptosis of infected macrophages is one way in which the host deals with intracellular pathogens and that M. tuberculosis can inhibit this process. To assess the relevance of this process for human disease, we compared the expression of multiple genes involved in the activation of the extrinsic ("death receptor initiated") pathway of apoptosis in 29 tuberculosis patients, 70 tuberculosis contacts and 27 community controls from Ethiopia. We found that there is a strong upregulation of genes for factors that promote apoptosis in PBMC from individuals with active disease, including TNF-alpha and its receptors, Fas and FasL and pro-Caspase 8. The anti-apoptotic factor FLIP, however, was also upregulated. A possible explanation for this dichotomy was given by fractionation of PBMC using CD14, which suggests that macrophage/monocytes may regulate several key molecules differently from non-monocytic cells (especially TNF-alpha and its receptors, a finding confirmed by protein ELISA) potentially reducing the sensitivity to apoptotic death of monocyte/macrophages--the primary host cell for M. tuberculosis. This may represent an important survival strategy for the pathogen.

High diversity of group A streptococcal emm types among healthy schoolchildren in Ethiopia.

BACKGROUND: Although the prevalence of rheumatic heart disease in Ethiopia is one of the highest in the world, the epidemiology of group A streptococci (GAS) in this country is little known. GAS typing is a hallmark of both the epidemiology and understanding of diseases caused by these organisms. We have therefore conducted this study to investigate the emm (M-protein gene) type distribution of GAS carriers among Ethiopian schoolchildren. METHODS: In the present study, we performed emm typing of 82 GAS isolates collected from the throats of healthy schoolchildren (6-14 years of age) residing in 3 different urban sites in Ethiopia: Addis Ababa, Gondar, and Dire Dawa. RESULTS: We report high diversity of GAS isolates recovered from healthy schoolchildren. Eighty-two isolates represented 43 different sequence types. Thirteen newly described subtypes were detected in this study. Of the emm types prevalent in the study communities, 46% were not included in the 26-valent GAS vaccine. CONCLUSIONS: The high diversity of emm types encountered within 3 months of collection suggest that production of a vaccine candidate based on the M-protein amino termini appears to be impractical for this population. We suggest that investigations of other vaccine candidates, including the C5a peptidase, GAS carbohydrate, and fibronectin-binding proteins, as well as conserved M-protein region vaccines, should be intensified to address the needs of this population.

Household decision-making process and childhood cerebral malaria in The Gambia.

Mortality from childhood cerebral malaria remains unacceptably high in endemic regions. This survey was conducted between June and December 2001 among 69 primary caregivers of children admitted for cerebral malaria in Bansang Hospital, Central River Division (CRD), The Gambia to describe decision-making process at the family level that could have impact on malaria mortality. Thirty two percent of children presented in coma after 24 h of onset of illness. The eldest person in the compound or the father was responsible for taking decision on when hospital treatment was necessary in 85% of the cases. Mothers who were the primary caregivers made such decisions only in 7% of the cases. Cultural norms in a community are important factors affecting preferences at the household level and could influence important medical decisions. This survey suggests that patriarchs and/or fathers are important target groups for health education and project implementation programs.

Influence of placental malaria infection on foetal outcome in the Gambia: twenty years after Ian Mcgregor.

Malaria infection in pregnancy has serious health consequences among mothers and offspring. The influence of placental malaria infection on foetal outcome was studied in a Gambian rural setting where few pregnant women take antimalarial chemoprophylaxis. During July-December 1997, three hundred thirteen mother-newborn pairs (singletons only) were consecutively recruited into a study of the effects of placental malaria infection on the outcome of pregnancy. Placental blood and tissue were collected at delivery. Babies were clinically assessed until discharge. The overall prevalence of placental malaria infection was 51.1% by placental histology and 37.1% by blood smear. The primigravid women were more susceptible to placental malaria than the multigravidae (65.3% vs 44.7%, p=0.01). Placental malaria was significantly associated with pre-term deliveryand intrauterine growth retardation (p<0.01), and there was a four-fold risk of delivering low-birth-weight babies if mothers had parasitized placentae [OR=4.42, 95% confidence interval (CI) 2.10-9.27]. A reduction of mean birth-weight of babies by 320 g was associated with placental malaria infection (p<0.001). Similarly, a two-fold risk of stillbirth delivery (OR=2.22, 95% CI 1.04-4.72) was observed among the infected mothers. The findings showed that there was still an overall poor foetal outcome associated with placental malaria infection. The findings of this study confirm the findings of an earlier study by McGregor in the Gambia that the low birth-weight rate is significantly higher if the placenta is parasitized. In addition, this study observed that the high stillbirth and prematurity rates were associated with placental malaria infection. The findings of the present study suggest undertaking of effective malaria-control strategies during pregnancy, such as use of insecticide-impregnated bednets, intermittent and early treatment for malaria, and antimalarial chemoprophylaxis, in the Gambia.