Genomic epidemiology of carbapenemase-producing Gram-negative bacteria at the human-animal-environment interface in Djibouti city, Djibouti.

The emergence of carbapenem resistance is a major public health threat in sub-Saharan Africa but remains poorly understood, particularly at the human-animal-environment interface. This study provides the first One Health-based study on the epidemiology of Carbapenemase-Producing Gram-Negative Bacteria (CP-GNB) in Djibouti City, Djibouti, East Africa. In total, 800 community urine samples and 500 hospital specimens from humans, 270 livestock fecal samples, 60 fish samples, and 20 water samples were collected and tested for carbapenem resistance. The overall estimated CP-GNB prevalence was 1.9 % (32/1650 samples) and specifically concerned 0.3 % of community urine samples, 2.8 % of clinical specimens, 2.6 % of livestock fecal samples, 11.7 % of fish samples, and 10 % of water samples. The 32 CP-GNB included 19 Escherichia coli, seven Acinetobacter baumannii, five Klebsiella pneumoniae, and one Proteus mirabilis isolate. Short-read (Illumina) and long-read (Nanopore) genome sequencing revealed that carbapenem resistance was mainly associated with chromosomal carriage of blaNDM-1, blaOXA-23, blaOXA-48, blaOXA-66, and blaOXA-69 in A. baumannii, and with plasmid carriage in Enterobacterales (blaNDM-1 and blaOXA-181 in E. coli, blaNDM-1, blaNDM-5 and blaOXA-48 in K. pneumoniae, and blaNDM-1 in P. mirabilis). Moreover, 17/32 CP-GNB isolates belonged to three epidemic clones: (1) A. baumannii sequence type (ST) 1697,2535 that showed a distribution pattern consistent with intra- and inter-hospital dissemination; (2) E. coli ST10 that circulated at the human-animal-environment interface; and (3) K. pneumoniae ST147 that circulated at the human-environment interface. Horizontal exchanges probably contributed to carbapenem resistance dissemination in the city, especially the blaOXA-181-carrying ColKP3-IncX3 hybrid plasmid that was found in E. coli isolates belonging to different STs. Our study highlights that despite a relatively low CP-GNB prevalence in Djibouti City, plasmids harboring carbapenem resistance circulate in humans, animals and environment. Our findings stress the need to implement preventive and control measures for reducing the circulation of this potentially emerging public health threat.

Molecular investigation of malaria-infected patients in Djibouti city (2018-2021).

BACKGROUND: The Republic of Djibouti is a malaria endemic country that was in pre-elimination phase in 2006-2012. From 2013, however, malaria has re-emerged in the country, and its prevalence has been increasing every year. Given the co-circulation of several infectious agents in the country, the assessment of malaria infection based on microscopy or histidine-rich protein 2 (HRP2)-based rapid diagnostic tests (RDT) has shown its limitations. This study, therefore, aimed to assess the prevalence of malaria among febrile patients in Djibouti city using more robust molecular tools. METHODS: All suspected malaria cases reported to be microscopy-positive were randomly sampled (n = 1113) and included in four health structures in Djibouti city over a 4-year period (2018-2021), mainly during the malaria transmission season (January-May). Socio-demographic information was collected, and RDT was performed in most of the included patients. The diagnosis was confirmed by species-specific nested polymerase chain reaction (PCR). Data were analysed using Fisher's exact test and kappa statistics. RESULTS: In total, 1113 patients with suspected malaria and available blood samples were included. PCR confirmed that 788/1113 (70.8%) were positive for malaria. Among PCR-positive samples, 656 (83.2%) were due to Plasmodium falciparum, 88 (11.2%) Plasmodium vivax, and 44 (5.6%) P. falciparum/P. vivax mixed infections. In 2020, P. falciparum infections were confirmed by PCR in 50% (144/288) of negative RDTs. After the change of RDT in 2021, this percentage decreased to 17%. False negative RDT results were found more frequently (P < 0.05) in four districts of Djibouti city (Balbala, Quartier 7, Quartier 6, and Arhiba). Malaria occurred less frequently in regular bed net users than in non-users (odds ratio [OR]: 0.62, 95% confidence interval [CI]: 0.42-0.92). CONCLUSIONS: The present study confirmed the high prevalence of falciparum malaria and, to a lesser extent, vivax malaria. Nevertheless, 29% of suspected malaria cases were misdiagnosed by microscopy and/or RDT. There is a need to strengthen the capacity for diagnosis by microscopy and to evaluate the possible role of P. falciparum hrp2 gene deletion, which leads to false negative cases of P. falciparum.

Chikungunya Outbreak in Country with Multiple Vectorborne Diseases, Djibouti, 2019-2020.

During 2019-2020, a chikungunya outbreak occurred in Djibouti City, Djibouti, while dengue virus and malaria parasites were cocirculating. We used blotting paper to detect arbovirus emergence and confirm that it is a robust method for detecting and monitoring arbovirus outbreaks remotely.

Plasmodium falciparum pfhrp2 and pfhrp3 Gene Deletions and Relatedness to Other Global Isolates, Djibouti, 2019-2020.

Deletions of pfhrp2 and paralogue pfhrp3 (pfhrp2/3) genes threaten Plasmodium falciparum diagnosis by rapid diagnostic test. We examined 1,002 samples from suspected malaria patients in Djibouti City, Djibouti, to investigate pfhrp2/3 deletions. We performed assays for Plasmodium antigen carriage, pfhrp2/3 genotyping, and sequencing for 7 neutral microsatellites to assess relatedness. By PCR assay, 311 (31.0%) samples tested positive for P. falciparum infection, and 296 (95.2%) were successfully genotyped; 37 (12.5%) samples were pfhrp2+/pfhrp3+, 51 (17.2%) were pfhrp2+/pfhrp3-, 5 (1.7%) were pfhrp2-/pfhrp3+, and 203 (68.6%) were pfhrp2-/pfhrp3-. Histidine-rich protein 2/3 antigen concentrations were reduced with corresponding gene deletions. Djibouti P. falciparum is closely related to Ethiopia and Eritrea parasites (pairwise GST 0.68 [Ethiopia] and 0.77 [Eritrea]). P. falciparum with deletions in pfhrp2/3 genes were highly prevalent in Djibouti City in 2019-2020; they appear to have arisen de novo within the Horn of Africa and have not been imported.

SARS-CoV-2 Infections in Vaccinated and Unvaccinated Populations in Camp Lemonnier, Djibouti, from April 2020 to January 2022.

The global pandemic caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has highlighted the disparity between developed and developing countries for infectious disease surveillance and the sequencing of pathogen genomes. The majority of SARS-CoV-2 sequences published are from Europe, North America, and Asia. Between April 2020 and January 2022, 795 SARS-CoV-2-positive nares swabs from individuals in the U.S. Navy installation Camp Lemonnier, Djibouti, were collected, sequenced, and analyzed. In this study, we described the results of genomic sequencing and analysis for 589 samples, the first published viral sequences for Djibouti, including 196 cases of vaccine breakthrough infections. This study contributes to the knowledge base of circulating SARS-CoV-2 lineages in the under-sampled country of Djibouti, where only 716 total genome sequences are available at time of publication. Our analysis resulted in the detection of circulating variants of concern, mutations of interest in lineages in which those mutations are not common, and emerging spike mutations.

Epidemiology of the first and second waves of COVID-19 pandemic in Djibouti and the vaccination strategy developed for the response.

Since the first case of COVID-19 in Djibouti in March 2020 up to the end of May 2021, the country experienced two major epidemic waves of confirmed cases and deaths. The first wave in 2020 progressed more slowly in Djibouti compared with other countries in the Eastern Mediterranean Region. The second wave in 2021 appeared to be more aggressive in terms of the number and severity of cases, as well as the overall fatality rate. This study describes and analyses the epidemiology of these two waves of the COVID-19 pandemic in Djibouti and highlights lessons learnt from the National Plan for Introduction and Deployment of COVID-19 vaccines developed and implemented by the Ministry of Health of Djibouti.From 17 March 2020 up to 31 May 2021, Djibouti officially reported 11 533 confirmed cases of COVID-19 with 154 related deaths (case fatality rate, CFR: 1.3%), with an attack rate of 1.2%. The first epidemic wave began in epidemiological week 16/2020 (12-18 April) and ended in epidemiological week 25/2020 (14-20 June) with 4274 reported cases and 46 deaths (CFR: 1.1%). The second wave began in epidemiological week 11/2021 (14-20 March) and ended in epidemiological week 18/2021 (2-8 May) with 5082 reported cases and 86 deaths (CFR: 1.7%).A vaccination campaign was launched by the President of the Republic in March 2021; approximately 1.6% of the population were vaccinated in only two months' time. Early Preparedness, multisectoral and multicoordinated response, and collaboration with WHO are among the major lessons learnt during the pandemic in Djibouti.

Oesophageal carcinoma in the horn of Africa Ten year cumulative experience in two hospitals in Djibouti.

INTRODUCTION: In this paper we report on our experience of diagnosis, treatment and follow up of cases of cancer of the oesophagus treated in Balbala Cheiko Hospital and in the Djibouty Military Hospital. Oesophageal cancer, mainly squamous cellular type, is the prevalent cancer of the gastrointestinal tract (GIT) observed in our two Hospitals. Djibouti is a small pacific country located in the Horn of Africa in the tropics, bordered by Somaliland in the south, Ethiopia in the southwest, Eritrea in the north and the Red Sea and the Gulf of Aden in the east. Yemen lies across the Gulf of Aden. Djibouti is the principal maritime port for Ethiopia. The country was formerly French Somaliland and it became independent from France in June 1977. It is a multi-ethnic nation with a population of just over 900,000. MATERIAL AND METHODS: From January 2011 to April 2021, we observed 159 patients diagnosed with cancer of the oesophagus: 89 females representing 56 % and 70 males representing 44 %. An Oesophageal Cancer Card (see Annex 1) was completed for each patient. 107 patients (67.30%) reported regularly (twice a week) chewing of khat (see Annex 2) and 68 patients (42,76%) regularly smoked more than 20 cigarettes and drank more than three very hot cups of coffee or tea per day. All patients underwent an oesophagoscopy with biopsy. Squamous Cell Carcinoma (OSCC) was confirmed by histology in all cases, 89 of them being females (64%) which is surprisingly different from data reported in the literature which reports a general prevalence of males. 60 patients (37.7 % of the total) underwent surgery. The Ivor-Lewis operation was the most frequent type of surgery and was done in 44 patients (66.6%). RESULTS: Our ten years experience involved two hospitals serving a large area. Cancer of the oesophagus (OC) was the prevalent gastrointestinal cancer we observed, second only to female breast cancer. There are no facilities in the country for radiotherapy. It is very difficult to report on long term survival because most of patients live in rural areas which are very difficult to reach and they rarely return for medical check-ups. The best survival recorded was a 48 year old Afar male who was still alive 6 years after an Ivor-Lewis operation was performed for squamous carcinoma on 3 April 2014 and checked on September 2020. A further 6 patients (2 males and 4 females, 3 with adenocarcinoma and 3 with squamous cell carcinoma) recently checked are still alive and come in regularly for check-up. CONCLUSIONS: Oesophageal cancer is one of the most frequent cancers found in the Horn of Africa and our experience in Djibouti confirms the data of the literature 16,28,29. A peculiarity in our study is the high prevalence in the female population. Our recommendation is to set-up an oesophageal cancer unit (OCU) with a team of specialists: gastroenterologist, surgical oncologist, anaesthesiologists, pathologists, nutritionalists and trained nurses who could ensure, not only hospital support, but also the active post operative follow up of patients. The implementation of a National Cancer Register would be mandatory. KEY WORDS: Oesophageal Cancer, Ivor Lewis Operation, Follow up, Djibouti.

Prevalence and antimicrobial susceptibility pattern of urinary tract infection among pregnant women attending Hargeisa Group Hospital, Hargeisa, Somaliland.

The aim of this study was to determine the prevalence, antimicrobial susceptibility pattern and associated factors of urinary tract infection (UTI) among pregnant women attending Hargeisa Group Hospital (HGH), Hargeisa, Somaliland. A cross-sectional study was conducted at HGH, Hargeisa, Somaliland and participants were selected by systematic random sampling technique. Clean catch midstream urine samples were collected from 422 participants and cultured and antimicrobial susceptibility pattern was determined for the isolates. Univariable and multivariable logistic regression analyses were utilized to identify the independent risk factors for UTI. The prevalence of UTI was 16.4% (95% CI 13.3-19.9). The predominant bacteria isolate was E. coli (43.5%) followed by Coagulase negative staphylococcus (CoNS) 11(16%), S. aureus 9(13%), K. pneumonia 6(8.7%), Pseudomonas aeruginosa 5(7.2%), Proteus mirabilis 4(5.8%), Citrobacter spp 3(4.4%) and M. morganii 1(1.5%) Gram negative bacilli were resistant to ampicillin (96%) and tetracycline (71.4%) and Gram-positive cocci were also resistant to ampicillin (90%), tetracycline (55%). Multidrug resistance was observed in 85.5% of bacterial isolated. No formal education participants, previous history of catheterization and previous history of UTI had 3.18, 3.22 and 3.73 times respectively more likely to develop UTI than their counterparts. Culture and susceptibility test is vital for appropriate management of UTI in the study area.

Emergence of Indian lineage of ECSA chikungunya virus in Djibouti, 2019.

The chikungunya virus (CHIKV) originated from Africa and has spread worldwide. Since 2017, multiple chikungunya outbreaks have been reported in the Horn of Africa, without molecular characterization. In November 2019, an autochthonous acute chikungunya infection was diagnosed in a French patient living in Djibouti, marking the re-emergence of the virus in the country. The strain was isolated and fully sequenced. Phylogenetic analysis revealed that the Djiboutian strain belongs to the Indian lineage of the Eastern/Central/South African (ECSA) genotype. Two mutations highly increasing the virus's fitness in Aedes aegypti, the sole vector present in Djibouti city, were identified.

COVID-19 pandemic in Djibouti: Epidemiology and the response strategy followed to contain the virus during the first two months, 17 March to 16 May 2020.

First cases of COVID-19 were reported from Wuhan, China, in December 2019, and it progressed rapidly. On 30 January, WHO declared the new disease as a PHEIC, then as a Pandemic on 11 March. By mid-March, the virus spread widely; Djibouti was not spared and was hit by the pandemic with the first case detected on 17 March. Djibouti worked with WHO and other partners to develop a preparedness and response plan, and implemented a series of intervention measures. MoH together with its civilian and military partners, closely followed WHO recommended strategy based on four pillars: testing, isolating, early case management, and contact tracing. From 17 March to 16 May, Djibouti performed the highest per capita tests in Africa and isolated, treated and traced the contacts of each positive case, which allowed for a rapid control of the epidemic. COVID-19 data included in this study was collected through MoH Djibouti during the period from 17 March to 16 May 2020. A total of 1,401 confirmed cases of COVID-19 were included in the study with 4 related deaths (CFR: 0.3%) and an attack rate of 0.15%. Males represented (68.4%) of the cases, with the age group 31-45 years old (34.2%) as the most affected. Djibouti conducted 17,532 tests, and was considered as a champion for COVID-19 testing in Africa with 18.2 tests per 1000 habitant. All positive cases were isolated, treated and had their contacts traced, which led to early and proactive diagnosis of cases and in turn yielded up to 95-98% asymptomatic cases. Recoveries reached 69% of the infected cases with R0 (0.91). The virus was detected in 4 regions in the country, with the highest percentage in the capital (83%). Djibouti responded to COVID-19 pandemic following an efficient and effective strategy, using a strong collaboration between civilian and military health assets that increased the response capacities of the country. Partnership, coordination, solidarity, proactivity and commitment were the pillars to confront COVID-19 pandemic.

Adenovirus Infections in African Humans and Wild Non-Human Primates: Great Diversity and Cross-Species Transmission.

Non-human primates (NHPs) are known hosts for adenoviruses (AdVs), so there is the possibility of the zoonotic or cross-species transmission of AdVs. As with humans, AdV infections in animals can cause diseases that range from asymptomatic to fatal. The aim of this study was to investigate the occurrence and diversity of AdVs in: (i) fecal samples of apes and monkeys from different African countries (Republic of Congo, Senegal, Djibouti and Algeria), (ii) stool of humans living near gorillas in the Republic of Congo, in order to explore the potential zoonotic risks. Samples were screened by real-time and standard PCRs, followed by the sequencing of the partial DNA polymerase gene in order to identify the AdV species. The prevalence was 3.3 folds higher in NHPs than in humans. More than 1/3 (35.8%) of the NHPs and 1/10 (10.5%) of the humans excreted AdVs in their feces. The positive rate was high in great apes (46%), with a maximum of 54.2% in chimpanzees (Pan troglodytes) and 35.9% in gorillas (Gorilla gorilla), followed by monkeys (25.6%), with 27.5% in Barbary macaques (Macaca sylvanus) and 23.1% in baboons (seven Papio papio and six Papio hamadryas). No green monkeys (Chlorocebus sabaeus) were found to be positive for AdVs. The AdVs detected in NHPs were members of Human mastadenovirus E (HAdV-E), HAdV-C or HAdV-B, and those in the humans belonged to HAdV-C or HAdV-D. HAdV-C members were detected in both gorillas and humans, with evidence of zoonotic transmission since phylogenetic analysis revealed that gorilla AdVs belonging to HAdV-C were genetically identical to strains detected in humans who had been living around gorillas, and, inversely, a HAdV-C member HAdV type was detected in gorillas. This confirms the gorilla-to-human transmission of adenovirus. which has been reported previously. In addition, HAdV-E members, the most often detected here, are widely distributed among NHP species regardless of their origin, i.e., HAdV-E members seem to lack host specificity. Virus isolation was successful from a human sample and the strain of the Mbo024 genome, of 35 kb, that was identified as belonging to HAdV-D, exhibited close identity to HAdV-D members for all genes. This study provides information on the AdVs that infect African NHPs and the human populations living nearby, with an evident zoonotic transmission. It is likely that AdVs crossed the species barrier between different NHP species (especially HAdV-E members), between NHPs and humans (especially HAdV-C), but also between humans, NHPs and other animal species.

Cross-sectional prevalence study of MERS-CoV in local and imported dromedary camels in Saudi Arabia, 2016-2018.

The Middle East Respiratory Syndrome-Coronavirus (MERS-CoV) is an endemic virus in dromedaries. Annually, Saudi Arabia imports thousands of camels from the Horn of Africa, yet the epidemiology of MERS-CoV in these animals is largely unknown. Here, MERS-CoV prevalence was compared in imported African camels and their local counterparts. A total of 1399 paired sera and nasal swabs were collected from camels between 2016 and 2018. Imported animals from Sudan (n = 829) and Djibouti (n = 328) were sampled on incoming ships at Jeddah Islamic seaport before unloading, and local camels were sampled from Jeddah (n = 242). Samples were screened for neutralizing antibodies (nAbs) and MERS-CoV viral RNA. The overall seroprevalence was 92.7% and RNA detection rate was 17.2%. Imported camels had higher seroprevalence compared to resident herds (93.8% vs 87.6%, p <0.01) in contrast to RNA detection (13.3% vs 35.5%, p <0.0001). Seroprevalence significantly increased with age (p<0.0001) and viral RNA detection rate was ~2-folds higher in camels <2-year-old compared to older animals. RNA detection was higher in males verses females (24.3% vs 12.6%, p<0.0001) but seroprevalence was similar. Concurrent positivity for viral RNA and nAbs was found in >87% of the RNA positive animals, increased with age and was sex-dependent. Importantly, reduced viral RNA load was positively correlated with nAb titers. Our data confirm the widespread of MERS-CoV in imported and domestic camels in Saudi Arabia and highlight the need for continuous active surveillance and better prevention measures. Further studies are also warranted to understand camels correlates of protection for proper vaccine development.

Current practice in diagnosis and treatment of breast cancer in Cheicko Balbala Hospital Djibouti.

INTRODUCTION: This report details the results of the first breast cancer (BC) prevalence study done in Djibouti, a small country in the Horn of Africa. The study was done in the Surgical Department of Balbala Hospital (also known as the Italian Hospital). PATIENTS AND METHODS: 102 female patients with clinical BC were evaluated between 2012 and 2017. All patients came directly to the hospital without a prior referral. Fine Needle Aspiration (FNA) was carried out on all suspected lesions representing 40.6 % of patients. A biopsy was carried out on all clinically evident lesions. RESULTS: Following histopathological confirmation for all patients, 86 women (84,31%) accepted surgical procedure and clinico-histopathological staging was possible. 16 (15.69%) women refused surgery. There are no radiotherapy and chemotherapy facilities in Djibouti however hormonal therapy, Tamoxifen, is available. CONCLUSIONS: The Italian Government built the Hospital in 1985 in Balbala, a District of Djibouti Ville ,with a population of over 250.000. It is an example of a successful cooperation between Italy and Djibouti in the health sector. Following a long period of assistance and support from the Italian Ministry of Foreign Affairs, the Hospital is now taken completely managed by the Ministry of Health of Djibouti . The hospital is one of the main referral hospitals in the country. Better provision of information to the local population and medical general practitioner about breast cancer would improve diagnosis, the treatment and the overall prognosis of this disease. KEY WORDS: Breast Cancer, Epidemiology, Surgery, Italian Balbala Hospital Djibouti.

The contribution of pediatric surgery to poverty trajectories in Somaliland.

BACKGROUND: The provision of health care in low-income and middle-income countries (LMICs) is recognized as a significant contributor to economic growth and also impacts individual families at a microeconomic level. The primary goal of our study was to examine the relationship between surgical conditions in children and the poverty trajectories of either falling into or coming out of poverty of families across Somaliland. METHODS: This work used the Surgeons OverSeas Assessment of Surgical Need (SOSAS) tool, a validated household, cross-sectional survey designed to determine the burden of surgical conditions within a community. We collected information on household demographic characteristics, including financial information, and surgical condition history on children younger than 16 years of age. To assess poverty trajectories over time, we measured household assets using the Stages of Progress framework. RESULTS: We found there were substantial fluxes in poverty across Somaliland over the study period. We confirmed our study hypothesis and found that the presence of a surgical condition in a child itself, regardless of whether surgical care was provided, either reduced the chances of moving out of poverty or increased the chances of moving towards poverty. CONCLUSION: Our study shows that the presence of a surgical condition in a child is a strong singular predictor of poverty descent rather than upward mobility, suggesting that this stressor can limit the capacity of a family to improve its economic status. Our findings further support many existing macroeconomic and microeconomic analyses that surgical care in LMICs offers financial risk protection against impoverishment.

Five years following first detection of Anopheles stephensi (Diptera: Culicidae) in Djibouti, Horn of Africa: populations established-malaria emerging.

The Asian malaria mosquito, Anopheles stephensi, is a well-known and important vector of Plasmodium falciparum and P. vivax. Until 2013, its geographical distribution was confined to central and southern Asia including the Arabian Peninsula. In the Horn of Africa (HoA) Region, An. stephensi was first recorded from Djibouti in 2012, when it was linked geographically and temporally with an unusual outbreak of urban P. falciparum malaria. In 2016, An. stephensi was detected in the neighbouring Somali Region of Ethiopia. In order to determine whether An. stephensi populations have become established in Djibouti and contributed to the unusual rise in local malaria cases there, we carried out continuous vector surveillance from January 2013 to December 2017, investigated seasonal changes in An. stephensi population densities and bionomics, analysed available literature describing malaria in Djibouti since 2013, and investigated whether An. stephensi may have contributed to local malaria transmission by detecting circumsporozoite antigen of P. falciparum and P. vivax in female anophelines. From 2013 to 2016, seasonal activity of An. stephensi in urban Djibouti City primarily occurred during the colder, wetter season between September and May, with either no or rare trap catches from June to August. Unlike past years, this species was detected year-round, including the extremely hot summer months of June to August 2017. This change in seasonal occurrence may indicate that An. stephensi populations are adapting to their new environment in sub-Saharan Africa, facilitating their spread within Djibouti City. Among the 96 female An. stephensi investigated for malaria infectivity, three (3.1%) were positive for P. falciparum circumsporozoite antigen, including one P. falciparum/P. vivax VK 210 double infection. Subsequent to the unusual resurgence of local malaria in 2013, with 1684 confirmed cased reported for that year, malaria case numbers increased continuously, peaking at 14,810 in 2017. Prior to 2016, only P. falciparum malaria cases had been reported, but in 2016, autochthonously acquired P. vivax malaria cases occurred for the first time at a rate of 16.7% among all malaria cases recorded that year. This number increased to 36.7% in 2017. Our data indicate that the dynamics of malaria species in Djibouti is currently changing rapidly, and that An. stephensi can be involved in the transmission of both P. falciparum and P. vivax, simultaneously. Considering the extremely high potential impact of urban malaria on public health, the timely deployment of optimal multinational vector surveillance and control programs against An. stephensi is strongly recommended, not only for the HoA Region, but for the entire African continent.

Molecular epidemiological of extended-spectrum ß-lactamase producing Escherichia coli isolated in Djibouti.

INTRODUCTION: While the molecular epidemiology of extended-spectrum-b-lactamase (ESBL)-producing E. coli is well known in Europe due to effective surveillance networks and substantial literature, data for Africa are less available, especially in Djibouti. METHODOLOGY: We studied 31 isolates of ESBL-producing E. coli from Djibouti and compared these molecular results with data available in Africa. RESULTS: Susceptibility rates were 3.2% for ceftazidim, 48.4% for piperacillin-tazobactam, 90.3% for amikacine and 16.1% for ofloxacin. No isolate showed resistance to carbapenems or colistin. 30 E. coli (96.8%) were positive to blaCTX-M-15, 1 (3.2%) to blaCTX-M-14  and 10 (32.3%) to narrow-broad-spectrum blaTEM. No blaSHV were detected. Fluoroquinolone resistance analysis showed that 30 ofloxacin-resistant E. coli had the mutation Ser-83->Leu on the gyrA gene. 24 E. coli (77.4%) harboured the plasmid-borne aac(6 ')-Ib-cr gene. No E. coli carried the genes qnrA, qnrB and qepA. 10 isolates (32.3%) belonging to the ST131 clone. The plasmid incompatibility group most widely represented in our collection was IncFIA/IB/II. CONCLUSIONS: There is no major difference with African epidemiology. In particular, we notice the international diffusion of specific clonal group ST131.

Culture and Next-generation sequencing-based drug susceptibility testing unveil high levels of drug-resistant-TB in Djibouti: results from the first national survey.

Djibouti is a small country in the Horn of Africa with a high TB incidence (378/100,000 in 2015). Multidrug-resistant TB (MDR-TB) and resistance to second-line agents have been previously identified in the country but the extent of the problem has yet to be quantified. A national survey was conducted to estimate the proportion of MDR-TB among a representative sample of TB patients. Sputum was tested using XpertMTB/RIF and samples positive for MTB and resistant to rifampicin underwent first line phenotypic susceptibility testing. The TB supranational reference laboratory in Milan, Italy, undertook external quality assurance, genotypic testing based on whole genome and targeted-deep sequencing and phylogenetic studies. 301 new and 66 previously treated TB cases were enrolled. MDR-TB was detected in 34 patients: 4.7% of new and 31% of previously treated cases. Resistance to pyrazinamide, aminoglycosides and capreomycin was detected in 68%, 18% and 29% of MDR-TB strains respectively, while resistance to fluoroquinolones was not detected. Cluster analysis identified transmission of MDR-TB as a critical factor fostering drug resistance in the country. Levels of MDR-TB in Djibouti are among the highest on the African continent. High prevalence of resistance to pyrazinamide and second-line injectable agents have important implications for treatment regimens.

Trial Evaluating Ambulatory Therapy of Travelers' Diarrhea (TrEAT TD) Study: A Randomized Controlled Trial Comparing 3 Single-Dose Antibiotic Regimens With Loperamide.

BACKGROUND: Recommended treatment for travelers' diarrhea includes the combination of an antibiotic, usually a fluoroquinolone or azithromycin, and loperamide for rapid resolution of symptoms. However, adverse events, postdose nausea with high-dose azithromycin, effectiveness of single-dose rifaximin, and emerging resistance to front-line agents are evidence gaps underlying current recommendations. METHODS: A randomized, double-blind trial was conducted in 4 countries (Afghanistan, Djibouti, Kenya, and Honduras) between September 2012 and July 2015. US and UK service members with acute watery diarrhea were randomized and received single-dose azithromycin (500 mg; 106 persons), levofloxacin (500 mg; 111 persons), or rifaximin (1650 mg; 107 persons), in combination with loperamide (labeled dosing). The efficacy outcomes included clinical cure at 24 hours and time to last unformed stool. RESULTS: Clinical cure at 24 hours occurred in 81.4%, 78.3%, and 74.8% of the levofloxacin, azithromycin, and rifaximin arms, respectively. Compared with levofloxacin, azithromycin was not inferior (P = .01). Noninferiority could not be shown with rifaximin (P = .07). At 48 and 72 hours, efficacy among regimens was equivalent (approximately 91% at 48 and 96% at 72 hours). The median time to last unformed stool did not differ between treatment arms (azithromycin, 3.8 hours; levofloxacin, 6.4 hours; rifaximin, 5.6 hours). Treatment failures were uncommon (3.8%, 4.4%, and 1.9% in azithromycin, levofloxacin, and rifaximin arms, respectively) (P = .55). There were no differences between treatment arms with postdose nausea, vomiting, or other adverse events. CONCLUSIONS: Single-dose azithromycin, levofloxacin, and rifaximin with loperamide were comparable for treatment of acute watery diarrhea. CLINICAL TRIAL REGISTRATION: NCT01618591.

A mixed-methods study of maternal near miss and death after emergency cesarean delivery at a referral hospital in Somaliland.

OBJECTIVE: To explore maternal near miss and death after emergency cesarean delivery in Somaliland, including the impact of the prerequisite for family consent. METHODS: A facility-based, mixed-methods study was conducted to assess all maternal near misses and deaths recorded at a referral hospital that provided services to women from all regions of Somaliland. The data sources comprised a quantitative prospective cross-sectional study using the WHO near-miss tool (performed from August 1 to December 31, 2015) and qualitative interviews with 17 healthcare providers working at the referral hospital who were in direct contact with the women in labor (performed from January 15 to March 15, 2015). RESULTS: Of the 138 maternal near misses and deaths recorded, 50 (36%) were associated with emergency cesarean delivery. The most frequent maternal complication was severe pre-eclampsia (n=17; 34%), and the most frequent underlying causes were hypertensive disorders (n=31; 62%) and obstetric hemorrhage (n=15; 30%). Healthcare providers were often prevented from performing emergency cesarean delivery until the required consent had been received from the woman's extended family. CONCLUSION: Maternity care in Somaliland must be improved, and the issue of legal authority for consent examined, to ensure both safe and timely provision of emergency cesarean delivery.