Haematological and immunological reference intervals for adult population in the state of Amhara, Ethiopia

Assessment of the hematological profiles among COVID-19 patients during the first and second waves in Ethiopia: A multicenter retrospective cohort study

Background

The coronavirus disease 2019 is highly infectious and patients with coronavirus diseases demonstrated a series of clinical symptoms caused by severe acute respiratory syndrome coronavirus-2. Without a break of the wave's hematological profile of the patients is still ambiguous and differs from wave to wave.

Objective

This study aimed to assess the hematological profile among coronavirus disease 2019 patients during the first and the second waves in Ethiopia.

Methods

A multi-centered facility-based retrospective cohort study design was conducted at six coronavirus disease 2019 treatment centers. A total of 538 study participants were enrolled in the selected coronavirus disease 2019 treatment centers during the first and second waves of the pandemic. The demographic characteristics, underlying diseases, symptoms, and hematological parameters of patients were recorded. Data were entered into Epi-Data Manager 4.6 and analyzed using STATA 14.2. An independent sample t-test was used to assess the mean differences in hematological parameters across waves. Associations between categorical variables across waves were also determined using Chi-square and Fisher exact tests.

Results

Among the total study participants, 240 (44.6%) and 298 (55.4%) patients were taken from wave-1 and wave-2, respectively. The average age of the study participants was 56.44 ± 16.25 years. The most frequent comorbidities in this study were hypertension, diabetes mellitus, ischemic heart disease, and asthma. The most presenting symptoms of COVID-19 infection across the two waves were presented. In the first wave, dry cough 166 (69.2%), fatigue 153 (63.75%), shortness of breath 148 (61.67%), and fever accounted 116 (48.33%), while during the second wave, dry cough 242 (81.2%), fatigue 244 (81.88%) shortness of breath 204 (68.47%) and fever account 180 (60.40%). White blood cells (WBC), neutrophils, and lymphocytes had shown increment during the first wave. Platelet count and platelet distribution width (p < 0.001) had significant mean differences across the two waves, while the other had no significant mean difference.

Conclusion

In the present study, dry cough, fatigue, shortness of breath, and fever were found to be the most presenting symptoms of COVID-19 infection across the two waves. Only the platelet count and platelet distribution width had significant mean differences across the two waves, while the other had no significant mean difference across waves.

Factors associated with CD4 + cell count recovery among males and females with advanced HIV disease

OBJECTIVE

HIV/AIDS mortality remains significantly high in sub-Saharan Africa, mostly driven by opportunistic infections and advanced HIV disease (AHD). This study aimed to assess CD4 + cell count recovery following ART initiation and factors associated with immune reconstitution.

METHODS

We conducted a prospective cohort study between 2015 and 2016. HIV-infected adults (≥18 years) with AHD (CD4 + cell count ≤100 cells/μl) receiving care at 20 outpatient HIV treatment facilities in Harare, Zimbabwe were enrolled. CD4 + cell count recovery (CD4 + cell count >200 cells/μl) was assessed following 12-month ART initiation and factors associated with immune reconstitution were investigated using logistic regression analysis. All statistical analyses were performed on Statistical Package for the Social Sciences (SPSS) version 23.

RESULTS

1320 participants were enrolled and 56.4% were males. The median (interquartile range, IQR) age was 37 (32-43) years. Tuberculosis was seen in 16.0%. Of the 739 participants that had CD4 + cell count at 12 months, CD4 + cell count recovery above 200 cells/μl was observed in 163 (22.1%) participants. Median (IQR) CD4 + cell count at 12-months increased to 127 (75-190) cells/μl from 31 (14-55) at baseline. Factors associated with CD4 + cell count recovery were younger age at baseline [odds ratio (OR) ≥40/<40  = 0.58, 95% confidence interval (CI): 0.40-0.85, P  = 0.005), sex (OR female/male  = 2.07, 95% CI: 1.44-2.99, P  < 0.0001) and baseline CD4 + cell count (OR ≥50/<50  = 1.60, 95% CI: 1.10-2.33, P  = 0.013).

CONCLUSION

A significant proportion (77.9%) of patients seeking care with AHD in a resource limited setting failed to recover a CD4 + cell count >200 cells/μl. Male sex, older age and low CD4 + cell count at ART initiation were factors associated with poor immune reconstitution. Better differentiated care deliveries targeting this vulnerable population are critical for improving clinical outcomes and quality of life of the patients.

Reference Intervals of Haematological Parameters for Apparently Healthy Adults in Northeast Ethiopia

Background

Clinical laboratory reference intervals play a vital role in evaluating overall well-being, tracking the progression of diseases, and detecting potential harmful effects and complications. Despite evidence revealing disparities, many African nations currently rely on reference intervals for blood analysis obtained mainly from Western populations. This practice increases the risk of misidentifying and misdiagnosing healthy individuals. The aim of this study was to establish common hematological parameters reference intervals for healthy adults in Northeast Ethiopia.

Methods

This community-based cross-sectional study consisted of 328 individuals who were presumed to be in good health. To assess their blood-related characteristics, blood samples were collected and analyzed using the advanced Dirui BF-6500 analyzer, along with serological testing. In accordance with guidelines provided by the Clinical and Laboratory Standards Institute, the study employed a non-parametric approach to calculate the medians and 95% confidence intervals. To explore potential variations between males and females, a statistical test known as the Mann-Whitney U-test was used to compare the reference intervals.

Results

The established reference intervals were: white blood cells 3.5-11.3×109/L; red blood cells 4.0-6.1×1012/L; hemoglobin 11.2-17.5g/dL; hematocrit 35.4-52.0%; MCV 77.9-93.8fl; MCH 24.7-32.0pg; MCHC 306-349g/L; RDW-CV 12.1-13.8% and platelet 131-391×109/L. The reference values of monocytes, eosinophils, red blood cells, hemoglobin, hematocrit and RDW-CV in males were higher than females, while females had significantly higher platelet counts compared to males. The reference intervals discovered differed from the reference intervals now in use, those mentioned in earlier research in Ethiopia or other African nations, as well as those conducted on Western populations.

Conclusion

In the adult demographic of Northeast Ethiopia, specific reference intervals for commonly observed hematological parameters were established, tailored to the local community. Consequently, these reference intervals hold the potential to enhance informed decision-making within this population, by providing valuable guidance when interpreting laboratory test outcomes.

Hematological abnormalities and associated factors among metabolic syndrome patients at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia

BACKGROUND

Metabolic Syndrome (MetS) is a cluster of interconnected metabolic diseases. Hematological abnormalities are common but neglected complications of MetS. Thus, this study aimed to determine the magnitude of hematological abnormalities and their associated factors among MetS patients at the University of Gondar comprehensive specialized hospital, Northwest Ethiopia.

METHOD

A hospital-based cross-sectional study was conducted at the University of Gondar comprehensive specialized hospital from March to May 2022. A total of 384 MetS patients were selected using a systematic random sampling technique. Data were collected using pre-tested structured questionnaires and checklists. Anthropometric and blood pressure measurements were taken, and blood sample was collected for complete blood count determination. Stool and blood film examinations were performed to detect intestinal and malaria parasites, respectively. Data were entered into EpiData 3.1 and analyzed by Stata 14.0 software. Bivariate and multivariate logistic regression models were fitted to identify factors associated with hematological abnormalities. A p-value of < 0.05 was considered statistically significant.

RESULTS

The magnitude of anemia, leukopenia, leukocytosis, thrombocytopenia, and thrombocytosis was found to be 13.3%, 0.5%, 2.9%, 1.6%, and 2.3%, respectively. Being male (AOR = 2.65, 95% CI: 1.14, 6.20), rural residency (AOR = 5.79, 95% CI: 1.72, 19.51), taking antihypertensive medications (AOR = 3.85, 95% CI: 1.16, 12.78), having elevated triglyceride level (AOR = 2.21, 95% CI: 1.03, 4.75), and being overweight or obese (AOR = 0.32, 95% CI: 0.16, 0.64) were significantly associated with anemia.

CONCLUSIONS

Anemia was the most prevalent hematological abnormality identified in the present study, followed by leukocytosis and thrombocytosis. Anemia was a mild public health problem among MetS patients in the study area. Routine anemia screening for all MetS patients, especially for those with significant associated factors, may help in the early detection and effective management of anemia, which subsequently improves the patients' quality of life.

Red blood cell distribution width as a predictor of cardiovascular outcomes in extensive aortoiliac disease

BACKGROUND

Aortoiliac peripheral artery disease may lead to disabling lower limb claudication or to lower limb chronic threatening ischemia, which is associated with increased short and long-term morbi-mortality. The red blood cell distribution width-coefficient of variation (RDW-CV) has been able to predict outcomes in other atherosclerotic diseases, such as myocardial infarction and stroke. The main objective of this study was to assess the predictive ability of perioperative RDW-CV in accurately predicting short and long-term major adverse cardiovascular events (MACE) and all-cause mortality in patients submitted to aortoiliac revascularization due to extensive aortoiliac atherosclerotic disease.

METHODS

From 2013 to 2020, patients who underwent aortoiliac revascularization due to severe aortoiliac disease were included in a prospective cohort. Blood samples were taken preoperatively and the patient's demographics, comorbidities, and postoperative outcomes were assessed. A multivariate Cox regression model was used to adjust for confounding and assess the independent effect of these prognostic factors on the outcomes.

RESULTS

The study group included 107 patients. Median follow-up was 57 (95% CI: 34.4-69.6) months. Preoperative RDW-CV was increased in thirty-eight patients (35.5%). Increased RDW-CV was associated with congestive heart failure - adjusted odds ratio of 5.043 (95% CI: 1.436-17.717, P=0.012). It could predict long-term occurrence of MACE (adjusted hazard ratio [aHR] 1.065, 95% CI: 1.014-1.118, P=0.011), all-cause mortality (aHR=1.069, 95% CI: 1.014-1.126, P=0.013), acute heart failure (AHF) (aHR=1.569, 95% CI: 1.179-2.088, P=0.002), and stroke (aHR=1.343, 95% CI: 1.044-1.727, P=0.022).

CONCLUSIONS

RDW is a widely available and low-cost marker that was able to independently predict long-term AHF, stroke, MACE, and all-cause mortality in patients with extensive aortoiliac disease submitted to revascularization. This biomarker could help assess which patients would likely benefit from stricter follow-up in the long-term.

Bacteriology of community-acquired pneumonia, antimicrobial susceptibility pattern and associated risk factors among HIV patients, Northeast Ethiopia: cross-sectional study

Objective

Pneumonia is an opportunistic infection and it is a major cause of mortality and morbidity among human immunodeficiency virus/acquired immune deficiency syndrome-positive patients. Previous studies have shown the dominant pathogens bacterial isolates were K. pneumoniae 27.0%, S. aureus 20.8%, S. pneumoniae 18.8% and E. coli 8.3%. This study aimed to determine bacteriology of community-acquired pneumonia, antimicrobial susceptibility pattern and associated risk factors among human immunodeficiency virus patients in the Northeast Ethiopia: cross-sectional study.

Methods

A health facility-based cross-sectional study was conducted from January to April 2021 at six health facilities in Dessie Town. A total of 378 community-acquired pneumonia patients suspected to be human immunodeficiency virus-positive were recruited using a consecutive sampling technique. Sociodemographic and clinical data were collected using a structured questionnaire. A two-milliliter sputum specimen was collected aseptically from each study participant. Samples were cultivated on blood agar, chocolate agar and MacConkey agar to isolate bacterial pathogens. To identify bacteria pathogens Gram stain, colony morphology and biochemical tests were performed. The Kirby-Bauer Disc Diffusion method was used to perform the antimicrobial susceptibility test. Descriptive statistics, logistic regression analysis was carried out using Statistical package for social science version 25 software. p-value < 0.05 with a corresponding 95% confidence interval (CI) was considered for statistical significance.

Result

The overall prevalence of bacterial pneumonia was 175 (46.3%). Gram-negative bacteria accounted for 119 (68%) and the predominant isolates identified were Streptococcus pneumoniae 49 (28%) followed by Klebsiella pneumoniae 46 (26.3%), Pseudomonas aeruginosa 34 (19.4%). There were 148 (84.6%) multidrug-resistant bacteria overall. Statistically significant factors included viral load, cigarette smoking, cluster of differentiation 4 count, alcohol use, World Health Organization clinical stages III and IV and low white blood cell count.

Conclusion

The study found that both multidrug resistance and bacterial pneumonia were high. Thus, bacterial culture and antimicrobial susceptibility tests should be routinely performed in health facilities in order to prevent and control the spread of bacterial infection and concurrent drug resistance.

Region-specific laboratory reference intervals are important: A systematic review of the data from Africa

Region-specific laboratory reference intervals (RIs) are important for clinical trials and these data are often sparse in priority areas for research, including Africa. We reviewed data on RIs from Africa to identify gaps in the literature with a systematic review of PubMed for RI studies from Africa published ≥2010. Search focus included clinical analytic chemistry, hematology, immunological parameters and RIs. Data from adults, adolescents, children, pregnant women, and the elderly were included. We excluded manuscripts reporting data from persons with conditions that might preclude clinical trial participation in studies enrolling healthy volunteers. Of 179 identified manuscripts, 80 were included in this review, covering 20 countries with the largest number of studies in Ethiopia (n = 23, 29%). Most studies considered healthy, nonpregnant adults (n = 55, 69%). Nine (11%) studies included pregnant women, 13 (16%) included adolescents and 22 (28%) included children. Recruitment, screening, enrollment procedures and definition of age strata varied across studies. The most common type of RIs reported were hematology (66, 83%); 14 studies (18%) included flow cytometry and/or T cell counts. Other common tests or panels included liver function assays (32, 40%), renal function assays (30, 38%), lipid chemistries (17, 21%) and serum electrolytes (17, 21%). The number of parameters characterized ranged from only one (three studies characterized either CD4+ counts, D-dimer, or hemoglobin), to as many as 40. Statistical methods for calculating RIs varied. 56 (70%) studies compared their results to international RI databases. Though most presented their data side-by-side with international data with little accompanying analysis, nearly all reported deviation from comparator RI data, sometimes with half or more of otherwise healthy participants having an "out of range" result. We found there is limited local RI data available in sub-Saharan Africa. Studies to fill this gap are warranted, including efforts to standardize statistical methods to derive RIs, methods to compare with other RIs, and improve representative participant selection.

Reference Intervals for Absolute and Percentage CD4+ T Lymphocytes among an Apparently Healthy Population in Addis Ababa, Ethiopia

Background

Reference intervals for clinical laboratory parameters differ based on several factors, including age, sex, genetic variation, and geographic location. This variation influences clinical decisions and treatment monitoring. Currently, Ethiopia has used adopted reference intervals from manufacturer values derived from non-Africans. Therefore, the aim this study was to determine reference intervals for absolute and percentage CD4⁺ T cells for an apparently healthy population in Addis Ababa, Ethiopia.

Methods

A community-based cross-sectional study was conducted on 361 apparently healthy people in four subcities in Addis Ababa from January to June 2019. Sociodemographic and clinical data were collected using a structured questionnaire after informed consent had been obtained. Blood samples were collected and CD4⁺ T-lymphocyte enumeration performed using a BD FACSPresto near-patient CD4 counter. Data were entered and analyzed using SPSS 20. Reference intervals were determined by a nonparametric test estimating percentiles 2.5 (lower limit) and 97.5 (upper limit) with 95% CIs. P<0.05 was considered statistically significant.

Results

A total of 337 (183 female and 154 male) healthy participants of median age 28 (IQR 17–35) years were included in the final analysis. Medians of absolute and percentage CD4⁺ T-cell counts (932.0 and 42.9, respectively) of female participants were significantly higher than male participants (802.5 and 38.7, respectively; P<0.05). Reference intervals for absolute CD4⁺ T-cell count and percentages in males were 483.8–1,310 cells/µL and 18.1–57.3 and in females 447.8–1,479.8 cells/µL and 25.6–58.9, respectively.

Conclusion

The CD4⁺ T-count reference intervals established in this study showed some inconsistency from the manufacturer’s provided values and other studies and also revealed sex differences, necessitating sex-specific locally established reference intervals.

CD4+ cell count recovery after initiation of antiretroviral therapy in HIV-infected Ethiopian adults

Background

CD4+ cell count recovery after effective antiretroviral therapy (ART) is an important determinant of both AIDS and non-AIDS morbidity and mortality. Data on CD4+ cell count recovery after initiation of ART are still limited in Sub-Saharan Africa. The aim of this study was to assess CD4+ cell count recovery among HIV-infected adults initiating ART in an Ethiopian setting.

Methods

A retrospective cohort study of HIV-infected adults initiating ART between September 2008 and June 2019 was carried out. CD4+ cell count recovery was defined as an increase in CD4+ cell count of >100 cells/mm³ from baseline or achievement of a CD4+ cell count >500 cells/mm³ at 12 months after ART initiation. Factors associated with CD4+ cell count recovery were evaluated using logistic regression analysis.

Results

Of the 566 patients included in this study, the median baseline CD4+ cell count was 264 cells/mm³ (IQR: 192–500). At 12 months after ART initiation, the median CD4+ cell count increased to 472 cells/mm³, and the proportion of patients with CD4+ cell count < 200 cells/mm³ declined from 28.3 to 15.0%. A total of 58.0% of patients had an increase in CD4+ cell count of >100 cells/mm³ from baseline and 48.6% achieved a CD4+ cell count >500 cells/mm³ at 12 months. Among patients with CD4+ cell counts < 200, 200–350 and >350 cells/mm³ at baseline, respectively, 30%, 43.9% and 61.7% achieved a CD4+ cell count >500 cells/mm³ at 12 months. In multivariable analysis, poor CD4+ cell count recovery (an increase of ≤100 cells/mm³ from baseline) was associated with older age, male sex, higher baseline CD4+ cell count and zidovudine-containing initial regimen. Factors associated with poor CD4+ cell count recovery to reach the level >500 cells/mm³ included older age, male sex and lower baseline CD4+ cell count.

Conclusions

CD4+ cell count failed to recover in a substantial proportion of adults initiating ART in this resource-limited setting. Older age, male sex and baseline CD4+ cell count are the dominant factors for poor CD4+ cell count recovery. Novel therapeutic approaches are needed focusing on high risk patients to maximize CD4+ cell count recovery and improve outcomes during therapy.

A Critical Review on the Standardization and Quality Assessment of Nonfunctional Laboratory Tests Frequently Used to Identify Inborn Errors of Immunity

Inborn errors of immunity (IEI), which were previously termed primary immunodeficiency diseases, represent a large and growing heterogeneous group of diseases that are mostly monogenic. In addition to increased susceptibility to infections, other clinical phenotypes have recently been associated with IEI, such as autoimmune disorders, severe allergies, autoinflammatory disorders, benign lymphoproliferative diseases, and malignant manifestations. The IUIS 2019 classification comprises 430 distinct defects that, although rare individually, represent a group affecting a significant number of patients, with an overall prevalence of 1:1,200-2,000 in the general population. Early IEI diagnosis is critical for appropriate therapy and genetic counseling, however, this process is deeply dependent on accurate laboratory tests. Despite the striking importance of laboratory data for clinical immunologists, several IEI-relevant immunoassays still lack standardization, including standardized protocols, reference materials, and external quality assessment programs. Moreover, well-established reference values mostly remain to be determined, especially for early ages, when the most severe conditions manifest and diagnosis is critical for patient survival. In this article, we intend to approach the issue of standardization and quality control of the nonfunctional diagnostic tests used for IEI, focusing on those frequently utilized in clinical practice. Herein, we will focus on discussing the issues of nonfunctional immunoassays (flow cytometry, enzyme-linked immunosorbent assays, and turbidimetry/nephelometry, among others), as defined by the pure quantification of proteins or cell subsets without cell activation or cell culture-based methods.

Hematological and CD4+ T- cell count reference interval for pregnant women attending antenatal care at Hawassa University Comprehensive Specialized Hospital, Hawassa Southern Ethiopia

BACKGROUND

Pregnancy is a state characterized by physiological, hematological, and immunological changes. However, the reference intervals (RI) being used in clinical practice in Ethiopia are derived from non-local general populations. Therefore; this study was aimed to determine the reference interval of hematological and immunological profiles among healthy pregnant mothers attending Hawassa University Hospital.

METHODS

A cross-sectional study in a total of 360 healthy pregnant women was enrolled from January to April 2019, at Hawassa University hospital. Sociodemographic and obstetric data were collected using a structured questionnaire. Blood samples collected from each participant were used to define the hematological parameters. The median and 95% intervals were calculated for the immunological and hematological profiles. P-value 0.05 was considered statistically significant.

RESULT

A total of 360 healthy pregnant women were enrolled in this study. The age range of the participants was 18-45 years. 342(95%) were married and 270 (75%) of the participants were multigravida. The overall median CD4+ T-cell and total WBC counts (cells/mm3) were 602 and 7.58 respectively. The overall median value for lymphocytes, neutrophils, monocytes, eosinophils, and basophil count was (cells/mm3) was 2.21, 6.74, .63, .53, and 0.09 respectively. Whereas the median RBC and platelet count was 4.48×106/μLand 212×106/μL. The median value of hematological profiles in the first, second, and third trimesters was TWBC (103/μL) (7.90, 8.30, 8.65), RBC (106/μL) (4.5, 4.6, 4.62), and PLT (103/μL) (210, 209,161) respectively. The CD4 T cell count median value was (600, 598, and 591) in the first, second, and third trimesters. Significant changes were observed in hematological and immunological parameters between trimesters (P < 0.05).

CONCLUSION

Significant changes were observed in hematological and immunological parameters between trimesters (P < 0.05). Considerable differences were also seen between the values in this study and other studies from Ethiopia and other countries, indicated the need for the development of local reference intervals for pregnant women.

Immunological status and virological suppression among HIV-infected adults on highly active antiretroviral therapy

BACKGROUND

World Health Organization (WHO) recommends that viral load ([VL) is a primary tool that clinicians and researchers have used to monitor patients on antiretroviral therapy (ART), an antiviral drug against retroviruses. Whereas, CD4 cell counts can only be used to monitor clinical response to ART in the absence of VL testing service. Therefore, this study is aimed to assess the level of immunological status and virological suppression, and identify associated factors among human immunodeficiency virus ([HIV)-infected adults who were taking antiretroviral drugs of combination regimen know as highly active antiretroviral therapy (HAART).

METHODS

A hospital-based cross-sectional study was conducted at the University of Gondar comprehensive specialized referral hospital from February to April 2018. A total of 323 adult participants on HAART were selected using a systematic random sampling technique and enrolled into the study. Blood samples for viral load determination and CD4 cell count were collected. Binary logistic regression analysis was used to determine factors associated with immunologic status and virological suppression in HIV patients on HAART. Odds ratio with 95% CI was used to measure the strength of association.

RESULTS

Virological suppression (VL level < 1000 copies/ml) was found in 82% (95% CI 77.7, 86.1) of study participants, and it has been associated with CD4 cell count between 350 and 499 cells/mm³ (adjusted odds ratio (AOR) = 2.56; 95% CI 1.14, 5.75) and > 499 cells/mm³ (AOR = 7.71; 95% CI 3.48, 17.09) at VL testing and current age > 45 years old (AOR = 5.99; 95% CI 2.12, 16.91). Similarly, favorable immunological status (≥ 400 cells/mm³ for male and ≥ 466 cells/mm³ for female) was observed in 52.9% (95% CI 47.4, 58.8) of the study participants. Baseline CD4 cell count of > 200 cells/mm³, age at enrollment of 26 through 40 years old, and urban residence were significantly associated with favorable immunological status.

CONCLUSION

Though the majority of HIV-infected adults who were on HAART had shown viral suppression, the rate of suppression was sub-optimal according to the UNAIDS 90-90-90 target to help end the AIDS pandemic by 2020. Nonetheless, the rate of immunological recovery in the study cohort was low. Hence, early initiation of HAART should be strengthened to achieve good virological suppression and immunological recovery.