Competency Assessment on Gram Stain Examination and Interpretation Among Medical Laboratory Professionals Working in Selected Hospitals of Addis Ababa, Ethiopia

Background

Laboratory test results are the cornerstone for patient diagnosis and treatment. Gram staining is a classic laboratory test method used to differentiate between bacteria. Competence assessment can help identify gaps and provide suggestions to academics, researchers, and policymakers to address competency gaps. In Ethiopia, there is no evidence of competency assessment by medical laboratory professionals using the Gram-staining technique.

Objective

To assess the competency of medical laboratory professionals on Gram stain examination and interpretation in selected hospitals of Addis Ababa, Ethiopia.

Methods

A cross-sectional study was conducted to assess the competency of medical laboratory professionals on Gram stain examination and interpretation from September 2015 to December 2017.

Results

Of 190 participants, 55 (28.9%) participants scored low knowledge, 131 (68.9%) scored medium knowledge, and only 4 (2.1%) respondents scored high knowledge. From the study variables, education level, supervision by regional or federal government bodies, and training about Gram staining were significantly associated with the knowledge level of study participants. Forty eight (25.3%), 78 (41%), and 64 (33.7%) participants scored low, medium, and high skill level, respectively, from a total of 190 participants. From skill level analysis, hospital type, microscope type, and availability of health information resources were significantly associated with skill levels. There were 44 observations (4%) with major errors and 321 observations (28%) with very major errors from all 1140 observations. Of all observations, 321 (28.2%) reported without grading, 39 observations (3.4%) reported gram-positive bacteria as gram-negative bacteria, and 15 observations (1.4%) reported gram-negative bacteria as gram-positive bacteria.

Conclusion

The current study found that most medical laboratory professionals work without supervision or refresher training in Gram stain examination and interpretation. Hence, medical laboratory professionals' knowledge and skill levels are unsatisfactory. Regular competence assessments, training, and follow-up are necessary to improve the professional competence in medical laboratories.

Antibacterial activity and phytochemical screening of traditional medicinal plants most preferred for treating infectious diseases in Habru District, North Wollo Zone, Amhara Region, Ethiopia

Ethiopia's healthcare system relies on traditional medicinal practices that use medicinal plants to treat human and livestock ailments. However, the lack of empirical validation regarding the efficacy of these treatments against specific infectious diseases necessitates rigorous scientific investigations. The objective of this study was to investigate the antibacterial activity and phytochemical screening on five selected medicinal plant species, namely Solanum somalense Franchet., Verbascum sinaiticum Benth., Rumex nervosus Vahl, Withania somnifera (L.) Dunal and Calpurnia aurea (Ait.) Benth. The plants were first identified jointly with local informants and later considering mainly their high informant consensus and fidelity level values for their efficacy in treating infectious diseases in the area. Ethanol and aqueous extracts were prepared from the plant materials, and their antibacterial activities were evaluated against standard bacterial strains, representing both gram-positive and gram-negative types. To assess the antibacterial activity of the extracts, the minimum inhibitory concentration (MIC) was determined using the broth dilution method. Additionally, phytochemical screening was performed using standard qualitative tests to identify various secondary metabolites. The results indicated antibacterial efficacy in the ethanol extracts of S. somalense, W. somnifera, and C. aurea against particular bacterial strains (S. somalense against S. agalactiae with MIC of 1.5 mg/mL; W. somnifera against S. aureus and E. coli, with MIC of 2 mg/mL; C. aurea against E. coli and K. pneumoniae, with MICs of 3 mg/mL and 3.5 mg/mL, respectively). The results of the phytochemical screening indicated the presence of steroids, alkaloids, flavonoids, saponins, and terpenoids. The selected medicinal plants demonstrated promising antibacterial activity against certain bacterial strains. The current findings support the long-standing claim of the traditional medical system of the study area for their continued use of these plants in their treatment of infectious diseases. Further investigation is required to isolate the responsible active compounds and characterize the constituents and description of their antibacterial effect for possible use in areas where these infectious diseases are major health problems.

High rate of non-vaccine targeted high-risk HPV genotypes circulate among women in Eastern Ethiopia

The World Health Organization [WHO] recommends a genotype-specific human papillomavirus [HPV] vaccination as a primary prevention strategy to control the burden of cervical cancer globally. In Ethiopia, where the non-vaccine-targeted HPV genotypes have not been adequately studied, a vaccination initiative was launched in 2018 targeting HPV-6,-11, -16, and -18 for girls aged 14-18 years. The co-existence of both vaccine-targeted and non-targeted genotypes is a serious concern, as it can accelerate cancer progression. Therefore, this study was conducted to determine the prevalence of non-vaccine-targeted HPV genotypes and assess the level of multiple infections with other genotypes in eastern Ethiopia. A health facility-based cross-sectional study including 110 women with positive HPV DNA results was conducted from April to August 2021. A structured questionnaire to collect demographic and clinical data was used. Cervical swabs were collected using L-shaped FLOQSwabs. Women's cytological profile was determined based on Pap smear test results. An automated nucleic acid extraction system using STARMag 96 ProPrep Universal Extraction Kit was utilized following the manufacturer's protocol. An amplification assay in real-time was employed to amplify and identify the HPV Late 1 [L1] gene, which is utilized for genotyping purposes. Following this, the collected data was entered into Epi data version 3.1 software, and the analysis was performed using STATA version 14. A total of 110 women [age range 30-60 years, mean age = 36.5 years and SD ± 6.9] had positive HPV DNA results and were included in the study. Among these, 108 women had valid co-testing [Pap test and HPV DNA test] results for further analysis, and the results of the remaining 2 women were rejected. Overall, the prevalence of non-vaccine-targeted HPV was 56 (51.8%, 95%CI [0.42, 0.61]), of which 28 women (25.4%, 95%CI [0.18, 0.34]) had a single non-vaccine HPV genotype infection. The remaining 29 women (26.4%, 95% CI: 0.190-0.355) experienced multiple infections. The non-vaccine-targeted genotypes of HPV-35 accounted for 11 cases (10%, 95%CI [0.06, 0.17]), HPV-68 was detected in 9 women (8.2%, 95%CI [0.04, 0.15]), HPV-56 and HPV-66 were both found in 8 cases each (7.3%, 95%CI [0.04, 0.14]) of the total. In addition, out of these 108 women, 93 (86.1%, 95%CI [0.78, 0.91]) had low-grade squamous intraepithelial lesions, 13 (12%, 95%CI [0.07, 0.20]) no intraepithelial lesion or malignancy, and two (1.9%, 95%CI [0.01, 0.07]) high-grade squamous intraepithelial lesions. Furthermore, there was no statistical difference [p = 0.755] between vaccine-targeted and non-vaccine-targeted genotypes as the primary cause of cervical lesions. In conclusion, the findings of the present study highlight the existence of a notable prevalence of multiple infections caused by non-vaccine-targeted HPV genotypes. Therefore, it is recommended that both the Federal and regional health bureaus to evaluate the range of hr HPV genotypes protected by the current HPV vaccine and explore the option of transitioning from the quadrivalent HPV vaccine to a novavalent vaccine that includes seven high-risk HPV genotypes.

Health-related quality of life of adults with cutaneous leishmaniasis at ALERT Hospital, Addis Ababa, Ethiopia

BACKGROUND

Cutaneous leishmaniasis (CL) is a growing public health threat in Ethiopia. Leishmania aethiopica is the predominant causative organism. Affected individuals develop chronic skin lesions on exposed parts of the body, mostly on the face, which are disfiguring and cause scarring. The effects of CL on the health-related quality of life (HRQoL) of affected individuals has not been assessed in Ethiopia.

OBJECTIVE

To assess HRQoL in adults with active CL at ALERT Hospital, Addis Ababa, Ethiopia.

METHODS

A cross-sectional study was done using the Amharic version of the Dermatology Life Quality Index (DLQI). Trained health staff administered the DLQI.

RESULTS

Three hundred and two adults with active CL participated and all of them exhibited a reduced HRQoL. The median DLQI score was 10 (IQR 8). Almost half of the participants reported very poor HRQoL, 36.4% and 11.3% fell within the very large and extremely large effect categories respectively. DLQI scores were higher (median 18) in patients diagnosed with diffuse cutaneous leishmaniasis (DCL) compared to those with localized cutaneous leishmaniasis (LCL). The DLQI domain of 'work and school' was the most affected, scoring 73.3% and 66.6% of total possible score for female and male respectively, followed by that of 'symptom and feeling' (at 50.0% and 56.6% for female and male respectively). Men were more affected than women in the domains of 'leisure' (P = 0.002) and 'personal relationships' (P = 0.001). In the multivariate ordinal logistic regression site of lesion, clinical phenotype and age of participant remained associated with significantly poor HRQoL.

CONCLUSION

The HRQoL impairment associated with CL is significant. Thus, patient-reported outcome measure should be used to assess the efficacy of treatments along with clinical outcome measures.

Phenotypic and genotypic drug susceptibility patterns of Mycobacterium tuberculosis isolates from pulmonary tuberculosis patients in Central and Southern Ethiopia

INTRODUCTION

The persistence of tuberculosis (TB) infection in some patients after treatment has highlighted the importance of drug susceptibility testing (DST). This study aimed to determine the drug susceptibility patterns of Mycobacterium tuberculosis (M. tuberculosis) isolates from pulmonary TB (PTB) patients in Central and Southern Ethiopia.

METHODS

A health institution-based cross-sectional study was conducted between July 2021 and April 2022. Sputum samples were collected from newly diagnosed smear microscopy and/or Xpert MTB/RIF-positive PTB patients. The samples were processed and cultivated in Lowenstein-Jensen (LJ) pyruvate and glycerol medium. M. tuberculosis isolates were identified using polymerase chain reaction (PCR) based region of difference 9 (RD9) deletion typing. Phenotypic DST patterns of the isolates were characterized using the BACTEC MGIT™ 960 instrument with SIRE kit. Isoniazid (INH) and Rifampicin (RIF) resistant M. tuberculosis isolates were identified using the GenoType® MTBDRplus assay.

RESULTS

Sputum samples were collected from 350 PTB patients, 315 (90%) of which were culture-positive, and phenotypic and genotypic DST were determined for 266 and 261 isolates, respectively. Due to invalid results and missing data, 6% (16/266) of the isolates were excluded, while 94% (250/266) were included in the paired analysis. According to the findings, 14.4% (36/250) of the isolates tested positive for resistance to at least one anti-TB drug. Gene mutations were observed only in the rpoB and katG gene loci, indicating RIF and high-level INH resistance. The GenoType® MTBDRplus assay has a sensitivity of 42% and a specificity of 100% in detecting INH-resistant M. tuberculosis isolates, with a kappa value of 0.56 (95%CI: 0.36-0.76) compared to the BACTEC MGIT™ DST. The overall discordance between the two methods was 5.6% (14/250) for INH alone and 0% for RIF resistance and MDR-TB (resistance to both INH and RIF) detection.

CONCLUSION

This study reveals a higher prevalence of phenotypic and genotypic discordant INH-resistant M. tuberculosis isolates in the study area. The use of whole-genome sequencing (WGS) is essential for gaining a comprehensive understanding of these discrepancies within INH-resistant M. tuberculosis strains.

Trend analysis of malaria in urban settings in Ethiopia from 2014 to 2019

BACKGROUND

Urbanization generally improves health outcomes of residents and is one of the potential factors that might contribute to reducing malaria transmission. However, the expansion of Anopheles stephensi, an urban malaria vector, poses a threat for malaria control and elimination efforts in Africa. In this paper, malaria trends in urban settings in Ethiopia from 2014 to 2019 are reported with a focus on towns and cities where An. stephensi surveys were conducted.

METHODS

A retrospective study was conducted to determine malaria trends in urban districts using passive surveillance data collected at health facilities from 2014 to 2019. Data from 25 towns surveyed for An. stephensi were used in malaria trend analysis. Robust linear models were used to identify outliers and impute missing and anomalous data. The seasonal Mann-Kendal test was used to test for monotonic increasing or decreasing trends.

RESULTS

A total of 9,468,970 malaria cases were reported between 2014 and 2019 through the Public Health Emergency Management (PHEM) system. Of these, 1.45 million (15.3%) cases were reported from urban settings. The incidence of malaria declined by 62% between 2014 and 2018. In 2019, the incidence increased to 15 per 1000 population from 11 to 1000 in 2018. Both confirmed (microscopy or RDT) Plasmodium falciparum (67%) and Plasmodium vivax (28%) were reported with a higher proportion of P. vivax infections in urban areas. In 2019, An. stephensi was detected in 17 towns where more than 19,804 malaria cases were reported, with most of the cases (56%) being P. falciparum. Trend analysis revealed that malaria cases increased in five towns in Afar and Somali administrative regions, decreased in nine towns, and had no obvious trend in the remaining three towns.

CONCLUSION

The contribution of malaria in urban settings is not negligible in Ethiopia. With the rapid expansion of An. stephensi in the country, the receptivity is likely to be higher for malaria. Although the evidence presented in this study does not demonstrate a direct linkage between An. stephensi detection and an increase in urban malaria throughout the country, An. stephensi might contribute to an increase in malaria unless control measures are implemented as soon as possible. Targeted surveillance and effective response are needed to assess the contribution of this vector to malaria transmission and curb potential outbreaks.

Detection of blaKPC and blaNDM carbapenemase genes among Klebsiella pneumoniae isolates in Addis Ababa, Ethiopia: Dominance of blaNDM

Background

Infections caused by Klebsiella pneumoniae have been difficult to control because of the worldwide emergence of carbapenem-resistant isolates mainly due to carbapenemase production. Information regarding carbapenemase-producing K. pneumoniae is still scarce in Ethiopia. Therefore, the current study aimed to determine the prevalence of carbapenemase-producing K. pneumoniae and to assess the occurrence of bla_NDM and bla_KPC carbapenemase genes_.

Methods

A cross-sectional study was conducted from September 2018 to February 2019 at Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia. A total of 132 non-duplicate K. pneumoniae isolates were studied. Phenotypic confirmation of carbapenemase production was done by modified Carbapenem Inactivation Method (mCIM). Multiplex PCR was performed for the detection of carbapenemase-encoding genes bla_KPC, and bla_NDM.

Results

Out of the total 132 K. pneumoniae isolates, 39 (29.6%) were non-susceptible to one or more carbapenems. The prevalence of carbapenemase-producing isolates from the total was 28 (21.2%) with mCIM of which the most dominant gene was bla_NDM 26 (92.9%) and one isolate carried bla_KPC concomitantly. Carbapenemase-producing K. pneumoniae isolates were 100% non-susceptible to half of the antimicrobials used in the study, including meropenem and ertapenem. Previous use of carbapenems was associated with carbapenemase production (P = 0.004).

Conclusions

The prevalence of carbapenemase-producing K. pneumoniae isolates was worrying in the study area. To our knowledge, the study described the emergence of bla_NDM and bla_KPC gene carrying K. pneumoniae in Ethiopia for the first time. Further large-scale molecular-based studies, including other carbapenemase genes and sequencing of K. pneumoniae, are warranted to have a clear awareness about the presence of antimicrobial resistance high-risk clones in Ethiopia.

The epidemiology and detectability of asymptomatic plasmodium vivax and plasmodium falciparum infections in low, moderate and high transmission settings in Ethiopia

BACKGROUND

As countries move to malaria elimination, detecting and targeting asymptomatic malaria infections might be needed. Here, the epidemiology and detectability of asymptomatic Plasmodium falciparum and Plasmodium vivax infections were investigated in different transmission settings in Ethiopia.

METHOD

A total of 1093 dried blood spot (DBS) samples were collected from afebrile and apparently healthy individuals across ten study sites in Ethiopia from 2016 to 2020. Of these, 862 were from community and 231 from school based cross-sectional surveys. Malaria infection status was determined by microscopy or rapid diagnostics tests (RDT) and 18S rRNA-based nested PCR (nPCR). The annual parasite index (API) was used to classify endemicity as low (API > 0 and < 5), moderate (API ≥ 5 and < 100) and high transmission (API ≥ 100) and detectability of infections was assessed in these settings.

RESULTS

In community surveys, the overall prevalence of asymptomatic Plasmodium infections by microscopy/RDT, nPCR and all methods combined was 12.2% (105/860), 21.6% (183/846) and 24.1% (208/862), respectively. The proportion of nPCR positive infections that was detectable by microscopy/RDT was 48.7% (73/150) for P. falciparum and 4.6% (2/44) for P. vivax. Compared to low transmission settings, the likelihood of detecting infections by microscopy/RDT was increased in moderate (Adjusted odds ratio [AOR]: 3.4; 95% confidence interval [95% CI] 1.6-7.2, P = 0.002) and high endemic settings (AOR = 5.1; 95% CI 2.6-9.9, P < 0.001). After adjustment for site and correlation between observations from the same survey, the likelihood of detecting asymptomatic infections by microscopy/RDT (AOR per year increase = 0.95, 95% CI 0.9-1.0, P = 0.013) declined with age.

CONCLUSIONS

Conventional diagnostics missed nearly half of the asymptomatic Plasmodium reservoir detected by nPCR. The detectability of infections was particularly low in older age groups and low transmission settings. These findings highlight the need for sensitive diagnostic tools to detect the entire parasite reservoir and potential infection transmitters.

Occult Hepatitis B virus infection among HIV negative and positive isolated anti-HBc individuals in eastern Ethiopia

The absence of hepatitis B surface antigen (HBsAg) and the presence of antibody to hepatitis B core antigen (anti-HBc) in the blood of apparently healthy individuals may not indicate the absence of circulating hepatitis B virus (HBV) and might be infectious. Despite the risk of HBV transmission, there has been no report from Ethiopia examining this issue; therefore, this study determined occult HBV infection (OBI) among isolated anti-HBc (IAHBc) HIV negative and HIV positive individuals on ART in eastern Ethiopia. A total of 306 IAHBc individuals were included in this study. DNA was extracted, amplified, and detected from plasma using a commercially available RealTime PCR platform (Abbott m2000rt) following the manufacturer's instructions. Data were entered into EPI Data version 3.1, cleaned, and analyzed using Stata version 13. Descriptive analysis was used to calculate prevalence, summarize sociodemographic data and other factors. From the 306 IAHBc individuals (184 HIV positive and 122 HIV negative) included in the study, 183 (59.8%) were female of which 142 (77.6%) were within the reproductive age group. DNA extraction, amplified and detection was conducted in 224 individuals. The overall OBI prevalence was 5.8% (5.6% in HIV negative and 6% in HIV positive) among the IAHBc individuals. The HBV DNA concentration among the occult hepatitis B individuals was < 200 IU/mL, indicating a true occult. This study reported the burden of OBI, which pauses a significant public health problem due to the high burden of HBV infection in the country. OBI may cause substantial risk of HBV transmission from blood transfusion, organ transplantation as well as vertical transmission as screening is solely dependent on HBsAg testing.

A serologic study of dengue in northwest Ethiopia: Suggesting preventive and control measures

BACKGROUND

Dengue is one of the most serious and rapidly spreading arboviral diseases in the world. Despite many acute febrile illnesses in Ethiopia, the burden of illness due to dengue in the country is largely unknown. Thus, the present study aimed to provide the first baseline data on seroprevalence and associated risk factors of dengue virus (DENV) infection in the country.

METHODS

A cross-sectional study of febrile patients who were visiting Metema and Humera hospitals in Northwest Ethiopia from March 2016 to May 2017 was conducted. Blood samples were collected from each participant and serum samples were separated and tested for IgM and IgG antibodies against DENV infection by enzyme-linked immunosorbent assay (ELISA). Risk factors associated with the prevalence of anti-DENV antibodies were tested using logistic regression analysis.

RESULTS

Of the 600 samples tested, the overall seroprevalence against DENV infection was 33.3%, while the seroprevalence by the study area was 40% in Metema and 27.5% in Humera. The overall prevalence of IgM and IgG antibodies against DENV infection was 19% and 21% respectively. Of these, 6.7% were positive for both IgM and IgG antibodies. Residence and occupational status were significantly associated with the prevalence of anti-DENV IgM seropositivity and anti-DENV IgM-/G+serostatus. The seasonal variation was significantly associated with the prevalence of anti-DENV IgM but not with anti-DENV IgM-/G+serostatus. The prevalence of anti-DENV IgM-/G+serostatus was significantly higher in Metema than Humera. High prevalence of anti-DENV IgM seropositivity was found in the summer and spring, with a peak in the month of August. The presence of uncovered water either indoor or outdoor and lack of mosquito net use was identified as risk factors for DENV infection.

CONCLUSIONS

These findings provide the preliminary data on seroprevalence and associated risk factors of DENV infection in the country. The presence of antibodies against DENV infection indicates dengue as one of the causes of undifferentiated febrile illnesses in the study areas. This suggests that prevention and control measures should be designed considering the risk factors identified by this study. Furthermore, we recommend a large-scale study to include DENV infection in the differential diagnosis of all febrile illnesses in Ethiopia.

Malnutrition and lipid abnormalities in antiretroviral naïve HIV-infected adults in Addis Ababa: A cross-sectional study

BACKGROUND

Both under- and over-nutrition may occur among human immunodeficiency virus (HIV)-infected individuals and impact on the course of the acquired immune deficiency syndrome (AIDS) and its management due to the close interaction between immunity and nutrition. We investigated occurrence of undernutrition, excess weight and lipid abnormalities among antiretroviral naïve HIV-infected adults in Addis Ababa, Ethiopia.

METHODS

A cross-sectional study on 594 antiretroviral therapy (ART) naïve HIV-infected adults was conducted in four hospitals in Addis Ababa from February to September 2013. Hematological parameters (CD4+ T cell count and hemoglobin concentration), fasting serum glucose, total cholesterol (TC) and triglycerides (TG) were determined. Information on socio-demographic, anthropometric and World Health Organization (WHO) clinical stages was collected from patient clinical records, and triangulated by structured questionnaire. Height and weight measurements were taken and body mass index (BMI), undernutrition (BMI <18.5 kg/m2) and excess weight (BMI ≥25 kg/m2) determined. Statistical comparisons were made to identify significant factors associated with nutritional status and lipid profiles.

RESULTS

The prevalence of undernutrition was 15.1%, and the prevalence of excess weight was 22.1%, including 5.4% who were obese. The prevalence of hypercholesterolemia was 16.6% and it was higher in women (18.9%) than in men (11.0%) (p<0.05). However, the prevalence of hypertriglyceridemia was 29.8%. There was significant positive Spearman correlation between CD4+ T cell count and serum TC (r = 0.210, p<0.001), but no correlation was observed between CD4+ T cell count and TG (r = -0.007, p>0.05). Age categories 30-39 and 40-79, and WHO clinical stages III/IV for undernutrition; age categories 30-39 and 40-79, WHO clinical stages III/IV and TC ≥200 mg/dL for excess weight; and being female, age categories 30-39 and 40-79, and hypertriglyceridemia for hypercholesterolemia were found to be independent predictors by binomial logistic regression analysis.

CONCLUSION

Undernutrition, excess weight, hypercholesterolemia and hypertriglyceridemia were variably prevalent in ART naïve HIV-infected populations. This emphasizes the need for targeted nutritional programs as an integral part of HIV/AIDS care. Lipid levels need to be monitored regularly in patients whether on or off ART. In addition, improvement on household income and positive change in lifestyle and/or nutritional treatment to reduce morbidity and mortality are necessary interventions in HIV/AIDs patient management.