Strategic response to COVID-19 in Ethiopia

COVID-19, the novel coronavirus, has posed a major threat to low- and middle-income countries (LMICs) due to inadequate health infrastructure and human resources. Ethiopia, a low-income country with the second largest population in Africa, has coordinated a strategic response, leveraging existing infrastructure and health systems and mobilizing public health professionals and specialist expert physicians for a multifaceted, unified government approach and adaptive response. Resource limitations, particularly in critical care, have still posed challenges, but the public health and clinical interventions thus far have prevented the catastrophic toll that many predicted. As the pandemic continues, Ethiopia expects to use a triple care model integrated at all levels, consisting of COVID-19 care, isolation care for suspected cases, and essential health services, and urges intensified non-pharmaceutical interventions alongside equitable global vaccine distribution as the ultimate answers to pandemic control. This paper draws on existing data, national planning and guidelines, and expertise from health leadership to describe this response in hopes of providing an example of how future large-scale health challenges might be faced in LMICs, using Ethiopia's successes and challenges in facing the pandemic.

Undernutrition was a prevalent clinical problem among older adult patients with heart failure in a hospital setting in Northwest Ethiopia

Background

Undernutrition is a frequently noticed medical problem in patients with heart failure. It is caused by poor nutrient intake, malabsorption, systemic inflammation, neurohumoral activation, oxidative stress, and hypermetabolic state. Undernutrition results in a decrease in the quality of life and the survival rate in patients with heart failure. There is a paucity of documentation on undernutrition among patients with heart failure in sub-Saharan African countries. The study aimed to determine the magnitude and associated factors of undernutrition among older adult patients with heart failure in the hospital setting in Northwest Ethiopia.

Methods

An institutional-based cross-sectional study was conducted at the University of Gondar Hospital, Northwest Ethiopia, between 1 June 2021 and 31 October 2021. A consecutive sampling method was used to recruit 262 study subjects. A Mini-nutritional assessment-full form (MNA-FL) Questionnaire was used to extract nutritional information among patients with heart failure. Patients with heart failure, who scored MNA-FL score <17, were declared to have undernutrition. The data were entered into EPI Info version 4.6.0.0 and then exported to SPSS version 26 for analysis. Explanatory variables associated with undernutrition in patients with heart failure were analyzed by applying a logistic regression model. A P-value of <0.05 was used to declare a significant association.

Results

A total of 262 patients with heart failure were included in the study. The mean age (± SD) of the study subjects was 64.6 (± 9.2) years. Hypertensive heart disease (111/262, 42%) was the most common cause of heart failure. Hypertension was the frequently observed comorbid disease. Based on the MNA-FL score for nutritional status, 75 out of 262 (28.6%, 95% CI: 22.9–34.4%) were undernourished (MNA-FL < 17), while 124 out of 262 (47.3%, CI: 41.5–53.1%) were at risk of undernutrition (MNA-FL = 17–23.5). The remaining 63 out of 262 (24.1%, 95% CI: 18.2–29.8%) study subjects were well nourished (MNA-FL > 24). On a multivariate analysis, patients with severe heart failure (New York Heart Association (NYHA) functional class III/IV) (AOR = 4.287, CI: 2.012–9.134, P-value < 0.001), with a duration of illness of 3–5 years (AOR = 3.225, CI: 1.138–9.137, P-value = 0.028), with a duration of illness of >5 years (AOR = 4.349, CI: 1.592–11.879, P-value = 0.001), presence of comorbidities (AOR = 2.29, CI: 1.06–4.96, P-value = 0.036), who underwent treatment with loop diuretics (AOR = 2.983, CI: 1.407–6.326, P-value = 0.040), and who reside in a rural area (AOR = 5.119, CI: 2.481–10.560, P-value < 0.001) were at risk of developing undernutrition.

Conclusion

Undernutrition was a significant clinical problem in older patients with heart failure. Nutritional interventions should be prioritized for patients with chronic and severe heart failure.

Factors associated with stroke associated pneumonia among adult stroke patients admitted to university of Gondar hospital, Northwest Ethiopia

Stroke is the major cause of disability and death in sub-Saharan African countries. The presence and severity of complications play a major role in the outcome of stroke. Stroke associated pneumonia is often noticed post stroke infection that has been linked to an increased risk of hospital mortality, a longer hospital stay and higher healthcare expenses. Report on details of stroke-associated pneumonia has never been documented in countries of sub-Saharan Africa. This study aimed to determine the incidence and risk factors of stroke-associated pneumonia among adult stroke patients in hospital settings, Northwest Ethiopia. The study was undertaken at a stroke care unit, University of Gondar hospital between January 1, 2020 and December 31, 2020. A convenience sampling method was used to recruit study subjects. Relevant clinical history was taken, focused physical examination was done, and brain imaging (CT scan or MRI) was performed to settle the diagnosis of stroke. A modified Centre for Disease Control and Prevention (CDC) criteria was used to diagnose stroke-associated pneumonia. All patients with stroke-associated pneumonia were treated according to the 2016 Infectious Diseases Society of America/American Thoracic Society Clinical Practice Guidelines. The Data were cleaned in Epi Info version 4.6.0.2, and analyzed using SPSS version 26. Variables associated with stroke-associated pneumonia were computed using logistic regression analysis. P value < 0.05 was considered to declare statistical significance. The study comprised a total of 325 adult stroke patients. The mean age of study subjects was 65.2 years (SD ± 15.7). The most prevalent type of stroke was ischemic stroke, which accounted for 68% of all cases. Hemiparesis (94%), facial palsy (87%), and swallowing disturbance (51%) were the frequently noticed neurological findings. Stroke-associated pneumonia complicated 116/325 (36%) of stroke patients. Multi-variate regression analysis revealed that patients who were elderly (age > 75 years) (AOR = 3.910, CI 1.181-12.936, P = 0.026), had swallowing disturbance (AOR = 4.656, CI 2.356-9.202, P-value < 0.001), epileptic seizures (AOR = 2.678, 95% CI 1.253-5.721, P-value < 0.001) and moderate to severe stroke (NIHSS score = 16-21) (AOR = 5.994, 95% CI 2.043-17.585, P-value < 0.001) were at risk of developing stroke-associated pneumonia. SAP was a substantial medical complication among stroke patients. Early identification and prompt intervention measures for the identified risk factors might address the burden of SAP.

Peptic ulcer disease among dyspeptic patients at endoscopy unit, University of Gondar hospital, Northwest Ethiopia

Background

Dyspepsia is a common complaint in upper gastrointestinal disorders. It is described as predominant epigastric pain lasting for at least one month. Globally, peptic ulcer disease occurs in 3.5–32% of patients with dyspepsia. Helicobacter pylori (H. pylori) infection and non-steroidal anti-inflammatory drugs/aspirin use are the widely known risk factors for peptic ulcer disease. There was no recent document on H. pylori infection rate among patients with peptic ulcer disease in Ethiopia. This study aimed to determine magnitude and associated factors of peptic ulcer disease among dyspeptic patients in Northwest Ethiopia.

Methods

An institutional-based cross sectional study was conducted at the University of Gondar hospital, Northwest Ethiopia. A convenience sampling method was used to recruit 218 study subjects. A pre-designed semi-structured questionnaire was used to extract clinical information. Olympus flexible fiber-optic endoscope (Olympus, GIF-E 600, Olympus Corp., Hamburg, Germany) was used to confirm the presence of peptic ulcer disease. Diagnosis of active H. pylori infection was made using the fecal H. pylori Antigen 25 T Card Test (Anamol Lab., Pvt. Ltd., Palghar, India). The Data were entered into EPI Info version 4.6.0.2, and then exported to SPSS version 20 for analysis. Explanatory variables associated with peptic ulcer disease were analyzed by applying logistic regression model. P value < 0.05 was used to declare significant association.

Result

A total of 218 dyspeptic patients who underwent upper gastrointestinal endoscopic evaluations were included in the study. The mean (+ SD) age of patients was 42 ± 16.4 years. Forty nine percent (95% CI 42.4–56.2) of dyspeptic patients had active H. pylori infection. Peptic ulcer disease was diagnosed in 35% (95% CI 31.4–39.2) of patients with dyspepsia. H. pylori infection (AOR = 6.298, 95% CI 2.965–13.378, P value <  0.001) and NSAIDs/ASA use (AOR = 6.252, 95% CI 2.925–13.362, P value <  0.001) were identified as risk factors for peptic ulcer disease.

Conclusion

Medical treatment of peptic ulcer disease should target treatment of H. pylori infection and cautious use of non-steroidal anti-inflammatory drugs/aspirin.

Achieving high treatment success for multidrug-resistant TB in Africa: initiation and scale-up of MDR TB care in Ethiopia--an observational cohort study

Background

In Africa, fewer than half of patients receiving therapy for multidrug-resistant TB (MDR TB) are successfully treated, with poor outcomes reported for HIV-coinfected patients.

Methods

A standardised second-line drug (SLD) regimen was used in a non-governmental organisation–Ministry of Health (NGO-MOH) collaborative community and hospital-based programme in Ethiopia that included intensive side effect monitoring, adherence strategies and nutritional supplementation. Clinical outcomes for patients with at least 24 months of follow-up were reviewed and predictors of treatment failure or death were evaluated by Cox proportional hazards models.

Results

From February 2009 to December 2014, 1044 patients were initiated on SLD. 612 patients with confirmed or presumed MDR TB had ≥24 months of follow-up, 551 (90.0%) were confirmed and 61 (10.0%) were suspected MDR TB cases. 603 (98.5%) had prior TB treatment, 133 (21.7%) were HIV coinfected and median body mass index (BMI) was 16.6. Composite treatment success was 78.6% with 396 (64.7%) cured, 85 (13.9%) who completed treatment, 10 (1.6%) who failed, 85 (13.9%) who died and 36 (5.9%) who were lost to follow-up. HIV coinfection (adjusted HR (AHR): 2.60, p<0.001), BMI (AHR 0.88/kg/m², p=0.006) and cor pulmonale (AHR 3.61, p=0.003) and confirmed MDR TB (AHR 0.50, p=0.026) were predictive of treatment failure or death.

Conclusions

We report from Ethiopia the highest MDR TB treatment success outcomes so far achieved in Africa, in a setting with severe resource constraints and patients with advanced disease. Intensive treatment of adverse effects, nutritional supplementation, adherence interventions and NGO-MOH collaboration were key strategies contributing to success. We argue these approaches should be routinely incorporated into programmes.

Genomic profiles and predictive biological networks in oxidant-induced atherogenesis

Atherogenic stimuli trigger complex responses in vascular smooth muscle cells (VSMCs) that culminate in activation/repression of overlapping signal transduction cascades involving oxidative stress. In the case of benzo[a]pyrene (BaP), a polycyclic aromatic hydrocarbon present in tobacco smoke, the atherogenic response involves interference with redox homeostasis by oxidative intermediates of BaP metabolism. The present studies were conducted to define genomic profiles and predictive gene biological networks associated with the atherogenic response of murine (aortic) VSMCs to BaP. A combined oxidant-antioxidant treatment regimen was used to identify redox-sensitive targets during the early course of the atherogenic response. Gene expression profiles were defined using cDNA microarrays coupled to analysis of variance and several clustering methodologies. A predictor algorithm was then applied to gain insight into critical gene-gene interactions during atherogenesis. Supervised and nonsupervised analyses identified clones highly regulated by BaP, unaffected by antioxidant, and neutralized by combined chemical treatments. Lymphocyte antigen-6 complex, histocompatibility class I component factors, secreted phosphoprotein, and several interferon-inducible proteins were identified as novel redox-regulated targets of BaP. Predictor analysis confirmed these relationships and identified immune-related genes as critical molecular targets of BaP. Redox-dependent patterns of gene deregulation indicate that oxidative stress plays a prominent role during the early stages of BaP-induced atherogenesis.

Lack of effect of gender on retinopathy in the mouse

BACKGROUND

The reported effect of gender on retinopathy of prematurity has been controversial. The goal of this study was to determine the effect of gender on oxygen-induced retinopathy in a mouse model.

METHODS

Oxygen-induced retinopathy was produced in C57BL6 mice by exposure to 75% oxygen from postnatal day (P) 7 for 5 days. Animals were returned to room air on P12 and killed on P17-21. Gender was determined by inspection. Retinopathy was evaluated by a retinopathy scoring system and by quantifcation of extraretinal neovascular nuclei on retinal sections.

RESULTS

Both males and females developed similar degrees of retinopathy. Males had a median total retinopathy score of 9 (25th, 75th quartile: 8, 11) and females had score of 9 (25th, 75th quartile: 7, 10). Retinal subscores of blood vessel growth, blood vessel tufts, extraretinal neovascularzation, haemorrhage and blood vessel tortuosity were similar in both groups. Males and females had a similar number of neovascular nuclei on retinal sections.

CONCLUSIONS

Gender does not alter the development of oxygen-induced retinopathy in the C57BL6 mouse.

Captopril improves retinal neovascularization via endothelin-1

PURPOSE

The purpose of this study was to determine the effect of an angiotensin converting enzyme inhibitor, captopril, on oxygen-induced retinopathy (OIR) in the mouse. Endothelin-1 (ET-1) expression is assessed in a mouse model of OIR.

METHODS

OIR was produced in C57BL6 mice. Captopril (0.5mg/kg/d SC) was given from P7 (post natal day 7) for 5 days. Retinopathy was assessed by a retinal scoring system and by quantification of extra retinal neovascular nuclei on retinal sections at P17 to P20. The expression of ET-1 was determined using a reverse transcriptase polymerase chain reaction.

RESULTS

Pups treated with captopril during hyperoxia had a lower median retinopathy score of 4.5 (25th, 75th quartile: 3, 6.4) compared with animals exposed to hyperoxia alone with median score 9.5 (25th, 75th quartile: 7.1, 10.4; P < 0.001). The pups treated with captopril during hyperoxia had significant reduction in number of nuclei extending beyond the inner limiting membrane (15.8 +/- 16.7, mean +/- SD) when compared with the animals exposed to hyperoxia only (50.4 +/- 28.0; P < 0.01). ET-1 expression in the retina increased 4.1-fold from P7 to P12 and a 1.9-fold increase from P12 to P17. Overall, there was an 8-fold increase in ET-1 expression from P7 to P17. Hyperoxia increased ET-1 expression by 2.1-fold at P12 over room air-reared animals. At P17, there was a 2.9-fold increase in retinal ET-1 expression when compared with room air. At P17, there was a 6.2-fold suppression in ET-1 expression in captopril-treated animals when compared with the oxygen only-treated animals.

CONCLUSIONS

Captopril reduces retinal neovascularization in a mouse model of oxygen-induced retinopathy. ET-1 expression is increased from P7 to P17, altered by hyperoxic exposure and relative hypoxic recovery and modulated by captopril in a mouse model of OIR.

Dexamethasone alters TNF-alpha expression in retinopathy

TNF-alpha has been found in the retina. Hyperoxia and hypoxia regulate TNF-alpha expression. TNF-alpha is an important factor in inflammation and angiogenesis. Dexamethasone inhibits TNF-alpha production. Changes in TNF-alpha expression in the retina may play an important role in the development of oxygen-induced retinopathy. Oxygen-induced retinopathy was produced in C57BL6 mice by exposure to 75% oxygen at Postnatal Day 7 (P7) for 5 days and the mice recovered in room air until Day 17 (P17). Dexamethasone was administered at 0.5 mg/kg/day once daily subcutaneously during the 5 days of oxygen exposure. TNF-alpha expression was evaluated at Day 7 prior to oxygen exposure, at Day 12 (P12) immediately upon removal from oxygen, and at Day 17, the time of maximal vasoproliferation by RT-PCR. TNF-alpha is developmentally regulated in the retinae of C57BL6 mice. From P7 to P12, there is a 3-fold increase in TNF-alpha expression and from P7 to P17 there is a 2.7-fold increase. There was 2.7-fold suppression in expression immediately following oxygen exposure at P12. The expression was dramatically increased at P17, the time of maximal vasoproliferation. Dexamethasone inhibited the expression of TNF-alpha at P17 by 6.4-fold. At this dose, it also suppressed the baseline TNF-alpha expression in the mouse model. In summary, TNF-alpha is altered in the development of oxygen-induced retinopathy in the mouse. It increased markedly during the vasoproliferative phase and was suppressed by dexamethasone. Modulation of TNF-alpha expression may provide a potential site of action for future therapeutic targets.

Dexamethasone and critical effect of timing on retinopathy

PURPOSE

Administration of corticosteroids soon after birth has been reported to have deleterious, protective, and no effect on retinopathy of prematurity. Conflicting results may be due to timing of corticosteroid administration. The goal of this study was to determine effects of pretreatment and late dexamethasone on retinopathy in a mouse model.

METHODS

The C57BL6 mouse model of oxygen-induced retinopathy (by placing animals in 75% oxygen from postnatal days 7 through 12) was used to create retinal neovascularization. Dexamethasone at 0.5 mg/kg per day was administered from day 1 through day 5 in the pretreatment group. The late-treatment group received 5 days of dexamethasone at the same dose beginning on day 12. Mice were killed at days 17 through 20, and retinal vasculature was assessed by a retinal scoring system of wholemount preparation after high-molecular-weight fluorescein-labeled dextran perfusion. In addition, retinal neovascularization was assessed by quantification of extraretinal neovascular nuclei in retinal sections. Statistical significance was defined as P: < 0.05 and was determined by the Kruskal-Wallis test, Mann-Whitney test, and Student's t-test.

RESULTS

Oxygen-exposed animals that received treatment with dexamethasone before oxygen exposure had an improvement in retinopathy, with a median score of 6 (5,7; 25th,75th quartiles) compared with 10 (8,11) in the untreated oxygen-exposed (P: < 0.05). The group treated late (after oxygen exposure) with dexamethasone had a median score of 10 (9,11). Pretreatment reduced extraretinal vascularization, when assessed by quantification of neovascular nuclei, to a mean +/- SEM of 19 +/- 9, significantly less than in the untreated oxygen-exposed group (55 +/- 12; P: < 0.05). No difference was observed in the late-treatment group when compared with the untreated oxygen-exposed group. Significant growth retardation, indicated by body weight, was observed in the pretreatment (P: < 0.01) and late-treatment (P: < 0. 05) groups when compared with the control group.

CONCLUSIONS

Timing of dexamethasone administration was critical to the inhibition of development of retinopathy in the mouse model. Degree of growth retardation, measured by body weight, also appeared to be time dependent. These data may explain the different results of clinical observations with respect to corticosteroid treatment, timing, and development of retinopathy.