Effect of the enhancing nutrition and antenatal infection treatment (ENAT) intervention on birth weight in Ethiopia: a cluster randomized controlled trial

BACKGROUND

The Enhancing Nutrition and Antenatal Infection Treatment (ENAT) intervention was implemented in Ethiopia to improve newborn birth weight (BW) by strengthening the contents and quality of antenatal care (ANC), especially point-of-care testing for maternal infections. This study examined the effect of the ENAT intervention on birth weight.

METHODS

We conducted a cluster randomized controlled trial of 22 clusters (health centers), randomized equally between 11 intervention and 11 control clusters. This study enrolled and followed pregnant women from ANC booking to the end of pregnancy or loss to follow-up. The primary outcome was mean BW, and the incidence of low birth weight (LBW) was the secondary outcome. We presented univariate comparisons of outcomes between the intervention and control arms for mean BW and LBW. Multilevel analyses using random effects models were performed to adjust for clustering and individual-level covariates.

RESULTS

We enrolled and followed up 4,868 and 4,821 pregnant women in the intervention and control arms, respectively, from March 2021-July 2022. During follow-up, 3445 pregnant women in the intervention and 3192 in the control delivered in the health centers, and BW measurements of their babies were recorded within 48 h. The mean BW was 3,152 g (standard deviation (SD) = 339.8 g) in the intervention and 3,044 g (SD = 353.8 g) in the control arms (mean difference, 108 g; 95% confidence interval (CI): 91.3-124.6; P = 0.000). Adjusting for clustering and several covariates, the mean BW remained significantly higher in the intervention arm than in the control arm (adjusted ß coef., 114.3; p = 0.011). The incidence of LBW was 4.7% and 7.3% in the intervention and control arms, respectively. The adjusted risk of LBW was significantly lower by 36% in the intervention arm than in the control arm (adjusted relative risk, 0.645; p = 0.027).

CONCLUSION

This study provided sufficient evidence of the effectiveness of the ENAT intervention in improving birth weight in the study population. The intervention demonstrated that an increase in birth weight can be attained by availing point-of-care testing, strengthening infection prevention, and maternal nutrition within the ANC platform of public health facilities in a low-income setting.

TRIAL REGISTRATION

Registered at Pan African Clinical Trial Registry (PACTR) database dated 09/05/2023, https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=25493 . The unique identification number for the registry is PACTR202305694761480.

Evaluating the integration of tuberculosis screening and contact investigation in tuberculosis clinics in Ethiopia: A mixed method study

Background

Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated.

Objective

To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia.

Methods

The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation.

Results

Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult.

Conclusions

Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.

Identification of Functional and Expression Polymorphisms Associated With Risk for Antineutrophil Cytoplasmic Autoantibody-Associated Vasculitis

Objective

To identify risk alleles relevant to the causal and biologic mechanisms of antineutrophil cytoplasmic antibody (ANCA)–associated vasculitis (AAV).

Methods

A genome‐wide association study and subsequent replication study were conducted in a total cohort of 1,986 cases of AAV (patients with granulomatosis with polyangiitis [Wegener's] [GPA] or microscopic polyangiitis [MPA]) and 4,723 healthy controls. Meta‐analysis of these data sets and functional annotation of identified risk loci were performed, and candidate disease variants with unknown functional effects were investigated for their impact on gene expression and/or protein function.

Results

Among the genome‐wide significant associations identified, the largest effect on risk of AAV came from the single‐nucleotide polymorphism variants rs141530233 and rs1042169 at the HLA–DPB1 locus (odds ratio [OR] 2.99 and OR 2.82, respectively) which, together with a third variant, rs386699872, constitute a triallelic risk haplotype associated with reduced expression of the HLA–DPB1 gene and HLA–DP protein in B cells and monocytes and with increased frequency of complementary proteinase 3 (PR3)–reactive T cells relative to that in carriers of the protective haplotype. Significant associations were also observed at the SERPINA1 and PTPN22 loci, the peak signals arising from functionally relevant missense variants, and at PRTN3, in which the top‐scoring variant correlated with increased PRTN3 expression in neutrophils. Effects of individual loci on AAV risk differed between patients with GPA and those with MPA or between patients with PR3‐ANCAs and those with myeloperoxidase‐ANCAs, but the collective population attributable fraction for these variants was substantive, at 77%.

Conclusion

This study reveals the association of susceptibility to GPA and MPA with functional gene variants that explain much of the genetic etiology of AAV, could influence and possibly be predictors of the clinical presentation, and appear to alter immune cell proteins and responses likely to be key factors in the pathogenesis of AAV.

Identification and characterization of a carboxysomal γ-carbonic anhydrase from the cyanobacterium Nostoc sp. PCC 7120

Carboxysomes are proteinaceous microcompartments that encapsulate carbonic anhydrase (CA) and ribulose 1,5-bisphosphate carboxylase/oxygenase (Rubisco); carboxysomes, therefore, catalyze reversible HCO3 (-) dehydration and the subsequent fixation of CO2. The N- and C-terminal domains of the β-carboxysome scaffold protein CcmM participate in a network of protein-protein interactions that are essential for carboxysome biogenesis, organization, and function. The N-terminal domain of CcmM in the thermophile Thermosynechococcus elongatus BP-1 is also a catalytically active, redox regulated γ-CA. To experimentally determine if CcmM from a mesophilic cyanobacterium is active, we cloned, expressed and purified recombinant, full-length CcmM from Nostoc sp. PCC 7120 as well as the N-terminal 209 amino acid γ-CA-like domain. Both recombinant proteins displayed ethoxyzolamide-sensitive CA activity in mass spectrometric assays, as did the carboxysome-enriched TP fraction. NstCcmM209 was characterized as a moderately active and efficient γ-CA with a k cat of 2.0 × 10(4) s(-1) and k cat/K m of 4.1 × 10(6) M(-1) s(-1) at 25 °C and pH 8, a pH optimum between 8 and 9.5 and a temperature optimum spanning 25-35 °C. NstCcmM209 also catalyzed the hydrolysis of the CO2 analog carbonyl sulfide. Circular dichroism and intrinsic tryptophan fluorescence analysis demonstrated that NstCcmM209 was progressively and irreversibly denatured above 50 °C. NstCcmM209 activity was inhibited by the reducing agent tris(hydroxymethyl)phosphine, an effect that was fully reversed by a molar excess of diamide, a thiol oxidizing agent, consistent with oxidative activation being a universal regulatory mechanism of CcmM orthologs. Immunogold electron microscopy and Western blot analysis of TP pellets indicated that Rubisco and CcmM co-localize and are concentrated in Nostoc sp. PCC 7120 carboxysomes.

Real time RT-PCR quantification and Northern analysis of cerato-ulmin ( CU) gene transcription in different strains of the phytopathogens Ophiostoma ulmi and O. novo-ulmi

Cerato-ulmin is a surface protein that belongs to the class of fungal proteins known as hydrophobins. This class II hydrophobin is produced throughout the life cycle and in all developmental stages of Ophiostoma novo-ulmi and O. ulmi; the aggressive and non-aggressive pathogens responsible for Dutch elm disease. Since yeast/mycelial transitions are often important to pathogenesis in dimorphic fungi such as Ophiostoma, we have examined the levels and abundance of cu mRNA in the yeast and mycelial stages of this fungus. The fungus contains one copy of the cu gene per haploid genome, located on chromosome IV. Our studies have been done using phosphoimager-based Northern analysis and real-time quantitative RT-PCR (qRT-PCR) to measure levels of cu mRNA. These measurements were made in both yeast-like and mycelial stages of the pathogen. Two wild-type, aggressive, strains of O. novo-ulmi (VA30 and H327) and one wild type non-aggressive strain of O. ulmi (H5) were analysed. As controls, we have utilized two types of mutants that we had previously generated, the null cu mutants THEK5-8 and THEK5-8-1, and a cu over-expression mutant, H5-tf16. Data generated by both Northern hybridization and real-time qRT-PCR analyses demonstrate that there is no cu mRNA transcription in the null mutants. The Northern analysis clearly showed that the over-expressing mutant H5-tf16 produces much more cu mRNA than the non-aggressive or aggressive strains. The quantitative data generated using qRT-PCR demonstrated that mycelium generally had 20-60% more cu mRNA than the yeast form. The non-aggressive strain of O. ulmi (H5) produces one-tenth as much cu mRNA as the aggressive strains (VA30 and H327). When transformed with additional copies of the cu gene, this same non-aggressive strain (H5-tf16) expressed about 20 times more cu mRNA than the wild type H5 strain. These data were consistently generated in multiple real-time qRT-PCR experiments with different RNA preparations, clearly demonstrating that the quantitative abundance values obtained were reproducible. Our study represents the first report on the use of real-time qRT-PCR to compare and quantify gene transcription in different growth phases of a fungal pathogen.

Inter-current and nosocomial infections among visceral leishmaniasis patients in Ethiopia: an observational study

From July 1989 up to September 1997, a total of 247 non-HIV associated visceral leishmaniasis (VL) patients were treated on outpatient basis in rural clinics (195 patients) and hospitalised in the Northern-Omo Regional Hospital (18 patients) and in Addis Ababa referral hospitals (34 patients). Patients treated in the rural clinics and in the Regional hospital originated from the same endemic area and had comparable baseline characteristics. Overall rates of complications (inter-current/concurrent infectious or non-infectious diseases or deaths) in the three categories were 10.7, 38.9 and 61.6%, while case fatality rates were 2.5, 5.6 and 11.7%, respectively. Nosocomial bacterial infections occurred in 16.6% of patients treated in the Regional hospital and 32.3% of patients treated in Addis Ababa referral hospitals, and these infections accounted for 42.8 and 52.4% of the complications seen in the respective categories. Among VL patients originating from the same endemic place and with comparable baseline clinical data, patients treated hospitalised had significantly higher rates of complications than patients treated on outpatient basis (P<0.001). Patients who had complications during the course of VL therapy had significantly lower pre-treatment haemoglobin levels. Considering the extra cost of hospitalisation and risk of nosocomial infections and petavalent antimonial therapy being fairly safe, we recommend that VL patients, unless with serious complications, should preferably be treated on ambulatory basis with follow-up to monitor response and inter-current infections if any.

Case of tuberous sclerosis

Tuberous Sclerosis (TSc) is a benign multi-system hamaertomatosis and is one of the neurocutaneous syndromes (2, 3, 7). The first case of tuberous sclerosis in a 27 years old female patient is reported from Ethiopia. The importance of meticulous evaluation of a patient as a whole to reach at the right diagnosis is stressed. The clinicopathological features of tuberous sclerosis are discussed with literature review.