Large scale evaluation of WHO's ultrasonographic staging system of schistosomal periportal fibrosis in Ethiopia

OBJECTIVES: To evaluate the recent WHO's ultrasonographic diagnostic staging system of schistosomal periportal thickening/fibrosis and to assess intra/inter-observer variation associated with its use. METHODS: Local standard of portal branch wall thickness (PBWT) for height was established using 150 healthy subjects. Intra and inter-observer variation in image pattern identification and PBWT measurements were assessed in 94 and 35 subjects, respectively, with differing stages of periportal thickening fibrosis. WHO's diagnostic criteria were evaluated in 2,451 community members (1,277 males, 1,174 females; mean age 18.8 years) with an overall Schistosoma mansoni prevalence estimate of 65.9%. RESULTS: There were no significant inter/intra-observer variations in image pattern identification and PBWT measurements. Based on Ethiopian PBWT-for-height standard, 128/2,451 (5.2%) had insipient, 46/2,451 (1.9%) had possible/probable and 112/2451 (4.6%) had definite/advanced periportal thickening/fibrosis. Comparable figures were obtained using the Senegalese PBWT-for-height standard and there was good agreement between Ethiopian and Senegalese healthy control-based diagnostic criteria in classifying the 286 subjects into stages of periportal thickening/fibrosis (kappa = 0.87, P < 0.001). CONCLUSIONS: With further improvement, the WHO's ultrasonographic diagnostic criteria can be used in health institutions and community surveys. Image pattern based assessment is simple and more reproducible than PBWT based assessment of periportal thickening/fibrosis. The latter is, however, more useful in clarifying the status of an individual with doubtful image pattern, and in monitoring post-treatment outcome of periportal thickening/fibrosis. Considering the comparability of PBWT-for-height standards, setting one international standard of PBWT-for-height is more practical than developing local standards for each endemic area.     

Cervical Cancer in Ethiopia: Survival of 1,059 Patients Who Received Oncologic Therapy

Background.

Almost 500,000 women are newly diagnosed with cervical cancer (CC) every year, the majority from developing countries. There is little information on the survival of these patients. Our primary objective was to evaluate consecutive CC patients presenting over 4 years at the only radiotherapy center in Ethiopia.

Methods.

All patients with CC from September 2008 to September 2012 who received radiotherapy and/or surgery were included (without brachytherapy). Vital status was obtained through telephone contact or patient cards.

Results.

Of 2,300 CC patients, 1,059 patients with standardized treatment were included. At the end of the study, 249 patients had died; surviving patients had a median follow-up of 16.5 months; the 10% and 90% percentiles were 3.0 and 32.7 months, respectively. Mean age was 49 years (21–91 years). The majority of patients presented with International Federation of Gynecology and Obstetrics stage IIb–IIIa (46.7%). Because of progression during the waiting time (median 3.8 months), this proportion declined to 19.3% at the beginning of radiotherapy. The 1- and 2-year overall survival probabilities were 90.4% and 73.6%. If assuming a worst-case scenario (i.e., if all patients not available for follow-up after 6 months had died), the 2-year survival probability would be 45.4%.

Conclusion.

This study gives a thorough 4-year overview of treated patients with CC in Ethiopia. Given the limited treatment availability, a relatively high proportion of patients survived 2 years. More prevention and early detection at all levels of the health care system are needed. Increasing the capacity for external-beam radiation as well as options for brachytherapy would facilitate treatment with curative intention.     

Ultrasound evaluation of abdominal masses in Ethiopian child patients

The aim of this study was to assess the pattern of abdominal masses and evaluate the value of ultrasound in paediatric abdominal masses. We used a cross-sectional study of abdominal masses in children attending a university teaching hospital. The common abdominal masses were: Wilms' tumour, 12 (14.8%); lymphoma, 11 (13.6%); appendiceal mass/abscess, 11 (13.6%); neuroblastoma, 7 (8.6%); TB, 6 (7.4%); hydronephrosis, 5 (6.2%); abdominal wall abscess, 6 (7.4%); hydatidcyst, 4 (4.9%); mesenteric cyst, 3 (3.7%); and intussusceptions, 3 (3.7%). Identification of a purely cystic mass was suggestive of benign lesion (odds ratio [OR] = 118, P = 0.0001) and masses found in the <5 years age group tend to be malignant (OR = 2.77). The most common sites of origin were kidneys, retroperitoneal extra renal and gastrointestinal tract. The overall diagnostic accuracy of ultrasound was 88.9%.     

Population genomic structure and adaptation in the zoonotic malaria parasite Plasmodium knowlesi

Malaria cases caused by the zoonotic parasite Plasmodium knowlesi are being increasingly reported throughout Southeast Asia and in travelers returning from the region. To test for evidence of signatures of selection or unusual population structure in this parasite, we surveyed genome sequence diversity in 48 clinical isolates recently sampled from Malaysian Borneo and in five lines maintained in laboratory rhesus macaques after isolation in the 1960s from Peninsular Malaysia and the Philippines. Overall genomewide nucleotide diversity (π = 6.03 × 10⁻³) was much higher than has been seen in worldwide samples of either of the major endemic malaria parasite species Plasmodium falciparum and Plasmodium vivax. A remarkable substructure is revealed within P. knowlesi, consisting of two major sympatric clusters of the clinical isolates and a third cluster comprising the laboratory isolates. There was deep differentiation between the two clusters of clinical isolates [mean genomewide fixation index (F_ST) = 0.21, with 9,293 SNPs having fixed differences of F_ST = 1.0]. This differentiation showed marked heterogeneity across the genome, with mean F_ST values of different chromosomes ranging from 0.08 to 0.34 and with further significant variation across regions within several chromosomes. Analysis of the largest cluster (cluster 1, 38 isolates) indicated long-term population growth, with negatively skewed allele frequency distributions (genomewide average Tajima’s D = −1.35). Against this background there was evidence of balancing selection on particular genes, including the circumsporozoite protein (csp) gene, which had the top Tajima’s D value (1.57), and scans of haplotype homozygosity implicate several genomic regions as being under recent positive selection.The zoonotic malaria parasite Plasmodium knowlesi is a significant cause of human malaria, with a wide spectrum of clinical outcomes including high parasitemia and death (1–4). Long known as a malaria parasite of long-tailed and pig-tailed macaques (5), the first large focus of human cases was described only in 2004 in the Kapit Division of Sarawak in Malaysian Borneo (6). Since then infections have been described from almost all countries in Southeast Asia (2, 7). Travelers to the region from Europe, North America, and Australasia also have recently acquired P. knowlesi malaria (7, 8). Until the application of molecular assays for specific detection, human P. knowlesi malaria was largely misdiagnosed as Plasmodium malariae, a morphologically similar but distantly related species (1, 6, 9, 10). Studies in the Kapit Division of Sarawak in Malaysian Borneo have indicated that P. knowlesi malaria is primarily a zoonosis with macaques as reservoir hosts (11) and that the forest-dwelling mosquito species Anopheles latens is the local vector for P. knowlesi (12). Other members of the Anopheles leucosphyrus group are vectors in different parts of Southeast Asia and may determine the geographical distribution of transmission (13, 14).Although P. knowlesi malaria is regarded as an emerging infection, there clearly have been increased efforts in detection made since its existence as a significant zoonosis was discovered, and specific detection has been enhanced by the declining numbers of human cases caused by other malaria parasites in Southeast Asia (15). Aside from the first two human cases described several decades ago (5), there is direct evidence of human P. knowlesi infections from ∼20 y ago in Malaysian Borneo and Thailand obtained by retrospective molecular analysis of material from archived blood spots and slides (10, 16), and molecular population genetic evidence indicates the zoonosis has been in existence for a much longer time (11). The genetic diversity of P. knowlesi is high within humans as well as macaques, with sequence data on three loci [the circumsporozoite protein (csp) gene, 18S rRNA, and mtDNA genome] indicating extensive shared polymorphism and no fixed differences between P. knowlesi parasites from humans and monkeys sampled in the same area in Sarawak, Malaysian Borneo (6, 11). Analysis of samples from a smaller number of humans and monkeys in Thailand showed alleles of the P. knowlesi merozoite surface protein 1 (msp1) gene to be similarly diverse in both hosts (16), and there were shared polymorphisms of the csp gene in parasites from a few infections examined in humans and macaques in Singapore (17). Recent multilocus microsatellite analysis has indicated a deep population subdivision in P. knowlesi associated with long-tailed and pig-tailed macaques; both major types infect humans and occur sympatrically at most sites in Malaysia, but the two types show some additional geographical differentiation across sites (18).Human populations have grown very rapidly in the Southeast Asian region and encroach on most of the wild macaque habitats, so it is vital to know if P. knowlesi parasites are adapting to human hosts or to anthropophilic mosquito vector species, either of which could cause human–mosquito–human transmission. Initial analysis of the P. knowlesi reference genome sequence (strain H) highlighted some unique features of the genome of this species (19), namely, schizont infected cell agglutination variant (SICAvar) and knowlesi interspersed repeat (KIR) variant antigen genes, which were widely dispersed instead of being predominantly localized in subtelomeric regions as seen in large gene families in Plasmodium falciparum and Plasmodium vivax (20). Here, we analyzed genomewide diversity in P. knowlesi and conducted scans for signatures of balancing and directional selection, revealing extremely high genetic diversity and significant structuring of this species into subpopulation clusters that appear to be reproductively isolated as well as loci that show evidence of recent strong selection.     

The hazard of pregnancy loss and stillbirth among women in Kersa,East Ethiopia: A follow up study

BackgroundAlthough pregnancy loss causes considerable challenge to women’s health, population-based studies in rural areas are not widely available in low-income countries. This study aims to determine the hazard of pregnancy loss and related factors in the rural communities of Ethiopia.MethodologyA prospective community-based study was conducted over a period of 1 year. Pregnancy was identified as early as possible by a pregnancy urine test. All pregnant women identified during the screening were followed up at their home until termination of pregnancy or delivery of the neonate. The total follow-up time was 7802 ‘pregnant person months’. A Cox regression analysis was done to estimate the hazard of pregnancy loss.ResultOut of a total of 1438 terminated pregnancies, 143 (9.9%) did not end in live birth, 116 ended due to bleeding and 27 were stillbirths. Whilst the hazard of pregnancy loss was low among women with pregnancy interval of two or more years [AHR 0.3 (95% CI: 0.15, 0.43)], it was high among women having unplanned pregnancy [AHR 2.2 (95% CI: 1.56, 3.11)], among those who complained STI like symptoms during the index pregnancy [AHR 4.5 (95% CI: 2.79, 7.38)] and among those never received antenatal care [AHR 1.8 (95% CI: 1.13, 2.73)].ConclusionPregnancy loss was higher amongst women experienced unplanned pregnancy, complained STI like symptoms and women who had not attended antenatal care services.RecommendationTo reduce pregnancy loss in rural Ethiopia expanding and promoting the use of family planning, antenatal services and other reproductive health care is necessary.