Evaluation of the effect of targeted Mass Drug Administration and Reactive Case Detection on malaria transmission and elimination in Eastern Hararghe zone, Oromia, Ethiopia: a cluster randomized control trial

Background

Reactive and proactive case detection measures are widely implemented by national malaria elimination programs globally. Ethiopia decided to include Reactive Case Detection (RCD) and targeted Mass Drug Administration (tMDA) approaches as part of their elimination strategy along with rigorous evaluation. The purpose of this study is to compare the impact of RCD and tMDA on malaria elimination over the 2-year study period, by looking at the annual parasite incidence before and after the intervention.

Methods

The study will be conducted in the East Hararghe zone of Ethiopia. Malaria transmission in the area is low to moderate. This study will deploy a community-based, three-arm, cluster-randomized control trial implemented over 2 years. Forty-eight clusters (16 clusters per arm) will be selected based on the annual number of confirmed malaria cases seen in the cluster. All clusters will receive the current standard of care in terms of malaria elimination interventions provided by the national malaria control program. In addition, following the identification of malaria parasite infection, individuals who reside within a 100-m radius of the index case will receive a diagnosis for malaria and treatment if positive in the RCD arm or presumptive treatment in the tMDA arm. The primary effectiveness endpoint will be measured at baseline and endline for each intervention arm and compared to the control arm using a difference in difference approach.

Discussion

This randomized controlled trial will provide evidence of the impact of the proposed intervention approaches for malaria elimination.

Trial registration

ClinicalTrials.gov NCT04241705. Registration date: January 27, 2020.

Baseline malaria prevalence at the targeted pre-elimination districts in Ethiopia

Background

Encouraged by the previous success in malaria control and prevention strategies, the Ethiopian ministry of health launched malaria elimination with a stepwise approach by primarily targeting the low-transmission Districts and their adjacent areas/zones in order to shrink the country’s malaria map progressively. Hence, this community survey was conducted to establish baseline malaria information at the preliminary phase of elimination at targeted settings.

Methods

A community-based cross-sectional survey was conducted at 20 malaria-elimination targeted Districts selected from five Regional states and one city administration in Ethiopia. The GPS-enabled smartphones programmed with Open Data Kit were used to enumerate 9326 study households and collect data from 29,993 residents. CareStart™ Malaria PAN (pLDH) Rapid Diagnostic Tests (RDTs) were used for blood testing at the field level. Armpit digital thermometers were used to measure axillary temperature.

Result

Overall malaria prevalence by RDTs was 1.17% (339/28973). The prevalence at District levels ranged from 0.0 to 4.7%. The proportion of symptomatic cases (axillary temperature > 37.5^oc) in the survey was 9.2% (2760/29993). Among the 2510 symptomatic individuals tested with RDTs, only 3.35% (84/2510) were malaria positive. The 75.2% (255/339) of all malaria positives were asymptomatic. Of the total asymptomatic malaria cases, 10.2% (26/255) were under-five children and 89.8% (229/255) were above 5 years of age.

Conclusion

The study shows a decrease in malaria prevalence compared to the reports of previous malaria indicator surveys in the country. The finding can be used as a baseline for measuring the achievement of ongoing malaria elimination efforts. Particularly, the high prevalence of asymptomatic individuals (0.88%) in these transmission settings indicates there may be sustaining hidden transmission. Therefore, active case detection with more sensitive diagnostic techniques is suggested to know more real magnitude of residual malaria in the elimination-targeted areas.

Peri-Operative Inflammatory Cytokines in Plasma of the Elderly Correlate in Prospective Study with Postoperative Changes in Cognitive Test Scores

Increasingly, postoperative cognitive dysfunction (POCD) is recognized as a complication after surgery in the elderly; but it's etiology remains unclear. Here we examine changes in cytokine levels during both the pre-operative and postoperative period, comparing them with long term variation in cognitive test scores. Forty-one patients aged 65 and older undergoing major surgery with general anesthesia were recruited after written consent in this IRB approved study. Thirty went on to complete this prospective, non-interven-tional and non-randomized study. Plasma levels of cytokines Il-6, Il-8, Il-10, and TNF were determined using ELISA with MILLIPLEX Multi-Analyte Profiling (Billerica, MA). All subjects had neurocognitive tests pre-operatively and 6 months post-surgery, including Paragraph Recall Immediate and Delayed, Digit Span Forward (DSF) and Backward (DSB), and Trail Making A and B. Spearman's Rho and repeated measure rank analysis were used to examine the dependence of z score changes in cognitive tests (baseline versus 6 months) as a function of 3 cytokine time points (presurgical, post anesthesia care unit (PACU), and post-operative day one (POD1)). A greater increase in PACU inflammatory burden correlated with a greater decline in performance on the DSB (IL6, IL8; r>-0.560; p<= 0.008). DSF changes correlated slightly better with pre-surgical cytokines, declining more with higher cytokines (IL6, r= -0.551, p=0.002; IL8, -0.468, 0.009). TNF, examining all 3 values, changed only slightly postoperatively, but still correlated with a decline in DSB (p=0.014). Thus, cognitive performance, over 6 months post surgery, declines with elevated perioperative inflammation. Specific cytokines at specific perioperative times may impact specific cognitive functions, serving as diagnostics as well as contributing causation.

A Randomized, Double Blind Study to Evaluate the Efficacy of Palonosetron with Dexamethasone Versus Palonosetron Alone for Prevention of Post-Operative Nausea and Vomiting in Subjects Undergoing Bariatric Surgeries with High Emetogenic Risk

Introduction:

Postoperative (PONV) and postdischarge (PDNV) nausea and vomiting are common (60-70%) after bariatric surgery. Palonosetron (Pal), a novel 5-HT3 antagonist, is an effective antiemetic with a prolonged duration of action in the setting of PDNV. We hypothesized that combination therapy with Palonosetron (Pal) and dexamethasone (Dex) would improve treatment in comparison to Palonosetron alone in patients at high risk for PONV.

Methods:

In this study, patients undergoing bariatric laparoscopic surgery under general anesthesia, a subgroup of a larger Phase IV clinical trial of patients who had laparoscopic surgery, were randomized to 8 mg Dex + 0.075mg Pal or saline + 0.075mg Pal. Data was collected postoperatively at 2, 6, 24 and 72 hrs. A Functional Living Index-Emesis (QOL-FLIE) test was administered at 96 hrs.

Results:

We enrolled 76 ASA 1-2 patients with at least 3 PONV risk factors. Both randomization groups had a low incidence of vomiting in the PACU (Pal, 0.0%; Pal + Dex, 5.4%) as well as at 72 hours (0.0% both groups). Complete response (no vomiting, no rescue medication) was not different between treatment groups at any time intervals. Cumulative success rates over the entire 72 hrs were 60.4% (Pal alone) vs. 60.0% (Pal + Dex). Nausea scores (4 point ordinal scale) were not different between groups for any time intervals. Cumulative success scores for nausea (score = “none”; 0-72 hrs) were 41.9% for the Pal group, and 55.2% for the Pal+ Dex group. The Pal + Dex group showed a trend toward greater satisfaction on the QOL-FLIE scores with the greatest differences in the “nausea domain”.

Discussion:

The combination therapy (Pal + Dex) did not significantly reduce the incidence of PONV or PDNV when compared with Pal alone although a trend was observed indicating the possible increased efficacy of multi-drug therapy. There was no change in comparative efficacy over 72 hrs, possibly due to the low incidence of PDNV in both groups.

A snapshot of the biodiversity and clustering of Mycobacterium tuberculosis in Oman using spoligotyping

SETTINGS

National Tuberculosis Reference Laboratory, Central Public Health Laboratory, Ministry of Health, Oman.

OBJECTIVE

To use spoligotyping to explore the genetic population structure and clustering of Mycobacterium tuberculosis isolates among nationals and immigrants in Oman.

METHODS

Using spoligotyping, we characterised all available isolates from 2007, and randomly selected isolates from 2005 and 2006. A total of 312 clinical isolates from the same number of patients diagnosed with tuberculosis (TB) in 2005-2007 were included in the study.

RESULTS

Of 312 isolates, 69% were in clusters ranging from 2 to 38 isolates. The proportion of clustering was 58% among 2005-2006 samples and 67% among 2007 samples, with higher clustering among Omanis than among immigrants. The study showed that M. tuberculosis Indian family lineages, CAS1_Delhi, CAS and EAI5 were the predominant strains. Around 50% of the immigrants shared strains with Omanis. Twelve of the 19 INH-monoresistant strains and the two multidrug-resistant strains were in clusters (P = 0.81).

CONCLUSION

This study demonstrates the predominance in Oman of the strain family commonly found on the Indian sub-continent. A high proportion of immigrant strains were in the same clusters as Omani strains. To better ascertain the transmission dynamics of M. tuberculosis, we recommend that stringent molecular and conventional epidemiological methods be applied.

Evaluation of seven tests for the rapid detection of multidrug-resistant tuberculosis in Uganda

SETTINGS

National Tuberculosis (TB) Reference Laboratory and Department of Medical Microbiology, College of Health Sciences, Makerere University, Kampala, Uganda.

OBJECTIVE

To evaluate head-to-head rapid tests for drug susceptibility testing (DST) of Mycobacterium tuberculosis against rifampicin (RMP) and isoniazid (INH) in a resource-limited setting.

METHODS

Thirty-one well-characterised strains of M. tuberculosis were tested with the nitrate reductase assay (NRA), microscopic observation drug susceptibility (MODS), MGIT 960 (Mycobacterium Growth Indicator Tube 960), Genotype MTBDRplus, Alamar blue, MTT and resazurin assays. The proportion method on Löwenstein-Jensen medium was used as the reference test.

RESULTS

NRA correctly identified the resistant strains, with 100% sensitivity and specificity. MGIT 960 detected all multidrug-resistant strains but missed one RMP-monoresistant strain. Genotype MTBDRplus detected all RMP-resistant strains, but the sensitivity for detection of INH resistance was lower (88%). Sensitivity and specificity ranged from 86% to 100% for MODS and from 57% to 100% for the Alamar blue, MTT and resazurin assays. Test results were obtained within 2-14 days.

CONCLUSION

In the study setting, NRA, MGIT 960 and Genotype MTBDRplus gave excellent detection of multidrug-resistant tuberculosis, with significantly shorter time to results compared to conventional testing.

Results of the external quality assessment of Mycobacterium tuberculosis drug susceptibility testing in Russia, 2005-2007

SETTING

External quality assessment (EQA) of Mycobacterium tuberculosis drug susceptibility testing (DST) in bacteriological tuberculosis (TB) laboratories in the Russian Federation.

OBJECTIVE

To improve the EQA of DST of first-line anti-tuberculosis drugs using proficiency testing in the Russian Federation.

METHOD

Three rounds of DST proficiency testing using Mycobacterium tuberculosis isolates provided by the Swedish Institute for Infectious Disease Control, a World Health Organization Supranational Reference Laboratory (SRL). In total, 42 TB laboratories in the Russian civilian and prison sectors participated in at least one round of proficiency testing, and 17 laboratories participated in all three rounds.

RESULTS

Ninety-seven per cent (87/89) of reports were received for the three rounds: 67% of laboratories in the first round and 86% of laboratories in the second round demonstrated >or=95% accuracy for isoniazid, and respectively 72% and 80% of laboratories in the first and second rounds reported >or=95% accuracy for rifampicin.

CONCLUSION

Coordination with the SRL network resulted in the introduction of 90 well-characterised strains for EQA in the Russian Federation. Successive rounds of DST proficiency testing have helped to identify highly proficient laboratories that will be used as expert laboratories for proficiency testing in the future.

Nasal boost with adjuvanted heat-killed BCG or arabinomannan–protein conjugate improves primary BCG-induced protection in C57BL/6 mice

Today it is generally accepted that the Bacillus Calmette-Guerin (BCG) vaccine protects against childhood tuberculosis (TB) but this immunity wanes with age, resulting in insufficient protection against adult pulmonary TB. Hence, one possible strategy to improve the protective efficacy of the BCG vaccine would be to boost in adulthood. In this study, using the mouse model, we evaluated the ability of two new TB vaccine candidates, heat-killed BCG (H-kBCG) and arabinomannan-tetanus toxoid conjugate (AM-TT), given intransally in a novel Eurocine adjuvant, to boost a primary BCG-induced immune response and to improve protection. Young C57BL/6 mice were vaccinated with conventional BCG and, 6 months later, boosted intranasally with adjuvanted H-kBCG or AM-TT, or subcutaneously with BCG. Ten weeks after the booster, mice were challenged intravenously with M. tuberculosis (Mtb) strain H37Rv. In spleens, there was a significant reduction of cfu counts in mice boosted with either H-kBCG or AM-TT vaccines compared to the non-boosted BCG-vaccinated mice. None of the boosting regimens significantly reduced bacterial loads in lungs, compared to non-boosted BCG vaccination. However, the extent of granulomatous inflammation was significantly reduced in the lungs of mice that received two of the booster vaccines (AM-TT and conventional BCG), as compared with sham-vaccinated mice. All boosted groups, except for mice boosted with the AM-TT vaccine, responded with a proliferation of spleen T cells and gamma interferon production comparable to that induced by a single BCG vaccination.

A mycobacterial lipoarabinomannan specific monoclonal antibody and its F(ab') fragment prolong survival of mice infected with Mycobacterium tuberculosis

Lipoarabinomannan (LAM) is a major structural carbohydrate antigen of the outer surface of Mycobacterium tuberculosis. High antibody titres against LAM are often seen in active tuberculosis (TB). The role of such LAM-specific antibodies in the immune response against TB is unknown. Here we have investigated a monoclonal antibody (MoAb) SMITB14 of IgG1 subclass and its corresponding F(ab')(2) fragment directed against LAM from M. tuberculosis strain H37Rv. MoAb SMITB14 was shown by immunofluorescence to bind to whole cells of the clinical isolate M. tuberculosis strain Harlingen as well as to M. tuberculosis H37Rv. The binding of MoAb SMITB14 to LAM was inhibited by arabinomannan (AM) and oligosaccharides (5.2 kDa) derived from LAM, showing that the MoAb binds specifically to the AM carbohydrate portion of LAM. In passive protection experiments BALB/c mice were infected intravenously with M. tuberculosis Harlingen. MoAb SMITB14 was added intravenously either prior to, or together with, the bacteria. The antibody proved to be protective against the M. tuberculosis infection in terms of a dose-dependent reduction in bacterial load in spleens and lungs, reduced weight loss and, most importantly, increased long-term survival.

Immunization with heat-killed Mycobacterium bovis bacille Calmette–Guerin (BCG) in Eurocine™ L3 adjuvant protects against tuberculosis

The current live attenuated vaccine against tuberculosis, BCG, poses a risk of disseminated infections in immunocompromised subjects. Therefore, in this study we compared the protective effect of a heat-killed bacille Calmette-Guerin (H-kBCG) vaccine given in a new adjuvant (Eurocine L3) with the protection provided by the conventional live attenuated BCG vaccine in mice (C57BL/6 and BALB/c) challenged with virulent Mycobacterium tuberculosis (strain Harlingen). The H-kBCG vaccine alone, in accordance with earlier studies, did not give any or only gave slight protection compared to sham-vaccinated controls. However, the same vaccine given with Eurocine L3 adjuvant, either formulated as a suspension or as an emulsion, afforded significant levels of protection. This protection was at least as good as that of the control live attenuated BCG vaccine. The Eurocine L3 adjuvant is approved for human use as a nasal vaccine adjuvant and a successful phase I trial with nasal immunization with diphtheria vaccine has recently been performed in Sweden. Here we show that, in mice, intranasal priming with H-kBCG in Eurocine L3 adjuvant followed by intranasal booster resulted in the same level of protection as subcutaneous priming followed by intranasal booster. All H-kBCG formulations in the Eurocine L3 adjuvant elicited mycobacterial antigen-specific serum IgG and IFN gamma responses. In general, among the different vaccine formulation(s) in the Eurocine L3 adjuvant those that produced a relatively high Th2 response, as measured by IgG1/IgG2a ratio and IFN gamma production in vitro, were the most protective. In conclusion, H-kBCG in Eurocine L3 adjuvant could represent a safe and a more stable alternative to the conventional live BCG vaccine.

Schistosome transmission, water-resource development and altitude in northern Ethiopia

Schistosomiasis continues to be a major public-health problem, not least in association with water-resource developments. The impact of microdam construction in the northern Ethiopian highlands, in relation to possible increased risks of Schistosoma mansoni infection, has now been assessed. The results of incidence studies, carried out on 473 individuals sampled across eight microdam sites at altitudes of 1800-2225 m above sea level, indicated an overall annual incidence of 0.20 infections/person at risk. A multivariate Poisson regression model showed altitude and sex to be significant risk factors for infection, whereas proximity to a microdam was not significant, except possibly at very high altitudes. It was concluded that altitude was the major factor in this environment and that therefore, at least in terms of public-health planning, microdams should be sited as high as local geography permits.

Increasing the practice of health promotion initiatives by licensed premises

Licensees of all licensed premises in the Hunter Region of New South Wales, Australia, were offered free services to encourage adoption of health promotion initiatives relating to responsible service of alcohol, environmental tobacco smoke, healthy food choices, breast and cervical cancer prevention, and the prevention of HIV/AIDS. A total of 239 premises participated in the follow-up survey. Increases in prevalence ranged between 11% and 59% for alcohol-related initiatives. The prevalence of smoke-free areas and healthy food choices increased from 32% to 65% and 42% to 96%, respectively, and the provision of cancer prevention information increased from 3% to 59%. Licensed premises represent a particularly challenging sector for health promotion practitioners to work in. The results of this study suggest that the adoption of health promotion initiatives by licensed premises can be increased. A considerable opportunity therefore exists for health promotion practitioners to become more actively involved in facilitating the adoption of such initiatives in this setting.

Rapid diagnosis of tuberculosis by detection of mycobacterial lipoarabinomannan in urine

There is an urgent need for improved tools for laboratory diagnosis of active tuberculosis (TB). Here, we describe two methods, a catch-up ELISA and a dipstick test based on the detection in urine of lipoarabinomannan (LAM). LAM is a major and specific glycolipid component of the outer mycobacterial cell wall. Preliminary experiments showed that LAM is excreted in the urine of mice injected intraperitoneally with a crude cell wall preparation of Mycobacterium tuberculosis. Both methods were highly sensitive, detecting LAM at concentrations of 1 ng/ml and 5 pg/ml, respectively. Of 15 patients with active TB, all showed intermediate to high levels of LAM in their urine (absorbance values from 0.3 to 1.2, mean 0.74). Only one sample showed an absorbance value below the chosen cut off value of 0.4. All but one of the urine samples from 26 healthy nursing workers exhibited OD value below 0.4 cut off. These methods may prove valuable for rapid and simple diagnosis of TB in particular in developing countries lacking biosafety level 3 (BSL3) facilities.

The cost of integrating hepatitis B virus vaccine into national immunization programmes: a case study from Addis Ababa

National programmes of hepatitis B virus (HBV) vaccination are recommended by the World Health Organization for all countries. Countries suffering the highest burden of HBV disease are those most needy of universal vaccination, but are frequently of very low income and resources for health care are scarce. The introduction of HBV vaccination would inevitably stretch these resources further even with support of donor agencies. Thus an assessment of the cost-effectiveness of HBV vaccination is desirable to assist in decision making about resource allocation. We describe here a method for estimating the additional costs of introducing HBV vaccination into the Expanded Programme on Immunization (EPI) at a national level. Of fundamental importance is that this method enables costs to be assessed prior to the introduction of vaccination. We illustrate the method using a study carried out at the sub-national level, in the city of Addis Ababa, Ethiopia, but which can be expanded countrywide. The method, in brief, involved the use of a number of questionnaires which could be used to estimate the costs associated with the EPI programme from a large sample of the static clinics as well as from central sources. Since unit costs were collected along with the quantities of resources used and estimates of the capacity used for certain facilities (such as refrigerators), the additional cost of introducing HBV vaccine could be estimated largely by extrapolation of the resources used in vaccinating against diphtheria/pertussis/tetanus vaccine (which, similar to HBV vaccine, requires three doses). The estimation of costs is only part of the information required to make decisions on resource allocation, and should be used in association with measures of the burden of disease due to the infection in the community and effectiveness of the control programme at reducing this burden. The prediction of the latter, based upon a sound epidemiological understanding of the infection, is the subject of a forthcoming paper.

Isoflurane pretreatment ameliorates postischemic neurologic dysfunction and preserves hippocampal Ca2+/calmodulin-dependent protein kinase in a canine cardiac arrest model

BACKGROUND

Inhalational anesthetics are neuroprotective in rat models of global ischemia. To determine whether isoflurane at a clinically relevant concentration is neuroprotective in a canine model of cardiac arrest, we measured neurologic function and hippocampal Ca2+/calmodulin-dependent protein kinase II (CaMKII) content 20 h after cardiac arrest.

METHODS

We tested the neuroprotective effect of 30 min of 1.5% isoflurane exposure before 8 min of global ischemia induced with ventricular fibrillation. Animals were randomized to four groups: control, isoflurane-control, ischemia, and isoflurane-ischemia. After resuscitation and 20 h of intensive care, each animal's neurologic deficit score was determined by two blinded evaluators. The hippocampal content of CaMKII, determined by immunoblotting, was measured by an individual blinded to the treatment groups. CaMKII activity was measured in samples from the cortex, hippocampus, and striatum of animals in each group.

RESULTS

Isoflurane-ischemic animals had a median neurologic deficit score of 22.6% compared with 43.8% for the ischemic animals (P < 0.05). Hippocampal levels of the beta-subunit of CaMKII (CaMKIIbeta) were relatively preserved in isoflurane-ischemic animals (68 +/- 4% of control) compared with ischemic animals (48 +/- 2% of control; P < 0.001), although both groups were statistically significantly lower than control (P < 0. 001 ischemia vs. control and P < 0.05 isoflurane-ischemia vs. control).

CONCLUSIONS

Isoflurane is an effective neuroprotective drug in a canine cardiac arrest model in terms of both functional and biochemical criteria.

Household risk factors for malaria among children in the Ethiopian highlands

Malaria transmission varies from village to village and even from family to family in the same village. The current study was conducted in northern Ethiopia to identify risk factors responsible for such variations in a hypoendemic highland malaria setting: 2114 children aged < 10 years living in 6 villages situated close to small dams at altitudes from 1775 to 2175 m were monitored. Monthly malaria incidence was determined 4 times over a 1-year period during 1997. Incidence results were then analysed by 14 individual and household factors using Poisson multivariate regression. Among 14 factors analysed, use of irrigated land (rate ratio[RR] = 2.68, 95% CI 1.64-4.38), earth roof (RR = 2.15, 95% CI 1.31-3.52), animals sleeping in the house (RR = 1.92, 95% CI 1.29-2.85), windows (RR = 1.84, 95% CI 1.30-2.63), open eaves (RR = 1.85, 95% CI 1.19-2.88), no separate kitchen (RR = 1.57, 95% CI 1.10-2.23), and 1 sleeping room (RR = 1.52, 95% CI 1.05-2.20), were significantly associated with malaria. The proportion of infection among children exposed to one or no risk factor was 2.1%, increasing with the number of risk factors and reaching 29.4% with 5 or more. Further studies are needed to confirm the importance of particular risk factors, possibly leading to simple health education and control measures that could become part of routine control programmes, implemented with inter-sectoral collaboration.

Incidence of malaria among children living near dams in northern Ethiopia: community based incidence survey

OBJECTIVE

To assess the impact of construction of microdams on the incidence of malaria in nearby communities in terms of possibly increasing peak incidence and prolonging transmission.

DESIGN

Four quarterly cycles of malaria incidence surveys, each taking 30 days, undertaken in eight at risk communities close to dams paired with eight control villages at similar altitudes but beyond flight range of mosquitoes.

SETTING

Tigray region in northern Ethiopia at altitudes of 1800 to 2225 m.

SUBJECTS

About 7000 children under 10 years living in villages within 3 km of microdams and in control villages 8-10 km distant.

MAIN OUTCOME MEASURES

Incidence of malaria in both communities.

RESULTS

Overall incidence of malaria for the villages close to dams was 14.0 episodes/1000 child months at risk compared with 1.9 in the control villages-a sevenfold ratio. Incidence was significantly higher in both communities at altitudes below 1900 m.

CONCLUSIONS

There is a need for attention to be given to health issues in the implementation of ecological and environmental development programmes, specifically for appropriate malaria control measures to counteract the increased risks near these dams.

B-scan ultrasonography in ophthalmic diseases

Real time B-scan ultrasonography was utilised on 318 eyes of 298 patients for evaluation of 285 (90%) eyes with opaque media; three (1%) eyes, with clear media but suspected intraocular abnormalities and for proptosis in 30 (9%) cases. Two hundred and nine (66%) eyes had one or more detectable abnormalities. The most common abnormality was retinal detachment (39%) followed by vitreous opacities (31%), eye ball size abnormalities (12%), intraocular foreign bodies (4%), posterior staphyloma (3%) and retinal detachment with vitreous opacities (2%). Twenty eight out of thirty patients evaluated for proptosis had abnormal orbital tissue patterns. Solid and cystic tissue patterns each accounted for 32% of the abnormal orbital studies followed by thyroid orbitopathy (25%), non specific (7%), and infiltrative (4%) tissue patterns. Detailed findings of B-scan ultrasonographic study is given in this paper. The paper reports further experience with the procedure in a developing country. In areas where other imaging techniques are not available the procedure is a valuable method of evaluating the eye and orbit for any detectable abnormalities and for planning management.

Causes of removal of the eye in Ethiopia

The causes of removal of the eye in 282 patients are presented. A decreasing linear trend with increasing age as causes of removal of the eye is observed. The most common causes of removal of the eye were: traumatic globe rupture (33%) malignancy (21%), ugly corneal staphyloma (11%) and panophthalmitis without external cause (11%). The M:F ratio was 2.2:1 and relative frequency of causes of removal of the eye in males and females is shown to be different. Findings on other demographic data, duration of clinical history, causes of trauma and mode of surgery is reported. The need for early presentation is discussed and preventive measures are suggested.

A biphasic system for primary isolation of mycobacteria compared to solid medium and broth culture

A biphasic culture system, the MB Check, was compared with conventional culture on Löwenstein-Jensen egg (LJ) solid medium and with Bactec broth culture for primary isolation of mycobacteria from clinical samples. A total of 104 mycobacterial isolates was detected from 985 samples examined by the three methods. The most sensitive primary isolation was with LJ culture and MB Check; these methods detected 93% and 87% of all positive cultures, respectively. MB Check allowed a somewhat more rapid detection than LJ culture. The presence of atypical mycobacteria was demonstrated most rapidly with the Bactec system.

Bacteraemia in febrile out-patient children

In order to study the occurrence of bacteraemia, 634 consecutively febrile children aged less than or equal to 14 years with Initial rectal temperature or 39 degrees C and above were evaluated. The overall frequency of bacteraemia was 7.7% (49 cases). Salmonellae, Streptococci and Staphylococci accounted for 57%, 16% and 14% respectively. No statistically significant difference was noted between cases and controls with regard to the nutritional status mean age in months +/- SD (55.9 +/- 49.1 vs 39 +/- 41), and haemoglobin levels in g/dl +/- SD (11.1 +/- 1.5 vs 11.1 +/- 1.5) (P greater than 0.05). None of the parameters studied was a strong predictor of bacteraemia and systemic bacterial infection did not strongly correlate with the magnitude of the clinical illness.