Progress in controlling the transmission of schistosome parasites in Southern Ethiopia: the Geshiyaro Project in the Wolaita Zone

BACKGROUND

This paper describes changes in the prevalence and intensity of schistosome parasite infections in a project integrating mass drug administration (MDA), water, sanitation, and hygiene (WaSH), and behavioral change interventions.

METHODS

The Geshiyaro Project comprises three intervention arms. Arm 1 is subdivided into "Arm 1 pilot" (one district) and Arm 1 (four other districts), both receiving integrated community-wide MDA with intensive WaSH interventions. Arm 2 involves 17 districts with community-wide MDA interventions, while Arm 3 serves as a control with school-based MDA interventions in three districts. A total of 150 individuals, stratified by age group, were randomly selected from each of the 45 sentinel sites. Arm sizes were 584 (Arm 1 pilot), 1636 (Arm 1), 2203 (Arm 2), and 2238 (Arm 3). Statistical tests were employed to compare infection prevalence and intensity across the different arms.

RESULTS

The prevalence of schistosome parasite infection ranged from 0% to 2.6% and from 1.7% to 25.7% across districts, employing the Kato-Katz (KK) and point-of-care circulating cathodic antigen (POC-CCA) diagnostics, respectively. The mean infection intensity level showed no marked difference between baseline and follow-up surveys when measured by KK, except in Arm 2 (t = 6.89, P < 0.0001). Infection prevalence decreased significantly in Arm 1 (t = 8.62, P < 0.0001), Arm 2 (t = 6.94, P < 0.0001), and Arm 3 (t = 8.83, P < 0.0001), but not in Arm 1 pilot (t = 1.69, P = 0.09) by POC-CCA, when trace was considered positive. The decrease was significant only in Arm 1 (t = 3.28, P = 0.0001) and Arm 2 (t = 7.62, P < 0.0001) when the trace was considered negative in POC-CCA. Arm 2 demonstrated a significant difference in difference (DID) compared to the control group, Arm 3, regardless of whether trace in POC-CCA was considered positive (DID = 3.9%, df = 8780, P = 0.025) or negative (DID = -5.2, df = 8780, P = 0.0004).

CONCLUSIONS

The prevalence of schistosomiasis was low when employing the KK diagnostic but moderate in some locations by the POC-CCA diagnostic. The infection level had decreased across all arms of the Geshiyaro study at mid-term of the 7-year project, but further efforts are needed to reduce the rate of parasite transmission based on the POC-CCA diagnostic scores.

Spatial heterogeneity in mass drug administration from a longitudinal epidemiological study assessing transmission interruption of soil transmitted helminths in the Wolaita zone of southern Ethiopia (Geshiyaro Project)

OBJECTIVES

Deworming programmes of soil-transmitted helminths are generally monitored and evaluated by aggregating drug coverage and infection levels at a district level. However, heterogeneity in drug coverage at finer spatial scales means indicators may remain above thresholds for elimination as a public health problem or of transmission in some areas. This paper aims to highlight the misleading information that aggregating data at larger spatial scales can have for programme decision making.

METHODS

Drug coverage data from the Geshiyaro project were compared at two spatial scales with reference to the World Health Organisation's targets. District (woreda) and village (kebele) level were compared. The association between infection levels and drug coverage was analysed by fitting a weighted least-squares function to the mean intensity of infection (eggs per gram of faeces) against drug coverage.

RESULTS

The data show clearly that when the evaluation of coverage is aggregated to the district level, information on heterogeneity at a finer spatial scale is lost. Infection intensity decreases significantly (p = 0.0023) with increasing drug coverage.

CONCLUSION

Aggregating data at large spatial scales can result in prematurely ceasing deworming, prompting rapid infection bounce-back. There is a strong need to define context-specific spatial scales for monitoring and evaluating intervention programmes.

Accuracy of the direct agglutination test for diagnosis of visceral leishmaniasis: a systematic review and meta-analysis

BACKGROUND

Parasitological investigation of bone marrow, splenic or lymph node aspirations is the gold standard for the diagnosis of visceral leishmaniasis (VL). However, this invasive test requires skilled clinical and laboratory staff and adequate facilities, and sensitivity varies depending on the tissue used. The direct agglutination test (DAT) is a serological test that does not need specialised staff, with just minimal training required. While previous meta-analysis has shown DAT to have high sensitivity and specificity when using parasitology as the reference test for diagnosis, meta-analysis of DAT compared to other diagnostic techniques, such as PCR and ELISA, that are increasingly used in clinical and research settings, has not been done.

METHODS

We conducted a systematic review to determine the diagnostic performance of DAT compared to all available tests for the laboratory diagnosis of human VL. We searched electronic databases including Medline, Embase, Global Health, Scopus, WoS Science Citation Index, Wiley Cochrane Central Register of Controlled Trials, Africa-Wide Information, LILACS and WHO Global Index. Three independent reviewers screened reports and extracted data from eligible studies. A meta-analysis estimated the diagnostic sensitivity and specificity of DAT.

RESULTS

Of 987 titles screened, 358 were selected for full data extraction and 78 were included in the analysis, reporting on 32,822 participants from 19 countries. Studies included were conducted between 1987-2020. Meta-analysis of studies using serum and DAT compared to any other test showed pooled sensitivity of 95% (95%CrI 90-98%) and pooled specificity of 95% (95%CrI 88-98%). Results were similar for freeze-dried DAT and liquid DAT when analysed separately. Sensitivity was lower for HIV-positive patients (90%, CrI 59-98%) and specificity was lower for symptomatic patients (70%, CrI 43-89%). When comparing different geographical regions, the lowest median sensitivity (89%, CrI 67-97%) was in Western Asia (five studies).

CONCLUSIONS

This systematic review and meta-analysis demonstrates high estimated pooled sensitivity and specificity of DAT for diagnosis of VL, although sensitivity and specificity were lower for different patient groups and geographical locations. This review highlights the lack of standardisation of DAT methods and preparations, and the lack of data from some important geographical locations. Future well-reported studies could provide better evidence to inform test implementation for different patient populations and use cases.

PROSPERO REGISTRATION

CRD42021240830.

Individual longitudinal compliance to neglected tropical disease mass drug administration programmes, a systematic review

Repeated distribution of preventative chemotherapy (PC) by mass drug administration forms the mainstay of transmission control for five of the 20 recognised neglected tropical diseases (NTDs); soil-transmitted helminths, schistosomiasis, lymphatic filariasis, onchocerciasis and trachoma. The efficiency of such programmes is reliant upon participants swallowing the offered treatment consistently at each round. This is measured by compliance, defined as the proportion of eligible participants swallowing treatment. Individually linked longitudinal compliance data is important for assessing the potential impact of MDA-based control programmes, yet this accurate monitoring is rarely implemented in those for NTDs. Longitudinal compliance data reported by control programmes globally for the five (PC)-NTDs since 2016 is examined, focusing on key associations of compliance with age and gender. PubMed and Web of Science was searched in January 2022 for articles written in English and Spanish, and the subsequent extraction adhered to PRISMA guidelines. Study title screening was aided by Rayyan, a machine learning software package. Studies were considered for inclusion if primary compliance data was recorded for more than one time point, in a population larger than 100 participants. All data analysis was conducted in R. A total of 89 studies were identified containing compliance data, 57 were longitudinal studies, of which 25 reported individually linked data reported by varying methods. The association of increasing age with the degree of systematic treatment was commonly reported. The review is limited by the paucity of data published on this topic. The varying and overlapping terminologies used to describe coverage (receiving treatment) and compliance (swallowing treatment) is reviewed. Consequently, it is recommended that WHO considers clearly defining the terms for coverage, compliance, and longitudinal compliance which are currently contradictory across their NTD treatment guidelines. This review is registered with PROSPERO (number: CRD42022301991).

Iron homeostasis in full-term, normal birthweight Gambian neonates over the first week of life

Human neonates elicit a profound hypoferremia which may protect against bacterial sepsis. We examined the transience of this hypoferremia by measuring iron and its chaperone proteins, inflammatory and haematological parameters over the first post-partum week. We prospectively studied term, normal weight Gambian newborns. Umbilical cord vein and artery, and serial venous blood samples up to day 7 were collected. Hepcidin, serum iron, transferrin, transferrin saturation, haptoglobin, c-reactive protein, α1-acid-glycoprotein, soluble transferrin receptor, ferritin, unbound iron-binding capacity and full blood count were assayed. In 278 neonates we confirmed the profound early postnatal decrease in serum iron (22.7 ± 7.0 µmol/L at birth to 7.3 ± 4.6 µmol/L during the first 6-24 h after birth) and transferrin saturation (50.2 ± 16.7% to 14.4 ± 6.1%). Both variables increased steadily to reach 16.5 ± 3.9 µmol/L and 36.6 ± 9.2% at day 7. Hepcidin increased rapidly during the first 24 h of life (19.4 ± 14.4 ng/ml to 38.9 ± 23.9 ng/ml) and then dipped (32.7 ± 18.4 ng/ml) before rising again at one week after birth (45.2 ± 19.1 ng/ml). Inflammatory markers increased during the first week of life. The acute postnatal hypoferremia in human neonates on the first day of life is highly reproducible but transient. The rise in serum iron during the first week of life occurs despite very high hepcidin levels indicating partial hepcidin resistance.Trial Registration: clinicaltrials.gov (NCT03353051). Registration date: November 27, 2017.

Predisposition to soil-transmitted helminth reinfection after four rounds of mass drug administration: results from a longitudinal cohort in the Geshiyaro project, a transmission elimination feasibility study in the Wolaita zone of southern Ethiopia

BACKGROUND

Current WHO strategies for reaching soil-transmitted helminths (STH) elimination as a public health problem excludes treating certain adult populations in endemic areas, creating infection reservoirs that drive 'bounce back' of STH infection to pretreatment levels post-mass drug administration (MDA). Predisposition is a widespread, but poorly understood phenomena among helminth infections where individuals are predisposed to reinfection after repeated treatments.

METHODS

This analysis uses Geshiyaro project data, an STH control programme exploring transmission interruption by community-wide MDA and enhanced water, sanitation and hygiene during 2019-2023. Parasitological survey data from longitudinal cohorts are analysed using Kendall's Tau-b rank correlation to assess the evidence for predisposition to light or heavy infection between four consecutive rounds of MDA.

RESULTS

Correlation analyses revealed the strongest evidence for predisposition to heavy or light Ascaris lumbricoides infection was between survey 1 and 2 (Tau-b 0.29; p<0.001). Overall patterns were not observed for Trichuris trichiura or hookworm infections, however, some significant and notable correlations were recorded for some stratifications and time points.

CONCLUSIONS

Evidence for predisposition in endemic settings in southern Ethiopia with low STH prevalence suggests that more targeted approaches to MDA in those predisposed to infection may be a sensible control strategy if cheap, point of care diagnostics are available.

Longitudinal monitoring of prevalence and intensity of soil-transmitted helminth infections as part of community-wide mass drug administration within the Geshiyaro project in the Bolosso Sore district, Wolaita, Ethiopia

Mass drug administration (MDA), targeted at school-aged children (SAC) is recommended by the World Health Organization for the control of morbidity induced by soil-transmitted helminth (STH) infection in endemic countries. However, MDA does not prevent reinfection between treatment rounds, and research suggests that only treating SAC will not be sufficient to interrupt transmission of STH. In countries with endemic infection, such as Ethiopia, the coverage, community-groups targeted, and rates of reinfection will determine how effective MDA is in suppressing transmission in the long-term. In this paper, individually-linked longitudinal data from three epidemiological STH surveys conducted between November 2018 and November 2020 in the Wolaita region of Ethiopia are analysed to determine how STH prevalence and intensity changes according to individual level treatment data collected over two rounds of MDA. This study demonstrates that while community-wide MDA successfully reduces overall infection intensity across the villages treated, the observed levels of non-compliance to treatment by individuals acts to maintain levels of parasite abundance whereby transmission interruption is not possible at to, despite reasonable levels of MDA coverage in the communities studied (ranging from 65% to 84% of the village populations). This quantifies with substantial data the often-postulated difference between coverage (accepting treatment) and compliance (swallowing of treatment), the latter impacting the former to a previously unquantified level. The paper highlights the need to focus treatment to partially treated, or never treated groups of individuals within existing community wide MDA control activities to interrupt the transmission of STH, and to reduce the basic reproductive number, R0, of the parasites to less than unity in value.

Iron Homeostasis over the First Week of Life: A Prospective Cohort Study in Hospital-Delivered Gambian Neonates

Objectives

Full-term newborns elicit an immediate postnatal hypoferremia at birth. We examined whether preterm and low birthweight babies are capable of a similar response. The transience of this innate defence in full-term babies was assessed by measuring iron, inflammatory and haematological parameters over the first postpartum week.

Methods

We conducted an observational study of 152 babies who were either preterm (&gt;32 to &lt;37weeks gestational age) and/or low birthweight (&lt;2500 g) (PTB/LBW) and 278 term, normal-weight babies (FTB/NBW). Blood was sampled from the umbilical cord and matched venous blood samples were taken from all neonates between 6–24 hours after delivery. Term, normal-weight babies were then randomised to a second blood draw at 25–80 h (V2), 81–136 h (V3) or 137–192 h (V4). We measured haematological, iron and inflammatory markers in all samples.

Results

PTB/LBW and FTB/NBW babies decreased serum iron 3-fold within 12 h of postpartum life compared to cord blood (7.5 ± 4.5 vs 23.3 ± 7.1 ng/ml, P &lt; 0.001, n = 425). Transferrin saturation showed a similar decline. C-reactive protein levels increased over 10-fold (P &lt; 0.001) and hepcidin levels doubled (P &lt; 0.001). No difference was observed in these responses between study groups. FTB/NBW newborns then steadily increased serum iron (16.5 ± 3.9 µmol/L) and TSAT (36.7 ± 9.2%) by V4 (P for trend &lt;0.0001 for each). Hepcidin (45.2 ± 19.1 ng/ml) increased during this period (P for trend &lt;0.0001), showing only a weak influence on serum iron and TSAT. Inflammatory markers increased from V1 to V4.

Conclusions

Premature and low birthweight babies mount a rapid postnatal hypoferremia equal to that in term babies. Data suggest that this hepcidin-mediated response is triggered by acute inflammation at birth. This evolved method of protection against septicaemia is transient, with a later increase in serum iron despite very high hepcidin. This indicates hepcidin resistance possibly caused by macrophage iron saturation. Pharmacological prolongation of hypoferremia might offer an ancillary tool in the arsenal against infection, however, it would need to overcome the hepcidin resistance we now report.

Funding Sources

Bill & Melinda Gates Foundation.

Early postnatal hypoferremia in low birthweight and preterm babies: A prospective cohort study in hospital-delivered Gambian neonates

BACKGROUND

Neonates, particularly those born preterm (PTB) and with low birthweight (LBW), are especially susceptible to bacterial and fungal infections that cause an estimated 225,000 deaths annually. Iron is a vital nutrient for the most common organisms causing septicaemia. Full-term babies elicit an immediate postnatal hypoferremia assumed to have evolved as an innate defence. We tested whether PTB and LBW babies are capable of the same response.

METHODS

We conducted an observational study of 152 babies who were either PTB (born ≥32 to <37 weeks gestational age) and/or LBW (<2500 g) (PTB/LBW) and 278 term, normal-weight babies (FTB/NBW). Blood was sampled from the umbilical cord vein and artery, and matched venous blood samples were taken from all neonates between 6-24 h after delivery. We measured haematological, iron and inflammatory markers.

FINDINGS

In both PTB/LBW and FTB/NBW babies, serum iron decreased 3-fold within 12 h of delivery compared to umbilical blood (7·5 ± 4·5 vs 23·3 ± 7·1 ng/ml, P < 0·001, n = 425). Transferrin saturation showed a similar decline with a consequent increase in unsaturated iron-binding capacity. C-reactive protein levels increased over 10-fold (P < 0·001) and hepcidin levels doubled (P < 0·001). There was no difference in any of these responses between PTB/LBW and FTB/NBW babies.

INTERPRETATION

Premature or low birthweight babies are able to mount a very rapid hypoferremia that is indistinguishable from that in normal term babies. The data suggest that this is a hepcidin-mediated response triggered by acute inflammation at birth, and likely to have evolved as an innate immune response against bacterial and fungal septicaemia.

TRIAL REGISTRATION

clinicaltrials.gov (NCT03353051). Registration date: November 27, 2017.

FUNDING

Bill & Melinda Gates Foundation (OPP1152353).

ADP-ribosylation activity in pertussis vaccines and its relationship to the in vivo histamine-sensitisation test

Pertussis toxin (PTx) is a major virulence factor produced by Bordetella pertussis. In its detoxified form (PTd), it is an important component of acellular pertussis vaccines although some residual PTx activity may likely be present because of the limitations of the detoxification processes used. Furthermore, different detoxification procedures have been shown to result in different amino acid side-chain modifications for the resulting PTd. The histamine-sensitisation test (HIST) in mice is currently used for the safety testing of these vaccines. However, an alternative test is needed because of large assay variability and ethical concerns. The ADP-ribosylation enzyme activity of PTx is thought to be the major factor responsible for the histamine-sensitising activity detected in vivo. In the present study, the ADP-ribosylation activity in different acellular pertussis-based combination vaccine formulations was measured and compared with reactivity in the HIST. The results indicated that different products showed differences in ADP-ribosylation activity and a level which would be significant in relation to the reactivity seen in the HIST could not be defined, except for vaccines that contain genetically detoxified PTx, which do not have enzymatic activity nor in vivo toxicity. Different detoxification procedures as well as formulation factors could contribute to this variation. Relying solely on the residual enzyme activity of PTx in vaccines containing chemically detoxified PTd may not fully reflect the in vivo reactivity observed by the HIST. Refinement of the in vitro test to include a step which monitors the B-subunit activity of PTx may provide a better correlation with the in vivo HIST.

[Biliary stenosis in patients treated with liver transplantation. Diagnostic approach]

Between April 1986 and August 1994, 393 orthotopic liver transplantation (OLT) have been performed at "12 de Octubre" Hospital. Among these ones we consider 274 OLT made in 223 adults and in 47 children (4 intraoperative deaths). The reconstruction of the biliary tract was performed with a choledocho-choledochostomy with T tube (CD-CD T) in 131 patients, a choledocho-choledochostomy without T tube or stent (CD-CD) in 75, a Roux-en-y-hepatico-jejunostomy (H-J) in 248, a hepatico-jejunostomy with stent (H-J St) in 13 and a choledocho-cholecisto-jejunostomy (CD-CC-J) in 3 patients. Thirthy six (13.3%) patients developed biliary complications (30 adults and 6 childrens). Fourteen (18.6%) occurred in CD-CD reconstruction and 13 (11.4%) in CD-CD T. The most common complications were leakage and stricture. Thirteen ERCP were performed in 12 patients (1 failed), all adults (CD-CD T: 3; CD-CD: 10). The main indication for ERCP was cholestasis and inability of non invasive methods ultrasound, scintigraphy and computerized tomography in determining the underlying etiology. ERCP was successful in all 12 patients: detecting strictures in 8, strictures + lithiasis in 1, stricture+lekage in 1 and leakage in 2. No complications were encountered after ERCP in our patients. ERCP is the method of choice in diagnosis of biliary complications in CD-CD biliary reconstruction.

Results of orthotopic liver transplantation: a personal experience

The authors report on their experience of 158 liver transplants performed on 135 patients. Nineteen underwent re-transplantation and four of these required a second re-transplantation; total number of re-transplantations: 23 (14.6%). Hepatic cirrhosis was the most common indication (50.6%), of which alcoholic cirrhosis was the most common type (32.5%). The authors briefly report on their operative techniques and the results of their procedures. The operative mortality (30 days) was 13.3% (18 out of 135 patients). Complications included nine cases of hepatic artery thrombosis (5.7%), four of arterial stenosis (2.5%), one case of portal venous stenosis (0.63%), four cases of post-operative portal venous thrombosis (2.5%), seven of biliary fistula (4.4%; five following choledochocholedochostomy and two following choledochojejunostomy), and two cases of common bile duct stenosis (1.3%). The actuarial survival rate at 48 months is 80%.

Respiratory health effects of alkali dust in residents near desiccated Old Wives Lake

Several years of drought have contributed to the desiccation of Old Wives Lake, a shallow, alkaline lake in southern Saskatchewan. The prevailing northwest wind, which blows across the 177-km2 dry lake bed, has generated airborne sodium sulfate, silt, and clay. Residents have reported nasal, eye, and respiratory irritation. A cross-sectional design that included 300 controls and 300 exposed subjects elucidated the potential adverse respiratory health effects of exposure to blowing alkali salt and dust. An increased prevalence of current cough, current wheeze, chronic cough, chronic wheeze, chronic eye irritation, and chronic nasal irritation was identified in the exposed population. Smoking-adjusted odds ratios were consistent with the prevalence ratios. Lung function did not differ between the exposed and the control populations. Rainfall during the study period reduced airborne dust levels and may have precluded demonstration of previously reported adverse effects.

Relationship between airways responsiveness and the development of chronic obstructive pulmonary disease

The idea that increases in airways responsiveness--either as a result of exposure to cigarette smoke and/or pre-existing increases in bronchial responsiveness, possibly genetically mediated--might be causal in the pathogenesis of the development of COPD in cigarette smokers presents an attractive hypothesis. The fact that a relatively small proportion of cigarette smokers develop COPD begs for specific susceptibilities as an explanation of selective pathogenesis. In our view, the evidence for modest increases in airways responsiveness in cigarette smokers who do not have asthma or allergies is convincing. Such increases in bronchial responsiveness are modest when compared to patients with asthma and may have a different mechanism. However, the demonstration by Verma et al that two types of patients with cigarette smoke-induced COPD, "bronchitis" patients and "emphysematous" patients, have virtually identical alterations in bronchial responsiveness, and that these alterations appear to be a function of airways caliber, has led us to believe that the changes in airways tone in patients with COPD may be reflective more of changes in airways geometry imposed by the development of disease rather than a measurement of a risk factor in the development of COPD. Of the epidemiologic studies that have emerged throughout the 1980s, problems of possible inclusion of asthmatic subjects in the study groups and of baseline airflow rates as a function of bronchial responsiveness have limited the ability of data to implicate increases in airways responsiveness as a risk factor in the development of COPD.(ABSTRACT TRUNCATED AT 250 WORDS)