Publications by authors named "Hailemichael Desalegn"

30 Publications

  • Page 1 of 1

Gastrointestinal endoscopy capacity in Eastern Africa.

Endosc Int Open 2021 Nov 12;9(11):E1827-E1836. Epub 2021 Nov 12.

Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, United States.

Limited evidence suggests that endoscopy capacity in sub-Saharan Africa is insufficient to meet the levels of gastrointestinal disease. We aimed to quantify the human and material resources for endoscopy services in eastern African countries, and to identify barriers to expanding endoscopy capacity. In partnership with national professional societies, digestive healthcare professionals in participating countries were invited to complete an online survey between August 2018 and August 2020. Of 344 digestive healthcare professionals in Ethiopia, Kenya, Malawi, and Zambia, 87 (25.3 %) completed the survey, reporting data for 91 healthcare facilities and identifying 20 additional facilities. Most respondents (73.6 %) perform endoscopy and 59.8 % perform at least one therapeutic modality. Facilities have a median of two functioning gastroscopes and one functioning colonoscope each. Overall endoscopy capacity, adjusted for non-response and additional facilities, includes 0.12 endoscopists, 0.12 gastroscopes, and 0.09 colonoscopes per 100,000 population in the participating countries. Adjusted maximum upper gastrointestinal and lower gastrointestinal endoscopic capacity were 106 and 45 procedures per 100,000 persons per year, respectively. These values are 1 % to 10 % of those reported from resource-rich countries. Most respondents identified a lack of endoscopic equipment, lack of trained endoscopists and costs as barriers to provision of endoscopy services. Endoscopy capacity is severely limited in eastern sub-Saharan Africa, despite a high burden of gastrointestinal disease. Expanding capacity requires investment in additional human and material resources, and technological innovations that improve the cost and sustainability of endoscopic services.
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http://dx.doi.org/10.1055/a-1551-3343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8589549PMC
November 2021

Hepatitis C elimination in Africa: Seizing the moment for hepatitis-C free future.

Arab J Gastroenterol 2021 09 13;22(3):249-251. Epub 2021 Sep 13.

Endemic Medicine Department, Cairo University Hospitals, Cairo, Egypt. Electronic address:

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http://dx.doi.org/10.1016/j.ajg.2021.07.002DOI Listing
September 2021

Promotion of gastrointestinal endoscopy in Sub-Saharan Africa: What is needed, and how can ESGE and WEO help?

Endosc Int Open 2021 Jul 17;9(7):E1001-E1003. Epub 2021 Jun 17.

Department of Transplantation Medicine, Faculty of Medicine, Oslo University Hospital - Rikshospitalet, Oslo, Norway. Co-chair of the Committee of Activities to Reach Africa - World Endoscopy Organization.

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http://dx.doi.org/10.1055/a-1495-5215DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8211488PMC
July 2021

Mother-to-Child Transmission of Hepatitis B Virus in Ethiopia.

Vaccines (Basel) 2021 Apr 26;9(5). Epub 2021 Apr 26.

Regional Centre for Imported and Tropical Diseases, Ullevål, Oslo University Hospital, 0424 Oslo, Norway.

High viral load and positive hepatitis B e-antigen (HBeAg) results are risk factors for mother-to-child transmission (MTCT) of hepatitis B virus (HBV). In sub-Saharan Africa, little is known about the distribution of these risk factors, as well as early childhood HBV transmission. In this study, Ethiopian women aged 18-45 years with chronic hepatitis B were assessed for the presence of HBeAg and high viral load. Their children below 4 years of age were invited for assessment of viral markers, defining active HBV infection as a positive hepatitis B s-antigen (HBsAg) and/or detectable HBV DNA. In total, 61 of 428 HBV-infected women (14.3%) had a positive HBeAg result and/or a high viral load. Of note, 26 of 49 women (53.1%) with viral load above 200,000 IU/mL were HBeAg negative. Among 89 children born of HBV-infected mothers (median age 20 months), 9 (10.1%) had evidence of active HBV infection. In conclusion, one in seven women with chronic hepatitis B had risk factors for MTCT, and HBeAg was a poor predictor of high viral load. One in ten children born of HBV-infected women acquired HBV-infection despite completing their scheduled HBV vaccination at 6, 10 and 14 weeks of age.
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http://dx.doi.org/10.3390/vaccines9050430DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8145487PMC
April 2021

Perspectives of Protocol Based Breaking Bad News among Medical Patients and Physicians in a Teaching Hospital, Ethiopia.

Ethiop J Health Sci 2020 Nov;30(6):1017-1026

Department of Internal medicine, St. Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia.

Background: Discussing potentially bad outcomes is a standard communication task in clinical care. Physicians' awareness on ways to communicate bad news is considered low. SPIKES protocol is the most popular strategy used by physicians, but its practice and patients' perception are not known. This study attempted to fill the knowledge gap on protocol implementation, patient preference and physician effects.

Methods: Hospital-based descriptive cross-sectional study was conducted at SPHMMC from May 1 to June 30 using structured interviews administered to patients and physicians. Three hundred and sixty patients and 111 physicians were included. Assessment of SPIKES performance, patient satisfaction, patient preference, and physician awareness, attitude and effects were studied.

Results: Performance of SPIKES protocol was setting (74.5%), perception (51.1%), invitation (56.3%), knowledge (15.9%), emotion (22.3%) and summary (10.1%). Only 30.6% of the patients were entirely satisfied with the interaction, and 19.2% with knowledge attained. Patient satisfaction was associated with physician asking how much information they like (P=0.025). Patient desire and report showed variation. Eighty-two percent of the physicians were not aware of the protocol, and 83.8% had no training. Half of the physicians feel depressed after disclosure.

Conclusions: Patient satisfaction with communication process and knowledge is poor, as is performance of SPIKES components. Satisfaction is related to being asked how much patients want to know. Patients' desires on how to be told news is different from how it is done. Breaking bad news increases feeling of depression. Awareness and training on the protocol are deficient; medical schools should incorporate it into their studies and implement proper follow-up.
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http://dx.doi.org/10.4314/ejhs.v30i6.21DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8047232PMC
November 2020

Validity of a point-of-care viral load test for hepatitis B in a low-income setting.

J Virol Methods 2021 03 29;289:114057. Epub 2020 Dec 29.

Regional Centre for Imported and Tropical Diseases, Oslo University Hospital Ullevål, PO Box 4956, Nydalen, 0424, Oslo, Norway; Department of Infectious Diseases, Vestfold Hospital Trust, PO Box 2168, 3103, Tønsberg, Norway. Electronic address:

The recent launch of the first point-of-care Xpert® hepatitis B virus (HBV) viral load kit from Cepheid could help to scale up treatment for chronic hepatitis B (CHB) in resource-limited settings. This study aimed to assess the performance of the Xpert kit under field conditions in Ethiopia. One-hundred-and-thirty CHB patients with viral loads ranging from <1 log to>7 log IU/mL were randomly sampled. The viral load was assessed with both the Xpert and the gold standard Abbott RealTime HBV Viral Load assay in each patient. There was a high correlation between the viral loads assessed by Xpert and Abbott (r = 0.948, p < 0.001). The Bland-Altman plot showed a small bias between the two assays, with an on average 0.23 log IU/mL higher viral load result of the Xpert kit; 4 samples differed by>1 log IU/mL. Using the treatment threshold of 2000 IU/mL in both tests, Xpert had a sensitivity of 94 %, specificity of 71 %, positive predictive value of 70 %, and negative predictive value of 95 %. In conclusion, the Xpert kit demonstrated good validity for the measurement of HBV viral load in a real-life setting.
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http://dx.doi.org/10.1016/j.jviromet.2020.114057DOI Listing
March 2021

Assessment of Noninvasive Markers of Liver Fibrosis in Patients With Chronic Hepatitis C in Ethiopia.

Clin Liver Dis (Hoboken) 2020 Oct 3;16(4):168-172. Epub 2020 Nov 3.

Centre for Imported and Tropical Diseases Oslo University Hospital Ullevål Oslo Norway.

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http://dx.doi.org/10.1002/cld.1040DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7609704PMC
October 2020

Impact of the COVID-19 pandemic on gastrointestinal endoscopy in Africa.

Endosc Int Open 2020 Aug 7;8(8):E1097-E1101. Epub 2020 Aug 7.

Endoscopy Unit, Nuovo Regina Margherita Hospital, Rome, Italy.

As with all other fields of medical practice, gastrointestinal endoscopy has been impacted by the COVID-19 pandemic. However, data on the impact of the pandemic in Africa, especially sub-Saharan Africa are lacking. A web-based survey was conducted by the International Working Group of the European Society for Gastrointestinal Endoscopy and the World Endoscopy Organization to determine the impact and effects the COVID-19 pandemic has had on endoscopists in African countries. Thirty-one gastroenterologists from 14 countries in north, central, and sub-Saharan Africa responded to the survey. The majority of respondents reduced their endoscopy volume considerably. Personal protective equipment including FFP-2 masks were available in almost all participating centers. Pre-endoscopy screening was performed as well. The COVID-19 pandemic has had a substantial impact on gastrointestinal endoscopy in most African countries; however, the impact may not have been as devastating as expected.
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http://dx.doi.org/10.1055/a-1210-4274DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7413826PMC
August 2020

Introduction of birth dose of hepatitis B virus vaccine to the immunization program in Ethiopia: an economic evaluation.

Cost Eff Resour Alloc 2020 22;18:23. Epub 2020 Jul 22.

Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA 02115 USA.

Background: Hepatitis B virus (HBV) infection is an important cause of morbidity and mortality with a very high burden in Africa. The risk of developing chronic infection is marked if the infection is acquired perinatally, which is largely preventable through a birth dose of HBV vaccine. We examined the cost-effectiveness of a birth dose of HBV vaccine in a medical setting in Ethiopia.

Methods: We constructed a decision analytic model with a Markov process to estimate the costs and effects of a birth dose of HBV vaccine (the intervention), compared with current practices in Ethiopia. Current practice is pentavalent vaccination (DPT-HiB-HepB) administered at 6, 10 and 14 weeks after birth. We used disability-adjusted life years (DALYs) averted to quantify the health benefits while the costs of the intervention were expressed in 2018 USD. Analyses were based on Ethiopian epidemiological, demographic and cost data when available; otherwise we used a thorough literature review, in particular for assigning transition probabilities.

Results: In Ethiopia, where the prevalence of HBV among pregnant women is 5%, adding a birth dose of HBV vaccine would present an incremental cost-effectiveness ratio (ICER) of USD 110 per DALY averted. The estimated ICER compares very favorably with a willingness-to-pay level of 0.31 times gross domestic product per capita (about USD 240 in 2018) in Ethiopia. Our ICER estimates were robust over a wide range of epidemiologic, vaccine effectiveness, vaccine coverage and cost parameter inputs.

Conclusions: Based on our cost-effectiveness findings, introducing a birth dose of HBV vaccine in Ethiopia would likely be highly cost-effective. Such evidence could help guide policymakers in considering including HBV vaccine into Ethiopia's essential health services package.
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http://dx.doi.org/10.1186/s12962-020-00219-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7374878PMC
July 2020

Is resistance to direct-acting antivirals in sub-Saharan Africa a threat to HCV elimination? Recommendations for action.

J Hepatol 2020 03 10;72(3):583-584. Epub 2019 Dec 10.

Department of Infectious and Tropical Diseases, Saint-Antoine Hospital, Paris, France; Institut Pierre Louis d'Épidémiologie et de Santé Publique, INSERM, Sorbonne Université, Paris, France.

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http://dx.doi.org/10.1016/j.jhep.2019.10.017DOI Listing
March 2020

Hepatitis B in sub-Saharan Africa-How many patients need therapy?

J Viral Hepat 2020 06 22;27(6):560-567. Epub 2019 Dec 22.

Division of Hepatology, Department of Medicine, Faculty of health Sciences, University of Cape Town and Groote Schuur Hospital, Cape Town, South Africa.

Hepatitis B is endemic in sub-Saharan Africa with ~60 million people chronically infected. While prevention, through vaccination, is central to elimination strategies, only 11 countries have birth dose vaccination and full vaccine coverage remains at suboptimal levels. Furthermore, to fully realize elimination, those chronically infected need to be identified, assessed for therapy and then linked to care. Given current treatment criteria, the precise quantum of people warranting therapy, according to criteria, is essentially unknown. The issue is further complicated by data to suggest differences in the numbers of people requiring treatment when applying WHO as compared to European Association for the Study of the Liver, EASL, criteria. Optimal determination of treatment eligibility is further hindered by the lack of available tools to adequately assess individual patients. It is conceivable that accurately determining the number of those requiring treatment, given the heterogeneity of hepatitis B in Africa, is difficult. Better studies and data are required. More signifcantly, improved access and availability to the diagnostic tools needed to assess patients in additon to access to drugs are as, if not more important, to achieve elimination.
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http://dx.doi.org/10.1111/jvh.13247DOI Listing
June 2020

A novel score to select patients for treatment in chronic hepatitis B: Results from a large Ethiopian cohort.

J Hepatol 2019 10 2;71(4):840-841. Epub 2019 Aug 2.

Regional Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway; Aklilu Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia.

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http://dx.doi.org/10.1016/j.jhep.2019.04.006DOI Listing
October 2019

Predictors of mortality in patients under treatment for chronic hepatitis B in Ethiopia: a prospective cohort study.

BMC Gastroenterol 2019 May 15;19(1):74. Epub 2019 May 15.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.

Background: Antiviral treatment for chronic hepatitis B (CHB) is largely unavailable in sub-Saharan Africa; hence, little is known about the prognosis after initiating treatment in African CHB patients. In this study we aimed to assess predictors of mortality in one of the largest CHB cohorts in sub-Saharan Africa.

Methods: Two-hundred-and-seventy-six CHB patients who started treatment with tenofovir disoproxil fumarate at a public hospital in Ethiopia between March 18, 2015, and August 1, 2017, were included in this analysis. Patients were followed up until October 1, 2017, and deaths were ascertained through hospital records and telephone interview with relatives. Decompensated cirrhosis was defined as current or past evidence of ascites, either by clinical examination or by ultrasonography. Cox proportional hazard models were used to identify independent predictors of mortality.

Results: Thirty-five patients (12.7%) died during follow-up, 33 of whom had decompensated cirrhosis at recruitment. The median duration from start of treatment to death was 110 days (interquartile range 26-276). The estimated survival was 90.3, 88.2 and 86.3% at 6, 12 and 24 months of follow-up, respectively. Independent predictors of mortality were decompensated cirrhosis (adjusted hazard ratio [AHR] 23.68; 95% CI 3.23-173.48; p = 0.002), body mass index < 18.5 kg/m2 (AHR 3.65; 95% CI 1.73-7.72; p = 0.001) and older age (per 1-year increment; AHR 1.06; 95% CI 1.02-1.10; p = 0.007).

Conclusions: Decompensated cirrhosis, low body mass index and older age were independent predictors of mortality. Improved access to antiviral treatment and earlier initiation of therapy could improve the survival of African CHB patients.

Trial Registration: NCT02344498 ( ClinicalTrials.gov identifier). Registered 16 January 2015.
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http://dx.doi.org/10.1186/s12876-019-0993-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6521482PMC
May 2019

The WHO guidelines for chronic hepatitis B fail to detect half of the patients in need of treatment in Ethiopia.

J Hepatol 2019 06 28;70(6):1065-1071. Epub 2019 Mar 28.

Regional Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway; Department of Infectious Diseases, Vestfold Hospital Trust, Tønsberg, Norway. Electronic address:

Background & Aims: In 2015, the World Health Organization (WHO) issued guidelines for the management of chronic hepatitis B (CHB) in low- and middle-income countries, but little is known about the applicability of the WHO treatment criteria in sub-Saharan Africa. The aim of this study was to evaluate the diagnostic performance of the WHO guidelines in a large CHB cohort in Ethiopia.

Methods: Treatment-naïve adults who attended a public CHB clinic in Addis Ababa were included in this analysis. All patients underwent a standardized evaluation at recruitment, including blood tests and transient elastography (Fibroscan®). A Fibroscan result >7.9 kPa was used to define significant fibrosis and >9.9 kPa to define cirrhosis. Treatment eligibility was assessed using the most recent guidelines from the European Association for the Study of the Liver (EASL) as the 'gold standard'.

Results: Out of 1,190 patients with CHB, 300 (25.2%) were eligible for treatment based on the EASL 2017 guidelines and 182 (15.3%) based on the WHO 2015 guidelines. The sensitivity and specificity of the WHO criteria were 49.0 and 96.1%, respectively. Most patients (94 of 182; 51.6%) who fulfilled the WHO criteria had decompensated cirrhosis and might have a dismal prognosis even with therapy. Only 41 of 115 patients (35.7%) with compensated cirrhosis, who are likely to benefit the most from therapy, were eligible for treatment based on the WHO criteria.

Conclusions: The WHO guidelines for CHB failed to detect half of the patients in need of treatment in Ethiopia, implying the need for a revision of the WHO treatment criteria.

Lay Summary: Antiviral therapy prevents disease progression and death in patients with chronic hepatitis B (CHB), but the identification of patients in need of treatment is a challenge in low- and middle-income countries. The World Health Organization (WHO) has suggested treatment eligibility criteria for use in such settings, but in our study the WHO criteria detected less than half of those in need of therapy in a large Ethiopian cohort of 1,190 patients with CHB. Our findings suggest that the WHO criteria might be unsuitable in sub-Saharan Africa.

Trial Registration Number: NCT02344498 (ClinicalTrials.gov identifier). Registered 16 January 2015.
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http://dx.doi.org/10.1016/j.jhep.2019.01.037DOI Listing
June 2019

Treatment of chronic hepatitis B in sub-Saharan Africa: 1-year results of a pilot program in Ethiopia.

BMC Med 2018 12 17;16(1):234. Epub 2018 Dec 17.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, PO Box 4956 Nydalen, 0424, Oslo, Norway.

Background: The World Health Organization has set an ambitious goal of eliminating viral hepatitis as a major public health threat by 2030. However, in sub-Saharan Africa, antiviral treatment of chronic hepatitis B (CHB) is virtually unavailable. Herein, we present the 1-year results of a pilot CHB treatment program in Ethiopia.

Methods: At a public hospital in Addis Ababa, CHB patients were treated with tenofovir disoproxil fumarate based on simplified eligibility criteria. Baseline assessment included liver function tests, viral markers, and transient elastography (Fibroscan). Changes in laboratory markers were analyzed using Wilcoxon signed-rank tests. Adherence to therapy was measured by pharmacy refill data.

Results: Out of 1303 patients, 328 (25.2%) fulfilled the treatment criteria and 254 (19.5%) had started tenofovir disoproxil fumarate therapy prior to September 1, 2016. Of the patients who started therapy, 30 (11.8%) died within the first year of follow-up (28 of whom had decompensated cirrhosis), 9 (3.5%) self-stopped treatment, 7 (2.8%) were lost to follow-up, and 4 (1.6%) were transferred out. In patients who completed 12 months of treatment, the median Fibroscan value declined from 12.8 to 10.4 kPa (p < 0.001), 172 of 202 (85.1%) patients with available pharmacy refill data had taken ≥ 95% of their tablets, and 161 of 189 (85.2%) patients with viral load results had suppressed viremia. Virologic failure (≥ 69 IU/mL) at 12 months was associated with high baseline HBV viral load (> 1,000,000 IU/mL; adjusted OR 2.41; 95% CI 1.04-5.55) and suboptimal adherence (< 95%; adjusted OR 3.43, 95% CI 1.33-8.88).

Conclusions: This pilot program demonstrated that antiviral therapy of CHB can be realized in Ethiopia with good clinical and virologic response. Early mortality was high in patients with decompensated cirrhosis, underscoring the need for earlier detection of hepatitis B virus infection and timely initiation of treatment, prior to the development of irreversible complications, in sub-Saharan Africa.

Trial Registration: NCT02344498 (ClinicalTrials.gov identifier). Registered 16 January 2015.
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http://dx.doi.org/10.1186/s12916-018-1229-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296040PMC
December 2018

"Fatal Gastrointestinal and Peritoneal Ischemic Disease" of Unknown Cause at Arba Minch Hospital, Southern Ethiopia.

Can J Gastroenterol Hepatol 2018 23;2018:6598960. Epub 2018 Oct 23.

Department of Internal Medicine, Saint Paul's Hospital Millennium Medical College, Ethiopia.

Gastrointestinal and peritoneal ischemic disease due to unknown etiology present with intestinal obstruction and/or peritonitis otherwise in healthy patient emerged as fatal disease at Arba Minch General Hospital. This disorder was diagnosed based on intraoperative finding. Clinical presentation and natural history of disease progression were similar. It is estimated that about 6-10 lives are being claimed each year at Arba Minch Hospital with this disease of unidentified cause accounting for the largest figure of surgical department. Here we report case analysis and literature review illustrating clinical presentation, workup, preoperative diagnosis, intraoperative diagnosis, and final outcome of fatal gastrointestinal and peritoneal ischemic disease.
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http://dx.doi.org/10.1155/2018/6598960DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6218790PMC
May 2019

CLINICAL ASSESSMENT OF CARDIOVASCULAR DISEASE ASSOCIATED RISK FACTORS IN JIMMATOWN, SOUTHWEST ETHIOPIA; A COMMUNITY BASED CROSS – SECTIONAL STUDY.

Ethiop Med J 2017 Jan;55(1):3-9

Introduction: Cardiovascular disease has been identified as emerging epidemic in developing world and Sub-saharan Africa. The prevalence of risk factors associated with cardiovascular disease is not clearly established in our country. We conducted this study to determine the prevalence of cardiovascular disease associated risk factors in Jimma town.

Methods: A cross-sectional study was conducted in sampled adults in Jimma town. Multi-stage sampling was used by combining simple random sampling to select kebeles of Jimma town and then systematic random sampling to select the house hold .An individual was selected with a lottery method if there were more than one adult in the house hold who fulfills inclusion criteria. Data were collected using the World Health Organization standardized structured questionnaire on cardiovascular risk assessment for developing countries. The study variables included anthropometric measurements, demographic information and behavioral risk factors. The data variables were computed using SPSS version 20.

Results: Majority (70.9%) of the respondents have one or more of the seven cardiovascular disease risk factors assessed. Nearly one forth (23.8%) of the study participants were hypertensive, 6.2% were known diabetes and the prevalence of smoking was 11.8% among males 2% among females. The prevalence of overweight/obesity was 26.8 %.

Conclusion: Majority were found to have at least one of the risk factors for cardiovascular disease. Hypertension and diabetes mellitus were the most common. Screening programs, health education and awareness creation are recommended to prevent the development of the disease. Large scale prospective study with laboratory data will help to further analyze and strengthen the results for policy makers.
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January 2017

Response to Non-invasive fibrosis markers for chronic hepatitis B in sub-Saharan Africa.

Liver Int 2017 11;37(11):1739

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.

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http://dx.doi.org/10.1111/liv.13425DOI Listing
November 2017

Hepatitis delta virus infection in a large cohort of chronic hepatitis B patients in Ethiopia.

Liver Int 2018 06 20;38(6):1000-1009. Epub 2017 Oct 20.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.

Background & Aims: Hepatitis D virus (HDV) infection is associated with a more severe outcome in patients with chronic hepatitis B (CHB); however, little is known about the presence of HDV in sub-Saharan Africa. We aimed to determine the prevalence of HDV infection, as well as its clinical, biological and virological characteristics, in a large CHB cohort in Ethiopia.

Methods: In total, 1267 HIV-negative CHB patients at St. Paul's Hospital Millennium Medical College in Addis Ababa were screened for anti-HDV antibodies using ELISA assays. Confirmed positive samples were further tested for HDV RNA using a consensus commercial real-time RT-PCR assay. HDV genotypes were also determined for RNA-positive samples by nucleotide sequencing followed by phylogenetic analyses. Demographical, clinical and biological data from patients were recorded and compared based on HDV RNA results.

Results: Most patients (n = 748, 59.0%) were men, and the median age was 31 years (interquartile range 26-40). Anti-HDV antibodies were detected in 19 individuals (1.5%), 12 of whom were HDV RNA-positive with a viral load ranging from <2 to >8 log 10 IU/mL. All strains were genotype 1. HDV RNA-positive patients were more likely to have significant liver fibrosis (63.6% vs 24.7%, P = .007) and cirrhosis (45.5% vs 16.4%, P = .024).

Conclusions: HDV infection is rare in Ethiopia but is associated with more advanced liver fibrosis.
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http://dx.doi.org/10.1111/liv.13607DOI Listing
June 2018

Early experiences from one of the first treatment programs for chronic hepatitis B in sub-Saharan Africa.

BMC Infect Dis 2017 06 19;17(1):438. Epub 2017 Jun 19.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Box 4956 Nydalen, 0424, Oslo, PO, Norway.

Background: Treatment for chronic hepatitis B (CHB) is virtually absent in sub-Saharan Africa. Here we present early experiences from a pilot program for treatment of CHB in Ethiopia.

Methods: Adults (≥18 years) with CHB were included in a cohort study at St. Paul's Hospital Millennium Medical College, Addis Ababa, from February 2015. The baseline assessment included liver function tests, viral markers and transient elastography (Fibroscan 402, Echosense, France). Logistic regression models were used to identify predictors of fibrosis. Tenofovir disoproxil fumarate (TDF) was initiated based on the European Association for the Study of the Liver (EASL) criteria, with some modifications. The initial 300 patients underwent a more comprehensive evaluation and are presented here.

Results: One-hundred-and-thirty-eight patients (46.0%) were women and median age was 30 years (interquartile range 26-40). Co-infections were rare: four patients (1.3%) were anti-HCV positive, 11 (3.7%) were anti-HDV positive, whereas 5 (1.7%) had HIV-infection. The majority were hepatitis B e-antigen (HBeAg) negative (n = 262; 90.7%) and had a normal (≤40 U/L) alanine aminotransferase (ALT) (n = 245; 83.1%). Of 268 patients with a valid Fibroscan result, 79 (29.5%) had significant fibrosis (>7.9 kPa). Independent predictors of fibrosis were male sex, age > 35 years and viral load >20,000 IU/ml. In total, 74 patients (24.7%) started TDF therapy, of whom 46 (62.2%) had cirrhosis.

Conclusions: The majority were HBeAg negative and had normal ALT. However, one quarter of the patients were in need of antiviral treatment, underscoring the need to scale up CHB treatment on the African continent.

Trial Registration: NCT02344498 ( ClinicalTrials.gov identifier). Registered 16 January 2015.
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http://dx.doi.org/10.1186/s12879-017-2549-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5477340PMC
June 2017

Characteristics, management, and outcomes of patients with hepatocellular carcinoma in Africa: a multicountry observational study from the Africa Liver Cancer Consortium.

Lancet Gastroenterol Hepatol 2017 02 3;2(2):103-111. Epub 2016 Dec 3.

Department of Internal Medicine, School of Medical Sciences, Cape Coast, Ghana.

Background: Hepatocellular carcinoma is a leading cause of cancer-related death in Africa, but there is still no comprehensive description of the current status of its epidemiology in Africa. We therefore initiated an African hepatocellular carcinoma consortium aiming to describe the clinical presentation, management, and outcomes of patients with hepatocellular carcinoma in Africa.

Methods: We did a multicentre, multicountry, retrospective observational cohort study, inviting investigators from the African Network for Gastrointestinal and Liver Diseases to participate in the consortium to develop hepatocellular carcinoma research databases and biospecimen repositories. Participating institutions were from Cameroon, Egypt, Ethiopia, Ghana, Ivory Coast, Nigeria, Sudan, Tanzania, and Uganda. Clinical information-demographic characteristics, cause of disease, liver-related blood tests, tumour characteristics, treatments, last follow-up date, and survival status-for patients diagnosed with hepatocellular carcinoma between Aug 1, 2006, and April 1, 2016, were extracted from medical records by participating investigators. Because patients from Egypt showed differences in characteristics compared with patients from the other countries, we divided patients into two groups for analysis; Egypt versus other African countries. We undertook a multifactorial analysis using the Cox proportional hazards model to identify factors affecting survival (assessed from the time of diagnosis to last known follow-up or death).

Findings: We obtained information for 2566 patients at 21 tertiary referral centres (two in Egypt, nine in Nigeria, four in Ghana, and one each in the Ivory Coast, Cameroon, Sudan, Ethiopia, Tanzania, and Uganda). 1251 patients were from Egypt and 1315 were from the other African countries (491 from Ghana, 363 from Nigeria, 277 from Ivory Coast, 59 from Cameroon, 51 from Sudan, 33 from Ethiopia, 21 from Tanzania, and 20 from Uganda). The median age at which hepatocellular carcinoma was diagnosed significantly later in Egypt than the other African countries (58 years [IQR 53-63] vs 46 years [36-58]; p<0·0001). Hepatitis C virus was the leading cause of hepatocellular carcinoma in Egypt (1054 [84%] of 1251 patients), and hepatitis B virus was the leading cause in the other African countries (597 [55%] of 1082 patients). Substantially fewer patients received treatment specifically for hepatocellular carcinoma in the other African countries than in Egypt (43 [3%] of 1315 vs 956 [76%] of 1251; p<0·0001). Among patients with survival information (605 [48%] of 1251 in Egypt and 583 [44%] of 1315 in other African countries), median survival was shorter in the other African countries than in Egypt (2·5 months [95% CI 2·0-3·1] vs 10·9 months [9·6-12·0]; p<0·0001). Factors independently associated with poor survival were: being from an African countries other than Egypt (hazard ratio [HR] 1·59 [95% CI 1·13-2·20]; p=0·01), hepatic encephalopathy (2·81 [1·72-4·42]; p=0·0004), diameter of the largest tumour (1·07 per cm increase [1·04-1·11]; p<0·0001), log α-fetoprotein (1·10 per unit increase [1·02-1·20]; p=0·0188), Eastern Cooperative Oncology Group performance status 3-4 (2·92 [2·13-3·93]; p<0·0001) and no treatment (1·79 [1·44-2·22]; p<0·0001).

Interpretation: Characteristics of hepatocellular carcinoma differ between Egypt and other African countries. The proportion of patients receiving specific treatment in other African countries was low and their outcomes were extremely poor. Urgent efforts are needed to develop health policy strategies to decrease the burden of hepatocellular carcinoma in Africa.

Funding: None.
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http://dx.doi.org/10.1016/S2468-1253(16)30161-3DOI Listing
February 2017

Are non-invasive fibrosis markers for chronic hepatitis B reliable in sub-Saharan Africa?

Liver Int 2017 10 23;37(10):1461-1467. Epub 2017 Mar 23.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.

Background: In the absence of liver biopsy, the World Health Organization recommends non-invasive tests, such as aspartate aminotransferase to platelet ratio index and FIB-4, to assess liver fibrosis in patients with chronic hepatitis B. However, these tests are not well validated in sub-Saharan Africa. Recently, a new marker, gamma-glutamyl transpeptidase to platelet ratio, was found to be more accurate in an African setting, but this needs confirmation in other cohorts.

Methods: A treatment program for chronic hepatitis B was initiated in Addis Ababa, Ethiopia, in 2015. Non-invasive tests were compared with transient elastography (Fibroscan 402, Echosense, France) using the following thresholds: no fibrosis (≤7.9 kPa), significant fibrosis (>7.9 kPa) and cirrhosis (>11.7 kPa). The diagnostic accuracy was estimated by calculating the area under the receiver operating characteristics curve.

Results: Of 582 treatment-naïve patients, 141 (24.2%) had significant fibrosis and 90 (15.5%) had cirrhosis. The area under the receiver operating characteristics curve of aspartate aminotransferase to platelet ratio index, FIB-4 and gamma-glutamyl transpeptidase to platelet ratio was high both to diagnose significant fibrosis (0.79 [95% CI 0.75-0.84], 0.79 [95% CI 0.75-0.84], 0.80 [95% CI 0.75-0.85]) and cirrhosis (0.86 [95% CI 0.81-0.91], 0.86 [95% CI 0.81-0.91], 0.87 [95% CI 0.82-0.91]). The specificity was high for all tests (94%-100%); however, the sensitivity was poor both to detect fibrosis (10%-45%) and cirrhosis (10%-36%).

Conclusions: Aspartate aminotransferase to platelet ratio index, FIB-4 and gamma-glutamyl transpeptidase to platelet ratio had good diagnostic properties to detect liver fibrosis and cirrhosis in patients with chronic hepatitis B in East Africa. However, the sensitivity was low, and only 10% of patients with cirrhosis were detected using aspartate aminotransferase to platelet ratio index at the World Health Organization recommended threshold.
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http://dx.doi.org/10.1111/liv.13393DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5637891PMC
October 2017

Dry Blood Spots a Reliable Method for Measurement of Hepatitis B Viral Load in Resource-Limited Settings.

PLoS One 2016 7;11(11):e0166201. Epub 2016 Nov 7.

Centre for Imported and Tropical Diseases, Oslo University Hospital, Ullevål, Oslo, Norway.

Background & Aims: Hepatitis B virus (HBV) quantification is essential in the management of chronic hepatitis B, both to determine treatment eligibility and in the monitoring of treatment effect. This test, however, is rarely available in resource-limited settings due to high costs and stringent requirements for shipment and storage of plasma. Dried Blood Spots (DBS) can be a convenient alternative to plasma, but its use for HBV monitoring has not been investigated under real-life conditions in Africa.

Methods: The performance of DBS in HBV quantification was investigated using a modified commercial test (Abbott RealTime HBV assay). Paired DBS and plasma samples were collected from an HBV positive cohort in Addis Ababa, Ethiopia. DBS were stored at ambient temperature for 4-39 days before shipment to the laboratory.

Results: Twenty-six paired samples were selected covering the total range of quantification, from 2.14 log IU/ml to >7 log IU/ml. HBV was detected in 21 of 21 (100%) DBS from patients with a corresponding plasma viral load above 2.70 log IU/ml. The mean difference between plasma and DBS was 0.59 log IU/ml, and the correlation was strong (R2 = 0.92). In stability studies there was no significant change in DBS viral load after storage at room temperature for up to 12 weeks.

Conclusions: This study suggests that DBS can be a feasible and reliable alternative to plasma for quantification of HBV in resource-limited settings. DBS can expand access to antiviral treatment for patients in low- and middle-income countries.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0166201PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5098817PMC
June 2017

A case report of celiac disease; a report done at Tikur Anbessa Specialized Hospital, Addis Ababa.

Ethiop Med J 2013 Jul;51(3):209-14

A 23 year old male patient who was diagnosed to have malabsorption syndrome secondary to celiac disease after he presented with 08 months' duration of chronic diarrhea, significant weight loss and marked body weakness with easy fatigability. Celiac disease is one of the rare causes of malabsorption in African countries. The diagnosis requires appropriate clinical history, high index of suspicion, exclusion of common causes of chronic diarrhea and confirmation by histology after the characteristic endoscopy appearance is identified. Supportive care and gluten restriction was advised and the patient has shown marked improvement in symptoms and general wellbeing. Celiac disease needs to be considered in patients who present with chronic diarrhea that doesn't respond to conventional management.
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July 2013
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