INTRODUCTION

Tuberculosis (TB) is an ancient disease that afflicted humankind for thousands of years(1). Based on 2019 world health organization (WHO) ann ual TB report, Ethiopia ranked 10th among the 20 high burden countries (HBC) and one of the top three in Africa with 114, 233 TB cases at a rate of 151/ 100,000 population (2). Over the last several years, 32 %, 30% and 38% of TB cases were extrapulmonary tu berculosis (EPTB), smear negative pulmonary TB (PT B‑) and smear positive pulmonary (PTB+), respective- ly (3).

Enclosed in 2019 WHO global TB report to Ethiopia, TB/HIV co-infection rate was 5% (2). However, based on two systematic reviews conducted in 2018, much higher rates of TB/HIV coinfection, 22% (4) and 25.6% (5) were reported. Specifically, the TB/HIV co- infection rate was reached to plateau, 26.7% in Amha- ra Regional State (ARS) (5). Taken together, Ethiopia is one among the 14 TB, MDR-TB and TB/HIV co- infection HBC (6).

Tuberculosis in Ethiopia showed spatial clustering and heterogeneity at region, zone and district level (7, 8). It also showed temporal variation, with the highest

CNR observed during April-June (the end of the dry season) and the lowest notification rate during October-December (the beginning of the dry sea- son) (9, 10). The high rate of Mycobacterium tu- berculosis (Mtb) transmission during the winter months might be due to indoor activities, seasonal change in immune function, delays in the diagnosis and treatment of TB and community food security

(9). Additionally, several religious and cultural festivities are held during month of October- December which might lead to population gather- ing and hence TB transmission. This period is also considered as the vacation season for farmers in Ethiopia and is noted for increased health seeking behavior of farmers which may lead to detection of more TB cases.

Tuberculosis CNR mapping and delineation of areas in to TB hot and cold spots is documented by a few studies in Ethiopia (7, 9-11) and globally (12). However, any similar observations from a specific location are always of interest. Moreover, there are new insights in this study not addressed by previous studies. For instance, previous studies failed to address EPTB spatial distribution.

Moreover, our finding described the correlation of EPTB with HIV and their urban-rural disparity. Thus, the aim of this study was to determine the CNR of all forms of TB, TB types (PTB and EPTB) and TB/HIV co-infection at regional and lower administrative lev- els (Zones and Woredas). Of these, Woreda level TB, EPTB and TB/HIV co-infection CNR mapping were done.

METHODS

Study design and period

The study was conducted using data collected and archived between

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July 2014 and June 2018 in Amhara Regional State (ARS).

Amhara National Regional State of Ethiopia was di- vided in to 13 Zones and 181 Woredas (Figure 1). The Republic of Ethiopia has five tier administrative structures.

These are Federal Government, regional govern- ments, zones (intermediary or oversight bodies), dis- trict (commonly known as Woreda) and kebele (non- budgeted smallest administrative unit) (13).

Participants and variables

All registered TB and TB/HIV co-infected cases be- tween July 2014 and June 2018 were included in this study. TB patients were classified as PTB+, PTB- and EPTB. The PTB+ cases refer to a patient from whom at least one biological specimen is positive for Mtb by WHO recommended diagnostic technology. Clinical- ly diagnosed TB (PTB-) case refers to a patient who does not fulfill the criteria for PTB+ case but has been diagnosed with active TB by an experienced clinician (14). EPTB refers to TB involving organs other than the lungs. Diagnosis of EPTB is based on bacteriolog- ical, histological or clinical evidences (14).

Data sources and measurement

The health management information system (HMIS) databases were the secondary source of the data and that of the TB unit register at Directly Observed Treat- ment, Short-Course (DOTs) clinic were the primary sources (14).

The absolute number of regional, zonal and Woreda TB (all forms of TB, PTB+, PTB-, and EPTB) and TB/HIV co-infection were documented across the four years. The CNR of all forms of TB was calculated by dividing all cases of TB by Woreda or zonal popula- tion and then reported as per 100,000 populations. By this calculation, the trends of all forms of TB were assessed over the four-year period. The proportion of EPTB and TB/HIV co-infection was computed by dividing the number of EPTB and TB/HIV co-infected cases by all forms of TB and then multiplied by

100.The total TB data were disaggregated by age and gender. The regional TB/HIV co-infection CNR was also determined.

All forms of TB and TB/HIV co-infection rates were assessed and compared among the included zones and Woredas over the four years to identify the most prev- alent types of conditions.

Using the WHO annual TB report data of the 30 HBC (3), we roughly classified TBCNR of Woredas into: low (≤50 TB /105 population), moderate (50.1-114 TB /105 population), high (114.1-221 TB /105 popula- tion) and extremely high (>221 TB /105populations). Woreda EPTB proportions were classified as low (0- 15%, globally acceptable range), moderate (15.1-31%, nationally acceptable range), high (31.1-48%, higher than national average) and extremely high (>48 %) (3, 15). In the same fashion, the proportion of TB/HIV co -infection was classified as extremely high (>20%), high (12.1-20%), moderate (7.1-12 %) and low (<7%).

Statistical Analysis

Using the excel spread sheet, the regional and zonal TB, TB types and TB/HIV co-infection data were summarized using frequency, percentage, mean, medi- an and range. Regional and zonal TB CNRs were dis- played using line graphs. The CNR of EPTB and TB/ HIV co-infection were graphed using bar graphs. The Woreda TB, EPTB and TB/HIV co-infection CNR mapping were done using ArcGIS 10.3 (ArcGIS Desktop, ESRI 2011. Redlands, Canada).

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The spatial data used for the maps were taken from Map library which is a public domain that can be accessed at www.maplibrary.org.

RESULTS

During the four-year period of 2014 to 2018, a total of 90,248 TB cases were notified and of these, 42, 911 (47.5%) were EPTB. Amhara regional state contributed for around 18.8% of annual na- tional TB CNR. The identified TB cases were dis- aggregated by age and gender. As such, TBCNR was reached plateaus at 25-34 years of age fol- lowed by 15-24 years of age. Not only the highest TBCNR but also the most infectious cases were also documented in these age groups. The propor- tion of EPTB appears to be higher below 15 years of age and particularly among children under 5 years of age. Smear negative TB is proportionally more frequent than other forms in the age groups above 45 years. Smear positive TB appears to be proportionally higher in frequency than other forms among young adults (15-44 years of age) (Figure 2).

Of the total 90,248 new TB cases, 55% and 45% were males and females, respectively. Conversely, when we took female and male separately and disaggregated by types of TB, EPTB is much higher among females (51%) than males (45%).

Of the 13 zones in the region, North Gondar (recently divided in three administrative zones) was the highest

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TB reporting zone accounting for 16.64% of the cas- es across the four fiscal years followed by West Gojam 12.85% and South Wello 12.66% zones. It was evident that the absolute numbers of TB types) were related with the total population size. Extra- pulmonary TB was the highest notified clinical phe- notype in all zones except in North Shewa Zone (Figure 3).

It was a good achievement that, 99% of the new TB cases have been screened for HIV. Of those screened, 8% of TB cases were co-infected with HIV.

Proportionally highest TB/HIV co-infection CNR was reported from big towns such as Dessie, Gondar, and Bahir Dar; 21%, 20% and 16%, respectively (Figure 4).

Figure 5 below depicts the pattern of TBCNR over the four years period among106 Woredas. The TBCNR was >221/100000 population per year in Metema, Bahir Dar town and Dessie over the years. Kombolcha, Ankasha, Gondar, Kobo and Sanja were also among the highest TB reporting woredas (Figure 5). Surprisingly, high TBCNR was reported from urban woreda than corresponding rural woredas signaling the phenomena of hotspot and cold spot di- chotomy.

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For instance, Gendawuha, Kobo Town, Burie Town, Bati Town were hotspots for Metema, Raya Kobo, Burie Zuria and Bati Zuria Woredas, respectively. Taken together, Metema, Sanja, Bahir Dar, Gondar, Dessie, Chagni, Kemissie town, Kobo town, Bati, Woreta, Shewarobit, Dangla town, Jawi, Kombol- cha, Injibara town, and Woldia were considered TB hotspot woredas across the study period (Figure 5).

Contrary to the CNR of all forms of TB, the propor- tion of EPTB was higher in majority of rural Woredas compared to urban Woredas. The EPTB CNR ranged between 49% and 66% in 63 Woredas. Most of these Woredas were from western Amhara but also extend- ing to eastern Amhara, forming an “EPTB belt of Am- hara” or “EPTB hand of Amhara” (Figure 6A, Sup- plementary Material 1).

Closer look at figure 6b shows that the proportion of TB/HIV co-infection was ≥15% in 18 Woredas. Some of these include Lalibela (26%), Debre Markos (22%), Dessie (21%), Enemay, Gondar and Bati each (20%), Kobo town, Shewarobit and Tehuledere each 19% (Figure 6B).

EPTB proportions (Figure 6A): Low (Green): 0-15%

(globally acceptable range); Moderate (Lime): 15.1-31%

(nationally acceptable range); High (Yellow): 31.1-48%

(higher than national average); Extremely high (Red): >48 %). The proportion of TB/HIV co-infection (Figure 6B): Low (Green): <7%; Moderate (Lime): 7.1-12 %; High (Yellow):12.1-20%; Extremely high (Red): >20%. EPTB: Extra pulmonary tuberculosis; ARN: Amhara Regional State, TB/HIV: Tuberculosis/Human Immune Deficiency Virus

Collectively, it can be concluded that, the CNR of TB was population dependent, higher in urban than rural Woredas. Moreover, the declining rate of TB is prom- ising but very stagnant for infectious form of TB. In ARS, TB and TB/HIV co-infection CNR exhibited heterogeneous spatial pattern. Additionally, the pro- portion of EPTB is relatively higher in rural than ur- ban Woredas but the reverse is true in case of TB/HIV co-infection rate.

DISCUSSION

A total of 92,379.00 TB cases including relapse were notified during the four-year period with a mean annu- al CNR of 23, 095 TB cases. The annual TB CNR in ARS was 113/100,000 which was lower than the 2019 annual WHO TB report of Ethiopia, 151/100000 (2). The TBCNR reached plateau at 25-34 years of age followed by 15-24 years of age. Not only the highest CNR of TB but also the most infectious cases were also documented at these similar age groups (Table 1, Figure 2). Why TBCNR is high at these age ranges is not well understood. It is known that, age range of 15- 34 is the economically productive age group. On the other hand, poverty and TB are linked via malnutri- tion, immunity, poor housing and crowded housing

(16, 17). Hence, crippling of these age range by M. tuberculosis might have long term evolutionary

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advantage for the bacteria. Overall, age range of 15 -44 is the most socially and physically interactive periods which might give the fitness advantage for the bacteria to transmit.

Furthermore, TBCNR is population size depend- ent; the high number of population at these age ranges might be another possible explanation. The high CNR of HIV at these age range might also be additional evolutionary pressure for progression to active TB.

The regional TB/HIV co-infection rate was gauged at 8% which was in line with the national estimate of 7% (3). Among zones, regional big towns such as Dessie, Gondar, and Bahir Dar were the highest TB/HIV co-infection reservoirs. Similar with our report, a study by Datiko et al (2008) found high TB/HIV co-infection CNR in urban than rural (18). This study concluded that, TB/HIV co-infection follows the HIV epidemiology rather than TB epi- demiology.

For the first time, this study deciphers the direction and CNR map of EPTB in ANRS. Figure 6a shows EPTB West-East belting directions which have a wider (palm like) geographic coverage in the west- ern Amhara and radiating towards Eastern Amha- ra. The high CNR of EPTB in Ethiopia and in par- ticular, ANRS was the subject of intense research (19, 20). Kodaman et al asserted that, severe dis- ease like EPTB is the outcome of a coevolutionary mismatch (21). Multiple reports support the higher prevalence of EPTB among females than males (22-24).

A study by Ganchua et al (2018) explained the role of lymph node (LN) as ecological niche for Mtb (25). This study determined that LNs are generally poor at killing Mtb compared with lung granulo- ma. This is because, granulomas that form in LNs lack B cell-rich tertiary lymphoid structures. With this, LNs are not only sites of antigen presentation and immune activation during infection, but also can serve as predator free niche for Mtb (25).

In general, a high rate of Mtb niche shift from pul- monary to LN in ARS, Ethiopia is the subject of further discussion. The high CNR of EPTB in rural than urban Woredas call for further study but might be related with delayed diagnosis (9, 26, 27) among other factors.

Our assessment identified high burden TB, EPTB and TB/HIV co-infection Woredas (Figs 5-6). Ad- ditionally, Figures 5-6 shows the presence of heter- ogeneous spatial distribution of all forms of TB (Figure5), EPTB (Figure 6a) and TB/HIV

co-infection (Figure 6b). Heterogeneous spatial distri- bution of all forms of TB was in line with Alene et al 2019. Based on spatial autocorrelation using Moran's I statistic, local indicators of spatial association (LISA) analysis and Bayesian models, a high-high cluster of CNR was found in northwest Ethiopia (7, 10). It showed that the incidence of notified TB was signifi- cantly associated with poor health care access and good knowledge about TB (7).

Rural/urban TBCNR dissimilarity might be due to population density, social mixing, delay in diagnosis, poverty, and access to health facility (28). In such dissimilarity and hot and cold spot scenario, transmis- sion dynamic models suggested hotspot targeted screening and intervention is more effective at lower- ing community-wide TB incidence when TB spills over transmission is expected from hotspots towards TB cold spot area [29]. However, it should be certain that the difference is true and free from detection and other bias [29].

The current high TB and TB/HIV prevalent areas (hotspots) are characterized by high population move- ment, social mixing, congregation, urban type, and commercial corridors. Thus, hotspots might not be driven by local transmission event alone rather migra- tion or aggregation of vulnerable hosts [29] might have significant share. Migration plays an important role not only to ignite the epidemic in areas previously cases free, but over the course of the entire epidemic [30].

In general, this study has several implication on policy related issues. For instance, the mapping is used for identification of predictors of diseases patterns and visualized the magnitude of TB across Zones and Woredas. Moreover, this TB CNR mapping study might be a footsstep for designing a model for coevo- lutionary study. This study pinpoints the most TB, EPTB and TB/HIV affected Woredas and Towns and this information would be an input on debate regard- ing alternative intervention measures. These current TB maps can also be used as baseline from which interventions success or failure can be monitored [31, 32].

This study described the correlation of EPTB with HIV and their urban-rural disparity. However, due to the retrospective nature of the study, spatial covariates were not considered in the analysis and only notifica- tion rate mapping was done. TB and TB/HIV co- infection CNR might depend on availability of nearby health service and socioeconomic status. Thus, this CNR might not mirror the true incidence and preva- lence of the diseases in the respective administrative units.

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CONCLUSION

The detailed information comprehended and envel- oped in this study is the first in terms of giving a detail evaluation of TB and EPTB epidemiology in ANRS. In the four-year TBCNR study, 90,248 TB cases were notified and registered in regional HMIS database. Amhara Region contributed for around 18.8% of annual national TB CNR. Of the total notified cases, 47.5% were EPTB. The pro- portion of EPTB among notified cases was be- tween 49% and 66% in 63 Woredas. Most of these Woredas are from western Amhara but also ex- tending to eastern Amhara; ‘EPTB belt of Amha- ra”. Contrary to the CNR of all forms of TB, the proportion of notified EPTB cases were higher in rural Woredas compared to urban Woredas.

The TB/HIV co-infection CNR was 8%. Proportionally highest TB/HIV co-infection rate was reported from regionally big towns such as Dessie, Gondar and Bahir Dar; 21%, 20% and 16%, respectively. Hence, TB/HIV co-infection CNR depended on the HIV epidemiology rather than TB. Hence, TB case finding can be best inte- grated with HIV programmatic management.

In General, like other chronic diseases (eg. Diabtes Mellitus), the epidemiology TB in Amhara region is somehow exceptional compared with other re- gion/country. Hence, pathogen, host and environ- mental factor must be integrated to better under- stand TB in the region and in Ethiopia at large. Additionally, to better understand the driving fac- tors for TB in Amhara Region, hotspot versus cold spot ecological study is desirable.

ABBREVIATIONS

ANRS: Amhara National Regional State; BCG:

Bacillus Calmette–Guérin; CNR: Case notification

rate; DOTs: Directly Observed Treatment, Short-

Course ; EPTB: Extrapulmonary tuberculosis;

HBC: High burden countries; HIV: Human

immunedeficency virus; HMIS: Health Infor-

mation Management System; LISA: local indica-

tors of spatial association; LN: Lymph node; MDR

-TB: Multidrug resistance TB;; Mtb: M. tuber-

culosis; MTBC: Mycobacterium tuberculosis

complex; PTB+: smear positive pulmonary PTB;

RR:Rifanmpicine resistance; TB: Tuberculo- sis; TBCNR:TB case notification rate; WHO: World Health Organization.

DECLARATIONS

Ethics approval and consent to participate

The study was approved by Amhara Regional Ethical Review Committee (RERC). The HMIS archived da- tabase contains institutional level data and did not contain any patient identifier. The data were kept con- fidentially and used for the purpose of the study only.

Consent for publication

Not applicable

Availability of data and material

The datasets supporting the conclusions of this article are included within the article and its additional files. Any additional material can be obtained upon reasona- ble request.

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Competing interests

The authors declare that they have no competing interests.

Funding

This research received no specific grant from any funding agency.

Acknowledgements

Authors express deep appreciation to Amhara Na- tional Regional Health Bureau Research Direc- torate for approving the proposal. Moreover, we also thank the Amhara Regional state the HMIS department for their kind cooperation during data extraction.

Supplementary Material

Table S1: Full Woreda TB, EPTB and TB/HIV data used for mapping figure 5 and 6

INTRODUCTION

Syphilis, caused by spirochete Treponema pallidum, is an important public health problem worldwide. Syphi- lis is transmitted through close contact such as sexual contact and from a mother to fetus during pregnancy or birth and result in stillbirth and infant death in about 40% of cases [1]. Syphilis causes significant morbidity and mortality among adults, infants, and young children. The infection is usually asymptomatic but can cause ulceration in the genital area that could enhance the transmission of sexually transmitted dis- eases [2].

Even though the burden of syphilis is declining, the prevalence of syphilis remains high in most African countries with an estimated prevalence of 3.24 [3]. The prevalence of syphilis varies based on the study period, study population, and across different coun- tries. Most importantly, all segments of society are not equally affected by syphilis. Some groups such as female commercial sex workers (FCSW), pregnant women, and Human Immuno Deficiency Virus/ Acquired Immuno Deficiency Syndrome (HIV/AIDS) patients are disproportionately affected by syphilis as compared to the general population [4, 5].

According to the report of the World Health Or- ganization (WHO), the prevalence of syphilis among FCSWs was >5% in ten countries [6]. Whereas, countries such as Somaliland (3.1%) [7] and Kenya (3.3%) [8] reported a prevalence of less than 10%. A high prevalence of syphilis among FSWs from Uganda (21%) [9] and Addis Ababa, Ethiopia (52.4 [10] was reposted.

In Ethiopia, antenatal-based surveillance of HIV and syphilis is carried out by Ethiopian Public Health Institute (EPHI). EPHI reported incon- sistent prevalence of syphilis over different years: the prevalence of syphilis was 2.7% and 2.3% in 2007 and 2009 respectively [11]. The prevalence increased from 1% in 2012 to 1.2% in 2014 [12]. The participants of the survey were only pregnant women who visited the antenatal care clinics.

There are several studies that attempted to meas- ure the prevalence of syphilis among blood do- nors [13, 14] and pregnant women in Ethiopia [15, 16]. According to Kebede et al. (17), syphilis is considered as one of the public health im- portant diseases in Ethiopia; however, there are few published data indicating the burden of syph- ilis among FCSWs in Ethiopia [10].

As to the Authors knowledge, there is no study that addressed this issue in the Southern parts of Ethiopia. Having data on the prevalence of syphilis among FCSWs will help to strengthen existing prevention methods or design other suitable mechanisms to pre- vent and control the dissemination of syphilis. The aim of this study was to investigate the seroprevalence of syphilis and associated factors among FCSWs in Hawassa City, Ethiopia.

METHODS

Study design and period

An Institution-based cross-sectional study was con- ducted from July 5 to November 25, 2018.

Study area

This study was conducted in Hawassa City, Ethiopia at an integrated service on health and development organization (ISHDO) private clinic. Hawassa is found 275 Km from Addis Ababa, the capital of Ethi- opia. The total population of the city is 328,283. ISH- DO is one of the non-governmental clinics which is dedicated in providing health-related services for FCSWs residing in Hawassa area.

Variables of the study

Dependent variable: T. pallidum antibody test result.

Independent Variables: Marital status, educational status, place of residence, use of condom, frequency of condom use, use of stimulant, history of genital ulcer, place of sex.

Study population

Female Commercial sex workers who work in Hawas- sa area and obtain health and social-related services from the ISHDO clinic.

Operational definition

Female sex worker: Women who receive money or goods in exchange for sexual services.

Sample size determination and sampling technique The sample size was determined using single propor- tion formula by considering 50% prevalence of syphi- lis, with a 95% confidence interval, 5% margin of error, and using correction formula (since the number of FSWs was less than 10,000). Based on the above assumptions, the total sample size was 381. To recruit participants, a systematic random sampling technique was used. Assuming a five-month study period, a total of 620 FCSWs were expected to visit ISHDO clinic according to the clinic plan and the past five month’s performance report. To determine the sample interval, the estimated value (n=640) was divided by the sample size (n=381), which would be 1.7 (K~2). The first participant was selected by using lottery methods. Then onwards, every second participant was included until the sample size is reached. The partici- pants were approached at the ISHDO clinic.

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The blood sample was collected and transported to the Microbiology laboratory of Hawassa University Comprehensive Specialized Hospital.

Eligibility criteria

Female Commercial Sex Workers aged greater than 16yrs and who were willing to participate were in- cluded in the study. FCSWs that were not voluntary were excluded from the study.

Data collection

Before data collection, study participants were in- formed about the study: procedures to be carried out, benefits, risks, rights, and confidentiality. The background data were collected from FSWs after obtaining written informed consent using a struc- tured questionnaire. From all study participants, 5 ml of blood was collected in test tubes with an anti- coagulant. The whole blood was centrifuged at 5000 revolutions/minute for 10 minutes to prepare plas- ma. Antibodies to T. pallidum were confirmed by using a syphilis test strip (Gaungzhou wondfo bio- tech China). The sensitivity and specificity of the test strip were 100% and 98% respectively. In brief, three drops of plasma were added to the sample pad of the strip; the result was read and recorded after 10 minutes. The distinct red line on the control and test regions indicated a positive test result.

As part of quality control, the questionnaire was translated from English to Amharic and then trans- lated back to English to check the consistency. The questionnaire was pretested on 5% of the total sam- ple size. During the study, data were checked daily for completeness. For laboratory work, the manu- facturer’s manual was followed carefully. The test kit was checked by using known positive and nega- tive controls before using for the study.

Data analysis

SPSS version 21 software was used for data analy- sis; results were summarized and presented in tables and text. The logistic regression model was used to determine predictors of syphilis infection. A p-value of less than 0.05 was considered statistically signifi- cant.

Ethics approval and consent to participate

Ethical clearance was obtained from Hawassa Uni- versity College of Medicine and Health Sciences institutional review board (IRB) with the reference number IRB026/10. Permission was requested and obtained from the study site (ISHDO clinics). Study participants were recruited after informed written consent was obtained. They were informed not to participate or might leave the study at any time. Confidentiality was kept by using codes instead of names that could relate to the participants

DISCUSSION

Female Sex workers are prone to syphilis, one of the sexually transmitted diseases, as compared to the gen- eral population because of the nature of their work. The seroprevalence of syphilis among FSW identified in this study was 4.2% which is in line with a report from Burkina Faso (5.6%) [18]. In contrast to our study, high prevalence of syphilis among FSWs was reported from several countries such as Addis Ababa Ethiopia (52.4%) [10], Argentina (45.7%) [19], Rwan- da (51.1%) [20], Brazil (14%) [21], China (7.5-8.8%)

[22].The finding of the current study is higher than the study conducted in Togo (2.2%, 0.8%) [23, 24]. The difference observed could be due to the study design, laboratory methods used and period with an earlier study reporting higher prevalence than recent studies. [25]. The other reasons are laboratory meth- ods used and sample size used.

Relatively, the prevalence of syphilis is well studied among blood donors and pregnant women in Ethiopia. The prevalence of syphilis detected in this study is in line with the prevalence of syphilis reported among blood donors [13, 14] and HIV/AIDS patients [15, 16] reported from Ethiopia. Our finding is low compared to the previous reports of syphilis among FSWs from Ethiopia [10]; however, it is difficult to make a sub- stantial comment on the status of our finding whether it is high or low since there are no similar studies from Ethiopia. We noted the importance of addressing the magnitude of syphilis among FSWs at a large scale in Ethiopia. Even though none of the factors assessed were significantly associated with the prevalence of syphilis, the high prevalence was noted among those who place sexual activity was a hotel, those who had a genital ulcer, and those who did not use condoms. The absence of association could be due to a small sample or a limitation of quantitative study. Future qualitative studies will possibly identify the protective and/ or exposing risk factors to the high-risk popula- tion like FCSW to Syphilis.

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Limitations of the study: There are limited studies to compare our findings with others. the study car- ries a risk to recall bias and some sensitive infor- mation may not be revealed by participants. the design of the study and. The low power of the study was additional limitation of the study.

Strength of the study: In this study, we tried to as- sess the magnitude of syphilis among segments of the population who are prone to sexually transmit- ted diseases

Conclusions

Syphilis is one of the public health important dis- eases in Ethiopia. In this study, a relatively low se- roprevalence of syphilis was found among FSWs in Hawassa. None of the factors were significantly associated with the seroprevalence of syphilis. Large-scale studies incorporating mixed methods will yield not only the prevalence but the determi- nants for the low prevalence in High- risk popula- tions.

Abbreviations

FSW: Female Sex Worker, HIV/AIDS: Human Im- muno Deficiency Virus/Acquired Immuno Defi- ciency Syndrome, WHO: World Health Organiza- tion, RPR: Rapid Plasma Reagin, ISHDO: integrat- ed service on health and development organization

Acknowledgment

We would like to acknowledge the staff of Integrat- ed Service on Health and Development Organiza- tion and Hawassa University Comprehensive Spe- cialized Hospital. We thank study participants for their participation.

Competing interests

The authors declare that this manuscript was ap- proved by all authors in its current form and that no competing interest exists.

INTRODUCTION

Cardiovascular diseases (CVDs) are a group of disor- ders of the heart and blood vessels. Rheumatic heart disease(RHD) is one of the CVDs that result in dam- age to the heart muscle and valves from rheumatic fever caused by streptococcal bacteria(1). Cardiovas- cular diseases (CVDs) are the leading cause of death globally; evidence shows that more people die annual- ly from CVDs than from any other cause. Nearly, 17.9 million people died from CVDs in 2016, representing 31% of all global deaths. Over three-quarters of CVD deaths take place in low- and middle-income countries (1, 2).

RHD remains an important public health challenge across the globe; it accounts for more than 15.6 mil- lion cases worldwide each year, however, low and middle-income countries are disproportionately affect- ed (3, 4). The disease persists in all countries of WHO regions, however, the African, South-East

Asia, and Western Pacific regions are the worst affected, accounting for 84% of all prevalent cases and 80% of all estimated deaths due to RHD(5).

According to health institution level studies con- ducted in Africa, RHD is the main cause of heart failure and is responsible for more than 34.0% of cardiovascular disease-related hospital admissions (6, 7). RHD mostly affects the population in low and middle-income countries, particularly; where poverty is widespread. RHD commonly affects chil- dren and can result in life-long disability or death. Effective early intervention can prevent premature mortality from RHD(4, 8).

A country like Ethiopia, whose economy is very weak, and the population living standard is very low, and more than 30% of the population living below the national poverty line bears the highest potential risk of communicable diseases including RHD (9). In addition, as RHD is more common in

young age, and Ethiopia is a country of young popula- tion with over 70 percent of the total population is below the age of 30, and about 45 percent of the popu- lation is below 15 years of age, as a consequence, the country pertains highest potential risk of RHD, and other cardiovascular diseases (10, 11). However, stud- ies conducted on cardiovascular disease including RHD are very scarce.

Therefore, this study aimed to determine the pattern of RHD among patients suspected of heart disease and who underwent echocardiography examinations. Fur- thermore, our study aims to produce hypotheses for future study directions and to have some insight into the contributing factors for RHD.

METHOD AND MATERIALS

Study design and setting: a cross-sectional study de- sign was used among patients visiting cardiac clinics from October 1, 2019 to October 1, 2020. The study was conducted in two hospitals (Felege Hiwot Refer- ral and Addinas General) hospitals. The hospitals are found in Bahir Dar City, located at 560 km distance from Addis Ababa, the capital city of Ethiopia. These hospitals are a few of the health institutions that pro- vide cardiovascular disease examinations and inter- ventions in the city. Patients suspected of a cardiac problem from different health institutions and nearby regions are commonly referred to these hospitals for diagnosis and intervention.

Echocardiographic examination was performed in the parasternal long axis, short axis, apical four chambers, and occasionally in the subcostal and suprasternal views using GE and Sonoscape echocardiography machines at Adinas & Felege Hiwot hospitals. Indices were analyzed and presented in the left ventricle sys- tolic diameter (LVIDS), left ventricle diastolic diame- ter (LVIDD), and the ejection fraction (EF). All the echocardiographic diagnoses were based the Ameri- can Society of Echocardiogram and World Heart Fed- eration guidelines (12, 13).

Study period: we included patients who received echocardiographic examinations from October 1, 2019, to October 1, 2020) and the data was collected from June 15, to May 10, 2021.

Sample size and sampling technique

All patients for whom echocardiography diagnostic tests were carried out in the two hospitals during the selected one-year period were included in this study. A total of 849 cardiac disease suspected patients were included in our final analysis. As eligibility criteria, our analysis considered only the first echocardio- graphic examination reports of each patient in the study.

Study variables

Both hospitals use cardiac disease examination tools consisting of age, the gender of the patients, and the echocardiographic diagnosis.

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Rheumatic heart disease, is the outcome varia- ble of interest for this study, and age, and gender were independent factors available on the charts and used for this study.

Other cardiac disorders: ischemic heart disease, hypertensive heart disease, Pericardial Effusion, Dilated Cardiomyopathy (DCMP), Degenerative valvular heart diseases (DVHD), Cor-plumonale, pulmonary hypertension, etc

Operational definitions

RHD: According to the World Heart Federation (WHF) criteria for echocardiographic diagnosis of RHD as defined by the presence of any evidence of mitral or aortic regurgitation seen in two planes associated with at least two of the following mor- phologic abnormalities of the regurgitating valve: restricted leaflet motility, focal or generalized val- vular thickening, and abnormal sub-valvular thick- ening (13).

Ischemic heart disease: were documented by detec- tion of regional wall motion abnormality on a dif- ferent region of the heart (such as loss systolic thickening, hypokinesia, akinesia dyskinesia) and associated with LV systolic dysfunction(14).

Hypertensive heart disease: was diagnosed in the presence of any or combination of the following abnormalities: left ventricular diastolic dysfunction (e.g. altered E: A ratio), left ventricular hypertro- phy, left ventricular systolic dysfunction, and dilat- ed left atrium, a surrogate of impaired LV filling in the presence of hypertension(15).

Pericardial Effusion: This was diagnosed when there is echo-free space between the visceral and parietal pericardium(16).

Dilated Cardiomyopathy (DCMP),: was diagnosed when there are dilated heart chambers with normal or decreased wall chambers as well as impaired LV systolic function(17).

Cor-plumonale: was present when there is dilated and hypertrophied right ventricle (RV), evidence of increased RV systolic pressure D-shaped LV in diastole (diastolic flattening of the LV septum) (18).

Data management and analysis

The data received from the hospitals were entered into SPSS software version 26 for analysis. Data cleaning was performed to make it ready for analy- sis. Then after descriptive statistics such as fre- quency distributions, percentages for categorical variables, and median, and interquartile range for the continuous variable were performed. Logistic regression analysis between rheumatic heart dis- ease, and demographic factors (sex and age) were performed to see the crude effect of these factors on rheumatic heart disease. The results were pre- sented in tables, and figures for the descriptive study, and odds ratio with its 95% confidence level and p-values were used for the logistic regression analysis.

Ethical approval

Ethical clearance was obtained from the research and the ethical review committee of Bahir Dar University. Permissions were received from Felege Hiwot Refer- ral Hospital and Addinas General Hospital to use the echocardiography data from the cardiac unit. The data were anonymous; there are no names or any personal identifier in the data.

RESULTS

Demographic characteristics of patients visiting car- diac clinics in Bahir Dar city

This study analyzed a total of 849 patients suspected of having cardiac disorder for which echocardiog- raphy examinations were done. About 55% of the study participants were males, and 44% were younger than 49 years of age. The ages of the respondents were varied between 6 and 103 years, the median and inter- quartile range for the ages was 52, and 34.6 years re- spectively. This study was conducted in two hospitals, 490 (57.7%) of the cases were from Addinas hospital, and the remainings were from FelgeHiwot hospital

(table 1).

Cardiac diseases distribution among patients under- went echocardiography examinations in Bahir Dar city

Out of 849 individuals with health problems that un- derwent echocardiography diagnosis 406 (47.2%) had a definite cardiac disease. The prevalence of RHD was 76 (9.0%); it accounts for 18.2% of the total cases of

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revealed that the prevalence of hypertensive heart disease (HHD) was 80(9.4%), ischemic heart dis- ease (IHD) was 59(6.9%), degenerative valvular heart disease (DVHD) was 63(7.4%), and dilated cardiomyopathy (DCMP) was, 56(6.6%) (Table 2).

Table 2: Diagnostic classifications of cardiac patients using Transthoracic Echocardiography Examinations in Bahir Dar city

Regression analysis of rheumatic heart disease by sex and age among patients underwent echocardi- ography examinations

This study is based on echocardiographic diagnostic tests in patients suspected of cardiac disease. Our data contain only sex and age as potential confound- ing factors that entered both in bivariate and multi- variate regression analysis. Both the sex and age of the patients showed associations with RHD. The study revealed that females were more likely to be positive for RHD, where the odds of having a posi- tive diagnosis for RHD among females was nearly three times that for male patients (AOR= 2.9, 95%CI: 1.6-5.4). Similarly,

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the age of the respondents was showed strong as- sociations with RHD; the odds of disease were significantly higher among the young age group than older ones. The odds of RHD among respond- ents whose age was 35 years or younger was sev- enteen times that of respondents older than 50 years of age (table 6).

Table 6: Regression analysis of rheumatic heart disease for sex and age among patients who under- went echocardiography examinations in Bahir Dar city

Discussions

Current evidence shows that CVDs are the leading causes of death globally. Low and middle-income countries are disproportionately affected by the dis- ease, where over 80% of these deaths take place (2, 19). However, there is a limited number of studies available to show the burden, distribution, and deter- minant factors for CVDs including RHD in low- income countries. Therefore, this study was aimed to determine the prevalence and the associated factors of RHD among cardiac disease suspected patients.

Accordingly, 406 (47.8%) of patients who underwent echocardiographic examinations reported having a definite cardiac disease. Our finding is supported by a study conducted in Buea, South West Region of Cameroon, where 45.2% of patients who had under- gone echocardiographic tests had a definite CVS (20). In the current study, nearly one in ten patients (9.0%) of the study participants that received echo- cardiographic tests were positive for RHD. This find- ing is in accordance with a study conducted by Nige- rian savannah, where 9.8% of the study subjects with abnormal results had an echocardiographic diagnosis of RHD (21). However, the magnitude of RHD in the current study is much higher than other studies, where the proportion of RHD lies in the ranges of 3.1% to 6.5% (20, 22, 23). The difference may be attributed to several reasons such as

variations in socioeconomic status, gender ratio, and age composition in the study population. In addition, our study domain was patients suspected of cardiac disease and who visited cardiac treat- ment centers seeking interventions; this might in- crease the magnitude of RHD in our study popula- tion unlike similar studies conducted among appar- ently healthy individuals.

In this study, of the cardiac patients with mitral stenosis, 56(96.6%) were positive for RHD. This is supported by the evidence that most mitral stenosis cases among cardiac patients are caused by RHD (24). Likewise, studies conducted so far revealed that in most of the cases, cardiac patients with mi- tral stenosis were positive for RHD (25, 26). Our findings also showed that nearly, 30% of patients who reported having mitral regurgitations were positive for RHD. This finding is in line with simi- lar other study findings where the RHD manifests as congestive heart failure due to valvular involve- ment including mitral valve regurgitations (27, 28). In this study, the prevalence of RHD was signifi- cantly higher among females compared to males, 61(80%) vs. 15(20%) respectively. Furthermore, the odds of having RHD among the female was about three times more likely as compared to their male counterparts in patients suspected of cardiac diseases. This finding is supported by several

pieces of evidence, where the female sex is at higher risk of acquiring RHD compared to males. A review study conducted on the impacts of gender on RHD, all review articles included were showed that a female predominance for RHD (29).

Similarly, a study conducted in India showed that the prevalence of RHD was more than two-fold higher in females than males (71.4% vs. 29.6%) (30). Besides, several studies across the globe indicated that the risk of RHD varies for women and men (31-33).

The age of the respondents showed a strong associa- tion with RHD; the disease was significantly higher among the young age group than older ones. The odds of RHD among respondents younger than 35 years of age was more than seventeen times that of older than 50 years of age. Evidence showed that virtually any- one at any age can get RHD; however, the risk is highest among children and young adults (34-36). Our finding is supported by the evidence from other stud- ies that RHD is more prevalent among young age than older ones; a study conducted in Fiji Oceania among participants between the ages of 5 to 65 years, almost half of RHD cases occurred before age 40 years (37). Similarly, several studies conducted across the globe indicated that the risks of RHD inversely correlated with age, showing that as the age of study participants increases the risk of RHD decreases (8, 36, 38).

This study was conducted merely based on echocardi- ographic examinations done for cardiac disease sus- pected patients. The data was primarily collected for the purpose of diagnosis and intervention. Our study has drawbacks in terms of controlling confounding factors for RHD, because the data composed of only sex and age as confounding factors; the remaining data is all about clinical information such as sign, symptom, specific diagnosis of cardiac diseases, and intervention plan.

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Conclusion

In this study, one in ten cardiac suspected cases were positive for RHD. Males and females with the cardiac disorder have different risk profiles for rheumatic heart disease that might have a substan- tial impact on the prognosis and treatment out- comes. The odds of RHD among the females is three times that of males. In addition, the odds of RHD inversely decreases with age, the young age groups were at a higher risk of getting the disease compared to older ones. In general, RHD is sub- stantially higher in this study compared to several studies available, indicating that it is an important public health challenge to our community. There- fore, interventions should be tailor the magnitude of the problem, and should also target females and young age groups.

Competing interests

The authors declare that they have no competing interests.

Authors’ contribution

HB and ZAA- conceptualized the study, designed the study, performed data analysis, interpreted the findings, and drafted the manuscript.

MA, YK, AG, YA…and GTW - critically re- viewed the report and manuscript.

All authors read and approved the final version of the manuscript.

ACKNOWLEDGMENT

We received the data from the Felege Hiwot Refer- ral Hospital and Addinas General Hospital. We like to thank the Felege Hiwot Referral Hospital and Addinas Hospital administration offices for grating us the data.

INTRODUCTION

Amblyopia is a unilateral or, less commonly, bilateral reduction in corrected visual acuity in the absence of visible organic abnormalities and is due to misdi- rected, blurred, or absent retinal images during devel- opment of the visual system (1). It is the second lead- ing cause of bilateral visual impairment in children after refractive errors, and has been reported as the leading cause of unilateral visual impairment in pedi- atric patients (2,3).

Anisometropia, constant unilateral strabismus, bilat- eral isoametropia, amblyogenic unilateral or bilateral astigmatism and ocular media opacities are causes of Amblyopia (4).

The overall prevalence of amblyopia varies between

1.6to 3.6% for preschool and school population and from 3.25% to 5.3% in clinical population in different regions of the world (5).

Amblyopia, being unilateral, commonly even severe cases may not be detected by parents or care givers

(6). And failure to detect and treat amblyopia at young age, when the prognosis for successful treatment is best, leads to permanent visual impairment, adverse effects on school performance, poor fine motor skills, weak social interactions, and self –image (7). An am- blyopic individual is at a significantly higher risk of becoming blind compared to an individual with nor- mal visual acuity and individuals with childhood- onset unilateral amblyopia have a greater lifetime risk of eventual bilateral visual impairment and age-related macular degeneration (8).

There are very few studies focused on amblyopia from sub-Saharan Africa countries. The preva- lence of amblyopia among school children in Gha- na and Nigeria were 9.9%, and 0.3% respectively. And anisometropia was the major amblyogenic factor in these studies (9, 10).

Understanding the prevalence, burden and pattern of Amblyopia is important for adequate healthcare planning in an effort to establish a routine school eye screening. In Ethiopia there is paucity of pub- lished data on prevalence and pattern of amblyo- pia. Hence, this study was conducted to estimate the prevalence and determine the causes of ambly- opia among children aged 7-15 years in Wolliso town, Southwest Ethiopia.

SUBJECTS AND METHODS

This school based cross- sectional study was car- ried out in May 2018 in Wolliso town, Southwest Ethiopia. For this research purpose public schools were defined as schools supported by either public or government funds and whereas private schools were defined as schools run and supported by pri- vate individuals or a corporation.

The department of Ophthalmology of Addis Ababa University’s Institutional Review Boards gave approval for the research and informed written consent was obtained from parents and/or legally authorized representatives of the study partici- pants.

Requisition letters were sent to all the selected schools seeking permission from the respective school heads. All study procedures adhered to the principles out- lined in the Declaration of Helsinki for human subject research. Those children with visual impairment were referred to the nearby hospital and managed accord- ingly.

Using Leslie-Kish formula a sample size of 1226 was calculated (11) and 4 schools (2 publics and 2 private) were selected using a random cluster sampling meth- od. A multistage random sampling technique was used in recruiting the students, aged range from 7-15 years, in each grade level/class using the class registers as the sampling frame.

Pre –survey trainings were conducted to the research team to familiarize themselves with the standard oper- ating procedures involved in the study. The first step of the study was screening of the students within the school compound. A large room inside the school premises was selected for the screening program. Monocular distance visual acuity was tested using a logarithm of minimum angle of resolution (logMAR) chart. Step 2 was conducted at the nearby hospital. The parents/guardians of students whose Best Correct- ed Visual Acuity (BCVA) worse than or equal to 6/12 (or ≤ 6/12) in at least one eye, in absence of any or- ganic lesion according to Amblyopia Treatment Stud- ies (12), were requested to bring their children to the nearby, Saint Lukas hospital, for further evaluation. In the outpatient department, a detailed history about past and present ocular problems and treatments was obtained from the parents by the principal investigator of the study. Distance visual acuity was re-checked using the Snellen’s chart. Assessment of ocular align- ment, ocular motility and associated deviation, and slit lamp examination for the assessment of any anterior segment pathology was performed. A detailed fundus examination was done with 90D lens to rule out any posterior segment pathology.

Cycloplegic refraction by streak retinoscope was per- formed after pupillary dilation using 1% cyclopento- late eye drops.

Operational DefinitionFor the purpose of this study , amblyopia was defined as BCVA < 6/12 the affected eye without any underlying structural abnormality of the visual pathway, a 2-line difference between the two eyes, and the presence of an amblyogenic factor. The severity of amblyopia was further graded into mild (BCVA 6/12-6/18), moderate (BCVA 6/18–6/

36)and severe (BCVA <6/36) ( 12). Standard defini- tions for various types of amblyopia were used for diagnosis (12). Bilateral amblyopia was defined as best VA in both eyes ≤ 6/12.

Anisometropic amblyopia includes patients who had amblyopia in the presence of anisometropia that is 1.5 D or greater in spherical equivalent, or a 1.5 D or greater difference in astigmatism between the eyes in the absence of any measurable heterotropia at distance or near.

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Strabismic amblyopia included that due to conflict- ing visual inputs between the eyes due to squint. Combined amblyopia includes either patients with a heterotropia at distance or near along with aniso- metropia of 1.5D or more in spherical equivalent or a 1.5 D or more difference in astigmatism in any meridian between the eyes. (5, 12)

Data generated were collected using a structured data collection form, and statistical analysis was done using SPSS 21.0 version (SAS Institute, Cary, NC 2010) software. Statistical association between categorical variables was computed using Fisher’s exact test and Pearson chi-square (χ2 ) test. P < 0. 05 was considered statistically signifi- cant.

RESULTS

In total, we screened 1,226 children of which 63 (5.14 %; 95% CI: 3.9%-6.4%) were found to have amblyopia. No student was reported to have been treated for amblyopia previously. The mean age of children with amblyopia was 10.45+ 2.09 years with age range between 7 to 15 years. Almost half amblyopic children 30 (47.6 %) were between 10- 12 years old (Table 1).

TABLES AND FIGURES

Table 1: Age at presentation and gender distri- bution of amblyopia among school children at Wolliso town, Southwest Ethiopia, May 2018.

Thirty-nine of the subjects, 61.9% were female. There was no significant difference in amblyopia prevalence between males and females (P = 0.367).

Fifty-two (82.5%) subjects with amblyopia were from public schools (Table 1). There was statistical association between students from public school and amblyopia. (p=0.003).

From 63 children identified as amblyopic, 42(66.67 %) had bilateral and 21 (33.33 %) had unilateral am- blyopia. Hence a total number of 105 amblyopic eyes of 63 children were studied. Among unilateral ambly- opic children 9 had in the right and 12 had in the left eye as shown in table 2.

Table 2: Laterality and causes of amblyopia among school children at Wolliso town, Southwest Ethiopia, May 2018.

FIGURE 1: Distribution of amblyogenic factors with gender among school children , May 2018, Wolliso Town, Southwest Ethiopia.

Anisometropic amblyopia and isometropic amblyopia were the commonest types of amblyopia accounting 31 (49.2%) and 23(36.5%) of the subjects respectively

(Fig 1). For both anisometropic and isometropic am- blyopia, myopia was the commonest type of refractive error, contributing 43 (80%) of the subjects.

From seven sensory derivational amblyopia five had unilateral, one had bilateral corneal opacity and one had ptosis. Both Strabismic cases were exotropia.

As far as the severity of amblyopia is concerned, mild amblyopia was seen in 39(37.14 %), moderate ambly- opia in 22(20.95%), and severe in 44(41.90%). Rela- tively severe amblyopia was higher than mild and

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moderate as shown in table 3. Majority of severe amblyopia patients had sensory derivational am- blyopia. Severity of amblyopia was statistically associated with derivational amblyopia (p= 0.013). All the types of amblyopia were significantly more common in the public school students (P = 0.016).

DISCUSSION:

Amblyopia is the most common cause of monocu- lar vision loss in children with an estimated preva- lence of 1.6 to 3.6% (1). Early diagnosis and treat- ment of amblyopia result in better outcomes (13). In this population-based study, we reported the prevalence and pattern of amblyopia among school children aged 7–15 years at Wolliso town, South- west Ethiopia.

Prevalence of amblyopia varies due to different age-group of studied populations and different factors prevailing in that region, like literacy rate, frequency of visual screening programmes and geographical factors. Accordingly, the prevalence of amblyopia worldwide varies. In a multi-ethnic pediatric eye disease study (MEPEDS) conducted on African-Americans and Hispanics, amblyopia was detected in 2.6% of Hispanic/Latino children and 1.5% of African-American children (14). A study from Iran (2010) reported the prevalence of amblyopia was 2.32 in boys and 2.26% in girls (8). The criteria for diagnosis of amblyopia are almost the same in these studies. Prevalence of amblyopia among African countries varies from 0.3 to 9.1% (9, 10, 15).

The sampled population, study design (clinical/ population based), the criteria used to define am- blyopia and location could account for the differ- ence in these studies. With similar study design with ours, a cross-sectional study in Indian school children aged between 5 and 15 years showed that the prevalence of amblyopia was 1.1% (16). The results of these studies is very low compared to our study. The higher prevalence of amblyopia in the Ethiopian studies might be due to poor awareness amongst general population on importance of visu- al assessment and lack of regular school screening programs nation wide and limited knowledge on the conditions by guardians.

We found no significant difference in the preva- lence of amblyopia between different age groups. These finding is comparable with many other stud- ies in children and adults, where these studies have shown no increase or decrease in the prevalence of amblyopia with age (17,18). Most studies, like ours, have reported that the difference in the preva- lence of amblyopia is not significant for sex and the difference mostly results from sampling errors or differences in the response rate and participation of women and men in screening programs (6,19).

Our findings showed a higher prevalence of amblyo- pia in females than males which is also in line with studies from other countries (20, 21). Gender biases in eye health service delivery might be a reason for such difference in female students.

Two third of the cases in this study had bilateral am- blyopia, which is quite different from other studies made by Fu et al (5), (66.7%) and Chia et al. (3) (69.7%) . Bilateral amblyopia is predominant because isometropic amblyopia is common causes of amblyo- pia in our study.

The results of our study showed that the prevalence of amblyopia was 4 times higher in public school partici- pants as compared with those with private school chil- dren. It is obvious parents with better socioeconomic status send their children to private schools. And high- er socioeconomic status in parents/ guardians have a direct positive effect on use of effective health care services, leading to a decrease in the prevalence of visual disorders, including amblyopia (22).

The main cause of amblyopia varies between studies, depending on how the amblyopia is defined and the characteristics of the study sample. The type of am- blyopia seen in different aspect countries also varies. Our findings showed nearly half, 49.2%, of the ambly- opic cases had anisometropic amblyopia and 36.5% had isometropic amblyopia. Hence, in this study the amblyopia caused by the refractive error was 85.7 %, which was comparable with a report from china , (85.2%), (18), and India (86.9%) (23). In the present study, the prevalence of strabismus was 3.17%, simi- lar to other studies (24, 25). It is possible that Strabis- mic amblyopia is detected early due to the obvious deviation of eyes and therefore can be managed in a timely manner compared to other forms of amblyopia which may go undetected for a long time.

And besides lack of a school screening programs can be the reason for higher number of refractive error as a cause for amblyopia.

Limitation

Our study has some limitations. Small-angle strabis- mus and intermittent strabismus may have been missed given the nature of both conditions.

REFERENCES

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This could have underestimated the prevalence of strabismus. The other limitation of the study is that we used a Snellen chart to measure visual acuity rather than an Early Treatment Diabetic Retinopa- thy Study chart, so the impact of ‘‘the crowding effect’’ could not be measured. Consequently, some children with mild amblyopia may have been missed, while others with more severe amblyopia may have been misclassified as having moderate amblyopia.

Conclusions

The result of this study showed that the prevalence of amblyopia among school children in Wolliso town, Southwest Ethiopia was higher than other Sub Saharan African countries. The lack of a regu- lar vision screening program in the study area could be considered as the main causes for late diagnosis of amblyopia. Therefore, a regular school based vision screening initiatives program is recommended.

Competing interest

The authors declare that this manuscript was ap- proved in its form and that no competing interest exists.

ACKNOWLEDGEMENT

This study was supported by a grant from CBM. The study sponsor had no involvement in the study design; in the collection, analysis and interpreta- tion of data; in the writing of the report ; and in the decision to submit the paper for publication. We are indebted to the kindness of all the staffs who were unduly supportive in all ways throughout the study period. We are also grateful to the school directors and teachers who facilitated the data col- lection within the respective schools.

INTRODUCTION

Status epilepticus (SE) is a neurological emergency which may occur in people with epilepsy (PWE) as well as in those with- out epilepsy. It is associated with high morbidity, mortality and low quality of life thus in PWE episodes of SE have added clinical relevance (1,2). In 2015, the International League Against Epilepsy defined SE as a bilateral tonic–clonic activity lasting longer than 5 minutes, and absence SE and as focal SE as exceeding 10 minutes (3). Because of the time-locked defi- nition of SE ascertaining the incidence of SE in the community is wrought with many challenges (4) thus most available stud- ies are hospital based. In a review of population-based studies, Sanchez et all (4) reported an overall incidence of SE 9.9 to 41 per 100,000/year ranging from 3.5 to 41 per 100 000 per year. Recent studies from Europe have reported incidence rate of

36.1to 81.1 per 100 000 per year based on the new ILAE 2015 definition of SE(5,6).

Few studies have reported on SE in Africa(7,8). Bhalla et al (7) in 2014 reported an incidence of 10.8 per 100 000 population and Kariuki et al (8) reported a prevalence rate of 2.3 per 1000. Apart from using different definitions for SE, these studies included people without epilepsy and children. Based on few available studies in SSA, SE in Africa is reported to be high in Children, hospital-based studies and PWE who are not on anti- epileptic drugs (9,10). Most cases of documented SE are likely

to be seizures with predominantly motor features. In Austria, the age and sex adjusted incidence of a first episode of non- convulsive SE and SE with prominent motor phenomena was 12.1 and 24 per 100 000 adults per year, respectively (5).

In Sub-Saharan Africa (SSA), risk factors for SE include infec- tions and non-adherence to medication. In Kenya, for example, documented risk factors for SE were neurologic impairments, acute encephalopathy, previous hospitalization, and presence of antibody titers to falciparum malaria and HIV (8). Risk factors for SE and seizure clusters seizure (SC) have been reported to be similar (11,12). SE is a strong determinant of quality of life in PWE/their caregivers and the cost of treating epilepsy (1,13,14) . In SSA, SE may be treated at home and possibly in unorthodox way which may result in high morbidity and mor- tality.

Despite the potential for poor outcomes of SE in PWE, there is little, or no research related to the subject in Nigeria. Recogniz- ing incidence and patterns of SE is helpful in preventing unto- ward consequences of SE. The aim of this study was to describe the caregiver reported frequency and pattern of SE in PWE attending neurology outpatient clinic in Enugu.

METHODS

This was a cross-sectional descriptive study carried out in 3 major hospitals in the city of Enugu, Enugu State Nigeria. The Hospitals were the University of Nigeria Teaching Hospital, Enugu State University Teaching Hospital, and the Memfys Hospital for Neurosurgery. These three tertiary hospitals offer both secondary and tertiary epilepsy care in the city and receive patients from all parts of southeast Nigeria and beyond.

Study participants :The plan was to collect the data of all con- secutive consenting epilepsy patients who attend the neurology clinic of these hospitals. All consecutive consenting patients accompanied by caregivers in which case the caregiver must have been an eyewitness of the seizure were included in the study. We excluded patients with possible psychogenic non- epileptic seizures and single epileptic seizures. Cases where seizure duration could not be truly determined with some level of certainty were excluded from the present analysis. Cases of incomplete data or illegible lasting less than 5 minutes were also excluded. The study period was 9 months.

Data collection tools and procedures: Data was collected using

asemi-structured questionnaire. The questionnaire contained open ended and as well as multiple choice questions and con- sisted of three principal sections. The first section was on gen- eral information about the respondents such as age and sex and related characteristics. The second section contained questions on the age on onset of epilepsy, age of first treatment and fami- ly history. The third section was focused on clinical characteris- tics of seizures such as prediction of seizures, seizure triggers, duration of seizures in minutes or recurrent seizures during which the patients did not recover consciousness. The question- naire was constructed in simple English to match the expected reading level of most persons that completed primary school (6 years of basic education). Cues to remember seizure duration were given to informants. Such cues include questions like (1) do you think that seizures lasted as long as the time you have been in this clinic? (2) did seizures last as long as it took you to get to a hospital or call for help? The study questionnaire was designed by the principal investigator and reviewed by the oth- er authors and senior colleagues in neurology both in Enugu and outside. The mean time for filling out the questionnaire was 5 minutes. All questionnaires were filled in the English lan- guage either by the caregiver (self-administered) and some- times with help from the investigators. Data were collected by neurology registrars, senior registrars and consultants.

Completed questionnaires were retrieved the same day. In cases where the respondent did not understand English, a translation in the local language was used. In such cases, the items on the questionnaire were read out to the respondents, and their en- dorsed options were ticked by the investigator. The study proto- col was reviewed by the ethics committee of the Teaching Hos- pitals. All participants gave their informed consent after reading or having the consent form read for them.

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Operational definitions: SE was defined as seizures lasting more than 5 minutes for generalized seizures and 10 minutes for focal seizures3. CS was defined as series of seizures close- ly grouped in time with shorter than normal inter ictal periods or as an increase over the patient's typical seizure frequency in a day or week (15). Epilepsy was defined based on the In- ternational League Against Epilepsy criteria.

Data analysis: The SPSS version 22 (IBM Corporation, New York, USA) was used for data management and statistical analysis. Data were presented in tables. The statistical methods included Mann-Whitney U test for unpaired observations and Chi-squared test for comparison of categorical data. Distribu- tion of types of seizures was calculated as the percentage of participants. Mean and median were calculated, and values were presented as tables where applicable. In all, p < 0.05 was regarded as statistically significant. Conclusions were drawn at this level of significance at 95% confidence level.

RESULTS

Description of participants: Data of 154 PWE were reviewed and analysed. Males were 80(51.9%) and 74(48.1%) were females. The male to female ratio was 0.9:1. Most participants were aged 20-29 years (42.9%) with a mean age of 32.4(17.3) years. Males were older than females by almost 7 years (p<0.0). Other characteristics of the patients are shown in Table 1. Before presenting to the hospital 40(26%) used tradi- tional herbal drugs while 36(23.4%) resorted to prayer as a sole means of treatment.

Seizure characteristics: Reported seizures characteristics are shown in Table 2. The mean age of onset of epilepsy in the cohort was 20.9 years (with a median of 17 years); earlier in females (14.4 years) than males 26.3 years) (p <0.01). The peak age of onset of epilepsy in SE was 0 to 9 years. The mean time taken from the age of onset to the age of going to the hospital was similar in both males and females. P=0.2. The 6-month seizure freedom was 9.7%. More males reported a family history of epilepsy. P=0.03. About 45.5% reported a clinical history of generalized seizures. Among those that had focal seizures clinically, 38(45.2%) could always predict the onset of seizures while the rest did so sometimes. Clinically seizures were reported to be similar every time by 107 (69.5%).

A total of 56(36.4%) confirmed that they had experienced pro- longed seizures that lasted more than 5 minutes for generalized seizures and 10 minutes for focal seizures in the past. Sex distri- bution SE showed that males (36.3%) and females (36.5%) re- ported a history of status in the past. P=0.98. Seizure related admissions were reported in 14(9.1%) of PWE more in females 11(14.9%) than males 3(3.8%). See Table 3. Figure 1, showed that history of SE appears to be bimodal; 40% below the age of 20 years and 50% after the after of 50 years.

Table 3 shows the proportion of PWE with various risk factors who had SE. About 54.5% of those with stroke, 47.9% of pa- tients who had CS reported a history of SE. A large proportion of dementia cases also had CS and SE although the overall number was small. Factors that correlated with past history of SE were: history of CS, family history of epilepsy and having no past history of seizure related admissions.

Table 3. Distribution of status epilepticus by various documented risk factors

*Multiple risk factor was recorded. #Percentage of risk factors.

DISCUSSION

Seizure frequency and pattern are strong determinants of quali- ty of life in epilepsy as well as the burden of epilepsy. Alt- hough in PWE, seizures are generally sporadic or even infre- quent, however, they may experience prolonged seizures (status epilepticus) and even cluster seizures. Identification of SE in the community is very important because of the associat- ed high morbidity, mortality as well as the associated high di- rect and indirect health costs in epilepsy(13,14).

In the index study, the male to female ratio of PWE with a his- tory of SE was 0.9:1. SE was reported by 36.4%: males (36.3%) and females 36.5%). P=0.98. About 54.5% of PWE who had stroke experienced SE. A large proportion of demen- tia cases also had SE although the numbers were small. Fur- thermore, the age distribution of SE was bimodal (before 20 years and after 50 years), and a large proportion of PWE with SE also had experienced SC. Factors that correlated with SE were history of SC, family history of epilepsy and no history of seizure related admissions.

The seizure related characteristics in the index study were sim- ilar to other published works from Nigeria (16,17). The age distribution of the patients in the index study may suggest a changing pattern of epilepsy risk factors or increasing aware- ness of epilepsy in the country. Younger mean-age-of-onset in females may be attributed to a better health seeking behaviour among females. Another factor responsible for this may be relatively large proportion of individuals with hypertension, diabetes and stroke. These disorders are generally commoner in older males. Clinically, 54.5% had focal seizures, a finding which may be explained by the high rates of risk factors for focal seizures in the study. This is similar to previous studies (18). Six-month seizure freedom in the index study was a mere 9.7% while 24.7% reported within 24 hours of seizures. These

findings support previous reports on seizure control in PWE in Nigeria(17). These may be related to several factors including non-adherence, uses of unorthodox medicine, seizure severity and alcohol (18).

The sex and age distribution of PWE who reported a history of SE showed same sex distribution and a bimodal age distribu- tion. In the US, Dham et al(19) reported a bimodal distribution of SE with the first peak in the first decade of life and the sec- ond after 60 years. Double peak in the incidence of SE was also reported in a review by Sanchez et al(4). Current demo- graphic in Nigeria and SSA have shown a rise in the older age group; therefore, SE is likely to become a common problem and an important health issue in years to come. Similar to some previous studies, the gender distribution of SE has been report- ed to be similar in males and females. Male to female ratio varied also from one study to the other with some reporting more males and others more females (4). In Ethiopia, Amare et al(20) reported a male-to-female ratio of SE of 1.5:1 which is different from the index study. In a study by Kariuki et al (8) there was an equal gender distribution.

There are no community-based studies on SE in Nigeria. Com- munity-based studies are frequently limited by recall bias and the ability of onlookers to recognize seizure-types and record their duration appropriately. Even in hospital settings in Nige- ria, EEG monitory is not frequently carried out hence there are likely to be low rates of detection.

The definition of SE has evolved over the past decades, how- ever, the incidence of SE has not differed much using different definitions. Leitinger et al (5) reported that reducing the diag- nostic time of SE increased the incidence only moderately by 10%. The overall incidence of SE range from 5.2 to 41 per 100,000/year (7) with an average of 9.9 per 100 000. Kantanen, et al (6) reported an annual age-adjusted incidence of 81.1/100,000 based on the new ILAE 2015 definition of SE.

The age and sex adjusted incidence of a first episode of SE, Non-convulsive statue epilepticus and SE with prominent mo- tor phenomena (including Convulsive SE) was 36.1 per 100 000 adults per year in Austria (5). In SSA, Kiruiki and his col- leagues reported an overall prevalence of 2.3 per 1,000 from three sites in Kenya(8). Their study included children and were limited to predominantly motor seizures and people without epilepsy. The reported incidence of SE in the index study (36.3%) is similar in males and females. This finding is within the rates reported by previous studies. The prevalence of SE in this study may be affected by several factors listed in table 4 which have been linked to SE in previous studies. Further- more, our cohort may represent patients with severe forms of epilepsy.

The incidence of SE is affected by age, geographical location, comorbidities and possibly family history (6,21). Similar to the index study in most adult studies there is a spike after the age of 50 (5,22). Geographical factors affect socio cultural charac- teristics of the population as well as disease pattern(4). For an example, whereas in Kenya (8), Malaria and HIV were associ- ated with SE, in Finland (6) alcohol withdrawal was the single most common acute symptomatic etiology in the study by Kantenen et al (6,23). The relationship between SE and non- adherence and no previous hospital visit have also been docu- mented in PWE(8). These two factors are important in SSA because large treatment gap and poverty.

In the index study, SE was reported in 54.5% of those with a history of stroke and 35.3% of those with Traumatic Brain Injury (TBI). Other cases with small but significant proportion of SE were those with meningitis and alcohol abuse. These findings are in support of previous studies that reported stokes, TBI and infections as common causes of SE a pattern which tends to vary between countries (4). SE has also been reported to be common in neurodegenerative disorders (4). African studies have reported infections and non-adherence to be high on the list of risk factors(8-10,20). Sadarangani et al(10), in Kenyan children, found that 71% of SE cases had an infectious cause, 53% attributed to malaria. Likewise, Amare et al (20) described CNS infections as the primary source of SE in Ethi- opia. However, these studies were not limited to PWE. SE may also be related to the premorbid state of the patients (4,24,25). Metabolic disorders such as hyperglycemia, uremia and acidosis of other etiologies are common causes of SE in non-epilepsy patients and may trigger status in PWE. Another risk factor for SE reported in the literature is family history.

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In a population-based twin study reported a high pattern of SE concordance between monozygotic twins compared to dizygot- ic twins, linking familial predisposition and possible genetics factors to the risk of developing SE(25). Family history of epi- lepsy was reported in 14% of our cohort and correlated to a history of SE in the index study.

Factors that may precipitate/cause SE can also precipitate SC. These risk factors include TBI, longer duration of epilepsy and poor seizure control(26). SE has a direct effect on mortality, quality of life and increased health cost. It leads to repeated admissions in the emergency room or even in the intensive care unit. In the index study seizure related admissions negatively correlated to a history of SE. The reason for this is not clear. Large prospective studies are needed to shed more light on this finding. SE is a condition for which data on incidence, etiolo- gy, risk factors and outcomes are required for proper decision- making and for the allocation of resources by policy makers. These resources need to be used in the development of strate- gies that help improve prevention, diagnosis and reduce mor- bidity and mortality.

Limitations: This study has some limitations. Firstly, data used in this might have been affected by recall bias which may affect the true incidence of SE. Secondly, the timing of seizures may not be very accurate and subjective. Thirdly, only predom- inately motor seizures are observable, and subtle form of sei- zure are likely to be overlooked. Our study addressed only sur- vivors. Mortality rates of SE are important in assessing the true burden of this complication of epilepsy.

Finally, questionnaires were administered in English which may introduce some language bias because some medical terms in English do not have direct local equivalents. These limitations notwithstanding, this study has provided data for comparison for future studies. Large multi-center and commu- nity-based studies are needed to accurately document the preva- lence of SE in Nigeria.

Conclusion:The reported lifetime history of SE among PWE attending a tertiary hospital clinic in Enugu is high. This may suggest both poor seizure control and/or seizure severity. Care- ful patient education will improve both adherence and emergen- cy management of epilepsy to reduce the morbidity of epilepsy in the community.

INTRODUCTION

Gastrointestinal (GI) surgery-associated anastomotic leaks (ALs) have been one of the main causes underlying postopera- tive morbidity and mortality irrespective of the continual im- provements in surgical procedures. The frequency and conse- quences of anastomotic failure (partial or complete disruption of anastomosis with leakage of contents) vary widely accord- ing to the sites, definitions, and types of resections within the GI tract (1, 2). Varying rates of ALs are found (1) based on the anastomosis site involved: rectum (8-41%), colon (3-29%), small intestine (1-3%), bile ducts (10-16%), pancreas (9-16%), stomach (1-9%), and esophagus (2-16%).

In systematic reviews of 97 studies, a total of 56 separated def- initions of AL were identified. Combination of clinical features and radiological investigations were used to define and detect anastomotic leak. However, there is no universally accepted definition of anastomotic leak at any site (3).

Studies conducted to identify the incidence and risk factors for anastomotic leak are from the developed world where patient characteristics and availability and utility of diagnostic tools are different from that in the developing world. Several studies have identified risk factors for GI anastomotic leakage with no general consensus on which risk factors consistently feature

(1).

An anastomotic defect in colon causes leakage of colonic con- tent into the abdominal and or pelvic space leading to peritoni- tis, abscess formation, and sepsis that can be fatal. The inci- dence of colorectal anastomotic leak (CAL) varies between 3% and 19%, with associated mortality rates ranging from 10 % to

20 %. Moreover, CAL is a risk factor for local recurrence of colorectal cancer (4).

AL typically becomes clinically apparent between the 5 and the 8 postoperative days, but many exceptions exist (5, 6). The occurrence of gastrointestinal AL is associated with signifi- cantly increased mortality, morbidity, and prolonged hospital stay as well as considerable extra costs (4, 7). Knowledge on the risk factors may influence procedure related decisions and treatment, and possibly reduce the rate of leakage.

The aims of this study were to evaluate the pattern of AL after GI resection and anastomosis, its perioperative risk factors, morbidity and mortality rates related to AL, and to provide surgical professionals, researchers and hospitals with baseline information for further investigation and guideline develop- ment to reduce rate of AL and improve outcome of patients.

MATERIALS AND METHODS

This was a multicenter retrospective study of medical records of patients with GI resection and anastomosis undertaken at Tikur Anbessa, Menelik II, Yekatit 12 and Zewditu Memorial Hospitals in Addis Ababa during the period of January 1, 2017 to December 31, 2018.

During the study period, a total of 556 patients had GI resec- tion and anastomosis. Of these, charts of 414 patients were retrieved and 62 patients were excluded from the study because four were pediatric patients, 12 patients had insufficient data, and 46 patients had bypass procedures. The documents of 352 patients make the basis for the analysis of this study.

Structured questionnaires were prepared for data collection and the study proposal was approved by the Institutional Review Board of Addis Ababa University, College of Health Sciences. At the four hospitals, operating room registers, medical charts, discharge summaries, and death certificates of patients were used for data collection. Demographic fea- tures, comorbid conditions, diagnoses for which GI resection and anastomosis were performed, and presence or absence of perioperative infection, bowel preparation, antibiotic use, blood transfusion, and serum albumin level were determined. Emphasis was also made on the urgency of the operation, operating professional, and duration and type of the proce- dure as well as the duration of hospital stay and postopera- tive complications. The collected data were checked for completeness, and entered into computer and the SPSS ver- sion 23 package was used for statistical analysis.

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RESULTS

The mean (±SD) age of patients was 48(±17) years; about 75% of patients were ≤ 60 years of age. Majority (72.2%) of patients were male and 257 (73.0%) were urban residents. The most common reasons for gastrointestinal anastomosis were redundant sigmoid colon and sigmoid volvulus (27.8%) fol- lowed by small bowel obstruction (SBO) (14.8%). The rest of the diagnoses in decreasing order of frequency included colo- rectal cancer (12.8%), esophageal cancer (12.2%), and end colostomy for 26 benign and 9 malignant diseases (9.9%), gastric cancer (5.4%), IBD (4.8%), and 10 penetrating and 3 blunt abdominal trauma (3.7%), and others (8.5%) including mesenteric ischemia, ileostomy or abdominal TB (10 each). Cancer accounted for 35.8% of all patients that underwent GI anastomosis (Table 1).

As is shown in Table 2, most patients (79.9%) underwent elec- tive anastomotic procedures, in 224 (63.6%) procedures related to the colon. GI resection and anastomosis were performed in 41.8% of patients without preoperative mechanical bowel prep- aration. Serum albumin level was determined in 70.5% of pa- tients, out of which 15.3% had low serum albumin levels. Evi- dences of infection (pus and GI content in the peritoneum, ab-

scess or fistula) were noted during anastomosis in 6.8% of patients. Blood transfusion was given for 6.8% of patients. The type of operative procedures in decreasing order of frequency were colocolic anastomosis (33.5%), enteroenterostomy (18.2%), ileocolic anastomosis (15.6%), colorectal anastomo- sis (13.9%), esophagectomy (12.2%), gastrectomy (5.4%), and jejunotransverse (and coloanal anastomoses (0. 3% each).

The participating surgical disciplines included general, colo- rectal, and cardiothoracic surgery. Majority of the operations (70.8%) were performed by residents and general surgeons. Colorectal and cardiothoracic surgeons operated on 15.9% and 13.4% of patients respectively.

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The surgical procedure lasted 90 minutes or more in 94.6%, 2 to 3 hours in 61.4%, more than 3 hours in 9.7%, and more than 5 hours in 0.6% of patients (Table 2).

As depicted in Table 3, anastomotic leak was detected in 35 of 352 patients (9.9%) in this study. AL detection day varied from the 2nd to the 14th postoperative days; and majority of the leaks (21, 60%) were detected on the 5th to 8th postoperative days, and (10, 28.6%) on the 7th postoperative day. Majority of leaks (21, 60%) were detected by GI content or fluid dis- charge via incisional wounds or drainage tubes. Relaparotomy was performed on 8.8% of patients after GI resection and anastomosis, but 71.4% (25/35) of patients that developed anastomotic leak required relaparotomy, and the rest (10/35) were managed conservatively as enterocutaneous fistula whereas only 1.9% (6/311) of patients who did not develop leak required relaparotomy, for wound dehiscence and post- operative collection.

About 60.0% of patients stayed in hospital for one week or more, 54 (15.4%) for more than two weeks, and 34 (9.7%) stayed for more than three weeks. The mean postoperative hospital stay was 12±12.35 days, with a median stay of 8 days and IQR of 7 to 11 days. When conditions of patients on discharge were as- sessed, 25 patients (7.1%) died in hospital after GI anastomosis (Table 3).

On bivariate analysis (Table 4), emergency procedure, presence of infection, absence of mechanical bowel preparation, and low serum albumin level were significantly associated with AL. AL was significantly high with increase in age and prolonged dura- tion of surgery. Sex, duration of procedure, low preoperative HCT level, and pre or intraoperative blood transfusion was not significantly associated with the development of AL.

AL rate following enteroenterostomy (Table 5) was high (17.2%) followed by esophagectomy (16.3%), gastrectomy (10.5%), colorectal anastomosis (10.2%), ileocolic anastomo- sis (9.1%) and colocolic anastomosis (4.2%), but ileorectal anastomosis did not leak (P=0.019). Majority of the proce- dures (240 patients) were performed by residents and general surgeons. There were differences in the leak rates among the different surgical professionals, but the differences were not statistically significant (P=0.434).

Anastomotic leakage rate was found to be a little bit higher in malignant conditions than benign conditions. (13/126, 10.3% vs 22/226, 9.73%), but the difference was not statistically sig- nificant (P=0.357). AL was associated with significantly in- creased mortality, morbidity, and prolonged hospital stay (Table 6). The rate of death in patients who developed AL

was 48.3% compared to the 3.5% death rate in those who did not develop AL. Most patients (71.4%) with AL had relaparotomy compared to the 1.9% relaparotomy rate in those without AL. Majority of patients (62.9%) with AL stayed more than 3 weeks in hospital, whereas only 3.8% of patients without AL stayed that long.

Variables which were statistically significant on bivariate analysis were included in multivariate analysis (Table 6) to see their independent effect on the occurrence of AL. Absence of bowel preparation was strongly associated with AL on bi- variate analysis but became out of the range for significance on multivariate analysis. The variable that had strong inde- pendent association with AL was a low serum albumin level (p<0.0001).

Patients who had low serum albumin were 19 times more likely to develop AL compared to those who had normal serum albumin. The other variable which was independently associated with oc- currence of AL was emergency procedures (p=0.018) where pa- tients were 4.6 times more likely to develop AL than those who underwent elective procedures.

DISCUSSION

Anastomotic leak is perhaps the most dreaded complication following intestinal surgery and is one of the leading causes of postoperative morbidity and mortality despite improvements in surgical care. The rates and complications of AL vary consider- ably depending on the definition, risk factors, site, and type of GI tract resection (1,2).

Majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak. The diagnostic methods commonly used when a leakage is suspected are CT scan, contrast enema, endoscopic examina- tion, and reoperation (8). In our series, except one patient who developed wound dehiscence and the leak was detected on re- operation, all ALs were detected and defined clinically only. There is no universally accepted definition of anastomotic leak at any site (3, 9).

In this study, the rate of AL increased with increase in age of patients and pronged duration of surgery, but the increase was not significant and congruent to the findings by others (4, 7, 10, and 11). In our study, female patients developed AL more fre- quently than males (12.2% vs. 9.1%) even though the variation was not statistically significant (P=0.370). In other studies, AL

occurred more commonly in male patients (12, 13). The varia- tion could be due to small sample size of female patients in our study.

Studies have identified risk factors for GI anastomotic leakage, but there is no universal agreement on which risk factors con- sistently feature (1). Amrika Seshadri (7) reported that serum albumin, need for blood transfusion and others as strongly as- sociated factors for AL. In a retrospective study, male sex, perioperative transfusion, presence of cardiovascular disease and proximal tumor location were predictive factors of anasto- motic leakage after gastrectomy for gastric cancer and the leak- age rate was 1.9% (13). In a prospective study, Nair et al (14) reported a 35.0% rate of anastomotic disruption in patients undergoing emergency small bowel anastomosis, a much high- er rate than our finding. There are clearly many patient and disease factors that contribute to anastomotic leak. AL has been associated with a 6% to 39% mortality rate (15). In this study, emergency procedure, the presence of infection, the ab- sence of bowel preparation, and low serum albumin were sig- nificantly associated with anastomotic leak, but on multivariate analysis only emergency procedures (P=0.018) and low serum albumin(P<0.0001) remained significantly associated with anastomotic leakage. This is because of the fact that patients were operated on without bowel preparation on emergency bases which possibly is a confounding variable. This finding is in line with the findings in several other studies (7, 14, and 16).

DISCUSSION

Anastomotic leak is perhaps the most dreaded complication following intestinal surgery and is one of the leading causes of postoperative morbidity and mortality despite improve- ments in surgical care. The rates and complications of AL vary considerably depending on the definition, risk factors, site, and type of GI tract resection (1,2).

Majority of studies used a combination of clinical features and radiological investigations to define and detect anasto- motic leak. The diagnostic methods commonly used when a leakage is suspected are CT scan, contrast enema, endoscopic examination, and reoperation (8). In our series, except one patient who developed wound dehiscence and the leak was detected on reoperation, all ALs were detected and defined clinically only. There is no universally accepted definition of anastomotic leak at any site (3, 9).

In this study, the rate of AL increased with increase in age of patients and pronged duration of surgery, but the increase was not significant and congruent to the findings by others (4, 7, 10, and 11). In our study, female patients developed AL more frequently than males (12.2% vs. 9.1%) even though the variation was not statistically significant (P=0.370). In other studies, AL occurred more commonly in male patients (12, 13). The variation could be due to small sample size of fe- male patients in our study.

Studies have identified risk factors for GI anastomotic leak- age, but there is no universal agreement on which risk factors consistently feature (1). Amrika Seshadri(7) reported that serum albumin, need for blood transfusion and others as strongly associated factors for AL. In a retrospective study, male sex, perioperative transfusion, presence of cardiovascu- lar disease and proximal tumor location were predictive fac- tors of anastomotic leakage after gastrectomy for gastric can- cer and the leakage rate was 1.9% (13). In a prospective study, Nair et al (14) reported a 35.0% rate of anastomotic disruption in patients undergoing emergency small bowel anastomosis, a much higher rate than our finding. There are clearly many patient and disease factors that contribute to anastomotic leak. AL has been associated with a 6% to 39% mortality rate (15). In this study, emergency procedure, the presence of infection, the absence of bowel preparation, and low serum albumin were significantly associated with anasto- motic leak, but on multivariate analysis only emergency pro- cedures (P=0.018) and low serum albumin (P<0.0001) re- mained significantly associated with anastomotic leak- age.This is because of the fact that patients were operated on without bowel preparation on emergency bases which possi- bly is a confounding variable. This finding is in line with the findings in several other studies (7, 14, and 16).

In general, the rate of AL varies depending on the tissue anas- tomosed, and the rates include, stomach, 1.1-3.3%, small in- testine, 1.0-3.8%, ileocolic, 2.0-6.5%, colocolic, 3.0-5.4%,

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colorectal, 4.0-26%, and ileorectal, 5.0-19%. AL is known to be correlated with worse prognosis after curative resection for colorectal cancer (15). In the present study, the rates of AL were 16.3% in esophagogastrostomy, 10.5% in gastrectomy and gastrojejunostomy, 17.2% in enteroenterostomy, 9.1% in ileocolic anastomosis, 4.2% in colocolic anastomosis, and 10.2% in colorectal anastomosis. Compared to the preceding report, AL rates in gastric, small bowel and ileocolic anasto- mosis were higher in our study probably due to nutritional deficiencies or emergency procedures. Contrary to our finding where ileorectal anastomosis did not leak, higher incidences of AL, probably related to disease or patient factors, were found in other reports (1,15). The overall AL rate of 9.9% observed in this study is similar to the reported rates that ranged from 1.8% to 15.4% in many studies (2, 10, 16-19). Esophagogas- trostomy, ileocolic, colocolic and colorectal AL rates were comparable with the findings in other series (2, 4, 10, 11, 15, 16, 20, 21). In our series, anastomotic leakage rate was slightly higher in malignant than benign conditions (10.3 % vs 9.73%), but the difference was not statistically significant (P=0.357).

AL presents in a dramatic fashion early or more often in a far subtler fashion, often relatively late in the postoperative period (22). In majority of our patients (60.0%), in agreement with another report (6), AL was detected between the 5th and 8th postoperative days, and on the 14th postoperative day in one patient.

The consequences of AL are peritonitis, fistula or abscess for- mation, postoperative infection, and increased hospital costs and mortality (20, 23, 24). It causes considerable morbidity and mortality to the patient, and it doubles the length of hospi- tal stay (7).

In this study, 40.0% of patients developed peritonitis, and the death rate in patients who developed AL was 48.3% compared to the 3.5% in those who did not develop AL. Previous reports showed a 3% to 39% and 8 to 10-fold mortality rates after AL (2, 4, 7, 20). In our series, the mortality rate was higher than the above reported rates, which may be explained by lack of early suspicion, late clinical detection and or delayed interven- tion since this study could not find usage of diagnostic imag- ing techniques for the detection of leakage.

In our study, the risk of relaparotomy was high in patients with AL; most patients (71.4%) with AL had relaparotomy com- pared to the 1.9% relaparotomy rate in those without AL. Compared to a 3.8% of patients without AL, 62.9% of patients with AL stayed more than 3 weeks in hospital. AL is associat- ed with significantly prolonged hospital stay as well as consid- erable extra costs (4,7).

Conclusion and recommendation:

The incidence of AL in gastrointestinal anastomosis in our series was 9.9%. Low serum albumin and emergency proce- dures are strong risk factors for AL. The occurrence of AL significantly increases the rate of relaparotomy, sepsis, postop- erative mortality and duration of hospital stay.

Awareness of the risk factors, suspicion of AL, and thorough evaluation of patients may impact perioperative decision- making, surgical technique and patient care.

Optimization of nutrition prior to elective GI anastomosis may prevent AL and its far-reaching consequences.

Emergency GI resection and anastomosis should be handled with utmost care. Prospective studies should be conducted to identify determinant factors for AL. We also recommend the four hospitals to have better patient record keeping.

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ACKNOWLEDGMENT

We would like to thank the administrations of Tikur Anbessa, Menelik II, ZM, and Yekatit 12 Hospitals for cooperation dur- ing data collection. We also thank the Addis Ababa University College of Health Sciences for funding the study.

INTRODUCTION

Satisfaction of medical professionals is a key factor in delivering quality medical care. It is important to note that, not only is it vital to keep the professional moti- vated to stay in their respective specialty; it is also an indirect measure of patient outcome (1). In addition, it affects patient care by also increasing the tendency of professionals to unionize and participate in a strikes (2, 3).

Professional satisfaction is also strongly associated with patient satisfaction (4-6). According to a study in Japan, having a high income as well as, working in large hospitals were associated with high satisfaction, whereas, older age and night shifts were associated with dissatisfaction (8).

Factors affecting work satisfaction may also vary de- pending on time, with changes in practice, patient load, and income over time. Published works also show that close to half of all radiology professionals reported a decreased level of satisfaction in their job, as compared to five years prior (7, 8).

Although there are published research works in Ethiopia that analyze the radiological services, no published works so far investigate the level of satis- faction among radiology professionals. Therefore, the main aim of this survey is to do a baseline as- sessment of the level of professional/ job satisfac- tion of radiologists in local practice.

METHODS

Study design

This was a cross-sectional survey conducted on a source population of 140 radiologists who attended the 22nd annual radiology conference in 2017

Study setting

The study was conducted in Addis Ababa, Ethiopia during the 22nd annual conference of the Radiology Society of Ethiopia.

Study population and procedure

The study participants were all radiologists who have a minimum work experience of two years. 40 out of 140 radiologists who have work experience of less than two years were excluded from the study. The remaining 100 met the inclusion criteria. Among those eligible, 80 of them consented to participate in the survey.

Data collection and analysis

Data was collected using a structured questionnaire which contains sociodemographic characteristics, area and type of practice, staffing character, work sched- ule, number of institutions that the radiologist is work- ing or practicing in, stability within the current institu- tion, and career plans. Satisfaction was measured us- ing a five-level Likert scale. Data was entered into SPSS version 20 and analyzed. Descriptive and ana- lytical statistics were used as applicable. The depend- ent variable was satisfaction and independent varia- bles included age, sex, years of experience, income, and type of practice, and multivariate logistic regres- sion was used to test the association between the two variables. Statistically, a significant association was taken for p values <0.05.

Ethical considerations

Participation in the survey was voluntary. Informed consent was obtained from all respondents, and indi- vidual identifiers were not used during data collection. Ethical clearance was obtained from the Research and Ethics Committee of the Department of Radiology. Permission was obtained from the radiology society.

RESULTS

Out of the 100 eligible radiologists, 80 of the partici- pants in the study complied making the response rate 80 %. Around 2/3rd of the respondents were males and 55.1% of them were <45yrs of age (Table I).

All levels of professional experience above 2 years were represented and only 1.3% of the respondents were above the age of 65 (figure I & II). Among the participants, 68% of the respondents had 2-10 years of experience, while 31.3% had above 10 years (figure II). 74 (92.5%) of the respondents were general radiol- ogists and only 6 (7.5%) were subspecialists.

Concerning the area of practice, 88.8% of the re- spondents were practicing either in Addis Ababa or other larger cities. 88.4% were in clinical practice during the time of data collection and 70% percent of the respondents were full-time employees. Those who were working in private practice accounted for 41.3% of the respondents and the rest were working in gov- ernment institutions and uninformed services (Table II). The data showed that half of the respondents were working in only one institution while the remaining half was working in two or more institutions.

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The overall satisfaction level of radiologists in this study was 62.8%., 31.3% of respondents reported to be satisfied with their current monthly income and 53.8% of respondents were indifferent. Con- cerning stability of respondents, 83.8% of respond- ents were stable during the past two years with 52.3% having no plan to change their current working place within the next one year. Among the participants, 78.8% also had a plan to keep the current practice rather than change practice or ca- reer path (Table I).

Radiologists who were male and in the age group of 35 -44 were more likely to be satisfied than the females or younger, and older age groups (P-value

=0.02 & 0.01 respectively). (Table II) Radiologists working in larger cities other than Addis Ababa also reported to be satisfied than those working in Addis and smaller cities. Those who were working in small cities reported more dissatisfaction than those radiologists working in Addis Ababa and other large cities, respectively (P -value = 0.00). Those radiologists in clinical prac- tice also reported better satisfaction than those who were in academic practice (P-value = 0.03). (Table II)

The study also found that those radiologists who had longer years of experience (>11yrs) were more likely to encourage college-age students to join medicine than those who had <10years of experi- ence (P- value= 0.01) (table II).

Figure I: Age distribution of Ethiopian radiologists participated in the survey, Addis Ababa, 2017 GC.

Figure II: Category of years of professional experi- ences of Ethiopian radiologists, Addis Ababa, 2017GC