Molecular Epidemiology of Hepatitis B, Hepatitis C, and HIV-1 Co-Infections in Ethiopia: Implications for Disease Burden and Intervention Strategies.

BACKGROUND: Hepatitis B virus (HBV) exhibits high prevalence rates within Ethiopia. The genetic diversity of HBV, marked by mixed genotype infections, may hold significant implications for the trajectory of disease and responses to treatment. Ethiopia grapples with a substantial public health challenge posed by co-infections involving HBV, hepatitis C virus (HCV), and human immunodeficiency virus 1 (HIV-1), particularly among vulnerable populations. METHODS: A comprehensive investigation into HBV, HCV, and HIV-1 co-infection was conducted. A total of 7,789 blood samples were meticulously analyzed, among which 815 exhibited HBV positivity. Among the HBV-positive samples, 630 were subjected to genotyping procedures, resulting in the identification of a prevalent trend of mixed infections characterized by HBV genotypes A/E/F (67.30%). Serological assessments were performed on 492 specimens to ascertain the presence of HCV and HIV-1 co-infections, revealing respective co-infection rates of 13.02% for HBV/HIV, 3.31% for HBV/HCV, and 2.07% for triple infection. RESULTS: The investigation revealed the intricate prevalence of co-infections in Ethiopia, notably underlining the continued transmission of viruses. The prominent occurrence of mixed HBV genotypes A/E/F suggests dynamic viral interactions and ongoing transmission pathways. These findings accentuate the necessity for targeted interventions and enhanced patient care, as co-infections carry significant clinical complexities. CONCLUSIONS: This study furnishes crucial insights into the molecular epidemiology of HBV, HCV, and HIV-1 co-infections in Ethiopia. The acquired knowledge can contribute to the advancement of strategies for clinical management and the formulation of public health interventions aimed at ameliorating the burden of viral infections within the nation.

A Case Report of Belly Dancer Dyskinesia in a 54 Years Old Female: Gastroenterology Meets Neurology.

Dyskinesia limited only to the axial musculature is very rare, and if it is localized to the anterior abdominal wall, it is called belly dancer's dyskinesia. Despite reports of variable clinical characteristics, a common feature is a myriad of involuntary, repetitive, sometimes painful, and often rhythmic movements of the anterior abdominal wall, with the majority being bilateral, resembling that of a belly dancer. As the symptom is mainly localized to the abdomen, patients could visit a gastroenterology service thinking it might be associated with underlying visceral pathology. Since the first report in 1990, only a few cases of belly dancer dyskinesia have been reported over the years. We herein report the case of a 54 years old female who presented to our OPD with a recurrent painless writhing movement of the abdomen, diagnosed as belly dancer dyskinesia and successfully treated with chlordiazepoxide.

A Case of Severe 2,4-Dichlorophenoxyacetic Acid Poisoning Causing Diagnostic and Treatment Challenges.

2,4-Dichlorophenoxyacetic acid is a poisonous herbicide. Though poisoning reports from this compound are rare, there is a tendency toward increased use of it in the agrarian society of Ethiopia. We herein report a case of a young female farmer from rural Ethiopia who was admitted to a local hospital after presenting with loss of consciousness and excess oral secretions 2 hours after a suicidal ingestion of an unknown toxic agent. She was originally treated for organophosphate poisoning, and then transferred to Saint Peter's Hospital in Addis Ababa for more intensive care. There, ingestion of 2,4-D was confirmed, and she received supportive care, mechanical ventilation, and forced alkaline diuresis. Despite these interventions, she died several days later. Due to the similarity of some clinical signs with organophosphate poisoning in acute settings, there are possible missed cases of 2,4-D acid herbicide poisoning. No specific treatment is known, so a high index of suspicion for early detection, decontamination, and initiation of supportive care is crucial to improve survival after exposure. In addition, local policies on proper and controlled use of these herbicides are needed to improve awareness among users and prevent accidental and intentional exposures.

Increasing Burden of Acute Hepatitis A among Ethiopian Children, Adolescents, and Young adults: A Change in Epidemiological Pattern and Need for Hepatitis A Vaccine.

Background: Hepatitis A is a vaccine-preventable, feco-oral infection due to poor sanitary conditions. It is predominantly acquired during early childhood and results in lasting acquired protective immunity. However, it results in severe disease which can end up in acute fulminant hepatitis and hepatic failure when acquired during adolescence and adulthood. The prevalence of acute hepatitis A is increasing among children, adolescents, and young adults from higher-income households. They acquire this infection at a later age when they are exposed for the first time to contaminated food and drinks after being brought up in a relatively clean environment. This calls for the introduction of the Hepatitis A vaccine in Ethiopia; possibly as part of the Expanded Program on Immunization (EPI). Methods: Socio-demographic and clinical data were collected from patients who were diagnosed to have hepatitis A infection at Adera Medical Center in 2020. Results: This study showed that clinical acute hepatitis A is becoming common among children, adolescents, and young adults from relatively high-income families. Among patients with acute hepatitis, 89% were from middle and high-income families. Conclusions: There is a need for the incorporation of hepatitis A vaccine in the Ethiopian EPI program.

Acquired Hepatocerebral Degeneration After a Splenorenal Shunt in the Sub-Saharan Africa Context: A Case Report and Brief Review of Literature.

Acquired hepatocerebral degeneration (AHD) is a neurologic syndrome caused by liver dysfunction and long-standing portosystemic shunting. The pathogenesis of the condition is predominantly considered to be related to the deposition of manganese in parts of the brain due to shunting. We report a case of a 25-year-old male who underwent splenectomy and splenorenal shunt for recurrent upper GI bleeding (UGIB) due to esophageal varices caused by non-cirrhotic portal hypertension (NCPH). He presented with bradykinesia, hypophonia, gait instability, and rigidity of the lower extremities 18 months after the procedure was done.

Drug-induced esophageal injuries with an atypical presentation mimicking acute coronary syndrome.

BACKGROUND: Pill-induced esophageal injury may cause severe complications if not diagnosed in a timely fashion. The condition is under-recognized and under-reported, and some patients present with atypical clinical or endoscopic features mimicking other common conditions. If the diagnosis is missed the patient will continue to take the offending drug, potentially worsening the illness. We present a case in which acute coronary syndrome was the initial working diagnosis leading to a delay in diagnosis of doxycycline-induced esophageal injury. The patient developed multiple esophageal ulcers and hemorrhage. CASE PRESENTATION: A 50-year-old male driver with a history of hypertension and dyslipidemia was brought to the emergency department with complaints of severe retrosternal chest pain, vomiting, diaphoresis and syncope. On initial evaluation, acute coronary syndrome was considered due to the clinical presentation and history of cardiovascular risk factors. Electrocardiogram and serum troponins were normal. On the second day of his admission, the patient developed odynophagia and bloody vomitus. Esophagogastroduodenoscopy revealed extensive esophageal ulcerations with hemorrhage. The patient was taking Doxycycline capsules for an acute febrile illness. Doxycycline is the oral medication most commonly reported to cause esophageal injury. Doxycycline was discontinued, and the patient was treated with intravenous omeprazole and oral antacid suspension. The patient improved, was discharged after 6 days of hospitalization, and reported resolution of all symptoms at an outpatient follow-up visit 3 weeks later. CONCLUSION: Medication-induced esophageal injury can present with atypical symptoms mimicking acute coronary syndrome. This condition should be included in the initial differential diagnosis of patients presenting with acute chest pain, especially those taking oral medications known to cause esophageal injury.

Treatment of Hepatitis C Genotypes 1 to 5 in Sub-Saharan Africa Using Direct-Acting Antivirals.

There is limited knowledge of the use of direct acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) in sub-Saharan Africa. We prospectively evaluated individuals infected with HCV genotypes 1 to 5 in Addis Ababa, Ethiopia. Liver fibrosis was assessed by AST-platelet ratio index score and cirrhosis by imaging and laboratory values. All 164 individuals completed treatment. The majority of patients had genotype 4 (76%), and 19% of participants showed evidence of cirrhosis. Sustained virologic response (SVR) across all genotypes was 98.8%. In those with cirrhosis, SVR was 93.5% and in non-cirrhotics 100%. Our study demonstrates broad genotype successful treatment of HCV with DAAs in sub-Saharan Africa, demonstrating the feasibility of HCV elimination in resource-limited settings.

Single center analysis of therapy and outcomes of hepatocellular carcinoma in Sub-Saharan Africa.

PURPOSE: To evaluate the characteristics and response to therapy for HCC in sub-Saharan Africa. PATIENTS AND METHODS: We retrospectively evaluated demographic, clinical and outcome variables of HCC in a referral clinic in Ethiopia from 2016 to 2018. Survival assessment was performed using the Mann-Whitney test. Associations between categorical variables was assessed using Pearson Chi-square test. RESULTS: We report 46 HCC cases with a median age of 54 years (IQR 45-62) and 50% female. Viral hepatitis was the most common underlying etiology, with 41% of subjects infected with hepatitis B virus (HBV) and 45% with hepatitis C. The median MELD was 12 (IQR 8-17), we found no association between survival and a MELD score 15, regardless of underlying disease (pr=0.61, p>0.05). 31% of individuals underwent supportive treatment with a median survival of 27 days (IQR 19-181), 18% used Sorafenib (median survival of 94 days, IQR 24-121), and trans-arterial chemoembolization (TACE) was utilized in 16% (median survival of 352 days, IQR 30-436). HBV cases were diagnosed younger (31% before the age of 40) and those on Tenofovir had a longer median survival than those off Tenofovir (121 vs 34 days). CONCLUSION: Our study found that antiviral treatment of HBV infection was associated with longer survival in HCC. Furthermore, Sorafenib seemed beneficial in patients that used this modality and NLR was a good prognostic factor.

Prevalence of human papillomavirus and Helicobacter pylori in esophageal and gastroesophageal junction cancer biopsies from a case-control study in Ethiopia.

BACKGROUND: Ethiopia lies in the high-risk corridor of esophageal squamous cell carcinoma in East Africa, where individuals with this malignancy often do not report established risk factors, suggesting unidentified etiologies. Here, we report the prevalence of mucosal human papillomavirus (HPV) and of Helicobacter pylori (H. pylori) detection in endoscopy-obtained esophageal and gastroesophageal junction biopsies and in oral cell specimens taken at the time of esophageal cancer diagnosis in a case-control study in Addis Ababa, Ethiopia. METHODS: DNA extraction was performed from fresh frozen tissue and oral cell pellets obtained with saline solution gargling subsequently fixed with ethanol. Mucosal HPV and H. pylori DNA was detected using highly sensitive assays that combine multiplex polymerase chain reaction and bead-based Luminex technology. The proportions of specimens testing positive were expressed as percentages, with binomial 95% confidence intervals. Agreement of results between tissue biopsy and oral cell specimens was estimated using the kappa statistic. Comparison of study participants' characteristics by test results was done using the Pearson chi-square test. RESULTS: HPV DNA was detected in 1 of 62 tumor specimens (2, 95% confidence interval (CI): 0-9%), corresponding to HPV16 type. HPV DNA was detected in the oral cavity of 7 cases (11, 95% CI: 5-22%) and 4 of 56 matched healthy controls (7, 95% CI: 2-17%), with multiple HPV types detected. Detection of H. pylori DNA was 55% (95% CI: 42-68%), and 20 of 34 H. pylori-positive specimens (59, 95% CI: 41-75%) were positive for the cagA gene. Agreement of detection rates between tissue and oral cells in cases was poor for HPV and for H. pylori. CONCLUSIONS: The prevalence of mucosal-type HPV was very low, whereas H. pylori was more commonly detected, with a high proportion testing positive for the pro-inflammatory gene cagA. These novel findings remain to be replicated in larger studies and with the addition of serological determinations to better understand their biological significance in the context of esophageal and gastroesophageal junction cancers.

Qat use and esophageal cancer in Ethiopia: A pilot case-control study.

BACKGROUND: Qat (Catha edulis) chewing is reported to induce lesions in the buccal mucosa, irritation of the esophagus, and esophageal reflux. Case series suggest a possible etiological role in oral and esophageal cancers. This pilot study aimed to generate preliminary estimates of the magnitude and direction of the association between qat use and esophageal cancer (EC) risk and to inform the logistics required to conduct a multi-center case-control study. METHODS: Between May 2012 and May 2013, 73 EC cases (including 12 gastro-esophageal junction cases) and 133 controls matched individually on sex, age, and residence were enrolled at two endoscopy clinics and a cancer treatment hospital in Addis Ababa. A face-to-face structured questionnaire was administered. Qat use was defined as ever having chewed qat once a week or more frequently for at least one year. Odds ratios were calculated using conditional logistic regression. RESULTS: Only 8% of cases resided in Addis Ababa. Qat use was more frequent in cases (36%) than in controls (26%). A 2-fold elevation in EC risk was observed in ever qat chewers compared with never users in unadjusted conditional logistic regression (OR = 2.12; 95% CI = 0.94, 4.74), an association that disappeared after adjusting for differences in tobacco use, consumption of alcohol and green vegetables, education level, and religion (OR = 0.95; 0.22, 4.22). Among never tobacco users, however, a non-significant increase in EC risk was suggested in ever qat users also after adjustment. Increases in EC risk were observed with ever tobacco use, alcohol consumption, low consumption of green vegetables, a salty diet, illiteracy, and among Muslims; the four latter associations were significant. CONCLUSIONS: This pilot study generated EC risk estimates in association with a habit practiced by millions of people and never before studied in a case-control design. Results must be interpreted cautiously in light of possible selection bias, with some demographics such as education level and religion differing between cases and controls. A large case-control study with enrolment of EC cases and carefully matched controls at health facilities from high-risk areas in the countryside, where the majority of cases occur, is needed to further investigate the association between qat use and EC.

Chronic viral hepatitis: policy, regulation, and strategies for its control and elimination in Ethiopia.

BACKGROUND: Hepatitis B and C are silent killers not yet recognized as major public health challenges in many developing countries with huge disease burden. In Ethiopia, Hepatitis B is endemic with an average prevalence of 10.8 %, and the prevalence of Hepatitis C is 2 %. The prevalence of both infections, however, is likely to be underreported due to the lack of diagnostic facilities and appropriate surveillance systems. Ethiopia is also among the many Sub-Sahara African countries lacking a coordinated and systematic national response to chronic viral hepatitis. The objective of this study is to examine the current level of response to viral Hepatitis B & C in Ethiopia with the aim to bring identified gaps to the attention of relevant stakeholders and policy makers. METHODS: This cross-sectional qualitative study was based on semi-structured in-depth interviews with 21 key informants from health facilities, health offices, pharmaceutical companies, regulatory bodies, professional association and blood bank units. Participants were selected purposively based on their role in the national hepatitis response. The investigators also reviewed available policy and strategy documents, standards of practice and surveys, and paid visits to pharmaceutical premises to check the availability of antiviral drugs. Thematic analysis was employed to make sense of the data. During the data analysis process, all the authors critically read the materials, and data was triangulated by source, interpreter view and thematic perspective to ensure accurate representation and comprehensiveness, and validation of the interviewees' responses. Once each investigator reviewed the data independently, the team reached a common understanding of the scope and contexts of the information attained. Data were subsequently reduced to key concepts, and case stories were taken with successive revisions. The key concepts were later coded into most basic meaningful categories. The World Health Organization (WHO) global hepatitis response framework was used to organize the analysis. RESULTS: Ethiopia is in the process of preparing strategic plan and guidelines for viral hepatitis. However, the country still lacks the required partnerships, and resource mobilization as a national health response is limited. Community awareness on the disease transmission and its sequel is poor. Viral hepatitis screening services are not widely available except for the occasional mandatory medical checkups for work or travel purposes. Healthcare providers often take no further action after diagnosing patients with viral hepatitis due to lack of treatment guidelines and strategic frameworks for screening, diagnosis, and treatment. Besides, drugs that are effective in the treatment of viral hepatitis are not available, mainly due to regulatory challenges. CONCLUSIONS: Viral hepatitis and its disease burden are getting little attention in Ethiopia and many low-income countries. The levels of technical guidance and financial support from the international community are low. To date, the response to the infections in Ethiopia is patchy. Thus, the country needs to formulate policy and strategies in the areas of disease surveillance, risk group identification and screening, use of the birth dose of hepatitis B vaccine, and care and treatment. Improving availability of data on viral hepatitis, access to low-cost generic drugs and developing and dissemination of treatment guidelines are also critical. Leveraging the successful Health Extension Program for a hepatitis response, and exploring ways to learn from and integrate into the HIV/AIDS program should also be considered.

COMMON GENOTYPES AND TREATMENT OUTCOMES OF HCV INFECTION AMONG ETHIOPIAN PATIENTS: A PROSPECTIVE STUDY.

BACKGROUND: The treatment response of HCV infection is dependent on genotype and stage of the disease. However, genotype pattern and treatment outcomes of HCV infection among Ethiopian patients has not been studied so far. OBJECTIVES: To evaluate the common HCV genotypes and treatment outcomes among Ethiopian adult patients. METHOD: Adult patients aged 18 and above with HCV infection referred from various regions of the country were included in the study after written informed consent. As there was no free or insurance coverage for treatment of HCV infection in the country, those who could afford to pay for treatment with PEG Interferon and Ribavirin were recruited during January 1, 2008 through December 31,2013 at United Vision, Adera. Old Airport, and Mexico referral higher clinics in Addis Ababa. Patients with decompensated cirrhosis and pregnant ladies were excluded from the study. The patients were counseled on treatment options, cost, treatment outcomes, adverse drug effects, and possible complications. Data were collected on demographic features, clinical characteristics, viral genotypes, and treatment outcomes during follow up visits until six months after completion of recommended standard treatment. Data were analyzed using SPSS software. RESULTS: A total of 200 adults with chronic HCV infection were treated with PEG-Interferon and Ribavirin (for 24 or 48 weeks according to the genotypes) during the study period. Of the 200 patients enrolled in the study, 120 (60%) were male, 90% were from Addis Ababa, and the median age was 48 years. Sixty per cent of the patients were infected with genotype 4,17% with genotype 1, 13.5% with genotype 2 and 9.5% with genotype 3. Eighty percent of the patients had end of treatment response; of these, 74.4% had undetectable HCV RNA at 6th month after end of treatment. The end of treatment response was noted to be close to 90% for patients with HCV genotypes 2 and.3 infections. CONCLUSION: This study indicates that genotype 4 is the prevalent HCV genotype followed by 1, 2, and 3 among Ethiopian patients. Treatment with interferon and ribavirin was well tolerated and provided a very good response.

A 60 year old Ethiopian farmer diagnosed with tick paralysis at Adera Medical Center.

A 60 year old farmer from west Shewa in Ethiopia presented on February 13 2014, with right arm flaccid monoplegia after bitten by a tick stuck to his right arm pit. The case was initially misdiagnosed as cellulitis. To our knowledge, tick paralysis has not been reported from Ethiopia. We report the case presentation with literature review.

Outbreak of epidemic dropsy in Ethiopia: the clinical and therapeutic observation.

INTRODUCTION: Epidemic dropsy results from ingestion of argemone oil contaminated food staffs. The oil from Argemone Mexican seeds contains toxic alkaloids called sanguinarine and dehydrosangunarine. These cause wide spread capillary dilatation, proliferation and leakages. This leads to oedema, hypovolemia and hypotension. OBJECTIVE: To describe the socio-demographic and clinical manifestations of the patients affected with epidemic dropsy in Tikur Anbessa specialized Hospital (TASH). METHODS: A case series study was conducted in an outbreak with unusual cases which was later diagnosed to be epidemic dropsy. Clinical evaluation of suspects was done and optimal therapy given for the complications detected and information was filled in structured format by medical residents and medial chart records review was made for occurrence of new complications in the end of 9 months. RESULTS: A total of 164 patients were seen at TASH from 26 households, in 8 sub-cities of Addis Ababa. A wide range of age group was affected with 70% from 16 to 40 years of age. There was no case among less than 5 years of age. Females were affected more than threefold as compared to males. All the patients manifested with bilateral leg swelling and pitting oedema. It was tender in 50 (30.4%) of them while 43 (26.2%) had erythema. Tachycardia was the next common manifestation occurring in 135 (82.3%), followed by cough in 123 (75%), anaemia in 59 (36%), headache in 58 (35.4%), shortness of breathing in 52 (31.2%), hair loss in 44 (26.8%) and respiratory distress in 35 (21.3%). Abdominal pain, hepatomegally, nausea and vomiting were also seen. There was abnormality in the chest X-ray of 31 (27.2%). Hair loss, tingling and burning extremities, difficulty of standing, hyperpigmentation, pruritic rash and eye symptoms were observed lately during follow up. Five of the patients died while in hospital care due to acute respiratory distress syndrome (ARDS). CONCLUSIONS: The commonest clinical manifestation in our patients is bilateral leg swelling which is similar to other outbreaks of epidemic dropsy elsewhere. The mortality rate is also comparable with other series but all cases died by ARDS in our series which is unusual in other reports. As this is the first reported epidemics in Ethiopia the findings will create awareness of clinical features of epidemic dropsy among clinicians, and therefore, helps for diagnoses of similar problems in the future.

Outbreak investigation of epidemic dropsy in Addis Ababa, Ethiopia:.

BACKGROUND: A 17 year old female patient who presented to a tertiary Hospital in Addis Ababa with bilateral painful leg swelling of two months and shortness of breath, associated with cough and haemoptysis of one week duration was reported to the Ministry of Health and the Addis Ababa Health Bureau. The condition was later detected in 18 individuals from 4 households indicating occurrence of an outbreak of unknown cause in Addis Ababa which lasted during May-July 2008. OBJECTIVE: An outbreak investigation was initiated to identify the cause and prevent further spread, morbidity and mortality. METHODS: Using semi-structured questionnaire, quantitative assessment involving individual cases and affected households was conducted to detect aetiology and risk factors. Unaffected households as well as unaffected members of affected households were also included for comparison purpose. Record review of patients visiting hospitals was also done. Data were collected through house to house visits, and using interview of cases admitted to hospital. Samples of cooking oil were collected for laboratory testing. Data analysis was done using SPSS. RESULTS: A total of 182 patients, 50 (27.5%) males and 132 (72.5%) females, were identified till the outbreak was controlled fully. Age varied from 6-90 years. Death was confirmed in 12 cases, 8 of whom were female. The majority of the patients came from the adjoining Lideta (39.0%) and Kolfe Keranyo (31.9%) subcities. History of illness ranged from less than a week to 12 weeks before presentation. Out of the 106 household members of the 24 affected households identified during the first phase of the investigation, 83 were affected. Most family members who infrequently take meals at home, and children aged 3 years and below were spared. The 21 visited affected households from Kolfe keranyo, Lideta and Bole subcities bought cooking oil produced by a firm in Lideta subcity and all had bought their last supplies in March and April 2008. Samples of cooking food oil taken from this firm and from the affected households were found to have alkaloids of Argemone Mexicana. The number of new cases dropped to zero within 6 weeks after the source was closed. CONCLUSION: The occurrence of bilateral leg swelling in more than one family member of affected households, that bought cooking oil from the same source, sparing the toddlers, and those who infrequently take meals at home, further strengthened by laboratory confirmation of presence of argemone alkaloids in the cooking oil samples taken from the affected households and the common sources led to the diagnosis of the outbreak to be epidemic dropsy.

Laboratory investigation of epidemic dropsy in Addis Ababa, Ethiopia.

BACKGROUND: Food adulteration including adulteration of edible oils may cause serious health problems. One of the most common edible adulterants is argemone oil. An outbreak of epidemic dropsy occurred in Addis Ababa during May-June, 2008. One hundred and eighty two cases were recorded with twelve confirmed deaths. Dietary history of the cases revealed that vegetable oils were the usual cooking medium. OBJECTIVE: The aim of the study was hence to investigate the causes of this outbreak. METHODS: Contaminant identification was done using standard chemical tests, complemented with TLC. Toxicity study was done using Swiss albino mice feed with contaminated and non contaminated standard diet for 30 days. RESULTS: Laboratory investigation of the edible oils has indicated that 47 of the 280 edible oils analyzed were adulterated with argemone oil. About 81% of the edible oil samples collected from Lideta sub-city were adulterated with argemone oil. Toxicological investigation of the adulterated oils also indicated typical features of argemone alkaloid poisoning in mice. CONCLUSION: Results of both laboratory analysis and toxicological studies confirmed consumption of edible oils adulterated with argemone oil as the cause of epidemic dropsy in Addis Ababa.

Epidemic dropsy: case report and the morphologic features in a patient who died at Tikur Anbessa Specialized Hospital.

Epidemic dropsy results from the consumption of edible oils adulterated with argemone mexicana oil. In a 2008 epidemic in Addis Ababa five patients died and in one of these a partial autopsy has been performed. The clinical impression of acute respiratory distress syndrome has been confirmed by the demonstration of massive diffuse alveolar damage. These features are consistent with findings reported in similar epidemics.