The Ethiopian National Immunization Technical Advisory Group (E-NITAG): Establishment, Achievements and the Future.

The National Immunization Program (NIP) was introduced in Ethiopia in 1980. The NIP has expanded the number of vaccines from six to more than 14 in 2023. However, decisions on new vaccine introduction and other vaccine-related matters were not systematically deliberated nationally. Thus, the need to establish a national body to deliberate on vaccine and vaccination matters, in addition to the global immunization advisory groups, has been emphasized in the last decade. This article presents the establishment and achievements of the Ethiopian NITAG. The E-NITAG was established in 2016 and maintained its active role in providing recommendations for new vaccine introduction and improving the delivery of routine vaccines. The external assessment indicated the E-NITAG was highly functional and played a critical role in enhancing the vaccination practice in Ethiopia, especially during the COVID-19 pandemic. The absence of a dedicated secretariat staff was the major bottleneck to expanding the role of the E-NITAG beyond responding to MOH requests. The E-NITAG must be strengthened by establishing a secretariat that can eventually grow as an independent institution to address complex vaccine-related issues the NIP needs to address.

Using a mentorship model to localise the Practical Approach to Care Kit (PACK): from South Africa to Ethiopia.

The Federal Ministry of Health, Ethiopia, recognised the potential of the Practical Approach to Care Kit (PACK) programme to promote integrated, comprehensive and evidence-informed primary care as a means to achieving universal health coverage. Localisation of the PACK guide to become the 'Ethiopian Primary Health Care Clinical Guidelines' (PHCG) was spearheaded by a core team of Ethiopian policy and technical experts, mentored by the Knowledge Translation Unit, University of Cape Town. A research collaboration, ASSET (heAlth Systems StrEngThening in sub-Saharan Africa), has brought together policy-makers from the Ministry of Health and health systems researchers from Ethiopia (Addis Ababa University) and overseas partners for the PACK localisation process, and will develop, implement and evaluate health systems strengthening interventions needed for a successful scale-up of the Ethiopian PHCG. Localisation of PACK for Ethiopia included expanding the guide to include a wider range of infectious diseases and an expanded age range (from 5 to 15 years). Early feedback from front-line primary healthcare (PHC) workers is positive: the guide gives them greater confidence and is easy to understand and use. A training cascade has been initiated, with a view to implementing in 400 PHC facilities in phase 1, followed by scale-up to all 3724 health centres in Ethiopia during 2019. Monitoring and evaluation of the Ministry of Health implementation at scale will be complemented by indepth evaluation by ASSET in demonstration districts. Anticipated challenges include availability of essential medications and laboratory investigations and the need for additional training and supervisory support to deliver care for non-communicable diseases and mental health. The strong leadership from the Ministry of Health of Ethiopia combined with a productive collaboration with health systems research partners can help to ensure that Ethiopian PHCG achieves standardisation of clinical practice at the primary care level and quality healthcare for all.

Impact of rotavirus vaccine introduction and genotypic characteristics of rotavirus strains in children less than 5 years of age with gastroenteritis in Ethiopia: 2011-2016.

INTRODUCTION: A monovalent rotavirus vaccine was introduced in the Ethiopian Expanded Program on Immunization from November 2013. We compared impact of rotavirus vaccine introduction on rotavirus associated acute diarrhea hospitalizations and genotypic characteristics of rotavirus strains pre-and post-vaccine introduction. METHODS: Sentinel surveillance for diarrhea among children <5 years of age was conducted at 3 hospitals in Addis Ababa, Ethiopia from 2011 to 2017. Stool specimens were collected from enrolled children and tested using an antigen capture enzyme immunoassay. Rotavirus positive samples (156 from pre- and 141 from post-vaccination periods) were further characterized by rotavirus genotyping methods to identify the predominant G and P types circulating during the surveillance era. RESULTS: A total of 788 children were enrolled during the pre- (July 2011-June 2013) and 815 children during the post-vaccination (July 2014-June 2017) periods. The proportion of diarrhea hospitalizations due to rotavirus among children <5 years of age declined by 17% from 24% (188/788) in the pre-vaccine period and to 20% (161/185) in post-vaccine introduction era. Similarly, a reduction of 18% in proportion of diarrhea hospitalizations due to rotavirus in children <12 months of age in the post (27%) vs pre-vaccine (33%) periods was observed. Seasonal peaks of rotavirus declined following rotavirus vaccine introduction. The most prevalent circulating strains were G12P[8] in 2011 (36%) and in 2012 (27%), G2P[4] (35%) in 2013, G9P[8] (19%) in 2014, G3P[6] and G2P[4] (19% each) in 2015, and G3P[8] (29%) in 2016. DISCUSSION: Following rotavirus vaccine introduction in Ethiopia, a reduction in rotavirus associated hospitalizations was seen in all age groups with the greatest burden in children <12 months of age. A wide variety of rotavirus strains circulated in the pre- and post-vaccine introduction periods.

Hospital-based surveillance for rotavirus gastroenteritis in children younger than 5 years of age in Ethiopia: 2007-2012.

BACKGROUND: Rotavirus surveillance was initiated in Ethiopia to estimate the burden of rotavirus gastroenteritis in children <5 years of age, to generate data to assist the policy-making process for new vaccine introduction and to monitor impact of vaccination on disease burden after introduction. METHODS: Sentinel surveillance was conducted at 3 hospitals in Addis Ababa, Ethiopia using a standardized WHO surveillance protocol from August 2007 to March 2012. Children <5 years of age, hospitalized for the primary reason of treatment for acute gastroenteritis, were enrolled, stool samples were collected and tested for group A rotavirus using an enzyme immunoassay. Confirmed positive specimens were further characterized by rotavirus genotyping. RESULTS: A total of 1841 children were enrolled and 21% were rotavirus positive. Children 6-12 months of age had the highest proportion of rotavirus (36%) followed by children <6 months of age (23%). There was no significant difference between sexes. Significant differences in clinical characteristics, such as vomiting, vomiting episodes, cases with vomiting and diarrhea among rotavirus positive cases, were observed. Rotavirus circulated year round with peak prevalence from October through January. The most prevalent detected genotypes were G1P[8] (20%), G12P[8] (17%) and G3P[6] (15%), respectively. CONCLUSIONS: Rotavirus infection is common in Ethiopian children. A safe and effective intervention against the infection is needed to prevent severity of the disease. Rotavirus vaccine introduction is planned before the end of 2013. The established surveillance system and the data generated can be used to monitor the impact of rotavirus vaccination program on severe disease.

Zinc during and in convalescence from diarrhea has no demonstrable effect on subsequent morbidity and anthropometric status among infants <6 mo of age.

BACKGROUND: Preventing illness and improving growth in the first 6 mo of life is critical to reducing infant mortality. Zinc given for 14 d at the start of diarrhea has been shown to decrease the incidence and prevalence of diarrhea and pneumonia and improve growth in the 2-3 mo after, but no trial has been done in infants <6 mo of age. OBJECTIVE: This study sought to assess the effect of 14 d of zinc supplementation on subsequent morbidity and growth among infants 1-5 mo of age living in Pakistan, India, and Ethiopia. DESIGN: Infants with acute diarrhea were randomly assigned to receive zinc (10 mg/d; n = 538) or placebo (n = 536) for 2 wk. Weekly follow-up visits were conducted for 8 wk after the diarrhea episode. Incidence and prevalence of diarrhea and prevalence of respiratory infections including pneumonia were compared between the groups. Changes in weight, length, and corresponding z scores during the 8 wk of follow-up were also compared. RESULTS: One thousand seventy-four infants were enrolled at the start of follow-up. The groups did not differ significantly in the proportion of infants with at least one episode of diarrhea or respiratory infections. Infants who received zinc had more days of diarrhea (rate ratio = 1.20) than did the infants who received placebo. The groups had similar prevalences of pneumonia and overall respiratory infections. No significant differences in the mean changes in weight-for-age, length-for-age, and weight-for-length z scores were observed between the groups overall or in stratified analyses. CONCLUSION: Young infants do not appear to benefit from 2 wk of zinc, unlike what has been observed among older children.

Neonatal gastrointestinal surgical emergencies: a 5- year review in a teaching hospital Addis Ababa, Ethiopia.

OBJECTIVE: A five year retrospective review of medical records of newborns admitted for gastrointestinal surgical emergencies was done. This study was intended to see the pattern of presentation, mode of intervention and surgical outcome of these cases and for provision of feed-back to the surgeon-pediatrician team who are involved in the care of such newborns. METHODS: The study included cases admitted to the Neonatal Unit of the Department of Pediatrics and Child Health, Tikur Anbessa Specialized Hospital, Addis Ababa, during the period of January 1, 1997 to December 31, 2001. RESULTS: A total of 60 cases admitted during the above-mentioned period were reviewed. Thirty-six (60%) were males, 23 (38%) were females, while one newborn had ambiguous genitalia. Imperforate anus has accounted for 27 (45%) of the 60 cases; jejunoileal atresia and esophageal atresia with or without tracheoesophageal each accounted for 12 (20%) cases; while 9 (15%) had other lesions. Of the 60 cases surgical intervention was performed on 43 (72%) newborns. Of the 12 newborns with esophageal atresia with or with out tracheoesophageal fistula. only one newborn was discharged alive; 7 out of 12 newborns with jejunoileal atresia died, 4 cases discharged improved while the outcome for 1 newborn was not known. Of the newborns with imperforate anus, 8 (47%) of the 17 with the high type and 1 (10%) of the 10 with low-type died CONCLUSION: Early diagnosis, availability of diagnostic service and prompt surgical intervention with optimal pre- and post-operative care are necessary to increase survival of newborns with such problems.

Zinc supplementation for the treatment of diarrhea in infants in Pakistan, India and Ethiopia.

OBJECTIVE: This randomized, placebo controlled trial was designed to assess the safety and efficacy of 10-mg zinc supplementation for the treatment of acute diarrhea in infants. METHODS: A total of 1110 infants aged 28 days to 5 months with acute diarrhea were enrolled and randomized to receive either zinc (n = 554) or placebo (n = 556) for 14 days. Diarrhea history, anthropometric status, breast-feeding status and socioeconomic indicators were assessed at baseline. The homes of all infants were visited every 3 days until the diarrhea episode was over. The number of stools, presence of blood and additional illnesses were recorded daily. RESULTS: The geometric mean duration of the diarrhea episode was 0.21 days longer among infants receiving zinc versus those receiving placebo, but this was not statistically significant and no difference was observed after controlling for sex, exclusive breast-feeding and length for age Z score. There were no differences in any subgroup (ie, sex, baseline length for age Z score, exclusive breast-feeding or site after controlling for the remaining subgroup variables). There were no differences in reported stool frequency or among the proportion of episodes lasting longer than 7 days. Rates of vomiting were similar in the zinc and placebo groups. CONCLUSIONS: Young infants do not appear to benefit from zinc supplementation for the treatment of diarrhea.

Green banana and pectin improve small intestinal permeability and reduce fluid loss in Bangladeshi children with persistent diarrhea.

To evaluate the effects of green banana and pectin (nondigestible, dietary sources of colonic shortchain fatty acids [SCFA]) on intestinal permeability, 57 boys (5-12 months) with persistent diarrhea (> or = 14 days) were given a week's treatment with a rice-based diet containing either cooked green banana (n = 19), pectin (n = 17), or rice diet alone (n = 21). Intestinal permeability was assessed before and after treatment by giving a lactulose-mannitol (LM) drink and measuring urinary recovery after 5 hr. Treatment with banana significantly (P < 0.05) reduced lactulose recovery, increased mannitol recovery, and decreased the LM ratio, indicating improvement of permeability. Pectin produced similar results. Permeability changes were associated with a 50% reduction in stool weights which correlated strongly (green banana, r2 = 0.84, pectin, r2 = 0.86) with the LM ratio. Green banana-derived and SCFA-mediated stimulation of colonic as well as small bowel absorption is responsible for their antidiarrheal effects. The antidiarrheal effects of green banana and pectin are mediated by improvement of small intestinal permeability in addition to their known colonotrophic effects.