Catha edulis and chronic liver disease in eastern Ethiopia

Chronic liver disease (CLD) is a major cause of morbidity and mortality worldwide. In Africa, the relative burden of CLD by aetiology is largely unknown although hepatitis B virus, alcohol misuse and hepatitis C virus are thought to be major causes. CLD has recently been reported as the leading cause of mortality in adults in eastern Ethiopia, but no studies exploring the aetiological spectrum of CLD are available, and hence, relevant preventative measures cannot be implemented. This work set out to explore the aetiological spectrum of CLD in eastern Ethiopia and assess potential risk factors for the development of CLD, including the habitual use of khat (Catha edulis). The results of this thesis are based on three studies of 150 patients with CLD and 300 control subjects without CLD. The diagnosis of CLD was established by clinical and radiological criteria. All study subjects were assessed using a semi-structured interview, standardized clinical examination and extensive laboratory testing. We found that approximately one third of CLD in eastern Ethiopia was attributed to chronic HBV infection, whereas alcoholic liver disease and chronic HCV infection was rare. Interestingly, after ruling out viral hepatitis, alcohol misuse, autoimmune liver disease, metabolic liver disease and parasitic infections, the underlying aetiology of CLD in eastern Ethiopia was still unexplained in more than 50% of the patients. Simultaneously, we found that more than 80% of the CLD patients used khat on a daily basis. Overall, a significant association was found between khat use and the risk for developing chronic liver disease, particularly in men; this risk was strong (adjusted odds ratio 5.67; 95% confidence interval 1.85-17.37) and dose-dependent, suggesting a causal relationship. Given the assumption of causality, more than 80% of CLD among men in this region is attributable to khat chewing. Since khat is increasingly available and habitual khat chewing is expanding worldwide, the health consequences of khat use, both on an individual and a public health level, are profound

Deskriptiv oppgave om sykehusbasert nyfødtomsorg ved Edna Adan Maternity Hospital, Hargeisa Somaliland

The problem statement for this student project is: descriptive assessment on hospital neonatal care at Edna Adan Maternity Hospital (EAMH) in Hargeisa, Somaliland. This project is an observational study, which does not include any interventions or comparative analysis, due to inadequate framework to conduct such a study. The mortality among children illustrates massive health challenges in Somaliland. We therefore wish to focus on newborn care, which is an important factor for reaching the goals of MDG 4. We wanted to devote our attention to the procedures and practices implemented in newborn care at a selected hospital in Somaliland, during the first 24 hours of life. We made our own registration chart, which included information about the mother, delivery details, information about the newborn and which interventions being done to the newborn included the clinical examination. During our stay we observed 32 deliveries. Key aspects in our observations included breastfeeding, immunization, vitamin K-injection, care of the umbilical cord, temperature care, clinical examination and resuscitation. We have discussed our findings related to relevant health statistics from the region and recommendations from WHO on neonatal care. Our general impression is that the neonatal care at EAMH has many strengths. In the context of other hospitals in Hargeisa they hold a high standard. The hospital realizes that they have room for improvement, and we have had a desire to shed light on this through concrete proposals to simple measures that can improve neonatal care

High Seroprevalence of Autoantibodies Typical of Autoimmune Liver Disease in Eastern Ethiopia: Is Chewing of Khat (Catha edulis) a Triggering Factor?

Background. Recent studies have identified chewing of khat (Catha edulis) as an independent risk factor for liver injury; however, the pathogenetic mechanism remains poorly understood. Case series have found markers of autoimmune hepatitis in patients with khat-related liver disease, suggesting that khat chewing might trigger an autoimmune response. The aims of the present study were (i) to assess the prevalence of autoantibodies typical for autoimmune liver diseases in a healthy population in Ethiopia and (ii) to explore the hypothesis that khat usage triggers autoimmunity. Methods. Consenting adults (≥18 years) without known autoimmune disease or manifest liver disease were included. One-hundred-and-sixty-nine individuals with current khat use were compared to 104 individuals who never used khat. Seroprevalence of antinuclear (ANA), antismooth muscle (SMA), and antimitochondrial antibodies (AMA) were determined and compared between the groups using logistic regression models to adjust for age and sex. Results. Overall, 2.6% of the study subjects were positive for ANA, 15.4% for SMA, and 25.6% for AMA. When comparing khat users to nonusers, ANA was detected in 4.1% vs. 0% (p=0.047), SMA in 16.0% vs. 14.4% (p=0.730), and AMA in 24.9% vs. 26.9% (p=0.704). ANA was excluded from multivariable analysis since there was no seropositive in the reference group. After adjusting for sex and age, no significant association between khat use and SMA or AMA was found. Conclusions. No association between khat usage and the seropresence of SMA or AMA was found, weakening the hypothesis that khat-related liver injury is mediated through autoimmune mechanisms. However, the seroprevalences of AMA and SMA were strikingly high in this Ethiopian population compared to global estimates, suggesting that diagnostic algorithms for autoimmune liver diseases developed in Europe and North America might lead to misdiagnosis of patients on the African continent

Five-year results of a treatment program for chronic hepatitis B in Ethiopia

Abstract Background In sub-Saharan Africa, less than 1% of treatment-eligible chronic hepatitis B (CHB) patients receive antiviral therapy. Experiences from local CHB programs are needed to inform treatment guidelines and policies on the continent. Here, we present 5-year results from one of the first large-scale CHB treatment programs in sub-Saharan Africa. Methods Adults with CHB were enrolled in a pilot treatment program in Addis Ababa, Ethiopia, in 2015. Liver enzymes, viral markers, and transient elastography were assessed at baseline and thereafter at 6-month intervals. Tenofovir disoproxil fumarate was initiated based on the European Association for the Study of the Liver (EASL) criteria, with some modifications. Survival analysis was performed using the Kaplan–Meier method. Results In total, 1303 patients were included in the program, of whom 291 (22.3%) started antiviral therapy within the initial 5 years of follow-up. Among patients on treatment, estimated 5-year hepatocellular carcinoma-free survival was 99.0% in patients without cirrhosis at baseline, compared to 88.8% in patients with compensated cirrhosis, and 54.2% in patients with decompensated cirrhosis (p < 0.001). The risk of death was significantly higher in patients with decompensated cirrhosis at baseline (adjusted hazard ratio 44.6, 95% confidence interval 6.1–328.1) and in patients older than 40 years (adjusted hazard ratio 3.7, 95% confidence interval 1.6–8.5). Liver stiffness declined significantly after treatment initiation; the median change from baseline after 1, 3, and 5 years of treatment was − 4.0 kPa, − 5.2 kPa, and − 5.6 kPa, respectively. Conclusions This pilot program demonstrates the long-term benefits of CHB therapy in a resource-limited setting. The high mortality in patients with cirrhosis underscores the need for earlier detection of CHB and timely initiation of antiviral treatment in sub-Saharan Africa. Trial registration The study was registered at ClinicalTrials.gov (NCT02344498) on January 26, 2015