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Objectives To implement and evaluate the effectiveness of a 10-module blended learning course on tuberculosis diagnosis for Ethiopian health care professionals. Methods This implementation science research was conducted within the routine in-service training for health care professionals in Ethiopia. A combined web-based and face-to-face acid-fast bacilli microscopy course was designed and its applicability studied after 6 weeks of enrollment of 108 medical laboratory professionals. A survey was conducted to capture participants' feedback on the course. Results Of 108 participants enrolled, 81 attended and 73 (90%) completed the course; 72 (94%) had no experience taking online courses. Mean percentages of quizzes, assignments/exercises, and hands-on scores were 88%, 70%, and 95%, respectively. No significant differences were found in scores between participants from public, private, and nongovernmental health facilities ( P = .386) or between higher and lower level facilities ( P = .533). Participants' overall satisfaction with the course was 88%. Conclusions Blended learning was an effective pedagogic approach for this category of professionals because of the crucial need for hands-on training for practicing and translating knowledge into skills. This approach also had the advantages of keeping the costs of the entire course low and reaching a greater number of participants, all without significant disruption of work schedules.

The global public health community has set ambitious treatment targets to end the HIV/AIDS pandemic. With the notable absence of a cure, the goal of HIV treatment is to achieve sustained suppression of an HIV viral load, which allows for immunological recovery and reduces the risk of onward HIV transmission. Monitoring HIV viral load in people living with HIV is therefore central to maintaining effective individual antiretroviral therapy as well as monitoring progress toward achieving population targets for viral suppression. The capacity for laboratory-based HIV viral load testing has increased rapidly in low- and middle-income countries, but implementation of universal viral load monitoring is still hindered by several barriers and delays. New devices for point-of-care HIV viral load testing may be used near patients to improve HIV management by reducing the turnaround time for clinical test results. The implementation of near-patient testing using these new and emerging technologies may be an essential tool for ensuring a sustainable response that will ultimately enable an end to the HIV/AIDS pandemic. In this report, we review the current and emerging technology, the evidence for decentralized viral load monitoring by non-laboratory health care workers, and the additional considerations for expanding point-of-care HIV viral load testing.

In questo lavoro di tesi vengono presentati i risultati di uno studio finalizzato alla caratterizzazione geofisica del sottosuolo del bacino di Amatrice, e all'individuazione del bedrock sismico, utili, tra le altre cose, alla valutazione della risposta sismica locale. Si è, quindi, cercato di identificare contrasti di impedenza sismica, connessi a condizioni geologico-strutturali e stratigrafiche locali, che influenzino la variazione in ampiezza del moto del suolo. La metodologia utilizzata per tale valutazione è la tecnica HVSR (Horizontal to Vertical Spectral Ratio) (Nakamura, 1989), basata sulla misura dei rapporti medi fra le ampiezze spettrali delle componenti orizzontali e verticale del rumore sismico ambientale (funzione H/V). I valori di picco della funzione H/V individuano le frequenze di risonanza dei terreni. Tali frequenze risultano inversamente proporzionali alle profondità dei contrasti di impedenza sismica presenti all'interfaccia tra litotipi diversi; l'entità di tali contrasti è, invece, legata al picco di ampiezza in corrispondenza della frequenza di risonanza. L'area di studio è il bacino di Amatrice, noto anche come bacino della Laga, uno de bacini sedimentari più grandi dell'Appennino Centrale nel quale è avvenuta la sequenza sismica del 24 agosto 2016. Nel presente elaborato è descritta la fase di raccolta dati eseguiti durante l'attività di tesi e la fase di trattamento ed elaborazione dei suddetti dati tramite il software Geopsy (SESAME W. G., 2004). L'elaborazione dei dati acquisiti è stata integrata con studi geologico/strutturali svolti nell'area d'esame, oltre che con analisi geo-stratigrafiche e geofisiche precedenti. È stato esplorato un transetto di circa 10 Km, orientato SW-NE, circa perpendicolare alle strutture della catena Appenninica ed integrato da misure ad esso adiacenti. L'interpretazione dei dati geofisici, ottenuta costruendo e vincolando i modelli con le informazioni precedenti, ha consentito di ottenere un modello delle velocità delle onde sismiche la cui interpretazione geologica ha permesso di ricostruire una sezione sismo-stratigrafica. Il confronto tra il modello e la sezione geologica dell'area mostra una rilevante complessità strutturale legata all'azione di numerose faglie normali e sovrascorrimenti. In particolare, lungo il transetto principale, sono state individuate cinque faglie principali.

Affordable point-of-care tests for hepatitis C (HCV) viraemia are needed to improve access to treatment in low- and middle-income countries. Our aims were to determine the target limit of detection (LOD) necessary to diagnose the majority of people with HCV eligible for treatment, and identify characteristics associated with low-level viraemia (LLV) (defined as the lowest 3% of the distribution of HCV RNA) to understand those at risk of being misdiagnosed.We established a multi-country cross-sectional dataset of first available quantitative HCV RNA measurements linked to demographic and clinical data. We excluded individuals on HCV treatment. We analysed the distribution of HCV RNA and determined critical thresholds for detection of HCV viraemia. We then performed logistic regression to evaluate factors associated with LLV, and derived relative sensitivities for significant covariates.The dataset included 66,640 individuals with HCV viraemia from across the world. The LOD for the 95th and 99th percentiles were 3,311 IU/ml and 214 IU/ml. The LOD for the 97th percentile was 1,318 IU/ml (95% CI 1,298.4-1,322.3). Factors associated with LLV, defined as HCV RNA 1,318 IU/ml, were younger age 18-30 vs. 51-64 years (odds ratios [OR] 2.56; 95% CI 2.19-2.99), female vs. male sex (OR 1.32; 95% CI 1.18-1.49), and advanced fibrosis stage F4 vs. F0-1 (OR 1.44; 95% CI 1.21-1.69). Only the younger age group had a decreased relative sensitivity below 95%, at 93.3%.In this global dataset, a test with an LOD of 1,318 IU/ml would identify 97% of viraemic HCV infections among almost all populations. This LOD will help guide manufacturers in the development of affordable point-of-care diagnostics to expand HCV testing and linkage to care in low- and middle-income countries.We created and analysed a dataset from 12 countries with 66,640 participants with chronic hepatitis C virus infection. We determined that about 97% of those with viraemic infection had 1,300 IU/ml or more of circulating virus at the time of diagnosis. While current diagnostic tests can detect as little as 12 IU/ml of virus, our findings suggest that increasing the level of detection closer to 1,300 IU/ml would maintain good test accuracy and will likely enable development of more affordable portable tests for use in low- and middle-income countries.

The use of standardized tools for continuous quality improvement of laboratory services is crucial to identify service gaps, plan targeted interventions, and prove successes. Laboratory quality improvement tools (LQITs) were developed and applied for 18 months at five health centers and one faith-based hospital laboratories in Southwest Showa Zone in Ethiopia to assess and monitor the quality of malaria and acid-fast bacilli (AFB) microscopy total testing processes. For the six laboratories, baseline malaria microscopy scores were 55%, 42%, 52%, 55%, 54%, and 61%. Similarly, baseline AFB microscopy scores were 49%, 41%, 46%, 58%, 44%, and 70%. On the sixth quarter for the first four laboratories and the fourth quarter for the last two laboratories, malaria microscopy scores were 89%, 88%, 88%, 90%, 88%, and 89%, whereas AFB microscopy scores were 90%, 88%, 89%, 95%, 88%, and 90%. All laboratories scored above 85% for both services at the end of interventions. BACKGROUND Many health programs in sub-Saharan African countries are often implemented using a vertical strategy to address disease-specific issues. On one hand, this silo approach has the benefit of reaching lower health facilities, where the majority of the population accesses the health system, and hence, a specific disease can be significantly controlled. On the other hand, by only tackling a single infection, a great opportunity for strengthening the laboratory as a whole is missed. The unprecedented investments in programs to fight human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in many resource-limited settings have resulted in major developments in the diagnostic capac- ity of medical laboratories to support HIV care and treatment initiatives in many countries. Taking advantage of the improvements of diagnostic services related to HIV/AIDS, the Federal Ministry of Health (FMOH) in Ethiopia gave the mandate to the Ethiopian Health and Nutrition Research Institute (EHNRI) to enhance the quality of all services pro- vided by medical laboratories, not only a specific program or disease. This approach is directed to the implementation of a Master Plan for the Public Health Laboratory System in Ethiopia 1 for the period 2009-2013 by the EHNRI/FMOH and its national and international partner organizations. At present, in Ethiopia, FMOH/EHNRI supports 39 medi- cal laboratories from government hospitals, national and regional public health laboratories, and non-governmental faith-based hospital to accreditation through assessments, trainings, supportive supervision, and mentoring. This effort is the first large-scale effort for accrediting medical laborato- ries in Ethiopia, and it is one of the numerous initiatives to support the accreditation of secondary and tertiary medical laboratories in sub-Saharan Africa according to the five-star accreditation scheme of the World Health Organization

Background Literature on mortars has mainly focused on the identification and characterization of their components in order to assign them to a specific historical period, after accurate classification. For this purpose, different analytical techniques have been proposed. Aim of the present study was to verify whether the combination of thermal analysis and chemometric methods could be used to obtain a fast but correct classification of ancient mortar samples of different ages (Roman era and Renaissance). Results Ancient Roman frescoes from Museo Nazionale Romano (Terme di Diocleziano, Rome, Italy) and Renaissance frescoes from Sistine Chapel and Old Vatican Rooms (Vatican City) were analyzed by thermogravimetry (TG) and differential thermal analysis (DTA). Principal Component analysis (PCA) on the main thermal data evidenced the presence of two clusters, ascribable to the two different ages. Inspection of the loadings allowed to interpret the observed differences in terms of the experimental variables. Conclusions PCA allowed differentiating the two kinds of mortars (Roman and Renaissance frescoes), and evidenced how the ancient Roman samples are richer in binder (calcium carbonate) and contain less filler (aggregate) than the Renaissance ones. It was also demonstrated how the coupling of thermoanalytical techniques and chemometric processing proves to be particularly advantageous when a rapid and correct differentiation and classification of cultural heritage samples of various kinds or ages has to be carried out. Graphical abstract PCA analysis of TG data allows differentiating mortar samples from different ages (Roman era and Renaissance).

Providing regular external quality assessment of primary level laboratories and timely feedback is crucial to ensure the reliability of testing capacity of the whole laboratory network. This study was aimed to assess the diagnostic performances of primary level laboratories in Southwest Showa Zone in Ethiopia. An external quality assessment protocol was devised whereby from among all the samples collected on-site at 4 health centers (HCs), each HC sent to a district hospital (DH) on a weekly basis 2 TB slides (1 Ziehl-Neelsen stained and another unstained), 2 malaria slides (1 Giemsa stained and another unstained), and 2 blood samples for HIV testing (1 whole blood and another plasma) for a comparative analysis. Similarly, the DH preserved the same amount and type of specimens to send to each HC for retesting. From October to November 2011, 192 single-blinded specimens were rechecked: 64 TB slides, 64 malaria slides, and 64 blood specimens for HIV testing. The analyses demonstrated an overall agreement of 95.3% (183/192) between the test and the retest, and 98.4% (63/64), 92.2% (59/64,) and 95.3% (61/64) for TB microscopy, malaria microscopy, and HIV rapid testing, respectively. Of the total TB slides tested positive, 20/23 (87%) were quantified similar in both laboratories. The agreement on HIV rapid testing was 100% (32/32) when plasma samples were tested either at HC (16/16) or at DH (16/16), while when whole blood specimens were tested, the agreement was 87.5% (14/16) and 93.8% (15/16) for samples prepared by HCs and DH, respectively. Results of this new approach proved that secondary laboratories could play a vital role in assuring laboratory qualities at primary level HCs, without depending on remotely located national and regional laboratories to provide this support.

Effective implementation and sustainability of quality laboratory programmes in Sub-Saharan Africa relies on the development of appropriate staff retention strategies. Assessing the factors responsible for job satisfaction and retention is key for tailoring specific interventions aiming at improving the overall impact of health programmes. A survey was developed to assess these factors among 224 laboratorians working in the laboratory programme the University of Maryland implemented in seven Sub-Saharan African countries. Lack of professional development was the major reason for leaving the previous job for 28% of interviewees who changed jobs in the past five years. Professional development/training opportunities was indicated by almost 90% (195/224) of total interviewees as the most important or a very important factor for satisfaction at their current job. Similarly, regular professional development/opportunities for training was the highest rated incentive to remain at their current job by 80% (179/224). Laboratory professionals employed in the private sector were more likely to change jobs than those working in the public sector (P = 0.002). The findings were used for developing specific strategies for human resources management, in particular targeting professional development, aiming at improving laboratory professionals within the University of Maryland laboratory programme and hence its long-term sustainability.

Improving access to CD4 testing in resource-limited settings can be achieved through both centralized and decentralized testing networks. Decentralized testing models are more suitable for countries where the HIV epidemic affects a large portion of rural populations. Timely access to accurate CD4 results is crucial at the primary level of the health system. For the past 7 years, the Institute of Human Virology of the University of Maryland School of Medicine has implemented a flexible and sustainable three-phase model: (1) site assessment and improvement, (2) appropriate technology selection with capacity building through practical training and laboratory mentoring, and (3) quality management system strengthening and monitoring, to support accessibility to reliable CD4 counting at the point of service. CD4 testing capacity was established in 122 of 229 (53%) laboratories supported in Nigeria, Uganda, Kenya, Zambia, Tanzania, and Rwanda. Among those in rural settings, 46% (69/151) had CD4 testing available at site level, with a functioning flow cytometer installed at 28% (8/29) and 50% (61/122) of level 1 and level 2 sites, respectively. To strengthen local capacity, a total of 1,152 laboratory technicians were trained through 188 training sessions provided both on-site and at central locations. The overall quality of CD4 total testing procedure was assessed at 76% (92/121) of the laboratories, with 25% (23/92), 34% (31/92), and 33% (30/92) of them reporting excellent, good, and satisfactory performance. Balancing country-specific factors with the location of the clinic, number of patients, and the expected workload, was crucial in adapting this flexible model for decentralizing CD4 testing. The close collaboration with local governments and private vendors was key to successfully expanding access to CD4 testing within the framework of HIV care and treatment programs and for the sustainability of medical laboratories in resource-limited settings. © 2011 International Society for Advancement of Cytometry