Search

Biniam Getachew,1,* Semaria Solomon,2,* Blen Teshome Ramet,2 Tirumebet Mezgebu,2 Demelash Bezabih Ewnetu,2 Noni MacDonald3 1Independent Public Health Consultant, Addis Ababa, Ethiopia; 2St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia; 3Dalhousie University, Halifax, Nova Scotia, Canada*These authors contributed equally to this workCorrespondence: Biniam Getachew Addis Ababa, EthiopiaTel +251 911 380964Email biniongech@gmail.comIntroduction: Providing adequate nutrition to preterm infants who are born to HIV-positive mothers is more challenging due to the mother’s underlying health and nutrition status. The understanding of these issues and active participation of the mothers have a significant role in giving continuous care for HIV-exposed preterm infant. Hence, this study aimed to explore the experience of HIV-positive mothers’ feeding practice of their preterm infants, and health workers to identify barriers and facilitators of feeding HIV-exposed preterm infants.Methods: A phenomenological qualitative study design was conducted in Addis Ababa, Ethiopia, between May 1, 2016 and March 31, 2017. Mothers who gave birth to HIV-exposed preterm infants at the study sites’ follow-up clinic were traced and invited by the healthcare providers to voluntarily participate in this study. Fifteen in-depth interviews with mothers of HIV-exposed preterm infants and seven key informant interviews with health professionals and policymakers were carried out. The interviews were transcribed and translated and then manually analyzed thematically.Results: The health education given during antenatal care (ANC) did not consider the feeding practice needs for HIV-exposed preterm infants. Child health status, desire to have a healthy infant, financial constraints and family support were among the influential factors in the feeding practice of HIV-exposed preterm infants mentioned by the study participants. HIV-exposed preterm infant feeding procedure neither has a guideline nor is clearly mentioned in the national HIV guidelines.Conclusion: The desire to have a healthy infant was a major facilitator for feeding of HIV-exposed premature infants. However, financial constraints majorly limited the option to be only exclusive breastfeeding. This became even more problematic for the mother if the premature infant became ill and could not breastfeed well.Keywords: HIV/AIDS, HIV-exposed, preterm infant, infant feeding, Ethiopia

Background\udNeonatal sepsis is a primary cause of neonatal mortality and is an urgent global health concern, especially within low-income and middle-income countries (LMICs), where 99% of global neonatal mortality occurs. The aims of this study were to determine the incidence and associations with neonatal sepsis and all-cause mortality in facility-born neonates in LMICs.\udMethods\udThe Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS) study recruited mothers and their neonates into a prospective observational cohort study across 12 clinical sites from Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Data for sepsis-associated factors in the four domains of health care, maternal, birth and neonatal, and living environment were collected for all mothers and neonates enrolled. Primary outcomes were clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality in neonates during the first 60 days of life. Incidence proportion of livebirths for clinically suspected sepsis and laboratory-confirmed sepsis and incidence rate per 1000 neonate-days for all-cause mortality were calculated. Modified Poisson regression was used to investigate factors associated with neonatal sepsis and parametric survival models for factors associated with all-cause mortality.\udFindings\udBetween Nov 12, 2015 and Feb 1, 2018, 29 483 mothers and 30 557 neonates were enrolled. The incidence of clinically suspected sepsis was 166·0 (95% CI 97·69–234·24) per 1000 livebirths, laboratory-confirmed sepsis was 46·9 (19·04–74·79) per 1000 livebirths, and all-cause mortality was 0·83 (0·37–2·00) per 1000 neonate-days. Maternal hypertension, previous maternal hospitalisation within 12 months, average or higher monthly household income, ward size (>11 beds), ward type (neonatal), living in a rural environment, preterm birth, perinatal asphyxia, and multiple births were associated with an increased risk of clinically suspected sepsis, laboratory-confirmed sepsis, and all-cause mortality. The majority (881 [72·5%] of 1215) of laboratory-confirmed sepsis cases occurred within the first 3 days of life.\udInterpretation\udFindings from this study highlight the substantial proportion of neonates who develop neonatal sepsis, and the high mortality rates among neonates with sepsis in LMICs. More efficient and effective identification of neonatal sepsis is needed to target interventions to reduce its incidence and subsequent mortality in LMICs.\udFunding\udBill & Melinda Gates Foundation.

Semaria Solomon,1,* Berhanu Yitayew,2,* Abebaw Kebede3 1Department of Microbiology, Immunology and Parasitology, St. Paul’s Hospital Millennium Medical College (SPHMMC), Addis Ababa, Ethiopia; 2College of Health Science, Debre Berhan University (DBU), Debre Berhan, Ethiopia; 3TB/HIV Research Directorate, Ethiopian Public Health Institute (EPHI), Addis Ababa, Ethiopia*These authors contributed equally to this workCorrespondence: Semaria Solomon, P.O.Box: 25181/1000, Addis Ababa, Ethiopia, Email semariasol@gmail.comIntroduction: Pregnancy can pose a risk to women on tuberculosis (TB) treatment with a threat to the wellbeing of the mother and fetus. Physiological and stress-related effects result when pregnancy occurs during TB illness and while on treatment. Hence, this study aimed to assess contraceptive utilization, unmet need among women on TB treatment, and integration of family planning (FP) services with TB clinics in Addis Ababa, Ethiopia.Methods: A facility-based cross-sectional study was conducted using an interviewer-administered questionnaire. A total of 316 women aged 18– 49 who were on TB treatment were enrolled. Contraceptive utilization rate, unmet need, and integration of FP and TB services were determined. Logistic regression models were conducted to identify factors associated with contraceptive utilization.Results: Among women on TB treatment 49 (41.9%) were using contraceptives. Out of contraceptive users, 10 (34.5%) used contraceptives to limit and 18 (62.1%) used to space. Only parity had a significant association with contraceptive utilization. Women who had 1– 3 children were less likely to use contraception than those who had ≥ 4 children. Among women who were married or sexually active, 12 (18.9%) had an unmet need. Of the study participants, 144 (45.6%) had been informed about FP services at the TB clinics.Conclusion: The contraceptive utilization rate in the current study (41.9%) is slightly higher than the national prevalence (36.2%) yet it is still low. Furthermore, the unmet need (18.9%) was lower than the national report for the general population (22%). Educating women about the risk of getting pregnant while visiting the health facility for TB medication will help to improve their chances of better recovery and avoid medication side effects on the fetus. TB guidelines can consider providing FP counseling when initiating treatment to provide women with the power of information to make deliberate decisions.Keywords: TB, contraceptive, unmet need

Introduction: Pregnancy can pose a risk to women on tuberculosis (TB) treatment with a threat to the mother, fetus, and family at large. Contraceptive counseling and provision should be an integral part of TB clinics. Physiological and stress-related effects result when pregnancy occurs on TB illness and while treatment. Hence, this study aimed to assess contraceptive utilization, unmet need among women on TB treatment, and integration of family planning (FP) services with TB clinics in Addis Ababa, Ethiopia.Methods: A facility-based cross-sectional study was conducted using an interviewer-administered questionnaire. A total of 316 women aged 18-49 who were on TB treatment were recruited from one TB referral hospital and five randomly selected health centers in Addis Ababa with a response rate of 100%. The contraceptive utilization rate, unmet need, and integration of FP and TB services were determined. Logistic regression models were conducted to identify factors associated with contraceptive utilization.Result: Among women on TB treatment 49 (41.9%) were using contraceptives. Out of contraceptive users, 10 (34.5%) used contraceptive to limit and 18 (62.1%) used to space. In multiple logistic regression only parity had a significant association with contraceptive utilization. Women who had 1-3 children had 0.351 odds of having used contraception than those who had no children (AOR=0.351, 95% CI 0.152, 0.815, p=0.001). Among women who were married or sexually active, 12 (18.9%) had an unmetneed. Of the study participants, 144 (45.6% )have been informed about FP services at the TB clinics.Conclusion: The contraceptive utilization rate of women in the current study is slightly higher than the national prevalence yet it is still very low. Furthermore, the unmet need was lower than the national report for the general population However, more attention should be given to raise awareness of utilization in this group. Educating women about the risk of getting pregnant while visiting the health facility for TB medication will help improve their chances of better recovery, avoid medication side effects on the fetus, and improve their quality of life. TB guidelines can consider providing FP couselings when initiating treatment to provide women with the power of information to make deliberate decisions.

Antimicrobial resistance in neonatal sepsis is rising, yet mechanisms of resistance that often spread between species via mobile genetic elements, ultimately limiting treatments in low- and middle-income countries (LMICs), are poorly characterized. The Burden of Antibiotic Resistance in Neonates from Developing Societies (BARNARDS) network was initiated to characterize the cause and burden of antimicrobial resistance in neonatal sepsis for seven LMICs in Africa and South Asia. A total of 36,285 neonates were enrolled in the BARNARDS study between November 2015 and December 2017, of whom 2,483 were diagnosed with culture-confirmed sepsis. Klebsiella pneumoniae (n = 258) was the main cause of neonatal sepsis, with Serratia marcescens (n = 151), Klebsiella michiganensis (n = 117), Escherichia coli (n = 75) and Enterobacter cloacae complex (n = 57) also detected. We present whole-genome sequencing, antimicrobial susceptibility and clinical data for 916 out of 1,038 neonatal sepsis isolates (97 isolates were not recovered from initial isolation at local sites). Enterobacterales (K. pneumoniae, E. coli and E. cloacae) harboured multiple cephalosporin and carbapenem resistance genes. All isolated pathogens were resistant to multiple antibiotic classes, including those used to treat neonatal sepsis. Intraspecies diversity of K. pneumoniae and E. coli indicated that multiple antibiotic-resistant lineages cause neonatal sepsis. Our results will underpin research towards better treatments for neonatal sepsis in LMICs., Genomic and clinical analysis of 916 bacterial isolates from neonates with sepsis in seven low- and middle-income countries (the BARNARDS study) reveals that the main species present were antimicrobial-resistant Klebsiella, Escherichia coli and Enterobacter.

Introduction Newborn sepsis accounts for more than a third of neonatal deaths globally and one in five neonatal deaths in Ethiopia. The first-line treatment recommended by WHO is the combination of gentamicin with ampicillin or benzylpenicillin. Gram-negative bacteria (GNB) are increasingly resistant to previously effective antibiotics. Objectives Our goal was to estimate the prevalence of antibiotic-resistant gram-negative bacteremia and identify risk factors for antibiotic resistance, among newborns with GNB sepsis. Methods At a tertiary hospital in Ethiopia, we enrolled a cohort pregnant women and their newborns, between March and December 2017. Newborns who were followed up until 60 days of life for clinical signs of sepsis. Among the newborns with clinical signs of sepsis, blood samples were cultured; bacterial species were identified and tested for antibiotic susceptibility. We described the prevalence of antibiotic resistance, identified newborn, maternal, and environmental factors associated with multidrug resistance (MDR), and combined resistance to ampicillin and gentamicin (AmpGen), using multivariable regression. Results Of the 119 newborns with gram-negative bacteremia, 80 (67%) were born preterm and 82 (70%) had early-onset sepsis. The most prevalent gram-negative species were Klebsiella pneumoniae 94 (79%) followed by Escherichia coli 10 (8%). Ampicillin resistance was found in 113 cases (95%), cefotaxime 104 (87%), gentamicin 101 (85%), AmpGen 101 (85%), piperacillin-tazobactam 47 (39%), amikacin 10 (8.4%), and Imipenem 1 (0.8%). Prevalence of MDR was 88% (n = 105). Low birthweight and late-onset sepsis (LOS) were associated with higher risks of AmpGen-resistant infections. All-cause mortality was higher among newborns treated with ineffective antibiotics. Conclusion There was significant resistance to current first-line antibiotics and cephalosporins. Additional data are needed from primary care and community settings. Amikacin and piperacillin-tazobactam had lower rates of resistance; however, context-specific assessments of their potential adverse effects, their local availability, and cost-effectiveness would be necessary before selecting a new first-line regimen to help guide clinical decision-making.

Background Sepsis is a major contributor to neonatal mortality, particularly in low-income and middle-income countries (LMICs). WHO advocates ampicillin–gentamicin as first-line therapy for the management of neonatal sepsis. In the BARNARDS observational cohort study of neonatal sepsis and antimicrobial resistance in LMICs, common sepsis pathogens were characterised via whole genome sequencing (WGS) and antimicrobial resistance profiles. In this substudy of BARNARDS, we aimed to assess the use and efficacy of empirical antibiotic therapies commonly used in LMICs for neonatal sepsis. Methods In BARNARDS, consenting mother–neonates aged 0–60 days dyads were enrolled on delivery or neonatal presentation with suspected sepsis at 12 BARNARDS clinical sites in Bangladesh, Ethiopia, India, Pakistan, Nigeria, Rwanda, and South Africa. Stillborn babies were excluded from the study. Blood samples were collected from neonates presenting with clinical signs of sepsis, and WGS and minimum inhibitory concentrations for antibiotic treatment were determined for bacterial isolates from culture-confirmed sepsis. Neonatal outcome data were collected following enrolment until 60 days of life. Antibiotic usage and neonatal outcome data were assessed. Survival analyses were adjusted to take into account potential clinical confounding variables related to the birth and pathogen. Additionally, resistance profiles, pharmacokinetic–pharmacodynamic probability of target attainment, and frequency of resistance (ie, resistance defined by in-vitro growth of isolates when challenged by antibiotics) were assessed. Questionnaires on health structures and antibiotic costs evaluated accessibility and affordability. Findings Between Nov 12, 2015, and Feb 1, 2018, 36 285 neonates were enrolled into the main BARNARDS study, of whom 9874 had clinically diagnosed sepsis and 5749 had available antibiotic data. The four most commonly prescribed antibiotic combinations given to 4451 neonates (77·42%) of 5749 were ampicillin–gentamicin, ceftazidime–amikacin, piperacillin–tazobactam–amikacin, and amoxicillin clavulanate–amikacin. This dataset assessed 476 prescriptions for 442 neonates treated with one of these antibiotic combinations with WGS data (all BARNARDS countries were represented in this subset except India). Multiple pathogens were isolated, totalling 457 isolates. Reported mortality was lower for neonates treated with ceftazidime–amikacin than for neonates treated with ampicillin–gentamicin (hazard ratio [adjusted for clinical variables considered potential confounders to outcomes] 0·32, 95% CI 0·14–0·72; p=0·0060). Of 390 Gram-negative isolates, 379 (97·2%) were resistant to ampicillin and 274 (70·3%) were resistant to gentamicin. Susceptibility of Gram-negative isolates to at least one antibiotic in a treatment combination was noted in 111 (28·5%) to ampicillin–gentamicin; 286 (73·3%) to amoxicillin clavulanate–amikacin; 301 (77·2%) to ceftazidime–amikacin; and 312 (80·0%) to piperacillin–tazobactam–amikacin. A probability of target attainment of 80% or more was noted in 26 neonates (33·7% [SD 0·59]) of 78 with ampicillin–gentamicin; 15 (68·0% [3·84]) of 27 with amoxicillin clavulanate–amikacin; 93 (92·7% [0·24]) of 109 with ceftazidime–amikacin; and 70 (85·3% [0·47]) of 76 with piperacillin–tazobactam–amikacin. However, antibiotic and country effects could not be distinguished. Frequency of resistance was recorded most frequently with fosfomycin (in 78 isolates [68·4%] of 114), followed by colistin (55 isolates [57·3%] of 96), and gentamicin (62 isolates [53·0%] of 117). Sites in six of the seven countries (excluding South Africa) stated that the cost of antibiotics would influence treatment of neonatal sepsis. Interpretation Our data raise questions about the empirical use of combined ampicillin–gentamicin for neonatal sepsis in LMICs because of its high resistance and high rates of frequency of resistance and low probability of target attainment. Accessibility and affordability need to be considered when advocating antibiotic treatments with variance in economic health structures across LMICs. Funding The Bill & Melinda Gates Foundation.

Background: Neonatal sepsis is the third leading cause of neonatal mortality, behind prematurity and intrapartum-related complications. The main objectives of this study are to assess the proportion of sepsis in preterm newborns and identify the etiologic agents and their antibiotic sensitivity patterns. Methods: A longitudinal observational study was done from July 2016 to May 2018. Whenever clinical diagnosis of sepsis was made, blood cultures and antibiotic susceptibility tests were done. Result: We did 690 blood cultures, 255 (36.9%) showing bacterial growth. The most commonly isolated bacteria were Klebsiella species 78 (36.6%), Coagulase negative Staphylococcus 42 (19.7%) and Staphylococcus aureus 39 (18.3%). Gram-positive bacteria showed high resistance to penicillin (98.9%) and ceftriaxone (91.3%) whereas Gram-negative bacteria were highly resistant to gentamicin (83.2%) and ceftriaxone (83.2%). Conclusion: Resistance to the more commonly used antibiotics such as ampicillin and gentamycin was very high, necessitating reconsideration of the empiric use of these antibiotics.

Background. Diagnosis using reliable tools and treatment followingin vitroantimicrobial susceptibility tests are critical to proper addressing of antibiotic-resistantSalmonellainfection.Methodology. A cross-sectional study was conducted to assess the practice of diagnosis and treatment of salmonellosis in Addis Ababa. Tube Widal test (for blood samples only), culture, biochemical and carbohydrate fermentation, serotyping, and antimicrobial susceptibility tests were employed for both blood and stool samples.Results. Of all the diseases listed in the diagnosis, nontyphoidal (n=72, 13.71%) and typhoidal (n=47, 8.95%) salmonellosis were the second and third common diseases. Among the 288 blood samples, almost half were positive for O, H, or both antigens. However, only 1 (0.68%) of the positive blood samples yieldedSalmonellaisolate during culture. The study demonstrated low specificity (0.68%) and positive predictive value (48.78%) of Widal test. Conversely, the test showed 100% sensitivity and negative predictive values.Salmonellaisolates were identified from 7 (7.07%) of 99 stool samples. Two-thirds of salmonellosis suspected patients received antibiotic treatment. However, only half of the confirmed salmonellosis patients were treated with appropriate antibiotics. All of the isolates were susceptible to ciprofloxacin and ceftriaxone but resistant to ampicillin.Conclusions. Majority of the patients who participated in this study were wrongly diagnosed using symptoms, clinical signs, and tube Widal test. Consequently, most of the patients received inappropriate treatment.

The natural killer (NK) cell activating receptor NKp46/NCR1 plays a critical role in elimination of virus infected and tumor cells. The NCR1 gene can be transcribed into five different splice variants, but the functional importance and physiological distribution of NKp46 isoforms are not yet fully understood. Here we shed light on differential expression of NKp46 splice variants in viral respiratory tract infections and their functional difference at the cellular level. NKp46 was the most predominantly expressed NCR in the nasal lavage of patients infected with three respiratory viruses: respiratory syncytia virus, adenovirus, human metapneumovirus, or influenza A. Noticeable correlations were observed between expression of NKp46 and IFN-γ or TNF-α, which indicates strong infiltration of and cytokine production by NK cells within the respiratory tract after viral infection. Expression of NKp30 was far lower and NKp44 was absent in all patients. Domain 1-negative NKp46 splice variants (i.e. NKp46 isoform d) were the predominantly expressed isoform in nasal lavage following viral infections. Using our unique anti-NKp46 mAb, D2-9A5, which recognizes the D2 extracellular domain, and a commercial anti-NKp46 mAb, 9E2, which recognizes D1 domain, allowed us to identify a small subset of NKp46 D1-negative splice variant-expressing cells within cultured human primary NK cells. This NKp46 D1-negative subset also showed higher degranulation efficiency in term of CD107a surface expression. NK-92 cell lines expressing NKp46 D1-negative and NKp46 D1-positive splice variants also showed functional differences when interacting with cancer cell. A NKp46 D1-negative isoform-expressing NK-92 cell line showed enhanced degranulation activity. To our knowledge, we provide the first evidence showing the physiological distribution and functional importance of human NKp46 splice variants under pathological conditions.

Background: The human cytomegalovirus (CMV) is one of the major causes of congenital infections. Maternal infection poses the risk of congenital CMV infection and occurs in 0.5%-22% of all life births. CMV is more widespread in developing countries and in communities with lower socioeconomic status. Objective: The aim of the study was to determine the prevalence of CMV infection and identify risk factors of CMV seropositivity. Method: Using cross sectional study design a total of 200 pregnant women were consecutively recruited from ANC attendees from June to July 2014. Blood samples were collected from all study participants and structured questionnaire was introduced to gather socio-demographic and risk factor related data. ELISA was used to detect anti-CMV IgG and IgM. SPSS version 20 was used to analyze the data, and regression was also applied to see the strength of association. Results: Out of 200 participants CMV-IgG and CMV-IgM were detected from 177 (88.5%), and 31 (15.5%) respectively. Women who were immune/positive only for IgG were 147 (73.5%). The second group was those who had primary infection {IgG (+) plus IgM (+)} and this consisted of 30 (15.0%) participants. Eleven percent of those participants had no anti-CMV infection. In the last category, one pregnant woman was identified as having a recent primary infection. There was no statistical significant factor detected between CMV positivity rate with any obstetrical, and socio-demographical characteristic (P-value

There is a need for rapid, practical and accurate tuberculosis diagnostic tools that are adapted to resource-poor settings in order to ensure that those affected receive proper and timely treatment. Light-Emitting-Diode microscopy (LED) has recently been endorsed by the WHO for diagnosis of TB in these countries. A much recent smear diagnosis method, PREVI Fluo TB by using LED microscopy, has been made available. However, due to the novelty of the method, there is no information available on the specificity and sensitivity when compared to established methods such as the ordinary LED-Auramine O or the classical widely used Ziehl- Neelsen (ZN) in TB positive persons. This study was undertaken to compare the sensitivity, specificity, positive predictive value and negative predictive value of PREVI Fluo TB stain with ZN method and Auramine O-LED microscopy taking culture as reference. A prospective cross sectional study was conducted in St. Paul’s Hospital Millennium Medical College, Addis Ababa, Ethiopia. Spot- Morning-Spot sputum samples from 248 TB suspected study participants were collected. The smear detection rate of PREVI Fluo TB, ZN, Auramine O and culture were found to be 35 (14.1%), 24(9.7%), 44(17.7%) and 30(12.1%) respectively. The sensitivity of the PREVI Fluo TB method was 76.67%, better than ZN and slightly less than Auramine O which were 59.07% and 78.13% respectively. Nevertheless, the specificity (94.5%) was lower than ZN (96.79%) and higher than Auramine O (91.2%). The negative likelihood ratio of PREVI Fluo TB, ZN, and Auramine O methods were 0.25, 0.45, and 0.24 respectively. The PREVI Fluo TB method had a PPV of 65.71% which is higher than the Auramine O (56.82%) but with a comparable NPV (96.71% and 96.57% respectively). The respective agreements of the ZN, Auramine O and PREVI Fluo TB methods with the gold standard were K=0.585, K=0.621 and K=0.664. There was a substantial agreement of PREVI Fluo TB result with ZN (k=0.636) and Auramine O methods (K=0.745).Given the practical benefits of PREVI Fluo TB for TB diagnosis, and comparable accuracy to the current standard of Auramine O fluorescence method and the gold standard culture, PREVI Fluo TB should be considered by TB diagnostic laboratories, as an alternative diagnostic tool for conventional Auramine O fluorescent stain.

Background: There is evidence that symptom screening for TB in HIV positive individuals misses the appropriate investigative procedures to confirm for proper diagnosing of TB. High value should be placed in ensuring that TB is diagnosed early in HIV positive individuals, which have an increased likelihood of having undetected TB and high risk of poor health outcomes in the absence of early diagnosis and treatment. Objective: The aim of the study was to determine the prevalence of TB among HIV positive individuals with asymptomatic states at St. Paul’s Hospital millennium Medical College Addis Ababa, Ethiopia. Methods: A cross-sectional study was conducted from May to August, 2014 at SPHMMC. The study included 95 (34 male and 61 female) HIV positive individuals with no TB symptoms (current cough, fever, night sweat, and weight loss). Structured questionnaire was used to collect socio-demographic and clinical related data. The prevalence of TB was determined on the basis of AFB, Xpert MTB/RIF findings and diagnosis with chest X-ray. Result: Out of the 95 participants, the prevalence of undiagnosed Tuberculosis among asymptomatic HIVpatients was 1.1%. The socio-demographic characteristics and related risk factors were not significantly associated with TB finding rate by smear positive and Xpert assay. Our finding also showed a 27% abnormal chest X- ray suggestive of TB. In these HIV positive participants, presence of a patient with previous TB history was significantly abnormal by chest X-ray finding than a patient without TB history. Conclusion: The present finding of asymptomatic undiagnosed Pulmonary TB among HIV-patient is 1.1% (both with AFB and Xpert) in the study area. This showed there is a chance of transmissions of TB to contacts before the proper diagnosis and treatment is made. While the symptom screening algorithm missed the 1.1% TB cases, the AFB technique was able to detect the asymptomatic and missed TB case that was also detected by Xpert assay. TB control programs must consider TB disease prevalence when estimating the possible performance of any screening algorithm. National TB control program should weigh the risks, benefits and cost of screening all asymptomatic and symptomatic HIV infected individuals for TB by Xpert assay.