Demographic characteristics of study participants
A total of 524 school children (283 males and 241 females) were included in this study. The mean ± SD age of the participants was 12.2 ± 2.74 years. About 49% of the study participants were within the age group of 11-14 years (Table 2).
Table 2: Socio-demographic characteristics of all participants among primary school children in Gondar town, Northwest Ethiopia, January to April 2019
Characteristics of children (n = 524)
|
Frequency
|
%
|
Sex
|
Male
|
283
|
54%
|
Female
|
241
|
46%
|
Age
|
7-10
|
148
|
28.2%
|
11-14
|
257
|
49%
|
15-18
|
119
|
22.7%
|
Religion
|
Orthodox
|
419
|
80.0%
|
Muslim
|
100
|
19.1%
|
Protestant
|
2
|
0.4%
|
Catholic
|
1
|
0.2%
|
Other
|
2
|
0.4%
|
Residence
|
Rural
|
10
|
1.9%
|
Urban
|
514
|
98.1%
|
Grade level
|
1-4
|
253
|
48.3%
|
5-8
|
271
|
51.7%
|
Oropharyngeal carriage isolates
The overall prevalence of Neisseria meningitidis was 53(10.1%) (95% CI: 7.6, 12.8). Meningococcal carriage identified among male 30/53 (56.6%) was higher than females 23/53 (43.4%) (Table3).
Table 3: Distribution of oropharyngeal isolates by age, sex and school among primary school children in Gondar town, Northwest Ethiopia, January to April 2019
School
|
Age
|
N. meningitides (N=53)
|
M
|
F
|
Abiwot fire
|
7-10
|
1
|
0
|
11-14
|
3
|
0
|
15-18
|
6
|
0
|
Hibret
|
7-10
|
0
|
1
|
11-14
|
1
|
2
|
15-18
|
0
|
3
|
AtseBekafa
|
7-10
|
0
|
1
|
11-14
|
0
|
4
|
15-18
|
0
|
0
|
TsadikuYohanis
|
7-10
|
5
|
4
|
11-14
|
1
|
5
|
15-18
|
0
|
0
|
Meseret
|
7-10
|
1
|
0
|
11-14
|
7
|
0
|
15-18
|
3
|
0
|
Chechela
|
7-10
|
0
|
0
|
11-14
|
2
|
2
|
15-18
|
0
|
1
|
Total n (%)
|
30(56.6)
|
23(43.4)
|
Serogroup distribution of N. meningitidis
All types of invasive meningococcal serogroups were identified, of which, serogroup A was the leading isolate with the isolation rate of 13 (24.5%) followed by serogroup Y/W135, 11(20.7%). Serogroup B, 4 (7.5%) was the least identified isolate. Serogroup A dominates on male (15.1%) than female (9.4%) (Table 4).
Table 4: Serogroup distribution of N. meningitidis isolates by age and sex among primary school children in Gondar town, Northwest Ethiopia, January to April 2019
Age
|
Serogroups (N = 53)
|
Total n (%)
|
|
A(n=13)
|
B(n=4)
|
C(n=8)
|
Y/W135=11
|
X(n=5)
|
NG(n=12)
|
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
M
|
F
|
|
7-10
|
0
|
2
|
2
|
0
|
2
|
0
|
1
|
1
|
1
|
2
|
1
|
1
|
13(24.5)
|
11-14
|
6
|
3
|
1
|
1
|
2
|
3
|
2
|
3
|
0
|
0
|
3
|
3
|
27(50.9)
|
15-18
|
2
|
0
|
0
|
0
|
1
|
0
|
2
|
2
|
1
|
1
|
3
|
1
|
13(24.5)
|
Total
(%)
|
8
(15.1)
|
5
(9.4)
|
3
(5.7)
|
1
(1.9)
|
5
(9.4)
|
3
(5.7
|
5
(9.4
|
6
(11.3)
|
2
(3.8)
|
3
(5.7)
|
7
(13.2)
|
5
(9.4)
|
53(100)
|
Antimicrobial susceptibility patterns of N. meningitidis
Neisseria. meningitidis isolates were tested against routinely used antimicrobial agents. In this study, most of the meningococci isolates showed a high level of resistance to trimethoprim/ sulfamethoxazole (73.6%), ciprofloxacin (45.3%) and cefotaxime (35.8%). However, the majority of the isolates were susceptible to azithromycin (96.2%), chloramphenicol (92.5%) and minocycline (88.7%) (Table5).
Table 5: Antimicrobial susceptibility patterns of meningococcal isolates among primary school children in Gondar town, Northwest Ethiopia, January to April 2019
Antimicrobials
|
Sensitivity
|
N. meningitidis (n= 53)
|
A=13
|
B=4
|
C=8
|
W/Y=11
|
X=5
|
NG=12
|
Total (=53)
n (%)
|
Cefotaxime
|
S
|
8
|
1
|
7
|
5
|
3
|
10
|
34(64.2)
|
R
|
5
|
3
|
1
|
6
|
2
|
2
|
19 (35.8)
|
Minocycline
|
S
|
9
|
3
|
8
|
10
|
5
|
12
|
47 (88.7)
|
R
|
4
|
1
|
|
1
|
|
|
6 (11.3)
|
Meropenem
|
S
|
10
|
3
|
8
|
9
|
5
|
10
|
45 (84.9)
|
R
|
3
|
1
|
|
2
|
|
2
|
8 (15.1)
|
Azithromycin
|
S
|
12
|
4
|
8
|
10
|
5
|
12
|
51 (96.2)
|
R
|
1
|
|
|
1
|
|
|
2 (3.8)
|
Ciprofloxacin
|
S
|
7
|
2
|
6
|
4
|
2
|
7
|
28 (52.8)
|
I
|
|
|
|
1
|
|
|
1 (1.9)
|
R
|
6
|
2
|
2
|
6
|
3
|
5
|
24 (45.3)
|
Trimethoprim/ sulfamethoxazole
|
S
|
1
|
|
1
|
3
|
|
5
|
10 (18.9)
|
I
|
1
|
|
|
|
1
|
2
|
4 (7.5)
|
R
|
11
|
4
|
7
|
8
|
4
|
5
|
39 (73.6)
|
Chloramphenicol
|
S
|
13
|
3
|
8
|
8
|
5
|
12
|
49 (92.5)
|
I
|
|
|
|
1
|
|
|
1 (1.9)
|
R
|
|
1
|
|
2
|
|
|
3 (5.7)
|
Rifampin
|
S
|
8
|
2
|
7
|
8
|
5
|
9
|
39 (73.6)
|
I
|
2
|
|
1
|
|
|
1
|
4 (7.5)
|
R
|
3
|
2
|
|
2
|
|
2
|
9 (17)
|
Note: A= Serogrup A, B= Serogroup B, C= Serogroup C, W/Y= Serogroup W/Y, X= Serogroup X, NG= non-serogroupable, S=sensitive, R= resistance, I= intermediate
Multidrug resistance pattern of N. meningitidis
Multidrug resistance pattern of N. meningitis isolates was also determined. Overall, most of the meningococcal isolates showed a high level of multidrug resistance with the rate of 32(60.4%). On the serogroup level, serogroup B was 100% MDR followed by serogroup X, 80% and serogroup Y/W-135, 72.7%. Only 9 (16.9%) of the meningococcal isolates had no resistance for all class of antimicrobials tested. Similarly, about 50% of non-serogroupable (NG) isolates had no resistance to the tested class of antimicrobials (Table6).
Table 6: Multi-drug resistance pattern for Neisseria meningitidis isolates among primary school children in Gondar town, Northwest Ethiopia, January to April 2019.
Serogroup
|
Anti-microbial sensitivity pattern
|
Total
|
MDR ≥2 class
|
|
R0
|
R1
|
R2
|
R3
|
R4
|
>R5
|
|
n/N (%)
|
A
|
1
|
3
|
2
|
3
|
3
|
1
|
13
|
9/13(69.2)
|
B
|
0
|
0
|
2
|
1
|
0
|
1
|
4
|
4/4(100)
|
C
|
1
|
5
|
1
|
1
|
0
|
0
|
8
|
2/8(25)
|
Y/W135
|
1
|
2
|
3
|
2
|
1
|
2
|
11
|
8/11(72.7)
|
X
|
0
|
1
|
4
|
0
|
0
|
0
|
5
|
4/5(80)
|
NG
|
6
|
1
|
1
|
3
|
1
|
0
|
12
|
5/12(41.7)
|
Total
|
9
|
12
|
13
|
10
|
5
|
4
|
53
|
32/53 (60.4)
|
Percentile
|
16.9
|
22.7
|
24.5
|
18.9
|
9.4
|
7.6
|
100
|
60.4
|
Key: R0: No resistance for any class of antimicrobial R1: Resistance for one class of antimicrobials
R2: Resistance for two class of antimicrobial R3: Resistance for three class of antimicrobials
R4: Resistance for four class of antimicrobials R>5: Resistance for five class of antimicrobials
Associated risk factors of study participants
In this study, the average family size of students was 5.3 people per household and the average number of rooms per household was 2.3. From all study participants, 21% had a history of hospitalization at least for one day at health institutions. Of the total participants, the majority of (60.5%) had a history of tonsillectomy. among the study participants who had a history of treatment before two weeks of the study period, 19.3% had poor treatment adherence. About 10.1% of the family of the study participants smokes cigarettes while 29.2% of the family had a history of living in crowded area (Table7).
Table 7: Bivariate and multivariate analysis of risk factors for oropharnygeal carriage among primary school children in Gondar town, Northwest Ethiopia, January to April 2019
Variables
|
N. meningitidis
Yes n(%) No n(%)
|
CORa (95% C.I.) c
|
AORb (95% C.I.) c
|
P-value
|
Sex
|
Male
|
30(10.6)
|
253(89.4)
|
1.12(0.634- 1.99) ***
|
_
|
_
|
Female
|
23(9.5)
|
218(90.5)
|
1
|
_
|
_
|
Age
|
7-10
|
13(8.8)
|
135(91.2)
|
1.274(0.567 – 2.86) ***
|
_
|
_
|
11-14
|
27(10.5)
|
230(89.5)
|
1.045(0.519 -2.105) ***
|
_
|
_
|
15-18
|
13(10.9)
|
106(89.1)
|
1
|
_
|
_
|
Grade level
|
1-4
|
24(9.5)
|
229(90.5)
|
0.875(0.494 – 1.55) ***
|
_
|
_
|
5-8
|
29(10.7)
|
242(89.3)
|
1
|
_
|
_
|
Family size
|
>5
|
29(13.9)
|
180(86.1)
|
1.953(1.103-3.46) **
|
2.71(1.41-5.18)
|
0.003
|
≤5
|
24(7.6)
|
291(92.4)
|
1
|
1
|
|
Number of beds/ houses
|
Only one
|
42(10.5)
|
360(89.6)
|
1.18(0.586-2.364) ***
|
_
|
_
|
> one
|
11(9)
|
111(91)
|
1
|
_
|
_
|
Sharing utensils
|
Yes
|
48(12.1)
|
349(87.9)
|
3.356(1.31-8.62) **
|
4.15(1.49-11.58)
|
0.007
|
No
|
5(3.9)
|
122(96.1)
|
1
|
1
|
|
History of family visiting crowded area
|
Yes
|
16(10.5)
|
137(89.5)
|
1.05(0.568-1.958) ***
|
_
|
_
|
No
|
37(9.97)
|
334(90.03)
|
1
|
_
|
_
|
Visiting healthcare institutions
|
Yes
|
46(11.4)
|
358(88.6)
|
2.07(0.911-4.723) **
|
2.76(1.098-6.94)
|
0.031
|
No
|
7(5.8)
|
113(94.2)
|
1
|
_
|
_
|
Hospitalization
|
Yes
|
14(12.7)
|
96(87.3)
|
1.40(0.732-2.687) ***
|
_
|
_
|
No
|
39(9.4)
|
375(90.6)
|
1
|
_
|
_
|
Antibiotics adherence
|
Yes
|
39(12.1)
|
384(87.9)
|
1
|
_
|
_
|
No
|
14(13.9)
|
87(86.1)
|
1.584(0.824-3.05) **
|
_
|
_
|
Tonsillectomy
|
Yes
|
40(12.6)
|
277(87.4)
|
2.155(1.123-4.136) **
|
2.84(1.36-5.93)
|
0.006
|
No
|
13(6.3)
|
194(93.7)
|
1
|
1
|
|
Kitchen location
|
Indoor
|
50(11.7)
|
379(88.3)
|
4.046(1.234-13.26) **
|
5.55(1.53-20.17)
|
0.009
|
Outdoor
|
3(3.2)
|
92(96.8)
|
1
|
1
|
|
Passive smoker
|
Yes
|
8(15.1)
|
45(84.9)
|
1.68(1.25-6.82) **
|
4.62(1.65-12.89)
|
0.004
|
No
|
45(9.6)
|
426(90.4)
|
1
|
1
|
|
Number of students per class
|
≤40
|
1(1.7)
|
57(98.3)
|
1
|
1
|
|
>40
|
52(11.2)
|
414(88.8)
|
7.159(0.971-52.79) **
|
7.81(1.02-59.78)
|
0.048
|
Risk factors analysis for oropharyngeal carriage of N. meningitidis
In bivariable logistic regression analysis associated factors with P-value < 0.2 were transferred to multivariable logistic regression to the significant association of these factors. Multivariable logistic statistical analysis showed that N. meningitidis oropharyngeal carriage had a significant association with family size (Adjusted Odds Ratio (AOR; 2.71 95% CI 1.41-5.18, P= 0.003)), sharing utensils (AOR; 4.15, 95% CI 1.49-11.58, P=0.007), attending healthcare institutions (AOR;2.76, 95% CI 1.098-6.94, P=0.031),history of tonsillectomy (AOR;2.84, 95% CI 1.36-5.93, P=0.006), indoor kitchen (AOR;5.55, 95% CI, 1.53-20.17 P=0.009), parental cigarette smoking (AOR;4.62, 95% CI,1.65-12.89, P=0.004) and number of students per classroom (AOR;7.81, 95% CI, 1.02 59.78,P=0.048) (Tables 7).