Tuberculosis in South Ethiopia

Mesay-Paper 1Dangisso MH, Datiko DG, Lindtjørn B (2014) Trends of Tuberculosis Case Notification and Treatment Outcomes in the Sidama Zone, Southern Ethiopia: Ten-Year Retrospective Trend Analysis in Urban-Rural Settings. PLoS ONE 9(12): e114225. doi:10.1371/journal.pone.0114225

Background: Ethiopia is one of the high tuberculosis (TB) burden countries. An analysis of trends and differentials in case notifications and treatment outcomes of TB may help improve our understanding of the performance of TB control services. Methods: A retrospective trend analysis of TB cases was conducted in the Sidama Zone in southern Ethiopia. We registered all TB cases diagnosed and treated during 2003–2012 from all health facilities in the Sidama Zone, and analysed trends of TB case notification rates and treatment outcomes.

Results: The smear positive (PTB+) case notification rate (CNR) increased from 55 (95% CI 52.5–58.4) to 111 (95% CI 107.4–114.4) per 105 people. The CNRs of PTB+ in people older than 45 years increased by fourfold, while the mortality of cases during treatment declined from 11% to 3% for smear negative (PTB-) (X2 , trend P,0.001) and from 5% to 2% for PTB+ (X2trend, P,0.001). The treatment success was higher in rural areas (AOR 1.11; CI 95%: 1.03–1.2), less for PTB- (AOR 0.86; CI 95%: 0.80–0.92) and higher for extra-pulmonary TB (AOR 1.10; CI 95%: 1.02– 1.19) compared to PTB+. A higher lost-to-follow up was observed in men (AOR 1.15; CI 95%: 1.06–1.24) and among PTB- cases (AOR 1.14; CI 95%: 1.03–1.25). More deaths occurred in PTB-cases (AOR 1.65; 95% CI: 1.44–1.90) and among cases older than 65 years (AOR 3.86; CI 95%: 2.94–5.10). Lastly, retreatment cases had a higher mortality than new cases (6% vs 3%).

Conclusion: Over the past decade TB CNRs and treatment outcomes improved, whereas the disparities of disease burden by gender and place of residence reduced and mortality declined. Strategies should be devised to address higher risk groups for poor treatment outcomes.

Tuberculosis in the Arsi Zone in Ethiopia

Shallo D. Hamusse, Meaza Demissie, Dejene Teshome, Bernt Lindtjørn. Fifteen-year trend in treatment outcomes among patients with pulmonary smear-positive tuberculosis and its determinants in Arsi Zone, Central Ethiopia.  Glob Health Action 2014, 7: 25382

Background: Directly Observed Treatment Short course (DOTS) strategy is aimed at diagnosing 70% of infectious tuberculosis (TB) and curing 85% of it. Arsi Zone of Ethiopia piloted DOTS strategy in 1992. Since then, the trend in treatment outcomes in general and at district-level in particular has not been assessed. The aim of this study was to analyse the trend in TB treatment outcomes and audit district-level treatment outcomes in the 25 districts of Arsi Zone.

Design: A retrospective cohort study design was employed to audit pulmonary smear-positive (PTB +) patients registered between 1997 and 2011. Demographic and related data were collected from the TB unit registers between January and March 2013. The 15-year trend in treatment outcomes among PTB+ patients and district-level treatment outcomes was computed.

Results: From 14,221 evaluated PTB+ cases, 11,888 (83.6%) were successfully treated. The treatment success rate (TSR) varied from 69.3 to 92.5%, defaulter rate from 2.5 to 21.6%, death rate from 1.6 to 11.1%, and failure rate from 0 to 3.6% across the 25 districts of the zone. The trend in TSR increased from 61 to 91% with the increase of population DOTS coverage from 18 to 70%. There was a declining trend in defaulter rate from 29.9 to 2.1% and death rate from 8.8 to 5.4% over 15 years. Patients aged 25–49 years (Adjusted Odd Ratio (AOR), 0.23; 95% CI: 0.21–0.26) and ≥50 years (AOR, 0.43; 95% CI: 0.32–0.59), re-treatment cases (AOR, 0.61; 0.41, 0.67), and TB/HIV co-infection cases (AOR, 0.45; 95% CI: 0.31–0.53) were associated with unsuccessful treatment outcomes.

Conclusions: DOTS expansion and improving population DOTS coverage in Arsi has led to a significant increase in treatment success and decrease in death and defaulter rates. However, there is a major variation in treatment outcomes across the 25 districts of the zone, so district-specific intervention strategy needs to be considered. The low TSR among re-treatment cases might be due to the high rate of MDR-TB among this group, and the issue needs to be further investigated to identify the extent of the problem.


Biomass fuel in households and risk of tuberculosis

Woldesemayat EM, Datiko DG, Lindtjorn B. Use of biomass fuel in households is not a risk factor for pulmonary tuberculosis in South Ethiopia. The international journal of tuberculosis and lung disease.  2014;18(1):67-72.

SETTING: Rural settings of Sidama Zone in southern Ethiopia.

OBJECTIVE: To investigate the association between exposure to biomass fuel smoke and tuberculosis (TB).

DESIGN: A matched case control study in which cases were adult smear-positive pulmonary tuberculosis (PTB) patients on DOTS-based treatment at rural health insti- tutions. Age-matched controls were recruited from the community.

R E S U LT S : Of 355 cases, 350 (98.6%) use biomass fuel for cooking, compared to 801/804 (99.6%) controls. PTB was not associated with exposure to the biomass fuel smoke. None of the factors such as heating the house, type of stove, presence of kitchen, presence ofadequate cooking room ventilation, light source and number of rooms in the house was associated with the presence of TB. However, TB determinants such as sex, household contact with TB, history of TB treatment, smoking and presence of a smoker in the household have previously shown an association with TB.

CONCLUSION: We found no evidence of an association between the use of biomass fuel and TB. Low statistical power due to the selection of neighbourhood controls might have contributed to this negative finding. We would advise that future protocols should not use neigh- bourhood controls and that they should include measure- ments of indoor air pollution and of exposure duration.

Eskindir Loha defended his PhD thesis

On Tuesday September 3, 2013, Eskindir Loha defended his PhD thesis.

The title of the work is: “Variation in malaria transmission in southern Ethiopia: The impact of prevention strategies and a need for targeted intervention”.

Summary of Thesis

In Ethiopia, 60 per cent of the population is at risk of malaria. The transmission of the disease is unstable, and hence, the possibility of epidemics demanded continuous vigilance and preparedness of the health system. Meanwhile, the complexity of the transmission of the disease has become an impediment to retain the effectiveness of prevention and control strategies. Understanding factors that play role in disease transmission at different locations, the pattern of disease transmission, the impact of prevention and control strategies and challenges in control efforts were deemed crucial for the way forward.

This thesis analysed the local variations in the link between potential determinants of transmission – meteorological factors and malaria incidence. For this, we used datasets from 35 locations found in the Southern Nations and Nationalities People’s Region and registered within the period 1998 to 2007. The findings implied that the variability in the models to be principally attributed to regional differences, and a single model that fits all locations was not found. Although there is a biological link between meteorological factors and malaria transmission, the link is affected by local conditions and non-meteorological factors.

With the understanding of a need to incorporate non-meteorological factors, in an attempt to predict disease incidence, a detailed investigation was carried out in Chano Mille Kebele – one of the malarious Kebeles of Arba Minch Zuria district, Gamo Gofa zone, south Ethiopia. A prospective cohort study was conducted for two years with a weekly visit to each of 1,388 households. The findings showed that rainfall increased and indoor residual spraying with Deltamethrin reduced falciparum malaria incidence. Higher disease incidence was observed among males, children 5–14 years old, insecticide-treated net non-users, the poor, and people who lived closer to vector breeding site. Meanwhile, we identified spatio-temporal clusters of high disease rates within a 2.4 area of the Kebele.

Mass distribution of insecticide-treated nets neither showed community-wide benefit nor influenced the spatio-temporal clustering of malaria, though proved to be protective at the individual level. Further analysis on insecticide-treated nets showed that the proportion of insecticide-treated net use reached a maximum of 69 per cent despite a near universal coverage (98.4 per cent) was achieved. Sleeping under the insecticide-treated nets was influenced by gender, age and proximity to the vector breeding site. Factor compromising the usable life of insecticide-treated nets and a lack of convenient space to hang more than one net were reported.

The local variations in meteorology-malaria link, the heterogeneous risk carried by different population segments and the observed effect of prevention strategies may help to revisit the approaches towards malaria – for which I forwarded specific recommendations.

Use of bed nets to prevent malaria

The objective of this study was to characterize the pattern related to ITN use in one village in south Ethiopia. A huge discrepancy was reported between ownership versus utilization of insecticide-treated bed nets (ITNs). To acquire the benefits of ITNs, households need to use and not merely own them.

Eskindir Loha, Kebede Tefera and Bernt Lindtjørn. Freely distributed bed-net use among Chano Mille residents, south Ethiopia: a longitudinal study. Malaria Journal 2013, 12:23 doi:10.1186/1475-2875-12-23

Background:  A huge discrepancy was reported between ownership versus utilization of insecticide-treated bed nets (ITNs). To acquire the benefits of ITNs, households need to use and not merely own them. The objective of this study was to characterize the pattern of, and assess factors related to ITN use in one village in south Ethiopia.

Methods:  A prospective cohort study involving 8,121 residents (in 1,388 households) was carried out from April 2009 to April 2011 (101 weeks). Every week, individuals were asked whether they slept under an ITN the night before the interview. Descriptive statistics was used to report the availability and use of ITN. A negative, binomial, probability, distribution model was fitted to find out significant predictors of ITN use. Reasons for not using ITN were summarized.

Results:  The total number of ITNs available at the beginning of the study was 1,631 (1.68 ITNs per household). On week 48, 3,099 new ITNs (PermaNet2.0) were distributed freely (2.3 ITNs per household). The number of households who received at least one new ITN was 1,309 (98.4%). The percentage of children <5 years and pregnant women not using ITNs exceeded that of other adults. The mean (range; SD) ITN use fraction before and after mass distribution was 0.20 (0.15-0.27; 0.03) and 0.62 (0.47-0.69; 0.04), respectively. Before mass ITN distribution, the most frequent reason for not using ITN was having worn out bed nets (most complained the bed nets were torn by rats); and after mass ITN distribution, it was lack of convenient space to hang more than one ITN. Males, younger age groups (mainly 15–24 years) and those living away from the vector-breeding site were less likely to use ITN.

Conclusions:  The ITN use fraction reached to a maximum of 69% despite near universal coverage (98.4%) was achieved. Gender, age differences and distance from vector breeding site were associated with ITN use. Strategies may need to be designed addressing disproportions in ITN use, lack of convenient space to hang more than one ITN (for those receiving more than one), and measures to prolong usable life of ITNs.

Podoconiosis: a form of elephantiasis

Recently I read the following text in a new and good website about Podo:

“Podoconiosis (or simply ‘podo’) is a form of elephantiasis or swelling of the lower leg triggered by prolonged exposure to irritant minerals in red clay soils. There is no infectious or contagious agent: no parasite, no bacterium, no virus is involved. It was classified as a Neglected Tropical Disease by the World Health Organisation in 2011.

An estimated 4 million people in highland tropical Africa are affected with podoconiosis, and evidence suggests widespread endemicity in more than 15 countries throughout the world.

Although the disease is both preventable (by avoiding contact with irritant soil) and treatable (through simple, inexpensive foot hygiene and protection), there are as yet no government-backed assistance programs for addressing prevention and treatment of podoconiosis.

Individuals afflicted with podoconiosis suffer debilitating physical effects, including attacks when the leg becomes warm, painful and even more swollen, and are ostracised from their communities because of misconceptions about the cause of podoconiosis”.

You can read more about this important public health problem at:

Excellent for Centre for International Health

Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.


Can we improve health policy?

This is a central question in public health research. Epidemiological research aims to improve our understanding of diseases, or to improve health. Improving health often needs policy changes, either at institutional, regional or national level.

Operational research is defined as: “The search for knowledge on interventions, strategies, or tools that can improve the quality, effectiveness, or coverage of programmes in which the research is being done” 1.

Operational research involves descriptive, case–control, and cohort analysis. Some say that basic science research and randomised controlled trials is not operational research. However, effectiveness trials show if an intervention works, and should in my view form an integral part of operational research. Results from such randomised trials can benefit in diverse settings of routine care.

Many researchers believe that doing good research and publishing the results in high-quality journals lead to policy change. Unfortunately, this is a naive view. Here I present a few examples showing that policy change is more that doing good research: it wants a close cooperation with policy-makers.

Improving tuberculosis control

Although tuberculosis treatment success rates have improved in Ethiopia, low case notification rate, mainly because of inability to access the health service, remains a challenge. Using community health workers, we enrolled health extension workers in providing health education, sputum collection and treatment. This improved treatment, case detection, occurs because of increased access to the diagnostic services 2. This approach also reduced costs by 63%, and is economically attractive to the health service and patients, caregivers and the community 3.

The Ministry of Health Ethiopia recently backed this approach, and Health Extension Workers now take part in tuberculosis control in Ethiopia.

The policy change was mainly brought about by close communication and involvement of key policy people in carrying out the research.

Antiretroviral treatment in district hospitals

About  ten years ago we started antiretroviral treatment in south Ethiopia. Our question was: Is antiretroviral treatment possible to do at rural hospitals? Our group showed that antiretroviral treatment in resource limited settings  is possible 4, and cost-effective 5.

It is important for HIV infected patients to take their drugs regularly. Interruptions in treatment lead to viral strains that are resistant to the cheapest medications, and to higher rates of illness and death. Unfortunately, many AIDS patients do not return to collect their antiretroviral medications (“lost to follow-up”).

In a recent review of 2191 adult HIV patients in south Ethiopia, we show that patients now start at earlier stages of their illness. Early treatment start improved survival 6. Unfortunately, 25 per cent were lost before they started treatment. This percentage has increased during recent years. Forty per cent of those lost to follow up had died.

This are examples of research that provides  information on how antiretroviral treatment programmes work in the country,

Health care financing

About 14 years ago we started a work to make the hospital sustainable managerially and financially. These were previous mission run hospitals. Over the years, the hospitals managed to become managerially and financially sustainable within a regional context.

And, this model of hospital finance formed a part of the evidence for health care financing in Ethiopia.  The evidence came from evaluations of the hospital services and accounts, as well as external independent audits. There were no formal peer-reviewed publications.

Reducing maternal deaths

In line with the Millennium Development Goal for maternal health (MDG-5), we have since 2008 been running a health programme to reduce maternal mortality in south-west Ethiopia. Based on experience from other countries, we aimed to develop a decentralised delivery of care. Staff at remote rural health centres should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Through this public health project we train staff from many rural hospitals and health centres to do comprehensive emergency obstetric care. We also equip the institutions, and regularly carry our supervision of the work. The project strengthens the antenatal services so the health extension workers can help normal deliveries and identify and refer women in need of help during delivery to health institutions. We enable these health institutions to practise safe delivery. As most maternal deaths occur with delivery, particular attention is on intrapartum care.

After four years, the number of the health care coverage has increased from 1 per 1,3 million people (2 hospitals  for  a population of 2,6 million people) to 1 per  270.000 people (11 institutions  for a population of 2,9 million). The future success of such a programme is that local hospitals start training staff, and supervise staff at the remote health centres and hospitals.

This project is mainly an education programme, and serves as a pilot model for the region. We have presented our experiences at several meetings, and publications will soon be available. But more important, representatives from other regions visit us, and plan to use our experiences in their efforts to reduce maternal deaths.


These examples from practical health work and research in Ethiopia show we should inform people in position to change policy. Engaging policy makers in the work is often more important than publications.


1. Zachariah R, Harries AD, Ishikawa N, et al. Operational research in low-income countries: what, why, and how? Lancet Infect Dis. 2010;9:711–717.

2. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS ONE. 2009;4(5):e5443.

3. Datiko DG, Lindtjørn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS ONE. 2010;5(2):e9158.

4. Jerene D, Naess A, Lindtjørn B. Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a …. AIDS Research and Therapy. 2006.

5. Bikilla AD, Jerene D, Robberstad B, Lindtjørn B. Cost-effectiveness of anti-retroviral therapy at a district hospital in southern Ethiopia. Cost effectiveness and resource allocation : C/E. 2009;7:13.

6. Mulissa Z, Jerene D, Lindtjørn B. Patients present earlier and survival has improved, but pre-ART attrition is high in a six-year HIV cohort data from Ethiopia. PLoS ONE. 2010;5(10):e13268.


PhD Reviews

Global Health Action (GHA) is an international, peer-reviewed Open Access journal, which was launched in 2008. It is affiliated with the Umeå Centre for Global Health Research (CGH) in Sweden.

The Journal is registered in PubMed, and reaches a global audience in 190 countries.

The journal has recently started a new area of editorial content called PhD Reviews.

They invite young researchers that have recently defended their PhDs within the field of global health to write a paper based on their cover stories. One background reason for this is that Scandinavian PhDs are usually based on a set of articles synthesized into a “cover story” of some 30-50 pages. Some of these syntheses provide excellent reviews of the research area but they seldom reach beyond the host institution or the close collaborators and examiners. Condensing them into a PhD Review may also serve as incentive for the young researcher to publish their first post doc paper as a sole author.

You may find a few examples at their website,, or by clicking here to find the section ‘PhD Reviews.

200 Countries, 200 Years, 4 Minutes

I have for many years known Hans Rosling. He is a professor in Stockholm. He started working in rural Africa, described the Konzo nutritional disorder, and is now a not only an excellent teacher, but also global educator.

Please visit his homepage and download some of the very good software that he has developed. This software is free, and the teaching materials are useful tools to learn both students and professionals.

Now, please watch the film from YouTube (BBC Four):

Statistics come to life when Swedish academic superstar Hans Rosling graphically illustrates global development over the last 200 years.