Malaria, anaemia and undernutrition

On Friday June 22, 2018 Taye Gari Anaya will defend his PhD thesis at the University of Bergen. 

The title of his thesis is: “Malaria, anaemia and undernutrition in a drought-affected area of the Rift Valley of Ethiopia: Experiences from a trial to prevent malaria”.

Malaria, anaemia and malnutrition are interconnected, and often coexist in prevalent areas such as in sub-Saharan Africa, including Ethiopia. Although individuals in all ages of life are affected by these conditions, children under the age of 5 represent the most vulnerable group. Ethiopia is planning to reduce these conditions to a level where they are not public health problems Meanwhile, for the success of this aim, a description of the occurrence and interaction of malaria, anaemia and undernutrition could help to design tailored, efficient and effective control strategies.  

This thesis measures the effect of malaria prevention on anaemia reduction, and assesses the association between malaria, anaemia and undernutrition among a cohort of children aged 6 to 59 months old followed in a drought-affected rural area in south-central, Ethiopia.

The study showed a large variation in malaria incidence among villages in the same district. Despite community wide malaria prevention effort, an unexpected increase in anaemia prevalence was observed over a year. Malaria infection was a risk factor for undernutrition, although undernutrition was not a risk for malaria infection. There could be a need to prioritise villages nearer to the main mosquito breeding sites for malaria control. Moreover, a close follow-up of the nutritional status of children with malaria infection may be needed. 

Biographical

Taye Gari Ayana is from Hawassa in south Ethiopia. He completed Master degree in Public Health from Addis Ababa University in Ethiopia. From 2013 he has been affiliated with the Centre for International Health as a PhD candidate. Now he is a lecturer at the School of Public Health, at Hawassa University in Ethiopia. His supervisors were Professor Bernt Lindtjørn, Dr Eskindir Loha and Dr Wakgari Deressa. 

Maternal Mortality and Stillbirths More than Halved

The 2017 Annual report from the Centre for International Health at the University of Bergen writes about the implementation reserach in south Ethiopia:

Making standard delivery services available for all is the most important factor for improving maternal mortality. Furthermore, the study suggests that stillbirths can also be reduced if the health services focus on improved obstetric care.

Professor Bernt Lindtjørn led a project in south-western Ethiopia studying how a number of interventions could reduce maternal mortality and stillbirths. As a result of the research efforts, there was 64% reduction in maternal mortality and a 46% reduction in stillbirths.

Lindtjørn explains that there are several reasons why mothers die in childbirth, but he highlights that the main causes are insufficient numbers of institutions and trained personnel, as well as a lack of access to services (i.e. transportation) as being the most important factors.

The project’s positive results were associated with increasing the numbers of trained staff, increasing the num- bers of institutions undertaking Comprehensive Emergency Obstetric Care (CEmOC), increasing the numbers of mothers having Caesarean sections, increasing in the numbers of antenatal controls and referrals, improving access to health service, decreasing in number of home deliveries and decreasing the use of traditional birth attendants.

The goals for the project were straight forward and included making small hospitals available for rural popu- lations, improving referrals (i.e. from health posts to health centres to hospitals when necessary), undertaking additional training for non-clinical physicians, nurses, midwives, and health extension workers, making essential equipment available, and supervising the health care services on offer.

The project was based on the principle of “learning by doing” and involved short courses in Basic Emergen- cy Obstetric Care (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC), as well as anaesthesiolo- gy, scrub nursing and Continuing Medical Education (CME). It also included Master and PhD training in Public Health: one PhD and 6 master degrees resulted from the project.

The publications from this project can be viewed here.

The risk for death remains high for patients treated for tuberculosis in Ethiopia

Dangisso MH, Woldesemayat EM, Datiko DG, Lindtjorn B. Long-term outcome of smear-positive tuberculosis patients after initiation and completion of treatment: A ten-year retrospective cohort study. PLoS One. 2018;13(3):e0193396. Epub 2018/03/13. doi: 10.1371/journal.pone.0193396. PubMed PMID: 29529036; PubMed Central PMCID: PMCPMC5846790.

Background: The status of tuberculosis (TB) patients since initiation of treatment is unknown in South Ethiopia. The objective of this study was to assess the long-term outcomes of smear-positive TB patients since initiation and completion of treatment, which includes TB recurrence and mortality of TB patients.

Methods: We did a retrospective cohort study on 2,272 smear-positive TB patients who initiated treatment for TB from September 1, 2002-October 10, 2012 in health facilities in Dale district and Yirgalem town administration. We followed them from the date of start of treatment to either the date of interview or date of death.

Results: Recurrence rate of TB was 15.2 per 1000 person-years. Recurrence was higher for re-treatment cases (adjusted hazard ratio (aHR), 2.7; 95% CI, 1.4-5.3). Mortality rate of TB patients was 27.1 per 1,000 person-years. The risk was high for patients above 34 years of age (aHR, 2.1; 95% CI, 1.2-3.9), poor patients (aHR, 1.3; 95% CI, 1.0-1.8), patients with poor treatment outcomes (aHR, 6.7; 95% CI, 5.1-8.9) and for patients treated at least 3 times (aHR 4.8; 95% CI, 2.1-11.1). The excess mortality occurred among patients aged above 34 years was high (41.2/1000 person years).

Conclusions: High TB recurrence and death of TB patients was observed among our study participants. Follow-up of TB patients with the risk factors and managing them could reduce the TB burden.

Successful midway evaluations for 7 PhD students at Hawassa University

On Thursday April 25, seven PhD students admitted to the joint PhD degree programme between the Hawassa University and the University of Bergen, had their mid-way evaluations. Evaluators were senior staff from both Hawassa University and the University of Bergen.

The midway evaluation has the following goals:

  • to find the status regarding the progress and development of the individual PhD project
  • to give the candidate the possibility to present the whole project for a committee

The following students presented their research:

Alemselam Zebdewos: Preventing iron deficiency anaemia: Evaluation of amaranth grain supplementation to 2-5 years old children in southern Ethiopia, a randomized controlled trial

Samrawit Hailu: Childhood illness and health service utilization in Wonago District, South Ethiopia. A community –based cohort study

Sewhareg Belay: Intimate Partner violence during pregnancy: Prevalence, health effect and knowledge about it in Sidama zone, Southern Ethiopia

Hiwot Hailu: Assessment of school health problems in Gedeo Zone, Southern Ethiopia

Bereket Yohannes: Assessing validity of the ‘Household Food Insecurity Access Scale’, and seasonality in food insecurity and undernutrition in rural Southwest Ethiopia

Mehretu Belayneh: Magnitude, seasonality and spatial distribution of under-nutrition among children aged 6-59 months, Boricha, Southern Ethiopia

Moges Tadesse: Maternal and Neonatal illnesses, its economic burden, and health service utilisation in rural Ethiopia: A community-based prospective cohort study

Residual malaria transmission

Abraham M, Massebo F, Lindtjørn B: High entomological inoculation rate of malaria vectors in area of high coverage of interventions in southwest Ethiopia: Implication for residual malaria transmission. Parasite Epidemiology and Control 2017, 2:61-69.

Abstract
In Ethiopia, vector control is the principal strategy to reduce the burden of malaria. The entomological indicators of malaria transmission such as density, sporozoite rate and entomological inoculation rate (EIR) are parameters used to assess the impact of the interventions and the intensity of malaria transmission. The susceptibility of malaria vectors also determines the effectiveness of insecticide based vector control tools. Hence, the aim of the study was to assess the species composition, sporozoite rate and EIR, and insecticide susceptibility status of malaria vectors.

33 houses (18 for Centre for Disease Control and Prevention (CDC) light traps and 15 for exit traps) were randomly selected to sample Anopheles mosquitoes from October 2015 to May 2016. Plasmodium circum-sporozoite proteins (CSPs) of An. arabiensis and An. pharoensis were determined using Enzyme-Linked Immuno-Sorbent Assay (ELISA).

Five Anopheles species were identified from CDC Light traps and exit traps. An. arabiensis (80.2%) was the predominant species, followed by An. pharoensis (18.5%). An. pretoriensis, An. tenebrosus and An. rhodesiensis were documented in small numbers. 1056 Anopheles mosquitoes were tested for CSPs. Of which nine (eight An. arabiensis and one An. pharoensis) were positive for CSPs with an overall CSP rate of 0.85% (95% CI: 0.3–1.4). Five Anopheles mosquitoes were positive for P. falciparumand four were positive for P.vivax_210. P. falciparum CSP rate of An. arabiensis was 0.46% (95% CI: 0.13–1.2) and it was 0.54% (95% CI: 0.01–2.9) for An. pharoensis. The overall EIR of An. arabiensis was 5.3 infectious bites per/person (ib/p)/eight months. An. arabiensis was resistant to dieldrin (mortality rate of 57%) and deltamethrin with mortality rates of 71% but was fully susceptible to propoxur and bendiocarb. Based on the EIR of An. arabiensis, indoor malaria transmission was high regardless of high coverage of indoor-based interventions.

Finally, there was an indoor residual malaria transmission in a village of high coverage of bed nets and where the principal malaria vector is susceptibility to propoxur and bendiocarb; insecticides currently in use for indoor residual spraying. The continuing indoor transmission of malaria in such village implies the need for new tools to supplement the existing interventions and to reduce indoor malaria transmission.

The epidemiology of highland malaria in Ethiopia: a study from Butajira area

On May 30th, 2013, Adugna Woyessa defended his PhD thesis at Addis Ababa University. The PhD thesis The epidemiology of highland malaria in Ethiopia: a study from Butajira area aims to  describe human malaria transmission  in rural south central Ethiopian highlands.

Abstract

Background:In Ethiopia, malaria is a major public health problem with seasonal and unstable distribution. Because of the country’s diverse topography and climate, transmission of malaria varies with space and time; while the variability is more pronounced in highlands with low transmission. This calls for better understanding of malaria. However, there is paucity of information on magnitudeof malaria, risk factors, effective use of vector control measures such as insecticide-treated nets in relationship with malaria infection and performance of multi-species detecting malaria rapid diagnostic tests (RDTs) where Plasmodium falciparum and Plasmodium vivax co-exist at highlands of low-endemicity.

Objectives:To describe the epidemiology of highland malaria with emphasis to the magnitude and associated factors as well as interventions in various altitudesof Butajira area, south-central Ethiopia.

METHODS: Community-based repeated cross-sectional studies were conducted in six rural kebeles of Meskan and Mareko Districts from October 2008 to June 2010in Butajira area, Ethiopia. The kebeles (Hobe, Bati Lejano, Dirama, Shershera Bido, Yeteker and Wurib) were selected in such a way that two were from one altitudinal stratum thus making a total of three strata: low (1,800-1,899 meters above sea level), mid-level (1,900-1,999 meters above sea level), and high (2,000-2,300 meters above sea level) altitudes. These kebeles are part of Demographic Surveillance System Site of the Butajira Rural Health Program). A multi-stage sampling method was used to recruit study participants. The various stages were kebeles as first-stage, villages as second-stage, and households as third-stage units.   A total of 3,393 individuals were recruited from randomly sampled 750 households in 16 villages. Probability proportion to size sampling method was applied to allocate the number of households to be sampled from each kebeleand village. The study obtained data from household interview, survey and recruiting all self-reported febrile cases.  Household interview was undertaken by trained data collectors using pre-tested structured questionnaire. Household altitude reading and geo-reference was recorded from geographical positioning system location. Seasonal blood surveys were made on quarterly basis between Oct. 2008 and Jun. 2010. From the sampled households, all family members who consented to participate were requested for blood films. Besides, self-reported febrile cases were simultaneously checked for malaria infection using RDTs. CareStartTMMalaria Plasmodium falciparum/ Plasmodium vivax combo test result was compared with microscopy. Analytical tools including descriptive statistics, multilevel analysis, principal component analysis, and complex sample analysis were employed.

Main findings: The unadjusted prevalence of malaria was found to be 0.93 % [95% CI 0.79-1.07]; of 19, 207 people, 178 were positive; adjusted prevalence of malaria was estimated at 0.78 (95% CI: 0.48-1.29); of 19, 199 people, 178 were positive. Plasmodium vivax was dominant (86.5%, n=154) and the rest of the cases were due to Plasmodium falciparum (12.4%, n=22, seven with gametocyte) and mixed infections (1.1%, n=2).The prevalence varied among villages with the highest prevalence of 2.8% in Dadesso and Horosso villages (both <1,850 masl), and the lowest prevalence of 0.0% in Sunke Wenz and Akababi village (2,100-2,180 masl). Malaria prevalence decreased with altitude: 1.91% [95% CI (1.55-2.27)] in low, 1.37% [95% CI (0.87-1.87)] in mid-level and 0.36% [95% CI (0.25-0.47)] in high altitude zones; the highest prevalence was found at low altitude between October and November 2009. Moreover, malaria varied among age groups and the variation was different at different at altitudes. It reached its peak in children aged one to four yearsYonkers at mid-level and one to nine years at low altitudes. However, its prevalence at higher altitude was low and was similar across all age groups. Plasmodium falciparum malaria occurred rarely throughout the survey periods, with relatively more cases in October-November 2009 in the low altitude zone. Plasmodium vivax was found in all survey periods. However, its prevalence differed with respect to survey period and altitude. Variables like age (children aged below five and 5-9 years), altitude (low and mid-level altitude), and in houses with holes as individual-level factors; and village-level variables explained most of the variation (ICC= 94%) in individual malaria infection. The estimates of village-level variances showed well marked differences in malaria infection.

Only 28.5% [95%CI 25.8-31.4] of the 739 households surveyed owned at least an ITN.  Household ITN ownership was associated with household heads with no formal education, male-headed households, more beds in the house, absence of mosquito source reduction, and nonexistence of main water body. Male-headed households were also more associated with increased ITN ownership than female-headed ones. Households with ITN observed hanging, two and more number of ITN owned, not doing source reduction and less than a kilometredistance from main water body showed high association with use of ITN while the presence of more ITN observed hanging was a good predictor. Higher prevalence was found among people surveyed from ITN-owning than non-ITN-owning households (2.1% versus 0.5%). Malaria infection was more often observed in households owning at least an ITN than in their counterparts (unadjusted OR 4.1 [95% C.I. 2.2-7.6]; F (1, 22) =25.2, P<0.001).

Data obtained from a total of 2,394 self-reported febrile cases: 66.8% (n=1,598) from health facilities and the rest 33.2% (n=796) from surveys. Higher proportionof Plasmodium positives and both Plasmodium falciparum and Plasmodium vivaxwere detected at health facilities compared to what was seen in the survey. However, more mixed infections were observed in the latter. Low sensitivity of the test was observed in all Plasmodium species (90.8%, 95% CI: 82.9-95.3), and Plasmodium falciparum (87.5%, 52.9-97.8) in survey; and Plasmodium vivax (92.8%, 95% CI: 89.3-95.2) at health facilities. Low specificity of Plasmodium vivax (87.5%, 95% CI: 52.9-97.8) was found at the survey and all Plasmodium species (82.7%, 95% CI: 80.5-84.8) at health facilities. Very low PPV was detected in all Plasmodium species (76.7%, 95% CI: 67.7-83.8), and Plasmodium falciparum (87.5%, 95% CI: 52.9-97.8) at the survey and all Plasmodium species (64.3%, 95% CI: 60.5-68.1) and Plasmodium falciparum (77.2%, 95% CI: 67.6-84.5) at health facilities.  Low NPV was observed in Plasmodium vivax both in the survey (87.5%, 95% CI: 52.9-97.8) and health facilities (77.2: 67.6-84.5).The measure of agreement or kappa score was almost perfect agreement in all categories, except in all Plasmodium species with substantial agreement.

Conclusions and recommendations: This thesis demonstrates that low prevalence of malaria with age and altitude dependent distribution was found in highlands with low transmission in south-central Ethiopia. Plasmodium vivax was the dominant species more prevalent throughout the survey. There was very low ITN use that might have also hardly protected children in ITN-owning households. Performance of malaria RDT detecting Plasmodium falciparum and Plasmodium vivax vary between health facility-based and survey setting for both species. A malaria intervention that prioritises children below 10 years appears to be practically feasible to reduce malaria transmission. Strengthening surveillance to help in evidence-informed decision of vector control is recommendable. Furthermore, future studies should target designing more frequent survey and application of PCR for evaluation of RDT performance.

Publications:

Woyessa A, Deressa W, Ali A, Lindtjorn B. Ownership and use of long-lasting insecticidal nets for malaria prevention in Butajira area, south-central Ethiopia: complex samples data analysis. BMC public health 2014; 14: 99.

Woyessa A, Deressa W, Ali A, Lindtjørn B. Evaluation of CareStartTM malaria Pf/Pv combo test for Plasmodium falciparum and Plasmodium vivax malaria diagnosis in Butajira area, south-central Ethiopia. Malaria Journal 2013, 12:218 doi:10.1186/1475-2875-12-218

Woyessa A, Deressa W, Ali A, Lindtjørn B. Malaria risk factors in Butajira area, south-central Ethiopia: a multilevel analysis. Malaria Journal 2013, 12:273. 

Woyessa A, Deressa W, Ali A, Lindtjørn B. Prevalence of malaria infection in Butajira area, south-central Ethiopia. Malaria Journal 2012, 11:84

The full-text thesis can be downloaded here. 

Reducing maternal deaths in Southwest Ethiopia

Lindtjørn B, Mitiku D, Zidda Z, Yaya Y (2017) Reducing Maternal Deaths in Ethiopia: Results of an Intervention Programme in Southwest Ethiopia. PLoS ONE 12(1): e0169304. doi:10.1371/journal.pone.0169304

Background  In a large population in Southwest Ethiopia (population 700,000), we carried out a complex set of interventions with the aim of reducing maternal mortality. This study evaluated the effects of several coordinated interventions to help improve effective coverage and reduce maternal deaths. Together with the Ministry of Health in Ethiopia, we designed a project to strengthen the health-care system. A particular emphasis was given to upgrade existing institutions so that they could carry out Basic (BEmOC) and Comprehensive Emergency Obstetric Care (CEmOC). Health institutions were upgraded by training non-clinical physicians and midwives by providing the institutions with essential and basic equipment, and by regular monitoring and supervision by staff competent in emergency obstetric work.

Results  In this implementation study, the maternal mortality ratio (MMR) was the primary outcome. The study was carried out from 2010 to 2013 in three districts, and we registered 38,312 births. The MMR declined by 64% during the intervention period from 477 to 219 deaths per 100,000 live births (OR 0.46; 95% CI 0.24–0.88). The decline in MMR was higher for the districts with CEmOC, while the mean number of antenatal visits for each woman was 2.6 (Inter Quartile Range 2–4). The percentage of pregnant women who attended four or more antenatal controls increased by 20%, with the number of women who delivered at home declining by 10.5% (P<0.001). Similarly, the number of deliveries at health posts, health centres and hospitals increased, and we observed a decline in the use of traditional birth attendants. Households living near to all-weather roads had lower maternal mortality rates (MMR 220) compared with households without roads (MMR 598; OR 2.72 (95% CI 1.61–4.61)).

Conclusions  Our results show that it is possible to achieve substantial reductions in maternal mortality rates over a short period of time if the effective coverage of well-known interventions is implemented.

Joint PhD Programme

Joint-PhDs are doctorates, which are done at two degree-awarding institutions. This doctorate means that you are fully registered in two universities, having to comply with admission requirements, and assessment regulations at both institutions, and it will result in one jointly awarded PhD (one diploma with the two university logos).

The other benefits for students are:

  • Access to complementary facilities and resources
  • Exposure to two cultural approaches to research
  • International student mobility
  • Enhanced acquisition of research and transferable skills, such as negotiation skills, use of videoconferencing, adaptability…
  • Better networking opportunities

Recently, Hawassa University and the University of Bergen agreed on such a joint PhD degree.

This programme is funded by The South Ethiopia Network of Universities in Public Health (SENUPH), and nine PhD students have been registered at the home institution which in this case is Hawassa University. The currently available financial support is for staff at Hawassa, Dilla and Wolaita Sodo universities. We plan to admit seven more students (four women and three men) in September 2016.

You can get more information about the admission requirements and about topics that this programme will prioritise by writing to Dr Eskindir Loha or to Professor Bernt Lindtjørn.

The structure of the joint PhD programme can be downloaded here.

Yalio Yaya defends his PhD thesis

Yaliso-front-pageThe overall objective of the PhD thesis is to measure and compare maternal and neonatal mortality and obstetric services through community- and facility-based methods in southern Ethiopia. Yaliso Yaya used four different methods to measure maternal mortality:

  1. A prospective community-based birth registry managed by health extension workers in 75 rural villages in three districts in south Ethiopia (population 421 639)
  2. A household survey conducted in 6 572 households in 15 randomly selected rural villages in the district of Bonke, with questions about pregnancy and birth outcomes in the last five years
  3. A household survey among 8 503 adult siblings using the sisterhood method
  4. A facility-based review of records in all 63 health centres and three hospitals in Gamo Gofa zone.

Neonatal mortality was measured with the second method, and emergency obstetric services were assessed through the facility-based review.

The thesis is based on a thorough and systematic registration of adverse events during several years, using multiple methods. This allows validation of estimates, and it presents detailed and precise information about maternal mortality rates from rural south Ethiopia.

A special focus of the work is on the finding that community based health workers (Health Extension Workers) can be used to generate maternal mortality data, thus alleviating the chronic problem of unavailability of valid and timely mortality data.

The PhD thesis can be downloaded here.

Measuring maternal mortality

Yaya Y, Data T, Lindtjørn B (2015) Maternal Mortality in Rural South Ethiopia: Outcomes of Community-Based Birth Registration by Health Extension Workers.PLoS ONE 10(3): e0119321. doi: 10.1371/journal.pone.0119321

Introduction
Rural communities in low-income countries lack vital registrations to track birth outcomes. We aimed to examine the feasibility of community-based birth registration and measure maternal mortality ratio (MMR) in rural south Ethiopia.

Methods
In 2010, health extension workers (HEWs) registered births and maternal deaths among 421,639 people in three districts (Derashe, Bonke, and Arba Minch Zuria). One nurse-supervisor per district provided administrative and technical support to HEWs. The primary outcomes were the feasibility of registration of a high proportion of births and measuring MMR. The secondary outcome was the proportion of skilled birth attendance. We validated the completeness of the registry and the MMR by conducting a house-to-house survey in 15 randomly selected villages in Bonke.

Results
We registered 10,987 births (81·4% of expected 13,492 births) with annual crude birth rate of 32 per 1,000 population. The validation study showed that, of 2,401 births occurred in the surveyed households within eight months of the initiation of the registry, 71·6% (1,718) were registered with similar MMRs (474 vs. 439) between the registered and unregistered births. Overall, we recorded 53 maternal deaths; MMR was 489 per 100,000 live births and 83% (44 of 53 maternal deaths) occurred at home. Ninety percent (9,863 births) were at home, 4% (430) at health posts, 2·5% (282) at health centres, and 3·5% (412) in hospitals. MMR increased if: the male partners were illiterate (609 vs. 346; p= 0·051) and the villages had no road access (946 vs. 410; p= 0·039). The validation helped to increase the registration coverage by 10% through feedback discussions.

Conclusion
It is possible to obtain a high-coverage birth registration and measure MMR in rural communities where a functional system of community health workers exists. The MMR was high in rural south Ethiopia and most births and maternal deaths occurred at home.