New and important research from Arba Minch University

Arba Minch University has recently published three important papers. This work comes from the resaearch group on malaria and leishmaniasis. You will find the references with links to fulltext papers below:

Mekuriaw W, Balkew M, Messenger LA, Yewhalaw D, Woyessa A, Massebo F. The effect of ivermectin® on fertility, fecundity and mortality of Anopheles arabiensis fed on treated men in Ethiopia. Malaria Journal. 2019;18(1).

Pareyn M, Van den Bosch E, Girma N, van Houtte N, Van Dongen S, Van der Auwera G, et al. Ecology and seasonality of sandflies and potential reservoirs of cutaneous leishmaniasis in Ochollo, a hotspot in southern Ethiopia. PLoS Negl Trop Dis. 2019;13(8):e0007667

Pareyn M, Kochora A, Van Rooy L, Eligo N, Vanden Broecke B, Girma N, et al. Feeding behavior and activity of Phlebotomus pedifer and potential reservoir hosts of Leishmania aethiopica in southwestern Ethiopia. PLoS Negl Trop Dis. 2020;14(3):e0007947.

New article: Few pregnant women seek health care in Gedeo in southern Ethiopia

Borde MT, Loha E, Johansson KA, Lindtjorn B (2019) Utilisation of health services fails to meet the needs of pregnancy-related illnesses in rural southern Ethiopia: A prospective cohort study. PLoS ONE 14(12): e0215195.

Although maternal survival has improved in the last decades, evidence on illnesses and the use of health services during pregnancy remains scarce. Therefore, we aimed to assess the incidence and risk factors for illnesses among pregnant women and measure the use of health services. A prospective cohort study was conducted in three kebeles in rural southern Ethiopia among 794 pregnant women from May 2017 to July 2018. Each woman was followed every two weeks at home. Poisson and survival regression models were used for analysis. The incidence rate of episodes of illnesses was 93 per 100 pregnant-woman-weeks (95%CI: 90.6, 94.2), with an average of eight episodes of illnesses per woman. Anaemia accounted for 22% (177 of 794 women), and hypertension 3% (21 women of 794 women). However, utilization of health services for any illness episodes was only 8% (95%CI: 7.6%, 8.9%). The main reasons for not using health services were that the women thought the illness would heal by itself, women thought the illness was not serious, women could not afford to visit the health institutions, or women lacked confidence in the health institutions. The risk factors for illnesses are having many previous pregnancies in life time (ARR = 1.42; 95%CI = 1.02, 1.96), having history of stillbirth (ARR = 1.30; 95%CI = 1.03, 1.64), having history of abortion (AHR = 1.06; 95%CI = 1.02, 1.11), and walking more than 60 minutes to access the nearest hospital (AHR = 1.08; 95%CI = 1.03, 1.14). The risk factors for low use of health services are also having history of abortion (AHR = 2.50; 95%CI = 1.00, 6.01) and walking more than 60 minutes to access the nearest hospital (AHR = 1.91; 95%CI = 1.00, 3.63). Rural Ethiopian pregnant women experience a high burden of illness during pregnancy. Unfortunately, very few of these women utilize health services.

New paper: Reversal of Choroquine resistance in Zambia

Sitali L, Mwenda MC, Miller JM, Bridges DJ, Hawela MB, Chizema-Kawesha E, Chipeta J &  Lindtjørn B. En-route to the ‘elimination’ of genotypic chloroquine resistance in Western and Southern Zambia, 14 years after chloroquine withdrawal. Malar J. 2019;18(1):391. Epub 2019/12/05.

Background  Anti-malarial resistance is, and continues to be a significant challenge in the fight against malaria and a threat to achieving malaria elimination. In Zambia, chloroquine (CQ), a safe, affordable and well-tolerated drug, was removed from use in 2003 due to high levels of resistance evidenced with treatment failure. This study sought to investigate the prevalence of chloroquine resistance markers in Southern and Western Provinces of Zambia 14 years after the withdrawal of CQ.

Methods  Data from a cross-sectional, all-age household survey, conducted during the peak malaria transmission season (April–May 2017) was analysed. During the all-age survey, socio-demographic information and coverage of malaria interventions were collected. Consenting individuals were tested for malaria with a rapid diagnostic test and a spot of blood collected on filter paper to create a dried blood spot (DBS). Photo-induced electronic transfer–polymerase chain reaction (PET–PCR) was used to analyse the DBS for the presence of all four malaria species. Plasmodium falciparum positive samples were analysed by high resolution melt (HRM) PCR to detect the presence of genotypic markers of drug resistance in the P. falciparum chloroquine resistance transporter (Pfcrt) and P. falciparum multi-drug resistance (Pfmdr) genes.

Results  A total of 181 P. falciparum positive samples were examined for pfcrt K76T and MDR N86. Of the 181 samples 155 successfully amplified for Pfcrt and 145 for Pfmdr N86. The overall prevalence of CQ drug-resistant parasites was 1.9% (3/155), with no significant difference between the two provinces. No N86Y/F mutations in the Pfmdr gene were observed in any of the sample.

Conclusion  This study reveals the return of CQ sensitive parasites in Southern and Western Provinces of Zambia 14 years after its withdrawal. Surveillance of molecular resistant markers for anti-malarials should be included in the Malaria Elimination Programme so that resistance is monitored country wide.

New article: Can we measure household Food Insecurity?

Kabalo, Bereket Yohannes, Seifu Hagos Gebreyesus, Eskindir Loha, and Bernt Lindtjørn. “Performance of an Adapted Household Food Insecurity Access Scale in Measuring Seasonality in Household Food Insecurity in Rural Ethiopia: A Cohort Analysis.” BMC Nutrition 5, no. 1 (2019/11/20 2019): 54.

Background  Seasonality poses a considerable food security challenge in Ethiopia. Yet, measuring seasonal variations in food insecurity, particularly the dimension of food access, lacks an adequately validated tool. We therefore evaluated the performance of an adapted Household Food Insecurity Access Scale (HFIAS) to estimate seasonal variations in food insecurity (FI) among subsistence villagers in Ethiopia.

Methods  We employed a cohort study design using a panel of four repeated measurements taken in June, September, and December in the year 2017, and in March 2018. The study recruited 473 villagers from the drought-affected Wolaita area in southwest Ethiopia. The performance of the HFIAS was evaluated via internal consistency (Chronbach’s alpha values) and criterion validation techniques. The set of criteria include: parallelism between affirmative responses to FI questions and wealth strata; dose-response relationship between FI and dietary intake; and also FI severity and household wealth status.

Results  This study revealed that the HFIAS had satisfactory performance in four repeated measurements. The likelihood of affirmative responses to questions about FI decreased with ascending wealth quintiles. We observed an inverse dose-response relationship between FI and wealth status, and between FI and household dietary diversity.

Conclusions  The HFIAS showed an acceptable potential for measuring seasonal variations in FI in the study area. Our findings complement efforts to evaluate the scale’s applicability in various settings, in order to promote cross-culture monitoring and comparisons. However, it required a careful adaption for contextual and cultural sensitivities.

Book Chapter: Developing a sustainable PhD programme: Experiences from southern Ethiiopia

We recently published a chapter about the ideas behind the development of our SENUPH programme in southern Ethiopia:

Lindtjørn, Bernt, Moges Tadesse, and Eskindir Loha. “Developing a Sustainable Phd Programme: Experiences from Southern Ethiopia “ Chap. 18 In Sharing Knowledge Transforming Societies. The Norhed Programme 2013 – 2020, edited by Tor Halvorsen, KS Orgeret and R Krøvel, 442-56. Cape Town, Bergen: African Minds and University of Bergen, 2019.

See book chapter here Lindtjorn-NORHED chapter 18

Reducing poverty

Intervention studies, and especially randomised controlled trials, has been in the health tool box for many years. In medicine, we usually examine one intervention and look at one outcome. About 20 years ago, economists, furthermore, began to use these powerful methods.

Now, this year’s Nobel prize in economics gives an outstanding recognition to Abhijit Banerjee, Indian born professor at Massachusetts Institute of Technology, to Esther Duflo, a French born professor also at MIT, and to Michael Kremer, professor at Harvard University.

Their great achievements are that they introduced randomised controlled trials to obtaining reliable answers about the best ways to fight poverty. They divided the question of reducing poverty into smaller and more manageable, questions – for example, the most effective interventions for improving educational outcomes or child health. They show by doing so, questions are generally best answered via carefully designed experiments among the people who are, for the most part, affected.

In the research that we do, we frequently find that poverty is an underlying cause of a health problem, as can be seen by for example malnutrition. Now, the challenge is to identify smaller steps that could reduce poverty and subsequently malnutrition using their novel concept of breaking the problems into tinier and manageable proportions.

I hope that development agencies and governments, in collaboration with universities, will use such tools to improve their work.

New article: Spatiotemporal clustering of malaria in southern-central Ethiopia: A community-based cohort study

Solomon T, Loha E, Deressa W, Gari T, Lindtjørn B (2019) Spatiotemporal clustering of malaria in southern-central Ethiopia: A community-based cohort study. PLoS ONE 14(9): e0222986.

Introduction  Understanding the spatiotemporal clustering of malaria transmission would help target interventions in settings of low malaria transmission. The aim of this study was to assess whether malaria infections were clustered in areas with long-lasting insecticidal nets (LLINs) alone, indoor residual spraying (IRS) alone, or a combination of LLINs and IRS interventions, and to determine the risk factors for the observed malaria clustering in southern-central Ethiopia.

Methods   A cohort of 34,548 individuals residing in 6,071 households was followed for 121 weeks, from October 2014 to January 2017. Both active and passive case detection mechanisms were used to identify clinical malaria episodes, and there were no geographic heterogeneity in data collection methods. Using SaTScan software v 9.4.4, a discrete Poisson model was used to identify high rates of spatial, temporal, and spatiotemporal malaria clustering. A multilevel logistic regression model was fitted to identify predictors of spatial malaria clustering.

Results   The overall incidence of malaria was 16.5 per 1,000 person-year observations. Spatial, temporal, and spatiotemporal clustering of malaria was detected in all types of malaria infection (P. falciparum, P. vivax, or mixed). Spatial clustering was identified in all study arms: for LLIN + IRS arm, a most likely cluster size of 169 cases in 305 households [relative risk (RR) = 4.54, P<0.001]; for LLIN alone arm a cluster size of 88 cases in 103 households (RR = 5.58, P<0.001); for IRS alone arm a cluster size of 58 cases in 50 households (RR = 7.15, P<0.001), and for control arm a cluster size of 147 cases in 377 households (RR = 2.78, P<0.001). Living 1 km closer to potential vector breeding sites increased the odds of being in spatial clusters by 41.32 fold (adjusted OR = 41.32, 95% CI = 3.79–138.89).

Conclusions   The risk of malaria infection varied significantly between kebeles, within kebeles, and even among households in areas targeted for different types of malaria control interventions in low malaria transmission setting. The results of this study can be used in planning and implementation of malaria control strategies at micro-geographic scale.


Low immunization coverage in Wonago district, southern Ethiopia: A community-based cross-sectional study

Hailu S, Astatkie A, Johansson KA, Lindtjørn B (2019) Low immunization coverage in Wonago district, southern Ethiopia: A community-based cross-sectional study. PLoS ONE 14(7): e0220144.

Introduction  Immunization is a cost-effective intervention that prevented more than 5 million deaths worldwide from 2010 to 2015. Despite increased vaccination coverage over the past four decades in many African countries, including Ethiopia, universal coverage has not yet been reached. Only 39% of children aged 12–23 months received full vaccinations in Ethiopia, according to the 2016 Ethiopian Demographic Health Survey. This study aimed to evaluate immunization coverage and identify individual and community factors that explain incomplete vaccination coverage among children aged 6–36 months in the Wonago district of southern Ethiopia.

Methods  We conducted a community-based, cross-sectional study in three randomly selected kebeles in the Wonago district from June to July 2017. Our nested sample of 1,116 children aged 6–36 months included 923 child-mother pairs (level 1) within kebeles (level 2). We conducted multilevel regression analysis using STATA software.

Results  Among participants, 85.0% of children aged 12–36 months received at least one vaccine, and 52.4% had complete immunization coverage. After controlling for several individual and community variables, we identified six significant predictor variables for complete immunization: Older mothers’ age (AOR = 1.05, 95% CI: 1.00–1.09), higher utilization of antenatal care (AOR = 1.36, 95% CI: 1.14–1.62), one or more tetanus-toxoid vaccination during pregnancy (AOR = 2.64, 95% CI: 1.43–4.86), mothers knowing the age at which to complete child’s vaccinations (AOR = 2.00, 95% CI: 1.25–3.20), being a female (AOR = 0.64, 95% CI: 0.43–0.95), and child receiving vitamin A supplementation within the last 6 months (AOR = 2.79, 95% CI: 1.59–4.90). We observed a clustering effect at the individual and community levels with an intra-cluster correlation coefficient of 48.1%.

Conclusions  We found low immunization coverage among children in the Wonago district of southern Ethiopia, with significant differences across communities. Promoting maternal health care and community service could enhance immunization coverage.

Bed nets, indoor spraying and malaria mosquitoes

Kenea O, Balkew M, Tekie H, Deressa W, Loha E, Lindtjørn B, et al. Impact of combining indoor residual spraying and long-lasting insecticidal nets on Anopheles arabiensis in Ethiopia: results from a cluster randomized controlled trial. Malaria Journal. 2019;18(1):182.

Background Indoor residual house spraying (IRS) and long-lasting insecticidal nets (LLINs) are the key front-line malaria vector interventions against Anopheles arabiensis, the sole primary malaria vector in Ethiopia. Universal coverage of both interventions has been promoted and there is a growing demand in combinations of interventions for malaria control and elimination. This study compared the impact on entomological outcomes of combining IRS and LLINs with either intervention alone in Adami Tullu district, south-central Ethiopia. The epidemiological outcomes were recently published on a separate paper.

Methods This factorial, cluster-randomized, controlled trial randomized villages to four study arms: IRS + LLIN, IRS, LLIN, and control. LLINs (PermaNet 2.0) were provided free of charge. IRS with propoxur was applied before the main malaria transmission season in 2014, 2015 and 2016. Adult mosquitoes were collected in randomly selected villages in each arm using CDC light trap catch (LTC) set close to a sleeping person, pyrethrum spray catch (PSC), and artificial pit shelter (PIT), for measuring mosquito host-seeking density (HSD), indoor resting density (IRD), and outdoor resting density (ORD), respectively. Human landing catch (HLC) was performed in a sub-set of villages to monitor An. arabiensis human biting rates (HBR). Mean vector densities and HBR were compared among study arms using incidence rate ratio (IRR) calculated by negative binomial regression.

Results  There were no significant differences in mean densities (HSD, IRD, ORD) and HBR of An. arabiensis between the IRS + LLIN arm and the IRS arm (p > 0.05). However, mean HSD, IRD, ORD, and HBR were significantly lower in the IRS + LLIN arm than in the LLIN alone arm (p < 0.05). All An. arabiensis tested for malaria infection were negative for Plasmodium species. For this reason, the entomological inoculation rate could not be determined.

Conclusions The IRS + LLIN were as effective as IRS alone in reducing densities and HBR of An. arabiensis. However, the effectiveness of the two interventions combined was higher than LLINs alone in reducing densities and HBR of the vector. Added impact of the combination intervention against malaria infectivity rates of An. arabiensis compared to either intervention alone remains unknown and warrants further research.

Trial registration PACTR201411000882128. Registered 8 September 2014,