Author Archives: Bernt Lindtjørn

Malaria control or elimination?

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Malaria controlAbout ten years ago, the global health community was cautious about aiming at malaria eradication. The experiences from the 1960s and 1970s left some severe scars on such campaigns. Recently, the Gates Foundation has led the shift in approach and mobilised others to join efforts to end the disease. However, while malaria is preventable and treatable, eradication requires new tools (see figure).

A good vaccine would be highest on the agenda. Although vaccine trials show promising results, the vaccine efficacy is unfortunately too low to eradicate the disease.

Our recent study on the prevention of malaria in the Rift Valley of Ethiopia also shows some of the limited effects of insecticide-treated bed nets. In addition, we have observed that many of the mosquito bites take place at times when people do not use their bed nets. Our mosquito studies show that indoor residual spraying with insecticides can reduce the density of mosquitoes both inside the houses as well as outside the houses. Furthermore, a recent and unpublished study from south-west Ethiopia supporter previous findings that improving housing can reduce the entomological inoculation rates, which is a measure on how dangerous the mosquitoes are in transmitting malaria.

We, therefore, also support that several new tools are required. So, maybe the time is right to assess the combination of many interventions that would include active case finding, treatment, insecticide treated bed nets, indoor residual spraying, improved housing, and other vector control measures; such as reducing the out-door density of malaria mosquitoes.

Human-biting activities of Anopheles species in Ethiopia

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Kenea O, Balkew M, Tekie H, Gebre-Michael T, Deressa W, Loha E, Lindtjørn B, Overgaard HJ: Human-biting activities of Anopheles species in south-central Ethiopia. Parasites & vectors 2016, 9(1):1-12.

Abstract

Background    Indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) are the key malaria vector control interventions in Ethiopia. The success of these interventions rely on their efficacy to repel or kill indoor feeding and resting mosquitoes. This study was undertaken to monitor human-biting patterns of Anopheles species in south-central Ethiopia.

Methods   Human-biting patterns of anophelines were monitored for 40 nights in three houses using human landing catches (HLC) both indoors and outdoors between July and November 2014, in Edo Kontola village, south-central Ethiopia. This time coincides with the major malaria transmission season in Ethiopia, which is usually between September and November. Adult mosquitoes were collected from 19:00 to 06:00 h and identified to species. Comparisons of HLC data were done using incidence rate ratio (IRR) calculated by negative binomial regression. The nocturnal biting activities of each Anopheles species was expressed as mean number of mosquitoes landing per person per hour. To assess malaria infections in Anopheles mosquitoes the presence of Plasmodium falciparum and P. vivax circumsporozoite proteins (CSP) were determined by enzyme-linked immunosorbent assay (ELISA).

Results   Altogether 3,408 adult female anophelines were collected, 2,610 (76.6 %) outdoors and 798 (23.4 %) indoors. Anopheles zeimanni was the predominant species (66.5 %) followed by An. arabiensis (24.8 %), An. pharoensis (6.8 %) and An. funestus (s.l.) (1.8 %).

The overall mean anopheline density was 3.3 times higher outdoors than indoors (65.3 vs19.9/person/night, IRR: 3.3, 95 % CI: 1.1–5.1, P = 0.001). The mean density of An. zeimanni, An. pharoensis and An. funestus (s.l.) collected outdoors was significantly higher than indoors for each species (P < 0.05). However, the mean An. arabiensis density outdoors was similar to that indoors (11.8 vs 9.4/person/night, IRR: 1.3, 95 % CI: 0.8–1.9, P = 0.335). The mean hourly human-biting density of An. arabiensis was greater outdoors than indoors and peaked between 21:00 and 22:00 h. However, An. arabiensis parous population showed high indoor man biting activities during bedtimes (22:00 to 05:00 h) when the local people were indoor and potentially protected by IRS and LLINs. All mosquito samples tested for CSP antigen were found negative to malaria parasites.

Conclusions   Results show much greater mosquito human-biting activities occurring outdoors than indoors and during early parts of the night, implying higher outdoor malaria transmission potential in the area. However, high bedtime (22:00 to 05:00 h) indoor biting activities of parous An. arabiensissuggest high potential intervention impact of IRS and LLINs on indoor malaria transmission.

New information about malnutrition in Ethiopia

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Seifu-thesis coverNew PhD: On September 16, Seifu Hagos Gebreyesus from Ethiopia, shall defend his PhD work at the University of Bergen:

Spatial variations in child undernutrition in Ethiopia: Implications for intervention strategies

Summary

Background: Ethiopia is one of the countries with the highest burden of undernutrition, with rates of stunting and underweight as high as 40% and 25%, respectively. National efforts are underway for an accelerated reduction of undernutrition by the year 2030. However, for this to occur, understanding the spatial variations in the distribution of undernutrition on a varying geographic scale, and its determinants will contribute a quite a bit to enhance planning and implementing nutrition intervention programmes.

Objectives: The aim of this thesis was to evaluate the large- and small-scale spatial variations in the distribution of undernutrition indicators, the underlying processes and the factors responsible for the observed spatial variations.

Methods: We used nationally available climate and undernutrition data to evaluate the macro-scale spatial pattern of undernutrition and its determinants. We applied a panel study design, and evaluated the effect of growing seasonal rainfall and temperature variability on the macro-scale spatial variations (Paper I). We conducted a repeated cross- sectional survey to assess the performance of the Household Food Insecurity Access Scale (HFIAS) developed internationally to measure household food insecurity. The results from this validation work were used to modify the HFIAS items for subsequent papers (Papers III and IV). We conducted a census on six randomly selected kebeles to evaluate the spatial patterns of undernutrition on a smaller scale (Paper III). For Paper IV, we conducted a cross-sectional survey on a representative sample, and employed a Bayesian geo-statistical model to help identify the risk factors for stunting, thereby accounting for the spatial structure (spatial dependency) of the data.

Results: In Paper I, we demonstrated spatial variations in the distribution of stunting across administrative zones in the country, which could be explained in part by rainfall. However, the models poorly explained the variation in stunting within an administrative zone during the study period. We indicated that a single model for all agro-ecologic zones may not be appropriate. In Paper II, we showed that the internal consistency of the HFIAS’ tools, as measured by Cronbach’s alpha, was adequate. We observed a lack of reproducibility in HFIAS score among rural households. Therefore, we modified the HFAIS tool, and used it for subsequent surveys in this thesis (Papers III and IV). In Paper III, spatial clustering on a smaller scale (within a kebele) was found for wasting and severe wasting. Spatial clustering on a higher scale (inter-kebele) was found for stunting and severe stunting. Children found within the identified cluster were 1.5 times more at risk of stunting, and nearly five times more at risk of wasting, than children residing outside this cluster. In Paper IV, we found a significant spatial heterogeneity in the distribution of stunting in the district. Using both the local Anselin Moran’s I (LISA) and the scan statistics, we identified statistically significant clusters of high value (hotspots) and a most likely significant cluster for stunting in the eastern part of the district. We found that the risk of stunting was higher among boys, children whose mother or guardian had no education and children who lived in a food-insecure household. We showed that including a spatial component (spatial structure of the data) into the Bayesian model improved the model fit compared with the model without this spatial component.

Conclusion: We demonstrated that stunting and wasting exhibited a spatial heterogeneity, both on a large and small scale, rather than being distributed randomly. We demonstrated that there is a tendency for undernourished cases (stunting and wasting) to occur near each other than to occur homogeneously. We demonstrated a micro-level spatial variation in risk and vulnerability to undernutrition in a district with a high burden of undernutrition. Identifying such areas where a population at risk lives is central in assisting a geographical targeting of intervention. We recommend further study, possibly using a trial design or implementation research approach, to help evaluate the feasibility and benefits of geographically targeting nutritional interventions.

The thesis can be downloaded here.

Important research on tuberculosis control

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Mesay-thesis title

New PhD: On September 5, Mesay Hailu Dangisso from Ethiopia, shall defend his PhD work at the University of Bergen:

Tuberculosis control in Sidama in Ethiopia. Programme performance and spatial epidemiology

The Sustainable Development Goals are to end the TB epidemic by reducing the incidence of TB by 90 % and by reducing mortality by 95% by 2035 from what was in 2015. Globally, access to TB diagnostic and treatment facilities (DOTS) has improved, and millions of TB cases have been notified and treated, which has resulted in many lives being saved. In recent years in Ethiopia, TB control services have been substantially expanded and decentralized, which has improved access to TB care. Assessing trends in TB programme performance (case notification and treatment outcomes), as well as the spatial distribution and variations of the disease, could help in understanding the differentials in accessibility to TB control services, the distribution of disease burden and help in understanding the effectiveness of TB control programmes.

We assessed the distribution of- and accessibility to TB control facilities and trends in TB control programme performance in both urban and rural settings, by age category and by gender, and assessed the case notification rates of childhood TB over 10 years. We also assessed trends of the treatment outcomes of TB cases in order to identify high-risk groups for adverse treatment outcomes. Lastly, we explored spatial distribution and spatio-temporal clustering of the disease over 10 years to identify areas with the highest TB case notifications, and to identify the spatial variations in disease occurrence.

Over 10 years, the accessibility to- and coverage of TB control facilities has improved. Thus, TB control service coverage increased by 36%, and the proportion of locations within 10 km of the nearest TB diagnostic facility also increased. However, we noted variations in physical accessibility between areas in the study area. The mean distance from the nearest smear microscopy unit was 7.6 km in 2003 and declined to 3.2 km in 2012. The substantial expansion of primary health-care services, including TB control facilities and community-based intervention, has contributed to an increase in TB CNRs and treatment outcomes. From this finding, we suggest that a concerted effort be made to improve the accessibility to TB control facilities in areas with low case notification and poor accessibility.

An analysis of the trends of TB case notification and treatment outcomes in different settings based on the correct address, by age category and gender, and place of residence, could help understand the performance of TB control programmes and the epidemiology of TB within a community. We found that the CNRs for all forms of- and smear-positive TB increased steadily between 2003 and 2012. The CNR of smear-positive TB in the 45-year and above age groups rose by nearly fourfold. The disparity between men and women in CNR declined from 16 per 100,000 people in 2003 to eight per 100,000 people in 2012, with the male to female ratio also declining from 1.3:1 to 1.1:1. The increase in CNRs could be attributed to improved access to TB care and community-based interventions.

Over a decade, treatment success increased, whereas mortality and lost-to-follow-up declined. However, more deaths occurred among smear-negative TB cases, in children and among older patients. Targeted interventions are needed to address high-risk groups for adverse treatment outcomes.

The burden of childhood TB is one of the indicators used for assessing the ongoing transmission of the disease within a community. Assessing the case notification and treatment outcome of childhood TB could provide essential evidence to help understand the effectiveness of TB control programmes and the disease burden. Thus, we assessed childhood TB case notification and treatment outcomes over a decade. The mean CNRs for new cases of TB of all forms were 30 per 100,000 children, and no decline was observed in childhood TB cases over a 10-year study period. A community-based active case-finding intervention increased TB case notification in adults and in older children (10-14-year-olds); however, the case notification did not increase among younger children (less than five-years old). This could be explained by inadequate diagnostic facilities for childhood TB despite the community-based intervention, which focuses on symptomatic screening, followed by sputum-smear microscopy and the substantial expansion of TB control services. Better diagnostic facilities and interventions are required to increase case detection, and to improve treatment outcome among younger children.

The burden of TB varies between- and within countries because of differentials in health service performance and the varying distribution of risk factors that increase the transmission of- and susceptibility to the disease. An analysis of the disease burden in coarser geographic or administrative units could hide the burden of the disease at lower administrative units. Therefore, we assessed the distribution of the disease in different geographic settings in the study area, and looked for the pattern of the disease transmission over years, as well as for evidence of spatio- temporal clustering. We found spatial variations in both the disease distribution and spatial and space-time clustering of the disease in the central, northern and northwestern areas of the study area. This could be explained by sustained transmission, disproportionate distribution of risk factors, varying access to TB care and varying TB programme performance, all of which require targeted interventions.

In conclusion, in a population with a high prevalence of tuberculosis, we show that access to tuberculosis diagnostic and treatment facilities, in addition to the performance of TB control programmes, improved from 2003 to 2012. However, we identified areas with poor accessibility to diagnostic and treatment facilities. The low and constant case notification rate in childhood TB is an area of concern, and may indicate an underdiagnosis of childhood tuberculosis. Moreover, the distribution of tuberculosis has changed over time, and in different areas, thereby suggesting a high transmission or variable access to diagnosis and treatment. As a result, the variations in case notification rates, and in accessibility to tuberculosis control services represent challenges on how to improve the organization and performance of TB control.

To download the thesis please clic here.

Smallpox and eliminating other diseases

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 Dr. Donald A. Henderson, who led the World Health Organization’s war on smallpox, administering a smallpox vaccination in Ethiopia, around 1972. The last known case was in 1977. (Photo WHO)

 

 

Dr. Donald A. Henderson was an American physician who coordinated the World Health Organisation’s efforts to eradicate smallpox. After smallpox had been declared eradicated in 1980, he returned to the US, and became the Dean of what is now the Johns Hopkins Bloomberg School of Public Health. Dr. Donald A. Henderson died this month and will be remembered as a great scientist and public health physician.

As a child in late 1950s I remember a smallpox epidemic in Dilla in Ethiopia. I was so fortunate to have met this remarkable man, and listen to a talk he had at WHO in Geneva. Because of the success in eradicating smallpox, many believe that it also should be possible to eliminate other diseases such as poliomyelitis, Guinea worm, measles, or even malaria. I find it interesting to read that Dr Henderson was rather skeptical about these new eradication initiatives. Both the characteristics of the diseases, as well as the efforts put into getting rid of the diseases differed from what was the strategy to eradicate smallpox.

Incidence of tuberculosis among school-going adolescents in South India

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Uppada DR, Selvam S, Jesuraj N, Lau EL, Doherty TM, Grewal HMS, Vaz M, Lindtjørn B: Incidence of tuberculosis among school-going adolescents in South India. BMC Public Health 2016, 16:1-11.

Background  Tuberculosis (TB) incidence data in vaccine target populations, particularly adolescents, are important for designing and powering vaccine clinical trials. Little is known about the incidence of tuberculosis among adolescents in India. The objective of current study is to estimate the incidence of pulmonary tuberculosis (PTB) disease among adolescents attending school in South India using two different surveillance methods (active and passive) and to compare the incidence between the two groups.

Methods  The study was a prospective cohort study with a 2-year follow-up period. The study was conducted in Palamaner, Chittoor District of Andhra Pradesh, South India from February 2007 to July 2010. A random sampling procedure was used to select a subset of schools to enable approximately 8000 subjects to be available for randomization in the study. A stratified randomization procedure was used to assign the selected schools to either active or passive surveillance. Participants who met the criteria for being exposed to TB were referred to the diagnostic ward for pulmonary tuberculosis confirmation. A total number of 3441 males and 3202 females between the ages 11 and less than 18 years were enrolled into the study.

Results  Of the 3102 participants in the active surveillance group, four subjects were diagnosed with definite tuberculosis, four subjects with probable tuberculosis, and 71 subjects had non-tuberculous Mycobacteria (NTM) isolated from their sputum. Of the 3541 participants in the passive surveillance group, four subjects were diagnosed with definite tuberculosis, two subjects with probable tuberculosis, and 48 subjects had non-tuberculosis Mycobacteria isolated from their sputum. The incidence of definite + probable TB was 147.60 / 100,000 person years in the active surveillance group and 87 / 100,000 person years in the passive surveillance group.

Conclusion  The incidence of pulmonary tuberculosis among adolescents in our study is lower than similar studies conducted in South Africa and Eastern Uganda – countries with a higher incidence of tuberculosis and human immunodeficiency virus (HIV) than India. The study data will inform sample design for vaccine efficacy trials among adolescents in India.

Primary and secondary anti-tuberculosis drug resistance in Ethiopia

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Hamusse S, Teshome D, Hussen M, Demissie M, Lindtjorn B. Primary and secondary anti-tuberculosis drug resistance in Hitossa District of Arsi Zone, Oromia Regional State, Central Ethiopia. BMC Public Health 2016; 16(1):

Background: Multidrug-resistant tuberculosis (MDR-TB) drugs which is resistant to the major first-line anti-TB drugs, Isoniazid and Rifampicin, has become a major global challenge in tuberculosis (TB) control programme. However, its burden at community level is not well known. Thus, the aim of study was to assess the prevalence of primary and secondary resistance to any first line anti-TB drugs and MDR TB in Hitossa District of Oromia Regional State, Central Ethiopia.

Methods: Population based cross- sectional study was conducted on individuals aged ≥15 years. Those with symptoms suggestive of TB were interviewed and two sputum specimens were collected from each and examined using Lowenstein-Jensen (LJ) culture medium. Further, the isolates were confirmed by the Ziehl-Neelsen microscopic examination method. Drug susceptibility test (DST) was also conducted on LJ medium using a simplified indirect proportion method. The resistance strains were then determined by percentage of colonies that grew on the critical concentration of Isoniazid, Streptomycin, Rifampicin and Ethambutol.

Results: The overall resistance of all forms of TB to any first-line anti-TB drug was 21.7 %. Of the total new and previously treated culture positive TB cases, 15.3 and 48.8 % respectively were found to be a resistant to any of the first-line anti-TB drugs. Further, of all forms of TB, the overall resistance of MDR-TB was 4.7 %. However, of the total new TB cases, 2.4 % had primary while 14.3 % had secondary MDR-TB. Resistance to any of the first-line anti-TB drugs (adjusted odd ratio (AOR), 8.1; 95 % CI: 2.26–29.30) and MDR-TB (AOR), 7.1; 95 % CI: 2.6–43.8) was found to be linked with previous history of anti-TB treatment.

Conclusions: The study has identified a high rate of primary and secondary resistance to any of the first-line anti-TB drugs and MDR-TB in the study area. The resistance may have resulted from sub-optimal performance of directly observed treatment short-course (DOTS) programme in the detecting infectious TB cases and cure rates in the study area. Anti-TB drug resistance is linked with previous TB treatment. There is a need to strengthen DOTS and DOTS-Plus programmes and expand MDR-TB diagnostic facilities in order to timely diagnose MDR-TB cases and provide appropriate treatment to prevent the spread of MDR-TB in Ethiopia.

The poor use bed nets less for malaria protection

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Hailu A, Lindtjørn B, Deressa W, Gari T, Loha E, Robberstad B. Equity in long-lasting insecticidal nets and indoor residual spraying for malaria prevention in a rural South Central Ethiopia. Malaria Journal 2016; 15(1): 1-11.

Background: While recognizing the recent achievement in the global fight against malaria, the disease remains a challenge to health systems in low-income countries. Beyond widespread consensuses about prioritizing malaria prevention, little is known about the prevailing status of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) across different levels of wealth strata. The aim of this study was to evaluate the socioeconomic related dimension of inequalities in malaria prevention interventions.

Methods: This study was conducted in July–August 2014 in Adami Tullu district in the South-central Ethiopia, among 6069 households. A cross-sectional data were collected on household characteristics, LLIN ownership and IRS coverage. Principal component analysis technique was used for ranking households based on socioeconomic position. The inequality was measured using concentration indices and concentration curve. Decomposition method was employed in order to quantify the percentage contribution of each socioeconomic related variable on the overall inequality.

Results: The proportion of households with at least one LLIN was 11.6 % and IRS coverage was 72.5 %. The Erreygers normalized concentration index was 0.0627 for LLIN and 0.0383 for IRS. Inequality in LLIN ownership was mainly associated with difference in housing situation, household size and access to mass-media and telecommunication service.

Conclusion: Coverage of LLIN was low and significant more likely to be owned by the rich households, whereas houses were sprayed equitably. The current mass free distribution of LLINs should be followed by periodic refill based on continuous monitoring data.

Quality of delivery care services

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Tesfaye R, Worku A, Godana W, Lindtjorn B: Client Satisfaction with Delivery Care Service and Associated Factors in the Public Health Facilities of Gamo Gofa Zone, Southwest Ethiopia:In a Resource Limited Setting. Obstetrics and Gynecology International 2016, 2016:1-7.

Background. Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. This study presents findings from a multidimensional study of client satisfaction from the Gamo Gofa Zone in Southwest Ethiopia. Methods. A facility based cross-sectional study using exit interviews was conducted from 2014. Client satisfaction was measured using a survey adopted from the Donabedian quality assessment framework. Thirteen health institutions were randomly sampled of 66 institutions in Gamo Gofa Zone. Logistic regression was used to determine predictors of client satisfaction.

Results. The overall satisfaction level of the clients in this study was 79.1% with (95% CI; 75–82). Women attending health centres were more likely satisfied than women attending hospitals . The proportion of women who complained about an unfriendly attitude or unresentful care from health workers was higher in the hospitals. The presence of support persons during child birth improved client satisfaction (AOR = 6.23 95% CI; 2.75–14.1) and women who delivered with caesarean section are four times more likely satisfied than those who deliver vaginally (AOR 3.6 95% CI; 1.44–9.06). Client satisfaction was reduced if the women had to pay for the services (AOR = 0.27 95% CI; 0.09–81).

Conclusions. The study shows that overall satisfaction level is good. More emphasis should be put on giving women friendly care, particularly at the hospitals.

 

Malaria in the Rift Valley in Ethiopia

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Gari T, Kenea O, Loha E, Deressa W, Hailu A, Balkew M, Gebre-Michael T, Robberstad B, Overgaard HJ, Lindtjørn B: Malaria incidence and entomological findings in an area targeted for a cluster-randomized controlled trial to prevent malaria in Ethiopia: results from a pilot study. Malaria Journal 2016, 15.

Background  This study was part of the work to prepare for a cluster-randomized controlled trial to evaluate the effect of combining indoor residual spraying and long-lasting insecticidal nets on malaria incidence. A pilot study was done to estimate the variations of malaria incidence among villages, combined with entomological collections and an assessment of susceptibility to insecticides in malaria vectors.

Methods  A cohort of 5309 residents from four kebeles (the lowest government administrative unit) in 996 households was followed from August to December 2013 in south-central Ethiopia. Blood samples were collected by a finger prick for a microscopic examination of malaria infections. A multilevel mixed effect model was applied to measure the predictors of malaria episode. Adult mosquitoes were collected using light traps set indoors close to a sleeping person, pyrethrum spray sheet catches and artificial outdoor pit shelters. Enzyme-linked immunosorbent assays were used to detect the sources of mosquito blood meals, while mosquito longevity was estimated based on parity. The World Health Organization’s tube bioassay test was used to assess the insecticide susceptibility status of malaria vectors to pyrethroids and carbamates.

Results  The average incidence of malaria episode was 4.6 per 10,000 person weeks of observation. The age group from 5 to 14 years (IRR = 2.7; 95 % CI 1.1–6.6) and kebeles near a lake or river (IRR = 14.2, 95 % CI 3.1–64) were significantly associated with malaria episode. Only 271 (27.3 %) of the households owned insecticide-treated nets. Of 232 adult Anophelesmosquitoes collected, Anopheles arabiensis (71.1 %) was the predominant species. The average longevity of An. arabiensiswas 14 days (range: 7–25 human blood index days). The overall human blood index (0.69) for An. arabiensis was higher than the bovine blood index (0.38). Statistically significant differences in Anopheline mosquitoes abundance were observed between the kebeles (P = 0.001). Anopheles arabiensis was susceptible to propoxur, but resistant to pyrethroids. However, An. pharoensis was susceptible to all pyrethroids and carbamates tested.

Conclusions  This study showed a high variation in malaria incidence and Anopheles between kebeles. The observed susceptibility of the malaria vectors to propoxur warrants using this insecticide for indoor residual spraying, and the results from this study will be used as a baseline for the trial.