New Article: Trends in TB case notification over fifteen years in Arsi in Ethiopia

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Hamusse SD, Demissie M, Lindtjorn B. Trends in TB case notification over fifteen years: the case notification of 25 Districts of Arsi Zone of Oromia Regional State, Central Ethiopia. BMC public health 2014; 14(1): 304.

Background  The aims of tuberculosis (TB) control programme are to detect TB cases and treat them to disrupt transmission, decrease mortality and avert the emergence of drug resistance. In 1992, DOTS strategy was started in Arsi zone and since 1997 it has been fully implemented. However, its impact has not been assessed. The aim of this study was, to analyze the trends in TB case notification and make a comparison among the 25 districts of the zone.

Methods  A total of 41,965 TB patients registered for treatment in the study area between 1997 and 2011 were included in the study. Data on demographic characteristics, treatment unit, year of treatment and disease category were collected for each patient from the TB Unit Registers.

Results  The trends in all forms of TB and smear positive pulmonary TB (PTB+) case notification increased from 14.3 to 150 per 100,000 population, with an increment of 90.4% in fifteen years. Similarly, PTB+ case notification increased from 6.9 to 63 per 100,000 population, an increment of 89% in fifteen years. The fifteen-year average TB case notification of all forms varied from 60.2 to 636 (95% CI: 97 to 127, P<0.001) and PTB+ from 10.9 to 163 per 100,000 population (95% CI: 39 to 71, p<0.001) in the 25 districts of the zone. Rural residence (AOR, 0.23; 95% CI: 0.21 to 0.26) and districts with population ratio to DOTS sites of more than 25,000 population (AOR, 0.40; 95% CI: 0.35 to 0.46) were associated with low TB case notification. TB case notifications were significantly more common among 15-24 years of age (AOR, 1.19; 95% CI:1.03 to 1.38), PTB- (AOR, 1.46; 95% CI: 1.33 to 64) and EPTB (AOR, 1.49; 95% CI; 1.33 to 1.60) TB cases.

Conclusions  The introduction and expansion of DOTS in Arsi zone has improved the overall TB case notification. However, there is inequality in TB case notification across 25 districts of the zone. Further research is, recommended on the prevalence, incidence of TB and TB treatment outcome to see the differences in TB distribution and performance of DOTS in treatment outcomes among the districts.

Publications on Reducing Maternal Deaths

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Yaya Y, Lindtjørn B. High maternal mortality in rural south-west Ethiopia: estimate by using the sisterhood method. BMC Pregnancy and Childbirth 2012; 12: 136.

Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjørn B. Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia. BMC Health Services Research 2013; 13(1):459.

Yaya Y, Eide KT, Norheim OF, Lindtjørn B. Maternal and neonatal mortality in south-west Ethiopia: Estimates and socio-economic inequality. Under review in PLoS ONE (2014)

Yaya Y, Data T, and Lindtjørn B. Maternal mortality in rural Ethiopia: Feasibility of community-based birth registration by the Health Extension Workers (Manuscript submitted 2014).

Master Degree Thesis

Tadesse Data. Quality check household survey on community birth registry in Bonke woreda in Gamu Gofa Zone in South-west Ethiopia. 2011.Addis Continental Institute of Public Health and University of Gondar.

Meseret Girma Abate. Assessment of availability and utilisation of Emergency Obstetric Care Services In Gamo Gofa Zone, SNNRP, Ethiopia. 2011. Addis Continental Institute of Public Health and University of Gondar.

Ongoing Master degree research projects:

Rahel Tesfaye. Assessment Of Quality Of Intrapartum Care In   Gamo-Gofa Zone, SNNRP, Ethiopia. Arba Minch University, expected to finish in 2014.

Demeke Damota. Factors affecting institutional delivery in Arba Minch Town (Gamo Gofa Zone). Expected to finish in 2014.

Zillo Zidda. Topic: Results of Caesarean sections done in the RMM project.  Arba Minch University, expected to finish in 2015.

Demissew Mitike. Topic: Increasing institutional delivery rates in Seggen Zone.  Arba Minch University, expected to finish in 2015.

Planned publications:

Reducing maternal mortality in South Ethiopia: Results of a decentralised health care model (2008 – 2013): 2014 Manuscript.

Preliminary reports:

Lindtjørn B. Caesarean sections done by health officers in south-west Ethiopia. See Report (26. November 2009).

Report on Reducing maternal mortality projects in South Ethiopia (2013)

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The aim of the work is to reduce maternal deaths, reduce deaths among newborns, and increase the number of deliveries at institutions. Our work aims to strengthen the health system by improving work at institutions doing comprehensive emergency obstetrics, and at health centres doing basic emergency obstetric care.

Our work, which consists of training, supervision and equipping and supporting institutions, focus to increase quality of services and better access for women to essential delivery services, and to improve health services for newborn. We thus work with health posts in kebeles, with health centres and hospitals.

We collaborate with the Midwife School in Arba Minch, and currently they are evaluating how good midwives do their work after they graduated from the school. This will give us essential information on how to improve the quality of midwife training, and thus of RMM type of work.

To monitor this work and see if the project meets its societal objectives (reduced death rates), we register births and maternal deaths in four woredas with a population of about 600.000. Our results show that maternal deaths have since 2008 been reduced by 2/3. The number of institutions doing comprehensive emergency care is now about one institution per 250.000 people, a dramatic improvement since 2007 when the figure was one institution per 2.5 million people. The institutional delivery rates have increased substantially, and the use of traditional birth attendants is decreasing. We also see some early signs of decreasing neonatal deaths. In some areas the institutional delivery rates approach 60%. We believe the main reason for these good results is increased access to essential health care.

Even if our results are encouraging, many challenges remain. The birth registration shows that highest maternal deaths rates are among women who live in remote areas, and among women who report illness during pregnancy. One study show that children born to poor women have higher death rates compared with richer families. So, in the coming years will focus on improved quality of care, particularly focusing on improving access, and on managing illness during pregnancy. We will also try to develop tools to identify the poor that are in need of special attention.

Biomass fuel in households and risk of tuberculosis

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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.

Inadequate lifesaving emergency obstetric services in south-west Ethiopia

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Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjorn B. Lifesaving emergency obstetric services are inadequate in south-west Ethiopia: a formidable challenge to reducing maternal mortality in Ethiopia. BMC health services research 2013;13(1):459.

Background
Most maternal deaths take place during labour and within a few weeks after delivery. The availability and utilization of emergency obstetric care facilities is a key factor in reducing maternal mortality; however, there is limited evidence about how these institutions perform and how many people use emergency obstetric care facilities in rural Ethiopia. We aimed to assess the availability, quality, and utilization of emergency obstetric care services in the Gamo Gofa Zone of south-west Ethiopia.

Methods
We conducted a retrospective review of three hospitals and 63 health centres in Gamo Gofa. Using a retrospective review, we recorded obstetric services, documents, cards, and registration books of mothers treated and served in the Gamo Gofa Zone health facilities between July 2009 and June 2010.

Results
There were three basic and two comprehensive emergency obstetric care qualifying facilities for the 1,740,885 people living in Gamo Gofa. The proportion of births attended by skilled attendants in the health facilities was 6.6% of expected births, though the variation was large. Districts with a higher proportion of midwives per capita, hospitals and health centres capable of doing emergency caesarean sections had higher institutional delivery rates. There were 521 caesarean sections (0.8% of 64,413 expected deliveries and 12.3% of 4,231 facility deliveries). We recorded 79 (1.9%) maternal deaths out of 4,231 deliveries and pregnancy-related admissions at institutions, most often because of post-partum haemorrhage (42%), obstructed labour (15%) and puerperal sepsis (15%). Remote districts far from the capital of the Zone had a lower proportion of institutional deliveries (<2% of expected births compared to an overall average of 6.6%). Moreover, some remotely located institutions had very high maternal deaths (>4% of deliveries, much higher than the average 1.9%).

Conclusion
Based on a population of 1.7 million people, there should be 14 basic and four comprehensive emergency obstetric care (EmOC) facilities in the Zone. Our study found that only three basic and two comprehensive EmOC service qualifying facilities serve this large population which is below the UN’s minimum recommendation. The utilization of the existing facilities for delivery was also low, which is clearly inadequate to reduce maternal deaths to the MDG target.

Screening houses prevents malaria

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The results of this randomized trial show that screening doors and windows, and closing openings on walls and eves by mud reduced the overall indoor densities of An. arabiensis by 40%. Although screening intervention reduced indoor density of An. arabiensis at all abdominal stages, the reduction was substantially higher against unfed An. arabiensis. The intervention was based on locally bought materials, and was affordable.

 Massebo F, Lindtjorn B. The effect of screening doors and windows on indoor density of Anopheles arabiensis in south-west Ethiopia: a randomized trial. Malar J 2013; 12(1): 319.

Eskindir Loha defended his PhD thesis

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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 sq.km 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.

Two new malaria articles

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Our malaria research group recently published two new articles about malaria in south Ethiopia:

Massebo F, Balkew M, Gebre-Michael T, Lindtjorn B. Entomologic Inoculation Rates of Anopheles arabiensis in Southwestern Ethiopia. Am J Trop Med Hyg 2013.

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. 

The San Francisco Declaration on Research Assessment

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In May 2013, more than 480 researchers and 80 scientific organisations published a declaration condemning the use of the journal impact factor to measure scholarly success.  Journals and organisations such as Science, Proceedings of The National Academy Of Sciences (PNAS), Times Higher Education, and Wellcome Trust are among the organisations backing this call.

The San Francisco Declaration on Research Assessment states the journal impact factor is misused to assess the significance of work by scientists who publish in those journals. A number of themes run through these recommendations:

  • “the need to eliminate the use of journal-based metrics, such as Journal Impact Factors, in funding, appointment, and promotion considerations;
  • the need to assess research on its own merits rather than on the basis of the journal in which the research is published; and
  • the need to capitalise on the opportunities provided by online publication (such as relaxing unnecessary limits on the number of words, figures, and references in articles, and exploring new indicators of significance and impact)”.

The first and general recommendation is:  “Do not use journal-based metrics, such as Journal Impact Factors, as a surrogate measure of the quality of individual research articles, to assess an individual scientist’s contributions, or in hiring, promotion, or funding decisions.”

The declaration concludes that we need a cultural change where papers are mainly evaluated for their own scientific merit.

A note in Nature (2005) stated that research assessment “rests too heavily on the inflated status of the impact factor”. And the biologist Stephen Curry of Imperial College London wrote in a blog post: “I am sick of impact factors and so is science”.