Treating tuberculosis

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We recently published the following article:

Datiko DG, Lindtjørn B (2010) Cost and Cost-Effectiveness of Treating Smear-Positive Tuberculosis by Health Extension Workers in Ethiopia: An Ancillary Cost-Effectiveness Analysis of Community Randomized Trial. PLoS ONE 5(2): e9158. doi:10.1371/journal.pone.0009158

ABSTRACT:

Background

Evidence for policy- and decision-making related to the cost of delivering tuberculosis (TB) control is lacking in Ethiopia. We aimed to determine the cost and cost-effectiveness of involving health extension workers (HEWs) in TB treatment under a community-based initiative in Ethiopia. This paper presents an ancillary cost-effectiveness analysis of data from a RCT, from which the main outcomes have already been published.

Methodology/Principal Findings

Options of treating TB patients in the community by HEWs in the health posts and general health workers at health facility were compared in a community-randomized trial. Costs were analysed from a societal perspective in 2007 in US dollars using standard methods. We prospectively enrolled smear-positive patients, and calculated the cost-effectiveness in terms of the cost per patient successfully treated. The total cost for each successfully treated smear-positive patient was higher in health facilities (US$161.9) compared with the community-based approach (US$60.7). The total, patient and care giver costs of community-based treatment were lower than health facility DOT by 62.6%, 63.9% and 88.2%, respectively. Involving HEWs added a total cost of US$8.80 to the health service per patient treated in the health posts in the community.

Conclusions/Significance

Community-based treatment by HEWs costs only 37% of what treatment by general health workers costs for similar outcomes. Involving HEWs in TB treatment is a cost-effective treatment alternative to the health service and to the patients and their caregivers. Therefore, there is both an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia. However, community-based treatment would require initial investment for implementation, training and supervision.

Trial Registration

ClinicalTrials.gov NCT00913172

2010 AAAS

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During the last week I have attended the Annual Meeting of AAAS in San Diego. This is the largest gathering of interdisciplinary research. For me it was an interesting meeting.

I learned that much of the current research in biology and health is interdisciplinary, and mathematical modelling plays an important role in the research.

It was also interesting to learn about efforts to stop the spread in southern Africa:

  • Antiretroviral treatments (ARVs) and universal testing could stop the spread of Aids in South Africa within five years, a top scientist says.
  • In Botswana, a research group from Los Angeles is evaluating if one antiretroviral drug (monotherapy) can be given to disease free individuals and thus reduce disease incidence.

One of the main themes in many of the sessions were the increasing worry about public distrust in science. Several Leading scientists admitted the recent controversies surrounding climate research have damaged the image of science as a whole.

The President of the US National Academy of Sciences, Ralph Cicerone, said the controversial e-mail exchanges about climate change data had caused people to suspect that scientists “oppressed free speech” and that some feel that scientists are suppressing dissent.

Several speakers agreed that scientists needed to be more open about their findings. Recent polls, including one carried out by the BBC, have suggested that climate scepticism is on the rise.

Some highlights at the meeting is found here.

More time for research?

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I collaborate with several Ethiopian universities. Recently, I did some Google Scholar searches on publications from some selected universities. For example, Hawassa University has 198 references, and Arba Minch University has 66 hits. By camparison, the University of Bergen had 78000 and the University of Oslo 143000 hits. Similarly, a PubMed search showed one publication from Arba Minch University and 31 publications from Hawassa University. My own, and older University in Bergen, with a similar student population as the two Ethiopian Universities had 5900 publications.


The Ethiopian Universities are young. However, after having worked with them I notice some important differences with European universities:

  1. There are few staff with research background in Ethiopia. Many university teachers are fresh graduates from universities.
  2. The teaching and administrative load on staff at Ethiopian Universities is huge. As soon as staff receive their masters or PhD degrees, they are given higher administrative positions.
  3. On the positive side, many staff are eager to learn about research, and the number of research proposals at the universities is increasing year by year.

Recently, evaluations of higher education in Ethiopia showed the students receive training of limited practical relevance. Students are not well prepared for the tasks they meet when they start their working career.


Countries such as Ethiopia, with one of the highest expected economic growths in the world in 2010, need to strengthen their universities. I believe university teachers need to get more time to do research. This would, I think, make the teaching more research based, so the students learn from research experience in Ethiopia, and not from abstract examples found in textbooks from rich countries.


New role of senior authors

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Recently, the editors of the journals Science, Nature, and the Proceedings of the National Academy of Sciences discussed the role of senior authors.

The journals raise a new topic or requirement, and discuss the roles, duties and responsibilities of the senior authors. For example, Science now wants the senior author for a group to confirm that he or she has personally reviewed the original data. He or she must also make sure the data selected for publication in specific figures and tables have been correctly presented.

In this way, Science aims to identify a few senior authors who collectively take responsibility for all the data presented in each published paper.  Up till now, usually the first author has been asked to accept this responsibility.

This will in my view soon also raise the issue of data storage. Should the senior author also keep copies the datasets, and copies of log books?

The Editorial in Science finally wishes to promote good mentoring and the journal discusses how mentors and supervisors should be acknowledged.

2009 report on “Reducing Maternal Mortality Project”

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Deaths from maternal causes represent the leading cause of deaths among women of reproductive age in Ethiopia. Thus, in line with the Millennium Development Goal for maternal health (MDG-5), this health project aims to reduce maternal mortality among the target population by two-thirds by 2015.

Experience from other countries show that two conditions are needed to reduce maternal deaths: Staff should be able to carry out comprehensive emergency obstetric care, and these services should be available to and used by pregnant women.

Vision and aims of project

In this public programme, we work with the Southern Nations, Nationalities and Peoples’ Regional State (SNNPRS) Health Bureau of Ethiopia (RHB) to improve maternal health and reduce maternal and neonatal deaths among the target population. The target population for this project are pregnant women in the following administrative areas of south-west Ethiopia:             Gamu Gofa Zone, South Omo Zone, Basketo Special Woreda, Dirashe Special Woreda and Konso Special Woreda.

The Project works with two levels of health institutions responsible for delivery services. Health extension workers are responsible for the kebele antenatal work, and hospitals and health centres are responsible for delivery services in the woredas and zones.

Our work has four components:

  1. Train non-clinician physicians (health officers) and midwives to carry out comprehensive emergency obstetric care (see
  2. Equip institutions to carry out comprehensive obstetric services
  3. Make delivery services available through health extension workers to all local communities and thus to pregnant women among a population of 2.6 million people.
  4. Using a simple, cost-effective, and sustainable tool to monitor maternal and newborn deaths. These community-based birth and death registries use health extension workers to register all births and deaths that occur in rural communities

Work in 2009

During 2009, 10 health officers, 10 anaesthetic nurses and 10 scrub nurses received training in Arba Minch Hospital. They now work at their home institutions. It is encouraging to see the these teams of health staff at Kemba and Konso Health centres, and Chencha, Saula, Gidole and Arba Minch hospitals routinely do emergency obstetrics, including caesarean sections. In November another four health officers and anaesthesia nurses started their training. In addition, we have trained about 150 HEWs and 30 midwives and clinical nurses.

Our project represents the first try In Ethiopia to train non-clinician physicians on a larger scale, and we are encouraged to see that comprehensive obstetric care is done at health centres in Konso and Kemba. In 2009, the number of caesarean sections increased by almost fifty per cent among our target populations, and the number of institutions routinely doing emergency obstetric care increased from two to seven.

Monitoring of work

As in many other African countries, Ethiopia lacks information on how many mothers die before, during or after delivery. Thus, by involving staff from regional health authorities, universities and health colleges, we have developed tools for community based birth registries. In 2009 we carried out pilot studies, and validated the tools to register births and deaths. In December we started birth and death registration for the population in Dirashe Special Woreda. This registration will enable the project to oversee if maternal deaths are reduced by two-thirds by 2015. Two master students now study at Gondar University, and one PhD student shall soon start at the University of Bergen.

We use experienced staff to follow and support the health officers at the rural institutions. In addition we continuously review the quality of the work at all institutions. So far, the results are encouraging and are comparable similar work started in other African countries.

Priorities for 2010

In 2010 we shall continue to strengthen the institutions, and through our Quality assurance, we systematic monitor and evaluate the work to ensure that standards of quality are being met. In 2010, our main emphasis shall be to strengthen the capacity of health extension workers, health posts and smaller health centres. The goal is to improve institutional birth coverage and that pregnant women in need of institutional care are referred in time.

More information is found at:

http://www.lindtjorn.no/page1/page11/page11.html

http://bernt.w.uib.no/my-research-areas/reproductive-healthproject/reducing-maternal-and-neonatal-mortality/

http://bernt.w.uib.no/training-programme/

Influenza confusion

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For years, scientists have warned that an influenza pandemic, similar to the 1918 Spanish flu, might cause a global catastrophe.

We will remember the 2009 H1N1 pandemic more for causing confusion than catastrophe.

Although the new H1N1 virus is dangerous for the young and for pregnant women, in otherwise healthy people it causes a disease no more severe than seasonal flu. Up till now, the new H1N1 virus eventually showed more weaknesses than strengths in the world’s ability to combat such a pandemic:

  1. The World Health Organization held lengthy debates about using the name “pandemic”.
  2. When the virus was discovered, it had been circulating in humans for months. It was thus too late to control its spread with quarantines and antiviral drugs.
  3. Regrettably, many countries began useless travel bans and quarantines.
  4. WHO used consultants from the influenza vaccine industry. Only after recommending on large-scale vaccine production, did the public learn about their conflict of interests.
  5. The predictions about the extent and timing of the epidemics were poor. And, some governments, for example in Norway, scared its population by telling them that thousands would die.

Nevertheless, the biggest wake-up call has been to develop and produce vaccines on a large-scale. Unfortunately, it came too little and too late, and was only available during the pandemic’s second wave.

Each country should now review what happened. If this pandemic might serve as a trial run for the vicious killer that may come one day, there might be some important lessons that we learned.

The Bergen Summer Research School

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The Bergen Summer Research School aims to produce and disseminate research-based education to address some important global challenges. These challenges include Climate and environmental changes, health challenges and new diseases as well as widespread and severe poverty of certain groups and regions. These issues call for interdisciplinary spaces for debate, and joint learning.

Short description for the 2010 course on Research Methods in Climate Change and Health:

Global climate change may lead to changes in extreme weather events such heatwaves, droughts, extreme rainfall and severe storminess. This may affect human health by bringing about changes in the ecology of infectious diseases. To address the impact of climate change on affect human health a broad research approach including social, demographic, and economic aspects is needed.

The course will explore the links between human health and the earth’s environment, and consider the implications of those links for human health in a changing environment.

The central objective of the course is to help develop and strengthen local and regional scientific knowledge and capacity to deal with the impacts of climate variability and climate change on human health.

For full course description and syllabus: click here (PDF)

The course is by Bjerknes Centre for Climate Research and Centre for International Health at University of Bergen

Course leaders are:

  • Bernt Lindtjørn, Professor, University of Bergen, Centre for International Health
  • Asgeir Sorteberg, Associate Professor, University of Bergen, Bjerknes Centre for Climate Research
  • Ellen Viste, Research Fellow, University of Bergen, Geophysical Institute
  • Thorleif Markussen Lunde, Research Fellow, University of Bergen, Centre for International Health

Ethiopian Journal of Health Development

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The latest issue of Ethiopian Journal of Health Development contains an interesting Special Issue on its 25 years history. The Special Issue also includes an Index.

 

From a problematic start, the journal is today the most important medical and public health journal in Ethiopia. Over the last 25-years, the journal has published 704 articles in 58 regular and 12 Special issues.

 

The Journal is an Open Access Journal, and all the issues can be viewed and downloaded at ejhd.uib.no.

 

Many readers use this online service. Each month about 500 visitors read or download full-text articles. The readers come from 99 countries and most readers are from Ethiopia, United States, United Kingdom, Canada, Norway, Germany, India, Australia, Netherlands and Switzerland.