Better tuberculosis control

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One of the main strategies to control tuberculosis is to find and treat people with active disease. Unfortunately, the case detection rates remain low in many countries. Thus, we need interventions to find and treat sufficient number of patients to control tuberculosis.

We investigated whether involving health extension workers (HEWs: trained community health workers) in tuberculosis control improved smear-positive case detection and treatment success rates in southern Ethiopia.

We carried out a community-randomized trial in southern Ethiopia. Involving community health workers in tuberculosis control improved the case detection and treatment success rates for smear-positive patients and for women in particular.

We think our approach improved service access, and recommend this could be applied in settings with low health service coverage and a shortage of health workers.
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Datiko DG, Lindtjørn B (2009) Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial. PLoS ONE 4(5): e5443. doi:10.1371/journal.pone.0005443

Entomology

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Understanding the mosquitoes is important for malaria control. As part of our research in Ethiopia, we collect larvae, pupae and adult mosquitoes.For example in our study area Chano, near Arba Minch in south Ethiopia, Fekadu Massebo does this every month. This is done through light traps, in-door spraying, and in pit shelters, and from breeding sites.

We do this to study species composition, adult density, feeding and resting habits, parasite infection and infectivity, longevity, and seasonality. By doing this we will find out the monthly, seasonal and annual entomological infections rates (EIR), and observe possible associations between EIR and disease burden.

Recently, we also visited the Gidole Highlands further south. Our question was if malaria transmission takes place at higher altitudes. Information from the hospital suggest that people living at an altitude of 2200 m, get malaria. We found many anopheles larvae and pupae. We shall now analyse them at Arba Minch University, and see if we can identify anopheles species that transmit malaria.

ART programme and task shifting

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The use of antiretroviral drugs, and HIV counselling and testing in Ethiopia has increased in Ethiopia. Dr Degu Dare, who was among the first to start ART at rural hospitals in Ethiopia, is the co-author of a recent paper in PLoS Medicine (1).

Has this expansion of ART affected the performance of other health programmes such as tuberculosis and maternal and child health services is the question they asked.

Very interestingly, the authors document task shifting to the health officers, nurses, and health extension workers, and that this might be responsible for the successes of the ART programme in Ethiopia. However, HIV prevention interventions and management of chronic care patients are lagging behind. This may be because doctors leave the public sector to work for NGOs.
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1. Assefa Y, Jerene D, Lulseged S, Ooms G, Van Damme W (2009) Rapid Scale-Up of Antiretroviral Treatment in Ethiopia: Successes and System-Wide Effects. PLoS Med 6(4): e1000056. doi:10.1371/ journal.pmed.1000056

Cost of HIV treatment

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As little is known about the costs of HIV treatment in Ethiopia, Asfaw Bikilla recently published a paper comparing the average cost of antiretroviral therapy in a typical district hospital in Ethiopia.

The paper provides much needed detailed cost estimates for ART provision in low resource African settings. There is a real lack of data in this area, and these data might be useful for other researchers and policy makers.

The average cost for each patient per year was US $ 235. An extra average cost of US $29 was estimated for admitted patients. The major cost driver under the ART scheme was the ART costs.

Article: Bikilla AD , Jerene D, Robberstad B and Lindtjorn B. Cost estimates of HIV care and treatment with and without anti-retroviral therapy at Arba Minch Hospital in southern Ethiopia. Cost Effectiveness and Resource Allocation 2009, 7:6doi:10.1186/1478-7547-7-6

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Malaria research in south Ethiopia

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Malaria remains one of the leading causes of sickness and death in south Ethiopia. Recent information suggests that malaria now also occurs in the highlands. Demographic changes, poverty, climate instability and change, and drug and insecticide resistance have been the hindrances to the control malaria.

We study malaria transmission in Chano near Arba Minch, and our studies include research on disease occurrence (epidemiology) and description of the mosquitoes (entomology).

We aim to describe risk factors associated with malaria incidence, and to evaluate the clinical and parasitological response to Artemether – Lumefantrine drugs. Using data from the last 10 years, we shall do mathematical and statistical modelling to see how malaria is related to the climate. In the mosquito studies, we shall determine the abundance, species composition, biting rates and resting behaviour of mosquitoes.

Intervention studies

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During the past years there has been many papers on patient and treatment delay of tuberculosis. The reasons for delay seem to be with the patient: Delay is often associated with illiteracy, distance from the health institution, gender, poverty, and knowledge about tuberculosis.

Over the years, we have also published on this topic. However, I now doubt if we a need for any more cross-sectional studies. I often receive questions from editors to review such papers, and they do not contain anything new.

So, this raises the question on how many descriptive studies do we need before doing anything for the patients? Does a study showing any association between lack of knowledge on tuberculosis prove that educating the population would reduce delay? I doubt that we can make such a conclusion.

More emphasis should be on how to reduce delay. We need more intervention studies. And these intervention studies should focus on the providers’, and not on the patients’ side. One example of an intervention study is by Estifanos Birru. He showed that active case finding reduces patient delay.

Malaria

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Climate warming may worsen development in Africa and may affect human health by bringing about changes in the ecology of infectious diseases. There is therefore a need to enhance the ability to adapt to future climate change. Malaria is a major public health problem in Ethiopia. Unfortunately, there are no practical tools to predict malaria epidemics based on climate forecasts. Such tools would be useful in making efficient use of the limited resources for malaria control.

In this project, scientists from Ethiopia and Norway shall collaborate on a programme to incorporate climate variability and forecast information for malaria epidemics. The collaboration aims to strengthen PhD and masters programmes in and will strengthen international collaboration on climate and health research.

Over a five-year period (2007 – 2011), this project will combine new population-based malaria transmission information with climate and land use variability data to develop an early warning to predict malaria epidemics in Ethiopia.

For more information please visit the EMaPS blog

About this blog

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My name is Bernt Lindtjørn. I am a professor in International Health at the University of Bergen.

I combine practical public health and clinical medicine, mostly in Ethiopia, with research and teaching.

It is important for me to see the disease control, research efforts, teaching and organizational work result in sustainable health programmes in countries with limited resources.