HIV among children in Ethiopia

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Westerlund E, Jerene D, Mulissa Z, Hallström I and Lindtjørn B. Pre-ART retention in care and prevalence of tuberculosis among HIV-infected children at a district hospital in southern Ethiopia. BMC Pediatrics 2014, 14:250

Abstract

Background  The Ethiopian epidemic is currently on the wane. However, the situation for infected children is in some ways lagging behind due to low treatment coverage and deficient prevention of mother-to-child transmission. Too few studies have examined HIV infected children presenting to care in low-income countries in general. Considering the presence of local variations in the nature of the epidemic a study in Ethiopia could be of special value for the continuing fight against HIV. The aim of this study is to describe the main characteristics of children with HIV presenting to care at a district hospital in a resource-limited area in southern Ethiopia. The aim was also to analyse factors affecting pre-ART loss to follow-up, time to ART-initiation and disease stage upon presentation.

Methods  This was a prospective cohort study. The data analysed were collected in 2009 for the period January 2003 through December 2008 at Arba Minch Hospital and additional data on the ART-need in the region were obtained from official reports.

Results   The pre-ART loss to follow-up rate was 29.7%. Older children (10-14 years) presented in a later stage of their disease than younger children (76.9% vs. 45.0% in 0-4 year olds, chi-square test, chi2 = 8.8, P = 0.01). Older girls presented later than boys (100.0% vs. 57.1%, Fisher’s exact test, P = 0.02). Children aged 0-4 years were more likely to be lost to follow-up (40.0 vs. 21.8%, chi-square test, chi2 = 5.4, P = 0.02) and had a longer time to initiate ART (Cox regression analysis, HR: 0.50, 95% CI: 0.25-0.97, P = 0.04, controlling for sex, place of residence, enrolment phase and WHO clinical stage upon presentation). Neither sex was overrepresented in the sample. Tuberculosis prevalence upon presentation and previous history of tubercolosis were 14.5% and 8% respectively.

Conclusions  The loss to follow-up is alarmingly high and children present too late. Further research is needed to explore specific causes and possible solutions.

Malaria prevention trial

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MalTrials-poster-Challenges in Malaria Research1Deressa W, Loha E, Balkew M, Desalegne A, Gari T, Gebremichael T, Kenea O, Jima D, Robberstad B, Overgaard H, Lindtjorn B: Combining long-lasting insecticidal nets and indoor residual spraying for malaria prevention in Ethiopia: study protocol for a cluster randomized controlled trial. Malaria Journal 2014, 13:P25.

Poster presentation

Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the two main malaria prevention strategies in Ethiopia. Although both interventions have been shown to be effective in reducing malaria transmission when applied independently, there is conflicting evidence that the two in combination is better than either one alone. The main objectives of this trial are to determine the added protection value against malaria and to evaluate the cost-effectiveness when applying IRS and LLINs together, or LLINs or IRS independently.

This trial will be conducted in Adami Tullu district of Oromia Regional State in Ethiopia from 2014 to 2016. The project will use a cluster randomized controlled trial, with four “arms”: IRS+LLINs, LLINs alone, IRS alone and control (routine practice). The sample size includes 40 clusters in each arm, each cluster with 35-45 households. Each household and each inhabitant in the household will be given a unique identification number. Households will be mapped using global positioning system. At the start of the trial, all households in the IRS+LLINs and LLINs alone “arms” of the study will be provided new LLINs free of charge. IRS with an insecticide (propoxur) will be applied in IRS+LLINs and IRS alone arms twice a year throughout the study.

Each household will be visited weekly, and blood samples will be collected from each household member with fever or history of fever. Thick and thin blood smears will be taken by finger prick and rapid diagnostic tests will be used to detect malaria at field level. Data on all self-reporting malaria patients attending health posts will be collected. The cost-effectiveness and entomological studies will be simultaneously conducted. Analysis will be based on intention to treat principle. Ethical clearance was obtained from the Ministry of Science and Technology in Ethiopia and the University of Bergen.

This trial aims to provide evidence on the combined use of IRS and LLINs for malaria prevention. We aim to answer the following research questions: Can the combined use of LLINs and IRS significantly reduce malaria incidence compared with the use of LLIN or IRS alone? And is the reduced incidence justifiably compared to the added costs? Will the combined use of LLINs and IRS reduce vector density, infection, longevity and the entomological inoculation rate? Such data is crucial in order to maximize the impact of the intervention on malaria morbidity and mortality.

MalTrials-poster-Challenges in Malaria Research

Strengthening malaria and climate research in Ethiopia

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Lindtjorn-Malaria conference posterLindtjorn B, Loha E, Deressa W, Balkew M, Gebremichael T, Sorteberg A, Woyessa A, Animut A, Diriba K, Massebo F, et al: Strengthening malaria and climate research in Ethiopia. Malaria Journal 2014, 13:P56.

Poster presentation

The project “Ethiopian Malaria Prediction System” implemented from 2007 to 2012 combined new population-based malaria transmission information with climate and land use variability data to develop an early warning tool to predict malaria epidemics in Ethiopia. Scientists from Ethiopia and Norway collaborated to incorporate climate variability and forecast information for malaria epidemics.

Our study shows that the association between weather and malaria is complex. Statistical models can predict malaria for large areas. However, as malaria transmission varies and depends on local environmental conditions, we need to have good and local knowledge about each area. However, weather variability is the main driver of malaria in Ethiopia.

While the generation of precipitation depends on local ascent and cooling of the air, our research provided new data on the transport of moisture into the country that may improve weather forecasting. We developed a new classification of climate zones, have mapped drought episodes in Ethiopia during the last decades, and have improved seasonal weather forecasting. Our hydrology studies show that potential climate change differs among the Ethiopian river basins, with river flows being sensitive to variations in rainfall, and less to temperature changes.

The computer model, Open Malaria Warning, incorporates hydrological, meteorological, mosquito-breeding, land-use data, and cattle densities to find out when and where outbreaks are likely to occur. We validated the model with data for malaria transmission in the highlands and lowlands, characterizing malaria transmission over some years in both highlands and lowlands. This provided us with new knowledge on malaria transmission in Ethiopia, how intense the seasonal transmission is, and how malaria occurs in different populations and areas. Our study showed that indigenous malaria transmission during a non-epidemic year takes place above 2000 m altitude. We also showed the ideal temperature for malaria transmission is about 25°C, underlining that global warming may lead to increased risk of malaria in highland areas, and less in the lowlands with already high average temperatures. However, to validate such models, there is a need for several years of active monitoring of malaria cases and mosquito densities. Unfortunately, such data is rare in Africa, and we need to invest in long-term monitoring of malaria transmission.

Lindtjorn-Malaria conference poster

Tuberculosis in the Arsi Zone in Ethiopia

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Shallo D. Hamusse, Meaza Demissie, Dejene Teshome, Bernt Lindtjørn. Fifteen-year trend in treatment outcomes among patients with pulmonary smear-positive tuberculosis and its determinants in Arsi Zone, Central Ethiopia.  Glob Health Action 2014, 7: 25382 –

Background: Directly Observed Treatment Short course (DOTS) strategy is aimed at diagnosing 70% of infectious tuberculosis (TB) and curing 85% of it. Arsi Zone of Ethiopia piloted DOTS strategy in 1992. Since then, the trend in treatment outcomes in general and at district-level in particular has not been assessed. The aim of this study was to analyse the trend in TB treatment outcomes and audit district-level treatment outcomes in the 25 districts of Arsi Zone.

Design: A retrospective cohort study design was employed to audit pulmonary smear-positive (PTB +) patients registered between 1997 and 2011. Demographic and related data were collected from the TB unit registers between January and March 2013. The 15-year trend in treatment outcomes among PTB+ patients and district-level treatment outcomes was computed.

Results: From 14,221 evaluated PTB+ cases, 11,888 (83.6%) were successfully treated. The treatment success rate (TSR) varied from 69.3 to 92.5%, defaulter rate from 2.5 to 21.6%, death rate from 1.6 to 11.1%, and failure rate from 0 to 3.6% across the 25 districts of the zone. The trend in TSR increased from 61 to 91% with the increase of population DOTS coverage from 18 to 70%. There was a declining trend in defaulter rate from 29.9 to 2.1% and death rate from 8.8 to 5.4% over 15 years. Patients aged 25–49 years (Adjusted Odd Ratio (AOR), 0.23; 95% CI: 0.21–0.26) and ≥50 years (AOR, 0.43; 95% CI: 0.32–0.59), re-treatment cases (AOR, 0.61; 0.41, 0.67), and TB/HIV co-infection cases (AOR, 0.45; 95% CI: 0.31–0.53) were associated with unsuccessful treatment outcomes.

Conclusions: DOTS expansion and improving population DOTS coverage in Arsi has led to a significant increase in treatment success and decrease in death and defaulter rates. However, there is a major variation in treatment outcomes across the 25 districts of the zone, so district-specific intervention strategy needs to be considered. The low TSR among re-treatment cases might be due to the high rate of MDR-TB among this group, and the issue needs to be further investigated to identify the extent of the problem.

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Climate, food production and malnutrition

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Seifu Hagos, Torleif Lunde, Damen H Mariam, Tassew Woldehanna and Bernt Lindtjørn. Climate change, crop production and child under nutrition in Ethiopia; a longitudinal panel study. BMC Public Health 2014, 14:884 doi:10.1186/1471-2458-14-884

Background  The amount and distribution of rainfall and temperature influences household food availability, thus increasing the risk of child undernutrition. However, few studies examined the local spatial variability and the impact of temperature and rainfall on child undernutrition at a smaller scale (resolution). We conducted this study to evaluate the effect of weather variables on child under nutrition and the variations in effects across the three agroecologies of Ethiopia.

Methods  A longitudinal panel study was conducted. We used crop productions (cereals and oilseeds), livestock, monthly rainfall and temperature, and child under nutrition data for the period of 1996, 1998, 2000 and 2004. We applied panel regression fixed effects model.

Results  The study included 43 clusters (administrative zones) and 145 observations. We observed a spatiotemporal variability of rainfall, stunting and underweight. We estimated that for a given zone, one standard deviation increase in rainfall leads to 0.242 standard deviations increase in moderate stunting. Additionally, a one standard deviation increase temperature leads to 0.216 standard deviations decrease in moderate stunting. However, wasting was found to be poorly related with rainfall and temperature. But severe wasting showed a positive relationship with the quadratic term of rainfall.

Conclusions  We conclude that rainfall and temperature are partly predicting the variation in child stunting and underweight. Models vary in predicting stunting and underweight across the three agroecologic zones. This could indicate that a single model for the three agroecologies may not be not applicable.

Ownership and use of long-lasting insecticidal nets for malaria prevention in Ethiopia

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Woyessa A, Deressa W, Ali A, Lindtjorn B. Ownership and use of long-lasting insecticidal nets for malaria prevention in Butajira area, south-central Ethiopia: complex samples data analysis. BMC public health 2014; 14: 99.

BACKGROUND: Despite the encroaching of endemic malaria to highland-fringe areas above 2000 meters above sea level in Ethiopia, there is limited information on ownership and use of mosquito nets for malaria prevention. Thus, this study was designed to assess long-lasting insecticidal nets (LLIN) possession and use for malaria prevention in highland-fringe of south-central Ethiopia.

METHODS: A multi-stage sampling technique was employed to obtain household data from randomly selected households using household head interview in October and November 2008. Household LLIN possession and use was assessed using adjusted Odds Ratio obtained from complexsamples logistic regression analysis.

RESULTS: Only less than a quarter (23.1%) of 739 households interviewed owned LLINs with more differences between low (54.2%) high (3.5%) altitudes (Χ2 =253, P < 0.001). Higher LLIN ownership was observed in illiterate (adj.OR 35.1 [10.6-116.2]), male-headed (adj.OR 1.7 [1.051-2.89]), owning two or more beds (adj.OR 2.7 [1.6-4.6]), not doing draining/refilling of mosquito breeding sites (adj.OR 3.4 [2.1-5.5]) and absence of rivers or streams (adj.OR 6.4 [3.5-11.8]) of household variables. The presence of ≥2 LLINs hanging (adj.OR 21.0 [5.2-85.1]), owning two or more LLINs (adj.OR 4.8 [1.3-17.5]), not doing draining/refilling of mosquito breeding sites (adj.OR 4.2 [1.3-13.6]), low wealth status (adj.OR 3.55 [1.04-12.14]), and < 1 km distance from absence of rivers or streams (adj.OR 3.9 [1.2-12.1]) of households was associated with more likely use of LLIN. The LLIN ownership was low in the highlands, and most of the highland users bought the bed nets themselves.

CONCLUSIONS: This study found a low household LLIN ownership and use in the highland-fringe rural area. Therefore, improving the availability and teaching effective use of LLIN combined with removal of temporary mosquito breeding places should be prioritized in highland-fringe areas.

Update: RMM projects in south-west Ethiopia

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The aim of the RMM (Reducing Maternal Mortality) programme in Saggen, Gamo Gofa Zone and in Basketto is to reduce maternal and neonatal deaths.

RMM-institutionsDuring the first phase (2008 – 2011), we worked to set up and strengthen institutions doing Comprehensive Emergency Obstetric care (CEmOC). Arba Minch Hospital was the training centre, Saula Hospital and Chencha Hospital, and Kemba, Basketto and Melo Health Centres started to do caesarean sections through support by our project. All these institutions are now regularly doing caesarean.

The challenge we noted during the first phase was that large populations living in our target areas still have limited access to delivery services.

During the second phase (2012 – 2016) we aim to increase the coverage of Basic and Comprehensive Emergency Obstetric Care. Our aim is to improve the access to delivery services. We do this by strengthening health centres to do Basic Emergency Obstetric Care. We also link the work at these health centres to health posts in the kebeles, and to improve referrals to institutions doing caesarean sections.

During the last year the number of institutions doing Comprehensive Emergency Obstetric care (CEmOC) has increased by four; in Bonke woreda (Gezzeso), in Beto and in Selam Berr (Kucha), and in Kolme and in Gawada.. The map shows the institutions doing CEmOC on the area. So, The number of institutions doing comprehensive emergency care is now about one institution per 250.000 people, a great improvement since 2007 when the figure was one institution per 2.5 million people.

We also collaborate with the Midwife School in Arba Minch, and currently they are evaluating how well the midwives that graduated from their school are performing (See Master thesis by Rahel Tesfaye). This will give us essential information on how to improve the quality of midwife training, and thus of RMM 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. In a recent research we have shown that it is possible to achieve high coverage community birth registration in rural Ethiopia. Such registration can be an important tool to monitor births and birth outcomes such as maternal mortality in resource-limited settings (Yaliso et al 2014, PLoSONE in press).  Our results (unpublished) show that maternal deaths have since 2008 been reduced by 2/3. The institutional delivery rates have also 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%.

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.

Publications

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

Yaya Y, Eide KT, Norheim OF, Lindtjørn B (2014) Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality.PLoS ONE 9(4): e96294. doi:10.1371/journal.pone.0096294

Girma M, Yaya Y, Gebrehanna E, Berhane Y, Lindtjørn B. (2013). 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, Lindtjørn B (2012). High maternal mortality in rural south-west Ethiopia: estimate by using the sisterhood method. BMC Pregnancy and Childbirth 2012; 12: 136.

Rahel Tesfaye. Client Satisfaction with Delivery Care Services and Associated Factors in the Public Health Facility of Gamo Gofa Zone, South West Ethiopia. 2014. Arba Minch University and Addis Continental Institute of Public Health.

For complete list of publications from this project click here.

New master thesis on patient satisfaction at delivery services

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Rahel Tesfaye.Client Satisfaction with Delivery Care Services and Associated Factors in the Public Health Facility of Gamo Gofa Zone, South West Ethiopia. 2014. Arba Minch University and Addis Continental Institute of Public Health.

Background Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. Satisfied women may be more likely to follow to health providers’ recommendations. And, studying patient satisfaction can help to improve services, and reduce costs. However, so far there few reports on client satisfaction on delivery care from developing countries. This study presents findings from a multi-dimensional study of client satisfaction from the Gamo Gofa Zone in South-West Ethiopia.

Objective The aim of this study was to assess how satisfied clients using delivery services at public health facilities are Gamo Gofa zone in South-West Ethiopia.

Methods Using exit interviews and we did a facility based cross sectional study in December 2013 and January 2014. We measured client satisfaction using a survey adopted from the Donabedian quality assessment framework. We randomly sampled 13 of 66 institutions in Gamo Gofa. The number of delivering mothers in each health institution was based on proportional to size allocation. We used logistic regression to determine predictors of client satisfaction.

Results Most of mothers (79%; 95% CI; 75-82%) were satisfied with delivery care. The presence of support persons during child birth improved satisfaction (AOR=8.19 95% CI; 3.49-18.8). ), as were women who delivered with caesarean section (AOR 2.99; 95% CI; 1.17 -7.66). However, client satisfaction was reduced if the women had to pay for the services (AOR=0.13 95%CI; 0.06-0.29). Women attending hospitals were less satisfied (69%) than women attending health centres (94%). The proportion of women who complained about an unfriendly attitude from health workers was higher in the hospitals.

Conclusions The study shows that that overall satisfaction level good, but there is room for improvements. More emphasis should be to have women friendly care, especially at the hospitals

Diriba Korecha Dadi’s PhD on Predicting Seasonal Climate in Ethiopia

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On April 25, 2014 Diriba Korecha Dadi defended his PhD at the University of Bergen. Diriba was a part of the research programme “Ethiopian Malaria Prediction System”.

The Abstract of the thesis is found at: http://malaria.w.uib.no/emaps/phd-studies/diriba-korecha/

His thesis, Characterizing the Predictability of Seasonal Climate in Ethiopia, can be downloaded http://malaria.b.uib.no/files/2014/06/DiribaPhD.pdf

Maternal and Neonatal Mortality in South-West Ethiopia

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Yaya Y, Eide KT, Norheim OF, Lindtjørn B (2014) Maternal and Neonatal Mortality in South-West Ethiopia: Estimates and Socio-Economic Inequality. PLoS ONE 9(4): e96294. doi:10.1371/journal.pone.0096294

Introduction  Ethiopia has achieved the fourth Millennium Development Goal by reducing under 5 mortality. Nevertheless, there are challenges in reducing maternal and neonatal mortality. The aim of this study was to estimate maternal and neonatal mortality and the socio-economic inequalities of these mortalities in rural south-west Ethiopia.

Methods  We visited and enumerated all households but collected data from those that reported pregnancy and birth outcomes in the last five years in 15 of the 30 rural kebeles in Bonke woreda, Gamo Gofa, south-west Ethiopia. The primary outcomes were maternal and neonatal mortality and a secondary outcome was the rate of institutional delivery.

Results  We found 11,762 births in 6572 households; 11,536 live and 226 stillbirths. There were 49 maternal deaths; yielding a maternal mortality ratio of 425 per 100,000 live births (95% CI:318–556). The poorest households had greater MMR compared to richest (550 vs 239 per 100,000 live births). However, the socio-economic factors examined did not have statistically significant association with maternal mortality. There were 308 neonatal deaths; resulting in a neonatal mortality ratio of 27 per 1000 live births (95% CI: 24–30). Neonatal mortality was greater in households in the poorest quartile compared to the richest; adjusted OR (AOR): 2.62 (95% CI: 1.65–4.15), headed by illiterates compared to better educated; AOR: 3.54 (95% CI: 1.11–11.30), far from road (≥6 km) compared to within 5 km; AOR: 2.40 (95% CI: 1.56–3.69), that had three or more births in five years compared to two or less; AOR: 3.22 (95% CI: 2.45–4.22). Households with maternal mortality had an increased risk of stillbirths; OR: 11.6 (95% CI: 6.00–22.7), and neonatal deaths; OR: 7.2 (95% CI: 3.6–14.3). Institutional delivery was only 3.7%.

Conclusion  High mortality with socio-economic inequality and low institutional delivery highlight the importance of strengthening obstetric interventions in rural south-west Ethiopia.