Tuberculosis in the Arsi Zone in Ethiopia

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

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.

Biomass fuel in households and risk of tuberculosis

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.

Ethiopian community health workers improve TB Care

Some years ago we did two trials [1 2] to improve case finding of tuberculosis in South Ethiopia. Our study from Sidama in South Ethiopia showed that involving Health Extension workers in Tuberculosis control improved the case detection (from 69 to 122 %) for smear-positive patients and females in particular [1]. We advised that this intervention could be used as an option to improve case detection and provide patient-centred services in high-burden countries. In a later study, we showed that this intervention is a cost-effective treatment alternative to the health service and to the patients and their caregivers [3].

We advised there is both an economic and public health reason to consider involving HEWs in TB treatment in Ethiopia.

Now a large consortium (Stop TB Partnership’s TB REACH initiative and implemented by the Southern Region Health Bureau and the Liverpool school of Tropical Medicine in collaboration with the Ministry of Health and the Global Fund) has scaled up this intervention in Sidama [4]. Their findings are similar to our earlier research: “Community-based interventions made TB diagnostic and treatment services more accessible to the poor, women, elderly and children, doubling the notification rate (from 64 to 127%) and improving treatment result. They advise that this approach could improve TB diagnosis and treatment in other high burden settings”.

I hope that they also present some findings on how this good intervention can be made sustainable in settings such as Sidama.

References

1. Datiko DG, Lindtjørn B. Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 2009;4(5):e5443 doi: 10.1371/journal.pone.0005443[published Online First: Epub Date]|.

2. Shargie EB, Morkve O, Lindtjorn B. Tuberculosis case-finding through a village outreach programme in a rural setting in southern Ethiopia: community randomized trial. Bull World Health Organ 2006;84(2):112-9 

3. Datiko DG, Lindtjorn B. Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 2010;5(2):e9158 doi: 10.1371/journal.pone.0009158[published Online First: Epub Date]|.

4. Yassin MA, Datiko DG, Tulloch O, et al. Innovative Community-Based Approaches Doubled Tuberculosis Case Notification and Improve Treatment Outcome in Southern Ethiopia. PLoS ONE 2013;8(5):e63174 doi: 10.1371/journal.pone.0063174[published Online First: Epub Date]|.

Tuberculosis research in Ethiopia

This  research team works mainly to improve control of tuberculosis in south Ethiopia. We have worked on methods to improve case finding, and improve access to diagnosis and treatment for rural populations.

Currently three PhD students and two experienced Ethiopian researchers work on these studies:

  1. Endrias Markos works to improve new tools to find tuberculosis cases in rural Sidama in Ethiopia. He also studies the potential effect of inn-door air pollution on tuberculosis occurrence
  2. Mesay Hailu works on a project to map how tuberculosis occurrence varies from year to year, and to describe the geographical variations in the occurrence of pulmonary tuberculosis
  3. Shallo Daba works on a project to look at the geographical distribution of tuberculosis in the Arsi area of south-central Ethiopia, and to measure tuberculosis prevalence and multidrug resistance pattern.

Two former PhD students at the University of Bergen (Dr Meaza Demissie, PhD 2002; and Dr. Daniel Gemechu, PhD 2011) also work on these studies, and serve as co-supervisors for the PhD students.

Excellent for Centre for International Health

Recently, The Research Council of  Norway evaluated health research in Norway.

The core research groups at Centre for International Health both received the grade “Excellent” by an international expert panel which evaluated medicine and health research in Norway.

The evaluation panel concludes that “the Centre for International Health is the leading research centre within international and global health in the Nordic countries, and one of the leading centres in Europe”.

CIH combines biomedical and public-health research. Both the Child Health and Nutrition, and the HIV and TB Research group received “excellent” grades. Both research groups address important research questions, and base their research on long-term collaboration with universities in Asia and Africa. The research also addresses  the needs of the population, and translates research findings into improved treatment and better control of diseases.

Read the full evaluation report here.

 

Improving tuberculosis control in Ethiopia

ResearchBlogging.org

Ethiopia, with over 80 million people, is heavily affected by tuberculosis, complicated by poverty and HIV infection, limited access to the health service and shortage of health workers.

We recently reviewed tuberculosis control programme in South Ethiopia. Although treatment success rates have improved during the last decade, low case notification rate, mainly because of inability to access the health service, remains a challenge.

Using community health workers, we enrolled health extension workers (HEWs) in providing health education, sputum collection and providing treatment. This improved case detection, and more significantly for women, because the community-based sputum collection increased access to the diagnostic services. Similarly, community-based treatment improved the treatment success of smear-positive patients (90%) compared with to health facility-based treatment (83%). This approach also reduced the total costs by 63%. Thus, such interventions are economically attractive to the health service and patients, caregivers and the community.

Community based intervention improve access for the poor and for women to have better access to the health service. It is effective and an economically attractive alternative to the traditional health services.

By improving health service delivery to the affected community living in high burden countries, this is an example of how operational research in developing countries provide evidence for  policy change. Recently, this approach was endorsed by the Ministry of Health Ethiopia. Health Extension Workers shall now be involved in tuberculosis control in Ethiopia.

This research has been carried out by Daniel Gemechu Datiko. This week he defends his PhD at the University of Bergen. You can read his thesis at: Improving Tuberculosis Control in Ethiopia: Performance of TB control programme, community DOTS and its cost-effectiveness.

The two most important papers in his thesis are:

Datiko, D., & Lindtjørn, B. (2009). Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial PLoS ONE, 4 (5) DOI: 10.1371/journal.pone.0005443

Datiko, D., & 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) DOI: 10.1371/journal.pone.0009158

Active case finding in tuberculosis

ResearchBlogging.orgEven if 36 million patients with tuberculosis were successfully treated, and up to 6 million lives were saved during the past 15 years, tuberculosis remains a major public health problem. More than 9 million cases occur every year.

Unfortunately, only a little more that half of the expected cases are identified yearly and receive proper care. We therefore need novel measures to diagnose, treat, and thus stop transmission of tuberculosis.

Many have previously questioned the role of active case finding in reducing tuberculosis prevalence. Recently, several active case-finding strategies for tuberculosis were tested and proved to be effective, both in urban (Corbett, Bandason et al. 2010) and rural settings (Datiko and Lindtjørn 2009). The Lancet study (Corbett, Bandason et al. 2010) also documented the effect on the prevalence of culture-positive tuberculosis. The study from Ethiopia also showed that active case finding is a cost-effective strategy (Datiko and Lindtjørn 2010).

These studies highlight active case-finding in tuberculosis control efforts, especially in settings where HIV is prevalent and in weak health systems.

Some of the research priorities for countries with weak health systems should include:

  • Evaluate tools for effective active case-finding so it reduces tuberculosis prevalence. To do this we should also set up good records on tuberculosis prevalence, and thus be able to document a future decline in tuberculosis prevalence.
  • We need to develop different models for active case finding in communities. By this, I mean practical tools on how to do this in a local community. We are starting a new research in Ethiopia to develop “tuberculosis suspect registries” in the communities as a tool to identify patients with tuberculosis.
  • In addition, we urgently need fast, accurate, and simple diagnostic test.

And, scaling up active case-finding outside health institutions needs to be paired with increased scientific interest, research investment, and political commitment for high-quality basic and operational research.

Corbett, E., Bandason, T., Duong, T., Dauya, E., Makamure, B., Churchyard, G., Williams, B., Munyati, S., Butterworth, A., & Mason, P. (2010). Comparison of two active case-finding strategies for community-based diagnosis of symptomatic smear-positive tuberculosis and control of infectious tuberculosis in Harare, Zimbabwe (DETECTB): a cluster-randomised trial The Lancet, 376 (9748), 1244-1253 DOI: 10.1016/S0140-6736(10)61425-0

Datiko DG, Lindtjorn B (2009) Health extension workers improve tuberculosis case detection and treatment success in southern Ethiopia: a community randomized trial. PLoS One 4: e5443.

Datiko DG, Lindtjorn B (2010) Cost and cost-effectiveness of smear-positive tuberculosis treatment by Health Extension Workers in Southern Ethiopia: a community randomized trial. PLoS One 5: e9158.

Active case-finding to improve tuberculosis control.

Is active case finding necessary to control tuberculosis in developing countries?

Tuberculosis is one of the world’s leading causes of death and disease. Despite effective treatment, tuberculosis still results in several million deaths each year. Reducing the burden of global TB disease is a part the Millennium Development Goals. Earlier, health authorities thought that DOTS (Direct Observed Treatment, Short course) would control tuberculosis. However, we now recognize that DOTS alone is unable of reducing TB incidence in high endemic countries.

Active case finding is to find, diagnose, and treat and follow up tuberculosis patients in the local communities.

To find out the efficacy of community-based case finding, we did a community randomized trial and cost-effectiveness analysis in south Ethiopia. The trial Ethiopia aimed to evaluate if community health workers could improved smear-positive case detection and treatment success rates (Datiko and Lindtjørn, 2009 and Datiko and Lindtjørn, 2010).

The study showed that involving of health extension workers (HEWs) in sputum collection and treatment improved smear-positive case detection and treatment success rate, possibly because of an improved service access. This finding has policy implications and could be applied in settings with low health service coverage and a shortage of health workers.

Recently, National TB Control Programme in Ethiopia started to decentralize case finding and treatment to local communities (in Ethiopia called kebeles) using community based-treatment by health extension workers.

We plan to follow up our earlier studies and develop a model for community DOTS in rural Ethiopia. We aim to improve the community-based implementation of case finding and treatment of TB in rural settings of southern Ethiopia. This will try to develop community-based tuberculosis registries, and registries of patients with symptoms suggestive of tuberculosis.  Through this work we aim to see if case finding and treatment outcomes can be improved on a larger scale and involving larger populations

Datiko, D., & Lindtjørn, B. (2009). Health Extension Workers Improve Tuberculosis Case Detection and Treatment Success in Southern Ethiopia: A Community Randomized Trial PLoS ONE, 4 (5) DOI: 10.1371/journal.pone.0005443

Datiko, D., & 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) DOI: 10.1371/journal.pone.0009158