Smallpox and eliminating other diseases

 Dr. Donald A. Henderson, who led the World Health Organization’s war on smallpox, administering a smallpox vaccination in Ethiopia, around 1972. The last known case was in 1977. (Photo WHO)



Dr. Donald A. Henderson was an American physician who coordinated the World Health Organisation’s efforts to eradicate smallpox. After smallpox had been declared eradicated in 1980, he returned to the US, and became the Dean of what is now the Johns Hopkins Bloomberg School of Public Health. Dr. Donald A. Henderson died this month and will be remembered as a great scientist and public health physician.

As a child in late 1950s I remember a smallpox epidemic in Dilla in Ethiopia. I was so fortunate to have met this remarkable man, and listen to a talk he had at WHO in Geneva. Because of the success in eradicating smallpox, many believe that it also should be possible to eliminate other diseases such as poliomyelitis, Guinea worm, measles, or even malaria. I find it interesting to read that Dr Henderson was rather skeptical about these new eradication initiatives. Both the characteristics of the diseases, as well as the efforts put into getting rid of the diseases differed from what was the strategy to eradicate smallpox.

Incidence of tuberculosis among school-going adolescents in South India

Uppada DR, Selvam S, Jesuraj N, Lau EL, Doherty TM, Grewal HMS, Vaz M, Lindtjørn B: Incidence of tuberculosis among school-going adolescents in South India. BMC Public Health 2016, 16:1-11.

Background  Tuberculosis (TB) incidence data in vaccine target populations, particularly adolescents, are important for designing and powering vaccine clinical trials. Little is known about the incidence of tuberculosis among adolescents in India. The objective of current study is to estimate the incidence of pulmonary tuberculosis (PTB) disease among adolescents attending school in South India using two different surveillance methods (active and passive) and to compare the incidence between the two groups.

Methods  The study was a prospective cohort study with a 2-year follow-up period. The study was conducted in Palamaner, Chittoor District of Andhra Pradesh, South India from February 2007 to July 2010. A random sampling procedure was used to select a subset of schools to enable approximately 8000 subjects to be available for randomization in the study. A stratified randomization procedure was used to assign the selected schools to either active or passive surveillance. Participants who met the criteria for being exposed to TB were referred to the diagnostic ward for pulmonary tuberculosis confirmation. A total number of 3441 males and 3202 females between the ages 11 and less than 18 years were enrolled into the study.

Results  Of the 3102 participants in the active surveillance group, four subjects were diagnosed with definite tuberculosis, four subjects with probable tuberculosis, and 71 subjects had non-tuberculous Mycobacteria (NTM) isolated from their sputum. Of the 3541 participants in the passive surveillance group, four subjects were diagnosed with definite tuberculosis, two subjects with probable tuberculosis, and 48 subjects had non-tuberculosis Mycobacteria isolated from their sputum. The incidence of definite + probable TB was 147.60 / 100,000 person years in the active surveillance group and 87 / 100,000 person years in the passive surveillance group.

Conclusion  The incidence of pulmonary tuberculosis among adolescents in our study is lower than similar studies conducted in South Africa and Eastern Uganda – countries with a higher incidence of tuberculosis and human immunodeficiency virus (HIV) than India. The study data will inform sample design for vaccine efficacy trials among adolescents in India.

Primary and secondary anti-tuberculosis drug resistance in Ethiopia

Hamusse S, Teshome D, Hussen M, Demissie M, Lindtjorn B. Primary and secondary anti-tuberculosis drug resistance in Hitossa District of Arsi Zone, Oromia Regional State, Central Ethiopia. BMC Public Health 2016; 16(1):

Background: Multidrug-resistant tuberculosis (MDR-TB) drugs which is resistant to the major first-line anti-TB drugs, Isoniazid and Rifampicin, has become a major global challenge in tuberculosis (TB) control programme. However, its burden at community level is not well known. Thus, the aim of study was to assess the prevalence of primary and secondary resistance to any first line anti-TB drugs and MDR TB in Hitossa District of Oromia Regional State, Central Ethiopia.

Methods: Population based cross- sectional study was conducted on individuals aged ≥15 years. Those with symptoms suggestive of TB were interviewed and two sputum specimens were collected from each and examined using Lowenstein-Jensen (LJ) culture medium. Further, the isolates were confirmed by the Ziehl-Neelsen microscopic examination method. Drug susceptibility test (DST) was also conducted on LJ medium using a simplified indirect proportion method. The resistance strains were then determined by percentage of colonies that grew on the critical concentration of Isoniazid, Streptomycin, Rifampicin and Ethambutol.

Results: The overall resistance of all forms of TB to any first-line anti-TB drug was 21.7 %. Of the total new and previously treated culture positive TB cases, 15.3 and 48.8 % respectively were found to be a resistant to any of the first-line anti-TB drugs. Further, of all forms of TB, the overall resistance of MDR-TB was 4.7 %. However, of the total new TB cases, 2.4 % had primary while 14.3 % had secondary MDR-TB. Resistance to any of the first-line anti-TB drugs (adjusted odd ratio (AOR), 8.1; 95 % CI: 2.26–29.30) and MDR-TB (AOR), 7.1; 95 % CI: 2.6–43.8) was found to be linked with previous history of anti-TB treatment.

Conclusions: The study has identified a high rate of primary and secondary resistance to any of the first-line anti-TB drugs and MDR-TB in the study area. The resistance may have resulted from sub-optimal performance of directly observed treatment short-course (DOTS) programme in the detecting infectious TB cases and cure rates in the study area. Anti-TB drug resistance is linked with previous TB treatment. There is a need to strengthen DOTS and DOTS-Plus programmes and expand MDR-TB diagnostic facilities in order to timely diagnose MDR-TB cases and provide appropriate treatment to prevent the spread of MDR-TB in Ethiopia.

The poor use bed nets less for malaria protection

Hailu A, Lindtjørn B, Deressa W, Gari T, Loha E, Robberstad B. Equity in long-lasting insecticidal nets and indoor residual spraying for malaria prevention in a rural South Central Ethiopia. Malaria Journal 2016; 15(1): 1-11.

Background: While recognizing the recent achievement in the global fight against malaria, the disease remains a challenge to health systems in low-income countries. Beyond widespread consensuses about prioritizing malaria prevention, little is known about the prevailing status of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) across different levels of wealth strata. The aim of this study was to evaluate the socioeconomic related dimension of inequalities in malaria prevention interventions.

Methods: This study was conducted in July–August 2014 in Adami Tullu district in the South-central Ethiopia, among 6069 households. A cross-sectional data were collected on household characteristics, LLIN ownership and IRS coverage. Principal component analysis technique was used for ranking households based on socioeconomic position. The inequality was measured using concentration indices and concentration curve. Decomposition method was employed in order to quantify the percentage contribution of each socioeconomic related variable on the overall inequality.

Results: The proportion of households with at least one LLIN was 11.6 % and IRS coverage was 72.5 %. The Erreygers normalized concentration index was 0.0627 for LLIN and 0.0383 for IRS. Inequality in LLIN ownership was mainly associated with difference in housing situation, household size and access to mass-media and telecommunication service.

Conclusion: Coverage of LLIN was low and significant more likely to be owned by the rich households, whereas houses were sprayed equitably. The current mass free distribution of LLINs should be followed by periodic refill based on continuous monitoring data.

Quality of delivery care services

Tesfaye R, Worku A, Godana W, Lindtjorn B: Client Satisfaction with Delivery Care Service and Associated Factors in the Public Health Facilities of Gamo Gofa Zone, Southwest Ethiopia:In a Resource Limited Setting. Obstetrics and Gynecology International 2016, 2016:1-7.

Background. Ensuring patient satisfaction is an important means of secondary prevention of maternal mortality. This study presents findings from a multidimensional study of client satisfaction from the Gamo Gofa Zone in Southwest Ethiopia. Methods. A facility based cross-sectional study using exit interviews was conducted from 2014. Client satisfaction was measured using a survey adopted from the Donabedian quality assessment framework. Thirteen health institutions were randomly sampled of 66 institutions in Gamo Gofa Zone. Logistic regression was used to determine predictors of client satisfaction.

Results. The overall satisfaction level of the clients in this study was 79.1% with (95% CI; 75–82). Women attending health centres were more likely satisfied than women attending hospitals . The proportion of women who complained about an unfriendly attitude or unresentful care from health workers was higher in the hospitals. The presence of support persons during child birth improved client satisfaction (AOR = 6.23 95% CI; 2.75–14.1) and women who delivered with caesarean section are four times more likely satisfied than those who deliver vaginally (AOR 3.6 95% CI; 1.44–9.06). Client satisfaction was reduced if the women had to pay for the services (AOR = 0.27 95% CI; 0.09–81).

Conclusions. The study shows that overall satisfaction level is good. More emphasis should be put on giving women friendly care, particularly at the hospitals.


Malaria in the Rift Valley in Ethiopia

Gari T, Kenea O, Loha E, Deressa W, Hailu A, Balkew M, Gebre-Michael T, Robberstad B, Overgaard HJ, Lindtjørn B: Malaria incidence and entomological findings in an area targeted for a cluster-randomized controlled trial to prevent malaria in Ethiopia: results from a pilot study. Malaria Journal 2016, 15.

Background  This study was part of the work to prepare for a cluster-randomized controlled trial to evaluate the effect of combining indoor residual spraying and long-lasting insecticidal nets on malaria incidence. A pilot study was done to estimate the variations of malaria incidence among villages, combined with entomological collections and an assessment of susceptibility to insecticides in malaria vectors.

Methods  A cohort of 5309 residents from four kebeles (the lowest government administrative unit) in 996 households was followed from August to December 2013 in south-central Ethiopia. Blood samples were collected by a finger prick for a microscopic examination of malaria infections. A multilevel mixed effect model was applied to measure the predictors of malaria episode. Adult mosquitoes were collected using light traps set indoors close to a sleeping person, pyrethrum spray sheet catches and artificial outdoor pit shelters. Enzyme-linked immunosorbent assays were used to detect the sources of mosquito blood meals, while mosquito longevity was estimated based on parity. The World Health Organization’s tube bioassay test was used to assess the insecticide susceptibility status of malaria vectors to pyrethroids and carbamates.

Results  The average incidence of malaria episode was 4.6 per 10,000 person weeks of observation. The age group from 5 to 14 years (IRR = 2.7; 95 % CI 1.1–6.6) and kebeles near a lake or river (IRR = 14.2, 95 % CI 3.1–64) were significantly associated with malaria episode. Only 271 (27.3 %) of the households owned insecticide-treated nets. Of 232 adult Anophelesmosquitoes collected, Anopheles arabiensis (71.1 %) was the predominant species. The average longevity of An. arabiensiswas 14 days (range: 7–25 human blood index days). The overall human blood index (0.69) for An. arabiensis was higher than the bovine blood index (0.38). Statistically significant differences in Anopheline mosquitoes abundance were observed between the kebeles (P = 0.001). Anopheles arabiensis was susceptible to propoxur, but resistant to pyrethroids. However, An. pharoensis was susceptible to all pyrethroids and carbamates tested.

Conclusions  This study showed a high variation in malaria incidence and Anopheles between kebeles. The observed susceptibility of the malaria vectors to propoxur warrants using this insecticide for indoor residual spraying, and the results from this study will be used as a baseline for the trial.

Does location matter? A study of malnutrition amongst Ethiopian children

Each month, a paper is selected by one of the Editors of the five Nutrition Society Publications (British Journal of Nutrition, Public Health Nutrition, Nutrition Research Reviews, Proceedings of the Nutrition Society and Journal of Nutritional Science). This month, Seifu Hagos Gebreyesus’ paper on ‘Local spatial clustering of stunting and wasting among children under the age of 5 years: implications for intervention strategies’ was selected.

Seifu wrote on The Nutrition Socienty Blog:

As malnutrition is a major public health problem in Ethiopia, we aimed to find out how the acute and chronic forms of undernutrition occur in the districts and kebeles (a kebele is the smallest administrative unit in Ethiopia). Such knowledge could be helpful in improving our understanding of the distribution of undernutrition on a local scale, as well as designing targeted nutrition intervention programmes.

For this purpose, we surveyed children aged less than five years, who were found in 1744 households. We measured children’s height, weight, and the geographic locations (latitudes and longitudes) of households. Using data from 2371 children aged less than five years of age, we evaluated how malnutrition is distributed within a district and kebeles.

Although many believe that undernutrition is equally distributed within an area, we found that children living in locations within a district are more susceptible to undernutrition than children in other locations but living in the same district. For example, children living in these locations were 1.5 times more likely to be stunted and 1.7 times more likely to be severely stunted than children living in other locations within the district. Similarly, in some kebeles, children living in some small areas experience more acute malnutrition (wasting and severe wasting).

Our finding has important implications to nutritional intervention strategies. Stunting and wasting are not equally distributed in an area, suggesting that planning of nutrition interventions may need to consider the variations in the vulnerability.

To help accelerate the reduction of malnutrition, it could be important to consider targeting locations where more susceptible children live. The approach would help reach children who are most likely to benefit from intervention programmes.

We recommend that this research needs to be repeated in other areas of Ethiopia and other developing countries. We also would like to recommend further study possibly using an implementation research approach to evaluate the feasibility, advantages and effectiveness of targeting nutritional interventions.

More malaria among wasted children

Shikur B, Deressa W, Lindtjørn B. Association between malaria and malnutrition among children aged under-five years in Adami Tulu District, south-central Ethiopia: a case–control study. BMC Public Health 2016; 16(1): 1-8.

Background: Malaria and malnutrition are the major causes of morbidity and mortality in under-five children in developing countries such as Ethiopia. Malnutrition is the associated cause for about half of the deaths that occur among under-five children in developing countries. However, the relationship between malnutrition and malaria is controversial still, and it has also not been well documented in Ethiopia. The aim of this study was to assess whether malnutrition is associated with malaria among under-five children.

Methods: A case–control study was conducted in Adami Tulu District of East Shewa Zone in Oromia Regional State, Ethiopia. Cases were all under-five children who are diagnosed with malaria at health posts and health centres. The diagnosis was made using either rapid diagnostic tests or microscopy. Controls were apparently healthy under-five children recruited from the community where cases resided. The selection of the controls was based on World Health Organization (WHO) cluster sampling method. A total of 428 children were included. Mothers/caretakers of under-five children were interviewed using pre-tested structured questionnaire prepared for this purpose. The nutritional status of the children was assessed using an anthropometric method and analyzed using WHO Anthro software. A multivariate logistic analysis model was used to determine predictors of malaria.

Results: Four hundred twenty eight under-five children comprising 107 cases and 321 controls were included in this study. Prevalence of wasting was higher among cases (17.8 %) than the controls (9.3 %). Similarly, the prevalence of stunting was 50.5 % and 45.2 % among cases and controls, respectively. Severe wasting [Adjusted Odds Ratio (AOR) =2.9, 95 % CI (1.14, 7.61)] and caretakers who had no education [AOR = 3, 95 % CI (1.27, 7.10)] were independently associated with malarial attack among under-five children.

Conclusion: Children who were severely wasted and had uneducated caretakers had higher odds of malarial attack. Therefore, special attention should be given for severely wasted children in the prevention and control of malaria.

Joint PhD Programme

Joint-PhDs are doctorates, which are done at two degree-awarding institutions. This doctorate means that you are fully registered in two universities, having to comply with admission requirements, and assessment regulations at both institutions, and it will result in one jointly awarded PhD (one diploma with the two university logos).

The other benefits for students are:

  • Access to complementary facilities and resources
  • Exposure to two cultural approaches to research
  • International student mobility
  • Enhanced acquisition of research and transferable skills, such as negotiation skills, use of videoconferencing, adaptability…
  • Better networking opportunities

Recently, Hawassa University and the University of Bergen agreed on such a joint PhD degree.

This programme is funded by The South Ethiopia Network of Universities in Public Health (SENUPH), and nine PhD students have been registered at the home institution which in this case is Hawassa University. The currently available financial support is for staff at Hawassa, Dilla and Wolaita Sodo universities. We plan to admit seven more students (four women and three men) in September 2016.

You can get more information about the admission requirements and about topics that this programme will prioritise by writing to Dr Eskindir Loha or to Professor Bernt Lindtjørn.

The structure of the joint PhD programme can be downloaded here.

Combining long-lasting insecticidal nets and indoor residual spraying for malaria prevention in Ethiopia: study protocol for a cluster randomized controlled trial

Wakgari-Trials-protocolDeressa W, Loha E, Balkew M, Hailu A, Gari T, Kenea O, Overgaard HJ, Gebremichael T, Robberstad B, and Lindtjørn B. Combining long-lasting insecticidal nets and indoor residual spraying for malaria prevention in Ethiopia: study protocol for a cluster randomized controlled trial. Trials 2016, 17:20

Long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) are the main malaria prevention interventions in Ethiopia. There is conflicting evidence that the combined application of both interventions is better than either LLINs or IRS used alone. This trial aims to investigate whether the combination of LLINs (PermaNet 2.0, Vestergaard Frandsen, Lausanne, Switzerland) with IRS using propoxur will enhance the protective benefits and cost-effectiveness of the interventions against malaria and its effect on mosquito behavior, as compared to each intervention alone.

This 2 x 2 factorial cluster randomized controlled trial is being carried out in the Adami Tullu district in south-central Ethiopia for about 116 weeks from September 2014 to December 2016. The trial is based on four arms: LLINs + IRS, LLINs alone, IRS alone and control. Villages (or clusters) will be the unit of randomization. The sample size includes 44 clusters per arm, with each cluster comprised of approximately 35 households (about 175 people). Prior to intervention, all households in the LLINs + IRS and LLINs alone arms will be provided with LLINs free of charge. Households in the LLINs + IRS and IRS alone arms will be sprayed with carbamate propoxur once a year just before the main malaria transmission season throughout the investigation. The primary outcome of this trial will be a malaria incidence based on the results of the rapid diagnostic tests in patients with a fever or history of fever attending health posts by passive case detection. Community-based surveys will be conducted each year to assess anemia among children 5–59 months old. In addition, community-based malaria prevalence surveys will be conducted each year on a representative sample of households during the main transmission season. The cost-effectiveness of the interventions and entomological studies will be simultaneously conducted. Analysis will be based on an intention-to-treat principle.

This trial aims to provide evidence on the combined use of LLINs and IRS for malaria prevention by answering the following research questions: Can the combined use of LLINs and IRS significantly reduce the incidence of malaria compared with the use of either LLINs or IRS alone? And is the reduced incidence justifiable compared to the added costs? Will the combined use of LLINs and IRS reduce vector density, infection, longevity and the entomological inoculation rate? These data are crucial in order to maximize the impact of vector control interventions on the morbidity and mortality of malaria.

Trial registration
PACTR201411000882128 (8 September 2014).