Abstract: ABSTRACT: BACKGROUND: Delaying sexual initiation has been promoted as one of the methods of decreasing risks of HIV among young people. In traditional countries, such as Ethiopia, retaining virginity until marriage is the norm. However, no one has examined the impact of this traditional norm on sexual behaviour and risk of HIV in marriage. This study examined the effect of virginity norm on having sex before marriage and sexual behaviour after marriage among rural Ethiopian youth. METHODS: We did a cross-sectional survey in 9 rural and 1 urban area using a probabilistic sample of 3,743 youth, 15-24 years of age. Univariate analysis was used to assess associations between virginity norm and gender stratified by area, and between sexual behaviour and marital status. We applied Kaplan-Meier and Cox regression analysis to estimate age at sexual debut and assessed the predictors of premarital sex among the never-married using SPSS. RESULTS: We found that maintaining virginity is still a way of securing marriage for girls, especially in rural areas; the odds of belief and intention to marry a virgin among boys was 3-4 times higher among rural young males. As age increased, the likelihood of remaining a virgin decreased. There was no significant difference between married and unmarried young people in terms of number of partners and visiting commercial sex workers. Married men were twice more likely to have multiple sexual partners than their female counterparts. A Cox regression show that those who did not believe in traditional values of preserving virginity (adjusted hazard ratio [AHR] =2.91 [1.92-4.40]), alcohol drinkers (AHR = 2.91 [1.97-4.29]), Khat chewers (AHR = 2.36 [1.45-3.85]), literates (AHR= 18.01 [4.34-74.42]), and the older age group (AHR=1.85 [1.19-2.91]) were more likely to have premarital sex than their counterparts. CONCLUSIONS: Although virginity norms help delay age at sexual debut among rural Ethiopian youth, and thus reduces vulnerability to sexually transmitted infections and HIV infection, vulnerability among females may increase after marriage due to unprotected multiple risky sexual behaviours by spouses. The use of preventive services, such as VCT before marriage and condom use in marriage should be part of the HIV/AIDS prevention and control strategies.
Abstract: BACKGROUND: Defaulting from treatment remains a challenge for most tuberculosis control programmes. It may increase the risk of drug resistance, relapse, death, and prolonged infectiousness. The aim of this study was to determine factors predicting treatment adherence among smear-positive pulmonary tuberculosis patients. METHODS AND FINDINGS: A cohort of smear-positive tuberculosis patients diagnosed and registered in Hossana Hospital in southern Ethiopia from 1 September 2002 to 30 April 2004 were prospectively included. Using a structured questionnaire, potential predictor factors for defaulting from treatment were recorded at the beginning of treatment, and patients were followed up until the end of treatment. Default incidence rate was calculated and compared among preregistered risk factors. Of the 404 patients registered for treatment, 81 (20%) defaulted from treatment. A total of 91% (74 of 81) of treatment interruptions occurred during the continuation phase of treatment. On a Cox regression model, distance from home to treatment centre (hazard ratio [HR] = 2.97; p < 0.001), age > 25 y (HR = 1.71; p = 0.02), and necessity to use public transport to get to a treatment centre (HR = 1.59; p = 0.06) were found to be independently associated with defaulting from treatment. CONCLUSIONS: Defaulting due to treatment noncompletion in this study setting is high, and the main determinants appear to be factors related to physical access to a treatment centre. The continuation phase of treatment is the most crucial time for treatment interruption, and future interventions should take this factor into consideration.
Abstract: BACKGROUND: To benefit from available care and treatment options, patients should first be counselled and tested for HIV. Our aim was to assess the acceptability of HIV testing among tuberculosis patients under routine care conditions in south Ethiopia. METHODS: We interviewed all adult tuberculosis patients who were treated at Arba Minch Hospital in Ethiopia between January and August 2005. After recording socio-demographic information and tuberculosis treatment history, we referred those patients who showed initial willingness to a counsellor for HIV counselling and testing. Rapid test methods were used following a pretest counselling session. The results were disclosed during a post-test counselling session. We used the logistic regression method to assess factors associated with willingness and acceptability. RESULTS: 190 adult tuberculosis patients were treated at the hospital and all of them consented to take part in the study. Their median age was 30 years (range, 15-68) and 52% of them were males. 49 patients (26%) were previously tested including 29 (59%) HIV positive. Of 161 patients (excluding the 29 already positive), 118 (73%) were willing to be tested and 58% (68/118) of those willing accepted the test. The overall acceptability rate was 35% (56/161). Fourteen (20.6%) were HIV positive and women were more likely to be HIV infected (p = 0.029). Unemployment and self-perceived high risk of HIV infection were associated with initial willingness (OR [95%CI]:2.6 [1.3-5.5] vs. 5.0 [1.1-22.4], respectively). However, only being unemployed was associated with accepting the test (OR = 4.2; 95%CI = 1.9-9.3). CONCLUSION: The low acceptability of HIV counselling and testing among tuberculosis patients poses a challenge to the scale-up of TB/HIV collaborative efforts. There is a need for alternative counselling and testing strategies.
Abstract: SETTING: A rural district in Southern Ethiopia. OBJECTIVE: To estimate the prevalence of smear-positive pulmonary tuberculosis (TB). DESIGN: In this cross-sectional study, adults aged >14 years were surveyed by home-to-home visit, and asked about cough of > or = 2 weeks with or without sputum, chest pain or difficulty in breathing. Symptomatic suspects submitted three sputum samples for standard smear microscopy. RESULTS: Of 16697 adults surveyed, 436 (2.6%) were symptomatic and submitted sputum samples. Thirteen (3%) were positive for acid-fast bacilli, and the prevalence of smear-positive TB was 78 per 100 000 population (95%CI 36-120). Twenty-four smear-positive cases identified through the existing health care delivery were on anti-tuberculosis medication at the time of the survey. The ratio of smear-positive cases on treatment to those newly detected by the survey was 2:1. CONCLUSION: The prevalence of TB in this rural setting was unexpectedly low. For every two cases of smear-positive TB on treatment, there was one undetected infectious case in the community. However, as our screening technique did not allow detection of cases who did not report symptoms, the true prevalence may have been underestimated.
Abstract: OBJECTIVE: To ascertain whether case-finding through community outreach in a rural setting has an effect on case-notification rate, symptom duration, and treatment outcome of smear-positive tuberculosis (TB). METHODS: We randomly allocated 32 rural communities to intervention or control groups. In intervention communities, health workers from seven health centres held monthly diagnostic outreach clinics at which they obtained sputum samples for sputum microscopy from symptomatic TB suspects. In addition, trained community promoters distributed leaflets and discussed symptoms of TB during house visits and at popular gatherings. Symptomatic individuals were encouraged to visit the outreach team or a nearby health facility. In control communities, cases were detected through passive case-finding among symptomatic suspects reporting to health facilities. Smear-positive TB patients from the intervention and control communities diagnosed during the study period were prospectively enrolled. FINDINGS: In the 1-year study period, 159 and 221 cases of smear-positive TB were detected in the intervention and control groups, respectively. Case-notification rates in all age groups were 124.6/10(5) and 98.1/10(5) person-years, respectively (P = 0.12). The corresponding rates in adults older than 14 years were 207/10(5) and 158/10(5) person-years, respectively (P = 0.09). The proportion of patients with >3 months' symptom duration was 41% in the intervention group compared with 63% in the control group (P<0.001). Pre-treatment symptom duration in the intervention group fell by 55-60% compared with 3-20% in the control group. In the intervention and control groups, 81% and 75%, respectively of patients successfully completed treatment (P = 0.12). CONCLUSION: The intervention was effective in improving the speed but not the extent of case finding for smear-positive TB in this setting. Both groups had comparable treatment outcomes.
Abstract: BACKGROUND: HAART has improved the survival of HIV infected patients. However, compared to patients in high-income countries, patients in resource-poor countries have higher mortality rates. Our objective was to identify independent risk factors for death in Ethiopian patients treated with HAART. METHODS: In a district hospital in Ethiopia, we treated adult HIV infected patients with HAART based on clinical and total lymphocyte count (TLC) criteria. We measured body weight and complete blood cell count at baseline, 4 weeks later, then repeated weight every month and complete blood cell count every 12 weeks. Time to death was the main outcome variable. We used the Kaplan Meier and Cox regression survival analyses to identify prognostic markers. Also, we calculated mortality rates for the different phases of the follow-up. RESULTS: Out of 162 recruited, 152 treatment-naïve patients contributed 144.1 person-years of observation (PYO). 86 (57%) of them were men and their median age was 32 years. 24 patients died, making the overall mortality rate 16.7 per 100 PYO. The highest death rate occurred in the first month of treatment. Compared to the first month, mortality declined by 9-fold after the 18th week of follow-up. Being in WHO clinical stage IV and having TLC< or = 750/mcL were independent predictors of death. Haemoglobin (HGB) < or = 10 g/dl and TLC<= 1200/mcL at baseline were not associated with increased mortality. Body mass index (BMI) < or = 18.5 kg/m2 at baseline was associated with death in univariate analysis. Weight loss was seen in about a third of patients who survived up to the fourth week, and it was associated with increased death. Decline in TLC, HGB and BMI was associated with death in univariate analysis only. CONCLUSION: The high mortality rate seen in this cohort was associated with advanced disease stage and very low TLC at presentation. Patients should be identified and treated before they progress to advanced stages. The underlying causes for early death in patients presenting at late stages should be investigated.
Abstract: BACKGROUND: Although highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available. RESULTS: We followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19-0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03-0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment. CONCLUSION: HAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes.
Abstract: BACKGROUND: DOTS as a strategy was introduced to the tuberculosis control programme in Southern region of Ethiopia in 1996. The impact of the programme on treatment outcomes and the trend in the service coverage for tuberculosis has not been assessed ever since. The aim of the study was to assess trends in the expansion of DOTS and treatment outcomes for tuberculosis in Hadiya zone in Southern Ethiopia. METHODS: 19,971 tuberculosis patients registered for treatment in 41 treatment centres in Hadiya zone between 1994 and 2001 were included in the study. The data were collected from the unit tuberculosis registers. For each patient, we recorded information on demographic characteristics, treatment centre, year of treatment, disease category, treatment given, follow-up and treatment outcomes. We also checked the year when DOTS was introduced to the treatment centre. RESULTS: Population coverage by DOTS reached 75% in 2001, and the proportion of patients treated with short course chemotherapy increased from 7% in 1994 to 97% in 2001. Treatment success for smear-positive tuberculosis rose from 38% to 73% in 2000, default rate declined from 38% to 18%, and treatment failure declined from 5% to 1%. Being female patient, age 15-24 years, smear positive pulmonary tuberculosis, treatment with short course chemotherapy, and treatment at peripheral centres were associated with higher treatment success and lower defaulter rates. CONCLUSION: The introduction and expansion of DOTS in Hadiya has led to a significant increase in treatment success and decrease in default and failure rates. The smaller institutions exhibited better treatment outcomes compared to the larger ones including the zonal hospital. We identified many patients with missing information in the unit registers and this issue needs to be addressed. Further studies are recommended to see the impact of the programme on the prevalence and incidence of tuberculosis.
Abstract: CONTEXT: The natural course of HIV disease progression among resource-poor patient populations has not been clearly defined. OBJECTIVE: To describe predictors of HIV disease progression as seen at an outpatient clinic in a resource-limited setting in rural Ethiopia. DESIGN: This prospective cohort study included all adult HIV patients who visited an outpatient clinic at Arba Minch hospital in South Ethiopia between January 30, 2003 and April 1, 2004. Clinical and hematologic measurements were done at baseline and every 12 weeks thereafter until the patient was transferred, put on antiretroviral therapy, was lost to follow-up, or died. Community agents reported patient status every month. SETTING: A district hospital with basic facilities for HIV testing and patient monitoring. MAIN OUTCOME MEASURES: Death, diagnosis of tuberculosis, and change in disease stage. RESULTS: We followed 207 patients for a median duration of 19 weeks (range, 0-60 weeks). A total of 132 (64%) of them were in WHO stage III. The overall mortality rate was 46 per 100 person-years of observation (PYO). Mortality increased with advancing disease stage. Diarrhea, oral thrush, and low total lymphocyte count were significant markers of mortality. The incidence of tuberculosis was 9.9 per 100 PYO. Baseline history of easy fatigability and fever were strongly associated with subsequent development of tuberculosis. CONCLUSIONS: The mortality rate and the incidence of tuberculosis in our cohort are among the highest ever reported in sub-Saharan Africa. We identified oral thrush, diarrhea, and total lymphocyte count as predictors of mortality, and easy fatigability and fever as predictors of tuberculosis. The findings have practical implications for patient care in resource-limited settings.
Abstract: BACKGROUND: Knowledge of the antioxidant profile and its relation to lipid peroxidation in tuberculosis patients with or without accompanying HIV infection is scarce, particularly in developing countries. OBJECTIVE: The objective was to further investigate the interaction between HIV, tuberculosis, and antioxidants and their relations with markers of oxidative stress in a large population of Ethiopians. DESIGN: In a cross-sectional study, we evaluated antioxidants and markers of oxidative stress in Ethiopian tuberculosis patients with (n = 25) and without (n = 100) HIV infection and in Ethiopian (n = 45) and Norwegian (n = 25) healthy control subjects. RESULTS: Concentrations of the antioxidant vitamins C and E and of vitamin A were significantly lower in tuberculosis patients than in healthy Ethiopians. Tuberculosis patients also had significantly lower thiol concentrations, particularly of the reduced forms. Tuberculosis patients, particularly those who were co-infected with HIV, had higher malondialdehyde concentrations than did control subjects. High malondialdehyde concentrations were associated with clinical severity as measured by the Karnofsky Performance Status Index and anthropometric scores. Ethiopian control subjects had lower concentrations of vitamin E and higher concentrations of malondialdehyde than did Norwegian control subjects. CONCLUSIONS: Our findings further support a link between oxidative stress, tuberculosis, and HIV infection. However, whether antioxidant supplementation will improve tuberculosis outcome or is of importance for its prevention should be further examined in future prospective studies.
Abstract: Non-compliance is a major problem in the treatment of tuberculosis (TB). This paper assesses the effectiveness of "TB clubs" in improving compliance with TB treatment and their impact in improving societal attitudes associated with TB. The study utilised both quantitative (cohort study) and qualitative (focus group discussion and an in-depth interview) methods. The cohort study was conducted in two rural districts of Northern Ethiopia. A total of 128 sputum positive pulmonary patients were enrolled and followed, 64 in the TB club and 64 in the comparison groups, to determine treatment outcome of anti-TB therapy. The impact of the TB clubs in changing societal attitudes and behaviour associated with TB was assessed using qualitative methods.The treatment completion rate was significantly better (X2=5.41, P<0.02) in the TB club group, 44 out of 64 patients (68.7%) completed treatment in TB club while only 30 of the 64 (46.8%) completed treatment in the comparison group. The defaulter rate was also significantly lower (X2=11.57, P<0.001) in the TB club group 8/64 (12.5%) compared to 26/64 (40.6%) in the comparison group. The qualitative part of the study also demonstrated remarkable changes in patients' understanding of TB, patients' initial reaction to a TB diagnosis, misconceptions as to the cause and treatment of TB, the social isolation and compliance and belief in the modern health care in the TB club area.The complementary results obtained from the quantitative and qualitative components of the study indicate that the TB club approach has a significant impact in improving patients' compliance to anti-TB treatment and in building positive attitudes and practice in the community regarding TB. This study, thus, provides convincing evidences that the TB club approach is useful in delivering TB treatment successfully in rural populations. Further large-scale studies are needed to find out whether this approach is applicable on a national scale and to other developing countries.
Abstract: SETTING: Four kebeles (lowest administrative units) in a typical district of Addis Ababa, Ethiopia. OBJECTIVE: To determine the prevalence of smear-positive pulmonary tuberculosis (TB) in an adult population by using a screening questionnaire and sputum examination. DESIGN: A house-to-house visit was conducted. All those 14 years of age and above were screened for the presence of symptoms. Three sputum samples were collected from persons who had symptoms for acid-fast bacilli (AFB) examination. RESULTS: A total of 12,149 individuals were screened, of whom 173 had symptoms suggestive of TB. Twenty-three were positive for AFB (189/100,000, 95% CI 112-267). No association was observed between smear positivity and socio-demographic factors. Only two of the 23 patients were on anti-tuberculosis treatment (8.7%, 95% CI 1.5-29.5). CONCLUSION: This simple and cost-effective method provides a fairly realistic estimate of the prevalence of TB. Thus with further development of the method it can be used to monitor the progress of TB programmes in resource-poor settings.
Abstract: BACKGROUND: Delay in the diagnosis of tuberculosis may worsen the disease, increase the risk of death and enhance tuberculosis transmission in the community. This study aims to determine the length of delay between the onset of symptoms and patients first visit to health care (patient delay), and the length of delay between health care visit and the diagnosis of tuberculosis (health service delay). METHODS: A cross sectional survey that included all the public health centres was conducted in Addis Ababa from August 1 to December 31 1998. Patients were interviewed on the same day of diagnosis using structured questionnaire. RESULTS: 700 pulmonary TB patients were studied. The median patient delay was 60 days and mean 78.2 days. There was no significant difference in socio-demographic factors in those who delayed and came earlier among smear positives. However, there was a significant difference in distance from home to health institute and knowledge about TB treatment among the smear negatives. The health service delay was low (median 6 days; mean 9.5 days) delay was significantly lower in smear positives compared to smear negatives. Longer health service delay (delay more than 15 days) was associated with far distance. CONCLUSIONS: The time before diagnosis in TB patients was long and appears to be associated with patient inadequate knowledge of TB treatment and distance to the health centre. Further decentralization of TB services, the use of some components of active case finding, and raising public awareness of the disease to increase service utilization are recommended.
Abstract: The study was undertaken to investigate the year-to-year and seasonal variations in stunting among preschool children living at subsistence level in rural Ethiopia. Five thousand five hundred and eight anthropometric measurements were taken in 678 children (324 boys and 354 girls). The study classified 11.4% and 54.4% of the measurements as wasted and stunted respectively. Stunting occurred more frequently among girls (56.7%) and increased with increasing age. The prevalence of stunting increased from 47% in 1989 to 61% in 1994. In this subsistence farming community, the prevalence of stunting varied over time, especially among children aged 12-23 months. This may have practical consequences both for development work and for future research. Monitoring of year-to-year variations in stunting may suggest some indications of its long-term development in the community. Long-term studies are needed to understand the dynamics of the state of chronic malnutrition.
Abstract: Anastrozole (Arimidex) is a novel, selective, and potent aromatase inhibitor used for the treatment of postmenopausal breast cancer. The drug has been shown to inhibit in vivo aromatization by 96--97% and to suppress plasma estrogen levels by 84--94%. However, the effects of anastrozole on intratumoral estrogen levels have not been studied. Here we report the effects of neoadjuvant treatment with anastrozole on intratumoral levels of estrone (E(1)), estradiol (E(2)), and estrone sulfate (E(1)S), measured by a highly sensitive RIA following a multistep purification procedure involving high-pressure liquid chromatography. Tumor tissue was obtained prior to treatment and after 15 weeks on therapy with anastrozole (1 mg once daily) from 12 postmenopausal women with locally advanced breast cancer (T(3)--T(4) and/or N(2)). Pretreatment tissue levels of E(2), E(1), and E(1)S were 217.9 (69.8--679.9), 173.6 (83.9--358.9), and 80.7 (31.4--207.3) fmol/g tissue (geometric mean values with 95% confidence interval, respectively). Treatment with anastrozole suppressed tissue E(2), E(1), and E(1)S levels by 89.0% (73.2--95.5%), 83.4% (63.2--92.5%), and 72.9% (47.3--86.1%), respectively, compared with baseline levels, with no significant difference between responders and nonresponders. Plasma levels of E(2), E(1), and E(1)S were suppressed by 86.1, 83.9, and 94.2%, respectively. Anastrozole caused a decrease in the immunoexpression of the proliferation markers Ki67 and pS2 in all of the patients, with a trend for a more profound suppression in those achieving an objective response. The mean percentage of apoptotic cells was found to be decreased in responders and increased in nonresponders after 15 weeks of anastrozole therapy. Our results reveal anastrozole to cause a significant suppression of tissue estrogen levels and to influence the biology of primary estrogen receptor-positive breast cancers in postmenopausal women.
Abstract: A cross-sectional survey was conducted between 1 August and 31 December, 1998 in Addis Ababa, Ethiopia to determine the rate of primary drug resistance to anti-tuberculosis drugs and to investigate its possible association with HIV infection. Sputum culture, sensitivity to first-line anti-tuberculosis drugs and HIV testing were done for 236 sputum smear-positive pulmonary tuberculosis patients. Primary drug resistance level (single or multidrug resistance) had not changed significantly since 1994. Primary resistance occurred more often among HIV-positive than among HIV-negative patients. The association between drug resistance and HIV will have a serious impact in the control of tuberculosis because in recent years the prevalence of HIV has increased dramatically in Ethiopia. Therefore, further studies on drug resistance and HIV infection and the establishment of drug resistance surveillance are recommended.
Abstract: We evaluated the treatment results of 239 patients with sputum positive pulmonary tuberculosis (TB) and describe potential factors associated with reduced programme performance in aTB treatment programme in Ethiopia.The TB registry was incomplete and 64 (26.8%) patients were not recorded in the control programme. Of the 239 patients, 34.3% received short-course chemotherapy (SCC) as a first treatment, 5.9% received SCC having previously been treated with standard long-course chemotherapy (LCC), and 54.4% were initially put on LCC. After excluding the 75 patients (31.4%) who were transferred to other health institutions outside the control area, 100 (61.0%; 95% CI 53.0-68.4) were cured (22.6%) or completed the treatment (38.4%) falling short of the target of 85%. Five months or later during treatment 1.8% remained smear-positive, 7.3% died and 29.9% interrupted their treatment. Sputum tests were done in 78% of the eligible patients at 2 months, in 20% at 5 months and in 60.2% at the expected time of treatment completion. By July 1998, 5.4% of the patients initially on LCC had relapsed and were retreated with SCC. None of those initially cured with SCC needed to be retreated. Compared with patients in theTB registry, non-registered patients had lower treatment completed and cure rates (42.3% versus 65.2%; P = 0.047), more patients were transferred out of the TB programme (59.4% versus 21.1%; P<0.001) and the defaulter rate was higher (57.7% versus 24.6%; P=0.002). Weaknesses in the programme performance include organizational issues such as the under use of theTB registry, deficient follow-up procedures, the common usage of LCC and unsatisfactory rates of defaulting.
Abstract: We organised a prospective series to study, the epidemiology and causes of burns in the city of Bergen, Norway. We included 361 patients treated during one year at the casualty centre or at the burn centre at the hospital. Thirty-six per cent (n = 131) of the patients were less than 15 years old, and 9% (n = 33) were over 60. The incidence of burns was 17/10,000 inhabitants, 0.7 for patients who were admitted and 17 for outpatients. Burns were most common among male subjects aged 40 years or less, while women were more at risk in the older age groups. Almost half the injuries were caused by scalds, and 92 (26%) were from contact with hot surface. Scalds were more common among women than among men, while firework and flame burns were more common among men. Burns occurred at home in 227 patients (63%), at work in 58 (16%), and during leisure activities in 76 (21%). The mean surface area burned was 3.5% total body surface area (TBSA); patients who were admitted had a TBSA of 18% compared with 1.8% among those treated as outpatients.
Abstract: Despite the heavy burden of tuberculosis in Ethiopia, little is known about the length of time taken by the patient to seek medical care. We therefore assessed the duration of symptoms before treatment starts in patients with pulmonary tuberculosis. We studied 198 patients (134 men and 66 women) from Yirga Alem, Ethiopia, who were consecutively treated for newly diagnosed pulmonary tuberculosis. Tuberculosis was considered proven when a Ziehl-Neelsen stain of sputum showed acid-fast bacilli. The mean duration was 5.9 months, with a median (range) duration of illness for all patients of 4 months (0.5-36 months). Seventy-five percent of the patients had a duration of illness of more than 2 months, and in 25% of the patients, the illness lasted more than 8 months. Patients with severe disease had a longer duration. Patients with a long duration of symptoms had a greater number of bacilli on direct microscopy of their sputum, suggesting a higher degree of infectivity. Married patients, persons with no formal education, and people living in rural areas had long illness duration. Also, patients with occupations such as farmers, housewives, soldiers, and houseworkers had increased risk compared with students. In south Ethiopia, patients with pulmonary tuberculosis present late to treatment. For some patients, the long pretreatment duration may have had consequences for the severity of the disease and for poor treatment results. Interventions that aim at earlier case detection may therefore be appropriate.
Abstract: This study compares the prevailing sensitivity of bacterial isolates to common antimicrobials during the two-year 1985-87, 1990-92 and 1996-97 periods at Yirga Alem Hospital in southern Ethiopia. All specimens were from patients attending the hospital. We studied 1371 specimens, 337,671 and 363 specimens from the periods 1985-87, 1990-92 and 1996-97, respectively. The study confirms earlier observations of widespread resistance to commonly used antibiotics. Significant increases in the rate of resistance during this thirteen-year period were observed for Neisseria gonorrhoea against erythromycin, trimethoprim-sulphamethoxazole and tetracyclines, for Escherichia coli against ampicillin and trimethoprim-sulphamethoxazole and for Proteus species against ampicillin. We observed a decrease in the prevalence of resistance for Klebsiella and Proteus species against chloramphenicol.
Abstract: 406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.
Abstract: Patients with HIV infection have atypical clinical features of pulmonary tuberculosis; however, our knowledge on how malnutrition affects the clinical presentation is limited. We studied the influence of malnutrition and HIV infection on the clinical and radiological features of pulmonary tuberculosis (TB). We studied 239 consecutive acid fast bacillus-positive adult patients. Patients were investigated by clinical, radiological, anthropometric and laboratory methods. 78% of the patients were malnourished (BMI < 18.5) and 43% were severely malnourished (BMI < 16). 20% were HIV-positive. HIV-positive TB had significantly more oral candidiasis (OR = 3.72), diarrhoea (OR = 2.71), generalized lymphadenopathy (OR = 2.63), skin disorders (OR = 2.27), neuropsychiatric illness (OR = 2.44), hilar lymphadenopathy (OR = 2.07), but less cavitation (OR = 0.64) and upper lung lobe involvement (OR = 0.70). HIV-negative and severe malnourished patients presented more often with dyspnoea (OR = 1.44), diarrhoea (OR = 1.64), night sweat (OR = 1.83), and less with haemoptysis (OR = 0.58) and cavitation (OR = 0.64). The size of Mantoux was associated with HIV infection and malnutrition. In a logistic regression analysis both HIV status and malnutrition were associated with atypical presentation of pulmonary tuberculosis. Malnutrition and HIV infection both contribute for atypical presentation of pulmonary tuberculosis. The risk of such atypical presentation is particularly high among the severely malnourished HIV-infected patients.
Abstract: BACKGROUND: It is commonly believed that households are relatively homogeneous with respect to nutritional status and occurrence of diseases. We therefore examined how anthropometric measurements are correlated between different household members in famine-prone Ethiopian communities. METHODS: We studied 1147 people in the Elka village in the Rift Valley. RESULTS: The results show that the correlations between the state of nutrition among household individuals are weak. Thus, anthropometric indices of young children, older children and adult men are an inefficient means of screening for maternal malnutrition. The low sensitivity and high specificity suggest that intra-household members may not fully share risk factors for malnutrition. CONCLUSIONS: We question the commonly held view on the use of childhood nutritional indicators as proxies of household nutritional risks. Our study may have practical implications for screening programmes and interventions during famines. There is no short cut to separate screening of population subgroups.
Abstract: STUDY OBJECTIVES: To compare two ethnically distinct Ethiopian populations (Oromo Arsi in Elka in the Rift Valley and Anyuak in Punjido in Gambella) for two widely used anthropometric indices of protein-energy malnutrition: body mass index < 18.5 and arm muscle circumference < 80% of the median of the US NHANES reference data. DESIGN: Anthropometric measurements were made in two cross sectional community surveys. SETTING: The Elka village in the central Rift Valley and the Punjido village in western Ethiopia. PARTICIPANTS: 1170 and 560 people from all age groups in Elka and Punjido, respectively. MAIN RESULTS: Estimates of the prevalence of malnutrition in each group differed considerably when defined from the body mass index, but were quite similar when the arm muscle circumference was used. Data for children indicated that the boys and girls in one group (Punjido) were taller but had about the same weights for age as those in the other group (Elka), suggesting that the low body mass indices among the Punjido might have a genetic basis. CONCLUSIONS: Body mass index systematically overestimates the prevalence of malnutrition among the Anyuaks in Punjido. Local reference data from a well nourished Anyuak sample or from an ethnically related population is needed to evaluate appropriately malnutrition using the body mass index. This study shows that care must be taken when assessing different ethnic groups using existing international anthropometric references.
Abstract: We describe the height and weight velocities of 1529 preschool Ethiopian children from two rural and semi-urban communities. Compared to international references, our results show a marked deficit in both height and weight velocities. Most importantly, these deficits occurred among the youngest children. As most of the children had normal body proportions, the weight velocity deficits are probably a consequence of increasing prevalence of stunting alone.
Abstract: The occurrence of night blindness and serum vitamin A concentrations among children in rural Bangladesh were studied in relation to protein energy malnutrition, dietary habits and intake of vitamin A capsules. In 1992, 124 night-blind children were registered in a cross-sectional survey in the northern part of Bangladesh, and age-, sex- and neighbourhood-matched controls were selected. Of these, the first reported night-blind child from a household (n = 105) and their controls were included in the analyses. Our results showed that night blindness was associated with protein energy malnutrition when using the mid-upper arm circumference (MUAC) as a measure of nutritional status. The odds ratio for a confirmed diagnosis of night blindness among children with a MUAC < 80% of the reference versus normal children was 5.4 (CI 1.9-15.5). Low MUAC was associated with low intake of beta-carotene-rich and vitamin A-containing foods as well as with low serum vitamin A in the total series of cases and controls. This may indicate that night blindness is only one aspect of the general protein energy malnutrition problems in this population. We therefore suggest that measures to prevent vitamin A-related morbidity and mortality should include improvement of the general diet with increased consumption of dietary vitamin A.
Abstract: BACKGROUND. From Africa, our knowledge on how malnutrition and diseases influence the ability to work is limited. In a one-year population-based study, we investigated the effects of nutritional status, illness and socioeconomic factors on the activity pattern in a rural population in southern Ethiopia. METHODS. From July 1991 to June 1992, 226 people (109 men and 117 women) from the Elka na Mataramofa village in the Rift Valley were examined every 3 months. Information on the occurrence of illness and measurement of nutritional status were collected every 3 months. At the same time we interviewed each person for seven consecutive days to assess the pattern of activities. RESULTS. Men and women had a mean estimated energy expenditure (SD) of 2937 kcal (951) and 1977 (513) kcal, respectively. The mean body mass index (BMI) (SD) was 19.7 (2.3) for men and 20.0 (2.6) for women. Men showed a significant seasonal variation in estimated energy expenditure that was highest during the pre-harvest time. Women did not show such a seasonal variation. In a multivariate analysis, sex, age, state of nutrition, period prevalence and severity of diseases and seasonality influenced estimated energy expenditures. CONCLUSIONS. Both low BMI and illness are significantly associated with low estimated energy expenditure. Most likely, this represents an example of the vicious circle of malnutrition, disease and activity that affects subsistence farming communities. Development work that improves the state of nutrition and health of the adult population may therefore enhance the work performance of rural populations.
Abstract: The 1972-73 and 1984-85 famines varied significantly among different populations within famine areas at the regional, community and household levels. Political and social factors were crucial in this pattern. Evidence from both pastoral and farming areas indicates that the development of community-based resources may be less disruptive socially and economically and result in less morbidity and mortality than dependence on relief shelters. Areas needing further study are identified.
Abstract: To assess the population dynamics of drought-prone communities, we investigated 605 households in the pastoralist Boran community of Dubluk and in the agricultural community of Elka, both located in southern Ethiopia. The age and sex composition of the population as well as records of births, deaths and patterns of migration were observed for 2 consecutive years. Repeated surveys of the same households revealed much higher rates for deaths and births than did cross-sectional surveys with a one-year recall period. Indirect mortality estimates showed that the under 5 years mortality rates (per 1000 births) were 135 in Dubluk and 219 in Elka. Highest crude death rates were observed in Elka during periods of meningitis and malaria epidemics. During the period of observation, death rates fluctuated to a greater extent than birth rates. Both communities had very high rates of natural increase: in Dubluk 39.0/1000 and in Elka 37.1/1000. In Dubluk, this rate was far higher than any previously recorded and may have indicated that fertility regulating mechanisms, traditionally inherent in the pastoralist social organization, had become weaker as part of cultural changes. Dubluk represented a semi-nomadic society with a moderately high mobility pattern. Peak periods of migration coincided with times of food scarcity in Elka.
Abstract: To assess dietary habits and nutritional state in drought-prone areas of southern Ethiopia, we studied 334 households in a pastoral and 282 in an agricultural community. Milk and cereals were the main sources of food among children of the pastoral Boran in Dubluk, while cereals with limited supplements of animal products or legumes formed the main sources of food among children of the agricultural population of Elka in the Rift valley. Of the children in Elka, 54.9% were stunted, as compared with 19.5% among children in Dubluk. Also, stunting occurred at an earlier age among the Elka children. Prevalences of wasting were less than 5% in both communities. Improvement in the state of nutrition of the pastoral children followed soon after the main rains, but occurred later and after the main harvest among the agricultural children. In contrast to arm circumference, the weight-for-height measure showed marked seasonal variation. Socio-economic factors, such as family wealth and crowding, significantly influenced the state of nutrition among the children. Nutritional recovery following the prolonged drought among the agricultural children was slow and associated with families acquiring more wealth.
Abstract: This is a prospective study on the possible association between protein energy malnutrition and risk of infection in a pastoralist and in an agricultural community in southern Ethiopia. A total of 425 children under 5 years of age were observed for 8 months. In general, malnourished children had a significantly higher incidence of diarrhoeal disease, even after controlling for possible confounding social, economic, and environmental effects, as well as for past history of illness. However, the extent of this association between nutritional state and morbidity differed between the two study populations. Thus, only wasting was associated with increased incidence of diarrhoeal disease among the pastoralist, whereas wasting, stunting, low weight for age, and low arm circumference all showed such an association in the agricultural community. Demographic and socio-economic characteristics as well as differences in the prevalence of stunting may explain this discrepancy.
Abstract: We describe the incidence of some childhood infections in drought prone areas of southern Ethiopia. Our results are based on 24 months' biweekly observations of 828 children aged 0-5 years in the pastoralist community of Dubluk and the agricultural community of Elka. An average of 23% of the children in Dubluk and 13% in Elka were sick during any 2-week period. Diarrhoeal diseases represented the main cause of morbidity, but the yearly number of diarrhoeal episodes were lower than previously reported from Ethiopia. Respiratory tract infections and to a lesser extent diarrhoeal diseases, showed highest incidence rates during the main dry season. The highest incidence of lower respiratory tract infections coincided with an outbreak of measles. In Dubluk, children who lived near to the wells had higher incidence rates than those who lived further away, probably reflecting the importance of crowding on transmission rates. In Elka, literacy of mothers was associated with reduced incidence of both diarrhoeal and respiratory tract infections, whereas the use of open pit latrines was associated with increased diarrhoeal incidence. The decline in disease incidence in this region during the last months of our study may reflect an improvement of nutritional status.
Abstract: A retrospective case-control study of children less than 5 years of age with diarrhoea was conducted at a hospital in southern Ethiopia. 21 cases (deaths) and 84 controls were studied. Severe dehydration, fever, pneumonia, acute and chronic malnutrition and age greater than 12 months were risk factors significantly associated with death. A simple score system to identify children at risk of dying is presented.
Abstract: The major health problems in developing countries are associated with poverty, lack of food, poor sanitation, hygiene and high population growth. Malaria and schistosomiasis have increased along with more frequent use of large scale irrigation schemes. During recent decades some countries have managed to control the communicable diseases. However, new health problems have developed, often as a result of environmental degradation and uncontrolled population growth. Urbanization and industrialization are closely related to, and often cause pollution, ecological imbalances and occupational health problems. Indoor air pollution is a neglected problem. Health workers in third world must identify problems and seek solutions by applying epidemiological principles. National and international cooperation are both needed to cope with the problems.
Abstract: Hospitals can serve as an important complement to Primary Health Care. Therefore it is necessary to undertake periodic reviews of hospital function. We reviewed hospital use and pattern of referral by analyzing 4,797 admissions, at a regional hospital in southern Ethiopia. The main causes of sickness were related to childbirth, gastrointestinal disorders, infectious diseases and injuries. Acute diseases were more common in the younger age-groups. Infections were the main cause of death. Hospital use was inversely proportional to distance from the patient's home, but varied for different groups of patients. Thus, the effect of proximity was more obvious for poor patients, for women, and for children. The study demonstrates limitations in hospital function in third world countries, and recommends closer cooperation between primary and secondary levels of health care.
Abstract: During the 1985-86 famine children from two areas in Southern Ethiopia were studied to assess a possible association between malnutrition and diarrhoeal disease. Malnutrition did not increase the incidence of diarrhoeal disease. However, malnourished children were more severely affected by the infection. Nutritional rehabilitation reduced the demand for treatment of diarrhoea and probably contributed to a decrease in crude childhood mortality.
Abstract: OBJECTIVE--To assess the effects of drought on mortality in children. DESIGN--Prospective epidemiological study forming part of nutritional monitoring during famine relief work. SETTING--24 Food distribution sites in Arero and Borana provinces in southern Ethiopia. PATIENTS--A monthly average of 14,173 and 5,334 children under 5 were examined in 1985 and 1986, respectively. Altogether 148,966 child months (105,872 for 1985 and 43,094 for 1986) were available for analysis. INTERVENTION--The families of all children were supplied with food each month. Basic medical care was also provided. MAIN OUTCOME MEASURE--Mortality in children under 5. RESULTS--A 40% increase in crude mortality was observed among children living in traditional and stable societies. The severe consequences were observed mainly among children living in relief shelters, where a threefold to fourfold increase in crude mortality was recorded among children. Increased childhood mortality was also associated with high prevalence of malnutrition, living in the most arid areas, and the dry season. A long period of food aid was needed to normalise the nutritional state, especially for children living in relief shelters. CONCLUSIONS--The most severe consequences of the widespread famine that occurred in the Arero and Borana provinces of southern Ethiopia during 1985-6 were seen among children living in relief shelters. Early food intervention may decrease the scale of migration and thus also reduce the severe consequences of a famine.
Abstract: This study from the Sidamo Regional Hospital presents the prevailing sensitivity to common antimicrobials among 337 bacterial isolates from abscesses, infected wounds, urine or gonorrhoeal infections. As expected, Staphylococcus aureus Escherichia cloi, Proteus supp and Streptococcus pyogenes were most frequently grown from abscesses and infected wounds, whereas E. coli, Proteus spp, Klebsiella spp, and coagulase negative staphylococci dominated in urinary tract infections. Very high rates of reduced sensitivity, including multiresistance to commonly used antibiotics, were detected. Of 54 isolates of Niesseria gonorrhoeae 84% were resistant to penicillin-G by disc diffusion method. Beta lactamase production was detected in 4 of 6 isolates tested.
Abstract: All of the 104 strains isolated from tuberculosis patients in Sidamo Regional Hospital were identified as M. tuberculosis. Primary single drug resistance to isoniazid and streptomycin was represented by two strains in each case. Four strains showed double drug resistance to the same drugs. None were resistant to thiacetazone, rifampicin and ethambutol.
Abstract: Parts of southern Ethiopia were form 1983 to 1985 affected by drought and famine. This study describes the prevalence of marasmus and kwashiorkor in four drought-affected regions: Bale, Sidamo, Gamu Gofa and southern Shoa. An analysis of 37,511 children in the 1-5 year age group representing 212 communities has been performed. The study demonstrates that both marasmus and kwashiorkor are facets of drought. The epidemiologies of kwashiorkor and marasmus differ: marasmus is the most common form of acute malnutrition in all areas, while kwashiorkor is found in a limited number of communities only. These latter communities have a subsistence farming economy, most often in ensete-growing areas. In the lowland semi-arid regions, which have an agro-pastoralist economy, kwashiorkor is virtually absent. These epidemiological findings are discussed in relation to different theories of the aetiology and pathogenesis of kwashiorkor.
Abstract: A retrospective study of biopsies taken at three hospitals in Southern Ethiopia has been carried out to describe the cancer pattern in the Sidamo and Gamu Gofa regions. A histologically verified cancer diagnosis was recorded in 1154 patients. The bias that appear in the data are discussed. This includes aspects of hospital coverage, age and sex distribution and bias that arise from a lack of diagnostic facilities, especially to diagnose deep seated tumours. Taking these bias into consideration, the cancer pattern in Southern Ethiopia is outlined. Among men, hepatic carcinoma, lymphomas and superficial malignancies (skin cancers including melanomas and superficial soft tissue sarcomas) are the most common malignancies while among women, cervical, breast and ovarian cancers predominate. It is noted that most of the Kaposi's sarcomas recorded are from the Sidamo area. Hodgkin's disease and Burkitt's lymphoma are most common among childhood lymphomas, whereas non-Hodgkin lymphomas of other types dominate among adults. Cancer of the stomach is the second most common internal malignancy among both men and women.
Abstract: In a retrospective study eleven cases with Burkitt's lymphoma have been diagnosed at three rural hospitals in the Sidamo and Gamu Gofa Regions of South Ethiopia. The clinical picture is heterogeneous with an abdominal mode of presentation being most frequently observed. It is concluded that South Ethiopia has an incidence of Burkitt's lymphoma between that of endemic countries (e.g. Uganda) and non-endemic countries such as the USA.
Abstract: Two relatively age-independent indicators--weight-for-height and mid upper-arm circumference--have been widely used to assess acute malnutrition in drought-affected communities in southern Ethiopia. Compared with weight for height, arm circumference (with cut-off points of 12.5 cm and 13.5 cm) greatly exaggerates acute malnutrition prevalence rates. New cut-off points (11 cm and 13 cm) are therefore proposed which significantly reduce false-positive rates and make weight for height and arm circumference classifications more comparable in the assessment of acute malnutrition.
Abstract: In a 12-year retrospective study of patients with kala-azar from Gidole Hospital in south-west Ethiopia it is demonstrated that most patients are diagnosed during the months August to November with another small peak from March to May. It is suggested that transmission is associated with two main periods of annual rainfall.
