Self-Medication and Safety Profile of Medicines Used among Pregnant Women in a Tertiary Teaching Hospital in Jimma, Ethiopia: A Cross-Sectional Study.

BACKGROUND: Despite the potential foetal and maternal risks of self-medication, studies on self-medication and safety profile of medicines used during pregnancy are scarce. This study determined the prevalence, predictors and safety profile of medicines used for self-medication during pregnancy at Jimma University Medical Centre (JUMC) in Ethiopia. METHODS: A hospital-based cross sectional study was conducted on 1117 hospitalized pregnant women or postpartum women in the maternity and gynaecology wards at JUMC between February and June 2017. Data were collected using an interviewer-administered structured questionnaire and by reviewing patient medical records. Data were analysed using descriptive statistics and logistic regression. RESULT: Nearly 3 out of 10 women reported taking at least one type of conventional medicine for self-medication, mainly analgesics 92.3%. Almost 75.0% of the self-medicated women used medicines classified as probably safe and 13.6% as potentially risky to use during pregnancy. Medicinal plant use, religion and access to a health facility near their residency were significantly associated with self-medication during pregnancy. CONCLUSIONS: Self-medication is common among pregnant women at JUMC. Most women used medicines classified as safe to use during pregnancy. There is need for enlightenment of pregnant women on the potential dangers of self-medication during pregnancy to prevent foetal and maternal risks.

Synergy between Th1 and Th2 responses during Mycobacterium tuberculosis infection: A review of current understanding.

Induction of Th1 (cell-mediated) immunity and associated production of IFN-γ by CD4+ T cells has been widely used as a marker of protective immunity against tuberculosis (TB). This is based on two assumptions. The first is the widely accepted view that Mycobacterium tuberculosis (Mtb), the causative agent of TB is an obligate intracellular pathogen, and the second is based on the Th1/Th2 paradigm, which posits that polarization of CD4+ T cells into type1 (cell-mediated) and type 2 (humoral) is central for proper induction of protective immunity against pathogens. However, almost all licensed vaccines currently in use are primarily anti-body based whether intracellular or extra-cellular. In addition, converging data from both animal models and humans indicate that the production of IFN-γ alone is not sufficient to confer protection against TB. In addition, a substantial body of the literature suggests that, in addition to Th1 cells, antibody classes and sub-classes are protective against TB. In a recent study, we have shown that there is a synergy between IFN-γ (cell-mediated) and IgA (humoral) in human population in an endemic setting. In this review, current data from both animal and human studies that support mixed Th1 and Th2 responses that are protective against Mtb and other pathogens are presented.

Traditional healers' role in the detection of active tuberculosis cases in a pastoralist community in Ethiopia: a pilot interventional study.

BACKGROUND: Pastoralists rely on traditional healers (THs) for general health problems. However, some studies indicate that such practices result in delays in the diagnosis and treatment of tuberculosis (TB) cases. This study aims to assess the role of traditional healers in the detection and referral of active TB cases in a pastoralist community. METHODS: We identified 22 traditional healers from 7 villages of Kereyu pastoralist community in the Fentale district in Ethiopia in January 2015. We trained these THs in identifying presumptive TB symptoms and early referral to the nearby healthcare facilities. The training was held during a 1 week period that included a visit to their villages and follow-up. A 1 day meeting was held with the traditional healers, the district TB care and prevention coordinator and health extension workers from the selected sub-district to discuss the referral link between THs and the nearby healthcare facilities. Health providers working at the TB units in the selected healthcare facilities were oriented about the training given and planned involvement of THs in referring presumptive TB case. In addition, documentation of the presumptive TB cases was discussed. RESULTS: We succeeded in tracing and interviewing 8 of the 22 THs. The rest were on seasonal migration. According to the THs report for the 1 year period, these 8 THs had referred 24 TB suspects to the healthcare facilities. Sputum smear microscopy confirmed 13 of the 24 suspects as having TB cases. Among those confirmed, 10 completed treatment and three were on treatment. Five presumptive TB cases were confirmed non TB cases through further evaluation at the healthcare facilities and six of the presumptive TB cases were lost to follow up by the THs. Whereas, four of the presumptive TB cases were lost to follow up to the healthcare facility. CONCLUSIONS: Results of the present study indicate that THs can contribute to the detection of undiagnosed active TB cases in a pastoralist community, provided they are given appropriate training and support.

Health care providers' knowledge, attitude and perceived stigma regarding tuberculosis in a pastoralist community in Ethiopia: a cross-sectional study.

BACKGROUND: Tuberculosis (TB) remains the prime killer disease among infectious diseases. TB control depends on early case detection and treatment in a directly observed treatment short course (DOTS) programme. The success of DOTS depends on the ability of the health care system to identify and properly manage TB cases. The present study aims to assess healthcare provider (HCP) knowledge, attitude and perceived stigma regarding TB and perception about traditional healers. METHODS: A descriptive cross sectional study was conducted among 108 HCPs using a semi-structured, self-administered questionnaire from September 2014 to January 2015. The study district has a high TB burden area with one district hospital, 4 health centres, and 18 health posts. All health facilities and HCPs available during the study period in the district were included in the study. Statistical software for social science (SPSS) version 22 and STATA version 14 were used to enter and analyse data, respectively. RESULTS: The majority (64%) of the HCPs had poor overall knowledge regarding TB, and 67.6 and 57.6% had poor knowledge regarding TB diagnosis and nature of the disease, respectively. Moreover, most 66.7 and 55.6% of the HCPs had an unfavourable attitude towards TB and TB control systems, respectively. Slightly under half (49.1%) of the HCPs had a favourable attitude towards TB patients, and the majority (88.9%) had low perceived stigma. The majority (87.0%) of the HCPs indicated the importance of community involvement in TB control activity. Moreover, most (60.2%) of the HCPs showed willingness to collaborate with traditional healers (THs) on TB control activity. CONCLUSIONS: Healthcare workers' knowledge gap and unfavourable attitude towards TB control systems reported in this study may cause poor TB care delivery. HCPs' perception of the importance of community involvement in TB control and willingness to collaborate with THs on TB management could be an opportunity to strengthen the World Health Organization's (WHO's) component of End TB strategy through community engagement. Training and workshops could be used to address the knowledge gap and the unfavourable attitude regarding TB among HCPs.

IgA and IgG against Mycobacterium tuberculosis Rv2031 discriminate between pulmonary tuberculosis patients, Mycobacterium tuberculosis-infected and non-infected individuals.

As part of a major project to investigate protective and diagnostic immune markers against tuberculosis (TB), we measured antibody isotype responses to Mycobacterium tuberculosis (Mtb) antigens (LAM, Rv2031, and HBHA) in cohorts of 149 pulmonary tuberculosis patients (PTBP), 148 household contacts (HHCs), and 68 community controls (CCs) in an endemic setting. ELISA was used to measure levels of IgA, IgG, and IgM from sera of cohorts at baseline, and at 6 and 12 months from entry. The results show that there were significant differences in IgA, IgG, and IgM responses to the different antigens and in the three cohorts. At baseline, the level of IgM against RV2031 and LAM did not vary between cohorts, but the levels of IgA and IgG against Rv2031 were significantly higher in PTB patients than HHCs and CCs, followed by HHCs, and the lowest in CCs. In patients, there was a significant variation in antibody responses before and after chemotherapy. The levels of IgA and IgG against HBHA, and IgA against Rv2031 decreased significantly and remained low, while IgA and IgG against LAM increased significantly and remained high following chemotherapy. However, the levels of IgM against Rv2031 and LAM increased at 6 months but decreased again at 12 months. IgM against HBHA did not show any significant variation before and after chemotherapy. Similarly, there were also significant variations in antibody responses in HHCs over time. Our results show that there are significant variations in IgA, IgG and IgM responses to the different antigens and in the three cohorts, implying that not all antibody isotype responses are markers of clinical TB. In addition, the current and previous studies consistently show that IgA and IgG against Rv2031 discriminate between clinical disease, Mtb-infected and non-infected individuals.

IFN-γ against the 38-kDa antigen of Mycobacterium tuberculosis discriminates pulmonary tuberculosis from infection and infection from exposure: evidence from a study of human population in a high endemic setting.

Mycobacterium tuberculosis (Mtb) 38-kDa antigen is an immunogenic lipoprotein that induces strong T-cell responses in experimental animals. However, there is limited information on the role of this antigen in human population. In this article, we present the dynamics of pro-inflammatory (IFN-γ and TNF-α) and anti-inflammatory cytokine (IL-10) against the 38 kDa in cohorts of pulmonary TB (PTB) patients, household contacts (HHCs), and community controls (CCs) in a high endemic setting. Whole blood assay was used to determine the levels of cytokines in 149 patients, 149 HHCs, and 68 CCs at baseline, 6 months, and 12 months. At baseline, the level of IFN-γ was significantly (p < 0.0001) higher in CCs and HHCs than in untreated patients. CCs had significantly (p < 0.05) higher level of IFN-γ than HHCs. There was no significant difference between treated and untreated patients, and there was no significant change in HHCs over 12 months. At baseline, the levels of IL-10 and TNF-α were significantly (p < 0.0001) higher in patients than in HHCs and CCs. No significant change was observed between treated patients and untreated patients and HHCs over time. The study shows that IFN-γ against the 38 kDa discriminates clinical TB from infection and infection from exposure, suggesting its potential for immune protection and diagnosis.

Knowledge, attitude and perceived stigma towards tuberculosis among pastoralists; Do they differ from sedentary communities? A comparative cross-sectional study.

BACKGROUND: Ethiopia is ninth among the world high tuberculosis (TB) burden countries, pastoralists being the most affected population. However, there is no published report whether the behavior related to TB are different between pastoralist and the sedentary communities. Therefore, the main aim of this study is to assess the pastoralist community knowledge, attitude and perceived stigma towards tuberculosis and their health care seeking behavior in comparison to the neighboring sedentary communities and this may help to plan TB control interventions specifically for the pastoralist communities. METHOD: A community-based cross-sectional survey was carried out from September 2014 to January 2015, among 337 individuals from pastoralist and 247 from the sedentary community of Kereyu district. Data were collected using structured questionnaires. Three focus group discussions were used to collect qualitative data, one with men and the other with women in the pastoralist and one with men in the sedentary groups. Data were analyzed using Statistical Software for Social Science, SPSS V 22 and STATA. RESULTS: A Lower proportion of pastoralists mentioned bacilli (bacteria) as the cause of PTB compared to the sedentary group (63.9% vs. 81.0%, p<0.01), respectively. However, witchcraft was reported as the causes of TB by a higher proportion of pastoralists than the sedentary group (53.6% vs.23.5%, p<0.01), respectively. Similarly, a lower proportion of pastoralists indicated PTB is preventable compared to the sedentary group (95.8% vs. 99.6%, p<0.01), respectively. Moreover, majority of the pastoralists mentioned that most people would reject a TB patient in their community compared to the sedentary group (39.9% vs. 8.9%, p<0.001), respectively, and the pastoralists expressed that they would be ashamed/embarrassed if they had TB 68% vs.36.4%, p<0.001), respectively. CONCLUSION: The finding indicates that there is a lower awareness about TB, a negative attitude towards TB patients and a higher perceived stigma among pastoralists compared to their neighbor sedentary population. Strategic health communications pertinent to the pastoralists way of life should be planned and implemented to improve the awareness gap about tuberculosis.

IFN-γ and IgA against non-methylated heparin-binding hemagglutinin as markers of protective immunity and latent tuberculosis: Results of a longitudinal study from an endemic setting.

BACKGROUND: Heparin-binding hemagglutinin (HBHA) is a surface protein involved in epithelial attachment and extrapulmonary dissemination of Mycobacterium tuberculosis. HBHA is attracting increasing attention for its vaccine and diagnostic potential. In a longitudinal study, we investigated non-methylated, recombinant HBHA-specific cytokine and antibody profiles in cohorts of TB patients, their contacts and community controls in an endemic setting. METHODS: Whole blood assay was done at baseline, 6 and 12 months in patients and contacts, and at entry in controls. ELISA was used to measure IFN-γ, TNF-α and IL-10 (from supernatants), and IgG, IgM and IgA (from sera). RESULTS: Fifty-three percent of controls and 72.1% of contacts were QFT-GIT positive. Baseline IFN-γ was significantly higher in community controls and contacts compared to untreated TB patients (p < 0.0001). Controls had significantly higher IgA and lower IgM compared to both untreated TB patients and contacts (p < 0.0001). IL-10 was significantly higher in untreated TB patients compared to contacts and controls (p < 0.0001). In treated TB patients, IFN-γ significantly increased (p < 0.0001) whereas IL-10 significantly decreased (p < 0.001). CONCLUSION: This study reports for the first time that anti-HBHA IgA could have the potential as a biomarker of protective immunity. In addition, non-methylated, recombinant HBHA-induced IFN-γ could be used as a biomarker of protective immunity and latent TB.

Prevalence of tuberculosis, HIV, and TB-HIV co-infection among pulmonary tuberculosis suspects in a predominantly pastoralist area, northeast Ethiopia.

BACKGROUND: TB-HIV co-infection is one of the biggest public health challenges in sub-Saharan Africa. Although there is a wealth of information on TB-HIV co-infection among settled populations in Africa and elsewhere, to our knowledge, there are no published reports on TB-HIV co-infection from pastoral communities. In this study, we report the prevalence of TB, HIV and TB-HIV co-infection among pulmonary TB suspects in the Afar Regional State of Ethiopia. DESIGN: In a cross-sectional study design, 325 pulmonary TB suspects were included from five health facilities. Three sputum samples (spot-morning-spot) were collected from each participant. Sputum samples were examined for the presence of acid fast bacilli using Ziehl-Neelsen staining method, and culture was done on the remaining sputum samples. Participants were interviewed and HIV tested. RESULTS: Of the 325 pulmonary TB suspects, 44 (13.5%) were smear positive, and 105 (32.3%) were culture positive. Among smear-positive patients, five were culture negative and, therefore, a total of 110 (33.8%) suspects were bacteriologically confirmed pulmonary TB patients. Out of 287 pulmonary TB suspects who were tested for HIV infection, 82 (28.6%) were HIV positive. A significantly higher proportion of bacteriologically confirmed pulmonary TB patients [40 (40.4%)] were HIV co-infected compared with patients without bacteriological evidence for pulmonary TB [42 (22.3%)]. However, among ethnic Afar pastoralists, HIV infections in smear- and/or culture-negative pulmonary TB suspects [7 (7.6%)] and bacteriologically confirmed pulmonary TB patients [4 (11.8%)] were comparable. On multivariable logistic regression analysis, Afar ethnicity was independently associated with low HIV infection [OR=0.16 (95% CI: 0.07-0.37)], whereas literacy was independently associated with higher HIV infection [OR=2.21 (95% CI: 1.05-4.64)]. CONCLUSIONS: Although the overall prevalence of TB-HIV co-infection in the current study is high, ethnic Afars had significantly lower HIV infection both in suspects as well as TB patients. The data suggest that the prevalence of HIV infection among Afar pastoralists is probably low. However, population-based prevalence studies are needed to substantiate our findings.

Lipoarabinomannan-specific TNF-α and IFN-γ as markers of protective immunity against tuberculosis: a cohort study in an endemic setting.

Lipoarabinomannan (LAM) is a virulent factor used for entry and survival of Mycobacterium tuberculosis (Mtb) in macrophages. Although the role of LAM for the diagnosis of tuberculosis (TB) has been extensively investigated, its cytokine response during natural Mtb infection in humans is largely unknown. In this study, LAM-specific IFN-γ, TNF-α, and IL-10 levels following whole blood assay were measured in untreated pulmonary TB patients, their contacts and community controls at baseline. In treated patients and contacts, cytokines were also measured at 6 and 12 months. At entry, 52.8% and 74.8% of controls and contacts were QFT-GIT positive, respectively. At baseline, untreated TB patients and contacts had significantly lower IFN-γ and TNF-α response compared to community controls (p < 0.0001). Besides, untreated patients had significantly higher TNF-α and IL-10 response compared to their contacts (p < 0.0001). At 6 months, contacts and treated TB patients had significantly increased INF-γ and TNF-α response (p < 0.0001). In TB patients, IFN-γ increased 10-fold following chemotherapy suggesting its potential role for treatment monitoring. The data suggests that LAM might have an anti-inflammatory effect during clinical TB and early Mtb infection. The data also suggests that LAM-induced IFN-γ and TNF-α could be used as biomarkers of protective immunity.

Pro- and anti-inflammatory cytokines against Rv2031 are elevated during latent tuberculosis: a study in cohorts of tuberculosis patients, household contacts and community controls in an endemic setting.

Tuberculosis (TB) is among the leading causes of morbidity and mortality. The causative agent, Mycobacterium tuberculosis (Mtb), has evolved virulent factors for entry, survival, multiplication and immune evasion. Rv2031 (also called alpha crystallin, hspX, 16-kDa antigen), one of the most immunogenic latency antigens, is believed to play a key role in long-term viability of Mtb. Here, we report the dynamics of pro-inflammatory (IFN-γ, TNF-α) and anti-inflammatory (IL-10) cytokines against Rv2031 using whole blood assay in human cohorts in a TB endemic setting. Cytokine responses to ESAT-6-CFP-10 were also measured for comparison. Blood samples were collected from smear positive pulmonary TB patients and their contacts at baseline, 6 and 12 months, and from community controls at entry. At baseline, 54.4% of controls and 73.2% of contacts were QFT-GIT test positive. Baseline IFN-γ, TNF-α and IL-10 responses to Rv2031 were significantly higher in controls compared to contacts and untreated patients (p<0.001). Furthermore, untreated patients had significantly higher TNF-α and IL-10 responses to Rv2031 compared to contacts (p<0.001). In contacts and treated patients, IFN-γ, TNF-α and IL-10 responses to Rv2031 significantly increased over 12 months (p<0.0001) and became comparable with the corresponding levels in controls. There was a positive and significant correlation between Rv2031 and ESAT-6-CFP-10 specific cytokine responses in each study group. The fact that the levels of IFN-γ, TNF-α and IL-10 against Rv2031 were highest during latent TB infection may indicate their potential as markers of protection against TB. Taken together, the findings of this study suggest the potential of IFN-γ, TNF-α and IL-10 against Rv2031 as biomarkers of the host response to Mtb during convalescence from, and the absence of, active tuberculosis.

QuantiFERON-TB Gold In-Tube test conversions and reversions among tuberculosis patients and their household contacts in Addis Ababa: a one year follow-up study.

BACKGROUND: QuantiFERON-TB Gold In-Tube® (QFT-GIT) test is used for the diagnosis of latent tuberculosis (TB) infection. Besides, QFT-GIT test could allow tracking changes in immune response among TB patients and their contacts. In high TB burden settings, reports on QFT-GIT conversions and reversions among TB patients and their contacts are limited. As part of a major project to study immune responses to TB infection, we investigated QFT-GIT test conversions and reversions among smear positive pulmonary TB patients and their household contacts over 12 months. METHODS: We followed a total of 107 HIV negative participants (33 patients and 74 contacts) in Addis Ababa. We did QFT-GIT test at baseline and 12 months later according to the manufacturer's instructions. RESULTS: At baseline, 25/33 (75.8%) of the patients and 50/74 (67.6%) of the contacts were QFT-GIT positive. At 12 months, 2 more patients (1 test negative and 1 indeterminate) became test positive. Besides, 11/24 (45.8%) test negative contacts became positive. Only one patient and one contact who were test positive at baseline became test negative 12 months later. At 12 months, the proportions of QFT-GIT test positives for patients and contacts were, therefore, 78.8% and 81.1%, respectively. Among contacts, the proportion of QFT-GIT test positives at 12 months was significantly higher compared to the corresponding proportion at baseline (McNemar, p = 0.006); similarly, the median IFN-γ response significantly increased at 12 months compared with the baseline level (Wilcoxon matched-pairs signed rank test, p = 0.01). Patients, however, had comparable median IFN-γ levels at baseline and 12 months later (p = 0.56). CONCLUSION: Nearly half of QFT-GIT negative household contacts at baseline became positive at 12 months. This suggests that repeated screening of QFT-GIT negative contacts may be needed for epidemiological studies and interventions of latent TB in an endemic setting. A large longitudinal study may be needed to confirm our observations.

Strain diversity of Mycobacterium tuberculosis isolates from pulmonary tuberculosis patients in Afar pastoral region of Ethiopia.

Data on genotypic diversity of Mycobacterium tuberculosis complex (MTBC) is important to understand its epidemiology, human adaptation, clinical phenotypes, and drug resistance. This study aimed to characterize MTBC clinical isolates circulating in a predominantly pastoralist area in Ethiopia, a country where tuberculosis is the second leading cause of mortality. Culture of sputum samples collected from a total of 325 pulmonary TB suspects was done to isolate MTBC. Spoligotyping was used to characterize 105 isolates from culture positive slopes and the result was compared with an international database. Forty-four spoligotype patterns were observed to correspond to 35 shared-types (SITs) containing 96 isolates and 9 orphan patterns; 27 SITs containing 83 isolates matched a preexisting shared-type in the database, whereas 8 SITs (n = 13 isolates) were newly created. A total of 19 SITs containing 80 isolates were clustered within this study (overall clustering of 76.19%). Three dominant lineages (T, CAS, and Manu) accounted for 76.19% of the isolates. SIT149/T3-ETH was one of the two most dominant sublineages. Unlike previous reports, we show that Manu lineage strains not only constitute a dominant lineage, but are also associated with HIV infection in Afar region of Ethiopia. The high level of clustering suggests the presence of recent transmission that should be further studied using additional genotyping markers.

Community-based prevalence of undiagnosed mycobacterial diseases in the Afar Region, north-east Ethiopia.

BACKGROUND: Information on the community-based prevalence of tuberculosis (TB) in different settings is vital for planning, execution and evaluation of strategies to control the disease. OBJECTIVE: To assess community-based prevalence of undetected active pulmonary TB (PTB) in pastoralists of the Amibara District. METHODS: Between March and April 2010, a community-based cross-sectional survey of undiagnosed active PTB was conducted in the pastoralists of the Amibara District of the Afar Region, north-east Ethiopia. The study participants were interviewed for symptoms suggestive of PTB using a structured questionnaire. Sputum samples were collected and processed for smear microscopy and culture. Mycobacterium genus typing was performed using a multiplex polymerase chain reaction (PCR). RESULTS: Out of 222 individuals who had symptoms suggestive of PTB, 4 (1.8%) were found positive by smear microscopy, while mycobacterial growth was observed on 62 (27.9%) samples. Mycobacterium genus typing was carried out for 42 of these 62 samples; 39 (92.9%) gave a positive signal for the genus Mycobacterium. Of these, 23 (59%) isolates proved to be members of the Mycobacterium tuberculosis (Mtb) complex, while the remaining 16 (41.0%) were found to be members of non-tuberculous Mycobacteria (NTM) species. CONCLUSION: Sputum culture is highly sensitive, and it is the gold standard for the bacteriological diagnosis of PTB, while smear microscopy is less sensitive to detect acid fast bacilli (AFB) in stained sputum smears. The findings of the present study warrant the strengthening of culture facility services in the study area. The study also provides important preliminary information on the status of NTM infection in the pastoral setting. Nevertheless, further investigations into the species identification of the NTM infections would be useful in the study area.

Tuberculosis in Goats and Sheep in Afar Pastoral Region of Ethiopia and Isolation of Mycobacterium tuberculosis from Goat.

A cross sectional study was conducted on 2231 small ruminants in four districts of the Afar Pastoral Region of Ethiopia to investigate the epidemiology of tuberculosis in goats and sheep using comparative intradermal tuberculin skin test, postmortem examination, mycobacteriological culture and molecular typing methods. The overall animal prevalence of TB in small ruminants was 0.5% (95% CI: 0.2%-0.7%) at ≥4 mm and 3.8% (95% CI: 3%-4.7%) at cutoff ≥2 mm. The herd prevalence was 20% (95% CI: 12-28%) and 47% (95% CI: 37-56%) at ≥4 mm and ≥2 mm cut-off points, respectively. The overall animal prevalence of Mycobacterium avium complex infection was 2.8% (95% CI: 2.1-3.5%) and 6.8% (95% CI: 5.8-7.9%) at ≥4 mm and ≥2 mm cut-off points, respectively. Mycobacteriological culture and molecular characterization of isolates from tissue lesions of tuberculin reactor goats resulted in isolation of Mycobacterium tuberculosis (SIT149) and non-tuberculosis mycobacteria as causative agents of tuberculosis and tuberculosis-like diseases in goats, respectively. The isolation of Mycobacterium tuberculosis in goat suggests a potential transmission of the causative agent from human and warrants further investigation in the role of small ruminants in epidemiology of human tuberculosis in the region.

Diagnostic and treatment delay among Tuberculosis patients in Afar Region, Ethiopia: a cross-sectional study.

BACKGROUND: TB is a major public health problem globally and Ethiopia is 8th among the 22 high burden countries. Early detection and effective treatment are pre-requisites for a successful TB control programme. In this regard, early health seeking action from patients' side and prompt diagnosis as well as initiation of treatment from the health system's side are essential steps. The aim of this study was to assess delay in the diagnosis and treatment of TB in a predominantly pastoralist area in Ethiopia. METHODS: On a cross-sectional study, two hundred sixteen TB patients who visited DOTS clinics of two health facilities in Afar Region were included consecutively. Time from onset of symptoms till first consultation of formal health providers (patients' delay) and time from first consultation till initiation of treatment (health system's delay) were analyzed. RESULTS: The median patients' and health system's delay were 20 and 33.5 days, respectively. The median total delay was 70.5 days with a median treatment delay of 1 day. On multivariate logistic regression, self-treatment (aOR. 3.99, CI 1.50-10.59) and first visit to non-formal health providers (aOR. 6.18, CI 1.84-20.76) were observed to be independent predictors of patients' delay. On the other hand, having extra-pulmonary TB (aOR. 2.08, CI 1.08- 4.04), and a first visit to health posts/clinics (aOR. 19.70, CI 6.18-62.79), health centres (aOR. 4.83, CI 2.23-10.43) and private health facilities (aOR. 2.49, CI 1.07-5.84) were found to be independent predictors of health system's delay. CONCLUSIONS: There is a long delay in the diagnosis and initiation of treatment and this was mainly attributable to the health system. Health system strengthening towards improved diagnosis of TB could reduce the long health system's delay in the management of TB in the study area.

Association of the level of IFN-γ produced by T cells in response to Mycobacterium tuberculosis-specific antigens with the size of skin test indurations among individuals with latent tuberculosis in a highly tuberculosis-endemic setting.

There is growing evidence showing the potential of T-cell-based gamma interferon (IFN-γ) release assays (IGRAs) for predicting the risk of progression of Mycobacterium tuberculosis (Mtb) infection, though there is little information from tuberculosis (TB)-endemic settings. In this study, we assessed the association between the level of IFN-γ produced by T cells in response to Mtb-specific antigens and the size of skin test indurations in 505 adult individuals who were screened for latent tuberculosis infection (LTBI) using the QuantiFERON-TB Gold In Tube (QFTGIT) assay and tuberculin skin test (TST). There was a strong positive correlation between the level of IFN-γ induced by the specific antigens and the diameter of the skin indurations (Spearman's rho = 0.6, P < 0.001). Body mass index and parasitic infection were not associated with the level of IFN-γ production or the TST reaction. In linear regression analysis, the size of the skin test indurations was significantly associated with the mean level of IFN-γ [coefficient, 0.65; 95% confidence interval (CI), 0.47 to 0.82, P < 0.001]. Similarly, results from logistic regression analysis demonstrated that individuals who had skin test indurations ≥ 10 mm were 6.82 times more likely than individuals who had skin test indurations < 10 mm to have high levels of IFN-γ (i.e. positive QFTGIT result) (adjusted odd ratio = 6.82; 95% CI, 3.67 to 12.69, P < 0.001). In conclusion, the results of this study could provide indirect evidence for the prognostic use of the QFTGIT assay for progression of Mtb infection, though prospective follow-up studies are needed to provide direct evidence.

Community-based cross-sectional survey of latent tuberculosis infection in Afar pastoralists, Ethiopia, using QuantiFERON-TB Gold In-Tube and tuberculin skin test.

BACKGROUND: There is little information concerning community-based prevalence of latent tuberculosis infection (LTBI) using T-cell based interferon-γ (IFN-γ) release assays (IGRAs), particularly in TB endemic settings. In this study, the prevalence of LTBI in the Afar pastoral community was assessed using QuantiFERON-TB Gold In-Tube (QFTGIT) and tuberculin skin tests (TST). METHODS: A community-based cross-sectional survey of LTBI involving 652 apparently healthy adult pastoralists was undertaken in the pastoral community of Amibara District of the Afar Region between April and June 2010. RESULTS: The prevalence of LTBI was estimated as 63.7% (363/570) using QFTGIT at the cut-off point recommended by the manufacturer (≥0.35 IU/ml IFN-γ), while it was 74.9% (427/570) using a cut-off point≥0.1 IU/ml IFN-γ. The QFTGIT-based prevalence of LTBI was not significantly associated with the gender or age of the study participants. However, the prevalence of LTBI was 31.2% (183/587) using TST at a cut-off point≥10 mm of skin indurations, and it was higher in males than females (36.8% vs. 23.5%, X2=11.76; p<0.001). There was poor agreement between the results of the tests (k=0.098, 95% CI, 0.08-0.13). However, there was a positive trend between QFTGIT and TST positivity (X2=96.76, P<0.001). Furthermore, individuals with skin indurations≥10 mm were 13.6 times more likely to have positive results using QFTGIT than individuals with skin indurations of 0 mm (adjusted OR=13.6; 95%CI, 7.5 to 24.7, p<0.001). CONCLUSIONS: There is currently no agreed gold standard for diagnosis of LTBI. However, the higher prevalence of LTBI detected using QFTGIT rather than TST suggests that QFTGIT could be used for epidemiological studies concerning LTBI at the community level, even in a population unreactive to TST. Further studies of adults and children will be required to assess the effects of factors such as malnutrition, non-tuberculosis mycobacterial infections, HIV and parasitic infections on the performance of QFTGIT.

Knowledge of cervical tuberculosis lymphadenitis and its treatment in pastoral communities of the Afar region, Ethiopia.

BACKGROUND: Infection with Mycobacterium bovis (Mb) predominantly causes cervical TB lymphadenitis (TBL). Raw milk is considered the main source of Mb infection and raw milk is a major food source for Afar pastoralists. The aim of this study was to assess Afar pastoralists' knowledge concerning cervical TBL and its treatment. METHODS: A community-based cross-sectional survey involving 818 interviewees was conducted in two districts of the Afar Region, Ethiopia. In addition, two focus group discussions (FGDs) were conducted in each of the study areas, one with men and the other with women. RESULTS: Of the 818 interviewees [357 (43.6%) females and 461 (56.4%) males], 742 (90.7%) reported that they had knowledge of cervical TBL, mentioning that swelling(s) on the neck resulting in a lesion and scar are common symptoms. However, only 11 (1.5%) individuals mentioned that bacteria or germs are the causative agents of TBL. Three interviewees and a male discussant mentioned drinking raw milk as the cause of TBL. A considerable proportion (34.2%) of the interviewees and almost all the discussants suggested herbal medicine as an effective treatment. Male study participants were 1.82 times more likely to have overall knowledge of TBL than female study participants (adjusted OR, 1.82; 95% CI, 1.32 to 2.51, p < 0.001). CONCLUSION: The pastoral community members in the study areas had little biomedical knowledge of the cause, the source of infection and the transmission route of cervical TBL. Furthermore, most community members believed that herbal medicines are the most effective treatment for TBL. Therefore, TB control programs in the Afar Region require the incorporation of public health education introducing current biomedical knowledge of the disease. In addition, further studies are important to elucidate which medicinal plants are used by Afar pastoralists to treat TBL.

Pathology of camel tuberculosis and molecular characterization of its causative agents in pastoral regions of Ethiopia.

A cross sectional study was conducted on 906 apparently healthy camels slaughtered at Akaki and Metehara abattoirs to investigate the pathology of camel tuberculosis (TB) and characterize its causative agents using postmortem examination, mycobacteriological culturing, and multiplex polymerase chain reaction (PCR), region of difference-4 (RD4)-based PCR and spoligotyping. The prevalence of camel TB was 10.04% (91/906) on the basis of pathology and it was significantly higher in females (χ(2) = 4.789; P = 0.029). The tropism of TB lesions was significantly different among the lymph nodes (χ(2) = 22.697; P = 0.002) and lung lobes (χ(2) = 17.901; P = 0.006). Mycobacterial growth was observed in 34% (31/91) of camels with grossly suspicious TB lesions. Upon further molecular characterization using multiplex PCR, 68% (21/31) of the colonies showed a positive signal for the genus Mycobacterium, of which two were confirmed Mycobacterium bovis (M. bovis) by RD4 deletion typing. Further characterization of the two M. bovis at strains level revealed that one of the strains was SB0133 while the other strain was new and had not been reported to the M. bovis database prior to this study. Hence, it has now been reported to the database, and designated as SB1953. In conclusion, the results of the present study have shown that the majority of camel TB lesions are caused by mycobacteria other than Mycobacterium tuberculosis complex. And hence further identification and characterization of these species would be useful towards the efforts made to control TB in camels.