Efficiency of TB service provision in the public and private health sectors in Ethiopia.

BACKGROUND: The Ethiopian Government has identified efficiency of TB services as a key priority in planning and budgeting. Understanding the magnitude and sources of inefficiencies is key to ensuring value for money and improved service provision, and a requirement from donors to justify resource needs. This study identifies the cost of providing a wide range of TB services in public and private facilities in Ethiopia.METHODS: Financial and economic unit costs were estimated from a health provider´s perspective, and collected retrospectively in 26 health facilities using both top-down (TD) and bottom-up (BU) costing approaches for each TB service output. Capacity inefficiency was assessed by investigating the variation between TD and BU unit costs where the factor was 2.0 or more.RESULTS: Overall, TD unit costs were two times higher than BU unit costs. There was some variation across facility ownership and level of care. Unit costs in urban facilities were on average 3.8 times higher than in rural facilities.CONCLUSION: We identified some substantial inefficiencies in staff, consumable and capital inputs. Addressing these inefficiencies and rearranging the TB service delivery modality would be important in ensuring the achievement of the country´s End TB strategy.

Foot and mouth disease in selected districts of western Ethiopia: seroprevalence and associated risk factors.

A study was conducted in western Ethiopia--in two districts of Oromia state and four districts of Beneshangul Gumuz state--to determine the seroprevalence of foot and mouth disease and the associated risk factors, using multistage random sampling. A 3ABC blocking enzyme-linked immunosorbent assay was used to measure antibody against the non-structural protein of foot and mouth disease virusto differentiate between vaccinated and infected animals.Atotal of 1,144 sera from 181 herds were collected and examined. The overall seroprevalence at animal level and herd level was 9% (95% Cl 7.2-10.6) and 38.1% (95% CI 29.1-47.1), respectively. Statistically significant differences (p < 0.05) were recorded among different species, with 13%, 5% and 3% seropositivity in cattle, sheep and goats, respectively. Statistically significant differences (p < 0.05) in herd seroprevalence were observed among districts, with 52%, 50%, 50%, 44%, 21% and 11% in Gidami, Begi, Tongo, Bambasi, Mange and Asosa districts, respectively. In univariable and multivariable logistic regression, the variables that had a positive relationship with seroprevalence at herd level (p < 0.05) were herd size, contact of livestock with ungulate wildlife, and contact of animals with animals/herds of a different peasant association. Univariable and multivariable logistic regression analysis indicated that, at the animal level, age and species had a statistically significant association (p < 0.05) with seropositivity. In conclusion, herd size, contact of livestock with ungulate wildlife, contact between herds from different peasant associations, and the age and species of the animals were the main risk factors for virus circulation in the study area.

Low CD4+ T-cell count and high HIV viral load precede the development of tuberculosis disease in a cohort of HIV-positive ethiopians.

SETTING: Prospective cohort study, Ethiopia. OBJECTIVE: To study changes in biological markers of HIV infection progression before and after development of TB disease. DESIGN: A longitudinal study of 804 adult factory workers (95 HIV-positive, 709 HIV-negative), who were followed every 6 months for a median of 3.8 years. RESULTS: Overall, the incidence rate of TB was 10/ 222 = 45.1 (95%CI 24.3-83.9) per 1000 person-years of observation (PYO) among HIV-1-positive participants, compared to 14/2,054 = 6.8 (95%CI 4.0-11.5) per 1,000 PYO among HIV-1-negative participants (incidence rate ratio 6.62, 95%CI 2.94-14.9). Among the 10 HIV-positive participants who subsequently developed TB disease, the CD4 count was low (median 201/microl, range 45-419), and viral load high (median 4.97 log copies/ml, range 3.70-5.58), at the routine follow-up visit prior to TB diagnosis. Following TB treatment, plasma viral load remained persistently elevated despite clinical resolution of TB disease, and seven of the 10 patients died within a median time of 8 months. CONCLUSION: In this cohort, HIV-infected Ethiopians who developed TB disease already had low CD4 counts and high viral load prior to the diagnosis of TB. Viral load did not decrease following TB treatment, leading to a poor overall prognosis in these patients.

Low CD4+ T-cell count and high HIV viral load precede the development of tuberculosis disease in a cohort of HIV-positive Ethiopians.

SETTING: Prospective cohort study, Ethiopia. OBJECTIVE: To study changes in biological markers of HIV infection progression before and after development of TB disease. DESIGN: A longitudinal study of 804 adult factory workers (95 HIV-positive, 709 HIV-negative), who were followed every 6 months for a median of 3.8 years. RESULTS: Overall, the incidence rate of TB was 10/222 = 45.1 (95%CI 24.3-83.9) per 1000 person-years of observation (PYO) among HIV-1-positive participants, compared to 14/2054 = 6.8 (95%CI 4.0-11.5) per 1000 PYO among HIV-1-negative participants (incidence rate ratio 6.62, 95%CI 2.94-14.9). Among the 10 HIV-positive participants who subsequently developed TB disease, the CD4 count was low (median 201/microliter, range 45-419), and viral load high (median 4.97 log copies/ml, range 3.70-5.58), at the routine follow-up visit prior to TB diagnosis. Following TB treatment, plasma viral load remained persistently elevated despite clinical resolution of TB disease, and seven of the 10 patients died within a median time of 8 months. CONCLUSION: In this cohort, HIV-infected Ethiopians who developed TB disease already had low CD4 counts and high viral load prior to the diagnosis of TB. Viral load did not decrease following TB treatment, leading to a poor overall prognosis in these patients.

Low incidence of syphilis among factory workers in Ethiopia: effect of an intervention based on education and counselling.

BACKGROUND: The prevalence and incidence of syphilis infection were examined in a cohort study of factory workers in Ethiopia. METHOD: Between February 1997 and March 1999, 409 men and 348 women were enrolled and followed in the cohort study. RESULTS: The prevalence (95% CI) of past/current syphilis (positive TPPA serology) was 28.9% (25.7% to 32.3%), and factors associated with past/current syphilis were markers of risky sexual behaviours including HIV infection. In this cohort of factory workers subject to public information/education meetings, testing for HIV antibodies, and individual counselling, the incidence (97.5% one sided CI) of new syphilis infections was 0/691 = 0 (0 to 0.5) per 100 person years. CONCLUSION: This study has documented a reduction in risky sexual behaviours and a low syphilis incidence among factory workers participating in a cohort study on HIV infection progression in Addis Ababa.

Distribution of lymphocyte subsets in healthy human immunodeficiency virus-negative adult Ethiopians from two geographic locales.

Immunological values for 562 factory workers from Wonji, Ethiopia, a sugar estate 114 km southeast of the capital city, Addis Ababa, Ethiopia, were compared to values for 218 subjects from Akaki, Ethiopia, a suburb of Addis Ababa, for whom partial data were previously published. The following markers were measured: lymphocytes, T cells, B cells, NK cells, CD4(+) T cells, and CD8(+) T cells. A more in depth comparison was also made between Akaki and Wonji subjects. For this purpose, various differentiation and activation marker (CD45RA, CD27, HLA-DR, and CD38) expressions on CD4(+) and CD8(+) T cells were studied in 60 male, human immunodeficiency virus-negative subjects (30 from each site). Data were also compared with Dutch blood donor control values. The results confirmed that Ethiopians have significantly decreased CD4(+) T-cell counts and highly activated immune status, independent of the geographic locale studied. They also showed that male subjects from Akaki have significantly higher CD8(+) T-cell counts, resulting in a proportional increase in each of the CD8(+) T-cell compartments studied: naïve (CD45RA(+)CD27(+)), memory (CD45RA(-)CD27(+)), cytotoxic effector (CD45RA(+)CD27(-)), memory/effector (CD45RA(-)CD27(-)), activated (HLA-DR(+)CD38(+)), and resting (HLA-DR(-)CD38(-)). No expansion of a specific functional subset was observed. Endemic infection or higher immune activation is thus not a likely cause of the higher CD8 counts in the Akaki subjects. The data confirm and extend earlier observations and suggest that, although most lymphocyte subsets are comparable between the two geographical locales, there are also differences. Thus, care should be taken in extrapolating immunological reference values from one population group to another.

Tumour necrosis factor, interleukin-6 and C-reactive protein in patients with louse-borne relapsing fever in Ethiopia.

The serum concentrations of tumour necrosis factor (TNF), interleukin-6 (IL-6) and C-reactive protein (CRP) were studied in 25 patients with louse-borne relapsing fever, to evaluate their association with the level of bacteraemia, anti-borrelia chemotherapy and the presence of a Jarish-Herxheimer reaction (JHR). Although there was an association between the level of bacteraemia and the development of JHR and complications during treatment, TNF, IL-6 and CRP concentrations were not associated with the JHR. TNF concentrations increased after the administration of antibiotics and remained high for 24 h. IL-6 was elevated on admission but soon decreased. CRP was high on admission and remained so throughout the illness. The observed elevations in TNF, IL-6 and CRP may be associated more with the administration of antibiotics than with the presence of a JHR.

Louse-borne relapsing fever in Ethiopian children: a clinical study.

An outbreak of louse-borne relapsing fever, caused by the return to their original recruitment areas of soldiers at the end of 30 years of fighting in northern Ethiopia, was reported in the Arsi region. We studied 103 infants and children with louse-borne relapsing fever who were admitted to Asella Hospital between 1 May 1991 and 30 April 1992. Twenty-one per cent of the patients had a clear history of contact with sick ex-soldiers; 42% were students admitted to the hospital following the re-opening of schools after the summer vacation. The common clinical features of the disease were fever in 100%, headache in 84.5%, chills in 74%, abdominal pain in 51%, epistaxis in 20%, hepatomegaly in 26%, splenomegaly in 14%, petechial rash in 34% and jaundice in 10%. Differences in symptoms and signs according to age are described. Observed complications were pneumonia in 14% and central nervous system involvement in 10%. Four children went into deep coma, and two of them died. Severe disease was associated with a high density of spirochaetes in blood smears. Patients were treated with two low doses of penicillin or one dose of penicillin followed by, according to age, chloramphenicol or tetracycline, and with intravenous fluids. The case fatality rate was 1.9%. Jarisch-Herxheimer reactions occurred in 61% of patients. There were relapses in 2.9% of treated patients.

Louse-borne relapsing fever. A clinical and an epidemiological study of 389 patients in Asella Hospital, Ethiopia.

An outbreak of louse-borne relapsing fever, due to the return of soldiers to their original recruitment areas, after the end of thirty years of fighting in northern Ethiopia, was reported in Arsi region, southern Ethiopia. The epidemic spread to different members of the community and eventually the schools. We studied 389 patients affected by the epidemic and who were admitted to Asella Hospital between June 1991 and May 1992. Twenty-seven per cent of the patients were ex-soldiers; 28% were students, who were admitted to the hospital since the schools were opened after the summer vacations. The common clinical features of the disease were fever (99%), headache (92%), hepatosplenomegaly (66%), myalgia (55%), arthralgia (51%), petechial rash (43%), epistaxis (24%) and jaundice (23%). Observed complications were pneumonia (10%), pulmonary edema (6%), myocarditis (3%) and 6 abortions in 15 pregnancies. Patients were treated with low dose penicillin and i.v. fluids. The in-hospital case fatality rate was 3.6%. Jarisch-Herxheimer reaction occurred in 43% of the patients. 1.8% of the patients had relapses after treatment.