The outcome of tuberculosis treatment at a rural hospital in southern Ethiopia.

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.

Peptic ulcer disease in south Ethiopia is strongly associated with Helicobacter pylori.

Helicobacter pylori infection was detected in 93% of 174 patients with a peptic ulcer compared with 63% of 116 patients with normal findings (chi 2 = 37.3; P < 0.001) in a cohort of 834 consecutive patients examined by gastroscopy in Yirga Alem Hospital in south Ethiopia. Fourteen patients were given 14 days' treatment with metronidazole 500 mg t.i.d., doxycycline 100 mg b.i.d. and bismuth subnitrate mixture 150 mg q.i.d. Of 10 patients who returned for follow-up, only 2 patients were free from H. pylori and cured. Nineteen strains of H. pylori from 19 consecutive patients in the same hospital were tested for resistance in vitro against metronidazole, doxycycline and ampicillin. All but 1 were highly resistant to metronidazole; 2 were fully and 14 intermediate resistant against doxycycline. All strains were fully sensitive in vitro to ampicillin. Thus, peptic ulcer was strongly associated with H. pylori in south Ethiopia, but eradication of the infection was hampered by antibiotic resistance.

Delay in Treatment of Pulmonary Tuberculosis: An Analysis of Symptom Duration Among Ethiopian Patients.

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.

HIV infection and malnutrition change the clinical and radiological features of pulmonary tuberculosis.

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.

Rapid growth of Helicobacter pylori.

The ability of six variants of a new charcoal medium and Skirrow's medium to grow Helicobacter pylori in 3 and 5 days was studied using 20 different strains of Helicobacter pylori. The main admixtures for the charcoal media were serum, whole blood, and egg yolk emulsion. For this purpose, serum was significantly better and egg yolk emulsion significantly worse than whole blood. The addition of Iso Vitalex resulted in significantly improved growth on the charcoal media. Skirrow's medium showed very poor performance after three days of incubation and needed a long incubation time.

A two year retrospective study of birth weight in Sidamo Regional Hospital.

This is a two year retrospective analysis of 1,260 live single births at Sidamo Regional Hospital during 1989-1990. The mean birth weight was 3,243 g (SD +/- 625). There were 678(53.8%) boys and 582(46.2%) girls. The mean birth weight for boys and girls were 3,324 g (SD +/- 622) and 3147 g (SD +/- 611), respectively (t = 5.05; p < 0.001). There were significant correlations between birth weight and the age of the mother (r = 0.20; p < 0.001) as well as with parity (r = 0.15; p < 0.001). Eight per cent of the babies had birth weight less than 2,500 g. Five per cent of boys and 11% of girls had low birth weights (chi 2 = 8.8; p < 0.002). Higher proportion of low birth weight was also found among the young and primiparous mothers. A multiple linear regression analysis showed a significant and independent effect of maternal age and sex of the baby on birth weight. The findings are in general agreement with previous studies from Ethiopia and other developing countries. However, as this study is based on hospital data, community-based studies are needed to examine the true pattern of birth weights as hospital data may be biased.

A six month prospective study on different aspects of abortion.

A six month prospective study on various aspects of abortion was conducted from April 1, 1991 to Sept. 30, 1991 in Sidamo Regional Hospital (Yirgalem). A total of 185 cases of abortion were seen. Of these, 64 (35%) were induced and 121 (65%) were spontaneous. There were 2 deaths in the illegally induced group abortion, 1 death in the other group. Induced abortion was higher in age group 20-24 (61%), single (65%), unemployed (70%), nulliparous (48%) and 7-12 grade educational level (67%). The pregnancy was unwanted in all cases of induced abortion and in 50 (41%) of the spontaneous cases. The common instruments used for inducing abortion were plastic catheters (58%) and metallic instruments (32%). The abortionists were mainly health workers (55%). The mean hospital stay was 6.3 days for illegally induced and 2.1 days for spontaneous abortions. The incidence of septic abortion was found to be statistically significantly higher in induced than in spontaneous abortion (p < 0.001) while haemorrhagic shock was not (p > 0.05). The type of anaesthesia and required procedure are also analyzed in this study. Eighty-eight percent of the study population did not use any type of contraception. The role of contraception in preventing unwanted pregnancy and therefore induced abortion is discussed.

PIP: In a 6-month prospective study conducted at Sidamo Regional Hospital (Yirgalem, Ethiopia) from April 1 to September 30, 1991, 185 cases of abortion were admitted. 64 (35%) of these abortions were illegally induced and 121 (65%) were spontaneous. During the study period, there were 443 gynecological admissions; thus, illegal abortion comprised 14% of total cases treated. There were 2 deaths in the induced abortion group (0.8% case fatality). 50 (78%) women with illegal abortions were under 25 years of age and 42 (66%) were unmarried. Instruments most often used to induce abortion were plastic catheters (56%) and metallic objects (32%); the procedure was performed by health workers in 55% of cases and friends in 39%. 122 (66%) of women admitted with induced abortion required evacuation and curettage. Complications of illegal abortion included septicemia (36 cases), hemorrhagic shock (12 cases), pelvic abscess (11 cases), and cervical trauma (22 cases). The mean hospital stay for induced abortion was 6.3 days compared with 2.1 days for spontaneous abortion. 83% of women in the induced abortion group were using no form of contraception prior to the unwanted pregnancy, 11% were using a method incorrectly, and 6% were considered to be proper users. Since 41% of women in the spontaneous abortion group reported that their pregnancy was unwanted, it is possible that some may have in fact undergone an illegal abortion. Unable to be measured were the long-term effects of illegal abortion, including chronic pelvic inflammatory disease and infertility. Overall, these findings document the magnitude of the problem of illegal abortion in Ethiopia and indicate an urgent need for contraceptive education among young women.