Use of biomass fuel in households is not a risk factor for pulmonary tuberculosis in South Ethiopia.

SETTING: Rural settings of Sidama Zone in southern Ethiopia. OBJECTIVE: To investigate the association between exposure to biomass fuel smoke and tuberculosis (TB). DESIGN: A matched case control study in which cases were adult smear-positive pulmonary tuberculosis (PTB) patients on DOTS-based treatment at rural health institutions. Age-matched controls were recruited from the community. RESULTS: Of 355 cases, 350 (98.6%) use biomass fuel for cooking, compared to 801/804 (99.6%) controls. PTB was not associated with exposure to the biomass fuel smoke. None of the factors such as heating the house, type of stove, presence of kitchen, presence of adequate cooking room ventilation, light source and number of rooms in the house was associated with the presence of TB. However, TB determinants such as sex, household contact with TB, history of TB treatment, smoking and presence of a smoker in the household have previously shown an association with TB. CONCLUSION: We found no evidence of an association between the use of biomass fuel and TB. Low statistical power due to the selection of neighbourhood controls might have contributed to this negative finding. We would advise that future protocols should not use neighbourhood controls and that they should include measurements of indoor air pollution and of exposure duration.

Mortality in successfully treated tuberculosis patients in southern Ethiopia: retrospective follow-up study.

SETTING: The tuberculosis (TB) programme in the Sidama zone of southern Ethiopia. OBJECTIVE: To measure excess mortality in successfully treated TB patients. DESIGN: In a retrospective cohort study of TB patients treated from 1998 to 2006, mortality was used as an outcome measure, and was calculated per 100 person-years of observation (PYO) from the date of completion of treatment to date of interview if the patient was alive, or to date of death. Kaplan-Meier and Cox regression methods were used to determine the survival and hazard ratios. An indirect method of standardisation was used to calculate the standard mortality ratio (SMR). RESULTS: A total of 725 TB patients were followed for 2602 person-years: 91.1% (659/723) were alive and 8.9% (64/723) had died. The mortality rate was 2.5% per annum. Sex, age and occupation were associated with high mortality. More deaths occurred in non-farmers (SMR = 9.95, 95%CI 7.17-12.73). DISCUSSION: The mortality rate was higher in TB patients than in the general population. More deaths occurred in non-farmers, men and the elderly. Further studies are required to identify the causes of death in these patients.

Mortality Decreases among Young Adults in Southern Central Ethiopia

Background: Despite the anticipated high impact of HIV and AIDS among young people; AIDS related mortality is not well documented because of the lack of death registration systems in Ethiopia. The objective of this analysis was to investigate the trends in mortality among young adults (aged 10-24 years) in the era of the AIDS epidemic. Methods: We analyzed data for young adults aged between 10-24 years using the Butajira Rural Health Programme (BRHP) open cohort database. The study covers 1 urban and 9 rural communities; which were initially randomly selected from the Butajira district. The BHRP database covers the period 1987-2004; recording vital events and migration at the household level after an initial baseline census in 1987; using village-based data collectors. The data included 34;150 young people who contributed a total of 248;154 person years. Results: In the 18-year follow-up period; 1;030 young adults died; giving an age-specific crude mortality rate of 4.2 per 1;000 person-years. The trends of mortality in this population declined from 6 per 1;000 person-years in 1987- 1989 to less than 2 per 1;000 person-years in 2002-2004. Deaths due to HIV were recorded at a rate of only 0.02 per1;000 person-years; according to causes of death reported by family care givers. A multivariate regression model showed that young adults from the rural highlands and lowlands had a higher risk of death (adjusted rate ratios 1.99 [1.40-2.83] and 2.58 [1.82-3.66] respectively) than young urban adults; even after adjusting for water source; literacy and housing type. The earlier cohorts (1987-1989 and 1990-1994) had higher risks of mortality than the latest cohort (1999-2004) - (adjusted rate ratios 1.91 [1.59-2.29] and 2.03 [1.75-2.35] respectively). Conclusion: A remarkable decline in mortality was observed in this population with little sign of excessive HIV/AIDS-related mortality appearing during this 18-year period. However; the occurrence of AIDS-related deaths in the latter part of the study period suggests appropriate interventions to counter the developing HIV epidemic are justified

Mortality Decreases among Young Adults in Southern Central Ethiopia

Background: Despite the anticipated high impact of HIV and AIDS among young people; AIDS related mortality is not well documented because of the lack of death registration systems in Ethiopia. The objective of this analysis was to investigate the trends in mortality among young adults (aged 10-24 years) in the era of the AIDS epidemic. Methods: We analyzed data for young adults aged between 10-24 years using the Butajira Rural Health Programme (BRHP) open cohort database. The study covers 1 urban and 9 rural communities; which were initially randomly selected from the Butajira district. The BHRP database covers the period 1987-2004; recording vital events and migration at the household level after an initial baseline census in 1987; using village-based data collectors. The data included 34;150 young people who contributed a total of 248;154 person years. Results: In the 18-year follow-up period; 1;030 young adults died; giving an age-specific crude mortality rate of 4.2 per 1;000 person-years. The trends of mortality in this population declined from 6 per 1;000 person-years in 1987- 1989 to less than 2 per 1;000 person-years in 2002-2004. Deaths due to HIV were recorded at a rate of only 0.02 per 1;000 person-years; according to causes of death reported by family care givers. A multivariate regression model showed that young adults from the rural highlands and lowlands had a higher risk of death (adjusted rate ratios 1.99 [1.40-2.83] and 2.58 [1.82-3.66] respectively) than young urban adults; even after adjusting for water source; literacy and housing type. The earlier cohorts (1987-1989 and 1990-1994) had higher risks of mortality than the latest cohort (1999-2004) - (adjusted rate ratios 1.91 [1.59-2.29] 2.03 [1.75-2.35] respectively). Conclusion: A remarkable decline in mortality was observed in this population with little sign of excessive HIV/AIDS-related mortality appearing during this 18-year period. However; the occurrence of AIDS-related deaths in the latter part of the study period suggests appropriate interventions to counter the developing HIV epidemic are justified

Prevalence of smear-positive pulmonary tuberculosis in a rural district of Ethiopia.

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.

Community tuberculosis care through "TB clubs" in rural North Ethiopia.

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.

A rapid survey to determine the prevalence of smear-positive tuberculosis in Addis Ababa.

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.

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.

Influence of neoadjuvant anastrozole (Arimidex) on intratumoral estrogen levels and proliferation markers in patients with locally advanced breast cancer.

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.

Sensitivity to anti-tuberculosis drugs in HIV-positive and -negative patients in Addis Ababa.

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.

Epidemiology of burns in Bergen, Norway.

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.

Increasing incidence of resistance to antimicrobials in Sidamo.

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.

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.

[406 femoral fractures in children]. / 406 femurfrakturer hos barn.

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.

Nutritional assessment of two famine prone Ethiopian communities.

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.

Intra-household correlations of nutritional status in rural Ethiopia.

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.

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.

Protein energy malnutrition, vitamin A deficiency and night blindness in Bangladeshi children.

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.

Growth velocity among preschool Ethiopian children.

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.