Insecticide-treated bed nets and residual indoor spraying reduce malaria in areas with low transmission: a reanalysis of the Maltrials study

BACKGROUND

The malaria incidence data from a malaria prevention study from the Rift Valley, Central Ethiopia, were reanalysed. The objective was to investigate whether including an administrative structure within the society, which may have required consideration in the protocol or previous analysis, would provide divergent outcomes on the effect measures of the interventions.

METHODS

A cluster-randomized controlled trial lasting 121 weeks with 176 clusters in four groups with 6071 households with 34,548 persons was done: interventions combining indoor residual spraying (IRS) and insecticide-treated nets (ITNs), IRS alone, ITNs alone and routine use. The primary outcome was malaria incidence. A multilevel negative binomial regression model was employed to examine the impact of the kebele (smallest administrative unit) and the proximity of homes to the primary mosquito breeding sites as potential residual confounders (levels). The study also assessed whether these factors influenced the effect measures of the interventions.

RESULTS

The study's initial findings revealed 1183 malaria episodes among 1059 persons, with comparable effects observed across the four intervention groups. In the reanalysis, the results showed that both ITN + IRS (incidence rate ratio [IRR] 0.63, P < 0.001) and ITN alone (IRR 0.78, P = 0.011) were associated with a greater reduction in malaria cases compared to IRS (IRR 0.90; P = 0.28) or the control (reference) group. The combined usage of IRS with ITN yields better outcomes compared to the standalone use of ITN and surpasses the effectiveness of IRS in isolation.

CONCLUSION

The findings indicate that implementing a combination of IRS and ITN and also ITN alone decrease malaria incidence. Furthermore, there was an observed synergistic impact when ITN and IRS were used in combination. Considering relevant social structures as potential residual confounders is of paramount importance.

TRIAL REGISTRATION

PACTR201411000882128 (08 September 2014).

High human blood meal index of mosquitoes in Arba Minch town, southwest Ethiopia: an implication for urban mosquito-borne disease transmission

Unplanned human population shifts in urban areas are expected to increase the prevalence of vector-borne diseases. This study aimed to investigate mosquito species composition, blood meal sources, and malaria vectors in an urban area. Indoor-resting adult mosquitoes were collected using Prokopack and host-seeking mosquitoes using Centers for Disease Control and Prevention light traps in Arba Minch town. Larval collection from artificial containers was done in those houses selected for adult mosquito collection. Anopheles adults collected and emerged from larvae were identified morphologically using a taxonomic key. ELISA was used to identify blood meal sources in freshly fed Anopheles and Culex mosquitoes, and CSP of Anopheles mosquitoes. A total of 16,756 female mosquitoes were collected. Of these, 93% (15,571) were Culex, 6% (1016) were Anopheles, and 1% (169) were Aedes mosquitoes. Out of the 130 adult mosquitoes that were raised from larvae collected from the containers, 20% were An. rhodesiensis, while the remaining 80% were Aedes mosquitoes. Out of 823 mosquitoes tested for blood meal origins, 86.3% (710/823) tested positive for human blood, 2.2% (18/823) tested positive for bovine blood, and 11.5% (95/823) were negative for human and bovine antibodies. Anopheles gambiae complex had a human blood meal index (HBI) of 50% (90/180; CI 42.3-57.5%) and a bovine blood meal index (BBI) of only 0.5% (95% CI 0.01-3.1%). Culex HBI was 96.7% (620/641), and its BBI index was 2.4% (15/641). While it was low (0.8%) in Culex, the proportion of An. gambiae complex with unidentified blood meal sources was 49.5% (95 CI% 41.9-56.9%). Among the 1016 Anopheles mosquitoes tested, a single An. gambiae complex (0.1%; 1/1016) was positive for P. vivax CSP. The high HBI indicates frequent contact between humans and vectors. To reduce human exposure, personal protection tools should be implemented.

Anopheles arabiensis continues to be the primary vector of Plasmodium falciparum after decades of malaria control in southwestern Ethiopia

BACKGROUND

Investigating the species distribution and their role in malaria transmission is important as it varies from place to place and is highly needed to design interventions appropriate to the site. The current study aimed to investigate the Anopheles mosquito species distribution and their infection rate in southwestern Ethiopia.

METHODS

The study was conducted in 14 malaria-endemic kebeles (the smallest administrative unit), which were situated in eight different malaria-endemic districts and four zones in southwestern Ethiopia. Ten per cent of households in each village were visited to collect adult mosquitoes using Centers for Disease Control and Prevention (CDC) light traps. The larval and pupal collection was done from breeding sites within the villages, and reared to adults. Female mosquitoes were morphologically identified. The head and thorax of adult Anopheles mosquitoes were tested for circumsporozoite proteins (CSPs) using ELISA. At the same time, legs, wings, and abdomen were used to identify sibling species using PCR targeting the rDNA intergenic spacers region for species typing of the Anopheles funestus group and the internal transcribed spacer 2 region genes for Anopheles gambiae complex.

RESULTS

A total of 1445 Anopheles mosquitoes comprising eight species were collected. Of 813 An. gambiae complex tested by PCR, 785 (97%) were Anopheles arabiensis, and the remaining 28 (3%) were not amplified. There were 133 An. funestus group captured and tested to identify the species, of which 117 (88%) were positive for Anopheles parensis, and 15 (11%) were not amplified. A single specimen (1%) showed a band with a different base pair length from the known An. funestus group species. Sequencing revealed this was Anopheles sergentii. Among 1399 Anopheles tested for CSPs by ELISA, 5 (0.4%) An. arabiensis were positive for Plasmodium falciparum and a single (0.07%) was positive for Plasmodium vivax.

CONCLUSIONS

Anopheles arabiensis continues to play the principal role in malaria transmission despite implementing indoor-based interventions for decades. Sequencing results suggest that An. sergentii was amplified by the An. funestus group primer, producing PCR amplicon size of different length. Therefore, relying solely on amplifying a specific gene of interest in grouping species could be misleading, as different species may share the same gene.

Southern Ethiopian skilled birth attendant variations and maternal mortality: A multilevel study of a population-based cross-sectional household survey

Studies examining skilled birth attendants (SBA) use and its correlation with maternal mortality at lower administrative levels are scarce. This study assessed the coverage and variations of SBA, the physical accessibility of health facilities for SBA, and the association of SBA with maternal mortality. A cross-sectional study using a population-based household survey was conducted in six Sidama National Regional State, southern Ethiopia districts, from July 2019 to May 2020. Women who had given birth in the past two years before the study were included. Stata 15 and ArcGIS 10.4.1 were used for data analysis. A multilevel logistic regression analysis was conducted to assess the effect of the sampling units and identify factors independently associated with SBA. The association between SBA and maternal mortality was examined using maternal mortality household survey data. A total of 3191 women who had given birth in the past two years and resided in 8880 households sampled for the associated maternal mortality household survey were interviewed. The coverage of SBA was 46.7%, with high variations in the districts. Thirty percent of SBA use was accounted for by the differences among the districts. One-third of the women travel more than two hours on foot to access the nearest hospital. Districts with low coverage of SBA and located far away from the regional referral centre had high maternal mortality. Education of the mother, occupation of the husband, pregnancy-related complications, use of antenatal care, parity, and distance to the nearest hospital and health centre were associated with the use of SBA. The coverage of SBA in the Sidama Region was low, with high variations in the districts. Low SBA use was associated with high maternal mortality. Due attention should be given to districts with low coverage of SBA and those located far away from the referral centre. Access to hospitals has to improve. All women should be encouraged to get antenatal care services.

Malaria misdiagnosis in the routine health system in Arba Minch area district in southwest Ethiopia: an implication for malaria control and elimination

BACKGROUND

Plasmodium falciparum and Plasmodium vivax are coendemic in Ethiopia, with different proportion in different settings. Microscopy is the diagnostic tool in Ethiopian health centres. Accurate species-specific diagnosis is vital for appropriate treatment of cases to interrupt its transmission. Therefore, this study assessed the status of species-specific misdiagnosis by microscope compared with polymerase chain reaction (PCR).

METHODS

A health facility based cross-sectional study was conducted from November 2019 to January 2020 in Kolla Shelle Health centre, Arba Minch Zuria district. The study population were suspected malaria cases, who visited the health centre for a diagnosis and treatment. Consecutive microscopy positive cases as well as a sample of microscopically negative cases were included for molecular analysis by polymerase chain reaction (PCR).

RESULTS

254 microscopically negative and 193 microscopically positive malaria suspects were included. Of the 193 malaria positive cases, 46.1% [95% confidence interval (CI) 38.9-53.4] (89/193) were P. falciparum infection, 52.3% (95% CI 45.0-59.5) (101/193) were P. vivax infection, and 1.6% (3/193) had mixed infection of P. falciparum and P. vivax. Of the microscopically positive cases of P. falciparum, 3.4% (3/89) were P. vivax and 11.2% (10/89) were mixed infections with P. falciparum and P. vivax and a single case was negative molecularly. Similarly, of the microscopically positive P. vivax cases, 5.9% (6/101) were P. falciparum and 1% (1/101) was mixed infection. Single case was negative by molecular technique. Of the 254 microscopically negative cases, 0.8% were tested positive for P. falciparum and 2% for P. vivax by PCR. Considering molecular technique as a reference, the sensitivity of microscopy for detecting P. falciparum was 89.2% and for P. vivax, it was 91.2%. The specificity of microscopy for detecting P. falciparum was 96.1% and for P. vivax, it was 97.7%. However, the sensitivity of microscopy in detecting mixed infection of P. falciparum and P. vivax was low (8.3%).

CONCLUSION

There were cases left untreated or inappropriately treated due to the species misidentification. Therefore, to minimize this problem, the gaps in the microscopic-based malaria diagnosis should be identified. It is recommended to regularly monitor the competency of malaria microscopists in the study area to improve species identification and diagnosis accuracy.

Maize pollen diet enhances malaria mosquito longevity and infectivity to Plasmodium parasites in Ethiopia

Although larval diet quality may affect adult mosquito fitness, its impact on parasite development is scarce. Plant pollen from Zea mays, Typha latifolia, and Prosopis juliflora was ultraviolet-sterilized and examined for effects on larval development, pupation rate, adult mosquito longevity, survival and infectivity. The control larvae were fed Tetramin fish food as a comparator food. Four treatment and two control groups were used for each pollen diet, and each experimental tray had 25 larvae. Female An. arabiensis were starved overnight and exposed to infectious blood using a membrane-feeding system. The Kaplan-Meier curves and log-rank test were used for analysis. The Z. mays pollen diet increased malaria mosquito survival and pupation rate (91.3%) and adult emergence (85%). Zea mays and Tetramin fish food had comparable adulthood development times. Adults who emerged from larvae fed Z. mays pollen had the longest average wing length (3.72 mm) and were more permissive to P. vivax (45%) and P. falciparum (27.5%). They also survived longer after feeding on infectious blood and had the highest number of P. vivax oocysts. Zea mays pollen improved larval development, adult mosquito longevity, survival and infectivity to Plasmodium. Our findings suggest that malaria transmission in Z. mays growing villages should be monitored.

Infectivity of symptomatic Plasmodium vivax cases to different generations of wild-caught and laboratory-adapted Anopheles arabiensis using a membrane feeding assay, Ethiopia

When measuring human to mosquito transmission of Plasmodium spp., laboratory-adapted (colony) mosquitoes can be utilized. To connect transmission studies to the local epidemiology, it can be important to comprehend the relationship between infectivity in laboratory-adapted (colony) and wild-caught (wild) mosquitoes of the same species. Microscopically confirmed Plasmodium vivax cases were recruited from health facilities in Arba Minch town, and a nested polymerase chain reaction (nPCR) was used for subsequent confirmation. We performed paired membrane-feeding assays using colony An. arabiensis and three generations of wild origin An. arabiensis. Anopheles arabiensis aged 3-6 days were fed after being starved for 8-14 h. Microscopically, the oocyst development was evaluated at day 7 after feeding. Circumsporozoite proteins (CSPs) assay was carried out by enzyme-linked immunosorbent assay (ELISA). In 19 paired feeding experiments, the feeding efficiency was more than doubled in colony (median: 62.5%; interquartile range, IQR: 35-78%) than in wild mosquitoes (median: 28.5%; IQR: 17.5-40%; P < 0.001). Among the 19 P. vivax gametocyte-positive blood samples, 63.2% (n = 12) were infective to wild An. arabiensis and 73.7% (n = 14) were infective to colony An. arabiensis. The median infection rate was twice as high (26%) in the colony than in the wild (13%) An. arabiensis, although the difference was marginally insignificant (P = 0.06). Although the observed difference was not statistically significant (P = 0.19), the median number of oocysts per midgut was more than twice as high (17.8/midgut) in colony than in wild (7.2/midgut) An. arabiensis. The median feeding efficiency was 26.5% (IQR: 18-37%) in F1, 29.3% (IQR: 28-40%) in F2 and 31.2% (IQR: 30-37%) in F3 generations of wild An. arabiensis. Also, no significant difference was observed in oocyst infection rate and load between generations of wild An. arabiensis. CSP rate of P. vivax was 3.1% (3/97; 95% CI: 0.6-8.8%) in wild and 3.6% (3/84; 95% CI: 0.7-10.1%) in colony An. arabiensis. The results of the present study revealed that oocyst infection and load/midgut, and CSP rate were roughly comparable, indicating that colony mosquitoes can be employed for infectivity studies, while larger sample sizes may be necessary in future studies.

Antenatal care utilization and compliance with national and WHO guidelines in rural Ethiopia: a cohort study

Background

Antenatal health care utilization has the potential to influence maternal and new-born health. In this study, we assessed compliance of antenatal care utilization with national and World Health Organization (WHO) guidelines. We also examined association of antenatal care utilization with adverse pregnancy outcomes as secondary outcome.

Methods

This was a community-based cross sectional study conducted from July 2016 to November 2017 in rural south-central Ethiopia. We described antenatal care received by pregnant women, whom we followed at three prescheduled visits during pregnancy and collected birth data at time of delivery. Extent of antenatal care content received, timing of antenatal care, place of antenatal care and place and mode of delivery were obtained and computed in accordance with national and WHO guidelines. For adverse pregnancy outcomes, computed as sum of low birth weight, preterm birth, intrauterine foetal death, and stillbirth, the exposure variable used was antenatal care utilization.

Results

Seven hundred and four (704) women participated in the study, and 536 (76.1%) had attended at least one antenatal care visit. Among women who attended antenatal care visit, majority, 421 (79.3%), had done so at health centres and hospitals, while 110 (20.7%) attended at health post. Average number of antenatal care visits was 2.5, which is less than that recommended in national and WHO guidelines. Only 18 (2.6%) women had attended antenatal care in their first trimester, which is low in contrast to the expected 100% specified in the guidelines. Less than half (47%) of the women delivered in a health facility. This is in contrast to the 100% expected health institution deliveries. Low birth weight was 7.9% (n = 48), and preterm birth was 4.9% (n = 31). There were 12 twin pregnancies, three stillbirths, 11 spontaneous abortions, and two intrauterine foetal deaths. We did not find significant association between adverse pregnancy outcomes and antenatal care utilization (COR = 1.07, 95% CI 0.62, 1.86).

Conclusion

This study showed that antenatal care service utilization in the study area was markedly low compared to that recommended in national and WHO guidelines. The obtained antenatal health care utilization was not associated with the registered adverse pregnancy outcomes.

Seasonality and predictors of childhood stunting and wasting in drought-prone areas in Ethiopia: a cohort study

BACKGROUND AND OBJECTIVES

Over centuries, Ethiopia has experienced severe famines and periods of serious drought, and malnutrition remains a major public health problem. The aims of this study were to estimate seasonal variations in child stunting and wasting, and identify factors associated with both forms of child malnutrition in drought-prone areas.

METHODS

This cohort study was conducted among a random sample of 909 children in rural southern Ethiopia. The same children were followed for 1 year (2017-2018) with quarterly repeated measurements of their outcomes: height-for-age and weight-for-height indices (Z-scores). Linear regression models were used to analyse the association between both outcomes and baseline factors (eg, household participation in a social safety net programme and water access) and some time-varying factors (eg, household food insecurity).

RESULTS

Child wasting rates varied with seasonal household food insecurity (ᵪ² _trend = 15.9, p=0.001), but stunting rates did not. Household participation in a social safety net programme was associated with decreased stunting (p=0.001) and wasting (p=0.002). In addition to its association with decreased wasting (p=0.001), protected drinking water access enhanced the association between household participation in a social safety net programme and decreased stunting (p=0.009). Absence of a household latrine (p=0.011), lower maternal education level (p=0.001), larger family size (p=0.004) and lack of non-farming income (p=0.002) were associated with increased child stunting.

CONCLUSIONS

Seasonal household food insecurity was associated with child undernutrition in rural Ethiopia. Strengthening community-based food security programmes, such as the Ethiopian social safety net programme, could help to reduce child undernutrition in drought-prone areas. Improving clean water access and sanitation could also decrease child undernutrition.Key terms: Z-scores; Social safety net program; Water access.

Influence of intrauterine factors on birth weight and on child linear growth in rural Ethiopia: A prospective cohort study

Introduction

Little is known about the influence of intrauterine fetal factors on childhood growth in low-income countries. The objective of this study was to examine the influence of intrauterine fetal growth on child linear growth in rural Ethiopia.

Methods

We conducted a prospective community-based cohort study from July 2016 to October 2018. All pregnant women with gestational age of 24 weeks or below living in 13 kebeles, in central Ethiopia were enrolled. The fetuses were followed from pregnancy up to 11–24 months after birth. We measured biparietal diameter, head circumference, femoral length, and abdominal circumference at 26, 30 and 36 weeks of pregnancy. At birth, we measured infant weight. At 11–24 months of age, z-scores of length- for- age, and weight-for-length were calculated. A multilevel, mixed-effect, linear regression model was used to examine the influence of fetal, newborn, maternal, household factors and residence area on child linear growth.

Results

We included 554 children. The prevalence rate of stunting was 54.3% and that of wasting was 10.6%. Fetal biparietal diameter, head circumference, and abdominal circumference, were significantly associated with birth weight. Femoral length z-score in early pregnancy, gestational age at delivery and child age were significantly associated with length-for-age z-score. Family size was significantly associated with length-for-age z-score. Family size and maternal height were associated with weight-for-height z-score. There was a large variation in length-for-age z-score (Intra cluster correlation, or ρ (rho) = 0.30) and weight-for-length z-score (ρ = 0.22) than of birth weight of new-born (ρ = 0.11) in kebeles indicating heterogeneity in clusters for length-for-age z-score and weight-for-length z-score than birth weight.

Conclusions

Child linear growth was influenced by fetal growth, duration of pregnancy, maternal height, and family size. Environmental factors that are associated with the area of residence play a bigger role for linear growth than for birth weight.

Modifiable cardiovascular disease risk factors among adults in southern Ethiopia: a community-based cross-sectional study

OBJECTIVE

To assess the prevalence, magnitude and factors associated with the number of major modifiable cardiovascular disease (CVD) risk factors.

DESIGN

Community-based cross-sectional study.

SETTING

General population in urban and rural Wolaita, southern Ethiopia.

PARTICIPANTS

A total of 2483 adults aged 25-64 years were selected using the three-stage random sampling.

OUTCOME MEASURES

Prevalence of major modifiable CVD risk factors, co-occurrences and the number of modifiable CVD risk factors.

RESULTS

The major modifiable CVD risk factors documented in the Wolaita area were smoking with a weighted prevalence of 0.8%, hypercholesterolaemia 5.0%, hypertriglyceridaemia 15.5%, low high-density lipoprotein cholesterol (HDL-C) 31.3%, high systolic blood pressure 22.2%, high diastolic blood pressure 22.4%, physical inactivity 44.1%, obesity 2.8% and hyperglycaemia 3.7%. The numbers of participants having ≥1, ≥2 and ≥3 major modifiable CVD risk factors in the study area were 2013, 1201 and 576 with a weighted prevalence of 75.8%, 42.3% and 19.4%, respectively. In general, there were 28 different combinations of major modifiable CVD risk factor co-occurrences. The combination of physical inactivity with low HDL-C was found in 19.7% of the study participants, followed by physical inactivity with hypertension of 17.8%. Urban residence, male gender, sugar-sweetened food consumption and older age had a positive association with the number of major modifiable CVD risk factors, while being a farmer had a negative association.

CONCLUSIONS

The prevalence and magnitude of major modifiable CVD risk factors in the study area were high. The components of the most prevalent combinations of major modifiable CVD risk factors should be targeted. Therefore, public health measures against major modifiable CVD risk factors such as promotion of physical exercise and reduction of sugar-sweetened food consumption have to be taken, targeting the vulnerable groups such as urban residents and older age.

Barriers to Management of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Damot Pulassa, Wolaita, South Ethiopia: A Phenomenological Study of Mothers and Health Service Providers

BACKGROUND

Management of children with moderate acute malnutrition (MAM) needs to improve to reduce the transition from MAM to severe acute malnutrition (SAM).

OBJECTIVE

This study aimed to assess barriers to management of MAM among children aged 6 to 59 months in Damot Pulassa, Wolaita, South Ethiopia.

METHOD

This descriptive phenomenological design used 6 focus group discussions with mothers or caregivers of children aged 6 to 59 months and 10 in-depth interviews with health service providers. Data were analyzed using Colaizzi's descriptive phenomenological method.

RESULT

Six themes were identified: Possible reasons for MAM; identification of a child with MAM; management services of MAM; maternal-level barriers; service provider-level barrier; and suggestions to improve the service. Shortage of food and money, selling out of self-produced food without having sufficient reserves at home, large household size, shame on having children with malnutrition, occasional house-to-house screening for MAM, family-initiated screening, leaving the management responsibility of children with MAM to the family, no provision of supplementary food, and lack of repeated follow-up visits were the main obstacles for managing MAM.

CONCLUSION

Maternal-level barriers and service provider-level barriers affect the management of MAM negatively in Damot Pulassa, Wolaita. Children with MAM living in the area ineligible for food supplementation could deteriorate to SAM. The provision of nutrition counseling to the mothers of children with MAM without food supplementation placed children with MAM at increased risk of negative outcomes. Thus, the government should give more attention and facilitation in promoting supplementary food into the existing management of MAM.

Cost-effectiveness of pulse oximetry and integrated management of childhood illness for diagnosing severe pneumonia

Pneumonia is a major killer of children younger than five years old. In resource constrained health facilities, the capacity to diagnose severe pneumonia is low. Therefore, it is important to identify technologies that improve the diagnosis of severe pneumonia at the lowest incremental cost. The objective of this study was to conduct a health economic evaluation of standard integrated management of childhood illnesses (IMCI) guideline alone and combined use of standard IMCI guideline and pulse oximetry in diagnosing childhood pneumonia. This is a cluster-randomized controlled trial conducted in health centres in southern Ethiopia. Two methods of diagnosing pneumonia in children younger than five years old at 24 health centres are analysed. In the intervention arm, combined use of the pulse oximetry and standard IMCI guideline was used. In the control arm, the standard IMCI guideline alone was used. The primary outcome was cases of diagnosed severe pneumonia. Provider and patient costs were collected. A probabilistic decision tree was used in analysis of primary trial data to get incremental cost per case of diagnosed severe pneumonia. The proportion of children diagnosed with severe pneumonia was 148/928 (16.0%) in the intervention arm and 34/876 (4.0%) in the control arm. The average cost per diagnosed severe pneumonia case was USD 25.74 for combined use of pulse oximetry and standard IMCI guideline and USD 17.98 for standard IMCI guideline alone. The incremental cost of combined use of IMCI and pulse oximetry was USD 29 per extra diagnosed severe pneumonia case compared to standard IMCI guideline alone. Adding pulse oximetry to the diagnostic toolkit in the standard IMCI guideline could detect and treat one more child with severe pneumonia for an additional investment of USD 29. Better diagnostic tools for lower respiratory infections are important in resource-constrained settings, especially now during the COVID-19 pandemic.

Large local variations in the use of health services in rural southern Ethiopia: An ecological study

Ethiopia is behind schedule in assuring accessible, equitable and quality health services. Understanding the geographical variability of the health services and adjusting small-area level factors can help the decision-makers to prioritize interventions and allocate scarce resources. There is lack of information on the degree of variation of health service utilisation at micro-geographic area scale using robust statistical tools in Ethiopia. Therefore, the objective of this study was to assess the health service utilisation and identify factors that account for the variation in health service utilisation at kebele (the smallest administrative unit) level in the Dale and Wonsho districts of the Sidama region. An exploratory ecological study design was employed on the secondary patient data collected from 1 July 2017 to 30 June 2018 from 65 primary health care units of the fifty-four kebeles in Dale and Wonsho districts, in the Sidama region. ArcGIS software was used to visualise the distribution of health service utilisation. SaTScan analysis was performed to explore the unadjusted and covariate-adjusted spatial distribution of health service utilisation. Linear regression was applied to adjust the explanatory variables and control for confounding. A total of 67,678 patients in 54 kebeles were considered for spatial analysis. The distribution of the health service utilisation varied across the kebeles with a mean of 0.17 visits per person per year (Range: 0.01-1.19). Five kebeles with health centres had a higher utilisation rate than other rural kebeles without health centres. More than half (57.4%) of the kebeles were within a 10 km distance from health centres. The study found that distance to the health centre was associated with the low health care utilisation. Improving the accessibility of health services by upgrading the primary health care units could increase the service use.

Prevalence of hypertension, and related factors among adults in Wolaita, southern Ethiopia: A community-based cross-sectional study

INTRODUCTION

Hypertension is a global public health challenge. There is a lack of evidence on the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia.

AIM

To assess the prevalence of hypertension, prehypertension, and related factors among adult populations of Wolaita, southern Ethiopia.

METHODS

A community-based cross-sectional study was conducted on 2483 adult residents, selected using a two-stage random sampling technique. The quantitative data collected from structured questionnaires; anthropometric and biochemical measurements were entered into EpiData version 3.1 using double-entry systems. We determined the weighted prevalence of hypertension and pre-hypertension for the two-stage survey. The multivariate logistic regression analysis was used to assess factors associated with hypertension and carried out after declaring the data set as survey data to account for the effect of clustering. An adjusted coefficient with 95% CI was used to ascertain the significance of the association.

RESULTS

The weighted prevalence of hypertension and prehypertension in the Wolaita area was 31.3% (27.7%-35.1%) and 46.4% (42.9%-50.0%) respectively. The weighted prevalence of hypertension of those who were not aware of their hypertension until the time of the survey was 29.8%% (26.5%-33.3%). Where the weighted prevalence of self-reported cases of hypertension was 2.2% (1.2%-3.8%). Obesity, sugar-sweetened food consumption, male sex, elevated total cholesterol, raised fasting blood sugar, and advancing age were positively associated with hypertension.

CONCLUSION

The prevalence of hypertension among adults in Wolaita was high. A small proportion of the affected people are aware of their high blood pressure. This study reported a high prevalence of pre-hypertension; which indicates a high percentage of people at risk of hypertension. It is essential to develop periodic screening programs, and primary intervention strategies such as the prevention of obesity, and reduction of sugar-sweetened food consumption.

A local-ingredients-based supplement is an alternative to corn-soy blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: A randomized controlled non-inferiority trial in Wolaita, Southern Ethiopia

BACKGROUND

Globally, moderate acute malnutrition (MAM) affects approximately 5% of children below five years of age. MAM is a persistent public health problem in Ethiopia. The current approach in Ethiopia for managing MAM is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. The objective of the study was to compare a local-ingredients-based supplement (LIBS) with the standard corn-soy blend plus (CSB+) in treating MAM among children aged 6 to 59 months to test the hypothesis that the recovery rate achieved with LIBS will not be more than 7% worse than that achieved with CSB+.

METHODS AND FINDINGS

We used an individual randomized controlled non-inferiority trial design with two arms, involving 324 children with MAM aged 6 to 59 months in Wolaita, Southern Ethiopia. One hundred and sixty-two children were randomly assigned to each of the two arms. In the first arm, 125.2 g of LIBS with 8 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. In the second arm, 150 g of CSB+ with 16 ml of refined deodorized and cholesterol-free sunflower oil/day was provided. Each child was provided with a daily ration of either LIBS or CSB+ for 12 weeks. Both intention-to-treat (ITT) and per-protocol (PP) analyses were done. ITT and PP analyses showed non-inferiority of LIBS compared with CSB+ for recovery rate [ITT risk difference = 4.9% (95% CI: -4.70, 14.50); PP risk difference = 3.7% (95% CI: -5.91, 13.31)]; average weight gain [ITT risk difference = 0.10 g (95% CI: -0.33 g, 0.53 g); PP risk difference = 0.04 g (95% CI: -0.38 g, 0.47 g)]; and recovery time [ITT risk difference = -2.64 days (95% CI: -8.40 days, 3.13 days); PP difference -2.17 days (95% CI: -7.97 days, 3.64 days]. Non-inferiority in MUAC gain and length/height gain was also observed in the LIBS group compared with the CSB+ group.

CONCLUSIONS

LIBS can be used as an alternative to the standard CSB+ for the treatment of MAM. Thus, the potential of scaling up the use of LIBS should be promoted.

TRIAL REGISTRATION

Pan-African Clinical Trial Registration number: PACTR201809662822990.

Spatial Variation of Child Stunting and Maternal Malnutrition after Controlling for Known Risk Factors in a Drought-Prone Rural Community in Southern Ethiopia

Background

Globally, understanding spatial analysis of malnutrition is increasingly recognized. However, our knowledge on spatial clustering of malnutrition after controlling for known risk factors of malnutrition such as wealth status, food insecurity, altitude and maternal characteristics is limited from Ethiopia. Previous studies from southern Ethiopia have shown seasonal patterns of malnutrition, yet they did not evaluate spatial clustering of malnutrition.

Objective

The aim of this study was to assess whether child stunting and maternal malnutrition were spatially clustered in drought-prone areas after controlling for previously known risk factors of malnutrition.

Methods

We used a community-based cohort study design for a one-year study period. We used SaTScan software to identify high rates of child stunting and maternal malnutrition clustering. The outcome based was the presence or absence of stunting and maternal malnutrition ([BMI] <18.5 kg/m2). We controlled for previously known predictors of child stunting and maternal malnutrition to evaluate the presence of clustering. We did a logistic regression model with declaring data to be time-series using Stata version 15 for further evaluation of the predictors of spatial clustering.

Results

The crude analysis of SaTScan showed that there were areas (clusters) with a higher risk of stunting and maternal malnutrition than in the underlying at risk populations. Stunted children within an identified spatial cluster were more likely to be from poor households, had younger and illiterate mothers, and often the mothers were farmers and housewives. Children identified within the most likely clusters were 1.6 times more at risk of stunting in the unadjusted analysis. Similarly, mothers within the clusters were 2.4 times more at risk of malnutrition in the unadjusted analysis. However, after adjusting for known risk factors such as wealth status, household food insecurity, altitude, maternal age, maternal education, and maternal occupation with SaTScan analysis, we show that child stunting and maternal malnutrition were not spatially clustered.

Conclusion

The observed spatial clustering of child stunting and maternal malnutrition before controlling for known risk factors for child stunting and maternal malnutrition could be due to non-random distribution of risk factors such as poverty and maternal characteristics. Moreover, our results indicated the need for geographically targeted nutritional interventions in a drought-prone area.

Low and unequal use of outpatient health services in public primary health care facilities in southern Ethiopia: a facility-based cross-sectional study

BACKGROUND

Outpatient department visits per individual for each year are one of the core indicators of healthcare delivery to assess accessibility or quality of services. In addition, this study aimed to assess health service utilisation and disease patterns in southern Ethiopia, by including the health authorities' suggestions to improve the services. No study has assessed this in Ethiopia previously.

METHODS

An institution-based cross-sectional design study was done in 65 primary health care units in Dale and Wonsho districts, in Sidama region, for all patients visiting health facilities from 1 July 2017 to 30 June 2018. We estimated the utilisation rate as visits per person per year, the odds ratio for health use and proportions of diseases' diagnoses. The results of our study were presented to local health authorities, and their suggestions for improvements were incorporated into the analysis.

RESULT

A total of 81,129 patients visited the health facilities. The annual outpatient health service utilisation was 0.18 (95% CI: 0.18-0.19) new visits per person per year. The health service utilisation rate per year for the rural population was lower than the urban utilisation by 91% (OR = 0.09; 95% CI: 0.08-0.09). Children in the age group of 5-14 years had lower odds of health service utilisation by 78% (OR = 0.22; 95% CI: 0.21-0.23), compared to children under 5 years of age. Females were four times (OR = 4.17; 95% CI: 4.09-4.25) more likely to utilise health services than males. Febrile illness constituted 17.9% (14,847 of 83,148) of the diagnoses in all age groups. Almost half of the febrile cases, 46.5% (3827 of 8233), were among children under 5 years of age. There were very few cases of non-communicable diseases diagnosed in the health facilities. The health authorities suggested improving diagnostic capacities at health centres, enhancing health professionals' skill and attitudes, and improving affordability and physical accessibility of the services.

CONCLUSION

The health service utilisation rate was low in Sidama. The use of health services was lower among rural residents, men, children and elderly, and health post users. Improving the quality, affordability and accessibility of the health services, by involving responsible stakeholders could increase service usage.

Iron deficiency anemia among children aged 2-5 years in southern Ethiopia: a community-based cross-sectional study

Background

Iron-deficiency anemia (IDA) is a common type of nutritional anemia in low-income countries, including Ethiopia. However, there is limited data on iron deficiency anemia prevalence and associated factors in Ethiopia, particularly for children aged 2 to 5 years.

Objectives

To establish the prevalence of iron deficiency anemia and associated risk factors, focusing on iron-rich food consumption among children aged 2 to 5 years in southern Ethiopia.

Methods

A community-based cross-sectional study was conducted in southern Ethiopia in 2017, involving 331 randomly selected children aged 2 to 5 years old. A structured questionnaire was used to collect information about the children and the households. Venous blood was collected from each child in a test tube to measure hemoglobin, ferritin, and C-reactive protein (CRP). Hemoglobin levels were determined using Hemocue^®301 and adjusted for altitude. Anemia was defined as hemoglobin levels <11 g/dl. Ferritin was adjusted for inflammation based on CRP concentration and low ferritin concentration defined as adjusted ferritin concentration <12 µg/L. IDA was considered when a child had both hemoglobin level <11g/dl and low ferritin concentration. Bi-variable and multivariable logistic regression models were performed to identify factors associated with IDA and iron-rich food consumption.

Results

The prevalence of iron deficiency anemia was 25%, and the total anemia prevalence was 32%. Only 15% of children consumed iron-rich foods in the preceding 24 h, and 30% of children consumed iron-rich foods at least once in the preceding week. IDA decreased as the height for age z-score increased (Adjusted Odds Ratio 0.7; 95% CI [0.5–0.9]). Mothers with increased educational level (AOR 1.1; 1.0–1.2) and households with increased dietary diversity (AOR 1.4; 1.2–1.6) consumed more iron-rich foods.

Conclusions

Iron deficiency anaemia was a moderate public health problem in southern Ethiopia, and the iron-rich food consumption was low. Interventions should focus on food supplementation and fortification, food diversification and nutritional education, and promoting women’s education.

Older children are at increased risk of Plasmodium vivax in south-central Ethiopia: a cohort study

BACKGROUND

Better understanding of the distribution of Plasmodium vivax and its risk factors could be used to prevent and control malaria infection. Therefore, the aim of this study was to characterize the distribution and risk factors of P. vivax, and to compare them with Plasmodium falciparum occurrence in south-central Ethiopia.

METHODS

A cohort of 34,548 individuals were followed for 121 weeks between 2014 and 2016 as part of larger cluster randomized controlled trial to evaluate the effect of long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS) on malaria prevention in Ethiopia. Weekly home visit (active search) and patient self- report to health post (passive search) between the weekly home visits were used to register malaria cases. A blood sample was collected by finger prick and malaria was diagnosed using rapid diagnostic test (RDT). Generalized estimating equation (GEE) Poisson model that accounts for repeated measure of malaria episodes was applied to assess the risk factors of P. vivax episode.

RESULTS

The overall incidence rate of P. vivax was 7.4 episodes per 1000 person-years of observation. The study showed households closer to the lake Zeway and Bulbula river (potential mosquito breeding sites) were more at risk of P. vivax infection (incidence rate ratio (IRR): 1.33; 95% CI = 1.23-1.45). Furthermore, the age group under 5 years (IRR: 1.40, 95% CI = 1.10-1.79), the age group 5-14 years (IRR: 1.27, 95% CI = 1.03-1.57), households with less educated household head (IRR: 1.63, 95% CI = 1.10-2.44) and house roof made of thatch/leaf (IRR: 1.35, 95% CI = 1.11-1.65) were at higher risk for P. vivax. Similar explanatory variables such as distance from the breeding sites, age group (under 5 years but not 5-14 years old), educational status and type of housing were also found to be the predictors of P. falciparum incidence.

CONCLUSION

Households living closer to a mosquito breeding site, age group under 15 years, less educated household heads and thatch/leaf roof housing were the risk factor for P. vivax. The result of this study can be used for tailored interventions for malaria control and prevention by prioritizing those living close to potential mosquito breeding site, enhancing bed net use of children less than 15 years of age, and improving housing.

Births and deaths in Sidama in southern Ethiopia: findings from the 2018 Dale-Wonsho Health and Demographic Surveillance System (HDSS)

Background

Sidama is one of the most densely populated areas in Ethiopia. Information about the demographic characteristics is scarce, and most studies were census based on interviews. Earlier population studies from Ethiopia did not sufficiently address the validity of measuring births, deaths, and age-composition.

Objective

To investigate the population characteristics in Sidama with an emphasis on fertility estimates, age, and death reporting.

Methods

This is a mixed-method cross-sectional study, conducted in Sidama in southern Ethiopia, using baseline data of newly established Dale-Wonsho Health and Demographic Surveillance System site in 2018. We used quantitative data of 5179 randomly selected households having 25,144 individuals. We collected information on deaths in the same study period and population from the traditional burial associations (Iddir). Qualitative data were collected using focus group discussions, and in-depth interviews. Life tables, age reliability indices and logistic regression were used to analyse the data.

Results

The total fertility rate was 2.9 children/woman, the crude birth rate was 22.8/1000 population and the crude death rate was 5.2/1000 population. The dependency ratio was 66/100 working-age population. Urban residents had higher birth rates (OR = 1.4 (95% CL: 1.05–1.78), and women with basic education had lower birth rates (OR = 0.6 (95% CL: 0.46–0.78) compared to those with no education. The age accuracy indices showed unreliable age reporting. The number of deaths increased from 29 to 132 when death reports from the Iddirs were included. There was under-reporting of neonatal and deaths of young children. Substituting national and regional mortality estimates, the life expectancy declined to an average of 53 years (range 48–58 years).

Conclusion

The fertility rate in Sidama is lower than previously reported and is affected by age, residence and education. As we have identified important measurement and reporting errors, future demographic surveillance sites should consider these limitations.

Identifying geographical heterogeneity of pulmonary tuberculosis in southern Ethiopia: a method to identify clustering for targeted interventions

Background

Previous studies from Ethiopia detected disease clustering using broader geographic settings, but limited information exists on the spatial distribution of the disease using residential locations. An assessment of predictors of spatial variations of TB at community level could fill the knowledge gaps, and helps in devising tailored interventions to improve TB control.

Objective

To assess the pattern of spatial distribution of pulmonary tuberculosis (PTB) based on geographic locations of individual cases in the Dale district and Yirga Alem town in southern Ethiopia.

Methods

The socio-demographic characteristics of PTB cases were collected using a structured questionnaire, and spatial information was collected using geographic position systems. We carried out Getis and Ord (Gi*) statistics and scan statistics to explore the pattern of spatial clusters of PTB cases, and geographically weighted regression (GWR) was used to assess the spatial heterogeneities in relationship between predictor variables and PTB case notification rates (CNRs).

Results

The distribution of PTB varied by enumeration areas within the kebeles, and we identified areas with significant hotspots in various areas ineach year. In GWR analysis, the disease distribution showed a geographic heterogeneity (non-stationarity) in relation to physical access (distance to TB control facilities) and population density (AICc = 5591, R² = 0.3359, adjusted R² = 0.2671). The model explained 27% of the variability in PTB CNRs (local R² ranged from 0.0002–0.4248 between enumeration areas). The GWR analysis showed that areas with high PTB CNRs had better physical accessibility to TB control facilities and high population density. The effect of physical access on PTB CNRs changed after the coverage of TB control facilities was improved.

Conclusion

We report a varying distribution of PTB in small and different areas over 10 years. Spatial and temporal analysis of disease distribution can be used to identify areas with a high burden of disease and predictors of clustering, which helps in making policy decisions and devising targeted interventions.

Co-morbid anaemia and stunting among children 2-5 years old in southern Ethiopia: a community-based cross-sectional study

BACKGROUND

In Ethiopia, 38% of children less than 5 years of age are stunted and 57% are anaemic. Both have a negative impact later in life on physical growth and cognitive development and often coexist. There are few studies in Ethiopia that assessed co-morbid anaemia and stunting (CAS) and context-specific factors associated with it.

OBJECTIVE

The objective of this study was to assess the prevalence of CAS, and factors associated with CAS among children aged 2 to 5 years, in southern Ethiopia.

METHODS

A community-based cross-sectional survey was conducted among 331 randomly selected children in 2017. Mothers were interviewed using a structured questionnaire to obtain child and household information. Anthropometric measurements and blood samples for haemoglobin were collected. Stunting was defined as height-for-age Z-scores (HAZ) less than -2 SDs and anaemia was defined as altitude-adjusted haemoglobin levels less than 11.0 g/dL. CAS was defined when a child was both stunted and anaemic. Crude and adjusted multinomial logistic regression analyses were used to identify factors associated with CAS.

RESULTS

Out of 331 children studied, 17.8% (95% CI 13.87% to 22.4%) had CAS. Factors found significantly linked with higher odds of CAS were increased child age (adjusted OR (AOR) 1.0 (1.0 to 1.1)) and no iron supplementation during the last pregnancy (AOR (95% CI) 2.9 (1.3 to 6.2)). One factor found significantly linked to lower odds of CAS was food secured households (AOR (95% CI) 0.3 (0.1 to 0.9)).

CONCLUSIONS

Co-morbid anaemia and stunting among children in the study area is of concern; it is associated with household food security, iron supplementation during pregnancy and child age. Therefore, comprehensive interventions focusing on improving household food security and promoting iron supplementation for pregnant women are suggested.

Development and nutritional evaluation of local ingredients-based supplements to treat moderate acute malnutrition among children aged below five years: A descriptive study from rural Wolaita, Southern Ethiopia

In Ethiopia, moderate acute malnutrition (MAM) is a persistent public health problem. The current management approaches for MAM among children are counseling in food-secure settings and food supplementation in chronically food-insecure areas. The objective of this study was to develop a local ingredients-based supplement (LIBS) for treating MAM among children. Collection of food ingredients (pumpkin seed, amaranth grain, flaxseed, peanut, and emmer wheat) was made. Sorting, soaking, drying, roasting, and milling of ingredients were done. Nutrient analysis was done using triplicate measurements of each nutrient. One-way ANOVA was used to analyze differences in means with ± standard deviation of nutrient measurements among the supplements. The nutrient content of four developed LIBS ranged from 20.3 g to 22.5 g for protein, 29.3 g to 33.5 g for fat, 509.5 kcal to 570.0 for kcal, 6.0 g to 8.5 g for fiber, 2.8 g to 3.7 g for moisture, and 2.1 g to 4.3 g for ash. The mineral and antinutrient components ranged from 75.6 mg to 115.6 mg for calcium, 473.1 mg to 570.2 mg for potassium, 79.3 mg to 114.4 mg for sodium, 4.1 mg to 5.6 mg for zinc, 8.2 mg to 10.2 mg for iron, 442.6 mg to 470.4 mg for phosphorous, and 2.1 mg to 4.3 mg for phytate. The LIBS with the highest portion of pumpkin seed had significantly highest amounts of protein, fat, calories, iron, zinc, and potassium. The results found were within the recommended range of required nutrients for the treatment of children with MAM. Therefore, LIBS may be used for the management of children with MAM.

Caesarean section rates analysed using Robson's 10-Group Classification System: a cross-sectional study at a tertiary hospital in Ethiopia

OBJECTIVE

The aim of this study was to assess the caesarean section (CS) rates using Robson's 10-Group Classification System among women who gave birth at Hawassa University Referral Hospital in southern Ethiopia.

DESIGN

Cross-sectional study design to determine CS rate using Robson's 10-Group Classification System.

SETTING

Hawassa University Referral Hospital in south Ethiopia.

PARTICIPANTS

4004 women who gave birth in Hawassa University Referral Hospital from June 2018 to June 2019.

RESULTS

The 4004 women gave birth to 4165 babies. The overall CS rate was 32.8% (95% CI: 31.4%-34.3%). The major contributors to the overall CS rates were: Robson group 1 (nulliparous women with singleton pregnancy at term in spontaneous labour) 22.9%; group 5 (multiparous women with at least one previous CS) 21.4% and group 3 (multiparous women without previous CS, with singleton pregnancy in spontaneous labour) 17.3%. The most commonly reported indications for CS were 'fetal compromise' (35.3%) followed by previous CS (20.3%) and obstructed labour (10.7%).

CONCLUSION

A high proportion of women giving birth at this hospital were given a CS, and many of them were in a low-risk group. Few had trial of labour. More active use of partogram, improving fetal heartbeat-monitoring system, implementing midwife-led care, involving a companion during labour and auditing the appropriateness of CS indications may help to reduce the CS rate.

Seasonal Variation of Household Food Insecurity and Household Dietary Diversity on Wasting and Stunting among Young Children in A Drought Prone Area in South Ethiopia: A Cohort Study

This study was conducted to evaluate seasonal patterns of household food insecurity, dietary diversity, and household characteristics on wasting and stunting among children in households followed for 1 year in the drought-prone areas of Sidama, Ethiopia. A cohort study design was employed. Data were collected on the pre-harvest season (March and June) and post-harvest season (September and December) of 2017. We studied 935 children aged 6 to 47 months. At four seasons over a year, we had 3,449 observations from 897 households and 82% (2,816) (95% CI: 80.3-82.9) were food in-secured households. Severe food insecurity was higher in the pre-harvest (March; food scarcity season) which was 69% as compared to 50% of September (P < .001). From 3,488 observations, 44% (1,533) (95% CI: 42.3-45.6) of children were stunted. Stunting showed seasonal variations with 38% (95% CI: 34.7-41.0) in March and 49% (95% CI: 45.8-52.5) in December. Six percent (95% CI: 5.0-6.6) of children were wasted, with higher prevalence in March (8%) as compared to 3% of September (P < .001). Moreover, household characteristics such as poverty level, education, occupation and the household food insecurity and dietary diversity were associated with subsequent wasting and stunting.

Pulse oximeter with integrated management of childhood illness for diagnosis of severe childhood pneumonia at rural health institutions in Southern Ethiopia: results from a cluster-randomised controlled trial

OBJECTIVE

To assess whether pulse oximetry improves health workers' performance in diagnosing severe childhood pneumonia at health centres in Southern Ethiopia.

DESIGN

Parallel cluster-randomised trial.

SETTING

Government primary health centres.

PARTICIPANTS

Twenty-four health centres that treat at least one pneumonia case per day in Southern Ethiopia. Children aged between 2 months and 59 months who present at health facilities with cough or difficulty breathing were recruited in the study from September 2018 to April 2019.

INTERVENTION ARM

Use of the Integrated Management of Childhood Illness (IMCI) algorithm and pulse oximeter.

CONTROL ARM

Use of the IMCI algorithm only.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the proportion of children diagnosed with severe pneumonia. Secondary outcomes included referred cases of severe pneumonia and treatment failure on day 14 after enrolment.

RESULT

Twenty-four health centres were randomised into intervention (928 children) and control arms (876 children). The proportion of children with severe pneumonia was 15.9% (148 of 928 children) in the intervention arm and 3.9% (34 of 876 children) in the control arm. After adjusting for differences in baseline variables children in the intervention arm were more likely to be diagnosed as severe pneumonia cases as compared with those in the control arm (adjusted OR: 5.4, 95% CI 2.0 to 14.3, p=0.001).

CONCLUSION

The combined use of IMCI and pulse oximetry in health centres increased the number of diagnosed severe childhood pneumonia.

TRIAL REGISTRATION NUMBER

PACTR201807164196402.

A Local Ingredients-Based Supplement Is Not Inferior to Corn-soya Blends Plus for the Treatment of Moderate Acute Malnutrition Among Children Aged 6 to 59 Months in Wolaita

Objectives

Moderate acute malnutrition (MAM) is widespread and a persistent public health problem in developing countries. Currently, the management approach of MAM is focused on food supplementation, but it is limited to chronically food-insecure areas. This study aims to develop local-ingredients based supplement (LIBS) and evaluate if it is comparable to the corn-soya blend plus (CSB+) in treating MAM among children aged 6 to 59 months in Wolaita, Ethiopia.

Methods

Collection of food ingredients that have the potential for making LIBS was done. Sorting, soaking, roasting, and milling of ingredients were done. The LIBS, with an improved amount of nutrients, was used to test the effectiveness in treating MAM. To evaluate the effectiveness of LIBS compared with CSB+ in treating MAM, we used a randomized controlled non-inferiority trial among 324 moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The daily ration was: 100 gm of LIBS plus 25.2 gm of sugar with 8 ml oil in the intervention group and 150 gm of CSB+ with 16 ml of oil in the control group. A chi-square test was used for the comparison of recovery rates between two groups. Kaplan-Meier (log-rank) survival analysis was done to estimate the recovery time and survival curves.

Results

Four food samples of LIBS were made with different portions of ingredients. One of the LIBS with the highest portion of pumpkin seed and selected for testing had an improved amount of protein, fat, energy, iron, zinc and potassium contents. Its proximate composition indicated protein and fat contents of 22.6 g/100 g and 32.9 g/100 g respectively. The trial results showed that there is no difference in baseline characteristics between the two groups (p &gt; 0.05). The recovery rate for LIBS (n = 105 of 162; 64.8%) was similar to that for CSB+ (n = 108 of 162; 66.7%) (P = 0.6). The duration of recovery was similar for the LIBS group, with a median of 56 days compared to 63 days for the CSB+ group (P = 0.92).

Conclusions

The LIBS has contained adequate amount of nutrients needed for the treatment of MAM. There was no difference in recovery rates as well as recovery times for those who received LIBS and those who received CSB+ . Thus, LIBS has the same potential to treat MAM as CSB+ .

Funding Sources

Norwegian Agency for Development Cooperation (NORAD); Norwegian Program for Capacity Development in Higher Education and Research for Development Program (NORHED).

Dietary Diversity and Nutritional Status of Children Aged 6 to 24 Months in Rural Sidama, Southern Ethiopia

Objectives

To describe dietary diversity score (DDS) of young children and to assess the association of DDS with stunting and anaemia (defined as haemoglobin level &lt;11 mg/dl) in rural Southern Ethiopia.

Methods

A cross-sectional household study was done in rural Dale Woreda, Southern Ethiopia from August to October 2018 among 804 caregiver-child (aged 6–24 months) pairs. Dietary history, anthropometric measurements and haemoglobin levels using HemoCue HB 301 portable machines were captured. Child DDS was assessed in a structured 24-hour recall on specific common food items with relevance for the standard 7-food groups DDS (WHO). Stunting was defined as length-for-age Z-score less than 2 SD from the population mean according to the WHO Child Growth Standards. Results from adjusted logistic regression models are presented for stunting and anaemia as the dependent variables (using SPSS software).

Results

Children received only foods from 1 and 2 food groups were 5.0% (40/804) and 14.9% (120/804), respectively. There was 43.9% (353/804) of children who had low DDS (received foods from less than four out of seven food groups) during 24 hours prior to the interviews. The prevalence of stunting was 47.8% (384/804) and 45.6% (367/804) for anaemia. The odds ratio for stunting was 2 and 3 times higher among children who did not receive legumes and flesh foods compared to those who received it: aOR = 2.0, 95% CI 1.2; 3.3 and 2.9, 95% CI 1.6; 5.5, respectively. Children who did not receive cereals and legumes had similarly increased risk of having haemoglobin level below 11 mg/dl compared to those who received it: aOR = 2.6, 95% CI 1.0; 6.8 and 2.8, 95% CI 1.7; 4.7, respectively.

Conclusions

In Dale Woreda, Southern Ethiopia, the prevalences of stunting and anaemia were high and children had low dietary diversity. Dietary diversity among young children must be considered in Ethiopian strategies promoting the health of children.

Funding Sources

NORAD (Norwegian Agency for development co-operation), through the NORHED (Norwegian program for capacity development in higher education and research for development) program.

Financial risk of seeking maternal and neonatal healthcare in southern Ethiopia: a cohort study of rural households

INTRODUCTION

Ethiopian households' out-of-pocket healthcare payments constitute one-third of the national healthcare budget and are higher than the global and low-income countries average, and even the global target. Such out-of-pocket payments pose severe financial risks, can be catastrophic, impoverishing, and one of the causal barriers for low utilisation of healthcare services in Ethiopia. This study aimed to assess the financial risk of seeking maternal and neonatal healthcare in southern Ethiopia.

METHODS

A population-based cohort study was conducted among 794 pregnant women, 784 postpartum women, and their 772 neonates from 794 households in rural kebeles of the Wonago district, southern Ethiopia. The financial risk was estimated using the incidence of catastrophic healthcare expenditure, impoverishment, and depth of poverty. Annual catastrophic healthcare expenditure was determined if out-of-pocket payments exceeding 10% of total household or 40% of non-food expenditure. Impoverishment was analysed based on total household expenditure and the international poverty line of ≈ $1.9 per capita per day.

RESULTS

Approximately 93% (735) of pregnant women, 31% (244) of postpartum women, and 48% (369) of their neonates experienced illness. However, only 56 households utilised healthcare services. The median total household expenditure was $527 per year (IQR = 390: 370,760). The median out-of-pocket healthcare payment was $46 per year (IQR = 46: 46, 92) with two episodes per household, and shared 19% of the household's budget. The poorer households paid more than did the richer for healthcare, during pregnancy-related and neonatal illness. However, the richer paid more than did the poorer during postpartum illness. Forty-six percent of households faced catastrophic healthcare expenditure at the threshold of 10% of total household expenditure, or 74% at a 40% non-food expenditure, and associated with neonatal illness (aRR: 2.56, 95%CI: 1.02, 6.44). Moreover, 92% of households were pushed further into extreme poverty and the poverty gap among households was 45 Ethiopian Birr per day. The average household size among study households was 4.7 persons per household.

CONCLUSIONS

This study demonstrated that health inequity in the household's budget share of total OOP healthcare payments in southern Ethiopia was high. Besides, utilisation of maternal and neonatal healthcare services is very low and seeking such healthcare poses a substantial financial risk during illness among rural households. Therefore, the issue of health inequity should be considered when setting priorities to address the lack of fairness in maternal and neonatal health.

Feeding behavior and activity of Phlebotomus pedifer and potential reservoir hosts of Leishmania aethiopica in southwestern Ethiopia

BACKGROUND

Cutaneous leishmaniasis (CL) is a major public health concern in Ethiopia. However, knowledge about the complex zoonotic transmission cycle is limited, hampering implementation of control strategies. We explored the feeding behavior and activity of the vector (Phlebotomus pedifer) and studied the role of livestock in CL transmission in southwestern Ethiopia.

METHODS

Blood meal origins of engorged sand flies were determined by sequencing host DNA. A host choice experiment was performed to assess the feeding preference of P. pedifer when humans and hyraxes are equally accessible. Ear and nose biopsies from livestock were screened for the presence of Leishmania parasites. Sand flies were captured indoor and outdoor with human landing catches and CDC light traps to determine at which time and where P. pedifer is mostly active.

PRINCIPAL FINDINGS

A total of 180 P. pedifer sand flies were found to bite hosts of 12 genera. Humans were the predominant blood meal source indoors (65.9%, p < 0.001), while no significant differences were determined outdoors and in caves. In caves, hyraxes were represented in blood meals equally as humans (45.5% and 42.4%, respectively), but the host choice experiment revealed that sand flies have a significant preference for feeding on hyraxes (p = 0.009). Only a single goat nose biopsy from 412 animal samples was found with Leishmania RNA. We found that P. pedifer is predominantly endophagic (p = 0.003), but occurs both indoors and outdoors. A substantial number of sand flies was active in the early evening, which increased over time reaching its maximum around midnight.

CONCLUSION

In contrast to earlier suggestions of exclusive zoonotic Leishmania transmission, we propose that there is also human-to-human transmission of CL in southwestern Ethiopia. Livestock does not play a role in CL transmission and combined indoor and outdoor vector control measures at night are required for efficient vector control.

Intrauterine growth patterns in rural Ethiopia compared with WHO and INTERGROWTH-21st growth standards: A community-based longitudinal study

INTRODUCTION

Children's well-being is highly influenced by their fetal growth. Adequate intrauterine growth (IUG) is a basic feature of a healthy pregnancy. The aim of our study was to assess IUG patterns in a rural and drought-affected population in the Rift Valley area of the Adami Tullu district in Oromia, Ethiopia.

METHODS

We conducted a longitudinal, community-based study of IUG patterns utilizing serial ultrasound measurements. Data were collected for 17 months, from July 2016 to November 2017. We included 675 singleton foetuses ≤ 24 weeks old, based on ultrasound-derived estimates of gestational age, and followed them until delivery. We obtained head circumference, biparietal diameter, abdominal circumference, femur length, and estimated fetal weight at 26, 30, and 36 weeks. Fetal weight was estimated using the Hadlock algorithm, and the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were developed from this model. We compared the biometric measurements and fetal weight data from our study to the World Health Organization (WHO) and INTERGROWTH-21st fetal growth reference standards.

RESULTS

Distribution of the biometric measurements and estimated fetal weights in our study were similar to those for the WHO and INTERGROWTH-21st references. Most measurements were between -2 and +2 of the reference z-scores. Based on the smoothed percentiles, the 5th, 50th, and 95th percentiles of our study had similar distribution patterns to the WHO chart, and the 50th percentile had a similar pattern to the INTERGROWTH-21st chart.

CONCLUSIONS

Our study determined fetal growth patterns in a drought-affected rural community of Ethiopia using common ultrasound biometric measurements. We found similar IUG patterns to those indicated in the WHO and INTERGROWTH-21st fetal growth reference standards.

Research protocol local ingredients-based supplementary food as an alternative to corn-soya blends plus for treating moderate acute malnutrition among children aged 6 to 59 months: a randomized controlled non-inferiority trial in Wolaita

BACKGROUND

In Ethiopia, 12.5% of children below 5 years are wasted, and 9.7% are moderately wasted. The present strategy for the management of moderate acute malnutrition (MAM) is a supplementary feeding program; however, this is only provided to chronically food-insecure areas. This randomized controlled non-inferiority trial examines if Local ingredients-based supplement (LIBS) is as effective as corn-soya blends plus (CSB+) in treating moderate acute malnutrition among children aged 6-59 months.

METHODS

A randomized controlled non-inferiority trial will be conducted with moderately wasted children aged 6 to 59 months in Wolaita, Ethiopia. The calculated sample size is 324 (i.e. with 162 children in each of two arms, to be assigned by randomization). The daily ration will be: 100 g of LIBS plus 25.2 g of sugar with 8 ml oil in the intervention group, and 150 g of CSB+ with 16 ml of oil in the control group. These interventions will be provided for a maximum period of 12 weeks, with follow-up performed on a weekly basis. Data analysis will be done using SPSS and STATA software. Both intention-to-treat and per protocol analyses will be done. Hazard ratio and Kaplan-Meier (log rank) curves of survival analysis will be done to predict the probability of recovery rate. Logistic regression will be used to test for interactions between independent and dependent variables. Analysis of variances, t-tests, fisher's exact test and chi-square tests will be used to assess baseline characteristics.

CONCLUSIONS

This paper will introduce to the existing research locally available nutritious foods which have the potential to enhance recovery from moderate acute malnutrition and to reduce the burden of malnutrition. The perceptions of mothers on feeding children with local ingredient-based supplementary food to assist recovery from moderate acute malnutrition will be the focus of in a qualitative study to follow; this will provide a further contribution in an evolving area of research.

TRIAL REGISTRATION

Pan-African Clinical Trial Registration number: PACTR201809662822990, retrospectively registered on 11/09/2018.

En-route to the 'elimination' of genotypic chloroquine resistance in Western and Southern Zambia, 14 years after chloroquine withdrawal

Background

Anti-malarial resistance is, and continues to be a significant challenge in the fight against malaria and a threat to achieving malaria elimination. In Zambia, chloroquine (CQ), a safe, affordable and well-tolerated drug, was removed from use in 2003 due to high levels of resistance evidenced with treatment failure. This study sought to investigate the prevalence of chloroquine resistance markers in Southern and Western Provinces of Zambia 14 years after the withdrawal of CQ.

Methods

Data from a cross-sectional, all-age household survey, conducted during the peak malaria transmission season (April–May 2017) was analysed. During the all-age survey, socio-demographic information and coverage of malaria interventions were collected. Consenting individuals were tested for malaria with a rapid diagnostic test and a spot of blood collected on filter paper to create a dried blood spot (DBS). Photo-induced electronic transfer–polymerase chain reaction (PET–PCR) was used to analyse the DBS for the presence of all four malaria species. Plasmodium falciparum positive samples were analysed by high resolution melt (HRM) PCR to detect the presence of genotypic markers of drug resistance in the P. falciparum chloroquine resistance transporter (Pfcrt) and P. falciparum multi-drug resistance (Pfmdr) genes.

Results

A total of 181 P. falciparum positive samples were examined for pfcrt K76T and MDR N86. Of the 181 samples 155 successfully amplified for Pfcrt and 145 for Pfmdr N86. The overall prevalence of CQ drug-resistant parasites was 1.9% (3/155), with no significant difference between the two provinces. No N86Y/F mutations in the Pfmdr gene were observed in any of the sample.

Conclusion

This study reveals the return of CQ sensitive parasites in Southern and Western Provinces of Zambia 14 years after its withdrawal. Surveillance of molecular resistant markers for anti-malarials should be included in the Malaria Elimination Programme so that resistance is monitored country wide.

Performance of an adapted household food insecurity access scale in measuring seasonality in household food insecurity in rural Ethiopia: a cohort analysis

Background

Seasonality poses a considerable food security challenge in Ethiopia. Yet, measuring seasonal variations in food insecurity, particularly the dimension of food access, lacks an adequately validated tool. We therefore evaluated the performance of an adapted Household Food Insecurity Access Scale (HFIAS) to estimate seasonal variations in food insecurity (FI) among subsistence villagers in Ethiopia.

Methods

We employed a cohort study design using a panel of four repeated measurements taken in June, September, and December in the year 2017, and in March 2018. The study recruited 473 villagers from the drought-affected Wolaita area in southwest Ethiopia. The performance of the HFIAS was evaluated via internal consistency (Chronbach's alpha values) and criterion validation techniques. The set of criteria include: parallelism between affirmative responses to FI questions and wealth strata; dose-response relationship between FI and dietary intake; and also FI severity and household wealth status.

Results

This study revealed that the HFIAS had satisfactory performance in four repeated measurements. The likelihood of affirmative responses to questions about FI decreased with ascending wealth quintiles. We observed an inverse dose-response relationship between FI and wealth status, and between FI and household dietary diversity.

Conclusions

The HFIAS showed an acceptable potential for measuring seasonal variations in FI in the study area. Our findings complement efforts to evaluate the scale's applicability in various settings, in order to promote cross-culture monitoring and comparisons. However, it required a careful adaption for contextual and cultural sensitivities.

Low immunization coverage in Wonago district, southern Ethiopia: A community-based cross-sectional study

INTRODUCTION

Immunization is a cost-effective intervention that prevented more than 5 million deaths worldwide from 2010 to 2015. Despite increased vaccination coverage over the past four decades in many African countries, including Ethiopia, universal coverage has not yet been reached. Only 39% of children aged 12-23 months received full vaccinations in Ethiopia, according to the 2016 Ethiopian Demographic Health Survey. This study aimed to evaluate immunization coverage and identify individual and community factors that explain incomplete vaccination coverage among children aged 6-36 months in the Wonago district of southern Ethiopia.

METHODS

We conducted a community-based, cross-sectional study in three randomly selected kebeles in the Wonago district from June to July 2017. Our nested sample of 1,116 children aged 6-36 months included 923 child-mother pairs (level 1) within kebeles (level 2). We conducted multilevel regression analysis using STATA software.

RESULTS

Among participants, 85.0% of children aged 12-36 months received at least one vaccine, and 52.4% had complete immunization coverage. After controlling for several individual and community variables, we identified six significant predictor variables for complete immunization: Older mothers' age (AOR = 1.05, 95% CI: 1.00-1.09), higher utilization of antenatal care (AOR = 1.36, 95% CI: 1.14-1.62), one or more tetanus-toxoid vaccination during pregnancy (AOR = 2.64, 95% CI: 1.43-4.86), mothers knowing the age at which to complete child's vaccinations (AOR = 2.00, 95% CI: 1.25-3.20), being a female (AOR = 0.64, 95% CI: 0.43-0.95), and child receiving vitamin A supplementation within the last 6 months (AOR = 2.79, 95% CI: 1.59-4.90). We observed a clustering effect at the individual and community levels with an intra-cluster correlation coefficient of 48.1%.

CONCLUSIONS

We found low immunization coverage among children in the Wonago district of southern Ethiopia, with significant differences across communities. Promoting maternal health care and community service could enhance immunization coverage.

Inadequate management of pneumonia among children in South Ethiopia: findings from descriptive study

BACKGROUND

Health system support is crucial for quality child healthcare. Therefore, this baseline survey, which is part of the community-based management study of severe pneumonia, was conducted to assess the state of health system support of IMNCI and iCCM, and health workers' knowledge in managing childhood pneumonia at health facilities.

METHODS

A survey was conducted in 99 government health institutions in South Ethiopia from 07 to 14 January, 2018. A questionnaire for health system support and case scenario for the management of severe pneumonia was adapted from the WHO health facility survey tool. The questionnaire's interview, facility observation, case scenario and retrospective record review were all used as data collection methods. Indicators of health system support in the context of an integrated management of childhood illness were used. Proportions for categorical variables and means for continuous variables were also computed for each indicator. Mean score was analysed for assessing the knowledge of health workers in managing the case scenario.

RESULTS

In the study area, only 12 (34%) of health centres and 18 (29%) of health posts received supervision, which included the observation of case management. The mean number of essential oral antibiotics for the home treatment of pneumonia available at the facility was 1.1 (95% CI 0.9 to 1.3), whereas the mean number of pre-referral drugs for the treatment of severe pneumonia was 1.3 (95% CI 1.0 to 1.6). Approximately 47 (48%; 95% CI 37.7 to 57.3) of the surveyed health facilities had materials and equipment to support vaccination services, and 71 (72%; 95% CI 62.8 to 80.6) of them had the vaccines on the day of the survey. Only four (4%; 95% CI 0.3 to 8.3) of the health facilities had all the essential job aids and supplies for providing services for pneumonia. The providers' mean knowledge score for the management of severe childhood pneumonia was 14.9 out of 22 correct answers.

CONCLUSION

There is a room to improve the health system support to integrated management of neonatal and childhood illness through supply chain management and knowledge of health workers in the management of severe pneumonia by providing training.

Impact of combining indoor residual spraying and long-lasting insecticidal nets on Anopheles arabiensis in Ethiopia: results from a cluster randomized controlled trial

BACKGROUND

Indoor residual house spraying (IRS) and long-lasting insecticidal nets (LLINs) are the key front-line malaria vector interventions against Anopheles arabiensis, the sole primary malaria vector in Ethiopia. Universal coverage of both interventions has been promoted and there is a growing demand in combinations of interventions for malaria control and elimination. This study compared the impact on entomological outcomes of combining IRS and LLINs with either intervention alone in Adami Tullu district, south-central Ethiopia. The epidemiological outcomes were recently published on a separate paper.

METHODS

This factorial, cluster-randomized, controlled trial randomized villages to four study arms: IRS + LLIN, IRS, LLIN, and control. LLINs (PermaNet 2.0) were provided free of charge. IRS with propoxur was applied before the main malaria transmission season in 2014, 2015 and 2016. Adult mosquitoes were collected in randomly selected villages in each arm using CDC light trap catch (LTC) set close to a sleeping person, pyrethrum spray catch (PSC), and artificial pit shelter (PIT), for measuring mosquito host-seeking density (HSD), indoor resting density (IRD), and outdoor resting density (ORD), respectively. Human landing catch (HLC) was performed in a sub-set of villages to monitor An. arabiensis human biting rates (HBR). Mean vector densities and HBR were compared among study arms using incidence rate ratio (IRR) calculated by negative binomial regression.

RESULTS

There were no significant differences in mean densities (HSD, IRD, ORD) and HBR of An. arabiensis between the IRS + LLIN arm and the IRS arm (p > 0.05). However, mean HSD, IRD, ORD, and HBR were significantly lower in the IRS + LLIN arm than in the LLIN alone arm (p < 0.05). All An. arabiensis tested for malaria infection were negative for Plasmodium species. For this reason, the entomological inoculation rate could not be determined.

CONCLUSIONS

The IRS + LLIN were as effective as IRS alone in reducing densities and HBR of An. arabiensis. However, the effectiveness of the two interventions combined was higher than LLINs alone in reducing densities and HBR of the vector. Added impact of the combination intervention against malaria infectivity rates of An. arabiensis compared to either intervention alone remains unknown and warrants further research. Trial registration PACTR201411000882128. Registered 8 September 2014, https://trialsjournal.biomedcentral.com/articles/10.1186/s13063-016-1154-2.

Long-lasting insecticidal nets and indoor residual spraying may not be sufficient to eliminate malaria in a low malaria incidence area: results from a cluster randomized controlled trial in Ethiopia

Background

Conflicting results exist on the added benefit of combining long-lasting insecticidal nets (LLINs) with indoor residual spraying (IRS) to control malaria infection. The main study objective was to evaluate whether the combined use of LLINs and IRS with propoxur provides additional protection against Plasmodium falciparum and/or Plasmodium vivax among all age groups compared to LLINs or IRS alone.

Methods

This cluster-randomized, controlled trial was conducted in the Rift Valley area of Ethiopia from September 2014 to January 2017 (121 weeks); 44 villages were allocated to each of four study arms: LLIN + IRS, IRS, LLIN, and control. Each week, 6071 households with 34,548 persons were surveyed by active and passive case detection for clinical malaria. Primary endpoints were the incidence of clinical malaria and anaemia prevalence.

Results

During the study, 1183 malaria episodes were identified, of which 55.1% were P. falciparum and 25.3% were P. vivax, and 19.6% were mixed infections of P. falciparum and P. vivax. The overall malaria incidence was 16.5 per 1000 person-years of observation time (PYO), and similar in the four arms with 17.2 per 1000 PYO in the LLIN + IRS arm, 16.1 in LLIN, 17.0 in IRS, and 15.6 in the control arm. There was no significant difference in risk of anaemia among the trial arms.

Conclusions

The clinical malaria incidence and anaemia prevalence were similar in the four study groups. In areas with low malaria incidence, using LLINs and IRS in combination or alone may not eliminate malaria. Complementary interventions that reduce residual malaria transmission should be explored in addition to LLINs and IRS to further reduce malaria transmission in such settings.

Trial registration PACTR201411000882128 (08 September 2014)

Electronic supplementary material

The online version of this article (10.1186/s12936-019-2775-1) contains supplementary material, which is available to authorized users.

Distribution of Plasmodium species and assessment of performance of diagnostic tools used during a malaria survey in Southern and Western Provinces of Zambia

Background

Zambia continues to make strides in reducing malaria burden through the use of proven malaria interventions and has recently pledged to eliminate malaria by 2021. Case management services have been scaled up at community level with rapid diagnostic tests (RDTs) providing antigen-based detection of falciparum malaria only. Key to national malaria elimination goals is the ability to identify, treat and eliminate all Plasmodium species. This study sought to determine the distribution of non-falciparum malaria and assess the performance of diagnostic tests for Plasmodium falciparum in Western and Southern Provinces of Zambia, two provinces planned for early malaria elimination.

Methods

A sub-set of individuals’ data and samples from a cross-sectional household survey, conducted during peak malaria transmission season in April and May 2017, was used. The survey collected socio-demographic information on household members and coverage of malaria interventions. Malaria testing was done on respondents of all ages using blood smears and RDTs while dried blood spots were collected on filter papers for analysis using photo-induced electron transfer polymerase chain reaction (PET-PCR). Slides were stained using Giemsa stain and examined by microscopy for malaria parasites.

Results

From the 1567 individuals included, the overall prevalence of malaria was 19.4% (CI 17.5–21.4) by PCR, 19.3% (CI 17.4–21.4) by RDT and 12.9% (CI 11.3–14.7) by microscopy. Using PET-PCR as the gold standard, RDTs showed a sensitivity of 75.7% (CI 70.4–80.4) and specificity of 94.2% (CI 92.8–95.4). The positive predictive value (PPV) was 75.9% (CI 70.7–80.6) and negative predictive value (NPV) was 94.1% (CI 92.1–95.4). In contrast, microscopy for sensitivity, specificity, PPV, and NPV values were 56.9% (CI 51.1–62.5), 97.7% (CI 96.7–98.5), 85.6% (CI 80.0–90.2), 90.4% (CI 88.7–91.9), respectively. Non-falciparum infections were found only in Western Province, where 11.6% of P. falciparum infections were co-infections with Plasmodium ovale or Plasmodium malariae.

Conclusion

From the sub-set of survey data analysed, non-falciparum species are present and occurred as mixed infections. As expected, PET-PCR was slightly more sensitive than both malaria RDTs and microscopy to detecting malaria infections.

Low use of long-lasting insecticidal nets for malaria prevention in south-central Ethiopia: A community-based cohort study

Introduction

A decline in malaria morbidity and mortality has been documented in Ethiopia since 2005 following a scale-up of the distribution of long-lasting insecticidal nets (LLINs). However, universal access to LLINs ownership and use has not yet been achieved. This study aimed to determine ownership and use of LLINs over time in south-central Ethiopia.

Methods

A cohort of 17,142 individuals residing in 3,006 households was followed-up from October 2014 to January 2017 (121 weeks). New PermaNet2.0 LLINs were given to households in October 2014. Once per week, the LLIN use status was documented for each individual. A survey was conducted after 110 weeks of LLIN distribution to determine LLIN ownership. A multilevel negative binomial regression model was fitted to identify significant predictors of LLIN use.

Results

At baseline, the LLIN ownership was 100%. After 110 weeks only 233 (8%) of the households owned at least one LLIN. The median proportion of LLIN use per individuals during the study period was only 14%. During the first year (week 1–52) the average LLIN use per individuals was 36% and during the second year (week 53–104) it was 4.6%. More frequent LLIN use was reported among age group [5–14 years (adjusted IRR = 1.13, 95% CI 1.04–1.22), 15–24 years (adjusted IRR = 1.33, 95% CI 1.23–1.45), ≥25 years (adjusted IRR = 1.99, 95% CI 1.83–2.17)] compared to <5 years, and household head educational status [read and write (adjusted IRR = 1.17, 95% CI 1.09–1.26), primary (adjusted IRR = 1.20, 95% CI 1.12–1.27), secondary or above (adjusted IRR = 1.20, 95% CI (1.11–1.30)] compared to illiterate. Having a family size of over five persons (adjusted IRR = 0.78, 95% CI 0.73–0.84) was associated with less frequent use of LLINs compared to a family size of ≤5 persons.

Conclusions

The study showed a low LLIN ownership after 110 weeks and a low LLIN use during 121 weeks of follow-up, despite 100% LLIN coverage at baseline. The study highlights the need to design strategies to increase LLIN ownership and use for setting similar to those studied here.

Reshaping the vector control strategy for malaria elimination in Ethiopia in the context of current evidence and new tools: opportunities and challenges

The core vector control measures, long-lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), reduce the risk of malaria infection by targeting indoor biting mosquitoes. These two interventions are found to be effective in malaria control, but not sufficient to eliminate malaria. The main challenges with LLINs and IRS are insecticide resistance, misuse of the interventions, host behaviour, such as staying out-door during early night or sleeping outdoor without using protective measures, and vector behaviour including feeding on bovine blood, outdoor biting and outdoor resting. Therefore, for complete interruption of malaria transmission in a defined area there is a need to consider a variety of interventions that can help prevent out-door as well as indoor malaria transmission. In Ethiopia, to achieve the malaria elimination goal, a mix of vector control tools, such as intensifying the use of LLINs and IRS, and supplemented by use of ivermectin administration, zooprophylaxis, odour-baited mosquito trapping, improving housing and larva control measures tailored to the local situation of malaria transmission, may be needed.

Cost-effectiveness of a combined intervention of long lasting insecticidal nets and indoor residual spraying compared with each intervention alone for malaria prevention in Ethiopia

Background

The effectiveness of long lasting insecticidal nets (LLINs) and indoor residual spraying (IRS), for malaria prevention, have been established in several studies. However, the available evidence about the additional resources required for a combined implementation (LLIN + IRS) with respect to the added protection afforded is limited. Therefore, the aim of this study was to compare the cost-effectiveness of combined implementation of LLINs and IRS, compared with LLINs alone, IRS alone, and routine practice in Ethiopia.

Methods

The study was performed alongside a cluster randomized controlled trial of malaria prevention conducted in Adami Tullu district, in Ethiopia, from 2014 to 2016. In addition, literature-based cost-effectiveness analysis—using effectiveness information from a systematic review of published articles was conducted. Costing of the interventions were done from the providers’ perspective. The health-effect was measured using disability adjusted life years (DALYs) averted, and combined with cost information using a Markov life-cycle model. In the base-case analysis, health-effects were based on the current trial, and in addition, a scenario analysis was performed based on a literature survey.

Results

The current trial-based analysis showed that routine practice is not less effective and therefore dominates both the combined intervention and singleton intervention due to lower costs. The literature-based analysis had shown that combined intervention had an incremental cost-effectiveness ratio of USD 1403 per DALY averted, and USD 207 per DALY averted was estimated for LLIN alone. In order for the ICER for the combined intervention to be within a range of 1 GDP per capita per DALY averted, the annual malaria incidence in the area should be at least 13%, and the protective-effectiveness of combined implementation should be at least 53%.

Conclusions

Based on the current trial-based analysis, LLINs and IRS are not cost-effective compared to routine practice. However, based on the literature-based analysis, LLIN alone is likely to be cost-effective compared to 3 times GDP per capita per DALY averted. The annual malaria probability and protective-effectiveness of combined intervention are key determinants of the cost-effectiveness of the interventions.

Trial registration PACTR201411000882128 (Registered 8 September 2014). http://www.pactr.org/ATMWeb/appmanager/atm/atmregistry?dar=true&tNo=PACTR201411000882128

Reducing stillbirths in Ethiopia: Results of an intervention programme

Previous studies from South Ethiopia have shown that interventions that focus on intrapartum care substantially reduce maternal mortality and there is a need to operationalize health packages that could reduce stillbirths. The aim of this paper is to evaluate if a programme that aimed to improve maternal health, and mainly focusing on strengthening intrapartum care, also would reduce the number of stillbirths, and to estimate if there are other indicators that explains high stillbirth rates. Our study used a "continuum of care" approach and focussed on providing essential antenatal and obstetric services in communities through health extension workers, at antenatal and health facility services. In this follow up study, which includes the same 38.312 births registered by community health workers, shows that interventions focusing on improved intrapartum care can also reduce stillbirths (by 46%; from 14.5 to 7.8 per 1000 births). Other risk factors for stillbirths are mainly related to complications during delivery and illnesses during pregnancy. We show that focusing on Comprehensive Emergency Obstetric Care and antenatal services reduces stillbirths. However, the study also underlines that illnesses during pregnancy and complications during delivery still represent the main risk factors for stillbirths. This indicates that obstetric care need still to be strengthened, should include the continuum of care from home to the health facility, make care accessible to all, and reduce delays.

Exploring the impact of house screening intervention on entomological indices and incidence of malaria in Arba Minch town, southwest Ethiopia: A randomized control trial

House is the major site for malaria infection where most human-vector contact takes place. Hence, improving housing might reduce the risk of malaria infection by limiting house entry of vectors. This study aimed to explore the impact of screening doors and windows with wire meshes on density and entomological inoculation rate (EIR) of malaria vector, and malaria incidence, and assess the acceptability, durability, and cost of the intervention. The susceptibility status of malaria vector was also assessed. A two-arm randomized trial was done in Arba Minch Town, southwest Ethiopia. 92 houses were randomly included in the trial. The baseline entomological and malaria prevalence data were collected. The mosquito sampling was done twice per household per month by Centers for Diseases Control and Prevention (CDC) light traps for six months. The baseline prevalence of malaria was assessed by testing 396 (83% of the 447 study participants) household members in all the eligible houses. The 92 houses were then randomized into control and intervention groups using mosquito and malaria prevalence baseline data to make the two groups comparable except the intervention. Then, we put wire-mesh on doors and windows of 46 houses. Post-screening mosquito collection was done in each household twice per month for three months. Each household member was visited twice per month for six months to assess malaria episodes. The frequency of damage to different structure of screening was measured twice. In-depth interview was conducted with 24 purposely selected household heads from intervention group. Speciation of Anopheles mosquito was done by morphological key, and the circum-sporozoite proteins (CSPs) analysis was done using enzyme-linked immunosorbent assay. A generalized estimating equation with a negative binomial distribution was used to assess the impact of the intervention on the indoor density of vectors. Clinical malaria case data were analyzed using Poisson regression with generalized linear model. Screening doors and windows reduced the indoor density of An. arabiensis by 48% (mean ratio of intervention to control = 0.85/1.65; 0.52) (P = .001). Plasmodium falciparum CSP rate was 1.6% (3/190) in the intervention houses, while it was 2.7% (10/372) in the control houses. The protective efficacy of screening intervention from CSP positive An. arabiensis was 41% (mean ratio of intervention to control = 1.6/2.7; 0.59), but was not statistically significant (P = .6). The EIR of An. arabiensis was 1.91 in the intervention group, whereas it was 6.45 in the control group. 477 participants were followed for clinical malaria (50.1% from intervention and 49.9% from the control group). Of 49 RDT positive cases, 45 were confirmed to be positive with microscopy. 80% (n = 36) cases were due to P. falciparum and the rest 20% (n = 9) were due to P. vivax. The incidence of P. falciparum in the intervention group was lower (IRR: 0.39, 95% CI: 0.2-0.80; P = .01) than in the control group. Using incidence of P. falciparum infection, the protective efficacy of intervention was 61% (95% CI: 18-83; P = .007). 97.9% of screened windows and 63.8% of screened doors were intact after eleven months of installation. Malaria mosquito was resistance (mortality rate of 75%) to the insecticide used for bed nets treatment. Almost all participants of intervention arm were willing to continue using screened doors and windows. Screening doors and windows reduced the indoor exposure to malaria vectors. The intervention is effective, durable and well-accepted. Hence, the existing interventions can be supplemented with house screening intervention for further reduction and ultimately elimination of malaria by reducing insecticide pressure on malaria vectors. However, further research could be considered in broad setting on different housing improvement and in the way how to scale-up for wider community.

Long-term outcome of smear-positive tuberculosis patients after initiation and completion of treatment: A ten-year retrospective cohort study

BACKGROUND

The status of tuberculosis (TB) patients since initiation of treatment is unknown in South Ethiopia. The objective of this study was to assess the long-term outcomes of smear-positive TB patients since initiation and completion of treatment, which includes TB recurrence and mortality of TB patients.

METHODS

We did a retrospective cohort study on 2,272 smear-positive TB patients who initiated treatment for TB from September 1, 2002-October 10, 2012 in health facilities in Dale district and Yirgalem town administration. We followed them from the date of start of treatment to either the date of interview or date of death.

RESULTS

Recurrence rate of TB was 15.2 per 1000 person-years. Recurrence was higher for re-treatment cases (adjusted hazard ratio (aHR), 2.7; 95% CI, 1.4-5.3). Mortality rate of TB patients was 27.1 per 1,000 person-years. The risk was high for patients above 34 years of age (aHR, 2.1; 95% CI, 1.2-3.9), poor patients (aHR, 1.3; 95% CI, 1.0-1.8), patients with poor treatment outcomes (aHR, 6.7; 95% CI, 5.1-8.9) and for patients treated at least 3 times (aHR 4.8; 95% CI, 2.1-11.1). The excess mortality occurred among patients aged above 34 years was high (41.2/1000 person years).

CONCLUSION

High TB recurrence and death of TB patients was observed among our study participants. Follow-up of TB patients with the risk factors and managing them could reduce the TB burden.

A qualitative study of use of long-lasting insecticidal nets (LLINs) for intended and unintended purposes in Adami Tullu, East Shewa Zone, Ethiopia

Background

Malaria poses a significant public health threat globally, across Africa and in Ethiopia. The use of long-lasting insecticidal nets (LLINs) is currently a proven prevention mechanism. Evidence is building on what happens to LLINs following mass distribution campaigns, with mixed results from different studies, some reporting very low use for intended purposes, others an encouraging level of using for intended purposes. In Ethiopia, between 2005 and 2015, about 64 million LLINs were distributed through periodic mass campaigns with the aims to achieve 100% coverage and 80% utilization. However, studies from rural Ethiopia showed variable LLINs coverage and utilization rate. The MalTrial Project, a collaborative venture between Hawassa University, Ethiopia and NROAID, Norway, has started a trial project in 2014 in Adami Tullu District of central Ethiopia. Quantitative surveys have established evidence on LLINs ownership and utilization, but the behavioural, sociocultural and socioeconomic dynamics of why LLINs’ use for intended purposes is low or why they are employed for other purposes remained elusive. The present qualitative study, building on the quantitative findings and framework, therefore, attempted to fill gaps in these areas using qualitative methods in selected localities of the district.

Methods

The study employed 7 focus groups, 16 individual interviews and observation to undertake data collection in January 2017. The data were analysed using NVivo Version 11 (QSR International) to transcribe, code and identify themes using thematic analysis approach.

Results

The study found out that certain households were more likely to use nets for intended needs in proper ways; a range of factors, notably socio-cultural and poverty, highly influence users’ ideas about the right ways and decisions to use and care for the nets; knowledge gaps and wrong perception exist regarding the purposes and life cycle of the nets; LLINs are employed for repurposed uses once they are considered non-viable, old, or lose their physical integrity; existence of misuse was acknowledged and understood as wrong; and values about gender roles further shape uses, misuses and repurposed use of the nets.

Conclusions

Behavioural, socio-cultural, economic and ecological conditions coupled with deficiencies in perceived bed net design and distribution policies; weak education, communication and social support structures were important in understanding and accounting for why a low level of intended use and a rampant misuse and repurposed use in Adami Tullu community of Ethiopia. A major nexus to address in order to improve intended use of LLINs lies, first and foremost, in economic poverty and socio-cultural factors that underlie much of the misuse and repurposed use of the nets.