The association between urban greenspace and psychological health among young adults in Addis Ababa, Ethiopia

INTRODUCTION

Psychological disorders are emerging as health priorities in Sub-Saharan Africa, specifically Ethiopia. Urban greenspace - parks, trees, and other vegetation integrated into urban form - may facilitate population psychological health, but is largely understudied outside high-income countries. We explore greenspace in relation to psychological health among young adults in Addis Ababa, Ethiopia.

METHOD

Greenspace exposure was calculated using the normalized difference vegetation index (NDVI) derived from publicly available satellite imagery (2018-2019). We used tests of spatial clustering to characterize greenspace distribution. Derived NDVI values were linked to Positive Outcomes for Orphans study participants to explore cross-sectional associations between greenspace exposure and psychological health (measured 2019-2021). Two continuous scores of psychological health were examined: total difficulties from the Strengths and Difficulties Questionnaire and depressive symptoms from the 8-item Patient Health Questionnaire. Multilevel generalized linear regression, nested by administrative units, was used to estimate the association between greenspace and psychological health. We also explored effect modification by gender and having income.

RESULTS

We found greenspace is spatially clustered in Addis Ababa, with high greenspace density in the northeast region and low greenspace density in the center of the city. Our findings suggest residing in greener areas is associated with fewer emotional and behavioral difficulties (β = -1.89; 95% CI: -3.50, -0.29), but not significantly associated with depressive symptomology (β = -0.61; 95% CI: -2.33, 1.11). We observed stronger associations between greenspace and total difficulties among those reporting any income and among males, and for the association between greenspace and depression symptomology among males.

CONCLUSION

We offer initial exploration into the role of greenspace in psychological well-being in Addis Ababa, with potential implications for urban communities across Sub-Saharan Africa. Further research should continue to explore how the built and natural environment could be leveraged in similar settings to promote population psychological health.

Socioeconomic inequalities in child growth failure in Ethiopia: findings from the 2000 and 2016 Demographic and Health Surveys

OBJECTIVE

Socioeconomic inequalities in child growth failure (CGF) remain one of the main challenges in Ethiopia. This study examined socioeconomic inequalities in CGF and determinants that contributed to these inequalities in Ethiopia.

METHODS

The Ethiopia Demographic and Health Surveys 2000 and 2016 data were used in this study. A pooled unweighted sample of the two surveys yielded 21514 mother-child pairs (10873 in 2000 and 10641 in 2016). We assessed socioeconomic inequalities in CGF indicators using the concentration curve and concentration index (CI). We then decomposed the CI to identify percentage contribution of each determinant to inequalities.

RESULTS

Socioeconomic inequalities in CGF have increased in Ethiopia between 2000 and 2016. The CI increased from -0.072 and -0.139 for stunting, -0.088 and -0.131 for underweight and -0.015 and -0.050 for wasting between 2000 and 2016, respectively. Factors that mainly contributed to inequalities in stunting included geographical region (49.43%), number of antenatal care visits (31.40%) and child age in months (22.20%) in 2000. While in 2016, inequality in stunting was contributed mainly by wealth quintile (46.16%) and geographical region (-13.70%). The main contributors to inequality in underweight were geographical regions (82.21%) and wealth quintile (27.21%) in 2000, while in 2016, wealth quintile (29.18%), handwashing (18.59%) and access to improved water facilities (-17.55%) were the main contributors. Inequality in wasting was mainly contributed to by maternal body mass index (-66.07%), wealth quintile (-45.68%), geographical region (36.88%) and paternal education (33.55%) in 2000, while in 2016, wealth quintile (52.87%) and urban areas of residence (-17.81%) were the main driving factors.

CONCLUSIONS

This study identified substantial socioeconomic inequalities in CGF, and factors that relatively contributed to the disparities. A plausible approach to tackling rising disparities may involve developing interventions on the identified predictors and prioritising actions for the most socioeconomically disadvantaged groups.

Trends in child growth failure among children under five years of age in Ethiopia: Evidence from the 2000 to 2016 Demographic and Health Surveys

INTRODUCTION

In a majority of low- and middle-income countries (LMICs), levels of child growth failure (CGF) have steadily declined since 2000. However, some countries show a different trend. Despite continued investment from the government of Ethiopia as well as donors, CGF levels are still high in Ethiopia. This study aimed to assess trends in CGF and associated sociodemographic, economic and water, sanitation, and hygiene (WASH) factors from 2000 to 2016 in Ethiopia.

METHODS

Data were taken from four rounds of the Ethiopia Demographic and Health Survey (EDHS). Children aged between 0 to 59 months were included. CGF indicators were categorised based on height-for-age z-score (HAZ) < -2 Standard deviation (SD), weight-for-age z-score (WAZ) < -2 SD and weight-for-height z-score (WHZ) < -2 SD. CGF trends were estimated for predicted probabilities and odds ratios (ORs) between 2000 and 2016.

RESULTS

A total sample size of 31978 for HAZ, 32045 for WAZ and 32246 for WHZ were included in the current study. Stunting decreased from an adjusted odds ratio (AOR) = 0.77 (95% CI: 0.67 to 0.88) in 2005 to an AOR = 0.45 (95% CI: 0.39 to 0.53) in 2016 compared with the year 2000. Compared with data in 2000, underweight decreased from an AOR of 0.70 (95% CI: 0.61 to 0.80) in 2005 to an AOR of 0.43 (95% CI: 0.36 to 0.50) in 2016. Wasting declined from an AOR of 0.91 (95% CI: 0.75 to 1.10) in 2005 to an AOR of 0.76 (95% CI: 0.61 to 0.94) in 2016, compared with data in 2000.

CONCLUSIONS

Between 2000 to 2016, there was a decline in CGF levels albeit the levels are still relatively high compared with the World Health Organization (WHO) cut-off levels for public health concern. Observed rates of change varied across sociodemographic, economic and WASH factors which suggest that interventions tailored towards addressing the imbalances across those factors are required.

The effect of access to water, sanitation and handwashing facilities on child growth indicators: Evidence from the Ethiopia Demographic and Health Survey 2016

INTRODUCTION

Poor access to water, sanitation, and handwashing (WASH) facilities frequently contribute to child growth failure. The role of access to WASH facilities on child growth outcomes in Ethiopia is largely unknown. The aim of this study was to determine individual and combined effects of access to WASH facilities on child growth outcomes.

METHODS

Data for this analysis was sourced from the recent Ethiopia Demographic and Health Survey (EDHS) 2016. A multivariable logistic regression model was applied to identify the separate and combined association of access to WASH facilities with child growth outcomes. Odds ratio (OR) and 95% confidence interval (CI) were estimated. Statistical significance was declared at p < 0.05.

RESULTS

Included in the analyses were data for children 0-59 months of age, which amounted to valid data for 9588 children with a height-for-age z-score (HAZ), 9752 children with a weight-for-age z-score (WAZ) and 9607 children with a weight-for-height z-score (WHZ). Children with access to improved combined sanitation with handwashing facilities had 29% lower odds of linear growth failure (stunting) (adjusted odds ratio (AOR) = 0.71; 95% CI: 0.51-0.99) compared with those with unimproved. Children with access to combined improved WASH facilities were 33% less likely to have linear growth failure (AOR = 0.67; 95% CI: 0.45-0.98). Access to improved handwashing alone reduced the odds of being underweight by 17% (AOR = 0.83; 95% CI: 0.71-0.98) compared with unimproved. Improved water and sanitation separately as well as combined WASH were not associated with decreased odds of underweight and wasting.

CONCLUSIONS

Combined access to improved water, sanitation and handwashing was associated with reduced child linear growth failure. Further research with robust methods is needed to examine whether combined WASH practices have synergistic effect on child growth outcomes.

Effect of water, sanitation and hygiene interventions alone and combined with nutrition on child growth in low and middle income countries: a systematic review and meta-analysis

OBJECTIVE

This study aimed to provide clarification on the benefits of water, sanitation and hygiene (WASH) alone separately and combined with nutrition in improving child growth outcomes.

DESIGN

Systematic review and meta-analysis.

METHODS

We conducted a systematic review using the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. PubMed, MEDLINE, EMBASE, Scopus, Cochrane Library, Web of Science and Science Direct were searched in May 2018 and last updated in April 2019. We included studies that reported WASH interventions alone separately or combined with nutrition. Fixed and random-effects models were used to estimate pooled effect in mean difference (MD). Heterogeneity and publication bias statistics were performed.

RESULTS

A total of 18 studies were included: 13 cluster randomised controlled trials (RCTs) and 5 non-randomised controlled trials (non-RCTs). Non-RCTs showed effect of WASH interventions alone on height-for-age z-score (HAZ) (MD=0.14; 95% CI 0.08 to 0.21) but RCTs did not. WASH alone of non-RCTs and RCTs that were delivered over 18-60 months indicated an effect on HAZ (MD=0.04; 95% CI 0.01 to 0.08). RCTs showed an effect for children <2 years (MD=0.07; 95% CI 0.01 to 0.13). Non-RCTs of WASH alone and those that included at least two components, improved HAZ (MD=0.15; 95% CI 0.07 to 0.23) but RCTs did not. WASH alone of non-RCTs and RCTs separately or together showed no effect on weight-for-age z-score (WAZ) and weight-for-height z-score (WHZ). Combined WASH with nutrition showed an effect on HAZ (MD=0.13; 95% CI 0.08 to 0.17) and on WAZ (MD=0.09; 95% CI 0.05 to 0.13) and was borderline on WHZ.

CONCLUSIONS

WASH interventions alone improved HAZ when delivered over 18-60 months and for children <2 years. Combined WASH with nutrition showed a strong effect on HAZ and WAZ and a borderline effect on WHZ. Integrated WASH with nutrition interventions may be effective inimproving child growth outcomes.

National mortality burden due to communicable, non-communicable, and other diseases in Ethiopia, 1990-2015: findings from the Global Burden of Disease Study 2015

BACKGROUND

Ethiopia lacks a complete vital registration system that would assist in measuring disease burden and risk factors. We used the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) estimates to describe the mortality burden from communicable, non-communicable, and other diseases in Ethiopia over the last 25 years.

METHODS

GBD 2015 mainly used cause of death ensemble modeling to measure causes of death by age, sex, and year for 195 countries. We report numbers of deaths and rates of years of life lost (YLL) for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases (NCDs), and injuries with 95% uncertainty intervals (UI) for Ethiopia from 1990 to 2015.

RESULTS

CMNN causes of death have declined by 65% in the last two-and-a-half decades. Injury-related causes of death have also decreased by 70%. Deaths due to NCDs declined by 37% during the same period. Ethiopia showed a faster decline in the burden of four out of the five leading causes of age-standardized premature mortality rates when compared to the overall sub-Saharan African region and the Eastern sub-Saharan African region: lower respiratory infections, tuberculosis, HIV/AIDS, and diarrheal diseases; however, the same could not be said for ischemic heart disease and other NCDs. Non-communicable diseases, together, were the leading causes of age-standardized mortality rates, whereas CMNN diseases were leading causes of premature mortality in 2015. Although lower respiratory infections, tuberculosis, and diarrheal disease were the leading causes of age-standardized death rates, they showed major declines from 1990 to 2015. Neonatal encephalopathy, iron-deficiency anemia, protein-energy malnutrition, and preterm birth complications also showed more than a 50% reduction in burden. HIV/AIDS-related deaths have also decreased by 70% since 2005. Ischemic heart disease, hemorrhagic stroke, and ischemic stroke were among the top causes of premature mortality and age-standardized death rates in Ethiopia in 2015.

CONCLUSIONS

Ethiopia has been successful in reducing deaths related to communicable, maternal, neonatal, and nutritional deficiency diseases and injuries by 65%, despite unacceptably high maternal and neonatal mortality rates. However, the country's performance regarding non-communicable diseases, including cardiovascular disease, diabetes, cancer, and chronic respiratory disease, was minimal, causing these diseases to join the leading causes of premature mortality and death rates in 2015. While the country is progressing toward universal health coverage, prevention and control strategies in Ethiopia should consider the double burden of common infectious diseases and non-communicable diseases: lower respiratory infections, diarrhea, tuberculosis, HIV/AIDS, cardiovascular disease, cancer, and diabetes. Prevention and control strategies should also pay special attention to the leading causes of premature mortality and death rates caused by non-communicable diseases: cardiovascular disease, cancer, and diabetes. Measuring further progress requires a data revolution in generating, managing, analyzing, and using data for decision-making and the creation of a full vital registration system in the country.

National disability-adjusted life years (DALYs) for 257 diseases and injuries in Ethiopia, 1990-2015: findings from the global burden of disease study 2015

BACKGROUND

Disability-adjusted life years (DALYs) provide a summary measure of health and can be a critical input to guide health systems, investments, and priority-setting in Ethiopia. We aimed to determine the leading causes of premature mortality and disability using DALYs and describe the relative burden of disease and injuries in Ethiopia.

METHODS

We used results from the Global Burden of Diseases, Injuries, and Risk Factors Study 2015 (GBD 2015) for non-fatal disease burden, cause-specific mortality, and all-cause mortality to derive age-standardized DALYs by sex for Ethiopia for each year. We calculated DALYs by summing years of life lost due to premature mortality (YLLs) and years lived with disability (YLDs) for each age group and sex. Causes of death by age, sex, and year were measured mainly using Causes of Death Ensemble modeling. To estimate YLDs, a Bayesian meta-regression method was used. We reported DALY rates per 100,000 for communicable, maternal, neonatal, and nutritional (CMNN) disorders, non-communicable diseases, and injuries, with 95% uncertainty intervals (UI) for Ethiopia.

RESULTS

Non-communicable diseases caused 23,118.1 (95% UI, 17,124.4-30,579.6), CMNN disorders resulted in 20,200.7 (95% UI, 16,532.2-24,917.9), and injuries caused 3781 (95% UI, 2642.9-5500.6) age-standardized DALYs per 100,000 in Ethiopia in 2015. Lower respiratory infections, diarrheal diseases, and tuberculosis were the top three leading causes of DALYs in 2015, accounting for 2998 (95% UI, 2173.7-4029), 2592.5 (95% UI, 1850.7-3495.1), and 2562.9 (95% UI, 1466.1-4220.7) DALYs per 100,000, respectively. Ischemic heart disease and cerebrovascular disease were the fourth and fifth leading causes of age-standardized DALYs, with rates of 2535.7 (95% UI, 1603.7-3843.2) and 2159.9 (95% UI, 1369.7-3216.3) per 100,000, respectively. The following causes showed a reduction of 60% or more over the last 25 years: lower respiratory infections, diarrheal diseases, tuberculosis, neonatal encephalopathy, preterm birth complications, meningitis, malaria, protein-energy malnutrition, iron-deficiency anemia, measles, war and legal intervention, and maternal hemorrhage.

CONCLUSIONS

Ethiopia has been successful in reducing age-standardized DALYs related to most communicable, maternal, neonatal, and nutritional deficiency diseases in the last 25 years, causing a major ranking shift to types of non-communicable disease. Lower respiratory infections, diarrheal disease, and tuberculosis continue to be leading causes of premature death, despite major declines in burden. Non-communicable diseases also showed reductions as premature mortality declined; however, disability outcomes for these causes did not show declines. Recently developed non-communicable disease strategies may need to be amended to focus on cardiovascular diseases, cancer, diabetes, and major depressive disorders. Increasing trends of disabilities due to neonatal encephalopathy, preterm birth complications, and neonatal disorders should be emphasized in the national newborn survival strategy. Generating quality data should be a priority through the development of new initiatives such as vital events registration, surveillance programs, and surveys to address gaps in data. Measuring disease burden at subnational regional state levels and identifying variations with urban and rural population health should be conducted to support health policy in Ethiopia.

Global Burden of Hypertension and Systolic Blood Pressure of at Least 110 to 115 mm Hg, 1990-2015

IMPORTANCE

Elevated systolic blood (SBP) pressure is a leading global health risk. Quantifying the levels of SBP is important to guide prevention policies and interventions.

OBJECTIVE

To estimate the association between SBP of at least 110 to 115 mm Hg and SBP of 140 mm Hg or higher and the burden of different causes of death and disability by age and sex for 195 countries and territories, 1990-2015.

DESIGN

A comparative risk assessment of health loss related to SBP. Estimated distribution of SBP was based on 844 studies from 154 countries (published 1980-2015) of 8.69 million participants. Spatiotemporal Gaussian process regression was used to generate estimates of mean SBP and adjusted variance for each age, sex, country, and year. Diseases with sufficient evidence for a causal relationship with high SBP (eg, ischemic heart disease, ischemic stroke, and hemorrhagic stroke) were included in the primary analysis.

MAIN OUTCOMES AND MEASURES

Mean SBP level, cause-specific deaths, and health burden related to SBP (≥110-115 mm Hg and also ≥140 mm Hg) by age, sex, country, and year.

RESULTS

Between 1990-2015, the rate of SBP of at least 110 to 115 mm Hg increased from 73 119 (95% uncertainty interval [UI], 67 949-78 241) to 81 373 (95% UI, 76 814-85 770) per 100 000, and SBP of 140 mm Hg or higher increased from 17 307 (95% UI, 17 117-17 492) to 20 526 (95% UI, 20 283-20 746) per 100 000. The estimated annual death rate per 100 000 associated with SBP of at least 110 to 115 mm Hg increased from 135.6 (95% UI, 122.4-148.1) to 145.2 (95% UI 130.3-159.9) and the rate for SBP of 140 mm Hg or higher increased from 97.9 (95% UI, 87.5-108.1) to 106.3 (95% UI, 94.6-118.1). For loss of DALYs associated with systolic blood pressure of 140 mm Hg or higher, the loss increased from 95.9 million (95% uncertainty interval [UI], 87.0-104.9 million) to 143.0 million (95% UI, 130.2-157.0 million) [corrected], and for SBP of 140 mm Hg or higher, the loss increased from 5.2 million (95% UI, 4.6-5.7 million) to 7.8 million (95% UI, 7.0-8.7 million). The largest numbers of SBP-related deaths were caused by ischemic heart disease (4.9 million [95% UI, 4.0-5.7 million]; 54.5%), hemorrhagic stroke (2.0 million [95% UI, 1.6-2.3 million]; 58.3%), and ischemic stroke (1.5 million [95% UI, 1.2-1.8 million]; 50.0%). In 2015, China, India, Russia, Indonesia, and the United States accounted for more than half of the global DALYs related to SBP of at least 110 to 115 mm Hg.

CONCLUSIONS AND RELEVANCE

In international surveys, although there is uncertainty in some estimates, the rate of elevated SBP (≥110-115 and ≥140 mm Hg) increased substantially between 1990 and 2015, and DALYs and deaths associated with elevated SBP also increased. Projections based on this sample suggest that in 2015, an estimated 3.5 billion adults had SBP of at least 110 to 115 mm Hg and 874 million adults had SBP of 140 mm Hg or higher.

The impact of dietary risk factors on the burden of non-communicable diseases in Ethiopia: findings from the Global Burden of Disease study 2013

Background

The burden of non-communicable diseases (NCDs) has increased in sub-Saharan countries, including Ethiopia. The contribution of dietary behaviours to the NCD burden in Ethiopia has not been evaluated. This study, therefore, aimed to assess diet-related burden of disease in Ethiopia between 1990 and 2013.

Method

We used the 2013 Global Burden of Disease (GBD) data to estimate deaths, years of life lost (YLLs) and disability-adjusted life years (DALYs) related to eight food types, five nutrients and fibre intake. Dietary exposure was estimated using a Bayesian hierarchical meta-regression. The effect size of each diet-disease pair was obtained based on meta-analyses of prospective observational studies and randomized controlled trials. A comparative risk assessment approach was used to quantify the proportion of NCD burden associated with dietary risk factors.

Results

In 2013, dietary factors were responsible for 60,402 deaths (95% Uncertainty Interval [UI]: 44,943-74,898) in Ethiopia—almost a quarter (23.0%) of all NCD deaths. Nearly nine in every ten diet-related deaths (88.0%) were from cardiovascular diseases (CVD) and 44.0% of all CVD deaths were related to poor diet. Suboptimal diet accounted for 1,353,407 DALYs (95% UI: 1,010,433-1,672,828) and 1,291,703 YLLs (95% UI: 961,915-1,599,985). Low intake of fruits and vegetables and high intake of sodium were the most important dietary factors. The proportion of NCD deaths associated with low fruit consumption slightly increased (11.3% in 1990 and 11.9% in 2013). In these years, the rate of burden of disease related to poor diet slightly decreased; however, their contribution to NCDs remained stable.

Conclusions

Dietary behaviour contributes significantly to the NCD burden in Ethiopia. Intakes of diet low in fruits and vegetables and high in sodium are the leading dietary risks. To effectively mitigate the oncoming NCD burden in Ethiopia, multisectoral interventions are required; and nutrition policies and dietary guidelines should be developed.

Electronic supplementary material

The online version of this article (doi:10.1186/s12966-016-0447-x) contains supplementary material, which is available to authorized users.

Burden of Diarrhea in the Eastern Mediterranean Region, 1990-2013: Findings from the Global Burden of Disease Study 2013

Diarrheal diseases (DD) are leading causes of disease burden, death, and disability, especially in children in low-income settings. DD can also impact a child's potential livelihood through stunted physical growth, cognitive impairment, and other sequelae. As part of the Global Burden of Disease Study, we estimated DD burden, and the burden attributable to specific risk factors and particular etiologies, in the Eastern Mediterranean Region (EMR) between 1990 and 2013. For both sexes and all ages, we calculated disability-adjusted life years (DALYs), which are the sum of years of life lost and years lived with disability. We estimate that over 125,000 deaths (3.6% of total deaths) were due to DD in the EMR in 2013, with a greater burden of DD in low- and middle-income countries. Diarrhea deaths per 100,000 children under 5 years of age ranged from one (95% uncertainty interval [UI] = 0-1) in Bahrain and Oman to 471 (95% UI = 245-763) in Somalia. The pattern for diarrhea DALYs among those under 5 years of age closely followed that for diarrheal deaths. DALYs per 100,000 ranged from 739 (95% UI = 520-989) in Syria to 40,869 (95% UI = 21,540-65,823) in Somalia. Our results highlighted a highly inequitable burden of DD in EMR, mainly driven by the lack of access to proper resources such as water and sanitation. Our findings will guide preventive and treatment interventions which are based on evidence and which follow the ultimate goal of reducing the DD burden.

Global, regional, and national comparative risk assessment of 79 behavioural, environmental and occupational, and metabolic risks or clusters of risks in 188 countries, 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Global Burden of Disease, Injuries, and Risk Factor study 2013 (GBD 2013) is the first of a series of annual updates of the GBD. Risk factor quantification, particularly of modifiable risk factors, can help to identify emerging threats to population health and opportunities for prevention. The GBD 2013 provides a timely opportunity to update the comparative risk assessment with new data for exposure, relative risks, and evidence on the appropriate counterfactual risk distribution.

METHODS

Attributable deaths, years of life lost, years lived with disability, and disability-adjusted life-years (DALYs) have been estimated for 79 risks or clusters of risks using the GBD 2010 methods. Risk-outcome pairs meeting explicit evidence criteria were assessed for 188 countries for the period 1990-2013 by age and sex using three inputs: risk exposure, relative risks, and the theoretical minimum risk exposure level (TMREL). Risks are organised into a hierarchy with blocks of behavioural, environmental and occupational, and metabolic risks at the first level of the hierarchy. The next level in the hierarchy includes nine clusters of related risks and two individual risks, with more detail provided at levels 3 and 4 of the hierarchy. Compared with GBD 2010, six new risk factors have been added: handwashing practices, occupational exposure to trichloroethylene, childhood wasting, childhood stunting, unsafe sex, and low glomerular filtration rate. For most risks, data for exposure were synthesised with a Bayesian meta-regression method, DisMod-MR 2.0, or spatial-temporal Gaussian process regression. Relative risks were based on meta-regressions of published cohort and intervention studies. Attributable burden for clusters of risks and all risks combined took into account evidence on the mediation of some risks such as high body-mass index (BMI) through other risks such as high systolic blood pressure and high cholesterol.

FINDINGS

All risks combined account for 57·2% (95% uncertainty interval [UI] 55·8-58·5) of deaths and 41·6% (40·1-43·0) of DALYs. Risks quantified account for 87·9% (86·5-89·3) of cardiovascular disease DALYs, ranging to a low of 0% for neonatal disorders and neglected tropical diseases and malaria. In terms of global DALYs in 2013, six risks or clusters of risks each caused more than 5% of DALYs: dietary risks accounting for 11·3 million deaths and 241·4 million DALYs, high systolic blood pressure for 10·4 million deaths and 208·1 million DALYs, child and maternal malnutrition for 1·7 million deaths and 176·9 million DALYs, tobacco smoke for 6·1 million deaths and 143·5 million DALYs, air pollution for 5·5 million deaths and 141·5 million DALYs, and high BMI for 4·4 million deaths and 134·0 million DALYs. Risk factor patterns vary across regions and countries and with time. In sub-Saharan Africa, the leading risk factors are child and maternal malnutrition, unsafe sex, and unsafe water, sanitation, and handwashing. In women, in nearly all countries in the Americas, north Africa, and the Middle East, and in many other high-income countries, high BMI is the leading risk factor, with high systolic blood pressure as the leading risk in most of Central and Eastern Europe and south and east Asia. For men, high systolic blood pressure or tobacco use are the leading risks in nearly all high-income countries, in north Africa and the Middle East, Europe, and Asia. For men and women, unsafe sex is the leading risk in a corridor from Kenya to South Africa.

INTERPRETATION

Behavioural, environmental and occupational, and metabolic risks can explain half of global mortality and more than one-third of global DALYs providing many opportunities for prevention. Of the larger risks, the attributable burden of high BMI has increased in the past 23 years. In view of the prominence of behavioural risk factors, behavioural and social science research on interventions for these risks should be strengthened. Many prevention and primary care policy options are available now to act on key risks.

FUNDING

Bill & Melinda Gates Foundation.

The global burden of injury: incidence, mortality, disability-adjusted life years and time trends from the Global Burden of Disease study 2013

Background

The Global Burden of Diseases (GBD), Injuries, and Risk Factors study used the disability-adjusted life year (DALY) to quantify the burden of diseases, injuries, and risk factors. This paper provides an overview of injury estimates from the 2013 update of GBD, with detailed information on incidence, mortality, DALYs and rates of change from 1990 to 2013 for 26 causes of injury, globally, by region and by country.

Methods

Injury mortality was estimated using the extensive GBD mortality database, corrections for ill-defined cause of death and the cause of death ensemble modelling tool. Morbidity estimation was based on inpatient and outpatient data sets, 26 cause-of-injury and 47 nature-of-injury categories, and seven follow-up studies with patient-reported long-term outcome measures.

Results

In 2013, 973 million (uncertainty interval (UI) 942 to 993) people sustained injuries that warranted some type of healthcare and 4.8 million (UI 4.5 to 5.1) people died from injuries. Between 1990 and 2013 the global age-standardised injury DALY rate decreased by 31% (UI 26% to 35%). The rate of decline in DALY rates was significant for 22 cause-of-injury categories, including all the major injuries.

Conclusions

Injuries continue to be an important cause of morbidity and mortality in the developed and developing world. The decline in rates for almost all injuries is so prominent that it warrants a general statement that the world is becoming a safer place to live in. However, the patterns vary widely by cause, age, sex, region and time and there are still large improvements that need to be made.

Attitude, reporting behavour and management practice of occupational needle stick and sharps injuries among hospital healthcare workers in Bale zone, Southeast Ethiopia: a cross-sectional study

Background

Although the prevalence of blood borne pathogens in many developing countries is high, documentation of infections due to occupational exposure is limited. Seventy percent of the world’s HIV infected population lives in Sub-Saharan Africa, but only 4 % of cases are reported from this region. Under reporting of needle stick and/or sharps injuries in healthcare facilities was common.

Methods

An institutional based cross-sectional study was conducted in December 2014 among healthcare workers in four hospitals of Bale zone, Southeast Ethiopia. A total of 362 healthcare workers were selected randomly from each of the working departments. Data were collected using self-administered questionnaire and were entered using Epi-Info version 3.5 and analysed using SPSS version 20.0. Multivariable logistic regression analysis was used to identify independent effect of each variable on the reporting behaviour of needle stick and/or sharp injury.

Results

Nearly six out of ten injuries (58.7 %) were not reported to the concerned body. The main reasons for not reporting the injuries were time constraint (35.1 %), sharps which caused injury were not used on any patient (27.0 %), the source patients did not have disease of concern (20.3 %), and lack of knowledge that it should be reported (14.9 %). Half of healthcare workers (HCWs) those who experienced injury had sought medical care next to self based action. Respondents with monthly salary of 450 to 1000 Ethiopian Birr (1 US Dollar = 22.00 Ethiopian Birr) were about six times more likely to report occupational needle stick and/or sharps injury (NSSI) than HCWs with salary of 2001 to 8379 birr (AOR = 5.73). However, HCWs who had no knowledge about probability of infection transmission through NSSI and not taking any self based measures after occurrence of injury were 45 % (AOR = 0.55) and 93 % (AOR = 0.07) less likely to report occupational injury than their counterparts, respectively.

Conclusions

Occupational needle stick and/or sharps injuries are common among HCWs at the study area. Even though majority of respondents were concerned about the risk of NSSI exposure, most respondents did not report it to the concerned body. Therefore, provision of on job training on the risk of occupational NSSI exposure may strengthen HCWs to practice timely reporting and its management in case of occupational injury exposure.

Global, regional, and national disability-adjusted life years (DALYs) for 306 diseases and injuries and healthy life expectancy (HALE) for 188 countries, 1990-2013: quantifying the epidemiological transition

BACKGROUND

The Global Burden of Disease Study 2013 (GBD 2013) aims to bring together all available epidemiological data using a coherent measurement framework, standardised estimation methods, and transparent data sources to enable comparisons of health loss over time and across causes, age-sex groups, and countries. The GBD can be used to generate summary measures such as disability-adjusted life-years (DALYs) and healthy life expectancy (HALE) that make possible comparative assessments of broad epidemiological patterns across countries and time. These summary measures can also be used to quantify the component of variation in epidemiology that is related to sociodemographic development.

METHODS

We used the published GBD 2013 data for age-specific mortality, years of life lost due to premature mortality (YLLs), and years lived with disability (YLDs) to calculate DALYs and HALE for 1990, 1995, 2000, 2005, 2010, and 2013 for 188 countries. We calculated HALE using the Sullivan method; 95% uncertainty intervals (UIs) represent uncertainty in age-specific death rates and YLDs per person for each country, age, sex, and year. We estimated DALYs for 306 causes for each country as the sum of YLLs and YLDs; 95% UIs represent uncertainty in YLL and YLD rates. We quantified patterns of the epidemiological transition with a composite indicator of sociodemographic status, which we constructed from income per person, average years of schooling after age 15 years, and the total fertility rate and mean age of the population. We applied hierarchical regression to DALY rates by cause across countries to decompose variance related to the sociodemographic status variable, country, and time.

FINDINGS

Worldwide, from 1990 to 2013, life expectancy at birth rose by 6·2 years (95% UI 5·6-6·6), from 65·3 years (65·0-65·6) in 1990 to 71·5 years (71·0-71·9) in 2013, HALE at birth rose by 5·4 years (4·9-5·8), from 56·9 years (54·5-59·1) to 62·3 years (59·7-64·8), total DALYs fell by 3·6% (0·3-7·4), and age-standardised DALY rates per 100 000 people fell by 26·7% (24·6-29·1). For communicable, maternal, neonatal, and nutritional disorders, global DALY numbers, crude rates, and age-standardised rates have all declined between 1990 and 2013, whereas for non-communicable diseases, global DALYs have been increasing, DALY rates have remained nearly constant, and age-standardised DALY rates declined during the same period. From 2005 to 2013, the number of DALYs increased for most specific non-communicable diseases, including cardiovascular diseases and neoplasms, in addition to dengue, food-borne trematodes, and leishmaniasis; DALYs decreased for nearly all other causes. By 2013, the five leading causes of DALYs were ischaemic heart disease, lower respiratory infections, cerebrovascular disease, low back and neck pain, and road injuries. Sociodemographic status explained more than 50% of the variance between countries and over time for diarrhoea, lower respiratory infections, and other common infectious diseases; maternal disorders; neonatal disorders; nutritional deficiencies; other communicable, maternal, neonatal, and nutritional diseases; musculoskeletal disorders; and other non-communicable diseases. However, sociodemographic status explained less than 10% of the variance in DALY rates for cardiovascular diseases; chronic respiratory diseases; cirrhosis; diabetes, urogenital, blood, and endocrine diseases; unintentional injuries; and self-harm and interpersonal violence. Predictably, increased sociodemographic status was associated with a shift in burden from YLLs to YLDs, driven by declines in YLLs and increases in YLDs from musculoskeletal disorders, neurological disorders, and mental and substance use disorders. In most country-specific estimates, the increase in life expectancy was greater than that in HALE. Leading causes of DALYs are highly variable across countries.

INTERPRETATION

Global health is improving. Population growth and ageing have driven up numbers of DALYs, but crude rates have remained relatively constant, showing that progress in health does not mean fewer demands on health systems. The notion of an epidemiological transition--in which increasing sociodemographic status brings structured change in disease burden--is useful, but there is tremendous variation in burden of disease that is not associated with sociodemographic status. This further underscores the need for country-specific assessments of DALYs and HALE to appropriately inform health policy decisions and attendant actions.

FUNDING

Bill & Melinda Gates Foundation.

Neurocognitive impairment in a large sample of homeless adults with mental illness

OBJECTIVE

This study examines neurocognitive functioning in a large, well-characterized sample of homeless adults with mental illness and assesses demographic and clinical factors associated with neurocognitive performance.

METHOD

A total of 1500 homeless adults with mental illness enrolled in the At Home Chez Soi study completed neuropsychological measures assessing speed of information processing, memory, and executive functioning. Sociodemographic and clinical data were also collected. Linear regression analyses were conducted to examine factors associated with neurocognitive performance.

RESULTS

Approximately half of our sample met criteria for psychosis, major depressive disorder, and alcohol or substance use disorder, and nearly half had experienced severe traumatic brain injury. Overall, 72% of participants demonstrated cognitive impairment, including deficits in processing speed (48%), verbal learning (71%) and recall (67%), and executive functioning (38%). The overall statistical model explained 19.8% of the variance in the neurocognitive summary score, with reduced neurocognitive performance associated with older age, lower education, first language other than English or French, Black or Other ethnicity, and the presence of psychosis.

CONCLUSION

Homeless adults with mental illness experience impairment in multiple neuropsychological domains. Much of the variance in our sample's cognitive performance remains unexplained, highlighting the need for further research in the mechanisms underlying cognitive impairment in this population.

Global, regional, and national incidence and mortality for HIV, tuberculosis, and malaria during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The Millennium Declaration in 2000 brought special global attention to HIV, tuberculosis, and malaria through the formulation of Millennium Development Goal (MDG) 6. The Global Burden of Disease 2013 study provides a consistent and comprehensive approach to disease estimation for between 1990 and 2013, and an opportunity to assess whether accelerated progress has occured since the Millennium Declaration.

METHODS

To estimate incidence and mortality for HIV, we used the UNAIDS Spectrum model appropriately modified based on a systematic review of available studies of mortality with and without antiretroviral therapy (ART). For concentrated epidemics, we calibrated Spectrum models to fit vital registration data corrected for misclassification of HIV deaths. In generalised epidemics, we minimised a loss function to select epidemic curves most consistent with prevalence data and demographic data for all-cause mortality. We analysed counterfactual scenarios for HIV to assess years of life saved through prevention of mother-to-child transmission (PMTCT) and ART. For tuberculosis, we analysed vital registration and verbal autopsy data to estimate mortality using cause of death ensemble modelling. We analysed data for corrected case-notifications, expert opinions on the case-detection rate, prevalence surveys, and estimated cause-specific mortality using Bayesian meta-regression to generate consistent trends in all parameters. We analysed malaria mortality and incidence using an updated cause of death database, a systematic analysis of verbal autopsy validation studies for malaria, and recent studies (2010-13) of incidence, drug resistance, and coverage of insecticide-treated bednets.

FINDINGS

Globally in 2013, there were 1·8 million new HIV infections (95% uncertainty interval 1·7 million to 2·1 million), 29·2 million prevalent HIV cases (28·1 to 31·7), and 1·3 million HIV deaths (1·3 to 1·5). At the peak of the epidemic in 2005, HIV caused 1·7 million deaths (1·6 million to 1·9 million). Concentrated epidemics in Latin America and eastern Europe are substantially smaller than previously estimated. Through interventions including PMTCT and ART, 19·1 million life-years (16·6 million to 21·5 million) have been saved, 70·3% (65·4 to 76·1) in developing countries. From 2000 to 2011, the ratio of development assistance for health for HIV to years of life saved through intervention was US$4498 in developing countries. Including in HIV-positive individuals, all-form tuberculosis incidence was 7·5 million (7·4 million to 7·7 million), prevalence was 11·9 million (11·6 million to 12·2 million), and number of deaths was 1·4 million (1·3 million to 1·5 million) in 2013. In the same year and in only individuals who were HIV-negative, all-form tuberculosis incidence was 7·1 million (6·9 million to 7·3 million), prevalence was 11·2 million (10·8 million to 11·6 million), and number of deaths was 1·3 million (1·2 million to 1·4 million). Annualised rates of change (ARC) for incidence, prevalence, and death became negative after 2000. Tuberculosis in HIV-negative individuals disproportionately occurs in men and boys (versus women and girls); 64·0% of cases (63·6 to 64·3) and 64·7% of deaths (60·8 to 70·3). Globally, malaria cases and deaths grew rapidly from 1990 reaching a peak of 232 million cases (143 million to 387 million) in 2003 and 1·2 million deaths (1·1 million to 1·4 million) in 2004. Since 2004, child deaths from malaria in sub-Saharan Africa have decreased by 31·5% (15·7 to 44·1). Outside of Africa, malaria mortality has been steadily decreasing since 1990.

INTERPRETATION

Our estimates of the number of people living with HIV are 18·7% smaller than UNAIDS's estimates in 2012. The number of people living with malaria is larger than estimated by WHO. The number of people living with HIV, tuberculosis, or malaria have all decreased since 2000. At the global level, upward trends for malaria and HIV deaths have been reversed and declines in tuberculosis deaths have accelerated. 101 countries (74 of which are developing) still have increasing HIV incidence. Substantial progress since the Millennium Declaration is an encouraging sign of the effect of global action.

FUNDING

Bill & Melinda Gates Foundation.

Global, regional, and national levels of neonatal, infant, and under-5 mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

Remarkable financial and political efforts have been focused on the reduction of child mortality during the past few decades. Timely measurements of levels and trends in under-5 mortality are important to assess progress towards the Millennium Development Goal 4 (MDG 4) target of reduction of child mortality by two thirds from 1990 to 2015, and to identify models of success.

METHODS

We generated updated estimates of child mortality in early neonatal (age 0-6 days), late neonatal (7-28 days), postneonatal (29-364 days), childhood (1-4 years), and under-5 (0-4 years) age groups for 188 countries from 1970 to 2013, with more than 29,000 survey, census, vital registration, and sample registration datapoints. We used Gaussian process regression with adjustments for bias and non-sampling error to synthesise the data for under-5 mortality for each country, and a separate model to estimate mortality for more detailed age groups. We used explanatory mixed effects regression models to assess the association between under-5 mortality and income per person, maternal education, HIV child death rates, secular shifts, and other factors. To quantify the contribution of these different factors and birth numbers to the change in numbers of deaths in under-5 age groups from 1990 to 2013, we used Shapley decomposition. We used estimated rates of change between 2000 and 2013 to construct under-5 mortality rate scenarios out to 2030.

FINDINGS

We estimated that 6·3 million (95% UI 6·0-6·6) children under-5 died in 2013, a 64% reduction from 17·6 million (17·1-18·1) in 1970. In 2013, child mortality rates ranged from 152·5 per 1000 livebirths (130·6-177·4) in Guinea-Bissau to 2·3 (1·8-2·9) per 1000 in Singapore. The annualised rates of change from 1990 to 2013 ranged from -6·8% to 0·1%. 99 of 188 countries, including 43 of 48 countries in sub-Saharan Africa, had faster decreases in child mortality during 2000-13 than during 1990-2000. In 2013, neonatal deaths accounted for 41·6% of under-5 deaths compared with 37·4% in 1990. Compared with 1990, in 2013, rising numbers of births, especially in sub-Saharan Africa, led to 1·4 million more child deaths, and rising income per person and maternal education led to 0·9 million and 2·2 million fewer deaths, respectively. Changes in secular trends led to 4·2 million fewer deaths. Unexplained factors accounted for only -1% of the change in child deaths. In 30 developing countries, decreases since 2000 have been faster than predicted attributable to income, education, and secular shift alone.

INTERPRETATION

Only 27 developing countries are expected to achieve MDG 4. Decreases since 2000 in under-5 mortality rates are accelerating in many developing countries, especially in sub-Saharan Africa. The Millennium Declaration and increased development assistance for health might have been a factor in faster decreases in some developing countries. Without further accelerated progress, many countries in west and central Africa will still have high levels of under-5 mortality in 2030.

FUNDING

Bill & Melinda Gates Foundation, US Agency for International Development.

Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013

BACKGROUND

The fifth Millennium Development Goal (MDG 5) established the goal of a 75% reduction in the maternal mortality ratio (MMR; number of maternal deaths per 100,000 livebirths) between 1990 and 2015. We aimed to measure levels and track trends in maternal mortality, the key causes contributing to maternal death, and timing of maternal death with respect to delivery.

METHODS

We used robust statistical methods including the Cause of Death Ensemble model (CODEm) to analyse a database of data for 7065 site-years and estimate the number of maternal deaths from all causes in 188 countries between 1990 and 2013. We estimated the number of pregnancy-related deaths caused by HIV on the basis of a systematic review of the relative risk of dying during pregnancy for HIV-positive women compared with HIV-negative women. We also estimated the fraction of these deaths aggravated by pregnancy on the basis of a systematic review. To estimate the numbers of maternal deaths due to nine different causes, we identified 61 sources from a systematic review and 943 site-years of vital registration data. We also did a systematic review of reports about the timing of maternal death, identifying 142 sources to use in our analysis. We developed estimates for each country for 1990-2013 using Bayesian meta-regression. We estimated 95% uncertainty intervals (UIs) for all values.

FINDINGS

292,982 (95% UI 261,017-327,792) maternal deaths occurred in 2013, compared with 376,034 (343,483-407,574) in 1990. The global annual rate of change in the MMR was -0·3% (-1·1 to 0·6) from 1990 to 2003, and -2·7% (-3·9 to -1·5) from 2003 to 2013, with evidence of continued acceleration. MMRs reduced consistently in south, east, and southeast Asia between 1990 and 2013, but maternal deaths increased in much of sub-Saharan Africa during the 1990s. 2070 (1290-2866) maternal deaths were related to HIV in 2013, 0·4% (0·2-0·6) of the global total. MMR was highest in the oldest age groups in both 1990 and 2013. In 2013, most deaths occurred intrapartum or postpartum. Causes varied by region and between 1990 and 2013. We recorded substantial variation in the MMR by country in 2013, from 956·8 (685·1-1262·8) in South Sudan to 2·4 (1·6-3·6) in Iceland.

INTERPRETATION

Global rates of change suggest that only 16 countries will achieve the MDG 5 target by 2015. Accelerated reductions since the Millennium Declaration in 2000 coincide with increased development assistance for maternal, newborn, and child health. Setting of targets and associated interventions for after 2015 will need careful consideration of regions that are making slow progress, such as west and central Africa.

FUNDING

Bill & Melinda Gates Foundation.

Cognitive function and fatigue after diagnosis of colorectal cancer

BACKGROUND

Cognitive impairment and fatigue have been associated with cancer and its treatment. We present baseline data from a large longitudinal study that evaluates cognitive function, fatigue, and potential underlying mechanisms following diagnosis of colorectal cancer (CRC).

PATIENTS AND METHODS

We evaluated CRC patients with stage I-III disease before or after surgery, participants with limited metastatic disease and healthy controls (HC). Neuropsychological evaluation included clinical and computerised tests. Participants completed questionnaires for fatigue and quality of life (QOL)-(FACT-F), anxiety/depression, and cognitive symptoms (FACT-Cog). Ten cytokines, clotting factors, sex hormones, carcinoembryonic antigen (CEA), and apolipoprotein E genotype were evaluated. Primary end points were cognitive function on clinical tests evaluated by a Global Deficit score (GDS) and fatigue. Associations between test results, demographic, and disease related factors were explored.

RESULTS

We assessed 291 participants with early-stage disease [median age 59 (23-75) years, 63% men], 72 with metastatic disease, and 72 HC. Using GDS, 45% (126/281) of participants with early-stage CRC had cognitive impairment versus 15% (11/72) of HC (odds ratio 4.51, 95% confidence interval 2.28-8.93; P < 0.001), with complex processing speed, attention/working memory, and verbal learning efficiency being most affected. Women with early-stage CRC had greater cognitive impairment than men [55/105 (52%) versus 71/176 (40%), P < 0.050]. Cognitive symptoms were self-reported by 21% (59/286) of early-stage patients versus 17% (12/72) of HC; fatigue by 52% (149/287) of early-stage patients and 26% (19/72) of HC (P < 0.0001). Women reported more fatigue than men (P = 0.003). Fatigue, QOL, anxiety/depression, and cognitive symptoms were associated with each other (r = 0.43-0.71), but not with neuropsychological performance. Most cytokines were elevated in cancer patients. Cognitive function was not associated with cytokines, sex hormones, clotting factors, CEA, or apolipoprotein E genotype.

CONCLUSIONS

The incidence of cognitive impairment was three to five times higher in CRC patients than HC, with women having higher impairment rates than men. The cognitive impairment profile suggests dysfunction primarily in fronto-subcortical brain systems.

TRIAL REGISTRATION

NCT00188331.

Hematological parameters and metabolic syndrome: findings from an occupational cohort in Ethiopia

AIMS

To examine associations between hematological parameters (i.e., hemoglobin, hematocrit, platelet counts, red blood cell (RBC), and white blood cell (WBC) counts) and components of metabolic syndrome (MetS) among working adults in Addis Ababa, Ethiopia.

MATERIALS AND METHODS

Participants were 1868 (1131 men and 737 women) working Ethiopian adults. MetS was classified according to the International Diabetes Federation criterion. Odds ratios (ORs) and 95% confidence intervals (95% CIs) of MetS were calculated using logistic regression procedures.

RESULTS

Hematologic parameters (hemoglobin, hematocrit, and RBC) were positively associated with MetS components (P(trend)<0.05). In both men and women, white blood cell (WBC) counts were positively associated with BMI and waist circumference (P<0.05). RBC counts were associated with diastolic blood pressure in men (P<0.05) and women (P<0.001). Men in the third quartile of hemoglobin concentrations had 2-fold increased odds (OR=1.99; 95% CI) of MetS compared with the lowest reference quartile (P(trend)=0.031) while women in the fourth hemoglobin quartile had 2.37-fold increased odds of having MetS compared with the reference group (P(trend)=0.003). Both men and women in the fourth quartiles of RBC counts had 2.26-fold and 3.44-fold increased odds of MetS (P=0.002 in men, P<0.001 in women). Among women, those in the fourth quartiles of hematocrit and platelet counts had 2.53-fold and 2.01-fold increased odds of MetS as compared with those in the reference group (P(trend)=0.004 and 0.065 respectively).

CONCLUSION

Our study findings provide evidence in support of using hematological markers for early detection of individuals at risk for cardiovascular disease.

Prevalence of Metabolic Syndrome among Working Adults in Ethiopia

Objective. To evaluate the prevalence of metabolic syndrome (MetS) according to the International Diabetes Federation (IDF) and Adult Treatment Panel (ATP) III criteria among working East African adults. Design. This cross-sectional study of 1,935 individuals (1,171 men and 764 women) was conducted among working adults in Addis Ababa, Ethiopia. The study was conducted in accordance with the STEPwise approach of the World Health Organization. Results. According to ATP III and IDF definitions, the overall prevalence of MetS was 12.5% and 17.9%, respectively. Using ATP III criteria, the prevalence of MetS was 10.0% in men and 16.2% in women. Application of the IDF criteria resulted in a MetS prevalence of 14.0% in men and 24.0% in women. The most common MetS components among women were reduced high-density lipoprotein-cholesterol (HDL-C) (23.2%) and abdominal obesity (19.6%); whilst reduced HDL-C concentrations (23.4%) and high blood pressure (21.8%) were most common among men. Conclusion. MetS and its individual components are prevalent among an apparently healthy working population in Ethiopia. These findings indicate the need for evidence-based health promotion and disease prevention programs; and more robust efforts directed towards the screening, diagnosis and management of MetS and its components among Ethiopian adults.

Milk production and feeding behavior in the camel (Camelus dromedarius) during 4 watering regimens

Camels survive and produce milk during recurrent prolonged hot and dry periods. The objective was to evaluate how different watering intervals affected milk production and feeding. Eight lactating camels (Camelus dromedarius) were recruited and subjected to 4 watering regimens in a Latin square design experiment performed at Haramaya University in Ethiopia. Each regimen lasted 16 d with 5 d of daily watering between periods: water was offered at 1,315 h once daily (W1); on d 4, 8, 12, and 16 (W4); on d 8 and 16 (W8); and on d 16 (W16). One camel became sick in the second period and its results were excluded. Camels were kept in a pen with minimal shade and a noon temperature of 30.9±0.1°C. They had free access to hay and were offered 2 kg of concentrates 3 times daily. At noon on d 1, 4, 8, 12, and 16, a blood sample was taken from the jugular vein before watering. All calves were kept together in a separate pen. Morning and afternoon calves stimulated milk let-down before the camels were hand-milked, after which the calves suckled, emptying the udder. Camels maintained the milk volume during water deprivation for about 1 wk, but they produced less milk during the second week during W16. Morning milk osmolality increased from 315±3 on d 1 to 333±3 mosm/kg on d 4 during W4 and from 321±3 on d 1 to 342±3 mosm/kg on d 8 during W8. After watering at 1315 h, milk osmolality decreased to 316±3 and 323±3 mosm/kg, respectively, the same afternoon and then increased during recurrent water deprivation to 338±3 (W4) and 347±3 mosm/kg (W8) on d 16, respectively. During W16, osmolality increased from 318±3 to 336±3 mosm/kg during the first 4 d of water deprivation, but during the remaining 12 d the further rise in osmolality was not higher compared with that on d 4. The change in milk osmolality was linearly correlated to plasma osmolality (r=0.8), but milk lactose content did not increase. Contrary to widespread belief, camels did not dilute their milk when dehydrated. Instead milk osmolality increased in parallel to blood osmolality. This study provides further support to earlier observations on camels' adaptation to their environment.

Laboratory reference values of complete blood count for apparently healthy adults in Ethiopia

BACKGROUND

The objective of this study was to evaluate reference intervals for complete blood cell count parameters among apparently healthy 1,807 adults from Addis Ababa, Ethiopia.

METHODS

Blood specimens were collected from each participant using standard procedures. The collected aliquots were processed according to standard operating procedures to determine participants' complete blood counts. Non-parametric methods were employed to calculate the reference intervals and 90% confidence intervals for complete blood counts.

RESULTS

Overall the results show that reference ranges for women are lower than men. The white blood cell count, neutrophil, lymphocyte, monocyte, eosinophil, and basophil reference values appear to be lower than values reported elsewhere.

CONCLUSIONS

Our study is the first comprehensive study on reference intervals of complete blood count among apparently healthy adults in Ethiopia. Future studies that assess other hematological parameters and studies that assess reference values for African pediatric populations are warranted.

Iodine concentration in salt at household and retail shop levels in Shebe town, south west Ethiopia

OBJECTIVES

To determine the level of iodine in the salt at the retail shop and consumption levels and assess the knowledge, attitude and practice (KAP) of food caterers and shopkeepers about iodized salt and iodine deficiency disorders (IDD).

DESIGN

Cross-sectional community based.

SETTING

Retail shops and households in Shebe town-Jimma zone, southwest Oromiya region.

SUBJECTS

Thirty three shopkeepers and 299 food caterers of households in Shebe town.

RESULTS

The iodine content of household salt samples ranged, from 0-75 PPM and that of the shop samples ranged from 0.1-75 PPM. Eighty one per cent of household salt samples and 82% of shop salt samples have iodine levels below the minimum standard set by the Quality and Standard Authority of Ethiopia. Knowledge about iodized salt was fairly lower for food caterers (21%) than shopkeepers (57.6%). More (80%) of shopkeepers have favourable attitude than household food caterers (50.6%). Improper practices of food caterers related to iodized salt were found to be associated with female sex (P<0.01), Amhara ethnicity (P<0.001), Orthodox religion (P=0.008), literacy status (P=0.04) and occupation (P=0.01). Good knowledge, about iodized salt was significantly associated with favourable attitude among food caterers (P<0.001).

CONCLUSION

This study demonstrated that high proportions of residents in Shebe town were consuming inadequately iodized salt. There is a marked loss of iodine from salt by the time it reaches to consumption level in that some households were found to use salt with zero iodine content, whereas, all salt samples collected from the shops have at least some iodine. Poor awareness about iodized salt among food caterers and even in shopkeepers was also disclosed in this study. Socio-demographic factors such as ethnicity, religion, sex, lower educational level of food caterers might have an influence on poor, household practices like exposure of salt to sunlight. Information, education and communication on the importance consuming iodized salt and its proper handling in the house and regular monitoring of the salt iodine level at consumer level is essential for elimination of IDD.

Species of ticks on camels and their seasonal population dynamics in Eastern Ethiopia

A study was conducted to identify the species of ticks found on camels (Camelus dromedarius) and their seasonal population dynamics in Eastern Ethiopia. Collection and identification of the ticks were undertaken at 2-month intervals from December 1997 to August 1999. On each occasion, all the visible adult ticks were collected from one side of the body of each of the same 17 camels. The most abundant species of ticks on the camels were Rhipiephalus pulchellus (85.2%), Hyalomma dromedarii (5.9%), Amblyomma gemma (4.0%) and Amblyomma variegatum (1.8%). The average tick load per camel was higher during rainy months than during dry months. The smallest number of ticks per camel was observed during the driest month (December), whereas the highest was recorded in the wettest month (August). Any strategy intended to mitigate problems of tick infestation of camels in this area should take into account the identified tick species and their season of abundance.

Studies on seasonal dynamics of ticks of ogaden cattle and individual variation in resistance to ticks in eastern Ethiopia

In this study the dominant tick species identified were Amblyomma cohaerens 52.2%, Rhipicephaluspravus 19.3% and A. variegatum 14.6%. A. cohaerens occurred throughout the sampling period and showed a peak during March. Their number declined significantly (P < 0.01) from August to December. R. pravus occurred from July to December only and peaking in September (P < 0.01). A. variegatum occurred in low numbers throughout the study period with a marked seasonal variation (P < 0.01) and abundant numbers of ticks were observed from May to July. The other tick species identified were Boophilus decoloratus, R. bergeoni and R. evertsi evertsi. Individual variation in tick infestation level was observed among the animals (P < 0.05). Since all the animals were of the same breed, age group and were managed similarly the selection of animals with low infestation level can be a component of tick control strategy.

Epidemiological studies on gastrointestinal helminths of dromedary (Camelus dromedarius) in semi-arid lands of eastern Ethiopia

A total of 752 dromedaries were examined and 75% were found to be harbouring nematode eggs. The mean EPG was 1831 and the range was from 100 to 21,200. The prevalence rates in the four-age groups examined were 59.6% (3-7 years), 72.4% (8-12 years), 76.1% (13-17 years) and 83.9% (18-22 years). The prevalence rate for females and males were 77.6 and 64.8%, respectively and for long dry, short rainy, short dry and long rainy seasons were 66, 80, 69 and 82.6%, respectively. The mean EPG of faeces was significantly (P<0.01) higher for older animals compared to other group of younger animals (3-7 years), for females compared to males, and for rainy compared to dry season. Sixteen dromedary gastrointestinal organs were used for identification and counts of helminths. Among the adult worms identified, from the abomasum, Haemonchus longistipes had a 94% prevalence rate. From the small intestine Trichostrongylus colubriformis, Trichostrongylus probolurus, Impalaia tuberculata and Strongyloides papillosus were identified with prevalence rates of 75, 25, 63 and 20%, respectively. Moreover, cestodes such as Moniezia benedeni, Moniezia expansa, Avitellina spp. and Stilesia globipunctata with prevalence rates of 31, 13, 25 and 19%, respectively, were identified. I. tuberculata was identified for the first time in this country from a dromedary.The pathological lesions were more pronounced in higher infestations. Infestation level over approximately 1000 of H. longistipes and 15,000 in mixed infection of T. colubriformis and I. tuberculata, caused gross lesions of ulcerated and hyperaemic mucosa, and the odour of the fluid were fetid. The microscopic lesions observed were sloughing of epithelium, necrosis of glands, atrophy and loss of villi, haemorrhages and cellular infiltration mainly of eosinophiles and lymphocytes.

Studies on Cephalopina titillator, the cause of 'Sengale' in camels (Camelus dromedarius) in semi-arid areas of Somali State, Ethiopia

The overall prevalence rate of Cephalopina titillator in 778 slaughtered camels was 71.7%, 55% in males and 85% in females. The mean larval counts in infested camels were 26.7 +/- 25.9 and 34.6 +/- 30.8, for males and females, respectively. There were highly significant differences (p < 0.001) in the number of larvae in camels of different ages and sexes and also between the wet and dry seasons. The average time to pupate was 4.9 +/- 4.6 minutes, and the pupation period was 21 +/- 2.4 days. The major gross lesions observed were congestion of the pharyngeal mucosa with profuse secretions, and haemorrhage in early cases. In some cases, there were ulcer-like lesions and nodules, which contained pus. The dominant microscopic lesions were infiltration of the lamina propria by eosinophils, lymphocytes and macrophages, hyperplasia of the stratified squamous epithelium, necrotic changes in the mixed glands and desquamation of epithelial cells. A survey using questionnaires revealed that all the camel owners called the disease caused by infestation with C. titillator 'Sengale' and that 87% of them considered that infestation with these larvae results in reduced milk production and body weight. The major clinical signs of the disease were sneezing and expulsion of larvae (68%), abnormal movement of the head (45%), grooming (44%), nasal discharge (40%), poor appetite (26.7%), difficulty in breathing (18%), and sometimes bleeding from the nostrils (18%) and coughing (27%).

Effect of season on the productivity of camels (Camelus dromedarius and the prevalence of their major parasites in eastern Ethiopia

The productivity and the prevalence rates of the major parasites of camels (Camelus dromedarius) kept under traditional management conditions at Errer valley, Ethiopia were assessed for a year (October 1997-September 1998). The daily milk offtake was significantly higher (p < 0.05) during the wet season (3.12 +/- 0.03 L) than during the dry season (1.49 +/- 0.04 L). Likewise, significantly higher (p < 0.05) daily weight gains (50.68 +/- 0.54 g) were observed during the wet season than during dry season in immature camels aged 1-4 years. Trypanosoma evansi, Sarcoptes scabiei and strongyle parasites were present throughout the year, but their prevalence rates were higher during the rainy months than during the dry months. The minimum and maximum point prevalence rates for T. evansi were 5.4% and 20.6%, respectively. Similarly, the point prevalence rates for S. scabiei also varied from 4.7% during the dry season to 21.7% during the rainy months. The highest strongyle egg counts per gram of faeces and highest point prevalence rate (85.7%) were observed in October, a rainy month, whereas the lowest number of eggs per gram of faeces and the lowest point prevalence rate (61.5%) were recorded in April, a dry month.

Mastitis in lactating camels (Camelus dromedarius) in Afar Region, north-eastern Ethiopia

Quarter milk samples (n = 543) from 152 traditionally managed lactating camels (Camelus dromedarius) in Afar Region, north-eastern Ethiopia were examined to determine the prevalence of camel mastitis and identify its bacterial causes. Out of 152 camels examined, 19 (12.5%) were diagnosed as clinical mastitis cases based on clinical signs and bacteriological examinations. Of the 257 California Mastitis Test (CMT) positive quarter milk samples 162 (63.0%) yielded pathogenic bacteria. A positive correlation was observed between CMT positive results and presence of major pathogens in camel milk samples. The main mastitis pathogens isolated were Staphylococcus aureus, coagulase-negative staphylococci, Streptococcus agalactiae, S. dysgalactiae, and other species of streptococci, Pasteurella haemolytica and E. coli. Results of the present study suggest that mastitis in Afar camels is prevalent, Gram-positive cocci are the major isolates from camel milk samples and the CMT can be used as a screening test for the detection of mastitis in camels.

Studies on the respiratory disease 'sonbobe' in camels in the eastern lowlands of Ethiopia

New epidemics of respiratory disease have caused 29.6 morbidity and 6.4% mortality in camels in the Somalia region of Ethiopia. The major clinical signs observed were fever of 40-41.5 degrees C, depression, cough, loss of appetite and a watery nasal discharge that became mucopurulent at a later stage. Finally, the camel became recumbent and extended its neck straight along the ground. Some of the animals died within 8-9 days. The major post-mortem lesions were hydrothorax, adhesion of the lung to the thorax, red and grey hepatization, emphysema, hydropericardium and fibrinous pericarditis. A treatment trial indicated that oxytetracycline was more effective than a combination of penicillin and streptomycin, the results showing a significant difference (p < 0.05) between the treated and control groups. The bacteria isolated from lung, thoracic fluid and whole blood were Pasteurella haemolytica. Further studies on the epidemiology of this disease, the identification of the serotypes involved, and the demonstration of any primary viral initiating agent are recommended to allow the development of preventive methods.

Financial losses caused by ovine fasciolosis in the Ethiopian highlands

An estimate of the economic loss due to ovine fasciolosis in the Ethiopian highlands was made based on available data on mortality, weight loss, reduced reproductive efficiency and liver condemnation at slaughter. The economic effects of fasciolosis were identified and models for estimating the financial loss presented. Ovine fasciolosis losses were estimated at 48.4 million Ethiopian Birr per year of which 46.5, 48.8 and 4.7% were due to mortality, productivity (weight loss and reproductive wastage) and liver condemnation, respectively. These losses can be reduced substantially by fasciolosis control programmes that may include the use of anthelmintics, grazing management and nutritional supplementation.

Factors affecting morbidity and mortality on-farm and on-station in the Ethiopian highland sheep

Factors affecting morbidity and mortality of the Ethiopian highland sheep were studied both on-farm and on-station at Debre Berhan between 1989 and 1990. Primary causes of infectious origin resulted in high proportional morbidity (88.4% on-farm) and mortality (72.9% on-farm and 71.8% on-station) rates. Nutritional and managemental factors were also responsible for mortalities in lambs. The most frequent secondary causes of morbidity and/or mortality were ectoparasites and nasal myiasis. Health management interventions on-station were not high enough to produce performance improvements above the on-farm levels. However, the occurrence of gastrointestinal parasites significantly (P < 0.05) differed between the two management systems. The frequency of some of the major causes of morbidity and mortality such as pneumonia, fasciolasis and enteritis were significantly (P < 0.01) affected by season and age of an animal. In order to alleviate the major health constraints identified in this study, a proper health management intervention involving vaccination, strategic anthelmintic treatment and feeding management are suggested.

Causes of lamb morbidity and mortality in the Ethiopian highlands

A study was conducted to investigate causes of lamb morbidity and mortality on farms and on-station at Debre Berhan during 1989 and 1990. It showed pneumonia (bacterial and/or verminous), starvation-mismothering exposure (SME) complex, gastrointestinal parasites, enteritis, abomasal impaction and physical injuries to be important health constraints on productivity. Neonatal mortalities were 51.5% and 46.3% on farms and on-station respectively and occurred owing to management problems such as SME, abomasal impaction and physical injuries. On the farms the lamb birth weight was 2.56 +/- 0.25 kg and was significantly (p < 0.05) affected by the dam's age, lambing weight, litter size, sex of lamb and year of lambing, but not by the season of lambing. Birth weight significantly (p < 0.05) influenced lamb mortality. Lambs with a low birth weight tended to die from SME. Morbidities and mortalities due to infectious causes increased in older lambs, suggesting that infections were acquired with age when resistance was lowered owing to inadequate nutrition and poor management. Heavy loss of lambs could be overcome by such health management interventions as foster mothering, warming lambs during the cold season and vaccination with polyvalent vaccines against pasteurellosis, clostridial infection and Dictyocaulus filaria.

Repeatability of measurements of packed cell volume and egg count as indicators of endoparasite load and their relationship with sheep productivity

Monthly measurements of packed cell volume (PCV) and nematode and trematode eggs per gram (EPG) were made in Ethiopian highland sheep at Debre Berhan, Dejen, Deneba, Tulu Meko and Wereilu from June 1988 to December 1989. High frequencies of low PCV, high nematode EPG and high trematode EPG were found at Tulu Meko. Among the productivity traits examined, body condition scores and live-weights were significantly (P less than 0.05) associated with differences in PCV and nematode and trematode EPG levels at most sites. The lambing interval was, however, not significantly (P greater than 0.05) affected by these variables. Monthly repeatabilities of PCV, body weight and body condition scores were 0.44 +/- 0.01, 0.71 +/- 0.01 and 0.35 +/- 0.01, respectively, while those of nematode (0.09 +/- 0.01) and trematode EPGs (0.20 +/- 0.02) were much lower. The high repeatability for PCV indicates that it was less affected by the variable factors influencing egg output, and hence it could be utilized in conjunction with nematode and trematode EPG levels for endoparasite monitoring. Repeatability of the lambing interval across parities was 0.43 +/- 0.14.

Clinical pharmacology of intravenous enoximone: pharmacodynamics and pharmacokinetics in patients with heart failure

Twenty-one patients with heart failure (New York Heart Association [NYHA] class II to IV) received a 24-hour infusion of enoximone followed by a 12-hour washout period. Patients were randomly assigned to one of four treatment groups. Groups I to III received an 0.5 mg/kg bolus, followed by a maintenance infusion of 2.5, 5.0, or 10.0 micrograms/kg/min. Group IV patients received a maintenance infusion of 5.0 micrograms/kg/min without a loading dose. Serial assessment of hemodynamics, plasma levels of enoximone and enoximone sulfoxide, and ventricular ectopy were performed. Enoximone produced a clinically significant increase in cardiac index, and a decrease in mean pulmonary artery wedge pressure and systemic vascular resistance in all groups. Enoximone mildly increased heart rate, and had a minimal effect on mean arterial pressure. There was no statistically significant change in ventricular ectopy during the infusion. Significant hemodynamic improvement was noted at even the lowest infusion rate, and did not increase in linear fashion at higher infusion rates. In patients who did not receive an initial loading bolus of 0.5 mg/kg, the increase in cardiac index was delayed by approximately 1 hour. Plasma concentrations of both enoximone and its major metabolite continued to rise throughout the 24-hour infusion in group III (10.0 micrograms/kg/min), rather than reaching steady state as predicted by the terminal exponential half-lives of these compounds. This is suggestive of nonlinear pharmacokinetics and indicates a potential for excessive accumulation of enoximone and its metabolite during prolonged infusion. These findings may have important implications in guiding the intravenous administration of enoximone.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacodynamics of enoximone during intravenous infusion

Twenty-one patients with heart failure (NYHA class II-IV) received a 24-hour infusion of enoximone, followed by a 12-hour washout period. Patients were randomly assigned to one of four treatment groups. Groups I-III received a 0.5 mg/kg bolus, followed by a maintenance infusion of 2.5, 5.0 or 10.0 micrograms/kg/minute. Group IV patients received a maintenance infusion of 5.0 micrograms/kg/minute without the bolus. Serial assessments of haemodynamics, plasma levels of enoximone and enoximone sulphoxide, and ventricular ectopy were performed. Enoximone produced a significant increase in cardiac index (28.1-46.7%) and a decrease in mean pulmonary artery wedge pressure (6.4-35.7%) and systemic vascular resistance (34.7-78.9%). Enoximone had minimal effect on heart rate and blood pressure. In patients who did not receive an initial bolus of 0.5 mg/kg, haemodynamic changes were delayed by approximately 1 hour. Significant haemodynamic improvement was noted at even the lowest infusion rate and did not increase in linear fashion at higher infusion rates. During infusion of enoximone at 10.0 micrograms/kg/minute, both enoximone and its sulphoxide accumulated non-linearly and did not achieve a steady state. No significant adverse effects were noted in these patients. Enoximone infusion at rates greater than 5.0 micrograms/kg/minute may confer minimal additional haemodynamic benefit, while resulting in significant accumulation of enoximone and enoximone sulphoxide. Ventricular ectopy did not increase significantly in most patients.

Toxoplasmosis in sheep, goats and cattle in central Ethiopia

In a seroepidemiological survey using an indirect haemagglutination assay, the prevalence rate of toxoplasmosis in central Ethiopia was 22.9% of 899 sheep, 11.6% of 753 goats and 6.6% of 785 cattle. There were high titres of 1:256 or more which suggest current infections. These results indicate that toxoplasmosis may be an important cause of reproductive wastage in small ruminants. The public health significance of this disease is discussed. Improved hygiene and management could reduce the prevalence of the disease.

The effects of enoximone on renal function in patients with congestive heart failure

Enoximone is an investigational cardiotonic agent with positive inotropic and vasodilatory properties. In this protocol the effects of enoximone on parameters of renal function in patients (n = 14) with New York Heart Association class II or III congestive heart failure were determined after intravenous (IV) treatment (2 mg/kg) and after chronic oral administration (150 mg t.i.d.), either alone or with added furosemide (40 mg b.i.d.). Glomerular filtration rate (GFR), effective renal plasma flow (ERPF), filtration fraction, mean arterial pressure (MAP), renal blood flow (RBF), and renal vascular resistance (RVR) were determined each time. Plasma volume (PV) was determined at baseline and after oral enoximone and after oral enoximone plus furosemide. Significant reductions in GFR (18%) and ERPF (20%) were observed after IV treatment but not after oral treatment with or without furosemide. MAP also was lowered significantly by 14% after IV administration but not after oral treatments. PV after oral enoximone plus furosemide was reduced significantly (31%) compared with baseline. These results demonstrate that enoximone produces acute reductions in GFR and ERPF when given intravenously but has no effect on parameters of renal function when given orally, either alone or with furosemide.

The effect of handling methods on subsequent plasma progesterone levels in sheep

The mean progesterone concentration in the plasma of 10 adult Ethiopian Highland sheep obtained immediately after slaughter was 10.56 +/- 3.98 ng/ml. Samples were subsequently incubated at 4 degrees C, room temperature (19-22 degrees C) or 26 degrees C as either plasma or intact but citrated blood. Failure to separate plasma affected the progesterone content at 2-72 h at room temperature or 26 degrees C (p less than 0.01 - p less than 0.0001). Incubation temperature affected the plasma concentration at 18 h (p less than 0.05) and 24 h (p less than 0.001). Although progesterone values were generally higher in separated plasma, disparity with the values from plasma separated from incubated citrated blood was small (r = 0.76-0.98). Progesterone concentration declined haphazardly after collection but sometimes exceeded the initial readings. This kept the average concentration of progesterone in plasma separated immediately after collection fairly constant and within 15% of zero time samples during the first 48 h.

The prevalence of cysticercosis and hydatidosis in Ethiopian sheep

Five hundred and sixty sheep, slaughtered at an Addis Ababa abattoir, were examined for cysticercosis and hydatidosis. The prevalence of the metacestodes of Taenia hydatigena was 37.1% and that of Echinococcus granulosus 16.4%. In addition, the age and sex prevalences of hydatid cysts, their organ distribution and the ratio of fertile cysts were determined.