Methods used in the spatial analysis of tuberculosis epidemiology: a systematic review.

BACKGROUND: Tuberculosis (TB) transmission often occurs within a household or community, leading to heterogeneous spatial patterns. However, apparent spatial clustering of TB could reflect ongoing transmission or co-location of risk factors and can vary considerably depending on the type of data available, the analysis methods employed and the dynamics of the underlying population. Thus, we aimed to review methodological approaches used in the spatial analysis of TB burden. METHODS: We conducted a systematic literature search of spatial studies of TB published in English using Medline, Embase, PsycInfo, Scopus and Web of Science databases with no date restriction from inception to 15 February 2017. The protocol for this systematic review was prospectively registered with PROSPERO ( CRD42016036655 ). RESULTS: We identified 168 eligible studies with spatial methods used to describe the spatial distribution (n = 154), spatial clusters (n = 73), predictors of spatial patterns (n = 64), the role of congregate settings (n = 3) and the household (n = 2) on TB transmission. Molecular techniques combined with geospatial methods were used by 25 studies to compare the role of transmission to reactivation as a driver of TB spatial distribution, finding that geospatial hotspots are not necessarily areas of recent transmission. Almost all studies used notification data for spatial analysis (161 of 168), although none accounted for undetected cases. The most common data visualisation technique was notification rate mapping, and the use of smoothing techniques was uncommon. Spatial clusters were identified using a range of methods, with the most commonly employed being Kulldorff's spatial scan statistic followed by local Moran's I and Getis and Ord's local Gi(d) tests. In the 11 papers that compared two such methods using a single dataset, the clustering patterns identified were often inconsistent. Classical regression models that did not account for spatial dependence were commonly used to predict spatial TB risk. In all included studies, TB showed a heterogeneous spatial pattern at each geographic resolution level examined. CONCLUSIONS: A range of spatial analysis methodologies has been employed in divergent contexts, with all studies demonstrating significant heterogeneity in spatial TB distribution. Future studies are needed to define the optimal method for each context and should account for unreported cases when using notification data where possible. Future studies combining genotypic and geospatial techniques with epidemiologically linked cases have the potential to provide further insights and improve TB control.

A novel Bayesian geospatial method for estimating tuberculosis incidence reveals many missed TB cases in Ethiopia.

BACKGROUND: Reported tuberculosis (TB) incidence globally continues to be heavily influenced by expert opinion of case detection rates and ecological estimates of disease duration. Both approaches are recognised as having substantial variability and inaccuracy, leading to uncertainty in true TB incidence and other such derived statistics. METHODS: We developed Bayesian binomial mixture geospatial models to estimate TB incidence and case detection rate (CDR) in Ethiopia. In these models the underlying true incidence was formulated as a partially observed Markovian process following a mixed Poisson distribution and the detected (observed) TB cases as a binomial distribution, conditional on CDR and true incidence. The models use notification data from multiple areas over several years and account for the existence of undetected TB cases and variability in true underlying incidence and CDR. Deviance information criteria (DIC) were used to select the best performing model. RESULTS: A geospatial model was the best fitting approach. This model estimated that TB incidence in Sheka Zone increased from 198 (95% Credible Interval (CrI) 187, 233) per 100,000 population in 2010 to 232 (95% CrI 212, 253) per 100,000 population in 2014. The model revealed a wide discrepancy between the estimated incidence rate and notification rate, with the estimated incidence ranging from 1.4 (in 2014) to 1.7 (in 2010) times the notification rate (CDR of 71% and 60% respectively). Population density and TB incidence in neighbouring locations (spatial lag) predicted the underlying TB incidence, while health facility availability predicted higher CDR. CONCLUSION: Our model estimated trends in underlying TB incidence while accounting for undetected cases and revealed significant discrepancies between incidence and notification rates in rural Ethiopia. This approach provides an alternative approach to estimating incidence, entirely independent of the methods involved in current estimates and is feasible to perform from routinely collected surveillance data.

General public knowledge, attitudes, and practices towards persons with epilepsy in South Ethiopia: A comparative community-based cross-sectional study.

INTRODUCTION: Despite being a common disorder, epilepsy is misunderstood by the general public, leading to fear, secrecy, stigmatization, and the risk of social discrimination. OBJECTIVE: This study aimed to compare knowledge, attitudes, and practices (KAP) towards persons with epilepsy among rural and urban dwellers in South Ethiopia. METHODS: A comparative cross-sectional community-based study was conducted among 1316 (656 from rural and 660 from urban) adult respondents in South Ethiopia. RESULTS: The most cited causes of epilepsy were brain disease (40.6%) by urban respondents and evil spirits (34.6%) by rural respondents. More urban (21.7%) than rural (16.5%) respondents believed that epilepsy is contagious (P=0.016). About 39% of rural compared with 7% of urban respondents would not allow their children to associate with a person with epilepsy (P<0.001), and 56.7% of rural compared with 24.8% of urban respondents objected to themselves or their children marrying someone with epilepsy (P<0.001). The majority of the respondents in both groups (75.5% from urban and 56.4% from rural) would recommend a medical doctor for the treatment of epilepsy, but herbal medicine and spiritual treatments such as prayers and Holy water were still commonly practiced. CONCLUSION: This study demonstrated a significant difference in epilepsy KAP between urban and rural dwellers, with the former having more positive attitudes. A comprehensive epilepsy educational campaign is necessary to advance understanding among the general population, thereby improving patient care.

Utilization of institutional delivery service at Wukro and Butajera districts in the Northern and South Central Ethiopia.

BACKGROUND: Ethiopia has one of the highest maternal mortality in the world. Institutional delivery is the key intervention in reducing maternal mortality and complications. However, the uptake of the service has remained low and the factors which contribute to this low uptake appear to vary widely. Our study aims to determine the magnitude and identify factors affecting delivery at health institution in two districts in Ethiopia. METHODS: A community based cross sectional household survey was conducted from January to February 2012 in 12 randomly selected villages of Wukro and Butajera districts in the northern and south central parts of Ethiopia, respectively. Data were collected using a pretested questionnaire from 4949 women who delivered in the two years preceding the survey. RESULTS: One in four women delivered the index child at a health facility. Among women who delivered at health facility, 16.1% deliveries were in government hospitals and 7.8% were in health centers. The factors that significantly affected institutional delivery in this study were district in which the women lived (AOR: 2.21, 95% CI: 1.28, 3.82), women age at interview (AOR: 1.96, 95% CI: 1.05, 3.62), women's education (AOR: 3.53, 95% CI: 1.22, 10.20), wealth status (AOR: 16.82, 95% CI: 7.96, 35.54), women's occupation (AOR: 1.50, 95% CI: 1.01, 2.24), antenatal care (4+) use (AOR: 1.77, 95% CI: 1.42, 2.20), and number of pregnancies (AOR: 0.25, 95% CI: 0.18,0.35). We found that women who were autonomous in decision making about place of delivery were less likely to deliver in health facility (AOR: 0.38, 95% CI: 0.23,0.63). CONCLUSIONS: Institutional delivery is still low in the Ethiopia. The most important factors that determine use of institutional delivery appear to be women education and household economic status.Women's autonomy in decision making on place of delivery did not improve health facility delivery in our study population.Actions targeting the disadvantaged, improving quality of services and service availability in the area are likely to significantly increase institutional delivery.

Validation of the condom use self-efficacy scale in Ethiopia.

BACKGROUND: The measurement of condom use self-efficacy requires contextually suitable, valid and reliable instruments due to variability of the scale across nations with different cultural and ethnic backgrounds. This study aims to construct a condom use self-efficacy scale suitable to Ethiopia (CUSES-E), based on the original scale developed by Brafford and Beck. METHODS: A cross-sectional study was conducted on a random sample of 492 students at Hawassa University. A self-administered questionnaire containing 28 items from the original scale was used to collect the data. Principal Component Analysis (PCA) with Varimax rotation was used to extract factor structures. Cronbach's alpha and item-total correlations were used to determine the internal consistency of the scale. The convergent and discriminant validity of the scale was verified using a correlation matrix. RESULTS: The PCA extracted three factors containing a total of 9-items. The extracted factors were labeled Assertiveness, Fear for partner rejection and Intoxicant Control, with internal consistency coefficients (Cronbach's alpha) of 0.86, 0.86 and 0.92, respectively. Altogether, the factors explained 77.8% of variance in the items. An evaluation of CUSES-E showed a significantly higher self-efficacy score among students who ever used condoms; P < 0.001. The correlation matrix revealed that all of the convergent correlations were higher than the discriminant ones, providing evidence in support of both types of validity. In the split sample validation, the communalities, factor loadings and factor structure were the same on the analysis on each half and the full data set, suggesting that the new scale is generalizable and replicable. CONCLUSION: This study of CUSES using an Ethiopian population found a different dimension to emerge, suggesting that the scale should be validated to local contexts before application. The CUSES-E is valid, reliable and replicable. Therefore, health cadres and researchers in Ethiopia can apply this scale to promote condom utilization to Ethiopian school youths. However, future research to develop a suitable scale (highly valid and reliable) in concordance with the local vernacular using a prior qualitative study is needed.

Transmission modeling to infer tuberculosis incidence prevalence and mortality in settings with generalized HIV epidemics.

Tuberculosis (TB) killed more people globally than any other single pathogen over the past decade. Where surveillance is weak, estimating TB burden estimates uses modeling. In many African countries, increases in HIV prevalence and antiretroviral therapy have driven dynamic TB epidemics, complicating estimation of burden, trends, and potential intervention impact. We therefore develop a novel age-structured TB transmission model incorporating evolving demographic, HIV and antiretroviral therapy effects, and calibrate to TB prevalence and notification data from 12 African countries. We use Bayesian methods to include uncertainty for all TB model parameters, and estimate age-specific annual risks of TB infection, finding up to 16.0%/year in adults, and the proportion of TB incidence from recent (re)infection, finding a mean across countries of 34%. Rapid reduction of the unacceptably high burden of TB in high HIV prevalence settings will require interventions addressing progression as well as transmission.

Xpert Ultra stool testing to diagnose tuberculosis in children in Ethiopia and Indonesia: a model-based cost-effectiveness analysis.

OBJECTIVES: The WHO currently recommends stool testing using GeneXpert MTB/Rif (Xpert) for the diagnosis of paediatric tuberculosis (TB). The simple one-step (SOS) stool method enables processing for Xpert testing at the primary healthcare (PHC) level. We modelled the impact and cost-effectiveness of implementing the SOS stool method at PHC for the diagnosis of paediatric TB in Ethiopia and Indonesia, compared with the standard of care. SETTING: All children (age <15 years) presenting with presumptive TB at primary healthcare or hospital level in Ethiopia and Indonesia. PRIMARY OUTCOME: Cost-effectiveness estimated as incremental costs compared with incremental disability-adjusted life-years (DALYs) saved. METHODS: Decision tree modelling was used to represent pathways of patient care and referral. We based model parameters on ongoing studies and surveillance, systematic literature review, and expert opinion. We estimated costs using data available publicly and obtained through in-country expert consultations. Health outcomes were based on modelled mortality and discounted life-years lost. RESULTS: The intervention increased the sensitivity of TB diagnosis by 19-25% in both countries leading to a 14-20% relative reduction in mortality. Under the intervention, fewer children seeking care at PHC were referred (or self-referred) to higher levels of care; the number of children initiating anti-TB treatment (ATT) increased by 18-25%; and more children (85%) initiated ATT at PHC level. Costs increased under the intervention compared with a base case using smear microscopy in the standard of care resulting in incremental cost-effectiveness ratios of US$132 and US$94 per DALY averted in Ethiopia and Indonesia, respectively. At a cost-effectiveness threshold of 0.5×gross domestic product per capita, the projected probability of the intervention being cost-effective in Ethiopia and Indonesia was 87% and 96%, respectively. The intervention remained cost-effective under sensitivity analyses. CONCLUSIONS: The addition of the SOS stool method to national algorithms for diagnosing TB in children is likely to be cost-effective in both Ethiopia and Indonesia.

TB Hackathon: Development and Comparison of Five Models to Predict Subnational Tuberculosis Prevalence in Pakistan.

Pakistan's national tuberculosis control programme (NTP) is among the many programmes worldwide that value the importance of subnational tuberculosis (TB) burden estimates to support disease control efforts, but do not have reliable estimates. A hackathon was thus organised to solicit the development and comparison of several models for small area estimation of TB. The TB hackathon was launched in April 2019. Participating teams were requested to produce district-level estimates of bacteriologically positive TB prevalence among adults (over 15 years of age) for 2018. The NTP provided case-based data from their 2010-2011 TB prevalence survey, along with data relating to TB screening, testing and treatment for the period between 2010-2011 and 2018. Five teams submitted district-level TB prevalence estimates, methodological details and programming code. Although the geographical distribution of TB prevalence varied considerably across models, we identified several districts with consistently low notification-to-prevalence ratios. The hackathon highlighted the challenges of generating granular spatiotemporal TB prevalence forecasts based on a cross-sectional prevalence survey data and other data sources. Nevertheless, it provided a range of approaches to subnational disease modelling. The NTP's use and plans for these outputs shows that, limitations notwithstanding, they can be valuable for programme planning.

Assortative social mixing and sex disparities in tuberculosis burden.

Globally, men have higher tuberculosis (TB) burden but the mechanisms underlying this sex disparity are not fully understood. Recent surveys of social mixing patterns have established moderate preferential within-sex mixing in many settings. This assortative mixing could amplify differences from other causes. We explored the impact of assortative mixing and factors differentially affecting disease progression and detection using a sex-stratified deterministic TB transmission model. We explored the influence of assortativity at disease-free and endemic equilibria, finding stronger effects during invasion and on increasing male:female prevalence (M:F) ratios than overall prevalence. Variance-based sensitivity analysis of endemic equilibria identified differential progression as the most important driver of M:F ratio uncertainty. We fitted our model to prevalence and notification data in exemplar settings within a fully Bayesian framework. For our high M:F setting, random mixing reduced equilibrium M:F ratios by 12% (95% CrI 0-30%). Equalizing male case detection there led to a 20% (95% CrI 11-31%) reduction in M:F ratio over 10 years-insufficient to eliminate sex disparities. However, this potentially achievable improvement was associated with a meaningful 8% (95% CrI 4-14%) reduction in total TB prevalence over this time frame.

Seroprevalence of SARS-CoV-2 antibody among individuals aged above 15 years and residing in congregate settings in Dire Dawa city administration, Ethiopia.

BACKGROUND: Determining the extent of seropositivity of SARS-CoV-2 antibody has the potential to guide prevention and control efforts. We aimed to determine the seroprevalence of SARS-CoV-2 antibody among individuals aged above15 years and residing in the congregate settings of Dire Dawa city administration, Ethiopia. METHOD: We analyzed COVID-19 seroprevalence data on 684 individuals from a community based cross-sectional survey conducted among individuals aged above 15 years and residing in congregate settings in Dire Dawa from June 15 to July 30, 2020. Data were collected using interview and blood sample collection. Participants were asked about demographic characteristics, COVID-19 symptoms, and their practice of preventive measures. Seroprevalence was determined using SARS-CoV-2 IgG test. Bivariate and multivariate multilevel mixed effects logistic regression model was fitted and statistical significance was set at p value < 0.05. RESULT: The estimated SARS-CoV-2 seroprevalence was 3.2% (95 % CI 2.0-4.8) in the study region with no differences by age and sex but considerable differences were observed by self-reported practice of COVID-19 preventive measures. The cluster effect is not significant (P = 0.396) which has suggested no evidence of heterogeneity in SARS-CoV-2 seroprevalence among the clusters. The odds of SARS-CoV-2 antibody seroprevalence were higher for individuals who were employed and work by moving from home to work area (AOR; 9.73 95% CI 2.51, 37.68), reported of not wearing facemasks when leaving home (AOR; 6.4 95% CI 2.30, 17.66) and did not practice physical distancing measures (AOR; 10 95% CI 3.01, 33.20) compared to their counterparts, respectively. Our estimated seroprevalence of SARS-CoV-2 among participants who reported not to have practiced social distancing measures was 12.8 (95% CI, 7.0, 19) and 1.5 (95% CI, 0.5, 2.5) among those who reported of practicing them. More than 80% of study participants reported of implementing infection prevention measures (face masks and physical distancing recommendations). CONCLUSION: The detected SARS-CoV-2 seroprevalence among the study participants was low at the time of the survey indicating higher proportion of population yet to be infected. COVID-19 preventive measures were associated with reduced seroprevalence and should be promoted to avoid transmission to the uninfected majority.

Geospatial clustering and modelling provide policy guidance to distribute funding for active TB case finding in Ethiopia.

Tuberculosis (TB) exhibits considerable spatial heterogeneity, occurring in clusters that may act as hubs of community transmission. We evaluated the impact of an intervention targeting spatial TB hotspots in a rural region of Ethiopia. To evaluate the impact of targeted active case finding (ACF), we used a spatially structured mathematical model that has previously been described. From model equilibrium, we simulated the impact of a hotspot-targeted strategy (HTS) on TB incidence ten years from intervention commencement and the associated cost-effectiveness. HTS was also compared with an untargeted strategy (UTS). We used logistic cost-coverage analysis to estimate cost-effectiveness of interventions. At a community screening coverage level of 95 % in a hotspot region, which corresponds to screening 20 % of the total population, HTS would reduce overall TB incidence by 52 % compared with baseline. For UTS to achieve an equivalent effect, it would be necessary to screen more than 80 % of the total population. Compared to the existing passive case detection strategy, the HTS at a CDR of 75 percent in hotspot regions is expected to avert 1,023 new TB cases over ten years saving USD 170 per averted case. Similarly, at the same CDR, the UTS will detect 1316 cases over the same period saving USD 3 per averted TB case. The incremental-cost effectiveness-ratio (ICER) of UTS compared with HTS is USD 582 per averted case corresponding to 293 more TB cases averted at an additional cost of USD 170,700. Where regional TB program spending was capped at current levels, maximum gains in incidence reduction were seen when the regional budget was shared between hotspots and non-hotspot regions in the ratio of 40% : 60%. Our analysis suggests that a spatially targeted strategy is efficient and cost-saving, with the potential for significant reduction in overall TB burden.

Barriers to Maternal and Child Health Care Service Uptake in Assosa Zone, Benishangul Gumuz Region, Ethiopia: A Qualitative Study.

BACKGROUND: Ethiopia has reduced maternal mortality from 871 to 412 per 100,000 live births between 2000 and 2016. In 2019, under-5 mortality rates in Ethiopia were 55 deaths per 1,000 live births. Benishangul Gumuz was the second-largest region in the under-5 mortality rate (98/1,000 live births) in the country. Maternal and child health care service uptake is an important indicator of health outcomes. This study is aimed at exploring major barriers to maternal and child health care uptake in Assosa Zone. METHODS: This study was conducted in the Bambasi, Menge, and Sherkole districts of the Assosa Zone from July 17 to August 31/2019. The study explored the life experience of study participants about MCH services. The sampling technique was purposive, and data collection methods were focus group discussions, key informant interviews, and in-depth interviews. Data were analyzed thematically. RESULT: The main barriers to child health care services were financial problems, lack of knowledge, preference of traditional medicines for a sick child, women having no time to care for their sick child, poor roads. poor health facility readiness, the poor economy of families, lack of ambulance, cultural and traditional beliefs, providers being male, and unprofessional behaviors which were the major barriers hindering the uptake of maternal health service utilization. CONCLUSION: Poor health facility readiness, indirect costs, inaccessibility to health facilities, and cultural and traditional practices were among the major barriers to service uptake identified by this research in the study area.

The role of geospatial hotspots in the spatial spread of tuberculosis in rural Ethiopia: a mathematical model.

Geospatial tuberculosis (TB) hotspots are hubs of TB transmission both within and across community groups. We aimed to quantify the extent to which these hotspots account for the spatial spread of TB in a high-burden setting. We developed spatially coupled models to quantify the spread of TB from geographical hotspots to distant regions in rural Ethiopia. The population was divided into three 'patches' based on their proximity to transmission hotspots, namely hotspots, adjacent regions and remote regions. The models were fitted to 5-year notification data aggregated by the metapopulation structure. Model fitting was achieved with a Metropolis-Hastings algorithm using a Poisson likelihood to compare model-estimated notification rate with observed notification rates. A cross-coupled metapopulation model with assortative mixing by region closely fit to notification data as assessed by the deviance information criterion. We estimated 45 hotspot-to-adjacent regions transmission events and 2 hotspot-to-remote regions transmission events occurred for every 1000 hotspot-to-hotspot transmission events. Although the degree of spatial coupling was weak, the proportion of infections in the adjacent region that resulted from mixing with hotspots was high due to the high prevalence of TB cases in a hotspot region, with approximately 75% of infections attributable to hotspot contact. Our results suggest that the role of hotspots in the geospatial spread of TB in rural Ethiopia is limited, implying that TB transmission is primarily locally driven.

Sequelae of multidrug-resistant tuberculosis: protocol for a systematic review and meta-analysis.

INTRODUCTION: The sequelae of multidrug-resistant tuberculosis (MDR-TB) are poorly understood and inconsistently reported. We will aim to assess the existing evidence for the clinical, psychological, social and economic sequelae of MDR-TB and to assess the health-related quality of life in patients with MDR-TB. METHODS AND ANALYSIS: We will perform a systematic review and meta-analysis of published studies reporting sequelae of MDR-TB. We will search PubMed, SCOPUS, ProQuest, Web of Science and PsychINFO databases up to 5 September 2017. MDR-TB sequelae will include any clinical, psychological, social and economic effects as well as health-related quality of life that occur after MDR-TB treatment or illness. Two researchers will screen the titles and abstracts of all citations identified in our search, extract data, and assess the scientific quality using standardised formats. Providing there is appropriate comparability in the studies, we will use a random-effects meta-analysis model to produce pooled estimates of MDR-TB sequelae from the included studies. We will stratify the analyses based on treatment regimen, comorbidities (such as HIV status and diabetes mellitus), previous TB treatment history and study setting. ETHICS AND DISSEMINATION: As this study will be based on published data, ethical approval is not required. The final report will be disseminated through publication in a peer-reviewed scientific journal and will also be presented at relevant conferences. PROSPERO REGISTRATION NUMBER: CRD42017073182.

Mental health disorders, social stressors, and health-related quality of life in patients with multidrug-resistant tuberculosis: A systematic review and meta-analysis.

BACKGROUND: Mental health disorders, social stress, and poor health-related quality of life are commonly reported among people with tuberculosis (TB). We conducted a systematic review and meta-analysis to quantify mental health disorders, social stressors, and health-related quality of life in patients with multidrug-resistant tuberculosis (MDR-TB). METHODS: We searched PubMed, SCOPUS, ProQuest, Web of Science, and PsycINFO databases for studies that reported data on mental health disorders, social stressors, and health-related quality of life among MDR-TB patients. Hand-searching the reference lists of included studies was also performed. Studies were selected according to pre-defined selection criteria and data were extracted by two authors. Pooled prevalence and weighted mean difference estimates were performed using random-effects meta-analysis. Heterogeneity was explored using meta-regression, and subgroup analyses were performed. RESULTS: We included a total of 40 studies that were conducted in 20 countries. Depression, anxiety, and psychosis were the most common mental health disorders reported in the studies. The overall pooled prevalence was 25% (95% confidence interval (CI): 14, 39) for depression, 24% (95% CI: 2, 57) for anxiety, and 10% (95% CI: 7, 14) for psychosis. There was substantial heterogeneity in the estimates. The stratified analysis showed that the prevalence of psychosis was 4% (95% CI: 0, 22) before MDR-TB treatment commencement, and 9% (95% CI: 5, 13) after MDR-TB treatment commencement. The most common social stressors reported were stigma, discrimination, isolation, and a lack of social support. Health-related quality of life was significantly lower among MDR-TB patients when compared to drug-susceptible TB patients (Q = 9.88, p = 0.01, I2 = 80%). CONCLUSIONS: This review found that mental health and social functioning are compromised in a significant proportion of MDR-TB patients, a finding confirmed by the poor health-related quality of life reported. Thus, there is a substantial need for integrating mental health services, social protection and social support into the clinical and programmatic management of MDR-TB.

Epidemiology and in-hospital outcome of stroke in South Ethiopia.

INTRODUCTION: Although the burden of stroke in Sub-Saharan Africa, including Ethiopia, is increasing, there are few available data on stroke in Ethiopia. OBJECTIVE: To describe the magnitude of risk factors, sub-types and in-hospital outcome of stroke at Hawassa University Referral Hospital, Ethiopia. METHODS: A prospective hospital-based study was conducted with all adult patients admitted to Hawassa University Referral Hospital with stroke diagnosis between May 2013 and April 2014. Computerized tomography scan was performed in all patients to confirm the type of stroke. Stroke severity at admission was assessed by the National Institute of Health Stroke Scale. Stroke outcome at discharge was measured using the modified Rankin stroke scale. RESULTS: A total of 163 stroke patients were recruited during the study period, of which 82 (50.3%) patients had ischemic stroke while 81 (49.7%) had hemorrhagic stroke. Stroke risk factors included hypertension (50.9%), cardiac diseases (16.6%), diabetes mellitus (7.4%), alcohol (10.4%), cigarette smoking (4.9%) and tuberculous meningitis (3.1%). In-hospital stroke mortality was 14.7%. The main predictors of in-hospital stroke mortality were stroke severity at admission, hemorrhagic stroke, decreased level of consciousness and seizure. CONCLUSION: The proportion of hemorrhagic stroke is higher than in Western countries. Hypertension is the most common risk factor for stroke. More than half of the patients were discharged with severe disability. We recommend establishing stroke units in resource limited countries like Ethiopia in order to reduce stroke mortality and post stroke disability.

When are patients lost to follow-up in pre-antiretroviral therapy care? a retrospective assessment of patients in an Ethiopian rural hospital.

BACKGROUND: There is concern about the increasing rates of loss to follow-up (LTFU) among pre-antiretroviral therapy (pre-ART) patients in Ethiopia. Little information is available regarding the time when pre-ART patients are lost to follow-up in the country. This study assessed the time when LTFU occurs as well as the associated factors among adults enrolled in pre-ART care in an Ethiopian rural hospital. METHODS: Data of all adult pre-ART patients enrolled at the Sheka Zonal Hospital between 2010 and 2013 were reviewed. Patients were considered lost to follow-up if they failed to keep scheduled appointments for more than 90 days. The Cox proportional hazards regression model was used to assess factors associated with time until LTFU. The Kaplan-Meier survival table was used to compare the LTFU experiences of patients, segregated by significant predictors. RESULTS: A total of 626 pre-ART patients were followed for 319.92 person-years of observation (PYOs) from enrolment to pre-ART outcomes, with an overall LTFU rate of 55.8 per 100 PYOs. A total of 178 (28.4%) pre-ART patients were lost to follow-up, 93% of which occurred within the first six months. The median follow-up time was 6.13 months. The independent predictors included: not having been started on co-trimoxazole prophylaxis (adjusted hazard ratio [AHR] = 1.77, 95% confidence interval [CI], 1.12-2.79), a baseline CD4 count of or above 350 cells/mm3 (AHR = 1.87, 95%CI, 1.02-3.45), and an undisclosed HIV status (AHR = 3.04, 95%CI, 2.07-4.45). CONCLUSION: A significant proportion of pre-ART patients is lost to follow-up. Not having been started on co-trimoxazole prophylaxis, presenting to care with a baseline CD4 cell count ≥350 cells/mm(3), and an undisclosed HIV status were significant predictors of LTFU among pre-ART patients. Thus, close monitoring and tracking of patients during this period is highly recommended. Those patients with identified risk factors deserve special attention.

Is Community Conversation Associated with Human Immunodeficiency Virus Voluntary Counseling and Testing Service Uptake in Rural Communities in Ethiopia? A Comparative Cross-sectional Study.

BACKGROUND: Voluntary counseling and testing (VCT) is a cost-effective tool to prevent and control human immunodeficiency virus (HIV)/acquired immodeficiency syndrome. Community conversation (CC) is a community-based strategy meant to enhance the community utilization of VCT. However, the role of CC in VCT service uptake has not yet been evaluated. AIMS: This study was conducted to compare VCT service utilization between rural communities with well CC performance and rural communities with poor CC performance in Shebedino woreda. MATERIALS AND METHODS: A cross-sectional comparative community-based study was conducted in 2010 among 462 selected adults in the age bracket of 15-59 years. VCT service uptake was compared between well CC performing communities and poor CC performing communities using two sample test of proportion. Predictors of VCT service uptake were determined using logistic regression model. RESULTS: Uptake of VCT service and the related VCT knowledge were statistically higher in well CC performing communities than poor CC performing communities; [73.0% vs. 54.1%, P < 0.001) vs. 97.8% vs. 93.8%, P = 0.034]. CC, VCT knowledge, and knowledge on HIV transmission were independent predictors of VCT service utilization. CONCLUSION: Uptake of VCT service is higher in well CC performing communities. Emphasis should be given to strengthen CC performance.

Tuberculosis treatment survival of HIV positive TB patients on directly observed treatment short-course in Southern Ethiopia: a retrospective cohort study.

BACKGROUND: Tuberculosis (TB) and HIV co-infection remains a major public health problem. In spite of different initiatives implemented to tackle the disease, many countries have not reached TB control targets. One of the major attributing reasons for this failure is infection with HIV. This study aims to determine the effect of HIV infection on the survival of TB patients. FINDINGS: A retrospective cohort study was employed to compare the survival between HIV positive and HIV negative TB patients (370 each) during an eight month directly observed treatment short-course (DOTS) period. TB patient's HIV status was considered as an exposure and follow up time until death was taken as an outcome. All patients with TB treatment outcomes other than death were censored, and death was considered as failure. Cox proportional hazard regression model was used to determine the hazard ratio (HR) of death for each main baseline predictor. TB/HIV co-infected patients were more likely to die; adjusted Hazard Rate (AHR) =1.6, 95%CI (1.01, 2.6) during the DOTS period. This risk was statistically higher among HIV patients during the continuation phase (p=0.0003), as a result HIV positive TB patients had shorter survival (Log rank test= 6.90, df= 2, p= 0.008). The adjusted survival probability was lower in HIV positive TB patients (< 15%) than HIV negative TB patients (> 85%) at the end of the DOTS period (8th month). CONCLUSION: TB treatment survival was substantially lower in HIV infected TB patients, especially during the continuation phase. Targeted and comprehensive management of TB/HIV with a strict follow up should be considered through the entire TB treatment period.