Ticks and tick-borne pathogens in livestock from nomadic herds in the Somali Region, Ethiopia.

Between May 2006 and January 2007, blood samples and ticks were randomly collected from 220 nomadic animals from Filtu and Dollo Odo districts, Libaan zone, in the Somali Region of Ethiopia. Overall, 81.5% cattle, 98.2% camels, 53.4% goats and 61.1% sheep were infested by ixodid ticks. Collected ticks (n = 1,036) were identified as Rhipicephalus pulchellus (40.1%), R. pravus (25.8%), Amblyomma gemma (9.4%), Hyalomma rufipes (13.3%), H. truncatum (2.8%), H. impeltatum (1.2%) and H. dromedarii (0.5%); immature stages (6.1%) belonged to the genera Rhipicephalus and Amblyomma. Tick infestation burden was evaluated by the Tick Abundance Score method on 57 animals from Dollo Odo in August 2006, and it was significantly higher in cattle and camels than in small ruminants (p < 0.001). Reverse Line Blot Hybridisation was applied to detect Theileria, Babesia, Ehrlichia and Anaplasma spp. Five out of 50 blood samples from Filtu, four from cattle and, surprisingly, one from a camel, were positive for Theileria mutans and two from cattle for T. velifera. Adult ticks (n = 104) from both districts were tested and A. gemma from cattle were positive to T. velifera (1) and Ehrlichia ruminantium (5 samples). Positive E. ruminantium samples were also tested by PCR targeting pCS20 and 16S rRNA genes and submitted to DNA sequencing. The phylogenetic reconstruction of pCS20 fragment showed the presence of the Somali region sequences in the East-South African group. Our results are the first available on ticks and selected tick-borne diseases from the Somali region of Ethiopia and could be used as preliminary information for planning sustainable control strategies for tick and tick-borne pathogens in the study area and in neighbouring areas with similar socio-ecological features.

Dynamics of impairment during and after treatment: the AMFES cohort.

This study investigates the dynamics of impairment during and after multidrug therapy treatment for the patient cohort of the prospective ALERT MDT Field Evaluation Study (AMFES). The impairment status was compared at intake, at release from treatment (rft), and at the time of the latest survey between 24 and 48 months after release from treatment (follow-up). The eye-hand-foot impairment score (EHF score), which is the sum of the WHO impairment grades of the eyes, hands, and feet, was used as tool for comparison. In all, 433 out of the 592 patients (224 PB and 209 MB) completed treatment in time and were assessed at release from treatment. The risk of getting impaired was 4% for the 113 PB and 21% for the 91 MB patients who were initially free from impairment. Out of the 111 initially impaired PB patients, 41% recovered or improved and 13% worsened in EHF score. For the 118 initially impaired MB patients, these figures were: recovery or improvement 43% and worsening 13%. Three hundred and twenty-three out of the 433 patients (158 PB and 165 MB) had a follow-up examination in between the next 24-48 months after rft. The risks of impairment at follow-up were 6% for the 79 PB and 18% for the 77 MB patients without impairment at rft. Out of the 79 PB patients with impairment at rft, 35% recovered or improved and 28% worsened. For the 88 impaired MB patients, these figures were: recovery or improvement 26% and worsening 27%. Patients showed a tendency to compensate EHF score improvement before rft by worsening after rft and vice versa. The first main conclusion is that the impairment status at intake was by far the most important determinant for future impairment. The second one is that the dynamics of impairment were less favourable after rft than before. Little is known about the long-term fate of leprosy patients with irreversible nerve damage and the associated risk of developing severe secondary impairment. Especially in this era of the leprosy elimination goal, we should give this accumulating patient group due attention in research and health policy agendas.

The ALERT MDT Field Evaluation Study (AMFES): a descriptive study of leprosy in Ethiopia. Patients, methods and baseline characteristics.

The ALERT MDT Field Evaluation Study (AMFES) is a long-term prospective study of 650 patients (594 new cases and 56 relapses after dapsone monotherapy), treated with fixed-duration multiple-drug therapy (MDT), as recommended by WHO. Follow-up has continued for up to 11 years from the start of treatment. This paper presents the methodology of the study and the baseline characteristics of the cohort, while accompanying papers examine the incidence of, and possible risk factors for, the various complications of leprosy, including relapse, reactions and nerve function impairment. The methods of diagnosis, classification and treatment with MDT are described; nerve function was assessed at every visit to the clinic using a standardized methodology, so that reactions and new impairment could be detected early and treated. Eighty-four per cent of new case had at least one thickened nerve, with the ulnar nerve most commonly involved. Seventy-seven per cent of cases completed treatment and only one adverse reaction to the MDT drugs was noted. Twenty-eight per cent of all patients were given steroids at one time or another, almost always for new nerve function impairment, and 3% of these developed significant complications of steroid treatment. Twenty-nine patients (5%) received hospital care, including 14 patients who underwent major surgery. Sixty-one per cent of the women over 19 years of age had at least one pregnancy, but pregnancies were much less common after leprosy was diagnosed.

The pattern of leprosy-related neuropathy in the AMFES patients in Ethiopia: definitions, incidence, risk factors and outcome.

The ALERT MDT Field Evaluation Study (AMFES) began in 1988 and followed patients prospectively for up to 10 years after release from treatment (RFT). This paper presents the findings from this cohort with regard to neuropathy and nerve damage. Five hundred and ninety-four new cases of leprosy are included in the study, 300 multibacillary (MB) and 294 paucibacillary (PB) cases. Fifty-five percent of patients had some degree of impairment at diagnosis and a further 73 (12%) developed new nerve function impairment (NFI) after starting multiple drug therapy (MDT). The overall incidence rate for neuropathy was 39 episodes per 100 PYAR in the first year after diagnosis, gradually declining to 12 episodes per 100 PYAR in the sixth year. In those patients without impairment at diagnosis, the incidence rate of neuropathy was 25 episodes per 100 PYAR for MB cases and 11 per 100 PYAR for PB cases in the first year; in 33% of MB cases whose first episode of neuropathy occurred after diagnosis, that first episode took place after the first year, or after the normal period of treatment with MDT. Seventy-three patients with neuropathy developing after diagnosis are reported more fully: 34 (47%) had only one nerve involved and of these 25 (73%) had a single, acute episode of neuropathy. Nine (27%) had further episodes. Thirty-nine (53%) had more than one nerve involved and of these 16 (41%) had a single, acute episode, while 23 (59%) had further episodes. The terms 'chronic' and 'recurrent' neuropathy are defined and used to describe the pattern of neuropathy in those with repeated attacks. In patients with no impairment at the start of the study, treatment with steroids resulted in full recovery in 88% of nerves with acute neuropathy but only 51% of those with chronic or recurrent neuropathy. The median time to full recovery from acute neuropathy was approximately 6 months, but in a few cases recovery occurred gradually over 2-3 years. Severe neuropathy was less likely to be followed by a complete recovery than mild or moderate neuropathy. Forty-two percent of nerves with acute neuropathy that were not treated with steroids also fully recovered. In the group of patients who were thought to have old, permanent impairments at diagnosis, full recovery of nerve function occurred in 87/374 (23%) of the nerves involved. The overall outcome is illustrated by examining the average EHF score for groups of patients. Patients with no new neuropathy after diagnosis show a gradual improvement in their EHF score, while those with any episodes of neuropathy after diagnosis show a gradual deterioration after completion of MDT. Possible explanations for these findings are discussed. Risk factors for neuropathy, for chronic and recurrent neuropathy, and for a poor outcome 5 years after release from treatment, are examined. Impairment at diagnosis was the main risk factor for a poor outcome, accompanied by the occurrence of chronic/recurrent neuropathy or a reversal reaction.

Reversal reactions in the skin lesions of AMFES patients: incidence and risk factors.

Reversal reactions affect the skin and/or nerves of leprosy patients. This paper looks at reversal reactions involving the skin in 594 new patients in central Ethiopia, followed for between 6 and 11 years after the start of treatment. The incidence of reversal reaction declines steadily after the start of treatment, but the first episode may occur as long as 5 years after diagnosis in both paucibacillary (PB) and multibacillary (MB) patients. Recurrent episodes occurred up to 6 years after diagnosis. PB patients were at greatest risk for reversal reaction in the first year after diagnosis and MB patients in the first 4 years. The highest incidence rate was 18 episodes per 100 person years in MB patients during the first year after diagnosis. The ratio of the incidence rates for the first 3 years in MB versus PB patients is 2.4 (95% CI 1.6-3.8). This study confirms that starting effective treatment and borderline classification are risk factors for reversal reactions. Pregnancy/delivery in the 6 months prior to diagnosis was a significant risk factor for presenting with a reversal reaction [relative risk (RR) 5.9 (95% CI 2.1-16.5)], but later pregnancies were not associated with an increased risk. Being female was a significant risk factor for the late appearance of the first episode of reversal reaction. Having a reversal reaction in the first year after diagnosis was a highly significant risk factor for the development of later reactions [RR in PB cases 11.9 (95% CI 3.4-41.7); in MB cases 6.4 (95% CI 3.8-10.6)]. Being HIV positive was a risk factor for developing recurrent reversal reactions, although only three out of 29 recurrent cases were HIV positive [RR 2.7 (95% CI 1.4-5.1)].

ENL reactions in the multibacillary cases of the AMFES cohort in central Ethiopia: incidence and risk factors.

Erythema nodosum leprosum (ENL), or type 2 leprosy reactions are an important complication of multibacillary leprosy. The AMFES cohort includes 300 new multibacillary cases that have been followed for up to 10 years from the start of treatment, in central Ethiopia. Sixteen (5.3%) patients had ENL reactions. The incidence of ENL was maximal in the second and third years after the start of treatment, reaching 6.9 episodes per 100 person years at risk. Factors associated with being lepromatous [LL classification and a high bacillary index (BI)] gave an increased risk of developing ENL; in the univariate analysis, LL classification gave a relative risk of 3.6 (95% CI 1.3-10) and a BI of 6 gave a relative risk of 8.6 (95% CI 2.3-32) for the development of ENL. HIV co-infection was found to be a risk factor in this cohort, but as the numbers involved are small (only two HIV positive patients had ENL), this finding must be confirmed in larger studies. Ten of the 16 cases had recurrent episodes and five had at least five episodes occurring over a period of more than 2 years. The management and prognosis of ENL reactions are discussed.

Relapses after fixed duration multiple drug therapy: the AMFES cohort.

Relapse rates after multiple-drug therapy (MDT) have been low, although there remains a concern about the possibility of late relapse in those with an initially high bacterial load. In all, 502 patients in the AMFES cohort completed fixed-duration MDT and are included in this report. There have been no confirmed relapses in the AMFES cohort, in a follow-up period of up to 8 years after completion of treatment, even in the 57 cases with an initial average bacillary index of > or = 4.0, 20 of whom have been followed for more than 5 years after ceasing MDT. Methods of diagnosing a relapse are discussed.

The effect of HIV status on the clinical picture of leprosy: a prospective study in Ethiopia.

No major interaction between HIV infection and leprosy has been documented. The ALERT MDT Field Evaluation Study (AMFES) has allowed the examination of possible interactions in a prospective manner, although the total number of HIV-positive individuals was not high at 22 (3.8%) of 581 patients tested. There was an excess number of deaths in the HIV-positive group: 27% compared with 5.7% in the HIV-negative group, although the causes of death were not recorded (relative risk 4.8; 95% CI 2.2-10.2). HIV-positive individuals had a higher risk of ENL reactions (relative risk 5.2; 95% CI 1.7-15.9). Reversal reactions and neuritis (both acute and chronic) were not significantly influenced by HIV status, although there was a possible increase in recurrent reversal reactions in HIV-positive cases (relative risk 2.2; 95% CI 0.98-4.7). There was no evidence to suggest an increased risk of developing leprosy or of developing multibacillary rather than paucibacillary disease. There was no association between HIV positivity and the development of impairment.

Factors associated with impairments in new leprosy patients: the AMFES cohort.

Data on the importance of the delay between onset of symptoms and registration as a risk factor for impairment are sparse. This study investigates the quantitative relationship between this delay, other risk factors and the impairment status in new leprosy patients. It reports on 592 new leprosy patients enrolled in 1988-1992 in the prospective ALERT MDT Field Evaluation Study in central Ethiopia (AMFES). The influence of the risk factors sex, age, delay, PB/MB classification in relation to BI, and prior dapsone treatment on the impairment status at intake is analysed. Estimates for the delay are based on patient recall. For the risk factors, odds ratios on impairment and on severity of impairment were calculated using both univariate and multivariate logistic regression. The registration delay was 2 years or more for 44% of new patients. The prevalence of impairment (WHO impairment grades 1 and 2 combined) increased continuously from 36% for new patients with a delay of 0-1 year to 81% for new patients with delays of 4 years or more. This prevalence also increased continuously with age; it rose from 26% in children to 80% for the age group 60 and over. In the multivariate regression, the odds ratios for new patients to be impaired were statistically significant for all delay categories (baseline 1-2 years) and age groups (baseline 15-29 years). No statistically significant differences in odds ratios were observed with respect to sex and PB/MB classification in relation to BI. Overall, 31% of new patients presented with WHO impairment grade 1 and 23% with grade 2. The risk on grade 2 also increased with the registration delay amongst the impaired new patients. Relatively few impaired males and relatively few impaired MB patients with a BI value of 3 or higher had grade 2 impairment. Registration delay and age are the main risk factors for presentation with impairment. Reduction of delay in central Ethiopia requires re-thinking of control methodologies. The search for ways to reduce delays in diagnosis and treatment should receive high priority in leprosy research and in leprosy control programmes.

Delay in presentation and start of treatment in leprosy patients: a case-control study of disabled and non-disabled patients in three different settings in Ethiopia.

The delay incurred by leprosy patients between the onset of symptoms and the start of treatment has not been well characterized. Because reducing this delay is likely to be the most productive of all activities aimed at preventing disability, we compared the various components of delay in disabled and nondisabled new leprosy cases in a case-control study. Disabled patients had a median overall delay of 26 months, while nondisabled patients incurred a delay of only 12 months. The total delay was divided into three components: a) the delay between the onset of symptoms and the first act of health-seeking behavior, which was significantly longer for disabled patients; b) the delay between the first action and the first visit to a recognized clinic, which was also significantly longer for disabled patients; and c) the delay between the first clinic visit and the start of treatment, which was important in some cases: in those patients whose delay was due to problems within the health services, disabled patients again had a significantly longer delay. The study also compared two rural areas of Ethiopia, one with high and one with low rates of disability in new cases. High rates of disability (and greater delay in starting treatment) were thus associated with high levels of stigma, being from the Christian rather than the Muslim community, and the use of traditional medicine. There was, surprisingly, no association with knowledge about the transmission, symptoms and curability of leprosy. Implications for health promotion activities are discussed.