Determinants of Statin Initiation Among Adult Diabetic Patients in Bonga, Ethiopia.

BACKGROUND: Diabetes mellitus (DM) is a chronic degenerative disease associated with a high risk of chronic complications and comorbidities. According t the World Health Organization, 16.7 million people worldwide die of cardiovascular diseases each year. AIM OF THE STUDY: The aim of this study is to evaluate determinants of statin initiation among diabetic patients. METHODS: A hospital-based cross-sectional study was conducted to evaluate statin initiation and determinants in Gebre Tsadik Shewa General Hospital, Bonga, Ethiopia. This hospital covers a catchment population of about 1.4 million and offers diagnosis and treatment in outpatient and inpatient settings in different departments. Epi data 4.0.2.49 and STATA 14.2 were used for data entry and analysis. Before analysis, presence of co-linearity and model fitness were checked. Chi-square statistics were used to check adequacy of cells for binary logistic regression. Bivariate analysis was done and p <0.25 was included in a multivariate model. Finally p-value less than 0.05 was considered a significant predictor. RESULTS: A total of 120 patients were included in this study, of which 77 (64.17%) were males. The mean age and standard deviation was 47.04 ± 12.13 years with 75% of patients ≥40 years. The mean duration of illness was 10.26 ± 0.6 years. Ninety-eight (81.67%) patients had varying comorbidities. Sixty-four (53.33%) patients developed complications. The majority of patients were evaluated by a general practitioner (GP). Fifty-one (42.5%) patients started statins. Of them, 31 (60.78%) started for secondary prevention. The majority of patients had atorvastatin with moderate dosage. Government insurance (p=0.029), polypharmacy (0.008), physician level of training (0.023) and previous counseling of patients about the importance of statins (p<001) were significantly associated with initiation of statins. CONCLUSION: Only near to 40% of patients started statins. Physician reluctance and unavailability of drugs were the most common reasons not to initiate statins. The hospital tries to provide medication. Physicians should evaluate patients in need of cardio-protective drugs.

Correction to: Monitoring changes in malaria epidemiology and effectiveness of interventions in Ethiopia and Uganda: Beyond Garki Project baseline survey.

Please be advised that one of the author names is incorrectly spelled in the published article: 'Irene Kyomuhagi' should be 'Irene Kyomuhangi'.

Health worker and policy-maker perspectives on use of intramuscular artesunate for pre-referral and definitive treatment of severe malaria at health posts in Ethiopia.

BACKGROUND: The World Health Organization (WHO) recommends injectable artesunate given either intravenously or by the intramuscular route for definitive treatment for severe malaria and recommends a single intramuscular dose of intramuscular artesunate or intramuscular artemether or intramuscular quinine, in that order of preference as pre-referral treatment when definitive treatment is not possible. Where intramuscular injections are not available, children under 6 years may be administered a single dose of rectal artesunate. Although the current malaria treatment guidelines in Ethiopia recommend intra-rectal artesunate or alternatively intramuscular artemether or intramuscular quinine as pre-referral treatment for severe malaria at the health posts, there are currently no WHO prequalified suppliers of intra-rectal artesunate and when available, its use is limited to children under 6 years of age leaving a gap for the older age groups. Intramuscular artesunate is not part of the drugs recommended for pre-referral treatment in Ethiopia. This study assessed the perspectives of health workers, and policy-makers on the use of intramuscular artesunate as a pre-referral and definitive treatment for severe malaria at the health post level. METHODS: In-depth interviews were held with 101 individuals including health workers, malaria focal persons, and Regional Health Bureaus from Oromia and southern nations, nationalities, and peoples' region, as well as participants from the Federal Ministry of Health and development partners. An interview guide was used in the data collection and thematic content analysis was employed for analysis. RESULTS: Key findings from this study are: (1) provision of intramuscular artesunate as pre-referral and definitive treatment for severe malaria at health posts could be lifesaving; (2) with adequate training, and provision of facilities including beds, health posts can provide definitive treatment for severe malaria using intramuscular artesunate where referral is delayed or not possible; (3) health workers at health centres and hospitals frequently use the intravenous route because it allows for co-administration of other drugs, but they find the intramuscular route easier to use at the health post level; (4) the reasons commonly cited against the management of severe malaria using intramuscular artesunate at health post level were: lack of capacity to manage complications and fear of irrational drug use; (5) use of intramuscular artesunate at health post level will require evidence on safety and feasibility before policy shift. CONCLUSION: From the perspective of health workers, use of intramuscular artesunate as pre-referral treatment of severe malaria cases at the health post is possible but dependent on training and availability of skilled workers. Use of intramuscular artesunate as definitive treatment at health posts was not supported, however, operational research to establish its feasibility, safety and efficacy was recommended to guide any implementation of such an intervention.

The usefulness of school-based syndromic surveillance for detecting malaria epidemics: experiences from a pilot project in Ethiopia.

BACKGROUND: Syndromic surveillance is a supplementary approach to routine surveillance, using pre-diagnostic and non-clinical surrogate data to identify possible infectious disease outbreaks. To date, syndromic surveillance has primarily been used in high-income countries for diseases such as influenza--however, the approach may also be relevant to resource-poor settings. This study investigated the potential for monitoring school absenteeism and febrile illness, as part of a school-based surveillance system to identify localised malaria epidemics in Ethiopia. METHODS: Repeated cross-sectional school- and community-based surveys were conducted in six epidemic-prone districts in southern Ethiopia during the 2012 minor malaria transmission season to characterise prospective surrogate and syndromic indicators of malaria burden. Changes in these indicators over the transmission season were compared to standard indicators of malaria (clinical and confirmed cases) at proximal health facilities. Subsequently, two pilot surveillance systems were implemented, each at ten sites throughout the peak transmission season. Indicators piloted were school attendance recorded by teachers, or child-reported recent absenteeism from school and reported febrile illness. RESULTS: Lack of seasonal increase in malaria burden limited the ability to evaluate sensitivity of the piloted syndromic surveillance systems compared to existing surveillance at health facilities. Weekly absenteeism was easily calculated by school staff using existing attendance registers, while syndromic indicators were more challenging to collect weekly from schoolchildren. In this setting, enrolment of school-aged children was found to be low, at 54%. Non-enrolment was associated with low household wealth, lack of parental education, household size, and distance from school. CONCLUSIONS: School absenteeism is a plausible simple indicator of unusual health events within a community, such as malaria epidemics, but the sensitivity of an absenteeism-based surveillance system to detect epidemics could not be rigorously evaluated in this study. Further piloting during a demonstrated increase in malaria transmission within a community is recommended.

Clinical Performance of Emergency Surgical Officers in Southern Ethiopia.

BACKGROUND: Serious shortage of gynecologists and surgeons for several decades leading to a three-year masters level training was initiated in 2009. However, systematic analysis was not done to assess the graduates' performance. The purpose of this study was to assess improvement in access to emergency surgical and obstetrical care services. METHODS: Both quantitative and qualitative methods were employed to assess the competence of emergency surgical officers (ESOs) in their decision making and surgical skills in eight hospitals between 2012 and 2014. Anesthesia time, post-operative hospital stay and change in hemoglobin level were, among others, used as proxy indicators of their surgical skills. RESULTS: A total of 4075 obstetric and surgical operations was performed in the study hospitals. Of which, 93% were done on emergency base. Of the total emergency procedures, 3570(94%) were done by ESOs. Nearly two-thirds (63%) of all the emergency operations were cesarean sections, which were done by ESOs. Out of 239 uterine ruptures, hysterectomy was done for 58%. The proportion of cesarean and instrumental deliveries over the total deliveries were 13% and 0.7%, respectively. Explorative laparotomies and appendectomies were the majority of the non-obstetric emergency operations. Interviewed staff in the respective hospitals stated that ESOs' clinical decision making, surgical skill and commitment to discharge their responsibilities were in the best possible. CONCLUSIONS: The study showed that deployment of ESOs made the emergency surgery services accessible to the majority, and their clinical decision making and surgical skills were remarkable.

Monitoring changes in malaria epidemiology and effectiveness of interventions in Ethiopia and Uganda: Beyond Garki Project baseline survey.

BACKGROUND: Scale-up of malaria interventions seems to have contributed to a decline in the disease but other factors may also have had some role. Understanding changes in transmission and determinant factors will help to adapt control strategies accordingly. METHODS: Four sites in Ethiopia and Uganda were set up to monitor epidemiological changes and effectiveness of interventions over time. Here, results of a survey during the peak transmission season of 2012 are reported, which will be used as baseline for subsequent surveys and may support adaptation of control strategies. Data on malariometric and entomological variables, socio-economic status (SES) and control coverage were collected. RESULTS: Malaria prevalence varied from 1.4 % in Guba (Ethiopia) to 9.9 % in Butemba (Uganda). The most dominant species was Plasmodium vivax in Ethiopia and Plasmodium falciparum in Uganda. The majority of human-vector contact occurred indoors in Uganda, ranging from 83 % (Anopheles funestus sensu lato) to 93 % (Anopheles gambiae s.l.), which is an important factor for the effectiveness of insecticide-treated nets (ITNs) or indoor residual spraying (IRS). High kdr-L1014S (resistance genotype) frequency was observed in A. gambiae sensu stricto in Uganda. Too few mosquitoes were collected in Ethiopia, so it was not possible to assess vector habits and insecticide resistance levels. ITN ownership did not vary by SES and 56-98 % and 68-78 % of households owned at least one ITN in Ethiopia and Uganda, respectively. In Uganda, 7 % of nets were purchased by households, but the nets were untreated. In three of the four sites, 69-76 % of people with access to ITNs used them. IRS coverage ranged from 84 to 96 % in the three sprayed sites. Half of febrile children in Uganda and three-quarters in Ethiopia for whom treatment was sought received diagnostic tests. High levels of child undernutrition were detected in both countries carrying important implications on child development. In Uganda, 7-8 % of pregnant women took the recommended minimum three doses of intermittent preventive treatment. CONCLUSION: Malaria epidemiology seems to be changing compared to earlier published data, and it is essential to have more data to understand how much of the changes are attributable to interventions and other factors. Regular monitoring will help to better interpret changes, identify determinants, modify strategies and improve targeting to address transmission heterogeneity.

Individual and household factors associated with use of insecticide treated nets in southern Ethiopia.

BACKGROUND: Although mass distribution has been considered as the best method to rapidly scale up the coverage of long-lasting insecticidal nets (LLINs) for malaria prevention, little information is available on determinants associated with net utilization at local settings. We studied individual and household factors associated with LLIN use in Halaba district in southern Ethiopia. METHODS: This is a population-based survey conducted in October 2008 in 16 randomly selected villages. Data on individual and household characteristics, LLIN ownership and use were collected through house-to-house visits. Univariate and multiple logistic regression models were used to examine the effect of each independent variable on LLIN use by respondents. RESULTS: A total of 1235 households participated in the study, and 755/1235 (61.1%) had owned at least one LLIN. Among LLIN-owning households, 419/629 (66.6%) children under the age of five years and 33/55 (60.0%) pregnant women slept under an LLIN the night before the survey. The number of LLINs hung in the household (adjusted OR [aOR] 13.2, 95% CI: 3.7-47.5) and knowledge about malaria (aOR 2.3, 95% CI: 1.2-4.5) were the two important predictors associated with LLINs use. CONCLUSIONS: A substantial gap between net ownership and use was identified. Hanging nets and knowledge of malaria predict higher odds of sleeping under an LLIN the previous night. More intensive research on factors that contribute to low LLIN usage is needed.

Effect of combining mosquito repellent and insecticide treated net on malaria prevalence in Southern Ethiopia: a cluster-randomised trial.

BACKGROUND: A mosquito repellent has the potential to prevent malaria infection, but there has been few studies demonstrating the effectiveness of combining this strategy with the highly effective long-lasting insecticidal nets (LLINs). This study aimed to determine the effect of combining community-based mosquito repellent with LLINs in the reduction of malaria. METHODS: A community-based clustered-randomised trial was conducted in 16 rural villages with 1,235 households in southern Ethiopia between September and December of 2008. The villages were randomly assigned to intervention (mosquito repellent and LLINs, eight villages) and control (LLINs alone, eight villages) groups. Households in the intervention villages received mosquito repellent (i.e., Buzz-Off petroleum jelly, essential oil blend) applied every evening. The baseline survey was followed by two follow-up surveys, at one month interval. The primary outcome was detection of Plasmodium falciparum, Plasmodium vivax, or both parasites, through microscopic examination of blood slides. Analysis was by intention to treat. Baseline imbalances and clustering at individual, household and village levels were adjusted using a generalized linear mixed model. RESULTS: 3,078 individuals in intervention and 3,004 in control group were enrolled into the study. Compared with the control arm, the combined use of mosquito repellent and LLINs significantly reduced malaria infection of all types over time [adjusted Odds Ratio (aOR) = 0.66; 95% CI = 0.45-0.97]. Similarly, a substantial reduction in P. falciparum malaria infection during the follow-up surveys was observed in the intervention group (aOR = 0.53, 95% CI = 0.31-0.89). The protective efficacy of using mosquito repellent and LLINs against malaria infection of both P. falciparum/P. vivax and P. falciparum was 34% and 47%, respectively. CONCLUSIONS: Daily application of mosquito repellent during the evening followed by the use of LLINs during bedtime at community level has significantly reduced malaria infection. The finding has strong implication particularly in areas where malaria vectors feed mainly in the evening before bedtime. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01160809.

Can interferon-gamma or interferon-gamma-induced-protein-10 differentiate tuberculosis infection and disease in children of high endemic areas?

BACKGROUND: Diagnosis of childhood tuberculosis (TB) is difficult in high TB burden settings. Interferon-gamma-induced protein 10 (IP10) has been suggested as a marker of TB infection and disease, but its ability to differentiate the two conditions remains uncertain. OBJECTIVES: To describe Interferon-gamma (INFγ) and IP10 expression in children with TB infection and disease and controls to assess their potential to differentiate latent and active TB. METHODS: This was a cross sectional study of 322 1-15 years old children with symptoms of TB (28 confirmed, 136 probable and 131 unlikely TB), 335 children in contact with adults with pulmonary TB and 156 community controls in Southern Ethiopia. The Tuberculin Skin Test (TST) and Quantiferon-In-Tube (QFT-IT) were performed. INFγ and IP10 were measured in plasma supernatants. RESULTS AND INTERPRETATION: Children with confirmed and probable TB and contacts were more likely to have TST+ (78.6%, 59.3% and 54.1%, respectively) than children with unlikely TB (28.7%) and controls (12.8%) (p<0.001). Children with confirmed TB (59.3%) and contacts (44.7%) were more likely to have INFγ+ than children with probable (37.6%) or unlikely TB (28.1%) and controls (13.1%) (p<0.001). IP10 concentrations were higher in INFγ+ children independently of TST (p<0.001). There was no difference between IP10 concentrations of children with confirmed TB and contacts (p = 0.8) and children with and without HIV (p>0.1). INFγ and IP10 can identify children with TB infection and disease, but cannot differentiate between the two conditions. HIV status did not affect the expression of IP10.