Community-Based Interventions for Newborns in Ethiopia (COMBINE): Cost-effectiveness analysis.

About 87 000 neonates die annually in Ethiopia, with slower progress than for child deaths and 85% of births are at home. As part of a multi-country, standardized economic evaluation, we examine the incremental benefit and costs of providing management of possible serious bacterial infection (PSBI) for newborns at health posts in Ethiopia by Health Extension Workers (HEWs), linked to improved implementation of existing policy for community-based newborn care (Health Extension Programme). The government, with Save the Children/Saving Newborn Lives and John Snow, Inc., undertook a cluster randomized trial. Both trial arms involved improved implementation of the Health Extension Programme. The intervention arm received additional equipment, support and supervision for HEWs to identify and treat PSBI. In 2012, ∼95% of mothers in the study area received at least one pregnancy or postnatal visit in each arm, an average of 5.2 contacts per mother in the intervention arm (4.9 in control). Of all visits, 79% were conducted by volunteer community health workers. HEWs spent around 9% of their time on the programme. The financial cost per mother and newborn was $34 (in 2015 USD) in the intervention arm ($27 in control), economic costs of $37 and $30, respectively. Adding PSBI management at community level was estimated to reduce neonatal mortality after day 1 by 17%, translating to a cost per DALY averted of $223 or 47% of the GDP per capita, a highly cost-effective intervention by WHO thresholds. In a routine situation, the intervention programme cost would represent 0.3% of public health expenditure per capita and 0.5% with additional monthly supervision meetings. A platform wide approach to improved supervision including a dedicated transport budget may be more sustainable than a programme-specific approach. In this context, strengthening the existing HEW package is cost-effective and also avoids costly transfers to health centres/hospitals.

Assessment of the impact of quality improvement interventions on the quality of sick child care provided by Health Extension Workers in Ethiopia.

BACKGROUND: Ethiopia has scaled up integrated community case management of childhood illness (iCCM), including several interventions to improve the performance of Health Extension Workers (HEWs). We assessed associations between interventions to improve iCCM quality of care and the observed quality of care among HEWs. METHODS: We assessed iCCM implementation strength and quality of care provided by HEWs in Ethiopia. Multivariate logistic regression analyses were performed to assess associations between interventions to improve iCCM quality of care and correct management of iCCM illnesses. FINDINGS: Children who were managed by an HEW who had attended a performance review and clinical mentoring meeting (PRCMM) had 8.3 (95% confidence interval (CI) 2.34-29.51) times the odds of being correctly managed, compared to children managed by an HEW who did not attend a PRCMM. Management by an HEW who received follow-up training also significantly increased the odds of correct management (odds ratio (OR) = 2.09, 95% CI 1.05-4.18). Supervision on iCCM (OR = 0.63, 95% CI 0.23-1.72) did not significantly affect the odds of receiving correct care. CONCLUSIONS: These results suggest PRCMM and follow-up training were effective interventions, while implementation of supportive supervision needs to be reviewed to improve impact.

Reduction in child mortality in Ethiopia: analysis of data from demographic and health surveys.

BACKGROUND: To examine changes in under-5 mortality, coverage of child survival interventions and nutritional status of children in Ethiopia between 2000 and 2011. Using the Lives Saved Tool, the impact of changes in coverage of child survival interventions on under-5 lives saved was estimated. METHODS: Estimates of child mortality were generated using three Ethiopia Demographic and Health Surveys undertaken between 2000 and 2011. Coverage indicators for high impact child health interventions were calculated and the Lives Saved Tool (LiST) was used to estimate child lives saved in 2011. RESULTS: The mortality rate in children younger than 5 years decreased rapidly from 218 child deaths per 1000 live births (95% confidence interval 183 to 252) in the period 1987-1991 to 88 child deaths per 1000 live births in the period 2007-2011 (78 to 98). The prevalence of moderate or severe stunting in children aged 6-35 months also declined significantly. Improvements in the coverage of interventions relevant to child survival in rural areas of Ethiopia between 2000 and 2011 were found for tetanus toxoid, DPT3 and measles vaccination, oral rehydration solution (ORS) and care-seeking for suspected pneumonia. The LiST analysis estimates that there were 60 700 child deaths averted in 2011, primarily attributable to decreases in wasting rates (18%), stunting rates (13%) and water, sanitation and hygiene (WASH) interventions (13%). CONCLUSIONS: Improvements in the nutritional status of children and increases in coverage of high impact interventions most notably WASH and ORS have contributed to the decline in under-5 mortality in Ethiopia. These proximal determinants however do not fully explain the mortality reduction which is plausibly also due to the synergistic effect of major child health and nutrition policies and delivery strategies.

Assessing the Quality of Sick Child Care Provided by Community Health Workers.

BACKGROUND: As community case management of childhood illness expands in low-income countries, there is a need to assess the quality of care provided by community health workers. This study had the following objectives: 1) examine methods of recruitment of sick children for assessment of quality of care, 2) assess the validity of register review (RR) and direct observation only (DO) compared to direct observation with re-examination (DO+RE), and 3) assess the effect of observation on community health worker performance. METHODS: We conducted a survey to assess the quality of care provided by Ethiopian Health Extension Workers (HEWs). The sample of children was obtained through spontaneous consultation, HEW mobilization, or recruitment by the survey team. We assessed patient characteristics by recruitment method. Estimates of indicators of quality of care obtained using RR and DO were compared to gold standard estimates obtained through DO+RE. Sensitivity, specificity, and the area under receiver operator characteristic curve (AUC) were calculated to assess the validity of RR and DO. To assess the Hawthorne effect, we compared estimates from RR for children who were observed by the survey team to estimates from RR for children who were not observed by the survey team. RESULTS: Participants included 137 HEWs and 257 sick children in 103 health posts, plus 544 children from patient registers. Children mobilized by HEWs had the highest proportion of severe illness (27%). Indicators of quality of care from RR and DO had high sensitivity for most indicators, but specificity was low. The AUC for different indicators from RR ranged from 0.47 to 0.76, with only one indicator above 0.75. The AUC of indicators from DO ranged from 0.54 to 1.0, with three indicators above 0.75. The differences between estimates of correct care for observed versus not observed children were small. CONCLUSIONS: Mobilization by HEWs and recruitment by the survey teams were feasible, but potentially biased, methods of obtaining sick children. Register review and DO underestimated performance errors. Our data suggest that being observed had only a small positive effect on the performance of HEWs.

Local understandings of care during delivery and postnatal period to inform home based package of newborn care interventions in rural Ethiopia: a qualitative study.

BACKGROUND: Despite a substantial decrease in child mortality in Ethiopia over the past decade, neonatal mortality remains unchanged (37/1000 live-births). This paper describes a qualitative study on beliefs and practices on immediate newborn and postnatal care in four rural communities of Ethiopia conducted to inform development of a package of community-based interventions targeting newborns. METHODS: The study team conducted eight key informant interviews (KII) with grandmothers, 27 in-depth interviews (IDI) with mothers; seven IDI with traditional birth attendants (TBA) and 15IDI with fathers, from four purposively selected communities located in Sidama Zone of Southern Nationalities, Nations, and Peoples (SNNP) Region and in East Shewa and West Arsi Zones of Oromia Region. RESULTS: In the study communities deliveries occurred at home. After cutting the umbilical cord, the baby is put to the side of the mother, not uncommonly with no cloth covering. This is largely due to attendants focusing on delivery of the placenta which is reinforced by the belief that the placenta is the 'house' or 'blanket' of the baby and that any "harm" caused to the placenta will transfer to the newborn. Applying butter or ointment to the cord "to speed drying" is common practice. Initiation of breastfeeding is often delayed and women commonly report discarding colostrum before initiating breastfeeding. Sub-optimal breastfeeding practices continue, due to perceived inadequate maternal nutrition and breast milk often leading to the provision of herbal drinks. Poor thermal care is also demonstrated through lack of continued skin-to-skin contact, exposure of newborns to smoke, frequent bathing-often with cold water baths for low-birth weight or small babies; and, poor hygienic practices are reported, particularly hand washing prior to contact with the newborn. CONCLUSION: Cultural beliefs and newborn care practices do not conform to recommended standards. Local perspectives related to newborn care practices should inform behaviour change messages. Such messages should target mothers, grandmothers, TBAs, other female family members and fathers.

Integrated community case management of childhood illness in Ethiopia: implementation strength and quality of care.

Ethiopia has scaled up integrated community case management of childhood illness (iCCM) in most regions. We assessed the strength of iCCM implementation and the quality of care provided by health extension workers (HEWs). Data collectors observed HEWs' consultations with sick children and carried out gold standard re-examinations. Nearly all HEWs received training and supervision, and essential commodities were available. HEWs provided correct case management for 64% of children. The proportions of children correctly managed for pneumonia, diarrhea, and malnutrition were 72%, 79%, and 59%, respectively. Only 34% of children with severe illness were correctly managed. Health posts saw an average of 16 sick children in the previous 1 month. These results show that iCCM can be implemented at scale and that community-based HEWs can correctly manage multiple illnesses. However, to increase the chances of impact on child mortality, management of severe illness and use of iCCM services must be improved.

Performance of Ethiopia's health system in delivering integrated community-based case management.

BACKGROUND: Analyzing complex health programs by their components and sub-components serves design, documentation, evaluation, research, and gap identification and prioritization. In 2012, we developed a rapid methodology to characterize integrated community case management (iCCM) programs, by assessing benchmarks for eight health system components in three program phases. OBJECTIVE. To assess iCCM benchmarks in Ethiopia three years after scale-up commenced, and to compare the benchmarks across the geographical region. METHODS. Six national iCCM experts scored each of 70 benchmarks (no, partial, or yes) and then were facilitated to reach consensus. RESULTS. Overall, iCCM benchmark achievement in Ethiopia was high (87.3%), highest for pre-introduction (93.0%), followed by introduction (87.9%) and scale-up (78.1%) phases. Achievement by system component was highest for coordination and policy (94.2%) and lowest for costing and finance (70.3%). Six regional, countries benchmark assessments, including two from Ethiopia 14 months apart, were highly correlated with program duration at scale (correlation coefficient: +0.88). CONCLUSION: Ethiopia has a mature, broad-based iCCM program. Despite limitations, the method described here rapidly, systematically, and validly characterized a complex program and highlighted areas for attention through government or partners.

Coverage and equitability of interventions to prevent child mortality in rural Jimma and West Hararghe Zones, Oromia Region, Ethiopia.

BACKGROUND: Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care, there is little evidence on equitability of preventive interventions in Ethiopia. PURPOSE: This article describes coverage of preventive interventions and how many interventions individual children received We also examined which factors were associated with the number of preventive interventions received, and assessed the extent to which interventions were equitably distributed. METHODS: We conducted a cross-sectional survey in 3,200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Mul- tiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally, we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles. RESULTS: Coverage was less than 50% for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone, gender, caretaker age, religion, and household wealth were all significantly associated with co-coverage, controlling for key covariates. Exclusive breastfeeding, vaccine uptake, and vitamin A supplementation were all relatively equitable. On the other hand, coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile. CONCLUSION: Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed, there were marked wealth-based inequities for interventions that are possessed at the household level, even among relatively homogeneous rural communities.

Integrated community case management: quality of care and adherence to medication in Beneshangul-Gumuz Region, Ethiopia.

BACKGROUND: The International Rescue Committee (IRC) supports implementation of integrated Community Case Management (iCCM) in all 20 woredas (districts) of Benishangul Gumuz Region (BSG) in Ethiopia. OBJECTIVES: To identify the gaps in the provision of quality iCCM services provided by Health Extension Workers (HEWs) and to assess caregivers' adherence to prescribed medicines for children under five years of age. METHODS: We conducted a cross-sectional descriptive study with both quantitative and qualitative study methods. We interviewed 233 HEWs and 384 caregivers, reviewed HEW records of 1,082 cases, and organized eight focus groups. RESULTS: Most cases (98%) seen by HEWs were children 2-59 months old, and 85% of the HEWs did not see any sick young infant. The HEWs' knowledge on assessments and classification and need for referral of cases was above 80%. However; some reported challenges, especially in carrying out assessment correctly and not checking for danger signs. Over 90% of caretakers reported compliance with HEWs' prescription. CONCLUSION: Partners have successfully deployed trained HEWs who can deliver iCCM according to protocol; however, additional support is needed to assure a supply of medicines and to mobilize demand for services, especially for young infants.

National Scale-Up of Integrated Community Case Management in Rural Ethiopia: Implementation and Early Lessons Learned

Background. Although under-five mortality in Ethiopia has decreased 67in the past two decades; many children still die from preventable or treatable conditions; mainly pneumonia; newborn problems; diarrhea; malaria and malnutrition. Most of these deaths can be avoided with timely and appropriate care; but access to and use of treatment remains inadequate. Community health workers appropriately trained; supervised; and supplied with essential equipment and medicines; can deliver case management or referral to most sick children. In 2010; Ethiopia added pneumonia to diarrhea; malaria and severe acute malnutrition; targeted for treatment in the integrated community case management (iCCM) strategy. Purpose. This article describes the national scale-up of iCCM implementation and early lessons learned. Methods. We reviewed data related to iCCM program inputs and processes from reports; minutes; and related documents from January 2010 through July 2013. We describe introduction and scale-up through eight health system components. Results.The government and partners trained and supplied 27;116 of the total 32;000 Health Extension Workers and mentored 80 of them to deliver iCCM services to over one million children. The government led a strong iCCM partnership that attracted development partners inimplementation; monitoring; evaluation; and research. Service utilization and weak supply chain remain major challenges. Conclusion:Strong MOH leadership; policy support; and national partnerships helped successful national iCCM scale-up and should help settle remaining challenges

Performance of Ethiopia's Health System in Delivering Integrated Community-Based Case Management

Background. Analyzing complex health programs by their components and subcomponents serves design; documentation; evaluation; research; and gap identification and prioritization. In 2012; we developed a rapid methodology to characterize integrated community case management (iCCM) programs by assessing benchmarks for eight health system components in three program phases. Objective. To assess iCCM benchmarks in Ethiopia three years after scale-up commenced; and to compare the benchmarks across the geographical region. Methods. Six national iCCM experts scored each of 70 benchmarks (no; partial; or yes) and then were facilitated to reach consensus. Results. Overall; iCCM benchmark achievement in Ethiopia was high (87.3); highest for pre-introduction (93.0); followed by introduction (87.9) and scale-up (78.1) phases. Achievement bysystem component was highest for coordination and policy (94.2) and lowest for costing and finance (70.3). Six regional countries' benchmark assessments; including two from Ethiopia 14 months apart; were highly correlated with program duration at scale (correlation coefficient: +0.88). Conclusion. Ethiopia has a mature; broad-based iCCM program. Despite limitations; the method described here rapidly; systematically; and validly characterized a complex program and highlighted areas for attention through government or partners

Coverage and Equitability of Interventions to Prevent Child Mortality in Rural Jimma and West Hararghe Zones; Oromia Region; Ethiopia

Background: Interventions to prevent childhood illnesses are important components of the Ethiopian Health Extension Program (HEP). Although the HEP was designed to reduce inequities in access to health care; there is little evidence on equitability of preventive interventions in Ethiopia. Purpose: This article describes coverage of preventive interventions and how many interventions individual children received. We also examined which factors were associated with the number of preventive interventions received; and assessed the extent to which interventions were equitably distributed. Methods: We conducted a cross-sectional survey in 3;200 randomly selected households in the rural Jimma and West Hararghe Zones of Ethiopia's Oromia Region. We calculated coverage of 10 preventive interventions and a composite of eight interventions (co-coverage) representing the number of interventions received by children. Multiple linear regressions were used to assess associations between co-coverage and explanatory variables. Finally; we assessed the equitability of preventive interventions by comparing coverage among children in the poorest and the least poor wealth quintiles. Results: Coverage was less than 50 for six of the 10 interventions. Children received on average only three of the eight interventions included in the co-coverage calculation. Zone; gender; caretaker age; religion; and household wealth were all significantly associated with co-coverage; controlling for key covariates. Exclusive breastfeeding; vaccine uptake; and vitamin A supplementation were all relatively equitable. On the other hand; coverage of insecticide-treated nets or indoor residual spraying (ITN/IRS) and access to safe water were significantly higher among the least poor children compared to children in the poorest quintile. Conclusion: Coverage of key interventions to prevent childhood illnesses is generally low in Jimma and West Hararghe. Although a number of interventions were equitably distributed; there were marked wealth-based inequities for interventions that are possessed at the household level; even among relatively homogeneous rural communities

Neonatal mortality in Ethiopia: trends and determinants.

BACKGROUND: The Ethiopian neonatal mortality rate constitutes 42% of under-5 deaths. We aimed to examine the trends and determinants of Ethiopian neonatal mortality. METHODS: We analyzed the birth history information of live births from the 2000, 2005 and 2011 Ethiopia Demographic and Health Surveys (DHS). We used simple linear regression analyses to examine trends in neonatal mortality rates and a multivariate Cox proportional hazards regression model using a hierarchical approach to examine the associated factors. RESULTS: The neonatal mortality rate declined by 1.9% per annum from 1995 to 2010, logarithmically. The early neonatal mortality rate declined by 0.9% per annum and was where 74% of the neonatal deaths occurred. Using multivariate analyses, increased neonatal mortality risk was associated with male sex (hazard ratio (HR) = 1.38; 95% confidence interval (CI), 1.23 - 1.55); neonates born to mothers aged < 18 years (HR = 1.41; 95% CI, 1.15 - 1.72); and those born within 2 years of the preceding birth (HR = 2.19; 95% CI, 1.89 - 2.51). Winter birth increased the risk of dying compared with spring births (HR = 1.28; 95% CI, 1.08 - 1.51). Giving two Tetanus Toxoid Injections (TTI) to the mothers before childbirth decreased neonatal mortality risk (HR = 0.44; 95% CI, 0.36 - 0.54). Neonates born to women with secondary or higher schooling vs. no education had a lower risk of dying (HR = 0.68; 95% CI, 0.49 - 0.95). Compared with neonates in Addis Ababa, neonates in Amhara (HR: 1.88; 95% CI: 1.26 - 2.83), Benishangul Gumuz (HR: 1.75; 95% CI: 1.15 - 2.67) and Tigray (HR: 1.54; 95% CI: 1.01 - 2.34) regions carried a significantly higher risk of death. CONCLUSIONS: Neonatal mortality must decline more rapidly to achieve the Millennium Development Goal (MDG) 4 target for under-5 mortality in Ethiopia. Strategies to address neonatal survival require a multifaceted approach that encompasses health-related and other measures. Addressing short birth interval and preventing early pregnancy must be considered as interventions. Programs must improve the coverage of TTI and prevention of hypothermia for winter births should be given greater emphasis. Strategies to improve neonatal survival must address inequalities in neonatal mortality by women's education and region.

A comparison of the National Center for Health Statistics and new World Health Organization growth references for school-age children and adolescents with the use of data from 11 low-income countries.

BACKGROUND: In 2007 new World Health Organization (WHO) growth references for children aged 5-19 y were introduced to replace the National Center for Health Statistics (NCHS) references. OBJECTIVE: This study aimed to compare the prevalence of stunting, wasting, and thinness estimated by the NCHS and WHO growth references. DESIGN: NCHS and WHO height-for-age z scores were calculated with the use of cross-sectional data from 20,605 schoolchildren aged 5-17 y in 11 low-income countries. The differences in the percentage of stunted children were estimated for each year of age and sex. The z scores of body mass index-for-age and weight-for-height were calculated with the use of the WHO and NCHS references, respectively, to compare differences in the prevalence of thinness and wasting. RESULTS: No systematic differences in mean z scores of height-for-age were observed between the WHO and NCHS growth references. However, z scores of height-for-age varied by sex and age, particularly during early adolescence. In children for whom weight-for-height could be calculated, the estimated prevalence of thinness (WHO reference) was consistently higher than the prevalence of wasting (NCHS reference) by as much as 9% in girls and 18% in boys. CONCLUSIONS: In undernourished populations, the application of the WHO (2007) references may result in differences in the prevalence of stunting for each sex compared with results shown when the NCHS references are used as well as a higher estimated prevalence of thinness than of wasting. An awareness of these differences is important for comparative studies or the evaluation of programs. For school-age children and adolescents across all ranges of anthropometric status, the same growth references should be applied when such studies are undertaken.

Case-control analysis of the health and nutrition of orphan schoolchildren in Ethiopia.

OBJECTIVES: To undertake a case-control analysis of the health, nutrition and caring practices of orphans enrolled in primary schools in Ethiopia. METHODS: Pupils of both sexes aged 7-17 who were randomly selected from Grades 3 and 4 of primary school during a national survey of schoolchildren in Ethiopia and who were classified as an orphan were matched by age, sex and school with non-orphans. Logistic regression was used to compare children in terms of indicators of anthropometric and nutritional status, chronic infections, personal hygiene, diet, caring practices and self-reported sensory disability. RESULTS: Of the 7752 children in the national survey, 1283 (16.9%) had lost either both parents or one parent. Of these orphans, 1048 were uniquely pair matched for the case-control analysis. About 60% of orphans had lost their father, and about 20% each had lost their mother or both parents. Orphans had better anthropometric measurements and indices than non-orphans, although the differences were small, and they were less likely to have a goitre (OR = 0.68, P = 0.011). There were no differences in the odds of infections. Orphans were less likely than non-orphans to have eaten breakfast or fruit and vegetables on the previous day and were more likely to report having trouble seeing and hearing. CONCLUSION: Orphans were slight better nourished than non-orphans, but this could have been a result of asystematic bias in underestimating the age of orphans. The indicators suggested that orphans were less well cared for than non-orphans, but the differences were small.

National survey of the health and nutrition of schoolchildren in Ethiopia.

OBJECTIVE: To estimate the prevalence of chronic health and nutritional conditions of schoolchildren in Ethiopia. METHODS: Cross-sectional survey in schools in each region randomly selected in proportion to size, then a random sample of 50-68 children in grades 3 and 4 in each school. Children were examined for signs of micronutrient deficiencies and chronic infections; weighed and measured; provided a faecal sample to diagnose intestinal parasitic infections; and were interviewed about their recent diet and hygiene practices. RESULTS: A total of 7572 children were studied in 142 schools in all 11 regions of Ethiopia. Nearly 17% of children were orphans. The prevalence of stunting was 22.3% and 23.1% of children were thin for age, but these may be underestimates as there was evidence that age may have been estimated based on stature when children enroll in school. Just under 10% of children were anaemic when altitude was accounted for. The overall prevalence of trachoma was 13% and children who washed their face before school were at lower risk of trachoma than children who had not. Children who reported that they had eaten fruits or vegetables the day before also had a lower risk of xerophthalmia than children who had not. Only 30% of children were infected with intestinal worms. CONCLUSIONS: Trachoma is a problem but anaemia and intestinal worms are relatively uncommon in Ethiopian schoolchildren. These data provide a basis for developing a school health policy and programmes.

The promise of a community-based approach to managing severe malnutrition: A case study from Ethiopia.

BACKGROUND: Community-based therapeutic care (CTC) is a new strategy in the arsenal of techniques to manage complex nutritional emergencies in rural communities. The CTC approach uses a newly developed ready-to-use therapeutic food, Plumpynut, to rehabilitate severely malnourished children in their home communities. Emerging literature has suggested the CTC strategy yielded results that were superior to those of programs limited to therapeutic feeding centers, as measured by rates of coverage and numbers of children rehabilitated. OBJECTIVE: To compare the effectiveness of the CTC strategy in combination with conventional treatments for acute malnutrition. The expectation was that this program would support the growing consensus on the effectiveness of CTC strategies. METHODS: Data from monitoring the initial phase of program implementation were reviewed to ascertain program impact. The number of children participating and the outcome of their participation were assessed. RESULTS: Families became key participants in the rehabilitation of their children, and communities became strengthened through the mobilization of local networks and the improved knowledge base of local health workers. Recovery rates were comparable with international standards, and coverage far exceeded that of traditional center-based care. CONCLUSIONS: CTC is an important tool to effectively address nutritional emergencies and may be a valuable entry point for long-term development, since it fosters capacity building and improvement in local communities. CTC programs may eventually be viewed as the entry point for more sustained development-oriented interventions, thus helping make the transition from relief to development.

Tuberculous meningitis in a district hospital from Southern Ethiopia.

In order to describe the clinical presentation, immediate outcome and risk factors associated with Tuberculous meningitis (TBM), 28 children with TBM were analyzed. The male to female ratio was 1.5:1. The mean age of the cases was 8 years (range 5 months-14 years). Nineteen (67%) of the patients were not vaccinated for Tuberculosis (TB). Nineteen (67%) patients had exposure to adults with pulmonary TB of which 14 (50%) were family members. Among these were four children who were vaccinated and their age range was from 7 month to 8 years. Thirteen (40%) were seen by health professionals with in three months before symptoms related to TBM, the mean duration of symptoms before seeking medical advice was 3.2 months. Using the weight height percentage of median, sixteen (57%) had malnutrition. Twenty (71%) patients were in stage three of TBM at presentation. Eleven (38%) had positive reaction to Mantoux test and 25 (89%) had abnormal chest radiography the most common finding being hilar lymphadenopathy. CSF (Cerebro Spinal Fluid) total cell count showed pleocytosis of < 200 in all but two cases (71%), and raised protein level on quantitative determination. Acid Fast Bacilli (AFB) test done in seven patients, was positive in two (29%) cases. One (4%) direct sputum smear and gastric aspirate culture were positive. Thirteen 13 (46%) patients died despite treatment and 9 (64%) had severe neurological complications. Delay at presentation advanced stage of TBM and unvaccinated state for tuberculosis were closely associated with poor outcome (P<0.05). Hence health workers who treat children should maintain high index of suspicion at all times and evaluate for TBM. The value of prophylaxis for children who have close contact with infectious cases should be evaluated in Ethiopia.