OBJECTIVES: To measure the progress towards reducing TB-related catastrophic costs in 19 zones of Amhara, Oromia, SNNP (Southern Nations and Nationalities, and Peoples) and Sidama Regions of Ethiopia. METHODS: A baseline survey was conducted in randomly selected health facilities from all districts within the 19 zones from November 2020 to February 2021. Interventions targeting the major drivers of catastrophic costs identified in the baseline survey, such as installation of 126 GeneXpert and 13 Truenat machines, securing connectivity of 372 GeneXpert, establishing alternative specimen referral systems, and capacity-building of health workers, were implemented. A follow-up survey was conducted from October to December 2022. The WHO generic tool was used to collect data based on probability proportional to size. Data were entered into STATA software, and the proportion of catastrophic costs was calculated and compared between the two surveys. RESULTS: A total of 433 and 397 patients participated in the baseline and follow-up surveys, respectively. The proportion of catastrophic costs reduced from 64.7% to 43.8% (P < 0.0001). The share of direct non-medical costs decreased from 76.2% to 19.2%, while medical and indirect costs increased from 11.6% and 12.3% to 30.4% and 52.4 %. CONCLUSION: The proportion of households facing TB-related catastrophic costs has significantly reduced over the 2-year period. However, it remains unacceptably high and varies among regions. Further reducing the catastrophic costs requires multisectoral response, reviewing the TB service exemption policy, further decentralisation and improving the quality of TB services.

BACKGROUND AND OBJECTIVES:Drug resistant tuberculosis (DR-TB) remains a global challenge with about a third of the cases are not detected. With the recent advances in the diagnosis and treatment follow-up of DR-TB, there have been improvements with treatment success rates. However, there is limited evidence on the successful models of care that have consistently registered good outcomes. Our aim was to assess Ethiopia's experience in scaling up an ambulatory, decentralized model of care while managing multiple regimen transition processes and external shocks. METHODS:This was a cross-sectional, mixed-method study. For the quantitative data, we reviewed routine surveillance data for the period 2009-2022 and collected additional data from publicly available reports. We then analyzed the data descriptively. Qualitative data were collected from program reports, quarterly presentations, minutes of technical working group meetings, and clinical review committee reports and analyzed thematically. RESULTS:The number of DR-TB treatment initiating centers increased from 1 to 67, and enrollment increased from 88 in 2010 to 741 in 2019, but declined to 518 in 2022. A treatment success rate (TSR) of over 70% was sustained. The decentralized and ambulatory service delivery remained the core service delivery model. The country successfully navigated multiple regimen transitions, including the recently introduced six-month short oral regimen. Several challenges remain, including the lack of strong and sustainable specimen transportation system, lack of established systems for timely tracing and linking of missed DR-TB cases, and data quality issues. CONCLUSIONS:Ethiopia scaled up a decentralized ambulatory model of care, kept up to date with recent developments in treatment regimens, and maintained a high TSR, despite the influence of multiple external challenges. The recent decline in case notification requires a deeper look into the underlying reasons. The feasibility of fully integrating DR-TB treatment and follow up at community level should be explored further.

Deaths related to multidrug-resistant TB among patients who had received a second-line anti-TB drugs in Ethiopia were analysed. Respectively 38/704 (5.4%) and 44/995 (4.4%) deaths were identified in two cohorts (2015 and 2022). In the 2015 cohort, severe malnutrition was less prevalent, previous treatment rates were three times higher, hypokalaemia was more frequent, and the use of the Xpert® MTB/RIF assay, respiratory failure and severe anaemia/pancytopenia were less common than in the 2022 cohort. We observed that there were variations in adverse events when different treatment regimens were used over different time periods. To ensure proper patient care, correct guidance must be consistently implemented.

Background Aligned with global childhood tuberculosis (TB) road map, Ethiopia developed its own in 2015. The key strategies outlined in the Ethiopian roadmap are incorporating TB screening in Integrated Maternal, Neonatal and Child Illnesses (IMNCI) clinic for children under five years (U5) and intensifying contact investigations at TB clinic. However, these strategies have never been evaluated. Objective To evaluate the integration of tuberculosis (TB) screening and contact investigation into Integrated Maternal, Neonatal and Child Illnesses (IMNCI) and TB clinics in Addis Ababa, Ethiopia. Methods The study used mixed methods with stepped-wedge design where 30 randomly selected health care facilities were randomized into three groups of 10 during August 2016-November 2017. The integration of TB screening into IMNCI clinic and contact investigation in TB clinic were introduced by a three-day childhood TB training for health providers. An in-depth interview was used to explore the challenges of the interventions and supplemented data on TB screening and contact investigation. Results Overall, 180896 children attended 30 IMNCI clinics and145444 (80.4%) were screened for TB. A total of 688 (0.4%) children had presumptive TB and 47(0.03%) had TB. During the pre-intervention period, 51873 of the 85278 children (60.8%) were screened for TB as compared to 93570 of the 95618 children (97.9%) in the intervention (p<0.001). This had resulted in 149 (0.30%) and 539 (0.6%) presumptive TB cases in pre-intervention and intervention periods (p<0.001), respectively. Also, nine TB cases (6.0%) in pre-intervention and 38 (7.1%) after intervention were identified (p = 0.72). In TB clinics, 559 under-five (U5) contacts were identified and 419 (80.1%) were screened. In all, 51(9.1%) presumed TB cases and 12 (2.1%) active TB cases were identified from the traced contacts. TB screening was done for 182 of the 275 traced contacts (66.2%) before intervention and for 237 of the 284 of the traced (83.5%) under intervention (p<0.001). Isoniazid prevention therapy (IPT) was initiated for 69 of 163 eligible contacts (42.3%) before intervention and for 159 of 194 eligible children (82.0%) under intervention (p<0.001). Over 95% of health providers indicated that the integration of TB screening into IMNCI and contact investigation in TB clinic is acceptable and practical. Gastric aspiration to collect sputum using nasogastric tube was reported to be difficult. Conclusions Integrating TB screening into IMNCI clinics and intensifying contact investigation in TB clinics is feasible improving TB screening, presumed TB cases, TB cases, contact screening and IPT coverage during the intervention period. Stool specimen could be non-invasive to address the challenge of sputum collection.

OBJECTIVE:To determine the yield of tuberculosis (TB) and the prevalence of Human Immuno-deficiency virus (HIV) among key populations in the selected hotspot towns of Ethiopia. METHODS:We undertook a cross-sectional implementation research during August 2017-January 2018. Trained TB focal persons and health extension workers (HEWs) identified female sex workers (FSWs), health care workers (HCWs), prison inmates, homeless, internally displaced people (IDPs), internal migratory workers (IMWs) and residents in missionary charities as key and vulnerable popuaiton. They carried out health education on the importance of TB screening and HIV testing prior to recruitment of the study participants. Symptomatic TB screening and HIV testing was done. The yield of TB was computed per 100,000 background key population. RESULTS:A total of 1878 vulnerable people were screened, out of which 726 (38.7%) presumptive TB cases and 87 (4.6%) TB cases were identified. The yield of TB was 1519 (95% CI: 1218.1-1869.9). The highest proportion (19.5%) and yield of TB case (6,286 (95% CI: 3980.8-9362.3)) was among HCWs. The prevalence of HIV infection was 6%, 67 out of 1,111 tested. IMWs and FSWs represented 49.3% (33) and 28.4% (13) of the HIV infections, respectively. There was a statistically significant association of active TB cases with previous history of TB (Adjusted Odds Ratio (AOR): 11 95% CI, 4.06-29.81), HIV infection (AOR: 7.7 95% CI, 2.24-26.40), and being a HCW (AOR: 2.42 95% CI, 1.09-5.34). CONCLUSIONS:The prevalence of TB in key populations was nine times higher than 164/100,000 national estimated prevalence rate. The prevalence of HIV was five times higher than 1.15% of the national survey. The highest yield of TB was among the HCWs and the high HIV burden was detected among the FSWs and IMWs. These suggest a community and health facility based integrated and enhanced case finding approaches for TB and HIV in hotspot settings.

Objective Seasonal variations affect the health system's functioning, including tuberculosis (TB) services, but there is little evidence about seasonal variations in TB case notification in tropical countries, including Ethiopia. This study sought to fill this gap in knowledge using TB data reported from 10 zones, 5 each from Amhara and Oromia regions. Methods Notified TB cases for 2010-2016 were analyzed using SPSS version 20. We calculated the quarterly and annual average TB case notification rates and the proportion of seasonal amplitudes. We applied Winters' multiplicative method of exponential smoothing to break down the original time series into seasonal, trend, and irregular components and to build a suitable model for forecasting. Results A total of 205,575 TB cases were identified (47.8% from Amhara, 52.2% from Oromia), with a male-to-female ratio of 1.2:1. The means of 8,200 (24%), 7,992 (23%), 8,849 (26%), and 9,222 (27%) TB cases were reported during July-September, October-December, January-March, and April-June, respectively. The seasonal component of our model indicated a peak in April-June and a trough in October-December. The seasonal amplitude in Amhara region is 10% greater than that of Oromia (p < 0.05). Conclusions TB is shown to be a seasonal disease in Ethiopia, with a peak in quarter four and a low in quarter two of the fiscal year. The peak TB case notification rate corresponds with the end of the dry season in the two agrarian regions of Ethiopia. TB prevention and control interventions, such as efforts to increase community TB awareness about TB transmission and contact tracing, should consider seasonal variation. Regional variations in TB seasonality may require consideration of geographic-specific TB case-finding strategies. The mechanisms underlying the seasonal variation of TB are complex, and further study is needed.

SETTING:Hawassa Prison, Southern Region of Ethiopia.OBJECTIVE:To determine the burden of pulmonary tuberculosis (TB) using active case finding among prisoners.DESIGN:In this cross-sectional study, prisoners were screened for TB using a symptom screen. Those with cough of 2 weeks had spot and morning sputum samples collected for acid-fast bacilli (AFB) smear microscopy and molecular diagnostic testing (Xpert® MTB/RIF).RESULTS:Among 2068 prisoners, 372 (18%) had a positive cough screen. The median age of these 372 persons was 23 years, 97% were male and 63% were from urban areas. Among those with a positive symptom screen, 8 (2%) were AFB sputum smear-positive and 31 (8%) were Xpert-positive. The point prevalence of pulmonary TB at the prison was 1748 per 100 000 persons. In multivariate analysis, persons with cough >4 weeks were more likely to have TB (OR 3.34, 95%CI 1.54-7.23).CONCLUSION:A high prevalence of TB was detected among inmates at a large Ethiopian prison. Active case finding using a cough symptom screen in combination with Xpert had high utility, and has the potential to interrupt transmission of Mycobacterium tuberculosis in correctional facilities in low- and middle-income, high-burden countries.

Abstract Background Health extension workers (HEWs) are the key cadre within the Ethiopian Health Extension Programme extending health care to rural communities. National policy guidance supports the use of mHealth to improve data quality and use. We report on a mobile Health Management Information system (HMIS) with HEWs and assess its impact on data use, community health service provision and HEWs’ experiences. Methodology We used a mixed methods approach, including an iterative process of intervention development for 2 out of 16 essential packages of health services, quantitative analysis of new registrations, and qualitative research with HEWs and their supervisors. Results The iterative approach supported ownership of the intervention by health staff, and 8833 clients were registered onto the mobile HMIS by 62 trained HEWs. HEWs were positive about using mHealth and its impact on data quality, health service delivery, patient follow-up and skill acquisition. Challenges included tensions over who received a phone; worries about phone loss; poor connectivity and power failures in rural areas; and workload. Discussion Mobile HMIS developed through collaborative and locally embedded processes can support quality data collection, flow and better patient follow-up. Scale-up across other community health service packages and zones is encouraged together with appropriate training, support and distribution of phones to address health needs and avoid exacerbating existing inequalities. Keywords CHWs, equity, ethics, Ethiopia, Health Management Information system, HEP, maternal health, mHealth, TB

BACKGROUND: Although children in contact with adults with tuberculosis (TB) should receive isoniazid (INH) preventive therapy (IPT), this is rarely implemented. OBJECTIVE: To assess whether a community-based approach to provide IPT at the household level improves uptake and adherence in Ethiopia. METHODS: Contacts of adults with smear-positive pulmonary TB (PTB+) were visited at home and examined by health extension workers (HEWs). Asymptomatic children aged <5 years were offered IPT and followed monthly. RESULTS: Of 6161 PTB+ cases identified by HEWs in the community, 5345 (87%) were visited, identifying 24 267 contacts, 7226 (29.8%) of whom were children aged <15 years and 3102 (12.7%) were aged <5 years; 2949 contacts had symptoms of TB and 1336 submitted sputum for examination. Ninety-two (6.9%) were PTB+ and 169 had TB all forms. Of 3027 asymptomatic children, only 1761 were offered (and accepted) IPT due to INH shortage. Of these, 1615 (91.7%) completed the 6-month course. The most frequent reason for discontinuing IPT was INH shortage. CONCLUSION: Contact tracing contributed to the detection of additional TB cases and provision of IPT in young children. IPT delivery in the community alongside community-based TB interventions resulted in better acceptance and improved treatment outcome.

The recent thematic series on close-to-community providers published in this journal brings together 14 papers from a variety of contexts and that use a range of research methods. The series clearly illustrates the renewed emphasis and excitement about the potential of close-to-community (CTC) providers in realising universal health coverage and supporting the sustainable development goals. This editorial discusses key themes that have emerged from this rich and varied set of papers and reflect on the implications for evidence-based programming. We are at a critical stage in the development of CTC programming and policy which requires the creation and communication of new knowledge to ensure the safety, sustainability, quality and accessibility of services, and their links with both the broader health system and the communities that CTCs serve.

SETTINGRural settings of Sidama Zone in southern Ethiopia.OBJECTIVETo investigate the association between exposure to biomass fuel smoke and tuberculosis (TB).DESIGNA matched case control study in which cases were adult smear-positive pulmonary tuberculosis (PTB) patients on DOTS-based treatment at rural health institutions. Age-matched controls were recruited from the community.RESULTSOf 355 cases, 350 (98.6%) use biomass fuel for cooking, compared to 801/804 (99.6%) controls. PTB was not associated with exposure to the biomass fuel smoke. None of the factors such as heating the house, type of stove, presence of kitchen, presence of adequate cooking room ventilation, light source and number of rooms in the house was associated with the presence of TB. However, TB determinants such as sex, household contact with TB, history of TB treatment, smoking and presence of a smoker in the household have previously shown an association with TB.CONCLUSIONWe found no evidence of an association between the use of biomass fuel and TB. Low statistical power due to the selection of neighbourhood controls might have contributed to this negative finding. We would advise that future protocols should not use neighbourhood controls and that they should include measurements of indoor air pollution and of exposure duration.

SETTINGThe tuberculosis (TB) programme in the Sidama zone of southern Ethiopia.OBJECTIVETo measure excess mortality in successfully treated TB patients.DESIGNIn a retrospective cohort study of TB patients treated from 1998 to 2006, mortality was used as an outcome measure, and was calculated per 100 person-years of observation (PYO) from the date of completion of treatment to date of interview if the patient was alive, or to date of death. Kaplan-Meier and Cox regression methods were used to determine the survival and hazard ratios. An indirect method of standardisation was used to calculate the standard mortality ratio (SMR).RESULTSA total of 725 TB patients were followed for 2602 person-years: 91.1% (659/723) were alive and 8.9% (64/723) had died. The mortality rate was 2.5% per annum. Sex, age and occupation were associated with high mortality. More deaths occurred in non-farmers (SMR = 9.95, 95%CI 7.17-12.73).DISCUSSIONThe mortality rate was higher in TB patients than in the general population. More deaths occurred in non-farmers, men and the elderly. Further studies are required to identify the causes of death in these patients.

SETTINGS: The tuberculosis control programme, southern region of Ethiopia.OBJECTIVE: To assess the impact of the expansion of the DOTS strategy on tuberculosis (TB) case finding and treatment outcome.DESIGN: Reports of TB patients treated since the introduction of DOTS in the region were reviewed. Patients were diagnosed and treated according to World Health Organization (WHO) recommendations. Case notification and treatment outcome reports were compiled quarterly at district level and submitted to the regional programme.RESULTS: Of 136572 cases registered between 1995 and 2004, 47% were smear-positive, 25% were smear-negative and 28% had extra-pulmonary tuberculosis (EPTB). In 2004, 94% of the health institutions were covered by DOTS. Between 1995 and 2004, the smear- positive case notification rate increased from 45 to 143 per 100000 population, the case detection rate from 22% to 45%, and the treatment success rate from 53% to 85%. The default and failure rates decreased from 26 % to 6 % and from 7 % to 1%, respectively.DISCUSSION: There was a steady increase in the treatment success rate with the decentralisation of DOTS. Although 94% coverage was achieved after 10 years, the stepwise scale-up was important in securing resources and dealing with challenges. The programme achieved 85% treatment success; however, with the current low case detection rate (45%), the 70% WHO target seems unachievable in the absence of alternative case-finding mechanisms.