Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia

<p>Abstract</p> <p>Background</p> <p>Delays seeking care worsen the burden of tuberculosis and cost of care for patients, families and the public health system. This study investigates costs of tuberculosis diagnosis incurred by patients, escorts and the public health system in 10 districts of Ethiopia.</p> <p>Methods</p> <p>New pulmonary tuberculosis patients ≥ 15 years old were interviewed regarding their health care seeking behaviour at the time of diagnosis. Using a structured questionnaire patients were interviewed about the duration of delay at alternative care providers and the public health system prior to diagnosis. Costs incurred by patients, escorts and the public health system were quantified through patient interview and review of medical records.</p> <p>Results</p> <p>Interviews were held with 537 (58%) smear positive patients and 387 (42%) smear negative pulmonary patients. Of these, 413 (45%) were female; 451 (49%) were rural residents; and the median age was 34 years. The mean (median) days elapsed for consultation at alternative care providers and public health facilities prior to tuberculosis diagnosis was 5 days (0 days) and 3 (3 days) respectively. The total median cost incurred from first consultation to diagnosis was $27 per patient (mean =$59). The median costs per patient incurred by patient, escort and the public health system were $16 (mean =$29), $3 (mean =$23) and $3 (mean =$7) respectively. The total cost per patient diagnosed was higher for women, rural residents; those who received government food for work support, patients with smear negative pulmonary tuberculosis and patients who were not screened for TB in at least one district diagnostic centers.</p> <p>Conclusions</p> <p>The costs of tuberculosis diagnosis incurred by patients and escorts represent a significant portion of their monthly income. The costs arising from time lost in seeking care comprised a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Getting treatment from alternative sources and low index of suspicion public health providers were key problems contributing to increased cost of tuberculosis diagnosis. Thus, the institution of effective systems of referral, ensuring screening of suspects across the district public health system and the involvement of alternative care providers in district tuberculosis control can reduce delays and the financial burden to patients and escorts.</p

Community health workers: their knowledge on pulmonary tuberculosis and willingness to be treatment supervisors Tigray, Northern Ethiopia

Background: Poor treatment adherence to tuberculosis treatment is a problem among rural patients Ethiopia. We aimed to decentralize directly observed treatment of tuberculosis at village level volunteer Community Health Workers (CHWs) in order to improve treatment adherence. However, need to determine their training needs and willingness to supervise treatment of patients with tuberculosis their respective villages. Objectives: To assess CHWs' knowledge of Pulmonary Tuberculosis (PTB) disease and their willingness supervise tuberculosis treatment. Method: A cross-sectional survey was conducted in 8 districts of Tigray, Ethiopia in June 2002. A 279 CHWs were selected from 70 villages using a multistage cluster sampling technique. CHWs interviewed by trained nurses using a structured questionnaire. Result: CHWs' mean and median knowledge score about PTB was 79.8% and 80% respectively. mentioned exposure to cold (43%) and bacteria (40.5%) as causes of PTB disease while coughing as its primary means of transmission. Most (90.3%) were willing to supervise tuberculosis treatment. CHWs who reside in rural villages (Adjusted Odds Ratio (AOR)=2.93; 95% Confidence Interval (CI)= 6.91) and those who had been entitled to free medical services (AOR=2.95; 95% CI=1.17-7.55) were willing to be treatment supervisors. CHWs were less likely to be treatment supervisors when accountability to more than one village-based institutions (AOR=0.35; 95% CI=0.14-0.91).Conclusion: CHWs should be trained on tuberculosis and its management prior to their involvement tuberculosis treatment supervision. Reducing CHWs' multiple responsibilities and continuous health support would be essential to sustain their volunteer services.The Ethiopian Journal of Health Development Vol. 19 2005: 28-3

Community knowledge, attitudes and practices on pulmonary tuberculosis and their choice of treatment supervisor in Tigray, Northern Ethiopia

Background: We planned to raise public awareness and decentralize directly observed tuberculosis treatment at village level using volunteer community members in order to reduce prolonged delays in seeking care and improve compliance to tuberculosis treatment. We do not know the magnitude of tuberculosis knowledge gap and preferred modality of tuberculosis treatment supervision among the public in Tigray. Objectives: To assess knowledge of pulmonary tuberculosis and to determine level of acceptance regarding villagebased tuberculosis treatment using volunteers among the general public.Method: A cross sectional survey was conducted among 838 adults (915 years) in 8 districts of Tigray region. Respondents selected from 70 villages using a multistage cluster sampling technique were interviewed using a pre-tested questionnaire in July 2002. Result: The mean and median knowledge score of respondents about pulmonary tuberculosis (PTB) was 5.24 and 6.67 (maximum score of 10) respectively. Female respondents (Adjusted Odds Ratio (AOR)=1.86; 95% Confidence interval (CI)=1.39-2.47), illiterates (AOR=1.64; 95% CI=1.1-2.47) and rural residents (AOR=1.95; 95% CI=1.37- 2.76) were more likely to have a low level of knowledge score. Among respondents who had prior knowledge of PTB (n=717), 599 (83.5%) accepted the idea of tuberculosis (TB) treatment by volunteer community members. Illiterates, rural residents, married and respondents with large family size were more likely to support supervised TB-treatment using volunteers. Respondents' preferred treatment supervisors were: volunteer community health workers (60%), public health staff (16.5%) and family members (12.7%).Conclusion: There is a wide knowledge gap among the public regarding PTB. The idea of organizing directly observed TB treatment using volunteers appears to be accepted. The Ethiopian Journal of Health Development Vol. 19 2005: 21-2

Delays and care seeking behavior among tuberculosis patients in Tigray of Northern Ethiopia

Background: Delayed initiation of treatment among tuberculosis patients is a common problem which might contribute to the high burden of tuberculosis in Ethiopia. There is paucity of evidence on the magnitude of delay and why patients fail to seek modern care early in Tigray. Objectives: To assess patient and health service delays and factors for delay among tuberculosis patients. Methods: Adult tuberculosis patients who began treatment (12/10/2001-15/05/2002) in 47 public health institutions were interviewed using a pre-tested questionnaire to gather information about their health seeking behaviour. Patient charts were also reviewed to determine the magnitude of delays. Result: The median patient delay for 42 pulmonary smear positive, 101 pulmonary smear negative and 94 extra-pulmonary tuberculosis patients was 90 days, 60 days and 90 days respectively, while the overall median health service delay was 9 days. Delayed first consultation (>21 days since onset of illness) was significantly higher among patients with no formal education (Adjusted Odds Ratio (AOR)=2.46; 95%Confidence Interval (CI)=1.21-5.01), among those treated first by a private and/or traditional practitioner (AOR=2.9; 95% CI=1.42-6.08), among those who thought their illness not serious (AOR=2.39; 95% CI= 1.52-3.78) and among those who suspected they had tuberculosis (AOR=2.5; 95% CI=1.18-5.29). Conclusion: This unacceptably long patient delay calls for identification and inclusion of feasible strategies to promote early treatment in the national tuberculosis control program. The Ethiopian Journal of Health Development Vol. 19 2005: 7-1

Reemergence of yellow fever in Ethiopia after 50 years, 2013: epidemiological and entomological investigations

Abstract Background Yellow Fever (YF) is a viral hemorrhagic disease transmitted by aedes mosquito species. Approximately, 200,000 cases and 30,000 deaths occur worldwide every year. In Ethiopia, the last outbreak was reported in 1966 with 2200 cases and 450 deaths. A number of cases with deaths from unknown febrile illness reported from South Ari district starting from November 2012. This investigation was conducted to identify the causative agent, source of the outbreak and recommend appropriate interventions. Methods Medical records were reviewed and Patients and clinicians involved in managing the case were interviewed. Descriptive data analysis was done by time, person and place. Serum samples were collected for serological analysis it was done using Enzyme-linked Immunosorbent Assay for initial screening and confirmatory tests were done using Plaque Reduction and Neutralization Test. Breteau and container indices were used for the entomological investigation to determine the risk of epidemic. Results A total of 141 Suspected YF cases with 43 deaths (CFR = 30.5%) were reported from November 2012 to October 2013 from South Omo Zone. All age groups were affected (mean 27.5, Range 1–75 Years). Of the total cases, 85.1% cases had jaundice and 56.7% cases had fever. Seven of the 21 samples were IgM positive for YF virus. Aedes bromeliae and Aedes aegypti were identified as responsible vectors of YF in affected area. The Breteau indices of Arkisha and Aykamer Kebeles were 44.4% and 33.3%, whereas the container indices were 12.9% and 22.2%, respectively. Conclusion The investigation revealed that YF outbreak was reemerged after 50 years in Ethiopia. Vaccination should be given for the affected and neighboring districts and Case based surveillance should be initiated to detect every case

Evaluation of the Pyrrolizidine Alkaloid Induced Liver Disease (PAILD) Active Surveillance System in Tigray, Ethiopia

Pyrrolizidine Alkaloid Induced Liver Disease has been an emerging public health problem in the Tigray region in Ethiopia since 2002, with 1033 cases, including 314 deaths, detected as of September 2011. Disease surveillance started in 2009 to determine the magnitude and distribution of the disease, to detect and manage cases, and to inform officials for resource allocation. Despite limited resources and logistical challenges, the system operated at a high standard and met its original objectives. Maintenance of this high level of operation will be an ongoing challenge but will be critical to ensure continual disease monitoring through this system

Evaluation of the Pyrrolizidine Alkaloid Induced Liver Disease (PAILD) Active Surveillance System in Tigray, Ethiopia

OBJECTIVE: To describe the results of the evaluation of the PAILD active surveillance system and lessons learned for similar surveillance efforts in a resource-limited setting. INTRODUCTION: A liver disease of unknown etiology, called unknown liver disease (ULD) by the community, was first identified in 2002 in Tigray; a rugged, semi-arid, mountainous region that is considered one of the most drought-prone and food insecure regions of Ethiopia. ULD is a chronic condition characterized by epigastric pain, abdominal distention, ascites, emaciation, and hepato/splenomegaly. In 2005, the Ethiopian Health and Nutritional Research Institute was assigned by the Ethiopia Ministry of Health to assist the Tigray Regional Health Bureau and oversee the disease investigation. In 2008, Centers for Disease Control and Prevention (CDC) assisted the Ethiopian team and jointly developed the surveillance tools. The surveillance system was implemented in 2009 with the objectives to determine the magnitude and distribution of the disease; identify disease trends; detect cases to provide them with clinical care; and inform health officials and funding bodies for resource allocation. After several investigations, a local plant containing a particular type of pyrrolizidine alkaloid (PA) toxin that contaminated local foodstuffs was identified as the etiologic agent, and ULD was renamed PAILD in 2011. METHODS: From 20 September to 1 October 2011, we conducted site visits, held semi-structured interviews with 20 staff members, reviewed reporting materials, and summarized the information flow including data collection, reporting, analysis, and dissemination. RESULTS: This surveillance system was implemented in 13 rural, resource-limited districts in the NW, Central and Western Zones. The system identified a total of 1033 cases, including 314 deaths, as of September 2011; guided medication distribution to the health facilities; served as a registry for patient follow up; and provided decision-makers with information needed to allocate resources. A large-scale training was conducted in 2010; however, high staff turnover and a lack of backup surveillance staff at each site suggested that additional training may be needed. Due to the absence of a diagnostic test, the case definition was very simple to enable frontline staff in the communities and at the health posts/centers to identify disease cases. These individuals travelled long distances by foot to deliver paper surveillance forms to the district health offices. A surveillance team placed in the NW Zonal office collected missing reports from the health facilities given limited transportation; however they have left since this evaluation. Information from the surveillance system was shared with partner agencies at the national level every 3 to 6 months; however, this information was not shared with frontline staff. CONCLUSIONS: The PAILD Active Surveillance System met its objectives as originally defined. Evaluation of this unique surveillance system for a chronic disease with unknown cause in a resource-limited setting provides several lessons that can inform similar surveillance efforts. Ongoing logistical challenges (e.g., shortage of paper forms, lack of transportation, and long distances between locations) complicated data collection and reporting. While electronic reporting may have helped overcome some of these difficulties, it was not feasible in this setting. Frontline staff identified cases in the community so that they could receive treatment; these key staff can be further incentivized by receiving regular training and surveillance reports. Ongoing support will be critical to overcome these unique challenges to ensure continual disease monitoring as interventions to disrupt PA exposure are implemented in the community

Sero-prevalence of yellow fever and related Flavi viruses in Ethiopia: a public health perspective

Abstract Background Yellow fever (YF) is a viral hemorrhagic fever, endemic in the tropical forests of Africa and Central and South America. The disease is transmitted by mosquitoes infected with the yellow fever virus (YFV). Ethiopia was affected by the largest YF outbreak since the vaccination era during 1960–1962. The recent YF outbreak occurred in 2013 in Southern part of the country. The current survey of was carried out to determine the YF seroprevalence so as to make recommendations from YF prevention and control in Ethiopia. Methodology A multistage cluster design was utilized. Consequently, the country was divided into 5 ecological zones and two sampling towns were picked per zone randomly. A total of 1643 serum samples were collected from human participants. The serum samples were tested for IgG antibody against YFV using ELISA. Any serum sample testing positive by ELISA was confirmed by plaque reduction neutralization test (PRNT). In addition, differential testing was performed for other flaviviruses, namely dengue, Zika and West Nile viruses. Result Of the total samples tested, 10 (0.61%) were confirmed to be IgG positive against YFV and confirmed with PRNT. Nine (0.5%) samples were antibody positive for dengue virus, 15(0.9%) forWest Nile virus and 7 (0.4%) for Zika virus by PRNT. Three out of the five ecological zones namely zones 1, 3 and 5 showed low levels (< 2%) of IgG positivity against YFV. A total of 41(2.5%) cases were confirmed to be positive for one of flaviviruses tested. Conclusion Based on the seroprevalence data, the level of YFV activity and the risk of a YF epidemic in Ethiopia are low. However additional factors that could impact the likelihood of such an epidemic occurring should be considered before making final recommendations for YF prevention and control in Ethiopia. Based on the results of the serosurvey and other YF epidemic risk factors considered, a preventive mass vaccination campaign is not recommended, however the introduction of YF vaccine in routine EPI is proposed nationwide, along with strong laboratory based YF surveillance