BackgroundTB Control Programmes rely on passive case-finding to detect cases. TB notification remains low in Ethiopia despite major expansion of health services. Poor rural communities face many barriers to service access.Methods and FindingsA community-based intervention package was implemented in Sidama zone, Ethiopia. The package included advocacy, training, engaging stakeholders and communities and active case-finding by female Health Extension Workers (HEWs) at village level. HEWs conducted house-to-house visits, identified individuals with a cough for two or more weeks, with or without other symptoms, collected sputum, prepared smears and supervised treatment. Supervisors transported smears for microscopy, started treatment, screened contacts and initiated Isoniazid preventive therapy (IPT) for children. Outcomes were compared with the pre-implementation period and a control zone. Qualitative research was conducted to understand community and provider perceptions and experiences.HEWs screened 49,857 symptomatic individuals (60% women) from October 2010 to December 2011. 2,262 (4·5%) had smear-positive TB (53% women). Case notification increased from 64 to 127/100,000 population/year resulting in 5,090 PTB+ and 7,071 cases of all forms of TB. Of 8,005 contacts visited, 1,949 were symptomatic, 1,290 symptomatic were tested and 69 diagnosed with TB. 1,080 children received IPT. Treatment success for smear-positive TB increased from 77% to 93% and treatment default decreased from 11% to 3%. Service users and providers found the intervention package highly acceptable.ConclusionsCommunity-based interventions made TB diagnostic and treatment services more accessible to the poor, women, elderly and children, doubling the notification rate and improving treatment outcome. This approach could improve TB diagnosis and treatment in other high burden settings.

SummaryBackground3 years before the 2015 deadline, Ethiopia achieved Millennium Development Goal 4. The under-5 mortality decreased 69%, from 205 deaths per 1000 livebirths in 1990 to 64 deaths per 1000 livebirths in 2013. To understand the underlying factors that contributed to the success in achieving MDG4, Ethiopia was selected as a Countdown to 2015 case study.MethodsWe used a set of complementary methods to analyse progress in child health in Ethiopia between 1990 and 2014. We used Demographic Health Surveys to analyse trends in coverage and equity of key reproductive, maternal health, and child health indicators. Standardised tools developed by the Countdown Health Systems and Policies working group were used to understand the timing and content of health and non-health policies. We assessed longitudinal trends in health-system investment through a financial analysis of National Health Accounts, and we used the Lives Saved Tool (LiST) to assess the contribution of interventions towards reducing under-5 mortality.FindingsThe annual rate of reduction in under-5 mortality increased from 3·3% in 1990–2005 to 7·8% in 2005–13. The prevalence of stunting decreased from 60% in 2000 to 40% in 2014. Overall levels of coverage of reproductive, maternal health, and child health indicators remained low, with disparities between the lowest and highest wealth quintiles despite improvement in coverage for essential health interventions. Coverage of child immunisation increased the most (21% of children in 2000 vs 80% of children in 2014), followed by coverage of satisfied demand for family planning by women of reproductive age (19% vs 63%). Provision of antenatal care increased from 10% of women in 2000 to 32% of women in 2014, but only 15% of women delivered with a skilled birth attendant by 2014. A large upturn occurred after 2005, bolstered by a rapid increase in health funding that facilitated the accelerated expansion of health infrastructure and workforce through an innovative community-based delivery system. The LiST model could explain almost 50% of the observed reduction in child mortality between 2000 and 2011; and changes in nutritional status were responsible for about 50% of the 469 000 lives saved between 2000 and 2011. These developments occurred within a multisectoral policy platform, integrating child survival and stunting goals within macro-level policies and programmes for reducing poverty and improving agricultural productivity, food security, water supply, and sanitation.InterpretationThe reduction of under-5 mortality in Ethiopia was the result of combined activities in health, nutrition, and non-health sectors. However, Ethiopia still has high neonatal and maternal morbidity and mortality from preventable causes and an unfinished agenda in reducing inequalities, improving coverage of effective interventions, and strengthening multisectoral partnerships for further progress.FundingBill & Melinda Gates Foundation and Government of Canada.

SummaryTo measure time to initial presentation and assess factors influencing the decision to seek medical attention, we interviewed 243 patients undergoing sputum examination for the diagnosis of tuberculosis (TB) at a rural health centre near Awassa, Ethiopia. A structured questionnaire was used. Median (mean + SD) patient delay was 4.3 (9.8 + 12.4) weeks. Delays over 4 weeks were significantly associated with rural residence, transport time over 2 h, overnight travel, transport cost exceeding US$1.40, having sold personal assets prior to the visit, and use of traditional medicine. The majority of patients cited economic or logistical barriers to health care when asked directly about causes of delay. Case-finding strategies for TB must be sensitive to patient delay and health systems must become more accessible in rural areas.

Tuberculous lymphadenitis (TBLN) is a common form of extrapulmonary tuberculosis with multiple differential diagnoses. Demonstration of the etiologic agent by smear microscopy or culture of fine needle aspirate (FNA) specimens is often unsuccessful. FNA specimens from 40 patients presenting at a rural health center in South Ethiopia and diagnosed as positive for TBLN on the basis of clinical and cytological criteria were analyzed for mycobacterial DNA by PCR. Thirty (75%) had cervical lymphadenitis and 11 (27.5%) were seropositive for human immunodeficiency virus (HIV). Three primer sets were initially used to identify the causative agent at the genus (antigen 85 complex), complex (IS6110 insertion sequence), and species (pncA gene and allelic variation) levels. Among the forty TBLN cases, 35 (87.5%) were positive by PCR at the genus and complex levels. Based on PCR for detection of allelic variation at position 169, 24 (68.6%) of the 35 were positive for Mycobacterium tuberculosis and 6 (17.1%) were positive for M. bovis. These six were positive in additional PCR assays using the JB21-JB22 primer set, which is highly specific for M. bovis. In developing countries with a high incidence of tuberculosis, tuberculous lymphadenitis (TBLN) is one of the most frequent causes of lymphadenopathy (12) and it is the most common form of extrapulmonary tuberculosis (16). TBLN also occurs with increased frequency in human immunodeficiency virus type 1 (HIV-1)-infected individuals (9, 27). Within the Mycobacterium tuberculosis complex, M. tuberculosis and M. bovis are the most common causative agents of TBLN. Which control measures and treatment are to be instituted depends on the most common causative agent in the area. Therefore, species identification is of paramount importance.Over the past decades, fine needle aspirate (FNA) cytology, an alternative procedure less invasive than excision biopsy, has assumed an important role in the diagnosis of peripheral lymphadenopathy. The cytological criteria for diagnosis of TBLN have been clearly defined (13,19). However, the amount of material obtained in FNA is usually so small that it is often inadequate for performance of acid-fast smear and culture examinations with reasonable sensitivity.Introduction of the PCR provided new possibilities for identification of mycobacteria in various types of clinical samples (3, 5); based on the amplification of common sequences, the identification time for detection of mycobacteria in clinical specimens was reduced (4, 8). The M. tuberculosis complex, consisting of M. tuberculosis, M. bovis, M. africanum, and M. microti, has been identified with a number of different targets, including the IS6110 insertion element sequence, using PCR methods (2, 6).In the present study, PCR was applied for assays of FNAs to identify the causative agent in TBLN in Ethiopia at the genus, complex, and species levels. MATERIALS AND METHODS Patients.The study was initiated after approval by the institutional and national ethical committees. FNAs which were collect...