Article Text
Abstract
Background Tuberculosis (TB) is a major cause of death in Ethiopia. One of the main barriers for TB control is the lack of access to health services.
Methods We evaluated a diagnostic and treatment service for TB based on the health extension workers (HEW) of the Ethiopian Health Extension Programme in Sidama Zone, with 3.5 million population. We added the services to the HEW routines and evaluated their effect over 4.5 years. 1024 HEWs were trained to identify individuals with symptoms of TB, request sputum samples and prepare smears. Smears were transported to designated laboratories. Individuals with TB were offered treatment at home or the local health post. A second zone (Hadiya) with 1.2 million population was selected as control. We compared TB case notification rates (CNR) and treatment outcomes in the zones 3 years before and 4.5 years after intervention.
Results HEWs identified 216 165 individuals with symptoms and 27 918 (12%) were diagnosed with TB. Smear-positive TB CNR increased from 64 (95% CI 62.5 to 65.8) to 127 (95% CI 123.8 to 131.2) and all forms of TB increased from 102 (95% CI 99.1 to 105.8) to 177 (95% CI 172.6 to 181.0) per 100 000 population in the first year of intervention. In subsequent years, the smear-positive CNR declined by 9% per year. There was no change in CNR in the control area. Treatment success increased from 76% before the intervention to 95% during the intervention. Patients lost to follow-up decreased from 21% to 3% (p<0.001).
Conclusion A community-based package significantly increased case finding and improved treatment outcome. Implementing this strategy could help meet the Ethiopian Sustainable Development Goal targets.
- tuberculosis
- diagnosis
- treatment
- health extension workers
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Footnotes
Handling editor Seye Abimbola
Contributors The study was conceived by DGD, MAY and LEC who, together with SJT, were alternating principal investigators over the years on behalf of REACH Ethiopia and the Liverpool School of Tropical Medicine. This was due to MAY, senior research fellow in Liverpool, moving to the Global Fund, and LEC moving to (and then returning from) TDR/WHO Geneva over 2 years. MAY and LEC developed the concept of the study and together with SJT prepared the initial protocol in 2009. DGD was the project director in Ethiopia. LB, SS and JC advised on the initial design of the intervention and, with MAY, on how to contextualise the study on its international policy relevance. The same authors provided technical support over the 5 years, high level advocacy, linkage to policymakers, and support to engage and influence the government supporting the upscale of the service and policy guidance. Data collection was led by DGD; data analysis and interpretation was conducted by DGD, LEC and MAY; SJT supported the interpretations on gender, equity and sustainability and led qualitative studies that supplemented the study. LEC, DGD, SJT and MAY wrote the first draft of the manuscript. All authors contributed to the final manuscript.
Funding The project was funded by the Global Affairs Canada, through the TB REACH Initiative of the Stop TB Partnership, Waves I and III project numbers T9-370-114 ETH and GAL W3/2013, and a grant from the UK Economic and Social Research Council (ESRC): grant reference ES/L007746/1. The funders played no role in the decision to publish or the interpretation of the data.
Competing interests SS and JC work at the Stop TB Partnership and coordinated the proposal review committee which makes funding allocations for TB REACH, but did not participate in the funding decisions. Their contribution focused on sharing lessons learnt from similar TB REACH projects, the contextualisation of the project within the international initiatives, suggesting ways the project could improve performance and engaging international stakeholders to promote support for the project. LB was the independent monitoring and evaluation expert and interpreted surveillance and the project’s databases over the project lifetime. She reported to TB REACH on project performance. Final decisions on project implementation were taken by DGD, MAY, SJT and LEC.
Ethics approval Ethical approval was obtained from the Research Ethics Committee of the Liverpool School of Tropical Medicine, UK (LSTM, protocol number 10.69).
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement The authors can share the databases upon request.