Health Extension Program workers will be trained to help prevent and control the spread of tuberculosis by increasing community awareness of the modes of transmission (including the relationship between tuberculosos and AIDS), signs and symptoms of tuberculosis infection and promoting the use of control measures. These workers will also educate and follow up tuberculosis patients on precautions they have to take to reduce the spread of the infection, and insure the patients are taking their drugs properly. Furthermore, the Health extension workers will offer childhood BCG vaccines, and teach villagers about such precautions as not sharing cups with relatives who have tuberculosis, helping coughing relatives to cover their mouths, and boiling milk.
Ethiopia is one of the top sixteen countries in the world, and one of the top three in Africa, with regard to the number of tuberculosis (TB) patients. Over a third of the population has been exposed to TB. The Annual Risk of TB Infection (ARTI) is at 2.2%. An estimated 377,030 Ethiopians (0.62% of the population) have active TB of all kinds, with more than 120,000 new cases in the last year (2003/ 04), nealry a third of which having smear-positive TB. 1
According to the Ministry of Health hospital statistics data, tuberculosis is one of the leading causes of morbidity, the fourth cause of hospital admission, and the second cause of hospital death in Ethiopia. Tuberculosis contributes to 4.6% of all Ethiopian DLYs2. Nearly a third of all TB cases are fatal, killing over 42,000 people in Ethiopia this year, excluding those who had HIV/AIDS. Social and biological factors that have aggravated the problem in Ethiopia include recurrent famine and widespread poverty that leads to severe malnutrition.
Studies have indicated that poverty is highly associated with tuberculosis. The association between socio-economic status and tuberculosis arises in a variety of ways. Exposure is associated with crowding and quality of housing (lighting, ventilation etc), which in turn may be associated with socio-economic status. Moreover, social mixing is associated with socio-economic status, perpetuating unequal disease distributions. Progression from infection to disease may depend on nutritional status and thus on poverty. The duration of infectiousness of source cases depends on access to adequate health care, which depends in part on socio-economic status. Besides being apgravated by poverty, tuberculosis itself contribites to poverty by decapacitating a person who would otherwise participate in economic activities.
One of the obstacles to providing tuberculosis testing and treatment in Ethiopia is the fact that than about half the population of Ethiopia lives more than 10 kilometers from a health facility, usually in regions with poor transport. Ethiopia has implemented the internationally recommended approach to TB control DOTS. DOTS has been delivered to all disticts in Ethiopia, and is being implemented in 119 hospitals, 519 health centers and 114 health stations accross the country.
Indicators % Population Affected No of People affected Prevalence of TB infection 36% 24.5 million Incidence of all forms of TB 0.36% 251,685 Incidence of Smear Positive TB 0.16% 109,452 TB Case Fatality Rate in untreated cases 22.3% 56,146
Source: WHO 2005, Global TB Report 2005
TB and HIV/AIDS
The association between HIV and TB has now been well identified, although the underlying causal mechanisms and immunological aspects remain poorly understood. It is well known that interaction between the two diseases dramatically increases the progression of both. Latent TB-infection in HIV-positive persons seems to reactivate at a rate of 10% per year (as opposed to 10% in a lifetime for HIV-negative persons)3. HIV-positive persons are prone to re-infection with a new strain from the community, and although evidence conflicts on this matter, drug resistance seems to occur more frequently. In general TB appears to be the first opportunistic infection in an HIV-infected person, while active TB has been shown to induce HIV virus-replication, thus accelerating the progression to AIDS. The clinical presentation of TB may be altered in HIV-positive patients, especially in progressed stages of HIV-infection when immunity is considerably compromised. Smear-negative and extra-pulmonary forms of TB are then more common and X-ray abnormalities are atypical.
% Population Affected
No of People affected
|HIV/ AIDS infection||
|Prevalence of TB*||
|TB cases with HIV/AIDS||
Sources: Ministry of Health 2004, AIDS in Ethiopia - Fifth Edition
*: WHO 2005, Global TB Report 2005
According to Ministry of Health documents, of all TB case incidences in 2003, 54,000 test sero-positive for HIV. In newly diagnosed TB patients, HIV co-infection occurs over 40% of the time. The incidence of co-infection is significant, and will rise over time, as the 25 million TB-infected people (1/3 of the population) continue to interact with the 1.5 million HIV/AIDS-infected group. 4
The government has established a decentralized system for the control of Tuberculosis and leprosy is represented at regional, zonal and district levels, which is supported by increased funding and staff.
The main focus has been towards capacity building in the control of TB, supervision, DOTS implementation, DOTS expansion and surveillance.
The DOTS approach has now been delivered to 522 districts (86%), with 50% of health facilities across the country implementing this approach. However, considering the prevailing low access to health facilities, which is estimated at a potential 61%, much work remains to be done.
The government is trying to reduce the spread and impact of the disease through an integrated program of capacity building, community involvement, treatment, and continuous improvement through operational research, particularly in conjunction with HIV/AIDS. Many of the program activities have been supported by the first round - Global Fund to fighting AIDS, Tuberculosis and Malaria in the March 2003, with 22.3 million USD of grant for five years (2003-2007); with close to 11 million earmarked for the first two years, 60% of which has already been disbursed.
1 WHO 2005, Global
TB Report 2004
2 The Policy and Human Resource Development Project (PHRD) Study No. 3
3 The Global Fund to Fight Aids, Tuberculosis and Malaria, Ethiopia Proposal, Fourth round, 2004
4 MOH 2004, AIDS in Ethiopia-Fifth Report