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Health extension workers improve tuberculosis case finding and treatment outcome in Ethiopia: a large-scale implementation study

Daniel G Datiko, Mohammed A Yassin, Sally J Theobald, L. Blok, Sahu Suvanand, Jacob Creswell, Luis E Cueva

Tuberculosis (TB) is a leading cause of death among infectious diseases and is responsible for 1.8million deaths each year. Over 4 million incident cases of TB worldwide fail to be diagnosed or linked into TB services every year and people with undetected TB have a high mortality and perpetuate disease transmission. Identifying and treating these individuals is crucial.


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 3.5million 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.


HEWs identified 216.165 individuals with symptoms and 27918 (12%) were diagnosed with TB. Smearpositive 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).


A community-based package significantly increased case finding and improved treatment outcome. Implementing this strategy could help meet the Ethiopian Sustainable Development Goal targets.

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