The burden attributable to primary headache disorders in children and adolescents in Ethiopia: estimates from a national schools-based study

BACKGROUND

We previously reported high prevalences of headache disorders among children (6-11 years) and adolescents (12-17 years) in Ethiopia. Here we provide data on headache-attributed burden collected contemporaneously from the same study participants. Part of the global schools-based programme within the Global Campaign against Headache, the study is the first to present such data from sub-Saharan Africa.

METHODS

A cross-sectional survey following the generic protocol for the global study was conducted in six schools (urban and rural), in Addis Ababa city and three regions of Ethiopia. The child or adolescent versions of the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) structured questionnaires were self-completed under supervision by pupils in class. Headache diagnostic questions were based on ICHD-3 beta but for the inclusion of undifferentiated headache (UdH).

RESULTS

Of 2,349 eligible participants, 2,344 completed the questionnaires (1,011 children [43.1%], 1,333 adolescents [56.9%]; 1,157 males [49.4%], 1,187 females [50.6%]; participating proportion 99.8%). Gender- and age-adjusted 1-year prevalence of headache, reported previously, was 72.8% (migraine: 38.6%; tension-type headache [TTH]: 19.9%; UdH: 12.3%; headache on ≥ 15 days/month (H15+): 1.2%). Mean headache frequency was 2.6 days/4 weeks but, with mean duration of 2.7 h, mean proportion of time with headache was only 1.0% (migraine: 1.4%; TTH: 0.7%; H15+: 9.1%). Mean intensity was 1.8 on a scale of 1-3. Symptomatic medication was consumed on about one third of headache days across headache types. Lost school time reportedly averaged 0.7 days over the preceding 4 weeks, representing 3.5% of school time, but was 2.4 days/4 weeks (12.0%) in the important small minority with H15+. However, actual absences with headache the day before indicated averages overall of 9.7% of school time lost, and 13.3% among those with migraine. Emotional impact and quality-of-life scores reflected other measures of burden, with clear adverse impact gradients (H15 + > migraine > TTH > UdH).

CONCLUSIONS

The high prevalence of headache among children and adolescents in Ethiopia, who represent half its population, is associated with substantial burden. Lost school time is probably the most important consequence. Estimates suggest a quite deleterious effect, likely to be reflected in both individual prospects and the prosperity of society.

Association between fluoride exposure in drinking water and cognitive deficits in children: A pilot study

Fluoride (F) exposure in drinking water may lead to reduced cognitive function among children; however, findings largely remain inconclusive. In this pilot study, we examined associations between a range of chronic F exposures (low to high: 0.4 to 15.5 mg/L) in drinking water and cognition in school-aged children (5-14 years, n = 74) in rural Ethiopia. Fluoride exposure was determined from samples of community-based drinking water wells and urine. Cognitive performance was measured using: 1) assessments of ability to draw familiar objects (donkey, house, and person), and 2) a validated Cambridge Neuropsychological Test Automated Battery's (CANTAB) Paired Associate Learning (PAL), which examines memory and new learning and is closely associated with hippocampus function of the brain. Associations between F and cognitive outcomes were evaluated using regression analysis, adjusting for demographic, health status, and other covariates. The median (range) of water and urine F levels was 7.6 (0.4-15.5 mg/L) and 6.3 (0.5-15.7 mg/L), respectively; these measures were strongly correlated (r = 0.74), indicating that water is the primary source of F exposure. Fluoride in drinking water was negatively associated with cognitive function, measured by both drawing and CANTAB test performance. Inverse relationships were also found between F and drawing objects task scores, after adjusting for covariates (p < 0.05). Further analysis using CANTAB PAL tasks in the children confirmed that F level in drinking water was positively associated with the number of errors made by children (p < 0.01), also after adjusting for covariates (p < 0.05). This association between water F and total errors made became markedly stronger as PAL task difficulty increased. Fluoride exposure was also inversely associated with other PAL tasksthe number of patterns reached, first attempt memory score and mean errors to success. These findings provide supportive evidence that high F exposures may be associated with cognitive deficits in children. Additional well-designed studies are critically needed to establish the neurotoxicity of F in children and adults exposed to both low levels known to protect dental caries, as well as excess F levels in drinking water.

Impact of refresher training on the outcomes of trachomatous trichiasis surgery

BACKGROUND/AIMS

Trachomatous trichiasis (TT) is a severe consequence of chronic inflammation/conjunctival scarring resulting from trachoma, the leading infectious cause of blindness worldwide. Our prospective cohort study evaluated the effectiveness of refresher training (RT) for experienced surgeons (1-22 years) on the outcomes of upper lid (UL) TT surgery in rural Ethiopia.

METHODS

Patients undergoing UL TT surgery in at least one eye by a participating surgeon were included. Patients were split into two cohorts: patients enrolled prior to (C1) and after (C2) RT. RT consisted of a 1-week programme with practice on a HEAD START mannequin and supportive supervision in live surgery by expert trainers. Data were collected at preoperative enrolment, and at 6-month and 12-month follow-up visits. The primary outcome was development of postoperative TT (PTT). A series of multivariate generalised estimating equations were fit to model PTT involving potential covariates of interest.

RESULTS

A total of 261 eyes contributed by 173 patients were studied between 2017 and 2019. By 1-year postoperatively, 37/128 eyes (28.9%) in C1 and 22/133 eyes (16.5%) in C2 had developed PTT (p=0.03). Other than surgeon RT participation, no factors studied were associated with differences in PTT.

CONCLUSION

Our results indicate a significant reduction in the risk of PTT after experienced surgeons' participation in RT as compared with eyes receiving surgery before RT. This observation suggests a significant potential benefit of the RT with HEAD START mannequin practice and supportive supervision during surgery, and suggests RT may be a valuable strategy to improve surgical outcomes.

Neuro-medical manifestations of fluorosis in populations living in the Main Ethiopian Rift Valley

Prolonged exposure to higher concentrations of fluoride (> 1.5 mg/L) is associated with dental and skeletal fluorosis. The effects of fluoride on dental and skeletal system have been studied extensively; however, the neurological consequences of fluoride in population-based studies are limited. The study aims to assess the epidemiology of neurological and other manifestations of fluorosis among rural populations living in the Main Ethiopian Rift valley. In this cross-sectional study, we enrolled 316 individuals from 23 rural communities in the Main Ethiopian Rift valley. Fluoride concentration was measured in drinking water samples collected from 23 community wells. Association between fluoride concentrations and clinical features of fluorosis was assessed using student t test, chi square, multivariable regression using adjusted odds ratio (OR). The mean fluoride concentration in the drinking water was 6.8 ± 4.3 mg/L (range: 0.3-15.5 mg/L). At least one clinical sign of skeletal fluorosis was observed in 54.4% (n = 175) of the study participants. Headache and joint pain reported by 67.1% and 56.3% of the participants as the most common neurological manifestation, and skeletal fluorosis symptom, respectively. The mean fluoride level was higher for those individuals who reported paresthesia compared to those with no-paresthesia. Loss of appetite, constipation, and fatigue were reported by 48.0%, 45.6%, and 56.6% of the participants, respectively. Signs of crippling fluorosis were observed in small proportion (1.6%) of the participants. Individuals who reported headache are most likely exposed to higher fluoride concentrations in drinking water compared to those reported no-headache (p < 0.001). The study demonstrates high prevalence of neuro-medical manifestations of fluorosis in population living in the Main Ethiopian Rift valley. Fluoride concentration in drinking water and joint pain were independent predictors of fluorosis.

The prevalence of headache disorders in children and adolescents in Ethiopia: a schools-based study

Background

The Global Burden of Disease (GBD) study establishes headache as the second-highest cause of disability worldwide. Because most headache data in GBD are from adults, leading to underestimation of headache-attributed burden, a global schools-based programme within the Global Campaign against Headache is contributing data from children (7–11 years) and adolescents (12–17 years). This national study in Ethiopia is the first in this programme reported from sub-Saharan Africa.

Methods

A cross-sectional survey following the generic protocol for the global study was conducted in six schools (urban and rural), in Addis Ababa city and three regions of Ethiopia. Structured questionnaires were self-completed under supervision by pupils within their classes. Headache diagnostic questions were based on ICHD-3 beta criteria but for the inclusion of undifferentiated headache (UdH).

Results

Of 2349 potential participants, 2344 completed the questionnaire (1011 children [43.1%], 1333 adolescents [56.9%]; 1157 males [49.4%], 1187 females [50.6%]), a participation proportion of 99.8%. Gender- and age-adjusted 1-year prevalence of headache was 72.8% (migraine: 38.6%; tension-type headache: 19.9%; UdH: 12.3%; all headache on ≥15 days/month: 1.2%; probable medication-overuse headache: 0.2%). Headache was more prevalent in females (76.2%) than males (71.0%), a finding reflected only in migraine among the headache types. Headache was more prevalent among adolescents (77.6%) than children (68.4%), reflected in all types except migraine, although prevalence of UdH fell sharply after age 14 years to 3.9%.

For headache overall, findings matched those in Turkey and Austria, obtained with the same questionnaire, but the high prevalence of migraine, not increasing with age, was surprising. The study highlighted diagnostic difficulties in young people, especially when poorly educated, with migraine diagnoses driven by improbably high proportions reporting nausea (44.8%) and vomiting (28.0%) as usual symptoms accompanying their headaches.

Conclusions

Headache is very common in children and adolescents in Ethiopia. This has major public-health implications, since half the country’s population are aged under 18 years.

Bone quality in fluoride-exposed populations: A novel application of the ultrasonic method

BACKGROUND

Various studies, mostly with animals, have provided evidence of adverse impacts of fluoride (F-) on bone density, collagen and microstructure, yet its effects on overall bone quality (strength) has not been clearly or extensively characterized in human populations.

OBJECTIVE

In this observational study, we assessed variation in an integrated measures of bone quality in a population exposed to wide-ranging F- levels (0.3 to 15.5 mg/L) in drinking water, using a novel application of non-ionizing ultrasonic method.

METHOD

We collected 871 speed of sound (SOS) measurements from 341 subjects residing in 25 communities, aged 10-70 years (188 males and 153 females). All subjects received scans of the cortical radius and tibia, and adults over the age of 19 received an additional scan of the phalanx. Associations between F- in drinking water and 24-h urine samples, and SOS as a measure of bone quality, were evaluated in bivariate and multivariable regressions adjusting for age, sex, BMI, smoking, and toothpaste use.

RESULTS

We found negative associations between F- exposure and bone quality at all three bones. Adult tibial SOS showed the strongest inverse association with F- exposure, which accounted for 20% of the variance in SOS measures (r = 0.45; n = 199; p < 0.0001). In adjusted analysis, a 1 mg/L increase in F- in drinking water was related to a reduction of 15.8 m/s (95% CI: -21.3 to -10.3), whereas a 1 mg/L increase in 24-h urinary F- (range: 0.04-39.5 mg/L) was linked to a reduction of 8.4 m/s (95% CI: -12.7, -4.12) of adult tibial SOS. Among adolescents, in contrast, weaker and non-significant inverse associations between F- exposure and SOS were found, while age, gender, and BMI were more significant predictors than in adults.

CONCLUSIONS

These results are indicative of a fluoride-induced deterioration of bone quality in humans, likely reflecting a combination of factors related to SOS: net bone loss, abnormal mineralization and collagen formation, or altered microarchitecture. The portable and low-cost ultrasound technique appears potentially useful for assessment of bone quality, and should be tested in other locations and for other bone-related disorders, to assess the feasibility of its more extensive diagnostic use in hard-to-reach rural regions.

The burden of headache disorders in Ethiopia: national estimates from a population-based door-to-door survey

BACKGROUND

Headache disorders are the third-highest cause of disability worldwide, with migraine and medication-overuse headache (MOH) the major contributors. In Ethiopia we have shown these disorders to be highly prevalent: migraine 17.7%, TTH 20.6%, probable MOH (pMOH) 0.7%, any headache yesterday (HY) 6.4%. To inform local health policy, we now estimate disability and other burdens attributable to headache in this country.

METHODS

In a cross-sectional survey using cluster-randomized sampling, we visited households unannounced in four diverse regions (urban and rural) of Ethiopia. We interviewed one member (18-65 years old) of each household using the HARDSHIP structured questionnaire. Screening and diagnostic questions based on ICHD-II were followed by burden enquiry in multiple domains. We estimated disability using disability weights (DWs) from the Global Burden of Disease 2013 study.

RESULTS

We interviewed 2385 participants (1064 [44.7%] male, 596 [25.0%] urban; participating proportion 99.8%). Reported mean intensity of migraine was 2.6 (scale 1-3). People with migraine spent 11.7% of their time in the ictal state (DW: 0.441); they were therefore 5.2% disabled overall. Pain and disability from TTH were much lower. Mean intensity of pMOH was 2.95. People with pMOH spent 60.2% of time with headache (DW: 0.223), and were 13.4% disabled. Average proportions of per-person lost productive time were, for migraine, 4.5% from paid work, 5.3% from household work; for pMOH they were 29.2% and 16.0%. There were highly-disabled minorities, and large gender differences, males losing more paid workdays, females more household workdays. All headache types were associated with impairments in quality of life. Across the population aged 18-65 years (effectively the working population), disability from headache was 1.4%, with 1.6% of workdays lost (half from migraine). Estimates from HY, eliminating recall error, were highly compatible.

CONCLUSIONS

Ethiopia is a low-income country, and cannot afford these losses - including, perhaps, 1.6% of GDP. Political action is necessary, aimed at mitigating both the economic burden and the associated ill health. WHO has recommended structured headache services with their basis in primary care as the most efficient, effective, affordable and equitable solution, potentially cost-saving. We believe they can be implemented within Ethiopia's existing health-care infrastructure.

Biomarkers of chronic fluoride exposure in groundwater in a highly exposed population

This study examined the relation between fluoride (F-) concentrations in fingernail clippings and urine and the prevalence and severity of enamel fluorosis (EF) among Ethiopian Rift Valley populations exposed to high levels of F- in drinking water. The utility of fingernail clippings as a biomarker for F- exposure and EF was also assessed for the first time in a high-F- region. The study recorded the EF status of 386 individuals (10 to 50years old), who consume naturally contaminated groundwater with widely varying F- concentration (0.6-15mg/L). The mean F- concentrations among residents of communities with primary reliance on groundwater were 5.1mg/kg (range: 0.5-34mg/kg) in fingernails and 8.9mg/L (range: 0.44-34mg/L) in urine. We show strong positive correlations between F- in drinking water and 12-hour urinary excretion (r=0.74, p<0.001, n=287), fingernail F- content (r=0.6, p<0.001, n=258), and mean individual measures of EF severity as measured using the Thylstrup and Fejerskov (TF) Index (r=0.42, p<0.001, n=316). The data indicate that both fingernail and urine measures are good biomarkers for F- exposure and EF outcomes, the latter being slightly more sensitive. Cases of moderate/severe EF were significantly more common among younger subjects (10 to 15years old) than older subjects (mostly >25years old) (p<0.001), consistent with their greater exposure to F- during early childhood, which is the only period of life the enamel is at risk of fluorosis. In this younger population, EF may be useful as a biomarker for identifying individuals with other potential health effects that depend on a specific age window of susceptibility. The finding of exceptionally high F- concentrations in water, fingernail clippings and urine in this region should motivate further investigations of other potential health consequences such as bone disease and abnormalities in the function of the neurological and endocrine systems.

The prevalence of primary headache disorders in Ethiopia

BACKGROUND

Knowledge of the epidemiology of primary headache disorders in sub-Saharan Africa (SSA) remains very limited. We performed a population-based survey in rural and urban areas of Ethiopia, using methods similar to those of an earlier study in Zambia and tested in multiple other countries by Lifting The Burden.

METHODS

In a cross-sectional survey we visited households unannounced in four regions of Ethiopia: the mostly urban populations in Addis Ababa and its environs and rural populations of selected districts in Oromia, Amhara and South Nations Nationalities and People's Regions States (SNNPRS). We used cluster-randomized sampling: within clusters we randomly selected households, and one adult member (18-65 years old) of each household. The HARDSHIP structured questionnaire, translated into the local languages, was administered face-to-face by trained interviewers. Demographic enquiry was followed by diagnostic questions based on ICHD-II criteria.

RESULTS

From 2,528 households approached, 2,385 of 2,391 eligible members (1,064 [44.7%] male, 596 [25.0%] urban) consented to interview (participating proportion 99.8%). Headache in the preceding year was reported by 1,071 participants (44.9% [95% CI: 42.4-46.3]; males 37.7%, females 49.9%), and headache yesterday by 170 (7.1% [6.2-8.2]; males 45 [4.1%], females 125 [9.2%]). Adjusted for gender, age and habitation (urban/rural), 1-year prevalence of migraine was 17.7%, of tension-type headache (TTH) 20.6%, of all headache on ≥15 days/month 3.2%, and of probable medication-overuse headache (pMOH) 0.7%. The adjusted prevalence of headache yesterday was 6.4%. Very few cases (1.6%) were unclassifiable. All headache disorders were more common in females. TTH was less common in urban areas (OR: 0.3; p < 0.0001), but pMOH was very strongly associated (OR: 6.1; p < 0.0001) with urban dwelling. Education was negatively associated with migraine (OR: 0.5-0.7; p < 0.05) but (at university level) positively with pMOH (OR: 2.9; p = 0.067). Income above ETB 500/month showed similar associations: negatively with migraine (OR: 0.8; p = 0.035), positively with pMOH (OR: 2.1; p = 0.164).

CONCLUSIONS

Findings for migraine and TTH in Ethiopia were quite similar to those from Zambia, another SSA country; pMOH was much less prevalent but, as in Zambia, essentially an urban problem. Primary headache disorders are at least as prevalent in SSA as in high-income western countries.

Impact of an educational comic book on epilepsy-related knowledge, awareness, and attitudes among school children in Ethiopia

INTRODUCTION

Epilepsy is of worldwide public health importance because it is common, often accompanied by physical and cognitive disabilities, and is widely stigmatized. The incidence of epilepsy in Ethiopia was reported to be 64/100,000 population and a prevalence of 520/100,000 population. A minority of subjects is treated, and religious and sociocultural beliefs influence the nature of treatment and care. One approach to support the development of positive attitudes toward individuals with disabilities is through the use of comics. Comics have been effective in creating awareness and educating about epilepsy.

MATERIAL AND METHODS

We conducted a cross-sectional study among randomly selected students from two preparatory schools (one from a city and the other from a rural area) in June 2014. We collected information using a structured KAP questionnaire before and after reading a comic book. The comic book relevance was assessed by 40 health professionals.

RESULT

One hundred sixteen students from urban and 110 from rural high schools were enrolled in the present study with an age distribution of 31.9% in 16-17years, 48.7% in 18-19years, and 19.5% in 20+years. Thirty percent of the urban school was male compared with sixty-five percent of the rural school. The comic book was recommended as useful educational material to be distributed among school children by 90% of interviewed health professionals (internists, neurologist, psychiatrists, residents, GPs, and nurses).

CONCLUSION

The comic book was appreciated by the Ethiopian high school students. After brief exposure to the comic book, students could extract a great deal of information, it could change misconceptions and provide correct information about epilepsy, and can be an effective approach to epilepsy awareness creation. Health professionals found the comic book to be very informative and recommended its distribution to students, teachers, nurses, libraries, and community/religious leaders. Illustrations were Ethiopian-oriented.

Fluoride exposure from groundwater as reflected by urinary fluoride and children's dental fluorosis in the Main Ethiopian Rift Valley

This cross-sectional study explores the relationships between children's F(-) exposure from drinking groundwater and urinary F(-) concentrations, combined with dental fluorosis (DF) in the Main Ethiopian Rift (MER) Valley. We examined the DF prevalence and severity among 491 children (10 to 15 years old) who are life-long residents of 33 rural communities in which groundwater concentrations of F(-) cover a wide range. A subset of 156 children was selected for urinary F(-) measurements. Our results showed that the mean F(-) concentrations in groundwater were 8.5 ± 4.1 mg/L (range: 1.1-18 mg/L), while those in urine were 12.1±7.3 mg/L (range: 1.1-39.8 mg/L). The prevalence of mild, moderate, and severe DF in children's teeth was 17%, 29%, and 45%, respectively, and the majority (90%; n=140) of the children had urinary F(-) concentrations above 3 mg/L. Below this level most of the teeth showed mild forms of DF. The exposure-response relationship between F(-) and DF was positive and non-linear, with DF severity tending to level off above a F(-) threshold of ~6 mg/L, most likely due to the fact that at ~6 mg/L the enamel is damaged as much as it can be clinically observed in most children. We also observed differential prevalence (and severity) of DF and urinary concentration, across children exposed to similar F(-) concentrations in water, which highlights the importance of individual-specific factors in addition to the F(-) levels in drinking water. Finally, we investigated urinary F(-) in children from communities where defluoridation remediation was taking place. The lower F(-) concentration measured in urine of this population demonstrates the capacity of the urinary F(-) method as an effective monitoring and evaluation tool for assessing the outcome of successful F(-) mitigation strategy in relatively short time (months) in areas affected with severe fluorosis.

The methodology of population surveys of headache prevalence, burden and cost: principles and recommendations from the Global Campaign against Headache

The global burden of headache is very large, but knowledge of it is far from complete and needs still to be gathered. Published population-based studies have used variable methodology, which has influenced findings and made comparisons difficult. Among the initiatives of the Global Campaign against Headache to improve and standardize methods in use for cross-sectional studies, the most important is the production of consensus-based methodological guidelines. This report describes the development of detailed principles and recommendations. For this purpose we brought together an expert consensus group to include experience and competence in headache epidemiology and/or epidemiology in general and drawn from all six WHO world regions. The recommendations presented are for anyone, of whatever background, with interests in designing, performing, understanding or assessing studies that measure or describe the burden of headache in populations. While aimed principally at researchers whose main interests are in the field of headache, they should also be useful, at least in parts, to those who are expert in public health or epidemiology and wish to extend their interest into the field of headache disorders. Most of all, these recommendations seek to encourage collaborations between specialists in headache disorders and epidemiologists. The focus is on migraine, tension-type headache and medication-overuse headache, but they are not intended to be exclusive to these. The burdens arising from secondary headaches are, in the majority of cases, more correctly attributed to the underlying disorders. Nevertheless, the principles outlined here are relevant for epidemiological studies on secondary headaches, provided that adequate definitions can be not only given but also applied in questionnaires or other survey instruments.

Diagnosis, prevalence estimation and burden measurement in population surveys of headache: presenting the HARDSHIP questionnaire

The global burden of headache is very large, but knowledge of it is far from complete and needs still to be gathered. Published population-based studies have used variable methodology, which has influenced findings and made comparisons difficult. The Global Campaign against Headache is undertaking initiatives to improve and standardize methods in use for cross-sectional studies. One requirement is for a survey instrument with proven cross-cultural validity. This report describes the development of such an instrument. Two of the authors developed the initial version, which was used with adaptations in population-based studies in China, Ethiopia, India, Nepal, Pakistan, Russia, Saudi Arabia, Zambia and 10 countries in the European Union. The resultant evolution of this instrument was reviewed by an expert consensus group drawn from all world regions. The final output was the Headache-Attributed Restriction, Disability, Social Handicap and Impaired Participation (HARDSHIP) questionnaire, designed for application by trained lay interviewers. HARDSHIP is a modular instrument incorporating demographic enquiry, diagnostic questions based on ICHD-3 beta criteria, and enquiries into each of the following as components of headache-attributed burden: symptom burden; health-care utilization; disability and productive time losses; impact on education, career and earnings; perception of control; interictal burden; overall individual burden; effects on relationships and family dynamics; effects on others, including household partner and children; quality of life; wellbeing; obesity as a comorbidity. HARDSHIP already has demonstrated validity and acceptability in multiple languages and cultures. Modules may be included or not, and others (eg, on additional comorbidities) added, according to the purpose of the study and resources (especially time) available.

Improving quality in population surveys of headache prevalence, burden and cost: key methodological considerations

Population-based studies of headache disorders are important. They inform needs assessment and underpin service policy for a set of disorders that are a public-health priority. On the one hand, our knowledge of the global burden of headache is incomplete, with major geographical gaps; on the other, methodological differences and variable quality are notable among published studies of headache prevalence, burden and cost. The purpose here was to start the process of developing standardized and better methodology in these studies. An expert consensus group was assembled to identify the key methodological issues, and areas where studies might fail. Members had competence and practical experience in headache epidemiology or epidemiology in general, and were drawn from all WHO world regions. We reviewed the relevant literature, and supplemented the knowledge gathered from this exercise with experience gained from recent Global Campaign population-based studies, not all yet published. We extracted methodological themes and identified issues within them that were of key importance. We found wide variations in methodology. The themes within which methodological shortcomings had adverse impact on quality were the following: study design; selection and/or definition of population of interest; sampling and bias avoidance; sample size estimation; access to selected subjects (managing and reporting non-participation); case definition (including diagnosis and timeframe); case ascertainment (including diagnostic validation of questionnaires); burden estimation; reporting (methods and results). These are discussed.

Epidemiology of skeletal fluorosis in Wonji Shoa Sugar Estate, Wonji, Ethiopia: a community based survey

INTRODUCTION

Endemic skeletal fluorosis is a form of chronic fluoride intoxication resulting from ingestion of excessive quantities of fluoride through drinking water. It is an important public health problem in parts of several developing countries including Ethiopia.

OBJECTIVE

The aim of this study is assess the magnitude of the problem at the community level.

MATERIALS AND METHODS

This community based, cross-sectional study was undertaken in Wonji-Shoa Sugar Estate. (WSSE). A base line census of the adult population of WSSE was carried out at the beginning of the study. A total of 578 subjects were selected by simple random sampling using a sampling frame which was prepared from the census results. For each study participant, information on socio-demographic characteristics, possible risk factors gathered and X-ray of the forearm PA and Lateral were taken using standard x-ray techniques.

RESULTS

The overall prevalence of skeletal fluorosis is 65.7%, with male to female prevalence ratio of 79.3% vs. 53%. The crude analysis of factors associated with skeletal fluorosis shows that, males than females and manual workers than others had significantly higher risk (Crude OR = 3.39, 95% CI = 2.31-4.95 and OR = 3.22, 95% CI = 2.20-4.72 respectively). On logistic regression, only sex, age and camp of residence remained significantly associated with skeletal fluorosis. Adjusted for other factors, males were more likely (about 2.5 times to be at risk than females and older people of age 55 years and above had about 20 times higher risk than young adults of age 15-24.

CONCLUSION

The finding of very high prevalence of radiological skeletal fluorosis (SKF) in this study highlights the importance of endemic SKF as a public health problem. Therefore, prompt measures are required to provide the community with safe drinking water to prevent development of crippling skeletal fluorosis.

Community attitudes towards epilepsy in a rural Ethiopian setting: a re-visit after 15 years

INTRODUCTION

Despite being a common disorder, epilepsy is perhaps the neurological condition least well understood by the general public and most likely to be associated with a wide range of misconceptions.

METHODS

A cross-sectional community-based survey was conducted in a predominantly rural area of central Ethiopia where there has been a continuous supply of anticonvulsant medications for the last 15 years. Our objective was to assess the impact of this treatment upon the attitudes of rural people towards epilepsy by comparing our findings to a community attitude survey conducted between 1986 and 1988. The method used is a cross-sectional survey.

RESULTS

The belief that epilepsy is a contagious illness is significantly less prevalent compared to earlier days, 30.7% vs. 44.6% (P < 0.0001). Considering epilepsy to be a form of mental illness has increased in the current sample 40.9% vs. 1.9% (P < 0.0001). Attribution of the aetiology to supernatural factors is significantly diminished and the belief that epilepsy is hereditary has significantly increased. Modern anticonvulsant medications are more favoured in the current study 4.5% vs. 0.9% (p < 0.0001), although they remained unpopular with the majority who still prefer traditional treatment. In general, female respondents' knowledge about how to help a convulsing person, ways of preventing further epileptic attacks, and causes of epilepsy was significantly less than that of the male respondents. Rural dwellers also showed more negative attitudes with regard to marriage and working with a person suffering from epilepsy. Positive attitudinal changes in the past few years were reported by 119 (19%) of the respondents, and the changes were attributed to the availability of medication in the area and increased awareness through health education given at clinics.

CONCLUSION

The results show ongoing negative attitudes towards epilepsy within the community. In addition to attempts to improve seizure control, our findings highlight the importance of ongoing educational programmes directed towards community misconceptions and negative attitudes about epilepsy.

The geographic distribution of fluoride in surface and groundwater in Ethiopia with an emphasis on the Rift Valley

This paper analyzes the most extensive database on fluoride distribution in Ethiopia. Of the total 1438 water samples tested, 24.2% had fluoride concentrations above the 1.5 mg/l recommended optimum concentration recommended by WHO. Regionally, by far the highest fluoride levels were recorded in the Rift Valley, where 41.2% of all samples exceeded the 1.5 mg/l level. Only 1.0% of the samples from the central and northwestern highlands and 10.0% in the southeastern highlands exceeded 1.5 mg/l. Larger proportions of deep wells (50.0%) and hot springs (90.0%) than shallow wells (27.2%) and cold springs (12.6%) exceeded the 1.5 mg/l level. The highest fluoride concentrations were recorded for Rift Valley lakes Shala (264.0 mg/l) and Abijata (202.4 mg/l) and the lowest in Lake Tana, and rivers, wells and springs in the highlands. The fluoride concentrations of the Awash River, which originates in the highlands and flows through the Rift Valley, increase downstream, giving concern over the current diversion of high-fluoride water from Lake Beseka. Of the various flourosis prevention methods tried in Ethiopia, the treatment of surface water has been shown to be the most feasible and effective for towns and large commercial farms in the Rift Valley, although defluoridation methods should be considered for smaller rural communities.

Drinking water quality in the Ethiopian section of the East African Rift Valley I--data and health aspects

Drinking water samples were collected throughout the Ethiopian part of the Rift Valley, separated into water drawn from deep wells (deeper than 60 m), shallow wells (<60 m deep), hot springs (T>36 degrees C), springs (T<32 degrees C) and rivers. A total of 138 samples were analysed for 70 parameters (Ag, Al, As, B, Ba, Be, Bi, Br, Ca, Cd, Ce, Cl, Co, Cr, Cs, Cu, Dy, Er, Eu, F, Fe, Ga, Gd, Ge, Hf, Hg, Ho, I, In, K, La, Li, Lu, Mg, Mn, Mo, Na, Nb, Nd, Ni, NO(2), NO(3), Pb, Pr, Rb, Sb, Se, Si, Sm, Sn, SO(4), Sr, Ta, Tb, Te, Th, Ti, Tl, Tm, U, V, W, Y, Yb, Zn, Zr, temperature, pH, conductivity and alkalinity) with ion chromatography (anions), spectrometry (ICP-OES and ICP-MS, cations) and parameter-specific (e.g. titration) techniques. In terms of European water directives and WHO guidelines, 86% of all wells yield water that fails to pass the quality standards set for drinking water. The most problematic element is fluoride (F), for which 33% of all samples returned values above 1.5 mg/l and up to 11.6 mg/l. The incidence of dental and skeletal fluorosis is well documented in the Rift Valley. Another problematic element may be uranium (U)-47% of all wells yield water with concentrations above the newly suggested WHO maximum acceptable concentration (MAC) of 2 microg/l. Fortunately, only 7% of the collected samples are above the 10 microg/l EU-MAC for As in drinking water.

High-fluoride drinking water. A health problem in the Ethiopian Rift Valley 1. Assessment of lateritic soils as defluoridating agents

PURPOSE

High-fluoride drinking water represents a health hazard to millions of people, not least in the East African Rift Valley. The aim of the present project was to establish a simple method for removing excessive fluoride from water.

MATERIAL AND METHODS

Based on geological maps and previous experience, 22 soil samples were selected in mountainous areas in central Ethiopia. Two experiments were performed: 1. After sieving and drying, two portions of 50 g were prepared from each soil and subsequently mixed with solutions of NaF (500 mL). Aliquots (5 mL) of the solutions were taken at pre-set intervals of 1 hour to 30 days for fluoride analysis--using an F-selective electrode. 2. After the termination of the 30-days test, liquids were decanted and the two soil samples that had most effectively removed fluoride from the NaF solutions were dried, and subsequently exposed to 500 mL aqua destillata. The possible F-release into the distilled water was assessed regularly.

RESULTS

Great variations in fluoride binding patterns were observed in the different soils. The percent change in F-concentration in the solutions, as compared to the original absolute value(F-), varied: at 1 hour from a decrease of 58% to an actual increase of 7.7%, while--at 30 days--all soil samples had caused a decrease in the F-concentration, varying from 0.5% to 98.5%. Only minute amounts of fluoride would leach from the fluoride-enriched soils.

CONCLUSION

Lateritic soils may remove excessive fluoride from drinking water. Methods for practical application of this principle should be tested at household level.

Incidence of epilepsy in rural central Ethiopia

PURPOSE

To study the incidence of epilepsy in a rural area of Ethiopia.

METHODS

A community-based study was performed in a random sample of villages with 61,686 inhabitants in a rural area of central Ethiopia. In a door-to-door survey, all inhabitants in the study area were interviewed about seizures. A standardized protocol was used. All new cases with epilepsy that had occurred since a previous study was made 3.5 years earlier were included. Fifty-three of the subjects were investigated with EEG.

RESULTS

One-hundred thirty-nine incident cases were identified, corresponding to an annual incidence of 64 in 100,000 inhabitants [95% confidence interval (CI) 44-84]. The corresponding rate for males was 72 (CI 42-102); for females, it was 57 (CI 31-84). The highest age-specific incidence occurred in the youngest age groups (0-9 years); the next highest was in the group aged 10-19 years. Generalized convulsive seizures occurred in 69%, partial seizures occurred in 20%, and unclassifiable seizures occurred in 11%. Seizures occurred daily in 10% and weekly in another 14%; 33% had monthly seizures. Twenty-two percent had a family history of epilepsy. A history of head trauma was ascertained in 5.7% and was the most common possible etiologic factor identified. Thirteen percent were treated with antiepileptic drugs (AEDs).

CONCLUSIONS

The incidence of epilepsy in Ethiopia is high. A high incidence in combination with a prevalence of epilepsy in the study area comparable to that in the rest of the world may be explained by a high degree of spontaneous remission of epilepsy and/or a high mortality due to epilepsy. Despite health education on epilepsy given to the community, a minority of subjects were treated with AEDs, which may reflect the inadequacies of the health services and transportation difficulties faced by the patients.

Symptomatic treatment of neurolathyrism with tolperisone HCL (Mydocalm): a randomized double blind and placebo controlled drug trial

The efficacy and safety of oral Tolperisone HCL was evaluated in double blind, placebo-controlled, randomized trial in 72 patients with neurolathyrism in stages I, II, and III of the disease at Kolla Duba Health Centre of Dembia District of North Gondar between January and April 1995. Taken orally daily for 12 weeks, tolperisone HCL (Mydocalm) in a dose of 150 milligrams (mgs) twice daily significantly improved subjective complaints such as muscle cramps, heaviness of the legs, startle attacks, flexor spasms and repeated falls. An overall subjective improvement was observed in 75% of the patients on tolperisone HCL and 39% of the placebo group (P = 0.002). When objectively assessed spastic muscle tone in the abductors, stiffness of Achilles and spontaneous ankle clonus were significantly reduced in tolperisone HCL group (P values = 0.001, 0.04, and 0.0001, respectively). Walking ability and speed of walking was also significantly improved. The drug is most effective in relieving symptoms of stage I and stage II disease. Some adverse effects like muscle pain, generalized body weakness and dizziness were recorded in patients taking the drug but all were minor and self limited, none requiring discontinuation of treatment. It is concluded that tolperisone is a well tolerated and efficacious drug for symptomatic treatment of neurolathyrism.

Perceptions of blindness

A study in a mainly rural area of Ethiopia has revealed that sighted, unilaterally blind and totally blind people have many misconceptions about blindness. The work of cure and prevention demands that widespread ignorance about the causes and implications of blindness be overcome.

Causes of visual impairment in central Ethiopia

A survey conducted on a stable, mainly rural population of 60,820 in Central Ethiopia revealed an overall blindness prevalence of 1.1%. A follow up study was carried out to accurately determine the etiologies and causes of visual loss and impairment. A detailed ophthalmic evaluation was done on 523 out of 872 individuals identified as being visually impaired. The results showed that 194 (37%) were blind (Categories 3, 4, and 5 = maximum visual acuity less than 3/60 in the better eye). One hundred and seven (21%) (Categories 1 & 2 = maximum visual acuity better than 3/60 to less than 6/18 in the better eye using the WHO categories of visual impairment). The rest 222 (43%) were blind in one eye only. The commonest anatomical cause of blindness is corneal (32%). Cataract (25%), atrophied globe(s) (20%) and glaucoma (17%) follow as the other leading causes. Trachoma (35%), degenerative conditions (35%) and other infections (9%) were the major etiologies of blindness. Similar pattern of anatomical causation was observed in those classified under categories of visual impairment 1 and 2, referred to as "low vision". The most important etiologies of low vision were trachoma (30%), degenerative (24%), trauma (13%) and other infections (8%). Trauma was the most important etiology of monocular blindness (39%). Blindness was either preventable or curable in 74% of the cases.

Paraplegia at the Tikur Anbessa Teaching Hospital: a seven year retrospective study of 164 cases

Admission analysis of adult non-traumatic paraplegia and paraparesis from 1981 to 1988 was carried out. Information was collected from charts of 223 consecutive admissions according to a pre-set protocol. Paraplegia or paraparesis was responsible for 164(13.4%) of all neurological admissions over the study period. The median age of the patients was 36 years with a male to female ratio of 1.7:1. Tuberculosis was the leading cause of paraplegia or paraparesis accounting for 47% of the cases. Tumours (20%), Landry-Guillain-Barre' syndrome (12.2%) and tropical spastic paraparesis (TSP) (9.8%) were important but less frequent causes in this series. Other causes like disc prolapse, transverse myelitis, spinal artery stroke and fluorosis were rarely encountered. Vertebral deformity (88.1%), vertebral tenderness (88.1%) and abnormal plain spinal X-ray (89%) were the most helpful findings in the diagnosis of tuberculous paraplegia. Nearly all cases of tuberculous paraplegia were treated medically alone. However, the outcome of treatment as judged by the treating physicians was good with a significant response recorded in 78%.

HIV infection and leprosy: a four-year survey in Ethiopia

Between 1988 and 1992 three cross-sectional surveys for antibodies to HIV were done in 644 Ethiopian patients with histologically proven leprosy. Whereas the frequency of HIV-1 infection gradually increased from 3.2% to 6.5%, the clinical presentation, number of new patients, and frequency of relapse did not differ between HIV negative and positive patients. Thus HIV appears unlikely to have a significant impact on the incidence of leprosy in sub-Sahelian populations.

Blood pressure patterns and its correlates in schoolchildren of an Ethiopian community

This study was undertaken to define blood pressure pattern in a sample of schoolchildren in an Ethiopian rural community. All schoolchildren below the age of 15 years in Butajira town formed the study population. Blood pressure measurement which was made according to the recommendations of the American Task Force on blood pressure control in children was found to be unimodal with almost symmetrical distribution. The mean systolic and mean diastolic blood pressure for both sexes combined was 106 +/- 14.8 and 70.5 +/- 4.5 mmHg, respectively. The mean systolic and mean diastolic blood pressures increased with age in both boys (P < 0.05) and girls (P < 0.01). Girls had significantly higher mean systolic and mean diastolic blood pressures than boys (P < 0.001). Similarly, girls had significantly higher pulse rate and arm-girth than boys which may partly explain the higher mean pressures in the girls. A multiple regression analysis showed that height, body mass index, arm-girth, and heart rate were significant in explaining the variations in systolic and diastolic blood pressures. In conclusion, except for the higher blood pressure in girls, our findings are similar to the majority of the reports from Africa and other parts of the world.

A survey of antibodies to hepatitis C virus in Ethiopia

Antibodies to hepatitis C virus (HCV) were measured in 1,580 Ethiopian subjects representing urban and rural populations. Sera found positive by a repeated second generation enzyme immunoassay (EIA) were subjected to three additional confirmatory tests. The overall confirmed seroprevalence was 2.0%. Less than 1% were confirmed to be seropositive in rural communities, with 1.4% positive among blood donors, 1.6% positive among patients with dermatologic disorders, 3.6% among leprosy patients, and 6.0% among patients attending a University Hospital clinic for neurologic disorders. The patients in the groups with leprosy and neurologic disorders have most likely been in ill health for many years and have sought relief by traditional healers or treatment at poorly equipped clinics. This group of patients demonstrated a high prevalence of antibodies to HCV. In Ethiopia, especially in small clinics, there is a shortage of syringes and needles and they have to be reused many times often with inadequate sterilization. Therefore, these syringes and needles may be contaminated, thus being a risk factor for HCV and HIV infection.

Multiple myeloma in Ethiopians: analysis of 22 cases

Twenty-two cases of multiple myeloma were seen in the Department of Internal Medicine, Tikur Anbessa (Black Lion) Hospital, a teaching and referral hospital in Addis Abeba, Ethiopia, from January 1983 to December 1990. The age range was 38 to 76 (mean +/- SD = 51.5 +/- 12.2) years; a third were in the fifth decade. The male:female ratio was 1.75:1. The common clinical findings were bone pain in 20 (91%), bone tenderness in 15 (68%), anaemia in 14 (64%) and spinal cord compression in 8 (36%). The erythrocyte sedimentation rate (ESR) was raised in 21. Serum protein was raised in 17 (77%) and hyperglobulinaemia was seen in 20 (91%). Serum uric acid, blood urea nitrogen (BUN) and calcium were elevated in 10, 8 and 5 patients respectively, Bence-Jones proteinuria and albuminuria were each found in 9 patients. All patients had radiological abnormalities; 9 had a combination of lytic lesions, osteoporosis and pathological fractures (41%). Ten patients presented in clinical stage III. Four patients are being followed after 3-84 (median 40.5) months; eight were lost to follow-up 1-8 (median 2.0) months after diagnosis. Ten patients have died after 1-55 (median 11) months. Multiple myeloma is not uncommon in Ethiopians. Except for a lower age at presentation, the clinical, haematological, biochemical, and radiological findings, and the response to therapy, are similar to those reported elsewhere.

Attitudes of rural people in central Ethiopia towards leprosy and a brief comparison with observations on epilepsy

To find out public attitudes toward leprosy a door-to-door survey was carried out in 1546 sampled households in the rural farming community of Meskan and Mareko in central Ethiopia, where the prevalence of leprosy is estimated to be 1:1000. Attitudes toward leprosy were compared with attitudes to epilepsy, studied in a previously performed survey in the same community. Eighty-seven per cent of the respondents were above the age of 25, and 59.5% were females. There were slightly more Muslims (54%) than Christians. The majority of the interviewees (87%) were farmers, with an illiteracy rate of 84%. Ninety-five per cent and 83%, respectively, were not willing to employ or work with a person having the disease. Seventy-five per cent would not allow their children to associate with a playmate suffering from leprosy. Comparative analysis of attitudes in the same community showed that negative attitudes toward leprosy were stronger than those toward epilepsy, particularly with regard to matrimonial associations, sharing of accommodation, and physical contact with an affected person. The reasons for these differences appear to be the community's deeply entrenched belief that leprosy is both hereditary and contagious, expressed respectively by 48% and 53% of the respondents. In order to minimize the perpetuation of negative attitudes, there is a need to educate and impress on the population that leprosy is a treatable infectious disease which is not congenitally acquired, and that it is even curable if detected early. The study reinforces previously proposed suggestions that, in developing countries such as Ethiopia, leprosy care should be integrated into the general health services.

Rheumatic heart disease prevalence among schoolchildren of an Ethiopian rural town

Rheumatic heart disease (RHD) is the most important cardiovascular disease in hospital practice in Ethiopia. However, the prevalence rate of RHD at the community level remains unknown. The current survey was undertaken to estimate its prevalence among schoolchildren of a central Ethiopian rural town (Butajira). Accordingly, 92.8% of the entire schoolchildren (n = 3.235) in the town were screened. Their mean age was 13.4 +/- 3.5 years. Fifteen children, accounting for a rate of 4.6/1,000, were noted to have findings consistent with RHD. Females and older children were more frequently affected. Only 2 of the 15 students were aware of their disease, and neither of them were on regular secondary prophylaxis. Our finding is consistent with the hospital-based reports that showed RHD to be a common disorder in clinical practice. At the same time, the lack of awareness about their disease noted among the cases is worrisome and deserves serious attention.

Attitudes of rural people in central Ethiopia towards epilepsy

In the farming community of the sub-district of Meskan and Mareko in central Ethiopia, where the prevalence of epilepsy is known to be 5.2/1000, a door-to-door survey was undertaken in 1546 sampled households to find out public attitudes to epilepsy. Nearly 64% of the respondents were in the age group of 14-50 years, and 58.6% were women. The majority (86%) were illiterate, and 94% had incomes of a subsistence level; 89% had heard or witnessed seizures. Traditional views on the association of evil spirits and superstition was prevalent. By 45% of the interviewees, the disease was believed to be contagious through physical contacts during an attack. Although there was sympathetic concern in the community for the person suffering from epilepsy, negative attitudes were strong on matrimonial associations, sharing of accommodation and physical contacts with affected persons, particularly when there were obvious signs and frequent attacks by seizures. The study demonstrates that the rural community has very poor knowledge of the causes and nature of epilepsy, and this has resulted in social deprivations and at times, rejection of the sufferers.

Clinical and electroencephalographic characteristics of epilepsy in rural Ethiopia: a community-based study

A community-based epidemiological study of neurological disorders was performed in a rural area in Ethiopia. The most prevalent neurological disorder identified was epilepsy, found in 316 persons. The prevalence of epilepsy was 5.2/1000 inhabitants at risk, 5.8 for males, 4.6 for females. The highest age-specific prevalence was found for ages 10-19 years. Generalized tonic-clonic seizures were the most common seizure type and occurred in 81%. On clinical grounds, partial seizures occurred in 20% and in 29% of these secondary generalization followed. During seizures, 8.5% had been injured by burns and 5.7% by trauma. Eighty-four percent had seizures at least monthly. Seizures occurred in 4.8% of siblings. Traditional treatment with local herbs, holy water and amulets was the most common. Only 1.6% had been treated with recognized antiepileptic drugs. Mental retardation was the most common associated disorder, found in 7.9% of the persons with epilepsy. During a period of 2 years, 8 persons died of status epilepticus and 1 from severe burns as a result of falling into a domestic fire during a seizure. EEG was recorded in 73%. Epileptiform activity occurred in 18%.

Community-based study of neurological disorders in rural central Ethiopia

Between 1986 and 1988 a door-to-door survey was conducted on a stable rural population of 60,820 in central Ethiopia. Trained lay health workers made a complete census and identified cases with symptoms and signs of neurological disorders, using specially designed questionnaires which, in a previous pilot study, were found to have a sensitivity of 91% and specificity of 85%. Neurological disorders in the rural population were epilepsy, postpoliomyelitis paralysis, mental retardation, peripheral neuropathy (mainly due to leprosy), and deaf-mutism with prevalence rates (cases/100,000 population) of 520, 240, 170, 150 and 130, respectively. The prevalence rates of the other less common neurological disorders were 62 for hemiparesis (15 of which were for cerebrovascular accidents), 20 for cerebral palsy, 16 for optic atrophy, 12 for perceptive deafness, 10 for tropical spastic paraparesis, 7 for Parkinson's disease and 5 for motor neuron disease, ataxia and chorea/athetosis. Among related non-neurological conditions, blindness, locomotor disability and deafness were predominant. The significance and role of such a neuroepidemiological study in laying the strategies for the prevention of neurological disorders and rehabilitation of patients are discussed in the context of a developing country.

Non-traumatic adhesive arachnoiditis as a cause of spinal cord syndromes. Investigation of 507 patients

Spinal cord syndromes with a mainly syringomyelic pattern of sensory diorders, radiculopathies, mixed paresis of varying degree (without any history of trauma), have been found in 507 out of 1305 new patients referred to out Clinic from January 1976 till 31 October 1977. In 105 randomised and unselected cases with these syndromes, myelographies have disclosed findings compatible with an adhesive spinal and/or cisternal arachnoiditis. A prospective study of the syndromes for evidence of infectious aetiology has been performed, in which tuberculosis, syphilis and other infections appear to be causative agents. A randomised therapeutic trial on a limited number of cases has been evaluated, as well as the results of specific therapy in a larger number of cases. Results of treatment have not been satisfactory. Operations were performed on only five patients and in no case was an autopsy obtained. Spinal cord syndromes due to non-traumatic adhesive arachnoiditis are discussed. The possible pathogenetic mechanisms the predominantly syringomyelic sensory deficits in those syndromes are briefly mentioned.