Volume 9 Number 2 August 1995

Relating fever

Several thousand cases of relapsing fever were reported annually to the MOH between 1981 and 1990, with the largest number in 1983 (43,727), when an epidemic occurred in Wolayita district. Between one quarter and one half of all cases reported annually between1987 and 1990: Wello (1987), Shewa (1988 & 89) and Gondar (1990). Another 10- 15% of the cases were reported annually from health facilities in Addis Ababa. Disproportionately more cases have been reported from the Ethiopian highlands than the lowlands, and Do

case was reported from Assab. Similarly most cases of relapsing fever are normally reported during the cool season, i.e. , August to December .

Whenever there is a highly susceptible population, there can be a major outbreak any time. This has been well documented, particularly when people have been badly malnourished. This is an observation throughout history, since epidemics have occurred after both world wars and also when people have been undernourished and forced to move in large numbers. Relapsing fever has rapidly spread and caused high mortality rates in Ethiopia during wars, civil unrest and famines. During the final stage of the war in 1991 , epidemics were reported from army camps and among displaced persons. Thirty three percent of the 3,610 cases reported by the MOH in 1984 -85 were hospitalized and 4.2% had died.
In many ways relapsing fever is a disease of deprivation and the challenge now is to show that it can be eradicated or at least reduced to such trivial numbers that it will no longer be a burden to health services. This can not happen until poor people have adequate shelter and are not too crowded.

HIV/AIDS

HIV appears to have been introduced to Ethiopia in 1984 or the year before, at a time when it was said to have become an endemic situation in some parts of East and Central Africa (20). Since then various studie:; on different segments of population showed that HIV infection was prevalent in the general population. Though the first cases of AIDS identified and reported were seven patients from Addis Ababa in 1986- 87, by 1984 the first 2 sero-positives were already detected and reported to the MOH (21). Since then the reported number of AIDS cases to the Department of AIDS control (DAC) of the MOH is increasing at an alarming rate (22).
As of July 31, 1994, (22) there were a total of 14,074 AIDS cases in Ethiopia, and an unpublished report indicates that there are 848 additional cases in August (Dr. Workneh Feleke, Head of AIDS control team, MOH - personal communication). Fifty five percent of all cases are reported from hospitals in Addis Ababa. Of these 43.2 % are residents of Addis Ababa, the capital city of the country .The sexually active group (15 -49 years) comprised 93.3 % of all cases. Around 87.1 % were due to heterosexual transmission and ,female to male ratio of total cases was 1:1.6.
Table 1: Distribution of AIDS cases by year of report

Year	Sex			Sex Raito (M:F)	Percent of Total
	Male	Female	Total
1886	1	1	2	1:1	0.01%
1987	12	5	17	2.4:1	0.12%
1988	67	18	85	3.7:1	0.60%
1989	128	62	190	2.1:1	1.35%
1990	292	156	448	1.9:1	3.18%
1991	585	300	885	1.9:1	6.29%
1992	1984	1272	3256	1.6:1	23.13%
1993	3187	1937	5124	1.6:1	36.41%
1994*	2438	1529	4067	1.5:1	28.90%
Total	8694	5380	14,074	1.6:1	100.00%

*Only up to July 31, 1994

(source: AIDS case surveillance report of Department of

Epidemiology and AIDS control, MOH, July 31, 1994 (22)

It can be seen that since late 1992, the proportion of reported cases is increasing dramatically. It is evident that the majority (74.7%) of cases are young, 20- 39 years of age, with an average male age of 32.6 years and females 27.1 years. Overall the average age of AIDS cases is 30.5 years. In terms of marital status, single men and women constitute 44 % of all cases followed by the married (35.4%), divorced and widowed (3%)

patients. Occupationally, government employees constitute 14% of all cases, followed by armed forces (11.6%), merchants (8%), house wives (7.4%), drivers (7%) and commercial sex workers (6%).
Some of the risk factors observed among the AIDS patients were history of Multi-Partner Sexual Contact (87.1 % ), maternal HIV or breast feeding (1.4% ), history of illegal injections (0.9% ), history of blood transfusion (0.85 % ) , intravenous drug abuse in 0.04 % and unspecified in 9.7% of all the cases.
Prevalence of HIV infection: Several sero- epidemiologic studies have been carried out in the country, mainly in urban areas and among the so called high risk groups as well as the general population. The first two HIV sero- positives were detected in 1984 while testing a collection of sera from hospital patients in Addis Ababa. Another study conducted among army recruits in 1986, showed that 4/5264 (0.076%) were positive for HIV. In the subsequent year the prevalence was 0.9%. Studies on commercial sex workers also show rising HIV prevalence. In 1986, females with multiple partner sexual contacts (MPSC)and males attending STD clinics had a prevalence of 6.7% and 1.4%, respectively. In 1988, a major sero-epidemiologic study among commercial sex workers in 23 towns out of Addis Ababa, investigated 6,234 women. The prevalence rates ranged from 1.3% in Mitsewa to 38.1 % in Dese town with the average for all towns being 17% .The highest prevalence rates (> 20%) was found in larger towns situated along the roads leading from Addis Ababa to Asab, Gondar and Mekele. The populations in the towns along the major truck roads were more frequently affected than those living in the town with less motor traffic. In Gondar and Bahar Dar towns, among the 367 and 324 women tested, the prevalence found was 14.7% and 35.9%, respectively. A study on HIV -1 prevalence among selected sex workers in Addis Ababa in 1989 revealed 24.7% positivity , the highest prevalence being among those in red-light houses.
A study among males -long distance truck drivers, their assistants and lorry technicians in July 1988 showed HIV sero-positivity rates of 13%, 12.9% and 4.1%, respectively. Among blood donors, the HIV prevalence rates have increased from 2.1% in 1986 to 2.3% in 1988 and among OPD attendants from zero in 1985- 86 to 3.5% in 1989, indicatingea steady spread of HIV infection to the general population in the country .
In summary , results of different studies show that the average HIV prevalence rate in the country in 1988 among MPSC females was 18.5% and in 198929.2%. The progression rates were higher in the initially low prevalence areas and vice versa. Among blood donors in Addis Ababa, it has increased from 2.3% (n=24,768) in 1987 to 3.7% (n =20,462) in 1989 and 6.5% in 1991. Positivity has also increased among military recruits from all regions from 0.8% in 1986 to 2.6% in 1991. The prevalence among scholarship winners going abroad was 3.2% in 1988 and 3.8% in 1989. Several studies assessing high risk behaviours and high risk groups have also been conducted in Ethiopia. The major risk factors associated with HIV infection (among commercial sex worker) are said to be high number of sexual partners, infection with other sexually transmitted disease, lack of general education and duration of involvement in prostitution (23). HIV infection was more common among persons who experienced other STDs as compared to those who didn't report STDs.
The truck drivers, who practised frequent contacts with female sex workers experienced STDs more frequently. Other high risk practices among males studied in Jimma town (24) revealed 47% had sex with MPSC \females, out of which only 24% had reported using condoms. Interestingly, high risk behaviour was found among those with the highest knowledge about AIDS (24). In Addis Ababa, a study among soldiers, showed that more single males were infected than married ones, and they had greater tendency to visit bars and have sexual contacts with female sex workers (25). Genital ulcers were significantly associated with multi-sexual contacts and with HIV infection. Among prisoners in Dire Dawa, 6% were positive for HIV-1 and more common among those concurrently having. syphilis and genital ulcers (26). A study among senior high school students in Addis Ababa indicated that among those sexually active students, 60.2% have reported to have had sexual relations with 2 -5 persons, and the majority of respondents used no protective methods at all (27). Among a similar group of students, but in a rural setting, the mean number of sexual partners was three, and 40% of these never used-condoms (28).
Among rural farmer male populations, in Central Ethiopia, high risk practices for HIV infection and transmission were documented among rural residing former soldiers, merchants and students. Within these groups, 45-50% had extra marital sexual contacts, 25-37% reported to live had sex with urban sex workers and only 10 -30% used condoms. In the same study 13.5 % of male farmers had extramarital sexual contacts in 3 months time, of which 7 % were with urban sex workers. Again high level of knowledge was associated with high risk behaviours (29). Another study in rural Gondar among male farmers found out that 7.5% (n=89) had practised extra-marital sex in 23 months preceding the survey. Consistently, higher knowledge was associated with high risk practices (30). In the same district (Oembia), another study revealed that 38.6%

of 112 government employees of Kolla Oiba town had a total of 82 high risk heterosexual contacts of which 55 were with commercial sex workers (31). A study done among students of Gondar College of medical Sciences, revealed that 61.4% (n=228) had more than one sexual partner. Of these 53 had contacts with sex workers and 12 students with STOs were self-reported. Condoms were used in only 47.8% of sexual contacts (31.). In Bahr Oar town, a community based study among sex workers showed that 50% of them persuaded their clients to use condoms, and of these, 51.9% were occasional users while 48.1% of sex workers used regularly.

The same study reported that 7.1 % of school youth in Bahr Oar town reported history of symptoms related to sexually transmitted diseases. Mean number of sex partners was found to be 3.9 and 69.9% of these out of

school youth never used condoms (33). Attitudes towards using condoms has also been studied by few investigators. Hailegnew reported that in Addis Ababa, 32% believed in condom use, II % had used condoms once or more in the past. Nevertheless, 47% of respondents were not sure about it's effectiveness and 12% did not like condoms at all, while 9% think that it will decrease their sexual gratification (34) .

According to the AIDS control department, using the" AIDS Calculator" , the cumulative number of AIDS cases will have exceeded 7000 in 1990 and will have increased to over 45,~ by the year 1993. If the transmission trend is not changed by the end of 1993, there would be 800,000 HIV infected persons in Ethiopia. Among children it was estimated that some 20,000 were infected in Ethiopia in 1990, and 50,000 would be infected by 1993 (5).
Control measures: As early as 1985, A Task Force on the prevention and control of HIV infection and AIDS in Ethiopia was established, immediately after the first laboratory diagnosed HIV cases were identified. Then short and medium term plans were developed in 1987, by giving highest priority to the development of national program (5). Later in 1987, the office of National AIDS Control Program (NACP) was established at a departmental level with two broad objectives of preventing HIV transmission and reducing the morbidity and mortality associated with HIV infection. The DAC coordinates the implementation of NACP in Ethiopia. Major activities include: Epidemiological Surveillance through laboratory network for HIV infection, HIV

surveillance, Surveillance of AIDS cases and intervention through prevention of transmission through blood transfusion, prevention of sexual transmission of the HIV, Social mobilization and condom promotion, education of the general population, promotion of condoms through social marketing and establishing counselling network for HIV / AIDS victims in Ethiopia (5).

At present all planning and implementation ACP activities are being carried out by the regions (35). Hence, the Dept. of Epidemiology and AIDS control in the MOH is expected to prepare national policy on HIV / AIDS, develop guidelines pertaining to HIV /STD/ AIDS in the Ethiopian context, secure funds from external sources, procure HIV kits, reagents, STD drugs, protective supplies, IEC materials from abroad and

distribute, monitor and evaluate at various levels. The department prepares monthly, quarterly and annual reports and distributes them to donors and regional health bureaux (RHB), compiles surveillance data sent from the regional health bureaux trains trainers and provide mass media education for the centre (35).

The Regional Health Bureaux are responsible for the overall AIDS/STDs prevention and control activities into their respective areas. Hence, the RHB are expected to carry out the following specific activities: creation of an epidemiologic surveillance system on HIV / AIDS in the region for monitoring the epidemic, establishing sentinel surveillance, assessing the existing resources and infra structures, the extent to which these could be used to support AIDS related activities. The same document (36) outlines expected tasks of

offices at zonal and Woreda levels.

The second medium term plan (1992- 1996) (36) is being implemented at present with priority interventions aimed at preventing transmission of HIV which will target individuals and groups with high risk behaviour. The promotion of early, effective management of STDs will be a major strategy and condom promotion will be further strengthened. Efforts to minimize transmission through blood will continue, notably by improving screening facilities for blood donations and promoting infection control practices. While prevention strategies are prioritized in the MTP, care and support for those infected and those who have already developed AIDS will not be neglected. The provision of home-based care and community support coupled with the improved availability and accessibility of counselling services will seek to reduce the personal and social impact of HIV infection. Trends of the epidemic will continue to be monitored through epidemiologic studies. Research activities are planned to focus on operational research (36).
Sources of information on epidemic diseases The Ministry of Health gathers information about epidemic diseases from the following reports

1. Monthly morbidity and mortality reports

2. Epidemic Diseases Report -used only when there is an out break

3. Weekly Epidemic Notification on 15 epidemic prone diseases including those discussed above.

However information received from these reports has been criticized as being incomplete, of poor quality and delayed. Some times distorted information is sent to the Ministry of Health in order to obtain more drugs (8).

Problems encountered by the Ministry of Health in disease surveillance and epidemic control(8):

1. In some health institutions people think that information is collected only to compile" the Annual Report "

2. Data are not analyzed and used for proper actiones at health institutions levels. Occasionally data are analyzed after a long period of time, some times past a year .The results of such delayed analyses may not have any use at all.

3. Weekly Disease Notification forms are not regularly sent. No feed back is given from higher bodies.

4. Lack of workers who have adequate knowledge and training on disease surveillance at the different levels of health care.

5. No or little running budget 6. Radio, telephone, roads and other means of communication are not available in many places. Therefore, reports are delayed.

7. Inadequate supervision to improve/develop quality, exchange and use of information. Recently the Ministry of Health has provided guidelines for the control of epidemic diseases. It has worked out objectives and strategies for different managerial levels, health care facilities and Community Health Services.

Emphasis was given to community participation by forming anti-epidemic committees at different levels (8).
Strategies outlined by the Ministry of health to Health bureaux and departments include: I. Maintaining adequate amount of drugs, medical instruments and equipment.

2. Reporting timely to concerned bodies

3. Monitoring activities of health institutions according to the" Surveillance and Epidemic

control Guidelines"

At the level of health institutions the following strategies were proposed.

1. Treatment of patients and isolation when necessary

2. Control and preventive measures depending on type of disease(immunization, isolation, chemoprophylaxis, insecticide spraying etc).

3. Disease surveillance at the time and after epidemic is over .

Epidemic diseases in Region 3 and North Gondar zone

According to the Annual Report of the Health Bureau of Region 3, major epidemic diseases in 1993-94 were malaria, relapsing fever , meningitis, bacillary dysentery, measles, and whooping cough. Table 2 shows distribution of cases and deaths due to these diseases.

Measures taken to combat the epidemics included treatment of cases and health education on prevention of disease. Training for 30 trainers and mid-level training for 222 health workers were conducted (37). The health bureau planned to vaccinate 54 % of the eligible children ( < 1 year of age) in the region against the six diseases of the EPI. However, of the target planned only 58% and 47% could be vaccinated against pertussis and measles, respectively (37).
The situation of AIDS case surveillance in Region 3 looks as follows: AIDS cases reported from East Gojam (220), West Gojam