Gunnar Aksel Bjune

• Wu, Tsung-Shu Joseph; Mvula, Matthew Vundu; Chado, Edward Kada Koma; Kamanga, Blessings Nthezemu; Mapemba, Daniel Denis & Billy, Rajab Enoch [Show all 13 contributors for this article] (2026). Establishing One Health Surveillance Platform for Electronic Integrated Disease Surveillance and Response in Malawi: Action Design Research Study. JMIR Public Health and Surveillance. 12. doi: 10.2196/72029. Full text in Research Archive Show summary

  Background Facing the threats of emerging and reemerging health issues requires One Health surveillance systems to provide information for integrated responses. Malawi started enhancing the electronic integrated disease surveillance and response (eIDSR) system in 2015, progressing with the aim of developing a One Health Surveillance Platform (OHSP) using District Health Information Software 2 (DHIS2) as its technical backbone, thereby supporting the COVID-19 pandemic response more resiliently and impacting the integrated disease surveillance and response (IDSR) performance. Digital solutions are critical components of One Health surveillance; however, evidence of the successful establishment and implementation of adaptive digital One Health surveillance systems is scarce. Objective This study aims to report on the establishment of the OHSP in Malawi and how an adaptive digital health solution contributed to strengthening and impacting the country’s eIDSR during the COVID-19 pandemic and beyond the pandemic. Methods The establishment of Malawi’s OHSP was based on the action design research methodology with a transdisciplinary approach. The core team reflected the multiple iterative processes of building the OHSP and formalized its impact on IDSR reporting quality. Results The OHSP core team conducted multiple iterative cycles to build the platform, leveraging lessons from previous eIDSR pilots, reusing digital health infrastructure, and developing DHIS2 digital solutions in 2019, right before the COVID-19 pandemic. The initial establishment was to cover 48.3% (14/29) of the country’s health districts. Pivoting from the initial plan as the COVID-19 pandemic emerged, the core team swiftly adapted the OHSP to scale up nationwide and assisted the health system in responding to the pandemic. The pandemic shock resulted in a national scale-up of the OHSP and impacted the national weekly IDSR reporting quality from nonexistence in 2015 to 97.8% and 74.5% for completeness and timeliness, respectively, in 2024. Conclusions The establishment of the OHSP significantly bolstered the surveillance function for weekly IDSR reporting. Government leadership and good coordination were key to success. Continuous capacity building, enhancement of community-level surveillance with digital innovations, adaptable technical infrastructure, and a reuse strategy can provide long-term sustainability for One Health surveillance. Malawi’s experience may apply to other countries with demonstrated value of resilient, government-led digital health interventions. Future efforts should focus on improving interoperability with other One Health domains and investing in infrastructure upgrades with local leadership and domestic funding to prepare for future emergencies.

• Noory, Bandar; Hassanain, Sara A.; Lindskog, Benedikte Victoria; Elsony, Asma & Bjune, Gunnar Aksel (2020). Exploring the consequences of decentralization: has privatization of health services been the perceived effect of decentralization in Khartoum locality, Sudan? BMC Health Services Research. doi: 10.1186/s12913-020-05511-z. Full text in Research Archive Show summary

  Background: The health system of Sudan has experienced several forms of decentralization, as well as, a radical reform. Authority and governance of secondary and tertiary health facilities have been shifted from federal to state levels. Moreover, the provision of health care services have been moved from large federal tertiary level hospitals such as Khartoum Teaching Hospital (KTH) and Jafaar Ibnoaf Hospital (JIH), located in the center of Khartoum, to smaller district secondary hospitals like Ibrahim Malik (IBMH), which is located in the southern part of Khartoum. Exploring stakeholders’ perceptions on this decentralisation implementation and its relevant consequences is vital in building an empirical benchmark for the improvement of health systems. Methods: This study utilised a qualitative design which is comprised of in-depth interviews and qualitative content analysis with an inductive approach. The study was conducted between July and December 2015, and aimed at understanding the personal experiences and perceptions of stakeholders towards decentralisation enforcement and the implications on public health services, with a particular focus on the Khartoum locality. It involved community members residing in the Khartoum Locality, specifically in catchments area where hospital decentralisation was implemented, as well as, affiliated health workers and policymakers. Results: The major finding suggested that privatisation of health services occurred after decentralisation. The study participants also highlighted that scrutiny and reduction of budgets allocated to health services led to an instantaneous enforcement of cost recovery user fee. Devolving KTH Khartoum Teaching and Jafar Ibnoaf Hospitals into peripherals with less. Capacity, was considered to be a plan to weaken public health services and outsource services to private sector. Another theme that was highlighted in hospitals included the profit-making aspect of the governmental sector in the form of drug supplying and profit-making retail. Conclusions: A change in health services after the enforcement of decentralisation was illustrated. Moreover, the incapacitation of public health systems and empowerment of the privatisation concept was the prevailing perception among stakeholders. Having contextualised in-depth studies and policy analysis in line with the global liberalisation and adjustment programmes is crucial for any health sector reform in Sudan.

• Riaz, Syeda Mariam; Bjune, Gunnar Aksel; Wiker, Harald G; Sviland, Lisbeth & Mustafa, Tehmina (2020). Mycobacterial antigens accumulation in foamy macrophages in murine pulmonary tuberculosis lesions: Association with necrosis and making of cavities. Scandinavian Journal of Immunology. ISSN 0300-9475. 91:e12866(4), p. 1–13. doi: 10.1111/sji.12866. Full text in Research Archive Show summary

  Understanding mechanisms of cavitation in tuberculosis (TB) is the missing link that could advance the field towards better control of the infection. Descriptions of human TB suggest that postprimary TB begins as lipid pneumonia of foamy macrophages that undergoes caseating necrosis and fragmentation to produce cavities. This study aimed to investigate the various mycobacterial antigens accumulating in foamy macrophages and their relation to tissue destruction and necrosis. Pulmonary tissues from mice with slowly progressive TB were studied for histopathology, acid‐fast bacilli (AFB) and presence of mycobacterial antigens. Digital quantification using Aperio ImageScope was done. Until week 12 postinfection, mice were healthy, and lesions were small with scarce AFB and mycobacterial antigens. Colony‐forming units (CFUs) increased exponentially. At week 16‐33, mice were sick, macrophages attained foamy appearance with an increase in antigens (P < .05), 1.5 log increase in CFUs and an approximately onefold increase in AFB. At week 37‐41, mice started dying with a shift in morphology towards necrosis. A >20‐fold increase in mycobacterial antigens was observed with only less than one log increase in CFUs and sevenfold increase in AFB. Secreted antigens were significantly (P < .05) higher compared to cell‐wall antigens throughout infection. Focal areas of necrosis were associated with an approximately 40‐fold increase in antigen MPT46, functionally active thioredoxin, and a significant increase in all secreted antigens. In conclusion, mycobacterial antigens accumulate in the foamy macrophages in TB lesions during slowly progressive murine pulmonary TB. Secreted antigens and MPT46 correlated with necrosis, thereby implying that they might trigger the formation of cavities.

• Sima, Bezawit Temesgen; Belachew, Tefera; Bjune, Gunnar Aksel & Abebe, Fekadu (2019). Traditional healers`role in the detection of active tuberculosis cases in a pastoralist community in Ethiopia: a pilot intervention study. BMC Public Health. 19(1). doi: 10.1186/s12889-019-7074-9. Full text in Research Archive Show summary

  Abstract Background: Pastoralists rely on traditional healers (THs) for general health problems. However, some studies indicate that such practices result in delays in the diagnosis and treatment of tuberculosis (TB) cases. This study aims to assess the role of traditional healers in the detection and referral of active TB cases in a pastoralist community. Methods: We identified 22 traditional healers from 7 villages of Kereyu pastoralist community in the Fentale district in Ethiopia in January 2015. We trained these THs in identifying presumptive TB symptoms and early referral to the nearby healthcare facilities. The training was held during a 1 week period that included a visit to their villages and follow-up. A 1 day meeting was held with the traditional healers, the district TB care and prevention coordinator and health extension workers from the selected sub-district to discuss the referral link between THs and the nearby healthcare facilities. Health providers working at the TB units in the selected healthcare facilities were oriented about the training given and planned involvement of THs in referring presumptive TB case. In addition, documentation of the presumptive TB cases was discussed. Results: We succeeded in tracing and interviewing 8 of the 22 THs. The rest were on seasonal migration. According to the THs report for the 1 year period, these 8 THs had referred 24 TB suspects to the healthcare facilities. Sputum smear microscopy confirmed 13 of the 24 suspects as having TB cases. Among those confirmed, 10 completed treatment and three were on treatment. Five presumptive TB cases were confirmed non TB cases through further evaluation at the healthcare facilities and six of the presumptive TB cases were lost to follow up by the THs. Whereas, four of the presumptive TB cases were lost to follow up to the healthcare facility. Conclusions: Results of the present study indicate that THs can contribute to the detection of undiagnosed active TB cases in a pastoralist community, provided they are given appropriate training and support.

• Wu, Tsung-Shu Joseph; Kagoli, Matthew; Kaasbøll, Jens Johan & Bjune, Gunnar Aksel (2018). Integrated Disease Surveillance and Response (IDSR) in Malawi: Implementation gaps and challenges for timely alert. PLOS ONE. 13(11), p. 1–19. doi: 10.1371/journal.pone.0200858. Full text in Research Archive Show summary

  Objective: The emerging and recent 2014 Ebola Virus Disease (EVD) outbreaks rang the bell to call upon efforts from globe to assist resource-constrained countries to strengthen public health surveillance system for early response. Malawi adopted the Integrated Disease Surveillance and Response (IDSR) strategy to develop its national surveillance system since 2002 and revised its guideline to fulfill the International Health Regulation (IHR) requirements in 2014. This study aimed to understand the state of IDSR implementation and differences between guideline and practice for future disease surveillance system strengthening. Methods: This was a mixed-method observational study. Quantitative data were to analyze completeness and timeliness of surveillance system performance from national District Health Information System 2 (DHIS2). Qualitative data were collected through interviews with 29 frontline health service providers from the selected district and key informants of the IDSR system implementation and administration at district and national levels. Findings: The current IDSR system showed relatively good completeness (76.4%) but poor timeliness (41.5%) of total expected monthly reports nationwide and zero weekly reports. The challenges of IDSR implementation revealed through qualitative data included lack of supervision, inadequate resources for training and difficulty to implement weekly report due to overwhelming paperwork at frontline health services. Conclusions: The differences between IDSR technical guideline and actual practice were huge. The developing information technology infrastructure in Malawi and emerging mobile health (mHealth) technology can be opportunities for the country to overcome these challenges and improve surveillance system to have better timeliness for the outbreaks and unusual events detection.

• Workneh, Mahteme Haile; Bjune, Gunnar Aksel & Solomon, Abebe Yimer (2017). Prevalence and associated factors of tuberculosis and diabetes mellitus comorbidity: A systematic review. PLOS ONE. 12(4). doi: 10.1371/journal.pone.0175925. Full text in Research Archive Show summary

  Introduction: The dual burden of tuberculosis (TB) and diabetes mellitus (DM) has become a major global public health concern. There is mounting evidence from different countries on the burden of TB and DM comorbidity. The objective of this systematic review was to summarize the existing evidence on prevalence and associated/risk factors of TBDM comorbidity at global and regional levels. Methods: Ovid Medline, Embase, Global health, Cochrane library, Web of science and Scopus Elsevier databases were searched to identify eligible articles for the systematic review. Data were extracted using standardized excel form and pilot tested. Median with interquartile range (IQR) was used to estimate prevalence of TBDM comorbidity. Associated/risk factors that were identified from individual studies were thematically analyzed and described. Results: The prevalence of DM among TB patients ranged from 1.9% to 45%. The overall median global prevalence was 16% (IQR 9.0%-25.3%) Similarly, the prevalence of TB among DM patients ranged from 0.38% to 14% and the overall median global prevalence was 4.1% (IQR 1.8%-6.2%). The highest prevalence of DM among TB patients is observed in the studied countries of Asia, North America and Oceania. On the contrary, the prevalence of TB among DM patients is low globally, but relatively higher in the studied countries of Asia and the African continents. Sex, older age, urban residence, tobacco smoking, sedentary lifestyle, poor glycemic control, having family history of DM and TB illness were among the variables identified as associated/risk factors for TBDM comorbidity. Conclusion: This systematic review revealed that there is a high burden of DM among TB patients at global level. On the contrary, the global prevalence of TB among DM patients is low. Assessing the magnitude and risk/associated factors of TBDM comorbidity at country/local level is crucial before making decisions to undertake TBDM integrated services.

• Hasle, Arne Gunnar; Raastad, Ragnhild; Bjune, Gunnar Aksel; Jenum, Pål & Heier, Lise (2017). Can a galacto-oligosaccharide reduce the risk of traveller's diarrhoea? A placebo-controlled, randomized, double-blind study. Journal of Travel Medicine (JTM). ISSN 1195-1982. 24(5). doi: 10.1093/jtm/tax057. Full text in Research Archive
• Gebreegziabher, Senedu Bekele; Bjune, Gunnar Aksel & Solomon, Abebe Yimer (2017). Applying tuberculosis management time to measure the tuberculosis infectious pool at a local level in Ethiopia. Infectious Diseases of Poverty. 6. doi: 10.1186/s40249-017-0371-6. Full text in Research Archive Show summary

  Background Measuring the size of the infectious pool of tuberculosis (TB) is essential to understand the burden and monitor trends of TB control program performance. This study applied the concept of TB management time to estimate and compare the size of the TB infectious pool between 2009 and 2014 in West Gojjam Zone of Amhara Region, Ethiopia. Methods New sputum smear-positive and smear-negative pulmonary TB (PTB) and retreatment cases who attended 30 randomly selected public health facilities in West Gojjam Zone from October 2013 to October 2014 were consecutively enrolled in the study. In order to determine the infectious period, the TB management time (number of days from the onset of cough until start of anti-TB treatment) was computed for each patient category. The number of undiagnosed TB cases was estimated and hence the TB management time for the undiagnosed category was calculated. The total size of the TB infectious pool during the study period for the study zone was estimated as the annual number of infectious person days. Results New smear-positive and smear-negative PTB cases contributed 25,050 and 12,931 infectious person days per year to the TB infectious pool, respectively. The retreatment and presently undiagnosed cases contributed 8840 and 34,310 infectious person days per year, respectively. The total size of the TB infectious pool in West Gojjam Zone during the study period was estimated at 81,131 infectious person days per year or 3405 infectious person days per 100,000 population per year. Compared to a similar study done in 2009 in the study area, the current study showed reduction of the TB infectious pool by 244,279 infectious person days. Conclusions TB management time is a simple and practical tool that may help to estimate and compare the changes in the size of the TB infectious pool at local level. It may also be used as an indicator to monitor the changes in TB control program performance.

• Gebreegziabher, Senedu Bekele; Bjune, Gunnar Aksel & Yimer, Solomon Abebe (2016). Total delay is associated with unfavorable treatment outcome among pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: A prospective cohort study. PLOS ONE. 11(7). doi: 10.1371/journal.pone.0159579. Full text in Research Archive Show summary

  Background delay in diagnosis and treatment of tuberculosis (TB) may worsen the disease, increase mortality and enhance transmission in the community. This study aimed at assessing the association between total delay and unfavorable treatment outcome among newly diagnosed pulmonary TB (PTB) patients. Methods A prospective cohort study was conducted in West Gojjam Zone, Amhara Region of Ethiopia from October 2013 to May 2015. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study from 30 randomly selected public health facilities. Total delay (the time period from onset of TB symptoms to first start of anti-TB treatment) was measured. Median total delay was calculated. Mixed effect logistics regression was used to analyze factors associated with unfavorable treatment outcome. Results Seven hundred six patients were enrolled in the study. The median total delay was 60 days. Patients with total delay of > 60 days were more likely to have unfavorable TB treatment outcome than patients with total delay of ≤ 60 days (adjusted odds ratio [AOR], 2.33; 95% confidence interval [CI], 1.04–5.26). Human immunodeficiency virus (HIV) positive TB patients were 8.46 times more likely to experience unfavorable treatment outcome than HIV negative TB patients (AOR, 8.46; 95% CI, 3.14–22.79). Conclusions Long total delay and TB/HIV coinfection were associated with unfavorable treatment outcome. Targeted interventions that can reduce delay in diagnosis and treatment of TB, and early comprehensive management of TB/HIV coinfection are needed to reduce increased risk of unfavorable treatment outcome.

• Gebreegziabher, Senedu Bekele; Yimer, Solomon Abebe & Bjune, Gunnar Aksel (2016). Qualitative Assessment of Challenges in Tuberculosis Control in West Gojjam Zone, Northwest Ethiopia: Health Workers’ and Tuberculosis Control Program Coordinators’ Perspectives. Tuberculosis Research and Treatment. ISSN 2090-150X. 2016. doi: 10.1155/2016/2036234. Full text in Research Archive Show summary

  Background Weak health systems pose many barriers to effective tuberculosis (TB) control. This study aimed at exploring health worker’s and TB control program coordinator’s perspectives on health systems challenges facing TB control in West Gojjam Zone, Amhara Region, Ethiopia. Methods This was a qualitative descriptive study. Eight in-depth interviews with TB control program coordinators and two focus group discussions among 16 health workers were conducted. Purposive sampling was used to recruit study participants. Thematic analysis was used to identify and analyse main themes. Results We found that intermittent interruptions of laboratory reagents and anti-TB drugs supplies, absence of trained and motivated health workers, poor TB data documentation, lack of adherence to TB treatment guideline, and lack of access to TB diagnostic tools at peripheral health institutions were challenges facing the TB control program performance in the study zone. Conclusions Ensuring uninterrupted supply of anti-TB drugs and laboratory reagents to all health institutions is essential. Continuous refresher training of health workers on standard TB care and data handling and developing and implementing a sound retention strategy to attract and motivate health professionals to work in rural areas are necessary interventions to improve the TB control program performance in the study zone.

• Workneh, Mahteme Haile; Bjune, Gunnar Aksel & Yimer, Solomon Abebe (2016). Diabetes mellitus is associated with increased mortality during tuberculosis treatment: a prospective cohort study among tuberculosis patients in South-Eastern Amahra Region, Ethiopia. Infectious Diseases of Poverty. 5(1). doi: 10.1186/s40249-016-0115-z. Full text in Research Archive Show summary

  Background There is growing evidence suggesting that diabetes mellitus (DM) affects disease presentation and treatment outcome in tuberculosis (TB) patients. This study aimed at investigating the role of DM on clinical presentations and treatment outcomes among newly diagnosed TB patients. Methods A prospective cohort study was conducted in South-Eastern Amhara Region, Ethiopia from September 2013 till March 2015. Study subjects were consecutively recruited from 44 randomly selected health facilities in the study area. Participants were categorized into two patient groups, namely, patients with TB and DM (TBDM) and TB patients without DM (TBNDM). Findings on clinical presentations and treatment outcomes were compared between the two patient groups. Cox proportional hazard regression analysis was applied to identify factors associated with death. Results Out of 1314 TB patients enrolled in the study, 109 (8.3 %) had coexisting DM. TBDM comorbidity [adjusted hazard ratio (AHR) 3.96; 95 % confidence interval (C.I.) (1.76–8.89)], and TB coinfection with human immunodeficiency virus (HIV) [AHR 2.59; 95 % C.I. (1.21–5.59)] were associated with increased death. TBDM and TBNDM patients did not show significant difference in clinical symptoms at baseline and during anti-TB treatment period. However, at the 2nd month of treatment, TBDM patients were more symptomatic compared to patients in the TBNDM group. Conclusions The study showed that DM is associated with increased death during TB treatment. DM has no association with clinical presentation of TB except at the end of the intensive phase treatment. Routine screening of TB patients for DM is recommended for early diagnosis and treatment of patients with TBDM comorbidity.

• Mengesha, Mulugeta Belay; Legesse, Mengistu; Ottenhoff, Tom H.M.; Mihret, Adane; Franken, Kees L & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2016). IFN-γ and IgA against non-methylated heparin-binding hemagglutinin as markers of protective immunity and latent tuberculosis: Results of a longitudinal study from an endemic setting. Journal of Infection. ISSN 0163-4453. 72(2), p. 189–200. doi: 10.1016/j.jinf.2015.09.040. Full text in Research Archive
• Workneh, Mahteme Haile; Bjune, Gunnar Aksel & Yimer, Solomon Abebe (2016). Prevalence and Associated Factors of Diabetes Mellitus among Tuberculosis Patients in South-Eastern Amhara Region, Ethiopia: A Cross Sectional Study. PLOS ONE. 11(1). doi: 10.1371/journal.pone.0147621. Full text in Research Archive Show summary

  Background The association between diabetes mellitus (DM) and tuberculosis (TB) is re-emerging worldwide. Recently, the prevalence of DM is increasing in resource poor countries where TB is of high burden. The objective of the current study was to determine the prevalence and analyze associated factors of TB and DM comorbidity in South-Eastern Amhara Region, Ethiopia. Methods This was a facility based cross-sectional study. All newly diagnosed TB patients attending selected health facilities in the study area were consecutively screened for DM. DM was diagnosed based on the World Health Organization diagnostic criteria. A pre-tested semi-structured questionnaire was used to collect socio-demographic, lifestyles and clinical data. Logistic regression analysis was performed to identify factors associated with TB and DM comorbidity. Result Among a total of 1314 patients who participated in the study, the prevalence of DM was estimated at 109 (8.3%). Being female [odds ratio (OR) 1.70; 95% confidence interval (CI) (1.10–2.62)], patients age [41–64 years (OR 3.35; 95% CI (2.01–5.57), 65–89 years (OR 3.18; 95% CI (1.52–6.64)], being a pulmonary TB case [(OR 1.69; 95% CI 1.09–2.63)] and having a family history of DM [(OR 4.54; 95% CI (2.36–8.73)] were associated factors identified with TB and DM comorbidity. Conclusion The prevalence of DM among TB patients in South-Eastern Amahra Region is high. Routine screening of TB patients for DM is recommended in the study area.

• Workneh, Mahteme Haile; Bjune, Gunnar Aksel & Yimer, Solomon Abebe (2016). Assessment of health system challenges and opportunities for possible integration of diabetes mellitus and tuberculosis services in South-Eastern Amhara Region, Ethiopia: A qualitative study. BMC Health Services Research. 16(135). doi: 10.1186/s12913-016-1378-6. Full text in Research Archive Show summary

  Background The double burden of tuberculosis (TB) and diabetes mellitus (DM) is a significant public health problem in low and middle income countries. However, despite the known synergy between the two disease conditions, services for TB and DM have separately been provided. The objective of this study was to explore health system challenges and opportunities for possible integration of DM and TB services. Methods This was a descriptive qualitative study which was conducted in South-Eastern Amhara Region, Ethiopia. Study participants included health workers (HWs), program managers and other stakeholders involved in TB and DM prevention and control activities. Purposive sampling was applied to select respondents. In order to capture diversity of opinions among participants, maximum variation sampling strategy was applied in the recruitment of study subjects. Data were collected by conducting four focus group discussions and 12 in-depth interviews. Collected data were transcribed verbatim and were thematically analyzed using NVivo 10 software program. Result A total of 44 (12 in-depth interviews and 32 focus group discussion) participants were included in the study. The study participants identified a number of health system challenges and opportunities affecting the integration of TB-DM services. The main themes identified were: 1. Unavailability of system for continuity of DM care. 2. Inadequate knowledge and skills of health workers. 3. Frequent stockouts of DM supplies. 4. Patient’s inability to pay for DM services. 5. Poor DM data management. 6. Less attention given to DM care. 7. Presence of a well-established TB control program up to the community level. 8. High level of interest and readiness among HWs, program managers and leaders at different levels of the health care delivery system. Conclusion The study provided insights into potential health systems challenges and opportunities that need to be considered in the integration of TB-DM services. Piloting TB and DM integrated services in selected HFs of the study area is needed to assess feasibility for possible full scale integration of services for the two comorbid conditions.

• Gebreegziabher, Senedu Bekele; Bjune, Gunnar Aksel & Yimer, Solomon Abebe (2016). Patients' and health system's delays in the diagnosis and treatment of new pulmonary tuberculosis patients in West Gojjam Zone, Northwest Ethiopia: a cross-sectional study. BMC Infectious Diseases. 16. doi: 10.1186/s12879-016-1995-z. Full text in Research Archive Show summary

  Background Tuberculosis (TB) is a major public health concern in the developing world. Early diagnosis and prompt initiation of treatment is essential for effective TB control. The aim of this study was to determine the length and analyze associated factors of patients’ and health system’s delays in the diagnosis and treatment of new pulmonary TB (PTB) patients. Methods A cross-sectional study was conducted in 30 randomly selected public health facilities in West Gojjam Zone, Amhara Region, Ethiopia. Newly diagnosed PTB patients who were ≥15 years of age were consecutively enrolled in the study. Patients’ delay (the time period from onset of TB symptoms to first presentation to a formal health provider) and health system’s delay (the time period from first presentation to a formal health provider to first start of TB treatment) were measured. Median patients’ and health system’s delays were calculated. Mixed effect logistic regression was used to analyze predictors of patients’ and health system’s delays. Results Seven hundred six patients were enrolled in the study. The median patients’ delay was 18 days (interquartile range [IQR]: 8–34 days) and the median health system’s delay was 22 days (IQR: 4–88 days). Poor knowledge of TB (adjusted odds ratio [AOR], 2.33; 95 % confidence interval [CI], 1.34–4.05), first visit to non-formal health provider (AOR, 47.56; 95 % CI, 26.31–85.99), self-treatment (AOR, 10.11; 95 % CI, 4.53–22.56) and patients’ age (≥45 years) (AOR, 2.99; 95 % CI, 1.14–7.81) were independent predictors of patients’ delay. Smear-negative TB (AOR, 1.88; 95 % CI, 1.32–2.68) and first visit to public health centers (AOR, 2.22; 95 % CI, 1.52–3.25) and health posts (AOR, 5.86; 95 % CI, 1.40–24.39) were found to be independent predictors of health system’s delay. Conclusions The health system’s delay in this study was long and contributed more than 50 % of the total delay. Better TB diagnostic tools to complement sputum smear microscopy are needed to early diagnose PTB cases at peripheral health facilities. In addition, due emphasis should be given to increase public awareness about symptoms and consequences of TB disease.

• Osman, R.K.; Mortimer, K.; Bjune, Gunnar Aksel & Sony, Sony El (2016). Chronic respiratory disease in adults treated for tuberculosis in khartoum, Sudan. Public Health Action. 6(3), p. 199–204. doi: 10.5588/pha.16.0030. Full text in Research Archive
• Mengesha, Mulugeta Belay; Bjune, Gunnar Aksel & Abebe, Fekadu (2015). Prevalence of tuberculosis, HIV, and TB-HIV co-infection among pulmonary tuberculosis suspects in a predominantly pastoralist area, northeast Ethiopia. Global health action. ISSN 1654-9716. 8:27949(1), p. 1–8. doi: 10.3402/gha.v8.27949. Full text in Research Archive
• Larsson, Geir; Bjune, Gunnar Aksel; Moum, Bjørn; Shenoy, K.T. & Småstuen, Milada Cvancarova (2015). A Risk Matrix Model for the Prediction of Intestinal Tuberculosis and Differentiation from Crohn’s Disease. Austin Journal of Gastroenterology. ISSN 2381-9219. 2(5). Full text in Research Archive
• Larsson, Geir; Shenoy, Kotacherry Thrivikrama; Ramasubramanian, Ramalingom; Thayumanavan, Lakshmikanthan; Balakumaran, Leena Kondarappassery & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2015). High faecal calprotectin levels in intestinal tuberculosis are associated with granulomas in intestinal biopsies. Infectious Diseases. ISSN 2374-4235. 47(3), p. 137–143. doi: 10.3109/00365548.2014.974206. Full text in Research Archive
• Mengesha, Mulugeta Belay; Legesse, Mengistu; Mihret, Adane; Ottenhoff, Tom HM; Franken, Kees Lumc & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2015). Pro-and-anti-inflammatory cytokines against Rv2031 are elevated during latent tuberculosis: a study in cohorts of tuberculosis patients, household contacts and community Controls in an endemic setting. PLOS ONE. p. 1–13. doi: 10.1371/journal.pone.0124134. Full text in Research Archive Show summary

  Tuberculosis (TB) is among the leading causes of morbidity and mortality. The causative agent, Mycobacterium tuberculosis (Mtb), has evolved virulent factors for entry, survival, multiplication and immune evasion. Rv2031 (also called alpha crystallin, hspX, 16-kDa antigen), one of the most immunogenic latency antigens, is believed to play a key role in long-term viability of Mtb. Here, we report the dynamics of pro-inflammatory (IFN-γ, TNF-α) and anti-inflammatory (IL-10) cytokines against Rv2031 using whole blood assay in human cohorts in a TB endemic setting. Cytokine responses to ESAT-6-CFP-10 were also measured for comparison. Blood samples were collected from smear positive pulmonary TB patients and their contacts at baseline, 6 and 12 months, and from community controls at entry. At baseline, 54.4% of controls and 73.2% of contacts were QFT-GIT test positive. Baseline IFN-γ, TNF-α and IL-10 responses to Rv2031 were significantly higher in controls compared to contacts and untreated patients (p<0.001). Furthermore, untreated patients had significantly higher TNF-α and IL-10 responses to Rv2031 compared to contacts (p<0.001). In contacts and treated patients, IFN-γ, TNF-α and IL-10 responses to Rv2031 significantly increased over 12 months (p<0.0001) and became comparable with the corresponding levels in controls. There was a positive and significant correlation between Rv2031 and ESAT-6-CFP-10 specific cytokine responses in each study group. The fact that the levels of IFN-γ, TNF-α and IL-10 against Rv2031 were highest during latent TB infection may indicate their potential as markers of protection against TB. Taken together, the findings of this study suggest the potential of IFN-γ, TNF-α and IL-10 against Rv2031 as biomarkers of the host response to Mtb during convalescence from, and the absence of, active tuberculosis.

• Mengesha, Mulugeta Belay; Legesse, Mengistu; Mihret, Adane; Bekele, Yonas; Bjune, Gunnar Aksel & Abebe, Fekadu (2015). Lipoarabinomannan-specific TNF-alpha and IFN-gamma as markers of protective immunity against tuberculosis: a cohort study in an endemic setting. APMIS - Journal of Pathologiy, Microbiology and Immunology. ISSN 0903-4641. 123(10), p. 851–857. doi: 10.1111/apm.12423. Full text in Research Archive
• Mengesha, Mulugeta Belay; Bjune, Gunnar Aksel & Abebe, Fekadu (2015). Tuberculosis and HIV infection among pulmonary tuberculosis suspects in a predominantly pastoralist area, Northeast Ethiopia. Global health action. ISSN 1654-9716. 8(27949), p. 1–7. doi: 10.3402/gha.v8.27949. Full text in Research Archive Show summary

  Background: TB-HIV co-infection is one of the biggest public health challenges in sub-Saharan Africa. Although there is a wealth of information on TB-HIV co-infection among settled populations in Africa and elsewhere, to our knowledge, there are no published reports on TB-HIV co-infection from pastoral communities. In this study, we report the prevalence of TB, HIV and TB-HIV co-infection among pulmonary TB suspects in the Afar Regional State of Ethiopia. Design: In a cross-sectional study design, 325 pulmonary TB suspects were included from five health facilities. Three sputum samples (spot-morning-spot) were collected from each participant. Sputum samples were examined for the presence of acid fast bacilli using Ziehl–Neelsen staining method, and culture was done on the remaining sputum samples. Participants were interviewed and HIV tested. Results: Of the 325 pulmonary TB suspects, 44 (13.5%) were smear positive, and 105 (32.3%) were culture positive. Among smear-positive patients, five were culture negative and, therefore, a total of 110 (33.8%) suspects were bacteriologically confirmed pulmonary TB patients. Out of 287 pulmonary TB suspects who were tested for HIV infection, 82 (28.6%) were HIV positive. A significantly higher proportion of bacteriologically confirmed pulmonary TB patients [40 (40.4%)] were HIV co-infected compared with patients without bacteriological evidence for pulmonary TB [42 (22.3%)]. However, among ethnic Afar pastoralists, HIV infections in smear- and/or culture-negative pulmonary TB suspects [7 (7.6%)] and bacteriologically confirmed pulmonary TB patients [4 (11.8%)] were comparable. On multivariable logistic regression analysis, Afar ethnicity was independently associated with low HIV infection [OR=0.16 (95% CI: 0.07–0.37)], whereas literacy was independently associated with higher HIV infection [OR=2.21 (95% CI: 1.05–4.64)]. Conclusions: Although the overall prevalence of TB-HIV co-infection in the current study is high, ethnic Afars had significantly lower HIV infection both in suspects as well as TB patients. The data suggest that the prevalence of HIV infection among Afar pastoralists is probably low. However, population-based prevalence studies are needed to substantiate our findings.

• Yimer, Solomon Abebe; Norheim, Gunnstein; Namouchi, Amine; Zegeye, Ephrem Debebe; Kinander, Wibeke & Tonjum, Tone [Show all 11 contributors for this article] (2015). Mycobacterium tuberculosis lineage 7 strains are associated with prolonged patient delay in seeking treatment for pulmonary tuberculosis in Amhara region, Ethiopia. Journal of Clinical Microbiology. ISSN 0095-1137. 53(4), p. 1301–1309. doi: 10.1128/JCM.03566-14. Full text in Research Archive
• Yimer, Solomon Abebe; Bjune, Gunnar Aksel & Holm-Hansen, Carol J. C. (2014). Time to first consultation, diagnosis and treatment of TB among patients attending a referral hospital in Northwest, Ethiopia. BMC Infectious Diseases. 14. doi: 10.1186/1471-2334-14-19. Full text in Research Archive Show summary

  Background Early detection and treatment of TB is essential for the success of TB control program performance. The aim of this study was to determine the length and analyze predictors of patients’, health systems’ and total delays among patients attending a referral hospital in Bahir Dar, Ethiopia. Methods A cross-sectional study was conducted among newly diagnosed TB cases?=?15 years of age. Delay was analyzed at three levels: the periods between 1) onset of TB symptoms and first visit to medical provider, i.e. patients’ delay, 2) the first visit to a medical provider and the initiation of treatment i.e. health systems’ delay and 3) onset of TB symptoms and initiation of treatment i.e. total delay. Uni- and multi-variate logistic regression analyses were performed to investigate predictors of patients’, health systems’ and total delays. Results The median time of patients’ delay was 21 days [(interquartile range (IQR) (7 days, 60 days)]. The median health systems’ delay was 27 days (IQR 8 days, 60 days) and the median total delay was 60 days (IQR 30 days, 121 days). Patients residing in rural areas had a three-fold increase in patients’ delay compared to those from urban areas [Adjusted Odds Ratio (AOR) 3.4; 95% (CI 1.3, 8.9)]. Extra-pulmonary TB (EPTB) cases were more likely to experience delay in seeking treatment compared to pulmonary (PTB) cases [(AOR 2.6; 95% (CI 1.3, 5.4)]. Study subjects who first visited health centres [(AOR) 5.1; 95% (CI 2.1, 12.5)], private facilities [(AOR) 3.5; 95% (CI 1.3, 9.7] and health posts [(AOR) 109; 95% (CI 12, 958], were more likely to experience an increase in health systems’ delay compared to those who visited hospitals. Conclusions The majority of TB patients reported to medical providers within an acceptable time after the onset of symptoms. Rural residence was associated with patients’ and total delays. Providing the population with information about TB symptoms and the importance of early health seeking may be an efficient way to decrease TB transmission, morbidity and mortality. Establishing efficient TB diagnostic and treatment facilities at the periphery level is imperative to reduce diagnostic delay and expedite TB treatment.

• Yimer, Solomon Abebe; Holm-Hansen, Carol J C; Storla, Dag Gustav Gundersen & Bjune, Gunnar Aksel (2014). Tuberculosis management time: an alternative parameter for measuring the tuberculosis infectious pool. Tropical medicine & international health. ISSN 1360-2276. 19(3), p. 313–320. doi: 10.1111/tmi.12246. Full text in Research Archive
• Larsson, Geir; Shenoy, Thrivikrama; Ramasubramanian, Ramalingom; Balakumaran, Leena Kondarappassery; Småstuen, Milada Cvancarova & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2014). Routine diagnosis of intestinal tuberculosis and Crohn´s disease in Southern India. World Journal of Gastroenterology (WJG). ISSN 1007-9327. 20(17), p. 5017–5024. doi: 10.3748/wjg.v20.i17.5017. Full text in Research Archive
• Belay, Mulugeta; Dagne, Daniel; Legesse, Mengistu; Mihret, Adane; Bekele, Yonas & Medhin, Girmay [Show all 8 contributors for this article] (2014). QuantiFERON-TB-Gold In-Tube test conversions and reversions among Tuberculosis patients and their household contacts in Addis Ababa: a one year follow-up study. BMC Infectious Diseases. 14:654. doi: 10.1186/s12879-014-0654-5. Full text in Research Archive Show summary

  Background QuantiFERON-TB Gold In-Tube® (QFT-GIT) test is used for the diagnosis of latent tuberculosis (TB) infection. Besides, QFT-GIT test could allow tracking changes in immune response among TB patients and their contacts. In high TB burden settings, reports on QFT-GIT conversions and reversions among TB patients and their contacts are limited. As part of a major project to study immune responses to TB infection, we investigated QFT-GIT test conversions and reversions among smear positive pulmonary TB patients and their household contacts over 12 months. Methods We followed a total of 107 HIV negative participants (33 patients and 74 contacts) in Addis Ababa. We did QFT-GIT test at baseline and 12 months later according to the manufacturer’s instructions. Results At baseline, 25/33 (75.8%) of the patients and 50/74 (67.6%) of the contacts were QFT-GIT positive. At 12 months, 2 more patients (1 test negative and 1 indeterminate) became test positive. Besides, 11/24 (45.8%) test negative contacts became positive. Only one patient and one contact who were test positive at baseline became test negative 12 months later. At 12 months, the proportions of QFT-GIT test positives for patients and contacts were, therefore, 78.8% and 81.1%, respectively. Among contacts, the proportion of QFT-GIT test positives at 12 months was significantly higher compared to the corresponding proportion at baseline (McNemar, p = 0.006); similarly, the median IFN-γ response significantly increased at 12 months compared with the baseline level (Wilcoxon matched-pairs signed rank test, p = 0.01). Patients, however, had comparable median IFN-γ levels at baseline and 12 months later (p = 0.56). Conclusion Nearly half of QFT-GIT negative household contacts at baseline became positive at 12 months. This suggests that repeated screening of QFT-GIT negative contacts may be needed for epidemiological studies and interventions of latent TB in an endemic setting. A large longitudinal study may be needed to confirm our observations.

• Belay, Mulugeta; Ameni, Gobena; Bjune, Gunnar Aksel; Couvin, David; Rastogi, Nalin & Abebe, Fekadu (2014). Strain diversity of Mycobacterium tuberculosis isolates from pulmonary tuberculosis patients in Afar pastoral Region of Ethiopia. BioMed Research International. ISSN 2314-6133. 2014. doi: 10.1155/2014/238532. Full text in Research Archive
• Larsson, Geir; Thrivikrama, Shenoy Koticherry; Ramasubramanian, Ramalingom; Lakshmikanthan, Thayumanavan; Kondarappassery, Balakumaran Leena & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2014). Faecal calprotectin levels differentiate intestinal from pulmonary tuberculosis: An observational study from Southern India. United European Gastroenterology Journal (UEG Journal). ISSN 2050-6406. doi: 10.1177/2050640614546947. Full text in Research Archive
• Kuznetsov, Vladimir; Grjibovski, Andrej; Mariandyshev, Andreyi O; Johansson, Eva & Bjune, Gunnar Aksel (2014). Two vicious circles contributing to a diagnostic delay for tuberculosis patients in Arkhangelsk. Emerging Health Threats Jour. 7. doi: 10.3402/ehtj.v7.24909. Full text in Research Archive Show summary

  Setting: Delay in tuberculosis (TB) diagnosis increases the infectious pool in the community and the risk of development of resistance of mycobacteria, which results in an increased number of deaths. Objective: To describe patients’ and doctors’ perceptions of diagnostic delay in TB patients in the Arkhangelsk region and to develop a substantive model to better understand the mechanisms of how these delays are linked to each other. Design: A grounded theory approach was used to study the phenomenon of diagnostic delay. Patients with TB diagnostic delay and doctors–phthisiatricians were interviewed. Results: A model named ‘sickness trajectory in health-seeking behaviour among tuberculosis patients’ was developed and included two core categories describing two vicious circles of diagnostic delay in patients with TB: ‘limited awareness of the importance to contact the health system’ and ‘limited resources of the health system’ and the categories: ‘factors influencing health-seeking behaviour’ and ‘factors influencing the health system effectiveness’. Men were more likely to report patient delay, while women were more likely to report health system delay. Conclusions: To involve people in early medical examinations, it is necessary to increase alertness on TB among patients and to improve health systems in the districts.

• Kuznetsov, Vladimir; Grjibovski, Andrej; Mariandyshev, Andrey O.; Johansson, Eva & Bjune, Gunnar Aksel (2014). A comparison between passive and active case finding in TB control in the Arkhangelsk region. International Journal of Circumpolar Health. ISSN 1239-9736. 73. doi: 10.3402/ijch.v73.23515. Full text in Research Archive Show summary

  Background. In Russia, active case finding (ACF) for certain population groups has been practiced uninterruptedly for many decades, but no studies comparing ACF and passive case finding (PCF) approaches in Russia have been published. Objective. The aim of this study was to describe the main differences in symptoms and diagnostic delay between patients who come to TB services through PCF and ACF strategies. Methods. A cross-sectional study was conducted among 453 new pulmonary tuberculosis (PTB) patients, who met criteria of TB diagnostic delay in Arkhangelsk. Results. ACF patients used self-treatment more often than PCF patients (90.1% vs. 24.6%) and 36.3% of them were alcohol abusers (as opposed to only 26.2% of PCF patients). The median patient delay (PD) in PCF was 4 weeks, IQR (1–8 weeks), and less than 1 week in ACF. Twenty-three per cent of the PCF patients were seen by a medical provider within the first week of their illness onset. Conclusion. Patients diagnosed through ACF tended to under-report their TB symptoms and showed low attention to their own health. However, ACF allowed for discovering TB patients earlier than PCF, and this was also the case for alcohol abusing patients. PCF systems should be supplemented with ACF strategies.

• Yimer, Solomon Abebe; Hailu, Elena; Derese, Yohannes; Bjune, Gunnar Aksel & Holm-Hansen, Carol J. C. (2013). Spoligotyping of Mycobacterium tuberculosis isolates among pulmonary tuberculosis patients in Amhara Region, Ethiopia. APMIS - Journal of Pathologiy, Microbiology and Immunology. ISSN 0903-4641. 121(9), p. 878–885. doi: 10.1111/apm.12046. Full text in Research Archive
• Kumbani, Lily C; Bjune, Gunnar Aksel; Chirwa, Ellen; Malata, Address & Odland, Jon Øyvind (2013). Why some women fail to give birth at health facilities: a qualitative study of women's perceptions of perinatal care from rural Southern Malawi. Reproductive Health. 10. doi: 10.1186/1742-4755-10-9. Full text in Research Archive Show summary

  Background: Despite Malawi government’s policy to support women to deliver in health facilities with the assistance of skilled attendants, some women do not access this care. Objective: The study explores the reasons why women delivered at home without skilled attendance despite receiving antenatal care at a health centre and their perceptions of perinatal care. Methods: A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using a semi- structured interview guide that collected information on women’s perception on perinatal care. A total of 12 in- depth interviews were conducted with women that had delivered at home in the period December 2010 to March 2011. The women were asked how they perceived the care they received from health workers before, during, and after delivery. Data were manually analyzed using thematic analysis. Results: Onset of labor at night, rainy season, rapid labor, socio-cultural factors and health workers’ attitudes were related to the women delivering at home. The participants were assisted in the delivery by traditional birth attendants, relatives or neighbors. Two women delivered alone. Most women went to the health facility the same day after delivery. Conclusions: This study reveals beliefs about labor and delivery that need to be addressed through provision of appropriate perinatal information to raise community awareness. Even though, it is not easy to change cultural beliefs to convince women to use health facilities for deliveries. There is a need for further exploration of barriers that prevent women from accessing health care for better understanding and subsequently identification of optimal solutions with involvement of the communities themselves.

• Kuznetsov, Vladimir; Grjibovski, Andrej; Mariandyshev, A.O.; Johansson, Eva; Enarson, Donald Arthus & Bjune, Gunnar Aksel (2013). Hopelessness as a basis for tuberculosis diagnostic delay in the Arkhangelsk region: a grounded theory study. BMC Public Health. 13. doi: 10.1186/1471-2458-13-712. Full text in Research Archive
• Dadi, Mengistu Legesse; Ameni, Gobena; Medhin, Girmay; Franken, Kees LMC; Kassa, Gezahegne Mamo & Ottenhoff, Tom HM [Show all 8 contributors for this article] (2013). IgA response to ESAT-6/CFP-10 and Rv2031 antigens varies in culture-confirmed pulmonary tuberculosis patients, healthy Mycobacterium tuberculosis infected and non-infected individuals in a tuberculosis endemic setting, Ethiopia". Scandinavian Journal of Immunology. ISSN 0300-9475. 78(3), p. 266–274. doi: 10.1111/sji.12080. Full text in Research Archive
• Sagbakken, Mette; Frich, Jan C; Bjune, Gunnar Aksel & Porter, John DH (2013). Ethical aspects of directly observed treatment for tuberculosis: a cross-cultural comparison. BMC Medical Ethics. 14. doi: 10.1186/1472-6939-14-25. Full text in Research Archive Show summary

  Background Tuberculosis is a major global public health challenge, and a majority of countries have adopted a version of the global strategy to fight Tuberculosis, Directly Observed Treatment, Short Course (DOTS). Drawing on results from research in Ethiopia and Norway, the aim of this paper is to highlight and discuss ethical aspects of the practice of Directly Observed Treatment (DOT) in a cross-cultural perspective. Discussion Research from Ethiopia and Norway demonstrates that the rigid enforcement of directly observed treatment conflicts with patient autonomy, dignity and integrity. The treatment practices, especially when imposed in its strictest forms, expose those who have Tuberculosis to extra burdens and costs. Socially disadvantaged groups, such as the homeless, those employed as day labourers and those lacking rights as employees, face the highest burdens. Summary From an ethical standpoint, we argue that a rigid practice of directly observed treatment is difficult to justify, and that responsiveness to social determinants of Tuberculosis should become an integral part of the management of Tuberculosis.

• Kassa, Gezahegne Mamo; Abebe, Fekadu; Worku, Yalelet; Legesse, Mengistu; Medhin, Girmay & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2012). Tuberculosis in goats and sheep in Afar pastoral region of Ethiopia and isolation of Mycobacterium tuberculosis from goat. Veterinary Medicine International. ISSN 2090-8113. doi: 10.1155/2012/869146. Full text in Research Archive
• Mengesha, Mulugeta Belay; Bjune, Gunnar Aksel; Ameni, Gobena & Abebe, Fekadu (2012). Diagnostic and treatment delay among tuberculosis patients in Afar Region, Ethiopia: a cross-sectional study. BMC Public Health. 12, p. 369–369. doi: 10.1186/1471-2458-12-369. Full text in Research Archive Show summary

  Background TB is a major public health problem globally and Ethiopia is 8th among the 22 high burden countries. Early detection and effective treatment are pre-requisites for a successful TB control programme. In this regard, early health seeking action from patients’ side and prompt diagnosis as well as initiation of treatment from the health system’s side are essential steps. The aim of this study was to assess delay in the diagnosis and treatment of TB in a predominantly pastoralist area in Ethiopia. Methods On a cross-sectional study, two hundred sixteen TB patients who visited DOTS clinics of two health facilities in Afar Region were included consecutively. Time from onset of symptoms till first consultation of formal health providers (patients’ delay) and time from first consultation till initiation of treatment (health system’s delay) were analyzed. Results The median patients’ and health system’s delay were 20 and 33.5 days, respectively. The median total delay was 70.5 days with a median treatment delay of 1 day. On multivariate logistic regression, self-treatment (aOR. 3.99, CI 1.50-10.59) and first visit to non-formal health providers (aOR. 6.18, CI 1.84-20.76) were observed to be independent predictors of patients’ delay. On the other hand, having extra-pulmonary TB (aOR. 2.08, CI 1.08- 4.04), and a first visit to health posts/clinics (aOR. 19.70, CI 6.18-62.79), health centres (aOR. 4.83, CI 2.23-10.43) and private health facilities (aOR. 2.49, CI 1.07-5.84) were found to be independent predictors of health system’s delay. Conclusions There is a long delay in the diagnosis and initiation of treatment and this was mainly attributable to the health system. Health system strengthening towards improved diagnosis of TB could reduce the long health system’s delay in the management of TB in the study area.

• Dadi, Mengistu Legesse; Ameni, Gobena; Kassa, Gezahegne Mamo; Medhin, Girmay; Bjune, Gunnar Aksel & Abebe, Fekadu (2012). Association of the level of IFN-gamma produced by T cells in response to Mycobacterium tuberculosis-specific antigens with the size of skin test indurations among individuals with latent tuberculosis in a highly tuberculosis-endemic setting. International Immunology. ISSN 0953-8178. 24(2), p. 71–78. doi: 10.1093/intimm/dxr102. Full text in Research Archive Show summary

  There is growing evidence showing the potential of T-cell-based gamma interferon (IFN-g) release assays (IGRAs) for predicting the risk of progression of Mycobacterium tuberculosis (Mtb) infection, though there is little information from tuberculosis (TB)-endemic settings. In this study, we assessed the association between the level of IFN-g produced by T cells in response to Mtb-specific antigens and the size of skin test indurations in 505 adult individuals who were screened for latent tuberculosis infection (LTBI) using the QuantiFERON-TB Gold In Tube (QFTGIT) assay and tuberculin skin test (TST). There was a strong positive correlation between the level of IFN-g induced by the specific antigens and the diameter of the skin indurations (Spearman’s rho 5 0.6, P < 0.001). Body mass index and parasitic infection were not associated with the level of IFN-g production or the TST reaction. In linear regression analysis, the size of the skin test indurations was significantly associated with the mean level of IFN-g [coefficient, 0.65; 95% confidence interval (CI), 0.47 to 0.82, P < 0.001]. Similarly, results from logistic regression analysis demonstrated that individuals who had skin test indurations ‡ 10 mm were 6.82 times more likely than individuals who had skin test indurations < 10 mm to have high levels of IFN-g (i.e. positive QFTGIT result) (adjusted odd ratio 5 6.82; 95% CI, 3.67 to 12.69, P < 0.001). In conclusion, the results of this study could provide indirect evidence for the prognostic use of the QFTGIT assay for progression of Mtb infection, though prospective follow-up studies are needed to provide direct evidence.

• Kumbani, Lily C; Chirwa, Ellen; Malata, Address; Odland, Jon Øyvind & Bjune, Gunnar Aksel (2012). Do Malawian women critically assess the quality of care? A qualitative study on women’s perceptions of perinatal care at a district hospital in Malawi. Reproductive Health. 9(30). doi: 10.1186/1742-4755-9-30. Full text in Research Archive Show summary

  Malawi has a high perinatal mortality rate of 40 deaths per 1,000 births. To promote neonatal health, the Government of Malawi has identified essential health care packages for improving maternal and neonatal health in health care facilities. However, regardless of the availability of health services, women’s perceptions of the care is important as it influences whether the women will or will not use the services. In Malawi 95% of pregnant women receive antenatal care from skilled attendants, but the number is reduced to 71% deliveries being conducted by skilled attendants. The objective of this study was to describe women’s perceptions on perinatal care among the women delivered at a district hospital. A descriptive study design with qualitative data collection and analysis methods. Data were collected through face-to-face in-depth interviews using semi-structured interview guides collecting information on women’s perceptions on perinatal care. A total of 14 in depth interviews were conducted with women delivering at Chiradzulu District Hospital from February to March 2011. The women were asked how they perceived the care they received from health workers during antepartum, intrapartum and postpartum. They were also asked about the information they received during provision of care. Data were manually analyzed using thematic analysis. Two themes from the study were good care and unsatisfactory care. Subthemes under good care were: respect, confidentiality, privacy and normal delivery. Providers’ attitude, delay in providing care, inadequate care, and unavailability of delivery attendants were subthemes under unsatisfactory care. Although the results show that women wanted to be well received at health facilities, respected, treated with kindness, dignity and not shouted at, they were not critical of the care they received. The women did not know the quality of care to expect because they were not well informed. The women were not critical of the care they received because they were not aware of the standard of care. Instead they had low expectations. Health workers have a responsibility to inform women and their families about the care that women should expect. There is also a need for standardization of the antenatal information that is provided.

• Yimer, Solomon Abebe; Holm-Hansen, Carol J. C. & Bjune, Gunnar Aksel (2012). Assessment of knowledge and practice of private practitioners regarding tuberculosis control in Ethiopia. Journal of Infection in Developing Countries. ISSN 2036-6590. 6(1), p. 13–19. doi: 10.3855/jidc.1927. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2012). Humiliation or care? A qualitative study of patients' and health professionals' experiences with tuberculosis treatment in Norway. Scandinavian Journal of Caring Sciences. ISSN 0283-9318. 26(2), p. 313–323. doi: 10.1111/j.1471-6712.2011.00935.x. Full text in Research Archive
• Yimer, Solomon Abebe; Agonafir, Mulualem; Derese, Yohannes; Sani, Yusuf; Bjune, Gunnar Aksel & Holm-Hansen, Carol J. C. (2012). Primary drug resistance to anti-tuberculosis drugs in major towns of Amhara region, Ethiopia. APMIS - Journal of Pathologiy, Microbiology and Immunology. ISSN 0903-4641. 120(6), p. 503–509. doi: 10.1111/j.1600-0463.2011.02861.x. Full text in Research Archive
• Gebremariam, Mekdes; Bjune, Gunnar Aksel & Frich, Jan C (2011). Lay beliefs of TB and TB/HIV co-infection in Addis Ababa, Ethiopia: a qualitative study. BMC Research Notes. 4. doi: 10.1186/1756-0500-4-277. Full text in Research Archive Show summary

  Background Knowledge about lay beliefs of etiology, transmission and treatment of TB, and lay perceptions of the relationship between TB and HIV is important for understanding patients' health seeking behavior and adherence to treatment. We conducted a study to explore lay beliefs about TB and TB/HIV co-infection in Addis Ababa, Ethiopia. Findings We conducted a qualitative study using in-depth interviews with 15 TB/HIV co-infected patients and 9 health professionals and focus group discussions with 14 co-infected patients in Addis-Ababa, Ethiopia. We found that a predominant lay belief was that TB was caused by exposure to cold. Excessive sun exposure, exposure to mud, smoking, alcohol, khat and inadequate food intake were also reported as causes for TB. Such beliefs initially led to self-treatment. The majority of patients were aware of an association between TB and HIV. Some reported that TB could transform into HIV, while others said that the body could be weakened by HIV and become more susceptible to illnesses such as TB. Some patients classified TB as either HIV-related or non-HIV-related, and weight loss was a hallmark for HIV-related TB. The majority of patients believed that people in the community knew that there was an association between TB and HIV, and some feared that this would predispose them to HIV-related stigma. Conclusion There is a need for culturally sensitive information and educational efforts to address misperceptions about TB and HIV. Health professionals should provide information about causes and treatment of TB and HIV to co-infected patients.

• Abebe, Dawit Shawel; Bjune, Gunnar Aksel; Ameni, Gobena; Biffa, Demelash & Abebe, Fekadu (2011). Prevalence of pulmonary tuberculosis and associated risk factors in Eastern Ethiopian prisons. The International Journal of Tuberculosis and Lung Disease. ISSN 1027-3719. 15(5), p. 668–673. doi: 10.5588/ijtld.10.0363. Full text in Research Archive
• Dadi, Mengistu Legesse; Ameni, Gobena; Kassa, Gezahegne Mamo; Medhin, Girmay; Bjune, Gunnar Aksel & Abebe, Fekadu (2011). Community-based cross-sectional survey of latent tuberculosis infection in Afar pastoralists, Ethiopia, using QuantiFERON-TB Gold In-Tube and tuberculin skin test. BMC Infectious Diseases. 11. doi: 10.1186/1471-2334-11-89. Full text in Research Archive Show summary

  Background There is little information concerning community-based prevalence of latent tuberculosis infection (LTBI) using T-cell based interferon-γ (IFN-γ) release assays (IGRAs), particularly in TB endemic settings. In this study, the prevalence of LTBI in the Afar pastoral community was assessed using QuantiFERON-TB Gold In-Tube (QFTGIT) and tuberculin skin tests (TST). Methods A community-based cross-sectional survey of LTBI involving 652 apparently healthy adult pastoralists was undertaken in the pastoral community of Amibara District of the Afar Region between April and June 2010. Results The prevalence of LTBI was estimated as 63.7% (363/570) using QFTGIT at the cut-off point recommended by the manufacturer (≥ 0.35 IU/ml IFN-γ), while it was 74.9% (427/570) using a cut-off point ≥ 0.1 IU/ml IFN-γ. The QFTGIT-based prevalence of LTBI was not significantly associated with the gender or age of the study participants. However, the prevalence of LTBI was 31.2% (183/587) using TST at a cut-off point ≥ 10 mm of skin indurations, and it was higher in males than females (36.8% vs. 23.5%, X2 = 11.76; p < 0.001). There was poor agreement between the results of the tests (k = 0.098, 95% CI, 0.08 - 0.13). However, there was a positive trend between QFTGIT and TST positivity (X2 = 96.76, P < 0.001). Furthermore, individuals with skin indurations ≥ 10 mm were 13.6 times more likely to have positive results using QFTGIT than individuals with skin indurations of 0 mm (adjusted OR = 13.6; 95%CI, 7.5 to 24.7, p < 0.001). Conclusions There is currently no agreed gold standard for diagnosis of LTBI. However, the higher prevalence of LTBI detected using QFTGIT rather than TST suggests that QFTGIT could be used for epidemiological studies concerning LTBI at the community level, even in a population unreactive to TST. Further studies of adults and children will be required to assess the effects of factors such as malnutrition, non-tuberculosis mycobacterial infections, HIV and parasitic infections on the performance of QFTGIT.

• Belay, Mulugeta; Bjune, Gunnar Aksel & Abebe, Fekadu (2011). Serodiagnosis performance of R-ESAT-6-CFP-10 in the diagnosis of pulmonary tuberculosis in Ethiopia. Mycobacterial Diseases. 1(2). doi: 10.4172/2161-1068.1000103. Full text in Research Archive
• Farah, Sameir Kamal Sayyed; Bjune, Gunnar Aksel; Damtew, Zufan Abera & Abdelaziz, Ali Omer (2011). Challenges and Opportunities of Integrating Primary Health Care Information System: Northern State, Sudan. Sudanese Journal of Public Health. ISSN 1990-7567. 6(3), p. 105–109. Full text in Research Archive Show summary

  This paper discusses outcome of studying challenges and opportunities of integrating Health Information System. The study was conducted in the settings of Primary Health Care programs in Northern State, Sudan. Qualitative case study was employed and data were collected through interviews, analysis of relevant documents, and observation of the settings. The results were analyzed using interpretive approach. The study findings indicated that fragmentation of Primary Health Care programs’ Information System is a major problem affecting system performance. Our study also showed that efforts to integrate Primary Health Care programs’ Information System might be challenged by the existing structural, socio-cultural and political contexts of the organization. On the other hand, opportunities for integration of the programs’ Information System lie in the existence of Health Information Center, which receives collected health data from all parts of the state and formulate common reports. Besides, most of the study participants were expressing optimism at outcomes of Information System integration. The need of considering structural, socio-cultural and political contexts of the organization is emphasised in order to address the identified challenges related to integrating Health Information Systems.

• Arntsen, A.; Sakhi, Amrit Kaur; Kalfoss, Torill; Maleta, Kenneth M.; Blomhoff, Rune & Duttaroy, Asim K. [Show all 7 contributors for this article] (2011). Lower plasma levels of selenium and glutathione in smear-positive tuberculosis patients in Malawi. Ethiopian Journal of Health Development. ISSN 1021-6790. 25(3), p. 230–232. Full text in Research Archive
• Yimer, Solomon Abebe; Holm-Hansen, Carol J C & Bjune, Gunnar Aksel (2011). The perspective of private practitioners regarding tuberculosis case detection and treatment delay in Amhara Region, Ethiopia: a cross-sectional study. BMC Research Notes. 4. doi: 10.1186/1756-0500-4-285. Full text in Research Archive Show summary

  Background Engaging all health care providers in tuberculosis (TB) control has been incorporated as an essential component of World Health Organization's Stop TB Strategy and the Stop TB Partnership's global plan 2006-2015. Ethiopia has a growing private health sector. The objective of the present study was to investigate the role of private practitioners (PPs) in TB case detection and assess their perspectives on TB treatment delay in Amhara Region, Ethiopia. Results A cross-sectional study among 112 PPs selected from private health facilities (PHF) in the region was conducted. The study was carried out between May and August 2008 and data was collected using a semi-structured questionnaire. Group differences were analyzed using one-way Anova test and a p-value of < 0.05 was considered statistically significant. In this study, PPs saw a median of 12 TB suspects and 1.5 patients a week. The mean number of TB suspects and patients seen varied significantly among the different professions with p < 0.009 and p < 0.004, respectively. Pulmonary TB patients referred by PPs were delayed up to one week before starting treatment at government health facilities. A 22% increase in the detection of smear-positive TB cases may be achieved by involving all PHFs in the TB control program in the region. Nineteen percent of the PPs indicated that TB patients' prior attendance to non medical health providers resulted in complication of disease and increased treatment delay for TB. Conclusion PPs manage a substantial number of TB suspects and patients in Amhara Region, Ethiopia. The GHF delay observed among TB patients referred by PPs to GHF is unnecessary. Expanding PPM-DOTS in the region and improving the quality of TB care at both government and private health facilities reduces treatment delay and increases TB case detection.

• Kassa, Gezahegne Mamo; Bayleyegn, Gizachew; Tessema, Tesfaye Sisay; Dadi, Mengistu Legesse; Medhin, Girmay & Bjune, Gunnar Aksel [Show all 8 contributors for this article] (2011). Pathology of Camel Tuberculosis and Molecular Characterization of Its Causative Agents in Pastoral Regions of Ethiopia. PLOS ONE. 6(1). doi: 10.1371/journal.pone.0015862. Full text in Research Archive
• Abebe, Dawit Shawel; Biffa, Demelash; Bjune, Gunnar Aksel; Ameni, Gobena & Abebe, Fekadu (2011). Assessment of knowledge and practice about tuberculosis among eastern Ethiopian prisoners. The International Journal of Tuberculosis and Lung Disease. ISSN 1027-3719. 15(2), p. 228–233. Full text in Research Archive
• Dadi, Mengistu Legesse; Ameni, Gobena; Kassa, Gezahegne Mamo; Medhin, Girmay; Bjune, Gunnar Aksel & Abebe, Fekadu (2011). Knowledge of cervical tuberculosis lymphadenitis and its treatment in pastoral communities of the Afar region, Ethiopia. BMC Public Health. 11(157). doi: 10.1186/1471-2458-11-157. Full text in Research Archive Show summary

  Background Infection with Mycobacterium bovis (Mb) predominantly causes cervical TB lymphadenitis (TBL). Raw milk is considered the main source of Mb infection and raw milk is a major food source for Afar pastoralists. The aim of this study was to assess Afar pastoralists' knowledge concerning cervical TBL and its treatment. Methods A community-based cross-sectional survey involving 818 interviewees was conducted in two districts of the Afar Region, Ethiopia. In addition, two focus group discussions (FGDs) were conducted in each of the study areas, one with men and the other with women. Results Of the 818 interviewees [357 (43.6%) females and 461 (56.4%) males], 742 (90.7%) reported that they had knowledge of cervical TBL, mentioning that swelling(s) on the neck resulting in a lesion and scar are common symptoms. However, only 11 (1.5%) individuals mentioned that bacteria or germs are the causative agents of TBL. Three interviewees and a male discussant mentioned drinking raw milk as the cause of TBL. A considerable proportion (34.2%) of the interviewees and almost all the discussants suggested herbal medicine as an effective treatment. Male study participants were 1.82 times more likely to have overall knowledge of TBL than female study participants (adjusted OR, 1.82; 95% CI, 1.32 to 2.51, p < 0.001). Conclusion The pastoral community members in the study areas had little biomedical knowledge of the cause, the source of infection and the transmission route of cervical TBL. Furthermore, most community members believed that herbal medicines are the most effective treatment for TBL. Therefore, TB control programs in the Afar Region require the incorporation of public health education introducing current biomedical knowledge of the disease. In addition, further studies are important to elucidate which medicinal plants are used by Afar pastoralists to treat TBL.

• Hasle, Gunnar; Bjune, Gunnar Aksel; Midthjell, Liv; Røed, Knut H. & Leinaas, Hans Petter (2011). Transport of Ixodes ricinus infected with Borrelia species to Norway by northward-migrating passerine birds. Ticks and Tick-borne Diseases. ISSN 1877-959X. 2(1), p. 37–43. doi: 10.1016/j.ttbdis.2010.10.004. Full text in Research Archive
• Kuznetsov, Vladimir; Grjibovski, Andrej; Maryandyshev, A O; Johansson, E & Bjune, Gunnar Aksel (2011). "I never go to doctors, as long as I can move": a narrative analysis of interview with a patient having Tuberculosis diagnostic delay experience. Human Ecology. ISSN 0300-7839. p. 54–58. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2010). Experiences of being diagnosed with tuberculosis among immigrants in Norway - Factors associated with diagnostic delay: A qualitative study. Scandinavian Journal of Public Health. ISSN 1403-4948. 38(3), p. 283–290. doi: 10.1177/1403494809357101. Full text in Research Archive Show summary

  Aims: The aim of this paper is to explore experiences of being diagnosed with tuberculosis (TB) among immigrants in Norway, with a view to factors associated with diagnostic delay. Methods: A qualitative study was conducted among 22 participants diagnosed with TB who originated from Somalia or Ethiopia. Results: One-third of the participants reported less than 2 months from onset of symptoms to treatment were initiated. The factors associated with little delay included a medical history that gave suspicion of TB, presenting with typical TB symptoms, or being screened for TB at arrival. Two-thirds of the participants told about extensive diagnostic processes. Persistent cough not accompanied by symptoms such as: weight loss and weakness; mild, diffuse, atypical, and/or intermittent symptoms; and a sense of not being a likely victim of TB could delay patients’ first initiative to seek help. Participants experienced that the diagnostic process in the health services could endure for months, even years. The diagnosis could be difficult to confirm, but health professionals appeared to have difficulties with associating their symptoms with TB. This resulted in delays in initiating diagnostic tests for TB, especially in cases of extra-pulmonary TB. Conclusions: Public health efforts to increase awareness about TB transmission, its diversity in manifestations, and its progression from latent to active disease, may decrease patient delay. An increased awareness among health professionals about typical and atypical symptoms of TB, aspects of the patient’s history, and being aware and sensitive to patients’ own interpretation of symptoms may reduce diagnostic delay in the health services.

• Dadi, Mengistu Legesse; Ameni, Gobena; Kassa, Gezahegne Mamo; Medhin, G; Bjune, Gunnar Aksel & Abebe, Fekadu (2010). Performance of QuantiFERON-TB Gold In-Tube (QFTGIT) for the diagnosis of Mycobacterium tuberculosis (Mtb) infection in Afar Pastoralists, Ethiopia. BMC Infectious Diseases. 10. doi: 10.1186/1471-2334-10-354. Full text in Research Archive
• Dadi, Mengistu Legesse; Ameni, Gobena; Medhin, G.; Shawel, Dawit; Bjune, Gunnar Aksel & Abebe, Fekadu (2010). Knowledge and perception of pulmonary tuberculosis in pastoral communities in the middle and Lower Awash Valley of Afar region, Ethiopia. BMC Public Health. 10. doi: 10.1186/1471-2458-10-187. Full text in Research Archive
• Gele, Abdikadir Ali; Sagbakken, Mette; Abebe, Fekadu & Bjune, Gunnar Aksel (2010). Barriers to tuberculosis care: a qualitative study among Somali pastoralists in Ethiopia. BMC Research Notes. 3(86). doi: 10.1186/1756-0500-3-86. Full text in Research Archive Show summary

  Background At the dawn of the third millennium, while the control of the second biggest infectious killer in the world (tuberculosis [TB]) is an international priority, millions of pastoralist communities in the Horn of Africa are struggling to access TB care. Prompt diagnosis and treatment of pastoralist TB patients remain to be a challenge in TB control programs in many countries in this region, where pastoralism is a common means of livelihood. Better understanding of community perceptions of TB and its management could help identify reasons for the delay in diagnosis of TB among pastoral communities. The aim of this study is to explore barriers delaying diagnosis among pastoralist TB patients in the Somali Regional State (SRS) of Ethiopia. Methods A qualitative study, including 19 respondents was conducted in the SRS of Ethiopia. Participatory Rural Appraisal (PRA) and informal interview techniques were employed to explore pastoralists' migration patterns, their perceptions of TB and their access to TB services. The influence of these factors on the delay of TB patients in receiving biomedical diagnosis was then assessed. Results We found that lack of access to formal health services as well as traditional beliefs leading to self treatment were barriers to prompt bio-medical diagnosis of TB among pastoralist TB patients in the SRS of Ethiopia. This study highlights that limited access to TB control programs is the most important barrier in early seeking of biomedical diagnosis of TB among pastoral communities with nomadic pastoralist being the most affected. Conclusions Diagnostic and treatment facilities should be established in strategic villages that pastoralist can reach in both dry and wet seasons. Such facilities may alleviate the observed long distance to health facilities and thus long delay in diagnosis of TB. This strategy should be compounded with a community based TB control approach, whereby basic medical training on TB management such as provision of health education, drug distribution and observations is provided to local traditional healers and religious leaders. This approach may improve pastoralists' perceptions of TB, hence eliminating the observed traditional believes associated with TB in pastoralists' context of the SRS.

• Sandberg, Kristin Ingstad; Andresen, Steinar & Bjune, Gunnar Aksel (2010). A new approach to global health institutions? A case study of new vaccine introduction and the formation of the GAVI Alliance. Social Science and Medicine. ISSN 0277-9536. 71(7), p. 1349–1356. doi: 10.1016/j.socscimed.2010.06.017. Full text in Research Archive
• Gebremariam, Mekdes; Bjune, Gunnar Aksel & Frich, Jan C (2010). Barriers and facilitators of adherence to TB treatment in patients on concomitant TB and HIV treatment: a qualitative study. BMC Public Health. 10. doi: 10.1186/1471-2458-10-651. Full text in Research Archive Show summary

  Background Tuberculosis is a major public health problem in Ethiopia, and a high number of TB patients are co-infected with HIV. There is a need for more knowledge about factors influencing treatment adherence in co-infected patients on concomitant treatment. The aim of the present study is to explore patients' and health care professionals' views about barriers and facilitators to TB treatment adherence in TB/HIV co-infected patients on concomitant treatment for TB and HIV. Methods Qualitative study using in-depth interviews with 15 TB/HIV co-infected patients and 9 health professionals and focus group discussions with 14 co-infected patients. Results We found that interplay of factors is involved in the decision making about medication intake. Factors that influenced adherence to TB treatment positively were beliefs in the curability of TB, beliefs in the severity of TB in the presence of HIV infection and support from families and health professionals. Barriers to treatment adherence were experiencing side effects, pill burden, economic constraints, lack of food, stigma with lack of disclosure, and lack of adequate communication with health professionals. Conclusion Health professionals and policy makers should be aware of factors influencing TB treatment in TB/HIV co-infected patients on concomitant treatment for TB and HIV. Our results suggest that provision of food and minimal financial support might facilitate adherence. Counseling might also facilitate adherence, in particular for those who start ART in the early phases of TB treatment, and beliefs related to side-effects and pill burden should be addressed. Information to the public may reduce TB and HIV related stigma.

• Wiker, Harald G; Mustafa, Tehmina; Bjune, Gunnar & Harboe, Morten (2010). Evidence for waning of latency in a cohort study of tuberculosis. BMC Infectious Diseases. 10. doi: 10.1186/1471-2334-10-37. Full text in Research Archive Show summary

  Background: To investigate how the risk of active tuberculosis disease is influenced by time since original infection and to determine whether the risk of reactivation of tuberculosis increases or decreases with age. Methods: Cohort analysis of data for the separate ten year birth cohorts of 1876-1885 to 1959-1968 obtained from Statistics Norway and the National Tuberculosis Registry. These data were used to calculate the rates and the changes in the rates of bacillary (or active) tuberculosis. Data on bacillary tuberculosis for adult (20+) age groups were obtained from the National Tuberculosis Registry and Statistics Norway from 1946 to 1974. Most cases during this period arose due to reactivation of remote infection. Participants in this part of the analysis were all reported active tuberculosis cases in Norway from 1946 to 1974 as recorded in the National Tuberculosis Registry. Results: Tuberculosis decreased at a relatively steady rate when following individual birth cohorts, but with a tendency of slower decline as time passed since infection. A mean estimate of this rate of decline was 57 % in a 10 year period. Conclusions: The risk of reactivation of latent tuberculosis decreases with age. This decline may reflect the rate at which latent tuberculosis is eliminated from a population with minimal transmission of tubercle bacilli. A model for risk of developing active tuberculosis as a function of time since infection shows that the rate at which tuberculosis can be eliminated from a society can be quite substantial if new infections are effectively prevented. The findings clearly indicate that preventative measures against transmission of tuberculosis will be the most effective. These results also suggest that the total population harbouring live tubercle bacilli and consequently the future projection for increased incidence of tuberculosis in the world is probably overestimated.

• Storla, Dag Gustav Gundersen; Yimer, Solomon Abebe & Bjune, Gunnar Aksel (2010). Can treatment delay be utilized as a key variable for monitoring the pool of infectious tuberculosis in a population? Journal of Infection in Developing Countries. ISSN 2036-6590. 4(2), p. 083–090. Full text in Research Archive
• Gele, Abdi Ali & Bjune, Gunnar Aksel (2010). Armed conflicts have an impact on the spread of tuberculosis: the case of the Somali Regional State of Ethiopia. Conflict and Health. 4(1). Full text in Research Archive
• Hasle, Gunnar; Bjune, Gunnar Aksel; Christensson, Dan; Røed, Knut H.; Whist, Anne Cathrine & Leinaas, Hans Petter (2010). Detection of Babesia divergens in southern Norway by using an immunofluorescence antibody test in cow sera. Acta Veterinaria Scandinavica (AVS). ISSN 0044-605X. 52. doi: 10.1186/1751-0147-52-55. Full text in Research Archive Show summary

  Background The incidence of bovine babesiosis, caused by Babesia divergens (Apicomplexa: Piroplasmida) has decreased markedly since the 1930 s, but may re-emerge as a consequence of climate change and changes in legislation and pasturing practices. This is a potentially serious disease, with both economical and animal welfare consequences. Therefore, there is a need to survey the distribution of B. divergens. Methods We tested sera from 306 healthy pastured cows from 24 farms along the southern Norwegian coast by using an indirect immunofluorescence IgG antibody test (IFAT). Fractions of seropositive cows were compared by calculating 95% CI. Results The results of this test showed that 27% of the sera were positive for B. divergens antibodies. The fraction of antibody-positive sera that we detected showed a two-humped distribution, with a high fraction of positives being found in municipalities in the western and eastern parts of the study area, while the municipalities between these areas had few or no positive serum samples. Conclusions Neither the farmers' observations nor the Norwegian Dairy Herd Recording System give an adequate picture of the distribution of bovine babesiosis. Serological testing of cows by using IFAT is a convenient way of screening for the presence of B. divergens in an area.

• Legesse, Mengistu; Ameni, Gobena; Mamo, Gezahegne; Medhin, Girmay; Abebe, Dawit Shawel & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2010). Knowledge and perception of pulmonary tuberculosis in pastoral communities in the middle and Lower Awash Valley of Afar region, Ethiopia. BMC Public Health. 10(187). doi: 10.1186/1471-2458-10-187. Full text in Research Archive Show summary

  Background Afar pastoralists live in the northeast of Ethiopia, confined to the most arid part of the country, where there is least access to educational, health and other social services. Tuberculosis (TB) is one of the major public health problems in Afar region. Lack of knowledge about TB could affect the health-seeking behaviour of patients and sustain the transmission of the disease within the community. In this study, we assessed the knowledge and perception of apparently healthy individuals about pulmonary tuberculosis (PTB) in pastoral communities of Afar. Methods Between March and May 2009, a community-based cross-sectional questionnaire survey involving 818 randomly selected healthy individuals was conducted in pastoral communities of Afar region. Moreover, two focus group discussions (FGDs), one with men and one with women, were conducted in each of the study area to supplement the quantitative study. Results The majority (95.6%) of the interviewees reported that they have heard about PTB (known locally as "Labadore"). However, the participants associated the cause of PTB with exposure to cold air (45.9%), starvation (38%), dust (21.8%) or smoking/chewing Khat (Catha edulis) (16.4%). The discussants also suggested these same factors as the cause of PTB. All the discussants and the majority (74.3%) of the interviewees reported that persistent cough as the main symptom of PTB. About 87.7% of the interviewees and all the discussants suggested that PTB is treatable with modern drugs. All the discussants and the majority (95%) of the interviewees mentioned that the disease can be transmitted from a patient to another person. Socio-cultural practices, e.g. sharing cups (87.6%), and house type (59.8%) were suggested as risk factors for exposure to PTB in the study areas, while shortage of food (69.7%) and chewing khat (53.8%) were mentioned as factors favouring disease development. Almost all discussants and a considerable number (20.4%) of the interviewees thought that men were the highest risk group to get PTB as well as playing a major role in the epidemiology of the disease. Conclusion The findings indicate that pastoral communities had basic awareness about the disease. Nevertheless, health education to transform their traditional beliefs and perceptions about the disease to biomedical knowledge is crucial.

• Abebe, Fekadu & Bjune, Gunnar Aksel (2009). The protective role of antibody responses during Mycobacterium tuberculosis infection. Clinical and Experimental Immunology. ISSN 0009-9104. 157(2), p. 235–243. doi: 10.1111/j.1365-2249.2009.03967.x. Full text in Research Archive
• Hasle, Gunnar; Bjune, Gunnar Aksel; Edvardsen, Erik; Jakobsen, Christer; Linnehol, Bjørn & Røer, Jan Erik [Show all 10 contributors for this article] (2009). Transport of ticks by migratory passerine birds to Norway. Journal of Parasitology. ISSN 0022-3395. 95(6), p. 1342–1351. doi: 10.1645/GE-2146.1. Full text in Research Archive
• Storla, Dag Gundersen; Kristiansen, Ingun; Oftung, Fredrik; Korsvold, Gro Ellen; Gaupset, Monica & Gran, Gerd [Show all 10 contributors for this article] (2009). Use of interferon gamma-based assay to diagnose tuberculosis infection in health care workers after short term exposure. BMC Infectious Diseases. 9. doi: 10.1186/1471-2334-9-60. Full text in Research Archive Show summary

  Background We intended to assess the risk for health care workers (HCWs) of acquiring M. tuberculosis infection after exposure to patients with sputum-smear positive pulmonary tuberculosis at three University Hospitals (Ullevål, Akershus, and Haukeland) in Norway. Methods We tested 155 exposed health care workers and 48 healthy controls both with a tuberculin skin test (Mantoux) and the T-SPOT.TB test, a recently developed interferon-γ release assays based on the M. tuberculosis-specific ESAT-6 and CFP10 antigens, to investigate if this test might improve infection control measures. Results Among the 155 exposed HCWs tested in this study, 27 individuals were defined as newly infected cases by TST after recent exposure, while only 3 of these had a positive T-SPOT.TB test. The number of T-SPOT.TB positives represents 11% of the individuals defined as recently infected by TST after exposure (3/27) and 2% of the total number of exposed people tested (3/155). In addition, 15 individuals had been previously defined as infected by TST before exposure of whom 2 subjects were T-SPOT.TB positive. All individuals detected as T-SPOT.TB positive belonged to the TST positive group (> 15 mm), and the percentage concordance between T-SPOT.TB and TST, including both previously and newly infected subjects, was 12% (5/42). The 48 control participants used in the study were all T-SPOT.TB negative, but 3 of these subjects were TST positive. Conclusion Our data indicate that the frequency of latent TB in the total cohort of HCWs is 3%, whereas the rate of transmission of TB to exposed individuals is approximately 2% and occurs through exposure periods of short duration. Thus, the risk of TB transmission to HCWs following TB exposure in a hospital setting in Norway is low, and improved screening approaches will benefit from the application of specific interferon-γ release assays.

• Baranov, AA; Mariandyshev, AO; Mannsåker, Turid; Dahle, Ulf R & Bjune, GA (2009). Molecular epidemiology and drug resistance of widespread genotypes of Mycobacterium tuberculosis in northwestern Russia. The International Journal of Tuberculosis and Lung Disease. ISSN 1027-3719. 13(10), p. 1288–1293. Full text in Research Archive
• Yimer, S; Holm-Hansen, Carol; Yimaldu, T & Bjune, G (2009). Evaluating an active case-finding strategy to identify smear-positive tuberculosis in rural Ethiopia. The International Journal of Tuberculosis and Lung Disease. ISSN 1027-3719. 13(11), p. 1399–1404. Full text in Research Archive
• Eick, Frode; Maleta, K; Govasmark, Espen; Duttaroy, Asim K. & Bjune, Gunnar Aksel (2009). Food intake of selenium and sulphur amino acids in tuberculosis patients and healthy adults in Malawi. The International Journal of Tuberculosis and Lung Disease. ISSN 1027-3719. 13(10), p. 1313–1315. Full text in Research Archive
• Yimer, Solomon; Holm-Hansen, Carol; Yimaldu, Tilahun & Bjune, Gunnar (2009). Health care seeking among pulmonary tuberculosis suspects and patients in rural Ethiopia: a community-based study. BMC Public Health. 9. doi: 10.1186/1471-2458-9-454. Full text in Research Archive Show summary

  Background Health care seeking is a dynamic process that is influenced by socio-demographic, cultural and other factors. In Ethiopia, there are limited studies regarding the health seeking behaviour of tuberculosis (TB) suspects and TB patients. However, a thorough understanding of patients' motivation and actions is crucial to understanding TB and the treatment of disease. Such insights would conceivably help to reduce delay in diagnosis, improve treatment adherence and thereby reduce transmission of TB in the community. The objective of this study was to describe and analyze health care seeking among TB suspects and pulmonary TB (PTB) cases in a rural district of the Amhara Region in Ethiopia. Methods Study kebeles were randomly selected in a cross-sectional study design. House-to-house visits were conducted in which individuals aged 15 years and above in all households of the kebeles were included. Subjects with symptoms suggestive of TB were interviewed about their health seeking behaviour, socio-demographic and clinical factors using a semi-structured questionnaire. Logistics regression analysis was employed to assess associations between the independent and outcome variables. Results The majority, 787 (78%), TB suspects and 33 (82.5%) PTB cases had taken health care actions for symptoms from sources outside their homes. The median delay before the first action was 30 days. In logistics regression, women (AOR 0.8, 95% CI 0.6, 0.9) were found to be less likely to visit a medical health provider than men. Those with a long duration of cough (AOR 1.5, 95% CI 1.03, 2.1) and those with a previous history of TB (AOR 1.5, 95% CI 1.03, 2.3) were more likely to visit a medical health provider compared to those with a shorter duration of cough and with no history of TB. Conclusion The majority of TB suspects and PTB cases had already taken health care actions for their symptoms at the time of the survey. The availability of a simple and rapid diagnostic TB test for use at the lowest level of health care and the involvement of all health providers in case finding activities are imperative for early TB case detection.

• Gele, Abdikadir Ali; Bjune, Gunnar Aksel & Abebe, Fekadu (2009). Pastoralism and delay in diagnosis of TB in Ethiopia. BMC Public Health. 9. doi: 10.1186/1471-2458-9-5. Full text in Research Archive Show summary

  Background Tuberculosis (TB) is a major public health problem in the Horn of Africa with Ethiopia being the most affected where TB cases increase at the rate of 2.6% each year. One of the main contributing factors for this rise is increasing transmission due to large number of untreated patients, serving as reservoirs of the infection within the communities. Reduction of the time between onset of TB symptoms to diagnosis is therefore a prerequisite to bring the TB epidemic under control. The aim of this study was to measure duration of delay among pastoralist TB patients at TB management units in Somali Regional State (SRS) of Ethiopia. Methods A cross sectional study of 226 TB patients with pastoralist identity was conducted in SRS of Ethiopia from June to September 2007. Patients were interviewed using questionnaire based interview. Time between onset of TB symptoms and first visit to a professional health care provider (patient delay), and the time between first visits to the professional health care provider to the date of diagnosis (medical provider's delay) were analyzed. Both pulmonary and extrapulmonary TB patients were included in the study. Result A total of 226 pastoralist TB patients were included in this study; 93 (41.2%) were nomadic pastoralists and 133 (58.8%) were agro-pastoralists. Median patient delay was found to be 60 days with range of 10–1800 days (83 days for nomadic pastoralists and 57 days for agro-pastoralists). Median health care provider's delay was 6 days and median total delay was 70 days in this study. Patient delay constituted 86% of the total delay. In multivariate logistic regression analysis, nomadic pastoralism (aOR. 2.69, CI 1.47–4.91) and having low biomedical knowledge on TB (aOR. 2.02, CI 1.02–3.98) were significantly associated with prolonged patient delay. However, the only observed risk factor for very long patient delay >120 days was distance to health facility (aOR.4.23, CI 1.32–13.54). Extra-pulmonary TB was the only observed predictor for health care providers' delay (aOR. 3.39, CI 1.68–6.83). Conclusion Patient delay observed among pastoralist TB patients in SRS is one of the highest reported so far from developing countries, exceeding two years in some patients. This long patient delay appears to be associated with patient's inadequate knowledge of the disease and distance to health care facility with nomadic pastoralists being the most affected. Regional TB control programmes need to consider the exceptional circumstances of pastoralists, to maximise their access to TB services.

• Nyombi, Balthazar Melchior; Holm-Hansen, Carol; Kristiansen, Knut Ivan; Bjune, Gunnar Aksel & Muller, Fredrik (2008). Prevalence of reverse transcriptase and protease mutations associated with antiretroviral drug resistance among drug-naive HIV-1 infected pregnant women in Kagera and Kilimanjaro regions, Tanzania. AIDS research and therapy. 5(13). Full text in Research Archive
• Bjune, Gunnar Aksel (2008). Tuberkulose - en sosialpolitisk sjukdom. In Larsen, Øivind; Alvik, Anne; Hagestad, Kristian & Nylenna, Magne (Ed.), Samfunnsmedisin. Gyldendal Akademisk. ISSN 9788205344594. p. 300–309. Full text in Research Archive Show summary

  Lærebok i samfunnsmedisin for legestudenter, medisinske kandidater med eksamen fra utlandet og oppslagsbok for alle som arbeider med samfunnsmedisin. Totalt omarbeidet ny-utgave av de samme redaktørers "Helse for de mange" (2003).

• Nyombi, Balthazar; Holm-Hansen, Carol; Kristiansen, Knut I; Bjune, Gunnar & Müller, Fredrik (2008). Prevalence of reverse transcriptase and protease mutations associated with antiretroviral drug resistance among drug-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions, Tanzania. AIDS research and therapy. 5. doi: 10.1186/1742-6405-5-13. Full text in Research Archive Show summary

  Background Access to antiretroviral drugs for HIV-1 infection has increased in sub-Saharan Africa (SSA) during the past few years. Mutations in the HIV-1 genome are often associated with treatment failure as indicated by viral replication and elevated levels of virus in the blood. Mutations conferring resistance to antiretroviral drugs are based on comparing gene sequences with corresponding consensus sequences of HIV-1 subtype B that represents only 10% of the AIDS pandemic. The HIV pandemic in SSA is characterized by high viral genetic diversity. Before antiretroviral drugs become more widely available, it is important to characterize baseline naturally occurring genetic mutations and polymorphisms associated with antiretroviral drug resistance among circulating HIV-1 subtypes. Methods The prevalence of mutations associated with antiretroviral drug resistance in protease (PR) and reverse transcriptase (RT) regions among antiretroviral treatment-naïve HIV-1 infected pregnant women was investigated in Bukoba (Kagera) and Moshi (Kilimanjaro) municipalities, Tanzania, between September and December 2005. The HIV-1 pol gene was amplified using primers recognizing conserved viral sequences and sequenced employing BigDye chemistry from 100 HIV-1 seropositive treatment-naïve pregnant women and 61 HIV-1 seropositive women who had received a single dose of Nevirapine (sdNVP). Positions 1–350 of the RT and 1–99 of the PR genes were analyzed for mutations based on the Stanford University HIV Drug Resistance Database. Results HIV-1 subtypes A, C, D, CRF10_CD and Unique Recombinant Forms (URF) were detected. Primary mutations associated with NRTI and NNRTI resistance were detected among 3% and 4% of treatment-naïve strains, respectively. Primary mutations associated with NRTI and NNRTI resistance were detected in 1.6% and 11.5% of women who had received sdNVP, respectively. None of the primary mutations associated with PI resistance was found. Polymorphisms detected in RT and PR sequences were mainly mutations that are found in the consensus sequences of non-B subtypes Conclusion Based on the WHO HIV Drug Resistance Research Network Threshold of less than 5%, the baseline prevalence of primary mutations among treatment-naïve HIV-1 infected pregnant women in Kagera and Kilimanjaro regions was low. The significance of HIV-1 subtype B polymorphic positions with respect to antiretroviral resistance identified among the prevalent HIV-1 subtypes is unknown. More studies addressing the correlation between polymorphic mutations, antiretroviral resistance and clinical outcome are warranted in regions where non-B subtypes are prevalent.

• Sagbakken, Mette; Frich, Jan C & Bjune, Gunnar Aksel (2008). Barriers and enablers in the management of tuberculosis treatment in Addis Ababa, Ethiopia: a qualitative study. BMC Public Health. 8. doi: 10.1186/1471-2458-8-11. Full text in Research Archive Show summary

  Background Non-adherence to tuberculosis (TB) treatment is an important barrier for TB control programs because incomplete treatment may result in prolonged infectiousness, drug resistance, relapse, and death. The aim of the present study is to explore enablers and barriers in the management of TB treatment during the first five months of treatment in Addis Ababa, Ethiopia. Methods Qualitative study which included 50 in-depth interviews and two focus groups with TB patients, their relatives and health personnel. Results We found that loss of employment or the possibility to work led to a chain of interrelated barriers for most TB patients. Daily treatment was time-consuming and physically demanding, and rigid routines at health clinics reinforced many of the emerging problems. Patients with limited access to financial or practical help from relatives or friends experienced that the total costs of attending treatment exceeded their available resources. This was a barrier to adherence already during early stages of treatment. A large group of patients still managed to continue treatment, mainly because relatives or community members provided food, encouragement and sometimes money for transport. Lack of income over time, combined with daily accumulating costs and other struggles, made patients vulnerable to interruption during later stages of treatment. Patients who were poor due to illness or slow progression, and who did not manage to restore their health and social status, were particularly vulnerable to non-adherence. Such patients lost access to essential financial and practical support over time, often because relatives and friends were financially and socially exhausted by supporting them. Conclusion Patients' ability to manage TB treatment is a product of dynamic processes, in which social and economic costs and other burdens change and interplay over time. Interventions to facilitate adherence to TB treatment needs to address both time-specific and local factors.

• Jani-Bølstad, Jagrati; Holm-Hansen, Carol; Mussá, Tufária; Zango, Arlinda; Manchica, Ivan & Bjune, Gunnar Aksel [Show all 7 contributors for this article] (2008). Assessment of measles immunity among infants in Maputo City, Mozambique. BMC Public Health. p. 386–386. Full text in Research Archive
• Nyombi, Balthazar M; Nkya, Watoky; Barongo, Longin; Bjune, Gunnar; Kristiansen, Knut I & Muller, Fredrik [Show all 7 contributors for this article] (2008). Evolution of human immunodeficiency virus type 1 serotypes in northern Tanzania: a retrospective study. APMIS - Journal of Pathologiy, Microbiology and Immunology. ISSN 0903-4641. 116(6), p. 507–514. doi: 10.1089/088922200415054. Full text in Research Archive

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• Yimer, Solomon Abebe; Norheim, Gunnstein; Namouchi, Amine; Zegeye, Efrem; Kinander, Wibeke & Bekele, Shiferaw [Show all 10 contributors for this article] (2015). Mycobacterium tuberculosis lineage 7 strains are associated with prolonged patient delay in pulmonary tuberculosis patients in Amhara Region, Ethiopia. Oral presentation at the World TB Summit to be held in London, UK 24th-26th March/2015. Full text in Research Archive
• Yimer, Solomon Abebe; Norheim, Gunnstein; Namouchi, Amine; Zegeye, Ephrem Debebe; Kinander, Wibeke & Tonjum, Tone [Show all 9 contributors for this article] (2015). Lineage 7 Mycobacterium tuberculosis strains are associated with longer patient delay in pulmonary TB patients. Full text in Research Archive
• Shero, Kebede Chimdessa; Legesse, Mengistu; Medhin, Girmay; Belay, Mulugeta; Bjune, Gunnar Aksel & Abebe, Fekadu (2014). Re-assessing tuberculin skin test (TST) for the diagnosis of tuberculosis (TB) among African migrants in Western Europe and USA. Journal of Tuberculosis Research. ISSN 2329-843X. 2(1), p. 4–15. doi: 10.4236/jtr.2014.21002. Full text in Research Archive
• Yimer, Solomon; Holm-Hansen, Carol J C; Storla, Dag Gustav Gundersen & Bjune, Gunnar Aksel (2014). Tuberculosis management time: an alternative parameter for measuring the tuberculosis infectious pool. Full text in Research Archive
• Mustafa, Tehmina; Wiker, Harald G; Harboe, Morten & Bjune, Gunnar Aksel (2014). Mycobacterial antigens disappear from host tissue during latent Mycobacterium tuberculosis infection. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2013). En sammenligning av DOT-behandling i Etiopia og Norge. Full text in Research Archive
• Legesse, Mengistu; Mamo, Gezahegne; Ameni, Gobena; Medhin, Girmay; Bjune, Gunnar Aksel & Abebe, Fekadu (2013). Community-based prevalence of undiagnosed mycobacterial diseases in the Afar Region, north-east Ethiopia. International Journal of mycobacteriology. ISSN 2212-5531. 2(2), p. 94–102. doi: 10.1016/j.imyco.2013.04.001. Full text in Research Archive
• Vogt, Yngve; Jani-Bølstad, Jagrati & Bjune, Gunnar Aksel (2012). Manglende tillit til vaksinering i U-land. Full text in Research Archive
• Larsson, Geir; Shenoy, K.; Røseth, Arne; Bjune, Gunnar Aksel & Moum, Bjørn (2011). Diagnosis and differentiation of intestinal tuberculosis and Crohn's disease by use of faecal and serum calprotectin. Inflammatory Bowel Diseases. ISSN 1078-0998. 17, p. S35–S35. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2011). Tuberculosis - from the patients' perspective. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2011). Patients’ and health professionals’ views and experiences with tuberculosis treatment in Norway among immigrants from Ethiopia. Tropical medicine & international health. ISSN 1360-2276. 16, p. 52–52. Full text in Research Archive
• Jani-Bølstad, Jagrati; Christie, Vibeke & Bjune, Gunnar Aksel (2011). Transformasjon av vitenskapelig tanke,arbeids og-vurderingsformer i master utdanning: MPhil i samfunnsmedisin. Full text in Research Archive
• Sagbakken, Mette; Frich, Jan C & Bjune, Gunnar Aksel (2010). Kampen mot tuberkulose. 130, p. 646–648. Full text in Research Archive
• Larsson, Geir; Shenoy, K.T.; Røseth, Arne; Bjune, Gunnar Aksel & Moum, Bjørn (2010). Evaluation of faecal and serum calprotectin in patients with intestinal tuberculosis. Scandinavian Journal of Gastroenterology. ISSN 0036-5521. 45, p. 72–72. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2009). Patients' and health professionals views and experiences with tuberculosis treatment in a low-endemic setting: a qualitative study. Full text in Research Archive
• Sagbakken, Mette; Bjune, Gunnar Aksel & Frich, Jan C (2009). Diagnostic delay among immigrants with tuberculosis in a low-endemic context. Full text in Research Archive
• Yimer, Solomon Abebe; Holm-Hansen, C & Bjune, G (2009). Measuring the prevalence of sputum smear-positive tuberculosis in a rural district of Ethiopia: an active case finding. Full text in Research Archive
• Wiker, Harald G; Mustafa, Tehmina; Bjune, Gunnar & Harboe, Morten (2008). Estimating the half-life of latent Mycobacterium tuberculosis infection based on the decline of tuberculosis in Norway. Full text in Research Archive
• Mamo, Gezahegne; Abebe, Fekadu; Worku, Yalelet; Hussein, Nesredin; Legesse, Mengistu & Tilahun, Getachew [Show all 9 contributors for this article] (2013). Bovine tuberculosis and its associated risk factors in pastoral and agro-pastoral cattle herds of Afar Region. northeast Ethiopia. Academic journals. Full text in Research Archive
• Yimer, Solomon & Bjune, Gunnar (2010). Millennium development goal six and the lost indicator for case detection in tuberculosis control: Investigating diagnostic delay and the infectious pool in Ethiopia. Unipub forlag. ISSN 9788280725059. Full text in Research Archive

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