title: Spatio-temporal analysis of smear-positive tuberculosis in the Sidama Zone, southern Ethiopia.
abstract: BACKGROUND
  Tuberculosis (TB) is a disease of public health concern, with a varying distribution across settings depending on socio-economic status, HIV burden, availability and performance of the health system. Ethiopia is a country with a high burden of TB, with regional variations in TB case notification rates (CNRs). However, TB program reports are often compiled and reported at higher administrative units that do not show the burden at lower units, so there is limited information about the spatial distribution of the disease. We therefore aim to assess the spatial distribution and presence of the spatio-temporal clustering of the disease in different geographic settings over 10 years in the Sidama Zone in southern Ethiopia.
  
  
  METHODS
  A retrospective space-time and spatial analysis were carried out at the kebele level (the lowest administrative unit within a district) to identify spatial and space-time clusters of smear-positive pulmonary TB (PTB). Scan statistics, Global Moran's I, and Getis and Ordi (Gi*) statistics were all used to help analyze the spatial distribution and clusters of the disease across settings.
  
  
  RESULTS
  A total of 22,545 smear-positive PTB cases notified over 10 years were used for spatial analysis. In a purely spatial analysis, we identified the most likely cluster of smear-positive PTB in 192 kebeles in eight districts (RR= 2, p<0.001), with 12,155 observed and 8,668 expected cases. The Gi* statistic also identified the clusters in the same areas, and the spatial clusters showed stability in most areas in each year during the study period. The space-time analysis also detected the most likely cluster in 193 kebeles in the same eight districts (RR= 1.92, p<0.001), with 7,584 observed and 4,738 expected cases in 2003-2012.
  
  
  CONCLUSIONS
  The study found variations in CNRs and significant spatio-temporal clusters of smear-positive PTB in the Sidama Zone. The findings can be used to guide TB control programs to devise effective TB control strategies for the geographic areas characterized by the highest CNRs. Further studies are required to understand the factors associated with clustering based on individual level locations and investigation of cases.
authors.affiliation: Center for International Health, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway; Sidama Zone Health Department, Hawassa, Ethiopia.
authors.forename: Mesay Hailu
authors.initials: MH
authors.lastname: Dangisso
authors.affiliation: Hawassa University, Hawassa, Ethiopia; Liverpool School of Tropical Medicine, Pembroke Place, Liverpool, L3 5QA, United Kingdom.
authors.forename: Daniel Gemechu
authors.initials: DG
authors.lastname: Datiko
authors.affiliation: Center for International Health, Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway.
authors.forename: Bernt
authors.initials: B
authors.lastname: Lindtjørn
mesh_terms: D001499:Bayes Theorem; D016000:Cluster Analysis; D005002:Ethiopia / Q000453:epidemiology; D005260:Female; D005843:Geography; D006801:Humans; D038622:Internationality; D008297:Male; D062211:Spatio-Temporal Analysis; D014397:Tuberculosis, Pulmonary / Q000453:epidemiology*