• Tackling female genital cutting in Somalia.

      Ford, N; Médecins Sans Frontières, 124-132 Clerkenwell Road, EC1R 5DJ, London, UK. (Elsevier, 2001-10-06)
    • Tackling mortality due to childhood tuberculosis

      Godreuil, S; Marcy, O; Wobudeya, E; Bonnet, M; Solassol, J (Elsevier, 2018-03-23)
    • Tailored HIV programmes and universal health coverage

      Holmes, CB; Rabkin, M; Ford, N; Preko, P; Rosen, S; Ellman, T; Ehrenkranz, P (World Health Organization, 2020-02-01)
      Improvements in geospatial health data and tailored human immunodeficiency virus (HIV) testing, prevention and treatment have led to greater microtargeting of the HIV response, based on location, risk, clinical status and disease burden. These approaches show promise for achieving control of the HIV epidemic. At the same time, United Nations Member States have committed to achieving broader health and development goals by 2030, including universal health coverage (UHC). HIV epidemic control will facilitate UHC by averting the need to commit ever-increasing resources to HIV services. Yet an overly targeted HIV response could also distort health systems, impede integration and potentially threaten broader health goals. We discuss current approaches to achieving both UHC and HIV epidemic control, noting potential areas of friction between disease-specific microtargeting and integrated health systems, and highlighting opportunities for convergence that could enhance both initiatives. Examples of these programmatic elements that could be better aligned include: improved information systems with unique identifiers to track and monitor individuals across health services and the life course; strengthened subnational data use; more accountable supply chains that supply a broad range of services; and strengthened community-based services and workforces. We argue that the response both to HIV and to broader health threats should use these areas of convergence to increase health systems efficiency and mitigate the harm of any potential decrease in health funding. Further investments in implementation and monitoring of these programme elements will be needed to make progress towards both UHC and HIV epidemic control.
    • Taking on the diabetes-tuberculosis epidemic in India: paving the way through operational research

      Satyanarayana, S; Kumar, A M V; Wilson, N; Kapur, A; Harries, A D; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2014-03-25)
    • A tale of two cities: restoring water services in Kabul and Monrovia

      Pinera, J-F; Reed, R A; Médecins Sans Frontières, Amsterdam, Netherlands; Water Engineering and Development Centre, Loughborough University, United Kingdom (2009-01-12)
      Kabul and Monrovia, the respective capitals of Afghanistan and Liberia, have recently emerged from long-lasting armed conflicts. In both cities, a large number of organisations took part in emergency water supply provision and later in the rehabilitation of water systems. Based on field research, this paper establishes a parallel between the operations carried out in the two settings, highlighting similarities and analysing the two most common strategies. The first strategy involves international financial institutions, which fund large-scale projects focusing on infrastructural rehabilitation and on the institutional development of the water utility, sometimes envisaging private-sector participation. The second strategy involves humanitarian agencies, which run community-based projects, in most cases independently of the water utilities, and targeting low-income areas. Neither of these approaches manages to combine sustainability and universal service. The paper assesses their respective strengths and weaknesses and suggests ways of improving the quality of assistance provided.
    • Target product profile (TPP) for chagas disease point-of-care diagnosis and assessment of response to treatment

      Porrás, Analía I; Yadon, Zaida E; Altcheh, Jaime; Britto, Constança; Chaves, Gabriela C; Flevaud, Laurence; Martins-Filho, Olindo Assis; Ribeiro, Isabela; Schijman, Alejandro G; Shikanai-Yasuda, Maria Aparecida; et al. (Public Library of Science, 2015-06-04)
    • Target Product Profile for a Diagnostic Assay to Differentiate between Bacterial and Non-Bacterial Infections and Reduce Antimicrobial Overuse in Resource-Limited Settings: An Expert Consensus

      Dittrich, S; Tadesse, BT; Moussy, F; Chua, A; Zorzet, A; Tängdén, T; Dolinger, DL; Page, AL; Crump, JA; D'Acremont, V; et al. (Public Library of Science, 2016-08-25)
      Acute fever is one of the most common presenting symptoms globally. In order to reduce the empiric use of antimicrobial drugs and improve outcomes, it is essential to improve diagnostic capabilities. In the absence of microbiology facilities in low-income settings, an assay to distinguish bacterial from non-bacterial causes would be a critical first step. To ensure that patient and market needs are met, the requirements of such a test should be specified in a target product profile (TPP). To identify minimal/optimal characteristics for a bacterial vs. non-bacterial fever test, experts from academia and international organizations with expertise in infectious diseases, diagnostic test development, laboratory medicine, global health, and health economics were convened. Proposed TPPs were reviewed by this working group, and consensus characteristics were defined. The working group defined non-severely ill, non-malaria infected children as the target population for the desired assay. To provide access to the most patients, the test should be deployable to community health centers and informal health settings, and staff should require <2 days of training to perform the assay. Further, given that the aim is to reduce inappropriate antimicrobial use as well as to deliver appropriate treatment for patients with bacterial infections, the group agreed on minimal diagnostic performance requirements of >90% and >80% for sensitivity and specificity, respectively. Other key characteristics, to account for the challenging environment at which the test is targeted, included: i) time-to-result <10 min (but maximally <2 hrs); ii) storage conditions at 0-40°C, ≤90% non-condensing humidity with a minimal shelf life of 12 months; iii) operational conditions of 5-40°C, ≤90% non-condensing humidity; and iv) minimal sample collection needs (50-100μL, capillary blood). This expert approach to define assay requirements for a bacterial vs. non-bacterial assay should guide product development, and enable targeted and timely efforts by industry partners and academic institutions.
    • Target Product Profile of a Molecular Drug-Susceptibility Test for Use in Microscopy Centers

      Denkinger, C M; Dolinger, D; Schito, M; Wells, W; Cobelens, F; Pai, M; Zignol, M; Cirillo, D M; Alland, D; Casenghi, M; et al. (Oxford University Press, 2015-04-01)
      Current phenotypic testing for drug resistance in patients with tuberculosis is inadequate primarily with respect to turnaround time. Molecular tests hold the promise of an improved time to diagnosis.
    • Targeting CD4 testing to a clinical subgroup of patients could limit unnecessary CD4 measurements, premature antiretroviral treatment and costs in Thyolo District, Malawi.

      Zachariah, R; Teck, R; Ascurra, O; Humblet, P; Harries, A D; Médecins sans Frontières, Medical Department (Operational Research HIV-TB), Brussels Operational Center, 94 Rue Dupre, Brussels, Belgium. zachariah@internet.lu (Elsevier, 2006-01)
      Malawi offers antiretroviral treatment (ART) to all HIV-positive adults who are clinically classified as being in WHO clinical stage III or IV without 'universal' CD4 testing. This study was conducted among such adults attending a rural district hospital HIV/AIDS clinic (a) to determine the proportion who have CD4 counts >or=350 cells/microl, (b) to identify risk factors associated with such CD4 counts and (c) to assess the validity and predictive values of possible clinical markers for CD4 counts >or=350 cells/microl. A CD4 count >or=350 cells/microl was found in 36 (9%) of 401 individuals who are thus at risk of being placed prematurely on ART. A body mass index (BMI) >22 kg/m(2), the absence of an active WHO indicator disease at the time of presentation for ART, and a total lymphocyte count >1,200 cells/microl were significantly associated with such a CD4 count. The first two of these variables could serve as clinical markers for selecting subgroups of patients who should undergo CD4 testing. In a resource-limited district setting, assessing the BMI and checking for active opportunistic infections are routine clinical procedures that could be used to target CD4 measurements, thereby minimising unnecessary CD4 measurements, unnecessary (too early) treatment and costs.
    • Targeting the vulnerable in emergency situations: who is vulnerable?

      Davis, A; Médecins Sans Frontières Holland, Nairobi, Kenya. (Elsevier, 1996-09-28)
      BACKGROUND: Emergencies such as wars and natural disasters increase the vulnerability of affected populations and expose these populations to risks such as disease, violence, and hunger. Emergency public health interventions aim to mitigate these effects by providing basic minimum requirements, reducing vulnerability, and reducing exposure to risk. Targeted services are generally aimed at children under 5. Mortality rates among young children are higher than the crude mortality rate (CMR) among the whole population in emergency settings, so attention is focused on this age group. However, even under normal conditions mortality is higher in young children. This analysis compared the relative risk of death for young children with that for older children and adults under normal conditions and in emergency settings. METHODS: Mortality data from refugee camps set up in response to three different emergencies were examined. Baseline mortality rates in the refugees' countries of origin were calculated from published data. Relative risks between normal and emergency conditions were calculated and compared. FINDINGS: Mortality rates were higher among children under 5 than among older children and adults both under normal circumstances and in the emergency setting in camps in Tanzania, Uganda, and Zaire. However, the relative risk for under-5 versus over-5 mortality was smaller under emergency conditions than under normal circumstances. Thus, children over 5 and adults are disproportionately more affected by exposure to emergency risks than are younger children. INTERPRETATION: If the objective of intervention, to reduce mortality, is to be achieved, the population over the age of 5 cannot be ignored. Emergency public health needs to develop specific tools to investigate risk in other age groups (as well as children under 5), to identify causes, and to design programmes to address such needs.
    • Task Sharing Within a Managed Clinical Network to Improve Child Health in Malawi

      O'Hare, B; Phiri, A; Lang, H-J; Friesen, H; Kennedy, N; Kawaza, K; Jana, C E; Chirambo, G; Mulwafu, W; Heikens, G T; et al. (BioMed Central, 2015-07-21)
      Eighty per cent of Malawi's 8 million children live in rural areas, and there is an extensive tiered health system infrastructure from village health clinics to district hospitals which refers patients to one of the four central hospitals. The clinics and district hospitals are staffed by nurses, non-physician clinicians and recently qualified doctors. There are 16 paediatric specialists working in two of the four central hospitals which serve the urban population as well as accepting referrals from district hospitals. In order to provide expert paediatric care as close to home as possible, we describe our plan to task share within a managed clinical network and our hypothesis that this will improve paediatric care and child health.
    • Task shifting for antiretroviral treatment delivery in sub-Saharan Africa: not a panacea.

      Philips, M; Zachariah, R; Venis, S; Analysis and Advocacy Unit, Médecins Sans Frontières, Brussels Operational Centre, Belgium. (Elsevier, 2008-02-23)
    • Task shifting in HIV/AIDS: opportunities, challenges and proposed actions for sub-Saharan Africa.

      Zachariah, R; Ford, N; Philips, M; Lynch, S; Massaquoi, M; Janssens, V; Harries, A D; Médecins Sans Frontières, Medical Department, Brussels Operational Center, Rue de Gasperich, Luxembourg. zachariah@internet.lu (Published by Elsevier, 2009-06)
      Sub-Saharan Africa is facing a crisis in human health resources due to a critical shortage of health workers. The shortage is compounded by a high burden of infectious diseases; emigration of trained professionals; difficult working conditions and low motivation. In particular, the burden of HIV/AIDS has led to the concept of task shifting being increasingly promoted as a way of rapidly expanding human resource capacity. This refers to the delegation of medical and health service responsibilities from higher to lower cadres of health staff, in some cases non-professionals. This paper, drawing on Médecins Sans Frontières' experience of scaling-up antiretroviral treatment in three sub-Saharan African countries (Malawi, South Africa and Lesotho) and supplemented by a review of the literature, highlights the main opportunities and challenges posed by task shifting and proposes specific actions to tackle the challenges. The opportunities include: increasing access to life-saving treatment; improving the workforce skills mix and health-system efficiency; enhancing the role of the community; cost advantages and reducing attrition and international 'brain drain'. The challenges include: maintaining quality and safety; addressing professional and institutional resistance; sustaining motivation and performance and preventing deaths of health workers from HIV/AIDS. Task shifting should not undermine the primary objective of improving patient benefits and public health outcomes.
    • Task Shifting the Management of Non-Communicable Diseases to Nurses in Kibera, Kenya: Does It Work?

      Some, D; Edwards, J K; Reid, T; Van den Bergh, R; Kosgei, R J; Wilkinson, E; Baruani, B; Kizito, W; Khabala, K; Shah, S; et al. (Public Library of Science, 2016-01-26)
      In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses.
    • Task-Sharing of HIV Care and ART Initiation: Evaluation of a Mixed-Care Non-Physician Provider Model for ART Delivery in Rural Malawi

      McGuire, Megan; Ben Farhat, Jihane; Pedrono, Gaelle; Szumilin, Elisabeth; Heinzelmann, Annette; Chinyumba, Yamikani Ntakwile; Goossens, Sylvie; Makombe, Simon; Pujades-Rodríguez, Mar (2013-09-16)
      Background: Expanding access to antiretroviral therapy (ART) in sub-Saharan Africa requires implementation of alternative care delivery models to traditional physician-centered approaches. This longitudinal analysis compares outcomes of patients initiated on antiretroviral therapy (ART) by non-physician and physician providers. Methods: Adults (≥15 years) initiating ART between September 2007 and March 2010, and with >1 follow-up visit were included and classified according to the proportion of clinical visits performed by nurses or by clinical officers(≥80% of visits). Multivariable Poisson models were used to compare 2-year program attrition (mortality and lost to follow-up) and mortality by type of provider. In sensitivity analyses only patients with less severe disease were included. Results: A total of 10,112 patients contributed 14,012 person-years to the analysis: 3386 (33.5%) in the clinical officer group, 1901 (18.8%) in the nurse care group and 4825 (47.7%) in the mixed care group. Overall 2-year program retention was 81.8%. Attrition was lower in the mixed care and higher in the clinical officer group, compared to the nurse group (adjusted incidence rate ratio [aIRR]=0.54, 95%CI 0.45-0.65; and aIRR=3.03, 95%CI 2.56-3.59,respectively). While patients initiated on ART by clinical officers in the mixed care group had lower attrition(aIRR=0.36, 95%CI 0.29-0.44) than those in the overall nurse care group; no differences in attrition were found between patients initiated on ART by nurses in the mixed care group and those included in the nurse group (aIRR=1.18, 95%CI 0.95-1.47). Two-year mortality estimates were aIRR=0.72, 95%CI 0.49-1.09 and aIRR=5.04,95%CI 3.56-7.15, respectively. Slightly higher estimates were observed when analyses were restricted to patients with less severe disease. Conclusion: The findings of this study support the use of a mixed care model with well trained and regularly supervised nurses and medical assistants to provide HIV care in countries with high HIV prevalence.
    • TB in disasters.

      Ford, N; Sizaire, V; Mills, E; Médecins Sans Frontières, Braamfontein, Johannesburg, South Africa. (2008-10)
    • TB treatment in a chronic complex emergency: treatment outcomes and experiences in Somalia

      Liddle, K F; Elema, R; Thi, S S; Greig, J; Venis, S; Médecins Sans Frontières (MSF), Amsterdam, The Netherlands (Oxford University Press, 2013-09-29)
      Médecins Sans Frontières (MSF) provides TB treatment in Galkayo and Marere in Somalia. MSF international supervisory staff withdrew in 2008 owing to insecurity but maintained daily communication with Somali staff. In this paper, we aimed to assess the feasibility of treating TB in a complex emergency setting and describe the programme adaptations implemented to facilitate acceptable treatment outcomes.
    • Teleradiology quality assurance - lessons learnt

      Spijker, Saskia (SpringerLink, 2014-06)
    • Teleradiology usage and user satisfaction with the telemedicine system operated by Médecins Sans Frontières

      Halton, Jarred; Kosack, Cara; Spijker, Saskia; Joekes, Elizabeth; Andronikou, Savvas; Chetcuti, Karen; Brant, William E; Bonnardot, Laurent; Wootton, Richard (Frontiers Media, 2014-10-28)
      Médecins Sans Frontières (MSF) began a pilot trial of store-and-forward telemedicine in 2010, initially operating separate networks in English, French, and Spanish; these were merged into a single, multilingual platform in 2013. We reviewed the pattern of teleradiology usage on the MSF telemedicine platform in the 4-year period from April 2010. In total, 564 teleradiology cases were submitted from 22 different countries. A total of 1114 files were uploaded with the 564 cases, the majority being of type JPEG (n = 1081, 97%). The median file size was 938 kb (interquartile range, IQR 163-1659). A panel of 14 radiologists was available to report cases, but most (90%) were reported by only 4 radiologists. The median radiologist response time was 6.1 h (IQR 3.0-20). A user satisfaction survey was sent to 29 users in the last 6 months of the study. There was a 28% response rate. Most respondents found the radiologist's advice helpful and all of them stated that the advice assisted in clarification of a diagnosis. Although some MSF sites made substantial use of the system for teleradiology, there is considerable potential for expansion. More promotion of telemedicine may be needed at different levels of the organization to increase engagement of staff.
    • Temporal and spatial analysis of the 2014-2015 Ebola virus outbreak in West Africa

      Carroll, Miles W; Matthews, David A; Hiscox, Julian A; Elmore, Michael J; Pollakis, Georgios; Rambaut, Andrew; Hewson, Roger; García-Dorival, Isabel; Bore, Joseph Akoi; Koundouno, Raymond; et al. (Macmillan, 2015-06-17)
      West Africa is currently witnessing the most extensive Ebola virus (EBOV) outbreak so far recorded. Until now, there have been 27,013 reported cases and 11,134 deaths. The origin of the virus is thought to have been a zoonotic transmission from a bat to a twoyear-old boy in December 2013 (ref. 2). From this index case the virus was spread by human-to-human contact throughout Guinea, Sierra Leone and Liberia. However, the origin of the particular virus in each country and time of transmission is not known and currently relies on epidemiological analysis, which may be unreliable owing to the difficulties of obtaining patient information. Here we trace the genetic evolution of EBOV in the current outbreak that has resulted in multiple lineages. Deep sequencing of 179 patient samples processed by the European Mobile Laboratory, the first diagnostics unit to be deployed to the epicentre of the outbreak in Guinea, reveals an epidemiological and evolutionary history of the epidemic from March 2014 to January 2015. Analysis of EBOV genome evolution has also benefited from a similar sequencing effort of patient samples from Sierra Leone. Our results confirm that the EBOV from Guinea moved into Sierra Leone, most likely in April or early May. The viruses of the Guinea/Sierra Leone lineage mixed around June/July 2014. Viral sequences covering August, September and October 2014 indicate that this lineage evolved independently within Guinea. These data can be used in conjunction with epidemiological information to test retrospectively the effectiveness of control measures, and provides an unprecedented window into the evolution of an ongoing viral haemorrhagic fever outbreak.