This section contains articles written during TB Union/MSF/SORT-IT Operational Research courses. They do not describe MSF work, but at least one author is from MSF in their role as course mentor.

Recent Submissions

  • "Stopping the itch": mass drug administration for scabies outbreak control covered for over nine million people in Ethiopia

    Enbiale, W; Baynie, TB; Ayalew, A; Gebrehiwot, T; Getanew, T; Ayal, A; Ayalew, M; De Vries, HJ; Takarinda, K; Manzi, M; et al. (Journal of Infection in Developing Countries, 2020-06-30)
    Introduction: In 2018, the Ethiopian Ministry of Health embarked on a Mass Drug Administration (MDA) campaign that involved over 9 million people in Ethiopia - the largest scabies MDA campaign ever conducted on a global level. We describe its implementation and report on a) numbers screened and identified with scabies, b) treatment category and drug type and c) human resources used, duration, and cost of the campaign. Methodology: The MDA campaign was conducted according to national guidelines and activities including: planning and organization, engagement of local leaders, community mobilisation and advocacy, awareness-raising among health workers, field implementation, and monitoring and evaluation. The campaign was conducted between July and August 2018. Results: The MDA campaign was implemented by about 15,000 people, mostly from the community, over an average of 6 days and reached 9, 057, 427 people. A total of 875,890 (9.7%) scabies cases were detected and 995,471 (11.0%) contacts received treatment. (Contact-to-case ratio = 1.3). Scabies prevalence varied, the highest prevalence was seen in Central Gondar (39.2%), South Gondar (16.7%) and North Gondar (15.0%), these neighbouring zones contributing more than two third of all scabies cases in the region. Of 1,738,304 (93%) who received treatment, 94% received ivermectin, the rest topical permethrin and sulfur. The average coverage capacity of an MDA campaign staff member was 84 people per day. The total cost was 11,696,333 United States Dollars (USD). Cost per 100,000 population = 129,135 USD. Conclusions: This experience of rapid-large scale implementation would be useful to scale up similar interventions and "stop the itch" in other regions of Ethiopia.
  • Clinical features and treatment outcomes of visceral leishmaniasis patients admitted to three centers in Oromia, Ethiopia

    Tekalign, S; Adera, C; den Boer, M; Miecha, H; Zewde, A; Mulugeta, D; Bishawu, T; Birru, W; Lema, A; Sahlu, T; et al. (Journal of Infection in Developing Countries, 2020-06-30)
    Introduction: In three health care facilities in the Oromia region, the aim of this study is to report on 1) the number of VL cases registered over time (2013-2018) and 2) the clinical profile, type of treatment used and response to treatment. Methodology: A retrospective cohort study was conducted among all VL cases admitted with a diagnosis of VL. Results: A total of 434 VL cases were registered at the three health facilities, but patient files were available for only 188. Most (51.6%) were children and only three presented with VL relapse. 78 (41.5%) of the 188 patients presented within one month of symptom onset. Concurrent severe acute malnutrition (27.1%), tuberculosis (6.4%) and malaria (6.4%) were common. There were only two cases with HIV coinfection. Fourty-three percent were treated with antimonials, 34% with antimonials combined with paromomycin and 23% with AmBisome. Amongst the 188 patients with patient files there were no deaths and one treatment failure. Six months outcome data were however missing for all. Aggregated data from the 434 VL cases reported three deaths, two treatment failures and one relapse. Conclusions: Children were most commonly affected, suggesting long-term endemicity. While short-term outcomes are encouraging, long-term follow-up data are required.
  • Is vitiligo associated with wearing plastic shoes in a podoconiosis endemic region of Ethiopia?

    Enbiale, W; Abebe, K; Debru, B; Van Griensven, J; Takarinda, K; Manzi, M; Zachariah, R (Journal of Infection in Developing Countries, 2020-06-30)
    Introduction: Endemic non-filarial elephantiasis also known as podoconiosis often affects bare footed farmers and is endemic in Ethiopia. The disease is prevented by wearing shoes. We recently observed several patients presenting to a dermatology clinic with skin depigmentation after wearing plastic shoes (“shoe-contact vitiligo”) which may deter shoe-wearing. We report on their sociodemographic and clinical characteristics. Methodology: This is a retrospective study of 17 months at tertiary level Hospital in Ethiopia. Patient data was retrieved from medical record department. We compared sociodemographic and clinical characteristics of patients presenting with idiopathic and shoe-contact vitiligo. Data was presented descriptively. Results: Of 460 vitiligo cases, 190 (41%) were shoe-contact vitiligo and the rest, idiopathic. The former was more common in females (Odds Ratio, OR = 2.5, P < 0.001) and those in rural areas (OR = 4.8, P < 0.001). Fifty-five percent with shoe-contact vitiligo had itching and/or burning sensation, compared to just 2% with idiopathic vitiligo (P < 0.001) and some had ulcerations (8%). Idiopathic vitiligo had no such findings. Skin discoloration occurred within three weeks (on average) after wearing plastic shoes, 91% of lesions were symmetrical and involved areas of the feet covered with plastic shoes. Symmetric lesions were observed in only 11% of idiopathic vitiligo (OR = 81, P < 0.001). Conclusions: Shoe-contact vitiligo was significantly associated with wearing cheap plastic shoes. The exact chemical culprit(s) needs to be identified. This will allow introducing quality control regulations and rigorous monitoring of shoe production sites.
  • Does training of Health Extension Workers reduce scabies load in district health facilities in rural Ethiopia?

    Gezmu, T; Enbiale, W; Asnakew, M; Bekele, A; Beresaw, G; Nigussie, M; Takarinda, K; Manzi, M; Zachariah, R (Journal of Infection in Developing Countries, 2020-06-30)
    Introduction: In 2017, Ethiopia included scabies management within the responsibility of health extension workers. In Kamba (the intervention district) workers were trained on scabies management. Whereas, in Arba Minch Zuria (the control district) there was no such training. This study assesses whether decentralization of scabies management to communities would reduce the load on health facilities and allow earlier scabies treatment access. Methodology: All individuals presenting with scabies before (January - June 2018) and after (August 2018-January 2019) the introduction of training (July 2018) in Kamba district and the Arba Minch Zuria district were included. We compared between the two districts in the period before and after training, the numbers of scabies cases presenting to health facilities, their demography, clinical characteristics and treatment. Results: There were 1,891 scabies cases in the intervention district and 809 in the control district. Scabies cases declined in the intervention district from 7.6 to 1.6 per 1,000 population (a 4.8-fold reduction). In the control district, scabies cases increased from 1.3 to 2.4 per 1,000 population (a 1.8-fold increase). In intervention district, the proportion of scabies patients with secondary skin infections reduced from 1,227 (78%, n = 1,565) to 156 (48%, n = 326, P < 0.001). In the control district the difference was insignificant 39 (14%, n = 288) to 86 (17%, n = 521, P = 0.2). Conclusions: Introducing trained health extension workers at community level were associated with reductions in health facility load for scabies and secondary infections. This is a wider community health benefit.
  • Gaps in Hepatitis B Vaccination Completion and Sero-Protection for People Who Inject Drugs in Hpakant, Myanmar, 2015-2018

    Yee, NS; Naing, AY; Cuesta, JG; Das, M; Dave, K (MDPI, 2020-05-12)
    Hepatitis B vaccination (HBV) is recommended for high-risk groups, such as people who inject drugs (PWIDs). As part of a harm reduction program by a non-governmental organization, hepatitis B screening, vaccination and antibody (HBAb) testing after completion of the vaccination schedule were offered to PWIDS in Myanmar. We determined the proportions of HBV non-completion and sero-unprotection among PWIDs enrolled in the program and their association with socio-demographic and clinical characteristics. We conducted a descriptive study based on routine program data in five selected clinics in Hpakant Township, Myanmar. PWIDs who were Hepatitis B antigen negative at screening during January 2015-December 2018 were included. Among 5386 participants eligible for HBV, 9% refused vaccination. Among those who accepted vaccination (n = 3177 individuals), 65% completed vaccination. Of those tested for HBsAb (n = 2202), 30% were sero-unprotected. Young-adults (aged 18-44 years) and migrant workers had a higher risk of incomplete vaccination. However, participants who used methadone had a lower risk of incomplete vaccination. Migrant workers had higher risk of not returning for HBsAb testing and HIV-positive participants had a higher risk of being HBV sero-unprotected. Efforts to increase HBV vaccination in PWIDs for young adults and clients during methadone and anti-retroviral services should be prioritized.
  • Factors influencing the return of inactive blood donors in a Cameroonian blood bank

    Ndoumba, AM; Tagny, CT; Nzedzou, G; Boum II, Y; Mbanya, D (Elsevier, 2020-04-19)
    Identify factors that influence the return of donors to increase their loyalty while improving blood safety is crucial in our context. Between October 2017 and April 2018, we conducted a descriptive cross-sectional study at the Blood Bank of the Yaoundé University Teaching Hospital. The study included all former donors who had not donated blood voluntarily for over a year. Quantitative variables were described using means and standard deviations. Fisher's exact test and Chi2 test were used for association measures between qualitative variables. Statistical test results were considered significant for a P<0.05 value. We interviewed a total of 101 inactive donors. The study population was 74.3% male, donors average 30±7 years. Female gender and good staff hospitality were the factors most associated with the intention to return. The barriers to donor return were mainly lack of information on blood needs (35.60%) and time constraint for blood donation (26.73%). Pro-social motivations such as altruism (30.70%) were the main possible sources of motivation cited. To reduce blood deficiency and mortality due to lack of blood products, non-financial material compensation, good outreach and communication strategy can increase inactive donors' loyalty and consequently in improving blood safety in our context.
  • Effects of real-time electronic data entry on HIV programme data quality in Lusaka, Zambia

    Moomba, K; Williams, A; Savory, T; Lumpa, M; Chilembo, P; Tweya, H; Harries, AD; Herce, M (International Union Against Tuberculosis and Lung Disease, 2020-03-21)
    Setting: Human immunodeficiency virus (HIV) clinics in five hospitals and five health centres in Lusaka, Zambia, which transitioned from daily entry of paper-based data records to an electronic medical record (EMR) system by dedicated data staff (Electronic-Last) to direct real-time data entry into the EMR by frontline health workers (Electronic-First). Objective: To compare completeness and accuracy of key HIV-related variables before and after transition of data entry from Electronic-Last to Electronic-First. Design: Comparative cross-sectional study using existing secondary data. Results: Registration data (e.g., date of birth) was 100% complete and pharmacy data (e.g., antiretroviral therapy regimen) was 90% complete under both approaches. Completeness of anthropometric and vital sign data was 75% across all facilities under Electronic-Last, and this worsened after Electronic-First. Completeness of TB screening and World Health Organization clinical staging data was also 75%, but improved with Electronic-First. Data entry errors for registration and clinical consultations decreased under Electronic-First, but errors increased for all anthropometric and vital sign variables. Patterns were similar in hospitals and health centres. Conclusion: With the notable exception of clinical consultation data, data completeness and accuracy did not improve after transitioning from Electronic-Last to Electronic-First. For anthropometric and vital sign variables, completeness and accuracy decreased. Quality improvement interventions are needed to improve Electronic-First implementation.
  • Outcomes of decentralizing hypertension care from district hospitals to health centers in Rwanda, 2013-2014

    Ngoga, G; Park, PH; Borg, R; Bukhman, G; Ali, E; Munyaneza, F; Tapela, N; Rusingiza, E; Edwards, JK; Hedt-Gauthier, B (International Union Against Tuberculosis and Lung Disease, 2019-12-21)
    Setting: Three district hospitals (DHs) and seven health centers (HCs) in rural Rwanda. Objective: To describe follow-up and treatment outcomes in stage 1 and 2 hypertension patients receiving care at HCs closer to home in comparison to patients receiving care at DHs further from home. Design: A retrospective descriptive cohort study using routinely collected data involving adult patients aged ⩾18 years in care at chronic non-communicable disease clinics and receiving treatment for hypertension at DH and HC between 1 January 2013 and 30 June 2014. Results: Of 162 patients included in the analysis, 36.4% were from HCs. Patients at DHs travelled significantly further to receive care (10.4 km vs. 2.9 km for HCs, P < 0.01). Odds of being retained were significantly lower among DH patients when not adjusting for distance (OR 0.11, P = 0.01). The retention effect was consistent but no longer significant when adjusting for distance (OR 0.18, P = 0.10). For those retained, there was no significant difference in achieving blood pressure targets between the DHs and HCs. Conclusion: By removing the distance barrier, decentralizing hypertension management to HCs may improve long-term patient retention and could provide similar hypertension outcomes as DHs.
  • Epidemiology and management of familial Mediterranean fever in Armenia: national audit from 1999 to 2018.

    Hovhannesyan, K; Sahakyan, S; Davtyan, K; Gasparyan, S; Sarkisyan, T; Reid, AJ (Clinical and Experimental Rheumatology Sas, 2019-12-09)
  • Frequency, characteristics and hospital outcomes of road traffic accidents and their victims in Guinea: a three-year retrospective study from 2015 to 2017

    Kourouma, K; Delamou, A; Lamah, L; Camara, BS; Kolie, D; Sidibé, S; Béavogui, AH; Owiti, P; Manzi, M; Ade, S; et al. (BMC, 2019-07-31)
    Background: Road traffic accidents (RTA) remain a global public health concern in developing countries. The aim of the study was to document the frequency, characteristics and hospital outcomes of road traffic accidents in Guinea from 2015 to 2017. Methods: We conducted a retrospective cohort study using medical records of RTA victims from 20 hospitals and a cross-sectional study of RTA cases from eight police stations in eight districts in Guinea, West Africa. Data analysis included descriptive statistics, trends of RTA, a sequence of interrupted time-series models and a segmented ordinary least-squares (OLS) regression. Results: Police stations recorded 3,140 RTA over 3 years with an overall annual increase in RTA rates from 14.0 per 100,000 population in 2015, to 19.2 per 100,000 population in 2016 (37.1% annual increase), to 28.7 per 100,000 population in 2017 (49.5% annual increase). Overall, the injury rates in 2016 and 2017 were .05 per 100,000 population higher on average per month (95% CI: .03-.07). Deaths from RTA showed no statistical differences over the 3 years and no association of RTA trends with season was found. Overall, 27,751 RTA victims were admitted to emergency units, representing 22% of all hospitals admissions. Most victims were males (71%) and young (33%). Deaths represented 1.4% of all RTA victims. 90% of deaths occurred before or within 24 h of hospital admission. Factors associated with death were being male (p = .04), being a child under 15 years (p = .045) or an elderly person aged ≥65 years (p < .001), and having head injury or coma (p < .001). Conclusions: RTA rates in Guinea are increasing. There is a need for implementing multisectoral RTA prevention measures in Guinea.
  • Neglected tropical diseases and the sustainable development goals: an urgent call for action from the front line

    Addisu, A; Adriaensen, W; Balew, A; Asfaw, M; Diro, E; Garba Djirmay, A; Gebree, D; Seid, G; Begashaw, H; Harries, AD; et al. (BMJ, 2019-02-08)
  • "Small small interventions, big big roles"- a qualitative study of patient, care-giver and health-care worker experiences of a palliative care programme in Kerala, India

    Philip, RP; Venables, E; Manima, A; Tripathy, JP; Philip, S (BMC, 2019-02-04)
    Background: Home-based palliative care is an essential resource for many communities. We conducted a qualitative study to explore perceptions of a home-based palliative care programme in Kerala, India, from the perspective of patients, their care-givers and the doctors, nurses and volunteers running the intervention. Methods: A descriptive qualitative study was carried out. One focus group discussion (FGD) was conducted with patients (n = 8) and two with male and female volunteers (n = 12); and interviews were conducted with doctors (n = 3), nurses (n = 3) and care-givers (n = 14). FGDs and interviews were conducted in Malayalam, audio-recorded, transcribed verbatim and translated into English. Transcripts were coded and analysed using manual content analysis. Results: Doctors, nurses and volunteers have interdependent roles in providing palliative care to patients, including mentorship, training, patient care and advocating for patient needs. Volunteers also considered themselves to be mediators between families and the programme. Care-givers were mainly female and were caring for relatives. They have physically demanding, psychologically stressful and socially restrictive experiences of care-giving. They felt that the programme facilitated their role as care-givers by giving them training and support. Patients with long standing illnesses felt that the programme enabled them to become more independent and self-reliant. The local community supports the programme through economic contributions and offering practical assistance to patients. Conclusion: The salient features of this programme include the provision of regular holistic care through a team of doctors, nurses and patients. The programme was perceived to have improved the lives of patients and their care-givers. The involvement of volunteers from the local community was perceived as a strength of the programme, whilst simultaneously being a challenge.
  • Are they there yet? Linkage of patients with tuberculosis to services for tobacco cessation and alcohol abuse - a mixed methods study from Karnataka, India

    Navya, N; Jeyashree, K; Madhukeshwar, AK; Anand, T; Nirgude, AS; Nayarmoole, BM; Isaakidis, P (BMC, 2019-02-01)
    Background: Tobacco use and alcohol abuse are associated with higher risk of tuberculosis (TB) infection, progression to active TB and adverse treatment outcomes among patients with TB. Revised National Tuberculosis Control Programme (RNTCP) treatment guidelines (2016) require the documentation of tobacco and alcohol use among patients with TB and their linkage to tobacco and alcohol abuse treatment services. This study aimed to assess the extent of documentation of tobacco and alcohol usage data in the TB treatment card and to explore in-depth, the operational issues involved in linkage. Methods: A convergent parallel mixed methods study was conducted. All new TB treatment cards of adult patients registered under RNTCP between January and June 2017 in Dakshina Kannada district were reviewed to assess documentation. Document review was done to understand the process of linkage (directing patients to tobacco and alcohol abuse treatment services). In-depth interview of health care providers (n = 7) and patients with TB (n = 5) explored into their perspectives on linkage. Results: Among 413 treatment cards reviewed, tobacco use was documented in 322 (78%), of whom 86 (21%) were documented as current tobacco users. Sixteen (19%) out of these 86 patients were linked to tobacco cessation services. Alcohol usage status was documented in 319 (77%) cards of whom 71(17%) were documented as alcohol users. Eleven (16%) out of these 71 patients were linked to alcohol abuse treatment services. The questions in the treatment card lacked clarity. Guidelines on eliciting history of substance abuse and criteria for linkage were not detailed. Perceived enablers for linkage included family support, will power of the patients and fear of complications. Challenges included patient's lack of motivation, financial and time constraints, inadequate guidelines and lack of co-ordination mechanisms between TB programme and tobacco/alcohol abuse treatment services. Conclusion: Documentation was good but not universally done. Clear operational guidelines on linkage and treatment guidelines for health care providers to appropriately manage the patients with comorbidities are lacking. Lack of coordination between the TB treatment programme and tobacco cessation as well as alcohol treatment services was considered a major challenge in effective implementation of the linkage services.
  • I have heard about it for the first time from you! Implementation of tobacco control law by police personnel in India.

    Ahuja, N; Kathiresan, J; Anand, T; Isaakidis, P; Bajaj, D (International Union Against Tuberculosis and Lung Disease, 2018-12-21)
    Setting and Objetives: Police personnel, alongside other key stakeholders, are responsible for implementing the Cigarettes and Other Tobacco Products Act (COTPA) in India. This study aimed to assess knowledge and attitudes about COTPA among police personnel and explore enablers and barriers in implementing it. Design: This convergent parallel mixed-methods study used a self-administered questionnaire (quantitative) and key informant interviews (qualitative). Of 300 police personnel across all eight police stations in Daman, 155 participated. Quantitative data were analysed using descriptive statistics and the χ2 test. Qualitative data from in-depth interviews of six key informants from all coordinating departments were analysed thematically. Results: Overall, 63.2% of responders were aware of any tobacco control law in India, and only 12.9% were trained in its implementation. One person had conducted inspections for COTPA compliance in the last 12 months. The majority (78.1%) of the police personnel, and significantly more tobacco non-users than users (81.2% vs. 52.9%, P = 0.016), felt that enforcing anti-tobacco regulations is one of their most important functions. Perceived benefits of the act and formal authority to act were the two main enablers of COTPA implementation. Lack of awareness and coordination, competing priorities, concentration of authority with higher-ranking officials and evasion of the law by retailers and the public hampered effective implementation of the law. Conclusion: Knowledge about the COTPA was average and implementation poor. Sensitisation and training of implementers, systematic transparent reporting and creating awareness among public are recommended for effective implementation.
  • Does the Structured Operational Research and Training Initiative (SORT IT) continue to influence health policy and/or practice?

    Tripathy, JP; Kumar, AM; Guillerm, N; Berger, SD; Bissell, K; Reid, A; Zachariah, R; Ramsay, A; Harries, AD (Taylor & Francis, 2018-08-01)
    The Structured Operational Research and Training Initiative (SORT IT) is a successful model of integrated operational research and capacity building with about 90% of participants completing the training and publishing in scientific journals.
  • Body and mind: retention in antiretroviral treatment care is improved by mental health training of care providers in Ethiopia

    Berheto, TM; Hinderaker, SG; Senkoro, M; Tweya, H; Deressa, T; Getaneh, Y; Gezahegn, G (BioMed Central, 2018-07-20)
    Ethiopia has achieved a high coverage of antiretroviral treatment (ART), but maintaining lifelong care is still a great challenge. Mental illnesses often co-exist with HIV/AIDS and may compromise the retention on ART. In order to improve prolonged retention in ART care, basic training in mental health care was introduced for ART providers, but this hasn't been evaluated yet. The aim of this study was to examine if this training has improved patient retention in care.
  • Building the capacity of public health programmes to become data rich, information rich and action rich

    Harries, AD; Khogali, M; Kumar, AMV; Satyanarayana, S; Takarinda, KC; Karpati, A; Olliaro, P; Zachariah, R (International Union Against Tuberculosis and Lung Disease, 2018-06-21)
    Good quality, timely data are the cornerstone of health systems, but in many countries these data are not used for evidence-informed decision making and/or for improving public health. The SORT IT (Structured Operational Research and Training Initiative) model has, over 8 years, trained health workers in low- and middle-income countries to use data to answer important public health questions by taking research projects through to completion and publication in national or international journals. The D2P (data to policy) training initiative is relatively new, and it teaches health workers how to apply 'decision analysis' and develop policy briefs for policy makers: this includes description of a problem and the available evidence, quantitative comparisons of policy options that take into account predicted health and economic impacts, and political and feasibility assessments. Policies adopted from evidence-based information generated through the SORT IT and D2P approaches can be evaluated to assess their impact, and the cycle repeated to identify and resolve new public health problems. Ministries of Health could benefit from this twin-training approach to make themselves 'data rich, information rich and action rich', and thereby use routinely collected data in a synergistic manner to improve public health policy making and health care delivery.
  • Integration of tobacco cessation and tuberculosis management by NGOs in urban India: a mixed-methods study

    Gupte, HA; Zachariah, R; Sagili, KD; Thawal, V; Chaudhuri, L; Verma, H; Dongre, A; Malekar, A; Rigotti, NA (International Union Against Tuberculosis and Lung Disease, 2018-06-21)
  • Are village health volunteers as good as basic health staffs in providing malaria care? A country wide analysis from Myanmar, 2015

    Linn, NYY; Kathirvel, S; Das, M; Thapa, B; Rahman, Mm; Maung, TM; Kyaw, AMM; Thi, A; Lin, Z (BioMed Central, 2018-06-20)
    Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar.
  • How has the Zimbabwe mycobacterial culture and drug sensitivity testing system among re-treatment tuberculosis patients functioned during the scale-up of the Xpert MTB/RIF assay?

    Timire, C; Takarinda, KC; Harries, AD; Mutunzi, H; Manyame-Murwira, B; Kumar, AMV; Sandy, C (Oxford University Press, 2018-06-01)
    In Zimbabwe, while the Xpert MTB/RIF assay is being used for diagnosing tuberculosis and rifampicin-resistance, re-treatment tuberculosis (TB) patients are still expected to have culture and drug sensitivity testing (CDST) performed at national reference laboratories for confirmation. The study aim was to document the Xpert MTB/RIF assay scale-up and assess how the CDST system functioned for re-treatment TB patients.

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