Cotrimoxazole prophylaxis for HIV-positive TB patients in developing countries

Despite provisional recommendations from the World Health Organization and UNAIDS that cotrimoxazole (CTX) prophylaxis be offered to all individuals living with AIDS, including HIV-positive patients with TB, its routine use in developing countries particularly Africa has been minimal. Concerns were expressed regarding its effectiveness in areas of high bacterial resistance, that its widespread use might substantially increase bacterial cross-resistance in the community and that this intervention might promote resistance of malaria parasites to sulphadoxine-pyrimethamine. We review the current evidence on the above concerns and highlight the main operational considerations related to implementing CTX prophylaxis as a basic component of care for HIV-positive TB patients in developing countries.

Acceptability and Technical Problems of the Female Condom Amongst Commercial Sex Workers in a Rural District of Malawi

A study was conducted among commercial sex workers (CSWs) in rural southern Malawi, in order to (a) assess the acceptability of the female condom and (b) identify common technical problems and discomforts associated with its use. There were 88 CSWs who were entered into the study with a total of 272 female condom utilizations. Eighty-six (98%) were satisfied with the female condom, 80% preferred it to the male condom and 92% were ready to use the device routinely. Of all the utilizations, the most common technical problem was reuse of the device with consecutive clients, 6% after having washed it, and 2% without any washing or rinsing. The most common discomforts that were reported included too much lubrication (32%), device being too large (16%), and noise during sex (11%).

This study would be useful in preparing the introduction of the female condom within known commercial sex establishments in Malawi.

Cost of hospitalisation for non-communicable diseases in India: are we pro-poor?

OBJECTIVES

To estimate out-of-pocket (OOP) expenditure due to hospitalisation from NCDs and its impact on households in India.

METHODS

The study analysed nationwide representative data collected by the National Sample Survey Organisation in 2014 that reported health service utilisation and healthcare-related OOP expenditure by income quintiles and by type of health facility (public or private). The recall period for inpatient hospitalisation expenditure was 365 days. Consumption expenditure was collected for a recall period of 1 month. OOP expenditure amounting to >10% of annual consumption expenditure was termed as catastrophic. Weighted analysis was performed.

RESULTS

The median expenditure per episode of hospitalisation due to NCDs was USD 149 - this was ~3 times higher among the richest quintile compared to poorest quintile. There was a significantly higher prevalence of catastrophic expenditure among the poorest quintile, more so for cancers (85%), psychiatric and neurological disorders (63%) and injuries (63%). Mean private-sector OOP hospitalisation expenditure was nearly five times higher than that in the public sector. Medicines accounted for 40% and 27% of public- and private-sector OOP hospitalisation expenditure, respectively.

CONCLUSION

Strengthening of public health facilities is required at community level for the prevention, control and management of NCDs. Promotion of generic medicines, better availability of essential drugs and possible subsidisation for the poorest quintile will be measures to consider to reduce OOP expenditure in public-sector facilities.

Diabetes mellitus and tuberculosis: programmatic management issues

In August 2011, the World Health Organization and the International Union Against Tuberculosis and Lung Disease launched the Collaborative Framework for Care and Control of Tuberculosis (TB) and diabetes mellitus (DM) to guide policy makers and implementers in combatting the epidemics of both diseases. Progress has been made, and includes identifying how best to undertake bidirectional screening for both diseases, how to provide optimal treatment and care for patients with dual disease and the most suitable framework for monitoring and evaluation. Key programmatic challenges include the following: whether screening should be directed at all patients or targeted at those with high-risk characteristics; the most suitable technologies for diagnosing TB and diabetes in routine settings; the best time to screen TB patients for DM; how to provide an integrated, coordinated approach to case management; and finally, how to persuade non-communicable disease programmes to adopt a cohort analysis approach, preferably using electronic medical records, for monitoring and evaluation. The link between DM and TB and the implementation of the collaborative framework for care and control have the potential to stimulate and strengthen the scale-up of non-communicable disease care and prevention programmes, which may help in reducing not only the global burden of DM but also the global burden of TB.

Does research through Structured Operational Research and Training (SORT IT) courses impact policy and practice?

SETTING

Structured Operational Research and Training Initiative (SORT IT) courses are well known for their output, with nearly 90% of participants completing the course and publishing in scientific journals.

OBJECTIVE

We assessed the impact of research papers on policy and practice that resulted from six SORT IT courses initiated between July 2012 and March 2013.

DESIGN

This was a cross-sectional study involving e-mail-based, self-administered questionnaires and telephone/skype/in-person responses from first and/or senior co-authors of course papers. A descriptive content analysis of the responses was performed and categorised into themes.

RESULTS

Of 72 participants, 63 (88%) completed the course. Course output included 81 submitted papers, of which 76 (94%) were published. Of the 81 papers assessed, 45 (55%) contributed to a change in policy and/or practice: 29 contributed to government policy/practice change (20 at national, 4 at subnational and 5 at hospital level), 11 to non-government organisational policy change and 5 to reinforcing existing policy. The changes ranged from modifications of monitoring and evaluation tools, to redrafting of national guidelines, to scaling up existing policies.

CONCLUSION

More than half of the SORT IT course papers contributed to a change in policy and/or practice. Future assessments should include more robust and independent verification of the reported change(s) with all stakeholders.

Research output after participants complete a Structured Operational Research and Training (SORT IT) course

Eighteen months after successfully completing one of six Structured Operational Research and Training Initiative (SORT IT) courses, e-mail questionnaires assessing post-course research output were returned by 63 participants (100% response rate). Thirty-two (51%) participants had completed new research projects, 24 (38%) had published papers, 28 (44%) had presented abstracts at conferences, 15 (24%) had facilitated at further OR courses, and 21 (33%) had reviewed scientific papers. Seven (11%) had secured further research funding and 22 (35%) stated that their institutions were involved in implementation or capacity building in operational research. Significant research output continues beyond course completion, further endorsing the value of the SORT IT model.

Mentorship for operational research capacity building: hands-on or hands-off?

Mentorship is a key feature of operational research training courses run by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières. During the recent South Pacific paper writing module, the faculty discussed 'hands-on' mentorship (direct technical assistance) vs. 'hands-off' mentorship (technical advice). This article explores the advantages and disadvantages of each approach. Our collective experience indicates that 'hands-on' mentorship is a valuable learning experience for the participant and a rewarding experience for the mentor. This approach increases the likelihood of successful course completion, including publishing a well written paper. However, mentors must allow participants to lead and take ownership of the paper, in keeping with a first author position.

Providing a gateway to prevention and care for the most at-risk populations in Bhutan: is this being achieved?

SETTING

Two free-standing urban human immunodeficiency virus (HIV) testing and counselling (HCT) centres in Bhutan offering services to the general population and targeting the most at-risk populations (MARPs).

OBJECTIVES

To assess the trend in testing for HIV, hepatitis B and syphilis in both the general population and MARPs, and to determine if sociodemographic and risk behaviour characteristics are associated with HIV, hepatitis B and syphilis seropositivity.

DESIGN

Cross-sectional study using client records, 2009 - 2012.

RESULTS

Of 7894 clients, 3009 (38%) were from the general population, while 4885 (62%) were from MARPs. Over the 4-year period, testing declined progressively among the general population, while it increased or remained static for MARPs. Of 4885 MARPs, seropositivity was respectively 0.7%, 1.3% and 1.2% for HIV, hepatitis B and syphilis. Female sex workers (FSWs) (relative risk [RR] 4.4, P = 0.03) and partners of person living with HIV (RR 25.9, P < 0.001) had a higher risk of being HIV-positive. FSWs had also a greater risk of being syphilis-positive (RR 9.1, P < 0.001).

CONCLUSION

The increase in uptake of HCT services by MARPs is a welcome finding; however, the relatively static trends call for the introduction of community outreach approaches. The critical gateway being provided to MARPs is an 'opportunity' for the expansion of the current service package.

Active and passive case detection strategies for the control of leishmaniasis in Bangladesh

SETTING

Two subdistricts in Bangladesh, Fulbaria and Trishal, which are hyperendemic for leishmaniasis.

OBJECTIVE

To determine 1) the numbers of patients diagnosed with visceral leishmaniasis (VL) and post-kala azar dermal leishmaniasis (PKDL) using an active case detection (ACD) strategy in Fulbaria and a passive case detection (PCD) strategy in Trishal, and 2) the time taken from symptoms to diagnosis in the ACD subdistrict.

DESIGN

A cross-sectional descriptive study of patients diagnosed from May 2010 to December 2011. The ACD strategy involved community education and outreach workers targeting households of index patients using symptom-based screening and rK-39 tests for suspected cases.

RESULTS

In the ACD subdistrict (Fulbaria) and PCD sub-district (Trishal), respectively 1088 and 756 residents were diagnosed with VL and 1145 and 37 with PKDL. In the ACD subdistrict, the median time to diagnosis for patients directly referred by outreach workers or self-referred was similar, at 60 days for VL and respectively 345 and 360 days for PKDL.

CONCLUSION

An ACD strategy at the subdistrict level resulted in an increased yield of VL and a much higher yield of PKDL. As PKDL acts as a reservoir for infection, a strategy of ACD and treatment can contribute to the regional elimination of leishmaniasis in the Indian sub-continent.

Measles in the Democratic Republic of Congo: an urgent wake-up call to adapt vaccination implementation strategies

All countries in Africa have made a commitment to eliminate measles by 2020. This is laudable, as measles elimination will have a crucial impact on reducing childhood mortality. An important operational challenge is the resurgence of measles outbreaks in a number of countries; one of the main reasons for this is that many children are being missed by vaccination programmes. In the Democratic Republic of Congo (DRC), outbreaks continue unabated despite repeated vaccination campaigns and high reported coverage by the Ministry of Health. This paper brings into question the effectiveness of the current approach and the need for better reflection on bottlenecks and strategies that can address this issue. If we are to eliminate measles by 2020, there will be a need for impetus, a need for decisive action to reach that goal and prevent unnecessary childhood deaths in countries such as the DRC.

Integrating tuberculosis and HIV services in rural Kenya: uptake and outcomes

SETTING

Seventeen rural public health facilities in Western Kenya that introduced three models of integrated care for tuberculosis (TB) and human immunodeficiency virus (HIV) patients.

OBJECTIVE

To assess the uptake and timing of cotrimoxazole preventive therapy (CPT) and antiretroviral treatment (ART) as well as anti-tuberculosis treatment outcomes among HIV-infected TB patients before (March-October 2010) and after (March-October 2012) the introduction of integrated TB-HIV care.

DESIGN

A before-and-after cohort study using programme data.

RESULTS

Of 501 HIV-infected TB patients, 357 (71%) were initiated on CPT and 178 (39%) on ART in the period before the introduction of integrated TB-HIV care. Following the integration of services, respectively 316 (98%) and 196 (61%) of 323 HIV-infected individuals were initiated on CPT and on ART (P < 0.001). The median time to CPT and ART initiation dropped from 7 to 2 days and from 42 to 34 days during the pre- and post-integration phases, respectively. Overall TB success rates did not vary with integration or with type of model instituted.

CONCLUSION

Integration of TB and HIV services enhanced uptake and reduced delay in instituting CPT and ART in rural health facilities. There is a need to increase impetus in these efforts.

Decline in adverse outcomes and death in tuberculosis patients in Malawi: association with HIV interventions

Between 2000 and 2012, the annual numbers of patients treated for tuberculosis (TB) in Malawi declined by 28%, from 28 234 to 20 463. During this time, the proportion of TB patients tested for the human immunodeficiency virus (HIV) increased from 6% to 87%. Most HIV-infected patients received cotrimoxazole preventive therapy, and the proportion receiving antiretroviral therapy increased to 88%. Between 2000 and 2008 there was a significant decline in all adverse outcomes (from 31% to 14%), and particularly in deaths (from 23% to 10%) and loss to follow-up (from 5.2% to 1.9%, P < 0.001). After 2008, there was no decrease in any adverse outcome. Ways to further reduce TB-associated mortality are discussed.

What happens after participants complete a Union-MSF structured operational research training course?

SETTING

Eight operational research (OR) courses run by the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins Sans Frontières (MSF) for participants from low- and middle-income countries. There is a knowledge gap about whether participants continue OR after course completion.

OBJECTIVES

To determine 1) the research output of participants and their institutions after course completion; 2) the influence of OR fellowships on output; and 3) the output of non-OR fellows stratified by sex, region and staff position.

DESIGN

A self-administered e-mail questionnaire survey.

RESULTS

Of 83 participants who completed a course, 76 (92%) responded to the questionnaire. Following course completion, 47 (62%) participants completed new research projects, 38 (50%) published papers (vs. 25 [33%] who had published before the course), 42 (55%) presented posters or oral abstracts at conferences, 33 (43%) facilitated at further OR courses, 29 (38%) reviewed scientific papers, 25 (33%) secured further OR funding and 55 (72%) said their institutions were involved in OR implementation or capacity building. OR fellows performed better than non-OR fellows. Among the latter, males and participants from Asia had better output than females and participants from Africa (P < 0.05).

CONCLUSION

The significant proportion of participants continuing to engage in OR after course completion provides encouraging evidence of the long-term value of this capacity building model.

High time to use rapid tests to detect multidrug resistance in sputum smear-negative tuberculosis in Belarus

SETTING

Belarus (Eastern Europe) is facing an epidemic of multidrug-resistant tuberculosis (MDR-TB). In 2012, rapid molecular diagnostics were prioritised for sputum smear-positive pulmonary tuberculosis (PTB) patients to diagnose MDR-TB, while pulmonary sputum smear-negative pulmonary TB (SN-PTB) patients were investigated using conventional methods, often delaying the diagnosis of MDR-TB by 2-4 months.

OBJECTIVE

To determine the proportion of MDR-TB among SN-PTB patients registered in 2012 and associated clinical and demographic factors.

DESIGN

Retrospective cohort study using countrywide data from the national electronic TB register.

RESULTS

Of the 5377 TB cases registered, 2960 (55%) were SN-PTB. Of the latter, 1639 (55%) were culture-positive, of whom 768 (47%) had MDR-TB: 33% (363/1084) were new and 73% (405/555) previously treated patients. Previous history of treatment, age, region, urban residence, human immunodeficiency virus (HIV) status and being a pensioner were independently associated with MDR-TB.

CONCLUSION

About half of culture-positive SN-PTB patients have MDR-TB and this rises to over 7/10 for retreatment cases. A national policy decision to extend rapid molecular diagnostics universally to all PTB patients, including SN-PTB, seems justified. Steps need to be taken to ensure implementation of this urgent priority, given the patient and public health implications of delayed diagnosis.

Retention in pre-antiretroviral treatment care in a district of Karnataka, India: how well are we doing?

SETTING

Antiretroviral treatment (ART) Centre in Tumkur district of Karnataka State, India. There is no published information about pre-ART loss to follow-up from India.

OBJECTIVE

To assess the proportion lost to follow-up (defined as not visiting the ART Centre within 1 year of registration) and associated socio-demographic and immunological variables.

DESIGN

Retrospective cohort study involving a review of medical records of adult HIV-infected persons (aged ⩾15 years) registered in pre-ART care during January 2010-June 2012.

RESULTS

Of 3238 patients registered, 2519 (78%) were eligible for ART, while 719 (22%) were not. Four of the latter were transferred out; the remaining 715 individuals were enrolled in pre-ART care, of whom 290 (41%) were lost to follow-up. Factors associated with loss to follow-up on multivariate analysis included age group ⩾45 years, low educational level, not being married, World Health Organization Stage III or IV and rural residence.

CONCLUSION

About four in 10 individuals in pre-ART care were lost to follow-up within 1 year of registration. This needs urgent attention. Routine cohort analysis in the national programme should include those in pre-ART care to enable improved review, monitoring and supervision. Further qualitative research to ascertain reasons for loss to follow-up is required to design future interventions.

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Open access for operational research publications from low- and middle-income countries: who pays?

Open-access journal publications aim to ensure that new knowledge is widely disseminated and made freely accessible in a timely manner so that it can be used to improve people's health, particularly those in low- and middle-income countries. In this paper, we briefly explain the differences between closed- and open-access journals, including the evolving idea of the 'open-access spectrum'. We highlight the potential benefits of supporting open access for operational research, and discuss the conundrum and ways forward as regards who pays for open access.

Sex, drugs and prisons: HIV prevention strategies for over 190 000 clients in Ukraine

SETTING

One hundred and forty non-governmental organisations implementing human immunodeficiency virus (HIV) prevention programmes among clients, including people who inject drugs, prisoners, female sex workers, men who have sex with men and street children in Ukraine, 2010-2011.

OBJECTIVE

Among enrolled clients, to assess factors associated with HIV testing, HIV retesting within a year of initial testing and HIV seroconversion.

DESIGN

Retrospective cohort study involving record reviews.

RESULTS

Of 192 487 clients, 42 109 (22%) underwent an initial HIV test (22% were positive). Among HIV-negative clients at baseline, 10 858 (27%) were retested within a year: 317 (3%) of these were HIV-positive. HIV testing and retesting rates were lower among prisoners (0.3%) and others (street children and partners of those in risk groups, 6%), and those who did not receive counselling or services such as condom and needle distribution. Individuals who were not counselled were more likely to seroconvert.

CONCLUSIONS

In this large cohort of high-risk groups from Eastern Europe, HIV testing was low and HIV sero-conversion was high. This is of public health concern, bringing into question the overall quality of counselling and how well it is tailored to the specific needs of various risk groups. Qualitative studies to understand the reasons for non-testing are urgently required for designing client-specific interventions.

Fostering interest in research: evaluation of an introductory research seminar at hospitals in rural Rwanda

SETTINGS

Partners In Health Rwanda, in collaboration with the Ministry of Health, leads a multipronged approach to develop research capacity among health workers, particularly in rural areas.

OBJECTIVES

To describe the characteristics of participants and to assess the impact of an introductory research seminar series in three district hospitals in rural Rwanda.

DESIGN

This was a retrospective cohort study of seminar participants. Data were sourced from personnel records, assessment sheets and feedback forms.

RESULTS

A total of 126 participants, including 70 (56%) clinical and 56 (44%) non-clinical staff, attended the research seminar series; 61 (48%) received certification. Among those certified, the median assessment score on assignments was 79%. Participants read significantly more articles at 6 and 12 months (median 2 and 4 respectively, compared to 1 at baseline, P < 0.01). There was also a significant increase (P ⩽ 0.05) in self-reported involvement in research studies (28%, baseline; 59%, 12 months) and attendance at other research training (36%, baseline; 65%, 12 months).

CONCLUSION

The introductory research seminar series provided an important opportunity for engagement in research among clinical and non-clinical staff. Such an activity is a key component of a comprehensive research capacity building programme at rural sites, and serves as an entry point for more advanced research training.

Severe acute maternal morbidity and associated deaths in conflict and post-conflict settings in Africa

SETTING

Five hospitals in four conflict and post-conflict countries (Democratic Republic of Congo, Somaliland, Sierra Leone and Burundi).

OBJECTIVES

To report among hospital deliveries: 1) the proportion of severe acute maternal morbidity (SAMM), 2) the pattern of SAMM, and 3) maternal deaths according to type of SAMM.

METHODS

An audit of data from a standardised database implemented in all the sites in the study.

RESULTS

Of the 18 675 deliveries, there were 6314 (34%) known SAMM cases with 63 associated deaths, implying that for every 100 SAMM cases there was one maternal death. In descending order, the death-to-SAMM ratios per 1000 deliveries were: 1:7 for sepsis, 6 for haemorrhage 1:70 for hypertensive disorder and 1:398 for obstructed labour. A substantial proportion of deaths (38%) that occurred in hospitals could not be categorised into the standardised SAMM conditions available in the database.

CONCLUSION

As this is the first study using multi-centre data from conflict and post-conflict countries, these findings are relevant to improving maternal health in such settings. Findings, implications and possible ways forward in addressing various challenges are discussed.

Is transcription of data on antiretroviral treatment from electronic to paper-based registers reliable in Malawi?

SETTING

Antiretroviral treatment (ART) clinics at one central hospital, three district hospitals and one mission hospital in the central and southern regions of Malawi.

OBJECTIVE

To measure the extent of inaccuracies in the transcription of case registration and recorded deaths between electronic medical data (EMR) and paper registers. This was done to inform the Ministry of Health on the reliability of the paper-based system as backup in case of EMR failure.

DESIGN

Retrospective analysis of routine programme data.

RESULTS

A total of 31 763 registrations and 2922 deaths in the EMR were compared with those in the paper registers. In one hospital, up to 24% of overall case registrations were missing from the paper registers. At other sites, the differences were minor and included duplicate patients who should have been classified as 'transfer in' patients in the paper register. There were major differences in the number of registered deaths in two of the five facilities.

CONCLUSION

There are varying degrees of agreement between the EMR and paper registers which compromise the use of the latter as a backup solution in case of EMR failure. The reasons for this unreliability and ways forward to address the problem are discussed.

Operational research capacity building in Asia: innovations, successes and challenges of a training course

A structured training course on operational research (OR) based on the model created by the International Union Against Tuberculosis and Lung Disease and Médecins Sans Frontières was conducted in the South Asian region in 2012. Many innovations were introduced into the administration, structure and content of the course. Of 12 participants, 11 successfully completed all pre-defined milestones. Several challenges were identified. The main challenges included shortage of time, especially for data analysis and interpretation, and insufficient numbers of experienced facilitators. Appropriate modifications have been made to the structure and processes of the next course scheduled for 2013. We describe these modifications and the innovations, successes and challenges of this model of training.

Are sputum samples of retreatment tuberculosis reaching the reference laboratories? A 9-year audit in Tanzania

SETTING

One reference and three zonal laboratories and 500 health facilities managing retreatment tuberculosis (TB) patients in Tanzania.

OBJECTIVES

The National Tuberculosis and Leprosy Programme (NTLP) requires that all notified cases of retreatment TB in Tanzania have sputum samples sent for culture and drug susceptibility testing (DST). This study determined 1) if the number of annually notified retreatment patients corresponded to the number of sputum samples received by the reference laboratories, and 2) the number of culture-positive samples and the number of cases undergoing DST.

DESIGN

Nine-year audit of country-wide programme data from 2002 to 2010.

RESULTS

Of the 40 940 retreatment TB patients notified by the NTLP, 3871 (10%) had their sputum samples received at the reference and zonal laboratories for culture and DST. A total of 3761 (97%) sputum samples were processed for culture, of which 1589 (42%) were found to be culture-positive and 1415 (89%) had DST performed.

CONCLUSIONS

There is a >90% shortfall between notified retreatment cases and numbers of sputum samples received, cultured and assessed for DST at reference and zonal laboratories. Steps needed to address this problem are discussed.

Countrywide audit of multidrug-resistant tuberculosis and treatment outcomes in Mongolia

SETTING

Eighteen treatment units for multidrug-resistant tuberculosis (MDR-TB) in Mongolia.

OBJECTIVE

To determine the total number of MDR-TB cases detected, their resistance patterns, the proportion and characteristics of cases starting treatment, the delay between diagnosis and treatment initiation, and the relation between treatment outcomes and drug resistance.

DESIGN

Retrospective cohort study using routine programme data.

RESULTS

Of 268 MDR-TB cases detected, 168 (63%) were resistant to HRES, 59 (22%) to HRS, 34 (13%) to HR and 7 (3%) to HRE. Of the 268 MDR-TB patients, 139 (52%) started treatment: 69 (50%) were secondary and/or university students, 35 (25%) were unemployed, 24 (17%) were currently employed and 14 (8%) retired, disabled or status was unrecorded. The median time from MDR-TB diagnosis to treatment initiation was 137 days (IQR 43-218). The treatment success rate was 69%; 9% failed treatment, which may indicate extensively drug-resistant TB (XDR-TB) or pre-XDR-TB.

CONCLUSION

Close to seven in 10 patients in Mongolia had a successful treatment outcome, which is encouraging. Specific problems included the high proportion of students, about half of all diagnosed patients accessed treatment and there was an unacceptable delay of 4 months to treatment. These issues need to be addressed.