Using timeliness metrics for household contact tracing and TB preventive therapy in the private sector, India

BACKGROUND

Although screening of household contacts (HHCs) of TB patients and provision of TB preventive therapy (TPT) is a key intervention to end the TB epidemic, their implementation globally is dismal. We assessed whether introducing a '7-1-7' timeliness metric was workable for implementing HHC screening among index patients with pulmonary TB diagnosed by private providers in Chennai, India, between November 2022 and March 2023.

METHODS

This was an explanatory mixed-methods study (quantitative-cohort and qualitative-descriptive).

RESULTS

There were 263 index patients with 556 HHCs. In 90% of index patients, HHCs were line-listed within 7 days of anti-TB treatment initiation. Screening outcomes were ascertained in 48% of HHCs within 1 day of line-listing. Start of anti-TB treatment, TPT or a decision to receive neither was achieved in 57% of HHC within 7 days of screening. Overall, 24% of screened HHCs in the '7-1-7' period started TPT compared with 16% in a historical control (P < 0.01). Barriers to achieving '7-1-7' included HHC reluctance for evaluation or TPT, refusal of private providers to prescribe TPT and reliance on facility-based screening of HHCs instead of home visits by health workers for screening.

CONCLUSIONS

Introduction of a timeliness metric is a workable intervention that adds structure to HHC screening and timely management..

Incidence of healthcare-associated infections with invasive devices and surgical procedures in Nepal

SETTING

Dhulikhel Hospital, Kathmandu University Hospital, Kathmandu, Nepal.

OBJECTIVES

1) To report the incidence of health-care-associated infections (HAIs), 2) to compare demographic, clinical characteristics and hospital outcomes in those with and without HAIs; and 3) to verify bacterial types in HAI and community-acquired infections (CAIs) among inpatients with invasive devices and/or surgical procedures.

DESIGN

This was a cohort study using secondary data (December 2017 to April 2018).

RESULTS

Of 1,310 inpatients, 908 (69.3%) had surgical procedures, 125 (9.5%) had invasive devices and 277 (21.1%) both. Sixty-six developed HAIs (incidence = 5/100 patient admissions, 95% CI 3.9-6.3). Individuals with HAIs had a 5.5-fold higher risk of longer hospital stays (⩾7 days) and a 6.9-fold risk of being in intensive care compared to the surgical ward. Unfavourable hospital exit outcomes were higher in those with HAIs (4.5%) than in those without (0.9%, P = 0.02). The most common HAI bacteria (n = 70) were Escherichia coli (44.3%), Enterococcus spp. (22.9%) and Klebsiella spp. (11.4%). Of 98 CAIs with 41 isolates, E. coli (36.6%), Staphylococcus aureus (22.0%) and methicillin-resistant S. aureus (14.6%) were common.

CONCLUSION

We found relatively low incidence of HAIs, which reflects good infection prevention and control standards. This study serves as a baseline for future monitoring and action.

Antibiotic resistance in patients with chronic ear discharge awaiting surgery in Nepal

SETTING

Biratnagar Eye Hospital, Biratnagar, Nepal, which offers ear surgery for chronic suppurative otitis media (CSOM).

OBJECTIVE

In patients with CSOM awaiting surgery, to determine the 1) sociodemographic characteristics 2) bacterial isolates and their antibiotic resistance patterns and 3) characteristics of those refused surgery, including antibiotic resistance.

DESIGN

A cohort study using hospital data, January 2018-January 2020.

RESULTS

Of 117 patients with CSOM and awaiting surgery, 64% were in the 18-35 years age group, and 79% were cross-border from India. Of 118 bacterial isolates, 80% had Pseudomonas aeruginosa and 16% had Staphylococcus aureus. All isolates showed multidrug resistance to nine of the 12 antibiotics tested. The lowest antibiotic resistance in P. aeruginosa was for vancomycin (29%) and moxifloxacin (36%), and for S. aureus, this was vancomycin (9%) and amikacin (17%). Fourteen (12%) patients underwent surgery: myringoplasty (n = 7, 50%), cortical mastoidectomy with tympanostomy (n = 4, 29%) and modified radical mastoidectomy (n = 3, 21%). Those infected with P. aeruginosa and with resistance to over six antibiotics were significantly more likely to be refused for surgery.

CONCLUSION

Patients awaiting ear surgery were predominantly infected with multidrug-resistant P. aeruginosa and were consequently refused surgery. This study can help inform efforts for improving surgical uptake and introducing cross-border antimicrobial resistance surveillance.

How can integrated care and research assist in achieving the SDG targets for diabetes, tuberculosis and HIV/AIDS?

Integrating the management and care of communicable diseases, such as tuberculosis (TB) and human immunodeficiency virus/acquired immune-deficiency syndrome (HIV/AIDS), and non-communicable diseases, particularly diabetes mellitus (DM), may help to achieve the ambitious health-related targets of the Sustainable Development Goals (SDG 3.3 and 3.4) by 2030. There are five important reasons to integrate. First, we need to integrate to prevent disease. In sub-Saharan Africa, in particular, HIV infection is the main driver of the TB epidemic, and antiretroviral therapy combined with isoniazid preventive therapy (IPT) can reduce TB case notification rates. In Asia, DM is another important driver of the TB epidemic, and preventing or controlling DM can reduce the risk of TB. Second, we need to integrate to diagnose cases. Between a third to a half of those living with HIV, TB or DM do not know they have the disease, and bi-directional screening, whereby TB patients are screened for HIV and DM or people living with HIV and DM are screened for TB, can help to identify these 'missing cases'. Third, we need to integrate to better treat and manage patients who have a combination of two or more of these diseases, so that treatment success and retention on treatment can be optimised. Fourth, we should integrate to ensure better infection control practices for both TB and HIV infection in health facilities and congregate settings, such as prisons. Finally, we should integrate and learn how to monitor, record and report, particularly in relation to the cascade of events implicit in the HIV/AIDS and TB 90-90-90 targets.

Building the capacity of public health programmes to become data rich, information rich and action rich

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

Setting and objectives: Tobacco use compromises tuberculosis (TB) treatment outcomes. Tobacco cessation is beneficial to TB patients at the individual level and from the perspective of a larger spectrum of non-communicable diseases associated with tobacco use. We assessed feasibility, effectiveness and provider perceptions on integrating brief tobacco cessation advice into routine TB care by DOTS providers from 27 TB treatment centres run by three non-governmental organisations (NGOs) in urban India. Design: A mixed-methods study (triangulation design) involving analysis of programme data and semi-structured interviews (quantitative) and thematic analysis of focus group discussions of TB treatment providers (qualitative) regarding brief advice and cessation support provided to self-reported tobacco users from August 2015 to July 2017. Results: All 27 centres initiated tobacco cessation. Of 2132 registered TB patients, 377 (18%) were tobacco users, 333 (88%) of whom used smokeless tobacco. There was a progressive drop in documentation of tobacco status at each visit, reaching respectively 36% and 30% at the end of treatment for new and retreatment TB patients. Seven-day point prevalence abstinence at 6 months was 32% among new and 15% among retreatment cases. Enablers for integration included NGO collaboration, supervision and capacity building. Challenges included providers spending 15-45 min per patient (10 min recommended), multiple addictions, documentation load, self-reporting and social normalisation of tobacco. Conclusions: Integration of tobacco cessation into routine TB care in an urban NGO setting was feasible, although without continued support, rigour in documentation declined. This should be scaled up with special attention paid to tackling smokeless tobacco and related operational challenges.

From diagnosis to case investigation for malaria elimination in Swaziland: is reporting and response timely?

Background: Swaziland is one of the southern African countries that aim to eliminate malaria by 2020. In 2010, the country introduced an Immediate Disease Notification System (IDNS) for immediate reporting of notifiable diseases, including malaria. Health facilities are to report malaria cases within 24 h through a toll-free telephone number (977), triggering an alert for case investigation at the patient's household within 48 h. We assessed the completeness of reporting in the IDNS, the subsequent case investigation, and whether it was done within the stipulated timelines. Methods: A cross-sectional study using routine country-wide data. Results: Of 1991 malaria cases notified between July 2011 and June 2015, 76% were reported in the IDNS, of which 68% were investigated-a shortfall of 24% in reporting and 32% in case investigations. Of the 76% of cases reported through the IDNS, 62% were reported within 24 h and 20% were investigated within 48 h. These shortcomings were most pronounced in hospitals and private facilities. Investigated cases (n = 1346) were classified as follows: 60% imported, 35% local and 5% undetermined. Conclusion: The utilisation of the IDNS for case reporting to trigger investigation is crucial for active surveillance. There is a need to address the reporting and investigation gaps identified to ensure that malaria cases receive appropriate interventions.

Three parallel information systems for malaria elimination in Swaziland, 2010-2015: are the numbers the same?

Background: To be able to eliminate malaria, accurate, timely reporting and tracking of all confirmed malaria cases is crucial. Swaziland, a country in the process of eliminating malaria, has three parallel health information systems. Design: This was a cross-sectional study using country-wide programme data from 2010 to 2015. Methods: The Malaria Surveillance Database System (MSDS) is a comprehensive malaria database, the Immediate Disease Notification System (IDNS) is meant to provide early warning and trigger case investigations to prevent onward malaria transmission and potential epidemics, and the Health Management Information Systems (HMIS) reports on all morbidity at health facility level. Discrepancies were stratified by health facility level and type. Results: Consistent over-reporting of 9-85% was noticed in the HMIS, principally at the primary health care level (clinic and/or health centre). In the IDNS, the discrepancy went from under-reporting (12%) to over-reporting (32%); this was also seen at the primary care level. At the hospital level, there was under-reporting in both the HMIS and IDNS. Conclusions: There are considerable discrepancies in the numbers of confirmed malaria cases in the HMIS and IDNS in Swaziland. This may misrepresent the malaria burden and delay case investigation, predisposing the population to potential epidemics. There is an urgent need to improve data integrity in order to guide and evaluate efforts toward elimination.

Driving towards malaria elimination in Botswana by 2018: progress on case-based surveillance, 2013-2014

Background: Reliable information reporting systems ensure that all malaria cases are tested, treated and tracked to avoid further transmission. Botswana aimed to eliminate malaria by 2018, and surveillance is key. This study focused on assessing the uptake of the new malaria case-based surveillance (CBS) system introduced in 2012, which captures information on malaria cases reported in the Integrated Disease Surveillance and Response (IDSR) system. Methods: This was a retrospective descriptive study based on routine data focusing on Ngami, Chobe and Okavango, three high-risk districts in Botswana. Aggregated data variables were extracted from the IDSR and compared with data from the CBS. Results: The IDSR reported 456 malaria cases in 2013 and 1346 in 2014, of which respectively only 305 and 884 were reported by the CBS. The CBS reported 34% fewer cases than the IDSR system, indicating substantial differences between the two systems. The key malaria indicators with the greatest variability among the districts included in the study were case identification number and date of diagnosis. Conclusion: The IDSR and CBS systems are essential for malaria elimination, as shown by the significant gaps in reporting between the two systems. These findings highlight the need for further investigation into these discrepancies. Strengthening the CBS system will help to reach the objective of malaria elimination in Botswana.

Low uptake of preventive interventions among malaria cases in Swaziland: towards malaria elimination

Settings: Swaziland is striving to achieve sustainable malaria elimination. Three preventive interventions are vital for reaching this goal: 1) effective household utilisation of long-lasting insecticide nets (LLINs), 2) indoor residual spraying (IRS), and 3) provision of chemoprophylaxis for those travelling to malaria-endemic areas. Objectives: To assess the uptake of preventive intervention among confirmed malaria cases. Design: A longitudinal study using nation-wide programme data from 2010 to 2015. Data on malaria cases from health facilities were sourced from the Malaria Surveillance Database System. Results: Of a total 2568 confirmed malaria cases in Swaziland, 2034 (79%) had complete data on case investigations and were included in the analysis. Of 341 (17%) individuals who owned LLINs, 169 (8%) used them; 338 (17%) had IRS and 314 (15%) slept in sprayed structures. Of 1403 travellers to areas at high malaria risk, 59 (4%) used any form of malaria prevention, including chemoprophylaxis. Conclusion: The uptake of all three key malaria prevention interventions is low, and could threaten the progress made thus far toward malaria elimination. Efforts to improve this situation, including qualitative research to understand the reasons for low uptake, are urgently needed.

Ending tuberculosis by 2030: can we do it?

The Sustainable Development Goals aim to end tuberculosis (TB) related deaths, transmission and catastrophic costs by 2030. Multisectorial action to accelerate socio-economic development, a new vaccine and novel diagnostics and medicines for treatment are key advances needed to end TB transmission. Achieving 90-90-90 targets for TB (i.e., 90% of vulnerable populations screened, 90% diagnosed and started on treatment, and at least 90% cured) will help accelerate progress towards reductions in mortality; however, passive case detection strategies, multidrug-resistant TB, human immunodeficiency virus coinfection and outdated pathways to care need to be overcome. Ending the catastrophic costs associated with TB will require expansion of health insurance coverage, comprehensive coverage of TB services, and limited indirect costs by vulnerable and poor populations.

Tuberculosis among migrants in Bishkek, the capital of the Kyrgyz Republic

Setting: Twenty-two first-line, two second-line and one tertiary health facility in Bishkek, the capital of Kyrgyzstan. Objectives: Among migrants, a marginalised population at risk for acquiring and transmitting tuberculosis (TB), we determined the proportion with TB among all registered TB cases. For those registered at primary-level facilities, we then reported on their demographic and clinical profiles and TB treatment outcomes. Design: This was a retrospective cohort analysis of 2012-2013 programme data. Results: Of 2153 TB patients registered in all health facilities, 969 (45%) were migrants, of whom 454 were registered in first-line facilities. Of these, 27% were cross-border migrants, 50% had infectious TB and 12% had drug-resistant TB. Treatment success was 74% for new cases and 44% for retreatment TB (the World Health Organization target is ⩾85%). Failure in new and retreatment TB patients was respectively 8% and 25%. Twenty-six individuals started on a first-line anti-tuberculosis regimen failed due to multidrug-resistant TB. Eight (25%) of 32 individuals on a retreatment TB regimen also failed. Loss to follow-up was 10% for new and 19% for retreatment TB. Conclusion: Migrants constituted almost half of all TB patients, drug resistance is prevalent and treatment outcomes unsatisfactory. Fostering inter-country collaboration and prioritising rapid TB diagnostics (Xpert^® MTB/RIF) and innovative ways forward for improving treatment outcomes is urgent.

Influence of the 2014-2015 Ebola outbreak on the vaccination of children in a rural district of Guinea

Setting: All health centres in Macenta District, rural Guinea. Objective: To compare stock-outs of vaccines, vaccine stock cards and the administration of various childhood vaccines across the pre-Ebola, Ebola and post-Ebola virus disease periods. Design: This was an ecological study. Results: Similar levels of stock-outs were observed for all vaccines (bacille Calmette-Guérin [BCG], pentavalent, polio, measles, yellow fever) in the pre-Ebola and Ebola periods (respectively 2760 and 2706 facility days of stock-outs), with some variation by vaccine. Post-Ebola, there was a 65-fold reduction in stock-outs compared to pre-Ebola. Overall, 24 facility-months of vaccine stock card stock-outs were observed during the pre-Ebola period, which increased to 65 facility-months of stock-outs during the Ebola outbreak period; no such stock-out occurred in the post-Ebola period. Apart from yellow fever and measles, vaccine administration declined universally during the peak outbreak period (August-November 2014). Complete cessation of vaccine administration for BCG and a prominent low for polio (86% decrease) were observed in April 2014, corresponding to vaccine stock-outs. Post-Ebola, overall vaccine administration did not recover to pre-Ebola levels, with the highest gaps seen in polio and pentavalent vaccines, which had shortages of respectively 40% and 38%. Conclusion: These findings highlight the need to sustain vaccination activities in Guinea so that they remain resilient and responsive, irrespective of disease outbreaks.

Management of malaria in children with fever in rural Sierra Leone in relation to the 2014-2015 Ebola outbreak

Setting: Sixty-eight primary health facilities, Koinadugu District, rural Sierra Leone. Objectives: Sierra Leone, a country with one of the highest burdens of malaria, was severely affected by the 2014-2015 Ebola virus disease outbreak. In under-five children, we compared trends in the completeness of malaria reports sent to the district office during the pre-Ebola, Ebola and post-Ebola periods, including the number of children with reported fever, malaria diagnostic testing performed and treatment for malaria initiated with artemisinin-based combination therapy (ACT). Design: A cross-sectional study. Results: Of 1904 expected malaria reports, 1289 (68%) were received. Completeness of reporting was 61% pre-Ebola, increased to 88% during the outbreak and dropped to 44% post-Ebola (P = 0.003). Total malaria testing (n = 105 558) exceeded the number of fever cases (n = 105 320). Pre-Ebola, 75% (n = 43 245) of all reported fever cases received malaria treatment, dropping to 34% (n = 50 453) during the Ebola outbreak. Of 36 804 confirmed malaria cases during Ebola, 17 438 (47%) were treated, significantly fewer than in the pre-Ebola period (96%, P < 0.001). Of the fever cases, 95% in both the pre- and post-Ebola periods received ACT, a rate that increased to 99% during the Ebola outbreak. Conclusion: Pre-existing gaps in malaria reporting worsened after the Ebola outbreak. Reassuringly, malaria testing matched fever cases, although only half of all confirmed cases received treatment during the outbreak, possibly explained by outbreak-related operational difficulties. These findings could be useful to guide health systems strengthening and recovery.

Paediatric care in relation to the 2014-2015 Ebola outbreak and general reporting of deaths in Sierra Leone

Setting: All peripheral health units countrywide in Sierra Leone and one hospital in Port Loko. Objectives: Sierra Leone was severely affected by the 2014-2015 Ebola outbreak, whose impact on paediatric care and mortality reports merits assessment. We sought to compare the periods before, during and after the Ebola outbreak, the countrywide trend in morbidities in children aged < 5 years and exit outcomes in one district hospital (Port Loko). During the Ebola outbreak period, gaps in district death reporting within the routine Health Management Information System (HMIS) were compared with the Safe and Dignified Burials (SDB) database in Port Loko. Design: This was a retrospective records analysis. Results: The average number of monthly consultations during the Ebola outbreak period declined by 27% for malaria and acute respiratory infections and 38% for watery diarrhoea, and did not recover to the pre-Ebola levels. For measles, there was an 80% increase during Ebola, which multiplied by 6.5-fold post-Ebola. The number of unfavourable hospital exit outcomes was 52/397 (13%) during Ebola, which was higher than pre-Ebola (47/496, 9%, P = 0.04). Of 6565 deaths reported in the Port Loko SDB database, only 2219 (34%) appeared in the HMIS, a reporting deficit of 66%. Conclusion: The Ebola disease outbreak was associated with reduced utilisation of health services, and appears to have triggered a measles epidemic. Almost 70% of deaths were missed by the HMIS during the Ebola outbreak period. These findings could guide health system responses in future outbreaks.

The Ebola outbreak and staffing in public health facilities in rural Sierra Leone: who is left to do the job?

Setting: The 82 public health facilities of rural Kailahun District, Sierra Leone. Objective: The 2014-2015 Ebola virus disease outbreak in Sierra Leone led the Ministry of Health and Sanitation and stakeholders to set minimum standards of staffing (medical/non-medical) for a basic package of essential health services (BPEHS). No district-level information exists on staffing levels in relation to the Ebola outbreak. We examined the staffing levels before the Ebola outbreak, during the last month of the outbreak and 4 months after the outbreak, as well as Ebola-related deaths among health care workers (HCWs). Design: This was a retrospective cross-sectional study. Results: Of 805 recommended medical staff (the minimum requirement for 82 health facilities), there were deficits of 539 (67%) pre-Ebola, 528 (65%) during the Ebola outbreak and 501 (62%) post-Ebola, hovering at staff shortages of >50% at all levels of health facilities. Of the 569 requisite non-medical staff, the gap remained consistent, at 92%, in the three time periods. Of the 1374 overall HCWs recommended by the BPEHS, the current staff shortage is 1026 (75%). Of 321 facility-based HCWs present during Ebola, there were 15 (14 medical and one non-medical staff) Ebola-related and three non-Ebola related deaths among HCWs. Conclusion: The post-Ebola health-related human resource deficit is alarmingly high, with very few staff available to work. We call for urgent political will, resources and international collaboration to address this situation.

Ten tips to improve the visibility and dissemination of research for policy makers and practitioners

Effective dissemination of evidence is important in bridging the gap between research and policy. In this paper, we list 10 approaches for improving the visibility of research findings, which in turn will hopefully contribute towards changes in policy. Current approaches include using social media (Facebook, Twitter, LinkedIn); sharing podcasts and other research outputs such as conference papers, posters, presentations, reports, protocols, preprint copy and research data (figshare, Zenodo, Slideshare, Scribd); and using personal blogs and unique author identifiers (ORCID, ResearcherID). Researchers and funders could consider drawing up a systematic plan for dissemination of research during the stage of protocol development.

Do incentivised community workers in informal settlements influence maternal and infant health in urban India?

Setting: The introduction of accredited social health activists (ASHAs, community workers) in the community is encouraged by the Government of India as being of universal benefit for maternal and infant health. Objectives: In two informal settlements in Chandigarh, India, one with ASHAs and the other without, we assessed 1) whether ASHAs influenced certain selected maternal and infant health indicators, and 2) perceptions among women who did not contact the ASHAs. Design: This was a mixed-methods study conducted from April 2013 to March 2016 using quantitative (retrospective programme data) and qualitative (free-listing) components. Results: The increase in institutional deliveries from 2013 to 2015 was marginal, and was similar in both areas (86-99% in the settlement with ASHAs and 88-97% in the settlement without). Bacille Calmette-Guérin and pentavalent vaccination coverage were close to 100% in both areas during the 3 years of the study. Antenatal registration in the first trimester increased from 49% to 52% in the settlement with ASHAs and from 53% to 71% in the settlement without. Between 18% and 35% of women did not complete at least three antenatal visits. 'Not knowing ASHAs' and 'not feeling a need for ASHAs' were the main reasons for not using their services. Conclusion: While success has been achieved for institutional deliveries and immunisation coverage even without the ASHAs, their presence plays an important role in improving antenatal indicators.

How do low-birthweight neonates fare 2 years after discharge from a low-technology neonatal care unit in a rural district hospital in Burundi?

OBJECTIVES

As neonatal care is being scaled up in economically poor settings, there is a need to know more on post-hospital discharge and longer-term outcomes. Of particular interest are mortality, prevalence of developmental impairments and malnutrition, all known to be worse in low-birthweight neonates (LBW, <2500 g). Getting a better handle on these parameters might justify and guide support interventions. Two years after hospital discharge, we thus assessed: mortality, developmental impairments and nutritional status of LBW children.

METHODS

Household survey of LBW neonates discharged from a neonatal special care unit in Rural Burundi between January and December 2012.

RESULTS

Of 146 LBW neonates, 23% could not be traced and 4% had died. Of the remaining 107 children (median age = 27 months), at least one developmental impairment was found in 27%, with 8% having at least five impairments. Main impairments included delays in motor development (17%) and in learning and speech (12%). Compared to LBW children (n = 100), very-low-birthweight (VLBW, <1500 g, n = 7) children had a significantly higher risk of impairments (intellectual - P = 0.001), needing constant supervision and creating a household burden (P = 0.009). Of all children (n-107), 18% were acutely malnourished, with a 3½ times higher risk in VLBWs (P = 0.02).

CONCLUSIONS

Reassuringly, most children were thriving 2 years after discharge. However, malnutrition was prevalent and one in three manifested developmental impairments (particularly VLBWs) echoing the need for support programmes. A considerable proportion of children could not be traced, and this emphasises the need for follow-up systems post-discharge.

Emergency obstetric care in a rural district of Burundi: What are the surgical needs?

OBJECTIVES

In a rural district hospital in Burundi offering Emergency Obstetric care-(EmOC), we assessed the a) characteristics of women at risk of, or with an obstetric complication and their types b) the number and type of obstetric surgical procedures and anaesthesia performed c) human resource cadres who performed surgery and anaesthesia and d) hospital exit outcomes.

METHODS

A retrospective analysis of EmOC data (2011 and 2012).

RESULTS

A total of 6084 women were referred for EmOC of whom 2534(42%) underwent a major surgical procedure while 1345(22%) required a minor procedure (36% women did not require any surgical procedure). All cases with uterine rupture(73) and extra-uterine pregnancy(10) and the majority with pre-uterine rupture and foetal distress required major surgery. The two most prevalent conditions requiring a minor surgical procedure were abortions (61%) and normal delivery (34%). A total of 2544 major procedures were performed on 2534 admitted individuals. Of these, 1650(65%) required spinal and 578(23%) required general anaesthesia; 2341(92%) procedures were performed by 'general practitioners with surgical skills' and in 2451(96%) cases, anaesthesia was provided by nurses. Of 2534 hospital admissions related to major procedures, 2467(97%) were discharged, 21(0.8%) were referred to tertiary care and 2(0.1%) died.

CONCLUSION

Overall, the obstetric surgical volume in rural Burundi is high with nearly six out of ten referrals requiring surgical intervention. Nonetheless, good quality care could be achieved by trained, non-specialist staff. The post-2015 development agenda needs to take this into consideration if it is to make progress towards reducing maternal mortality in Africa.

Ebola, fragile health systems and tuberculosis care: a call for pre-emptive action and operational research

The Ebola outbreak that started in late 2013 is by far the largest and most sustained in history. It occurred in a part of the world where pre-existing health systems were already fragile, and these deteriorated further during the epidemic due to a large number of health worker deaths; temporary or permanent closure of health facilities; non-payment of health workers; intrinsic fear of contracting or being stigmatised by Ebola among the population, which negatively influenced health-seeking behaviour; enforced quarantine of Ebola-affected communities, restricting the access of vulnerable individuals to health facilities; and late response by the international community. There are also reports of drug and consumable stockouts due to deficiencies in the procurement and supply chain as a result of overriding Ebola-related priorities. Providing tuberculosis (TB) care and achieving favourable treatment outcomes require a fully functioning health system, accurate patient tracking and high patient adherence to treatment. Furthermore, as Ebola is easily transmitted through body fluids, the use of needles-essential for TB diagnosis and treatment-needs to be avoided during an outbreak. We highlight ways in which a sustained Ebola outbreak could jeopardise TB activities and suggest pre-emptive preventive measures while awaiting operational research evidence.

Caesarean sections in rural Burundi: how well are mothers doing two years on?

SETTING

A caesarean section (C-section) is a life-saving emergency intervention. Avoiding pregnancies for at least 24 months after a C-section is important to prevent uterine rupture and maternal death.

OBJECTIVES

Two years following an emergency C-section, in rural Burundi, we assessed complications and maternal death during the post-natal period, uptake and compliance with family planning, subsequent pregnancies and their maternal and neonatal outcomes.

METHODS

A household survey among women who underwent C-sections.

RESULTS

Of 156 women who underwent a C-section, 116 (74%) were traced; 1 had died of cholera, 8 had migrated and 31 were untraceable. Of the 116 traced, there were no post-operative complications and no deaths. At hospital discharge, 83 (72%) women accepted family planning. At 24 months after hospital discharge (n = 116), 23 (20%) had delivered and 17 (15%) were pregnant. Of the remaining 76 women, 48 (63%) were not on family planning. The main reasons for this were religion or husband's non-agreement. Of the 23 women who delivered, there was one uterine rupture, no maternal deaths and three stillbirths.

CONCLUSIONS

Despite encouraging maternal outcomes, this study raises concerns around the effectiveness of current approaches to promote and sustain family planning for a minimum of 24 months following a C-section. Innovative ways of promoting family planning in this vulnerable group are urgently needed.

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.