Center for Operational Research

Paris, France

Center for Operational Research

Paris, France
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Kalua T.,Malawi Ministry of Health HIV | Barr B.A.T.,Centers for Disease Control and Prevention | Van Oosterhout J.J.,Dignitas International | Van Oosterhout J.J.,University of Malawi | And 13 more authors.
Journal of Acquired Immune Deficiency Syndromes | Year: 2017

The acceleration of prevention of mother-to-child transmission (PMTCT) activities, coupled with the rollout of 2010 World Health Organization (WHO) guidelines, led to important discussions and innovations at global and country levels. One paradigm-shifting innovation was Option B+ in Malawi. It was later included in WHO guidelines and eventually adopted by all 22 Global Plan priority countries. This article presents Malawi's experience with designing and implementing Option B+ and provides complementary narratives from Cameroon and Tanzania. Malawi's HIV program started in 2002, but by 2009, the PMTCT program was lagging far behind the antiretroviral therapy (ART) program because of numerous health system challenges. When WHO recommended Option A and Option B for PMTCT in 2010, it was clear that Malawi's HIV program would not be able to successfully implement either option without increasing existing barriers to PMTCT services and potentially decreasing women's access to care. Subsequent stakeholder discussions led to the development of Option B+. Operationalizing Option B+ required several critical considerations, including the complete integration of ART and PMTCT programs, systematic reduction of barriers to facilitate doubling the number of ART sites in less than a year, building consensus with stakeholders, and securing additional resources for the new program. During the planning and implementation process, several lessons were learned which are considerations for countries transitioning to "treat-all": Comprehensive change requires effective government leadership and coordination; national clinical guidelines must accommodate health system limitations; ART services and commodities should be decentralized within facilities; the general public should be well informed about major changes in the national HIV program; and patients should be educated on clinic processes to improve program monitoring. © 2017 Wolters Kluwer Health, Inc. All rights reserved.


Mauch V.,Radboud University Nijmegen | Mauch V.,KNCV Tuberculosis Foundation | Bonsu F.,National TB Control Programme | Gyapong M.,Dodowa Health Research Center Ghana Health | And 9 more authors.
International Journal of Tuberculosis and Lung Disease | Year: 2013

SETTING: The National Tuberculosis Programs of Ghana, Viet Nam and the Dominican Republic. OBJECTIVE: To assess the direct and indirect costs of tuberculosis (TB) diagnosis and treatment for patients and households. DESIGN: Each country translated and adapted a structured questionnaire, the Tool to Estimate Patients' Costs. A random sample of new adult patients treated for at least 1 month was interviewed in all three countries. RESULTS: Across the countries, 27-70% of patients stopped working and experienced reduced income, 5-37% sold property and 17-47% borrowed money due to TB. Hospitalisation costs (US$42-118) and additional food items formed the largest part of direct costs during treatment. Average total patient costs (US$538-1268) were equivalent to approximately 1 year of individual income. CONCLUSION: We observed similar patterns and challenges of TB-related costs for patients across the three countries. We advocate for global, united action for TB patients to be included under social protection schemes and for national TB programmes to improve equitable access to care. © 2013 The Union.


PubMed | Hanoi Medical University, National Tuberculosis Control Programme Viet Nam, Ministry of Health and Center for Operational Research
Type: Journal Article | Journal: Western Pacific surveillance and response journal : WPSAR | Year: 2016

Extensively drug-resistant tuberculosis (XDR-TB) represents an emerging public health problem worldwide. According to the World Health Organization, an estimated 9.7% of multidrug-resistant TB (MDR-TB) cases are defined as XDR-TB globally. The objective of this study was to determine the prevalence of drug resistance to second-line TB drugs among MDR-TB cases detected in the Fourth National Anti-Tuberculosis Drug Resistance Survey in Viet Nam.Eighty clusters of TB cases were selected using a probability-proportion-to-size approach. To identify MDR-TB cases, drug susceptibility testing (DST) was performed for the four major first-line TB drugs. DST of second-line drugs (ofloxacin, amikacin, kanamycin, capreomycin) was performed on isolates from MDR-TB cases to identify pre-XDR and XDR cases.A total of 1629 smear-positive TB cases were eligible for culture and DST. Of those, DST results for first-line drugs were available for 1312 cases, and 91 (6.9%) had MDR-TB. Second-line DST results were available for 84 of these cases. Of those, 15 cases (17.9%) had ofloxacin resistance and 6.0% were resistant to kanamycin and capreomycin. Five MDR-TB cases (6.0%) met the criteria of XDR-TB.This survey provides the first estimates of the proportion of XDR-TB among MDR-TB cases in Viet Nam and provides important information for local policies regarding second-line DST. Local policies and programmes that are geared towards TB prevention, early diagnosis and treatment with effective regimens are of high importance.


PubMed | University of New South Wales, Ca Mau Center for Social Disease Prevention, National Tuberculosis Program, University of Sydney and 2 more.
Type: Journal Article | Journal: The Lancet. Infectious diseases | Year: 2016

Community-wide screening for tuberculosis with Xpert MTB/RIF as a primary screening tool overcomes some of the limitations of conventional screening. However, concerns exist about the low positive predictive value of this test in screening settings. We did a cross-sectional assessment of this diagnostic test to directly estimate the actual positive predictive value of Xpert MTB/RIF when used in the setting of community-wide screening for tuberculosis, and to draw an inference about the specificity of the test for tuberculosis detection.Field staff visited households in 60 randomly selected villages in Ca Mau province, Vietnam. We included people aged 15 years or older who provided written informed consent and were able to produce 05 mL or more of sputum, irrespective of reported symptoms. Participants were tested with Xpert MTB/RIF, then those with positive results had two further sputum samples tested for smear microscopy and culture, and underwent chest radiography at the provincial TB Health Center. The positive predictive value of Xpert MTB/RIF was compared against two reference standards for tuberculosis diagnosis-a positive sputum culture for Mycobacterium tuberculosis, and a positive sputum culture or a chest radiograph consistent with active pulmonary tuberculosis. We then calculated the specificity of Xpert MTB/RIF for tuberculosis detection on the basis of these positive predictive values and disease prevalence in this setting.43435 adults consented to screening with Xpert MTB/RIF. Sputum samples of 05 mL or greater were collected from 23202 participants, producing 22673 valid results. 169 participants had positive Xpert MTB/RIF results (039% of those screened and 075% of those with valid sputum results). The positive predictive value of Xpert MTB/RIF was 610% (95% CI 528-687) when compared against a positive sputum culture and 839% (768-892) when compared against a positive sputum culture or chest radiograph consistent with active tuberculosis. On the basis of these positive predictive values, the specificity of Xpert MTB/RIF was determined to be between 9978% (95% CI 9971-9984) and 9993% (9988-9996).The positive predictive value and specificity of Xpert MTB/RIF in the context of community-wide screening for tuberculosis is substantially higher than that predicted in previous studies. Our findings support the potential role of Xpert MTB/RIF as a primary screening tool to detect prevalent cases of tuberculosis in the community.Australian National Health and Medical Research Council.


PubMed | McGill University, University of New South Wales, Ca Mau Center for Social Disease Prevention, National Tuberculosis Programme and 2 more.
Type: Journal Article | Journal: The international journal of tuberculosis and lung disease : the official journal of the International Union against Tuberculosis and Lung Disease | Year: 2016

Community-wide active case finding for tuberculosis (TB) using Xpert MTB/RIF as the primary screening tool, Ca Mau Province, Viet Nam.To determine whether macroscopic sputum quality characteristics (sputum colour and volume) can be used to predict Xpert MTB-negative sputum and hence exclude sputum samples from testing.Field staff conducted household visits to approximately 51,200 adults in 58 villages randomly selected from throughout the province. Sputum samples from all screened participants who were able to produce 1 ml sputum underwent macroscopic sputum assessment and were tested with Xpert.Of the 21,624 sputum samples tested, 159 (0.74%) were Xpert MTB-positive; 93% of the samples were 1-2 ml and nearly all were mucoid (93%) or mucopurulent (5.7%). One salivary sample was Xpert MTB-positive (2.0% of all salivary samples). The lowest positive predictive value for any sputum volume or colour characteristic was 0.66%. This was not substantially different from the overall prevalence of positive sputum Xpert MTB (0.74%).Sputum colour and volume cannot be used to predict the presence or absence of M. tuberculosis in sputum detected using Xpert. These sputum quality parameters cannot therefore be used to exclude sputum samples from testing for TB.


PubMed | World Health Organization, Parliament, Employees State Insurance Corporation Medical College and Post Graduate Institute of Medical science and Research, Directorate General of Armaments and 11 more.
Type: Journal Article | Journal: Public health action | Year: 2015

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 peoples 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.


Jha U.M.,Ministry of Health and Family Welfare | Satyanarayana S.,Center for Operational Research | Dewan P.K.,Office of the WHO Representative to India | Chadha S.,Office of the WHO Representative to India | And 4 more authors.
PLoS ONE | Year: 2010

Setting: Under India's Revised National Tuberculosis Control Programme (RNTCP), >15% of previously-treated patients in the reported 2006 patient cohort defaulted from anti-tuberculosis treatment. Objective: To assess the timing, characteristics, and risk factors for default amongst re-treatment TB patients. Methodology: For this case-control study, in 90 randomly-selected programme units treatment records were abstracted from all 2006 defaulters from the RNTCP re-treatment regimen (cases), with one consecutively-selected non-defaulter per case. Patients who interrupted anti-tuberculosis treatment for >2 months were classified as defaulters. Results: 1,141 defaulters and 1,189 non-defaulters were included. The median duration of treatment prior to default was 81 days (25%-75% interquartile range 44-117 days) and documented retrieval efforts after treatment interruption were inadequate. Defaulters were more likely to have been male (adjusted odds ratio [aOR] 1.4, 95% confidence interval [CI] 1.2-1.7), have previously defaulted anti-tuberculosis treatment (aOR 1.3 95%CI 1.1-1.6], have previous treatment from non-RNTCP providers (AOR 1.3, 95%CI 1.0-1.6], or have public health facility-based treatment observation (aOR 1.3, 95%CI 1.1-1.6). Conclusions: Amongst the large number of re-treatment patients in India, default occurs early and often. Improved pretreatment counseling and community-based treatment provision may reduce default rates. Efforts to retrieve treatment interrupters prior to default require strengthening. © 2010 Jha et al.


PubMed | Ministry of Public Health, Médecins Sans Frontières and Center for Operational Research
Type: Journal Article | Journal: Public health action | Year: 2015

A district hospital in Kabul, Afghanistan, supported by Mdecins Sans Frontires (MSF).To assess antibiotic prescribing practices in the out-patient department in summer (August 2013) and winter (January 2014).Cross-sectional study, using routinely collected hospital data and using World Health Organization (WHO) defined daily dose (DDD) methodology.An analysis of 4857 prescriptions (summer) and 4821 prescriptions (winter) showed that respectively 62% and 50% of all out-patients were prescribed at least one antibiotic. Prescriptions without a recorded diagnosis represented a sizeable proportion of all antibiotics prescribed. For upper respiratory tract infections (URTI), dental indications, urinary tract infections (UTI) and diarrhoea, good adherence to dosages recommended in the MSF standard treatment guidelines was observed when measured by DDD. However, certain drugs not indicated in the guidelines were prescribed, such as amoxicillin and metronidazole for UTI and azithromycin for URTI.Rates of antibiotic prescriptions for out-patients in a district hospital in Afghanistan were high, double the WHO recommendation of 30%. While systematic non-adherence to recommended dosages was not observed, inappropriate prescriptions for specific conditions may have occurred. This study suggests that knowledge about context-specific determinants of antibiotic prescribing is a first step towards promoting rational prescribing practices in such settings.


Nhung N.V.,National Tuberculosis Program | Hoa N.B.,Center for Operational Research | Sy D.N.,Viet Nam Association for Tuberculosis and Lung Disease | Hennig C.M.,World Health Organization | Dean A.S.,Global Tuberculosis Programme
International Journal of Tuberculosis and Lung Disease | Year: 2015

SETTING: Viet Nam's Fourth National Anti-Tuberculosis Drug Resistance Survey was conducted in 2011. OBJECTIVE: To determine the prevalence of resistance to the four main first-line anti-tuberculosis drugs in Viet Nam. METHODS: Eighty clusters were selected using a probability proportion to size approach. Drug susceptibility testing (DST) against the four main first-line antituberculosis drugs was performed. RESULTS : A total of 1629 smear-positive tuberculosis (TB) patients were eligible for culture. Of these, DST results were available for 1312 patients, including 1105 new TB cases, 195 previously treated TB cases and 12 cases with an unknown treatment history. The proportion of cases with resistance to any drug was 32.7% (95%CI 29.1-36.5) among new cases and 54.2% (95%CI 44.3-63.7) among previously treated cases.The proportion of multidrug-resistant TB (MDR-TB) cases was 4.0% (95%CI 2.5-5.4) in new cases and 23.3 (95%CI 16.7-29.9) in previously treated cases. CONCLUSIONS: The fourth drug resistance survey in Viet Nam found that the proportion of MDR-TB among new and previously treated cases was not significantly different from that in the 2005 survey. The National TB Programme should prioritise the detection and treatment of MDR-TB to reduce transmission of MDR-TB in the community. © 2015 The Union.


Hoa N.B.,Center for Operational Research | Khanh P.H.,WHO | Chinh N.V.,National Tuberculosis Programme Vietnam | Hennig C.M.,WHO
Tropical Medicine and International Health | Year: 2014

Objective: To describe and analyse the prescription patterns and treatment outcomes of MDR-TB patients managed within Green Light Committee (GLC) and outside (non-GLC) the National TB programme in Viet Nam. Methods: Retrospective cohort study with two elements: (i) in-depth interviews and focus group discussions with clinical doctors, hospital pharmacists, and the non-GLC patients with MDR-TB; (ii) review of treatment cards and patients' charts of all GLC and non-GLC patients with MDR-TB put on treatment during 2010. Results: Of 282 patients with MDR-TB, comprising 79 (28%) GLC patients MDR-TB and 203 (72%) non-GLC patients with MDR-TB, were enrolled in the study. Treatment delay was significantly higher in the GLC group (12.8 days) than the non-GLC group (2.3 days), (P = 0.004). The success rate was significantly better in GLC patients (84.8%) than in non-GLC patients (53.7%) (P < 0.001). The default rate was significantly higher in non-GLC patients than in GLC patients (25.6% vs. 6.3%), (P < 0.001). The risk of unsuccessful outcome was higher in non-GLC patients (Hazard ratio = 4.6, 95% CI: 1.8-11.8). Conclusions: The treatment outcomes of patients with MDR-TB in the GLC group were significantly better than in the non-GLC group. Reasons for the high default rate in non-GLC patients with MDR-TB must be further investigated. © 2014 John Wiley & Sons Ltd.

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