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Theron G.,Stellenbosch University | Theron G.,University of Cape Town | Jenkins H.E.,Brigham and Womens Hospital | Cobelens F.,KNCV Tuberculosis Foundation | And 4 more authors.
The Lancet | Year: 2015

Accelerating progress in the fight against tuberculosis will require a drastic shift from a strategy focused on control to one focused on elimination. Successful disease elimination campaigns are characterised by locally tailored responses that are informed by appropriate data. To develop such a response to tuberculosis, we suggest a three-step process that includes improved collection and use of existing programmatic data, collection of additional data (eg, geographic information, drug resistance, and risk factors) to inform tailored responses, and targeted collection of novel data (eg, sequencing data, targeted surveys, and contact investigations) to improve understanding of tuberculosis transmission dynamics. Development of a locally targeted response for tuberculosis will require substantial investment to reconfigure existing systems, coupled with additional empirical data to evaluate the effectiveness of specific approaches. Without adoption of an elimination strategy that uses local data to target hotspots of transmission, ambitious targets to end tuberculosis will almost certainly remain unmet. © 2015 Elsevier Ltd. Source


Zaidi S.M.A.,Interactive Research and Development | Khowaja S.,Interactive Research and Development | Lotia-Farrukh I.,Interactive Research and Development | Irani J.,Interactive Research and Development | And 3 more authors.
PLoS Neglected Tropical Diseases | Year: 2013

Background:Dog-bites and rabies are under-reported in developing countries such as Pakistan and there is a poor understanding of the disease burden. We prospectively collected data utilizing mobile phones for dog-bite and rabies surveillance across nine emergency rooms (ER) in Pakistan, recording patient health-seeking behaviors, access to care and analyzed spatial distribution of cases from Karachi.Methodology and Principal Findings:A total of 6212 dog-bite cases were identified over two years starting in February 2009 with largest number reported from Karachi (59.7%), followed by Peshawar (13.1%) and Hyderabad (11.4%). Severity of dog-bites was assessed using the WHO classification. Forty percent of patients had Category I (least severe) bites, 28.1% had Category II bites and 31.9% had Category III (most severe bites). Patients visiting a large public hospital ER in Karachi were least likely to seek immediate healthcare at non-medical facilities (Odds Ratio = 0.20, 95% CI 0.17-0.23, p-value<0.01), and had shorter mean travel time to emergency rooms, adjusted for age and gender (32.78 min, 95% CI 31.82-33.78, p-value<0.01) than patients visiting hospitals in smaller cities. Spatial analysis of dog-bites in Karachi suggested clustering of cases (Moran's I = 0.02, p value<0.01), and increased risk of exposure in particular around Korangi and Malir that are adjacent to the city's largest abattoir in Landhi. The direct cost of operating the mHealth surveillance system was USD 7.15 per dog-bite case reported, or approximately USD 44,408 over two years.Conclusions:Our findings suggest significant differences in access to care and health-seeking behaviors in Pakistan following dog-bites. The distribution of cases in Karachi was suggestive of clustering of cases that could guide targeted disease-control efforts in the city. Mobile phone technologies for health (mHealth) allowed for the operation of a national-level disease reporting and surveillance system at a low cost. © 2013 Zaidi et al. Source


Khan A.J.,Interactive Research and Development | Khan A.J.,Indus Hospital Research Center | Khowaja S.,Indus Hospital Research Center | Khan F.S.,Indus Hospital Research Center | And 12 more authors.
The Lancet Infectious Diseases | Year: 2012

Background: In many countries with a high burden of tuberculosis, most patients receive treatment in the private sector. We evaluated a multifaceted case-detection strategy in Karachi, Pakistan, targeting the private sector. Methods: A year-long communications campaign advised people with 2 weeks or more of productive cough to seek care at one of 54 private family medical clinics or a private hospital that was also a national tuberculosis programme (NTP) reporting centre. Community laypeople participated as screeners, using an interactive algorithm on mobile phones to assess patients and visitors in family-clinic waiting areas and the hospital's outpatient department. Screeners received cash incentives for case detection. Patients with suspected tuberculosis also came directly to the hospital's tuberculosis clinic (self-referrals) or were referred there (referrals). The primary outcome was the change (from 2010 to 2011) in tuberculosis notifications to the NTP in the intervention area compared with that in an adjacent control area. Findings: Screeners assessed 388 196 individuals at family clinics and 81 700 at Indus Hospital's outpatient department from January-December, 2011. A total of 2416 tuberculosis cases were detected and notified via the NTP reporting centre at Indus Hospital: 603 through family clinics, 273 through the outpatient department, 1020 from self-referrals, and 520 from referrals. In the intervention area overall, tuberculosis case notification to the NTP increased two times (from 1569 to 3140 cases) from 2010 to 2011-a 2·21 times increase (95% CI 1·93-2·53) relative to the change in number of case notifications in the control area. From 2010 to 2011, pulmonary tuberculosis notifications at Indus Hospital increased by 3·77 times for adults and 7·32 times for children. Interpretation: Novel approaches to tuberculosis case-finding involving the private sector and using laypeople, mobile phone software and incentives, and communication campaigns can substantially increase case notification in dense urban settings. Funding: TB REACH, Stop TB Partnership. © 2012 Elsevier Ltd. Source


Qazi F.,Interactive Research and Development | Khan U.,Interactive Research and Development | Khowaja S.,Interactive Research and Development | Javaid M.,Indus Hospital | And 6 more authors.
International Journal of Tuberculosis and Lung Disease | Year: 2011

Culture conversion is an interim monitoring tool for treatment of multidrug-resistant tuberculosis (MDR-TB). We evaluated the time to and predictors of culture conversion in pulmonary MDR-TB patients enrolled in the community-based MDR-TB management program at the Indus Hospital in Karachi, Pakistan. Despite strict daily directly observed therapy, monthly food incentives and patient counseling, the median time to culture conversion was 196 days (range 32-471). The cumulative probabilities of culture conversion by 2, 4, 6 and 12 months were respectively 6%, 33%, 47%, and 73%. Smoking, high smear grade at baseline and previous use of second-line drugs delayed culture conversion. © 2011 The Union. Source


Dowdy D.W.,Johns Hopkins University | Lotia I.,Interactive Research and Development | Creswell J.,Stop TB Partnership | Sahu S.,Stop TB Partnership | Khan A.J.,Interactive Research and Development
PLoS ONE | Year: 2013

Background:The potential population-level impact of private-sector initiatives for tuberculosis (TB) case finding in Southeast Asia remains uncertain. In 2011, the Indus Hospital TB Control Program in Karachi, Pakistan, undertook an aggressive case-finding campaign that doubled notification rates, providing an opportunity to investigate potential population-level effects.Methods:We constructed an age-structured compartmental model of TB in the intervention area. We fit the model using field and literature data, assuming that TB incidence equaled the estimated nationwide incidence in Pakistan (primary analysis), or 1.5 times greater (high-incidence scenario). We modeled the intervention as an increase in the rate of formal-sector TB diagnosis and evaluated the potential impact of sustaining this rate for five years.Results:In the primary analysis, the five-year intervention averted 24% (95% uncertainty range, UR: 18-30%) of five-year cumulative TB cases and 52% (95% UR: 45-57%) of cumulative TB deaths. Corresponding reductions in the high-incidence scenario were 12% (95% UR: 8-17%) and 27% (95% UR: 21-34%), although the absolute number of lives saved was higher. At the end of five years, TB notification rates in the primary analysis were below their 2010 baseline, incidence had dropped by 45%, and annual mortality had fallen by 72%. About half of the cumulative impact on incidence and mortality could be achieved with a one-year intervention.Conclusions:Sustained, multifaceted, and innovative approaches to TB case-finding in Asian megacities can have substantial community-wide epidemiological impact. © 2013 Dowdy et al. Source

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