Interactive Research and Development

Karachi, Pakistan

Interactive Research and Development

Karachi, Pakistan
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Schnippel K.,University of Cape Town | Firnhaber C.,Right to Care | Firnhaber C.,University of Witwatersrand | Berhanu R.,University of North Carolina at Chapel Hill | And 3 more authors.
Journal of Antimicrobial Chemotherapy | Year: 2017

Objectives: To estimate the prevalence of adverse drug reactions or events (ADR) during drug-resistant TB (DRTB) treatment in the context of settings with high HIV prevalence (at least 20% of patients). Methods: We conducted a systematic review and meta-analysis of articles in PubMed and Scopus. Pooled proportions of patients experiencing adverse events and relative risk with 95% CI were calculated. Results: The search yielded 24 studies, all observational cohorts. Ten reported on the number of patients experiencing ADR and were included in the meta-analysis representing 2776 study participants of whom 1943 were known to be HIV infected (70.0%). An average of 83% (95% CI: 82%-84%) of patients experienced one or more ADR. Among the seven articles (n"664 study participants) with information on occurrence of severe ADR, 24% (95% CI: 21%-27%) of patients experienced at least one severe ADR during drug-resistant TB treatment. Sixteen of the 24 studies analysed the relative risk of ADR by HIV infection, nine of which found no statistically significant association between HIV infection and occurrence of drug-related ADR. Therewas insufficient information to disaggregate risk by concomitant treatment with HIV antiretrovirals or by immunosuppression (CD4 count). Conclusions: No randomized clinical trials were found forWHO-recommended treatment of drug-resistant TB treatment where at least 20% of the cohort was coinfected with HIV. Nearly all patients (83%) experience ADR during DR-TB treatment. While no significant association between ADR and HIV coinfection was found, further research is needed to determine whether concomitant antiretrovirals or immunosuppression increases the risks for HIVinfected patients. © The Author 2017. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved.

Chandir S.,Interactive Research and Development | Chandir S.,Harvard University | Dharma V.K.,Interactive Research and Development | Siddiqi D.A.,Interactive Research and Development | Khan A.J.,Interactive Research and Development
Vaccine | Year: 2017

Despite multiple rounds of immunization campaigns, it has not been possible to achieve optimum immunization coverage for poliovirus in Pakistan. Supplementary activities to improve coverage of immunization, such as door-to-door campaigns are constrained by several factors including inaccurate hand-drawn maps and a lack of means to objectively monitor field teams in real time, resulting in suboptimal vaccine coverage during campaigns. Global System for Mobile Communications (GSM) - based tracking of mobile subscriber identity modules (SIMs) of vaccinators provides a low-cost solution to identify missed areas and ensure effective immunization coverage. We conducted a pilot study to investigate the feasibility of using GSM technology to track vaccinators through observing indicators including acceptability, ease of implementation, costs and scalability as well as the likelihood of ownership by District Health Officials. The real-time location of the field teams was displayed on a GSM tracking web dashboard accessible by supervisors and managers for effective monitoring of workforce attendance including ‘time in-time out’, and discerning if all target areas - specifically remote and high-risk locations - had been reached. Direct access to this information by supervisors eliminated the possibility of data fudging and inaccurate reporting by workers regarding their mobility. The tracking cost per vaccinator was USD 0.26/month. Our study shows that GSM-based tracking is potentially a cost-efficient approach, results in better monitoring and accountability, is scalable and provides the potential for improved geographic coverage of health services. © 2017 Elsevier Ltd

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.

Usman H.R.,University of Alabama at Birmingham | Khowaja S.,Interactive Research and Development | Omer S.B.,Emory University
Vaccine | Year: 2010

This study introduced food/medicine vouchers as an incentive to mothers of infants visiting Expanded Program on Immunization (EPI) centers in a low socio-economic area. The timely completion of diphtheria, tetanus and pertussis vaccines combined (DTP) series immunization rates between intervention and control cohorts were compared. The DTP up-to-date immunization coverage at 18 weeks of age increased two-fold (RR 2.20, 95% CI: 1.95-2.48, p < 0.001) in the incentive cohort compared to the no-incentive cohort. While increasing immunization coverage is a complex structural and behavioral process, food/medicine coupon may improve routine immunization coverage in developing countries. © 2010 Elsevier Ltd. All rights reserved.

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.

Theron G.,Stellenbosch University | Theron G.,University of Cape Town | Jenkins H.E.,Brigham and Women's Hospital | Cobelens F.,KNCV Tuberculosis Foundation | And 3 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.

Creswell J.,Stop TB Partnership | Codlin A.J.,Interactive Research and Development | Andre E.,Catholic University of Louvain | Micek M.A.,University of Washington | And 11 more authors.
BMC Infectious Diseases | Year: 2014

Background: The Xpert MTB/RIF assay has garnered significant interest as a sensitive and rapid diagnostic tool to improve detection of sensitive and drug resistant tuberculosis. However, most existing literature has described the performance of MTB/RIF testing only in study conditions; little information is available on its use in routine case finding. TB REACH is a multi-country initiative focusing on innovative ways to improve case notification.Methods: We selected a convenience sample of nine TB REACH projects for inclusion to cover a range of implementers, regions and approaches. Standard quarterly reports and machine data from the first 12 months of MTB/RIF implementation in each project were utilized to analyze patient yields, rifampicin resistance, and failed tests. Data was collected from September 2011 to March 2013. A questionnaire was implemented and semi-structured interviews with project staff were conducted to gather information on user experiences and challenges.Results: All projects used MTB/RIF testing for people with suspected TB, as opposed to testing for drug resistance among already diagnosed patients. The projects placed 65 machines (196 modules) in a variety of facilities and employed numerous case-finding strategies and testing algorithms. The projects consumed 47,973 MTB/RIF tests. Of valid tests, 7,195 (16.8%) were positive for MTB. A total of 982 rifampicin resistant results were found (13.6% of positive tests). Of all tests conducted, 10.6% failed. The need for continuous power supply was noted by all projects and most used locally procured solutions. There was considerable heterogeneity in how results were reported and recorded, reflecting the lack of standardized guidance in some countries.Conclusions: The findings of this study begin to fill the gaps among guidelines, research findings, and real-world implementation of MTB/RIF testing. Testing with Xpert MTB/RIF detected a large number of people with TB that routine services failed to detect. The study demonstrates the versatility and impact of the technology, but also outlines various surmountable barriers to implementation. The study is not representative of all early implementer experiences with MTB/RIF testing but rather provides an overview of the shared issues as well as the many different approaches to programmatic MTB/RIF implementation. © 2014 Creswell et al.; licensee BioMed Central Ltd.

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.

Alam A.,Indus Hospital | Amanullah F.,Indus Hospital | Baig-Ansari N.,Indus Hospital Research Center | Lotia-Farrukh I.,Interactive Research and Development | Khan F.S.,Interactive Research and Development
BMC Research Notes | Year: 2014

Background: Chronic kidney disease (CKD) is being increasingly recognized as a leading public health problem. However, there are limited data available with respect to prevalence of CKD in Pakistan, a developing South Asian country. The study presents the baseline findings of prevalence and risk factors for adult kidney disease in a Pakistani community cohort. Methods. A total of 667 households were enrolled between March 2010 and August 2011 including 461 adults, aged 15 and older. Mild kidney disease was defined as estimated Glomerular Filtration Rate (eGFR) ≥60 ml/min with microalbuminuria ≥ 30 mg/dl and moderate kidney disease was defined as eGFR <60 ml/min (with or without microalbuminuria). Results: The overall prevalence of kidney disease was 16.6% with 8.6% participants having mild kidney disease and 8% having moderate kidney disease. Age was significantly associated with kidney disease (p < 0.0001). The frequency of diabetes, hypertension and smoking differed significantly among the three groups, i.e., no kidney disease, mild kidney disease and moderate kidney disease. Conclusion: Our study results suggest that the burden of kidney disease in this population is found considerable and comparable to neighboring developing countries. We believe that these results have critical implications on health and economics of these countries and due to the epidemic of diabetes, hypertension, cardiovascular disease, smoking and association with worsening poverty, further rapid growth is expected. There is an urgent need for early recognition and prevention strategies based on risk factors and disease trends determined through longitudinal research. © 2014 Alam et al.; licensee BioMed Central Ltd.

Amanullah F.,Indus Hospital | Amanullah F.,Harvard University | Ashfaq M.,Interactive Research and Development | Khowaja S.,Interactive Research and Development | And 5 more authors.
International Journal of Tuberculosis and Lung Disease | Year: 2014

SETTING: Urban Karachi, Pakistan. OBJECTIVE: To describe the yield of a contact investigation protocol implemented among children living with drug-resistant tuberculosis (DR-TB) patients. DE S I GN: We implemented a contact investigation protocol in households of DR-TB patients treated at the Indus Hospital, Karachi, between January 2008 and April 2011. This included a detailed history and physical examination, tuberculin skin test, chest radiograph, smear microscopy and culture of sputum or gastric aspirate specimens, and drug susceptibility testing. Treatment supporters who visited DR-TB patients at home referred all child contacts for baseline evaluation and performed monthly assessments. We evaluated two age groups: 1) children aged <5 years, and 2) those aged 5-14 years. RESULTS: Among 133 children aged <15 years in 40 households, 40.4% (51/125) were moderately to severely underweight (weight-for-age Z-score <-2). Overall, 7.5% (10/133) had TB disease. This proportion was 6.5% (2/31) in those aged <5 years and 7.8% (8/102) in those aged 5-14 years. Seven (7/10) were smear-positive, and 4/10 had culture-confirmed multidrug-resistant Mycobacterium tuberculosis. CONCLUSION: We detected a high prevalence of TB in children who live with DR-TB patients, regardless of the age of the child. Child contacts of DR-TB patients are a high-yield population for detecting TB cases. © 2014 The Union.

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