Background Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious ... more Background Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious diseases. Limited evidence exists around programmatic outcomes of children and adolescents receiving DR-TB treatment. The study aimed to determine the final treatment outcomes, culture conversion rates and factors associated with unsuccessful treatment outcome in children and adolescents with DR-TB. Methods This is a descriptive study including children (0–9 years) and adolescents (10–19 years) with DR-TB were who were initiated on ambulatory based treatment between January 2017-June 2018 in Shatabdi hospital, Mumbai, India where National TB elimination programme(NTEP) Mumbai collaborates with chest physicians and Médecins Sans Frontières(MSF) in providing comprehensive care to DR-TB patients. The patients with available end-of-treatment outcomes were included. The data was censored on February 2020. Result A total of 268 patients were included; 16 (6%) of them were children (0–9 years)....
Background HIV programs are increasingly confronted with failing antiretroviral therapy (ART), in... more Background HIV programs are increasingly confronted with failing antiretroviral therapy (ART), including second-line regimens. WHO has provided guidelines on switching to third-line ART. In a Médecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive second-line ART failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented. Objective To document the outcome and genotype of presumptive second-line ART failure cases switched to third-line or maintained on second-line ART. Design Retrospective cohort study of patients referred between January 2011 and September 2017. Results The cases (n = 120) were complex with median 9.2 years of ART exposure, poor adherence at baseline, and exposure to multiple ART regimens other than recommended by WHO. Out of 90 evaluated cases, 39(43%) were maintained on second-line ART. Forty-nine (54%) were ever switched to third-line ART...
Background Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every ye... more Background Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every year across the globe. Though the treatment success rates for drug-resistant TB (DR-TB) in children are better than adults, children and adolescents face unique hurdles during DR-TB (MDR-TB, Pre-XDR TB and XDR-TB) treatment. This study aimed to understand the patients, guardians and healthcare providers’ perspectives about DR-TB treatment journey of patients and caregivers. Methods This is a qualitative study involving in depth-interviews of purposively selected adolescents (n = 6), patients guardians (for children and adolescents, n = 5) and health care providers (n = 8) of Médecins Sans Frontières (MSF) clinic, Mumbai, India. In-depth face to face interviews were conducted in English or Hindi language using interview guides during September-November 2019. The interviews were audio-recorded after consent. Thematic network analysis was used to summarize textual data. ATLAS.ti (version 7) w...
Background The emergence of dengue in malaria-endemic countries with limited diagnostic resources... more Background The emergence of dengue in malaria-endemic countries with limited diagnostic resources, such as Yemen, can be problematic because presumptive treatment of febrile cases as being malaria is a common practice. Co-infections with dengue and malaria are often overlooked and misdiagnosed as being a mono-infection because of clinical similarities. In Hodeidah city, Yemen, the capacity to conduct the diagnosis can be aggravated by the war context. To assess the magnitude of the problem, we determined the proportions of malaria, dengue and co-infection in relation to clinical characteristics among febrile outpatients. Methods This cross-sectional study included 355 febrile outpatients from Hodeidah city during the malaria transmission season (September 2018 –February 2019). Sociodemographic and clinical characteristics were collected using a pre-designed, structured questionnaire. Malaria was confirmed using microscopy and rapid diagnostic tests (RDTs), while dengue was confirmed...
Background The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant b... more Background The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant bedaquiline (BDQ) and delamanid (DLM) in treatment regimen for patients with drug-resistant tuberculosis (DR-TB) and limited therapeutic options, referred from other healthcare institutions, since 2016. The study documents the end-of-treatment outcomes, culture-conversion rates, and serious adverse events (SAEs) during treatment. Methods This was a retrospective cohort study based on routinely collected program data. In clinic, treatment regimens are designed based on culture drug sensitivity test patterns and previous drug exposures, and are provided for 20–22 months. BDQ and DLM are extended beyond 24 weeks as off-label use. Patients who initiated DR-TB treatment including BDQ and DLM (concomitantly for at least 4 weeks) during February 2016–February 2018 were included. Results Of the 70 patients included, the median age was 25 (interquartile range [IQR], 22–32) years and 56% were femal...
BACKGROUND No Indian studies have assessed the implementation of recent policy on pharmacy based ... more BACKGROUND No Indian studies have assessed the implementation of recent policy on pharmacy based surveillance and its contribution in TB notification. So, this study was conducted with objectives to describe: a) pharmacy based TB surveillance and TB notification, and b) experiences of pharmacy based surveillance implementation from the programme managers and pharmacists perspective. METHODS A mixed methods study-quantitative (cross-sectional) and qualitative (in-depth interviews) in two selected districts Dharmapuri and Salem districts of Tamil Nadu State, India. RESULTS In 2018, 45 (11%) of 397 pharmacies in Dharmapuri and 90 (6%) of 1457 pharmacies in Salem districts reported sale of anti-TB drugs to 1307 and 1673 persons respectively. Upon validation through direct patient contact 942 (72%) persons in Dharmapuri and 863 (52%) persons were identified as previously 'un-notified' TB patients. These patients constituted 20% and 29% of the total TB cases notified in Dharmapuri and Salem respectively. The enablers for implementing this activity were: understanding the importance of notification, availability of resources (manpower, computers) to record, report and validate the patient data, repeated trainings and partnerships. The barriers were: patients' hesitancy to share their details to pharmacists (confidentiality), cumbersome recording and reporting process, difficulties in recording patient details during high workload busy business hours. CONCLUSION This process contributed about one-fourth of the TB patients notified in these districts. Its implementation needs to be strengthened and should be scaled up in other parts of the country.
Background Imipenem, an intravenous antibiotic is recommended for use in drug resistant tuberculo... more Background Imipenem, an intravenous antibiotic is recommended for use in drug resistant tuberculosis (DR-TB) when an effective regimen with combination of other second line drugs is not possible. Though the treatment success rates with carbapenems are promising, the twice daily injection of Imipenem usually requires patients to be hospitalized. The Mé decins Sans Frontières independent clinic in Mumbai, India implemented ambulatory and home based management of patients receiving Imipenem through the use of port-a-cath. Objective We aimed to describe the adverse events and treatment outcomes of ambulatory pre-and XDR-TB patients initiated on imipenem through port-a-cath between January 2015 and June 2018 and to explore the challenges with this regimen as perceived by healthcare providers and patients. Methods A convergent mixed methods study with quantitative (longitudinal descriptive study using the routine data) and qualitative (descriptive study) part conducted concurrently. For the quantitative component, all XDR-TB and pre-XDR-TB initiated on imipenem containing regimen during January 2015-June 2018 were included. For qualitative component, interviews were carried out including patients who initiated on imipenem (n = 5) and healthcare providers (n = 7) involved in providing treatment. Treatment outcomes, culture conversion and
Hepatitis B vaccination (HBV) is recommended for high-risk groups, such as people who inject drug... more Hepatitis B vaccination (HBV) is recommended for high-risk groups, such as people who inject drugs (PWIDs). As part of a harm reduction program by a non-governmental organization, hepatitis B screening, vaccination and antibody (HBAb) testing after completion of the vaccination schedule were offered to PWIDS in Myanmar. We determined the proportions of HBV non-completion and sero-unprotection among PWIDs enrolled in the program and their association with socio-demographic and clinical characteristics. We conducted a descriptive study based on routine program data in five selected clinics in Hpakant Township, Myanmar. PWIDs who were Hepatitis B antigen negative at screening during January 2015–December 2018 were included. Among 5386 participants eligible for HBV, 9% refused vaccination. Among those who accepted vaccination (n = 3177 individuals), 65% completed vaccination. Of those tested for HBsAb (n = 2202), 30% were sero-unprotected. Young-adults (aged 18–44 years) and migrant wor...
Background Routine viral-load (VL) measurements along with enhanced adherence counselling (EAC) a... more Background Routine viral-load (VL) measurements along with enhanced adherence counselling (EAC) are recommended to achieve virological suppression among people living with HIV/AIDS (PLHA) on anti-retroviral therapy (ART). The Mumbai Districts AIDS Control Society along with Mé decins Sans Frontières has provided routine VL measurements and EAC to PLHA on ART at King Edward Memorial (KEM) hospital, Mumbai since October-2016. This study aims to describe the initial VL results and impact of EAC on viral suppression and factors associated with initial viral non-suppression among patients with an initial detectable VL, in a cohort of patients tested between October-2016 and September-2018. Methods This is a descriptive study of PLHA on ART who received VL testing and EAC during October-2016 to September-2018. Log-binomial regression was used to identify factors associated with a high VL. Results Among 3849 PLHA who underwent VL testing, 1603(42%) were female and median age was 42 years (IQR:35-48). Majority were referred for routine testing (3432(89%)) and clinical/immunological failure (233(6%)). Overall, 3402(88%) PLHA had suppressed VL at initial testing. Among 3432 tested for routine monitoring, 3141(92%) had VL suppressed. Of 291 with VL>1000c/ml, 253(87%) received EAC and after repeat VL, 70(28%) had VL<1000c/ ml. Among 233 referred for clinical/immunological failure, 122(52%) had VL>1000c/ml and 109 have been switched to second-line ART. CD4 count<500 (aOR-5.0[95%CI 3.8-6.5]), on ART for<5 years (aOR-1.5[1.1-2.0]) and age<15 years (aOR-5.2[3.0-8.9]) were associated with an initial VL>1000c/ml. Factors
While risk of tuberculosis (TB) is high among household contacts (HHCs) of pre-extensively drug r... more While risk of tuberculosis (TB) is high among household contacts (HHCs) of pre-extensively drug resistant (pre-XDR) TB and XDR-TB, data on yield of systematic longitudinal screening are lacking. We aim to describe the yield of systematic longitudinal TB contact tracing among HHCs of patients with pre-XDR-TB and XDR-TB. At the Médecins Sans Frontières (MSF) clinic, Mumbai, India a cohort comprising 518 HHCs of 109 pre-XDR and XDR index cases was enrolled between January 2016 and June 2018. Regular HHC follow-ups were done till one year post treatment of index cases. Of 518 HHCs, 23 had TB (21 on TB treatment and two newly diagnosed) at the time of first visit. Of the rest, 19% HHCs had no follow-ups. Fourteen (3.5%) TB cases were identified among 400 HHCs; incidence rate: 2072/100,000 person-years (95% CI: 1227–3499). The overall yield of household contact tracing was 3% (16/518). Of 14 who were diagnosed with TB during follow-up, six had drug susceptible TB (DSTB); six had pre-XDR-T...
BACKGROUND Government of India's Revised National TB Control Programme (RNTCP) has begun impl... more BACKGROUND Government of India's Revised National TB Control Programme (RNTCP) has begun implementing daily fixed dose combination (FDC) anti-TB treatment regimen for drug sensitive TB patients in which ethambutol is given for six months. Prolonged ethambutol use is known to cause ocular adverse drug events (ADE). OBJECTIVES To assess the magnitude of ocular ADEs in adult drug sensitive TB patients initiated on daily FDCs and to describe the demographic and clinical profile of patients with ocular ADEs. METHODS We conducted a retrospective cohort study involving review of RNTCP records of all adult (age >14 years) drug sensitive TB patients initiated on daily FDCs between1st January 2018 and 31st July 2018 in Thiruvananthapuram district, Kerala State, India. RESULTS 714 patients were initiated on daily FDCs during the study period. It was unknown whether all patients had undergone assessment for ocular ADEs. However, of these 714 patients, 8 patients (1.1%) were documented to have had ocular ADEs. Seven of these 8 patients had received ethambutol more than 15 mg/kg body weight and had developed ocular symptoms (decreased/blurring of vision) 3 months after TB treatment initiation. Ethambutol was stopped in all these 8 patients. In 5 patients it was recorded that ocular ADEs had resolved following stoppage of ethambutol and in the remaining it was unknown. CONCLUSION The study confirms the occurrence of ocular ADEs among drug sensitive TB patients on daily FDCs and recommends strengthening of systems for assessing, documenting and managing ocular ADE.
Médecins Sans Frontières (MSF) has been providing diagnosis and treatment for patients with tuber... more Médecins Sans Frontières (MSF) has been providing diagnosis and treatment for patients with tuberculosis (TB) via mobile clinics in conflict-affected border areas of Chhattisgarh, India since 2009. The study objectives were to determine the proportion of patients diagnosed with TB and those who were lost-to-follow-up (LTFU) prior to treatment initiation among patients with presumptive TB between April 2015 and August 2018. The study also compared bacteriological confirmation and pretreatment LTFU during two time periods: a) April 2015–August 2016 and b) April 2017–August 2018 (before and after the introduction of GeneXpert as a first diagnostic test). Community health workers (CHW) supported patient tracing. This study was a retrospective analysis of routine program data. Among 1042 patients with presumptive TB, 376 (36%) were diagnosed with TB. Of presumptive TB patients, the pretreatment LTFU was 7%. Upon comparing the two time-periods, bacteriological confirmation increased from ...
Background: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes... more Background: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. Methods: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. Results: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. Conclusion: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.
Background: Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and respon... more Background: Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and response strategy similar to "1-3-7" Chinese strategy to achieve sub-national elimination in six low-endemic region/states of the country. Among these, Yangon, Bago-East, and Mon region/states have implemented this malaria surveillance and response strategy with modification in 2016. The current study was conducted to assess the case notification, investigation, classification, and response strategy (NICR) in these three states. Methods: This was a retrospective cohort study using routine program data of all patients with malaria diagnosed and reported under the National Malaria Control Programme in 2016 from the above three states. As per the program, all malaria cases need to be notified within 1 day and investigated within 3 days of diagnosis and response to control (active case detection and control) should be taken for all indigenous malaria cases within 7 days of diagnosis. Results: A total of 959 malaria cases were diagnosed from the study area in 2016. Of these, the case NICR details were available only for 312 (32.5%) malaria cases. Of 312 cases, the case notification, investigation, and classification were carried out within 3 days of malaria diagnosis in 95.5% cases (298/312). Of 208 indigenous malaria cases (66.7%, 208/312), response to control was taken in 96.6% (201/208) within 7 days of diagnosis. Conclusion: The timeline at each stage of the strategy namely case notification, investigation, classification, and response to control was followed, and response action was taken in nearly all indigenous malaria cases for the available case information. Strengthening of health information and monitoring system is needed to avoid missing information. Future research on feasibility of mobile/tablet-based surveillance system and providing response to all cases including imported malaria can be further studied.
Background: The average expenditure incurred by patients in low-and middle-income countries towar... more Background: The average expenditure incurred by patients in low-and middle-income countries towards diagnosis and treatment of TB ranges from $55 to $8198. This out-ofpocket expenditure leads to impoverishment of households. One of the three main targets of the End TB Strategy (2016-2035) is that no TB-affected household suffers catastrophic costs due to TB. Study setting was free care under national tuberculosis program (NTP), Puducherry district, India. Objectives: The objectives of the study were among the newly diagnosed and previously treated tuberculosis (TB) patients, to (a) estimate patient costs during diagnosis and intensive phase of treatment, (b) determine the proportion of households experiencing catastrophic costs, and (c) explore coping strategies. Methods: An explanatory mixed methods design comprising both quantitative cost description and qualitative descriptive component was used. Catastrophic cost was defined as total TB care costs exceeding 20% of annual household income. Results: Of 102 TB patients included, two-thirds (69%) were male, 6% were HIV positive, and 45% reported at least one episode of hospitalization for TB care. The median (IQR) total cost of TB care was US$195 (52.1, 492.9) with a direct cost of US$65.3 (22.3, 156.5) and indirect cost of US$50.2 (0.9, 295.1). Overall, 32.4% of households experienced catastrophic costs due to TB care, significantly higher in patients with HIV coinfection (p = 0.009) and hospitalization (p = 0.009). Pledging jewels and borrowing money were major coping strategies. Cash assistance was the expected remedy from the patient perspective. Conclusion: Despite free TB care under NTP, more than a third incurred catastrophic costs towards TB care.
Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) ar... more Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar. This was a retrospective cohort study using record review of routinely collected programme data available in electronic format. All patients with undifferentiated fever screened and diagnosed for malaria in January-December 2015 by VHV and BHS under National Malaria Control Programme in Myanmar were included in the study. Unadjusted and adjusted prevalence ratios (aPR) were calculated to assess the effect of VHV/BHS on receipt of treatment by patients. Of 978,735 undifferentiated fever patients screened in 2015, 11.0% of patients were found malaria positive an...
Background Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious ... more Background Childhood and adolescent drug-resistant TB (DR-TB) is one of the neglected infectious diseases. Limited evidence exists around programmatic outcomes of children and adolescents receiving DR-TB treatment. The study aimed to determine the final treatment outcomes, culture conversion rates and factors associated with unsuccessful treatment outcome in children and adolescents with DR-TB. Methods This is a descriptive study including children (0–9 years) and adolescents (10–19 years) with DR-TB were who were initiated on ambulatory based treatment between January 2017-June 2018 in Shatabdi hospital, Mumbai, India where National TB elimination programme(NTEP) Mumbai collaborates with chest physicians and Médecins Sans Frontières(MSF) in providing comprehensive care to DR-TB patients. The patients with available end-of-treatment outcomes were included. The data was censored on February 2020. Result A total of 268 patients were included; 16 (6%) of them were children (0–9 years)....
Background HIV programs are increasingly confronted with failing antiretroviral therapy (ART), in... more Background HIV programs are increasingly confronted with failing antiretroviral therapy (ART), including second-line regimens. WHO has provided guidelines on switching to third-line ART. In a Médecins Sans Frontières clinic in Mumbai, India, receiving referred presumptive second-line ART failure cases, an evidence-based protocol consisting of viral load (VL) testing, enhanced adherence counselling (EAC) and genotype for switching was implemented. Objective To document the outcome and genotype of presumptive second-line ART failure cases switched to third-line or maintained on second-line ART. Design Retrospective cohort study of patients referred between January 2011 and September 2017. Results The cases (n = 120) were complex with median 9.2 years of ART exposure, poor adherence at baseline, and exposure to multiple ART regimens other than recommended by WHO. Out of 90 evaluated cases, 39(43%) were maintained on second-line ART. Forty-nine (54%) were ever switched to third-line ART...
Background Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every ye... more Background Childhood multidrug-resistant TB (MDR-TB) still affects around 25000 children every year across the globe. Though the treatment success rates for drug-resistant TB (DR-TB) in children are better than adults, children and adolescents face unique hurdles during DR-TB (MDR-TB, Pre-XDR TB and XDR-TB) treatment. This study aimed to understand the patients, guardians and healthcare providers’ perspectives about DR-TB treatment journey of patients and caregivers. Methods This is a qualitative study involving in depth-interviews of purposively selected adolescents (n = 6), patients guardians (for children and adolescents, n = 5) and health care providers (n = 8) of Médecins Sans Frontières (MSF) clinic, Mumbai, India. In-depth face to face interviews were conducted in English or Hindi language using interview guides during September-November 2019. The interviews were audio-recorded after consent. Thematic network analysis was used to summarize textual data. ATLAS.ti (version 7) w...
Background The emergence of dengue in malaria-endemic countries with limited diagnostic resources... more Background The emergence of dengue in malaria-endemic countries with limited diagnostic resources, such as Yemen, can be problematic because presumptive treatment of febrile cases as being malaria is a common practice. Co-infections with dengue and malaria are often overlooked and misdiagnosed as being a mono-infection because of clinical similarities. In Hodeidah city, Yemen, the capacity to conduct the diagnosis can be aggravated by the war context. To assess the magnitude of the problem, we determined the proportions of malaria, dengue and co-infection in relation to clinical characteristics among febrile outpatients. Methods This cross-sectional study included 355 febrile outpatients from Hodeidah city during the malaria transmission season (September 2018 –February 2019). Sociodemographic and clinical characteristics were collected using a pre-designed, structured questionnaire. Malaria was confirmed using microscopy and rapid diagnostic tests (RDTs), while dengue was confirmed...
Background The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant b... more Background The Médecins Sans Frontières Clinic in Mumbai, India, has been providing concomitant bedaquiline (BDQ) and delamanid (DLM) in treatment regimen for patients with drug-resistant tuberculosis (DR-TB) and limited therapeutic options, referred from other healthcare institutions, since 2016. The study documents the end-of-treatment outcomes, culture-conversion rates, and serious adverse events (SAEs) during treatment. Methods This was a retrospective cohort study based on routinely collected program data. In clinic, treatment regimens are designed based on culture drug sensitivity test patterns and previous drug exposures, and are provided for 20–22 months. BDQ and DLM are extended beyond 24 weeks as off-label use. Patients who initiated DR-TB treatment including BDQ and DLM (concomitantly for at least 4 weeks) during February 2016–February 2018 were included. Results Of the 70 patients included, the median age was 25 (interquartile range [IQR], 22–32) years and 56% were femal...
BACKGROUND No Indian studies have assessed the implementation of recent policy on pharmacy based ... more BACKGROUND No Indian studies have assessed the implementation of recent policy on pharmacy based surveillance and its contribution in TB notification. So, this study was conducted with objectives to describe: a) pharmacy based TB surveillance and TB notification, and b) experiences of pharmacy based surveillance implementation from the programme managers and pharmacists perspective. METHODS A mixed methods study-quantitative (cross-sectional) and qualitative (in-depth interviews) in two selected districts Dharmapuri and Salem districts of Tamil Nadu State, India. RESULTS In 2018, 45 (11%) of 397 pharmacies in Dharmapuri and 90 (6%) of 1457 pharmacies in Salem districts reported sale of anti-TB drugs to 1307 and 1673 persons respectively. Upon validation through direct patient contact 942 (72%) persons in Dharmapuri and 863 (52%) persons were identified as previously 'un-notified' TB patients. These patients constituted 20% and 29% of the total TB cases notified in Dharmapuri and Salem respectively. The enablers for implementing this activity were: understanding the importance of notification, availability of resources (manpower, computers) to record, report and validate the patient data, repeated trainings and partnerships. The barriers were: patients' hesitancy to share their details to pharmacists (confidentiality), cumbersome recording and reporting process, difficulties in recording patient details during high workload busy business hours. CONCLUSION This process contributed about one-fourth of the TB patients notified in these districts. Its implementation needs to be strengthened and should be scaled up in other parts of the country.
Background Imipenem, an intravenous antibiotic is recommended for use in drug resistant tuberculo... more Background Imipenem, an intravenous antibiotic is recommended for use in drug resistant tuberculosis (DR-TB) when an effective regimen with combination of other second line drugs is not possible. Though the treatment success rates with carbapenems are promising, the twice daily injection of Imipenem usually requires patients to be hospitalized. The Mé decins Sans Frontières independent clinic in Mumbai, India implemented ambulatory and home based management of patients receiving Imipenem through the use of port-a-cath. Objective We aimed to describe the adverse events and treatment outcomes of ambulatory pre-and XDR-TB patients initiated on imipenem through port-a-cath between January 2015 and June 2018 and to explore the challenges with this regimen as perceived by healthcare providers and patients. Methods A convergent mixed methods study with quantitative (longitudinal descriptive study using the routine data) and qualitative (descriptive study) part conducted concurrently. For the quantitative component, all XDR-TB and pre-XDR-TB initiated on imipenem containing regimen during January 2015-June 2018 were included. For qualitative component, interviews were carried out including patients who initiated on imipenem (n = 5) and healthcare providers (n = 7) involved in providing treatment. Treatment outcomes, culture conversion and
Hepatitis B vaccination (HBV) is recommended for high-risk groups, such as people who inject drug... more Hepatitis B vaccination (HBV) is recommended for high-risk groups, such as people who inject drugs (PWIDs). As part of a harm reduction program by a non-governmental organization, hepatitis B screening, vaccination and antibody (HBAb) testing after completion of the vaccination schedule were offered to PWIDS in Myanmar. We determined the proportions of HBV non-completion and sero-unprotection among PWIDs enrolled in the program and their association with socio-demographic and clinical characteristics. We conducted a descriptive study based on routine program data in five selected clinics in Hpakant Township, Myanmar. PWIDs who were Hepatitis B antigen negative at screening during January 2015–December 2018 were included. Among 5386 participants eligible for HBV, 9% refused vaccination. Among those who accepted vaccination (n = 3177 individuals), 65% completed vaccination. Of those tested for HBsAb (n = 2202), 30% were sero-unprotected. Young-adults (aged 18–44 years) and migrant wor...
Background Routine viral-load (VL) measurements along with enhanced adherence counselling (EAC) a... more Background Routine viral-load (VL) measurements along with enhanced adherence counselling (EAC) are recommended to achieve virological suppression among people living with HIV/AIDS (PLHA) on anti-retroviral therapy (ART). The Mumbai Districts AIDS Control Society along with Mé decins Sans Frontières has provided routine VL measurements and EAC to PLHA on ART at King Edward Memorial (KEM) hospital, Mumbai since October-2016. This study aims to describe the initial VL results and impact of EAC on viral suppression and factors associated with initial viral non-suppression among patients with an initial detectable VL, in a cohort of patients tested between October-2016 and September-2018. Methods This is a descriptive study of PLHA on ART who received VL testing and EAC during October-2016 to September-2018. Log-binomial regression was used to identify factors associated with a high VL. Results Among 3849 PLHA who underwent VL testing, 1603(42%) were female and median age was 42 years (IQR:35-48). Majority were referred for routine testing (3432(89%)) and clinical/immunological failure (233(6%)). Overall, 3402(88%) PLHA had suppressed VL at initial testing. Among 3432 tested for routine monitoring, 3141(92%) had VL suppressed. Of 291 with VL>1000c/ml, 253(87%) received EAC and after repeat VL, 70(28%) had VL<1000c/ ml. Among 233 referred for clinical/immunological failure, 122(52%) had VL>1000c/ml and 109 have been switched to second-line ART. CD4 count<500 (aOR-5.0[95%CI 3.8-6.5]), on ART for<5 years (aOR-1.5[1.1-2.0]) and age<15 years (aOR-5.2[3.0-8.9]) were associated with an initial VL>1000c/ml. Factors
While risk of tuberculosis (TB) is high among household contacts (HHCs) of pre-extensively drug r... more While risk of tuberculosis (TB) is high among household contacts (HHCs) of pre-extensively drug resistant (pre-XDR) TB and XDR-TB, data on yield of systematic longitudinal screening are lacking. We aim to describe the yield of systematic longitudinal TB contact tracing among HHCs of patients with pre-XDR-TB and XDR-TB. At the Médecins Sans Frontières (MSF) clinic, Mumbai, India a cohort comprising 518 HHCs of 109 pre-XDR and XDR index cases was enrolled between January 2016 and June 2018. Regular HHC follow-ups were done till one year post treatment of index cases. Of 518 HHCs, 23 had TB (21 on TB treatment and two newly diagnosed) at the time of first visit. Of the rest, 19% HHCs had no follow-ups. Fourteen (3.5%) TB cases were identified among 400 HHCs; incidence rate: 2072/100,000 person-years (95% CI: 1227–3499). The overall yield of household contact tracing was 3% (16/518). Of 14 who were diagnosed with TB during follow-up, six had drug susceptible TB (DSTB); six had pre-XDR-T...
BACKGROUND Government of India's Revised National TB Control Programme (RNTCP) has begun impl... more BACKGROUND Government of India's Revised National TB Control Programme (RNTCP) has begun implementing daily fixed dose combination (FDC) anti-TB treatment regimen for drug sensitive TB patients in which ethambutol is given for six months. Prolonged ethambutol use is known to cause ocular adverse drug events (ADE). OBJECTIVES To assess the magnitude of ocular ADEs in adult drug sensitive TB patients initiated on daily FDCs and to describe the demographic and clinical profile of patients with ocular ADEs. METHODS We conducted a retrospective cohort study involving review of RNTCP records of all adult (age >14 years) drug sensitive TB patients initiated on daily FDCs between1st January 2018 and 31st July 2018 in Thiruvananthapuram district, Kerala State, India. RESULTS 714 patients were initiated on daily FDCs during the study period. It was unknown whether all patients had undergone assessment for ocular ADEs. However, of these 714 patients, 8 patients (1.1%) were documented to have had ocular ADEs. Seven of these 8 patients had received ethambutol more than 15 mg/kg body weight and had developed ocular symptoms (decreased/blurring of vision) 3 months after TB treatment initiation. Ethambutol was stopped in all these 8 patients. In 5 patients it was recorded that ocular ADEs had resolved following stoppage of ethambutol and in the remaining it was unknown. CONCLUSION The study confirms the occurrence of ocular ADEs among drug sensitive TB patients on daily FDCs and recommends strengthening of systems for assessing, documenting and managing ocular ADE.
Médecins Sans Frontières (MSF) has been providing diagnosis and treatment for patients with tuber... more Médecins Sans Frontières (MSF) has been providing diagnosis and treatment for patients with tuberculosis (TB) via mobile clinics in conflict-affected border areas of Chhattisgarh, India since 2009. The study objectives were to determine the proportion of patients diagnosed with TB and those who were lost-to-follow-up (LTFU) prior to treatment initiation among patients with presumptive TB between April 2015 and August 2018. The study also compared bacteriological confirmation and pretreatment LTFU during two time periods: a) April 2015–August 2016 and b) April 2017–August 2018 (before and after the introduction of GeneXpert as a first diagnostic test). Community health workers (CHW) supported patient tracing. This study was a retrospective analysis of routine program data. Among 1042 patients with presumptive TB, 376 (36%) were diagnosed with TB. Of presumptive TB patients, the pretreatment LTFU was 7%. Upon comparing the two time-periods, bacteriological confirmation increased from ...
Background: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes... more Background: To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. Methods: This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May-August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. Results: Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. Conclusion: Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.
Background: Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and respon... more Background: Myanmar, a malaria endemic country of Southeast Asia, adopted surveillance and response strategy similar to "1-3-7" Chinese strategy to achieve sub-national elimination in six low-endemic region/states of the country. Among these, Yangon, Bago-East, and Mon region/states have implemented this malaria surveillance and response strategy with modification in 2016. The current study was conducted to assess the case notification, investigation, classification, and response strategy (NICR) in these three states. Methods: This was a retrospective cohort study using routine program data of all patients with malaria diagnosed and reported under the National Malaria Control Programme in 2016 from the above three states. As per the program, all malaria cases need to be notified within 1 day and investigated within 3 days of diagnosis and response to control (active case detection and control) should be taken for all indigenous malaria cases within 7 days of diagnosis. Results: A total of 959 malaria cases were diagnosed from the study area in 2016. Of these, the case NICR details were available only for 312 (32.5%) malaria cases. Of 312 cases, the case notification, investigation, and classification were carried out within 3 days of malaria diagnosis in 95.5% cases (298/312). Of 208 indigenous malaria cases (66.7%, 208/312), response to control was taken in 96.6% (201/208) within 7 days of diagnosis. Conclusion: The timeline at each stage of the strategy namely case notification, investigation, classification, and response to control was followed, and response action was taken in nearly all indigenous malaria cases for the available case information. Strengthening of health information and monitoring system is needed to avoid missing information. Future research on feasibility of mobile/tablet-based surveillance system and providing response to all cases including imported malaria can be further studied.
Background: The average expenditure incurred by patients in low-and middle-income countries towar... more Background: The average expenditure incurred by patients in low-and middle-income countries towards diagnosis and treatment of TB ranges from $55 to $8198. This out-ofpocket expenditure leads to impoverishment of households. One of the three main targets of the End TB Strategy (2016-2035) is that no TB-affected household suffers catastrophic costs due to TB. Study setting was free care under national tuberculosis program (NTP), Puducherry district, India. Objectives: The objectives of the study were among the newly diagnosed and previously treated tuberculosis (TB) patients, to (a) estimate patient costs during diagnosis and intensive phase of treatment, (b) determine the proportion of households experiencing catastrophic costs, and (c) explore coping strategies. Methods: An explanatory mixed methods design comprising both quantitative cost description and qualitative descriptive component was used. Catastrophic cost was defined as total TB care costs exceeding 20% of annual household income. Results: Of 102 TB patients included, two-thirds (69%) were male, 6% were HIV positive, and 45% reported at least one episode of hospitalization for TB care. The median (IQR) total cost of TB care was US$195 (52.1, 492.9) with a direct cost of US$65.3 (22.3, 156.5) and indirect cost of US$50.2 (0.9, 295.1). Overall, 32.4% of households experienced catastrophic costs due to TB care, significantly higher in patients with HIV coinfection (p = 0.009) and hospitalization (p = 0.009). Pledging jewels and borrowing money were major coping strategies. Cash assistance was the expected remedy from the patient perspective. Conclusion: Despite free TB care under NTP, more than a third incurred catastrophic costs towards TB care.
Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) ar... more Malaria is one of the major public health problems in Myanmar. Village health volunteers (VHV) are the key malaria diagnosis and treatment service provider at community level in addition to basic health staffs (BHS). This countrywide analysis aimed to assess and compare the accessibility to- and quality of malaria care (treatment initiation, treatment within 24 h and complete treatment delivery) between VHV and BHS in Myanmar. This was a retrospective cohort study using record review of routinely collected programme data available in electronic format. All patients with undifferentiated fever screened and diagnosed for malaria in January-December 2015 by VHV and BHS under National Malaria Control Programme in Myanmar were included in the study. Unadjusted and adjusted prevalence ratios (aPR) were calculated to assess the effect of VHV/BHS on receipt of treatment by patients. Of 978,735 undifferentiated fever patients screened in 2015, 11.0% of patients were found malaria positive an...
Uploads
Papers by Mrinalini Das