Anh Duc Ngo

Road traffic related mortality in Vietnam: Evidence for policy from a national sample mortality surveillance system

BackgroundRoad traffic injuries (RTIs) are among the leading causes of mortality in Vietnam. However, mortality data collection systems in Vietnam in general and for RTIs in particular, remain inconsistent and incomplete. Underlying distributions of external causes and body injuries are not available from routine data collection systems or from studies till date. This paper presents characteristics, user type pattern, seasonal distribution, and causes of 1,061 deaths attributable to road crashes ascertained from a national sample mortality surveillance system in Vietnam over a two-year period (2008 and 2009).MethodsA sample mortality surveillance system was designed for Vietnam, comprising 192 communes in 16 provinces, accounting for approximately 3% of the Vietnamese population. Deaths were identified from commune level data sources, and followed up by verbal autopsy (VA) based ascertainment of cause of death. Age-standardised mortality rates from RTIs were computed. VA questionnaires were analysed in depth to derive descriptive characteristics of RTI deaths in the sample.ResultsThe age-standardized mortality rates from RTIs were 33.5 and 8.5 per 100,000 for males and females respectively. Majority of deaths were males (79%). Seventy three percent of all deaths were aged from 15 to 49 years and 58% were motorcycle users. As high as 80% of deaths occurred on the day of injury, 42% occurred prior to arrival at hospital, and a further 29% occurred on-site. Direct causes of death were identified for 446 deaths (42%) with head injuries being the most common cause attributable to road traffic injuries overall (79%) and to motorcycle crashes in particular (78%).ConclusionThe VA method can provide a useful data source to analyse RTI mortality. The observed considerable mortality from head injuries among motorcycle users highlights the need to evaluate current practice and effectiveness of motorcycle helmet use in Vietnam. The high number of deaths occurring on-site or prior to hospital admission indicates a need for effective pre-hospital first aid services and timely access to emergency facilities. In the absence of standardised death certification, sustained efforts are needed to strengthen mortality surveillance sites supplemented by VA to support evidence based monitoring and control of RTI mortality.

Structural Barriers to Timely Initiation of Antiretroviral Treatment in Vietnam: Findings from Six Outpatient Clinics

In Vietnam, premature mortality due to AIDS-related conditions is commonly associated with late initiation to antiretroviral therapy (ART). This study explores reasons for late ART initiation among people living with HIV (PLHIV) from the perspectives of health care providers and PLHIV. The study was undertaken in six clinics from five provinces in Vietnam. Baseline CD4 counts were collected from patient records and grouped into three categories: very late initiators (≤100 cells/mm3 CD4), late initiators (100–200 cells/mm3) and timely initiators (200–350 cells/mm3). Thirty in-depth interviews with patients who started ART and 15 focus group discussions with HIV service providers were conducted and thematic analysis of the content performed. Of 934 patients, 62% started ART very late and 11% initiated timely treatment. The proportion of patients for whom a CD4 count was obtained within six months of their HIV diagnosis ranged from 22% to 72%. The proportion of patients referred to ART clinics by voluntary testing and counselling centres ranged from 1% to 35%. Structural barriers to timely ART initiation were poor linkage between HIV testing and HIV care and treatment services, lack of patient confidentiality and a shortage of HIV/AIDS specialists. If Vietnam’s treatment practice is to align with WHO recommendations then the connection between voluntary counselling and testing service and ART clinics must be improved. Expansion and decentralization of HIV/AIDS services to allow implementation at the community level increased task sharing between doctors and nurses to overcome limited human resources, and improved patient confidentiality are likely to increase timely access to HIV treatment services for more patients.

Trends in and determinants of loss to follow up and early mortality in a rapid expansion of the antiretroviral treatment program in Vietnam: findings from 13 outpatient clinics.

Background This study aims to describe the trends in and determinants of six month mortality and loss to follow up (LTFU) during 2005–2009 in 13 outpatient clinics in Vietnam. Method Data were obtained from clinical records of 3,449 Vietnamese HIV/AIDS patients aged 18 years or older who initiated ART between 1 January 2005 and 31 December 2009. Mantel-Haenszel chi-square test, log rank test were conducted to examine the trends of baseline characteristics, six month mortality and LTFU. Cox proportional hazards regression models were performed to compute hazard ratio (HR) and 95% Confidence Interval (CI). Results Though there was a declining trend, the incidence of six month mortality and LTFU remained as high as 6% and 15%, respectively. Characteristics associated with six month mortality were gender (HR females versus males 0.54, 95%CI: 0.34–0.85), years of initiation (HR 2009 versus 2005 0.54, 95%CI: 0.41–0.80), low baseline CD4 (HR 350–500 cells/mm3 versus <50 cells/mm3 0.26, 95%CI: 0.18–0.52), low baseline BMI (one unit increase: HR 0.96, 95%CI: 0.94–0.97), co-infection with TB (HR 1.61, 95%CI: 1.46–1.95), history of injecting drugs (HR 1.58, 95%CI: 1.31–1.78). Characteristics associated with LTFU were younger age (one year younger: HR 0.97, 95%CI: 0.95–0.98), males (HR females versus males 0.82, 95%CI: 0.63–0.95), and poor adherence (HR 0.55, 95%CI: 0.13–0.87). Conclusions To reduce early mortality, special attention is required to ensure timely access to ART services, particularly for patients at higher risk. Patients at risk for LTFU after ART initiation should be targeted through enhancing treatment counselling and improving patient tracing system at ART clinics.

Voices from Vietnam: experiences of children and youth with disabilities, and their families, from an Agent Orange affected rural region

This study examines the experiences of young people with disabilities from ethnic minorities, and their families, in central Vietnam. The study is set in an area contaminated by Agent Orange during the Vietnam War. Data were gathered from interviews with youth with disabilities and interviews and focus groups with mothers who had children with disabilities. Respondents expressed confronting multiple barriers to inclusion, education, health and well-being similar to other persons with disabilities and their families from around the world. Participants sought broad-ranging human rights as they described experiencing stigmatization and marginalization from negative social reaction toward disabilities and by residing in a location known for dioxin contamination. The participants’ voices are not only important in informing program responses to support implementation of Vietnam’s new National Law on Persons with Disabilities, but also timely as the US government considers proposed legislation providing material support for Vietnamese nationals affected by Agent Orange.

The use of reproductive healthcare at commune health stations in a changing health system in Vietnam.

BackgroundWith health sector reform in Vietnam moving towards greater pluralism, commune health stations (CHSs) have been subject to growing competition from private health services and increasing numbers of patients bypassing CHSs for higher-level health facilities. This study describes the pattern of reproductive health (RH) and family planning (FP) service utilization among women at CHSs and other health facilities, and explores socio-demographic determinants of RH service utilization at the CHS level.MethodsThis study was based on a cross-sectional survey conducted in Thua Thien Hue and Vinh Long provinces, using a multi-stage cluster sampling technique. Questionnaire-based interviews with 978 ever-married women at reproductive age provided data on socio-demographic characteristics, current use of FP methods, history of RH service use, and the health facility attended for their most recent services. Multiple logistic regression analyses were used to identify socio-demographic determinants of their use of CHS RH services.ResultsEighty nine percent of ever-married women reported current use of birth control with 49% choosing intra-uterine device (IUD). Eighty nine percent of pregnant women attended facility-based antenatal care (ANC) with 62% having at least 3 check-ups during their latest pregnancy. Ninety one percent of mothers had their last delivery in a health facility. Seventy-one percent of respondents used CHS for IUD insertion, 55% for antenatal check-ups, and 77% gynecological examination. District and provincial/central hospitals dominated the provision of delivery service, used by 57% of mothers for their latest delivery. The percentage of women opting for private ANC services was reported at 35%, though the use of private delivery services was low (11%). Women who were farmers, earning a lower income, having more than 2 children, and living in a rural area were more likely than others to use ANC, delivery, and/or gynecological check-up services at the CHS.ConclusionsWomen choice of providers for FP and RH services that help them plan and protect their pregnancies is driven by socio-economic factors. While the CHS retains significant utilization rates, it is under challenge by preferences for hospital-based delivery and the growing use of private ANC services.

Determinants of virological failure after 1 year's antiretroviral therapy in Vietnamese people with HIV: findings from a retrospective cohort of 13 outpatient clinics in six provinces

Objective This study examines the proportions and causes of virological failure after one year of antiretroviral therapy (ART) among people living with HIV (PLHIV) in Vietnam. It also evaluates the positive predictive value (PPV) of immunological criteria to detect treatment failure. Method A retrospective cohort of 3449 people with HIV who started ART between 1 January 2005 and 31 December 2009 in 13 outpatient clinics in Vietnam was studied. Multivariate logistic regression modeling was used to calculate crude and adjusted ORs and 95% CIs for associations between patient characteristics and virological failure. Results An estimated 6.5% (226/3449) of HIV patients in the participating clinics in Vietnam had confirmed virological failure one year after the start of ART. After adjusting for other factors, patients with a baseline CD4 count of 50–100 cells/mm3 and 101–200 cells/mm3 were statistically significantly less likely to have virological failure, compared to those with a baseline CD4 count lower than 50 cells/mm3 (OR=0.61, 95% CI 0.23–0.89; and OR=0.43, 0.18–0.78, respectively). In contrast, patients with a history of injecting drug use were statistically significantly more likely to have viraemia than otherwise (OR=1.32, 1.16–1.67). The PPV of the WHO immunological criteria was 60.1% (57.1–69.3%). Conclusions Routine viral load tests should be conducted early to detect virological failure and prevent unnecessary changes to second-line treatments. To improve treatment outcomes, timely ART initiation and adherence to treatment among those with history of injecting drug use should be promoted.

Determinants of antiretroviral therapy initiation and treatment outcomes for people living with HIV in Vietnam.

Abstract Objectives: This study explores patient characteristics that are significantly associated with very late combination antiretroviral therapy (cART) initiation (CD4 count ≤100 cells/mm3) and examines the association between patient characteristics and treatment outcomes, CD4 recovery, and mortality. Design: Data were obtained from the clinical records of 2,198 HIV/AIDS patients in 13 outpatient clinics across 6 provinces in Vietnam. Methods: Multivariate logistic regression and Cox proportional hazards regression were used to identify patient characteristics that are significantly associated with very late cART initiation and to measure relationships between patient characteristics and treatment outcomes. Results: Very late cART initiation was significantly associated with being male compared with female (odds ratio [OR], 0.36; 95% CI, 0.23–0.58), becoming HIV infected through injecting drugs (OR, 2.13; 95% CI, 1.09–4.14), and having opportunistic infections at cART initiation (OR, 1.69; 95% CI, 1.02–2.86). Being male (female vs male: hazard ratio [HR], 0.45; 95% CI, 0.20–0.98), very late cART initiation (timely vs late: HR, 0.18; 95% CI, 0.04–0.72), low baseline body mass index (BMI) (HR, 0.95; 95% CI, 0.92–0.98), and later baseline WHO clinical stage (WHO clinical stage IV vs combined group of stage I and II: HR, 5.70; 95% CI, 3.90–7.80) were significantly associated with death, whereas being female compared with male (HR, 1.51; 95% CI, 1.14–1.99) and timely cART initiation (HR, 35.45; 95% CI, 13.67–91.91) were significant predictors of CD4 recovery. Conclusions: Timely testing of patients for HIV, increasing use of CD4 count testing services, and starting cART earlier are essential to reduce mortality and improve treatment outcomes.

Cost-effectiveness of antiretroviral therapy expansion strategies in Vietnam

This study determines an optimal strategy for scaling up ART in Vietnam by examining three initiation thresholds [350 cells/mm(3), 500 cells/mm(3), and treat all people living with HIV (PLHIV) regardless of CD4 cell counts] and treatment commencement rates among treatment-eligible PLHIV ranging from 5% to 100% within 12 months of diagnosis. Incremental cost-effectiveness ratios (ICERs) were calculated using a Markov model, based on data from a cohort of 3449 patients who initiated ART between January 1, 2005 and December 31, 2009 in 13 outpatient clinics across six provinces in Vietnam. Our analyses indicated that raising treatment eligibility criteria, in line with WHO guidelines (CD4 ≤500 cells/mm(3)) or removing CD4-based criteria would both be cost-effective in Vietnam. However, the cost-effective strategy from an economic viewpoint is first to increase coverage substantially among those with lowest CD4 levels, and only when coverage increases towards saturation should initiation criteria be lifted. Universal coverage under current guidelines would cost an additional

Area-level socioeconomic characteristics and incidence of metabolic syndrome: a prospective cohort study

85 million and

Population-level approaches to achieve universal public health: the role of evidence and politics involved in the tobacco control policy in Vietnam

96 million per year if the treatment threshold was 500 cells/mm(3). These scenarios would avert 15,000 and 22,000 HIV-related deaths in 2010-2019, with ICERs of