Walter Kizito

The Structured Operational Research and Training Initiative for public health programmes

In 2009, the International Union Against Tuberculosis and Lung Disease (The Union) and Médecins sans Frontières Brussels-Luxembourg (MSF) began developing an outcome-oriented model for operational research training. In January 2013, The Union and MSF joined with the Special Programme for Research and Training in Tropical Diseases (TDR) at the World Health Organization (WHO) to form an initiative called the Structured Operational Research and Training Initiative (SORT IT). This integrates the training of public health programme staff with the conduct of operational research prioritised by their programme. SORT IT programmes consist of three one-week workshops over 9 months, with clearly-defined milestones and expected output. This paper describes the vision, objectives and structure of SORT IT programmes, including selection criteria for applicants, the research projects that can be undertaken within the time frame, the programme structure and milestones, mentorship, the monitoring and evaluation of the programmes and what happens beyond the programme in terms of further research, publications and the setting up of additional training programmes. There is a growing national and international need for operational research and related capacity building in public health. SORT IT aims to meet this need by advocating for the output-based model of operational research training for public health programme staff described here. It also aims to secure sustainable funding to expand training at a global and national level. Finally, it could act as an observatory to monitor and evaluate operational research in public health. Criteria for prospective partners wishing to join SORT IT have been drawn up.

Liposomal amphotericin B for complicated visceral leishmaniasis (kala-azar) in eastern Sudan: how effective is treatment for this neglected disease?

The aim of this study was to report the patient profile and treatment outcomes, including relapses, of patients with visceral leishmaniasis (VL) treated with liposomal amphotericin B (AmBisome) in Gedaref, Sudan.

Demographic characteristics and opportunistic diseases associated with attrition during preparation for antiretroviral therapy in primary health centres in Kibera, Kenya.

Using routine data from HIV‐positive adult patients eligible for antiretroviral therapy (ART), we report on routinely collected demographic characteristics and opportunistic diseases associated with pre‐ART attrition (deaths and loss to follow‐up). Among 2471 ART eligible patients, enrolled between January 2005 and November 2008, 446(18%) were lost to attrition pre‐ART. Adjusted risk factors significantly associated with pre‐ART attrition included age <35 years (Odds Ratio, OR 1.4, 95% Confidence Interval, CI 1.1–1.8), severe malnutrition (OR 1.5, 95% CI 1.1–2.0), active pulmonary tuberculosis (OR 1.6, 95% CI 1.1–2.4), severe bacterial infections including severe bacterial pneumonia (OR 1.9, 95% CI 1.2–2.8) and prolonged unexplained fever (>1 month), (OR 2.6, 95% CI 1.3–5.2). This study highlights a number of clinical markers associated with pre‐ART attrition that could serve as ‘pointers’ or screening tools to identify patients who merit fast‐tracking onto ART and/or closer clinical attention and follow‐up.

HIV with non-communicable diseases in primary care in Kibera, Nairobi, Kenya: characteristics and outcomes 2010–2013

BACKGROUND Antiretroviral therapy (ART) has increased the life expectancy of people living with HIV (PLHIV); HIV is now considered a chronic disease. Non-communicable diseases (NCDs) and HIV care were integrated into primary care clinics operated within the informal settlement of Kibera, Nairobi, Kenya. We describe early cohort outcomes among PLHIV and HIV-negative patients, both of whom had NCDs. METHODS A retrospective analysis was performed of routinely collected clinic data from January 2010 to June 2013. All patients >14 years with hypertension and/or diabetes were included. RESULTS Of 2206 patients included in the analysis, 210 (9.5%) were PLHIV. Median age at enrollment in the NCD program was 43 years for PLHIV and 49 years for HIV-negative patients (p<0.0001). The median duration of follow up was 1.4 (IQR 0.7-2.1) and 1.0 (IQR 0.4-1.8) years for PLHIV and HIV-negative patients, respectively (p=0.003). Among patients with hypertension, blood pressure outcomes were similar, and for those with diabetes, outcomes for HbA1c, fasting glucose and cholesterol were not significantly different between the two groups. The frequency of chronic kidney disease (CKD) was 12% overall. Median age for PLHIV and CKD was 50 vs 55 years for those without HIV (p=0.005). CONCLUSIONS In this early comparison of PLHIV and HIV-negative patients with NCDs, there were significant differences in age at diagnosis but both groups responded similarly to treatment. This study suggests that integrating NCD care for PLHIV along with HIV-negative patients is feasible and achieves similar results.

Caseload, management and treatment outcomes of patients with hypertension and/or diabetes mellitus in a primary health care programme in an informal setting

In three primary health care clinics run by Médecins Sans Frontières in the informal settlement of Kibera, Nairobi, Kenya, we describe the caseload, management and treatment outcomes of patients with hypertension (HT) and/or diabetes mellitus (DM) receiving care from January 2010 to June 2012.

Applying the ICMJE authorship criteria to operational research in low-income countries: the need to engage programme managers and policy makers

1 Medical Department (Operational Research Unit), Medecins sans Frontieres, Operational Centre Brussels, MSF-Luxembourg, Luxembourg, Luxembourg 2 Department of Molecular and Cellular Interactions, Flemish Institute of Biotechnology, Brussels, Belgium 3 Department of Microbiology, Institute of Tropical Medicine, Antwerp, Belgium 4 Department of Obstetrics and Gynecology, University of Nairobi, Nairobi, Kenya 5 Centre for International Health, University of Bergen, Bergen, Norway 6 Center for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France 7 International Union Against TB and Lung Disease, Kampala, Uganda 8 Medecins Sans Frontieres, Addis Ababa, Ethiopia 9 International Union Against Tuberculosis and Lung Disease, South East Asia office, New Delhi, India 10 Medecins Sans Frontieres, Somali Mission, Somalia 11 Medecins Sans Frontieres, Bujumbura, Burundi 12 National Institute for Medical Research, Dar Es Salaam, Tanzania 13 National Tuberculosis Control Programme, Harare, Zimbabwe 14 Medecins Sans Frontieres, Capetown, South Africa 15 Medecins Sans Frontieres, Nairobi, Kenya 16 Joint Center for Bioethics, University of Toronto, Toronto, Canada 17 London School of Hygiene and Tropical Medicine, London, UK

Task Shifting the Management of Non-Communicable Diseases to Nurses in Kibera, Kenya: Does It Work?

Background In sub-Saharan Africa there is an increasing need to leverage available health care workers to provide care for non-communicable diseases (NCDs). This study was conducted to evaluate adherence to Médecins Sans Frontières clinical protocols when the care of five stable NCDs (hypertension, diabetes mellitus type 2, epilepsy, asthma, and sickle cell) was shifted from clinical officers to nurses. Methods Descriptive, retrospective review of routinely collected clinic data from two integrated primary health care facilities within an urban informal settlement, Kibera, Nairobi, Kenya (May to August 2014). Results There were 3,554 consultations (2025 patients); 733 (21%) were by nurses out of which 725 met the inclusion criteria among 616 patients. Hypertension (64%, 397/616) was the most frequent NCD followed by asthma (17%, 106/616) and diabetes mellitus (15%, 95/616). Adherence to screening questions ranged from 65% to 86%, with an average of 69%. Weight and blood pressure measurements were completed in 89% and 96% of those required. Laboratory results were reviewed in 91% of indicated visits. Laboratory testing per NCD protocols was higher in those with hypertension (88%) than diabetes mellitus (67%) upon review. Only 17 (2%) consultations were referred back to clinical officers. Conclusion Nurses are able to adhere to protocols for managing stable NCD patients based on clear and standardized protocols and guidelines, thus paving the way towards task shifting of NCD care to nurses to help relieve the significant healthcare gap in developing countries.

Antiretroviral treatment uptake and attrition among HIV-positive patients with tuberculosis in Kibera, Kenya

Using data of human immunodeficiency virus‐positive patients with tuberculosis from three primary care clinics in Kibera slums, Nairobi, Kenya, we report on the proportion that started antiretroviral treatment (ART) and attrition (deaths, lost to follow‐up and stopped treatment) before and while on ART. Of 427 ART eligible patients, enrolled between January 2004 and December 2008, 70% started ART, 19% were lost to attrition and 11% had not initiated ART. Of those who started ART, 14% were lost to attrition, making a cumulative pre‐ART and ART attrition of 33%. ART uptake among patients with TB was relatively good, but programme attrition was high and needs urgent addressing.

Preventable but neglected: rickets in an informal settlement Nairobi, Kenya

SETTING The primary care clinics of Médecins Sans Frontières within the informal settlement of Kibera, Nairobi, Kenya. OBJECTIVE To describe the demographic and clinical characteristics of children clinically diagnosed with rickets from September 2012 to October 2013. DESIGN Descriptive retrospective case review of diagnosis and treatment course with vitamin D and calcium using routine programme data. RESULTS Of the 82 children who met the clinical diagnosis of rickets, 57% were male, with a median age of 12 months and 14 months for females. Children with rickets were found to have ⩽3 hours/week sunlight exposure for 71% of the children and malnutrition in 39%. Clinical findings on presentation revealed gross motor developmental delays in 44%. The loss to follow-up rate during treatment was 40%. CONCLUSIONS This study found that rickets is a common clinical presentation among children living in the informal settlement of Kibera and that there are likely multiple factors within that environment contributing to this condition. As rickets is a simply and inexpensively preventable non-communicable disease, we suggest that routine vitamin D supplementation be formally recommended by the World Health Organization for well-child care in Africa, especially in the contexts of informal settlements.

High mortality in tuberculosis patients despite HIV interventions in Swaziland.

SETTING All health facilities providing tuberculosis (TB) care in Swaziland. OBJECTIVE To describe the impact of human immunodeficiency virus (HIV) interventions on the trend of TB treatment outcomes during 2010-2013 in Swaziland; and to describe the evolution in TB case notification, the uptake of HIV testing, antiretroviral therapy (ART) and cotrimoxazole preventive therapy (CPT), and the proportion of TB-HIV co-infected patients with adverse treatment outcomes, including mortality, loss to follow-up and treatment failure. DESIGN A retrospective descriptive study using aggregated national TB programme data. RESULTS Between 2010 and 2013, TB case notifications in Swaziland decreased by 40%, HIV testing increased from 86% to 96%, CPT uptake increased from 93% to 99% and ART uptake among TB patients increased from 35% to 75%. The TB-HIV co-infection rate remained around 70% and the proportion of TB-HIV cases with adverse outcomes decreased from 36% to 30%. Mortality remained high, at 14-16%, over the study period, and anti-tuberculosis treatment failure rates were stable over time (<5%). CONCLUSION Despite high CPT and ART uptake in TB-HIV patients, mortality remained high. Further studies are required to better define high-risk patient groups, understand the reasons for death and design appropriate interventions.