Journal Article > LetterFull Text
Eur Respir J. 30 May 2024; Volume 63 (Issue 5); 2400436.; DOI:10.1183/13993003.00436-2024
Mesic A, Decuyper I, Ishaq S, Azizi T, Hadi Ziamal F, et al.
Eur Respir J. 30 May 2024; Volume 63 (Issue 5); 2400436.; DOI:10.1183/13993003.00436-2024
Journal Article > ResearchFull Text
Glob Public Health. 1 January 2023; Volume 18 (Issue 1); 2058047.; DOI:10.1080/17441692.2022.2058047
Sitali N, Briskin E, Foday J, Walker C, Keus K, et al.
Glob Public Health. 1 January 2023; Volume 18 (Issue 1); 2058047.; DOI:10.1080/17441692.2022.2058047
Since 2015 Médecins Sans Frontières (MSF) has been supporting the Ministry of Health (MoH) in Tonkolili district, Sierra Leone, with an integrated health care approach at the community, primary health centre (PHC), and hospital level. This programme is planned to be handed over to MoH. To prepare for this handover, a qualitative study exploring elements of a successful handover was undertaken in 2019. Focus group discussions (FGD) with the community members (n-48) and in-depth interviews (IDI) with MSF staff, community leaders, and MoH staff in Sierra Leone (n-15) were conducted. Data were audio-recorded, transcribed verbatim from English, Creole, and Themne, coded, and thematically analysed. Participants expressed that an optimal project handover and exit strategy should be a continuous, long-term, the staggered process included from the inception of the programme design. It requires clear communication and relationship building by all relevant stakeholders and demands efficient resources and management capacity. Associated policy implications are applicable across humanitarian settings on the handover of programmes where the government is functional and willing to accept responsibilities.
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 31 January 2008
Keus K, Houston S, Melaku Y, Burling S
Trans R Soc Trop Med Hyg. 31 January 2008
This is a descriptive report of a pilot project of tuberculosis (TB) treatment in a conflict zone. A TB programme was implemented by Médecins Sans Frontières(MSF)-Holland in a semi-nomadic population in a very insecure and underdeveloped area of Upper Nile province in Southern Sudan. Outcome measures were operational feasibility, default rate, and sputum smear conversion at 4 months. A cohort of TB patients was admitted over a 10-week period (July-September 2001). Adherence strategy, project implementation, and and contingency planning were adapted to local conditions. The treatment regimen (4 HRZE [4-month daily supervised regimen] followed by 3EH or 3TH [3-month unsupervised regimen]: isoniazid (H), rifampicin (R), pyrazinamide (Z), ethambutol (E) and thiacetazone (T)) was a variant on the Manyatta regimen developed for semi-nomads in Kenya. Of 163 patients, 84 (52%) were children aged < 15 years. Lymph node TB comprised 34% and spinal TB 15% of all patients. Among adults, 41% had smear-positive pulmonary disease. Only 1 patient (0.6%) defaulted. All sputum smear-positive patients who completed 4 months of therapy converted to smear-negative, although 2 were subsequently found to have relapsed. TB in complex emergency situations is an underrecognized priority. Using an approach adapted especially to this setting, TB treatment was successfully implemented with minimal risk of promoting drug resistance, in an unstable setting.
Journal Article > ResearchFull Text
Trans R Soc Trop Med Hyg. 31 January 2008
van den Broek IVF, Gatkoi T, Lowoko B, Nzila A, Ochong E, et al.
Trans R Soc Trop Med Hyg. 31 January 2008
The current first-line and second-line drugs for Plasmodium falciparum malaria in South Sudan, chloroquine and sulfadoxine-pyrimethamine (SP), were evaluated and compared with amodiaquine, in an MSF-Holland-run clinic in eastern Upper Nile, South Sudan from June to December 2001. Patients with uncomplicated malaria and fever were stratified by age group and randomly allocated to one of 3 treatment regimes. A total of 342 patients was admitted and followed for 14 d after treatment. The dropout rate was 10.2%. Of those who completed the study, 104 were treated with chloroquine (25 mg/kg, 3 d), 102 with SP (25 mg/kg sulfadoxine and 1.25 mg/kg pyrimethamine, single dose) and 101 with amodiaquine (25 mg/kg, 3 d). Adequate clinical response was observed in 88.5% of patients treated with chloroquine, 100% of patients treated with SP and 94.1% of patients treated with amodiaquine. In children aged < 5 years, the success rate was lower: 83.3% for chloroquine and 93.0% for amodiaquine. In adults no treatment failures were found, but children aged 5-15 years showed intermediate levels. In addition, we determined the initial genotypes of dhfr and dhps of 44 isolates from the SP-treated group and > 80% were found to be wild type for dhfr and 100% for dhps. Two percent of isolates had a single mutation and 16% had double mutations of dhfr. These data are in full agreement with the clinical effectiveness of SP. A change in malaria treatment protocols for South Sudan is recommended.
Journal Article > ResearchFull Text
Trop Med Int Health. 3 January 2022; Volume 27 (Issue 2); 207-215.; DOI:10.1111/tmi.13716
Mesic A, Ishaq S, Khan WH, Mureed A, Mar HT, et al.
Trop Med Int Health. 3 January 2022; Volume 27 (Issue 2); 207-215.; DOI:10.1111/tmi.13716
OBJECTIVES
To describe the effect of adaptations to a person-centred care with short oral regimens on retention in care for rifampicin-resistant TB (RR-TB) in Kandahar province, Afghanistan.
METHODS
The study included people with RR-TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR-TB regimens. During the trial, person-centred care was adapted. We included the data from people living with RR-TB treated in the period before and after the care model was adapted and applied Kaplan-Meier statistics to compare rates of retention in care.
RESULTS
Of 236 patients registered in the RR-TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person-centred care, pre-treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost-to-follow-up on treatment and 3.3% died (n = 3/90).
CONCLUSIONS
As person-centred care delivery and treatment regimens were adapted to better fit-specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR-TB in Kandahar, Afghanistan.
To describe the effect of adaptations to a person-centred care with short oral regimens on retention in care for rifampicin-resistant TB (RR-TB) in Kandahar province, Afghanistan.
METHODS
The study included people with RR-TB registered in the programme between 01 October 2016 and 18 April 2021. From 19 November 2019, the programme implemented a trial investigating the safety and effectiveness of short oral RR-TB regimens. During the trial, person-centred care was adapted. We included the data from people living with RR-TB treated in the period before and after the care model was adapted and applied Kaplan-Meier statistics to compare rates of retention in care.
RESULTS
Of 236 patients registered in the RR-TB programme, 146 (61.9%) were registered before and 90 (38.1%) after the model of care was adapted. Before adaptations enhancing person-centred care, pre-treatment attrition was 23.3% (n = 34/146), whilst under the adapted care model it was 5.6% (n = 5/90). Attrition on treatment was 22.3% (n = 25/112) before adaptations, whilst during the study period none of the participants were lost-to-follow-up on treatment and 3.3% died (n = 3/90).
CONCLUSIONS
As person-centred care delivery and treatment regimens were adapted to better fit-specific contextual challenges and the needs of the target population, retention in care improved amongst people with RR-TB in Kandahar, Afghanistan.
Journal Article > ResearchFull Text
Bedaquiline and delamanid result in low rates of unfavourable outcomes among TB patients in Eswatini
Int J Tuberc Lung Dis. 1 October 2020; Volume 24; DOI:10.5588/ijtld.20.0082
Vambe D, Kay AW, Furin J, Howard AA, Dlamini T, et al.
Int J Tuberc Lung Dis. 1 October 2020; Volume 24; DOI:10.5588/ijtld.20.0082
SETTING: Since 2015, Eswatini has been scaling up bedaquiline (BDQ) and delamanid (DLM) based drug-resistant TB treatment regimens under programmatic conditions.
OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution.
DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.
RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.
CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
OBJECTIVE: Identification of factors associated with treatment outcomes in patients receiving BDQ and/or DLM either as a new treatment initiation or drug substitution.
DESIGN: This is a retrospective cohort study of patients receiving BDQ and/or DLM in Eswatini between March 2015 and October 2018. We describe factors associated with unfavourable treatment outcomes (death, lost to follow-up, treatment failure and amplification of resistance) and culture conversion using multivariable flexible parametric survival and competing-risks regression analyses.
RESULTS: Of 352 patients receiving BDQ and/or DLM, 7.8% and 21.2% had an unfavourable treatment outcome at 6 and 24 months, respectively. Predictors were age ≥ 60 years (adjusted hazard ratio aHR 4.49, 95%CI 1.61–12.57) vs. age 20–39 years, and a treatment regimen combining both drugs (aHR 4.49, 95%CI 1.61–12.57) vs. BDQ only. The probability of culture conversion was increased for two health facilities and patients with a poly resistance profile (adjusted sub-hazard ratio 2.01, 95%CI 1.13–3.59) vs. multidrug resistance.
CONCLUSION: Single use of BDQ or DLM was associated with low rates of unfavourable outcomes, suggesting that these medications may be effectively adopted at scale under routine programmatic conditions. Combined use of BDQ and DLM was a risk factor for unfavourable outcomes and should prompt for collection of more data on the combined use of these medications.
Conference Material > Abstract
Briskin E, Smith JS, Caleo GNC, Lenglet AD, Pearlman J, et al.
MSF Scientific Days International 2021: Research. 18 May 2021
INTRODUCTION
In April 2020, “shielding” (separate living spaces with enhanced infection control support for groups at high risk of severe COVID-19 disease) was proposed for COVID-19 prevention in settings where lockdown is not feasible (i.e. displaced persons camps). MSF used qualitative methods to explore community perceptions of shielding and other potential COVID-19 prevention measures applicable in settings where it works. Nigeria and Sierra Leone served as initial pilot sites for this multi-site study that ultimately included 13 countries.
METHODS
We carried out qualitative assessments between April and August 2020 within 9 MSF-supported sites in Nigeria and Sierra Leone, with the aim of exploring community perceptions of potential COVID-19 prevention measures. Sites in Nigeria included internally displaced camps in two states, and in Sierra Leone, an open village setting. We conducted multiple rounds of participant-led individual in-depth qualitative interviews in the study sites between April-August 2020. We recruited participants purposively, ensuring participants recruited were representative of underlying demographic and ethnic diversity. Data were coded by hand on paper copies of transcripts and in NVivo12 and analyzed for key themes. Findings were built on through iteration with participants.
ETHICS
This study was approved by the MSF Ethics Review Board and by the Ethical Review Boards of Benue State, Nigeria, Zamfara State, Nigeria, and the District Health Management team,
Tonkolilli, Sierra Leone.
RESULTS
Participants reported that access to both COVID-19 and non- COVID-19 care was challenging due to fear of infection and practical difficulties attending care facilities. Key priorities noted
by participants included obtaining food, masks and handwashing, and continuing to get access to non-COVID-19 healthcare. In Nigeria, shielding (providing separate dwellings for high-risk
people) was described as a challenge.
Reasons for this included close living conditions affecting practicality, its impact on mental health, and the community’s inter-generational reliance. Shielding was only seen as feasible
with sustained provision of resources for shielded persons including COVID testing, food from the family, mobile phones, and socially distanced visitation. For Sierra Leone, previous
experiences (e.g. war, Ebola) influenced fears of separation and the possibility of infection from contact with strangers and health workers or health facilities. Lockdowns and school
closures have a negative effect on support networks and local economies, and in Sierra Leone increased the perceived risk of sexual and gender-based violence and exploitation. Participants reported the desire for self-management of contact tracing and transmission prevention activities within their communities. Context-specific activities to address these priorities were implemented in response.
CONCLUSION
The community-based feedback provided a better understanding of attitudes towards and feasibility of COVID-19 control measures. Commonalities were reported across sites, while
differences in findings across sites highlighted the importance of context-specific engagement. Early and continued community engagement allowed context-specific activities to address these priorities to be implemented in partnership with communities in response. Implemented activities included enhancement of handwashing points, subsidizing locally-produced cloth masks, and reinforcement of prevention and control for non-COVID diseases such as malaria.
CONFLICTS OF INTEREST
None declared.
In April 2020, “shielding” (separate living spaces with enhanced infection control support for groups at high risk of severe COVID-19 disease) was proposed for COVID-19 prevention in settings where lockdown is not feasible (i.e. displaced persons camps). MSF used qualitative methods to explore community perceptions of shielding and other potential COVID-19 prevention measures applicable in settings where it works. Nigeria and Sierra Leone served as initial pilot sites for this multi-site study that ultimately included 13 countries.
METHODS
We carried out qualitative assessments between April and August 2020 within 9 MSF-supported sites in Nigeria and Sierra Leone, with the aim of exploring community perceptions of potential COVID-19 prevention measures. Sites in Nigeria included internally displaced camps in two states, and in Sierra Leone, an open village setting. We conducted multiple rounds of participant-led individual in-depth qualitative interviews in the study sites between April-August 2020. We recruited participants purposively, ensuring participants recruited were representative of underlying demographic and ethnic diversity. Data were coded by hand on paper copies of transcripts and in NVivo12 and analyzed for key themes. Findings were built on through iteration with participants.
ETHICS
This study was approved by the MSF Ethics Review Board and by the Ethical Review Boards of Benue State, Nigeria, Zamfara State, Nigeria, and the District Health Management team,
Tonkolilli, Sierra Leone.
RESULTS
Participants reported that access to both COVID-19 and non- COVID-19 care was challenging due to fear of infection and practical difficulties attending care facilities. Key priorities noted
by participants included obtaining food, masks and handwashing, and continuing to get access to non-COVID-19 healthcare. In Nigeria, shielding (providing separate dwellings for high-risk
people) was described as a challenge.
Reasons for this included close living conditions affecting practicality, its impact on mental health, and the community’s inter-generational reliance. Shielding was only seen as feasible
with sustained provision of resources for shielded persons including COVID testing, food from the family, mobile phones, and socially distanced visitation. For Sierra Leone, previous
experiences (e.g. war, Ebola) influenced fears of separation and the possibility of infection from contact with strangers and health workers or health facilities. Lockdowns and school
closures have a negative effect on support networks and local economies, and in Sierra Leone increased the perceived risk of sexual and gender-based violence and exploitation. Participants reported the desire for self-management of contact tracing and transmission prevention activities within their communities. Context-specific activities to address these priorities were implemented in response.
CONCLUSION
The community-based feedback provided a better understanding of attitudes towards and feasibility of COVID-19 control measures. Commonalities were reported across sites, while
differences in findings across sites highlighted the importance of context-specific engagement. Early and continued community engagement allowed context-specific activities to address these priorities to be implemented in partnership with communities in response. Implemented activities included enhancement of handwashing points, subsidizing locally-produced cloth masks, and reinforcement of prevention and control for non-COVID diseases such as malaria.
CONFLICTS OF INTEREST
None declared.
Journal Article > ResearchFull Text
PLOS One. 17 October 2018; Volume 13 (Issue 10); e0205601.; DOI:10.1371/journal.pone.0205601
Verdecchia M, Keus K, Blankley S, Vambe D, Ssonko C, et al.
PLOS One. 17 October 2018; Volume 13 (Issue 10); e0205601.; DOI:10.1371/journal.pone.0205601
INTRODUCTION
Since 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.
METHOD
We conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient's univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.
RESULTS
From the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28-42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.
CONCLUSIONS
A model of care that included psychosocial support and patient's enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.
Since 2011 Médecins sans Frontières together with the eSwatini Ministry of Health have been managing patients with multi-drug resistant tuberculosis (MDR-TB) at Matsapha and Mankayane in Manzini region. This analysis describes the model of care and outcomes of patients receiving a 20 months MDR-TB treatment regimen between 2011 and 2013.
METHOD
We conducted a retrospective observational cohort study of MDR-TB patients enrolled for treatment between May 2011 and December 2013. An extensive package of psychological care and socio-economic incentives were provided including psychological support, paid treatment supporters, transport fees and a monthly food package. Baseline demographic details and treatment outcomes were recorded and for HIV positive patient's univariate analysis as well as a cox regression hazard model were undertaken to assess risk factors for unfavorable outcomes.
RESULTS
From the 174 patients enrolled, 156 (89.7%) were HIV co-infected, 102 (58.6%) were female, median age 33 years old (IQR: 28-42), 55 (31.6%) had a BMI less than 18 and 86 (49.4%) had not been previously treated for any form of TB. Overall cohort outcomes revealed a 75.3% treatment success rate, 21.3% mortality rate, 0.6% failure and 0.6% lost to follow-up rate. In the adjusted multivariate analysis, low BMI and low CD4 count at treatment initiation were associated with an increased risk of unfavorable outcome.
CONCLUSIONS
A model of care that included psychosocial support and patient's enablers led to a high level of treatment success with a very low lost to follow up rate. Limiting the overall treatment success was a high mortality rate which was associated with advanced HIV and a low BMI at presentation. These factors will need to be addressed in order to improve upon the overall treatment success rate in future.
Journal Article > ResearchFull Text
Am J Trop Med Hyg. 1 August 2003; Volume 69 (Issue 22); 184-187.
Ochong E, van den Broek IVF, Keus K, Nzila A
Am J Trop Med Hyg. 1 August 2003; Volume 69 (Issue 22); 184-187.
Amodiaquine, a 4-aminoquinoline compound, is being considered as an alternative to chloroquine and pyrimethamine/sulfadoxine where resistance in Plasmodium falciparum to both drugs has been selected. Although amodiaquine is more potent than chloroquine, its effectiveness is reduced in areas where chloroquine resistance is high. We report an association of the P. falciparum chloroquine resistance transporter (pfcrt) gene and the P. falciparum multiple drug resistance 1 (pfmdr1) gene, two chloroquine resistance markers, with chloroquine and amodiaquine efficacy in vivo in southern Sudan. The data show that the allele of the pfcrt gene with a lysine to threonine change at codon 76 is strongly associated with both chloroquine and amodiaquine resistance. No such association was observed with the pfmdr1 gene.
Journal Article > ResearchFull Text
PLoS Negl Trop Dis. 8 June 2010; Volume 4 (Issue 6); DOI:10.1371/journal.pntd.0000705
Gorski S, Collin SM, Ritmeijer KKD, Keus K, Gatluak F, et al.
PLoS Negl Trop Dis. 8 June 2010; Volume 4 (Issue 6); DOI:10.1371/journal.pntd.0000705
BACKGROUND: Risk factors associated with L. donovani visceral leishmaniasis (VL; kala azar) relapse are poorly characterized. METHODS: We investigated patient characteristics and drug regimens associated with VL relapse using data from Médecins Sans Frontières - Holland (MSF) treatment centres in Southern Sudan. We used MSF operational data to investigate trends in VL relapse and associated risk factors. RESULTS: We obtained data for 8,800 primary VL and 621 relapse VL patients treated between 1999 and 2007. Records of previous treatment for 166 VL relapse patients (26.7%) were compared with 7,924 primary VL patients who had no record of subsequent relapse. Primary VL patients who relapsed had larger spleens on admission (Hackett grade >or=3 vs 0, odds ratio (OR) for relapse = 3.62 (95% CI 1.08, 12.12)) and on discharge (Hackett grade >or=3 vs 0, OR = 5.50 (1.84, 16.49)). Age, sex, malnutrition, mobility, and complications of treatment were not associated with risk of relapse, nor was there any trend over time. Treatment with 17-day sodium stibogluconate/paromomycin (SSG/PM) combination therapy vs 30-day SSG monotherapy was associated with increased risk of relapse (OR = 2.08 (1.21, 3.58)) but reduced risk of death (OR = 0.27 (0.20, 0.37)), although these estimates are likely to be residually confounded. MSF operational data showed a crude upward trend in the proportion of VL relapse patients (annual percentage change (APC) = 11.4% (-3.4%, 28.5%)) and a downward trend in deaths (APC = -18.1% (-22.5%, -13.4%)). CONCLUSIONS: Splenomegaly and 17-day SSG/PM vs 30-day SSG were associated with increased risk of VL relapse. The crude upward trend in VL relapses in Southern Sudan may be attributable to improved access to treatment and reduced mortality due to SSG/PM combination therapy.