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1.  Care-Seeking and Management of Common Childhood Illnesses in Tanzania – Results from the 2010 Demographic and Health Survey 
PLoS ONE  2013;8(3):e58789.
Background
Malaria, pneumonia and diarrhoea continue to kill millions of children in Africa despite the available and effective treatments. Correct diagnosis and prompt treatment with effective drugs at the first option consulted for child care is crucial for preventing severe disease and death from these illnesses. Using the 2010 Demographic and Health Survey data, the present study aims to assess care-seeking and management of suspected malaria, pneumonia and diarrhoea at various health care facilities in Tanzania.
Methods
We analyzed data for 8176 children born within a 5 years period preceding the survey.The information was collected by interviewing 5519 women aged 15–49 years in 10,300 households selected from 475 sample points throughout Tanzania.
Results
The most common first option for child care was PHC facilities (54.8%), followed by private pharmacies (23.4%). These were more commonly utilized in rural compared to urban areas: 61.2% versus 34.5% for PHC facilities, and 26.5% versus 17.7% for pharmacies. Women in urban areas and those with higher level of education more commonly utilized higher level hospitals and private facilities as their first option for child care. Only one in four children with fever had received a blood test during the illness with lowest proportion being reported among children solely attended at PHC facilities. Use of abandoned antimalarial drugs for the treatment of suspected malaria was also observed in public health facilities and antibiotics use for diarrhoea treatment was high (49.0%).
Conclusions
PHC facilities and pharmacies most commonly provided sub-optimal care. These facilities were more commonly utilized as the first option for child care in rural areas and among the poor and non-educated families. These are groups with the highest child mortality, which calls for interventions’ targeting improvement of care at these facilities to further reduce child mortality from treatable illnesses in Tanzania.
doi:10.1371/journal.pone.0058789
PMCID: PMC3595288  PMID: 23554926
2.  Comparing HIV prevalence estimates from prevention of mother-to-child HIV transmission programme and the antenatal HIV surveillance in Addis Ababa 
BMC Public Health  2012;12:1113.
Background
In the absence of reliable data, antenatal HIV surveillance has been used to monitor the HIV epidemic since the late 1980s. Currently, routine data from Prevention of Mother-to-child HIV transmission (PMTCT) programmes are increasingly available. Evaluating whether the PMTCT programme reports provide comparable HIV prevalence estimates with the antenatal surveillance reports is important. In this study, we compared HIV prevalence estimates from routine PMTCT programme and antenatal surveillance in Addis Ababa with the aim to come up with evidence based recommendation.
Methods
Summary data were collected from PMTCT programmes and antenatal surveillance reports within the catchment of Addis Ababa. The PMTCT programme data were obtained from routine monthly reports from 2004 to 2009 and from published antenatal HIV surveillance reports from 2003 to 2009. Data were analysed using descriptive statistics.
Results
In Addis Ababa, PMTCT sites had increased from six in 2004 to 54 in 2009. The site expansion was accompanied by an increased number of women testing. There were marked increases in the rate of HIV testing following the introduction of routine opt-out HIV testing approach. Paralleling these increases, the HIV prevalence showed a steady decline from 10.0% in 2004 to 4.5% in 2009. There were five antenatal surveillance sites from 2003 to 2007 in Addis Ababa and they increased to seven by 2009. Four rounds of surveillance data from five sites showed a declining trend in HIV prevalence over the years. The overall antenatal surveillance data also showed that the HIV prevalence among antenatal attendees had declined from 12.4% in 2003 to 5.5% in 2009. The HIV prevalence estimates from PMTCT programme were 6.2% and 4.5% and from antenatal surveillance 6.1 and 5.5% in 2008 and 2009 respectively.
Conclusions
There were consistent HIV prevalence estimates from PMTCT programme and from antenatal surveillance reports. Both data sources showed a marked decline in HIV prevalence among antenatal care attendees in Addis Ababa. This study concludes that the routine data from the PMTCT programmes in Addis Ababa provides comparable HIV prevalence estimates with antenatal HIV surveillance data and could be used for monitoring trends.
doi:10.1186/1471-2458-12-1113
PMCID: PMC3533689  PMID: 23267693
Addis Ababa; ANC surveillance; HIV prevalence; PMTCT programme reports
3.  Factors associated with severe disease from malaria, pneumonia and diarrhea among children in rural Tanzania – A hospital-based cross-sectional study 
BMC Infectious Diseases  2012;12:219.
Background
Mild cases of malaria, pneumonia and diarrhea are readily treatable with complete recovery and with inexpensive and widely available first-line drugs. However, treatment is complicated and expensive, and mortality is higher when children present to the hospital with severe forms of these illnesses. We studied how care seeking behaviours and other factors contributed to severity of malaria, pneumonia and diarrhoea among children less than five years in rural Tanzania.
Methods
We interviewed consecutive care-takers of children diagnosed with malaria, pneumonia and/or diarrhea at Korogwe and Muheza district hospitals, in north-eastern Tanzania, between July 2009 and January 2010, and compared characteristics of children presenting with severe and those with non-severe disease.
Results
A total of 293 children with severe and 190 with non-severe disease were studied. We found persistent associations between severity of disease and caretaker’s lack of formal education (OR 6.6; 95% confidence interval (CI) 2.7-15.8) compared to those with post-primary education, middle compared to high socio-economic status (OR 1.9; 95% CI 1.2-3.2), having 4 or more children compared to having one child (OR 2.5; 95% CI 1.4-4.5), having utilized a nearer primary health care (PHC) facility for the same illness compared to having not (OR 5.2; 95% CI 3.0-9.1), and having purchased the first treatment other than paracetamol from local or drug shops compared to when the treatment was obtained from the public hospitals for the first time (OR 3.2; 95% CI 1.9-5.2). The old officially abandoned first line anti-malaria drug Sulfadoxin-pyrimethamine (SP) was found to still be in use for the treatment of malaria and was significantly associated with childrens’ presentation to the hospital with severe malaria (OR 12.5; 95% CI 1.6-108.0).
Conclusions
Our results indicate that caretakers with no formal education, with lower SES and with many children can be target groups for interventions in order to further reduce child mortality from treatable illnesses. Furthermore, the quality of the available drug shops and PHC facilities need to be closely monitored.
doi:10.1186/1471-2334-12-219
PMCID: PMC3482590  PMID: 22978351
Severe; Non-severe; Malaria; Pneumonia; Diarrhea; Dehydration
4.  Unfulfilled expectations to services offered at primary health care facilities: Experiences of caretakers of underfive children in rural Tanzania 
Background
There is growing evidence that patients frequently bypass primary health care (PHC) facilities in favour of higher level hospitals regardless of substantial additional time and costs. Among the reasons given for bypassing are poor services (including lack of drugs and diagnostic facilities) and lack of trust in health workers. The World Health Report 2008 “PHC now more than ever” pointed to the importance of organizing health services around people’s needs and expectations as one of the four main issues of PHC reforms. There is limited documentation of user’s expectations to services offered at PHC facilities. The current study is a community extension of a hospital-based survey that showed a high bypassing frequency of PHC facilities among caretakers seeking care for their underfive children at two district hospitals. We aimed to explore caretakers’ perceptions and expectations to services offered at PHC facilities in their area with reference to their experiences seeking care at such facilities.
Methods
We conducted four community-based focus group discussions (FGD’s) with 47 caretakers of underfive children in Muheza district of Tanga region, Tanzania in October 2009.
Results
Lack of clinical examinations and laboratory tests, combined with shortage of drugs and health workers, were common experiences. Across all the focus group discussions, unpleasant health workers’ behaviors, lack of urgency and unnecessary delays were major complaints. In some places, unauthorized fees reduced access to services.
Conclusion
The study revealed significant disappointments among caretakers with regard to the quality of services offered at PHC facilities in their areas, with implications for their utilization and proper functioning of the referral system. Practices regarding partial drugs administrations, skipping of injections, unofficial payments and consultations by unskilled health care providers need urgent action. There is also a need for proper accountability mechanisms to govern appropriate allocation and monitoring of health care resources and services in Tanzania.
doi:10.1186/1472-6963-12-158
PMCID: PMC3420314  PMID: 22697458
5.  Why caretakers bypass Primary Health Care facilities for child care - a case from rural Tanzania 
Background
Research on health care utilization in low income countries suggests that patients frequently bypass PHC facilities in favour of higher-level hospitals - despite substantial additional time and financial costs. There are limited number of studies focusing on user's experiences at such facilities and reasons for bypassing them. This study aimed to identify factors associated with bypassing PHC facilities among caretakers seeking care for their underfive children and to explore experiences at such facilities among those who utilize them.
Methods
The study employed a mixed-method approach consisting of an interviewer administered questionnaires and in-depth interviews among selected care-takers seeking care for their underfive children at Korogwe and Muheza district hospitals in north-eastern Tanzania.
Results
The questionnaire survey included 560 caretakers. Of these 30 in-depth interviews were conducted. Fifty nine percent (206/348) of caretakers had not utilized their nearer PHC facilities during the index child's sickness episode. The reasons given for bypassing PHC facilities were lack of possibilities for diagnostic facilities (42.2%), lack of drugs (15.5%), closed health facility (10.2%), poor services (9.7%) and lack of skilled health workers (3.4%). In a regression model, the frequency of bypassing a PHC facility for child care increased significantly with decreasing travel time to the district hospital, shorter duration of symptoms and low disease severity.
Findings from the in-depth interviews revealed how the lack of quality services at PHC facilities caused delays in accessing appropriate care and how the experiences of inadequate care caused users to lose trust in them.
Conclusion
The observation that people are willing to travel long distances to get better quality services calls for health policies that prioritize quality of care before quantity. In a situation with limited resources, utilizing available resources to improve quality of care at available facilities could be more appropriate for improving access to health care than increasing the number of facilities. This would also improve equity in health care access since the poor who can not afford travelling costs will then get access to quality services at their nearer PHC facilities.
doi:10.1186/1472-6963-11-315
PMCID: PMC3234197  PMID: 22094076
6.  Current status of medication adherence and infant follow up in the prevention of mother to child HIV transmission programme in Addis Ababa: a cohort study 
Background
Prevention of mother to child HIV transmission (PMTCT) programmes have great potential to achieve virtual elimination of perinatal HIV transmission provided that PMTCT recommendations are properly followed. This study assessed mothers and infants adherence to medication regimen for PMTCT and the proportions of exposed infants who were followed up in the PMTCT programme.
Methods
A prospective cohort study was conducted among 282 HIV-positive mothers attending 15 health facilities in Addis Ababa, Ethiopia. Descriptive statistics, bivariate and mulitivariate logistic regression analyses were done.
Results
Of 282 mothers enrolled in the cohort, 232 (82%, 95% CI 77-86%) initiated medication during pregnancy, 154 (64%) initiated combined zidovudine (ZDV) prophylaxis regimen while 78 (33%) were initiated lifelong antiretroviral treatment (ART). In total, 171 (60%, 95% CI 55-66%) mothers ingested medication during labour. Of the 221 live born infants (including two sets of twins), 191 (87%, 95% CI 81-90%) ingested ZDV and single-dose nevirapine (sdNVP) at birth. Of the 219 live births (twin births were counted once), 148 (68%, 95% CI 61-73%) mother-infant pairs ingested their medication at birth. Medication ingested by mother-infant pairs at birth was significantly and independently associated with place of delivery. Mother-infant pairs attended in health facilities at birth were more likely (OR 6.7 95% CI 2.90-21.65) to ingest their medication than those who were attended at home. Overall, 189 (86%, 95% CI 80-90%) infants were brought for first pentavalent vaccine and 115 (52%, 95% CI 45-58%) for early infant diagnosis at six-weeks postpartum. Among the infants brought for early diagnosis, 71 (32%, 95% CI 26-39%) had documented HIV test results and six (8.4%) were HIV positive.
Conclusions
We found a progressive decline in medication adherence across the perinatal period. There is a big gap between mediation initiated during pregnancy and actually ingested by the mother-infant pairs at birth. Follow up for HIV-exposed infants seem not to be organized and is inconsistent. In order to maximize effectiveness of the PMTCT programme, the rate of institutional delivery should be increased, the quality of obstetric services should be improved and missed opportunities to exposed infant follow up should be minimized.
doi:10.1186/1758-2652-14-50
PMCID: PMC3214767  PMID: 22017821
7.  Childhood tuberculosis deskguide and monitoring: An intervention to improve case management in Pakistan 
Background
Childhood tuberculosis (TB) has been a neglected area in national TB control programme (NTCP) in high burden countries. The NTP Pakistan adapted the global approaches by developing and piloting its policy guideline on childhood TB in ten districts of the country. We developed an intervention package including a deskguide and a monitoring tool and tested with the ongoing childhood TB care in a district. The objective of our study was to measure effectiveness of intervention package with deskguide and monitoring tool by comparing TB case finding and treatment outcomes among districts in 2008, and performance assessment in intervention district.
Method
An intervention study with cohort design within a routine TB control programme comparing case findings and treatment outcomes before and after the intervention, and in districts with and without intervention. We enrolled all children below 15 years registered at all nine public sector hospitals in three districts of Pakistan. The data was collected from hospital TB records.
Results
In eight months during 2007 there were 164 childhood TB cases notified, and after intervention in 2008 a total of 194 cases were notified. In intervention district case finding doubled (110% increase) and correct treatment practice significantly increased in eight months. Successful outcomes were significantly higher in intervention district (37,100%) compared to control district A (18, 18%, p < 0.05) and control district B (41, 72%, p < 0.05).
Conclusion
Childhood TB deskguide and structured monitoring was associated with improved case management and it augmented NTP policy. More development and implementation in all health services of the district are indicated.
doi:10.1186/1472-6963-11-187
PMCID: PMC3162501  PMID: 21831308
8.  Treatment delay among tuberculosis patients in Tanzania: Data from the FIDELIS Initiative 
BMC Public Health  2011;11:306.
Background
Several FIDELIS projects (Fund for Innovative DOTS Expansion through Local Initiatives to Stop TB) in Tanzania were conducted by the National Tuberculosis and Leprosy Programme (NTLP) during the years 2004-2008 to strengthen diagnostic and treatment services. These projects collected information on treatment delay and some of it was available for research purposes. With this database our objective was to assess the duration and determinants of treatment delay among new smear positive pulmonary tuberculosis (TB) patients in FIDELIS projects, and to compare delay according to provider visited prior to diagnosis.
Methods
Treatment delay among new smear positive TB patients was recorded for each patient at treatment initiation and this information was available and fairly complete in 6 out of 57 districts with FIDELIS projects enrolling patients between 2004 and 2007; other districts had discarded their forms at the time of analysis. It was analysed as a cross sectional study.
Results
We included 1161 cases, 10% of all patients recruited in the FIDELIS projects in Tanzania. Median delay was 12 weeks. The median duration of cough, weight loss and haemoptysis was 12, 8 and 3 weeks, respectively. Compared to Hai district Handeni had patients with longer delays and Mbozi had patients with shorter delays. Urban and rural patients reported similar delays. Patients aged 15-24 years and patients of 65 years or older had longer delays. Patients reporting contact with traditional healers before diagnosis had a median delay of 15 weeks compared to 12 weeks among those who did not. Patients with dyspnoea and with diarrhoea had longer delays.
Conclusion
In this patient sample in Tanzania half of the new smear positive pulmonary tuberculosis patients had a treatment delay longer than 12 weeks. Delay was similar in men and women and among urban and rural patients, but longer in the young and older age groups. Patients using traditional healers had a 25% longer median delay.
doi:10.1186/1471-2458-11-306
PMCID: PMC3115859  PMID: 21569434
9.  Are children with tuberculosis in Pakistan managed according to National programme policy guidelines? A study from 3 districts in Punjab 
BMC Research Notes  2010;3:324.
Background
The adherence to policies of National TB Control Programme (NTP) to manage a case of tuberculosis (TB) is a fundamental step to have a successful programme in any country. Childhood TB services faces an unmet challenge of case management due to difficulty with diagnosis and relatively new policies. For control of childhood TB in Pakistan, NTP developed and piloted its guidelines in 2006-2007. The objective of this study was to compare the documented case management practices of pediatricians and its impact on the outcome before and after introducing NTP policy guidelines.
Findings
An audit of case management practices of a historical cohort study was done in children below 15 years who were put on anti-tuberculosis treatment at all nine public hospitals in three districts in province of Punjab. The study period was two years pre-intervention (2004-05) and two years post-intervention (2006-07) after implementation of new NTP policy guidelines for childhood TB. There were 920 childhood TB cases registered during four years, 189 in pre-intervention period and 731 in post-intervention period. The practices changed significantly in post-intervention period for use of tuberculin skin test (63% of pulmonary cases, 19% of extrapulmonary cases and 67% for site unknown), and for the use of chest x-ray (69% of pulmonary cases, 16% of extrapulmonary cases and 74% for site unknown). Diagnostic scores were recorded for only a minority of cases (18%). The proportion of correct drugs pre- and post-intervention remained same. There were unknown treatment outcomes in 38 out of 141 cases (27%) in pre-intervention and in 483 out of 551 cases (87%) post-intervention, all among the 692 cases without documented treatment supporter.
Conclusions
The study has shown that pediatricians have started following parts of the national policy guidelines for management of childhood TB. The documented use of diagnostic tools is increased but record keeping of case management practices remained inadequate. This seems to increase case finding substantially but the treatment outcomes were poor mainly due to unknown outcomes. Development and implementation of standardized operational tools and regular monitoring system may improve the services.
doi:10.1186/1756-0500-3-324
PMCID: PMC3002365  PMID: 21114868
10.  Promising outcomes of a national programme for the prevention of mother-to-child HIV transmission in Addis Ababa: a retrospective study 
Background
Prevention of Mother-to-Child HIV Transmission (PMTCT) is still the most effective intervention in combating new HIV infections. In 2008, revised national PMTCT guidelines that incorporated new policies on HIV counselling and testing, antiretroviral prophylaxis regimen and infant HIV diagnosis came into effect in Ethiopia. In the present study we have examined trends in PMTCT service utilization and assessed the rate of MTCT in relation to policy changes in the national PMTCT programme.
Methods
Reports from February 2004 to August 2009 were reviewed in 10 sub-cities in Addis Ababa, Ethiopia. The data was collected from May to October 2009.
Results
The proportion of women who received HIV counselling and testing among new antenatal care attendees increased from 50.7% (95% CI 50.2-51.2) in 2007 to 84.5% (95% CI 84.1-84.9) in 2009 following the shift to routine opt-out testing. Nevertheless, in 2009 only 53.7% of the positive women and 40.7% of their infants received antiretroviral prophylaxis. The HIV prevalence among antenatal attendees decreased significantly from 10.5% in 2004 to 4.6% in 2009 in parallel to the increased number of women being tested. The HIV positive women were over 18 times (RR 18.5, p < 0.0001) more likely to be referred for treatment, care and support in 2009 than in 2004. The proportion of partners tested for HIV decreased by 14% in 2009 compared to 2004, although the absolute number was increasing year by year. Only 10.6% (95% CI 9.9-11.2) of the HIV positive women completed their follow up to infant HIV testing. The cumulative probability of HIV infection among babies on single dose nevirapine regimen who were tested at >=18 months was 15.0% (95% CI 9.8-22.1) in 2007, whereas it was 8.2% (95% CI 5.55-11.97) among babies on Zidovudine regimen who were tested at >=45 days in 2009.
Conclusion
The paper demonstrates trends in PMTCT service utilization in relation to changing policy. There is marked improvement in HIV counselling and testing service utilization, especially after the policy shift to routine opt-out testing. However, despite policy changes, the ARV prophylaxis uptake, the loss to follow up and the partner testing have remained unchanged across the years. This should be a matter of immediate concern and a topic for further research.
doi:10.1186/1472-6963-10-267
PMCID: PMC2944274  PMID: 20828384
11.  Delay in the diagnosis of tuberculosis in Nepal 
BMC Public Health  2009;9:236.
Background
Identifying reasons for delay in diagnosis and treatment of tuberculosis is important for the health system to find ways to treat patients as early as possible, and hence reduce the suffering of patients and transmission of the disease. The objectives of this study was to assess the duration of delay in the diagnosis of tuberculosis and to investigate its determinants.
Methods
A cross-sectional survey was conducted using a structured questionnaire in 307 new tuberculosis patients registered by the National Tuberculosis Programme (NTP) in all DOTS centres in Banke district of Nepal.
Results
The median patient delay was 50 days, the median health system delay was 18 days, and the median total delay was 60 days. Sputum smear negative participants had significantly lower risk of patient delay. Smokers using >5 cigarettes per day had higher risk of patient delay and health system delay.
Conclusion
Total delay in the diagnosis of tuberculosis in Banke district is shorter compared to other places in Nepal and neighbouring countries. The shorter delay for smear negative pulmonary tuberculosis raises suspicion that many of these patients are not examined according to the NTP manual before being diagnosed. Increasing public awareness of the disease and expansion of the facilities with assured quality could be helpful to reduce the delay in the diagnosis of tuberculosis.
doi:10.1186/1471-2458-9-236
PMCID: PMC2716339  PMID: 19602255
12.  Risk factors for maternal death in the highlands of rural northern Tanzania: a case-control study 
BMC Public Health  2008;8:52.
Background
Tanzania has one of the highest maternal mortality ratios in sub-Saharan Africa. Due to the paucity of epidemiological information on maternal deaths, and the high maternal mortality estimates found earlier in the study area, our objective was to assess determinants of maternal deaths in a rural setting in the highlands of northern Tanzania by comparing the women dying of maternal causes with women from the same population who had attended antenatal clinics in the same time period.
Methods
A case-control study was done in two administrative divisions in Mbulu and Hanang districts in rural Tanzania. Forty-five cases of maternal death were found through a comprehensive community- and health-facility based study in 1995 and 1996, while 135 antenatal attendees from four antenatal clinics in the same population, geographical area, and time-span of 1995–96 served as controls. The cases and controls were compared using multivariate logistic regression analyses. Odds ratios, with 95% confidence intervals, were used as an approximation of relative risk, and were adjusted for place of residence (ward) and age. Further adjustment was done for potentially confounding variables.
Results
An increased risk of maternal deaths was found for women from 35–49 years versus 15–24 years (OR 4.0; 95%CI 1.5–10.6). Women from ethnic groups other than the two indigenous groups of the area had an increased risk of maternal death (OR 13.6; 95%CI 2.5–75.0). There was an increased risk when women or husbands adhered to traditional beliefs, (OR 2.1; 95%CI 1.0–4.5) and (OR 2.6; 95%CI 1.2–5.7), respectively. Women whose husbands did not have any formal education appeared to have an increased risk (OR 2.2; 95%CI 1.0–5.0).
Conclusion
Increasing maternal age, ethnic and religious affiliation, and low formal education of the husbands were associated with increased risk of maternal death. Increased attention needs to be given to formal education of both men and women. In addition, education of the male decision-makers should be given high priority in the community, especially in matters concerning pregnancy and delivery preparedness, since their choice greatly affects the survival of the pregnant and delivering women.
doi:10.1186/1471-2458-8-52
PMCID: PMC2259340  PMID: 18257937
13.  Can Timely Vector Control Interventions Triggered by Atypical Environmental Conditions Prevent Malaria Epidemics? A Case-Study from Wajir County, Kenya 
PLoS ONE  2014;9(4):e92386.
Background
Atypical environmental conditions with drought followed by heavy rainfall and flooding in arid areas in sub-Saharan Africa can lead to explosive epidemics of malaria, which might be prevented through timely vector-control interventions.
Objectives
Wajir County in Northeast Kenya is classified as having seasonal malaria transmission. The aim of this study was to describe in Wajir town the environmental conditions, the scope and timing of vector-control interventions and the associated resulting burden of malaria at two time periods (1996–1998 and 2005–2007).
Methods
This is a cross-sectional descriptive and ecological study using data collected for routine program monitoring and evaluation.
Results
In both time periods, there were atypical environmental conditions with drought and malnutrition followed by massive monthly rainfall resulting in flooding and animal/human Rift Valley Fever. In 1998, this was associated with a large and explosive malaria epidemic (weekly incidence rates peaking at 54/1,000 population/week) with vector-control interventions starting over six months after the massive rainfall and when the malaria epidemic was abating. In 2007, vector-control interventions started sooner within about three months after the massive rainfall and no malaria epidemic was recorded with weekly malaria incidence rates never exceeding 0.5 per 1,000 population per week.
Discussion and Conclusion
Did timely vector-control interventions in Wajir town prevent a malaria epidemic? In 2007, the neighboring county of Garissa experienced similar climatic events as Wajir, but vector-control interventions started six months after the heavy un-seasonal rainfall and large scale flooding resulted in a malaria epidemic with monthly incidence rates peaking at 40/1,000 population. In conclusion, this study suggests that atypical environmental conditions can herald a malaria outbreak in certain settings. In turn, this should alert responsible stakeholders about the need to act rapidly and preemptively with appropriate and wide-scale vector-control interventions to mitigate the risk.
doi:10.1371/journal.pone.0092386
PMCID: PMC3974701  PMID: 24699034
14.  Is One Sputum Specimen as Good as Two during Follow-Up Cultures for Monitoring Multi Drug Resistant Tuberculosis Patients in India? 
PLoS ONE  2012;7(9):e45554.
Background
In India, the Revised National Tuberculosis Control Programme (RNTCP) has adopted the strategy of examining two specimens during follow-up culture examinations to monitor the treatment response of multi-drug resistant tuberculosis (MDR-TB) patients.
Objectives
To determine the incremental yield of the second sputum specimen during follow-up culture examinations among patients with MDR-TB and the effect on case management on changing from two to one specimen follow-up strategy.
Methods
A cross sectional record review of MDR-TB patients registered during 2008–09 under RNTCP was undertaken in three MDR-TB treatment sites of India.
Results
Of 1721 pairs of follow-up sputum culture examinations done among 220 MDR-TB patients, 451(26%) were positive with either of the two specimens; 29(1.7%) were culture positive only on the second specimen indicating the incremental yield. To detect one additional culture positive result on the second specimen, 59 specimens needed to be processed. If we had examined only one specimen, we would have missed 29 culture-positive results. By current RNTCP guidelines, however, a single specimen policy would have altered case management in only 3(0.2%) instances, where patients would have missed a one month extension of the intensive phase of MDR-TB treatment. There is no meaningful advantage in using two specimens for the monitoring of MDR-TB patients. A single specimen policy could be safely implemented with negligible clinical effect on MDR-TB patients and favourable resource implications for RNTCP.
doi:10.1371/journal.pone.0045554
PMCID: PMC3459961  PMID: 23029092
15.  Making stillbirths count, making numbers talk - Issues in data collection for stillbirths 
Background
Stillbirths need to count. They constitute the majority of the world's perinatal deaths and yet, they are largely invisible. Simply counting stillbirths is only the first step in analysis and prevention. From a public health perspective, there is a need for information on timing and circumstances of death, associated conditions and underlying causes, and availability and quality of care. This information will guide efforts to prevent stillbirths and improve quality of care.
Discussion
In this report, we assess how different definitions and limits in registration affect data capture, and we discuss the specific challenges of stillbirth registration, with emphasis on implementation. We identify what data need to be captured, we suggest a dataset to cover core needs in registration and analysis of the different categories of stillbirths with causes and quality indicators, and we illustrate the experience in stillbirth registration from different cultural settings. Finally, we point out gaps that need attention in the International Classification of Diseases and review the qualities of alternative systems that have been tested in low- and middle-income settings.
Summary
Obtaining high-quality data will require consistent definitions for stillbirths, systematic population-based registration, better tools for surveys and verbal autopsies, capacity building and training in procedures to identify causes of death, locally adapted quality indicators, improved classification systems, and effective registration and reporting systems.
doi:10.1186/1471-2393-9-58
PMCID: PMC2805601  PMID: 20017922

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