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Unbiased antimicrobial resistance prevalence estimates through population-based surveillance. Clin Microbiol Infect 2022; 29:429-433. [PMID: 35595126 DOI: 10.1016/j.cmi.2022.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 03/20/2022] [Accepted: 05/04/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Current antimicrobial resistance surveillance (AMR) is mainly laboratory-based. This approach can have inherent biases given the potential for selective specimen submission for microbiological analysis, and for its inability to map antibiotic susceptibility test results to a clinical syndrome. OBJECTIVES To discuss the need for population-based surveillance of AMR, and highlight the pros and cons of threshold surveys. SOURCES Studies on methodology for AMR surveillance published in the last 10 years, obtained through a PubMed search on antimicrobial resistance (all fields) and surveillance/method (MeSH term). CONTENT We discuss the use of threshold surveys to overcome the challenge of sample size in population-bases AMR surveys, which are a suitable approach in both low- and high-resource settings. IMPLICATION Scale up in the use of population-based threshold survey on the prevalence of AMR will provide necessary information to triangulate the data from routinely-reported laboratory-based AMR surveillance at the local, national and global level.
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Brar AS, Hedt-Gauthier BL, Hirschhorn LR. Mixed Methods Lot Quality Assurance Sampling: A novel, rapid methodology to inform equity focused maternal health programming in rural Rajasthan, India. PLoS One 2021; 16:e0250154. [PMID: 33914763 PMCID: PMC8084134 DOI: 10.1371/journal.pone.0250154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 03/31/2021] [Indexed: 11/18/2022] Open
Abstract
India has experienced a significant increase in facility-based delivery (FBD) coverage and reduction in maternal mortality. Nevertheless, India continues to have high levels of maternal health inequity. Improving equity requires data collection methods that can produce a better contextual understanding of how vulnerable populations access and interact with the health care system at a local level. While large population-level surveys are valuable, they are resource intensive and often lack the contextual specificity and timeliness to be useful for local health programming. Qualitative methods can be resource intensive and may lack generalizability. We describe an innovative mixed-methods application of Large Country-Lot Quality Assurance Sampling (LC-LQAS) that provides local coverage data and qualitative insights for both FBD and antenatal care (ANC) in a low-cost and timely manner that is useful for health care providers working in specific contexts. LC-LQAS is a version of LQAS that combines LQAS for local level classification with multistage cluster sampling to obtain precise regional or national coverage estimates. We integrated qualitative questions to uncover mothers' experiences accessing maternal health care in the rural district of Sri Ganganagar, Rajasthan, India. We interviewed 313 recently delivered, low-income women in 18 subdistricts. All respondents participated in both qualitative and quantitative components. All subdistricts were classified as having high FBD coverage with the upper threshold set at 85%, suggesting that improved coverage has extended to vulnerable women. However, only two subdistricts were classified as high ANC coverage with the upper threshold set at 40%. Qualitative data revealed a severe lack of agency among respondents and that household norms of care seeking influenced uptake of ANC and FBD. We additionally report on implementation outcomes (acceptability, feasibility, appropriateness, effectiveness, fidelity, and cost) and how study results informed the programs of a local health non-profit.
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Affiliation(s)
- Aneel Singh Brar
- Mata Jai Kaur Maternal and Child Health Centre, Sri Ganganagar, Rajasthan, India
- School of Anthropology and Museum Ethnography, University of Oxford, Oxford, Oxfordshire, United Kingdom
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
| | - Bethany L. Hedt-Gauthier
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, United States of America
- Department of Biostatistics, Harvard Chan School, Boston, Massachusetts, United States of America
| | - Lisa R. Hirschhorn
- Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, United States of America
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Dadzie D, Boadu RO, Engmann CM, Twum-Danso NAY. Evaluation of neonatal mortality data completeness and accuracy in Ghana. PLoS One 2021; 16:e0239049. [PMID: 33661920 PMCID: PMC7932152 DOI: 10.1371/journal.pone.0239049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 08/28/2020] [Indexed: 11/21/2022] Open
Abstract
Background Cause-specific mortality data are required to set interventions to reduce neonatal mortality. However, in many developing countries, these data are either lacking or of low quality. We assessed the completeness and accuracy of cause of death (COD) data for neonates in Ghana to assess their usability for monitoring the effectiveness of health system interventions aimed at improving neonatal survival. Methods A lot quality assurance sampling survey was conducted in 20 hospitals in the public sector across four regions of Ghana. Institutional neonatal deaths (IND) occurring from 2014 through 2017 were divided into lots, defined as neonatal deaths occurring in a selected facility in a calendar year. A total of 52 eligible lots were selected: 10 from Ashanti region, and 14 each from Brong Ahafo, Eastern and Volta region. Nine lots were from 2014, 11 from 2015 and 16 each were from 2016 and 2017. The cause of death (COD) of 20 IND per lot were abstracted from admission and discharge (A&D) registers and validated against the COD recorded in death certificates, clinician’s notes or neonatal death audit reports for consistency. With the error threshold set at 5%, ≥ 17 correctly matched diagnoses in a sample of 20 deaths would make the lot accurate for COD diagnosis. Completeness of COD data was measured by calculating the proportion of IND that had death certificates completed. Results Nineteen out of 52 eligible (36.5%) lots had accurate COD diagnoses recorded in their A&D registers. The regional distribution of lots with accurate COD data is as follows: Ashanti (4, 21.2%), Brong Ahafo (7, 36.8%), Eastern (4, 21.1%) and Volta (4, 21.1%). Majority (9, 47.4%) of lots with accurate data were from 2016, followed by 2015 and 2017 with four (21.1%) lots. Two (10.5%) lots had accurate COD data in 2014. Only 22% (239/1040) of sampled IND had completed death certificates. Conclusion Death certificates were not reliably completed for IND in a sample of health facilities in Ghana from 2014 through 2017. The accuracy of cause-specific mortality data recorded in A&D registers was also below the desired target. Thus, recorded IND data in public sector health facilities in Ghana are not valid enough for decision-making or planning. Periodic data quality assessments can determine the magnitude of the data quality concerns and guide site-specific improvements in mortality data management.
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Affiliation(s)
- Dora Dadzie
- Cape Coast Teaching Hospital, Cape Coast, Ghana
| | - Richard Okyere Boadu
- Department of Health Information Management, University of Cape Coast, Cape Coast, Ghana
| | - Cyril Mark Engmann
- Maternal, Newborn and Child Health and Nutrition, PATH, Seattle, WA, United States of America
- Department of Paediatrics, University of Washington School of Medicine, Seattle, WA, United States of America
- Department of Global Health, University of Washington School of Public Health, Seattle, WA, United States of America
| | - Nana Amma Yeboaa Twum-Danso
- TD Health, Accra, Ghana
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, United States of America
- * E-mail:
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Gersh JK, Barnabas RV, Matemo D, Kinuthia J, Feldman Z, Lacourse SM, Mecha J, Warr AJ, Kamene M, Horne DJ. Pulmonary tuberculosis screening in anti-retroviral treated adults living with HIV in Kenya. BMC Infect Dis 2021; 21:218. [PMID: 33632173 PMCID: PMC7908695 DOI: 10.1186/s12879-021-05916-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2020] [Accepted: 02/11/2021] [Indexed: 11/25/2022] Open
Abstract
Background People living with HIV (PLHIV) who reside in high tuberculosis burden settings remain at risk for tuberculosis disease despite treatment with anti-retroviral therapy and isoniazid preventive therapy (IPT). The performance of the World Health Organization (WHO) symptom screen for tuberculosis in PLHIV receiving anti-retroviral therapy is sub-optimal and alternative screening strategies are needed. Methods We enrolled HIV-positive adults into a prospective study in western Kenya. Individuals who were IPT-naïve or had completed IPT > 6 months prior to enrollment were eligible. We evaluated tuberculosis prevalence overall and by IPT status. We assessed the accuracy of the WHO symptom screen, GeneXpert MTB/RIF (Xpert), and candidate biomarkers including C-reactive protein (CRP), hemoglobin, erythrocyte sedimentation rate (ESR), and monocyte-to-lymphocyte ratio for identifying pulmonary tuberculosis. Some participants were evaluated at 6 months post-enrollment for tuberculosis. Results The study included 383 PLHIV, of whom > 99% were on antiretrovirals and 88% had received IPT, completed a median of 1.1 years (IQR 0.8–1.55) prior to enrollment. The prevalence of pulmonary tuberculosis at enrollment was 1.3% (n = 5, 95% CI 0.4–3.0%): 4.3% (0.5–14.5%) among IPT-naïve and 0.9% (0.2–2.6%) among IPT-treated participants. The sensitivity of the WHO symptom screen was 0% (0–52%) and specificity 87% (83–90%). Xpert and candidate biomarkers had poor to moderate sensitivity; the most accurate biomarker was CRP ≥ 3.3 mg/L (sensitivity 80% (28–100) and specificity 72% (67–77)). Six months after enrollment, the incidence rate of pulmonary tuberculosis following IPT completion was 0.84 per 100 person-years (95% CI, 0.31–2.23). Conclusions In Kenyan PLHIV treated with IPT, tuberculosis prevalence was low at a median of 1.4 years after IPT completion. WHO symptoms screening, Xpert, and candidate biomarkers were insensitive for identifying pulmonary tuberculosis in antiretroviral-treated PLHIV.
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Affiliation(s)
- Jill K Gersh
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA
| | - Ruanne V Barnabas
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, 325 9th Ave, Box 359762, Seattle, WA, 98102, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Daniel Matemo
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya.,School of Public Health and Community Development Maseno University, Kisumu, Kenya
| | - John Kinuthia
- Department of Global Health, University of Washington, 325 9th Ave, Box 359762, Seattle, WA, 98102, USA.,Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Zachary Feldman
- Albers School of Business and Economics, Seattle University, Seattle, WA, USA
| | - Sylvia M Lacourse
- Department of Medicine, Division of Allergy and Infectious Diseases, University of Washington, Seattle, WA, USA.,Department of Global Health, University of Washington, 325 9th Ave, Box 359762, Seattle, WA, 98102, USA
| | - Jerphason Mecha
- Department of Obstetrics and Gynaecology, Kenyatta National Hospital, Nairobi, Kenya
| | - Alex J Warr
- Department of Pediatrics, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Maureen Kamene
- National Tuberculosis, Leprosy, and Lung Disease Program, Nairobi, Kenya
| | - David J Horne
- Department of Global Health, University of Washington, 325 9th Ave, Box 359762, Seattle, WA, 98102, USA. .,Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA.
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Ginting F, Sugianli AK, Bijl G, Saragih RH, Kusumawati RL, Parwati I, de Jong MD, Schultsz C, van Leth F. Rethinking Antimicrobial Resistance Surveillance: A Role for Lot Quality Assurance Sampling. Am J Epidemiol 2019; 188:734-742. [PMID: 30608516 PMCID: PMC6438814 DOI: 10.1093/aje/kwy276] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 12/16/2018] [Accepted: 12/18/2018] [Indexed: 12/23/2022] Open
Abstract
Global surveillance of antimicrobial resistance (AMR) is a key component of the 68th World Health Assembly Global Action Plan on AMR. Laboratory-based surveillance is inherently biased and lacks local relevance due to aggregation of data. We assessed the feasibility, sensitivity, and affordability of a population-based AMR survey using lot quality assurance sampling (LQAS), which classifies a population as having a high or low prevalence of AMR based on a priori defined criteria. Three studies were carried out in Medan and Bandung, Indonesia, between April 2014 and June 2017. LQAS classifications for 15 antibiotics were compared with AMR estimates from a conventional population-based survey, with an assessment of the cost of a single LQAS classification using microcosting methodology, among patients suspected of urinary tract infection at 11 sites in Indonesia. The sensitivity of LQAS was above 98%. The approach detected local variation in the prevalence of AMR across sites. Time to reach LQAS results ranged from 47 to 138 days. The average cost of an LQAS classification in a single facility was US$466. The findings indicate that LQAS-based AMR survey is a feasible, sensitive, and affordable strategy for population-based AMR surveys, providing essential data to inform local empirical treatment guidelines and antimicrobial stewardship efforts.
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Affiliation(s)
- Franciscus Ginting
- Department of Internal Medicine, Faculty of Medicine, University of Sumatera Utara, H. Adam Malik Hospital, Medan, Indonesia
| | - Adhi Kristianto Sugianli
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Gidion Bijl
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
| | - Restuti Hidayani Saragih
- Department of Internal Medicine, Faculty of Medicine, University of Sumatera Utara, H. Adam Malik Hospital, Medan, Indonesia
| | - R Lia Kusumawati
- Department of Microbiology, Faculty of Medicine, University of Sumatera Utara, H. Adam Malik Hospital, Medan, Indonesia
| | - Ida Parwati
- Department of Clinical Pathology, Faculty of Medicine, Universitas Padjadjaran, Dr. Hasan Sadikin General Hospital, Bandung, Indonesia
| | - Menno D de Jong
- Department of Medical Microbiology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Constance Schultsz
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Department of Medical Microbiology, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
| | - Frank van Leth
- Amsterdam Institute for Global Health and Development, Amsterdam, the Netherlands
- Department of Global Health, Amsterdam University Medical Centers, Academic Medical Center, Amsterdam, the Netherlands
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Ombura IP, Onyango N, Odera S, Mutua F, Nyagol J. Prevalence of Drug Resistance Mycobacterium Tuberculosis among Patients Seen in Coast Provincial General Hospital, Mombasa, Kenya. PLoS One 2016; 11:e0163994. [PMID: 27711122 PMCID: PMC5053611 DOI: 10.1371/journal.pone.0163994] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 09/19/2016] [Indexed: 11/29/2022] Open
Abstract
Background Although prevention and control of spread of multi-drug resistant tuberculosis strains is a global challenge, there is paucity of data on the prevalence of DR-TB in patients diagnosed with TB in referral hospitals in Kenya. The present study assessed patients’ characteristics and prevalence of drug resistant TB in sputa smear positive TB patients presenting to Coast Provincial General Hospital (CPGH) in Mombasa, Kenya. Methods Drug resistance was evaluated in 258 randomly selected sputa smear TB positive cases between the periods of November 2011 to February 2012 at the CPGH-Mombasa. Basic demographic data was obtained using administered questionnaires, and clinical history extracted from the files. For laboratory analyses, 2mls of sputum was obtained, decontaminated and subjected to mycobacteria DNA analyses. Detection of first line drug resistance genes was done using MDRTDR plus kit. This was followed with random selection of 83 cases for second line drug resistance genes testing using Genotype MDRTBsl probe assay kit (HAINS Lifesciences, GmbH, Germany), in which ethambutol mutation probes were included. The data was then analyzed using SPSS statistical package version 19.0. Results Male to female ratio was 1:2. Age range was 9 to 75 years, with median of 30 years. New treatment cases constituted 253(98%), among which seven turned out to be PTB negative, and further grouped as 4 (1.6%) PTB negative and 3(1.1%) NTM. 237(91.7%) new cases were fully susceptible to INH and RIF. The remaining, 8 (3.1%) and 1(0.4%) had mono- resistance to INH and RIF, respectively. All the retreatment cases were fully susceptible to the first line drugs. HIV positivity was found in 48 (18.6%) cases, of which 46(17.8%) were co-infected with TB. Of these, 44 (17.1%) showed full susceptibility to TB drugs, while 2 (0.8%) were INH resistant. For the second line drugs, one case each showed mono resistance to both and FQ. Also, one case each showed drug cross poly resistance to both ETH and FQ, with second line injectable antibiotics. However, no significant statistical correlation was established between TB and resistance to the second line drugs p = 0.855. Conclusion The findings of this study showed the existence of resistance to both first and second line anti-tubercular drugs, but no MDR-TB and XDR-TB was detected among patients attending TB clinic at CPGH using molecular techniques.
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Affiliation(s)
- Ida Pam Ombura
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Noel Onyango
- Department of Clinical Medicine and Therapeutics, Unit of Medical Oncology, University of Nairobi, Nairobi, Kenya
| | - Susan Odera
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Florence Mutua
- Department of Medical Microbiology, University of Nairobi, Nairobi, Kenya
| | - Joshua Nyagol
- Department of Human Pathology, Unit of Immunology, University of Nairobi, Nairobi, Kenya
- * E-mail:
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