A D Harries

Publications (219)837.47 Total impact

• Article: Diagnosis of pulmonary tuberculosis in a pastoralist population in Ethiopia: are three sputum specimens needed?

  M Khogali, K Tayler-Smith, R Zachariah, M Gbane, S Zimble, T Weyeyso, A D Harries
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  ABSTRACT: OBJECTIVE: To assess the number of sputum specimens necessary for a reliable diagnosis of pulmonary tuberculosis (PTB) in a pastoralist population in Ethiopia. METHOD: Using routine data from Ethiopia, where three sputum specimens are currently recommended for the diagnosis of PTB, we documented, (i) the proportion of persons with suspected, PTB who submitted a first, second and third sputum specimen for smear examination and (ii) the incremental smear-positive yield from the first, to the second and third specimens. RESULTS: Of 505 persons with suspected PTB, 107 (22%) failed to submit three samples. Of 60 patients who submitted three sputum samples with at least one smear-positive sample, the first sputum sample was smear positive in 56 (93%) cases; the second sputum sample was the first to be positive in 3 (5%) cases and in only one case was the third sample the first to be smear positive (additional yield 2%). CONCLUSION: In a pastoralist setting, a reliable diagnosis of PTB can be achieved with two sputum specimens and PTB diagnosis may be adequate with just one sputum specimen. However, if this more radical approach was adopted, ways of increasing diagnostic sensitivity should be explored.
  Tropical Medicine & International Health 02/2013; · 2.80 Impact Factor
• Source

  Available from: Sharath Burugina Nagaraja

  Article: Fast-track writing of a scientifi c paper with 30 authors: how to do it Participants presented their data in Powerpoint format Writing the first draft

  S Satyanarayana, A M V Kumar, B N Sharath, A D Harries
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  ABSTRACT: had standardised tools for collecting and reporting on patient data (Tuberculosis-Diabetes Registers and quar-terly cohort report forms). This enabled every site to collect the same quarterly data, and collation of data from all the facilities was therefore straightforward. Early on in the project, offi cers from the Revised Na-tional Tuberculosis Control Programme and the South-East Asia Offi ce of the International Union Against Tu-berculosis and Lung Disease supervised the facilities to correct any errors in data collection. On Day 1, from 9 am to 3 pm, all participants pre-sented their collated data, the challenges they faced during implementation and potential solutions. Data were recorded by the facilitators and were used to write the paper. Writing a zero draft for the paper Before the module started, the four facilitators wrote a 'zero' draft of the paper. This consisted of a largely completed Introduction and Methods section (based on the protocol developed 12 months previously), a blank Results section and a brief Discussion covering some of the issues likely to arise. Pertinent references had already been downloaded and were added under References. On Day 1, from 3 pm to 5 pm, an agreement was reached on which journal should be selected for sub-mission and on how the tables should be prepared and formatted. Facilitators ensured that data from each site for the three quarters and the whole period of the study were collated into aggregate data, which in turn were entered in the tables. A Box summarising chal-lenges encountered during implementation was also prepared. In the evening, the Tables and the Box, along with the Figures, were sent to one of the facilitators charged with writing the fi rst draft.
  12/2012;
• Article: Achieving the Millennium Development Goal of reducing maternal mortality in rural Africa: an experience from Burundi.

  K Tayler-Smith, R Zachariah, M Manzi, W Van den Boogaard, G Nyandwi, T Reid, R Van den Bergh, E De Plecker, V Lambert, M Nicolai, S Goetghebuer, B Christaens, B Ndelema, A Kabangu, J Manirampa, A D Harries
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  ABSTRACT: OBJECTIVES: To estimate the reduction in maternal mortality associated with the emergency obstetric care provided by Médecins Sans Frontières (MSF) and to compare this to the fifth Millennium Development Goal of reducing maternal mortality. METHODS: The impact of MSF's intervention was approximated by estimating how many deaths were averted among women transferred to and treated at MSF's emergency obstetric care facility in Kabezi, Burundi, with a severe acute maternal morbidity. Using this estimate, the resulting theoretical maternal mortality ratio in Kabezi was calculated and compared to the Millennium Development Goal for Burundi. RESULTS: In 2011, 1385 women from Kabezi were transferred to the MSF facility, of whom 55% had a severe acute maternal morbidity. We estimated that the MSF intervention averted 74% (range 55-99%) of maternal deaths in Kabezi district, equating to a district maternal mortality rate of 208 (range 8-360) deaths/100 000 live births. This lies very near to the 2015 MDG 5 target for Burundi (285 deaths/100 000 live births). CONCLUSION: Provision of quality emergency obstetric care combined with a functional patient transfer system can be associated with a rapid and substantial reduction in maternal mortality, and may thus be a possible way to achieve Millennium Development Goal 5 in rural Africa.
  Tropical Medicine & International Health 11/2012; · 2.80 Impact Factor
• Article: Practicing medicine without borders: tele-consultations and tele-mentoring for improving paediatric care in a conflict setting in Somalia?

  R Zachariah, B Bienvenue, L Ayada, M Manzi, A Maalim, E Engy, J P Jemmy, A Ibrahim Said, A Hassan, F Abdulrahaman, O Abdulrahman, J Bseiso, H Amin, D Michalski, J Oberreit, B Draguez, C Stokes, T Reid, A D Harries
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  ABSTRACT: Objectives  In a district hospital in conflict-torn Somalia, we assessed (i) the impact of introducing telemedicine on the quality of paediatric care, and (ii) the added value as perceived by local clinicians. Methods  A 'real-time' audio-visual exchange of information on paediatric cases (Audiosoft Technologies, Quebec, Canada) took place between clinicians in Somalia and a paediatrician in Nairobi. The study involved a retrospective analysis of programme data, and a perception study among the local clinicians. Results  Of 3920 paediatric admissions, 346 (9%) were referred for telemedicine. In 222 (64%) children, a significant change was made to initial case management, while in 88 (25%), a life-threatening condition was detected that had been initially missed. There was a progressive improvement in the capacity of clinicians to manage complicated cases as demonstrated by a significant linear decrease in changes to initial case management for meningitis and convulsions (92-29%, P = 0.001), lower respiratory tract infection (75-45%, P = 0.02) and complicated malnutrition (86-40%, P = 0.002). Adverse outcomes (deaths and lost to follow-up) fell from 7.6% in 2010 (without telemedicine) to 5.4% in 2011 with telemedicine (30% reduction, odds ratio 0.70, 95% CI: 0.57-0.88, P = -0.001). The number needed to be treated through telemedicine to prevent one adverse outcome was 45. All seven clinicians involved with telemedicine rated it to be of high added value. Conclusion  The introduction of telemedicine significantly improved quality of paediatric care in a remote conflict setting and was of high added value to distant clinicians.
  Tropical Medicine & International Health 07/2012; 17(9):1156-1162. · 2.80 Impact Factor
• Source

  Available from: Sharath Burugina Nagaraja

  Article: Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients?

  R Zachariah, A D Harries, S Srinath, S Ram, K Viney, E Singogo, P Lal, A Mendoza-Ticona, A Sreenivas, N W Aung, B N Sharath, H Kanyerere, N van Soelen, N Kirui, E Ali, S G Hinderaker, K Bissell, D A Enarson, M E Edginton
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  ABSTRACT: The words 'defaulter', 'suspect' and 'control' have been part of the language of tuberculosis (TB) services for many decades, and they continue to be used in international guidelines and in published literature. From a patient perspective, it is our opinion that these terms are at best inappropriate, coercive and disempowering, and at worst they could be perceived as judgmental and criminalising, tending to place the blame of the disease or responsibility for adverse treatment outcomes on one side-that of the patients. In this article, which brings together a wide range of authors and institutions from Africa, Asia, Latin America, Europe and the Pacific, we discuss the use of the words 'defaulter', 'suspect' and 'control' and argue why it is detrimental to continue using them in the context of TB. We propose that 'defaulter' be replaced with 'person lost to follow-up'; that 'TB suspect' be replaced by 'person with presumptive TB' or 'person to be evaluated for TB'; and that the term 'control' be replaced with 'prevention and care' or simply deleted. These terms are non-judgmental and patient-centred. We appeal to the global Stop TB Partnership to lead discussions on this issue and to make concrete steps towards changing the current paradigm.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 06/2012; 16(6):714-7. · 2.73 Impact Factor
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  Available from: Sven Gudmund Hinderaker

  Article: High initial default in patients with smear-positive pulmonary tuberculosis at a regional hospital in Accra, Ghana.

  F K Afutu, R Zachariah, S G Hinderaker, H Ntoah-Boadi, E Apori Obeng, F Adae Bonsu, A D Harries
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  ABSTRACT: Sputum smear-positive TB patients, diagnosed in the laboratory, who never start anti-TB treatment are classified as 'initial defaulters'. In Ridge Hospital, Accra, Ghana, there were 84 laboratory confirmed TB cases in 2009, of whom 32 (38%) were initial defaulters. Cure and default rates based on this cohort were 54% and 43% respectively, compared with rates of 87% and 8% when using the cohort based on 52 patients registered for treatment. This study highlights the problem of initial defaulters, and shows that programme performance may be poor when patients in laboratory registers are used as the cohort to evaluate treatment outcomes.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 05/2012; 106(8):511-3. · 2.16 Impact Factor
• Source

  Available from: Sharath Burugina Nagaraja

  Article: INT J TUBERC LUNG Language in tuberculosis services: can we change to patient-centred terminology and stop the paradigm of blaming the patients? South Africa; *** Academic Model Providing Access to Healthcare (AMPATH)/Moi Teaching & Referral Hospital

  R Zachariah, A D Harries, S Srinath, S Ram, K Viney, E Singogo, P Lal, A Mendoza-Ticona, A Sreenivas, N W Aung, B N Sharath, H Kanyerere, N Van Soelen, N Kirui, E Ali, S G Hinderaker, K Bissell, D A Enarson, M E Edginton, Eldoret
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  ABSTRACT: DIS 16(6):714–717 © 2012 The Union http://dx.doi.org/10.5588/ijtld.11.0635
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 05/2012; · 2.73 Impact Factor
• Article: In reply to 'Should Xpert® MTB/RIF be rolled out in low-income countries?'.

  A Trébucq, A D Harries, H L Rieder
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 05/2012; 16(5):703-4. · 2.73 Impact Factor
• Article: In reply to 'Location of Xpert® MTB/RIF in centralised laboratories in South Africa undermines potential impact'.

  A Trébucq, A D Harries
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 05/2012; 16(5):702. · 2.73 Impact Factor
• Article: In reply to 'The need for building design professionals in operational research in low-income countries'.

  R Zachariah, E Ali, A Dahmane, S Srinath, T Reid, A D Harries
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 04/2012; 16(4):565-6. · 2.73 Impact Factor
• Article: In reply.

  R Zachariah, P Gomani, M Massaquoi, A D Harries
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 12/2011; 15(12):1714-5. · 2.73 Impact Factor
• Article: Xpert® MTB/RIF for national tuberculosis programmes in low-income countries: when, where and how?

  A Trébucq, D A Enarson, C Y Chiang, A Van Deun, A D Harries, F Boillot, A Detjen, P I Fujiwara, S M Graham, I Monedero, I D Rusen, H L Rieder
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  ABSTRACT: Xpert ® MTB/RIF offers new and important possibilities for the diagnosis of sputum smear-negative tuberculosis (TB) and/or rifampicin (RMP) resistance, and many are encouraging rapid and widespread implementation. This simple test can be implemented almost everywhere, and it provides results within a few hours. In low-income countries (LICs), however, its cost, environmental limitations (stable and regular electricity, adequate room temperature) and difficulties involved in supply and maintenance are major obstacles. While it may be suitable for major reference hospitals, operational research is needed to evaluate the test and its additional yield above high-quality smear microscopy and clinical algorithms before its use at the peripheral level. In the meantime, direct microscopy should remain the initial diagnostic test for TB suspects. In most LICs, the prevalence of RMP resistance among new TB patients is very low; an Xpert MTB/RIF result indicating RMP resistance will thus always need confirmation by another test. In a population at high risk of RMP resistance (> 15%), however, the positive predictive value for RMP resistance by Xpert MTB/RIF is high, and identification of RMP resistance is an excellent proxy for multidrug-resistant TB (MDR-TB). The assay should be widely used for this purpose if, and only if, excellent MDR-TB management is available, both for ethical reasons and to reduce the risk of extensively drug-resistant TB.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 12/2011; 15(12):1567-72. · 2.73 Impact Factor
• Source

  Available from: Unni Karunakara

  Article: Building leadership capacity and future leaders in operational research in low-income countries: why and how?

  R Zachariah, T Reid, S Srinath, J Chakaya, K Legins, U Karunakara, A D Harries
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  ABSTRACT: Very limited operational research (OR) emerges from programme settings in low-income countries where the greatest burden of disease lies. The price paid for this void includes a lack of understanding of how health systems are actually functioning, not knowing what works and what does not, and an inability to propose adapted and innovative solutions to programme problems. We use the National Tuberculosis Control Programme as an example to advocate for strong programme-level leadership to steer OR and build viable relationships between programme managers, researchers and policy makers. We highlight the need to create a stimulating environment for conducting OR and identify some of the main practical challenges and enabling factors at programme level. We focus on the important role of an OR focal point within programmes and practical approaches to training that can deliver timely and quantifiable outputs. Finally, we emphasise the need to measure successful OR leadership development at programme level and we propose parameters by which this can be assessed. This paper 1) provides reasons why programmes should take the lead in coordinating and directing OR, 2) identifies the practical challenges and enabling factors for implementing, managing and sustaining OR and 3) proposes parameters for measuring successful leadership capacity development in OR.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 11/2011; 15(11):1426-35, i. · 2.73 Impact Factor
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  Available from: msf.org

  Article: The experience of implementing a 'TB village' for a pastoralist population in Cherrati, Ethiopia.

  K Tayler-Smith, M Khogali, K Keiluhu, J-P Jemmy, L Ayada, T Weyeyso, A M Issa, G De Maio, A D Harries, R Zachariah
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  ABSTRACT: In Cherrati District, Somali Regional State (SRS), Ethiopia, despite a high burden of tuberculosis (TB), TB control activities are virtually absent. The majority of the population is pastoralist with a mobile lifestyle. TB care and treatment were offered using a 'TB village' approach that included traditional style residential care, community empowerment and awareness raising, provision of essential social amenities and essential food and non-food items. To describe 1) key aspects of the implementation of the TB village approach, 2) TB treatment outcomes and 3) the lessons learnt during implementation. Descriptive study. A total of 297 patients entered the TB village between September 2006 and October 2008; 271 (91%) patients were treated successfully, nine (3%) defaulted and 13 (4%) died. For pastoralist populations, a TB village approach may be effective for improving access to TB care, ensuring proper adherence to treatment and achieving good overall TB outcomes. The successes and challenges of this approach are discussed.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 10/2011; 15(10):1367-72. · 2.73 Impact Factor
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  Available from: Nils Eric Billo

  Article: The looming epidemic of diabetes-associated tuberculosis: learning lessons from HIV-associated tuberculosis.

  A D Harries, Y Lin, S Satyanarayana, K Lönnroth, L Li, N Wilson, L S Chauhan, R Zachariah, M A Baker, C Y Jeon, M B Murray, D Maher, I C Bygbjerg, D A Enarson, N E Billo, A Kapur
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  ABSTRACT: The prevalence of diabetes mellitus is increasing at a dramatic rate, and countries in Asia, particularly India and China, will bear the brunt of this epidemic. Persons with diabetes have a significantly increased risk of active tuberculosis (TB), which is two to three times higher than in persons without diabetes. In this article, we argue that the epidemiological interactions and the effects on clinical presentation and treatment resulting from the interaction between diabetes and TB are similar to those observed for human immunodeficiency virus (HIV) and TB. The lessons learned from approaches to reduce the dual burden of HIV and TB, and especially the modes of screening for the two diseases, can be adapted and applied to the screening, diagnosis, treatment and prevention of diabetes and TB. The new World Health Organization (WHO) and The Union Collaborative Framework for care and control of TB and diabetes has many similarities to the WHO Policy on Collaborative Activities to reduce the dual burden of TB and HIV, and aims to guide policy makers and implementers on how to move forward and combat this looming dual epidemic. The response to the growing HIV-associated TB epidemic in the 1980s and 1990s was slow and uncoordinated, despite clearly articulated warnings about the scale of the forthcoming problem. We must not make the same mistake with diabetes and TB. The Framework provides a template for action, and it is now up to donors, policy makers and implementers to apply the recommendations in the field and to 'learn by doing'.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 09/2011; 15(11):1436-44, i. · 2.73 Impact Factor
• Article: Antiretroviral treatment uptake and attrition among HIV-positive patients with tuberculosis in Kibera, Kenya.

  K Tayler-Smith, R Zachariah, M Manzi, W Kizito, A Vandenbulcke, J Sitienei, J Chakaya, A D Harries
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  ABSTRACT: 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.
  Tropical Medicine & International Health 08/2011; 16(11):1380-3. · 2.80 Impact Factor
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  Available from: Sharath Burugina Nagaraja

  Article: Public Health Action NOTES FROM THE FIELD Did successfully treated pulmonary tuberculosis patients undergo all follow-up sputum smear examinations?

  S Satyanarayana, S B Nagaraja, S Kelamane, J Jaju, S S Chadha, K Chander, H Vishnu, N C Wilson, A D Harries
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  ABSTRACT: two sputum samples (early morning and spot) on three occasions—at the end of the intensive phase of treatment (at 2 months for new TB and 3 months for retreatment TB), 2 months into the continuation phase (at 4 months for new TB and 5 months for re-treatment TB) and at the end of treatment. If the smear is positive at the end of the intensive phase, the inten-sive phase is extended by a month and the patients undergo follow-up sputum examination again 1 month later. Patients with smear-negative PTB submit two sputum samples on two occasions: at the end of the intensive phase and at the end of treatment. 3 Patients who complete treatment with negative sputum smears are recorded as successfully treated ('cured' in the case of sputum smear-positive cases and 'treatment com-pleted' in the case of sputum smear-negative cases). All TB patients are treated according to the princi-ples of directly observed treatment (DOT), whereby a trained paramedical worker or community member provides anti-tuberculosis drugs to the patient under direct observation. It is the responsibility of the DOT provider to remind patients to undergo all follow-up sputum examinations. A Senior Treatment Supervisor supervises DOT providers, maintains a TB register and documents treatment progress, including follow-up sputum examinations. 3 The accuracy of recording is verifi ed during routine supervision. 4 Study population The cohort of all new and retreatment PTB patients registered for treatment between October and Decem-ber 2008 in the four districts was used for the study, which was conducted in December 2009, when fi nal treatment outcomes were available. PTB patients with successful treatment outcomes (cured + treatment com-pleted) were included in the study.
  Public health action. 08/2011;
• Source

  Available from: Johan van Griensven

  Article: Retention and attrition during the preparation phase and after start of antiretroviral treatment in Thyolo, Malawi, and Kibera, Kenya: implications for programmes?

  R Zachariah, K Tayler-Smith, M Manzi, M Massaquoi, B Mwagomba, J van Griensven, I van Engelgem, L Arnould, E J Schouten, F M Chimbwandira, A D Harries
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  ABSTRACT: Among adults eligible for antiretroviral therapy (ART) in Thyolo (rural Malawi) and Kibera (Nairobi, Kenya), this study (a) reports on retention and attrition during the preparation phase and after starting ART and (b) identifies risk factors associated with attrition. 'Retention' implies being alive and on follow-up, whilst 'attrition' implies loss to follow-up, death or stopping treatment (if on ART). There were 11,309 ART-eligible patients from Malawi and 3633 from Kenya, of whom 8421 (74%) and 2792 (77%), respectively, went through the preparation phase and started ART. In Malawi, 2649 patients (23%) were lost to attrition in the preparation phase and 2189 (26%) after starting ART. Similarly, in Kenya 546 patients (15%) were lost to attrition in the ART preparation phase and 647 (23%) while on ART. Overall programme attrition was 43% (4838/11,309) for Malawi and 33% (1193/3633) for Kenya. Restricting cohort evaluation to 'on ART' (as is usually done) underestimates overall programme attrition by 38% in Malawi and 36% in Kenya. Risk factors associated with attrition in the preparation phase included male sex, age <35 years, advanced HIV/AIDS disease and increasing malnutrition. Considerable attrition occurs during the preparation phase of ART, and programme evaluations confined to on-treatment analysis significantly underestimate attrition. This has important operational implications, which are discussed here.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 07/2011; 105(8):421-30. · 2.16 Impact Factor
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  Available from: Thomas van den Akker

  Article: Reduced tuberculosis case notification associated with scaling up antiretroviral treatment in rural Malawi.

  R Zachariah, M Bemelmans, A Akesson, P Gomani, K Phiri, B Isake, T van den Akker, M Philips, A Mwale, F Gausi, J Kwanjana, A D Harries
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  ABSTRACT: To report on the trends in new and recurrent tuberculosis (TB) case notifications in a rural district of Malawi that has embarked on large-scale roll-out of antiretroviral treatment (ART). Descriptive study analysing TB case notification and ART enrolment data between 2002 and 2009. There were a total of 10,070 new and 755 recurrent TB cases. ART scale-up started in 2003, and by 2007 an estimated 80% ART coverage had been achieved and was sustained thereafter. For new TB cases, an initial increase in case notifications in the first years after starting ART (2002-2005) was followed by a highly significant and sustained decline from 259 to 173 TB cases per 100,000 population (χ(2) for trend 261, P < 0.001, cumulative reduction for 2005-2009 = 33%, 95%CI 27-39). For recurrent TB, the initial increase was followed by a significant drop, from 20 to 15 cases/100,000 (χ(2) for linear trend = 8.3, P = 0.004, constituting a 25% (95%CI 9-49) cumulative reduction between 2006 and 2009. From 2005 to 2009, ART averted an estimated 1164 (95%CI 847-1480) new TB cases and 78 (95%CI 23-151) recurrent TB cases. High ART implementation coverage is associated with a very significant declining trend in new and recurrent TB case notifications at population level.
  The international journal of tuberculosis and lung disease: the official journal of the International Union against Tuberculosis and Lung Disease 07/2011; 15(7):933-7. · 2.73 Impact Factor
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  Available from: openrepository.com

  Article: Vital registration in rural Africa: is there a way forward to report on health targets of the Millennium Development Goals?

  R Zachariah, B Mwagomba, D Misinde, B C Mandere, A Bemeyani, T Ginindza, H Cortier, K Bissel, A Jahn, A D Harries
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  ABSTRACT: Vital registration - the systematic recording of births and deaths - has both legal and health significance. In particular, accurate recording and reporting of vital statistics are public goods to enable the monitoring of progress towards achieving health related targets of the 2015 United Nations Millennium Development Goals (MDG). The reality in Africa is that most births and deaths cannot be traced in legal records or official statistics and as such, there is currently no way of assessing progress towards achieving MDG targets and this applies particularly to rural settings in Africa. From the context of a rural district in Malawi, we describe an informal traditional system for the reporting of deaths at village level, and discuss the potential opportunities, challenges and ways forward in the wider implementation and interpretation of vital data generated by such a system. Such a system might provide an interim solution for accelerating the production and use of district level vital statistics for legal, administrative, statistical purposes and to report on the MDG in rural Africa while waiting for more comprehensive national systems to become a reality.
  Transactions of the Royal Society of Tropical Medicine and Hygiene 06/2011; 105(6):301-9. · 2.16 Impact Factor