Operational Research

The promotion of research is one of the main components of the World Health Organizations Stop TB Strategy, which includes programme-based operational research (OR) which has been defined as Research into

Strategies, interventions, tools or knowledge which can improve program performance and/or health care delivery. The importance of OR in improving tuberculosis (TB) control was recognised a long time ago, and historical OR studies have been instrumental in the development of major strategies for TB control. Operational Research focuses at developing interventions that result in effective policies, better design of health systems, and more efficient methods of service delivery. Also, Operational research can help assess the effectiveness of new tools or interventions and determine the conditions and requirements that will maximize their effective use. It is though Research that we identify and address bottlenecks to implementation of existing policies and provide evidence from the perspective of patients and health systems alike.

OR in TB control is aimed at

1. Improving programme performance
2. Assessing the feasibility, effectiveness and impact of new strategies or interventions on TB control
3. Collecting evidence to guide policy recommendations on specific interventions.

Operational Research agenda for Tanzania was organized around 4 topics adopted from the document Priorities in Operational Research to improve TB care and control (WHO, 2011):

Area 1. Access, screening and diagnosis of TB

1. How much can new diagnostic centres in rural areas contribute to improve case detection?
2. How to detect patients without having typical TB signs and symptoms?
3. How to select/screen high risk clients for TB (e.g. diabetes, elderly)
4. How to improve use of available diagnostic tools e.g. GeneXpert and Chest x-ray? (Currently underutilized), and how much increase in TB case detection can be achieved? How to maximize/improve screening and diagnostic algorithms to improve TB yield?
5. What are the barriers to starting TB treatment, both patient delay and health systems delay? Impact of cost of TB diagnosis, treatment and loss of income?
6. What will be the impact (on quality, case notification and human resources) of integrating TB management with other services
7. How to improve sputum specimen transportation within the laboratory network?
8. How to reduce sample contamination?
9. What is the feasibility of using rats to screen TB in different settings (e.g. hospitals, community screening) and what is cost-effectiveness compared to GeneXpert?

Area 2. Sustainable collaboration with all care-providers

1. What is the capacity of care providers (do mapping) and how can this enhance linkages amongst different care providers?

Area 3. Prevention of TB in PLHIV and joint treatment of TB and HIV

1. i. Isoniazid preventive therapy (IPT) for PLHIV:
   1. Does IPT increase INH resistance?
   2. What is the IPT uptake in the country? Any challenges and opportunities?
   3. What is the optimal duration and protective effect of IPT? (not repeating trials that have been done elsewhere, but a meta-analysis of cohorts in different established groups offering IPT in the country) 
2. Miners, Migrants (Refugees)
   1. 1. What is the burden, drug resistance and dynamics of treatment in miners (adherence, monitoring treatment outcome)?
      2. How can we harmonize TB regimens and registers between countries?
3. Prisoners, PWID, Sex workers
4. What is the magnitude of TB/HIV co-infection in these risk populations?
5. What is the dynamics of treatment outcome in these risk populations (adherence, monitoring treatment outcome)?

Area 4. Access to and delivery of treatment for drug-susceptible and M/XDR-TB

1. Is there enough capacity to decentralize MDR-TB services – human resources, infrastructure, network, promoting community awareness
2. Will decentralization increase access to treatment?
   1. 1. reducing time to access
      2. Increasing acceptance and compliance
      3. Will it increase treatment success?
3. What is the sustainability of decentralization?
4. What socio-support can be obtained from the communities

How to implement new MDR-TB regimens properly? What level of pharmacovigilance to establish?