title: Challenges in detection and treatment of multidrug resistant tuberculosis patients in Vietnam.
abstract: BACKGROUND
  Vietnam is ranked 14(th) among 27 countries with high burden of multidrug-resistant tuberculosis (MDR-TB). In 2009, the Vietnamese government issued a policy on MDR-TB called Programmatic Management of Drug-resistant Tuberculosis (PMDT) to enhance and scale up diagnosis and treatment services for MDR-TB. Here we assess the PMDT performance in 2013 to determine the challenges to the successful identification and enrollment for treatment of MDR-TB in Vietnam.
  
  
  METHODS
  In 35 provinces implementing PMDT, we quantified the number of MDR-TB presumptive patients tested for MDR-TB by Xpert MTB/RIF and the number of MDR-TB patients started on second-line treatment. In addition, existing reports and documents related to MDR-TB policies and guidelines in Vietnam were reviewed, supplemented with focus group discussions and in-depth interviews with MDR-TB key staff members.
  
  
  RESULTS
  5,668 (31.2 %) of estimated 18,165 MDR-TB presumptive cases were tested by Xpert MTB/RIF and second-line treatment was provided to 948 out of 5100 (18.7 %) of MDR-TB patients. Those tested for MDR-TB were 340/3224 (10.5 %) of TB-HIV co-infected patients and 290/2214 (13.1 %) of patients who remained sputum smear-positive after 2 and 3 months of category I TB regimen. Qualitative findings revealed the following challenges to detection and enrollment of MDR-TB in Vietnam: insufficient TB screening capacity at district hospitals where TB units were not available and poor communication and implementation of policy changes. Instructions for policy changes were not always received, and training was inconsistent between training courses. The private sector did not adequately report MDR-TB cases to the NTP.
  
  
  CONCLUSIONS
  The proportion of MDR-TB patients diagnosed and enrolled for second-line treatment is less than 20 % of the estimated total. The low enrollment is largely due to the fact that many patients at risk are missed for MDR-TB screening. In order to detect more MDR-TB cases, Vietnam should intensify case finding of MDR-TB by a comprehensive strategy to screen for MDR-TB among new cases rather than targeting previously treated cases, in particular those with HIV co-infection and contacts of MDR-TB patients, and should engage the private sector in PMDT.
authors.affiliation: National Tuberculosis Control Program of Vietnam- National Lung Hospital (VNTP-NLH), Hanoi, Vietnam. hoangthanht@gmail.com.
authors.forename: Thuy Thi Thanh
authors.initials: TT
authors.lastname: Hoang
authors.affiliation: National Tuberculosis Control Program of Vietnam- National Lung Hospital (VNTP-NLH), Hanoi, Vietnam. vietnhung@yahoo.com.
authors.forename: Nhung Viet
authors.initials: NV
authors.lastname: Nguyen
authors.affiliation: Vietnam Association for Tuberculosis and Lung Disease, Hanoi, Vietnam. syminhquan@gmail.com.
authors.forename: Sy Ngoc
authors.initials: SN
authors.lastname: Dinh
authors.affiliation: National Tuberculosis Control Program of Vietnam- National Lung Hospital (VNTP-NLH), Hanoi, Vietnam. nguyenbinhhoatb@yahoo.com.|Centre for Operational Research, International Union Against Tuberculosis and Lung Disease, Paris, France. nguyenbinhhoatb@yahoo.com.
authors.forename: Hoa Binh
authors.initials: HB
authors.lastname: Nguyen
authors.affiliation: Department of Global Health and Amsterdam Institute for Global Health and Development, Academic Medical Center, Amsterdam, Netherlands. f.cobelens@amc-cpcd.org.
authors.forename: Frank
authors.initials: F
authors.lastname: Cobelens
authors.affiliation: Wellcome Trust Major Overseas Program, Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam. gthwaites@oucru.org.|Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom. gthwaites@oucru.org.
authors.forename: Guy
authors.initials: G
authors.lastname: Thwaites
authors.affiliation: KNCV Tuberculosis Foundation, Vietnam Country Office, Hanoi, Vietnam. nthuong139@gmail.com.
authors.forename: Huong Thien
authors.initials: HT
authors.lastname: Nguyen
authors.affiliation: Woolcock Institute Of Medical Research, Sydney, Australia. thuanh.nguyen@sydney.edu.au.
authors.forename: Anh Thu
authors.initials: AT
authors.lastname: Nguyen
authors.affiliation: Medisch Comite Nederland-Vietnam, Amsterdam, Netherlands. pamela.wright@mcnv.nl.
authors.forename: Pamela
authors.initials: P
authors.lastname: Wright
authors.affiliation: Nuffield Department of Clinical Medicine, Centre for Tropical Medicine, University of Oxford, Oxford, United Kingdom. heiman.wertheim@gmail.com.|Wellcome Trust Major Overseas Program, Oxford University Clinical Research Unit, (OUCRU), Hanoi, Vietnam. heiman.wertheim@gmail.com.|Department of Medical Microbiology, Radboudumc, Nijmegen, Netherlands. heiman.wertheim@gmail.com.
authors.forename: Heiman F L
authors.initials: HF
authors.lastname: Wertheim
mesh_terms: D060085:Coinfection; D003142:Communication; D019468:Disease Management; D017144:Focus Groups; D015658:HIV Infections / Q000150:complications; D006291:Health Policy; D006801:Humans; D008403:Mass Screening; D009169:Mycobacterium tuberculosis; D017149:Private Sector; D012293:Rifampin / Q000627:therapeutic use; D013183:Sputum; D018088:Tuberculosis, Multidrug-Resistant / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D014397:Tuberculosis, Pulmonary / Q000150:complications / Q000175:diagnosis* / Q000382:microbiology / Q000628:therapy; D014744:Vietnam
chemical_list: D012293:Rifampin