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Operational research on implementation of tuberculosis guidelines in Mozambique

Brouwer, Miranda

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Citation for published version (APA):Brouwer, M. A. (2015). Operational research on implementation of tuberculosis guidelines in Mozambique.

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Download date: 20 Jun 2019

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Acknowledgements!

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My! statement! that! I! was! doing! a! PhD! for! fun! in! my! spare! time! was! often! met! by! surprise! by! fellow!participants!of!the!graduate!school!courses.!Although!I!had!my!moments!of!doubt,!conducting!the!research!for!this!thesis!has!been!fun!and!a!great!learning!experience.!Part!of!the!fun!and!the!learning!was!because!I!worked!together!with!many!nice!and!knowledgeable!people!to!whom!I!am!very!grateful.!

First!I!would!like!to!thank!my!coPpromotor!Frank!van!Leth.!Without!your!support!I!would!not!have!managed!to!finalise!this!thesis.!We!started!talking!research!and!a!PhD!long!before!I!formally!started!(often!at!Union!conferences! on! the! way! back! at! Gare! du! Nord).! From! protocol! development! to! the! publication! of! the!results,! you! helped! with! almost! every! step.! You! happily! did! most! of! the! more! complicated! statistical!analysis,!and!showed!me!how!to!use!Zotero,!which! I!have!used!ever!since.!Not!only!did!we!talk!research!related! themes!when!we!met,! but! also! other! aspects! of! life! such! as! good! books,! films,! dance! shows! to!name!just!a!few.!The!manner!in!which!you!supported!me!is!the!way!I!now!try!to!support!others.!Most!of!your!support!towards!the!work!in!this!thesis!you!did!in!your!spare!time.!A!visit!to!Scotland!to!taste!some!samples!of!the!Scottish!water!of!life!is!my!way!of!thanking!you.!The!sample!size!still!needs!to!be!calculated.!

I!started!out!the!doctorate!trajectory!with!Martien!Borgdorff!as!promotor,!who!could!not!see!it!through!to!the!end!because!of!his!move!abroad.!Frank!Cobelens!succeeded!as!my!promotor.!Thank!you!both!for!your!stimulating!support!in!my!research!and!writing.!

I! thank! the!members! of! the! committee! for! their! willingness! to! evaluate!my! thesis.! I! find! it! particularly!special!that!professor!Johan!Groothoff,!who!made!me!aware!of!the!importance!of!public!health!in!my!very!first!year!at!medical!school!and!who!coPauthored!my!first!scientific!publication!many!years!ago,! is!part!of!the!committee.!!

I! also! thank!my!coPresearchers! in!Mozambique! for!all! their! support.!Agradeço!a!estimada!Doutora!Paula!Samo!Gudo,! que! na! ocasião! do! primeiro! estudo! era! chefe! do! Programa!Nacional! da! Tuberculose.! O! seu!suporte! foi! crucial! e! nossos! encontros! e! discussões! foram!produtivos! e! agradáveis.! Agradeço! a! caríssima!Doutora!Eliana!Coelho,!!com!quem!trabalhei!lado!a!lado!no!segundo!estudo.!Juntas!escrevemos!o!protocolo,!visitamos! as! províncias! de! Manica,! Sofala! e! Tete! para! conduzir! os! grupos! focais! e! juntas! também!analisamos!as!transcrições.!Eliana,!aprendi!muito!consigo.!Meus!sinceros!agradecimentos!a!outros!colegas!que! ajudaram! nessa! empreitada! em! Moçambique:! obrigada! a! Dra.! Carla! das! Dores! Mosse,! Dr.! Isaías!Manuel! Ramiro,! Dr.! Riaz!Mubarak,! Dra.! Paula! Perdigão,! Sr.! Chalice!Magé! Simbe,! Sra.! Elisa! Luís,! Sr.! Lino!Sixpense!e!Sr.!Tino!João!dos!Santos.!Ao!agradecer!nominalmente!a!esses!colegas,!corro!o!risco!de!esquecer!alguém,!e!por!isso,!peço!desculpas!antecipadamente.!

I! thank! all! the! people!who! helped!with! the! data! collection.!Agradeço! aos! seguintes! colegas:! Sra.! Celina!Joaquim,! Sr.! Eugénio! Alberto! Anselmo! e! Sr.! Nelson! Chico! Mafione! que! colheram! os! dados! do! primeiro!estudo.! Obrigada! a! Sr.! Pedro! Tenente! pela! ajuda! no! manuseio! dos! dados.! E! aos! seguintes! colegas! que!colheram! os! dados! do! segundo! estudo,!meu! agradecimento:! Sr.! Francisco! António,! Sr.!Manuel! Armando!Cumba,! Sra.! Elisa! Luís,! Sr.!Modesto! Pedro!Mafaledzomba,! Sr.! Nelson! Chico!Mafione! e! Sr.! Tino! João! dos!Santos.!!

For!the!data!collection!in!Uganda,!I!thank!Annet!Nakaweesa!and!Michael!Mukiibi.!Another!person!without!whom! I! would! not! have! managed! the! study! in! Uganda! is! Achilles! Katamba! at! Makerere! University! in!Kampala.!He!provided!the!necessary!material,!supported!the!data!collectors,!was!available!for!discussions!and!helped!with!the!formalities.!Thank!you!Achilles.!

I!thank!Health!Alliance!International!(HAI),!the!organisation!I!worked!for!in!Mozambique,!for!allowing!me!to!conduct!the!Mozambican!studies!in!this!thesis!as!part!of!their!activities.!I!also!thank!HAI!staff!for!assisting!me!after!I!left!Mozambique!with!inPcountry!communication.!

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We!lived!in!Mozambique!for!four!years.!I!thank!all!our!friends!and!colleagues,!from!Mozambique!and!many!other! places! in! the! world,! for! giving! us! a! wonderful! time! over! there.! A! special! word! of! thanks! goes! to!Luciana,! who! is! a! friend! and! a! colleague! and! a! coPadvocate! for! improving! TB! infection! prevention! and!control.!Your!Brazilian!mother!tongue!was!really!helpful!when!my!knowledge!of!Portuguese!failed!me.!

Diederike!was!the!one!‘calling’!me!to!Mozambique!in!the!first!place.!We!have!much!in!common:!same!birth!year,! study! in! Groningen! (you!were! ahead! of!me),! working! in! Zambia! (again! ahead! of!me),! stories! of! a!stolen!car,!research,!and!much!more.!You!proofread!many!of!the!papers!in!this!thesis.!Thank!you!and!may!we!continue!to!share!good!moments.!

The!library!of!Tilburg!University!became!the!place!where!I!could!focus!on!my!research.!Without!distraction!from!the!Internet!and!phone!it!is!a!quiet!place!where!all!one!can!do!is!work.!The!library!possesses!several!useful!books!on!qualitative!research!and!statistical!analysis,!which!helped!with!those!parts.!I!liked!working!there!so!much!that!I!now!use!the!library!as!my!office!away!from!home.!

Heleen!and!Wieneke,!thank!you!for!being!my!paranymphs.!Since!the!start!of!my!tropical!career!(Heleen)!en!my!tuberculosis!career!(Wieneke),!you!both!are!part!of!my!professional!life,!though!often!at!a!distance.!We!are!friends!as!well!as!colleagues!and!have!shared!many!good!moments!in!several!parts!of!the!world.!Wine!sampling! in! Enschede,!hill!walking! in! Scotland,!klaverjassen! in! the!Okavango!delta,! and! tasting! Ethiopian!food,!are!just!a!few!examples!of!the!global!fun!I!enjoyed!with!you.!

I!thank!my!family.!My!mother,!long!deceased,!always!encouraged!me!to!become!an!independent!person.!I!dedicate!this!thesis!to!her.!My!father!taught!me!lots!of!useful!business!skills,!which!I!use!regularly!now!that!I!run!my!own!business.!My!brothers!have!encouraged!me!all!through!my!life!even!though!they!may!not!be!aware!of!it.!Thank!you!all.!!

Paul,!how!would! I!have!managed!the!whole!project!without!you?!Not!only!your!rich!research!experience!assisted!my!work,!you!also!easily! found!the!missing!comma!in!my!R!syntax.!Much!more! importantly,!you!have!been!my!companion!on!life’s!journey!for!almost!two!decades.!May!this!journey!together!continue!for!many!years!to!come.!

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Portfolio!

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Curriculum!Vitae!

2011Ppresent:!Independent!consultant!!

2007P2010:!TB/HIV!advisor!to!National!TB!Control!Programme,!Mozambique!

1991P2006:!Medical!officer!in!The!Netherlands,!Zambia;!specialist!training!Public!Health;!TB!control!medical!officer!The!Netherlands,!addiction!services!medical!officer!Scotland!

1983P1991:!Rijksuniversiteit!Groningen,!Medical!School!

!

Publications!

!

van! Leth! F,! van! Crevel! R,!Brouwer!M.! Latent! tuberculosis! infection! as! a! target! for! tuberculosis! control.!Future!Microbiology.!In!press.!

Mbonze!N,!Tabala!M,!Wenzi!LK,!Bakoko!B,!Brouwer!M,!Creswell!J,!Van!Rie!A,!Behets!F,!Yotebieng!M.!Impact!of!Xpert!MTB/RIF!as!diagnostic!for!smearPnegative!presumptive!TB!cases!on!case!notification! in!Kinshasa,!DR!Congo.!Submitted.!

Nabukenya! MG,! Kawuma! HJS,! Brouwer! M,! Mudiope! P,! Vassall,! A.! Tuberculosis! retreatment! 'others'! in!comparison!with!classical!retreatment!cases!in!regional!hospitals,!Uganda.!Submitted.!

Brouwer!M,!Coelho!E,!Das!Dores!Mosse!C,!Van!Leth!F.!Implementation!of!Tuberculosis!Infection!Prevention!and!Control! in!Mozambican!health! care! facilities.! International! Journal! of! Tuberculosis! and! Lung!Disease!2015;!19!(1):!44P49.!

Brouwer! M,! Coelho! E,! Das! Dores! Mosse! C,! Brondi! L,! Winterton! L,! Van! Leth! F.! Health! care! Workers’!Challenges! in! the! Implementation! of! Tuberculosis! Infection! Prevention! and! Control! Measures! in!Mozambique.!PLoS!One.!2014!Dec!15;!9!(12):!e114364.!

Blok! L,! Creswell! J,! Stevens! R,! Brouwer! M,! Ramis! O,! Weil! O,! Klatser! P,! Sahu! S,! Bakker! M.! A! pragmatic!approach!to!measuring,!monitoring!and!evaluating!interventions!for!improved!tuberculosis!case!detection.!International!Health!2014,!Aug!6.!

Creswell! J,! Codlin! AJ,! Andre! E,! Micek! MA,! Bedru! A,! Carter! EJ,! Yadav! RPP,! Mosneaga! A,! Rai! B,! Banu! S,!Brouwer!M,! Blok! L,! Sahu! S,! Ditiu! L.! Results! from! early! programmatic! implementation! of! Xpert!MTB/RIF!testing!in!nine!countries.!BMC!Infectious!Diseases!2014,!14:!2.!

Brouwer! M,! Samo! Gudo! P,! Simbe! C,! Perdigão! P,! Van! Leth! F.! Benchmarking! to! assess! potential! underPdiagnosis!of!smearPnegative!and!extrapulmonary!tuberculosis.!A!case!study!from!Mozambique.!The!Open!Infectious!Diseases!Journal!2013,!7:!1P4.!

Brouwer!M,! Samo! Gudo! P,! Simbe! C,! Perdigão! P,! Van! Leth! F.! Are! routine! tuberculosis! programme! data!suitable!to!report!on!antiretroviral!therapy!use!of!HIVPinfected!tuberculosis!patients?!BMC!Research!Notes!2013,!6:!23.!

Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P,!Van!Leth!F.!The!effect!of!Tuberculosis!and!antiretroviral!treatment!on!CD4+!cell!count!response! in!HIVPpositive!Tuberculosis!patients! in!Mozambique.!BMC!Public!Health!2012,!12:!670.!

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Samo!Gudo!P,!Cuna!Z,!Coelho!E,!Maungate!S,!Borroni!E,!Miotto!P,!Ahmadova!S,!Brouwer!M,!Migliori!GB,!Zignol! M,! Cirillo! DM.! Is! MDRPTB! on! the! growth! in! Mozambique?! Results! of! a! national! drug! resistance!survey.!Eur!Respir!J!2011!38:!222P224.!

Brouwer!MA,!Keizer!ST.!Tuberculose!bij!asielzoekers.!Screening!bij!binnenkomst,!een!belangrijke!bijdrage!aan!de!bestrijding.!Infectieziekten!Bulletin!2003;!14!(2):!46P50.!

Brouwer!MA,!Linden!PJQ!van!der.!De!acardiacus:!bekend!doch!weinig!gezien.!Nederlands!Tijdschrift!voor!Obstetrie!en!Gynaecologie!1999;!112:!212P3.!

Brouwer!MA.!Caesarean!Section:!a!different!approach.!Tropical!Doctor!1998;!28!(3):!182P3.!

Brouwer!MA,!Groothoff! JW,!Mooyaart!EL,! Terpstra!S.!Het! vaststellen!van!de!behoefte!aan! zorg.!De!MRPscan!als!voorbeeld.!Medisch!Contact!1991;!46:!750!–!752.!

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Conference!proceedings!!

Poster!presentation.!Brouwer!M,!Coelho!E,!das!Dores!Mosse!C,!Brondi!L,!van!Leth,!F.!Tuberculosis!infection!control! and! prevention! in! Mozambique:! a! gap! between! daily! practice! and! guidelines.! 45th! World!Conference!on!Lung!Health!of!the!International!Union!Against!Tuberculosis!and!Lung!Disease,!2014.!

Oral!presentation.!Langa!E,!Brouwer!M,!Coelho!E,!Rahman!H,!Bossemeyer!D,!Brondi!L.!TB!infection!control!evaluations!leading!to!changes!in!guidelines!and!policies!in!Mozambique,!43rd!World!Conference!on!Lung!Health!of!the!international!Journal!of!Tuberculosis!and!Lung!Disease,!2012.!

Electronic!poster.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P.! Is!median!CD4+!TPcell!an! indicator! for!underPdiagnosis! of! some! forms! of! Tuberculosis! in!Mozambique?! International! AIDS! Society! Conference,!2010.!

Oral!presentation.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P.!Implementation!of!TB/HIV!activities!and!follow!up!of!HIV!positive!TB!patients!in!Mozambique.!2nd!South!African!TB!Conference,!2010.!

Oral!presentation.!Brouwer!M,!Samo!Gudo!P,!Simbe!C,!Perdigão!P,!Van!Leth!F.!ART!use!determines!CD4+!TPcell! response! during! and! after! Tuberculosis! treatment! in! HIV! positive! TB! patients! in!Mozambique.! Oral!Presentation!at!4th! International!Workshop!on!HIV!Treatment,!Pathogenesis!and!Prevention!Research! in!Resource!limited!Settings,!2010.!

Oral!presentation.!Scardigli!A,!Samo!Gudo!P,!Brouwer!M.!Coordination!between!TB!and!HIV!services!for!the!coPinfected!TB!patient:!a!real!challenge.!40th!World!Conference!on!Lung!Health!of!the!international!Journal!of!Tuberculosis!and!Lung!Disease,!2009.!

Poster!presentation.!Brouwer!MA,!Meijer!W.!Tuberculosis!screening!of!prisoners! in! the!Netherlands.!3rd!Congress! of! Lung! Health! of! the! International! Union! Against! Tuberculosis! and! Lung! Disease,! European!Region,!2004.!

Poster!presentation.!Brouwer!MA,!Post!PN.!INH!treatment!in!tuberculin!surveys:!a!decision!analysis.!33rd!World!Conference!on!Lung!Health!of!the!International!Union!Against!Tuberculosis!and!Lung!Disease,!2002.!

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Postgraduate+Courses++

+

Academic+Medical+Centre+Graduate+School:+

Advanced!Topics!in!Clinical!Epidemiology,!2014!

Computing!in!R,!2014!

Project!Management,!2013!

Basic!Course!Practical!Biostatistics,!2012!

Clinical!Epidemiology,!2012!

Infectious!Diseases,!2012!

Scientific!Writing!in!English!for!Publication,!2012!

Crash!course,!2011!

Expert!Management!of!Medical!Literature:!PubMed,!2011!

!

Other:+

DRLTB!Consultant!Training!Course.!World!Health!Organization,!2011!

WHO! Training! course! on! implementing! the! new! Stop! TB! Strategy:! MDR/XDR,! TB/HIV,! PPM,! Infection!control!and!more.!WHO!collaborating!Centre,!Italy,!2009!

+Teaching:+

Supply!Chain!Management!with!a!focus!on!TB,!The!UNION,!2013!&!2014!

TB! infection! control:! training! for! managers! at! the! national! and! subnational! levels.! WHO! collaborating!Centre,!Italy,!2009!

!

Contribution+to+guidelines:+

Ministério)de)Saúde,)Direcção)Nacional)de)Saúde)Pública,)Programa)Nacional)de)Controlo)da)Tuberculose.)

Política)e)Plano)Nacional)de)Controlo)da)Infecção)para)a)Tuberculose)em)Unidades)Sanitárias)e)ambientes)

conglomerados)de)Moçambique.!2010.!

Ministério)de)Saúde,)Direcção)Nacional)de)Saúde)Pública,)Programa)Nacional)de)Controlo)da)Tuberculose.)

Manual)de)Diagnóstico)e)Tratamento)de)Tuberculose)Resistente)e)MultiGDroga)Resistente.!2009.!

Commissie) voor) Praktische) Tuberculosebestrijding.) KNCV) Tuberculosefonds.) Handboek) TBCGbestrijding)

Nederland.!2008.!

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Affiliations! and! contributions! of! co:

authors!

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Chapter! 2! The! effect! of! Tuberculosis! and! antiretroviral! treatment! on! CD4+! cell! count! response! in! HIVPpositive!Tuberculosis!patients!in!Mozambique.!!

Chapter!3!Are!routine!tuberculosis!programme!data!suitable!to!report!on!antiretroviral!therapy!use!of!HIVPinfected!tuberculosis!patients?!!

Chapter! 4! Benchmarking! to! assess! potential! underPdiagnosis! of! smearPnegative! and! extrapulmonary!tuberculosis.!A!case!study!from!Mozambique.!!

For!chapter!2!–!4!the!coPauthors!are:!

Paula!Samu!Gudo!(PSG)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique!

Chalice!Magé!Simbe!(CMS)!P!Ministry!of!Health,!Provincial!Directorate,!Manica,!Mozambique!!

Paula!Perdigão!(PP)!P!Independent!chest!physician,!Maputo,!Mozambique!

Frank! van! Leth! (FL)! P! Department! of! Global! Health,! Academic!Medical! Center,! University! of! Amsterdam,!Amsterdam,!The!Netherlands;!KNCV!Tuberculosis!Foundation,!Den!Haag,!The!Netherlands!

Miranda!Brouwer!(MB),!PSG,!PP!and!FL!conceived!the!study;!MB,!PSG!and!CMS!developed!the!study!tools;!MB!and!CMS!coordinated!the!data!collection;!MB,!PSG,!PP!and!FL!analysed!the!data.!MB!drafted!the!first!versions! of! the! manuscripts,! and! all! coPauthors! provided! comments! and! suggestions! towards! the! final!manuscripts.!

Chapter!5!Health!care!Workers’!Challenges!in!the!Implementation!of!Tuberculosis!Infection!Prevention!and!Control!Measures!in!Mozambique.!!

Eliana!Coelho!(EC)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique!!

Carla!das!Dores!Mosse!(CDM)!P!Ministry!of!Health,!Provincial!Directorate,!Tete,!Mozambique!

Luciana!Brondi!(LB)!P!Independent!Consultant,!Edinburgh,!United!Kingdom!

Laura!Winterton!(LW)!P!Social!Anthropology,!University!of!Edinburgh,!United!Kingdom!

Frank! van! Leth! (FL)! P! Department! of! Global! Health,! Academic!Medical! Center,! University! of! Amsterdam,!Amsterdam,!The!Netherlands!

Miranda!Brouwer!(MB),!EC!and!FL!conceived!the!study;!MB,!EC!and!LB!developed!the!study!tools;!MB!and!EC!conduced!the!focus!group!discussions;!MB,!EC,!CDM,!LB!and!LW!analysed!the!data.!MB!drafted!the!first!version! of! the! manuscript,! and! all! coPauthors! provided! comments! and! suggestions! towards! the! final!manuscript.!

Chapter! 6! Implementation! of! Tuberculosis! Infection! Prevention! and! Control! in!Mozambican! health! care!facilities.!!

Eliana!Coelho!(EC)!P!Ministry!of!Health,!National!TB!Control!Programme,!Maputo,!Mozambique!!

Carla!das!Dores!Mosse!(CDM)!P!Ministry!of!Health,!Provincial!Directorate,!Tete,!Mozambique!

Frank! van! Leth! (FL)! P! Department! of! Global! Health,! Academic!Medical! Center,! University! of! Amsterdam,!Amsterdam,!The!Netherlands!

Miranda!Brouwer!(MB),!EC!and!FL!conceived!the!study;!MB!and!EC!developed!the!study!tools;!MB,!EC,!CDM!and! FL! analysed! the! data.! MB! drafted! the! first! version! of! the! manuscript,! and! all! coPauthors! provided!comments!and!suggestions!towards!the!final!manuscript.!

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About!the!author!

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Miranda!Brouwer!was!born!in!Winschoten,!The!Netherlands.!She!attended!secondary!school!in!Haren!and!received!her!gymnasium!beta!diploma!in!1982.!After!a!gap!year!in!Switzerland,!she!started!medical!school!in!Groningen!in!1983.!She!wanted!to!do!her!practical!years!on!the!island!of!Curaçao,!but!a!lottery!decided!differently:! Diaconessen! hospital! Groningen.! An! overseas! alternative! presented! itself! in! the! form! of! an!elective!period!at!the!University!Teaching!Hospital!in!Lusaka,!Zambia!(1990).!This!was!a!decisive!step!in!her!career,!and!ever!since,!Zambia!and!Africa!have!been!close!to!her!heart.!!

After!graduating!from!medical!school,!Miranda!started!the!tropical!doctor!training!programme.!Equipped!with!obstetric!and!surgical!skills,!a!diploma!from!the!Royal!Tropical!Institute!on!tropical!diseases,!and!lots!of!enthusiasm!and!common!sense,!she!returned!to!Zambia! in!1994!to!work!at!Our!Lady’s!Hospital!Chilonga.!She! learned! to! provide! medical! services! under! challenging! circumstances! such! as! shortage! of! staff! and!materials,! power! cuts! and! lack! of! running! water.! Moreover,! she! practised! public! health! in! addition! to!clinical!medicine.!

Upon!returning!to!The!Netherlands!early!1998,!she!briefly!started!a!career!in!obstetrics!and!gynaecology,!but! decided! that! public! health!was!more! appealing.! In! 1999! the! opportunity! arose! to! join! the!Dutch! TB!control! world,! again! a! major! decisive! moment! in! Miranda's! career.! She! trained! as! a! TB! doctor! at! the!Municipal!Health!Services!in!Tilburg!and!the!Netherlands!School!of!Public!Health!in!Utrecht,!and!qualified!as!a!specialist!in!2001.!!

Going!overseas!had!great!attraction!and!in!2004!she!moved!to!Edinburgh,!Scotland.!She!worked!partPtime!as!medical!officer!in!the!homeless!addiction!team!in!Glasgow!and!in!the!remaining!time!Miranda!developed!the!first!TB!control!handbook!for!The!Netherlands.!

Africa! still! pulled! hard! and! when! in! 2006! the! request! ‘why! don’t! you! join! us’! came! from! a! friend! in!Mozambique,! she! learned! Portuguese! and! moved.! First! to! Chimoio! in! central! Mozambique! where! she!worked!with! the! provincial! TB! and! HIV! programmes! on! TB/HIV! collaboration! and! integration.! Later! she!moved! to!Maputo! and! assisted! the!National! TB! Programme! as! a! technical! advisor.! During! this! time! she!conducted!most!of!the!research!of!which!the!results!are!presented!in!this!thesis.!

In!2011!she!returned!to!Tilburg,!The!Netherlands.!She!started!her!own!consulting!agency!working!mainly!in!TB! and! HIV! high! burden! countries.! She! works! as! an! independent! consultant! supporting! TB! and! HIV!programmes,! as!well! as! the!wider!health! care! system! to! further! improve! their! activities.! She!works!with!large! international! organisations! and! small! local! organisations! and! enjoys! both.! She! supports! the!development! of! national! strategic! plans,! funding! proposals! and! policies! and! guidelines,! undertakes!research!projects!and!evaluates!numerous!projects.!She!would!like!to!continue!this!work!for!many!years!to!come.!

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