Tracking and Treating Tuberculosis in Developing Countries
In rural Uganda, a patient is diagnosed with tuberculosis (TB), but never begins treatment. In Hanoi, Vietnam, someone with infectious TB might never be diagnosed because the health center where he or she would go to be tested is too far away. Adithya Cattamanchi, MD, a clinician at San Francisco General Hospital and Trauma Center (SFGH) and an assistant adjunct professor at the University of California San Francisco (UCSF) School of Medicine, states that, “Worldwide, only about half the number of TB cases that occur every year are actually detected and reported. Cattamanchi is addressing challenges in Uganda and Vietnam by using implementation science (ImS) techniques learned through the Training in Clinical Research program provided by UCSF's Clinical & Translational Science Institute (CTSI). ImS is focused on improving health by translating clinical findings into real-world interventions.
The usual process for diagnosing TB in Uganda took three patient visits to a health clinic: the first provided a sputum sample; the second visit on the following day provided another sputum sample; on the third visit, the patient received the test results. If TB infection was confirmed, the patient began treatment. The problem was that in developing countries such as Uganda, up to 50 percent of all patients never returned to the health center after the first visit. They either could not afford to take the time to return the next day with their second specimen, or they lived too far away from the health center. To make the process more convenient for patients to complete testing and, if needed, begin treatment in one visit, Cattamanchi’s team devised the idea of collecting only one specimen and making two smears on two different slides. They achieved the same level of sensitivity as the traditional method, but in a single visit. Cattamanchi and his team are now testing several interventions in six Ugandan health centers to improve the quality of TB diagnosis and treatment: same-day microscopy; the replacement of traditional light microscopes with LED microscopes; and an intervention in which researchers provide monthly report cards to clinic workers summarizing performance on quality indicators of TB evaluation. Sara Ackerman, PhD, MPH, a medical anthropologist and the ImS program coordinator, states that Cattamanchi’s work is “about tailoring research methods to the problem and then designing interventions that will bring about meaningful change—not just in individual behavior, but in communities, resources, and organizations.”
Cattamanchi and his team are also using technology in health interventions. While the majority of people in Hanoi have access to neighborhood health outposts, TB testing is only offered at district health centers. Cattamanchi is working with a Hanoi team to test a cell-phone-based LED microscope that will decentralize the process of diagnosis. He explains that the “health post worker collects the specimen, makes the smear, takes pictures of it with the microscope, and sends the images over the wireless network to the microscopist at the district health center, who reads the images and sends a text message with the results.” He adds that remote microscopy could potentially be used throughout the developing world where wireless telecommunications networks are becoming more prevalent. Cattamanchi and his team are also testing the impact of replacing traditional microscopy at the district health center level with a more sensitive and automated test called GeneXpert, which identifies TB bacilli by their DNA. Previously, only national laboratories could perform this type of test in a developing country. Cattamanchi says that the training he has received in ImS has been “essential to his work,” particularly in regard to qualitative research methods, in the design of less costly studies that are still scientifically accurate, and in writing the rather specialized grants for this work.
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