Though more than 3,500 people worldwide died of tuberculosis (TB) today, you won't see it reported in headlines of any major American newspaper. Neither will you see that March 24 is World TB Day simply because for many Americans it is a disease that doesn't hit home, but this could quickly change.
Drug-resistant strains of TB, the most deadly and costly form of the illness, had a brief moment in the spotlight in 2007 when an American lawyer made headlines after making several international trips while infected with multidrug-resistant TB (MDR-TB), a strain of TB resistant to the two most potent TB antibiotics. Drug resistant TB, like drug susceptible TB, is spread through the respiratory system simply by breathing the infectious particle coughed by a sick patient. It was a worrisome situation for the hundreds of people who were exposed to the drug-resistant strains while travelling on the same airplanes as the MDR-TB patient.
Just last month, the CDC was searching for more than 4,500 people in the LA area that had been exposed to the disease. In 2011, there were nearly 11,000 reported cases of TB in the U.S., and 1.3 percent of these cases were multidrug resistant. Despite this, tuberculosis and tuberculosis resistance is not considered a major issue in the United States.
Drug-resistant TB cases are on the rise: the World Health Organization predicts that by 2015, there could be as many as 2 million drug resistant cases around the world. Drug resistance occurs when patients are not compliant with their drug regimen. But patients are often not to blame for TB drug resistance. Drug resistance regularly occurs by the failures of resource strained health care systems to ensure treatment completion. Drug susceptible TB requires a six-month minimum treatment time, during which the patient must take a daily cocktail of drugs with several unpleasant side effects. Following only a few months of the treatment, usually as early as two months, the symptoms of tuberculosis tend to wane off -- but the side effects of the drugs remain. This leads patients to discontinue treatment early in the absence of a strong health care support system to ensure their follow-up. While there are drugs on the horizon that promise a shorter treatment time, they are still currently not available for use. Drug resistance cannot wait and requires an immediate response.
This problem is particularly poignant in resource-limited settings where TB is most prevalent. In the developing world, most of the medical record systems are still in paper-based formats. Human error and omissions in the paper records provide ample opportunity to lose patients to follow-up, especially during treatment times of six months as required for TB patients.
So how do we fix this?
Operation ASHA, an NGO based in New Delhi, India has developed one solution called eCompliance, an electronic, biometric tool to ensure that health workers can accurately follow-up with all TB patients. It is comprised of a software system on a simple notebook computer combined with a fingerprint scanner, all for a low cost of less than U.S. $250 per clinic.
eCompliance works by using the patient's fingerprints to record daily visits each time the patient comes to the clinic for a dose of medication. When the health worker observes a dose, they scan the patient's finger and the visit is automatically entered into a simple compliance log that allows healthcare workers to not only view each patient's history, but also to easily access a list of patients that have missed a daily dose. Health workers do not have to waste time thumbing through individual records of each patient. Instead, they easily find their patients, administer therapy, and provide the educational support that is need.
The system has already been proven to work effectively and efficiently in dense New Delhi slums. Operation ASHA has 26 clinics utilizing the system and less than three percent of patients are lost to follow-up. But is this successful system transferable when the distance between the healthcare worker and the patient's home is more than one kilometer?
A team from Columbia University's Earth Institute decided to test this exact question by taking the system to the opposite extreme of the India model. We adapted the Operation ASHA strategy for a rural African setting in Uganda. In that context, patients no longer go to the clinic while on TB treatment, but rather a community health worker goes to the patient's home with an eCompliance system to observe the patient taking the drugs and record the drug intake.
Our team implemented three systems (notebook + fingerprint scanner) in the Millennium Villages Project in Ruhiira, in the rural southwest of Uganda and trained three community health workers (CHWs) on the process of eCompliance. Some changes in the system were necessary to adapt to local constraints. For example, unlike urban India where the systems were clinic-based, the CHWs have to ensure the system's battery is always fully charged since electricity access is often not readily available and road quality or lack thereof means travel can be long and difficult.
Yet, even with these added challenges, the system has proven to be successful. Now the CHWs are able to easily and accurately identify when a patient has missed a dose and have a conversation with them to ensure that they do complete treatment, instead of missed doses going unnoticed and resulting in loss to follow-up. That is not to say that a patient never misses a meeting for observation, it is impossible to avoid all obstacles in a six-month plus period; events such as funerals or patient travel occasionally lead to a missed record.
The results in Ruhiira are a staggering improvement. The cluster of villages has a population of about 50,000. In 2011, the most recent year with full data, there were 52 TB cases diagnosed and placed on treatment and eight patients died. The eCompliance compliance system was implemented in July 2012; since then, 31 patients have been enrolled in the system, none of those patients have been lost to follow-up, and none have died.
Perhaps more importantly, the community and the patients are excited about the system. When the project was first implemented, the mother of one patient said she could not thank the eCompliance team enough for taking care of her son. She insisted that they take a few valuable pineapples as a gesture of her appreciation. Another health worker reported that community members told him how much they appreciated both him and the system. Now they can rely on him to always check on the health and treatment status of patients. In areas of the cluster where the system doesn't yet reach, patients are asking when they will get the new technology.
These results are remarkable, and mean better TB patient care not only for the Ruhiira village cluster, but also for TB follow up rates worldwide. If systems like eCompliance work in areas as different as dense urban Indian slums and sprawled rural Ugandan villages, we may be able to halt the increased incidence of drug resistant cases.
Stopping the incidence of drug resistance in India or Uganda may seem like an issue that is not relevant to those of us in the United States. But today it is more true than ever that TB anywhere means TB everywhere. The American lawyer likely picked up MDR-TB while doing development work. But the transfer of TB can be even more indirect. As globalization grows, and the number of people travelling increases, it is more important than ever to stop TB drug resistance and stop the spread of this deadly epidemic.
Moreover, the benefit of eCompliance is not limited to tuberculosis alone. There are other medical issues where the largest challenge to success is ensuring patient follow-up, particularly in resource-scarce settings. Other opportunities include ensuring delivery of consistent antenatal care to pregnant women, recording childhood vaccinations, and aiding prevention of HIV transmission from mother to child. eCompliance may be just the assistant that overworked doctors and health workers in disadvantaged areas need to easily, efficiently, and successfully care for all of their at-risk patients, including in the United States.
With a solution available, why are we continuing to ignore the problem?
Dr. Shelly Batra, co-founder and President of Operation ASHA, helped contribute to this article.