MDR-TB Treatment & Prevention

Dr. Nardell,I fully agree with you when you say that prompt diagnosis and effective treatment is the best way to 'turn the tap off' on MDR-TB.
My organisation, Operation ASHA, a 501C3 nonprofit, is serving 3.5 million slum dwellers in India's slums. We are doing active case finding, full and complete DOTS, and default tracking and education of patients ,families and communities. I have taken default tracking a step further by using technology. With the help of Microsoft Resaerch, we have devised hand held biometric devices to identify every patient and track every dose taken. Right now, 11 centres and about 500 patients are on biometrics.
I shall be in US from 7th Nov to present my work at the NIH conference in DC on technology and health.If possible, I would like to meet you and discuss my work.

Dr Nardel
Am realy interested in what you will present in nov unfortunately iwont be
there here in mombasa kenya am tagged with the responsibility of designing the
mechanism of following TB patient with a view to improve adherence.its costing
1.5million shillings(18800USD ) to treat one MDR patient you can see its
unsastainable something has to be done i willbe happy if you can share with me
on howhand held biometric works

salee
chw cordinator coast general hospital mombasa

I am replying here to both Drs Batra in India and Salee in Kenya.

Congratulations Dr. Batra on your great work tracking patients. That is great, but as important is to be sure each patient is getting the right therapy so that it is effective both to stop transmission and to achieve a durable cure. So, in addition to tracking and outreach to assure compliance (we favor "accompanyment" at PIH), the implementation of rapid diagnostics and drug susceptibility testing is essential. In that way there would be no MDR patients being ineffectively treated for drug susceptible TB resulting in ongoing transmission and treatment failure, and no XDR patients being treated for MDR TB with ongoing transmission and failure.

I some idea of the kind of biometric tracking you might be using, but you might explain it in more detail for Dr. Salee. In Karachi, Pakistan, the MDR program uses cell phones and geopositioning to keep track of every dose of every patient. Is that similar to your program? Please help Dr.Salee and the rest of us understand your interventions. Thanks.

Thank you Dr. Nardell for your kind comments.
More about my work: Operation ASHA is delivering DOTS, working in close collaboration with the governments TB control program. I have a dense network of DOTS centres, easily accessible, open early morning and late night, so no patient needs to miss work and wages in order to get the medicine. The DOTs providers are essentially slum dwellers themselves, who run small shops, temples, or even the local ' medical ' practictioners.  2 DOTS centres are supervised by one Counselor, who belongs to the same community that he serves, and is responsblie for educating families, taking care of side effects, ensuring compliance, and visiting patients for default tracking. The biometric intervention consists of a 10" computer, fingerprint device and a cellphone attached. When the patient comes for the first time, the counselor 'stores' his finger print in the computer and gives a uniques ID.Now when
patient comes for treatment, he has to first give his fingerprint, and be 'recognised' by the computer, only then is he given the medicine. At 10 pm, all patients who have missed the dose, the report goes via cellphone to the Counselor and Program Manager. When the counselor goes ...

Thank you Dr. Nardell for your kind comments.
More about my work: Operation ASHA is delivering DOTS, working in close collaboration with the governments TB control program. I have a dense network of DOTS centres, easily accessible, open early morning and late night, so no patient needs to miss work and wages in order to get the medicine. The DOTs providers are essentially slum dwellers themselves, who run small shops, temples, or even the local ' medical ' practictioners.  2 DOTS centres are supervised by one Counselor, who belongs to the same community that he serves, and is responsblie for educating families, taking care of side effects, ensuring compliance, and visiting patients for default tracking. The biometric intervention consists of a 10" computer, fingerprint device and a cellphone attached. When the patient comes for the first time, the counselor 'stores' his finger print in the computer and gives a uniques ID.Now when
patient comes for treatment, he has to first give his fingerprint, and be 'recognised' by the computer, only then is he given the medicine. At 10 pm, all patients who have missed the dose, the report goes via cellphone to the Counselor and Program Manager. When the counselor goes next day for default
tracking, he carries a similar intervention,, and has to take the patients finger print again. This prevents 'gaming' of the system.
I hope this explains everything. Will you beattending the Washington DC mhealth summit in Nov 8-10. I would love to meet and discuss.


Shelly Batra, MD
President, Operation ASHA
Fighting Tuberculosis Worldwide
www.opasha.org

sorry, but unfortunately, the Reliance Mobile doesn't seem to be working in
Uganda so it seems i will just stick to our local networks!!!

its a joke!

sorry i probed into your private exchange but could was just trying out
Sandeep's recommendation!

have a lovely day

ignatius

PS: i was looking around to see if the mobile technology for patient follow up
was not also being experimented in Uganda! will get you the feed back sooner
than later!

Dear Collegue

This is a good technology . I appreciate your work.

Can you say something on its feasibility and cost effectiveness for resource
poor settings?

Dr Ismael Hassen

Ethiopia

Dear colleagues,

Thank you to those who shared their thoughts so far. I would like to encourage everyone to share what method they use/have used in their setting for patient monitoring and support: community health workers, paper-based/coupons, or SMS for example, as this is a critical component of MDR-TB management.

I have also found the following information on this topic and wonder: has anyone in the community experience with any of these methods for patient monitoring?

- The role of family and community support to help patient remain compliant: http://www.ghdonline.org/drtb/discussion/mdr-tb-management/

- Mobilizing cell phones to improve antiretroviral adherence and follow-up in Kenya: a randomized controlled trial in progress: an interesting article and discussion – applications for MDR-TB treatment?
http://www.ghdonline.org/adherence/resource/mobilizing-cell-phones-to-improve...

- Mobile phones and community health workers: http://www.ghdonline.org/adherence/discussion/mobiles-in-malawi-enabling-chws...

- Text messages could hasten tuberculosis drug compliance: interesting piece in the lancet http://www.ghdonline.org/tech/resource/text-messages-could-hasten-tuberculosi...

- Also last April a panel discussion took place on lessons learned for Health Information Technology post-earthquake Haiti. The discussion quickly centered on data collection systems implementation and interoperability of reporting mechanisms and the following discussion brief provides a ...

Dear colleagues,

Thank you to those who shared their thoughts so far. I would like to encourage everyone to share what method they use/have used in their setting for patient monitoring and support: community health workers, paper-based/coupons, or SMS for example, as this is a critical component of MDR-TB management.

I have also found the following information on this topic and wonder: has anyone in the community experience with any of these methods for patient monitoring?

- The role of family and community support to help patient remain compliant: http://www.ghdonline.org/drtb/discussion/mdr-tb-management/

- Mobilizing cell phones to improve antiretroviral adherence and follow-up in Kenya: a randomized controlled trial in progress: an interesting article and discussion – applications for MDR-TB treatment?
http://www.ghdonline.org/adherence/resource/mobilizing-cell-phones-to-improve...

- Mobile phones and community health workers: http://www.ghdonline.org/adherence/discussion/mobiles-in-malawi-enabling-chws...

- Text messages could hasten tuberculosis drug compliance: interesting piece in the lancet http://www.ghdonline.org/tech/resource/text-messages-could-hasten-tuberculosi...

- Also last April a panel discussion took place on lessons learned for Health Information Technology post-earthquake Haiti. The discussion quickly centered on data collection systems implementation and interoperability of reporting mechanisms and the following discussion brief provides a list of IT resources that may be of use: http://www.ghdonline.org/tech/discussion/ghdonline-health-it-expert-panel-apr...

Thank you in advance for sharing your thoughts.

Best,
MDR moderators

P.S. Please remember that if you reply to “Per Post” email notification, then your message is directly posted in the entire community and sent to members with email notifications.

The cost of our biometric technology is very limited: about $2 per patient for six months of therapy for (normal) TB. It is as cost-effective as everything else we do.The biometric and EMR combination is substantially increasing the productivity. So the cost will be more than offset by savings in employee costs: the devices will more than pay for themselves.I am giving below additional details. Those who are interested may read more on http://www.dritte.org/nsdr10Operation ASHA’s Biometric & Electronic Medical Record System

Introduction

Biometrics terminal is a low-cost technology initiative for tracking the delivery of DOTS therapy.  The system consists of a netbook computer, a fingerprint reader, and a cell phone to relay local records to a server in the office.  It is designed to complement existing workflows in Directly Observed Therapy (DOT), whereby a health worker directly observes the swallowing of medication by patients.

When a patient in enrolled for medication, two of her finger prints (one of each hand) are stored in the system. Whenever the patient visits next for a dose of medicine, the visit is logged by recording her fingerprint with the system.  At the end of the day, the log ...

The cost of our biometric technology is very limited: about $2 per patient for six months of therapy for (normal) TB. It is as cost-effective as everything else we do.The biometric and EMR combination is substantially increasing the productivity. So the cost will be more than offset by savings in employee costs: the devices will more than pay for themselves.I am giving below additional details. Those who are interested may read more on http://www.dritte.org/nsdr10Operation ASHA’s Biometric & Electronic Medical Record System

Introduction

Biometrics terminal is a low-cost technology initiative for tracking the delivery of DOTS therapy.  The system consists of a netbook computer, a fingerprint reader, and a cell phone to relay local records to a server in the office.  It is designed to complement existing workflows in Directly Observed Therapy (DOT), whereby a health worker directly observes the swallowing of medication by patients.

When a patient in enrolled for medication, two of her finger prints (one of each hand) are stored in the system. Whenever the patient visits next for a dose of medicine, the visit is logged by recording her fingerprint with the system.  At the end of the day, the log of patients who did not visit during the day is relayed to the concerned counsellor and also uploaded to a central server, where it is imported into an Electronic Medical Record (EMR) system.  This technology is improving the transparency of medication delivery, enabling the program managers to offer targeted counselling and supervision. It has also automated the generation of monthly reports, which were complied manually.

Major Advantages

The system has many advantages, which are mentioned below.


Elimination
of human error
Elimination
of (deliberate) gaming to take undue advantage of the performance-linked
incentive system practiced by OpAsha.
Increase in
productivity of the staff, who spent about 30% of their time on
preparation and verification of statistical data
Increase in
productivity will ultimately result in reduction of staff cost and
increase cost-effectiveness of OpAsha’s model.


Patient’s attitude in a community

In any treatment program which is of this long duration as is the TB treatment regime, there are three kinds of
patients categorised on their commitment to adhere to the treatment.


Patients
who are committed and motivated to see the end of the disease
Patients
who have given up all hope, for various reasons, to live and fight, and
finally
Those who
need a push every now and then to keep them going to the DOTS centre
regularly and complete the long treatment.


It is the last category which makes up a big chunk of the patients. It is in this category that an intervention can show its maximum impact as the patients have a tendency of dwindling from either successfully completing the treatment or missing doses and ultimately defaulting.

Impact of Biometrics intervention

The biometric intervention sends patient visit logs regularly through SMS to a server from where it is downloaded to update the medical records maintained in the central office. A message containing missed dose patients is also received on the counsellor’s cell phone so that immediate remedial action can be taken. The supervisor on the other hand can also monitor, on a daily basis, each dose of every patient and take
action for the missed dose cases wherever necessary. In a nutshell, the biometric system provides timely and correct information to the provider as well as the supervisor so that the patients can get maximum benefit from the program.

Another compelling reason for introducing technological intervention like biometric in TB treatment program
is that it reassures the patients of our commitment towards treating and eradicating this disease. When patients see new and better inputs to the system, they too respond positively.

On another level, biometrics installed in health centres particularly TB treatment centres in underprivileged
communities where technology devices like these are still not common, can also become the talking point and this will in turn act as a medium to generate awareness about TB and its treatment centres in that area.

Biometrics and EMR as a complete system

These two ends together will increase staff productivity by reducing the time that a counsellor or a program manager spends in making various reports for monitoring purposes. This system (EMR+BM) will also ensure a timely and reliable flow of information across the organisation.

Ease of implementation

The biometric system consists of low-cost off-the-shelf components: a netbook, a fingerprint reader and a
low-end mobile phone (connected via USB). Its cost of less than $3 per patient for the treatment duration of 7 months can prove to be one of the most cost-effective yet efficient initiatives.

Our deployment in the field for the past 3 months has shown that this system is not only easy to use by the patients but is also equally simple and effort-free to operate by semi-literate counsellors.


Future Scope

·        
This system can be a building block for future expansions like integrating the devices with the local chest clinic and making the communication link both ways to immediately inform providers of any patient from his area who reported at the clinic or to report of sputum test result etc.

·        
This initiative can start with tracking patients suffering with various other diseases like HIV/ Hypertension/ Diabetes that need a close watch on the patient’s treatment.

·        
It can also serve as the database for sending reminders to patients in Continuation Phase to take their unsupervised medication

Publication

A research paper on this technology will be presented on June 15, 2010 at the 4th ACM Workshop on Networked Systems for Developing Regions in San Francisco http://www.dritte.org/nsdr10
.
Sandeep AhujaCEO, Operation ASHA   Fighting Tuberculosis Worldwidewww.opasha.org

Has the fingerprint reader been tested under "real" rural conditions? My Lenovo laptop, on many occasions, refuses to recognize my fingerprint when my fingers are too dry or too wet- conditions that are frequently found in rural situations.



Jay

Of course. The entire system has been tried for over a year now in the actual settings. After the glitches were removed, implementation is in progress and over 600 patients use the system regularly. To facilitate proper detection, many alternatives have been built in. First all ten fingers are initially registered and stored and the patient has the choice of using any of those ten. So even if nine fingers have cuts, the system still works. Secondly, every center is provided a "wet foam pad". It provides enough moisture to eliminate the dryness of patients' fingers. On the other hand, if the finger is dripping with moisture, the pad removes excess moisture. Using the foam pad is a small but important innovation I would say.
A small video of the biometric system in operation was made recently. It is an amateur production (we will have something professional in a few weeks) but will help capture the essence. It is available on http://www.youtube.com/watch?v=lPjA_Kc0tSM 
Sandeep AhujaCEO, Operation ASHA   Fighting Tuberculosis Worldwidewww.opasha.org

The Video does not show the fingerprint read process in real time. Also, what is being done for identifying contacts and their monitoring?

J

Dr. Hassen,
The biometirc intervention has proved its utility in resource limited settings. My DOTS Providers and Counselors, all slum-dwellers themselves, are able to operate the equipment, because  they are all able to read and write. My cost is an additional $2 per patient, and this itself is offset by increased productivity of the staff after installation of biometrics, whereby manpower costs go down.

Hopefully, it might be possible to modify the technology for purpose of those who are illiterate.

I am cc-ing Bill Theis, PhD, Researcher, who has been the one to perfect the technology, and also Sonali Batra, CTO Operation ASHA, in case there are any further questions. 
 
Shelly Batra, MD
President, Operation ASHA
Fighting Tuberculosis Worldwide
www.opasha.org

Operation ASHA is trying to make a more professional video which will be more
explicit.
 
Shelly Batra, MD
President, Operation ASHA
Fighting Tuberculosis Worldwide
www.opasha.org

Monitoring of all contacts is carried out rigorously. There is an MIS report which is used to follow that. Surprisingly, in some families, 4 out of 5 members of the family of a TB patient have been found to be positive. Our counsellors are paid an incentive for every extra detection (i.e. locating a suspect, sending her for a sputum test, collecting the report, sending her to the chest specialist for examination/ prescription, providing first counselling and the first dose with enrolment in the biometric system). So high detection can be achieved with minimal supervision.


Sandeep Ahuja
CEO, Operation ASHA
   Fighting Tuberculosis Worldwide
www.opasha.org