• TB
  • GeneXpert technology to help Nigeria fight TB

    Using modern technology to detect diseases such as Tuberculosis (TB) has helped to reduce it globally. But, much more’s needed.

    For Nigeria, TB’s a major public health concern. WHO’s 2016 TB report says “Unfortunately, case detection in Nigeria is still very low at 16 per cent, while Nigeria is among the six countries accounted for 60 per cent of the new cases in 2015: India, Indonesia, China, Nigeria, Pakistan and South Africa. Nigeria estimates an incidence of 586,000 new cases in 2015 and 180,000 deaths every year. Early and accurate diagnosis is essential for prompt and adequate treatment.”

    To address this challenge, the National Agency for the Control of AIDS (NACA) has donated the GeneXpert test device platform to the St. Kizito Clinic. An article in BIZTECHAFRICA says it includes the installation of the equipment and staff training on GeneXpert technology. The test will substantially improve TB diagnoses in the community. It’ll enable the detection of Multi-Drug Resistant Tuberculosis (MDRTB) too, which is especially hard to diagnose in HIV positive patients.

    Dr Abdur Razzaq, Acting Director of KNCV Tuberculosis Foundation in Nigeria said, “TB still constitutes a serious public health problem in Nigeria, despite the implementation of the DOTS centres since 1993 and the adoption of the WHO “Stop TB strategy” in 2006. We set 2017 as the year of accelerated case finding for TB, we believe that the GeneXpert machine in St Kizito Clinic will further improve their capability to detect TB cases and prevent further infections in the community.”

    The test’s reliability makes it a valuable tool in the fight against TB. That the results are available in under two hours and can identify resistance to the antibiotic rifampicin are major benefits compared to the current service. Normally, it can take weeks to have drug resistance results. The technology should help Nigeria strengthen its position in its fight against TB.

  • Nigeria and South Africa in TB top six

    The UN’s Sustainable Development Goal (SDG) 3 accords a high priority to combating TB by reducing its prevalence and ending the epidemic by 2030. It’s part of the cause of lower respiratory tract deaths, at 11% of all African’s deaths, it’s second, and close to, HIV/AIDS deaths as Africa’s top killer. TB’s global death rate’s rising, and Nigeria and South Africa are in the group of six countries accounting for 60% of deaths.

    WHO has issued a new TB facts sheet. In 2014, 9.6 million people fell ill with TB and 1.5 million died from the disease. Over 95% of TB deaths are in Low and Middle-Income Countries (LMIC). It’s in the top five causes of death for women aged 15 to 44. In 2014, an estimated 1 million children were ill with TB, of which, 140 000 died.

    Other facts from WHO are:

    1. TB is one of the top ten causes of death globally
    2. In 2015, 10.4 million people fell ill with TB and 1.8 million died from it, including 0.4 million people with HIV
    3. Over 95% of TB deaths are in low- and middle-income countries.
    4. Six countries account for 60% of the total, with India top followed by Indonesia, China, Nigeria, Pakistan and South Africa
    5. In 2015, about one million children became ill with TB and 170,000 children died of TB, excluding children with HIV
    6. TB’s a leading killer of HIV-positive people, with 35% of HIV deaths in 2015 due to TB
    7. Globally, some 480,000 people developed multidrug-resistant TB (MDR-TB) in 2015
    8. TB incidence has fallen by an average of 1.5% a year since 2000, but needs to accelerate to a  4% annual decline to achieve WHO’s End TB Strategy 2020 target
    9. About 49 million lives were saved through TB diagnosis and treatment between 2000 and 2015.

    WHO has a three part strategy:

    1. Integrated patient-centred care and prevention
    2. Bold policies and supportive systems
    3. Intensified research and innovation.

    eHealth can support each of these. It’s worth African health systems reviewing their eHealth strategies, plans and programmes to be sure that sufficient resources and innovation are included to address their TB epidemics. With appropriate interoperability and architecture, patient-centred eHealth for TB and also provide low cost data needed for research and innovation, leading to shorter timescales to find better solutions.

  • emocha mhealth solution for South Africa's MDR TB

    emocha, a mobile health platform developed by Johns Hopkins, launched a new platform in 2015 to help deliver more effective care for multi-drug resistant tuberculosis (MDR TB) patients. The system has been successfully implemented in three clinics in South Africa, and will now begin a phased national expansion, starting with 20 high-burden clinics across the Kwazulu-Natal and Eastern Cape districts over the next three months. 

    An estimated 500,000 people live with MDR TB globally. Close to 16,000 patients are diagnosed each year in South Africa, with less than half returning to the clinic for care after diagnosis. To bridge the gap, emocha integrates several providers onto its emocha platform, keeping each informed as patients progress. In a press release by emocha, the company  says a key aspect of their system is that miLINC interfaces with the National Health Lab Service (NHLS), which has a national network of 260 laboratories that serve over 80% of South Africa’s population. This allows for a rapid turn around in test results.

    The initiative’s a collaboration between public health experts at Johns Hopkins, public health non-profit Jhpiego, originally called the Johns Hopkins Program for International Education in Gynecology and Obstetrics, emocha, and the South African National Department of Health. Treatment for MDR TB is incredibly challenging. Patients have to take multi-drug regimens for months, and many patients have poor access to care and limited resources, further complicating their treatments. 

    The miLINC platform aims to connect primary care centres with centralised labs and public health management programmes. Three different apps have been developed, each for specific parts of the care continuum. The first app is designed for the initial points of contact, such as in a primary care clinic, where patients show up with TB symptoms. It lets primary care clinicians record patient information, symptoms, notes and assign a unique  number to each patient.

    The second app’s designed for health workers who track many cases. Test results from centralised TB labs are captured so health workers can identify patients with TB and help transfer them into appropriate TB clinics. The third app’s for specialised clinicians in the TB clinic and provides a point-of-care decision support tool for managing TB.

    All data captured is integrated with a number of other information sources in a centralised database. This is a powerful tool that public health officials can use to gain insights into the care system and the patient population, so helps them with population health management.

    Dr. Jason Farley, associate professor at Johns Hopkins and co-director of the Center for AIDS Research, has years of experience working on MDR TB in South Africa. He’s leading the initiative. Dr Farley’s optimistic about the role mHealth can play in addressing the MDR TB problem. He says “MDR-TB remains a global public health crisis. Rapid diagnosis must be followed by rapid linkage to care and initiation of treatment. Our smartphone applications, powered by emocha, will reduce the gap between diagnosis and linkage to care.”

    ----------------------

    Image from emocha 

  • More eHealth to stop TB

    TB incidence in Africa is unacceptably high. So are its mortality and drug resistance rates. Both are fueled by poor treatment adherence.

    For the vast majority of cases, TB is treatable. Success needs a few simple things to work: early diagnosis, access to treatment, and adherence for at least six months. This is the nub. Most of us aren’t good at following a treatment regimen, even if it’s simply a daily dose. Compliance deteriorates if we have to do it for months. So, well-trained health workers help. They’re called Directly Observed Treatment Short-course (DOTS) supporters, part of WHO’s DOTS programme.

    DOTS has five components:

    • Political commitment with increased and sustained financing
    • Case detection through quality-assured bacteriology
    • Standardised treatment, with supervision and patient support
    • An effective drug supply and management system
    • Monitoring and evaluation and impact measurement.

    eHealth and other technologies have an important role too. They’re emerging as a sustainable solution.

    In India, uNotify supports text messages, fingerprint scanners and intelligent pill dispensers to support treatment adherence. uNotify devices send information to a centralised server that monitors programme activity and alerts administrators when a patient misses a dose. In South AfricaOn Cue Compliance does much the same. It uses specially designed pill bottles fastened with a SIM card and transmitter. When the pill bottle’s opened, the transmitter relays a text message to a designated healthcare worker. If patients don’t open pill bottles on time, they receive a text message reminding them to take their medication. According to the programme’s reported results in the CHMI database, 90% of patients complied with their medication regimen, compared to a compliance rate of 22 to 60% without the system. Similar results have been achieved by SIMpill and Wisepill reported in eHNA.

    Protecting the drug supply chain is also important, since gaps in supply don’t do treatment adhernce any good. TexTB, in the Philippines, and the Uganda Health Information Network help to monitor and manage the supply of TB meds. The Ugandan programme reports 24% improvements in efficiency when compared with paper-based data management, where officials in five districts monitor drug and supply levels at health centers via PDAs.

    The MOTECH Suit, using Dimagi CommCare mobile phone-based tools for community health workers, provides health workers with text messages, electronic forms, job aids, medical protocols, alerts, and other features to identify and respond to symptoms for high-burden health issues like TB. World Health Partners uses text messages included in the MOTECH Suite to enable rural medical providers and consumers alike in Bihar, India to better manage their TB. D-tree International is developing a TB module to help health workers in Tanzania identify TB among HIV-infected clients; the module suggests diagnostic tests even when clients miss a visit.

    Africa’s healthcare is moving its eHealth role in TB treatment forward. There’s still plenty to do.

  • Treatment adherence is never easy

    When was the last time that you completed a full course of medication prescribed by your GP, taking each pill as prescribed, on time, every time? The truth is very few of us comply, which creates all kinds of problems both small, when it takes longer for us to recover, and big, when we help drug-resistant super bugs to take hold even more.

    It seems that South Africans know a thing or two about treatment adherence. This is not surprising, given the long, hard battle being fought in South Africa to bring challenges such as Tuberculosis and HIV, and their nefarious combination, under control, without creating escalating problems associated with poor treatment adherence, particularly drug resistance.

    Over the last decade South Africans have made valuable contributions to real-time support for treatment adherence. Dr David Green, as inventor and innovator of Simpill, and Ricci and Lloyd Marshall, a husband and wife team, as entrepreneurs and owners at Wisepill Technologies are good examples. Both use a portable medication dispenser with a GSM communicator, connected to Internet software that drives adherence services customized to patients’ unique medication regimens.

    Simpill was a pioneering concept, invented in the early 2000’s by Dr David Green to help TB patients remain compliant. It’s now used in a number of countries to help patients manage their chronic conditions and avoid costly and unpleasant hospital admissions needed to deal with poor treatment adherence.

    Wisepill was founded in 2007, contributing a suite of solutions to the real time adherence support. Wisepill’s been selected by Family Health International (FHI360) for their trials of antiretroviral agent Truvada and used by Massachusetts General Hospital (MGH), Harvard and Columbia Universities in HIV research in Uganda and in South Africa.

    In 2011, Wisepill won South Africa’s Department of Trade and Industry (DTI) Technology Award in the category of small businesses. Director and owner Ricci Marshall said, “Our focus has been on providing innovative products and service excellence in the field of medication adherence. It is gratifying to see our solutions being used more and more for personal adherence management as well as in clinical trials internationally.”

    So why don’t we see more of these technology solutions helping people stay healthy and avoid running up unnecessary costs? There are probably a number of reasons, though cost, often regarded as the key deterrent to serious scale-up, should not be one of them.

    When I first came across these devices I was curious about the cost question, so produced a cost minimisation assessment of a SIMpill pilot, with Prof Maurice Mars of University of KwaZulu-Natal. Our assessment published in January 2012 found that the discounted net present value, the estimated value for money quantified by the accumulated economic benefits less costs over a project cycle, was nearly half a million US dollars. It also showed substantial improvements in health outcomes.

    So either “if it sounds too good to be true it is” or something else is the limiting factor to their increased use, not costs. The real difficulty is that pilots do not deal with a wide range of additional, complicated issues necessary for wider implementation. Important factors such as integrating the new solution into regular working arrangements and dealing with affordability and the extra cash needed to finance the project.

    Economic assessments usually don’t address these issues, though they do help to point in the right direction, so that more substantial cost benefit analyses, or eHealth impact assessments can be applied to tease out the hard work that’s needed to realise real benefits.

    Without a doubt, real-time treatment adherence support is here to stay, and sound economic assessment methods will be critical tools to help position them properly. On both of these topics, South Africans are likely to continue to contribute, helping eHealth improve health and healthcare in Africa and elsewhere.

  • MDGs make way for SDGs this year

    This year, after 15 years, the UN’s Millennium Development Goals (MDG) reach the end of their life. The top priority for the UN’s new Sustainable Development Goals (SDG) is eradicating poverty. Better health is goal 3 of the 17 SDGs. It’s described as “Ensure healthy lives and promote well-being for all at all ages.” The components are:

    • Reduce the global maternal mortality ratio to less than 70 per 100,000 live births
    • End preventable deaths of new born children and under fives
    • End the epidemics of AIDS, tuberculosis, malaria, neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases
    • Reduce by a third premature mortality from non-communicable diseases by prevention and treatment and promote mental health and well being
    • Strengthen prevention and treatment of substance abuse
    • Halve global deaths and injuries from road traffi­c accidents
    • Ensure universal access to sexual and reproductive healthcare, including family planning, information and education, and integrating reproductive health into national strategies and programmes
    • Achieve universal health coverage, including financial risk protection, access to quality essential healthcare and safe, elective, quality and affordable essential medicines and vaccines for all
    • Substantially reduce deaths and illnesses from hazardous chemicals and air, water and soil pollution and contamination
    • Strengthen WHO’s Framework Convention on Tobacco Control
    • Support research and development of vaccines and medicines for the communicable and non-communicable diseases
    • Substantially increase health financing and the recruitment, development, training and retaining health workers
    • Strengthen the capacity for early warning, risk reduction and management of national and global health risks.

    These are wide-ranging. As a strategic framework for African countries’ eHealth plans, they reveal a need for an equivalent wide-ranging and integrated investment, and avoiding a set of independent initiatives. This requires moves towards interoperability, analytics and a socio-technical architecture that extends from healthcare to people and communities. Each of these needs an expansion to current endeavours and a sustainable investment.

  • South Africa's SHIP is almost a year on

    Changing and improving healthcare is challenging for all countries. There are always many dimensions to their initiatives that need integrating and coaxing. On 23 April 2013, the South African Department of Science and Technology (DST) launched its Strategic Health Innovation Partnerships (SHIP) as a joint partnership with the Medical Research Council (MRC) as a follow on to the MRC Innovation Centre which was established in 2004. Richard Gordon is SHIP’s director. As SHIP’s first birthday approaches, it seems like a good time to review its progress

    SHIP’s mission is to be a catalyst that develops innovative interventions and brings life-saving drugs, vaccines and medical devices to markets. Part of this is being a funding agency for leading multidisciplinary projects, and managing and coordinating health innovation for South Africa’s strategic disease and technology focus areas. Achieving these goals needs SHIP to:

    • Provide strategic and scientific leadership
    • Augment gaps in the innovation pipeline by leveraging non-financial resources
    • Use funds flexibility between disease focus areas based on project needs
    • Ensure that SHIP research is globally aligned and competitive through collaboration with other Product Development Partnership (PDP), Medicines for Malaria Venture and AERAS with its TB vaccine initiatives.

    The MRC pays for SHIP’s infrastructure and salaries. It includes the Technology Transfer unit that implements the MRC’s intellectual property policy and develops pathways to facilitate the seamless movement of new products and services from the laboratory to the market. It also has financial support from the Gates Foundation. This is consistent with the Foundations goal of Africa leading innovation.

    Some of SHIP’s initiatives are to:

    • Manage and fund multi-disciplinary, multi-institutional product research, development and innovation from discovery to proof-of-concept
    • Enhance South Africa’s science in the research and development capacity for novel or improved drugs, vaccines and other biologicals, diagnostics and medical devices for high priority diseases
    • Use partnerships with local universities, science councils and the private sector to facilitate the transfer of research outputs into improved health outcomes and social benefit.

    The result of these is a clutch of health technology PDPs, supported by the DST that will:

    • Improve the management and financing of health research, development and innovation
    • Leverage local and international funding by acting as a central conduit for foreign institutions seeking partnerships with South African research agencies
    • Manage the DST’s strategic health innovation initiatives.

    These initiatives are South Africa’s:

    A Request for Applications (RFA) document describes these. On 22 November 2013, SHIP opened a RFA for Tuberculosis Vaccine Development, HIV Vaccines and Preventions. It closed on 14 February 2014. Another recent initiative is the joint SHIP and the Helmholtz Institute TB Bilateral drug discovery summit in Braunschweig, Germany in October 2013.

    The additional momentum that SHIP brings to these health initiatives shows the added priority needed for eHealth projects. This helps them to go further and help secure the benefits for individuals, communities and the health and social care agencies.

    For more information contact Richard Gordon at Richard.Gordon@mrc.ac.za