Joint CAB Meeting in South Africa for STREAM

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There are now four STREAM Stage 2 sites in South Africa across three provinces. Each serves a very different community, but what unites them all is their commitment to finding better ways to treat MDR-TB through clinical research. Leading the community engagement efforts for STREAM, community advisory boards (CABs) at the STREAM Stage 2 sites are encouraged to share experiences and join efforts with each other and their study teams.

On 24 February 2018, the Community Liaisons Officers (CLOs) from all four Stage 2 sites met in Durban, Kwa Zulu Natal along with the members of the King Dinuzulu and Doris Goodwin Community Advisory Boards. On the hot Saturday morning, the turnout was impressive, with over 60 people in attendance. The Good Participatory Practice Guidelines for TB Drug Trials were presented by the Johannesburg CLO and participants discussed how to measure the impact of community engagement.


The Principal Investigator from King DinuZulu Hospital in Durban presented preliminary results from Stage 1 of the STREAM trial, and participants then turned to how they can best work with local Departments of Health to ensure the results are translated to improved programs and policies. Participants were also encouraged to attend local AIDS Council meetings to share the Stage 1 results.

A similar joint CAB meeting will be planned for next year to share ideas, reinforce commitment to community engagement and build sustainability of the South African CABs.

TREAT TB conducts MDR-TB Clinical Management Trainings for Nurses

According to the 2016 national tuberculosis (TB) prevalence survey, the burden of TB in the Philippines is estimated at 554 new cases of TB per 100,000 Filipinos. To address this high burden, the Philippines’ Department of Health seeks to intensify its concerted efforts in finding, diagnosing, and treating TB cases. 


In 2018, TREAT TB, a USAID supported project, in coordination with the Philippines’ National Tuberculosis Program (NTP), is focused on capacitating nurses from facilities in the three high burden regions in the country – National Capital Region, Region III, and Region IV-A. 

The significant role of nurses in the country’s campaign against tuberculosis can never be overstated. Nurses provide clinical care for patients with multidrug-resistant TB (MDR-TB), including identification and management of adverse events.  They also provide directly observed treatment and conduct contact tracing. 


From January 22 to February 03, 2018, TREAT TB will train 100 nurses from Regions IV-A and III on the clinical management of MDR-TB, with lectures ranging from TB diagnosis, managing side effects, and common errors in MDR-TB management. Learning is also facilitated with case presentations from the participants. The series of trainings was arranged by Vital Strategies – the implementing partner for TREAT TB –  and is being delivered by MDR-TB experts Dr. Ignacio Monedero and Dr. Patricia Macias from The International Union Against Tuberculosis and Lung Disease. 

As the first group of nurses concluded its training on Wednesday, they left with a lot more confidence and better knowledge in the management of their MDR-TB patients. One of the nurses commented, “This training gave me confidence in managing adverse drug reactions and it’s especially important as I am the only nurse in my area.” 

India starts screening patients for STREAM Stage 2

 Site initiation training at BJMC in September 2017.

Site initiation training at BJMC in September 2017.

India recently entered a new stage in its fight against multi-drug resistant tuberculosis (MDR-TB) by initiating the STREAM Stage 2 study at two sites.  The first STREAM patient in India was screened on December 18, 2017 at BJ Medical College (BJMC) and Civil Hospital in Ahmedabad.  The STREAM trial is evaluating new treatment regimens for MDR-TB patients, which could provide solutions for a country like India with a very high burden of MDR-TB. India is the first country from the World Health Organization’s South East Asia region to join the trial.

India has come on board with two sites - The National Institute for Research in Tuberculosis (NIRT) in Chennai and BJMC.  This is an important milestone in the history of the STREAM Trial.

 STREAM Trial investigators  at their site initiation training at NIRT in September 2017.

STREAM Trial investigators  at their site initiation training at NIRT in September 2017.

NIRT, known for the historic “Madras Study”, is an institute under the Indian Council for Medical Research (ICMR) dedicated to TB research for the last 5 decades and enjoys WHO Supranational Reference Laboratory status for the South East Asia Region.

BJ Medical College and Civil Hospital was the first site to roll out MDR-TB services in India in 2007.  It is also designated as  a centre of excellence in training on MDR-TB management.

Over the last five years, India has made significant gains in strengthening the programme architecture and implementation environment for TB control with several initiatives pertinent to the management of drug-resistant TB.  These include scale-up and expansion of programmatic management of drug resistant TB services to achieve country-wide coverage, launch of a Revised Technical and Operational Guidelines detailing regimen build-up for early treatment stratification guided by drug sensitivity testing results, and the roll-out of a Bedaquiline Conditional Access Programme to enhance access to newer drugs.

On India starting to enrol patients in STREAM Stage 2, Dr Soumya Swaminathan, the recently appointed Deputy Director General of WHO, who previously held the posts of Director General, ICMR and Secretary, Department of Health Research (2015-2017) and Director NIRT (2012-2015), commented: “This is an important milestone for India and the trial.  We are pleased to be participating in the trial and contributing to the much-needed development of shorter, more effective and tolerable regimens for MDR-TB.”


TREAT TB Highlights at The 48th Union World Conference on Lung Health, Guadalajara, Mexico

The 48th Union World Conference on Lung Health in Guadalajara, Mexico in October 2017 brought together physicians, researchers, public health professionals, community engagement stakeholders and the global TB community to collaborate, share experiences, and learn about global efforts for TB control. The TREAT TB Initiative highlighted its work through various fora at the conference. Some of our many events are highlighted below. 



Release of Preliminary Stage 1 Results
STREAM is the world’s first multi-country randomized clinical trial to test the efficacy, safety, and economic impact of shortened multidrug-resistant tuberculosis (MDR-TB) treatment regimens. Preliminary results for Stage 1 of the STREAM trial were released at The Union Conference at a symposium attended by more than 150 people. The preliminary results suggest the efficacy of the nine-month intervention regimen will be very close to the regimen recommended in the 2011 WHO guidelines, which has a duration of 20-24 months – both achieving favorable treatment outcomes in roughly 80% of participants. However, statistically, the preliminary results did not permit a conclusion to be made that the nine-month regimen meets the predetermined definition of non-inferiority to the 20-24 month regimen. Preliminary data from the health economics component of the trial demonstrated important savings for both the patient and the health system with the shortened treatment regimen.


5th Annual STREAM Investigators’ Meeting
In Guadalajara, investigators from STREAM trial sites around the world gathered for two days after the conference to share lessons learned and experiences with the trial. 

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Community Engagement
Community engagement leaders from STREAM sites in South Africa, Uganda, Georgia, Moldova, and Mongolia traveled to Guadalajara, where they led two sessions in the Encuentro space focused on building capacity for meaningful community engagement in research. Their sessions included a panel discussion to explore key challenges in community engagement - including how to improve sustainability and the role of the community in translating research results into policy change.  A second group, led by STREAM South African sites, held a skills-building session aimed at improving communications strategies for clinical trials using skits, testimonies, and small group discussions. The STREAM community engagement stakeholders also participated in meetings with the STREAM team to develop next year’s work plans and to share experiences from the preceding year.


Operational Research
TB and MDR-TB are serious threats to public health in Peru. TREAT TB conducted an operational research (OR) course for NTP staff in Peru aimed at providing them with the OR skills needed to strengthen TB control activities in the country. Abstracts from the participants’ research were presented at various events at the conference including a symposium on OR in Latin America, an oral abstract session, and two poster sessions.


Helping End TB in the Philippines: Recognizing the Front Line

Region VI in the island of Visayas has the largest percentage (25%; 105 of 509) of patients enrolled in the standard short treatment regimen (SSTR) for multidrug-resistant tuberculosis (MDR-TB) in the country since its introduction in January. The region has a total of 14 treatment facilities that care for these patients every single day during their 9-month regimen.

Western Visayas Medical Center (WVMC), in the heart of Iloilo province, is the pioneer treatment center in the region with its participation as one of 10 operational research (OR) sites for the short treatment regimen (STR – OR) in 2015. In July 2017, the TREAT TB team had the opportunity to visit, learn from, and provide technical assistance to WVMC staff.

Ms. Elena Nono has been a nurse in this facility since July 2015 when she was hired for the OR study. Through this experience with the regimen, she found the value of the short treatment regimen for patients. As she shared, “Nowadays, we have patients of varying ages and backgrounds. We have students and workers, so with the 9 months of treatment that we introduced, they could take leave from work or school for 1 semester unlike the 2-year conventional treatment regimen. This shortened regimen encourages patients to undergo treatment.”

 Nurse Elena and a fellow nurse at WVMC provide medications to SSTR patients every day.

Nurse Elena and a fellow nurse at WVMC provide medications to SSTR patients every day.

She administers drugs to more than 20 patients everyday and this shows her commitment to help patients be cured of MDR-TB. Her motivation came from her positive experience during the STR-OR phase, “With the OR phase of the STR, it was fulfilling to see the patients finish their 9-month treatment regimen. To date, four patients are still undergoing treatment because they were enrolled in December 2016.”

Nurse Elena was able to attend the TREAT TB Clinical Management training in April 2017. She shared how this training helped her in managing adverse drug reactions (ADR) that her patients experience especially during their first few weeks of treatment, “It has helped me address ADRs and better explain why the patients need to take their medications everyday. We learned to explain in layman’s terms that the bacteria have a sleep-wake cycle so the patients need to take medication every day.”

In the region, managing 14 treatment facilities with varying capacities is no easy task. Mr. Adrian Ramos, the region’s technical staff, is part of the team that monitors and oversees these facilities and their patients. He shared with us, “As the regional technical staff, I provide both technical and clinical advice to the facilities.”  

 Mr. Adrian Hort Ramos, Region VI technical staff, talks to a TB patient during a home monitoring visit.

Mr. Adrian Hort Ramos, Region VI technical staff, talks to a TB patient during a home monitoring visit.

He shared that aside from monitoring, he also conducts directly observed therapy and default tracing. Home and facility visits provide him an opportunity to be hands-on and listen to the patients. As he shared, “What motivates me aside from learning and experience is the power of empathy. I listen to the patients. With listening, you can discover what you do not know. With relationship building and counseling, we will know the underlying causes of why the patient interrupted [treatment] or why they are successful in their treatment. Empathy is part of the job.”

Elena and Adrian are just two of the hundreds of TB frontline staff in the region, but they mirror the dedication and commitment of the region to help fight and eradicate TB by finding and treating patients with MDR-TB one day at a time.