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.

GCP Course for Pharmacists

This week, TREAT TB launched an online Good Clinical Practice (GCP) course for pharmacists.  The course was developed for pharmacists involved in the STREAM Clinical Trial to build their capacity  in clinical research. Jan Komrska, the STREAM pharmacist highlighted that “Traditional GCP trainings consist of basic courses aimed at physicians and nurses involved in clinical trials.  In contrast, the TREAT TB/STREAM course is an interactive web based tool specifically tailored to the pharmacists involved in STREAM  to enhance their understanding of the critical role they play in the delivery of patient care to STREAM participants. It focuses on management and accountability of trial drugs.”

The course is accessible here and would be a useful tool for any pharmacist involved in clinical research.

STREAM Stage 2 is the result of a unique collaboration between USAID, Janssen Pharmaceuticals and The Union/Vital Strategies.

STREAM Uganda Commences Community Engagement Activities

The Uganda STREAM site in Kampala will start enrolling patients very shortly!  In keeping with the trial’s commitment to civil society participation in the trial, the STREAM team had its initial meeting  with community stakeholders,  even prior to enrolling the first patient. Dr. Conradie, an investigator with many years of experience with HIV and TB research, travelled to the Kampala site on the 12th and 13th of July to begin the process.   She commented that “On the first day of the visit, I met with most of the staff from the site. After presenting the rationale for community engagement, the site staff members did role plays to practice various scenarios for communicating about STREAM, including a mock radio show, a presentation to the Ministry of Health and then a more casual chat to people in ordinary social situations. This was a great way to practice effective communication, as it mirrors  engagement with all key stakeholders. We laughed and learned at the same time.”

On 13th July, community members attended a planning meeting with the aim of establishing a community advisory board (CAB) and planning its work. “I was very impressed at the broad range of people attending the meeting. Over 30 delegates participated, including members of the TB directorate, TB program managers, a chaplain, doctors and nurses from other sites, and most poignantly four people who had survived MDR-TB. I was struck yet again by the courage required to simply survive MDR-TB treatment. One young man stated that he would not wish MDR-TB on his worst enemy. Another talked about the stigma of MDR-TB in the community and how people backed away from him when they found out about his diagnosis, even after he had been cured. At the end of the meeting, Dr. Ivan Kimuli, the site's community liaison officer asked for volunteers to continue working on community engagement for STREAM, and there was an encouraging response,” said Dr. Conradie.  A CAB was formed, and enthusiastic participants from the meeting will be working to define its upcoming activities.
 

Focus on Zero Interruption in the Standard Short Treatment Regimen

TREAT TB concluded its first week of a 2-week technical assistance (TA) visit in the Philippines on July 21, 2017. The TA visit includes a total of eight (8) facility visits in three regions (Regions V, VI, and VII) and two (2) regional workshops (Regions V and VI) where the standard short treatment regimen (SSTR) is now being implemented.

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TREAT TB, USAID, the Philippines National TB Program (NTP), and partners, are united in their goal to achieve zero treatment interruption among patients with MDR-TB enrolled in the SSTR. Beginning with this end in mind, the team met with key implementers and managers in the regional facilities to understand the programmatic and clinical strengths of implementation of the SSTR to date. The goal was to identify and address challenges, particularly those related to adverse drug reactions, training, supervision, and monitoring and evaluation. The team also sought to strengthen buy-in at the regional level for the implementation of proposed responses and strategies needed to improve program outcomes at the national, regional, and local levels, including development of regional TB medical advisory committees (TB MAC) which will provide clinical management expertise to physicians and nurses.

This week, the team successfully conducted six (6) site visits in Regions VI and VII. One of the highlights of the first week was the Region VI workshop, which was well-attended by regional staff, facility physicians and nurses, and provincial and city health officials, and resulted in the creation of the TB MAC to improve MDR-TB outcomes.

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STREAM starts screening patients in Europe

On July 11, the first patient in Europe was screened for Stage 2 of the STREAM trial in Moldova. 

Although the country’s population is  only ~3 million, over 500 new MDR-TB cases were registered in 2016. Given the high burden of disease in the country,  Moldova was identified as a logical location for implementing the STREAM trial. The national TB referral and research hospital – Institute of Phthisiopneumology “Chiril Draganiuc” – in Chisinau quickly expressed strong interest in leading the trial in Moldova and has meticulously completed all preparations required to initiate screening.

Dr. Elena Tudor, principal investigator for STREAM in Moldova, has high hopes for improving treatment outcomes for her patients: “I would be pleased if my country could improve its current treatment success rate for MDR-TB patients which is [currently] at 57.1% and get closer to the success rate reported from Bangladesh with an approximate 80% success rate.”

Dr. Elena Tudor in front of the Institute of Phthisiopneumology “Chiril Draganiuc” in Chisinau, Moldova.

Dr. Elena Tudor in front of the Institute of Phthisiopneumology “Chiril Draganiuc” in Chisinau, Moldova.

STREAM Stage 2 is the result of a unique collaboration between USAID, Janssen Pharmaceuticals and The Union/Vital Strategies.  The STREAM team is proud to welcome the experienced study team from Moldova to the STREAM trial.