South Africa - Cost-Effectiveness of a Mass Active Case Finding program in Klerksdorp, South Africa.
In clinics and hospitals in Klerksdorp, South Africa, a Mass Active Case Finding (Mass ACF) initiative has been integrated into the Tuberculosis (TB) program in an effort to increase identification of undiagnosed TB and HIV. Household members of newly diagnosed TB cases seen in clinics and hospitals are consented and screened for active TB, latent TB, and HIV. Those with TB symptoms are asked to provide a sputum specimen for further testing. Household visits are conducted by four teams who, in total, visit approximately 40 households per week.
I could feel the car tires slide sideways in the mud as we slowed to a halt on what remained of the dirt path. The road, such as it was, turned to a muddy bog ahead, and it was evident that our rental car was not going to be able to take us any further. The study nurse looked out at the pouring rain, then back at me, grinning, and quipped, “You should have seen it out here last week.” Thirty minutes later we’d left the car and hauled our bags of study supplies along the overgrown verge of the muddy lane, hiked up a rocky drive, and wended our way through a towering field of maize to find what we were looking for: The thatched-roof home belonging to a recently-diagnosed tuberculosis (TB) patient. The study team made quick work of the surveys we had to administer; weighing household members, discussing the presence or absence of symptoms that might indicate an undiagnosed TB infection, going over an individual’s HIV testing history, and, eventually, collecting sputum specimens to test for TB.
As I carefully packed the specimen containers into the soft-sided cooler in preparation for our heading back out into the rain, I couldn’t help but smile. I had begun writing the protocol for this study almost exactly a year before this moment, and had spent the last eight months drafting consent forms, creating case report forms, building a database, and shepherding the project through the internal review boards on two continents. In a rare stroke of luck for an Epidemiology PhD student, I’d been given the opportunity to implement the study that would become the basis of my dissertation. Though funding for the pilot project was already in place, and the general concept for a tuberculosis case-finding study had been laid out, I was tasked with spending seven months in South Africa to make these plans a reality.
I had landed in Johannesburg, South Africa, six months before that day in the rain with far more data analysis experience than data collection skills. While my time as a Fellow at the Centers for Disease Control and Prevention (CDC) ensured that I was comfortable with cubicles and lines of SAS, STATA, or R code, I was still daunted by budgets, staff hiring, and actual study management. My awareness of these short-comings had motivated my desire to go to South Africa in the first place, but left me feeling woefully under-prepared and over-whelmed once I arrived. With generous input from my dedicated academic adviser at Hopkins, oversight from an experienced group of TB researchers in Johannesburg as well as a willing study team, my time in South Africa quickly became an incredible period of learning and growth. I drafted advertisements for our study positions and built a database in REDCap. A study coordinator and I interviewed a dozen nurses and counselors for our open positions, and created and revised a study budget. I worked with the finance department to oversee the creation of a contract between JHSPH and the South African research unit where I was working to facilitate the exchange of study funds. The assembled study team and I spent long hours poring over the study surveys, making changes, working on translations, and clarifying the information we were trying to collect.
Eventually, I returned to Baltimore and presented my research plans to colleagues and faculty in the Infectious Disease Epi. Department during my proposal seminar. I’ll spend the coming months over-seeing the remainder of data-collection from the US, and over the course of the coming year or two I’ll analyze the data and prepare manuscripts for publication. In addition to two more classical epidemiologic risk-factor studies, I’ll be building a decision analytic model to evaluate the cost-effectiveness of active case-finding interventions for TB in various South African settings. It is our hope that these analyses can inform policy makers and government officials in South Africa regarding the most efficient deployment of scarce TB-control resources.
While these analytic methods will be expanding my methodological limits, the soft-skills I gained during my time in South Africa will likely be the most valuable part of my dissertation work, and will inform my future career. After finishing my doctoral studies I plan to work in applied infectious disease epidemiology, ideally for the CDC. This work obviously requires strong analytical skills, but success also hinges on other factors that are less-emphasized in Epi. PhD programs: the ability to navigate new systems, collaborate with a range of partners, improvise when problems arise, and react flexibly to the limitations and delays that are inherent in international research projects. My time in South Africa, surrounded by capable and generous mentors, meant that I had the luxury of learning some of these skills in a supportive environment and in a real-world setting. I hope to spend the coming years of my PhD program continuing to expand both my analytical and operational skill-sets.
The funding from the GHEFP enabled me to build my research coordination skills in South Africa, and will assist in my growing further as an epidemiologist during the remainder of my doctoral studies as I continue to oversee the study from Baltimore and, eventually, analyze the data we collected. This experience has demonstrated to me the operational challenges faced by those tasked with implementing public health programs in low-resource settings, where a one-size-fits all approaches often fail to meet local needs and realities. My time in South Africa reinforced my desire to conduct monitoring and evaluation and operational research of public health programs globally in order to ensure that the programs thought up in settings like JHSPH actually work as intended in places like rural South Africa.