MDR-TB (research placement)
Mycobacterium tuberculosis (TB) remains the leading cause of death among persons living with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) in southern Africa1. Drug-resistant TB remains a growing threat to public health despite advances in treatment and diagnosis over the past decade2;3. South Africa has the world’s highest rate of TB/HIV co-infection and ranks fourth worldwide for both multi-drug resistant (MDR) TB incidence and HIV prevalence.
This is a cluster randomized study evalauting a nurse case management intervention for MDR-TB / HIV. It will occur across 2 provinces (KZN and Eastern Cape) in SA and 10 hospital-based sites.
Global Health Mentor: Jason E. Farley, PhD, MPH, CRNP, FAAN
Even in my jet lagged state, my eye was drawn to the cute shiny blue mini-van in the rental car parking lot. It was large enough to hold our luggage and still easy to maneuver. I was looking forward to driving it around South Africa until I realized that I was looking in the wrong parking spot. After waking up at 4 am for our flight, we had arrived in East London, South Africa and planned to drive immediately to the hospital to begin the data quality assurance process. Instead of a mini-van, our actual vehicle was a monster bus, named in honor of a large monster energy drink sign on the passenger’s side. It was huge and I managed to stall the bus within the first five minutes because I put the manual shift into third gear without sufficient speed or power.
Much like the monster bus, the data quality assurance process seemed daunting and overwhelming. What happens when the nursing note, doctor note, and medication record give three different doses for the multi-drug resistant tuberculosis (MDRTB) medication? How can we find the right labs for a patient when the patient’s name is often spelled multiple ways? I quickly realized the need to balance the optimal, ideal research standard with the reality of data collection processes in a resource limited setting. Ensuring accurate data is paramount, but in a fragmented health system, patient charts and study information often times are disjointed.
However like driving the monster bus, there were several important steps to understanding and successfully engaging in pragmatic global health research. First, it was a team effort. The PhD students, study coordinator and local nurses were each other’s best assets. I hopped out of the car to help Brittney navigate the monster bus’s terrible turning radius in tight spaces. Similarly, when faced with a challenge or question about the data process, we actively brainstormed together. I relied on my peers to understand the data and audit charts comprehensively. Second, facing both personal and research related challenges was a part of the process. Even after a few days of driving, I still stalled the monster bus, but with only two drivers I had to keep driving. In the quality assurance process, as a nurse researcher aiming to improve patient outcomes, I struggled with the minimal interaction with patients and even study nurses. We were students, but also data auditors, scouring and evaluating the nurses’ entered data. However, when we took the time to engage with the nurses we not only built trust but also heard their stories, many of which described the numerous ways that they had helped patients with their treatment, in turn, enriching study data. Finally, I learned to step back and understand the big picture. The monster bus was huge, but ultimately its size allowed us to be comfortable and safe during the trip. In the data assurance process, it was frustrating navigating details and discrepancies of each data point. However, as our PI reminded us, the overarching purpose of the study was to improve treatment and lives, and we saw evidence of this in the data review process. Overall, this experience helped me understand the difficulties and rewards of global health research, the importance and benefits of teamwork, the data collection and quality assurance process, and the challenges MDR-TB patients and medical professionals face to ensure successful treatment and improve outcomes. Turning in the keys to the monster bus at the end of this experience was bittersweet, but I expect that my own global health research will be richer and better informed after this experience and the monster bus was an important part of that story.
Caption: PhD students and the Nurse Case Manager demonstrating the use of the N-95 respiratory mask to prevent exposure to multi-drug resistant TB
Caption: The three PhD students and the Monster Bus, named because of the Monster energy drink sticker on the side of the road.
Caption: Bonding with the scanner: 100's of pages of data had to be scanned and learning to use sometimes finicky office supplies was an important data entry skill.