MDR-TB (practice 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 the largest public health intervention on MDR-TB to date in South Africa with support from the Global Fund and The Centers for Disease Control and Prevention.
Jason E. Farley, PhD, MPH
I made an international research trip to South Africa between July and August, 2015 through the Global Health Established Field Placement program in my capacity as a research assistant for data quality assurance and quality control of the on-going clustered randomized trial study team led by Dr. Jason Farley. The research I participated in was studying the benefits of having a nurse case manager to improve treatment response for patients with multi-drug resistant Mycobacterium tuberculosis (MDR-TB) in ten hospitals in South Africa.
First of all, it was very impressive in terms of achieving a chance to closely observe the large-scale clinical trial led by nurse researcher in the field of global health. Although nurse case management (NCM) models are common concepts and highly effective in practical settings in the United States, it was very innovative study because it was the first trial to evaluate the NCM model for improving MDR-TB treatment outcomes and to integrate MDR-TB/HIV into a simultaneous systems level intervention in South Africa.
By observing NCM’s daily practice, I found the one of the severe challenges and the most important concepts to lead global health study successfully would be evaluating the subjects’ understanding level. English is the second “official” language in South Africa, due to the low literacy level, we as researchers or intervention providers, always anticipate a high level of difficulty with reading. To address this, not only all consent forms in four different languages (English, Xhosa, Zulu, and Afrikaans) were provided but also all hired NCMs were fluent in speaking the patient’s most comfortable language, some difficulties and barriers in terms of evaluating subjects’ treatment outcome due to low literacy. In addition, since the average educational level of subjects was incomplete secondary school, I have learned that patient education and communication should be designed based on not only the barrier of language but also their understanding level.
Moreover, I have learned how to develop the study protocol to minimize research team members’ risk of infection if planning or designing a study in the field of communicable diseases. Based on the study protocol, I received N-95 respirator fit testing before leaving for South Africa and wore appropriately fitted N-95 respirator at all times while inside an area with known or suspect TB patient at site. Also, I was repeatedly instructed on how to assist patients with standard respiratory etiquette (i.e. covering ones mouth when coughing, using a tissue, hand hygiene after coughing) even though I am trained and educated clinical nurse. I brushed up that these small but careful concerns and efforts to minimize any chance of risk of infection for study team should be taken into account when developing a study protocol.
In sum, it was very priceless experience for me to observe how difficult leading and conducting global health research and learn what kinds of significant factors I should consider for my future global health research. Lastly, I am deeply grateful to the Center for Global Health for providing this great opportunity.
Assessment room: When patients were admitted or referred to the multi-drug resistant tuberculosis hospital, nurses measured patients’ vital signs, height, and weight before history taking in this room. After administration assessment, patient would see a doctor for physical assessment in a private exam room. The windows were always opened, and the room was well ventilated.
Meeting with onsite staff: I made a meeting with a dietitian to lead the nutritional support program for HIV and/or multi-drug resistant tuberculosis infected patients. We discussed about current South African nutritional guidance for malnourished population.
Meeting with PI: The team regularly met at Dr. Farley’s office located in Durban in South Africa to discuss what we’d learned from his international study what sources or lessons would be applied into our future study .
Transportation: We rented a mini van to commute multiple hospitals while staying in South Africa. Cars in South Africa are right-hand drive vehicles, with the gear shift operated with the left hand.
Patient Chart Review: Our research team reviewed more than 100 medical charts for data quality assurance and control before data entry process.