Silicon Valley Musings

Meeting with Dr. Midori Kato-Maeda, Stanford Center for Tuberculosis Research

Dr. Kato-Maeda works with Dr. Peter Small in the Stanford Center for Tuberculosis Research.

Dr. Kato-Maeda gave me a brief review of the tuberculosis. Tuberculosis is a bacterium that infests the lungs and it transmitted through small droplets made airborne when the infected cough or breathe. Currently one third of the world?s population has been exposed to tuberculosis. Most people develop a natural immunity. About five to ten percent of population develops the active disease.

Tuberculosis is concentrated in poor, over-crowded areas. Those with inhibited immune systems are particularly venerable. The increase in Africa?s tuberculosis cases is strongly associated with HIV.

A very good Tuberculosis overview by can be found in this September?s The Lancet Journal. An online copy can be found here (http://pdf.thelancet.com/pdfdownload?uid=llan.362.9387.editorial_and_review.27130.1&x=x.pdf).

The Center?s research focuses on the determining the DNA fingerprint of the different strains of TB bacteria. This information can be used to determine which strains are more easily transmitted, which are more drug resistant, etc. The center works closely with the Orizaba Health Jurisdiction in the Veracruz region of southern Mexico. The Center wants to use their research, along their understanding of a patient?s social network, to target treatment and education programs.

Orizaba has developed a very good tuberculosis program that complies with the WHO?s DOTS program, but Orizaba still has a fairly high tuberculosis load (~100 cases per 100,000 people). Many of the Orizaba?s TB patients are alcoholics. The health system is trying to leverage alcoholics support groups to increase TB treatment adherence.

The Center and Orizaba has used information technology in the past to study tuberculosis. One particular study used GPS to map the homes of TB patients and found a direct correlation between drug resistance in patients and how far from local clinic they live.

Dr. Kato-Maeda mentioned that information technology could benefit the training of health care workers. Currently much of the educational material is limited and is made available over teletype.

Dr. Kato-Maeda discussed attention to TB of the health care workers. Many health care workers are overworked.

They are treating people with diabetes, diarrhea, infections, etc. Many times treating these patients with more immediate or visible aliments will take precedent over observing ?healthy-looking? TB patients.

Since TB comes on slowly and gradually, TB patients don?t demand immediate attention or treatment. These two factors can make TB treatment a forgotten priority. Dr. Kato-Maeda thinks information technology and education could help keep TB treatment command the level of attention is requires.

The DOTS program stipulates that treatment must not start until the drugs necessary for the entire six month regiment are available and ear marked for the patient. [My Note: This may be an opportunity for personalizing the packaging and delivery of the treatment.]

Even though it is curable, suffers of TB are still very much stigmatized. The reasons are two fold: 1) during the first two months treatment, TB patients are contagious, and 2) TB has long been associated with poverty and homelessness.

TB treatments must be taken daily for a six month period, but it can sustain up to a fifteen day gap in treatment. That is treatment can be resumed within fifteen days. After a fifteen day gap, then TB patients must restart the entire six month treatment, usually with a different set of drugs to avoid drug resistance.

It is common practice for patients to come into the clinic every month to get a sputum-smear test to ensure the treatment is working.

In Orizaba, doctors are an authoritative figure, and their advice carries a great deal of weight. Unfortunately, it is common for doctors to move from clinic to clinic every three months. Nurses, who carry less authority, but are local and stay with a given clinic for long periods of time.

One of the things the Center is working on in Orizaba is using social networks to determine the spread of TB. They are using social connections to do proactive testing and finding latent infections (infected but not yet exhibiting active symptoms) in family members or coworkers. They are encouraging these people with latent infections to start treatment. It is again, a six to nine month regiment for people who feel and look healthy or are suffering from other externally manifested aliments.

Email thread with Dr. Kato Maeda regarding her recommended readings. My comments and questions are prefixed with ?SW>?]
Subject: Re: Some thoughts on the papers you recommended reading

SW> I have read through the BMJ papers on concordance. Thank you for pointing them out to me. I have also read the papers regarding the increase of drug resistance in Mexico.

SW> They have me thinking about two things: minimizing abandonment and increased personalization of treatment.

SW> Given a ten to fifteen percent abandonment rate, getting as many patients as possible on treatment seems to increases the drug resistant strains of tuberculosis. Currently DOT requires the entire course of treatment be available before treatment starts. Shouldn?t the necessary health services also be present to ensure complete adherence?

There should be at least a health care worker involved,

SW> To put it another way, would treating fewer patients and insuring they all complete their treatments be a better long term strategy for community as a whole.

In theory yes. In theory, you can not start treatment if you do not have the complete doses of medicine. In theory, you explain to the patient the importance of the treatment to decrease the risk of transmitting the infection to other members to the community. In the real world, it will be difficult to NOT to give treatment to a patient with tuberculosis. If you know that the patient has a high risk to non-adherence, ex. alcoholism, you need to find a way to try to assure the patient will take its medicine (ex. trade a drink for the treatment).

SW> Has anyone done a computer simulation to determine what would be the optimal ratio of untreated cases to abandoned cases over a long period of time?

Should be something around… I will look for it..

SW> Is there enough information regarding the effect of abandonment on drug resistance to build a reasonable simulation?

yes,

SW> I noticed in Peter?s [Dr. Peter Small] papers that there was no way of predicting who would abandon treatment. Have there been any studies that try to determine factors that cause abandonment?

Yes, in Orizaba the abandonment is of 9.2% if we analyze all the patients since the project started in….. 1994 (i think), around 600 patients. Most of these cases that abandoned treatment were diagnosed during the first years of the project, and were predominantly males, lower education, long time to diagnosis and maybe alcoholism.

Other published studies demonstrated that alcoholism, HIV, homeless were associated with low compliance with treatment.

SW> I have started to read Tracy Kidder?s book Mountains Beyond Mountains. He described Dr. Farmer s five hour hike to talk with a patient that had failed to show up for his treatment. An extreme example of abandonment management! I don t recall seeing anything in the WHO s DOTS program that addresses responses to abandonment. Did I miss it, or is it outside the scope of the DOTS program?

I think you are right. The goals of WHO is to avoid abandonment of treatment. I do not recall any “official program” that explains what to do if a patient abandons treatment. However what the health care worker usually do is to go to the patient’s house, investigate why he abandon treatment, try to solve the issue, educate, or find other incentives.

SW> Regarding personalized treatment, the notion that every patient has to have their personal regiment of drugs available before treatment commences is intriguing. I assume today that means there is a bottle of pills sitting in a cabinet in the clinic with the patients name on it.

Yes. However, the treatment is a standardized regimen. In other words, all pulmonary TB cases without previous history of TB treatment will receive X regimen, cases with TB that has been previously “multi treated”/abandon/ will receive Y regimen, etc.

Personalized treatment is a term used for the treatment that is “design” for each patient depending on the drug susceptibility profile of the M. tuberculosis isolates in each patient. THis is usually used in developed countries, where this lab services are available. In developing countries it may be used in patients where drug resistant TB is suspected.

SW> I wonder what other facets of the treatment could be personalized?

The method to guarantee that each dose of TB treatment is taken by the patient. Currently, in some countries like in Mexico, the direct administration of the treatment should be supervised by the health worker. In special circumstances, it can be supervised by a relative, friend, etc.

The method to deliver information about TB, as well as the information to be given to the patient. According to some of the papers on BMJ, the information should be “tailored” to each patient

SW> For example, Dr. BJ Fogg, has found while building persuasive software that reinforces behavior (e.g. taking breaks while using a PC to avoid carpal tunnel syndrome) that asking people up front to choose the type and frequency of reminders made them more receptive to the reminders later.

SW> Is there anyone in Mexico you could recommend I talk to (via email) about how they are dealing with abandonment or personalization?

I can give you the name and contact information of the person in charge of the TB control program at the National level, as well as the PI in charge of the Orizaba project.

I think the other aspect where IT can be useful is in the part of training on the health care workers. Reading through the papers it will be interesting in training HCW to detect/ tailor the information that facilitate the engagement of the patient to the TB treatment, training in communication skills, etc.