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TB Notes Newsletter

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No. 4, 2010

International Research and Programs Branch Update

The Global Health Delivery Project

Background and context

Through their work, Dr. Jim Yong Kim, Dr. Paul Farmer, and Professor Michael Porter of Harvard University saw a recurring and urgent need to understand and improve health care delivery systems, particularly in resource-limited settings. Stemming from their shared vision, the Global Health Delivery Project (GHD) was formed in 2006. The GHD is a partnership between leaders at Partners in Health, Harvard School of Public Health, Harvard Medical School, and the Brigham and Women’s Hospital.

In addition to other innovations, GHD developed and maintains GHDonline.org, a platform of professional virtual communities. This site enables health implementers from around the world and across organizations to engage in problem-solving, connect with peers, and share information to improve the delivery of health care in resource-limited settings. Only 2 years after initial launch, more than 3,600 global health implementers representing over 1,200 organizations in more than 130 countries have joined one or several GHDonline communities. The professions of these health implementers range from students and advocates to clinicians and IT professionals.

These online communities are focused on specific delivery challenges and guided by 30 expert moderators. Each offers a dedicated knowledge base accessible via “moderators' topics” and an integrated search engine that combs through GHDonline content, as well as a database of hundreds of news feeds and authoritative websites selected and updated by the GHDonline team.

Global health implementers can join GHDonline.org for free. They can then easily participate via e-mail by subscribing to “Per Post” e-mail notifications from the communities, or by sending information such as links and tips using the communities’ e-mail addresses.

How does one post or get involved?

Once they are members, health professionals can either sign in on GHDonline.org to visit a community and reply in discussions, add resources (links or files), or send an e-mail with their information, links, or advice to the communities—drtb@ghdonline.org for multidrug-resistant TB (MDR TB) and ic@ghdonline.org for TB infection control (IC)—thus sharing information instantly with fellow TB professionals and GHDonline members.

Members can also download and print or save very helpful peer-reviewed Discussion Briefs on various topics such as recommendations for transporting suspected and confirmed MDR TB patients and how to properly use particulate respirators for TB infection control. These briefs recap the critical knowledge exchanged by members in the communities with key references (from guidelines to studies) and recommendations.

Members with a fluent knowledge of several languages are further invited to translate discussion replies, briefs, and posts in their native language, thus making critical information accessible to as many global health implementers as possible, or to provide expert review for briefs.

In June 2008, several infection control experts—Edward Nardell, MD, Harvard Medical School, Paul A. Jensen, PhD, PE, CIH, CDC, and Grigory Volchenkov, MD, Vladimir Oblast Tuberculosis Dispensary—joined as co-moderators of the first interactive, professional community on GHDonline.org focused on TB IC.

Complementing the MDR TB Treatment & Prevention community and four other communities focused on Adherence & Retention, Health IT, HIV prevention, Global Surgery and Global Nursing, as many as half of GHDonline members have now joined the TB communities to discuss practical challenges and exchange tips and information resources (from links to files).

Infection control consultants, national TB program (NTP) managers, laboratory professionals, and many others discuss a broad range of TB-related issues, such as how to do respirator fit testing, TB laboratory proficiency standards, nurse-patient ratio in the MDR TB hospital, or treatment of MDR and extensively drug-resistant (XDR) TB in countries where second-line drugs are not available.

What makes this resource unique or important?

GHDonline.org is particularly important in resource-limited settings where the vast majority of cases are found, and where health implementers

  • often work in isolation,
  • have limited opportunities to consult with peers, or
  • can rarely exchange proven practices and access current information.

At its core, GHDonline.org is a collaborative effort and evidence-based platform. Members share advice on interventions, or knowledge that is applicable and important in the field, but perhaps not found in traditional publications. Partner organizations provide content, services, and tools to members to reduce duplication and build on existing knowledge and expertise.

One such partnership provides a 1-year complimentary subscription to UpToDate®, an electronic, peer-reviewed clinical information and decision-support resource, to qualifying members. This program was featured in the Globe in March: Second opinions, anywhere: Collaboration hopes to link doctors in developing countries to a digital network of support, expertise (http://www.boston.com/business/healthcare/articles/2010/03/01/collaboration_links_doctors_in_developing_countries_with_digital_colleagues/#_blank). GHDonline.org invites all organizations to join in this effort to build a global knowledge network for global health delivery.

Additionally, GHDonline.org is mostly text-based and built with a light user interface, thus allowing for access from unreliable Internet connections.

 

Whirly Bird
Photo: Creating a whirly bird that retains indoor heat during winter months for use in single-room homes in resource-poor settings was one of the challenges identified and discussed in GHDonline

Applications for TB Professionals

Following are several examples of how members of the GHDonline TB community have collaborated to address specific TB challenges.

Infection control at home

Dr. Hind Satti is Director of Partners in Health in Lesotho, a nongovernmental organization (NGO) providing community-based directly observed treatment, short-course, for multidrug-resistant TB. She shared her team’s practices and challenges for controlling the transmission of TB in single-room homes, and asked others to share their interventions. Dr. Satti received 18 replies in less than 72 hours; a total of 27 replies from 14 members were posted on this issue. Moderator Paul Jensen shared the image and specifications of a “whirly bird” ventilation device as a possible solution, and added that CDC is evaluating its use in the facilitation of natural air movement, which is critical to transmission control. Another member then identified a challenge to design a “whirly bird” that could ensure natural ventilation within the home but not let the heat out during winter months. With its contributors hailing from 10 countries and 12 organizations across three continents (Africa, Asia, and North America), this discussion demonstrates how a versatile website like GHDonline.org can contribute to the generation of practical “how to” guides, and at the same time bond and support global health professionals who often work in isolation.

 

Assessing Lab Proficiency Standards

As stated by the WHO, “lack of diagnostic capacity is a crucial barrier preventing an effective response to the challenges of TB-HIV and drug-resistant TB, with less than 5% of the estimated burden of MDR TB patients currently being detected.”[1] A member asked about the minimum volume of specimens for lab smear, culture, and drug-susceptibility testing needed in order to maintain lab proficiency. In less than a week, members from Belgium, Botswana, Brazil, the U.S., and Russia exchanged recommendations and key references. With 13 contributions in total, the practical recommendations and information resources shared in this discussion were then compiled in an easy-to-use peer-reviewed discussion brief on lab proficiency standards and quality assessment. The brief also represents an interactive how-to guide that will be updated on a regular basis to reflect the addition of information by members joining the exchange in the future.

Map showing routes and relationships between different sites.

Stemming from one question from a member in the U.S., the discussion Assessing Lab Proficiency Standards generated a back-and-forth from GHDonline members on four continents and led to a second question by a different member in the U.S., which was also answered. 

Using N 95 respirators/masks

On June 5, 2009, Dr. Rajbir Singh, the Regional Medical Coordinator for North India with the German Leprosy & TB Relief Association, asked how many days N95 masks could be used indoors. In the exchange that followed, a CDC engineer (Paul Jensen), a TB adviser in Azerbaijan, and the head doctor of a TB dispensary in Russia shared their knowledge and exemplified international, interdisciplinary collaboration through their participation. In a 3-day span, Singh was not only given clear directions on how long his team could use N95 masks indoors, but also received and shared manufacturers’ prices and recommendations for various models. Members shared their own practice: “I personally use two N95 or FFP2 respirators, with exhaust valves, per week” or “In my TB hospital in Vladimir, Russia, nurses need one respirator for one to two shifts, and doctors use 4 to 6 per month, depending on workload and time spent in high-risk zones.” This discussion is now archived and searchable by all, and because it is a web resource, GHDonline members can update prices and add recommendations as needed.

Outdoor sputum induction in South Africa

On December 15, 2008, a TB IC member asked fellow members if they knew of a protocol for sputum induction (SI) in outdoor settings that addresses environmental considerations, time needed between inductions, and precautions for health workers. Smear microscopy of sputum, often obtained by inducing sputum, is a key tool in TB diagnosis in resource-limited settings as it is low cost and more feasible than other less accessible procedures [2]. But the risk of infection is extremely high, especially indoors in congregate and resource-constrained settings.

Faced with similar challenges, 15 members representing 17 organizations and various professions located in the United States, the United Kingdom, the Netherlands, the Philippines, South Africa, Ghana, and Nigeria replied to the member’s question—13 responses being posted within 72 hours, 20 in total. Participants shared their organizations' protocols and, more importantly, the lessons they learned in the field from first-hand practical knowledge. They insisted on the importance of wind conditions and climate, on understanding the community environment and the potential need for booths, and on providing and properly using N95 masks.

Current challenges discussed in the TB communities range from the viability of TB organisms in air to a member in Azerbaijan asking about the recommended duration of TB regimen in case of extensive cavitation.

If you work in a health-care field such as TB or infection control or are otherwise involved in global health, perhaps as a student or volunteer, and wish to make a difference in the delivery of services to patients in resource-limited settings, join GHDonline and start contributing today!

—By Sophie Beauvais
Global Health Delivery Project at Harvard

References

  1. World Health Organization. Global Laboratory Initiative (GLI) Web page. Accessed August 10, 2010.
  2. Menzies D. Sputum induction: simpler, cheaper and safer - but is it better? American Journal of Respiratory and Critical Care Medicine 2003;167:676.
 

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