Lightning Talk about Tuberculosis by Luke Davis
March 21, 2024Information
Luke Davis, MD, Associate Professor of Epidemiology (Microbial Diseases) and of Medicine (Pulmonary); Affiliated Faculty, Yale Institute for Global Health
In the video, Luke talks about his implementation research focus, the complexities of tuberculosis, and its impact on global health.
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- 00:02<v ->Well, good afternoon everyone.</v>
- 00:03I want to talk today a little bit about my interest,
- 00:06and it looks like I need to pick up a different clicker,
- 00:11which is tuberculosis.
- 00:12So tuberculosis is the leading
- 00:14infectious cause of death worldwide.
- 00:16And we believe that last year
- 00:17it affected around 10.6 million people.
- 00:20The World WHO TB report comes out every year
- 00:23around this time,
- 00:24so the latest data that that we have is from 2021.
- 00:27And following the pandemic,
- 00:28there was a big decline in the number of people
- 00:30having access to quality assured diagnosis
- 00:35and initiation of treatment.
- 00:37But it's long been the case
- 00:38that a large proportion of people living with TB
- 00:41go undiagnosed.
- 00:42We think more than 4 million people.
- 00:43So one of the things that we're interested in
- 00:45is how can we identify those people?
- 00:47There's many reasons why they aren't diagnosed.
- 00:49One challenge of course, is that TB is often asymptomatic.
- 00:52So we need to identify better ways of screening
- 00:55and identifying people in the community
- 00:56who don't know they have symptoms.
- 00:58And then we need to improve access
- 00:59for people who do have his symptoms
- 01:00and encourage them to seek care
- 01:03in clinics where they can get diagnoses.
- 01:06The tool that we use in our laboratory for doing this work
- 01:08is called implementation science.
- 01:10I know there are probably a number of people in this room
- 01:11that have heard of this field,
- 01:14and there's a course that I teach in the fall,
- 01:16for those who are thinking about
- 01:17their courses for next fall,
- 01:19which goes over what implementation science is.
- 01:22But in short it is a systematic approach
- 01:26for the design, delivery and evaluation of strategies
- 01:28to improve the uptake of proven interventions
- 01:31into routine practice.
- 01:32And we think of it as a translational research discipline.
- 01:35Translational research
- 01:36involving multidisciplinary collaborations
- 01:38that move ideas from their foundational basis,
- 01:42whether that's in the laboratory,
- 01:43in fundamental biology
- 01:44as we were hearing about a little bit earlier from Brian.
- 01:47Or more on the other end of the spectrum
- 01:49here where our group works,
- 01:50which is thinking about how do we move
- 01:51from patients to practice
- 01:53and ultimately to public health.
- 01:55And it turns out that that discipline doesn't happen
- 01:58just when good ideas get published in journals
- 02:00showing that they're effective.
- 02:01It's really necessary to think about
- 02:03how would those ideas be adapted to a real world setting.
- 02:07So in the contexts of TB, I wanna talk about
- 02:09three different types of studies that we've done.
- 02:11Formative work to help us understand
- 02:13what the nature of the barriers are
- 02:14to delivering these evidence-based services for TB.
- 02:18Actual implementation studies
- 02:19where we introduce these ideas.
- 02:22And then evaluation studies
- 02:23where we try to figure out what works
- 02:25and why or why it doesn't work.
- 02:27And a lot of the work that I've done
- 02:29is in the area of contact investigation.
- 02:31So contact investigation,
- 02:32I think as everybody in the room is probably familiar,
- 02:34is a strategy where we look for high risk populations
- 02:37of having a disease like tuberculosis,
- 02:39among those that are close contacts
- 02:41to people with tuberculosis,
- 02:42knowing that to tuberculosis is transmitted
- 02:44from person to person through respiratory aerosols.
- 02:49And that work that we've done in the area
- 02:50of contact investigation
- 02:52has spanned different parts of the globe,
- 02:53because we know in different contexts
- 02:55there may be different reasons.
- 02:57We're interested in understanding
- 02:58both the generalizable reasons,
- 02:59why it's hard to do contact investigation,
- 03:02and also some of the setting specific regions.
- 03:05So for example here on the far left,
- 03:06in Columbia one of our scholars, Gustavo Diaz,
- 03:09who was a postdoctoral fellow at the GHS program,
- 03:12used routine public health data to map the barriers
- 03:15and characterize those.
- 03:17Here below, this is a qualitative research study
- 03:20that was looking at another aspect of TB care
- 03:22which is education and counseling,
- 03:23which is very important
- 03:25to get people newly diagnosed with TB
- 03:27to be willing to share the contact information
- 03:30of their close contacts,
- 03:30and also for them to be able to achieve
- 03:32good treatment outcomes on their own
- 03:34and get initiated in other therapies
- 03:36that may be important like HIV treatment.
- 03:39And so this is work that was carried out
- 03:40with Alisse Hannaford,
- 03:41who was a medical student at the time.
- 03:43Then the third example was looking at these similar methods,
- 03:46not just for TB case finding
- 03:48in the community that it's searching,
- 03:50but also for treatment of TB and for prevention
- 03:53as work that was done by Christina Parisi,
- 03:56who was an EMD student a few years back
- 03:58and is now a PhD student at the University of Florida.
- 04:01We're also interested in taking this information
- 04:03about barriers to delivery of care and try to combine it.
- 04:06So taking qualitative information,
- 04:08taking quantitative information,
- 04:09and developing strategies to try to change that.
- 04:12One of the strategies that we're very excited about
- 04:15is the use of collaborative design approaches,
- 04:18specifically human-centered design,
- 04:21where we try to come up with solutions
- 04:22that work for the communities that we're working with.
- 04:24And so here's an example in the middle of (indistinct)
- 04:27who's a laboratory manager in one of our projects in Uganda.
- 04:30We're using the human-centered design approach
- 04:32with the post-it notes to try to come up with good ideas.
- 04:36And than we've developed those
- 04:37into a couple of different types of strategies.
- 04:39So these are described in publications by Amanda Gupta,
- 04:42who's a research coordinator in our laboratory
- 04:45and a PhD student.
- 04:46And also by Joseph Tita,
- 04:49who's one of our qualitative scientists in Uganda.
- 04:52We're also a lot of times interested,
- 04:53even at the design phase,
- 04:54in thinking about what the costs are.
- 04:56A lot of times we wait until the end of a study
- 04:58to evaluate that.
- 04:59But in this particular project,
- 05:00we knew we learned from our prior work
- 05:02that it's very expensive to kind of develop strategy.
- 05:06So we looked at the cost strategy,
- 05:08and this was work led by Patricia Turimumahoro,
- 05:11who is currently a GHES scholar.
- 05:14So I'll just close by kind of describing
- 05:16the most exciting aspect of this work
- 05:18was actually evaluating where these strategies work.
- 05:20And we just recently completed a pragmatic trial
- 05:23using a stepped-wedge cluster-randomized design
- 05:25where we took a human-centered design approach
- 05:28that include multiple components.
- 05:29And these components include things
- 05:31that ease the multi-step process of contact investigation
- 05:35to kind of help participants, namely household contacts,
- 05:38better be able to engage in these services.
- 05:40Things like a motorcycle rider, to take them to the clinic.
- 05:44Educational strategies and also instructional information
- 05:47to help them produce sputum.
- 05:49And combining that with strategies of quality improvement
- 05:52to help community health workers better deliver that.
- 05:54And we are are just now looking at that preliminary data.
- 05:57It looks very promising
- 05:59that these strategies can be in fact impactful.
- 06:01And we're now testing those
- 06:02to other aspects like TB prevention.
- 06:05So with that, I'll close and see if there's any questions,
- 06:08or I can take them at the end.
- 06:09Thank you.
- 06:10(audience applauding)