Side Project Ideas

Now that the PMTCT project is running smoothly (and we are actually screening in the right place! fingers crossed...), I have been brainstorming side project ideas, and I think that I found a topic that I am very excited about. Ever since my first two weeks on the wards, it became very apparent that at Moi Teaching and Referral Hospital, adult tuberculosis is far better managed than pediatric tuberculosis. I attribute this to a combination of the following:

1) diagnosis is very difficult in kids and the scoring systems available have yet to be validated in HIV endemic and malnourished populations.
2) children contribute little to transmission so previous research efforts have focused more on adult TB.
3) In high burden TB regions, only 15-20% of TB cases are believed to be pediatric TB cases.
4) Clinicians lack updated knowledge regarding childhood TB diagnosis and treatment.

The last point became painfully obvious last Friday when I heard the following story on the wards:
An 8 month old girl was admitted with a one month history of dry cough, night sweats, and weight loss. She is HIV sero-exposed and has a history of a TB household contact. The Kenyan interns and students consulted two scoring systems and appropriately determined that she should be started on anti-TB meds. The Kenyan consultant came to rounds on Friday, and when he assessed this little girl, he instructed the team to take her off the TB drugs. When a student questioned how he arrived at his clinical decision, he responded "I can see tuberculosis in a child's face. This child does not have tuberculosis."
Even if you are not in the medical field, I think that you can guess that this diagnostic approach is not exactly accurate. This scenario can (and does) occur in any country, and for me, it reiterated the importance of continuing medical education particularly in low-resource settings. I think that it would be useful to create a refresher workshop for medical students and clinicians on pediatric TB diagnosis and management. It's a difficult topic, and I think that this will be a great opportunity to discuss issues that have been encountered on the wards and brainstorm what can be done in the future to do a better job at diagnosing and treating peds TB. I am going to talk to my mentor about it this week and hopefully this is a feasible goal to accomplish this year!

As for my official research project, I think that I am going to focus on household contacts of peds TB cases. It is believed that a significant number of childhood TB cases have an active TB household contact. As far as I can tell, follow up is not done on the active case in the household so I want to look into this a bit more, and hopefully implement screening to get these active cases diagnosed and treated!

I will post more details as the project gets going...

Cough Monitors

When people ask me what I'm doing in Kenya, my one line answer for my main project is usually the following: I am implementing a cough monitor in the PMTCT clinic to screen HIV+ pregnant mothers for TB. I was under the impression that this was a clear way to describe what I am doing. Apparently, I was completely wrong. After about 4 weeks in Kenya, another student innocently admitted to me that she imagined a cough monitor to be a machine - a baby monitor type of device that could somehow listen for cough. She was not the only one because when I told this story to others I received more shocked looks and comments. "Wait so the cough monitor isn't a machine?" "It's a person???" "Oh I thought it was a robot!!"

So to clarify, a cough monitor is a trained PERSON who is assigned to a ward or a clinic. His/her sole purpose is to survey patients for TB risk and TB disease. The cough monitor asks each patient 6 questions that can help determine if the patient is at risk for having active pulmonary TB (cough, household contacts etc). Depending on the patient's answers, the cough monitor collects a sputum sample from the patient to test for TB disease. The sample is sent to the TB lab and results are back the same day. The best part? TB screening AND treatment are FREE!

Two of my favorite short termers and I really got a kick out of the cough monitor robot idea, and we spent some time discussing what this robot would do if a cough monitor was actually robotic. They made me this wonderful present before they left Kenya!!



















Meet Neil the Cough Monitor
Features:
1) Large diameter straw in right breast pocket for easy sputum collection
2) Sputum results back in seconds
3) Culture and drug sensitivity capabilities with siren and light warning for XDR cases
4) User friendly conveyer belt tongue depressor distributes appropriate medications immediately to patient (combo pill available for intensive phase treatment! Limited supply of MDR treatment included!)
5) Large left eye xray device takes a chest xray in minutes

**Deluxe addition with lumbar puncture feature coming soon! Don't let any TB cases get past your cough monitor!

Important Lessons

I realized that I made my first significant mistake in my research this week. In my initial observations of the patient flow in the PMTCT clinic, I talked to the wrong people and was mislead to believe that all HIV + patients go through the antenatal clinic first for their initial visits. To make a long story short, they recently changed the patient flow and now all HIV+ patients have all of their antenatal clinic visits in the place I was originally supposed to implement a cough monitor! My implementation in the antenatal clinic would have worked great 6 months ago before the transition, however, now I am back to square one.

Luckily, it is only week 2 of our screening, and I'll be able to use the data collected to do a comparison study later sooo hakuna matata.

Anyway, my mentor wrote me a great email in response to my mistake:

Welcome to Kenya and OR (operations research) work in the developing world.

Lessons learned:

1.) Talk to everyone.

2.) Talk to everyone again.

3.) Talk to the heads and talk to the people in the trenches

4.) Walk the walk- meaning follow on the ground where you think the patients will be

5.) The most important lesson- ANYTHING THAT CAN GO WRONG WILL GO WRONG.

I am finding the challenges of conducting operations research in an entirely different culture and resource poor healthcare system to be the aspects I enjoy most about this work. There are moments that I feel like an undercover investigator attempting to unravel and understand the intricate nuances of what at times seems like an alternate universe. The environment causes me to slow down in my conversations and analyze phrases and facial expressions that I would never think twice about in the states. And, the moment I think that I have successfully figured out the system, it seems to transform right before my eyes as it did earlier this week!

The Kenyan response to my frustration? They smile and in unison respond "haraka haraka haina baraka, kwa hivyo polepole ndiyo mwendo" which means "hurrying has no blessing, going slowly is the way" I can feel my anxious American-programmed brain retaliating already! I can only hope that I get to a point this year when this approach feels more natural to me....