I have now been here in Neno District, Malawi, for a little over 4 weeks, and I will be here for another 3 weeks. Now that I am more than halfway done with my LiA, I wanted to give y'all an update :)
I have been working on several projects during my time here. Firstly, I wrote a study proposal to submit to the Malawi NHSRC (IRB) about use of an Ultra-Portable X-Ray program for TB screening. This involved shadowing the radiologist to see how the machine works, getting to know the institutional structures here to inform my study design, and writing a literature review and overall proposal for the study. The goal for this project was for me to help with the development of the proposal, then the team here will gather and analyze the data after I return to the US, and finally, I will help write the manuscript. The basic question we are trying to answer in this study is if the use of an ultra-portable X-ray (UPX) equipped with Computer Aided Detection (an AI tool) increases TB case detection rates in Neno District, Malawi.
Second, still in connection with the UPX program, I am working on developing a form to be used for physicians to document what happens to a patient after they are screened with the UPX. We have found that patients are being lost in the steps following the screening. Someone might get the X-Ray, but then the steps taken to follow up on that patient are not documented in one place. Another form is theoretically filled out once a diagnosis has been made but this does not account for all the patients that have presumptive TB that might get stuck somewhere in the pipeline from screening to care. Below is a draft of the form (but the physician exam and history sections still require more detail and development)
Third, I have been helping to develop a study proposal for the Community Sputum Collection Points (CSCP) program that is currently being expanded. To test for TB, the most common biological tests require Sputum Samples, which are essentially mucus and saliva that a patient coughs up. However, to collect these samples, patients often must come to a health facility to get tested. There are several issues with this model. One: People will only go to a health facility if they feel sick. This model is called passive case finding, where a patient must identify that there is an issue and seek out care. This is opposed to active case finding, in which trained individuals (physicians or community health workers) are the ones to identify symptoms and refer people to care. The second issue with the traditional model is that health centers are often far from the people who need care, resulting in physical and financial barriers that cause a huge portion of cases to remain unknown and untreated.
The CSCP program trains community health workers to actively screen for TB, going house to house in their villages. Then, if someone has symptoms, they are sent to a collection point in the community to submit a sputum sample for further testing. Bringing the testing to people instead of making people come to the testing has been shown to increase TB case notification elsewhere and will hopefully have the same impact here. The study I am designing will first involve a case-cohort stage to compare case notifications in villages with CSCPs and without CSCPs. The second step will involve a scorecard that an HSA (health surveillance assistant) will fill out about their respective collection point each month for about 3 months. The scorecard will look a bit like this:
Using that data, we identify weaknesses with the program and will design an intervention as part of a quality improvement project. Then, finally, a before-and-after study will be used to assess the impact of the QI project on case-notification rates. Overall, the study will have 3 steps and is considered a Type 1 Hybrid Study. I got to go into the field to witness a community health worker training for the CSCP training last week, and it was great to see the training in action. In a week or so, I will also go with the team to distribute the materials to get all the sites up and running.
Finally, I have had the privilege while being here to attend the morning handover at the hospital every day and get some exposure to the clinical setting here. This handover involves reviewing any patients that we admitted overnight and any special cases in the various wards of the hospital. On Wednesday, we do grand rounds where we go to each of the wards as we discuss them in morning handover. This experience has given me a lot of insight into what the challenges are in this specific healthcare setting. If there are any new TB patients that day, I will round on them with Dr. Dimitri Suffrin, who is the TB/HIV specialist and my advisor.
Overall, so much has happened in these past few weeks and this does not even touch on all the amazing friends I have made. Looking forward to the 3 more weeks I have here!