Operational research to combat tuberculosis
L’Initiative has been supporting operational research since its creation and, in 2018, began publishing an annual call for projects dedicated to groundbreaking programs. Two particularly innovative projects are under way in Ethiopia and Viet Nam.
In 2021, after 12 months of the Covid-19 health crisis that undid 12 years of progress in the global tuberculosis response, L’Initiative issued a call for projects entitled, “Operational research: combating tuberculosis, addressing the needs of vulnerable populations and involving them in the response”. According to Veronica Noseda, who oversees these projects, “one of the aims is to evaluate innovative strategies for the prevention, diagnosis and management of tuberculosis, targeting those most at risk. While community action has largely proven its worth in combating HIV, much remains to be done in the fight against tuberculosis. The aim is “to build on the experience and skills of vulnerable groups in implementing these strategies”.
Managing tuberculosis among injecting drug users in Viet Nam
The project selected in 2021 was Drive-TB, led by the National Institute of Health and Medical Research (INSERM) - mixed research unit (UMR) “Pathogenesis and control of chronic and emerging infections” of the University of Montpellier, in collaboration with the Hai Phong Medical University and Vietnamese NGO, SCDI. Co-financed by the National Agency for Research on AIDS and Viral Hepatitis - Emerging Infectious Diseases, it aims to curb tuberculosis among injecting drug users in the city of Haiphong, Viet Nam.
The project applies a community-based approach that has proven successful in the fight against AIDS. “Drive-TB follows on from the Drive-In programme, which aimed to control HIV within the same community,” explains Nicolas Nagot, the project’s operational manager at Montpellier University Hospital. “Drive-In offered large-scale HIV screening among injecting drug users in three waves of respondent-based sampling.”
In practice, this involves the first sampled persons recruiting other users for screening by distributing vouchers, with the incentive of a (small) financial reward for each voucher returned to the health centre run by SCDI-trained peers (users or former users). Using this method, which reaches out to the entire community, about two-thirds of Haiphong’s drug users were tested for HIV and referred to the appropriate health services for treatment. The same approach was then taken with hepatitis C, with similar success. However, the research team noted that mortality remained abnormally high due to tuberculosis. A cross-sectional study revealed incidence rates among drug users 20 to 50 times higher than average incidence rates in Viet Nam, which is among the world’s most tuberculosis-affected countries.
“Based on our experience of community intervention, we came up with Drive-TB to screen for tuberculosis on a large scale,” says Nicolas Nagot. The programme will be launched in 2023 and will involve four waves of sampling to cover as many users as possible. All participants will complete a questionnaire to assess tuberculosis symptoms, be given the opportunity to have a chest X-ray and have access to latent tuberculosis screening. Those diagnosed with active tuberculosis will be treated by community health workers, while those with latent tuberculosis will be offered preventive treatment.
Finally, as part of the programme community actors will also identify contact cases of those with the disease. For Nicolas Nagot, “the link between peers and users in terms of screening and care demonstrated its effectiveness in the HIV response”. By replicating this community-based approach, Drive-TB aims to drastically reduce tuberculosis transmission among Haiphong’s injecting drug users.
Reaching and treating remote populations in Ethiopia
Another operational research project supported by L’Initiative following the 2021 call for projects was “Reaching the unreached Addis Ababa population towards finding and treating all to end TB”.
Led by the Armauer Hansen Research Institute and Belgian NGO Apopo since June 2022, this 48-month project seeks to detect and treat more tuberculosis cases among the poor population of Addis Ababa, which is highly susceptible to the disease due to poor housing conditions, high vulnerability and limited access to health care services.
The detection protocol used in this project is particularly innovative, as Apopo trains sniffer rats to identify tuberculosis bacteria in sputum samples that would otherwise escape conventional microscopic testing. It therefore involves a “triage” technique, whereby certain samples are recovered that might test positive using more sophisticated molecular biology techniques, which are not widely available in the country. This project will directly benefit 450,000 vulnerable people in deprived urban areas, raising awareness of tuberculosis and screening through the involvement of community health workers.
For Veronica Noseda, “scientific evaluation of innovative strategies, adapted to local contexts and the lifestyles of vulnerable populations, is one of the keys to achieving a tuberculosis-free world”. Investing in operational research and implementation programs enables ongoing progress to reach its full potential to improve patients’ health and quality of life.