As reported by NPR Goats and Soda, health systems’ response to COVID-19 globally will likely set back TB elimination efforts by a decade or more. AA&D Board Member Dr. Salmaan Keshavjee and colleagues at the Stop TB Partnership, Harvard Medical School, and Socios En Salud in Peru describe how responses to the pandemic have precipitated restricted access to TB diagnosis and treatment while increasing the risk of TB transmission.
Read the full article here.
On December 17, 2019, the mayor of Mexicali, Marina del Pilar Ávila Olmeda, and Secretary of Health of Baja California, Alonso Pérez Rico, signed a declaration committing the city of Mexicali, Baja California the latest addition to the Zero TB Initiative (ZTBI).
Executive Director of Advance Access & Delivery (AA&D) Tom Nicholson, Global Program Officer Amanda Brumwell, and Data for Action Program Fellow Jade Tso were in attendance for the declaration signing and for critical programmatic meetings following the signing. As part of the event, Nicholson delivered an address and presentation on comprehensive strategies to eliminating TB as part of ZTBI, as well as opportunities for TB program strengthening in Mexicali. In the presence of dozens of health officials from Baja California and California, Mayor del Pilar Ávila Olmeda and Secretary Pérez Rico pledged their support for eliminating tuberculosis and expressed their hope for Mexicali being a leader in the region for this cause. Video coverage from the event is available here.
ZTBI Partners at declaration signing in Mexicali, Baja California
From left, AA&D Executive Director Tom Nicholson, Global Program Officer Amanda Brumwell, Data for Action Program Fellow Jade Tso, and Data for Action Program Intern Karen Xu
TB is an urgent threat to public health along the US-Mexico border and demands action from health officials, policymakers, and civil society in both countries. Health officials of Mexicali and Imperial County are already collaborating closely to develop and implement binational TB control strategies. Building off of this partnership and in response to their direct request for assistance, AA&D and ZTBI are working to strengthen and expand TB control programs in this area. The support of Mayor del Pilar Ávila Olmeda, Secretary Pérez Rico, and the health officials are an important and essential step to eliminating TB in Mexicali.
Nicholson, Brumwell, and Tso met with the Mexicali TB control team and with Imperial County Department of Public Health officials in El Centro, California, which is across the border from Mexicali, to lay the foundation for binational ZTBI activities. This exciting progress is made possible through the recent donation from the TB Foundation of Virginia to support TB elimination efforts on the US-Mexico border. During these meetings, teams discussed next steps for building and scaling comprehensive programs that are complementary to their binational counterparts and specific to this unique border context, including procurement mechanisms for consumables and developing mobile TB screening programs for active case finding.
Imperial County, CA
Mexicali’s declaration to become a Zero TB City demonstrates public and political support for making TB a greater health priority. This binational project, representing collaborations between both Mexicali and Imperial County governments, public health officials, and nonprofit leaders, has the potential to serve as an example for how local stakeholders can come together in the face of a public health crisis. The ultimate goal is to strengthen the health infrastructure in the region such that it is equipped not only to eliminate TB but address other pressing epidemiological issues including both infectious and noncommunicable diseases.
On May 6, AA&D Executive Director Tom Nicholson and Global Program Officer Amanda Brumwell visited the city of Mexicali in Baja California, Mexico, as AA&D’s ongoing Secretariat work for the Zero TB Initiative.
Nicholson and Brumwell visited Mexicali, a city of about a million people and located on the US-Mexico border, to meet with TB control officials, state epidemiologists, and nurses and doctors. The goal of their visit was to introduce the Zero TB Initiative’s comprehensive approach for TB elimination to stakeholders across the city and to understand the existing health infrastructure and TB services. They also met with Imperial County health officials in El Centro, California, which is directly across the US-Mexico border from Mexicali. Mexicali and Imperial County are already collaborating on binational initiatives to improve public health between outcomes between their two communities.
TB is an airborne, infectious disease that is responsible for 1.6 million deaths each year, and it remains an urgent public health threat globally despite being curable and preventable. Mexicali has one of the highest incidence rates of TB in Mexico with an estimated 57.8 per 100,000 people with the disease in 2018, while an unknown number of people are infected with TB but are not yet symptomatic. Many of these people have co-morbid diseases including HIV and diabetes, adding further complexity to the long and sometimes difficult treatment. Further, Mexicali is one of the critical cities for border-crossings between Mexico and the US. Many people in Mexicali travel daily to the US for work in the large industrial farms in Imperial County, presenting a uniquely challenging context for public health and TB control.
The goal of this visit was to identify gaps and opportunities for strengthening TB control activities with a comprehensive strategy. Officials expressed support for Zero TB in Mexicali and are moving forward with plans to launch a Zero TB Initiative. AA&D’s visit to Mexicali occurred ahead of a Zero TB Initiative training meeting in June, which will provide technical training for core components of Zero TB Initiative framework for searching actively for TB, treating appropriately all forms of the disease, and preventing infection and disease progression. AA&D’s visit was an important step towards developing solutions for eliminating TB in Mexicali, and lessons from this work will likely be applicable to other parts of Mexico with similar epidemiological burdens.
AA&D consultant Dr. Miranda Law presents on healthy eating and medication management at recent NCD-Link workshop
Dr. Miranda Law, a pharmaceutical supply chain and logistics expert from Howard University, traveled to Durban the week of February 25th to provide consultation to NCD-LINK project partners as screening activities kick off in Umlazi this month.
Dr. Law visited 4 of the project facilities during her time in Durban and spoke with patients, nursing staff, pharmacy assistants, and facility managers. Dr. Law worked with patients and personnel to better understand the existing practices for managing and dispensing medicines, educating patients about their medicines, utilizing community pick up points. The project team plans to incorporate findings from this work to strengthen existing plans and build opportunities to support the Department of Health in its priorities to integrate service delivery across disease areas.
Dr. Law also presented on the importance of healthy eating and medication management to a group of over 45 participants at the NCD-LINK workshop held in Durban. This workshop was hosted by IRD-South Africa, implementation lead for the NCD-LINK project, and focused on the integrated care model for screening and linking patients to treatment for tuberculosis (TB) and non-communicable diseases (NCDs). This workshop was attended by program staff, dieticians, nursing managers from project facilities, district coordinators from KwaZulu-Natal, and the KwaZulu-Natal Provincial Director of NCDs, among several other key leaders from the Department of Health for NCDs and TB.
The workshop and Dr. Law’s visit occurred in preparation for the official kick-off of activities for NCD-LINK, a collaborative project between Advance Access & Delivery, IRD-South Africa, the Lilly Global Health Partnership, the South African Medical Research Council, and the South African Department of Health to conduct community-based, integrated screening and linkage to care for TB and NCDs including diabetes and hypertension.
Pharmaceutical care serves as a vital element to the success of the NCD-LINK project. This trip highlighted the need to better understand how the existing pharmaceutical care system operates as the project considers opportunities to provide support to staff and patients across several core project areas including patient education, use of community pick-up points to collect medicines, enrollment of patients on chronic medication dispensing programs, and supporting facility and project staff as they roll out integrated screening and linkage to care programs in Umlazi.
This project presents a critical opportunity to support the Department of Health in its efforts to screen and link patients to treatment in eThekwini. The lessons learned from Dr. Law’s visit and from the NCD-LINK project will be shared widely with partners at both the District and Provincial Department of Health to inform integrated health care delivery in Durban and beyond.
TB HIV Care provides critical support and harm reduction resources for Durban’s growing drug user community.
AA&D is partnering with MASS Design to develop a set of design criteria and recommendations for improving the spaces and services provided to drug users and homeless individuals living in Durban, South Africa.
The City of Durban has embarked on a fast-track mission to address the needs of drug users and homeless individuals living in the Central Business District. Part of this plan is to improve existing facilities and expand services to meet the needs of this growing population. Over the last six months, AA&D and MASS have engaged in working discussions with city officials including the Deputy Mayor and the City Manager and partners from Durban University of Technology (DUT) and TB HIV Care to discuss the philosophy and architecture needed to meet the needs of Durban’s growing drug user community. A general consensus was reached through these deliberations that an integrated centre should be established for low-income and homeless people with a substance-use disorder. This interdisciplinary partnership between AA&D, MASS Design, DUT, TB HIV Care and the City of Durban presents an opportunity to apply evidence-based interventions to meet the unmet needs of drug users and homeless individuals in the city with the overall aim of reducing the harms associated with drug use for individuals, their families, and the community.
AA&D and MASS Design have been asked by city officials to contribute to a comprehensive brief that will inform design criteria and recommendations for the improvement and development state-of-the-art facilities to treat opioid addiction and deliver comprehensive harm reduction services. This work, spearheaded by AA&D Partnerships Lead Michael Wilson, builds on AA&D's past work to extend access to life-saving harm reduction resources including naloxone.
AA&D and MASS are currently engaged in discussions with drug users, social workers, and service providers across the wider Durban metro area to understand the impact of structural space on the delivery of care and support for this population.
University of Garmian researchers, Dr. Pegah Seidi and Nazdar Qudrat, visited a camp for internally displaced persons in Duhok, Iraq as part of an interdisciplinary project to understand gaps in care for mothers and children displaced by conflict.
In November of 2018, researchers from University of Garmian visited a camp in Northern Iraq for Internally Displaced Persons (IDPs). This visit is part of a multi-disciplinary research project supported a team from AA&D and UNC Chapel Hill to understand the gaps in medical and mental health care delivery for mothers and children displaced by conflict. Ultimately, the goal is not just to understand these needs, but to act upon them in a spirit of solidarity. The information gathered through this initial work will be used to inform future support for people in IDP camps, and similar post-conflict settings.
Currently, this research project seeks to understand mental health challenges and improve services for mothers and children of the Yazidi community who have been displaced by conflict in the country. Yazidis are an ethno-religious minority who have suffered extensively in past and ongoing conflicts in Iraq.
More than one tenth of Iraq’s population, or more than four million people, is estimated to be internally displaced, and more than 7.5 million Iraqis are estimated to experience profound mental trauma as a result of the ongoing conflicts in the country. Many of these affected communities have faced historic persecution as ethnic or religious minorities in Iraq, and the ongoing physical and mental health challenges as a result of violence and persecution are particularly acute.
The team, which includes Dr. Dilshad Jaff and Dr. Aunchalee Palmquist at UNC Chapel Hill, Dr. Pegah Seidi and Nazdar Qudrat of the University of Garmian, and Tom Nicholson, Michael Wilson, and Amanda Brumwell of AA&D, has been working together since spring of 2018 to understand mental health challenges, as well as the gaps in care to address these, among IDPs in complex emergency settings.
Dr. Seidi and Ms. Qudrat visited a camp of nearly 4,000 IDPs in Duhok, a city located in Iraqi Kurdistan where they conducted interviews with mothers of infants about their views on access to perinatal and postnatal medical care, mental health services, and gaps in the delivery of these important healthcare services. The University of Garmian-based research team also administered surveys to understand the level of trauma and depression among displaced mothers.
The goal of this project is to gather evidence of the ongoing but overlooked trauma and mental health concerns among this population while prioritizing maternal and infant health. Researchers hope that the findings from this project will translate to more inclusive health delivery pathways that integrate maternal and child health with mental health for severely traumatized mothers and infants. The group plans to continue data collection and analysis throughout 2019, visiting several camps across the region during this time. Team members are optimistic that the findings from this research can inform meaningful changes to the delivery of care for displaced mothers and children in complex emergency settings.
Consultation with hospital head doctors in Vladimir, Russian Federation shed light on challenges and advantages of programs in the city
On November 10, AA&D Executive Director Tom Nicholson visited the cities of Moscow and Vladimir in the Russian Federation as part of AA&D’s work to understand and address barriers to care for people with Hepatitis C (HCV).
In fall of this year, AA&D received funding to support a scoping project to understand the epidemiology of HCV in the Russian Federation and develop an actionable plan to address barriers to treatment for this disease. A core component of this work is to identify potential future paths for importation and delivery of direct-acting antivirals (DAAs), which are life-saving drugs that can cure what was once a chronic disease.
Nicholson visited Vladimir, a city of about half a million outside of Moscow, to meet with doctors, patients and former patients, policymakers, and leadership from local NGOs. The goal of this visit was to understand the scope of the HCV epidemic in Russia, as well as the challenges and opportunities related to logistical and financial barriers to patients benefiting from these new drugs.
An estimated 6 million people in Russia suffer from HCV, and the disease coincides with social and medical co-morbidities that can challenge access to effective care. Less than 2% of people receive care. And if treatment is received through the public sector, it is typically with older, less effective medicines. The reasons for limited access to treatment are complex, but include a limited selection of treatments that are registered in-country, as well as stigma related to social factors (e.g. drug use). The cost of treatment for HCV in Russia and in much of the rest of the world is often prohibitively expensive, forcing people to resort to other treatment options with questionable efficacy and safety. Compared to only a few years ago, the advent of DAAs has opened the opportunity to reverse the epidemic of HCV if comprehensive, cost-effective methods for care delivery can be identified and implemented.
Nicholson’s visit was focused on addressing barriers to effective treatment, with the goal of securing funding for ambitious projects that deliver high-quality care for patients. This work is an important step towards developing solutions for this pressing global health challenge in the near future.
On Monday, November 12th, team members from the Kenan Biddle Refugee Initiative held a workshop at the Center for New North Carolinians (CNNC) in Greensboro, NC.
Over the past year, Kenan Biddle Refugee Initiative team members have worked with service providers, community health workers, volunteers, and refugee community members to develop a training handbook for people working to serve the refugee community and improve access to much-needed services. The purpose of the workshop was introduce a draft of the handbook to people who interface between service providers and community members, understand the strengths and shortcomings of the handbook, and find opportunities to improve based on the experiences of workshop participants.
The handbook development and workshop are funded by the Kenan Biddle Partnership, a joint funding opportunity between the University of North Carolina at Chapel Hill and Duke University to support collaboration between students from both schools to engage and support the Triangle Area community. Over the past year, AA&D and its partners at Refugee Community Partnership (RCP), CNNC, and other North Carolina-based service providers have collaborated to understand the landscape of services that are available and accessible to refugee communities. The handbook is expected to be finalized in December 2018 and shared with partners in response to expressed need for comprehensive training for community health workers, resource navigators, volunteers, and other people working to support the communities in North Carolina.
The workshop was hosted by the CNNC, a University of North Carolina at Greensboro center to promote access and integration for refugees and immigrants in North Carolina. CNNC aims to improve the delivery of services for newcomers to North Carolina while conducting trainings and research to further support North Carolinian communities.
More information on the Kenan Biddle Partnership, CNNC, and RCP and their programs are available on their sites.
AA&D Executive Director and research partners met with Nobel Laureate Nadia Murad and fellow activist Abid Shamdeen on October 29.
On October 29, Nobel Peace Prize Laureate Nadia Murad spoke as a part of the Crown Lecture Series in Ethics at Duke University.
Nobel Laureate Murad spoke about her work to end sexual violence as a weapon of war. As a member of the ethno-religious Yazidi community from Northern Iraq, she knows of the lasting trauma to individuals and the community that such crimes can cause. In the face of intensified persecution in recent years, she has founded a nonprofit, Nadia’s Initiative, as a platform to advocate for women’s and minorities’ rights, especially in emergency and crisis settings.
AA&D, in its partnership with Duke, initiated the work to bring Nobel Laureate Murad to the Triangle. The Crown Lecture event was a successful push to shed light on the urgent humanitarian crisis in Iraq. Already, AA&D and its partners at UNC Chapel Hill and Garmian University have established a research project to understand mental health needs and challenges in maternal and child service delivery among the Yazidi. This research began in mid-2018 among mothers and children in internal displacement camps. Looking ahead, this consortium hopes that momentum will continue to build attention and action to address the crisis facing thousands of Yazidis.
More information about the event can be found at the Sanford School of Public Policy’s feature here.
The TB Drug Access Atlas is an interactive, web-based tool for mapping the supply and access of quality-assured, second-line drugs for MDR-TB. This tool presents the burden of MDR-TB at the global and country levels, and highlights work currently being done or planned around the following seven market indicators: affordability, delivery challenges, forecasting, market incentives, procurement, regimen complexity and regulatory complexity.
On October 28, the capital of Bangladesh became the latest city to sign onto the Zero TB Cities Initiative. Advance Access and Delivery, is the current secretariat for the initiative, alongside other founding partners at Interactive Research and Development, Harvard Medical School, and the Stop TB Partnership at the UN.
Partners In Health, Interactive Research and Development and the Zero TB Initiative welcome the release of interim results from STREAM Stage 1 clinical trial, which was conducted to study a new treatment regimen for multidrug-resistant tuberculosis (MDR-TB).
With the enormous burden across the world of both infectious diseases and non-communicable diseases (NCDs), health delivery programs need to be flexible but purposeful to address the multiple health challenges faced by individuals and communities. Despite much rhetoric about health systems strengthening and integration of health care services from national, international, and local health delivery programs, the detailed considerations in terms of policy and practice for even one area of this inquiry are many and complex.
A newly published report titled “Toward comprehensive global health care delivery: Addressing the double threat of tuberculosis and diabetes” offers examples and supporting data of settings where comprehensive programs are providing, or could provide, successful solutions to combatting multiple diseases in a way that is focused on patient care, efficiency, and strategic harmonization. This report focuses on diabetes, probably the largest public health challenge of the next several decades, and how it intersects with tuberculosis, the leading infectious killer of adults in the world.
With support from the Lilly Foundation, AA&D led a team of health delivery experts, academic faculty, and graduate researchers from Duke University Sanford School of Public Policy, University of North Carolina Eshelman School of Pharmacy, Partners In Health Russia, Harvard T.H. Chan School of Public Health, and Harvard Medical School Department of Global Health & Social Medicine in the writing and preparation of this report.
The authors focused on TB and diabetes, two disease areas in the top ten killers globally, to illustrate how even in a single overlapping and crucial area of global health care, the need for service integration, community-based solutions, inter-departmental and interdisciplinary cooperation, and quality improvement are pervasive and interconnected. They argue that a comprehensive platform is urgently needed to address global health challenges in coordinated fashion, rather than in administrative, academic, and institutional isolation.
“This deadly synergy manifests in programs, health systems, and patients’ bodies in many dangerous and challenging ways,” noted Tom Nicholson, lead author of the analysis. “This report considers how a coordinated, patient-centered approach might function practically in several high burden countries in the immediate future. Tuberculosis and diabetes in these settings are often considered either too difficult or too expensive to deal with on a population level by health care authorities, but a glance at the near-term implications of inaction in institutional, financial, and mostly importantly human terms, shows that inaction is simply not an option.”
The hope is that reports such as this help strengthen responses in each of the countries profiled with high burdens of both diseases—specifically Peru, Russia, South Africa, and India. For example, contributing authors to the report attended the first national tuberculosis-diabetes conference “International Symposium on TB-DM comorbidity: challenges and opportunities” in Lima, Peru, in May. The event was organized by the Instituto de Medicina Tropical Alexander von Humboldt & CRONICAS from Universidad Peruana Cayetano Heredia, TANDEM, and the London School of Hygiene and Tropical Medicine, with the support from the World Diabetes Foundation. AA&D Specialist and Contributing author Dr. Kei Alegria-Flores noted that “the Symposium highlighted academic and practical presentations on how TB and DM intersect across institutional lines; it was a long-awaited platform to start moving the needle on meaningful health systems strengthening across diseases in Peru.”
"Scalawag" magazine published first-person stories of two advocates who've spent years fighting for the humane treatment of drug users in North Carolina, including the following on Louise Vincent.
Opioid Crisis - In the News
With opioid users turning to public bathrooms for a secluded space to use, Many business owners and staff at public buildings don't know what to do. Some doctors, nurses and public health workers who help addiction patients argue any solution to the opioid crisis will need to include safe injection sites, where drug users can get high with medical supervision.
