|Year : 2021 | Volume
| Issue : 2 | Page : 182-187
Project extension for community healthcare outcomes improves care and treatment for multidrug-resistant tuberculosis patients in Tanzania
Daud Dunstan Peter1, Shabani Ramadhani Mziray2, Isack Augustino Lekule3, Victor Kitundu4, Salum Mohamed5, Riziki Michael Kisonga6, Stellah George Mpagama6, Bruce Baird Struminger7
1 Department of Clinical Services, Kibong'oto Infectious Diseases Hospital; Rural and Urban Community Health Based Organization, Kilimanjaro, Tanzania
2 Department of Medical Laboratory Services, Kibong'oto Infectious Diseases Hospital; Department of Biochemistry and Molecular Biology, Kilimanjaro Christian Medical University College, Moshi; Rural and Urban Community Health Based Organization, Kilimanjaro, Tanzania
3 Department of Preventive Services, National Tuberculosis and Leprosy Program, Dodoma, Tanzania
4 Department of Internal Medicine, Dodoma Regional Referral Hospital, Dodoma, Tanzania
5 Department of Infectious Diseases, Muhimbili National Hospital, Dar es Salaam, Tanzania
6 Department of Clinical Services, Kibong'oto Infectious Diseases Hospital, Kilimanjaro, Tanzania
7 Division of Infectious Diseases, The ECHO Institute, University of New Mexico Health Sciences Centre, New Mexico, United States
|Date of Submission||18-Apr-2021|
|Date of Acceptance||19-Jun-2021|
|Date of Web Publication||14-Jun-2021|
Daud Dunstan Peter
PO. Box: 12, Sanya Juu, Siha, Kilimanjaro
Source of Support: None, Conflict of Interest: None
Background: Project Extension for Community Healthcare Outcomes (Project ECHO) is a telementoring, case based virtual community of practice training and education model connecting experts to primary care clinicians (PCCs). Project ECHO has good evidence for favorable treatment outcomes on wide range of diseases. Since 2017, Tanzania hosts multidrug resistant tuberculosis (MDR TB) ECHO with hub at Kibong'oto Infectious Diseases Hospital. However, little is known on outcomes of MDR TB ECHO. This study aimed to describe the outcomes of MDR TB ECHO in managing MDR TB patients in Tanzania. Methods: Review of case studies was conducted at MDR TB ECHO hub in Tanzania. Up to June 2020, a total of 134 sessions and 60 patient cases were presented in MDR TB ECHO. This article describes outcomes of MDR TB ECHO in managing three selected complicated MDR TB patient cases presented. Case 1: Child with MDR TB, neck abscess, and anemia secondary to chronic illness. Case 2: Adult with MDR TB and end stage renal disease co morbidity. Case 3: Adult failing standard MDR TB treatment. Results: Anemia resolved in Case 1; surgical dressing was done to neck abscess and neck healed. Case 2 was initiated with end stage renal disease management; uremic encephalopathy and lower limb edema resolved. Case 3 was initiated with individualized MDR TB treatment. All three patients attained smear and culture conversion and continue with MDR TB treatment. Conclusions: To our knowledge, this is the first report on effectiveness of project ECHO in supporting PCCs in bringing favorable treatment outcomes to MDR TB patients. We advocate adaptation and scale up of ECHO model as an effective approach for strengthening management of MDR TB and other infectious diseases.
Keywords: Multidrug-resistant tuberculosis, multidrug-resistant tuberculosis Extension for Community Healthcare Outcomes, Project Extension for Community Healthcare Outcomes
|How to cite this article:|
Peter DD, Mziray SR, Lekule IA, Kitundu V, Mohamed S, Kisonga RM, Mpagama SG, Struminger BB. Project extension for community healthcare outcomes improves care and treatment for multidrug-resistant tuberculosis patients in Tanzania. Int J Mycobacteriol 2021;10:182-7
|How to cite this URL:|
Peter DD, Mziray SR, Lekule IA, Kitundu V, Mohamed S, Kisonga RM, Mpagama SG, Struminger BB. Project extension for community healthcare outcomes improves care and treatment for multidrug-resistant tuberculosis patients in Tanzania. Int J Mycobacteriol [serial online] 2021 [cited 2022 Aug 11];10:182-7. Available from: https://www.ijmyco.org/text.asp?2021/10/2/182/318389
| Introduction|| |
Tuberculosis (TB) is the chronic infectious disease caused by Mycobacterium tuberculosis. The disease can be localized in the lungs and other organs and orchestrate pulmonary TB and disseminated TB respectively. Globally, approximately ten million people develop active TB annually and Tanzania is one of the top 30 high burden countries. As one of the top ten diseases with high mortality rates worldwide, TB claimed the lives of 1.2 million HIV-negative people in 2018.
While TB is curable, there is on-going global expansion of multidrug-resistant TB (MDR-TB), a major public health concern that compromises the activity of the key anti-TB medicines. MDR-TB is defined by the World Health Organization as TB that is resistant to at least rifampicin and isoniazid, the main-stream anti-TB medicines. Globally, rifampicin-resistant (RR)/MDR-TB is diagnosed in 18% of previously treated TB cases and 3.5% of newly diagnosed TB cases. Globally, RR/MDR-TB claimed 230,000 lives in 2017. Drug-resistant TB survey conducted in 2017 in Tanzania depicts prevalence of 0.9 and 4.6% of MDR TB among new and previously treated TB cases respectively (unpublished data) and a total of 449 cases were notified in 2018. Up to June 2016, individuals diagnosed with RR/MDR-TB in Tanzania were hospitalized and treated at Kibong'oto Infectious Diseases Hospital (KIDH) for the entire intensive phase (six to eight months) followed by continuation phase of treatment at facility close to patient's home. KIDH is the National Centre of Excellence for managing TB and other infectious disease in Tanzania. From mid-2016, the Ministry of Health of Tanzania in collaboration with implementing partners, started to decentralize the RR/MDR-TB treatment initiation services from KIDH to newly established RR/MDR-TB treatment centres across the country. As of December 2018, a total of 111 RR/MDR-TB treatment centres started to provide MDR-TB treatment services countrywide. Among other objectives, decentralization aimed to provide RR/MDR-TB management close to patients' homesteads. Before decentralization, the primary care clinicians (PCCs) in the RR/MDR-TB treatment centres received training and one-on-one mentorship from KIDH for managing individuals with RR/MDR-TB. However, in order to strengthen the already established capacity of PCCs in managing RR/MDR-TB patients at remote treatment centres, a routine and on-going cost-effective mentoring approach is required from a multidisciplinary panel of experts from KIDH and other stakeholders. Project Extension for Community Healthcare Outcomes (Project ECHO), a telementoring virtual community of practice training and education model developed by the University of New Mexico School of Medicine, capacitates the PCCs in remote settings through virtual specialty consultation from the hub with a multidisciplinary panel of experts as well as peer-to-peer learning and sharing., By connecting PCCs to experts via video conferencing, the model facilitates sharing of knowledge, skills and experiences in managing a variety of diseases and conditions, and continues to bring favorable treatment outcomes,, in more than 35 countries worldwide. Tanzania introduced MDR-TB ECHO in the year 2017 to facilitate telementoring in managing RR/MDR-TB patients from KIDH (hub) to PCCs in RR/MDR-TB treatment centres (spokes). As of June 2020, a total of 134 sessions and 60 patient cases were presented in MDR-TB ECHO. This article describes the outcomes of MDR-TB ECHO in facilitating PCCs to successfully manage three complex RR/MDR-TB cases in Tanzania.
| Methods|| |
Design and settings
The review of case studies was conducted at the hub of the Project MDR-TB ECHO in Tanzania. It described the outcomes of Project ECHO in strengthening management of RR/MDR-TB patients in Tanzania through the case-based virtual community of practice approach. One hour was dedicated on every Tuesday of the week to conduct Project MDR-TB ECHO using the Zoom-video conference platform [Figure 1] to connect the panel of experts at the hub (KIDH) and several PCCs in RR/MDR-TB treatment centres (spokes) in Tanzania. Each session included a patient case presentation followed by discussion conducted for ½ h, with the remainder of the time reserved for didactic training and updates on diagnosis, and clinical management for the MDR-TB patients. At the time of the study, the hub consisted of the hub MDR-TB coordinator, a Physician with specialty in infectious diseases, General Physicians, Medical Doctors, a Medical Radiologist, a Community Health Specialist, Nurses, a Medical Laboratory Specialist, a Molecular Biologist, a Medical Microbiologist and Pharmacists. There were 111 spoke sites with PCCs ranging from Nurses, Direct-Observed Therapy Nurses, Clinical Officers, Medical Officers and Laboratory Technologists. Other invited stakeholders included the Regional TB and Leprosy Coordinators, District TB and Leprosy Coordinators, representatives from the Central Tuberculosis Reference Laboratory, representatives from the National TB and Leprosy Program and representatives from Tanzania Health Promotion Support.
|Figure 1: Multidrug-resistant tuberculosis Extension for Community Healthcare Outcomes telementoring session|
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De-identified patient cases were presented to Project MDR-TB ECHO via Zoom-video conferencing using the screen sharing features. Thorough discussions were conducted between the PCCs and the panel of experts in the hub with additional discussions with PCCs peers, and finally, the recommendations and plans for patient management were agreed upon. Following each session, the hub-ECHO coordinator, who is also an expert clinician for RR/MDR-TB, compiled and E-mailed all the clinical notes and the patient management plans to the PCCs in the spokes. Below are detailed descriptions of the three complicated cases of MDR-TB presented in the Project MDR-TB ECHO and their outcomes.
| Results|| |
Case 1: A child with pulmonary and extra-pulmonary multidrug-resistant tuberculosis
An 11-years old girl who had contact with the then presumed TB case (currently on MDR-TB medications) was initially treated for pneumonia several times without relief. She presented to PCC with gradual onset of productive cough associated with on and off low to high grade fever, excessive night sweats, loss of appetite, significant weight loss (nine kg) and growth faltering. Besides, the child presented with bilateral neck swelling accompanied with severe throbbing pain with pus discharge for 2 weeks. Her mother reported that the girl was previously diagnosed with TB and started anti-TB treatment in August, 2018 with no documentation of sputum results. She was on anti-TB for 4 months composed of fixed dose combinations of rifampicin + isoniazid + pyrazinamide + ethambutol for two months and rifampicin + isoniazid for 4 months; however, the child stopped anti-TB before completing 6 months of treatment because her mother thought she was cured from TB. The mother noted the re-appearance of TB symptoms to the child and resumed anti-TB treatment.
On physical examination by PCCs, the child was febrile (38.7°C), but had respiratory and pulse rate of 30 cycles/min and 118 beats/min respectively. She was neither dyspneic nor pale with Glasgow Coma Scale (GCS) of 15/15. She had cyanosis, neck abscess with enlarged bilateral axillary lymph nodes, submandibular lymph nodes [Figure 2]a. She had bilateral equal chest movements, dullness on right intra and infra mammary regions, with reduced bronchial breath sounds heard. No abnormalities were seen in other systems. The child was admitted to the surgical ward and reviewed by surgical team for neck abscess incision, drainage and dressing. The surgical incision, drainage and dressing were performed [Figure 2]b and [Figure 2]c and prescription of injection Meropenem 1 g once daily for 5 days was done. The PCCs consulted with surgical team and decided to collect pus and sputum for Xpert MTB/RIF assay. On November 8, 2019, both samples revealed MTB detection with rifampicin resistance.
|Figure 2: Treatment outcomes of neck abscess. (a) Neck abscess at diagnosis with enlarged bilateral axillary and submandibular lymph nodes. (b and c) Surgical incision and drainage at 2 weeks and 1 month of treatment with reduced lymph nodes enlargement. (d) Healed neck at month six of treatment|
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In November 12, 2019, the PCCs presented the case in MDR-TB ECHO session for expert recommendations in management of the child. After thorough discussion in MDR-TB ECHO session, it was recommended to continue with surgical dressing and to perform all baseline investigations for MDR-TB treatment initiation. Once the baseline investigations are done, the PCC was advised to present the case in the following MDR-TB ECHO session. In the follow-up MDR-TB ECHO session, the results for baseline laboratory investigations were as follows; sputum for acid fast bacilli was 1+, and HIV serology was negative. Baseline TB culture results were positive and the isolates were resistant to rifampicin and isoniazid, but susceptible to both floroquinolones and second-line injectable. Full blood picture (FBP) showed neutrophilia and anemia (Hb 5 g/dl), biochemistry results for liver enzymes were normal (alanine aminotransferase [ALT] 20.46 U/L, aspartate aminotransferase [AST] 40.52 U/L) with grade 3 nephrotoxicity (serum creatinine 114.70 μmol/L, creatinine clearance 30 ml/min). Electrocardiogram (ECG) revealed normal corrected QT interval (434 ms). Posterior-anterior abnormal chest X-ray results showed mild pleural effusion (left), right lower lung consolidation and widening of mediastinum [Figure 3].
After reviewing the baseline investigations, the panel of MDR-TB ECHO concluded that the child had MDR-TB and anemia secondary to chronic illness. The PCC was advised to initiate individualized MDR-TB regimen containing four second-line anti-TB medicines (delamanid 50 mg per oral 12 hourly for 6 months, cycloserine 250 mg per oral once daily for 18 months, Levofloxacin 260 mg per oral once daily for 18 months, Clofazimine 50 mg per oral once daily for 18 months, Ethambutol 390 mg per oral once daily for eighteen months) as per WHO and National guidelines for the management of RR/MDR-TB. Two units of blood transfusion and hematenics for 1 month were also recommended. Finally, the PCC was advised to continue with surgical dressing.
At month 6 of MDR-TB treatment, the PCC presented the case at MDR-TB ECHO session with substantial improvements. The child recovered from anemia with approximately 3-fold increase in Hb (13 g/dl), healed neck lesions [Figure 2]d, and is back to her daily activities including attending to school. All the TB signs and symptoms disappeared; TB smears were negative from Month one to six while TB culture results were negative from Month one to four. It was agreed in the MDR-TB ECHO session to stop Delamanid since the child has taken the medication for a recommended duration of 6 months. Other MDR-TB medications should continue as prescribed earlier. The patient is currently at month 12 of MDR-TB treatment and progresses well.
Case 2: A man with multidrug-resistant tuberculosis/end-stage renal disease co-morbidity
A 65-years old male, a known hypertensive and end-stage renal disease client on maintenance hemodialysis (three sessions per week), consulted the PCC with the main complaint of productive cough for 2 weeks. He had a history of confusion for 3 days and generalized body weakness for 1 week. He also presented with fever, excessive night sweats and significant weight loss, decreased urine output and bilateral lower limb pitting edema. The client did not report history of heartbeat awareness, chest pain or tightness, loss of consciousness, convulsion or headache. Also, the client had no history of vomiting, diarrhea or abdominal pain. No abnormalities were seen to other systems.
On admission, the client was confused (GCS 14/15) and aphasic, weak, ill looking, pale, not jaundiced, tachycardic, dyspneic, with bilateral pitting lower limb edema. Blood pressure (BP) was 131/75 mmHg, pulse rate 83 beats/minutes, and oxygen saturation (SPO2) of 92% on RA. Respiratory system-bilateral equal air entry with diffuse crepitation, cardiovascular system-S1 and S2 heard no murmur, abdominal examination revealed a soft abdomen which was non-tender and no organomegally.
The PCC ordered sputum for Xpert MTB/RIF assay which revealed MTB detection with rifampicin resistance. FBP showed leukocytosis (WBC-17.1 × 109/L) with mild anemia (Hb 10.3 g/dl) and mild thrombocytopenia (platelet count 126 × 109/L. Biochemistry analysis revealed grade 4 nephrotoxicity (serum creatinine was 722.6 μmol/L, and blood urea nitrogen (BUN) 31 mg/dl)) and normal serum electrolytes and liver enzymes levels ((Na + 134 mEq/L, K + 4.8 mEq/L, Ca2 + 2.09 mEq/L, PO4 1.69 mEq/L), (AST 20 U/L, ALT 18 U/L)). Echocardiogram revealed left ventricular hypertrophy with normal ejection fraction while ECG showed normal sinus rhythm. Chest X-ray showed increased cephalization on both lungs suggestive of pulmonary edema. Renal ultrasound revealed bilateral renal parenchyma diseases. By considering the clinical history together with laboratory and radiological tests, the PCC came up with diagnosis of MDR-TB and uremic syndrome.
The PCC presented the case in MDR-TB ECHO session and it was agreed to initiate the individualized MDR-TB regimen containing the following second line anti TB medicines: Bedaquiline 400 mg three times per week for 2 weeks, then 200 mg three times per week for 22 weeks, Linezolid 600 mg three times per week for 6 months, Levofloxacin 750 mg three times per week for 18 months, clofazimine 100 mg three times per week for 18 months, pyrazinamide two grams three times per week for 18 months. The panel of experts in MDR-TB ECHO further recommended continuation of maintenance hemodialysis, nephrology and cardiac clinic follow up and anti-hypertensive. Also, the PCC was advised to check electrolytes, and serum creatinine on weekly basis, and to provide injection Frusemide 60 mg twice daily for 5 days. The patient stayed in the ward for 1 month and was discharged after improvement. After 3 months of treatment, the patient was presented at MDR-TB ECHO as follow-up; he improved significantly with resolved uremic encephalopathy, as well as pulmonary and lower limb edema. Sputum culture converted from positive to negative at month two of treatment. Serum creatinine by half from baseline (722.6-350 μmol/L) while BUN dropped to normal level (31 to 8 mg/dl). Electrolytes and liver enzymes remained in the normal range and chest X-ray was normal. It was recommended in the MDR-TB ECHO session that the patient should continue with hemodialysis and anti TB treatment (levofloxacin 750 mg three times per week for 12 months, Clofazimine 100 mg three times per week for 12 months, Pyrazinamide two grams three times per week for 12 months). The patient is currently at month 11 of MDR-TB treatment and progresses well.
Case 3: A failure to standard MDR-TB regimen
A 31-years old female consulted the PCC with main complaints of productive cough for more than two weeks associated with weight loss, general body malaise and loss of appetite. Chest X-ray showed bilateral heterogeneous infiltrations. Sputum examination by Xpert MTB/RIF assay detected TB with rifampicin resistance. The baseline laboratory results were normal biochemistry and hematological indices (ALT 20 U/L, AST 30 U/L, creatinine 85 μmol/L, RBG 5.0 mmol/L and normal FBP). The PCC decided to initiate a standard MDR TB regimen for 18 months starting from May, 2017. The prescribed medicines were kanamycin 625 mg intramuscular once daily for 8 months, Tabs Levofloxacin 750 mg orally for 18 months, tabs pyrazinamide 1.6 g once daily for 18 months, tabs cycloserine 500 mg once daily for 18 months, tabs ethionamide 750 mg once daily for 18 months, tabs levofloxacin 750 mg once daily for 18 months, and Tabs Pyridoxine 100 mg once daily for 18 months. However, TB smears were positive at month two, three, and eight, followed by month 14-17 consecutively. TB cultures were positive at month 13. There was mild/moderate elevation of creatinine (103 μmol/L) and AST (45 U/L) at month nine to 11. At month 6, chest X-ray showed bilateral cavities and opacifications on upper zones of the lungs. Fibrotic changes were observed at month 12.
At month 18 of MDR-TB treatment, the PCC presented the case at MDR TB ECHO for discussions and technical advice on the management of the client. It was recommended that the client should continue with MDR-TB treatment and perform TB smear microscopy and culture at (Month 18, 19, 20), line probe assay (LPA), a molecular test for detecting Mycobacterium tuberculosis and genotypic TB drug susceptibility testing. It was also agreed to perform a control chest X-ray at month 20. Three months later, the PCC presented the case for the second time in the MDR-TB ECHO session with the results of TB smear microscopy and LPA. TB smear was positive at Month 18-20, LPA detected M. tuberculosis, and TB drug susceptibility as follows: RR, isoniazid-susceptible, fluoroquinolones-susceptible, amino glucosides/injectables-susceptible. However, the TB culture results were pending and it was agreed to wait for them before making a decision. Control chest X-ray revealed cavitation and opacities on left lung at month 20. The client completed MDR-TB treatment on January 14 2019. Four months after treatment completion, culture results for month 18, 19, 20 were released and were all positive.
The PCC visited the patient at home and collected sputum samples for TB smear microscopy, Xpert MTB/RIF, TB culture and DST, and LPA. TB smear microscopy was positive and Xpert MTB/RIF assay detected M. tuberculosis with rifampicin resistance. TB culture was positive and LPA detected M. tuberculosis and genotypic drug susceptibility results were as follows: RR, isoniazid-susceptible, fluoroquinolones-susceptible, amino glucosides/injectables – susceptible, and low-level kanamycin-susceptible. The PCC presented the case at the MDR-TB ECHO for the third time and after thorough review of the results and discussion it was concluded that the client failed the previous MDR-TB treatment. The PCC was advised to perform physical examination, assessing signs and symptoms, baseline investigations, trace phenotypic TB drug susceptibility results, counsel and educate the client on the need to restart MDR-TB treatment. It was recommended to initiate an 18-month individualized MDR-TB regimen with the following; Tabs Levofloxacin 750 mg once daily for 18 months, Tabs Bedaquiline 400 mg once daily for 2 weeks then 200 mg three times weekly for 22 weeks, Tabs Linezolid 600 mg once daily for 6 weeks, tabs clofazimine 100 mg once daily for 18 months, and para-amino salicylic acid four grams twice daily for 18 months.
Assessment of the signs and symptoms revealed that the client was ill looking, dyspneic, and weak. Respiratory tract system examination showed reduced chest movement on the right side, dullness percussion on both sides of the lungs, and bronchial breathing heard rhonchi and diminished air entry on both lungs. Body weight 43.7 kg, height 1.54 M, BP 104/75 mmHg, pulse rate 116 beats/min, respiratory rate 25 breaths/min. She had dry cough for 2 months which was more marked during the night, no aggravating and relieving factors. The condition associated with difficult breathing on exertion but not when laid flat, and no history of paranoximal nocturnal dyspnea. Reviews of other system were essentially normal. Results for baseline investigations were as follows; Biochemistry revealed mild liver enzymes elevation grade one (ALT 65.6 U/L), normal blood sugar (RBG 5.6 mmol/L), negative urine pregnancy test, low serum creatinine (0.00 μmol/L), serum electrolytes were not done, FBP showed anemia (Hb of 8 g/dl). Chest X-ray revealed opacification and cavitation on the left lobe and the right lower and upper lobe of the lung. ECG showed QTCF of 445 msec.
The patient was counseled and agreed to restart MDR-TB treatment. The patient started an 18-month individualized MDR-TB treatment on July 26, 2019. Follow-up TB smear microscopy converted to negative since month two of treatment. Follow-up TB culture converted to negative from month three, but reverted to positive at month nine. TB culture was contaminated at month 10 and became positive at month 12 of MDR-TB treatment. At month 13 of MDR-TB treatment the client had mild anemia (Hb 9.19 g/dl, an increase of about 1.2 g/dl compared to baseline) after being prescribed with combined tabs of Ferrous sulphate and folic acid 25.05 mg thrice daily for four weeks. Currently the patient is at month 15 of MDR-TB treatment.
Written informed consent and permission to use images was obtained from the cases and the mother of the child. The child provided assent to take part in the study.
| Discussion|| |
This study aimed to demonstrate the outcomes of MDR-TB ECHO in managing MDR-TB patients in Tanzania. Favorable treatment outcomes were observed to all the three complicated cases of MDR-TB that were presented, discussed, and managed via MDR-TB ECHO in Tanzania. The demonstrated achievements present the usefulness of project ECHO on mentoring the PCCs toward managing complicated cases of MDR-TB similar to other chronic diseases,,, and conditions, elsewhere. As opposed to telemedicine, whereby the consulted experts take full responsibility for managing the patient, Project ECHO provides telementoring to the PCCs by allowing them to work independently and responsibly as their expertise grow. The project ECHO case-based telementoring approach further provides the experts at the hub with an opportunity to learn from the PCCs. The MDR-TB patients were managed and treated by the PCCs in the same quality as the experts at the Centre of Excellence due to the fact that Project ECHO reduces professional isolation, promotes professional satisfaction and builds confidence to PCCs in managing complex medical cases.
This study further presents the cost-effectiveness of Project ECHO in managing chronic infectious diseases as described previously., Programmatically, the complicated cases of MDR-TB like those in this study were supposed to be referred to KIDH for further management. However, through virtual specialty consultation and telementorship via MDR-TB ECHO, time and travel costs to KIDH were saved as all the patients were effectively managed by the mentored PCCs in the primary health-care facilities.
Finally, the MDR-TB ECHO program leadership in Tanzania invites all interested colleagues around the world to request the ICT department of the Ministry of Health to join the platform for learning and sharing experience on diagnosing and managing MDR-TB patients.
| Conclusions|| |
To our knowledge, this is the first article reporting on the effectiveness of project ECHO to support PCCs to achieve favorable treatment outcomes in MDR-TB patients. Based on our successful experience, we advocate the adaptation and scale-up of the ECHO case-based virtual community of practice approach to strengthen management of MDR-TB and other infectious diseases.
The study was approved by the Northern Tanzania Health Research Ethics Committee with certificate number KNCHREC0003. The ethics committee is administered by three institutions namely Kibong'oto Infectious Diseases Hospital, the Nelson Mandela African Institution of Science and Technology, and Centre for Educational Development in Health, Arusha.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]