Category: Impact

Juliet Sekandi and the case of the treatable yet rapidly spreading disease

Tuberculosis is rampant in Uganda, where nearly 80,000 people develop the disease every year. While practicing there as the attending physician in charge of the public hospital’s TB clinic, Dr. Juliet Sekandi, assistant professor in the UGA College of Public Health, noticed that when people with TB came to her clinic, they often had been suffering for months from the painful breathing, extreme and persistent coughing, fatigue, and fever. Moreover, after the patients went home with their treatment, they would soon return with a household member (or two) who now also had TB.

TB is a highly contagious disease that spreads when the bacteria are ejected from a person’s lungs when they cough or even just speak. So, in a household of four or more people, it was unlikely that it would infect only one person. What’s more, the longer someone remains undetected, the further they spread the disease. What was it, Sekandi wondered, that was keeping people from seeking treatment, helping TB spread like wildfire? That question led her on an ongoing 15-year quest to understand the factors underlying people’s resistance to seeking help, and has spurred a solution using cell phones and artificial intelligence.

At the time, she was trained as an M.D., a field that focuses on finding and treating patients. But that approach wasn’t solving the larger issue of TB spreading throughout the community. For that, she knew she would need to use a public health perspective, which could both seek to prevent the disease from spreading and get care to people who didn’t have good access to it.

Using an exercise called active case finding, she went door to door in one of the capital city of Kampala’s poorest slums, asking people about their cough and to give her samples of their spit. She found that, of those who’d had a chronic cough for at least two weeks, 20% tested positive for TB. She also tested people for HIV and discovered that 30% of those found to have TB also had HIV—most of them unaware they were positive.

“Now, we have very effective medicine to treat TB,” said Sekandi. “So, if one in five is not showing up for treatment, it was clear we needed to find a way to improve our case detection.”

TB causes disease by attacking the body’s CD4 immune cells. As it turns out, so does the human-immunodeficiency virus (HIV), which can lead to AIDS. People with HIV/AIDS are more susceptible to catching TB because their CD4 cells are already depleted.

What was going on that led people to avoid medical treatment for two diseases that, either alone or together, can be fatal when left untreated, yet can be well-controlled if they are medicated properly? The answer was twofold: avoiding the health clinic and not finishing their medication.

patient signing in with nurse at clinic
A nurse enrolls a study volunteer in the DOT Selfie system, which is used to monitor TB patients as they take months-long courses of medication. Patients often stop taking their medicine when they feel better, leading to recurrent illness and drug-resistant strains of TB. With DOT Selfie, patients use their smartphones to record videos as evidence that they’ve taken their medication. (Photo courtesy of Juliet Sekandi)

Mobile Phone Charging Station in Mobile Phone Charging Station in Kabale, Uganda

UGA study using ‘selfies’ to encourage tuberculosis treatment

Researchers from the University of Georgia and Makerere University in Uganda have launched a project leveraging the popularity of selfies to promote tuberculosis (TB) treatment.

The intervention, dubbed DOT Selfie, is one of thirteen mobile health research projects funded by the National Institutes of Health and The Fogarty Center to improve health outcomes, health care services and health research in low- and middle- income countries.

TB is one of the world’s deadliest infectious diseases, and though the disease is treatable, almost one-third of TB patients do not follow prescribed treatment plans.

Non-adherence is a major obstacle to TB control in low- and middle-income countries, says Juliet Sekandi, an assistant professor in the Global Health Institute at UGA’s College of Public Health and lead investigator for DOT Selfie.

But many TB patients in these countries face their own barriers to treatment, she added.

“Major barriers to medication adherence include patient-related factors, such as stigma and lack of overall knowledge about TB, and they include systemic factors, such as the cost of travel to health clinics or long waiting times at health facilities due to high patient to health worker ratios,” said Sekandi.

Adherence challenges are particularly acute in sub-Saharan Africa, where TB rates can be as high as 800 per 100,000 and resources for delivery of health care are limited.

Directly observed therapy (DOT) is acknowledged as the best way to monitor and ensure TB treatment adherence, but this approach proves difficult in areas where there are health care gaps.

In recent years, mobile health tools, including the added video function of a smartphones, have helped overcome some of these barriers to adherence. But there is limited evidence describing the best ways to utilize mobile technologies.

Sekandi’s team is piloting the DOT Selfie project with around 150 TB patients in the Uganda, a country that is estimated to have 45,000 new cases of TB per year. It will be among the first trials to evaluate video DOT in an African setting.

DOT Selfie patients will use their smartphones to record and send time-stamped videos of their daily medication intake. In return, they receive a weekly reward for following their medication regime.

“The need for frequent travel to health facilities is eliminated, which is a big deal,” said Sekandi. “It also offers autonomy to take medications anywhere, anytime, perhaps in a location with more privacy.

Sekandi says she and her team are most excited about the potential impacts of this project to propel health care delivery forward in Uganda and the rest of Africa.

“The successful use of mobile technology will address some critical systemic barriers that persistently lead to poor health outcomes in Africa,” said Sekandi.

José F. Cordero honored by Puerto Rico Public Health Trust

The Puerto Rico Public Health Trust recently honored University of Georgia College of Public Health professor José F. Cordero by establishing an award in his name aimed at recognizing professionals in public health whose trajectories have a positive impact on institutions and citizens of the Island of Puerto Rico.

The new Dr. José Cordero Award was unveiled during “Caribbean Strong: Building Resistance with Equity” held Feb. 27 to March 1, 2019 in San Juan, Puerto Rico. The three-day summit, focused on disaster preparedness in the Caribbean region, was sponsored by the Puerto Rico Science, Technology & Research Trust and the Society for Disaster Medicine and Public Health, Inc.

“I am humbled by such recognition, particularly coming from a premier institution from Puerto Rico,” said Cordero.

Dr. Richard Besser, president and CEO of the Robert Wood Johnson Foundation and summit keynote speaker, presented the honor at an award ceremony held February 28.

“We highlight the excellent professional career of Dr. Cordero,” Besser said. “[His] contributions to the Puerto Rico Science, Technology and Research Trust have led to the creation of programs such as the Brain Trust for Tropical Diseases Research & Prevention, the P.R. Vector Control Unit, and the Puerto Rico Public Health Trust.”

A native of Puerto Rico, Cordero is the Gordhan and Jinx Patel Distinguished Professor of Public Health and head of the department of epidemiology and biostatistics in the College of Public Health, where he mentors graduate researchers in infectious disease studies and infant and maternal health. His own work is focused on improving maternal and infant health in Puerto Rico.

Cordero currently co-directs the Puerto Rico Test site for Exploring Contamination Threats (PROTECT) Center as well as the Center for Research on Early Childhood Exposure and Development (CRECE), both of which examine how exposure to environmental contaminants contributes to the high rate of preterm birth in Puerto Rico.

At the advent of the Zika epidemic in 2015, the PROTECT Center was poised to assist the CDC with Zika surveillance and prevention efforts in Puerto Rico. Cordero quickly became an expert on the risks Zika posed to expectant mothers and a key voice in advocating for Zika prevention education and funding.

In addition to his research and clinical work, Cordero serves as the executive director of the Puerto Rico Brain Trust for Tropical Diseases Research and Prevention, a group that seeks to facilitate and speed up the development of rapid tests, vaccines, vector control, and prevention strategies for diseases like Zika, Dengue, Chikungunya and others.

Cordero earned his medical degree from the University of Puerto Rico before moving to the mainland to expand his training in genetics and, later, epidemiology. His many contributions to public health include identifying nutritional deficiencies of infant formula, advocating for nutrient fortification in corn and flour to prevent neural tube defects in Hispanic children, promoting child immunizations in the U.S. to eliminate measles, mumps and rubella, and championing early diagnosis for children with autism.

For 27 years, Cordero served at the Centers for Disease Control and Prevention, where he focused on improving the health of mothers and children, and in 2006, Cordero returned to the island to lead the newly formed University of Puerto Rico Graduate School of Public Health.

“This award is the latest evidence of Cordero’s indelible impact on Puerto Rican communities, and will live on for those following in his footsteps doing great public health work,” said Marsha Davis, interim dean of the UGA College of Public Health. “This is a wonderful way to honor José whose commitment to the communities he serves has always been paramount.”


Faculty Spotlight: Juliet Sekandi

You may not realize it, but that Health application on your iPhone is good for a lot more than just counting the number of steps you take each day. It contains valuable information, tracking and personalized advice on health topics from nutrition and body measurements to vitals and reproductive health. There’s even an option to enter a “Medical ID,” which can provide your medical information to someone else in case of emergencies. This application is constantly updating and improving and is part of a much larger initiative emerging in public health called mobile health, or mHealth.

mHealth is a relatively new concept; so new, in fact, that no standardized definition exists. One description, from The Global Observatory for eHealth, defines mHealth as medical and public health practice supported by mobile devices, through the use of communication through calls and text messages as well as features such as GPS, Bluetooth technology, and 3 and 4G systems. Projects span from appointment reminders and patient monitoring to emergency calling lines and raising awareness over health issues.

Though the advanced nature of these technological services may only appear applicable to high-income countries, mHealth is actually seen as an opportunity to bridge the huge gap between healthcare needs and service delivery in lower-income countries. The World Health Organization claims that mHealth “has the potential to transform the face of health service delivery across the globe.”

The unique advantage of mHealth is its ability to capitalize on existing resources rather than needing to develop new ones altogether. There are over 5 billion wireless subscribers to mobile cellular networks in the world, and 65 percent of these subscribers live in low- and middle-income countries. Even in remote areas of low-income countries where medical infrastructure is lacking, many people have access to mobile phones. This presents healthcare workers with a valuable opportunity to wield existing technology and resources for providing underserved populations with information on how, when and where to seek care.

The Ministry of Health and Family Welfare of Bangladesh, for example, has taken advantage of the country’s increasing number of mobile phone users to improve the health of its citizens. In 2007, the Ministry launched a project to encourage citizens to get their children on National Immunization Day by sending SMS text messages to all mobile phone numbers in the country. After noticing a positive response from the campaign, the Ministry extended this project to raise awareness of other health campaigns, such as National Safe Motherhood Day and National Breastfeeding Week. By 2010, pregnant women in rural areas of the country could register to receive prenatal advice by gestation age.

The WHO and United Nations see mHealth as a catalyst for reaching the Millennium Development Goals—the UN’s targets for addressing extreme poverty and human rights—particularly those aimed at improving maternal and child health and reducing the burden of diseases such as HIV/AIDS, tuberculosis and malaria. Governments across the globe are taking part, with 83 percent of UN Member States reporting the use of at least one mHealth initiative. Some of the most common initiatives reported were health call centers and toll-free emergency calling lines, though many states also reported the use of initiatives like community mobilization and appointment reminders.

The Harvard School of Public Health is taking a leading role in this new field, with professors launching programs focused on improving maternal and child health and tracking and preventing the spread of disease. One assistant professor, for example, developed a text message application that allows nurses in rural Kenya to alert a main blood bank about shortages before the situation becomes an emergency.

Students and faculty at the University of Georgia are also getting involved. Dr. Juliet Sekandi, a Ugandan native, physician and UGA professor of Global Health, has taken a strong interest in the field of mHealth. She was inspired to take action after visiting her home country three years ago: “I noticed that a lot more people in the population owned personal mobile phones even when they didn’t have access to basic needs like potable water and electricity,” she says.

Dr. Sekandi is particularly passionate about using mobile technology to improve maternal health in rural Uganda, a serious issue in the area. Between 2011 and 2015, Uganda experienced 343 deaths by pregnancy-related causes per 100,000 live births, a staggering maternal mortality rate compared to 14 per 100,000 in the U.S. In the same time period, Uganda’s rate of neonatal mortality, or number of infants dying before 28 days of age, was 19 per 1,000 live births, once again unacceptably high compared with four per 100,000 in the U.S.

According to Dr. Sekandi, these high rates have a lot to do with the lack of information and awareness of what to do or where to go when health issues arise. Because of the limited availability of healthcare services and poor infrastructure, women in rural areas of Uganda must be extraordinarily proactive in their search for healthcare, especially during pregnancy.

Dr. Sekandi hopes to use mHealth to empower pregnant women with vital information such as where to go for prenatal care and birth assistance from trained health workers, early warning signs for problems associated with pregnancy, and where and when to take their babies for immunizations.

Along with a team of students, which she hopes to expand in the future, Dr. Sekandi plans to launch a pilot program in Uganda this summer. This team, a new club called MobileHealth at UGA, is currently focused on collecting old phones, developing a text messaging application containing educational information related to maternal health, and fundraising for the future.

Dr. Sekandi, although very hopeful, believes that the project’s greatest barriers will be in bringing the effort to scale and making it sustainable. Proper funding, she says, will be necessary to keep up with demands for the services this project can provide.

According to the second global survey on eHealth, many WHO Member States are still in the experimentation phase of implementing mHealth projects. There is a need for further information and evaluation of the effectiveness of certain mHealth applications. If mHealth initiatives are to become priorities, they must be properly evaluated and proven a worthwhile use of scarce resources, especially in lower-income countries.

But the potential for success is evident. As mobile technology constantly improves and the reach of subscribers expands, mHealth seems to be an inevitable and promising next step in improving healthcare around the world. And while developers continue to create technology for high-income markets – like the iPhone Health app and a new smartwatch device that reminds users to take medications when they eat – Dr. Sekandi’s project shows that mHealth can capitalize on existing resources to reach underserved populations with the greatest need for healthcare improvements.

Original article in Georgia Politial Review, February 8, 2016