How do we take an idea that has worked on a small scale and deliver it to tens of thousands of people? We have a fancy new phrase to describe that challenge—Type 2 Translational Research. But long before this was the name for it, some people have been getting on with the job of rolling out good ideas to entire populations.

In the not too distant past, pulmonary tuberculosis, or TB, was a major killer. The disease is spread through the air, passed on by coughing and spluttering. Most people who are infected do not develop the worst symptoms. But one in ten do. Left untreated, TB will kill them.

Some readers may recall the 1966 movie Alfie. In it, the titular character is a jack-the-lad who succumbs to TB. He is confined to a sanatorium to help him recover and to protect others from infection. By the time of the 2004 remake, TB was considered a thing of the past and so the ever irrepressible Alfie was saddled with a possible diagnosis of testicular cancer.

The reason was the antiobiotic streptomycin, develop six decades ago. After its introduction, the incidence rate plummeted.
But just as Alfie did not always do what he was told, so it is with TB sufferers. Patients don’t always take the drugs that will help them.

When the city of Baltimore went into economic decline in the 1960s and 70s, rates of homelessness, unemployment and drug abuse -and later HIV infection- shot up. So did TB. Between 1958 and 1978, TB became epidemic in this city of 600,000—the 20th largest in United States.
The problem was not a lack of a proven model. There was a cure. It was just that people were not taking their medicine.

The consequences were bad not just for carriers of the disease. Untreated, TB spreads. According to a study by Small and colleagues in the 1980s, in California every untreated case of TB resulted in 34 other patients falling prey to the disease and many others becoming infected.
The disease mutates as it advances making it more resistant to medication. By the late 80s, a resurgence of TB in the United States was costing the U.S. health system a billion dollars per year.

The solution to the problem had to come from a discipline that works at scale. Patrick Chaulk, President of the Maryland Patient Safety Center and previously with the Annie E. Casey Foundation and Johns Hopkins, devoted a good part of his career to making the proven model work.
In time, he and his colleagues came up with a deceptively simple plan for Baltimore. The solution was called Directly Observed Treatment or DOT. Put crudely, instead of giving patients drugs and hoping they took them, the patients came to centers where trained medical staff supervised their administration. The aim was to boost treatment completion rates, which in the late 80s and early 90s hovered around the 75% mark.

The results were striking. Between 1978 and 1992 the TB rate in the city declined by three-fifths and its infection rates fell from second in the nation to twenty-eighth. Put another way, without DOT, it is estimated there would have been 1,500 and potentially 2,200 more TB cases in the city. The program is estimated to have saved between $20 million and $30 million in Baltimore alone.

It was not called Type 2 translation at the time. But that is what Chaulk and his colleagues achieved. In the months to come, Prevention Action will focus its attention on similar stories where proven models were successfully taken to scale.

References

Karla Alwood and colleagues, ‘Effectiveness of supervised, intermittent therapy for tuberculosis in HIV-infected patients, AIDS, 1994, 8, 1103-1108

Patrick Chaulk and colleagues, ‘Eleven years of community-based directly observed therapy for tuberculosis’, JAMA, 1995, 274, 12, 945-951

Richard Moore and colleagues, ‘Cost-effectiveness of directly observed versus self-administered therapy for tuberculosis’, American Journal of Respiratory and Critical Care Medicine, 1996, 154, 1013-1019

Patrick Chaulk, ‘Modeling the epidemiology and economics of directly observed therapy in Baltimore, International Journal of Tuberculosis and Lung Disease, 2000, 4, 201-207

Links

http://www.marylandpatientsafety.org/
http://www.aecf.org/