Research on digital health and applications in the management of LTBI

Zelalem Temesgen, MD FIDSA AAHIVS

Professor of Medicine Executive Director, Mayo Clinic Center for Tuberculosis

Director, HIV Program

Recommendations

• Promote digital tools for information and education to

clients and clinicians.

• Develop digital tools for LTBI programmatic management.

• Promote research to assess the effectiveness of digital tools.

Haileyesus Getahun, Yohhei Hamada

Topics

• Contact tracing

• Identifying risk of reactivation

• Decision support

• Monitoring

• Education and knowledge

• Not intended to be a comprehensive review

• Not an endorsement

Contact Tracing

Epidemic Contact Tracing via Communication Traces

Farrahi K, et al. PLOS ONE 2014;9(5):e95133.

Correlating Badger Social Networks with Tuberculosis Infection

Weber, N et al. Current Biology. 2013;23(20):R915-R916

Quantifying social contacts in a household setting of rural Kenya using wearable proximity sensors

Kiti MC, et al. Epj Data Science. 2016;5:21

Darlington, SM et al. IBM South Africa

Identifying Risk of Reactivation

Lin PL, Flynn JL. J Immunol. 2010 Jul 1;185(1):15-22

Biomarkers for Identification of Latent Tuberculosis

Philana Ling Lin et al. Infect. Immun. 2009;77:4631-4642

Active-disease monkeys have more gross pathology at necropsy than latently infected monkeys.

Philana Ling Lin et al. Infect. Immun. 2009;77:4631-4642

Decision Support

Steele AW, et al. Am J Prev Med 2005;28(3):281–284.

Computerized Clinical Decision Support for LTBI Screening

• CDC LTBI guidelines were encoded into a computerized clinical decision support system

• Recommends further assessment of LTBI risk with certain criteria

• A guided web-based documentation tool to facilitate appropriate adherence to the

LTBI screening guideline

• 8463 patients at 2 primary care, outpatient clinics

• Baseline data collected for 15 weeks and study-phase data collected for 12 weeks.

Adherence with LTBI screening

guideline improved significantly

from 8.9% at baseline to 25.2%

during the study phase.

(183% increase, p < 0.001)

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52-year-old female, born in Vietnam, migrated to the USA at age 40 years, TST 10mm, IGRA positive, BCG<age 2 years, on hemodialysis for rare kidney disease, no diabetes. No known TB contact. The chest x-ray is clear. Results from the TST/IGRA calculator show the following risk estimates: • The cumulative risk of active tuberculosis disease, up to the age of 80, is:

48.87% • If treated with INH, the probability of clinically significant drug-induced hepatitis

is 2.3%, and the associated probability of hospitalization related to drug-induced hepatitis is 0.6%.

A decision aid for treatment of latent tuberculosis infection

Evidence synthesis

Observations clinical encounters

Designers Study team

Patient advisory groups Clinicians

Stakeholders

Initial prototype

Field testing

Modified prototype

Final Decision Aid

Evaluation Randomized Controlled Trials

Monitoring

WelTel LTBI: Effect of weekly messaging on LTBI treatment completion

Mia L van der Kop et al. BMJ Open 2014;4:e004362 Nhavoto JA, et al. PLOS ONE 12(4): e0176051.

Oren E, et al. Pilot Feasibility Stud. 2017; 3:15. Epub 2017 Mar 13.

Promoting adherence to treatment for latent TB infection through mobile phone text messaging (TXT4Med)

VDOT for Monitoring Adherence to LTBI Treatment (VMALT): A

Randomized Controlled Trial of Cell Phone Video Directly Observed

Therapy to Monitor Short-Course LTBI Treatment (2015-2020)

Funded by NIAID grant U01-AI116392; PI: Richard S. Garfein, PhD, MPH

www.ClinicalTrials.gov. Study Identifier: NCT02641106

Clinical

Lab.

Microbiology

Lab.

Molecular

Lab.

Pharmacology

Lab.

Radiology

Genomics

Proteomics

Metabolomics

Pharmacogenomics Transcriptomics

EHR

Knowledge

Base

Rule

Engine

Interface

Clinic

Patients

Patient Portal

Reporting

- Outcome

- AEs

Remote

Monitoring

Physiologic

Parameters

Reminders

Appointments

Education

Triage

Clinical

Decision

Support

Education and Knowledge

OnPar: A Challenging Case-Based Learning Game