Lessons Learned from Barcelona about Tuberculosis Treatment

emocha video Directly Observed Therapy highlighted at World TB Day Event

World Tuberculosis (TB) Day is observed every year on March 24 to commemorate the day that Dr. Robert Koch, a Nobel Prize-winning German physician and scientist, presented his discovery of the bacteria that causes TB — a disease that to this day kills roughly 1.7 million people around the globe.

World TB Day serves as an impetus to unite as an international community, form new partnerships, and come up with non-traditional approaches to improving the lives of people with TB. Events all over the world are held during the month of March to bring awareness to TB education, prevention, and treatment. On March 15, I was fortunate enough to celebrate this important day with colleagues in Barcelona working tirelessly to put an end to TB.

Medication Adherence Highlighted at World TB Day Conference

The expert panels at Barcelona’s World TB Day conference were comprised of providers focused on a variety of infectious disease topics, including medication adherence (whether patients take medication as prescribed). Medication adherence is a critical to the successful treatment of diseases, and directly observed therapy (DOT) — the practice of watching patients as they take medications — has been proven to help patients with TB, HIV, and other illnesses secure medication adherence.

I participated in a panel that focused on DOT and presented emocha’s work in Puerto Rico in which our video DOT technology helped patients adhere to medications, complete treatment, and end a recurring TB outbreak. Work from other emocha partners, such as Fresno County Health Departmentand the State of Maryland, were also highlighted. My panel included several public health experts, including Dr. Ernesto Jaramillo of the World Health Organization (WHO) and local experts in DOT: Dr. Joan Pau Millet and Carmen Ruiz of Serveis Clinics as well as Dr. Hernando Knobel from Hospital del Mar.

Tuberculosis Treatment and Directly Observed Therapy in Barcelona

Earlier that week, I visited the TB program at Agència Salut Pública Barcelona (ASPB) — the public health agency of Barcelona. The agency is responsible for managing the cases, evaluation, and surveillance on the disease in the city. The ASPB also has a team of six community health workers, led by Dr. Jesus Ospina, who help patients with psychosocial and socioeconomic needs. The team has been particularly instrumental in engaging immigrant populations.

The ASPB team outlined the TB trends in Barcelona over time. As a public health geek, it was fascinating to hear first-hand how demographic shifts have impacted programmatic challenges over the years. As of 2015, 16.3 percent of Barcelona’s population is comprised of immigrants, which has had a considerable impact on TB epidemiology in the city. A majority of TB cases are now among foreign-born persons, with the highest incidence of TB (125.9/100,000) found in a district of the city where most of the population immigrated from Pakistan, India, and Bangladesh. Cultural and linguistic barriers make communication between TB care teams and patients difficult and highlights the important role of community health workers as facilitators. New workflows have been incorporated to streamline cooperation and coordination between providers, community health workers, and patients.

I also visited Serveis Clinics, a 50-bed inpatient DOT unit in Barcelona that cares for patients with TB at high risk for nonadherence. The clinic also has a field DOT team to provide care to patients who are not residents in the facility and is the only one of its kind in Catalonia. All medication for patients in the facility, not just for TB, are given under direct observation and a pharmacy packages all of the medications in-house. It is staffed 24/7 to support patients throughout their TB treatment. Dr. Joan Pau Millet, co-Medical Director for the clinic, and Carmen Ruiz, head of the field DOT team, highlight an important point that many of us working in TB can relate to: ‘tenemos la suerte de trabajar en lo que nos gusta.’ This translates to “we are lucky to work in a field we like.” The passion, dedication, and willingness to help patients at all costs is obvious the moment you walk through the doors and meet the team. The history of the unit is available to read in Spanish along with summaries from all the Barcelona World TB Day conference speakers.

Finally, as a longtime FC Barcelona fan, I was thrilled to visit Camp Nou with Dr. Joan Cayla the day of the victorious Chelsea match, enabling Barça to advance to the quarter finals. The team motto, “mes que un club” (more than a club), was coined to immerse fans into the cultural fabric of the city. This has relevance to the city’s approach to TB elimination: patients, providers, health departments, local and federal agencies are a community united against TB.

Innovation to Achieve WHO Tuberculosis Elimination Goals

WHO recently published the Tuberculosis surveillance and monitoring in Europe 2018 report, which states, “The decreasing notification rates observed in most countries are reassuring, but annual rates of decline are still insufficient to achieve the WHO target of TB elimination by 2050 in European low-incidence countries. To achieve annual decreases of over 10 percent in notification rates, further efforts would be required to address the most vulnerable and hard-to-reach groups.” Expanding services provided by ASPB and Serveis Clinics with new technologies and approaches can help guide effective interventions to engage vulnerable populations.

It will take novel approaches to ensure WHO TB elimination targets are achieved. The speakers at the World TB Day event in Barcelona — as well as the public health leaders caring for people with TB around the city — are leading the charge to introduce innovation.