Doctor, teacher and researcher at the Oswaldo Cruz Foundation (Fiocruz), Margareth Maria Pretti Dalcolmo, whohas carried out a number of projects with the support of Fiotec, recently received a Merit Awardfrom the State of Rio de Janeiro. The award is recognition from the Legislative Assembly of Rio de Janeiro (Alerj) for her personal and professional dedication in favor of the less well-off. She is a specialist in clinical pulmonology, and has dedicated much of her professional life to the study of tuberculosis, especially in research and treatment protocols.
Today, Margaret is a member of the Advisory Committee on Tuberculosis of the Ministry of Health and works at the Professor Hélio Fraga Reference Center (CRHF) of the Oswaldo Cruz Foundation (Fiocruz), of which she was the founder. The Germano Gerhardt ReferenceOutpatient Clinic, CRHF, receives an average of 150 new cases of Multi-drug-resistant tuberculosis every year. In a special interview with the Fiotec interview communications team, the researcher talked about the award that she has received, the difficulties of treating tuberculosis and commented on the importance of Fiotec working in partnership with Fiocruz.
Fiotec: How did it feel to receive the Merit Awardfrom the State of Rio de Janeiro?
Margaret Dalcolmo: At first I was very surprised and accepted the honor as a gesture of generosity, since I currently do not hold political office. Over the last few years, I have collaborated with the School of the Legislative Assembly, chaired by state congressman Gilberto Palmares, who was the one who gave me this award. In addition, the members of the state congress followed the creation of the Hélio Fraga center, which a reference outpatient center for more complex tuberculosis cases and other mycobacterial diseases. I think that this historical background favored them granting me this honor; I received it with emotion and dedicated it to the patients, who are really the most important part of everything that we do.
Fiotec: Why is TB such a dangerous disease?
Margaret Dalcolmo: Tuberculosis is a dangerous disease because it is communicable, and can be transmitted from person to person. In other words, it is human contact that creates the right conditions for transmission, which is related to a number of individual factors (compromised cellular immunity, for example). Tuberculosis is also seen as a disease with a social impact, due to environmental factors influencing transmission, such as housing conditions and sanitation. Rio de Janeiro, for example, is a city where the incidence - 75 per 100,000 inhabitants - is higher than the national average, which is 38 per 100 000 inhabitants. And there are certain areas, such as the Rocinha community, where this rate is three or four times higher and is similar to Asian countries where the incidence is very high.
Fiotec: Why do housing conditions have such a great influence?
Margaret Dalcolmo: Because the interaction between people is much closer. For example: a tiny two-room house that houses five or six people. This is so much the case that when you detect one case of the disease, you don’t only treat that patient. On average four people are examined, including spouses, children and parents. All of them undergo a tuberculin skin test (purified protein derivative or PPD) and a chest X-ray. If the disease is not detected bacteriologically, by X-rays or PPD, we have the option of doing prophylaxis, which is what we call latent tuberculosis. This is the same one that we, the health workers, take. The person takes one of the drugs to combat tuberculosis for six months, but doesn’t do the complete treatment.
Fiotec: When was the Germano Gerhardt Reference Outpatient Clinic of the Professor Hélio Fraga Reference Center established?
Margaret Dalcolmo: In 1995 we started a protocol to validate a "standard" scheme, standardized throughout Brazil, for treating resistant forms of tuberculosis. Wetested the protocol here in Rio de Janeiro and other Brazilian states (Bahia, Pará, São Paulo and Rio Grande do Sul)for five years. In 2000, the Ministry of Health recognized this scheme, and then we needed a suitable place to actually act as a secondary and tertiary reference for patients in Rio. So, we created this place, which was not yet fitted with a biosecurity system like nowadays. Alongside this, the Hélio Fraga center, under a technical cooperation agreement with a U.S. NGO, created an epidemiological surveillance and monitoring system in Brazil. This was what I call the process of expansion of the outpatient clinic, which today has been incorporated into Fiocruz and is a model that should be followed. It has been decentralized and there are currently two other reference outpatient clinics in the city. All patients are seen according to where they live.
Fiotec: What characterizes the most complex cases of tuberculosis?
Margaret Dalcolmo: These are cases that the Unified Health System (SUS) network is not able to resolve, because they require a more complex approach. Patients with HIV who require special treatment, different from the standard, patients who have undergone organ transplants and have suppressed immunity due to the use of anti-rejection drugs, very elderly patients and children. In other words, all those that are out of the ordinary and cannot be treated with the fixed-dose combination of four drugs that make up the standard treatment regimen for tuberculosis in Brazil. In addition to these cases, there is a group of other mycobacterial disease-causing organisms that are classified as emerging in Brazil. We have improved our database and cases are reported and tracked from the time the patient initiates treatment until they are discharged, either here or in any other reference outpatient clinic in Brazil.
Fiotec: What is the importance of an interdisciplinary approach in treating complex tuberculosis cases?
Margaret Dalcolmo: The treatment of complex cases is not the same as the standard treatment, which lasts six months. Patients with resistant tuberculosis cases will undergo treatment for 18-24 months and remain in treatment for at least another three or four years. This requires an interdisciplinary team consisting of physicians, nurses, social workers, technicians and researchers, who are able to adequately accommodate a patient of such complexity.
Fiotec: What is the role of Fiotec in supporting development of the projects?
Margaret Dalcolmo: At first, we obtained considerable funding from the Ministry of Health to finance 12 subprojects developed by various researchers in Brazil, under our coordination. All these studies, including studies of communities, in the basic area, teaching in the area of tuberculosis, among others, have been completed. Without the support of Fiotec, their implementation would have been impossible. Fiocruz, by providing us researchers with an institution like Fiotec, allows us to provide for proper transparency in the management of projects. Fiotec also has an important role in alerting us about the points that often we researchers do not pay much attention to because we are more concerned with issues of a scientific, technical and academic nature. Moreover, today it is much easier to raise funds in an international institution, because we have the support of Fiotec in the financial management of projects. Therefore, its existence is undoubtedly valuable.
