Feasibility of focused cardiac ultrasound performed at mid-levels of the health care system in Tanzania

Cardiovascular disease (CVD) remains the No. 1 cause of death globally, and three-quarters of all cardiovascular-related deaths occur within low-and-middle-income countries. The burden of CVDs, a rapidly growing epidemic, has become an increasing public health problem in countries such as Tanzania.     

In 2012, the government of Tanzania, Muhimbili National Hospital, MUSC cardiology and other partners joined forces to establish the Jakaya Kikwete Cardiac Institute (JKCI), which now serves as the national referral center for advanced cardiac care in Tanzania. However, the success of the advanced cardiac care program has brought to light the dire need for strengthening capacity for diagnosis and management of cardiovascular disease at lower tiers of the Tanzania health care system.

Many patients referred to JKCI have either far-advanced diseases with limited options for treatment or mild cardiovascular disease that could be managed at lower levels of the health system in order to best prioritize the use of advanced care resources.  As in many developing countries, Tanzania faces a dual challenge of high rates of CVD and barriers to the accessibility of care, including physician shortages, long travel distances, and lack of equipment at local health care facilities to accurately diagnose or treat cardiovascular disease.

A potential game-changer to address these barriers is the GE Vscan, a pocket-sized, battery-powered, point of care ultrasound, which has the capability to markedly improve diagnostic capabilities in low-resource settings.  It could change the paradigm for cardiovascular care in the Tanzanian region.  Studies have shown point-of-care ultrasounds, such as the VScan, can help enable task-shifting to front line heath care workers – such as clinical officers, nurses, and mid-wives - in low-resource settings, however there is limited literature as to whether this modality could be successfully transferred for detection of cardiovascular disease. 

In this pilot study, Susan Dorman, M.D., an infectious disease-trained physician with 18 years of experience in international research, will investigate the feasibility and efficacy of a point-of-care cardiac ultrasound training program for front-line health care workers in middle tiers of the Tanzanian health care system.  Dorman will be working on this pilot project with MUSC cardiologists Peter Zwerner, M.D., Eric Powers, M.D., and Richard Bayer, M.D., who are part of a team of U.S. cardiologists who have partnered with Tanzanian cardiologist Mohamed Janabi, M.D. over many years to train Tanzanian physicians and build capacity in caring for patients with cardiovascular disease in Tanzania. 

The study team will train clinical officers from district (mid-level) hospitals located in administrative regions bordering Dar es Salaam on how to acquire and interpret basic cardiac ultrasound images using the Vscan. JCKI will serve as the training site.  Knowledge acquisition will be assessed in two different settings – initially in the training facility immediately post-training, and subsequently in the clinical officers’ settings of usual clinical practice. 

 “The Vscan ultrasound tool has been shown to improve outcomes when used for antenatal screening of pregnant women in resource-limited settings,” says Dorman. “We hope to better understand how cardiovascular care can be improved with the use of this tool in Africa and this project will be one of the first times the use of this tool is explored outside of major referral hospitals.” 

This study will be instrumental in helping design future studies focusing on at-risk populations in Tanzania and creating effective strategies for improving uptake and quality of CVD testing.  It is one innovation that has the potential to lay the foundation for changing CVD care practices in resource-limited settings and incorporating new clinical research into ongoing MUSC-associated cardiology clinical care activities in Tanzania.