DISPATCHES

Monitoring Therapy Adherence of

Tuberculosis Patients by using
Video-Enabled Electronic Devices

Alistair Story, Richard S. Garfein, Andrew experience, such as when access to care involves substan-tial
Hayward, Valiantsin Rusovich, Andrei Dadu, travel time, lost earnings, and other patient expenditures;
Viorel Soltan, Alexandru Oprunenco, Kelly when adverse drug reactions are frequent or consequential; or
Collins, Rohit Sarin, Subhi Quraishi, Mukta conversely, when patients feel better and their motivation to
Sharma, Giovanni Battista Migliori, Maithili finish treatment declines (4). For many, treatment is compli-
Varadarajan, Dennis Falzon cated by concomitant health conditions (e.g., HIV/AIDS) and
destabilizing socio-structural factors (e.g., substance abuse,
homelessness, poor health care access). New medicines cur-
A recent innovation to help patients adhere to daily tubercu- rently under study bring renewed hope to TB patients of
losis (TB) treatment over many months is video (or virtually) safer, simpler, and more effective regimens; however, all of
observed therapy (VOT). VOT is becoming increasingly fea-
these treatments still require several months to complete,
sible as mobile telephone applications and tablet computers
making adherence a continuing concern for the future (1).
become more widely available. Studies of the effectiveness of
The need for close, regular contact between caregiv-ers
VOT in improving TB patient outcomes are being conducted.
and TB patients receiving treatment has been long rec-
ognized and remains topical (5) (http://www.who.int/tb/
I n 2014, 1.5 million people globally died from tuberculosis
(TB) (1). Most TB patients are eminently curable by an
post2015_TBstrategy.pdf). Direct observation of treatment
(directly observed therapy, or DOT) was 1 of the 5 compo-
affordable course of treatment, although this treatment cur- nents of the strategy promoted by the World Health Orga-
rently takes a minimum of 6 months to complete and 2 years nization (WHO) and public health advocates to address the
or longer for multidrug-resistant tuberculosis (MDR-TB) (2). global TB emergency declared in the early 1990s (6), (http://
Millions of patients begin TB treatment each year but face
constant challenges to comply with daily medication, caus- www.who.int/tb/dots/whatisdots/en/). Recently, innovative
ing many to adhere inconsistently or to stop prematurely. approaches have been piloted that bridge the gap between
Treatment interruption increases the risk for acquired drug caregiver and patient and limit the cost and stress of frequent
resistance, treatment failure, disease progression, relapse and travel to health centers for DOT. Telephone video communi-
death; it also prolongs transmissibility (3). Loss to medical
follow-up is higher when patients have a negative treatment cation is an example, enabling health professionals to watch
patients take their medication, address patients’ concerns, and
provide advice and support (7,8). Video (or virtually)
Author affiliations: Find & Treat, University College London Hospitals,
observed therapy (VOT) was piloted by using videophones
London, UK (A. Story); University of California San Diego School of
connected to telephone landlines and has more recently
Medicine, La Jolla, California, USA (R.S. Garfein, K. Collins); Farr
evolved toward video-enabled mobile cellular devices. Mo-
Institute of Health Informatics, University College London, London (A.
bile telephones with video applications (smartphones) and
Hayward); World Health Organization Country Office, Minsk, Belarus
tablet computers are becoming increasingly affordable and
(V. Rusovich); World Health Organization (WHO) Regional Office for
Europe, Copenhagen, Denmark
reliable in high- and low-income settings. Furthermore, geo-
graphic coverage of cellular and internet networks is increas-
(A. Dadu); Center for Health Policies and Studies, Chisinau,
ingly available in places where telephone landline services
Moldova (V. Soltan); United Nations Development Programme,
had never existed or are facing obsolescence. Improved ac-
Chisinau (A. Oprunenco); National Institute of TB & Respiratory
cess to the technologies and infrastructure needed for VOT is
Diseases (NITRD), New Delhi, India (R. Sarin); ZMQ, New
foreseeable in both low- and middle-income countries in the
Delhi (S. Quraishi); WHO Country Office, Bangkok, Thailand
coming years. These same countries have the greatest share
(M. Sharma); European Respiratory Society, Lausanne,
of the global burden of TB and drug-resistant TB and are in
Switzerland (G.B. Migliori); WHO Collaborating Centre, Tradate,
urgent need of expanding their treatment programs. VOT
Italy (G.B. Migliori); WHO Global TB Programme, Geneva,
shows promise as a new patient-centered option to support
Switzerland (M. Varadarajan, D. Falzon)
TB patients. It offers patients freedom to take their
DOI: http://dx.doi.org/10.3201/eid2203.151620 medications when and where they choose, and it engenders a
more holistic approach to care.

538 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 22, No. 3, March 2016
 Monitoring Therapy Compliance of TB Patients

Efforts to use VOT for TB patient support are now gain- when patients have to visit TB clinics regularly or to have
ing momentum worldwide (9; http://www.youtube.com/ a DOT observer visit their home or workplace every day,
watch?v=is95C8tgOyo). Studies from the United States and which is culturally inappropriate in many societies and
Mexico show that smartphone VOT is acceptable, can save could aggravate stigma for the patient’s household.
resources, and improves patient commitment to treatment In early 2015, a multi-partner collaboration, led by WHO
even in highly mobile populations (10). In London, United and the European Respiratory Society, started to elaborate target
Kingdom, where DOT is recommended for treatment of product profiles (TPPs) for digital health products fo-cused
patients with multidrug-resistant TB and for other patients in specifically on topical challenges in the implementa-tion of the
unfavorable social circumstances, early findings from an new End TB Strategy (5,13). A TPP describes the characteristics
ongoing trial of VOT against traditional DOT is showing po- and requirements for a particular concept under development to
tential to improve adherence. Reduced costs to patients and help different stakeholders, including developers, define
healthcare providers are expected even when the expense of solutions to address specific problems. Participants in these
providing hardware and cellular data connection to patients discussions define the nature of the problem to be addressed, its
are factored in (11). For example, a smartphone used in this relative priority compared with other pressing needs, and match
study costs less than 1 episode of face-to-face contact with the need to an existing or forthcoming digital solution. Mindful
local community nursing. VOT has been used successfully in of the positive early re-sults, but also the need for appropriate,
TB patients in London since 2007, including among chil- evidence-based guid-ance on its use, the WHO/ERS initiative
dren, who tend to be proficient with this technology. Another has identified VOT as one of the digital tools in support of
trial has started in Moldova, a middle-income former Soviet treatment adherence to be followed closely with a TPP (13). We
Union country in Eastern Europe, to investigate the effec- propose to take forward the TPP of VOT as a collaborative group
tiveness of VOT by using the patient’s desktop computer or a of partners. This process will embrace a broad cross-section of
tablet computer provided by the study (12). A trial has also represen-tative users, developers, and policy makers. If evidence
recently been launched in the United States (by R.S.G.) to for the effectiveness of VOT continues to grow, technical details
compare the efficacy of VOT with traditional DOT for should be elaborated to guide further development and the
monitoring adherence to short-course treatment for latent TB eventual large-scale deployment of VOT. One of these is the
infection. The early promise of VOT has led TB providers in model by which software will be made available, conceiv-ably
Belarus, India, the United States, and elsewhere to start plan- through open-source or socially responsible licensing (14,15).
ning its implementation. Whichever approach is adopted, a sustainable means to enable
VOT should be viewed as a tool to facilitate patient/ VOT interventions worldwide, such as through public funds or
provider contact and not to supplant physical interaction insurance systems, will be needed.
between the patient and the healthcare professional. Pa-
tients would still need to visit clinics to collect
R.S.G. was supported by a National Institutes of Health grant
medication, to submit samples to the laboratory, and for
(U01 AI116392) for the writing of this paper; no other dedicated
assessment of response to treatment. Establishing VOT
financial support was otherwise provided for the other authors.
also requires sound investment, including the training of
A.D., D.F., V.R., M.S., and M. V. were all staff members of
patients and VOT observers.
VOT remains a relatively new and emerging technol- WHO at the time of writing of this paper.
ogy, with limited knowledge about its effectiveness and Dr. Story, the founder and clinical lead of the pan-London Find
limitations. To understand these effects and make the best use & Treat Service, has core expertise in tackling tuberculosis and
of precious public health resources, VOT must be eval-uated other communicable diseases among homeless people, drug
under more diverse conditions and settings to define its and alcohol users, prisoners and destitute migrants. His
function and compare it with other existing or emerging research interests include outreach, integrating point of care
technologies geared for the same purposes within an evolv- diagnostics on the street, case management, and the use of
ing landscape (e.g., short message service [texting] com- mobile internet technologies to promote engagement with
munication and electronic medication monitors). Likewise, health services and treatment continuity.
synergies between digital health and traditional approaches to
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April 2015: Emerging Viruses

Including:
• Reappearance of Chikungunya, Formerly Called Dengue, in the Americas
• Hantavirus Pulmonary Syndrome, Southern Chile, 1995–2012
• Animal-Associated Exposure to Rabies Virus among Travelers, 1997–2012
• Evolution of Ebola Virus Disease from Exotic Infection to Global Health Priority, Liberia,
Mid-2014
• Population Structure and Antimicrobial Resistance of Invasive Serotype IV Group B
Streptococcus, Toronto, Ontario, Canada
• Norovirus Genotype Profiles Associated with Foodborne Transmission, 1999–
2012
• Deaths Associated with Respiratory Syncytial and Influenza Viruses among Persons >5
Years of Age in HIV-Prevalent Area, South Africa
• Sequence Variability and Geographic Distribution of Lassa Virus, Sierra Leone
• Influenza A(H7N9) Virus Transmission between Finches and Poultry
• Highly Pathogenic Avian Influenza A(H5N1) Virus Infection among Workers at Live Bird
Markets, Bangladesh, 2009–2010
• Increased Risk for Group B Streptococcus Sepsis in Young Infants Exposed to HIV,
Soweto, South Africa, 2004–2008

http://wwwnc.cdc.gov/eid/articles/
issue/21/4/table-of-contents

540 Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 22, No. 3, March 2016