To DOTS and Beyond: Can Digital Solutions Turn the Tide for TB?
By Arin Dutta and Denise Silfverberg, HP+
As the world grapples with the COVID-19 pandemic — and expands measures of social distancing and quarantine — we are reminded of another disease that has long capitalized on humanity living in close quarters. Tuberculosis (TB) has been with humanity for a very long time. Over the last century we have deployed weapons against it in the form of improved antibiotics and diagnostic methods. In turn, it has developed its own adaptations, threatening to roll back some of our gains. In this “digital century” it is time that we expand the use of new tools to combat pathogens like COVID-19 and TB.
What’s Meant by Digital?
Digital refers to the set of technologies that allow for the generation, storage, and transmission of data — often in very large quantities — as well technologies that enable the manipulation, analysis, and swift use of such data. Data are now generated at the individual level in unprecedented ways, through our use of a variety of devices — mobile phones, laptops, tablets, e-readers — and our routine use of the Internet and mobile communication. Services that were previously entirely enabled through paper or partially electronic systems are now available via digital means, including medical and financial services. The expansion of the number of people with a digitally linked device and the ability of these devices to store, process, receive, and transmit data form the basis for an ongoing digital revolution. It is commonly suggested that this transformation is an opportunity in infectious disease control.
On this World Tuberculosis Day, we are in the midst of implementing programs to reach renewed United Nations goals for ending the global TB epidemic. One of the goals — to treat 7 million of the approximately 10 million TB cases annually — was met in 2018. But the world must pick up the pace to further meet the goal of treating 40 million TB cases between 2018 and 2022. Some of the goals for 2020 set in the World Health Organization’s “End TB Strategy” are unlikely to be met. Simply stated, the world is not reducing the incidence of TB fast enough outside of Europe, and connected to this, the number of TB deaths is not falling fast enough. Reducing incidence is difficult and requires a major investment in prevention, including TB preventive treatment. Expanding this will take renewed effort and is a priority for countries with a high HIV burden, the most significant co-morbid disease with TB. In the meantime, we must identify and treat all cases in order to meet the goal of reducing TB deaths by 35 percent by 2020 (from 2015). In 2018, the reduction was only at 11 percent.
Digital Solutions for Identifying Tuberculosis Cases
Digital solutions can help tackle some of the key challenges around TB identification.
Presumptive TB cases not referred for diagnostic testing
In low-income countries, especially in crowded urban areas, many people with severe coughs or chest pain seek medicine and advice from local pharmacists or drug shops. Instead of being referred for TB testing they are often misdiagnosed and sent home with antibiotics, which have limited efficacy in TB treatment and can worsen antibiotic resistance. One solution would be to incentivize these first-contact providers to refer suspected TB cases for testing. But how?
One option is to make it easier to screen and refer clients. Some digital tools, currently available for Android platforms, solve this problem. Currently in use in Nigeria, MATS (Mobile App for TB Screening) allows better in-facility referral of presumptive cases and could be expanded to the small-scale private sector for screening. Also in Nigeria, the TB-STARR app is focused on small private pharmacies and medicine vendors who use the app to screen and refer a client. The app also provides a clinically approved guide to conducting proper screening, based on symptoms, prior to referral.
Another option is to pay incentives to private providers to screen and refer clients, especially those confirmed to be infected. Paying incentives could be simplified by digital means. In Nigeria, with Global Fund grant support, national TB program implementers are paying an incentive (ranging from US$5 to $13) to private pharmacies, drug vendors, and community health extension workers for referring suspected TB cases who are later confirmed as infected via a diagnostic test. In addition, fees are paid to motorbike riders who pick up sputum (phlegm from the lungs) samples from providers and take them to an appropriate laboratory. The process of paying these incentives and fees, and tracking the process, could be simplified by using digital financial services, while avoiding cumbersome paper receipt trails and improving verification. A comprehensive digital app, extending the capability of the screening tools mentioned above, and linked to Nigeria’s rising mobile money and e-wallet platforms, has the promise of closing the loop on TB screening, referral, and sample transport.
In certain programs, based on feasibility, home pick-up of sputum and digital transmission of diagnostic results could be offered. If positive, a first batch of prescribed drugs could be sent to the client’s home, while maintaining contact digitally with a health worker, as discussed later. Such remote options have value when health systems impose social distancing or quarantine controls for other reasons.
Chest x-rays are still needed for screening and diagnosis, but use a lot of health system resources
X-ray machines are still expensive to install across the primary care level in low- and lower-middle-income countries in Africa and Asia. Yet they are a valuable tool, especially for diagnosing childhood TB. Reducing the ongoing cost of using the machines would increase their availability for TB. Digital chest X-ray technology, coupled with free software (NIOSH BViewer), reduces the ongoing cost of X-ray use, as this method requires no film to develop an image. More importantly, where trained radiologists and clinicians are in short supply, computer algorithms can provide initial diagnoses and accelerate decisions about the most appropriate course of action. Digital files can be transmitted to a remote computer or evaluated onsite. This technology is already in use in Zambia and South Africa.
Digital Solutions for Increasing Success in Treating TB Patients
Failure to successfully complete a course of TB treatment can be costly, for the patient and for the public health system. The longstanding directly observed therapy, short-course, or DOTS model, in its variations, intends to assure the completion of first-line treatment as per guidelines, with as much interaction of the patient and provider as is possible. To understand the potential for digital solutions, it’s important to understand the process. During the two-month “intensive phase,” patients are expected to be seen daily to take large, fixed-dose combination pills with up to four antibiotic agents. This is followed by a six-month “continuation phase,” where patients can largely self-administer a new medicine regimen, picking up their drugs monthly (or as required by the program). For certain patients, such as those being retreated, they may be called in to the health facility multiple times a week even in the continuation phase.
The DOTS model was instituted in 1991 to improve adherence for the entire course of treatment. However, there is evidence that DOTS is facing challenges outperforming other ways of managing cases. Visiting providers is burdensome for patients, who incur transport costs and missed work due to time spent visiting facilities. Such visits also lead to crowded outpatient departments and overburdened staff. Yet, the consequences of poor adherence are severe for patients and the health system. If treatment fails, or a patient relapses into active infection after incomplete treatment, the cost of the antibiotic regimen immediately increases up to three times.
Failure to treat successfully also leads to drug resistance. Of the half-million cases of drug-resistant TB in 2018, almost 80 percent were resistant to more than one of the standard antibiotics used in first-line treatment. Addressing the causes of such resistance is a major public health priority in countries with a high TB burden. Increasing the spread of resistance and its deepening (more antibiotics failing) would set up a pernicious cycle, where even never-infected individuals contract a resistant strain from the get-go, and the average cost of treating a patient increases significantly for the whole program.
Need to increase TB treatment adherence without increasing the burden on patients or healthcare staff
Community-based DOTS has been used as an effective alternative, or complement, to facility-based DOTS for some time and uses outreach workers to reduce the burden of clinical visits for the patient and the health system. However, it is limited in its scale by the availability of outreach workers. Digital adherence technologies include the use of telemedicine for case management in place of in-person visits. With 4G mobile networks putting improved connectivity in the hands of the average person in Africa and Asia, voice and video calls, possibly recorded at different times to allow for any connectivity issues, can be linked within a treatment management app to enable check-ins with health workers (or community workers). The video observed therapy (VOT) approach is in use in several countries and proved to be more effective in one high-income country setting.
While regular check-ins with a health worker may promote adherence and help anticipate and address issues that could occur during the course of treatment, it cannot guarantee adherence. Sending text messages as reminders may partially help. When telemedicine is unavailable, or the patient cannot use VOT, other options are available. Electronic medication monitoring (EMM), one of the World Health Organization’s recommended solutions, uses a pillbox linked to a device that records when the container is opened. Different options exist, from “smart pillboxes” that can send data via text messages to pillboxes paired with a device that uploads data when the user connects to the Internet. All of these allow health workers to remotely monitor adherence. In China, the additional cost of EMM per patient was only US$5. A benefit of EMM is that it allows more targeted use of facility-based DOTS. A self-administering patient can be proactively switched to clinical visits if they are found to be failing adherence.
There is More in the Digital Landscape for Tuberculosis Control
Digital technologies are contributing to the overall use of differentiated service delivery approaches for infectious disease case management, which recognize that a one-size-fits-all approach should not be the standard. Building on longstanding investments in better health information and logistical management systems, more data are collected and used today in every step of the TB service delivery continuum — from identifying a case to successfully treating it. Even further digital integration will allow for facility- and program-level managers to adapt and change service design to improve outcomes for the patient and, as a result, for the whole response.
As new diagnostic technologies are introduced for TB — and linked to connected devices — rapid transmission of diagnostic data and improved clinical decision-making, alongside patient-centered care, will become routine. Patients will increasingly find managing their own care using their devices and remotely linking with healthcare providers a matter of course. The question then is no longer, “How can digital technology be used innovatively in tuberculosis control?” But rather, “How can tuberculosis control be fully integrated and succeed in an already digital world?”