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Mukooza E, Schausberger B, Mmema N, Dlamini V, Aung A, Kerschberger B, Ciglenecki I, Vambe D, Wringe A. Understanding the role of video direct observed therapy for patients on an oral short-course regimen for multi-drug resistant tuberculosis: findings from a qualitative study in Eswatini. BMC Infect Dis 2024; 24:829. [PMID: 39148081 PMCID: PMC11325818 DOI: 10.1186/s12879-024-09744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 08/09/2024] [Indexed: 08/17/2024] Open
Abstract
BACKGROUND Improving treatment success rates among multi drug-resistant tuberculosis (MDR-TB) patients is critical to reducing its incidence and mortality, but adherence poses an important challenge. Video-based direct observed therapy (vDOT) may provide adherence benefits, while addressing the time and cost burden associated with community treatment supporter (CTS)-DOT. This study explored experiences of patients, family members and healthcare workers with different DOT modalities for adherence support in Eswatini. METHODS Between April 2021 and May 2022, thirteen men and five women with MDR-TB, ten healthcare workers, and nine caregivers were purposively sampled to include a range of characteristics and experiences with DOT modalities. Data were generated through individual in-depth interviews and a smartphone messaging application (WhatsApp). Data coding was undertaken iteratively, and thematic analysis undertaken, supported by Nvivo. RESULTS Four themes emerged that reflected participants' experiences with different DOT modalities, including stigma, efficiency, perceived risks of TB acquisition, and patient autonomy. vDOT was appreciated by patients for providing them with privacy and shielding them from stigmatisation associated with being seen in TB clinics or with community treatment supporters. vDOT was also seen as more efficient than CTS-DOT. Health workers acknowledged that it saved time, allowing them to attend to more patients, while many patients found vDOT more convenient and less expensive by removing the need to travel for in-person consultations. Health workers also appreciated vDOT because it reduced risks of TB acquisition by minimising exposure through virtual patient monitoring. Although many patients appreciated greater autonomy in managing their illness through vDOT, others preferred human contact or struggled with making video recordings. Most family members appreciated vDOT, although some resented feeling removed from the process of supporting loved ones. CONCLUSIONS vDOT was generally appreciated by MDR-TB patients, their family members and health workers as it addressed barriers to adherence which could contribute to improved treatment completion rates and reduced workplace exposure. However, patients should be offered an alternative to vDOT such as CTS-DOT if this modality does not suit their circumstances or preferences.
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Affiliation(s)
- Esther Mukooza
- Médecins sans Frontières (OCG), P.O.Box 325, Mantsholo Road, Mbabane, Eswatini.
| | | | - Nqobile Mmema
- Médecins sans Frontières (OCG), P.O.Box 325, Mantsholo Road, Mbabane, Eswatini
| | - Velibanti Dlamini
- Médecins sans Frontières (OCG), P.O.Box 325, Mantsholo Road, Mbabane, Eswatini
| | - Aung Aung
- Médecins sans Frontières (OCG), P.O.Box 325, Mantsholo Road, Mbabane, Eswatini
| | | | | | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Alison Wringe
- London School of Hygiene and Tropical Medicine (LSHTM), London, UK
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Kerschberger B, Daka M, Shongwe B, Dlamini T, Ngwenya S, Danbakli C, Mamba B, Nxumalo B, Sibanda J, Dube S, Dlamini LM, Mabhena E, Mukooza E, Crumley I, Ciglenecki I, Vambe D. The introduction of video-enabled directly observed therapy (video-DOT) for patients with drug-resistant TB disease in Eswatini amid the COVID-19 pandemic - a retrospective cohort study. BMC Health Serv Res 2024; 24:699. [PMID: 38831356 PMCID: PMC11145825 DOI: 10.1186/s12913-024-11151-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Accepted: 05/28/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND Video-enabled directly observed therapy (video-DOT) has been proposed as an additional option for treatment provision besides in-person DOT for patients with drug-resistant TB (DRTB) disease. However, evidence and implementation experience mainly originate from well-resourced contexts. This study describes the operationalization of video-DOT in a low-resourced setting in Eswatini facing a high burden of HIV and TB amid the emergence of the COVID-19 pandemic. METHODS This is a retrospectively established cohort of patients receiving DRTB treatment during the implementation of video-DOT in Shiselweni from May 2020 to March 2022. We described intervention uptake (vs. in-person DOT) and assessed unfavorable DRTB treatment outcome (death, loss to care) using Kaplan-Meier statistics and multivariable Cox-regression models. Video-related statistics were described with frequencies and medians. We calculated the fraction of expected doses observed (FEDO) under video-DOT and assessed associations with missed video uploads using multivariable Poisson regression analysis. RESULTS Of 71 DRTB patients eligible for video-DOT, the median age was 39 (IQR 30-54) years, 31.0% (n = 22) were women, 67.1% (n = 47/70) were HIV-positive, and 42.3% (n = 30) were already receiving DRTB treatment when video-DOT became available. About half of the patients (n = 37; 52.1%) chose video-DOT, mostly during the time when COVID-19 appeared in Eswatini. Video-DOT initiations were lower in new DRTB patients (aHR 0.24, 95% CI 0.12-0.48) and those aged ≥ 60 years (aHR 0.27, 95% CI 0.08-0.89). Overall, 20,634 videos were uploaded with a median number of 553 (IQR 309-748) videos per patient and a median FEDO of 92% (IQR 84-97%). Patients aged ≥ 60 years were less likely to miss video uploads (aIRR 0.07, 95% CI 0.01-0.51). The cumulative Kaplan-Meier estimate of an unfavorable treatment outcome among all patients was 0.08 (95% CI 0.03-0.19), with no differences detected by DOT approach and other baseline factors in multivariable analysis. CONCLUSIONS Implementing video-DOT for monitoring of DRTB care provision amid the intersection of the HIV and COVID-19 pandemics seemed feasible. Digital health technologies provide additional options for patients to choose their preferred way to support treatment taking, thus possibly increasing patient-centered health care while sustaining favorable treatment outcomes.
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Affiliation(s)
| | | | | | | | | | | | - Bheki Mamba
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | - Joyce Sibanda
- National TB Control Programme (NTCP), Manzini, Eswatini
| | - Sisi Dube
- National TB Control Programme (NTCP), Manzini, Eswatini
| | | | | | | | | | | | - Debrah Vambe
- National TB Control Programme (NTCP), Manzini, Eswatini
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Chen EC, Owaisi R, Goldschmidt L, Maimets IK, Daftary A. Patient perceptions of video directly observed therapy for tuberculosis: a systematic review. J Clin Tuberc Other Mycobact Dis 2024; 35:100406. [PMID: 38380432 PMCID: PMC10877938 DOI: 10.1016/j.jctube.2023.100406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024] Open
Abstract
Virtual modes of tuberculosis (TB) treatment monitoring have become increasingly relevant in the last decade with the advancements and increasing accessibility of technology. We conducted a systematic review comparing people with TB's perceptions of standard directly observed therapy (DOT) versus video directly observed therapy (vDOT). Studies were obtained from MEDLINE and EMBASE between January 1, 1974 and February 4, 2021. Of the 22 articles reviewed, a qualitative thematic analysis was performed, drawing on common themes from people with TB's perception of their care. 21 studies showed relative preference for and acceptance of vDOT over DOT. Factors that increased acceptability toward vDOT included cost and time saving, personal sense of empowerment, convenience, and privacy. Studies also showed greater adherence to treatment and subsequent improved health outcomes. vDOT has the potential to be an empowering, person-centered treatment modality for TB therapy. The role of social determinants such as place of residence, access to technology, and patient-provider communication requires further exploration.
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Affiliation(s)
- En Chi Chen
- Dahdaleh Institute of Global Health Research, York University, 88 The Pond Rd Suite 2150, North York, ON M3J 2S5, Canada
- Cumming School of Medicine, University of Calgary, 3330 Hospital Dr NW, Calgary, AB T2N 4N1, Canada
| | - Rumia Owaisi
- Dahdaleh Institute of Global Health Research, York University, 88 The Pond Rd Suite 2150, North York, ON M3J 2S5, Canada
- School of Global Health, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada
| | - Leah Goldschmidt
- Dahdaleh Institute of Global Health Research, York University, 88 The Pond Rd Suite 2150, North York, ON M3J 2S5, Canada
- School of Global Health, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada
| | - Ilo-Katryn Maimets
- Steacie Science and Engineering Library, York University, 136 Campus Walk, North York, ON M3J 1P3, Canada
| | - Amrita Daftary
- Dahdaleh Institute of Global Health Research, York University, 88 The Pond Rd Suite 2150, North York, ON M3J 2S5, Canada
- School of Global Health, York University, 4700 Keele Street, Toronto, ON M3J 1P3, Canada
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, Durban 4001, South Africa
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Garfein RS, Liu L, Cepeda J, Graves S, San Miguel S, Antonio A, Cuevas-Mota J, Mercer V, Miller M, Catanzaro DG, Rios P, Raab F, Benson CA. Asynchronous Video Directly Observed Therapy to Monitor Short-Course Latent Tuberculosis Infection Treatment: Results of a Randomized Controlled Trial. Open Forum Infect Dis 2024; 11:ofae180. [PMID: 38665171 PMCID: PMC11045025 DOI: 10.1093/ofid/ofae180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
Background Observing medication ingestion through self-recorded videos (video directly observed therapy [VDOT]) has been shown to be a cost-effective alternative to in-person directly observed therapy (DOT) for monitoring adherence to treatment for tuberculosis disease. VDOT could be a useful tool to monitor short-course latent tuberculosis infection (LTBI) treatment. Methods We conducted a prospective randomized controlled trial comparing VDOT (intervention) and clinic-based DOT (control) among patients newly diagnosed with LTBI who agreed to a once-weekly 3-month treatment regimen of isoniazid and rifapentine. Study outcomes were treatment completion and patient satisfaction. We also assessed costs. Pre- and posttreatment interviews were conducted. Results Between March 2016 and December 2019, 130 participants were assigned to VDOT (n = 68) or DOT (n = 62). Treatment completion (73.5% vs 69.4%, P = .70) and satisfaction with treatment monitoring (92.1% vs 86.7%, P = .39) were slightly higher in the intervention group than the control group, but neither was statistically significant. VDOT cost less per patient (median, $230; range, $182-$393) vs DOT (median, $312; range, $246-$592) if participants used their own smartphone. Conclusions While both groups reported high treatment satisfaction, VDOT was not associated with higher LTBI treatment completion. However, VDOT cost less than DOT. Volunteer bias might have reduced the observed effect since patients opposed to any treatment monitoring could have opted for alternative unobserved regimens. Given similar outcomes and lower cost, VDOT may be useful for treatment monitoring when in-person observation is prohibited or unavailable (eg, during a respiratory disease outbreak). The trial was registered at the National Institutes of Health (ClinicalTrials.gov NTC02641106). Clinical Trials Registration ClinicalTrials.gov NTC02641106; registered 24 October 2016.
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Affiliation(s)
- Richard S Garfein
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
| | - Lin Liu
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - Javier Cepeda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Susannah Graves
- Tuberculosis Control and Refugee Health Branch, San Diego County Health and Human Services Agency, San Diego, California, USA
| | - Stacie San Miguel
- Student Health Services, University of California, San Diego, California, USA
| | - Antonette Antonio
- Tuberculosis Control and Refugee Health Branch, San Diego County Health and Human Services Agency, San Diego, California, USA
| | - Jazmine Cuevas-Mota
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - Valerie Mercer
- Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, California, USA
| | - McKayla Miller
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
| | - Donald G Catanzaro
- Department of Biological Sciences, University of Arkansas, Fayetteville, Arkansas, USA
| | - Phillip Rios
- Qualcomm Institute, Calit2, San Diego Division, University of California, San Diego, California, USA
| | - Fredric Raab
- Qualcomm Institute, Calit2, San Diego Division, University of California, San Diego, California, USA
| | - Constance A Benson
- Division of Infectious Disease and Global Public Health, School of Medicine, University of California, San Diego, California, USA
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Wang X, Fu Q, Zhou M, Li Y. How Integrated Digital Tools Can Improve Tuberculosis Medication Adherence: A Longitudinal Study in China. Telemed J E Health 2024; 30:490-498. [PMID: 37498525 DOI: 10.1089/tmj.2023.0084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
Background: Poor medication adherence remains one of the major problems in the treatment of tuberculosis (TB) patients, while digital technologies have been proven effective to improve the treatment results. However, reports on the effectiveness of comprehensive practice integrating different intervention methods and technologies are limited. The aim of this study is to evaluate the effectiveness of an integrated digital adherence intervention for TB patients. Methods: We developed a digital adherence intervention platform integrating instant WeChat message, electronic medication monitors (EMMs), and manual reminders. The primary goal of the platform was to improve the accessibility of digital adherence technologies, and thus improve treatment adherence. TB patients were newly diagnosed at 10 TB-designated hospitals and came from 220 communities, from January to June 2022. The basic characteristics and treatment adherence of TB patients in WeChat, EMM, and conventional groups were compared, and the influencing factors of high medication adherence were analyzed by logistic regression. Results: A total of 2,498 TB patients were enrolled in the study, 14.5% were managed by digital technologies, 9.5% by WeChat, and 5.0% by EMM, respectively. After intervention, the median medication rate of TB patients was significantly higher in the WeChat group (95.3%) and EMM group (95.7%) compared with that of the conventional group (83.8%). On the contrary, the median number of missed medications among patients of the conventional group (nine times) was significantly higher than that in the WeChat (three times) group and EMM (three times) group. The proportion of high adherence (adherence medication rate ≥90%) among TB patients was 64.7%, 64.5%, and 43.2% in WeChat, EMM, and conventional group, respectively. Conclusions: The application of the integrated digital adherence intervention platform could significantly improve medication adherence among TB patients. The accessibility of digital adherence technologies could be improved by integrating complementary technologies in practice.
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Affiliation(s)
- Xiaojun Wang
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Qian Fu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Meilan Zhou
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
| | - Yuehua Li
- Wuhan Institute for Tuberculosis Control, Wuhan Pulmonary Hospital, Wuhan, China
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Abas SA, Ismail N, Zakaria Y, Yasin SM, Ibrahim K, Ismail I, Razali A, Sherzkawi MA, Ahmad N. Enhancing tuberculosis treatment adherence and motivation through gamified real-time mobile app utilization: a single-arm intervention study. BMC Public Health 2024; 24:249. [PMID: 38254065 PMCID: PMC10801941 DOI: 10.1186/s12889-023-17561-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/21/2023] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Finding innovative methods to enhance Tuberculosis treatment adherence in Malaysia is imperative, given the rising trend of non-adhere TB patients. Direct Observed Therapy (DOTS) has been used to ensure Tuberculosis (TB) drug compliance worldwide. However, due to its inconvenience, digitalizing this system into a virtual monitoring system via a mobile app can help deliver a more efficient tuberculosis management system. A gamified video-observed therapy is developed that connects three users the patient, supervisor, and administrator, allowing drug monitoring and patient loss to follow up with the patient tracking system. Thus, the objective of this study is to determine the impact of Gamified Real-time Video Observed Therapy (GRVOTS) mobile apps on patient medication adherence rates and motivation. METHODS 71 patients from 18 facilities participated in the 8-week single-arm intervention study. GRVOTS mobile apps were installed in their mobile apps, and patients were expected to fulfill tasks such as providing Video Direct Observe Therapy (VDOTS) daily as well as side effect reporting. At 3-time intervals of baseline,1-month, and 2-month intervals, the number of VDOT taken, the Malaysian Medication Adherence Assessment Tool (MyMAAT), and the Intrinsic Motivation Inventory (IMI) questionnaire were collected. One-sample t-test was conducted comparing the VDOT video adherence to the standard rate of 80%. RM ANOVA was used to analyze any significant differences in MyMAAT and IMI scores across three-time intervals. RESULTS This study involved 71 numbers of patients from 18 healthcare facilities who showed a significantly higher treatment adherence score of 90.87% than a standard score of 80% with a mean difference of 10.87(95% CI: 7.29,14.46; p < 0.001). The participants' MyMAAT and IMI scores significantly increased over 3-time intervals with the IMI Interest domain showing the highest mean difference 19.76 (95% CI: 16.37, 21.152: p < 0.001). CONCLUSIONS By utilizing GRVOTS, a mobile application based on gamification and real-time features, we can enhance motivation and medication adherence among TB patients, while also addressing the limitations of physical DOTS. TRIAL REGISTRATION IRCT20230308057657N1, Registered on (15/03/23).
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Affiliation(s)
- Siti Aishah Abas
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Sungai Buloh, Selangor, 47000, Malaysia
| | - Nurhuda Ismail
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Sungai Buloh, Selangor, 47000, Malaysia.
| | - Yuslina Zakaria
- Department of Pharmaceutical Life Sciences, Faculty of Pharmacy, Universiti Teknologi MARA Puncak Alam Campus, Puncak Alam, Selangor, 42300, Malaysia
| | - Siti Munira Yasin
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Sungai Buloh, Selangor, 47000, Malaysia
| | - Khalid Ibrahim
- Department of Public Health Medicine, Faculty of Medicine, Universiti Teknologi MARA Sungai Buloh Campus, Sungai Buloh, Selangor, 47000, Malaysia
| | - Ismassabah Ismail
- Centre of Foundation Studies, Universiti Teknologi MARA Cawangan Selangor, Kampus Dengkil, Dengkil, Selangor, 43800, Malaysia
| | - Asmah Razali
- Disease Control Division, Sector TB/Leprosy, Ministry of Health, Putrajaya, 62590, Malaysia
| | - Mas Ahmad Sherzkawi
- TB/Leprosy Disease Unit, Selangor State Health Department, Seksyen 9, Shah Alam, Selangor, 40100, Malaysia
| | - Norliza Ahmad
- TB/Leprosy Disease Unit, Negeri Sembilan State Health Department, Jalan Rasah, Bukit Rasah, Negeri Sembilan, Seremban, 70300, Malaysia
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Dirks LK, Bircher PM, González-Montalvo MDM, Kauffman AE, Prophete EJ, Bury MR, Spaulding AC. Video Directly Observed Therapy for Tuberculosis Treatment in Haitian Prisons: A Pattern of Group Adherence. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.12.29.23299977. [PMID: 38234774 PMCID: PMC10793512 DOI: 10.1101/2023.12.29.23299977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
Classification Research paper. Purpose Haitian provincial prisons historically were strapped to provide directly observed therapy (DOT) for persons with TB (PwTB) due to healthcare understaffing. A non-governmental organization addressed this gap via correctional officer-administered video DOT (VDOT). Approach A 16-month, quasi-experimental trial of officer-facilitated VDOT started in March 2019 at four prisons. Officers delivered doses directly without video when VDOT was inaccessible. Healthcare staff remotely tracked VDOT adherence asynchronously. Three fully-staffed prisons were controls. Our primary objective was to measure VDOT effectiveness for PwTB who began VDOT within 2 weeks of starting treatment. Our secondary objective was to measure program reach, implementation and maintenance through July 2023. Findings Reach-55 PwTB on VDOT met study criteria. Effectiveness: median/mean VDOT adherence for 55 individuals enrolled in the pilot were 70.8% and 60.2% respectively. Median/mean total adherence, including doses delivered by officers, were 100% and 93.5%. Implementation: VDOT adherence varied by site but not demographic characteristics; similarity of adherence patterns between subjects within a facility was high. Nursing staff reported that adherence in controls was 100%. Correctional officers reported high comfort with the program technology. Maintenance: Since the pilot, 387 PwTB have received TB medications via VDOT in the Haitian prison system. Originality VDOT for PwTB in low-resource Haitian prisons enabled close monitoring and follow-up; it could expand treatment options elsewhere. Total adherence neared that in control prisons. VDOT adherence varied by treatment day predominately in a group pattern, reflecting facility-level, rather than individual-level, factors.
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Sekandi JN, McDonald A, Nakkonde D, Zalwango S, Kasiita V, Kaggwa P, Kakaire R, Atuyambe L, Buregyeya E. Acceptability, Usefulness, and Ease of Use of an Enhanced Video Directly Observed Treatment System for Supporting Patients With Tuberculosis in Kampala, Uganda: Explanatory Qualitative Study. JMIR Form Res 2023; 7:e46203. [PMID: 37948121 PMCID: PMC10674141 DOI: 10.2196/46203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 10/12/2023] [Accepted: 10/14/2023] [Indexed: 11/12/2023] Open
Abstract
BACKGROUND In tuberculosis (TB) control, nonadherence to treatment persists as a barrier. The traditional method of ensuring adherence, that is, directly observed therapy, faces significant challenges that hinder its widespread adoption. Digital adherence technologies such as video directly observed therapy (VDOT) are emerging as promising solutions. However, as these novel technologies gain momentum, a critical gap is the lack of comprehensive studies evaluating their efficacy and the unique experiences of patients in Africa. OBJECTIVE The aim of this study was to assess patients' experiences that affected acceptability, usefulness, and ease of use with an enhanced VDOT system during monitoring of TB treatment. METHODS We conducted individual open-ended interviews in a cross-sectional exit qualitative study in Kampala, Uganda. Thirty participants aged 18-65 years who had completed the VDOT randomized trial were purposively selected to represent variability in sex, adherence level, and HIV status. We used a hybrid process of deductive and inductive coding to identify content related to the experience of study participation with VDOT. Codes were organized into themes and subthemes, which were used to develop overarching categories guided by constructs adapted from the modified Technology Acceptance Model for Resource-Limited Settings. We explored participants' experiences regarding the ease of use and usefulness of VDOT, thereby identifying the facilitators and barriers to its acceptability. Perceived usefulness refers to the benefits users expect from the technology, while perceived ease of use refers to how easily users navigate its various features. We adapted by shifting from assessing perceived to experienced constructs. RESULTS The participants' mean age was 35.3 (SD 12) years. Of the 30 participants, 15 (50%) were females, 13 (43%) had low education levels, and 22 (73%) owned cellphones, of which 10 (45%) had smartphones. Nine (28%) were TB/HIV-coinfected, receiving antiretroviral therapy. Emergent subthemes for facilitators of experienced usefulness and ease of VDOT use were SMS text message reminders, technology training support to patients by health care providers, timely patient-provider communication, family social support, and financial incentives. TB/HIV-coinfected patients reported the added benefit of adherence support for their antiretroviral medication. The external barriers to VDOT's usefulness and ease of use were unstable electricity, technological malfunctions in the app, and lack of cellular network coverage in rural areas. Concerns about stigma, disease disclosure, and fear of breach in privacy and confidentiality affected the ease of VDOT use. CONCLUSIONS Overall, participants had positive experiences with the enhanced VDOT. They found the enhanced VDOT system user-friendly, beneficial, and acceptable, particularly due to the supportive features such as SMS text message reminders, incentives, technology training by health care providers, and family support. However, it is crucial to address the barriers related to technological infrastructure as well as the privacy, confidentiality, and stigma concerns related to VDOT.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Adenike McDonald
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda
- Directorate of Public Health Services and Environment, Kampala Capital City Authority, Kampala, Uganda
| | - Vicent Kasiita
- Infectious Disease Institute, Makerere University, Kampala, Uganda
| | - Patrick Kaggwa
- Department of Epidemiology and Biostatistics, University of Georgia, Athens, GA, United States
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Robert Kakaire
- Global Health Institute, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
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Sejie GA, Mahomed OH. Mapping the effectiveness of the community tuberculosis care programs: a systematic review. Syst Rev 2023; 12:135. [PMID: 37537689 PMCID: PMC10399107 DOI: 10.1186/s13643-023-02296-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 07/26/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Tuberculosis is a significant global public health threat, especially in countries with limited resources. To improve tuberculosis care, the World Health Organization emphasizes the importance of considering a TB patient's journey across a variety of connected settings and facilities. A systematic review was conducted to map previously conducted studies to identify existing community TB implementation models, their effectiveness on cost, and treatment outcomes. METHODS Systematic search through various electronic databases MEDLINE, EBSCO (PsycINFO and CINAHL), Cochrane Library, EMBASE, WHO Regional Databases, gray literature, and hand-searched bibliographies was performed. Articles published in English between the years 2000 and 2022 with a substantial focus on community TB implementation models were considered for inclusion. Studies were excluded if the intervention was purely facility-based and those focusing exclusively on qualitative assessments. Two reviewers used standardized methods to screen titles, abstracts, and data charting. Included studies were assessed for quality using ROBINS-I and ROB 2. Analysis of study results uses a PRISMA flow diagram and quantitative approach. RESULTS A total of 6982 articles were identified with 36 meeting the eligibility criteria for analysis. Electronic medication monitors showed an increased probability of treatment success rate (RR 1.0-4.33 and the 95% CI 0.98-95.4) in four cohort studies in low- and middle-income countries with the incremental cost-effectiveness of $434. Four cohort studies evaluating community health worker direct observation therapy in low- and middle-income countries showed a treatment success risk ratio of up to 3.09 with a 95% CI of 0.06-7.88. (32,41,43,48) and incremental cost-effectiveness up to USS$410. Moreover, four comparative studies in low- and middle-income countries showed family directly observed treatment success risk ratio up to 9.07, 95% CI of 0.92-89.9. Furthermore, four short message service trials revealed a treatment success risk ratio ranging from 1.0 to 1.45 (95% CI fell within these values) with a cost-effectiveness of up to 350I$ compared to standard of care. CONCLUSIONS This review illustrates that community-based TB interventions such as electronic medication monitors, community health worker direct observation therapy, family directly observed treatment, and short message service can substantially bolster efficiency and convenience for patients and providers while reducing health system costs and improving clinical outcomes.
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Affiliation(s)
- Gabalape Arnold Sejie
- Discipline of Public Health Medicine, University of KwaZulu, Natal, Durban, South Africa
- Department of Health Promotion and Education, Boitekanelo College, Gaborone, Botswana
| | - Ozayr H. Mahomed
- Discipline of Public Health Medicine, University of KwaZulu, Natal, Durban, South Africa
- Dasman Diabetes Institute, Kuwait City, Kuwait
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10
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Chiang SS, Senador L, Altamirano E, Wong M, Beckhorn CB, Roche S, Coit J, Oliva Rapoport VE, Lecca L, Galea JT. Adolescent, caregiver and provider perspectives on tuberculosis treatment adherence: a qualitative study from Lima, Peru. BMJ Open 2023; 13:e069938. [PMID: 37202135 PMCID: PMC10201266 DOI: 10.1136/bmjopen-2022-069938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 05/09/2023] [Indexed: 05/20/2023] Open
Abstract
OBJECTIVES To understand the perspectives of adolescents (10-19 years old), their caregivers and healthcare providers regarding factors that impact adherence to tuberculosis (TB) treatment among adolescents. DESIGN We conducted in-depth interviews using semistructured interview guides based on the World Health Organization (WHO)'s Five Dimensions of Adherence framework, which conceptualises adherence as being related to the health system, socioeconomic factors, patient, treatment and condition. We applied framework thematic analysis. SETTING Between August 2018 and May 2019, at 32 public health centres operated by the Ministry of Health in Lima, Peru. PARTICIPANTS We interviewed 34 adolescents who completed or were lost to follow-up from treatment for drug-susceptible pulmonary TB disease in the preceding 12 months; their primary caregiver during treatment; and 15 nurses or nurse technicians who had ≥6 months' experience supervising TB treatment. RESULTS Participants reported numerous treatment barriers, the most common of which were the inconvenience of health facility-based directly observed therapy (DOT), long treatment duration, adverse treatment events and symptom resolution. The support of adult caregivers was critical for helping adolescents overcome these barriers and carry out the behavioural skills (eg, coping with the large pill burden, managing adverse treatment events and incorporating treatment into daily routines) needed to adhere to treatment. CONCLUSION Our findings support a three-pronged approach to improve TB treatment adherence among adolescents: (1) reduce barriers to adherence (eg, home-based or community-based DOT in lieu of facility-based DOT, reducing pill burden and treatment duration when appropriate), (2) teach adolescents the behavioural skills required for treatment adherence and (3) strengthen caregivers' ability to support adolescents.
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Affiliation(s)
- Silvia S Chiang
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Center for International Health Research, Rhode Island Hospital, Providence, Rhode Island, USA
| | | | | | | | | | - Stephanie Roche
- Division of Public Health Sciences, Fred Hutchinson Cancer Research Institute, Seattle, Washington, USA
| | - Julia Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Leonid Lecca
- Socios En Salud Sucursal Peru, Lima, Peru
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Jerome T Galea
- Department of Social Work, University of South Florida, Tampa, Florida, USA
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11
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Mangan JM, Burzynski J, deCastro BR, Salerno MM, Lam CK, Macaraig M, Reaves M, Kiskadden-Bechtel S, Bowers S, Sathi C, Dias MP, Goswami ND, Vernon A. Challenges associated with electronic and in-person directly observed therapy during a randomized trial. Int J Tuberc Lung Dis 2023; 27:298-307. [PMID: 37035970 PMCID: PMC10807436 DOI: 10.5588/ijtld.22.0583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND: Electronic directly observed therapy (eDOT) has been proposed as an alternative to traditional in-person DOT (ipDOT) for monitoring TB treatment adherence. Information about the comparative performance and implementation of eDOT is limited.METHODS: The frequency of challenges during DOT, challenge type, and effect on medication observation were documented by DOT method during a crossover, noninferiority randomized controlled trial. A logistic mixed-effects model that adjusted for the study design was used to estimate the percentage of successfully observed doses when challenges occurred.RESULTS: A total of 20,097 medication doses were scheduled for observation with either eDOT (15,405/20,097; 76.7%) or ipDOT (4,692/20,097; 23.3%) for 213 study participants. In total, one or more challenges occurred during 17.3% (2,672/15,405) of eDOT sessions and 15.6% (730/4,692) of ipDOT sessions. Among 4,374 documented challenges, 27.3% (n = 1,192) were characterized as technical, 65.9% (n = 2,881) were patient-related, and 6.9% (n = 301) were program-related. Estimated from the logistic model (n = 6,782 doses, 173 participants), the adjusted percentage of doses successfully observed during problematic sessions was 21.7% (95% CI 11.2-37.8) for eDOT and 4.2% (95% CI 1.1-14.7) for ipDOT.CONCLUSION: Compared to ipDOT, challenges were encountered in a slightly higher percentage of eDOT sessions but were more often resolved to enable successful dose observation during problematic sessions.
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Affiliation(s)
- J M Mangan
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, USA
| | - J Burzynski
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - B Rey deCastro
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, USA
| | - M M Salerno
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA, Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, NY, USA
| | - C K Lam
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, USA, Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - M Macaraig
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - M Reaves
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA, Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, NY, USA
| | - S Kiskadden-Bechtel
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA, Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, NY, USA
| | - S Bowers
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, USA, Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA
| | - C Sathi
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA, Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, NY, USA
| | - M P Dias
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, USA, Division of Pulmonary, Allergy & Critical Care, Columbia University, New York, NY, USA
| | - N D Goswami
- Division of Tuberculosis Elimination, Centers for Disease Control, Atlanta, GA, USA
| | - A Vernon
- Division of Viral Diseases, Centers for Disease Control, Atlanta, GA, USA
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12
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Stantliff TM, Housel L, Goswami R, Millow S, Cook G, Knapmeyer R, Easton C, Stryker SD, Williams KM, Walter M, Mooney J, Huaman MA. The Latent Tuberculosis Infection Cascade of Care During The COVID-19 Pandemic Response in a Mid-Sized US City. J Clin Tuberc Other Mycobact Dis 2023; 31:100367. [PMID: 37034439 PMCID: PMC10066584 DOI: 10.1016/j.jctube.2023.100367] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2023] Open
Abstract
Background The COVID-19 pandemic response may unintentionally disrupt multiple public health services, including tuberculosis control programs. We aimed to assess differences in the cascade of care for latent tuberculosis infection (LTBI) in a Midwest U.S. city during the COVID-19 pandemic response. Methods We conducted a retrospective cohort study of adult patients who presented for LTBI evaluation at the Hamilton County Public Health Tuberculosis Clinic in Ohio between 2019 and 2020. The pre-COVID-19 response period was defined as 01/2019 to 02/2020, and the COVID-19 pandemic response period (first wave) was defined as 04/2020 to 12/2020. We reviewed electronic medical records to extract sociodemographic information, medical history, follow-up and treatment data to define steps within the LTBI cascade of care. Logistic regressions were used to assess factors associated with LTBI treatment acceptance and completion, adjusted by potential confounders and COVID-19 period. Results Data from 312 patients were included. There was a significant decrease in the number of monthly LTBI referrals (median, 18 vs. 8, p = 0.02) and LTBI evaluations (median, 17.5 vs. 7, p < 0.01) during the first wave of COVID-19. The proportion for whom immigration was listed as the indication for LTBI testing also declined (30% vs. 9%; p < 0.01) during COVID-19. More LTBI diagnoses were based on interferon-gamma release assay (IGRA; 30% vs. 49%; p < 0.01) during the COVID-19 response period. The proportion of people in the clinic for whom treatment for LTBI was recommended was similar before and during COVID-19 (76% vs. 81%, p = 0.41), as was LTBI treatment acceptance rates (56% vs. 64%, p = 0.28), and completion rates (65% vs. 63%, p = 0.85). In multivariate analysis, LTBI treatment acceptance was associated with Hispanic ethnicity, younger age, male sex, IGRA being used for diagnosis, and non-healthcare occupation, independent of COVID-19 period. LTBI treatment completion was associated with taking a rifamycin-containing regimen, independent of COVID-19 period. Conclusion We observed a significant decline in the number of monthly LTBI referrals and evaluations during the first wave of COVID-19, revealing an unintended negative impact of the COVID-19 response in our region. However, LTBI treatment acceptance and completion rates were not affected during COVID-19.
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13
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Wong YJ, Thum CC, Ng KY, Lee SWH. Engaging community pharmacists in tuberculosis-directly observed treatment: a mixed-methods study. Prim Health Care Res Dev 2023; 24:e21. [PMID: 36946302 PMCID: PMC10050952 DOI: 10.1017/s1463423623000105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023] Open
Abstract
AIM This study aimed to evaluate the feasibility of implementing community pharmacy-based tuberculosis-directly observed treatment (TB-DOT) in Malaysia. BACKGROUND Tuberculosis (TB) eradication is one of the top priorities in the public health agenda in Malaysia. While public-private mix (PPM) initiatives have been launched, community pharmacists remain undervalued assets in TB management. METHODS A two-phase mixed-methods study targeting community pharmacists was conducted in Malaysia between March and October 2021. The first phase was an online self-administered survey developed according to the Consolidated Framework for Implementation Research (CFIR). The second phase was a semi-structured interview to allow deeper understanding on the quantitative results. Quantitative data were analysed using descriptive analysis while qualitative data were analysed using thematic analysis with a semi-inductive approach. The data were triangulated to enhance comprehensiveness and credibility of the findings. FINDINGS The survey was completed by 388 community pharmacists, and 23 pharmacists participated in the interview. Most community pharmacists indicated their willingness to serve as TB-DOT supervisors (70.1%). Qualitative results supported the findings. Community pharmacy-based TB-DOT service was perceived as an avenue to improve TB management and outcomes and to enhance the professional role of pharmacists in TB service at primary care settings. This was also perceived as a feasible intervention with the potential to strengthen the National TB Control programme. This initiative needs be reinforced with adequate support from the public healthcare sector for a strong partnership in ensuring success.
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Affiliation(s)
- Yen Jun Wong
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500Subang Jaya, Selangor, Malaysia
| | - Chern Choong Thum
- Department of Psychiatry, Hospital Sultan Abdul Aziz Shah Universiti Putra Malaysia, Persiaran Mardi - UPM, 43400Serdang, Selangor, Malaysia
| | - Khuen Yen Ng
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500Subang Jaya, Selangor, Malaysia
| | - Shaun Wen Huey Lee
- School of Pharmacy, Monash University Malaysia, Jalan Lagoon Selatan, 47500Subang Jaya, Selangor, Malaysia
- School of Pharmacy, Taylor's University Lakeside Campus, Jalan Taylors, 47500Subang Jaya, Selangor, Malaysia
- Center of Global Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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14
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Sekandi JN, Shi W, Zhu R, Kaggwa P, Mwebaze E, Li S. Application of Artificial Intelligence to the Monitoring of Medication Adherence for Tuberculosis Treatment in Africa: Algorithm Development and Validation. JMIR AI 2023; 2:e40167. [PMID: 38464947 PMCID: PMC10923555 DOI: 10.2196/40167] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/17/2022] [Accepted: 01/22/2023] [Indexed: 03/12/2024]
Abstract
Background Artificial intelligence (AI) applications based on advanced deep learning methods in image recognition tasks can increase efficiency in the monitoring of medication adherence through automation. AI has sparsely been evaluated for the monitoring of medication adherence in clinical settings. However, AI has the potential to transform the way health care is delivered even in limited-resource settings such as Africa. Objective We aimed to pilot the development of a deep learning model for simple binary classification and confirmation of proper medication adherence to enhance efficiency in the use of video monitoring of patients in tuberculosis treatment. Methods We used a secondary data set of 861 video images of medication intake that were collected from consenting adult patients with tuberculosis in an institutional review board-approved study evaluating video-observed therapy in Uganda. The video images were processed through a series of steps to prepare them for use in a training model. First, we annotated videos using a specific protocol to eliminate those with poor quality. After the initial annotation step, 497 videos had sufficient quality for training the models. Among them, 405 were positive samples, whereas 92 were negative samples. With some preprocessing techniques, we obtained 160 frames with a size of 224 × 224 in each video. We used a deep learning framework that leveraged 4 convolutional neural networks models to extract visual features from the video frames and automatically perform binary classification of adherence or nonadherence. We evaluated the diagnostic properties of the different models using sensitivity, specificity, F1-score, and precision. The area under the curve (AUC) was used to assess the discriminative performance and the speed per video review as a metric for model efficiency. We conducted a 5-fold internal cross-validation to determine the diagnostic and discriminative performance of the models. We did not conduct external validation due to a lack of publicly available data sets with specific medication intake video frames. Results Diagnostic properties and discriminative performance from internal cross-validation were moderate to high in the binary classification tasks with 4 selected automated deep learning models. The sensitivity ranged from 92.8 to 95.8%, specificity from 43.5 to 55.4%, F1-score from 0.91 to 0.92, precision from 88% to 90.1%, and AUC from 0.78 to 0.85. The 3D ResNet model had the highest precision, AUC, and speed. Conclusions All 4 deep learning models showed comparable diagnostic properties and discriminative performance. The findings serve as a reasonable proof of concept to support the potential application of AI in the binary classification of video frames to predict medication adherence.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Weili Shi
- School of Data Science, University of Virginia, Charlottesville, VA, United States
| | - Ronghang Zhu
- School of Computing, College of Engineering & Franklin College of Arts and Sciences, University of Georgia, Athens, GA, United States
| | - Patrick Kaggwa
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University, Kampala, Uganda
| | - Ernest Mwebaze
- Sunbird AI, Kampala, Uganda
- Artificial Intelligence Research Lab, College of Computing and Information Science, Makerere University, Kampala, Uganda
| | - Sheng Li
- School of Data Science, University of Virginia, Charlottesville, VA, United States
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15
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Margineanu I, Louka C, Akkerman O, Stienstra Y, Alffenaar JW. eHealth in TB clinical management. Int J Tuberc Lung Dis 2022; 26:1151-1161. [PMID: 36447317 PMCID: PMC9728950 DOI: 10.5588/ijtld.21.0602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 07/12/2022] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND: The constant expansion of internet and mobile technologies has created new opportunities in the field of eHealth, or the digital delivery of healthcare services. This TB meta-analysis aims to examine eHealth and its impact on TB clinical management in order to formulate recommendations for further development.METHODS: A systematic search was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses framework in PubMed and Embase of articles published up to April 2021. Screening, extraction and quality assessment were performed by two independent researchers. Studies evaluating an internet and/or mobile-based eHealth intervention with an impact on TB clinical management were included. Outcomes were organised following the five domains described in the WHO "Recommendations on Digital Interventions for Health System Strengthening" guideline.RESULTS: Search strategy yielded 3,873 studies, and 89 full texts were finally included. eHealth tended to enhance screening, diagnosis and treatment indicators, while being cost-effective and acceptable to users. The main challenges concern hardware malfunction and software misuse.CONCLUSION: This study offers a broad overview of the innovative field of eHealth applications in TB. Different studies implementing eHealth solutions consistently reported on benefits, but also on specific challenges. eHealth is a promising field of research and could enhance clinical management of TB.
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Affiliation(s)
- I Margineanu
- Department of Clinical Pharmacy and Pharmacology, University Medical Centrum Groningen, University of Groningen, Groningen, the Netherlands, Iasi Pulmonary Diseases University Hospital, Iasi, Romania
| | - C Louka
- Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - O Akkerman
- Tuberculosis Center Beatrixoord, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands, Department of Pulmonary Diseases and Tuberculosis, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Y Stienstra
- Department of Internal Medicine/Infectious Diseases, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands, Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, UK
| | - J-W Alffenaar
- Department of Clinical Pharmacy and Pharmacology, University Medical Centrum Groningen, University of Groningen, Groningen, the Netherlands, Faculty of Medicine and Health, School of Pharmacy, University of Sydney, Camperdown, NSW, Australia, Westmead Hospital, Sydney, NSW, Australia, Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Sydney, NSW, Australia
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Lippincott CK, Perry A, Munk E, Maltas G, Shah M. Tuberculosis treatment adherence in the era of COVID-19. BMC Infect Dis 2022; 22:800. [PMID: 36289485 PMCID: PMC9607764 DOI: 10.1186/s12879-022-07787-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 09/23/2022] [Accepted: 10/07/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND In-person directly observed therapy (DOT) is commonly used for tuberculosis (TB) treatment monitoring in the US, with increasing usage of video-DOT (vDOT). We evaluated the impact of COVID-19 on TB treatment adherence, and utilization and effectiveness of vDOT. METHODS We abstracted routinely collected data on individuals treated for TB disease in Baltimore, Maryland between April 2019 and April 2021. Our primary outcomes were to assess vDOT utilization and treatment adherence, defined as the proportion of prescribed doses (7 days/week) verified by observation (in-person versus video-DOT), comparing individuals in the pre-COVID and COVID (April 2020) periods. RESULTS Among 52 individuals with TB disease, 24 (46%) received treatment during the COVID-19 pandemic. vDOT utilization significantly increased in the COVID period (18/24[75%]) compared to pre-COVID (12/28[43%], p = 0.02). Overall, median verified adherence was similar pre-COVID and COVID periods (65% versus 68%, respectively, p = 0.96). Adherence was significantly higher overall when using vDOT (median 86% [IQR 70-98%]) compared to DOT (median 59% [IQR 55-64%], p < 0.01); this improved adherence with vDOT was evident in both the pre-COVID (median 98% vs. 58%, p < 0.01) and COVID period (median 80% vs. 62%, p = 0.01). CONCLUSION vDOT utilization increased during the COVID period and was more effective than in-person DOT at verifying ingestion of prescribed treatment.
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Affiliation(s)
- Christopher K Lippincott
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 1550 Orleans St, CRB-II, 1M-10, 21287, Baltimore, MD, USA
| | - Allison Perry
- Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Elizabeth Munk
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 1550 Orleans St, CRB-II, 1M-10, 21287, Baltimore, MD, USA
| | - Gina Maltas
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 1550 Orleans St, CRB-II, 1M-10, 21287, Baltimore, MD, USA
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins School of Medicine, 1550 Orleans St, CRB-II, 1M-10, 21287, Baltimore, MD, USA.
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Bachina P, Lippincott CK, Perry A, Munk E, Maltas G, Bohr R, Rock RB, Shah M. Programmatic Adoption and Implementation of Video-Observed Therapy in Minnesota: Prospective Observational Cohort Study. JMIR Form Res 2022; 6:e38247. [PMID: 35834671 PMCID: PMC9359306 DOI: 10.2196/38247] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 05/24/2022] [Accepted: 06/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background In-person directly observed therapy (DOT) is standard of care for tuberculosis (TB) treatment adherence monitoring in the US, with increasing use of video-DOT (vDOT). In Minneapolis, vDOT became available in 2019. Objective In this paper, we aimed to evaluate the use and effectiveness of vDOT in a program setting, including comparison of verified adherence among those receiving vDOT and in-person DOT. We also sought to understand the impact of COVID-19 on TB treatment adherence and technology adoption. Methods We abstracted routinely collected data on individuals receiving therapy for TB in Minneapolis, MN, between September 2019 and June 2021. Our primary outcomes were to assess vDOT use and treatment adherence, defined as the proportion of prescribed doses (7 days per week) verified by observation (in person versus video-DOT), and to compare individuals receiving therapy in the pre–COVID-19 (before March 2020), and post–COVID-19 (after March 2020) periods; within the post–COVID-19 period, we evaluated early COVID-19 (March-August 2020), and intra–COVID-19 (after August 2020) periods. Results Among 49 patients with TB (mean age 41, SD 19; n=27, 55% female and n=47, 96% non–US born), 18 (36.7%) received treatment during the post–COVID-19 period. Overall, verified adherence (proportion of observed doses) was significantly higher when using vDOT (mean 81%, SD 17.4) compared to in-person DOT (mean 54.5%, SD 10.9; P=.001). The adoption of vDOT increased significantly from 35% (11/31) of patients with TB in the pre–COVID-19 period to 67% (12/18) in the post–COVID-19 period (P=.04). Consequently, overall verified (ie, observed) adherence among all patients with TB in the clinic improved across the study periods (56%, 67%, and 79%, P=.001 for the pre–, early, and intra–COVID-19 periods, respectively). Conclusions vDOT use increased after the COVID-19 period, was more effective than in-person DOT at verifying ingestion of prescribed treatment, and led to overall increased verified adherence in the clinic despite the onset of the COVID-19 pandemic.
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Affiliation(s)
- Preetham Bachina
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | | | - Allison Perry
- Division of Epidemiology, Department of Population Health, New York University School of Medicine, New York, NY, United States
| | - Elizabeth Munk
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Gina Maltas
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Rebecca Bohr
- Hennepin County Public Health, Minneapolis, MN, United States
| | - Robert Bryan Rock
- Division of Infectious Disease, Department of Medicine, Hennepin Healthcare, Minneapolis, MN, United States
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, United States
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18
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Kordy F, Nashid N, Khan S, Read S, Macdougall G, Louch D, Arneson C, Bitnun A. Video directly observed therapy to improve adherence of human immunodeficiency virus infected adolescents to combination antiretroviral therapy: a proof-of-concept study. AIDS Care 2022; 35:417-424. [PMID: 35914111 DOI: 10.1080/09540121.2022.2104794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Adherence to antiretroviral therapy (ART) is a major challenge for many youth living with HIV (YLWH). In this prospective proof-of-concept study, we assessed the feasibility and acceptability of conducting a study of video directly observed therapy (VDOT) as a method of improving medication adherence in YLWH who had a history of poor adherence to ART. The study had four phases; phase I - VDOT daily (4 months) using Facetime®; phase II - daily texting (2 months); phase III - weekly texting (3 months); phase IV - no intervention (3 months). Participants were seen in clinic on a monthly basis for assessment and laboratory evaluation. Five of eight eligible participants were enrolled. All achieved virologic suppression one month after enrollment. Three of five completed the study protocol and maintained virologic suppression through the 12-month period of study. Participant responses to the end-of-study questionnaire indicated satisfaction with the intervention and thought VDOT was helpful to them. Healthcare providers thought that the intervention was effective for some youth but was at times burdensome. This proof-of-concept study demonstrated that VDOT may be effective at improving medication adherence in previously poorly adherent YLWH and that larger studies of VDOT for such patients are both feasible and warranted.
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Affiliation(s)
- Faisal Kordy
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Nancy Nashid
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Sarah Khan
- Department of Pediatrics, McMaster Children's Hospital, Hamilton Health Sciences, McMaster University, Hamilton, Canada
| | - Stanley Read
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Georgina Macdougall
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Debra Louch
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Cheryl Arneson
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
| | - Ari Bitnun
- Division of Infectious Diseases, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, Canada
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Lippincott C, Perry A, Munk E, Maltas G, Shah M. Tuberculosis treatment adherence in the era of COVID-19. RESEARCH SQUARE 2022:rs.3.rs-1777276. [PMID: 35860215 PMCID: PMC9298136 DOI: 10.21203/rs.3.rs-1777276/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND In-person directly observed therapy (DOT) is commonly used for tuberculosis (TB) treatment monitoring in the US, with increasing usage of video-DOT (vDOT). We evaluated the impact of COVID-19 on TB treatment adherence, and utilization and effectiveness of vDOT. METHODS We abstracted routinely collected data on individuals treated for TB disease in Baltimore, Maryland between April 2019 and April 2021. Our primary outcomes were to assess vDOT utilization and treatment adherence, defined as the proportion of prescribed doses (7 days/week) verified by observation (in-person versus video-DOT), comparing individuals in the pre- and post-COVID (April 2020) periods. RESULTS Among 52 individuals with TB disease, 24 (46%) received treatment during the COVID-19 pandemic. vDOT utilization significantly increased post-COVID (18/24[75%]) compared to pre-COVID (12/28[43%], p=0.02). Overall, median verified adherence was similar pre- and post-COVID (65% versus 68%, respectively, p=0.96). Adherence was significantly higher overall when using vDOT (median 86% [IQR 70-98%]) compared to DOT (median 59% [IQR 55%-64%], p<0.01); this improved adherence with vDOT was evident in both the pre-COVID (median 98% vs 58%, p<0.01) and post-COVID period (median 80% vs 62%, p=0.01). CONCLUSION vDOT utilization increased post-COVID and was more effective than in-person DOT at verifying ingestion of prescribed treatment.
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Hassan N, Aazam M, Tahir M, Yau KLA. Floating Fog: extending fog computing to vast waters for aerial users. CLUSTER COMPUTING 2022; 26:181-195. [PMID: 35464821 PMCID: PMC9014405 DOI: 10.1007/s10586-022-03567-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 12/22/2021] [Accepted: 01/28/2022] [Indexed: 06/14/2023]
Abstract
There are thousands of flights carrying millions of passengers each day, having three or more Internet-connected devices with them on average. Usually, onboard devices remain idle for most of the journey (which can be of several hours), therefore, we can tap on their underutilized potential. Although these devices are generally becoming more and more resourceful, for complex services (such as related to machine learning, augmented/virtual reality, smart healthcare, and so on) those devices do not suffice standalone. This makes a case for multi-device resource aggregation such as through femto-cloud. As our first contribution, we present the utility of femto-cloud for aerial users. But for that sake, a reliable and faster Internet is required (to access online services or cloud resources), which is currently not the case with satellite-based Internet. That is the second challenge we try to address in our paper, by presenting an adaptive beamforming-based solution for aerial Internet provisioning. However, on average, most of the flight path is above waters. Given that, we propose that beamforming transceivers can be docked on stationery ships deployed in the vast waters (such as the ocean). Nevertheless, certain services would be delay-sensitive, and accessing their on-ground servers or cloud may not be feasible (in terms of delay). Similarly, certain complex services may require resources in addition to the flight-local femto-cloud. That is the third challenge we try to tackle in this paper, by proposing that the traditional fog computing (which is a cloud-like but localized pool of resources) can also be extended to the waters on the ships harboring beamforming transceivers. We name it Floating Fog. In addition to that, Floating Fog will enable several new services such as live black-box. We also present a cost and bandwidth analysis to highlight the potentials of Floating Fog. Lastly, we identify some challenges to tackle the successful deployment of Floating Fog.
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Affiliation(s)
| | - Mohammad Aazam
- Present Address: University of Nottingham, Semenyih, Malaysia
| | - Mohammad Tahir
- Department of Computer Science, University of Turku Finland, Turku, Finland
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21
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Truong CB, Tanni KA, Qian J. Video-Observed Therapy Versus Directly Observed Therapy in Patients With Tuberculosis. Am J Prev Med 2022; 62:450-458. [PMID: 34916094 DOI: 10.1016/j.amepre.2021.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Revised: 10/13/2021] [Accepted: 10/18/2021] [Indexed: 11/01/2022]
Abstract
INTRODUCTION This systematic review and meta-analysis synthesized evidence in the effects of video-observed therapy versus that of directly observed therapy on medication adherence, treatment completion, and tuberculosis resolution among patients with tuberculosis. METHODS Potential studies were identified from MEDLINE, Embase, CINAHLdirect, and Cochrane from inception to February 1, 2021. Inclusion criteria included (1) tuberculosis-infected population, (2) video-observed therapy as an intervention, (3) directly observed therapy as the comparison group, and (4) patient's medication adherence or clinical outcomes. Data were collected in 2021. Random-effects meta-analyses were conducted using Mantel-Haenszel methods with RR for dichotomous outcomes (medication adherence, treatment completion, and bacteriological resolution) and generic inverse variance methods with a weighted mean difference for continuous outcomes (proportion of doses observed). RESULTS A total of 9 studies were included in the systematic review and meta-analysis. Compared with patients receiving directly observed therapy, patients with video-observed therapy were associated with improved medication adherence (RR=2.79, 95% CI=2.26, 3.45, I2=25%), the proportion of doses observed (weighted mean difference=0.22, 95% CI=0.06, 0.39, I2=96%), and bacteriological resolution (RR=1.06, 95% CI=1.01, 1.11, I2=0%) but with similar treatment completion (RR=1.33, 95% CI=0.73, 2.43, I2=98%). DISCUSSION Implementation of video-observed therapy improved medication adherence and bacteriological resolution compared with that of directly observed therapy in tuberculosis-infected patients.
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Affiliation(s)
- Cong B Truong
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Kaniz A Tanni
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, Alabama
| | - Jingjing Qian
- Department of Health Outcomes Research and Policy, Harrison School of Pharmacy, Auburn University, Auburn, Alabama.
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22
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Fekadu G, Jiang X, Yao J, You JHS. Cost-effectiveness of video-observed therapy for ambulatory management of active tuberculosis during the COVID-19 pandemic in a high-income country. Int J Infect Dis 2021; 113:271-278. [PMID: 34688946 PMCID: PMC8530791 DOI: 10.1016/j.ijid.2021.10.029] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 10/04/2021] [Accepted: 10/14/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE The coronavirus 2019 (COVID-19) pandemic caused suspension of directly observed therapy (DOT) for patients with active tuberculosis (TB). This study aimed to estimate the outcomes of pandemic-related DOT suspension and the cost-effectiveness of video-observed therapy (VOT) during the pandemic. METHODS A decision-analytic model was constructed to project outcomes of adult patients with active TB from the perspective of a US healthcare provider. Two model-based analyses were conducted: (1) before (with DOT) and during [with self-administered therapy (SAT)] the pandemic; and (2) VOT vs SAT during the pandemic. The primary outcome measures were direct medical costs and disability-adjusted life years (DALYs). RESULTS In the base-case analysis, care during the pandemic (with SAT) increased the cost (by US$285 per patient) and DALYs (by 0.2155 per patient) in comparison with DOT. Care with VOT reduced DALYs (by 0.4870) and costs (by US$1797) in comparison with SAT. On probabilistic sensitivity analysis, care during the pandemic (with SAT) increased DALYs in 100% of 10,000 simulations, and increased costs in 55.52% of instances. Care with VOT reduced DALYs and costs in 99.7% and 68.79% of instances, respectively. The probability of VOT being cost-effective was 99.4% at the willingness-to-pay threshold of 50,000 US$/DALY. CONCLUSION Suspension of DOT during the COVID-19 pandemic worsened treatment outcomes. VOT was found to be a cost-effective option for active TB care in an outpatient setting.
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Affiliation(s)
- Ginenus Fekadu
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Xinchan Jiang
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Jiaqi Yao
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Joyce H S You
- School of Pharmacy, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China.
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23
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Abstract
Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.
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Affiliation(s)
- Dawn Nolt
- Department of Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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Sekandi JN, Kasiita V, Onuoha NA, Zalwango S, Nakkonde D, Kaawa-Mafigiri D, Turinawe J, Kakaire R, Davis-Olwell P, Atuyambe L, Buregyeya E. Stakeholders' Perceptions of Benefits of and Barriers to Using Video-Observed Treatment for Monitoring Patients With Tuberculosis in Uganda: Exploratory Qualitative Study. JMIR Mhealth Uhealth 2021; 9:e27131. [PMID: 34704961 PMCID: PMC8581755 DOI: 10.2196/27131] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 08/15/2021] [Accepted: 09/07/2021] [Indexed: 01/19/2023] Open
Abstract
Background Nonadherence to treatment remains a barrier to tuberculosis (TB) control. Directly observed therapy (DOT) is the standard for monitoring adherence to TB treatment worldwide, but its implementation is challenging, especially in resource-limited settings. DOT is labor-intensive and inconvenient to both patients and health care workers. Video DOT (VDOT) is a novel patient-centered alternative that uses mobile technology to observe patients taking medication remotely. However, the perceptions and acceptability of potential end users have not been evaluated in Africa. Objective This study explores stakeholders’ acceptability of, as well as perceptions of potential benefits of and barriers to, using VDOT to inform a pilot study for monitoring patients with TB in urban Uganda. Methods An exploratory, qualitative, cross-sectional study with an exit survey was conducted in Kampala, Uganda, from April to May 2018. We conducted 5 focus group discussions, each comprising 6 participants. Groups included patients with TB (n=2 groups; male and female), health care providers (n=1), caregivers (n=1), and community DOT volunteer workers (n=1). The questions that captured perceived benefits and barriers were guided by domains adopted from the Technology Acceptance Model. These included perceived usefulness, ease of use, and intent to use technology. Eligible participants were aged ≥18 years and provided written informed consent. For patients with TB, we included only those who had completed at least 2 months of treatment to minimize the likelihood of infection. A purposive sample of patients, caregivers, health care providers, and community DOT workers was recruited at 4 TB clinics in Kampala. Trained interviewers conducted unstructured interviews that were audio-recorded, transcribed, and analyzed using inductive content analysis to generate emerging themes. Results The average age of participants was 34.5 (SD 10.7) years. VDOT was acceptable to most participants on a scale of 1 to 10. Of the participants, 70% (21/30) perceived it as highly acceptable, with scores ≥8, whereas 30% (9/30) scored between 5 and 7. Emergent themes on perceived benefits of VDOT were facilitation of easy adherence monitoring, timely follow-up on missed doses, patient-provider communication, and saving time and money because of minimal travel to meet in person. Perceived barriers included limited technology usability skills, inadequate cellular connectivity, internet access, availability of electricity, cost of the smartphone, and use of the internet. Some female patients raised concerns about the disruption of their domestic work routines to record videos. The impact of VDOT on privacy and confidentiality emerged as both a perceived benefit and barrier. Conclusions VDOT was acceptable and perceived as beneficial by most study participants, despite potential technical and cost barriers. Mixed perceptions emerged about the impact of VDOT on privacy and confidentiality. Future efforts should focus on training users, ensuring adequate technical infrastructure, assuring privacy, and performing comparative cost analyses in the local context.
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Affiliation(s)
- Juliet Nabbuye Sekandi
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | | | - Nicole Amara Onuoha
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Kampala, Uganda
| | | | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Robert Kakaire
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Paula Davis-Olwell
- Department of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, United States.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, United States
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
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Perry A, Chitnis A, Chin A, Hoffmann C, Chang L, Robinson M, Maltas G, Munk E, Shah M. Real-world implementation of video-observed therapy in an urban TB program in the United States. Int J Tuberc Lung Dis 2021; 25:655-661. [PMID: 34330351 PMCID: PMC8327629 DOI: 10.5588/ijtld.21.0170] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND: Video directly observed therapy (vDOT) was introduced to increase flexibility and meet patient-specific needs for TB treatment. This study aimed to assess the reach and effectiveness of vDOT for TB treatment under routine conditions in Alameda County, CA, USA, a busy, urban setting, from 2018 to 2020. METHODS: We prospectively evaluated routinely collected data to estimate 1) reach (proportion of patients initiated on vDOT vs. in-person DOT); and 2) effectiveness (proportion of prescribed doses with verified administration by vDOT vs. in-person DOT). RESULTS: Among 163 TB patients, 94 (58%) utilized vDOT during treatment, of whom 54 (57%) received exclusively vDOT. Individuals receiving vDOT were on average younger than those receiving in-person therapy (46 vs. 61 years; P < 0.001). The median time to vDOT initiation was 2.2 weeks (IQR 1.1–10.0); patients were monitored for a median of 27.0 weeks (IQR 24.6–31.9). vDOT led to higher proportions of verified prescribed doses than in-person DOT (68% vs. 54%; P < 0.001). Unobserved self-administration occurred for all patients on weekends based on clinic instructions, but a larger proportion of doses were self-administered during periods of in-person DOT than of vDOT (45% vs. 24%; P < 0.001). CONCLUSION: A TB program successfully maintained vDOT, reaching the majority of patients and achieving greater medication verification than in-person DOT.
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Affiliation(s)
- A Perry
- Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - A Chitnis
- Tuberculosis Control Section, Alameda County Public Health Department, San Leandro, CA
| | - A Chin
- Tuberculosis Control Section, Alameda County Public Health Department, San Leandro, CA
| | - C Hoffmann
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - L Chang
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Robinson
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - G Maltas
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - E Munk
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - M Shah
- Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, MD, USA
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Cost-effectiveness of artificial intelligence monitoring for active tuberculosis treatment: A modeling study. PLoS One 2021; 16:e0254950. [PMID: 34288951 PMCID: PMC8294556 DOI: 10.1371/journal.pone.0254950] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Accepted: 07/06/2021] [Indexed: 11/21/2022] Open
Abstract
Background Tuberculosis (TB) incidence in Los Angeles County, California, USA (5.7 per 100,000) is significantly higher than the U.S. national average (2.9 per 100,000). Directly observed therapy (DOT) is the preferred strategy for active TB treatment but requires substantial resources. We partnered with the Los Angeles County Department of Public Health (LACDPH) to evaluate the cost-effectiveness of AiCure, an artificial intelligence (AI) platform that allows for automated treatment monitoring. Methods We used a Markov model to compare DOT versus AiCure for active TB treatment in LA County. Each cohort transitioned between health states at rates estimated using data from a pilot study for AiCure (N = 43) and comparable historical controls for DOT (N = 71). We estimated total costs (2017, USD) and quality-adjusted life years (QALYs) over a 16-month horizon to calculate the incremental cost-effectiveness ratio (ICER) and net monetary benefits (NMB) of AiCure. To assess robustness, we conducted deterministic (DSA) and probabilistic sensitivity analyses (PSA). Results For the average patient, AiCure was dominant over DOT. DOT treatment cost $4,894 and generated 1.03 QALYs over 16-months. AiCure treatment cost $2,668 for 1.05 QALYs. At willingness-to-pay threshold of $150K/QALY, incremental NMB per-patient under AiCure was $4,973. In univariate DSA, NMB were most sensitive to monthly doses and vocational nurse wage; however, AiCure remained dominant. In PSA, AiCure was dominant in 93.5% of 10,000 simulations (cost-effective in 96.4%). Conclusions AiCure for treatment of active TB is cost-effective for patients in LA County, California. Increased use of AI platforms in other jurisdictions could facilitate the CDC’s vision of TB elimination.
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Characterizing the Clinical use of a Novel Video-assisted Dosing Protocol With Secure Medication Dispensers to Reduce Barriers to Opioid Treatment. J Addict Med 2021; 16:310-316. [PMID: 34282084 DOI: 10.1097/adm.0000000000000895] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Distance and travel costs to opioid treatment programs (OTPs), especially in rural communities, are barriers to treatment for opioid use disorder. Retention rates at 12 months in our OTP are 55% (range 53%-61%). We piloted a novel treatment platform utilizing a video directly observed therapy (VDOT) smartphone app and a secure medication dispenser to support adherence with take-home doses of methadone or buprenorphine while enabling patients to maintain prosocial activities, reduce time and cost of travel, and increase retention. METHODS Participants (n = 58) were adults in a Vermont OTP. Inclusion criteria included travel hardship, access to Wi-Fi or cellular network, and having an iPhone 4S or Android 4.0 or greater. Patients received a dispenser, VDOT app, clinic dispensed medication, counseling, and urine drug testing. Chart reviews assessed VDOT compliance, engagement in prosocial activities, travel costs and time savings, and treatment disposition/retention. Project-associated costs were examined. RESULTS Of the 15,831 expected videos, 15,581 (98.4%) were received and only 10 (0.063%) showed signs of medication noncompliance with 1 (0.0064%) showing an overt attempt at diversion. About 93% of participants engaged in prosocial activities, travel time and costs were reduced 86%, median cost saved $72 weekly, median travel time saved 5.5 hours weekly and 98% of participants were in treatment 12 months later. CONCLUSIONS VDOT participants using dispensers showed high levels of medication ingestion integrity, had favorable clinical stability, and lower travel time and costs. These findings suggest that using VDOT with dispensers may hold promise as an innovative platform for supporting medication adherence.
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Latif AI, Sjattar EL, Erika KA. Models and benefits of mobile health application to support patient with tuberculosis: A literature review. ENFERMERIA CLINICA 2021. [PMID: 32204135 DOI: 10.1016/j.enfcli.2019.07.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This study aims to evaluate and described the model and benefits of mobile health application to support patients with tuberculosis. METHODS The systematic literature search was conducted with PICO keywords on four databases PubMed, Scopus, ScienceDirect, and ProQuest articles reported in English for the last five years and M-health related to tuberculosis patients. RESULTS Based on six articles that have been analyzed, most patients and health workers responded to the use of M-health as a solution in tuberculosis care, especially medication adherence aspect. The results of the study also show that M-health can optimize tuberculosis care through mobile services. CONCLUSION M-health is needed in patients with care that requires a long period of time and requires routine and appropriate monitoring such as TB especially for medication adherence. Further, the absence of RCT methods becomes the main consideration and suggestion for further research.
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Affiliation(s)
- Aulia Insani Latif
- Graduate Program of Nursing, Faculty of Nursing, Hasanuddin University, Indonesia
| | - Elly Lilianti Sjattar
- Department of Medical-Surgical Nursing, Faculty of Nursing, Hasanuddin University, Indonesia.
| | - Kadek Ayu Erika
- Department of Pediatric Nursing, Faculty of Nursing, Hasanuddin University, Indonesia
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Beeler Asay GR, Lam CK, Stewart B, Mangan JM, Romo L, Marks SM, Morris SB, Gummo CL, Keh CE, Hill AN, Thomas A, Macaraig M, St John K, J Ampie T, Chuck C, Burzynski J. Cost of Tuberculosis Therapy Directly Observed on Video for Health Departments and Patients in New York City; San Francisco, California; and Rhode Island (2017-2018). Am J Public Health 2020; 110:1696-1703. [PMID: 32941064 DOI: 10.2105/ajph.2020.305877] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Objectives. To assess costs of video and traditional in-person directly observed therapy (DOT) for tuberculosis (TB) treatment to health departments and patients in New York City, Rhode Island, and San Francisco, California.Methods. We collected health department costs for video DOT (VDOT; live and recorded), and in-person DOT (field- and clinic-based). Time-motion surveys estimated provider time and cost. A separate survey collected patient costs. We used a regression model to estimate cost by DOT type.Results. Between August 2017 and June 2018, 343 DOT sessions were captured from 225 patients; 87 completed a survey. Patient costs were lowest for VDOT live ($1.01) and highest for clinic DOT ($34.53). The societal (health department + patient) costs of VDOT live and recorded ($6.65 and $12.64, respectively) were less than field and clinic DOT ($21.40 and $46.11, respectively). VDOT recorded health department cost was not statistically different from field DOT cost in Rhode Island.Conclusions. Among the 4 different modalities, both types of VDOT were associated with lower societal costs when compared with traditional forms of DOT.Public Health Implications. VDOT was associated with lower costs from the societal perspective and may reduce public health costs when TB incidence is high.
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Affiliation(s)
- Garrett R Beeler Asay
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Chee Kin Lam
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Brock Stewart
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Joan M Mangan
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Laura Romo
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Suzanne M Marks
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Sapna Bamrah Morris
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Caroline L Gummo
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Chris E Keh
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Andrew N Hill
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Anila Thomas
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Michelle Macaraig
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Kristen St John
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Teresita J Ampie
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Christine Chuck
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - Joseph Burzynski
- Garrett R. Beeler Asay, Chee Kin Lam, Brock Stewart, Joan M. Mangan, Suzanne M. Marks, Sapna Bamrah Morris, Andrew N. Hill, and Anila Thomas are with the Division of Tuberculosis Elimination; National Center for HIV/AIDS, Viral Hepatitis, STD and TB Prevention; Atlanta, GA. Laura Romo, Chris E. Keh, and Teresita J. Ampie are with the San Francisco Department of Public Health, Population Health Division, Disease Prevention and Control Branch, Tuberculosis Prevention and Control, San Francisco, CA. Caroline L. Gummo and Kristen St John are with the Rhode Island Department of Health, Center for HIV, Hepatitis, STD, and Tuberculosis Epidemiology, Providence. Michelle Macaraig, Christine Chuck, and Joseph Burzynski are with the Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
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Guo X, Yang Y, Takiff HE, Zhu M, Ma J, Zhong T, Fan Y, Wang J, Liu S. A Comprehensive App That Improves Tuberculosis Treatment Management Through Video-Observed Therapy: Usability Study. JMIR Mhealth Uhealth 2020; 8:e17658. [PMID: 32735222 PMCID: PMC7428914 DOI: 10.2196/17658] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 04/23/2020] [Accepted: 06/03/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Treatment of pulmonary tuberculosis (TB) requires at least six months and is compromised by poor adherence. In the directly observed therapy (DOT) scheme recommended by the World Health Organization, the patient is directly observed taking their medications at a health post. An alternative to DOT is video-observed therapy (VOT), in which the patients take videos of themselves taking the medication and the video is uploaded into the app and reviewed by a health care worker. We developed a comprehensive TB management system by using VOT that is installed as an app on the smartphones of both patients and health care workers. It was implemented into the routine TB control program of the Nanshan District of Shenzhen, China. OBJECTIVE The aim of this study was to compare the effectiveness of VOT with that of DOT in managing the treatment of patients with pulmonary TB and to evaluate the acceptance of VOT for TB management by patients and health care workers. METHODS Patients beginning treatment between September 2017 and August 2018 were enrolled into the VOT group and their data were compared with the retrospective data of patients who began TB treatment and were managed with routine DOT between January 2016 and August 2017. Sociodemographic characteristics, clinical features, treatment adherence, positive findings of sputum smears, reporting of side effects, time and costs of transportation, and satisfaction were compared between the 2 treatment groups. The attitudes of the health care workers toward the VOT-based system were also analyzed. RESULTS This study included 158 patients in the retrospective DOT group and 235 patients in the VOT group. The VOT group showed a significantly higher fraction of doses observed (P<.001), less missed observed doses (P<.001), and fewer treatment discontinuations (P<.05) than the DOT group. Over 79.1% (186/235) of the VOT patients had >85% of their doses observed, while only 16.4% (26/158) of the DOT patients had >85% of their doses observed. All patients were cured without recurrences. The VOT management required significantly (P<.001) less median patient time (300 minutes vs 1240 minutes, respectively) and transportation costs (¥53 [US $7.57] vs ¥276 [US $39.43], respectively; P<.001) than DOT. Significantly more patients (191/235, 81.3%) in the VOT group preferred their treatment method compared to those on DOT (37/131, 28.2%) (P<.001), and 92% (61/66) of the health care workers thought that the VOT method was more convenient than DOT for managing patients with TB. CONCLUSIONS Implementation of the VOT-based system into the routine program of TB management was simple and it significantly increased patient adherence to their drug regimens. Our study shows that a comprehensive VOT-based TB management represents a viable and improved evolution of DOT.
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Affiliation(s)
- Xujun Guo
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Yarui Yang
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Howard E Takiff
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China.,Pathogenomique Mycobacterienne Integree, Institut Pasteur, Paris, France.,Laboratorio de Genética Molecular, Instituto Venezolano de Investigaciones Cientificas, Caracas, Venezuela
| | - Minmin Zhu
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Jianping Ma
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Tao Zhong
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Yuzheng Fan
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Jian Wang
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
| | - Shengyuan Liu
- Department of Tuberculosis Control and Prevention, Shenzhen Nanshan Centre for Chronic Disease Control, Shenzhen, China
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31
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Rabinovich L, Molton JS, Ooi WT, Paton NI, Batra S, Yoong J. Perceptions and Acceptability of Digital Interventions Among Tuberculosis Patients in Cambodia: Qualitative Study of Video-Based Directly Observed Therapy. J Med Internet Res 2020; 22:e16856. [PMID: 32716309 PMCID: PMC7418013 DOI: 10.2196/16856] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Revised: 04/24/2020] [Accepted: 05/13/2020] [Indexed: 11/13/2022] Open
Abstract
Background Despite the development of effective drugs for treatment, tuberculosis remains one of the leading causes of death from an infectious disease worldwide. One of the greatest challenges to tuberculosis control is patient adherence to treatment. Recent research has shown that video-based directly observed therapy is a feasible and effective approach to supporting treatment adherence in high-income settings. However, few studies have explored the potential for such a solution in a low- or middle-income country setting. Globally, these countries’ rapidly rising rate of mobile penetration suggests that the potential for translation of these results may be high. Objective We sought to examine patient perceptions related to the use of mobile health, and specifically video-based directly observed therapy, in a previously unstudied patient demographic: patients with tuberculosis in a low-income country setting (Cambodia). Methods We conducted a cross-sectional qualitative study in urban and periurban areas in Cambodia, consisting of 6 focus groups with tuberculosis patients who were receiving treatment (standard directly observed therapy) through a nongovernmental organization. Results Familiarity with mobile technology and apps was widespread in this population, and overall willingness to consider a mobile app for video-based directly observed therapy was high. However, we identified potential challenges. First, patients very much valued their frequent in-person interactions with their health care provider, which may be reduced with the video-based directly observed therapy intervention. Second, there may be technical issues to address, including how to make the app suitable for illiterate participants. Conclusions While video-based directly observed therapy is a promising technology, even in country settings where mobile penetration is reportedly almost universal, it should be introduced with caution. However, the results were generally promising and yielded important insights that not only will be translated into the further adaptation of key features of video-based directly observed therapy for tuberculosis patients in Cambodia, but also can inform the future design and successful implementation of video-based directly observed therapy interventions in low- and middle-income settings more generally.
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Affiliation(s)
- Lila Rabinovich
- Center for Economic and Social Research, University of Southern California, Washington, DC, United States
| | - James Steven Molton
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | - Wei Tsang Ooi
- Department of Computer Science, National University of Singapore, Singapore, Singapore
| | - Nicholas Iain Paton
- Department of Medicine, National University of Singapore, Singapore, Singapore
| | | | - Joanne Yoong
- Center for Economic and Social Research, University of Southern California, Washington, DC, United States
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Nurses' Safety in Caring for Tuberculosis Patients at a Teaching Hospital in South West Nigeria. JOURNAL OF ENVIRONMENTAL AND PUBLIC HEALTH 2020; 2020:3402527. [PMID: 32612665 PMCID: PMC7315278 DOI: 10.1155/2020/3402527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 02/17/2020] [Accepted: 05/13/2020] [Indexed: 12/04/2022]
Abstract
Background Tuberculosis remains the leading cause of death due to infectious diseases worldwide ranking above HIV/AIDS, and Nigeria is rated as the 7th worldwide and the 2nd in Africa among the 30 countries highly burdened with tuberculosis worldwide. Aim To investigate the challenges encountered by nurses in the care of TB patients in a Federal Teaching Hospital in Nigeria. Setting. Ekiti State, Southwest Nigeria. Methods A qualitative contextual method was utilized with the sample size determined by data saturation. Data collection was done through an audiotaped, semistructured interview. The study sample consisted of 20 professional nurses working in the medical and paediatric wards of a selected Federal Teaching Hospital in South West, Nigeria. Data was analysed using Tesch's content analysis approach. Results The majority of the participants were females within the age group of 31–40 years. Challenges included inadequate availability of personal protective equipment (PPE), lack of isolation wards, delegating the care of tuberculosis patients to young inexperienced nurses, long process in diagnosing patients with tuberculosis, lack of policies protecting the nurses from exposure to tuberculosis, and inadequate training. The major concern was the fear of contracting tuberculosis. Conclusion The study suggested that there should be a provision of adequate personal protective equipment; tuberculosis designated wards and provision of periodic training to update the nurses on care of tuberculosis patients. Establishment and execution of hospital policies and practices along with support are equally essential in facilitating a safe workplace for nurses.
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Manyazewal T, Woldeamanuel Y, Holland DP, Fekadu A, Blumberg HM, Marconi VC. Electronic pillbox-enabled self-administered therapy versus standard directly observed therapy for tuberculosis medication adherence and treatment outcomes in Ethiopia (SELFTB): protocol for a multicenter randomized controlled trial. Trials 2020; 21:383. [PMID: 32370774 PMCID: PMC7201596 DOI: 10.1186/s13063-020-04324-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/10/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND To address the multifaceted challenges associated with tuberculosis (TB) in-person directly observed therapy (DOT), the World Health Organization recently recommended that countries maximize the use of digital adherence technologies. Sub-Saharan Africa needs to investigate the effectiveness of such technologies in local contexts and proactively contribute to global decisions around patient-centered TB care. This study aims to evaluate the effectiveness of pillbox-enabled self-administered therapy (SAT) compared to standard DOT on adherence to TB medication and treatment outcomes in Ethiopia. It also aims to assess the usability, acceptability, and cost-effectiveness of the intervention from the patient and provider perspectives. METHODS This is a multicenter, randomized, controlled, open-label, superiority, effectiveness-implementation hybrid, mixed-methods, two-arm trial. The study is designed to enroll 144 outpatients with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary TB who are eligible to start the standard 6-month first-line anti-TB regimen. Participants in the intervention arm (n = 72) will receive 15 days of HRZE-isoniazid, rifampicin, pyrazinamide, and ethambutol-fixed-dose combination therapy in the evriMED500 medication event reminder monitor device for self-administration. When returned, providers will count any remaining tablets in the device, download the pill-taking data, and refill based on preset criteria. Participants can consult the provider in cases of illness or adverse events outside of scheduled visits. Providers will handle participants in the control arm (n = 72) according to the standard in-person DOT. Both arms will be followed up throughout the 2-month intensive phase. The primary outcomes will be medication adherence and sputum conversion. Adherence to medication will be calculated as the proportion of patients who missed doses in the intervention (pill count) versus DOT (direct observation) arms, confirmed further by IsoScreen urine isoniazid test and a self-report of adherence on eight-item Morisky Medication Adherence Scale. Sputum conversion is defined as the proportion of patients with smear conversion following the intensive phase in intervention versus DOT arms, confirmed further by pre-post intensive phase BACTEC MGIT TB liquid culture. Pre-post treatment MGIT drug susceptibility testing will determine whether resistance to anti-TB drugs could have impacted culture conversion. Secondary outcomes will include other clinical outcomes (treatment not completed, death, or loss to follow-up), cost-effectiveness-individual and societal costs with quality-adjusted life years-and acceptability and usability of the intervention by patients and providers. DISCUSSION This study will be the first in Ethiopia, and of the first three in sub-Saharan Africa, to determine whether electronic pillbox-enabled SAT improves adherence to TB medication and treatment outcomes, all without affecting the inherent dignity and economic wellbeing of patients with TB. TRIAL REGISTRATION ClinicalTrials.gov, NCT04216420. Registered on 2 January 2020.
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Affiliation(s)
- Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa, P.O. Box 9086, Addis Ababa, Ethiopia
| | - Henry M. Blumberg
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, GA 30322 USA
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Chen SH, Wang I, Hsu HL, Huang CC, Liu YJ, Putri DU, Lee CH. Advantage in privacy protection by using synchronous video observed treatment enhances treatment adherence among patients with latent tuberculosis infection. J Infect Public Health 2020; 13:1354-1359. [PMID: 32376234 DOI: 10.1016/j.jiph.2020.03.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Revised: 03/11/2020] [Accepted: 03/12/2020] [Indexed: 01/20/2023] Open
Abstract
BACKGROUND Treatment of latent tuberculosis infection (LTBI) is an important strategy for active disease prevention. Conventional in-person DOT (CDOT) programs are challenged by patient dissatisfaction over problems of convenience and privacy. The present study assessed satisfaction to DOT program and treatment adherence of synchronous video observed treatment (SVOT) programs from patients' perspectives. METHODS A two-part questionnaire was presented to 240 subjects with LTBI who received a 9-month isoniazid treatment regimen along with mandatory DOT monitoring during January 2014 to December 2017. RESULTS Satisfactions with location arrangement (p<0.001), ensuring treatment adherence (p=0.027), and privacy issues (p=0.005) were superior in the SVOT group. The overall rate of LTBI treatment completion was 91.25%. One (1.25%) and 20 (12.50%) of the participants in the SVOT and CDOT groups, respectively, quit LTBI treatment (p=0.008). Development of adverse events [adjusted hazard ratio, aHR 8.01 (3.42-18.79)], and the concern of privacy infringement [aHR 5.86 (2.69-12.76)] by the DOT program independently increase the risk of withdrawal. SVOT program [aHR 0.21 (0.06-0.68)] and a belief in the importance of adherence on treatment efficacy [aHR 0.29 (0.08-0.98)] were independent predictors preventing patients from withdrawing from treatment. CONCLUSIONS A comprehensive patient-centered DOT program enables high treatment adherence for the 9-month isoniazid LTBI treatment. Furthermore, SVOT was associated with superior patients' satisfactions which translate into higher treatment completion rates. As treatment adherence is the key to the efficacy of LTBI treatment, SVOT should be a reasonable supplement for LTBI treatment.
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Affiliation(s)
- Szu-Hsuan Chen
- Department of Health, Taipei City Government, Taipei 11008, Taiwan
| | - Irene Wang
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Han-Lin Hsu
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan; School of Respiratory Therapy, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Chi-Ching Huang
- Department of Health, Taipei City Government, Taipei 11008, Taiwan
| | - Yi-Jun Liu
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Denise Utami Putri
- Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan
| | - Chih-Hsin Lee
- Division of Pulmonary Medicine, Department of Internal Medicine, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan; Pulmonary Research Center, Wan Fang Hospital, Taipei Medical University, Taipei 11696, Taiwan.
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Sekandi JN, Buregyeya E, Zalwango S, Dobbin KK, Atuyambe L, Nakkonde D, Turinawe J, Tucker EG, Olowookere S, Turyahabwe S, Garfein RS. Video directly observed therapy for supporting and monitoring adherence to tuberculosis treatment in Uganda: a pilot cohort study. ERJ Open Res 2020; 6:00175-2019. [PMID: 32280670 PMCID: PMC7132038 DOI: 10.1183/23120541.00175-2019] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/11/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Nonadherence to treatment remains an obstacle to tuberculosis (TB) control worldwide. The aim of this study was to evaluate the feasibility of using video directly observed therapy (VDOT) for supporting TB treatment adherence in Uganda. Methods From May to December 2018, we conducted a pilot cohort study at a TB clinic in Kampala City. We enrolled patients aged 18–65 years with ≥3 months remaining of their TB treatment. Participants were trained to use a smartphone app to record videos of medication intake and submit them to a secured system. Trained health workers logged into the system to watch the submitted videos. The primary outcome was adherence measured as the fraction of expected doses observed (FEDO). In a secondary analysis, we examined differences in FEDO by sex, age, phone ownership, duration of follow-up, reasons for missed videos and patients' satisfaction at study exit. Results Of 52 patients enrolled, 50 were analysed. 28 (56%) were male, the mean age was 31 years (range 19–50 years) and 35 (70%) owned smartphones. Of the 5150 videos expected, 4231 (82.2%) were received. The median FEDO was 85% (interquartile range 66%–94%) and this significantly differed by follow-up duration. Phone malfunction, uncharged battery and VDOT app malfunctions were the commonest reasons for missed videos. 92% of patients reported being very satisfied with using VDOT. Conclusion VDOT was feasible and acceptable for monitoring and supporting TB treatment. It resulted in high levels of adherence, suggesting that digital technology holds promise in improving patient monitoring in Uganda. Video directly observed therapy is feasible and acceptable for supporting and monitoring TB treatment adherence in a low-resource setting like Uganda. Digital health interventions hold promise as alternative methods for improving patient care.http://bit.ly/2Hxnvwu
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Affiliation(s)
- Juliet N Sekandi
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA.,Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Sarah Zalwango
- School of Public Health, Makerere University, Kampala, Uganda.,Kampala Capital City Authority, Dept of Public Health Service and Environment, Kampala, Uganda
| | - Kevin K Dobbin
- Dept of Epidemiology and Biostatistics, College of Public Health, University of Georgia, Athens, GA, USA
| | - Lynn Atuyambe
- School of Public Health, Makerere University, Kampala, Uganda
| | | | - Julius Turinawe
- School of Public Health, Makerere University, Kampala, Uganda
| | - Emma G Tucker
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | - Shade Olowookere
- Global Health Institute, College of Public Health, University of Georgia, Athens, GA, USA
| | | | - Richard S Garfein
- School of Medicine, University of California, San Diego, La Jolla, CA, USA
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Lee Y, Raviglione MC, Flahault A. Use of Digital Technology to Enhance Tuberculosis Control: Scoping Review. J Med Internet Res 2020; 22:e15727. [PMID: 32053111 PMCID: PMC7055857 DOI: 10.2196/15727] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Tuberculosis (TB) is the leading cause of death from a single infectious agent, with around 1.5 million deaths reported in 2018, and is a major contributor to suffering worldwide, with an estimated 10 million new cases every year. In the context of the World Health Organization’s End TB strategy and the quest for digital innovations, there is a need to understand what is happening around the world regarding research into the use of digital technology for better TB care and control. Objective The purpose of this scoping review was to summarize the state of research on the use of digital technology to enhance TB care and control. This study provides an overview of publications covering this subject and answers 3 main questions: (1) to what extent has the issue been addressed in the scientific literature between January 2016 and March 2019, (2) which countries have been investing in research in this field, and (3) what digital technologies were used? Methods A Web-based search was conducted on PubMed and Web of Science. Studies that describe the use of digital technology with specific reference to keywords such as TB, digital health, eHealth, and mHealth were included. Data from selected studies were synthesized into 4 functions using narrative and graphical methods. Such digital health interventions were categorized based on 2 classifications, one by function and the other by targeted user. Results A total of 145 relevant studies were identified out of the 1005 published between January 2016 and March 2019. Overall, 72.4% (105/145) of the research focused on patient care and 20.7% (30/145) on surveillance and monitoring. Other programmatic functions 4.8% (7/145) and electronic learning 2.1% (3/145) were less frequently studied. Most digital health technologies used for patient care included primarily diagnostic 59.4% (63/106) and treatment adherence tools 40.6% (43/106). On the basis of the second type of classification, 107 studies targeted health care providers (107/145, 73.8%), 20 studies targeted clients (20/145, 13.8%), 17 dealt with data services (17/145, 11.7%), and 1 study was on the health system or resource management. The first authors’ affiliations were mainly from 3 countries: the United States (30/145 studies, 20.7%), China (20/145 studies, 13.8%), and India (17/145 studies, 11.7%). The researchers from the United States conducted their research both domestically and abroad, whereas researchers from China and India conducted all studies domestically. Conclusions The majority of research conducted between January 2016 and March 2019 on digital interventions for TB focused on diagnostic tools and treatment adherence technologies, such as video-observed therapy and SMS. Only a few studies addressed interventions for data services and health system or resource management.
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Affiliation(s)
- Yejin Lee
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
| | - Mario C Raviglione
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland.,Centre for Multidisciplinary Research in Health Science (MACH), Università di Milano, Milan, Italy
| | - Antoine Flahault
- Institute of Global Health, Faculty of Medicine, University of Geneva, Geneva, Switzerland.,Global Studies Institute, University of Geneva, Geneva, Switzerland
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Garfein RS, Doshi RP. Synchronous and asynchronous video observed therapy (VOT) for tuberculosis treatment adherence monitoring and support. J Clin Tuberc Other Mycobact Dis 2019; 17:100098. [PMID: 31867442 PMCID: PMC6904830 DOI: 10.1016/j.jctube.2019.100098] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Directly observed therapy (DOT) for monitoring tuberculosis (TB) treatment is intended to reduce disease transmission, mortality and acquired drug resistance by facilitating treatment adherence and support. Synchronous (S-VOT) and asynchronous (A-VOT) video observed therapy are mHealth solutions for remotely monitoring medication ingestion. This paper synthesizes literature through December 2018 to describe existing VOT approaches, summarize evidence, identify knowledge gaps, evaluate VOT strengths and weaknesses, and examine patient and provider factors influencing VOT feasibility and acceptability. High rates of adherence and patient acceptance were obtained using both VOT methods. VOT reduced travel time for TB program staff and/or patients, improving program efficiency compared to in-person DOT while maintaining high patient satisfaction. The impact of VOT on TB treatment outcomes, such as cure and relapse, require further study with longer follow-up. Individual patient, provider and program factors should be considered in selecting either or both VOT approaches for provision of patient-centered care.
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Affiliation(s)
- Richard S. Garfein
- Division of Epidemiology, School of Medicine, University of California San Diego, 9500 Gilman Drive, Mailcode-0725, La Jolla, CA 92093-0725, USA
| | - Riddhi P. Doshi
- Division of Behavioral Sciences and Community Health, School of Dental Medicine, University of Connecticut Health Center, 263 Farmington Avenue, MC 6030, Farmington, CT 06030, USA
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Vernon A, Fielding K, Savic R, Dodd L, Nahid P. The importance of adherence in tuberculosis treatment clinical trials and its relevance in explanatory and pragmatic trials. PLoS Med 2019; 16:e1002884. [PMID: 31821323 PMCID: PMC6903706 DOI: 10.1371/journal.pmed.1002884] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Andrew Vernon and co-authors discuss adherence to therapy and its measurement in tuberculosis treatment trials.
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Affiliation(s)
- Andrew Vernon
- Clinical Research Branch, Division of TB Elimination, NCHHSTP, US Centers for Disease Control & Prevention, Atlanta, Georgia, United States of America
| | - Katherine Fielding
- TB Centre, London School of Hygiene & Tropical Medicine, London, United Kingdom
- Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Rada Savic
- Department of Bioengineering and Therapeutic Sciences, University of California, San Francisco, California, United States of America
| | - Lori Dodd
- National Institute for Allergy and Infectious Disease, National Institutes of Health, Washington DC, United States of America
| | - Payam Nahid
- Division of Pulmonary and Critical Care Medicine, University of California, San Francisco at San Francisco General Hospital, San Francisco, California, United States of America
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Nahid P, Mase SR, Migliori GB, Sotgiu G, Bothamley GH, Brozek JL, Cattamanchi A, Cegielski JP, Chen L, Daley CL, Dalton TL, Duarte R, Fregonese F, Horsburgh CR, Ahmad Khan F, Kheir F, Lan Z, Lardizabal A, Lauzardo M, Mangan JM, Marks SM, McKenna L, Menzies D, Mitnick CD, Nilsen DM, Parvez F, Peloquin CA, Raftery A, Schaaf HS, Shah NS, Starke JR, Wilson JW, Wortham JM, Chorba T, Seaworth B. Treatment of Drug-Resistant Tuberculosis. An Official ATS/CDC/ERS/IDSA Clinical Practice Guideline. Am J Respir Crit Care Med 2019; 200:e93-e142. [PMID: 31729908 PMCID: PMC6857485 DOI: 10.1164/rccm.201909-1874st] [Citation(s) in RCA: 230] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background: The American Thoracic Society, U.S. Centers for Disease Control and Prevention, European Respiratory Society, and Infectious Diseases Society of America jointly sponsored this new practice guideline on the treatment of drug-resistant tuberculosis (DR-TB). The document includes recommendations on the treatment of multidrug-resistant TB (MDR-TB) as well as isoniazid-resistant but rifampin-susceptible TB.Methods: Published systematic reviews, meta-analyses, and a new individual patient data meta-analysis from 12,030 patients, in 50 studies, across 25 countries with confirmed pulmonary rifampin-resistant TB were used for this guideline. Meta-analytic approaches included propensity score matching to reduce confounding. Each recommendation was discussed by an expert committee, screened for conflicts of interest, according to the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology.Results: Twenty-one Population, Intervention, Comparator, and Outcomes questions were addressed, generating 25 GRADE-based recommendations. Certainty in the evidence was judged to be very low, because the data came from observational studies with significant loss to follow-up and imbalance in background regimens between comparator groups. Good practices in the management of MDR-TB are described. On the basis of the evidence review, a clinical strategy tool for building a treatment regimen for MDR-TB is also provided.Conclusions: New recommendations are made for the choice and number of drugs in a regimen, the duration of intensive and continuation phases, and the role of injectable drugs for MDR-TB. On the basis of these recommendations, an effective all-oral regimen for MDR-TB can be assembled. Recommendations are also provided on the role of surgery in treatment of MDR-TB and for treatment of contacts exposed to MDR-TB and treatment of isoniazid-resistant TB.
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Lam CK, Fluegge K, Macaraig M, Burzynski J. Cost savings associated with video directly observed therapy for treatment of tuberculosis. Int J Tuberc Lung Dis 2019; 23:1149-1154. [PMID: 31718750 DOI: 10.5588/ijtld.18.0625] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVE: To calculate the per-session and annual direct program costs to implement directly observed therapy (DOT) for tuberculosis treatment and to conduct a cost attribution analysis under varying proportions of DOT utilization for four DOT types.DESIGN: Program data covering the study period from September 2014 to August 2015 in New York City (NYC) were used to conduct a retrospective bottom-up micro-costing economic evaluation. For each DOT type, potential per-session and annual program savings were estimated as the cost averted by adopting a uniform distribution of DOT alternatives. Sensitivity analyses explored aggregate cost impacts of unequal distributions.RESULTS: There was a total of 38 035 unique DOT visits, of which 12 002 (32%) were clinic-based (CDOT); 15 483 (41%) were field-based (FDOT); 7185 (19%) were live-video (LVDOT); and 3365 (9%) were recorded-video (RVDOT). The per-session direct costs (in 2016 $US) for DOT services delivered during the study period were $8.46 for CDOT; $19.83 for FDOT; $6.54 for LVDOT; and $5.35 for RVDOT. Sensitivity analyses supported the main findings.CONCLUSIONS: Significant cost savings were estimated with increased utilization of VDOT. Assuming equivalent treatment adherence, duration, completion, and adverse events across DOT types, RVDOT was the modality that most minimized cost.
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Affiliation(s)
- C K Lam
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA
| | - K Fluegge
- Policy, Planning and Strategic Data Use, Office of the First Deputy Commissioner, New York City Department of Health and Mental Hygiene, Queens, NY, Institute of Health and Environmental Research, Cleveland, OH, USA
| | - M Macaraig
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
| | - J Burzynski
- Bureau of Tuberculosis Control, New York City Department of Health and Mental Hygiene, Queens, NY
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Holzman SB, Atre S, Sahasrabudhe T, Ambike S, Jagtap D, Sayyad Y, Kakrani AL, Gupta A, Mave V, Shah M. Use of Smartphone-Based Video Directly Observed Therapy (vDOT) in Tuberculosis Care: Single-Arm, Prospective Feasibility Study. JMIR Form Res 2019; 3:e13411. [PMID: 31456581 PMCID: PMC6734854 DOI: 10.2196/13411] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 06/12/2019] [Accepted: 06/29/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND India accounts for nearly one-quarter of the global tuberculosis (TB) burden. Directly observed treatment (DOT) through in-person observation is recommended in India, although implementation has been heterogeneous due largely to resource limitations. Video DOT (vDOT) is a novel, smartphone-based approach that allows for remote treatment monitoring through patient-recorded videos. Prior studies in high-income, low disease burden settings, such as the United States, have shown vDOT to be feasible, although little is known about the role it may play in resource-limited, high-burden settings. OBJECTIVE The goal of the research was to assess the feasibility and acceptability of vDOT for adherence monitoring within a resource-limited, high TB burden setting of India. METHODS We conducted a prospective, single-arm, pilot implementation of vDOT in Pune, India. Outcome measures included adherence (proportion of prescribed doses observed by video) and verifiable fraction (proportion of prescribed doses observed by video or verbally confirmed with the patient following an incomplete/unverifiable video submission). vDOT acceptability among patients was assessed using a posttreatment survey. RESULTS A total of 25 patients enrolled. The median number of weeks on vDOT was 13 (interquartile range [IQR] 11-16). Median adherence was 74% (IQR 62%-84%), and median verifiable fraction was 86% (IQR 74%-98%). More than 90% of patients reported recording and uploading videos without difficulty. CONCLUSIONS We have demonstrated that vDOT may be a feasible and acceptable approach to TB treatment monitoring in India. Our work expands the evidence base around vDOT by being one of the first efforts to evaluate vDOT within a resource-limited, high TB burden setting. To our knowledge, this is the first reported use of vDOT in India.
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Affiliation(s)
- Samuel B Holzman
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Sachin Atre
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Tushar Sahasrabudhe
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Sunil Ambike
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Deepak Jagtap
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Yakub Sayyad
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Arjun Lal Kakrani
- Dr D Y Patil Medical College, Hospital, and Research Center, Dr D Y Patil Vidyapeeth, Pune, India
| | - Amita Gupta
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Vidya Mave
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Maunank Shah
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Cruz AT, Starke JR. Window Period Prophylaxis for Children Exposed to Tuberculosis, Houston, Texas, USA, 2007-2017. Emerg Infect Dis 2019; 25:523-528. [PMID: 30789136 PMCID: PMC6390765 DOI: 10.3201/eid2503.181596] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
In this retrospective study, we assessed the safety of window period prophylaxis and proportion of tuberculin skin test (TST) conversions in children <5 years of age who were exposed to an adult with tuberculosis disease during 2007-2017. Children included in this study had unremarkable examination and chest radiograph findings and negative test results for TB infection. In total, 752 children (41% cohabitating with the index patient) received prophylaxis during the window period, usually directly observed therapy with isoniazid. Hepatotoxicity and tuberculosis disease did not develop in any child. TST conversion occurred in 37 (4.9%) children and was associated with the index patient being the child's parent (odds ratio 3.2, 95% CI 1.2-8.2). TST conversion was not associated with sputum smear results, culture positivity, or cohabitation. Thresholds for initiation of window prophylaxis in exposed young children should be low given the safety of medication and difficulties with risk stratification.
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Monitoring Treatment of Childhood Tuberculosis and the Role of Therapeutic Drug Monitoring. Indian J Pediatr 2019; 86:732-739. [PMID: 30815840 DOI: 10.1007/s12098-019-02882-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 01/23/2019] [Indexed: 10/27/2022]
Abstract
Most children tolerate the first-line antibiotics used to treat Mycobacterium tuberculosis (TB) very well. The most common adverse effect is gastrointestinal distress unrelated to hepatotoxicity; the latter is seen in less than 1% of children. Despite the infrequency of hepatotoxicity, the potential long-term impact of hepatic insufficiency dictates that all children receiving antimycobacterial therapy should be evaluated periodically by symptom screening and physical examination. Routine measurement of transaminases in previously healthy, asymptomatic children is discouraged, as up to 40% of children will have transient, asymptomatic transaminase elevation that should not alter clinical management; measurement of serum liver enzymes is reserved for children who develop symptoms and those with existing liver disease or taking other potentially hepatotoxic drugs. Caregivers and personnel distributing directly-observed therapy need to be cognizant of potential drug toxicities and have a clear understanding of what to do if a child develops symptoms. There are substantial inter-patient variations in serum antibiotic concentrations when the same milligram per kilogram dose is given to different children of varying ages and sizes, reflecting differences in drug absorption and metabolism. While these variations may not impact the outcome of previously healthy children with mild disease, outcomes for children with human immunodeficiency virus infection or severe disease can be worse if sub-therapeutic drug concentrations are achieved. Therapeutic drug monitoring, wherein serum drug concentrations are used to optimize medication doses, should be considered for children with severe disease or if there is concern about alterations in drug absorption or metabolism.
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Tomines A. Pediatric Telehealth: Approaches by Specialty and Implications for General Pediatric Care. Adv Pediatr 2019; 66:55-85. [PMID: 31230700 DOI: 10.1016/j.yapd.2019.04.005] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alan Tomines
- Department of Pediatrics, UCLA Geffen School of Medicine, Los Angeles, CA, USA; Enterprise Information Services, Cedars-Sinai Medical Center, Los Angeles, CA, USA; Harbor-UCLA Medical Center, Torrance, CA, USA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA, USA.
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Putt ME, Reese PP, Volpp KG, Russell LB, Loewenstein G, Yan J, Pagnotti D, McGilloway R, Brennen T, Finnerty D, Hoffer K, Chadha S, Barankay I. The Habit Formation trial of behavioral economic interventions to improve statin use and reduce the risk of cardiovascular disease: Rationale, design and methodologies. Clin Trials 2019; 16:399-409. [PMID: 31148473 PMCID: PMC6663645 DOI: 10.1177/1740774519846852] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Low adherence to statin (HMG-CoA reductase inhibitors) medication is common. Here, we report on the design and implementation of the Habit Formation trial. This clinical trial assessed whether the interventions, based on principles from behavioral economics, might improve statin adherence and lipid control in at-risk populations. We describe the rationale and methods for the trial, recruitment, conduct and follow-up. We also report on several barriers we encountered with recruitment and conduct of the trial, solutions we devised and efforts we will make to assess their impact on our study. METHODS Habit Formation is a four-arm randomized controlled trial. Recruitment of 805 participants at elevated risk of atherosclerotic cardiovascular disease with evidence of sub-optimal statin adherence and low-density lipoprotein (LDL) control is complete. Initially, we recruited from large employers (Employers) and a national health insurance company (Insurers) using mailed letters; individuals with a statin Medication Possession Ratio less than 80% were invited to participate. Respondents were enrolled if a laboratory measurement of low-density lipoprotein was >130 mg/dL. Subsequently, we recruited participants from the Penn Medicine Health System; individuals with usual-care low-density lipoprotein of >100 mg/dL in the electronic medical record were recruited using phone, text, email, and regular mail. Eligible participants self-reported incomplete medication adherence. During a 6-month intervention period, all participants received a wireless-enabled pill bottle for their statins and daily reminder messages to take their medication. Principles of behavioral economics were used to design three financial incentives, specifically a Simple Daily Sweepstakes rewarding daily medication adherence, a Deadline Sweepstakes where participants received either a full or reduced incentive depending on whether they took their medication before or after a daily reminder or Sweepstakes Plus Deposit Contract with incentives divided between daily sweepstakes and a monthly deposit. Six months post-incentives, we compared the primary outcome, mean change from baseline low-density lipoprotein, across arms. RESULTS AND LESSONS LEARNED Health system recruitment yielded substantially better enrollment and was cost-efficient. Despite unexpected systematic failure and/or poor availability of two wireless pill bottles, we achieved enrollment targets and implemented the interventions. For new trials, we will routinely monitor device function and have contingency plans in the event of systemic failure. CONCLUSION Interventions used in the Habit Formation trial could be translated into clinical practice. Within a large health system, successful recruitment depended on identification of eligible individuals through their electronic medical record, along with flexible ways of contacting these individuals. Challenges with device failure were manageable. The study will add to our understanding of optimally structuring and implementing incentives to motivate durable behavior change.
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Affiliation(s)
- Mary E Putt
- 1 Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Peter P Reese
- 1 Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- 2 Renal Division, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- 8 The Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA
| | - Kevin G Volpp
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
- 4 Corporal Michael Crescenz VA Medical Center, Philadelphia, PA, USA
- 8 The Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA
| | - Louise B Russell
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
- 8 The Leonard Davis Institute of Health Economics (LDI), University of Pennsylvania, Philadelphia, PA, USA
| | - George Loewenstein
- 5 Department of Social and Decision Sciences, Carnegie Mellon University, Pittsburgh, PA, USA
| | - Jiali Yan
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - David Pagnotti
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Ryan McGilloway
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Troyen Brennen
- 6 Department of Health Policy & Management, T.H. Chan School of Public Health, Harvard University, Boston, MA, USA
| | - Darra Finnerty
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Karen Hoffer
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Sakshum Chadha
- 3 Department of Medical Ethics and Health Policy, Perelman School of Medicine, Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Iwan Barankay
- 7 Department of Management and Department of Business Economics and Public Policy, The Wharton School, University of Pennsylvania, Philadelphia, PA, USA
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Low Incidence and High Profile: Tuberculosis Control in Delaware. Dela J Public Health 2019; 5:60-62. [PMID: 34467030 PMCID: PMC8396758 DOI: 10.32481/djph.2019.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Tuberculosis (TB) is an infectious disease of global burden. While Delaware has low incidence of active TB compared to other locales, because of its small size these few cases tend to garner widespread attention. In this article, a study of one such case of active TB is presented. This case serves as a didactic example of the public health response to the complexities of treatment, including institutional, transient settings, and patient refusal. This consequently led to ordered directly observed therapy of the individual. The article concludes with a discussion of the law and legal implications for such cases in Delaware.
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