Article Start
Use of mobile phone text-messaging (or short message service/SMS as it is also known) could help tuberculosis patients in the world's most remote locations adhere to their treatment. The promising early results of this strategy are discussed in the World Report in this week's edition of The Lancet, written by freelance journalist Eliza Barclay.

Treatment for tuberculosis is a combination of strong antibiotics that must be taken for at least six months - and this can cause side-effects such as nausea, which can put patients off taking their tablets. To help people complete their treatment, WHO currently recommends the DOTS (directly observed, short course) strategy, in which a health worker watches the patient take their antibiotics every day. While this strategy has helped dramatically improve tuberculosis control around the world, it is insufficient or inaccessible for thousands of patients. It is also expensive and human-resource intensive.

Several disease control and technology specialists are now looking to SMS as a cost-effective way to communicate with and monitor hard-to-reach patients in remote locations. "The problem is enormous, and everything has to be done in order to prevent patients from defaulting", said Mario Raviglione, director of WHO's Stop TB Department. "Anything that can be done technologically to help solve this issue like these cellphone technologies would be useful."

Although tuberculosis is a disease affecting poor people, even those living on US$1 per day increasingly have access to mobile phones. There are more than 3� billion mobile-phone subscriptions worldwide. By the end of 2006, according to the International Telecommunications Union, 68% of those subscriptions were in developing countries. South Africa has proven a fertile testing ground for new drug-compliance technologies - 71% of DOTS treated patients were cured from tuberculosis; most patients who were not successfully treated under DOTS had stopped taking their medication.

The way the SMS strategy could work is provided in this example: London-based company SIMpill have made a small pill bottle that contains a SIM card and when opened, the SIM card delivers a SMS with a unique pill box identification number to a central server. The central server receives the incoming SMS and stores the data, but if no SMS is received at the designated time, the server contacts the patient via phone alerting them to take their medication. If the patient does not respond, the server contacts a caregiver who can follow-up with the patient. A trial at three clinics in Cape Town showed that, after 10 months of SIMpill, treatment adherence among 155 tuberculosis patients was 86-92% with a treatment success rate of 94%. As well as helping treatment adherence, the SMS strategy allows health workers to use their precious time for other tasks.

Other products and trials are also discussed in the World Report. X out TB is an SMS-based system in which patients urinate on a filter-paper diagnostic device after taking their medication. If their urine contains, as it should, the metabolites of their tuberculosis drugs, a code is generated which patients send via SMS to a central data system. Based on accumulated right answers (ie, correct codes) at the end of the month, patients receive rewards such as free mobile phone credit.

However, not all experts believe that mobile phone technology is necessary. According to Hamish Fraser, director of informatics and telemedicine for Partners in Health (PIH) and assistant professor at Harvard Medical School, the success of PIH's programmes without the use of SMS communication indicate that SMS-based health technologies may be unnecessary. "I think in developing countries, having a DOTS worker visit patients in their home is extremely effective", said Fraser. "We don't immediately feel there's a big gap there so I'm less sold on cellphones."

Raviglione, however, believes that SMS health technologies could have a role in improving communication in tuberculosis treatment and care. "Though the human aspect of tuberculosis care and control must not be forgotten or underemphasised, there's always great value in increasing communication between the patients and the clinicians", he said.

http://www.thelancet.com Vol 373 January 3, 2009

The Lancet
Article End