A critical challenge in tuberculosis treatment is to ensure that patients adhere to the full course of medication. In India, use of Directly Observed Therapy (DOT) in the public sector has been associated with high treatment success. However, direct observation introduces challenges for patients and providers, who need to undertake frequent travel throughout the course of treatment. It is also challenging for program managers to detect and respond to missed doses in an accurate and timely way. An alternative approach to ensuring medication adherence is via use of medication monitors that track each dose dispensed. For example, in China, an electronic medication monitor was recently shown1 to improve adherence to TB medications by 43%. Far from a technology-centric intervention, medication monitors are effective due to behavioral support: reminders to patients, monitoring by care providers, and automatic outreach to social networks. However, current medication monitors are prohibitively expensive, often costing up to $100 per device. Until now, their benefits have been out-of-reach for low-income patients in the developing world.
99DOTS is a low-cost approach for monitoring and improving TB medication adherence. It can be utilized either as a supplement to existing DOTS programs, or to enable remote observation of doses administered by patients or their family members. Using 99DOTS, each anti-TB blister pack is wrapped in a custom envelope, which includes hidden phone numbers that are visible only when doses are dispensed. After taking daily medication, patients make a free call to the hidden phone number, yielding high confidence that the dose was “in-hand” and has been taken.
It is important to note that 99DOTS requires only a small number of phone numbers. The numbers called by a patient may repeat over time; however, on each blister pack, the numbers are arranged in an unpredictable sequence. As treatment progresses, the sequence of numbers called is checked against the blister designs, thereby verifying that the patient is taking medication as intended.
99DOTS patients receive a series of daily reminders (via SMS and automated calls). Missed doses trigger SMS notifications to care providers, who follow up with personal, phone-based counseling. Real-time adherence reports are also available on the web.
Up until now, 99DOTS has registered over 59,910 patients, who have been enrolled across project sites. The map above illustrates the diversity of deployment sites. These deployments span across urban and rural sites across the country, and demonstrate the feasibility of using 99DOTS in different environments, highlighting opportunities and challenges unique to each locality.
Compared to the current standard of care, 99DOTS offers three key benefits. First, it reduces patients’ burden: instead of traveling to a center for every dose, patients can provide evidence of dosing from the comfort of their home. Second, it improves the efficiency of care providers: instead of waiting weeks or months for adherence records to be digitized, supervisors can view real-time adherence data for every patient and ensure prompt response to every missed dose. Finally, 99DOTS enables differentiated care: instead of mandating that all patients receive frequent counseling, adherent patients can proceed with less supervision, while limited program resources are focused on cases that need the most attention.
Please read our philosophy and beliefs in global access to learn more about the how 99DOTS is built, contributed, and released freely for global open access.