A gr8 way to ensure adherence to tuberculosis medication

An ingenious new system has been developed to make sure that patients with tuberculosis (TB) complete their entire course of treatment, thus preventing the emergence and spread of drug-resistant forms of the disease.

TB urine testXoutTB involves a paper strips embedded with chemicals that detect metabolites of the TB drug isoniazid in a patient’s urine. The strips contain four printed numbers, a certain combination of which react and turn a new colour when exposed to the urine of patients who have taken their medication.

Patients then send a mobile phone text message reporting the numbers on their strip to a central database.  Those patients who take the drugs consistently for 30 days are be rewarded with cell-phone minutes.

TB is a preventable but potentially deadly bacterial infection that kills almost 2 million people each year. Rates of TB have increased since the 1980s, in part due to the emergence of drug-resistant strains of the TB bacteria.

Drug resistance is a serious barrier to effective treatment of TB and to the permanent eradication of the disease, so serious that the World Health Organisation this week called the problem “a potentially explosive situation”.

Drug-resistant strains of TB emerge when the antibiotic used to treat the infection fails to kill all of the bacteria it targets. The surviving bacteria become resistant to that particular drug and pass this characteristic on to their descendants, thus spreading the trait.

The major cause of TB drug resistance is inadequate treatment, either because the wrong drugs are prescribed or because people don’t take the entire six-month course of medication.  In particular, TB medication has considerable side effects, so to many individuals there seems little incentive or personal gain to be had from taking the whole course of medication.

The new monitoring system, developed by José Gómez-Márquez and colleagues of the Innovations in International Health program at Massachusetts Institute of Technology, provides a clear monetary incentive to encourage patients to take the medications that will improve their health and also indirectly benefit the health of others.

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Can text messages be used to monitor health?

text-messageMobile phones are possibly one of the most ubiquitous pieces of technology in the 21st century.  In 2003 the Office of National Statistics reported that 75% of all adults in the UK owned or used a mobile phone, and Wikipedia estimates that the UK now has more mobile phones than people.

Text messaging has been the surprise success of mobile phones – who would have thought that people would prefer to write out a message to their friends rather than simply give them a quick call?  The latest statistics record that 4.7 million messages are being sent every hour in Britain, with 72% of women and 70% of men texting regularly.  These days, however, text messages are being put to much worthier use than simply catching up on last night’s gossip.

Earlier this month the BMJ reported that the ability to send a text message was a sure sign of recovery from a faint or a panic attack.  The authors of the study had spent several years working for the charity Festival Medical Services, helping out in the first aid tents at large British music festivals.  They noticed that teenagers who were brought in for medical attention would send a text message to their friends as soon as they were feeling better.  Given that sending a text message requires “a Glasgow coma scale score of 15 (fully conscious), an adequately functioning ‘executive system’ in the frontal lobes, and a high degree of manual dexterity and psychomotor coordination”, they concluded that this ability was reasonable grounds for discharge and successfully employed ‘the text test’ during busy times at this year’s Reading Festival.

Text messages have also been employed by heathcare trusts to monitor the medical status of patients.  Oxfordshire and Buckinghamshire Mental Health and Oxford University’s Department of Psychiatry have been using a daily text message to monitor the mood of mental health patients.  Patients receive a text message every morning and  respond with a letter in the range of A to E, which corresponds with mood on a scale from depression and euphoria.  This technique allows doctors to to plot mood swings in real time, monitor medication efficacy and assess whether a face-to-face appointment is needed, and removes the need for unreliable retrospective assessments.  The system is current being used with 150 patients and is due to be rolled out across Oxfordshire and Buckinghamshire in the new year.

In a similar vein, London’s Hammersmith & Fulham Primary Care Trust has been using text messages to establish the current smoking status of patients and, accordingly, their risk of developing cardiovascular disease.  As many as 49% of patients responded to texts enquiring whether they were active smokers, a much higher response rate than other methods of communication previously used.  Doctors were then able to quickly and efficiently update medical records.  The system that the Trust used, iPlato, began as a means of reducing missed GP appointments within the NHS and has now been adopted across 40 NHS organisations, including 36 Primary Care Trusts.  As well as monitoring smoking status, iPlato also uses text messages to establish methadone compliance, keep tabs on patients on weight management plans and helps patients stay up to date with prescriptions.

And it’s not just in the UK that healthcare providers are exploiting text messages to monitor patients.  The Infectious Disease Clinic at the University of Virginia is piloting a text messaging system to improve contact with HIV patients living in rural parts of the state. In the programme, patients are given a mobile phone that only receives texts about medication regimens and pending medical appointments, and can only call emergency and medical contacts.  Organizers hope that this initiative will help patients adhere to their treatment for longer than 6 months, the current drop off point.

Stanford University in California and the Centers for Disease Control and Prevention even held a conference on text messages and healthcare in February this year – Texting 4 Health.  The event “showcased applications, ideas, and insights on using mobile text messaging to improve personal and public health”.  Speakers from as far afield as Denmark and Scotland presented the text messaging strategies that are currently in use in their regions – HandyMentor for asthma self management and SweetTalk for diabetes reminders if you’re wondering – and techniques to provide health information and instigate healthy lifestyles via text messaging were presented (the full conference program and slides can be found here).

Given the widespread use of mobile phones, text messages could certainly be a cheap and far reaching way to monitor patients and disseminate public health information.  What do you think?  Are text messages the future of health management?  Are text messaging programmes going to be widely adopted for public health purposes in 2009?  Or are text messages good only for personal affairs and not for important medical information?

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