Tuberculosis treatment: There's an app for that

In the past, public health nurses had to drive all over the county to make sure tuberculosis patients were taking their medication as indicated.

Patients had to make an appointment during work hours so that nurses could watch them take their antibiotics.

Now, TB patients who are no longer contagious can take their medication wherever and whenever they like, and nurses can focus on in-depth monthly visits. To observe treatment, all nurses must do is watch a video of patients taking it.

That's because about one year ago, the county Tuberculosis Control Program fully implemented a mobile app – emocha – that allows patients to upload a video of themselves taking their daily medication.

The adoption of this application is the culmination of several years of collaborative work with researcher Richard Garfein, Ph.D., from University of California San Diego. Garfein helped pioneer the use of mobile video applications for TB therapy, including the development of another tuberculosis treatment app called SureAdhere. The process is called Video Directly Observed Therapy, or VDOT. It is secure and protects patients' confidentiality.

"We're very happy with the video app," Dr. Wilma Wooten, county public health officer, said, adding that San Diego County is one of the first counties in the state and the nation to use this system. "Using the Video Directly Observed Therapy saves traveling time since nurses don't have to go to people's homes daily."

When a patient is diagnosed with tuberculosis, antibiotic treatment immediately follows. The typical TB treatment lasts between six and nine months, but can go on for 18 months depending on the severity of the disease and where in the body the bacteria is located. Patients must take daily medication to treat the disease completely and keep it from becoming a public health threat.

That's why it is essential that patients complete the treatment as prescribed, and in order for that to happen, nurses need to directly observe the patient taking their medication.

Until last year, nurses had to go to patients' homes or use a landline and a video screen to observe patients taking their daily medication. It required appointments, and patients had to take their treatment when the nurses were on duty, which often interrupted the patients' work schedules.

Now, when a patient is diagnosed with tuberculosis, a nurse visits their home to show them how to download and use the VDOT app, which allows for 21 different languages.

"The application is very easy to follow," Krystal Liang, public health nurse supervisor with the county Tuberculosis Control Program, said. "Technology allows people to have more flexibility."

When using the video app, the patient has to be on camera at all times. The app tells patients what the date is, what medications they need to take, as well as the daily dosage.

But the app is not suitable for everyone. If a patient is having symptoms or side effects from the medication and lets the app know, it will not allow the patient to record the video.

"If they have side effects, we have to be present to assess the patient and keep a closer eye on them," Liang said.

About 140 patients are on tuberculosis treatment at any given time. About half of them use the video app, and the rest require home visits.

It is in part because some patients, Liang said, don't feel comfortable using smartphones or recording themselves and uploading a video.

Tuberculosis is found routinely in San Diego County. From 2013 to 2017, an average of 231 TB cases were reported in the region. Very few people catch TB from local exposure to the disease, and only an estimated 13 percent of cases result from local transmission.

Most people who develop TB disease in San Diego County were infected earlier in life, but the infection was either not diagnosed or not treated. Once someone is infected, the disease can develop later at any point during the person's life. People with TB infection can reduce the risk of developing disease by getting treated for the infection before it causes problems.

To ensure the public's safety, county nurses to make sure that every patient is taking their medication correctly. Otherwise their body could develop resistance, and it would take longer to cure.

"Sometimes, the patient feels better and wants to stop taking their medication, but the bacteria is still present in the body," Liang said. "The disease could progress, and they could pass it on to other people. That is why we follow the patient until they complete their treatment."

If a patient misses a day, a nurse visit immediately follows. If the video app is not working for the patient, the nurse visits will be reinstated.

"When there are concerns, we immediately address them," Liang said. "We always adjust the plan of care."

During the first year, the county spent $72,000 using the video app. And, according to Public Health Officer Wooten, the reduced need for in-person monitoring makes the cost well worth it.

Wooten said the goal is to have as many patients use the app as possible.

"With the video system, medication compliance has greatly improved, and that is a reassurance to the public," Wooten said