Can Digital Health Help Tackle TB? - The VOT Case
Tuberculosis (TB) is one of the world’s deadliest diseases with a staggering 25% of the world’s population affected by the infection resulting in an estimated 1.8 million deaths a year. As with many infectious conditions, a disproportionate amount of individuals affected by the disease are based in low and middle income countries, particularly those already infected by HIV. While the mortality rates associated with TB have promisingly declined an estimated 40% between 1990 and 2011 the global community continue to be faced with substantial deficits across the care continuum from diagnostics, optimal treatment access, and medication adherence support. With an increase in multi-drug resistant TB (MDR-TB), which has a 50% survival rate, it is becoming more pressing than ever to effectively address these shortfalls.
MSF has been working on responding to the TB epidemic for over 30 years now including field operations with MoHs (such as the interventions handed over to the Kenyan MoH in Kibera Nairobi in 2017) and also with academic partners such as the London School of Hygiene and Tropical Medicine. MSF recently reached a milestone with TB-PRACTECAL, an innovative tuberculosis trial evaluating new approaches to combat MDR-TB.
We’re not alone. The End TB Strategy by the Global TB Programme of the World Health Organization (WHO) and its associated organisations committed in to end the TB epidemic by 2035.
The audacious goal of the WHO is based around 3 key pillars which are more broadly aligned with the post-2015 Sustainable Development Goals:
Expanding the scope and reach of interventions for TB care and prevention
Maximising the benefits of health and development policies and systems, by engaging a broader cross-section of actors across government, communities and the private sector
Pursuing new scientific knowledge and innovations that can dramatically change TB prevention and care
The unprecedented growth in digital health solutions (including mobile health applications, electronic medical records, remote patient monitoring and beyond) lends itself to realising the goal of alleviating TB burden by 2035 in addition to demanding the collaboration of multi-stakeholder groups.
Digital health has numerous potential applications that could be applied and evaluated along the patient pathway including supporting early diagnostic tests, optimizing patient care, surveillance and monitoring, programmatic management and e-learning. When it comes to patient care digital solutions can be applied to the administration of drugs are monitoring of patient symptoms and outcomes, to preparing and following up with patients with timely information, to supporting access to care and support that addresses the holistic needs of patients, and crucially to enable adherence with the likes of video observed treatment adherence.
While digital health interventions are being closely examined for their efficacy and ability to reduce costs and improve outcomes in high income contexts many of these solutions and insights have limited transferability when it comes to their application in lower income contexts, the contexts where there also happens to be the greatest burden.
While a number of investigations, pilots and field trials have been launched in the past few years the widespread case and population health benefits has not yet been achieved, however the opportunity and the need are undeniable. With this awareness the MSF Sweden Innovation Unit launched the Video Observed TB Case in 2019 with the aim to understand the opportunity presenting itself and to contribute to the understanding of how these innovative approaches could be applied in MSF field operations and beyond.
An Introduction to the Video Observed Tuberculosis (VOT) Case
The VOT Case was launched with the aim to gain a deep understanding and mapping of current systems used for VoT and to assess the needs needed within MSF programs and provide the team with user friendly and appropriate technology.
Multidrug resistant tuberculosis (MDR-TB) is a strain of the TB that requires an intensive and prolonged treatment regimen that for the vast majority of patients results in side-effects, that according to many patients, are even more challenging to deal with than the disease itself.
Adherence to TB treatment is vital to prevent disease relapse or amplification of drug resistance. Current strategy of Directly Observed Therapy (DOT) involves daily intake of TB drugs in presence of healthcare provider. Long treatment periods (up to 2 years) are linked to loss of Quality Adjusted Life Years (QALY) for patients. DOT is expensive, resource-intensive and burdensome on patients, providers and health systems. As a result, DOT implementation is frequently inadequate.
Video Observed Treatment (VOT) involves patients’ video recording themselves using mobile phones while taking their medications and transferring the videos using a web based secure interface to DOT workers for review. VOT is a WHO approved treatment adherence tool for use in TB patients. VOT is accurate and provides reliable evidence that medications were swallowed. Additionally, it reduces the burden on providers and health systems and improves QALY for patients. VOT is not yet implemented across MSF-OCA projects.
We caught up with VOT Case Leader Francesc Galban to get some added insight into the purpose and process of the project:
“With the approach we are taking in the VOT Case we hope to strengthen care by not only increasing treatment adherence, but by endorsing a more holistic strategy to support patient needs over the course of treatment. By taking a patient-centered approach on the design of this platform, we seek to shift the Video Observed care paradigm discussion to Video Supported care, and to active engagement of patients as self-managers. So far we have supported the assessment and implementation of the existing MoH Belarus VOT platform as part of the TB PRACTECAL CT. We have also delineated our approach to VOT and a series of white papers that aim at supporting the broader MSF community, making an informed decision on how to best capitalise on this up and coming technology to support patient needs.”
SIU - What has been the greatest challenge you have identified so far that may serve as a barrier to scaling VOT in MSF field operations?
FG - “Besides the technology-based challenges that can impact on the wide-scale implementation of VOT, such as network availability and technology literacy; the enormous diversity of MSF contexts, makes a standardised implementation of a specific technological framework extremely difficult— having to take a case-by-case approach to a project-wide implementation might be the biggest challenge being faced at the moment.”
SIU - What are you focused on delivering right now?
FG - “My main objective is to first understand the implications, needs and challenges of remotely supporting patients throughout the provision of care. As a function of this process of understanding, we intend to devise a series of guidelines to enable a patient-centered implementation of tech-based platforms to make care as accessible as possible irrespective of the setting. In a way, we believe that, by taking this approach we might be able to democratise, as well as improve care, for population on risk of exclusion.”
SIU - What would be the ideal outcome/success of this case look like to you?
FG - “For a project of this nature, the ideal outcome is that we could learn from existing use cases, coming up with a set of parameters that can serve as a guidance for MSF initiatives looking into implementing VOT approaches; widening the spectrum of diseases covered by this platform, out with the reach of TB as a paradigmatic case, and moving into supporting a whole spectrum of conditions requiring treatment support. As such, integrating the wealth of knowledge, through a use case and lessons learned approach into an information database, that can help harmonise and tailor implementation procedures, for MSF stakeholders.”
SIU - What is next for the VOT Case?
FG - “After evaluating existing platforms, and devising a toolkit that can help us both understand as well as implement VOT technologies much more systematically, we hope to be able to be able to support a VOT use case implementation throughout the whole Lifecycle; that is, including the design, evaluation, implementation and roll-out of the platform, ensuring that communities are active participants of their own health, by integrating their feedback into the design of this framework.”
The Future of Digital Health and TB
To date, the opportunity for digital health supported TB care in low and middle income countries has remained largely untapped - but the tides are changing. For one, the WHO has just released their guideline recommendations on digital interventions for health system strengthening, contributed to by the Global TB Programme. While these guidelines are only one example of a much larger effort it signals a growing awareness of the digital opportunity and encourages future evidence based efforts. VOT, and other digitally enabled interventions, will take continuous evaluation to become a central support for tackling TB in LMICS, but with all the different variables at play one thing should remain constant - keeping the patient at the center of care.