Video-observed therapy for tuberculosis: strengthening care
Authors: Hamish Fraser, Salmaan Keshavjee
Journal: The Lancet (2019)

Despite being treatable since 1948, tuberculosis continues to cause disease in more than 9 million people each year, and almost 1·5 million largely preventable deaths.1Keshavjee S Dowdy D Swaminathan S Stopping the body count: a comprehensive approach to move towards zero tuberculosis deaths.Lancet. 2015; 386: e46-e47Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar Tuberculosis has overtaken HIV as the leading infectious killer of adults worldwide and, through airborne spread of untreated drug-resistant strains, is the largest contributor to global deaths due to antimicrobial drug resistance.2Owen J Pay drug companies $1bn for each new antibiotic, says report.BMJ. 2016; 353: i2863Crossref PubMed Scopus (1) Google Scholar However, this situation can be changed. A solution—outlined in the 2015 Lancet Series How to eliminate tuberculosis1Keshavjee S Dowdy D Swaminathan S Stopping the body count: a comprehensive approach to move towards zero tuberculosis deaths.Lancet. 2015; 386: e46-e47Summary Full Text Full Text PDF PubMed Scopus (23) Google Scholar—involves finding and treating those sick with tuberculosis disease, finding and treating those infected with Mycobacterium tuberculosis before they get the disease (ie, tuberculosis preventive therapy), and providing the necessary care so that those with tuberculosis infection and disease can complete treatment. In the early 1990s, WHO endorsed a global strategy to treat individuals who were sick with tuberculosis.3WHOThe five elements of DOTS. Geneva: World Health Organization.http://www.who.int/tb/dots/whatisdots/en/index2.htmlDate accessed: November 30, 2018Google Scholar This approach, which called for widespread distribution of an empirical four-drug, first-line regimen to individuals with M tuberculosis present on sputum smear microscopy, also mandated directly observed therapy (DOT). This led to much debate about the necessity of direct observation, regarding whether it improved adherence and whether it was a violation of a patient's dignity and human rights. Although some individuals can benefit from extra interactions with health-care systems, DOT can place an undue burden on individuals who already face many challenges completing therapy and might offer little added benefit for many.4Chaulk CP Kazandjan VA Directly observed therapy for treatment completion of pulmonary tuberculosis.JAMA. 1998; 279: 943-948Crossref PubMed Scopus (228) Google Scholar, 5Karumbi J Garner P Directly observed therapy for treating tuberculosis.Cochrane Database Syst Rev. 2015; 5 (CD003343.)Google Scholar In The Lancet, Alistair Story and colleagues6Story A Aldridge RA Smith CM et al.Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trial.Lancet. 2019; (published online Feb 21.)http://dx.doi.org/10.1016/S0140-6736(18)32993-3Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar report their study of a video-based approach to DOT (termed VOT) for populations at risk of not being able to complete their therapy. They enrolled 226 patients aged 16 years or older (165 men [73%]) with active tuberculosis in England, 58% of whom had a range of socioeconomic, substance abuse, or mental health problems, and randomly assigned them to traditional DOT (observations done three to five times per week in the home, community, or clinic settings) or VOT (daily remote observation using a custom smartphone app). The primary outcome was completion of 80% or more scheduled treatment observations over the first 2 months in the study. In an intention-to-treat analysis, 78 (70%) patients on VOT achieved the primary outcome compared with 35 (31%) patients on DOT (adjusted odds ratio 5·48, 95% CI 3·10–9·68; p<0·0001). The result was still significant when the analysis was restricted to patients who completed at least 1 week of observation, which included 90% of VOT patients but only 49% of DOT patients. Lower drop out of patients on VOT continued through the 6-month follow-up, with 77% of scheduled observations completed in the VOT arm compared with 39% in the DOT arm (p<0·0001). These results suggest that removing the onerous burden of having to visit a health worker every day was popular. VOT was also more cost-effective. Importantly, the patients were encouraged to seek support for any adverse events in the videos. This approach holds great promise for helping patients facing challenges in the treatment of tuberculosis, as well as other chronic diseases including HIV and diabetes. First, by lowering the barrier of participation in a system of regular care interaction for individuals at risk of not completing therapy, it shows a mechanism for delivering care and creating an important social network for caregiving. Second, it provides a mechanism for dealing with a high volume of people with active disease, and their close contacts (eg, household and work colleagues) requiring tuberculosis preventive therapy. Although VOT has been used in a variety of forms for almost a decade, Story and colleagues6Story A Aldridge RA Smith CM et al.Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trial.Lancet. 2019; (published online Feb 21.)http://dx.doi.org/10.1016/S0140-6736(18)32993-3Summary Full Text Full Text PDF PubMed Scopus (102) Google Scholar provide the strongest evidence to date that it can be effective for some of the most disadvantaged patients in a high-income country. VOT can also work in low-income and middle-income settings, but this will require shifting from surveillance approaches to a greater focus on caregiving. This could be achieved by using a phone call or text message to ask individuals if they are facing problems with their medicines or have other clinical or social needs, and reserving the sending of actual videos, with their concomitant resource requirements and costs, for patients with special needs. Barriers to sending large files like VOT videos (typically 4–6 MB in size) include not having a smartphone, a data plan, or sufficient local bandwidth, are widespread, as found in a study on pharmacovigilance in Kenya.7Agoro O Kibira S Freeman J Fraser HSF Barriers to the success of an electronic pharmacovigilance reporting system in Kenya. An evaluation three years post implementation.J Am Med Inform Assoc. 2018; 25: 627-634Crossref PubMed Scopus (11) Google Scholar We also require better understanding of the challenges that place an individual at higher risk of not being able to complete their therapy, and where text messages, medication monitors, traditional DOT, or VOT might best support adherence within a spectrum of care provision. To improve care delivery and achieve scalability, technically simple ideas like text messaging or VOT have to be able to work in complex psychological, social, and geographical environments. With continued fine tuning of the intervention and delivery, supporting technical requirements, and keeping the patients' needs and concerns central, VOT should have an important role in the fight to eliminate tuberculosis. We declare no competing interests. Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: a multicentre, analyst-blinded, randomised, controlled superiority trialVOT was a more effective approach to observation of tuberculosis treatment than DOT. VOT is likely to be preferable to DOT for many patients across a broad range of settings, providing a more acceptable, effective, and cheaper option for supervision of daily and multiple daily doses than DOT. Full-Text PDF Open Access