X out TB: Mobile Phones for Combatting Tuberculosis

Posted by CorinneRamey on Jun 20, 2008

The numbers should speak for themselves. In 2006, there were 9.2 million new tuberculosis (TB) cases and 1.7 million TB deaths. Of these cases, 5.3% were a tough strain of TB that is resistant to treatment (known as MDR-TB, or multiple drug resistant tuberculosis). The total cost of TB control programs in high burden countries is estimated to be about $2.3 billion in 2008. A team of students and faculty at the Massachusetts Institute of Technology has come up with an innovative response to this problem that uses mobile phones as both a reporting mechanism and incentive program. They call their solution "X out TB."

MobileActive sat down with two of the team members, Elizabeth Leshen and Jose Gomez-Marquez, to chat about the possibilities of mobile phones and incentives to increase TB compliance. Leshen is a junior at MIT majoring in biological engineering and Gomez-Marquez currently directs MIT's Innovations in International Health initiative. X out TB was born out of the MIT IDEAS competition, which encourages student groups to come up with new technologies to solve international development problems. In 2007, the competition focused on solving issues of TB noncompliance. Jose said he was initially attracted to the competition because he was intrigued by issues of noncompliance. "When we started we knew we had to find a hybrid system, it couldn't just be a new type of drug delivery system," he said. "The solution had to the change behavior of patients."

X out TB seeks to reduce the necessity of daily health worker monitoring of TB patients by offering patients incentives for compliance. Patients in the program are given monthly supplies of urinalysis test strips that are dispensed every 24 hours out of a special dispenser. The strips, developed by the X out TB team, contain four printed numbers and embedded chemicals that turn a certain combination of numbers a new color when they react with the urine of patients who have taken TB medication. Patients then send an SMS to a database reporting the numbers on their strip, which is monitored by health care workers and doctors. Leshen said that the teams decided to use SMS because it was a reliable, already existing technology. "Cell phones are an infrastructure that already exists. A lot of patients are already familiar with them and the phones are intuitive," said Leshen. "We didn't have to build any new infrastructure." Patients with high compliance rates are rewarded with mobile phone minutes or credit.

Leshen said that X out TB addresses many of current issues with TB noncompliance. "The way compliance is monitored currently in developing countries is a health care worker force feeds the patient their medicine," she said. "This scales poorly in rural areas, since it's hard to get a health care worker to go visit a patient every day." She said that often the workers don't show up; health worker absenteeism can be as high as 40% in some areas. "With our system, it puts the control in the patients' hands," Leshen said. "If they do their job, they'll get the reward."

It takes between six and eight months of daily medication to cure a patient of TB, and typical patients feel better after about three months. Due to the lack of symptoms, and the continued side effects of the medication, patients tend to stop taking the medicine when they no longer feel sick. "They only feel sick from the drug, and see no reason to keep taking their meds," said Leshen. "Even if they start skipping two doses a week, what they're actually doing is increasing the likelihood they'll develop drug resistant TB. In countries where health care is restricted, that's a problem." Multiple drug resistant TB is increasingly contagious, expensive and challenging to treat.

After developing prototypes of the special strips at MIT, the team conducted a feasibility trial in Nicaragua. Much of their time there was spent fixing the technology. Gomez-Marquez said they were able to use real samples of TB -- something difficult to get approval to use in Boston -- and were able to change the chemicals on the strips so that they didn't react to other substances -- like nicotine, for example -- that might be found in a patient's urine. They also talked to the Nicaraguan government about use of the X out TB system. "Once we talked to the government, we faced something that we didn't anticipate facing," said Gomez-Marquez. "We asked where they find gaps in their coverage, and officials said that they have 100% coverage, but we knew that people in rural areas weren't getting health care worker visits." He said this made it difficult to convince the government that a system like X out TB would be useful. "How can you convince a government that something is good for them when they're denying the problem?"

The team also changed the incentives for the project. Initially, they had intended to give people who stuck with their treatment a microfinance loans. "The whole goal with microfinance is you get a peer system from your family," said Gomez-Marquez. "But when we went to Nicaragua they really insisted on cell phone minutes." The minutes can either be uploaded to the user's phone or the team can pass out pre-paid phone cards. The team plans to continue their research with a longer trial in Karachi, Pakistan this August.

Currently, the project has been funded mainly by grants, competitions, and alumni donations through MIT. However, Leshen hopes that the program will become self sustaining in the future. "The people who would be buying into this program would be health care providers or governments," she said. "The money that the program would earn from its clients would enable it to be sustainable." According to Gomez-Marquez, X out TB is about 45% of the cost of standard TB treatment with health worker monitoring, which costs about $75-125 over the course of the six-month treatment. However, one of the barriers to adoption by governments may be that monitoring TB with technology is far from the norm. "This system goes against the grain right now with the current model of health care worker monitoring. A lot of people like community based monitoring systems because they strengthen the community and give people jobs," Leshen said. Although X out TB would still utilize occasional visits by health care workers, the frequency would be much less than that of current programs.

Although the project is still in its incipient stages, both Leshen and Gomez-Marquez have big plans for the future. "The big goal is to get patients to stick with their TB meds and to use X out TB not only to increase the health of patients that have TB but also to slow the incidence of drug resistance tuberculosis," said Leshen. Gomez-Marquez agreed. "In two years, I'd like to see the technology rolled out in at least four countries and get people to look at mobile phones and these type of diagnostics in a whole new light," he said. "My long term goal is to get people to start changing their minds that these technologies can be deployed in developing countries."

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