By Yen Duong
While historical novels and pop culture are filled with references to “consumption,” “wasting disease” and tuberculosis sanatoriums, TB is by no means a disease that’s only consigned to history. In 2017, 1.6 million people worldwide died from TB, the World Health Organization reports.
To combat the extremely contagious disease, since 1993 the WHO has recommended directly observed therapy (DOT), in which a provider watches patients take their daily pills.
“Tuberculosis is not as common [in the U.S.] as it is in many other countries, but it still very much exists,” explained Dr. Meg Sullivan, the medical director of Mecklenburg County Public Health. “When we identify a case of active tuberculosis, we have a public health responsibility to ensure the treatment is completed, to reduce the risk to the rest of the public.”
In 2018, 196 North Carolinians had verified cases of TB. The disease spreads when people breathe in bacteria from a patient coughing or speaking but not from touch, shared surfaces or shared food. Last month, Mecklenburg County, which has the highest TB rate in the state, updated its federally mandated DOT program with a contract with a new technology company. Instead of schlepping to the closest clinic, TB patients can now record selfie videos of themselves taking the pills and send them to the public health department.
In 2017, the Centers for Disease Control and Prevention reported about 9,000 TB cases nationally; Mecklenburg County had 34 cases. In these “active” cases, patients have become ill with symptoms such as painfully coughing up blood, night sweats and weight loss, among other symptoms.
Treatment takes a long time, though, and can be challenging for patients to complete, with side effects ranging from fatigue and nausea to jaundice and abdominal discomfort. TB infection is often treated with a six-month-long course of medications, which start off as four daily antibiotics and then whittle down to two. Clinicians must personalize the treatment for each patient, Sullivan said.
“A lot of it has to do with what were their initial cultures, when did they convert [to active TB], what is their sensitivities [to the medications]?” Sullivan said. “That’s why we can’t just say ‘someone will be on it for this amount of time,’ because we need to work with each patient individually.”
Some patients carry a drug-resistant strain of the TB bacteria which does not respond to one or more of the four usual antibiotics. Those patients work with their doctors to find effective treatments, which can include antibiotics with riskier side effects.
The CDC estimates that up to 13 million Americans could also be infected with symptomless “latent TB.” Otherwise healthy people may never become sick from their latent TB infection, and they cannot spread the bacteria.
“[In latent TB,] a little bit of the bacteria might live in your body but remain asleep … and never really wake up,” Sullivan said. “However, in people that are immunocompromised, … that can then reactivate the tuberculosis and lead to active [TB].”
For example, in people with HIV, latent TB is more likely to become active and require treatment, Sullivan said. Other at-risk populations include the elderly, people with a history of homelessness and people who have recently travelled internationally.
Though only active cases require DOT, the CDC recommends treating latent TB in at-risk patients with a similar but shorter course of drugs.
Caption: A comparison of tuberculosis cases in the two largest counties in North Carolina over the past 10 years. Data compiled from Wake County Public Health and Mecklenburg County Public Health. Graph credit: Yen Duong.
‘Like a public health crisis’
DOT ensures that patients adhere to their treatments, or take their medications as prescribed. Sebastian Seigeur, CEO of emocha, the technology company, said that while Americans spend $370 billion a year on medications, adherence rates remain around 50 percent.
“When patients don’t take medication, it doesn’t do anything,” Seigeur said. “We’re as a country [and] as a health system not getting the benefit of those medications, and neither are the patients when it’s not taken.
“It is almost like a public health crisis, that patients don’t take medications as prescribed.”
With video directly observed therapy, patients can take their medicine anytime instead of only when a clinic is open, and clinicians don’t need to travel to patients’ homes or workplaces to watch them.
“Having to take a medication every day, or sometimes you can switch it to three times a week, for a significant number of times: that is very, very, that can be very challenging,” Sullivan said. “I think having the video directly observed therapy option, so they can do it at their schedule in the comfort of their own home, is really a remarkable thing.”
A study partially funded by emocha showed that health departments saved over $1,000 per patient who completed treatment using vDOT as opposed to in-person observation five days a week.
“A lot of patients want to take their medication at night because they can sleep off the side effects,” Seigeur said. “So Mecklenburg County [public health officials] can wake up in the morning, and they’ve got 30-some patient visits to analyze, and they can do them all one after another.”
The vDOT option lets public health officials monitor patients on weekends as well, Seigeur said.
“The technology by itself does not improve medication adherence—it’s the engagement from Mecklenburg County to the patient that really drives it,” Seigeur said. “It’s like a virtual visit. […] It’s the idea that there’s somebody who’s on the other end, in engaging and supporting you through this treatment.”
When asked if the software presented any privacy concerns for patients, Seigeur pointed out that in-person DOT already requires much of patients.
“Vaccination is probably the best analogy,” Seigeur said. “We’re insisting that members of the public get vaccinated. [When] some people don’t want to do that, other people are put at risk.
“There’s a huge ethical dilemma on what you can ask patients to do. I don’t know that we have the solution to that.”