TUBERCULOSIS is an increasing public health problem in Cape Town. Poor adherence to treatment regimens results in a low cure rate and an increasing incidence of multi-drug resistant tuberculosis. Current usual care is to directly observe patients for all or most of their doses in the short course regimen. Direct observation has been shown to be no better than self-supervised care.¹ Further, in a Cochrane review it has not been shown to improve outcomes of care.²

Directly observed treatment (DOT) places a considerable burden on health centre staff. During 2001 there were a total of 3,559 and 3,432 TB cases requiring treatment in Cape Town's Khayelitsha and Nyanga districts respectively. On average, cases require 6.5 months of treatment. This equates to 1,928 and 1,859 patients respectively receiving directly observed TB treatment everyday in those districts.³ Adherence interventions, other than direct observation, are required that improve adherence and decrease the workload of the staff at health centres.

Now with a relatively simple, but innovative idea, a Cape Town doctor, David Green, has dramatically helped the fight against TB. He has introduced a Short Messaging Service (SMS) - a text message service that enables short messages of up to 160 characters to be transmitted between cell phones - to remind patients to take their medicines.

Dr Green has called this system Cell Phone Prompted Self Administered Therapy (PSAT). It is a system whereby selected patients are released from the requirement of direct observation and are prompted by the text message service of the GSM (Global System for Mobile Communications) standard to take their medication daily. This relieves patient loads for DOTS employees whilst not decreasing the cure rates currently achieved by DOTS. The decreased workload will allow staff to focus attention on patients who are poorly compliant, thereby increasing the likelihood of improving compliance amongst all TB patients (not only those on PSAT).

The programme's proposed framework for future research on adherence to treatment

Pilot studies at the Chapel Street Clinic in Cape Town have shown cell phone usage amongst 71% of the target population. Further, widespread patient and staff acceptability of this intervention have been shown. The local health authority is paying the R11.80 (US$1.3, approximately) per patient per month to run the SMS reminder service.

The system is simple, affordable and flexible - Dr Green enters the names of TB patients onto a database. Every half an hour his computer server reads the database and sends personal-ised messages to the patients, reminding them to take their medication. The technology that he uses is extremely low-cost - a freely available open source software operating system, web server, mail transport agent, applications and a database. When patients complained that their messages were boring, Dr Green sent them a variety of alerts, including jokes and lifestyle tips, with the result that he now has as database of over 800 messages that he changes on a daily basis. Of the 300+ patients involved in the pilot there were only five treatment failures, and WHO has singled out the scheme as an example of best practice. The initiative not only uses technology to address a real need effectively, but it does this in a simple, affordable and flexible way.

Dr David Green, The Compliance Service, Cape Town, South Africa. E-mail: david@on-cue.co.za, web site: http://www.compliance.za.net

This article is based on the text "Using cell phones to boost TB compliance" published in the E-Drug Electronic Discussion Group.

References

1. Zwarenstein M, Schoeman JH, Vundule C, et al. Randomised controlled trial of self-supervised and directly observed treatment of tuberculosis. Lancet, 1998;352:1340 - 1343.

2. Volmink J, Garner P. Directly observed therapy for treating tuberculosis (Cochrane Review). In The Cochrane Library, Issue 1, 2002. Oxford: Update Software.

3. Annual report Cape Metro Region 2001. Cape Town: 2001.