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Electronic reminders can help tuberculosis patients stay on medication

September 15, 2015

Reminders to take medication, delivered to patients via an electronic pillbox, may be able to improve adherence to tuberculosis (TB) treatment. The findings, reported this week in PLOS Medicine, are the result of a cluster randomized controlled trial by Shiwen Jiang of the Chinese Centers for Disease Control & Prevention, Katherine Fielding, of the London School of Hygiene & Tropical Medicine, and colleagues.

The study randomized 36 districts in the provinces of Heilongjiang, Jiangsu, Hunan, and Chongqing, China to receive one of four approaches to tuberculosis case management: medication reminders via text messages (1008 patients), a medication monitor box (997 patients), both (1064 patients), or neither (control, 1104 patients). Medication adherence for the 4173 TB patients included in the study was monitored by pill counts and the medication monitor box (supplied to all patients but only providing reminders to the appropriate intervention groups).

While patients in the control arm were non-adherent (percentage of patient-months with more than 20% of their doses missed) in 29.9% of the months, patients who received reminders from the medication box were non-adherent in 17.0% of the months, and in only 13.9% of months for patients who received reminders via both the medication box and text message. There was no significant difference from control arm for patients receiving text message reminders only. The researchers noted that there were difficulties with the equipment in all arms, including operator error and equipment malfunctions.

In an accompanying Perspective article, John Metcalfe of the University of California San Francisco and colleagues discuss the importance of adherence to TB medication, difficulties with the traditional method of ensuring adherence through directly observed treatment (DOT), and the importance of developing effective new methods that reduce burden to patients and are easier to implement at a large scales and in remote areas.

Metcalfe and colleagues say: "If replicated, [this study] will have important implications for global TB treatment in moving away from witnessed dosing, which is not universally feasible, towards a more personalized adherence model of patient-provider communication in which intervention is delivered where, when, and in whom it is needed to efficiently prevent adverse treatment outcome."

Fielding and colleagues say: "In a setting such as China where universal use of DOT is not feasible, innovative approaches to enable patients to adhere to TB treatment are needed. Widespread use of medication monitors in national TB control programs can benefit from the development of a low-cost and reliable medication monitor as well as evidence that its use can improve clinical outcomes."
Research Article

Funding: The study was funded by the Bill & Melinda Gates Foundation, grant number 51914 ( The funders (DPC, SH) contributed to design, running of the trial, and preparation of manuscript.

Competing Interests: The authors have declared that no competing interests exist.

Citation: Liu X, Lewis JJ, Zhang H, Lu W, Zhang S, Zheng G, et al. (2015) Effectiveness of Electronic Reminders to Improve Medication Adherence in Tuberculosis Patients: A Cluster-Randomised Trial. PLoS Med 12(9): e1001876. doi:10.1371/journal.pmed.1001876

Author Affiliations:

National Center for Tuberculosis Control and Prevention, Chinese Center for Disease Control and Prevention, Beijing, China
MRC Tropical Epidemiology Group, London School of Hygiene & Tropical Medicine, London, United Kingdom
Jiangsu Province Center for Disease Control and Prevention, Nanjing, Jiangsu, China
Chongqing Provincial Tuberculosis Dispensary, Chongqing, Chongqing, China
Heilongjiang Provincial Tuberculosis Dispensary, Harbin, Heilongjiang, China
Hunan Provincial Tuberculosis Dispensary, Changsha, Hunan, China
Dafeng County Center for Disease Control and Prevention, Dafeng, Jiangsu, China
China Office, Bill & Melinda Gates Foundation, Beijing, China


The London School of Hygiene & Tropical Medicine

Perspective Article

Funding: No specific funding.

Competing Interests: The authors have declared that no competing interests exist.

Citation: Metcalfe JZ, O'Donnell MR, Bangsberg DR (2015) Moving Beyond Directly Observed Therapy for Tuberculosis. PLoS Med 12(9): e1001877. doi:10.1371/journal.pmed.1001877

Author Affiliations:

Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California, San Francisco, San Francisco, California, United States of America
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York, United States of America
Massachusetts General Hospital, Harvard Medical School, Harvard School of Public Health, Boston, Massachusetts, United States of America
Mbarara University of Science and Technology, Mbarara, Uganda



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