e/mHealth for Tuberculosis Moldova experience

Dr. Viorel Soltan

Center for Health Policies and Studies

Republic of Moldova

Moldova

• Country in transition in Eastern Europe

• Territory: 33,846 sq.km; population: 4.1 million

• GNI per capita (Atlas): USD 2,460 (2013)

• Total number of notified TB cases, all forms (2013): 5,055

• Number of new TB cases (2013): 3,604

– Out of these, new SS+ cases: 1,159

• Case notification rate (new cases and relapses, 2013): 97.6 per 100,000 population

Moldova (cont.)

• Estimated MDR-TB new cases – 24% (21-26) and retreatment cases 62% (59-65)

• Total number of notified MDR-TB cases: 939 (2013), out of them 98% (919) enrolled in MDR-TB treatment

• 25.3% smokers among adult population (43.6% males and 5.6% females)

• 23.3% smoke tobacco daily

MDR-TB: new and retreatment cases

0.5

5.0

13.4

23.7

29.2

23.7 24.3

3.9

33.2

49.6

65.2 64.3 62.3 61.2

0.0

10.0

20.0

30.0

40.0

50.0

60.0

70.0

1995. 2000. 2005. 2010. 2011. 2012. 2013.

MDRTB New Cases % MDRTB Retreatment Cases %

mHealth program description

1. Started in 2013, original name: “mSupraveghere Tratament TB”

2. The aim of the program: to ensure continuity of treatment, reduce the default rate and increase adherence of TB patients during ambulatory treatment

3. 2,000 mobile phones have been distributed to the medical institutions network; 1731 patients have been enrolled by the end of 2014.

4. Applies simplest mobile technology through delivering SMS messages to remind regimes of treatment

5. Provide additional info on adverse reactions, treatment associated factors, health care facilities and services

6. Obtain feedback on in-take and provide notifications to patients if the administration was omitted.

INCLUSION CRITERIA:

Are initiating TB treatment;

Are over the age of 18 years old;

skills to use mobile technology; demonstrate sufficient ability to communicate via text messaging

informant consent of patient: patient motivation and desire to benefit from the programs

schedule adherence monitoring and control

EXCLUSION CRITERIA:

Individuals under the age of 18;

Unable to adequately send and receive text messages for any reason

Enrolled in another clinical trial that may assess or influence treatment adherence.

Patient decision

Health care provider decision

Eligibility

Programul mSupraveghere tratament antiTB

TB Patient Health care provider

Call Remote monitoring

TB Patient take the drugs

Drugs box

SMS reminder to patient

SMS reminder

SMS to PHC Notification

“Box not Open”

Notification ”Box Open”

Notification ”Box not open”

Sending notifications to patient if the administration was omitted

mHealth value chain

Source: V.Crudu, 2014

Added value interventions

• PHC Performance-based indicators

– # people from key affected populations investigated for TB

– # TB patients in care

– # patients who completed TB treatment in ambulatory care

• Community centers: multidisciplinary approach

• Ambulatory care model, including MDR-TB

• National incentive programs to TB patients

Treatment success and interruption rates, new TB cases, 2013

0

10

20

30

40

50

60

70

80

90

100

Treatment success Treatment interruption

National cohort, 2013 mHealth cohort, 2013

TB patient lost to follow-up

11.2 11.5

13.4 12.2

9.9 8.4

29.5

26.2

23.2 23.7 22.6

2007 2008 2009 2010 2011 2012

TB New Cases, SSM+ TB MDR Cases

TB incidence and mortality reduction: linked in part with TB targeted interventions

39

63

69

134

114.9

109.9

4.6

10

17

19

14.4

11.1

4

9

14

19

20

40

60

80

100

120

140

1990 1995 2000 2005 2012 2013

TB incidence - Rate/100000

TB Mortality - Rate/100000

Shortages in public health financing, including TB service

DOTS Plus implementation

DOTS implementation

Lessons learned

• mHealth value chain incomplete

• Mentality barriers

• Low level of training in use of modern technologies

• Lack of sustainable approaches

• Enabling environment factors (e.g. Security issues etc.)

Conclusions

1. Mobile communications are part of our everyday activities: they may transform our wellness and health care.

2. The role of mobile phones in promoting adherence to TB treatment is gaining importance in Moldova - the widespread connectivity, low costs, and growing popularity.

3. If combined with other technologies (EHR, client education, scheduling, voice/video tools): communication may improve.

4. TB patients feel the need to talk to health workers about their problems often and mobile phones can fulfill this function.

5. Informing family members along with patients through the mobile phones is also a good strategy to control the disease and to address other related health issues such as smoking