EMM (event monitoring device for medication support) boxes and sleeves; and
VOT (video-supported treatment).
EMM’s are divided into systems that make use of phone call or SMS technology and systems that use electronic sensors. VOT includes both synchronous (live) and asynchronous (recorded) videos. In addition to these DAT, Ramnath et al describes ingestible sensors as one of the main upcoming tools for TB adherence monitoring.
In this section, we go into more details of these key DAT, how they work and where they are being used. Furthermore, to make optimal use of the digital adherence data that is collected by DAT, electronic adherence platforms must be set up to store and visualize the data in a meaningful way. This section also explains how these adherence platforms work, their strengths and which platform technologies are currently available for use with the DATs in the market.
After reading this section, you should be able to describe and distinguish:
DAT categories and the different types available
How the different DATs work
The role of adherence platforms for adherence data visualization and utilization
SMS (short message service, or texting) is a standard, built-in function native to all types of cellphones worldwide, and is generally inexpensive and easy to use. It is widely applied for communication with outpatients, either via regular, automated messages to take their medications, or by supplying information related to their health or condition (one-way SMS), or by providing interaction with a health provider (two-way SMS). Although SMS-based interventions have been reported to improve medication adherence in studies of persons with non-TB conditions, studies have yet to show that standalone SMS reminder messages improve TB treatment adherence. More studies on patient reminders and interactive approaches are currently under way, and the popularity and affordability of SMS present a compelling case why further studies are needed to investigate its potential more exhaustively. Research has yet to look more creatively at how SMS can influence adherence behaviour other than by reminding people to take their pills, such as by channelling cash transfers when milestones are achieved, by combining SMS reminders with other digital solutions and by targeting other points along the patient pathway. Interactive SMS communication with patients, for instance, has the potential to triage patient care in real-time, thereby improving the quality and efficiency of patient support between in-person visits.
While SMS has the potential to be a powerful supplementary tool for digital adherence support, this implementation toolkit focuses more on the other DATs that have shown great promise for TB treatment adherence. As this toolkit is a dynamic resource, these sections will be updated with new information on DAT experiences, applicability, and strengths based on country implementations.
Event monitoring device for medication support (EMM) are tools that integrate a digital process and a physical medication package or storage device. EMM sleeves are a DAT that combines a paper or card stock sleeve that fits over a medication pill pack and includes printed instructions for the patient on how to take the daily medication dose and log this into the system. Dose reporting can be done by phone call or text message, depending on the country implementation. As the use of DATs continue to expand, daily medication dose may also be reported via USSD (Unstructured Supplementary Service Data), the method commonly used for topping up credit in prepaid phones.
Currently, there is one key example of the interactions with the EMM sleeve DAT-- 99DOTS – this is widely used in countries where DATs are implemented. In this approach, existing Fixed-Dose Combination (FDC) antibiotic medication blister packs are repackaged in a custom card stock sleeve with a series of unpredictable hidden toll-free phone numbers or SMS codes that are revealed each time a patient pops the pill out of the blister and takes their pills for the day. Patients interact with 99DOTS by making a (*free) call or sending a (*free) SMS daily to the revealed number, at which point the system will automatically log their medication intake on the adherence platform.
99DOTS is best suited for drug sensitive (DS) TB patients receiving their TB medication in standardized fixed-dose combination (FDC) blister packs.
Figure 1: EMM Sleeves
More details on 99DOTS and its use is described in the EMM - Sleeve subsection.
*Although the calls and SMS are toll free to the patient, this cost is covered by either the use of national toll free lines, or privately procured lines for the intervention
Event monitoring device for medication support (EMM) boxes make use of a simple low-cost medication box and a battery powered sensor. EMM boxes can be used in combination with a SIM card and mobile data connection for real-time transfer of adherence data to an adherence platform or by connecting the box via a cable to an internet-enabled computer to upload adherence data to the adherence platform. Patients store and organize their TB medications in the box, and when they open the box for daily medication intake, the sensor is activated and stores data on the device memory and/or sends dosing event information in real-time to the adherence platform using the mobile data connection. EMM boxes can usually be customized to divide compartments to sort by medications (including medication for other diseases) or daily dosing and can include treatment-specific instructions. EMM boxes can contain a small LED display and speaker to enable audio-visual reminders.
EMM boxes are appropriate for all patients who take non-injectable medications, and are particularly well-suited for drug resistant (DR)-TB patients, as the box is typically medication-agnostic and appropriate for storing the variety of diverse regimens possible.
Figure 2: EMM Box
More details on evriMED EMM boxes and its use is described in the EMM - Box subsection.
There are two main categories of VOT: synchronous and asynchronous. Synchronous VOT makes use of a real-time video connection between the patient and the health care provider in order for the health care provider to observe medication intake in real-time remotely. Asynchronous VOT utilizes video recording and mobile communication to remotely monitor and support TB medication intake. Using an asynchronous video approach, patients are guided to record videos of themselves ingesting their daily medication. These videos are sent and stored on an adherence platform, where they can be reviewed by the patient’s health care provider at any time. While most other DATs rely more on the technology as a proxy for daily dosing, VOT is the closest approach to “remote” Direct Observed Treatment (DOT), as the health care provider actually views the patients' medication intake.
VOT is suited for drug sensitive (DS), drug resistant (DR) TB patients and latent TB Infection (LTBI) patients. VOT does not require any specialized devices (EMM boxes) or printed materials (EMM sleeves) and can be implemented rapidly wherever smartphones are in use and does not require ongoing supply chain resources. However, the technology requirements such as mobile devices, mobile connectivity infrastructure, and technology literacy mean it is not well-suited for all patients and geographical contexts. VOT can be used for medications in any formulation, and changes in formulation or prescription does not affect the utilization of VOT, making it suitable for all types of regimen.
Figure 3: Video Observed Treatment (VOT)
There are several vendors with dedicated VOT solutions such as SureAdhere (standalone or integrated in the Everwell hub) and eMocha. More details on VOT and its use is described in the Video Supported Treatment subsection.
One example are Ingestible sensors also know as Wireless Observed Treatment (WOT) that make use of tiny silicon sensors the size of a grain of salt embedded in regular TB medication pills. When the patient swallows the pill, the sensor is activated by the stomach acids and transmits a signal determining the identity of the medicine and the time of ingestion of the pill to a patch attached to the patients's skin. This data is sent to a Bluetooth-enabled device where the data is stored.
One thing all digital adherence technologies described above have in common, is that they collect patient level data on the (daily) intake of TB medication collectively called ‘adherence data’. To make use of the collected data in a structured way an adherence software platform is required. All DATs come with their own dedicated platforms with a variety of functionalities and options for visualizations of adherence data. Adherence platforms usually come with mobile applications, web dashboards or email/SMS functionalities to provide overviews and actionable information to health care workers, patients and policy makers. In addition, adherence platforms can be integrated or made inter operable with other digital systems such as surveillance systems or diagnostic connectivity systems.
There are several countries that already use adherence technologies as part of routine care for TB patients while other countries have more recently piloting and/or scaling up DAT enabled interventions. The table below shows a non-exhaustive overview of mostly developing countries that have implemented DAT interventions in the last decade.
Figure 5: Countries implementing EMM sleeves*
Figure 6: Countries implementing EMM boxes*
Figure 7: Countries implementing VOT*
*Countries are included where DAT’s are currently implemented either in the public, private or research settings, independently of the scale of the implementation.
Table 1. Low and Middle income countries implementing DATs
Patient type and population
Expected number of patients enrolled
EMM box EMM sleeves
DS-TB patient in the private sector
National Capital Region
MDR TB patients
National Capital Region
DS-TB and DR-TB patients
900 (800 DS-TB, 100 (DR-TB)
DS-TB and DR-TB patients
650 (516 DS-TB, 134 DR-TB)
Gauteng, Western Cape, Kwa-Zulu Natal
DS-TB patients among mining population
Smear positive TB patients and presumptive TB cases
**this overview is not considered complete but provides an insight in several countries that are implementing DAT’s in LMIC’s.
Technology and treatment regimen
EMM sleeves are suitable for DS-TB patients that are treated with Fixed Dose Combination (FDC)
EMM boxes are suitable for DS-TB, DR-TB and LTBI patients independent of regimen or formulation
VOT is suitable for DS-TB, DR-TB and LTBI patients independent of regimen or formulation