1. Using Mobile Phones to Monitor and
Improve Adherence to Tuberculosis Medications
In collaboration with:
Central TB Division
October 2016

2. What is 99DOTS?
Goal: to provide 99% of the benefits of DOTS at a fraction of the cost and inconvenience to patients
Anti-TB drugs are wrapped in envelopes which are printed with hidden numbers behind the pills
When patients dispense a dose, they reveal a hidden TOLL FREE number which they call
This call gets reflected on our dashboard immediately as a taken dose

3. 99DOTS: Accurate Monitoring at Very Low Cost

4. 99DOTS: Accurate Monitoring at Very Low Cost
Combination of Caller ID and numbers called shows that doses are in patient’s hands.

5. Calendar View of Adherence

6. Responsibility of State Drug Stores (SDSs) for 99DOTS

7. Overall Responsibility
Ensure envelopes and extra boxes are shipped to EVERY district along with the drugs in the proportions mentioned in the attached sheet.
Districts must ensure that EVERY FDC dosage is wrapped in the 99DOTS envelopes sent by the SDS before stocking in an ART Center.
The procedure for wrapping was shown in the earlier slide.

8. Step 1 – Receive all Shipments

9. Step 1a – Receive all Shipments: Drugs
The SDS will receive drugs (4FDC for IP and 3FDC for CP) through regular Central Government Supply Chain

10. Step 1b – Receive all Shipments: 99DOTS Envelopes
These will be shipped from Everwell Health Solutions, Bangalore.
The SDS will receive 99DOTS envelopes for both IP and CP for 2/3/4/5 pills per day weight bands (each weight band has a different color envelope).
Envelopes are packed in small boxes of 100 each. Each small box will have a label on the outside.
At most 10 such boxes are in a big box. The big box will also have a label on the outside.

11. Step 1b – Receive all Shipments: 99DOTS Envelopes
Label on boxes
Boxes shipped

12. Note: Envelopes different for weight bands and IP/CP
2 pills
3 pills
4 pills
5 pills

13. Step 1c – Receive all Shipments: Empty boxes
These will be shipped by DCGPAC.
Number of boxes ~equal to number of FDC boxes received from Central Government.
Expect to receive a shipment with additional white boxes (9x5x5 inches each) to hold wrapped 99DOTS medications.

14. Step 2 – Distribute 99DOTS envelopes and drugs to districts

15. Step 2 – Distribute 99DOTS envelopes and drugs to districts
Select the SDS from the list
Type the Name of the district
Find out what fraction of TB- HIV patients in your jurisdiction are treated in this district (in %)
Enter this % into the excel sheet sent along with this presentation.
This will give you the number of drugs, envelopes, and empty boxes to be sent to each district for stocking at ART Centers.

16. Step 3 – Instruct Districts to wrap drugs before stocking at ART Center

17. Step 3 – Instruct Districts to wrap drugs before stocking at ART Center
Instruct the districts to wrap the medication around the envelopes, put them in boxes and stock in the ART centers.
Districts may also want to retain some fraction of medications (up to 60%) in their center rather than at ART center

18. 99DOTS: Accurate Monitoring at Very Low Cost

19. 99DOTS Wrapped FDC’s do not fit in the same box
The drugs after wrapping can be stored in –
The original FDC boxes,
The boxes in which the envelopes were sent (which have labels on the outside)
The additional white boxes sent (no labels)
If wrapping 99DOTS drugs at the SDS, use extra boxes and envelopes boxes to re-pack the wrapped medications. If wrapping 99DOTS drugs at the districts, send the districts empty boxes in order to hold the extra volume of wrapped medications.

20. Additional Slides

21. Envelopes different for weight bands and IP/CP
Whenever distributing 99DOTS envelopes to districts, distribute the correct ratio of dosages. Initial suggestion from CTD & NACO (You can use the excel sheet to do this, it is already done there):
2 pills/day
25% of envelopes
3 pills/day
61% of envelopes
4 pills/day
13% of envelopes
5 pills/day
1% of envelopes

22. Envelopes different for weight bands and IP/CP
Question: What to do when these ratios for weight bands are found to be different for any ART Center after some months of patient enrollment?
Answer: In case the actual usage is different than projected usage, districts should request additional envelopes, as needed, from the SDS. We have provisioned each SDS with 10% more envelopes than FDC medications to allow for variations in dosing across states and districts. Any further variations can be adjusted in the next shipments – for this distribution please use the ratio suggested (i.e. use excel sheet).

23. Wrapped drugs do not fit in the boxes
Question - After wrapping drugs in 99DOTS packaging, the wrapped drugs will not fit in the same box that they were originally packed in. Instead of packing 24 blisters per box, the wrapped medications will fit 12 per box. What to do then?
Answer- To account for this, the 99DOTS team has shipped additional boxes to each SDS. The boxes in which the envelopes have been sent can also be used to store wrapped drugs.