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

2. Topics Covered What is 99DOTS Features and Benefits of 99DOTS
Benefit to Patient
Benefit to Field Staff
Benefit to District Supervisors
99DOTS Workflow in TB-HIV collaborative intervention of ART and RNTCP department
99DOTS Dashboard Workflow
Overview of ART and RNTCP Responsibilities in 99DOTS
99DOTS Video

3. What is 99DOTS?
Strengthening DOTS monitoring through real-time adherence monitoring

4. 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 the 99DOTS dashboard and the 99DOTS Android Mobile App immediately as a taken dose

5. 99DOTS: Accurate Monitoring at Very Low Cost

6. How can the Patient data be accessed?
Different ways of accessing the patient data –
Web dashboard (
Every center will be given their own login ID and Password to access their patients
Different logins for ART center, DTC and field staff (with limited permissions)
Mobile app (For Android phones)
Most of the functions that you can do on the Web dashboard can be done through the mobile app
SMS Alerts for Staff and Treatment Supporters to take immediate action

7. Calendar View of Adherence

8. New patient (740XXXXXX) enrolled, Yelahanka district
SMS Alerts from 99DOTS
Reminders to Patients
Alerts to Staff
[0000]
Two of your
patients have
missed doses
SMS Message:
SMS Message:
[0000] Please
Two of your
take pills
Please
patients have
missed doses
today: Raj &
take pills Om
Raj (979XXXXXX)
& Om (812XXXXXX)
Notification of new patients
Analytics and Reports for Program
New patient (740XXXXXX) enrolled, Yelahanka district
SMS Message:
[0000] Please
take pills

9. Features of 99DOTS Calls are completely free for patients
Calls can be made even when the patient has no pre paid balance or the mobile is in roaming area
Any call from a registered patient number is marked as a dose taken (personal, shared, land line)
Numbers are not unique, but appear in an unpredictable sequence – ensures pill-in-hand adherence
When patients call, they hear “Thank you”
Calls immediately show up in the dashboard as taken doses
Automatic alerts and reminders to patients and supervisors for non-adherent patients
Adherence records available to field staff, medical officers, district staff and all other stakeholders in the program
Two of your
patients have
missed doses
Raj (979XXXXXX)
& Om (812XXXXXX)
SMS Message:
today: Raj & Om

10. Field Staff/Supervisors
Benefits of 99DOTS
Less travel
Increased convenience
Patients
Focused and more efficient care
Field Staff/Supervisors
Easy monitoring
Accurate reports
Program Officers

11. 99DOTS Workflow for TB-HIV Co-Infected Treatment

12. 99DOTS: Workflow - Summary
Patient’s sputum is sent for testing to the RNTCP center
CBNAAT testing for rapid microbiological diagnosis
Patient at ART Centre with symptoms of TB
Cough, Fever, Night sweats, Weight loss
Continuous monitoring and follow up by RNTCP staff
Patient is counseled at ART Centre to take medication in the 99DOTS packaging and registered on 99Dots website
Patient identified positive for TB

13. TB Medication Regimen Most patients undergo treatment for 6 months FDC
Intensive Phase (IP): 2 months
(Isoniazid, Rifampicin, Ethambutol, and Pyrazidamide) – 4FDC
Continuation Phase (CP): 4 months
(Isoniazid, Rifampicin, and Ethambutol) – 3FDC
FDC
Pills/Day based on weight band
Daily regime – easy with FDC
If patient takes full course, near certain-cure
After 2-3 weeks: feeling better
After 6 months: negligible chance of
relapse/resistance
4FDC
3 FDC

14. Does not receive FDCs or 99DOTS
FDC Drugs by Weight
WEIGHT CLASS
# OF PILLS
# STRIPS FOR 28 DAYS
< 25 kgs
Does not receive FDCs or 99DOTS
30 – 39 kgs
2 pills per day 2
40 – 54 kgs
3 pills per day 3
55 – 70 kgs
4 pills per day 4
> 70 kgs
5 pills per day 5
FDCs wrapped in custom 99DOTS envelopes based on weight (diagrams to follow)

15. 99DOTS Envelopes – Weight Band Wise
2 pills
3 pills
4 pills
5 pills

16. 99DOTS Envelopes – Universal
Each patient gets the same sleeve, regardless of weight band
Counselor/pharmacist should write number of pills/day patient should take on the envelope
Every day, a patient will take prescribed number of pills and reveal 1, 2, or 3 hidden phone numbers
Patient should call any one they reveal that day
Patient should start at pill 1 and move in sequence (1,2,3…28), completing each column, and starting from the top at each row

17. Patient counseling of 99DOTS
Explain 99DOTS, and importance of adherence (how many pills, every day, make free call)
6 months medication
Call is free, even without balance and can be done free even when roaming
Patient should follow path of pills
Patient should come back every 28 days when pills are finished
If patient has phone, administer first dose and make first call

18. 99DOTS Website and App Workflow
NOTE:
For detailed information on how to use the 99DOTS Website or the 99DOTS Mobile app to perform various tasks, see the respective guides available on the Training Materials page.

19. Snapshots of 99DOTS Website Dashboard

20. Snapshots of 99DOTS Mobile App

21. 99DOTS Dashboard Workflow
Step 1
RNTCP – District Login : Maintain Staff Details at District and TU level using the Staff Details menu in the 99DOTS Website and also configure alert frequency for the staff to receive SMS alerts
Step 2
ART Center Login: – Register Patient using the Add Case menu in the 99DOTS Website
Step 3
RNTCP – District Login: Assign correct TU for all new patients using the Treatment Center tab under patient details page in 99DOTS Website
Step 4
RNTCP – District Login: Link TU staff to some or all patients of the TU using the Staff Details menu in the 99DOTS Website
Step 5
RNTCP – District and TU Login – Monitor patients for adherence using the Calendar menu in the 99DOTS website. Add Notes/Tags after interacting with patients, and perform various patient management tasks from the patient details page.

22. 99DOTS Dashboard Workflow
STEP 1: Staff Details
STEP 2: Add Patient
STEP 3: Assign Patients to TU
Using the District Login, add District and TU staff details. These staff will get SMS alerts for patients listed under their district and TUs based on the alert frequency configured in this step. This is mandatory and extremely important.
Register Patient on 99DOTS (using ART login) – When registering patient, select the correct District to which the patient belongs. This allows the relevant district to see the patient.
From the list of Patients under District, select the required patient and allocate him/her to a TU within the district. Once patients are allocated a TU, TU Staff will start receiving alerts about the patient and see them from the TU login.
STEP 5: Patient Management
STEP 4: Link Patients to TU Staff S
Perform various on-going patient management tasks such as: Edit Patient Details, Edit Attention Required, Adding Notes and Tags, Editing Treatment Center, Marking Manual Dosage, Closing and Reopening a Case, Reports, etc.
From the Staff Details menu, link patients of a particular TU to the respective TU staff. TU staff can be linked to all patients of the TU or some patients of the TU. The TU staff will get SMS alerts for the patients they have been linked in this step.

23. Patient monitoring by RNTCP
Login to 99dots.org or 99DOTS Mobile app to see patient adherence/notes
Follow up with patients with low adherence
Respond to SMS alerts, and 99DOTS requests to follow up with patients
DOTS+ Supervisor/RNTCP team to review adherence at regular meetings
Add notes on patient behavior to log follow ups

24. 99DOTS – Adherence scenario
Patient ID
Patient name 1 2 3 4 5 6 7 8
1423
Rahul K.
Patient ID
Patient name 1 2 3 4 5 6 7 8
1423
Rahul K.
Today is the 8th day of Rahul’s treatment and he has not called in two days
Rahul gets a message reminding him to take his daily dose
The RNTC staff (STS, TBHVs, DPS, field staff) also gets a message alerting them that Rahul has not taken medication in 3 days
[0000]
Please take pills
They call Rahul, and counsels him on the importance of taking drugs every day
Rahul K. (740XXXXXXX) has not taken pills.
Rahul takes his medication, and calls the hidden number, so his adherence can be logged

25. Roles and Responsibilities of ART and RNTCP staff for TB-HIV Co-Infected treatment

26. 99DOTS TB-HIV Co-infected Treatment Responsibility Matrix
Task
Responsible Department
Ensuring that drugs are sent to ART Centers
RNTCP – District TB Office
Adding Staff Details at District and TU Level in 99DOTS website and linking them to patients. These staff will get SMS when a patient is added and when the patient misses to call the toll free number
RNTCP – DPS, or any other staff designated by DTO
Adding relatives or other persons close to the patient, community workers, etc. who would like to be intimated by SMS on non adherence and liking them to patients.
Registering Patients on 99DOTS website (selecting correct district, adding phone numbers, and assigning correct weight band)
ART Center – Data Manager
Assigning Patients to the correct TU under the district
RNTCP - DPS, or any other staff designated by DTO
Counseling Patients about 99DOTS and how to make a call after each dosage
Initially by ART Center Counselors/nurses/doctors while giving medicines. Later by RNTCP staff (for example, DPS, STS, TBHVs) who is responsible for monitoring patients adherence on 99DOTS website and responding to SMS alerts

27. Task
Responsible Department
Handing over 99DOTS wrapped drugs to patients
ART Center – Pharmacist
Ensuring that drugs are available, maintaining inventory, and issuing refills to patients
ART Center - Pharmacist
Editing Patient Details, like adding additional phone numbers, updating address change
ART Center – Data Manager and RNTCP - DPS, or any other staff designated by DTO
Monitoring patient list for adherence
RNTCP - DPS, or any other staff designated by DTO
Follow up with patience once non adherence SMS is received by the linked staff/provider
RNTCP – STS, TBHVs, DPS, Field workers, or any other staff designated by DTO
Adding Notes and Tags, marking manual doses, closing a case, downloading reports
Changing Treatment Center details, for example in the case of change of TU/District/ART Center of patient.
The DOTS Plus Supervisor (DPS) or any other staff designated by the District TB Officer (DTO) is accountable for all patients in his/her district. He/she can call patients directly after going through the dashboard and/or delegate this to the relevant field staff like STS, TBHVs, field workers, etc.

28. 99DOTS Training Video http://bit.ly/99DOTS-ENGLISH