99 DOTS and MERM boxes

99 DOTS

99 DOTS is an IT-enabled ‘pill-in-hand’ adherence monitoring system implemented by the National TB Elimination Programme (NTEP) for all Drug-sensitive TB (DS-TB) patients on a daily regimen.

Mechanism of 99 DOTS

• In this system, the medicine blister packs (Figure 1) are wrapped with envelopes which have unique toll-free phone numbers printed on them.
• Each time a patient dispenses the pills, they break through perforated flaps on the back of the envelope, revealing a hidden phone number.
• The patient is expected to give a call to this toll-free number from his/her registered mobile number to report that they have consumed the medication.
• This is documented and updated against the patients’ adherence record in Ni-kshay.
• The sequence of hidden numbers cannot be predicted by patients but is known by the system for each month of medication prescribed.
• If the call is not received from the patients by 3:00 p.m., an SMS reminder is sent to the patients on their registered mobile number.
• If the patient still does not consume medications, the issue is escalated to the authority chain till corrective action is taken.
• Additionally, the patient can also be remotely followed up with help of Call Centres or using an Interactive Voice Response (IVR).

Printing of 99 DOTS Envelopes

• Specification for the printing of 99 DOTS envelopes is provided by Central TB Division (CTD) to all states and the envelopes are printed at the state level and then distributed to the districts.
• The cost of printing and distribution of these envelopes should be budgeted in the state Programme Implementation Plan (PIP).

Advantages of 99 DOTS

• Enables the NTEP staff to prioritise patients who need to be visited and counselled.
• Empowers patients to be able to take charge of their own treatment.

                                                       Figure1: 99-DOTS Blister Pack

Figure 2: Colour-coded adherence calendar output of 99-DOTS patients based on calling

Medication Event Reminder Monitor (MERM) Box

The Medication Event Reminder Monitor (MERM) Box is an electronic pill box specially designed to monitor Multidrug-resistant TB (MDR-TB) treatment.

Mechanism of MERM

• Medications are dispensed in blister packs and each drug is placed in a different partitioned compartment within the pillbox.
• The MERM box contains a removable electronic battery-powered module when triggered by a magnetic sensor captures and stores data each time the container is opened, as a proxy for medication ingestion.
• The MERM is programmed to provide audio-visual reminders to the patients to take medications at a specific time of the day.
• The visual reminder consists of:
  • Green light: Corresponds to a label encouraging the patient to take a dose.
  • Yellow light: Alerts patients about the need to refill medications.
  • Red light: Indicates a low battery and the need to replace the MERM’s battery.

• The audio reminder consists of a ringing sound that would occur at the same time as the visual dose-taking reminder.

• The data from the MERM boxes is transmitted every 72 hours using cellular networks and recorded on a computer server.
• Each patient’s adherence history is presented as a colour-coded calendar (Figure 2) in which:
  • Green suggested that the MERM was opened on a given day: Suggesting probable medicine was consumed.
  • Red suggested that the device was not opened: Suggesting that medicine was probably not consumed.
• In case there is a series of possible missed doses, i.e., red-coloured calendar days, it would result in automated SMS notifications to the patients and also prompt the system to address the interrupting patients who are potentially at higher risk for unfavourable outcomes.

Advantages of MERM box

• Facilitates the identification of high-risk patients and prompt intervention by the system to improve adherence.
• Facilitates storage and organisation of the multiple medications of the MDR-TB regimens.
• Reduces the required frequency of patient visits to a health facility in comparison to facility-based DOT.

Figure 3:Medication Event Reminder Monitor (MERM) Box

Resources

• Procurement, Supply Chain Management & Preventive Maintenance, Module 6, CTD, MoHFW, India.
• 99DOTS: A Low-Cost Approach to Monitoring and Improving Medication Adherence. In Tenth International Conference on Information and Communication Technologies and Development (ICTD ’19), Cross et al., Ahmedabad, India, 2019.
• 99 DOTS. International Journal of Contemporary Medical Research, 2016;3(9):2760-2762.