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Video-Observed Treatment Instead of Directly Observed Treatment for TB

Smartphone-enabled video observation of tuberculosis treatment (VOT) was effective and has multiple advantages over traditional directly observed therapy (DOT).  In the full follow-up period, completed observations were significantly higher in the VOT than DOT group (77% vs. 39%, respectively). 

Directly observed treatment (DOT) for tuberculosis (TB) has been recommended to improve treatment completion particularly among groups with poor adherence. Smartphone technology makes video-observed treatment (VOT) feasible. U.K. investigators compared TB treatment completion using traditional DOT versus asynchronous VOT (recorded video clips forwarded and reviewed later).

Investigators randomized patients aged ≥16 years with active TB (MDR-TB excluded to DOT [direct observation 3–5 times per week]) or VOT. VOT participants received smartphones and training to record and send videos of themselves taking medication. Trained observers assessed whether participants had taken doses. Smartphone participants could report adverse events and could call and text. More than half of both groups gave histories of homelessness, imprisonment, drug or alcohol problems, or mental health problems.

In intention-to-treat analysis, 70% of 112 VOT participants completed at least 80% of observations during first 2 months (including among those at increased risk for nonadherence) versus 31% of 114 on DOT. In the full follow-up period, completed observations were significantly higher in the VOT than DOT group (77% vs. 39%, respectively). Positive sputum cultures did not differ significantly between VOT and DOT at 2 months. Adverse events were reported by more VOT-group than DOT-group participants. VOT required less staff time and was cheaper than DOT.


Video-enabled TB treatment observation resulted in greater confirmed treatment compliance than DOT and achieved good results even in patients at high risk for poor adherence. VOT took less time for health workers and patients, was cheaper, and did not reduce identification of adverse events. The study was too small to detect differences in culture conversion or resistance development. It did not include patients with multidrug-resistant TB. This approach could have broad applicability as smartphone technology is widely available in most countries; good internet and cellular connections are needed. These results led U.K. National Health Service in London to adopt VOT.

Mary E. Wilson, MD reviewing Story A et al. Lancet 2019 Feb 21

EDITOR DISCLOSURES AT TIME OF PUBLICATION:  Disclosures for Mary E. Wilson, MD at time of publication: Consultant/Advisory Board : FXB Center for Health and Human Rights, Harvard T.H. Chan School of Public Health; Fogarty International Center

Royalties : UpToDate

Editorial Boards : Travel Medicine and Infectious Diseases; Journal of Travel Medicine

CITATION(S):Story A et al. Smartphone-enabled video-observed versus directly observed treatment for tuberculosis: A multicentre, analyst-blinded, randomised, controlled superiority trial. Lancet 2019 Feb 21;