Puerto Rico is known as la cuativadora isla del encanto, or “the captivating island of enchantment.” My father was born in Utuado, in the mountains of the island, and because I lived in Miami for most of my life, I was able to stay connected to my cultural roots. Since moving to Baltimore to study public health at Johns Hopkins, I’ve craved soaking up the Caribbean sun to escape the winter blues. This lead me to take a vacation to visit friends on the island in October 2016. Little did I know that this personal trip would be the start of one of the most impactful public health projects I’ve been a part of.
The friends I was visiting all worked in public health. As anyone working in this space knows, you can’t put a bunch of public health nerds in a room -- even on a vacation -- without talking about what’s going on in the community. It was then that I first learned about a recurring tuberculosis (TB) outbreak at a facility for men with severe cognitive impairment. The home was located off the beaten path nestled in the rolling foothills of the mountains, making it difficult to access regularly.
Considering ongoing concerns about the Zika virus and staffing shortages, I was struck by the complex challenges that public health officials in Puerto Rico were facing. Through a partnership between the Puerto Rico Department of Health, U.S. Centers for Disease Control and Prevention (CDC), and emocha, we were able to overcome these barriers and help the men living in the facility through technology.
Timeline of the tuberculosis outbreak in Puerto Rico
Between 2010-2012, seven residents of the facility were diagnosed with active TB. Unfortunately, three of these individuals died before they were able to begin treatment. The remaining four men with active TB began the standard regimen of rifampin, isoniazid, pyrazinamide, and ethambutol (RIPE) under the supervision of facility staff.
In the same timeframe, an investigation determined that an additional 26 residents and 7 non-residents had latent TB infection (LTBI). Those with LTBI were reported to have completed treatment with 4 months of daily rifampin.
Several years later in 2016, 2 of the 4 residents who underwent treatment for active TB in 2012 died. On June 20, 2016, 1 of the 26 residents who had been treated for LTBI was diagnosed with advanced active TB, and testing proved that this patient’s disease was connected to the original cases from 2010-2012. This individual is known as the “index patient” since he was the first identified in a group of related cases.
An investigation determined that there are 10 additional residents with active TB and 6 residents with LTBI. These patients begin their respective treatment regimens.
Mobile technology’s role in halting the tuberculosis outbreak
TB is a highly contagious infectious disease. Medication adherence -- or taking medication as prescribed -- is critical as missed doses could lead to drug resistance and devastating health consequences. Directly Observed Therapy (DOT) -- having a healthcare worker watch patients take every dose of their medication -- is the standard of care for TB to ensure successful treatment completion, but is difficult to achieve. Like many local health departments, staffing shortages at the Puerto Rico Department of Health made administering daily in-person DOT at the facility not feasible. Similarly, the facility did not have the personnel needed to provide daily patient transport to the Department of Health’s clinic so that residents’ doses could be observed. Further complicating the situation was the lack of reliable internet connectivity at the facility, so live video chats were not an option.
emocha’s video DOT works asynchronously -- meaning that patients and providers do not have to be online at the same time. Patients also have the option of recording videos of themselves taking their medication while offline, securely storing them, and automatically uploading the videos once they are re-connected to the internet. Providers -- in this case the Puerto Rico Department of Health staff -- review the videos and assess adherence through a HIPAA-compliant web portal.
Medication adherence outcomes
One week prior to Christmas 2016, we deployed emocha’s video DOT platform to help stop the crisis. By May 19, 2017, all active TB and latent TB patients demonstrated clinical improvements in health over the six-month treatment program and the outbreak was declared contained.
The following outcomes were highlighted in the report published by the CDC this December:
- All patients completed their treatment regimens
- Patients with active TB achieved 92 percent medication adherence
- Patients with latent TB achieved 89 percent medication adherence
- Puerto Rico Department of Health saved 360 staff hours
My colleagues and I are proud to have played some role in helping those affected by this outbreak. Although Puerto Rico is now in the midst of other public health challenges caused by Hurricane Maria, it’s encouraging to know the impact that collaboration can have in overcoming them.
Want to learn more about how emocha has helped during times of crisis? Read this POLITICO Magazine article about how we helped to secure medication adherence after Hurricane Harvey.