CombaTB: An All-In-One Tuberculosis

Treatment Application
Abstract
Indonesia ranks 5th as the country with the highest burden of Tuberculosis (TB) in the world.
TB prevalence and mortality rate reaches 660.000 and 61.000, respectively. It happens
because most patients do not comply to the long duration of therapy, which results in
prolonged sickness, drug resistance, and death. An Android-based application is proposed to
monitor patient’s adherence to the treatment and educate the patient about TB. Physician,
patient, and community health center will be connected in this application. The primary
function of this application is to remind patient to take their medicine every day, attend an
appointment with the physician, and undergo sputum examination. To ensure the continuity
of the treatment, there will be a feature for drug delivery service. Patient will also be kept
motivated by personal challenges. TB flashcard and TB quiz are educative features aim to
increase the knowledge on preventing TB transmission and increasing treatment success. This
success of this application depends on patient-physician teamwork, collaboration with
community health center, as well as support from the government.

Keywords
Tuberculosis; android application; medical reminder; patient’s adherence

Introduction
Tuberculosis (TB) is a national public health concern that has drawn great attention for the
last 2 decades. Although national TB program has been developed in Indonesia, TB
prevalence (number of cases) and mortality rate (number of deaths per 100.000 population
each year) is still high. In 2010, 660.000 cases of TB were detected. Without a proper
management, this number will continue to rise as 430.000 new cases of TB are expected to
emerge each year.

TB is the second deadliest communicable disease in the world after HIV. In Indonesia, TB
kills 61.000 people annually. Furthermore, TB can also cause several complications that lead
to permanent disability, decreased productivity, and finally impoverishment of the infected
person. The loss of productivity and the addition of TB management funding will inevitably
affect national economy. With the current TB new cases and mortality rate, it is estimated
that Indonesia will incur roughly US$ 2,1 billion. This condition has put Indonesia as the 5 th
country with the highest burden of TB after India, China, Nigeria, and Pakistan.

TB is caused by acid-fast bacteria Mycobacterium tuberculosis. Unlike other type of bacteria,

M. tuberculosis can only be killed by powerful antibiotics, such as Rifampicin, Isoniazid,
Ethambuthol, and Pyrazinamide. Unfortunately, resistance towards these antibiotics develop
rapidly when the drug is used singly or the patient does not complete the course. Hence, a
specialized strategy is created, which obliges patient to take daily dosing of 3-4 combination
of drugs for 6-8 months without interruption.

The long course of treatment is a challenge for every patient. Most of them do not complete
the treatment because of many factors. This is a serious issue because inadherence to the
treatment contributes to prolonged sickness, drug resistance, and even death. To overcome
this problem, the government sets up another control strategy called directly observed
treatment (DOT) for patients who seek medical care in primary health care facilities. In this
strategy, a health worker, community health center “Puskesmas” volunteer (in Bahasa, we
call them kader Puskesmas), or someone appointed by the patient has to watch the patient
swallow their medication every day. However, the overall drop-out rate is still high due to the
poor implementation of DOT in private sector and higher health care facilities. In addition,
this system mainly depends on patient and his/her DOT supporter compliance. It is rather
difficult for health care provider, such as physician, to also monitor patient’s compliance to
the treatment.

Nowadays, smartphone and internet access has greatly influenced people’s lives. In
Indonesia, most people have already had access to smartphone, most of which are android-
based. Smartphone allow its users to communicate with other people, send data, and schedule
their daily routines easily. This makes smartphone application be a potentially useful tool to
monitor patient therapy that results in higher adherence and successful treatment.

Meanwhile, various methods have been attempted to increase patient adherence to treatment
of chronic diseases, such as hypertension and dyslipidemia. Those methods include
reminders, self-monitoring, reinforcement, counseling, and more supervision from the health
care providers. In a study conducted by A Christensen et al, electronic monitoring and
reminder device (not a smartphone application) is convinced to improve adherence by 6% in
patient with hypertension. However, a smartphone application with a similar function
specifically designed for TB treatment has not yet been established.

With its free, widely-used, and accessible characteristic, android application will be a
beneficial approach to lower TB incidence. An all-in-one TB android application is designed
to connect physicians, TB patients, and their DOT supporters through a forum which
hopefully will increase patient adherence to the treatment. This application is also equipped
with innovative features such as drug delivery service, personal challenges, TB flashcard, and
TB quiz. Hopefully this all-in-one TB application can close the loophole in the National TB
Program held by the Ministry of Health.

Materials and Methods

Android is an open source platform that makes it favored by many smartphone
manufacturers. For developers, Android has made it easy to create a mobile application by
providing all the necessary tools available for free.
Two basic softwares are required to develop an android application. First, Java Development
Kit (JDK) needs to be installed. Java is the main programming language used in Android
system. Hence, understanding Java is a very crucial basic. The main work (i.e. coding) will
be done using Android Studio. It is an official software provided by Android which already
includes an integrated development environment (IDE), software development kit (SDK)
tools, Android 6.0 (Marshmallow) platform, and an emulator to run the program for testing
purposes.

In this application, physicians, patients, and community health center “Puskesmas” are
connected in one forum. The primary function of this application is monitoring the patient’s
treatment according to the TB treatment guideline. This includes:
 Reminding the patients to take their medicine everyday until they are diagnosed TB-free,
 Notifying the physician before the patient’s drug supply is depleted,
 Reminding the patients to undergo routine sputum examination by the end of month-2, -5,
and -6

This application is also equipped with other functions, such as:

 Drug delivery service
 Personal challenges
 TB flashcard
 TB quiz

Application Design
The system begins when a patient is diagnosed with TB in a physician’s office. The physician
and the patient will need to install this application on their smartphones. Each one of them is
also required to register an account. The application will ask the users to choose their role (as
a physician, a patient, or community health center). Every patients need to fill in their several
information; full name, date of birth, address, contact number, body weight, history of
allergy.

Initially, the physician have to mark the date on which the patient was first diagnosed to have
TB. Then, the physician has to upload the drug prescription consisting the drug’s name, dose,
quantity, as well as the instructions on how much and when the patient have to take their
medicine. A daily reminder will be set according to that treatment plan. Every time the patient
has taken the medicine, he/she has to record it manually by checking a to-do-list box on the
application. It will then be sent to the server. This record will also appear on the physician’s
account to be supervised. This real-time information allows the physician to notice when the
patient misses taking their drug.

Although the overall course of TB treatment lasts for 6-8 months, physicians do not prescribe
the drugs all at once. Instead, they will prescribe 1 blister pack of anti-TB drug containing 28
tablets for 28 days. Given the initial quantity and the number of the drugs that has been
swallowed by the patient, this application can count the remaining drugs left. By the end of
the 3rd week when there are supposed to be 7 remaining tablets, this application will send a
notification to the physician. It will prompt the physician to either schedule an appointment
(if it is needed) or prescribe the drugs for the next phase. The drug will then be delivered to
the patient’s house using drug delivery service which will be explained in the next section.

The physician can also input other treatment plan, such as monthly appointment and sputum
examination schedule for month-2, -5, and -6 (according to the TB treatment guideline). The
application will issue an alarm on the patient’s smartphone 24 hours prior to the event.

Patient can also report any changes that he/she is experiencing, such as increasing body
weight or burning sensation on the extremities due to the drug’s adverse effect. Then, the
physician can give a feedback to the patient, for example dose adjustment or drug
substitution.

Additional Features
Drug Delivery Service
As mentioned in the previous section, in response to the drug supply alarm, the physician can
either schedule an appointment or prescribe the drugs for the next phase. For the latter option,
this application provides a feature for the physician to order the drug from the local
community health center “Puskesmas” and send it to the patient’s address. This option
requires cooperation with the local community health center “Puskesmas” because it is the
only health care facility that provides free anti-TB drugs regulated by our government. In
addition, Puskesmas has volunteers who can be employed to deliver the drugs to the patient’s
house.

Personal Challenges
Throughout the long course of treatment, it is important to keep the patients motivated and
aware of the progress they are making. For this purpose, we divide the long course into 3
levels. Each level have different targets. If the patient achieves the target by the end of the
level, a congratulation message will show up on the phone screen and the next target will be
displayed.

The levels are :

 Level 1 (month-0 to month-2) : achieve lower grade on sputum smear examination
 Level 2 (month-2 to month 4) : uninterrupted medication for 2 consecutive months
 Level 3 (month-4 to month-6) : negative mycobacterial sputum culture

TB Flashcard
TB flashcard is a set of information about TB presented in concise sentences and supported
by attractive pictures if necessary. It is created to educate the patients about their disease.
Hopefully, good knowledge will result in better output; successful treatment and preventing
the spread of disease.
The materials are classified into various topics as follow:
 Regarding the natural history of TB; etiology, pathophysiology, signs and symptoms
 Regarding anti-TB drugs; why patient compliance is important, adverse effects of the
drugs
 Regarding the diagnosis of TB; how to obtain the right sputum (specimen) for
mycobacterial examination
 Regarding the spread of TB; transmission of TB, cough etiquette

TB Quiz
In this feature, patients will be entertained by educative questions about TB. The quiz will be
in the form of multiple-choice question. There will be more than 100 questions in the
database, but only 10 questions show up for each round. By the end of the round, the
application will reveal the number of questions that have been answered correctly.

Conclusion
In this paper, we proposed a design idea of an application for monitoring TB patient’s
treatment. This android-based application will be equipped with various features; reminder,
drug delivery service, personal challenges, TB flashcard, and TB quiz. It can be implemented
anywhere, as long as the physician and the patient have a compatible device and an internet
connection. The success of this application depends on patient-physician teamwork.
Collaboration between physicians, patients, and community health center is also needed.
Support from the government, especially on the laboratory facilities, distribution and supply
of the drugs, needs to be enhanced.