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Mobile health (mHealth) is a rapidly emerging market, which has been implemented in a variety of different disease areas. Tuberculosis remains one of the most common causes of death from an infectious disease worldwide, and mHealth apps offer an important contribution to the improvement of tuberculosis treatment. In particular, apps facilitating dose individualization, adherence monitoring, or provision of information and education about the disease can be powerful tools to prevent the development of drug-resistant tuberculosis or disease relapse.
The aim of this review was to identify, describe, and categorize mobile and Web-based apps related to tuberculosis that are currently available.
PubMed, Google Play Store, Apple Store, Amazon, and Google were searched between February and July 2019 using a combination of 20 keywords. Apps were included in the analysis if they focused on tuberculosis, and were excluded if they were related to other disease areas or if they were games unrelated to tuberculosis. All apps matching the inclusion criteria were classified into the following five categories: adherence monitoring, individualized dosing, eLearning/information, diagnosis, and others. The included apps were then summarized and described based on publicly available information using 12 characteristics.
Fifty-five mHealth apps met the inclusion criteria and were included in this analysis. Of the 55 apps, 8 (15%) were intended to monitor patients’ adherence, 6 (11%) were designed for dosage adjustment, 29 (53%) were designed for eLearning/information, 3 (6%) were focused on tuberculosis diagnosis, and 9 (16%) were related to other purposes.
The number of mHealth apps related to tuberculosis has increased during the past 3 years. Although some of the discovered apps seem promising, many were found to contain errors or provided harmful or wrong information. Moreover, the majority of mHealth apps currently on the market are focused on making information about tuberculosis available (29/55, 53%). Thus, this review highlights a need for new, high-quality mHealth apps supporting tuberculosis treatment, especially those supporting individualized optimized treatment through model-informed precision dosing and video observed treatment.
Tuberculosis is an infectious disease caused by
This aim of this review was to discover, describe, and categorize Web-based and mHealth apps related to tuberculosis on the market. In 2016, Iribarren et al [
The PubMed database, Google Play Store, Apple Store, Amazon, and Google were searched extensively in Sweden between February and July 2019 using the keywords “TB,” “Tuberculosis,” “Tuberkulos,” “Tuberkulose,” “Tuberculose,” “TDM,” “Therapeutic Drug Monitoring,” “Model-informed precision dosing,” “Decision-support software,” “Clinical pharmacokinetics,” “Dosing,” “Individualized dosing,” “Personalized medicine,” “Dose calculator,” “VOT,” “VDOT,” “videoDOT,” “eDOT,” “video observed treatment,” and “virtually observed treatment”. The keywords were selected by searching the literature for reviews dealing with mobile interventions for tuberculosis treatment and video observed treatment (VOT). Furthermore, studies and reviews from references in previously discovered sources were included. The search was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines [
mHealth apps in all languages were included if they focused on active or latent tuberculosis and were excluded if they were dedicated to other infectious diseases, or if they were not created for health improvement (eg, games).
Discovered mHealth apps are summarized in tables in
Our search identified a total of 376 mHealth apps according to the selected keywords. After removal of duplicates and irrelevant apps, 69 apps were screened and assessed in detail, 11 of which were excluded because they were focused on other disease areas, and 3 were excluded because they were games unrelated to tuberculosis. Finally, 55 mHealth apps were included in this review (
The 55 mHealth apps meeting the inclusion criteria were categorized (
Flow chart of search strategy following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.
Categorization of the included mHealth apps (N=55).
Category | Description | n (%) | Examples |
Adherence monitoring | Assistance for patients to keep track of their daily drug intake; |
8 (15) | miDOT – EMOCHA; AiCure; SureAdhere; TBmCure; Wisepill evriMED |
Individualized dosing | Assistance for doctors with dosage adjustments based on certain patient characteristics; |
6 (11) | DoseMeRx; MwPharm; InsightRx; TDMx |
eLearning/information | Depiction of official guidelines; |
29 (53) | Tuberculosis TB treatment and Plan; ExplainTB; Tuberculosis TB Symptoms, Causes & Diet Help; TB mobile |
(Self-) Diagnosis | Diagnostics based on data input (eg, questionnaire answers, cough sound); apps for clinicians and students to train in tuberculosis diagnosis | 3 (6) | TuberSpot; TimBre for Tuberculosis (TB); Diagnosa Tuberkulosis (TB) |
Others | Evaluation of treatment costs; tracing of people having contact with an infected person; monitoring and tracking of patients with tuberculosis; assistance with data gathering; creation of laboratory reports | 9 (16) | CAD4TB; eDetection; TB eHealth; EdetectTB; LTBI Care |
VOT (synonyms: video directly observed treatment, electronically directly observed treatment, video directly observed treatment, mobile directly observed treatment) describes the daily remote observation of drug intake using a smartphone app. There are two strategies to perform VOT: synchronous and asynchronous VOT. Synchronous VOT involves a live video call between patients and health care personnel. In asynchronous VOT, patients record a video of themselves, which is then stored and forwarded for later viewing by the provider. Advantages of asynchronous VOT compared to synchronous VOT are that it can be used outside of business hours and no time with the provider has to be scheduled [
Out of the 8 mHealth apps for adherence control, 3 are intended for VOT (miDOT-EMOCHA, SureAdhere, and AiCure).
MiDOT is a medication adherence app developed by emocha Mobile Health Inc (Baltimore, MD, USA). The app uses asynchronous VOT technology (store-and-forward), and care teams then review the videos and engage daily. Patients can report side effects, and the app has an additional function to filter patients struggling with adherence or experiencing side effects. The app can be purchased for Android and Apple [
SureAdhere is an mHealth app for asynchronous VOT. The app development was initiated by Richard Garfein from the University of California San Diego, USA. The app is compatible with Apple and Android and must be purchased. Features include patient text message or email reminders, notification to providers after a missing dose, side effect reporting, and report generation [
AiCure is an mHealth app using artificial intelligence to confirm medication ingestion. The software captures video, audio, and behavioral data. This app has been used in clinical trials and for population health to ensure patient adherence. The built-in algorithms have been validated against plasma blood levels. The software gathers data that can then be reviewed by health care staff [
Wisepill evriMED is a VOT-like app, which is connected to a smart pill dispenser that registers opening of the pillbox and subsequently sends a signal to the app. This adherence monitoring app is classified as an electronically directly observed treatment solution [
Other apps developed to facilitate patients’ daily drug intake include Adhere2Tx-TB, Stop TB, TBmCure, and Sembuh TB, which alert and remind patients to take their medication on a regular basis (see
The 6 mHealth apps providing health care professionals with assistance in dose optimization are TB Doctor, Medical Management of MDR-TB, DoseMeRx, MwPharm, InsightRx, and TDMx.
TB Doctor and Medical Management of MDR-TB are mHealth apps that enable clinicians to calculate individual doses depending on a patient’s body weight with the help of dosing tables based on current guidelines both for drug-susceptible and resistant TB.
The remaining four tools (DoseMeRx, MwPharm, InsightRx, TDMx) have been developed for dose individualization of TB medication at the bedside based on more information than body weight (
DoseMeRx is a decision-support software for precision dosing using MIPD. The commercial cloud-based Web app, which is also available as a mobile app for Android and Apple, uses several published clinically validated population pharmacokinetic models for the calculation of individualized doses to reach the therapeutic target. All patient data are stored in a patient file and EHR integration is also possible. The software is registered as a class l medical device in Europe and Australia [
Overview of mHealth apps for model-informed precision dosing of tuberculosis drugs.
Feature | DoseMeRx | MwPharm | InsightRx | TDMx |
Available tuberculosis drugs | linezolid, bedaquiline, isoniazid, rifampicin, pyrazinamide, ethambutol, para-aminosalicylic acid, moxifloxacin, levofloxacin | isoniazid, rifampicin, ethambutol, streptomycin | ciprofloxacin, linezolid, rifampicin, meropenem, amikacin | meropenem, amikacin, rifampicin |
Compatibility | Mac, Windows, Linux, Android, iOS | Cloud-based platform | Cloud-based platform | Cloud-based platform |
Output from program | Doses and pharmacokinetic parameter estimates | Doses and pharmacokinetic parameter estimates | Doses and pharmacokinetic parameter estimates | Doses and pharmacokinetic parameter estimates |
Electronic health record integration | Yes: EPIC App Orchard, Cerner Millennium, Allscripts | Yes | Yes: EPIC App Orchard, Cerner Millennium, Meditech, Centricity | No |
Availability | Web-based | Web-based | Web-based | Web-based |
Required training | Minimal | Minimal | Minimal | Minimal |
Further information (reference) | [ |
[ |
[ |
[ |
Cost | Available at [ |
1250 Euro per license | Not publicly available | Free |
Medical device | Yes | Yes | No | No |
MwPharm (Mediware a.s.) was developed in 1982 at the University of Groningen, the Netherlands [
InsightRx (San Francisco, CA, USA) is a cloud-based Web app for precision dosing using a Bayesian approach; all implemented models are clinically validated [
TDMx is a cloud-based platform for precision dosing using a Bayesian approach (lead developer: Sebastian Wicha, University of Hamburg, Germany) [
A total of 29 mHealth apps were identified that focus on providing patients and health care professionals with information on tuberculosis. Most of these apps provide information related to causes, risk factors, symptoms, diagnostics, treatment, or diet. The apps mainly depict treatment guidelines, provide doctors and students the opportunity to improve their skills in tuberculosis treatment, or explain the disease and its therapy to patients (see
Three mHealth apps (TuberSpot, TimBre for Tuberculosis [TB], Diagnosa Tuberkulosis [TB]) supporting health care professionals and patients with a TB diagnosis were included in this review.
TuberSpot (SpotLab, Spain) is a game to identify tuberculosis bacilli in samples. This app teaches the user about shape, color, clusters, and how to differentiate tuberculosis bacilli from artifacts [
Nine mHealth apps could not be categorized within the above-mentioned categories. Their functionalities ranged from simulation of treatment costs (CAD4TB [Interactive Health Solutions, Pakistan]) [
Fifty-five mHealth apps related to tuberculosis were included in this review. In comparison to previous work on the topic [
Adherence is a major challenge in tuberculosis therapy since the treatment length ranges from 6 months for drug-susceptible tuberculosis [
Studies comparing directly observed treatment and VOT show that VOT is convenient for patients and providers, time and cost-effective, widely accepted among patients and health care personnel, and flexible [
Potential drawbacks of VOT could be less frequent interaction between patients and providers, and therefore a lack of side effect detection, that some patients might not have access to internet or smartphones, and that it requires a secure data and video transfer [
A substantial number of patients still fail to respond to treatment, have a relapse of disease, or develop drug-resistant tuberculosis [
The majority of the included apps focused on education for patients and health care professionals. Although patient education is certainly of great importance [
Based on our analysis, only 2 of the 55 apps (4%) are currently designated as medical devices (DoseMeRx, MwPharm), which is important to ensure the quality of mHealth apps in the European Union. In the future, once the new Medical Device Regulation is enforced, more apps claiming to have a medical purpose will have to be marketed as medical devices. This will likely lead to an increase in the number of high-quality apps for tuberculosis treatment.
Since the last review on this matter in 2016, 31 new apps have been introduced to the market, representing a 129% increase in the total number of apps available. In 2016, there were no apps for improvement of adherence [
The number of apps providing patients and health care personnel with information on tuberculosis has increased by 164% (from 11 to 29 apps) since 2016 [
The number of apps for diagnostics or other purposes has remained rather constant in the last few years. In the review from 2016 [
One major gap that was identified during this work was the availability of languages. Most apps are only available in English (39/55, 71%). This is problematic since the highest prevalence of tuberculosis cases includes nonEnglish-speaking countries such as China or Indonesia [
There are several limitations to this work. One drawback is that apps that are not free of charge or requiring a license were not purchased and consequently not scrutinized with respect to their functionalities. However, such apps were evaluated in this work and were described based on information retrieved from the app store or accompanying publications. Although it was not the aim of this review, the apps were not rated and ranked regarding their functionality and quality, as suggested in previous work [
Although the importance of the various mHealth apps currently on the market, such as tools for VOT, MIPD, or simplification of data management, for the improvement of tuberculosis treatment cannot be discounted, the majority (53%) of apps identified in this work were merely focused on providing information about tuberculosis, and many of these exhibited issues regarding spelling, grammar, or correctness of the information provided. Thus, this review demonstrates a need for more mHealth apps of high quality supporting tuberculosis treatment.
Tables of mHealth applications included in the review.
electronic health record
mobile health
model-informed precision dosing
Preferred Reporting Items for Systematic Reviews and Meta-Analyses
therapeutic drug monitoring
video observed treatment
World Health Organization
LK, SW, and US conducted the app review, wrote the manuscript, and revised the manuscript.
SW is the lead developer of TDMx. LK and US declare no conflicts of interest.