Integrated Mobile Health Applications Show Promise for Quicker Care of Drug-Resistant TB in South Africa

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BALTIMORE, MD, October 11, 2019—With an eye toward hastening the lag time between diagnosis and linkage to care for rifampicin-resistant tuberculosis (RR-TB) patients, researchers at Johns Hopkins and other institutions developed and tested a suite of mobile health applications that shows great promise for patient care and public health.

In a paper published by the International Journal of Tuberculosis and Lung Disease, Dr. Jason Farley and colleagues discuss the design and pilot implementation of miLINC, an integrated set of mobile health applications developed by JHU researchers and emocha Mobile Health and offered on its platform. In a small study, the team found that the approach was effective at linking patients to care (50% without the intervention versus 88% with it) and in much less time after diagnosis (from 17–22 days without the intervention to just under 4 days with it). The mean time-to-treatment endpoint achieved in this study exceeds that of the 5-day target called for in South Africa’s National Strategic Plan on HIV, STIs, and TB. While the study was limited in scope, these results warrant further studies in additional settings with larger cohorts.

According to Farley, “recent data on rifampicin-resistant TB suggest that most infections result from patient-to-patient contact, and not from poor adherence to treatment. So a big factor in disease spread is the amount of time that drug-resistant TB patients are in contact with others.” Findings from the study suggest that strategies involving integrated technology and well trained healthcare workers can shorten the time that infected patients circulate untreated in the population—a win for public health.

The miLINC suite comprises apps that chronical patient retention from enrollment through treatment initiation. The Primary Healthcare App enrolls patients suspected of having TB and uses barcode information from the South African National Health Laboratory Service for linking specimens. Patient information is encrypted and uploaded to a secure database in South Africa, and patient data is matched to specimen results from the NHLS through automated algorithms. Test results and prompts for follow up are sent to patients via text message.

Once rifampicin resistance is confirmed, the app notifies a linkage officer, who initiates contact for follow up. The Linkage/Tracking App documents all contact attempts and facilitates appointment scheduling at a local RR-TB treatment clinic. Once the treatment clinic visit is scheduled, the RR-TB Clinic App documents the patient visit and treatment initiation. All the apps feature reach-back capabilities that notify healthcare workers of status. For example, if the RR-TB Clinic reports a missed patient visit, that app reaches back to the Linkage Officer to follow up with the patient and reschedule the Clinic appointment. At every step, all actions in the miLINC suite are time stamped to determine the time lapse between linkage events. 

The miLINC project was developed and implemented over a 5-year period. The suite of apps was used from March 2015–March 2016 with healthcare workers at 3 clinical sites in the KwaZulu-Natal district of South Africa. 6,341 suspected TB patients were entered into the miLINC Primary Healthcare App, and 631 tested positive for TB. Of those, 41 patients were found to be rifampin resistant cases; of those 41 cases, 3 patients died before confirmed diagnosis, 2 were lost to follow-up, and 36 patients (88%) were linked to care. The mean time from enrollment to treatment initiation for the 36 patients was 3 days, 21 hours, 17 minutes. 

Jane McKenzie-White of the Johns Hopkins Center for Clinical Global Health Education is one of the inventors of the emocha platform and an investigator on the study: “Other studies we’ve conducted have shown that mobile health technology can improve patient retention and better adherence to medication, so we knew there was potential for shortening time to treatment for drug-resistant TB patients. But none of us suspected how dramatic the improvement would be.”

Study findings are now available online:


The miLINC application suite was developed by Johns Hopkins investigators with emocha Mobile Health, Inc., of Baltimore, MD. The emocha Mobile Health platform was invented by co-authors Robert Bollinger, Jane McKenzie-White, and Larry Chang of Johns Hopkins University and programmer Miguel Sitjar. Initially developed to help community health workers in Uganda better serve patients in remote areas, the platform has been commercialized and is now licensed by emocha Mobile Health, Inc. Johns Hopkins University owns shares of stock in emocha Mobile Health, Inc., and Bollinger, McKenzie-White, and Chang are advisors of emocha Mobile Health, Inc., and receive royalty payments from the company. Lead author Jason Farley and the university are entitled to royalties on the miLINC suite.