Directly Observed Therapy Strategy Research Articles

Evaluation of the Directly Observed Treatment's Acceptance by Tuberculosis Patients in the Republic of Macedonia.

BACKGROUND:Directly observed therapy (DOT) is a specific strategy endorsed by the World Health Organization in 1994 to improve adherence by requiring health workers, community volunteers or family members to observe and record tuberculosis (TB) patients for taking each dose. The implementation of DOT strategy in the National Tuberculosis Programme (NTP) in Macedonia was introduced in 2006 and was realised by 6 nurses engaged through the Project of Global Fund against HIV/AID and TB.AIM:This study aimed to evaluate how these visits conducted by the DOT nurses engaged through the GF were accepted by TB patients and to evaluate the impact on the treatment outcomes.PATIENTS AND METHODS:In this prospective study 105 TB patients who started treatment in 2016 and who were supposed to be visited by DOT nurses at their homes were included. All of these patients filled out a questionnaire compiled of 6 questions related to their opinion about the efficacy and usefulness of the visits managed by the nurses when they would come for check-ups at the Institute for Lung Diseases and Tuberculosis. The assessment of the efficacy of the work of DOT nurses was performed by analysis of the answers received by TB patients. The data were analysed with the method of description and was statistically prepared in the program SPSS for Windows, 17.0.RESULTS:The results from the analyses showed that the number of visited patients were not satisfied, because 29.52%% were never visited by a DOT nurse at their homes. A lot of patients (61.91%) were not willing to take medicines under the observed control by nurses. Those TB patients who were visited by DOT nurses thought that this type of visit is useful for them: they were satisfied by the attitude of the nurses during the visits, and they received enough explanations regarding TB.CONCLUSION:We can conclude that the DOT visits to TB patients are useful, contribute patients to complete the therapeutic regime without interruption, take care for every individual patient effectively, and protect the rest of society by preventing the development and spread of TB, including drug-resistant strains.

TUBERCULOSIS BURDEN IN LEBANON: EVOLUTION AND CURRENT STATUS.

In the absence of surveillance data and consolidated information about tuberculosis (TB) and its drug resistance burden in Lebanon, this retrospective study was conducted to shed light on TB and its other relevant aspects over the last 15 years in this country. To generate the TB data for this retrospective study, two main sources were used: 1) the records of patients in the National Tuberculosis Program (NTP); 2) the results of the Clinical Microbiology Laboratory (CML) at the American University of Beirut Medical Center (AUBMC). The TB data review pertained to its epidemiological aspect, implementation of the directly observed therapy strategy (DOTS) all over, the gender distribution, the impact of high risk groups (non-national population, Syrian refugees, patients with multi-drug resistance-TB [MDR-TB] and the inmate population) on the trend of TB in Lebanon between 1999 and 2013. Reviewed also are TB in children, extrapulmonary tuberculosis and the mycobacterium other than tuberculosis (MOTT). During the last 15 years, 7548 TB cases were diagnosed and evaluated at the NTP. After the decreasing of TB incidence from 13/100 000 population in 2001 to 9/100 000 in 2006, the incidence started to increase in 2007, reaching 20/100 000 in 2013, mostly due to increased cases among non-national population. Fluctuations in TB rates over the years were seen among children, inmates, MDR-TB, and HIV patients. MOTT isolates recovery rates also fluctuated during the study period, M. simiae being the most common. After the decreasing trends of TB incidence between 1999 and 2006, Lebanon has been experiencing an increasing incidence in tuberculosis population since 2007. This is mainly attributed to the dramatic increase of TB patients among non-nationals and the influx of Syrian refugees. The ongoing collaboration between the public and private sectors, improvements of the surveillance system and TB control are important factors for successful elimination of TB in this country.

Improving Treatment Completion Rates for Latent Tuberculosis Infection: A Review of Two Treatment Regimens at a Community Health Center

Prophylactic treatment of latent tuberculosis infection (LTBI) is necessary for controlling TB in low-incidence settings. However, treatment is often limited by poor completion rates. At a community health center serving low-income Hispanics, treatment completion among patients accepting 12 weekly doses of isoniazid (INH) plus rifapentine (RPT) administered as directly observed therapy (DOT) was compared with that among patients accepting nine months of daily self-administered INH during 2012 and 2013 (n=139). Among patients who agreed to treatment, INH-RPT combination therapy was associated with higher completion rates (OR 3.06; 95% CI, 1.23-7.62; p=.016) when compared to INH only. Overall completion rates were 77.8% (35/45) for INH-RPT combination therapy and 52.1% (49/94) for INH monotherapy. High completion rates for LTBI treatment can be achieved at a community health center using INH-RPT administered via DOT. Greater success treating with INH-RPT may be attributed to DOT strategy and a shorter treatment regimen.

Assessment of the quality of tuberculosis surveillance data in six selected states in Southern Nigeria

Introduction: Tuberculosis (TB) data are used to evaluate the effectiveness of TB program interventions, identify deficiencies, and inform policies and programs. These data are also used for advocacy, resource mobilization, and allocation, both nationally and internationally. This study is aimed at verifying the reliability of the data collated and submitted from the direct observation therapy strategy (DOTS) facilities to the National TB Program (NTP) in some selected states in Southern Nigeria. Materials and Methods: A total of 29 facilities providing TB services were purposively selected from six states in Southern Nigeria, based on the treatment success rate as reported in 2009. In each selected facility, the following records were reviewed for concordance: Patient treatment cards and facility TB register, facility TB register and facility laboratory register, facility TB register and local government area (LGA) TB register, and LGA TB register and TB quarterly reports. Furthermore, a total of 273 patients were selected for interview to validate the information contained in the treatment cards. Results: Agreement between the data sources was relatively high, though higher in some states than the others. Agreement between patient treatment card and facility TB register, and facility TB register and laboratory register were 97% and 85%, respectively. The lowest concordance was observed between the facility TB register and the LGA TB register. All the patients interviewed confirmed the information as recorded in their treatment cards. Conclusion: The study revealed that NTP data in Southern Nigeria is fairly reliable; however, there are variations observed among the states and at various levels. This study underlines the need to improve TB surveillance data in some states, particularly at the facility and at the LGA levels.

Lyapunov functions and global properties of some tuberculosis models

This work examines the global stability of the disease equilibria of three tuberculosis mathematical models that considered the effect of case detection vis a vis the implementation of the direct observation therapy strategy, factors that enhances the case detection rate and effect of heterogeneity in susceptibility and disease progression. Both linear and non-linear Lyapunov functions are constructed and used to show that the disease-free equilibrium is globally asymptotically stable when the corresponding effective reproduction number is less than or equal to one. However, under some special cases where the disease-induced death is insignificant, the endemic equilibrium is globally asymptotically stable when the effective reproduction number is greater than one.

Modelling the Effect of DOTS and Isolation on TB Transmission Dynamics

Abstract: A deterministic model for the transmission dynamics of Tuberculosis (TB) under Direct Observation Therapy Strategy (DOTS) and Isolation in Nigeria is developed and rigorously analysed. The model, consisting of mutually-exclusive epidemiological compartments representing the number of undetected, detected and isolated individuals who are treated under DOTS programme and those who developed Multi-drug resistance. The model has a disease free equilibrium (DFE), which is locally asymptotically stable, whenever the maximum of the associated reproduction numbers of the model (denoted by Rc) is less than unity. Furthermore, the model undergoes a backward bifurcation, where the disease-free equilibrium co-exists with a stable endemic equilibrium. Numerical simulations, using epidemiological and demographic data relevant to Nigeria obtained from WHO and USAID [35,36,38], shows that provided the rate at which the undetected individuals with active TB recovered exceeded a critical values, then DOTS, the STOP TB initiative programme of WHO can lead to effective elimination of TB in Nigeria. This suggest that the detection rate plays significant role in the elimination of TB. Furthermore, it is shown that if the progress or rate of individuals who are susceptible to TB is low, it can also lead to elimination of the disease in Nigeria. The results also shows that if the effective contact rate (  ) for TB infection remains below certain critical value (0.187), the disease can be eliminated.

The Prevalence and Pattern of Depression in Patients with Tuberculosis on Follow up at Jimma University Specialized Hospital and Jimma Health Center

Depression is an important public-health problem and is one of the leading causes of disease burden affecting 121 million people worldwide. The life time risk of depression in the general population is higher in women than men. However, the prevalence of depression in those with chronic illnesses is much higher. Depression and chronic illnesses co-exist because of physical changes from the illness trigger the depression resulting in vicious cycle. The prevalence of depression in tuberculosis patients is about 49%. It increases in prevalence with older age, duration of illness, disease severity and HIV Co infection. Aim of this study was to assess the prevalence of depression in the tuberculosis patients and its relationship with regard to socio demographic factors, disease characteristics, treatment factors and HIV infection. Institution based cross sectional survey was conducted by a face to face interview using standardized questioner, the Kessler, which has scores for classifying the patients having depression. It was conducted at Jimma University Specialized Hospital and Jimma Health Center Tuberculosis follow up clinics on 248 patients from January 1 to 29, 2010. In addition, reviewing of records of the patients was done. The study showed that 19.82% of tuberculosis patients were cases of depression from a total of 222 patients that were interviewed. Depression cases were 100% in older age group. From the total female population, depression cases were 25%. In widowed, it was 36.36%. Most of them (32.20%) were those who had attended secondary school. Farmers had higher depressive rate being 61.11%. Regarding disease characteristics, 21.86% of the depressed had pulmonary TB. Those who had illness lasting greater than 1.5 year had higher percentage being 71.43%. Majority of the depressed (26.75%) were in category I and 63.64% in initiation phase. Significant proportions (65.12%) of the depressed were HIV positive (x2=8.08, p-value = 0.001). There was significant percentage of depressed TB patients. The treatment of psychiatric co morbidities should be incorporate in the treatment of TB patients in order to achieve the goal of the Directly Observed Therapy strategy.

Knowledge about anti‐tuberculosis treatment among nurses at tuberculosis clinics

Nurses are primary responsible for Direct Observation Therapy Strategy and administration of anti-tuberculosis (TB) medications. Lack of knowledge might result with medication errors and ineffective TB control. The purpose of this study was to assess knowledge of nurses about anti-TB treatment. A descriptive cross-sectional study was conducted in Turkey with 208 nurses employed at TB and lung disease clinics of health-care settings in Ankara. Data were collected through a questionnaire, which included questions about demographics and a knowledge test with true-false questions related to TB treatment. Overall scores were high with a mean score of 18.5 out of 24, but there was knowledge deficiency in effects and side-effects of anti-TB drugs. Knowledge is foundational for any practice and for TB control. Clinical experience and continuing education after graduation influence the level of knowledge.

Multidrug Resistant Tuberculosis; a Pharmacological view based on Revised National Tuberculosis Control Programme DOTS-Plus Guidelines.

Directly Observed Therapy Strategy (DOTS) -Plus is a part of DOTS program that adds approach for multidrug resistance tuberculosis (MDR-TB) diagnosis, management, and treatment. WHO approved DOTS-Plus program began in 2000 and was established to encourage access to high quality second line drugs for appropriate use in MDR-TB control programs. The top priority is to prevent the emergence of MDR-TB by ensuring a low default rate of cases treated with first-line anti-TB drugs. If MDR-TB has emerged in a certain area, it should be treated in addition to improving the basic treatment. In this situation, accurate and reliable drug susceptibility testing, methods to support patients in order to ensure direct observation of complete treatment and the use of maximally effective regimens must be ensured. Second-line drugs should not be held back in patients with MDR-TB rather they have a good chance of cure with it, hence the treatment, if it is to be provided, should be optimally selected and administered. This review is highlighting the pharmacological view point of second line anti tubercular drug incorporated in DOTS-Plus therapy for MDR-TB.

Molecular epidemiology of tuberculosis in the Tula area, Central Russia, before the introduction of the Directly Observed Therapy Strategy

Tuberculosis remains a major public health concern in Russia and worldwide. Given the great geographical, ethnic, and socio-economic heterogeneities between Russian regions, epidemiological data cannot be generalized from a regional to a country-wide level. We present data on the epidemiology of tuberculosis in Central Russia. We report a high level of resistance to major antitubercular drugs in both new and previously treated patients in the region. The level of drug resistance in new cases was almost twice as high as the estimated average national level. The Mycobacterium tuberculosis strains that circulated in the region were predominantly represented by LAM-RUS and Beijing genotypes. These two lineages were strongly associated with drug resistance and clustering. Using molecular epidemiology techniques, we showed a high interpenetration by M. tuberculosis strains between the prison and civilian populations. A limited number of identical strains were responsible for the majority of drug-resistant tuberculosis cases in both settings.

Direct observation and completion of treatment of tuberculosis in rural areas of China

To analyse the current status of directly observed therapy (DOT) and completion of treatment of tuberculosis (TB) in two rural areas of China. Two rural counties with low DOT rates were deliberately selected as study sites. Face-to-face interviews were conducted by trained investigators with a structured questionnaire to investigate the characteristics of patients and the TB service that they had received. The associations between treatment completion and potential factors were estimated by computing odds ratios (ORs), as well as their 95% confidence intervals (CIs), from an unconditional logistic regression model. Among 601 patients, 2.2% were treated with direct observation by health workers, 6.2% were supervised by family members, and 91.7% were treated with self-administered therapy. The treatment completion rate was found to be significantly associated with sputum smear test and adverse reaction to anti-tuberculosis drugs, but not with direct observation by health workers (OR 1.81, 95% CI 0.23-14.38) or by family members (OR 1.14, 95% CI 0.38-3.41). Frequent home visiting by health workers (!1 visit/month) could help to increase the completion rate (OR 3.15, 95% CI 1.30-7.63). No significant difference was found in the rate of completion of TB treatment between direct observation and self-supervision groups in two rural areas with lower DOT coverage. How to build a feasible DOT strategy that is accepted by both patients and healthcare providers needs to be considered by policy-makers. Other elements apart from DOT are necessary to ensure a successful TB programme.

Incidência de tuberculose e taxa de cura, Brasil, 2000 a 2004

To describe the geographical distribution of tuberculosis incidence rates based on a set of epidemiological and operational indicators from information system database. Data from the Sistema de Informação de Agravos de Notificação (Brazilian Information System for Tuberculosis Notification) were collected after removal of improper repeat records and record linkage. Tuberculosis incidence rates were estimated according to geographical unit, age group, sex, clinical manifestation and treatment schedule and standardized for population age group distribution based on 2000 Population Census. In 2004, in Brazil, tuberculosis incidence rate was 41 per 100,000 inhabitants and 74,540 new cases were notified. Of these, 52.8% were pulmonary tuberculosis with positive bacilloscopy, 24.1% were under supervised treatment, 63.5% were from state capitals or metropolitan areas, and 54.9% were cured cases (complete treatment). After records with missing outcome data were excluded, cure rates were 72.4% for new cases, 47% for new HIV-positive cases, 64.9% for relapses, 64.5% for transfers in/out, and 40% for returns after default. Cure rate for new cases under supervised treatment was 77.1%. A higher proportion of records with missing outcome information was seen in recent years. Different incidence rates and treatment outcomes were found in different Brazilian states. To reach the 85% cure goal for new cases and to increase cure in HIV-positive and defaults cases additional efforts are needed by the Brazilian National Tuberculosis Program, including scaling up the Directly Observed Therapy Strategy.

Dynamics of Tuberculosis: The effect of Direct Observation Therapy Strategy (DOTS) in Nigeria

This paper presents mathematical models for tuberculosis and its dynamics under the implementation of the direct observation therapy strategy (DOTS) in Nigeria. The models establish conditions for the eradication of tuberculosis in Nigeria based on the fraction of detected infectious individuals placed under DOTS for treatment. Both numerical and qualitative analysis of the models were carried out and the effect of the fraction of detected cases of active TB on the various epidemiological classes is investigated. The results showed that, provided that the fraction of detected infectious individuals exceeded a critical value, there exists a globally stable disease free equilibrium. However, if this critical detection level is not reached, the disease-free equilibrium will be unstable even with the very high probability successful treatment under DOTS. The results showed that DOTS expansion in Nigeria must include significant increase in the detection rate of infectious individuals; otherwise the effect in reducing the incidence in Nigeria will not be achieved disregarding the tremendous efforts in any other direction, and the huge number of undetected cases will make DOTS insignificant with respect to tuberculosis control.

Overcoming resistance.

Overcoming resistance.

The Outcome of Tuberculosis Treatment after Implementation of the National Tuberculosis Control Program in Saudi Arabia

Tuberculosis is an endemic disease in Saudi Arabia. Efforts to control this disease started in 1992 with the establishment of a National Tuberculosis Control Committee. Field application of a national tuberculosis control program (NTCP) was implemented in Riyadh in 1996 by the Ministry of Health, according to the guidelines of the World Health Organization (WHO). This study was aimed at evaluating the outcome of tuberculosis treatment before and after the implementation of this program. All active tuberculosis cases admitted and treated in the Sahary Chest Hospital, Riyadh, were studied. The outcome of treatment was evaluated, and a comparison was made between 1995 (before the implementation of the NTCP) and the years 1996-1998 (after implementation). The total number of tuberculosis cases increased from 504 in 1995 to 726 (44%) in 1998. Cure rate increased from 24.4% to 36.2%, and the default rate decreased from 15% to only 1.2% during the same period. However, there was no change in the rate of completion of treatment, the rate of treatment failures, relapse or deaths. Although the cure rate slightly improved and the default rate decreased, the overall outcome of the implementation of the national tuberculosis control program was not satisfactory. A recommendation for speedy application of directly observed therapy strategy (DOTS) is made to improve the control of tuberculosis in Saudi Arabia.

Coping with Africa's increasing tuberculosis burden: are community supervisors an essential component of the DOT strategy? Directly observed therapy.

Tuberculosis incidence in Africa is increasing dramatically and fragile health systems are struggling to cope. Potential coping capacity may lie within affected communities but this capacity needs to be harnessed if tuberculosis is to be controlled. Since 1991 all patients with tuberculosis in Hlabisa health district, South Africa have been eligible for community-based directly observed therapy (DOT). Patients are supervised either by a health worker (HW) in a village clinic, or in the community by a community health worker (CHW) or a volunteer lay person (VLP). Tuberculosis incidence increased from 312 cases in 1991 to 1250 cases in 1996. By December 1995, 2622 (87%) of 3006 patients had received DOT, supervised mainly by VLP (56%) but also by HW (28%) and CHW (16%). The proportion supervised by HW fell from 46% in 1991 to 26% in 1995 (P < 0.0001). More patients supervised by VLP (85%) and CHW (88%) than by HW (79%, P = 0.0008) completed treatment. Case-holding by HW declined more between 1991 and 1995 (84% to 71%, P = 0.02) than did case-holding by both CHW (95% to 90%. P = 0.7) and VLP (88% to 84%, P = 0.4). Mortality was similar (4-6%) and stable over time, irrespective of the supervisor. High tuberculosis treatment completion rates are achievable and sustainable for several years in resource-poor settings despite a massively increased case load if community resources are harnessed. Patients may be more effectively supervised by voluntary lay people than by health workers under these circumstances, without being placed at increased risk. These findings suggest that community supervisors may be an essential component of any DOT strategy.