Directly Observed Treatment Short Course Programme Research Articles

The prevalence of and reasons for interruption of anti-tuberculosis treatment by patients at Mbekweni Health Centre in the King Sabata Dalindyebo (KSD) District in the Eastern Cape province

Background: In spite of effective therapy, tuberculosis (TB) is still a major health problem in developing countries. In 1993, therefore, the World Health Organization declared TB a global emergency. In South Africa, TB is one of the most prevalent diseases, with an incidence of 556 per 100 000 population. In spite of free TB drugs in the public service and the directly observed treatment short course (DOTS) strategies, there is still a high prevalence of TB and a high treatment interruption rate in rural South Africa. Methods: The objectives of this study were to establish the prevalence of TB and reasons for the interruption of TB treatment by patients attending Mbekweni Health Centre in King Sabata Dalidyebo (KSD) district in the Eastern Cape province. This was a crosssectional study in which data were collected from 15 July 2004 to 15 January 2005 from patients who were on TB treatment and interrupted their treatment between 6 August 2001 and 30 December 2003. Results: Of the 255 TB patients who attended for treatment, 121 (47.5%) had interrupted their treatment. Reasons given for interruption included change of living place (18.96%), no money to go to the clinic (15.52%), feeling better (13.78%), side effects of the drug (6.90%), did not know the treatment course (5.17%), physical disability either old or too sick to collect treatment and nobody to help (5.17%), clinic too far (1.73%), drug not available in the clinic (13.83%) and no reasons (8.62%). Conclusion: The prevalence of treatment interruption was high in this study. Change of living place, lack of money for visiting the clinic to collect treatment, feeling better, and no drugs at the clinic were the major reasons given for interruption of treatment. Ensuring the availability of TB drugs at the health centre/clinic, patient education about TB and strengthening the DOTS programme, including a stipend for the DOTS supervisors, would help to reduce the prevalence of treatment interruption. This article has been peer reviewed. Full text available at www.safpj.co.za

Where do tuberculosis patients go for treatment before reporting to DOTS clinics in southern Nigeria

Health-seeking patterns of persons with tuberculosis (TB) before reporting at the Directly Observed Treatment Short-course (DOTS) clinic for diagnosis and treatment were analysed. A total of 221 persons registered in the DOTS programme in 12 randomly selected rural and urban Local Government Areas in southern Nigeria were interviewed using a semi-structured questionnaire. Perceived causes of TB influenced first choice of treatment. Patients re-evaluated initial choices and shop for alternatives in persistent TB. Chemists were the first port of call for most patients. Those with unscientific causative theories of tuberculosis such as witchcraft engaged more in multiple health-seeking than those who indicated bacterial infection (P < 0.0001). The respondents had a median diagnostic-delay of 90 days. Delay in commencement of DOTS treatment was attributable to ignorance among patients and poor attitude of health workers. In conclusion, delay exists between recognition of symptoms and initiation of treatment in DOTS clinics partly because of ignorance among patients. Health workers' attitude to patients reporting at health clinics also discouraged the use of DOTS facilities. Consequently, it is recommended to address such delay through social mobilization of communities and through engaging Chemists in TB service delivery in this area.

Tuberculosis Recurrence and Mortality after Successful Treatment: Impact of Drug Resistance

BackgroundThe DOTS (directly observed treatment short-course) strategy for tuberculosis (TB) control is recommended by the World Health Organization globally. However, there are few studies of long-term TB treatment outcomes from DOTS programs in high-burden settings and particularly settings of high drug resistance. A DOTS program was implemented progressively in Karakalpakstan, Uzbekistan starting in 1998. The total case notification rate in 2003 was 462/100,000, and a drug resistance survey found multidrug-resistant (MDR) Mycobacterium tuberculosis strains among 13% of new and 40% of previously treated patients. A retrospective, observational study was conducted to assess the capacity of standardized short-course chemotherapy to effectively cure patients with TB in this setting.Methods and FindingsUsing routine data sources, 213 patients who were sputum smear-positive for TB, included in the drug resistance survey and diagnosed consecutively in 2001–2002 from four districts, were followed up to a median of 22 months from diagnosis, to determine mortality and subsequent TB rediagnosis. Valid follow-up data were obtained for 197 (92%) of these patients. Mortality was high, with an average of 15% (95% confidence interval, 11% to 19%) dying per year after diagnosis (6% of 73 pansusceptible cases and 43% of 55 MDR TB cases also died per year). While 73 (74%) of the 99 new cases were “successfully” treated, 25 (34%) of these patients were subsequently rediagnosed with recurrent TB (13 were smear-positive on rediagnosis). Recurrence ranged from ten (23%) of 43 new, pansusceptible cases to six (60%) of ten previously treated MDR TB cases. MDR M. tuberculosis infection and previous TB treatment predicted unsuccessful DOTS treatment, while initial drug resistance contributed substantially to both mortality and disease recurrence after successful DOTS treatment.ConclusionsThese results suggest that specific treatment of drug-resistant TB is needed in similar settings of high drug resistance. High disease recurrence after successful treatment, even for drug-susceptible cases, suggests that at least in this setting, end-of-treatment outcomes may not reflect the longer-term status of patients, with consequent negative impacts for patients and for TB control.

Domestic Returns from Investment in the Control of Tuberculosis in Other Countries

We hypothesized that investments to improve the control of tuberculosis in selected high-incidence countries would prove to be cost saving for the United States by reducing the incidence of the disease among migrants. Using decision analysis, we estimated tuberculosis-related morbidity, mortality, and costs among legal immigrants and refugees, undocumented migrants, and temporary visitors from Mexico after their entry into the United States. We assessed the current strategy of radiographic screening of legal immigrants plus current tuberculosis-control programs alone and with the addition of either U.S.-funded expansion of the strategy of directly observed treatment, short course (DOTS), in Mexico or tuberculin skin testing to screen legal immigrants from Mexico. We also examined tuberculosis-related outcomes among migrants from Haiti and the Dominican Republic using the same three strategies. As compared with the current strategy, expanding the DOTS program in Mexico at a cost to the United States of 34.9 million dollars would result in 2591 fewer cases of tuberculosis in the United States, with 349 fewer deaths from the disease and net discounted savings of 108 million dollars over a 20-year period. Adding tuberculin skin testing to radiographic screening of legal immigrants from Mexico would result in 401 fewer cases of tuberculosis in the United States but would cost an additional 329 million dollars. Expansion of the DOTS program would remain cost saving even if the initial investment were doubled, if the United States paid for all antituberculosis drugs in Mexico, or if the decline in the incidence of tuberculosis in Mexico was less than projected. A 9.4 million dollars investment to expand the DOTS program in Haiti and the Dominican Republic would result in net U.S. savings of 20 million dollars over a 20-year period. U.S.-funded efforts to expand the DOTS program in Mexico, Haiti, and the Dominican Republic could reduce tuberculosis-related morbidity and mortality among migrants to the United States, producing net cost savings for the United States.

Stable drug supply and distribution in an integrated healthcare delivery system, but unconfirmed need for daily witnessed dosing

We agree with Dr Harries that future large-scale antiretroviral treatment programmes in resource-poor settings would do well to emulate several aspects of the directly observed treatment short course (DOTS) strategy; specifically the consolidation of multilateral political support development of reliable diagnostic systems assured drug supply and infrastructure for comprehensive outcome assessment. We suggest caution however with respect to the role of daily witnessed dosing. Although this is only a single component of the DOTS strategy it has been promoted as a centrepiece of such programmes. Dr Harries acknowledges appropriate skepticism regarding the attributable impact of witnessed dosing on improving tuberculosis treatment outcomes. Others however have argued that witnessed dosing is an indispensable component of DOTS programmes. Witnessed dosing of HIV antiretroviral therapy is complicated by the need for lifelong treatment daily medication dosing and the consequent impact on individual rights in the setting of a highly stigmatizing disease. For these reasons we suggest that witnessed dosing is the most problematic element in the large-scale expansion of HIV treatment access in resource-poor settings based on the DOTS model. Otherwise we entirely agree with Dr Harries that HIV treatment programmes should be conceptualized as a broad package of support to the patient within the framework of a chronic care model similar to that of existing tuberculosis programmes. (excerpt)

Shifting the focus of tuberculosis research in India

India has a long and distinguished tradition of research in the field of tuberculosis (TB). Pioneering studies from India demonstrated the efficacy and safety of domiciliary treatment, the necessity of direct observation of treatment, the feasibility of case detection through sputum smear microscopy in primary health care institutions, and the effectiveness of intermittent short-course chemotherapy. These findings laid the foundation of directly observed treatment, short course (DOTS), which has been adopted by nearly 150 countries worldwide. Today, India has the second-largest and the fastest-growing DOTS programme in the world. A strong component of programme evaluation and operational research is needed to sustain and expand DOTS in the context of a suboptimal primary health care system, a large and unregulated private health care system, and the dual threats of HIV and multidrug-resistant TB (MDR-TB). Therefore, the focus of TB research in India has shifted to the following operational research areas: evaluating models to involve the private health sector; assessing the role of incentives in increasing treatment compliance; examining gender differentials in the access to TB services; assessing risk factors for delay in diagnosis; evaluating diagnosis, treatment and prevention of TB among HIV-infected persons; monitoring MDR-TB; estimating cost-effectiveness of the DOTS programme; monitoring the quality of smear microscopy services; and measuring the current burden of TB. Research for developing newer diagnostic tools, drugs and vaccines remains a long-term priority. Greater networking is needed among national researchers, programme managers and policy-makers to translate the findings of research into policies and programmes to make TB control in India more effective and efficient.

Review of the Current Status of Drug-Resistant Tuberculosis in Saudi Arabia

After years of decline tuberculosis has re-emerged as a serious public health problem worldwide. In 1993 the World Health Organization (WHO) declared tuberculosis to be a global emergency and according to a recent WHO report there were 7.96 million new cases in 1997 with 2 million deaths. Factors contributing to the resurgence of tuberculosis include the HIV epidemic immigration of persons from countries with high incidence rates and political turmoil in some developing countries which hinder efforts to control the disease. The spread of the disease poses a public health concern especially with increased drug resistance among M. tuberculosis strains which have acquired varying degrees of resistance to firstline anti-tuberculous drugs. The underlying causes of single drug-resistant M. tuberculosis (SDR-TB) and/or multidrug-resistant M. tuberculosis (MDR-TB) have been suggested to be the result of incorrect treatment poor compliance shortage of anti-tuberculous drugs due to financial constraints in some developing countries and deficient or deteriorating TB control programs resulting in inadequate administration of effective chemotherapy. Previous reports indicate that single-drug resistance and multi-drug resistance to M. tuberculosis are on the increase in both developed and developing countries. The prevalence of SDR-TB or MDR-TB in the Kingdom of Saudi Arabia is largely unknown except for a few studies confined to large centers. The objective of this article is to review published materials from different regions of the Kingdom on the prevalence of SDR-TB and MDR-TB and to draw a conclusion of the actual status of drug-resistant tuberculosis in Saudi Arabia with a discussion of the findings. (excerpt)

Directly observed treatment, short-course strategy and multidrug-resistant tuberculosis: are any modifications required?

Multidrug-resistant tuberculosis (MDRTB) should be defined as tuberculosis with resistance to at least isoniazid and rifampicin because these drugs are the cornerstone of short-course chemotherapy, and combined isoniazid and rifampicin resistance requires prolonged treatment with second-line agents. Short-course chemotherapy is a key ingredient in the tuberculosis control strategy known as directly observed treatment, short-course (DOTS). For populations in which multidrug-resistant tuberculosis is endemic, the outcome of the standard short-course chemotherapy regimen remains uncertain. Unacceptable failure rates have been reported and resistance to additional agents may be induced. As a consequence there have been calls for well-functioning DOTS programmes to provide additional services in areas with high rates of multidrug-resistant tuberculosis. These "DOTS-plus for MDRTB programmes" may need to modify all five elements of the DOTS strategy: the treatment may need to be individualized rather than standardized; laboratory services may need to provide facilities for on-site culture and antibiotic susceptibility testing; reliable supplies of a wide range of expensive second-line agents would have to be supplied; operational studies would be required to determine the indications for and format of the expanded programmes; financial and technical support from international organizations and Western governments would be needed in addition to that obtained from local governments.

First-line tuberculosis therapy and drug-resistant Mycobacterium tuberculosis in prisons

We assessed a programme of tuberculosis control in a prison setting in Baku, Azerbaijan. The programme used first-line therapy and DOTS (directly observed treatment, short course). 467 patients had sputum-positive tuberculosis. Their treatment regimens followed WHO guidelines, and they had regular clinical examinations and dietary supplements. Isolates were tested by standard methods for resistance to isoniazid, rifampicin, ethambutol, and streptomycin in three laboratories. Treatment success was defined as three consecutive negative sputum smears at end of treatment. Factors independently associated with treatment failure were estimated by logistic regression. Drug-resistance data on admission were available for 131 patients. 55% of patients had strains of Mycobacterium tuberculosis resistant to two or more antibiotics. Mortality during treatment was 11%, and 13% of patients defaulted. Overall, treatment was successful in 54% of patients, and in 71% of those completing treatment. 104 patients completed a full treatment regimen and remained sputum-positive. Resistance to two or more antibiotics, a positive sputum result at the end of initial treatment, cavitary disease, and poor compliance were independently associated with treatment failure. The effectiveness of a DOTS programme with first-line therapy fell short of the 85% target set by WHO. First-line therapy may not be sufficient in settings with a high degree of resistance to antibiotics.

Tuberculosis Patients Opinion for Directly Observed Treatment Short-Course (DOTS) Programme of Nepal

Background : DOTS is the most effective strategy available today for tuberculosis control. Objectives : To find out patients knowledge and opinion about DOTS programme of Nepal. Methods : The prospective study was conducted in tuberculosis patients attending DOTS programme in Nepal. Questionnaires are used to collect patient knowledge and opinion. Results : Tuberculosis was most (73%) commonly found in economically active age group (21-50 years old). The incidence of tuberculosis was found higher in male than in female, most of them were married (55%). Tuberculosis cases were commonly found in rural areas 59%, most of them were illiterate 27% and farmers 23.6% respectively. Majority of patients (72%) family size was large 5-7 persons. Knowledge about DOTS programme, majority of the patients (58.3%) answered correctly. The patient's opinion for improving DOTS programme of Nepal, most of them (26.6%) suggested to educate the TB patients and their family members about tuberculosis (method of transmission, dose and side effects of medicine, suitable method for disposable of sputum and other materials and what are the consequences, if drug doses are not completed), 20% of the respondents were of the view that the medicine for tuberculosis should be made available in each and every health care units, 17.6% suggested that according to patients problem drug should be allowed to bring home for one month, 10% suggested to improve behavior of health care workers, 7.3% suggested government should provide free balance diet along with free medicine, 5% suggested make more publicity and 13.3% of patients had no suggestion they thought it was satisfactory. Conclusion : To improve the efficacy of DOTS programme, along with free medicine and directly observed treatment, Tuberculosis control authority should design health education programme for patients, family members and community people such as mode of transmission, preventive methods of tuberculosis and consequences of incomplete treatment. Key words : DOTS; TB; Knowledge DOI: 10.3126/saarctb.v6i1.3063 SAARC J. Tuber. Lung Dis. HIV/AIDS 2009 VI (1) 39-45