Directly Observed Treatment Strategy Research Articles

Factors Influencing Knowledge on the Completion of Treatment among Tuberculosis Patients under Directly Observed Treatment Strategy (DOTS) in a Selected Health Facility, the Bahamas

Objective: To determine the factors influencing completion of DOTS in Tuberculosis treatment in the Bahamas. Methods: A quantitative, descriptive cross-sectional survey. Tuberculosis patients aged 18 years and above were considered regardless of the site or the smear status of their TB. The sample size was 40. Data analysis and interpretation were done using the statistical package for the social sciences software (SPSS version 22), through the exploration and calculation of descriptive (frequencies, percentages, means, standard deviations, and inferential (Anova) statistical methods. Statistical significance was determined to be a p - value of 0.05. Results: The mean age of the respondents, was 39.9 years, SD 11.65, and 73% of them were men. 63% of participants, 78% of whom were citizens of the Bahamas, reported having no annual income. Seventy-eight percent (31) of the participants said they had insufficient food and drink while they were unwell. More than half of the participants in the survey reported being on at least one pharmaceutical regimen, although 36% said they were not actively taking any of the prescription medications. Conclusion: Less than a third were noncompliant with DOTS, this was influenced by factors such as annual income, no family support, marital status, employment status, and educational level.

Cost of digital technologies and family-observed DOT for a shorter MDR-TB regimen: a modelling study in Ethiopia, India and Uganda

BackgroundIn 2017, the WHO recommended the use of digital technologies, such as medication monitors and video observed treatment (VOT), for directly observed treatment (DOT) of drug-susceptible TB. The WHO’s 2020 guidelines extended these recommendations to multidrug-resistant tuberculosis (MDR-TB), based on low evidence. The impact of COVID on health systems and patients underscored the need to use digital technologies in the management of MDR-TB.MethodsA decision-tree model was developed to explore the costs of several potential DOT alternatives: VOT, 99DOTS (Directly-observed Treatment, Short-course) and family-observed DOT. Assuming a 9-month, all-oral regimen (as evaluated within the STREAM trial), we constructed base-case cost models for the standard-of-care DOTs in Ethiopia, India, and Uganda, as well as for the three alternative DOT approaches. The models were populated with STREAM Stage 2 clinical trial outcome and cost data, supplemented with market prices data for the digital DOT strategies. Sensitivity analyses were conducted on key parameters.ResultsModelling suggested that the standard-of-care DOT approach is the most expensive DOT strategy from a societal perspective in all three countries evaluated (Ethiopia, India, Uganda), with considerable direct- and indirect-costs incurred by patients. The second most expensive DOT approach is VOT, with high health-system costs, largely caused by up-front technology expenditure.Each of VOT, 99DOTS and family-observed DOT would reduce by more than 90% patients’ direct and indirect costs compared to standard of care DOT.Results were robust to the sensitivity analyses.ConclusionsWhile data on the costs and efficacy of alternative DOT approaches in the context of shorter MDR-TB treatment is limited, our modelling suggests alternative DOT approaches can significantly reduce patient costs in all three countries. Health system costs are higher for VOT and lower for 99DOTS and family-observed therapy when compared to standard of care DOT, as low smartphone penetration and internet availability requires the VOT health system to fund the cost of making them available to patients.

Satisfaction of Tuberculosis Patients with Directly Observed Treatment Strategy under Pakistan Health Care Policy: A Mixed-Method Study.

(1) Background: Patients' satisfaction is based on the perceived health care services of individuals and is influenced by the level of care provided by the health care system. It is often based on the patients' expectations of care and self-assessment of their experiences. The success of the Directly Observed Treatment Strategy (DOTS) also depends on the quality of health care provided at the Tuberculosis (TB) centers, which can be evaluated by satisfaction levels of the patients. (2) Methods: A tuberculosis facility-based cross-sectional study was carried out in Khyber Pakhtunkhwa province in Pakistan. A mixed-method approach was adopted for data collection. An interviewer-administered questionnaire was used for quantitative data collection from 269 patients who were registered at 11 TB centers and private clinics. Qualitative data were collected through 20 in-depth interviews, 15 key informant interviews, and a focus-group discussion. Binary logistic regression was employed for analysis of the data. (3) Results: More than half of the respondents (63.94%) were satisfied with the DOTS strategy. A high percentage of patients were dissatisfied with the availability of safe water, waiting space for patients, waiting time, privacy, and the processing of appointments. Results from the binary logistic regression showed that gender (AOR = 2.21, CI 1.07-4.58, p = 0.033), marital status (AOR = 3.12, CI 1.45-6.73, p = 0.004), employment status (AOR = 5.22, CI 2.44-1.21, p = 0.000), home ownership (AOR = 3.82, CI 1.94-7.54, p = 0.000), literacy (AOR = 2.17, CI 1.11-4.25, p = 0.023), households' main occupation (AOR = 4.42, CI 1.12-17.38, p = 0.033), and level of income (AOR = 2.39, CI 1.13-5.04, p = 0.023) were the significant factors affecting satisfaction levels of the patients. (4) Conclusion: There are a number of areas that need improvement for successful TB eradication. Significant work is required to improve the quality of TB care in these specific areas from the patients' perspective. For instance, female health workers' involvement in the DOTS program can solve the problems of female respondents in rural areas. Improving the infrastructure facilities at the TB centers, allocation of doctors and nurses at the rural health centers would result in positive outcomes of the DOTS in Pakistan as well as in other developing countries.

Evaluation of daily anti-tubercular treatment in osteoarticular tuberculosis

Background: Management of osteoarticular tuberculosis is primarily based on pulmonary tuberculosis guidelines. Guidelines usually do not take into consideration specific organ system affection, though tube pathology and healing of affected organ is not the same. Therefore, routine guidelines are difficult to follow in osteoarticular tuberculosis and many treatment regimes are in vague. Therefore, routine tuberculosis (TB) treatment is not followed, and many regimes are in vague. The current study is undertaken to objectively evaluate daily drug regime in osteoarticular TB and has specific guidelines. Materials and Methods: Drug-sensitive osteoarticular TB cases were evaluated for daily anti-tubercular treatment (ATT) guided by clinical and radiological healing. Patients were categorized based on stage, severity, and site of infection. Vitamin C and iron were also included in the daily treatment regime. Ethambutol was included in the continuation phase. Outcomes in terms of radiological healing and duration of daily regimen were studied. Results: All patients at 6 months of daily ATT showed clinical improvement but persistent disease on imaging. On magnetic resonance imaging, 16 out of 52 patients showed worsening at 6 months. Earliest healing appeared at 8 months. Healing appears to be faster in surgically treated patients. There was no relapse till the shortest follow-up of 2 years. Conclusion: The directly observed treatment strategy (DOTS), three times a week, is enough in osteoarticular TB. Daily drug with a minimum duration of 9 months is necessary. Diagnosis is usually delayed due to deep-seated infections, hence advance diagnosis modalities and high index of suspicion help. The study does not encounter any case of drug resistance. Addition of vitamin C appears to increase effectiveness of drugs. Duration of ATT should be determined by the pre-treatment disease activity and response to ATT.

Short and long-term outcomes of video observed treatment in tuberculosis patients, the Republic of Moldova.

The Republic of Moldova is among the 18 high priority countries for tuberculosis (TB) in Europe. This study compared adherence and short and long-term TB treatment outcomes for TB patients who experienced asynchronous Video Observed Treatment (aVOT) during three months of outpatient treatment versus Directly Observed Treatment (DOT) in operational conditions in 2016-2017 in Chisinau. We used secondary data from the 2016-2017 Randomized Clinical Trial (RCT) that piloted the aVOT Strategy in Chisinau and data from the national TB register. Relative risk was selected as a measure of association in analysis of treatment strategies (aVOT and DOT under operational conditions) and short and long-term treatment outcomes. From 647 TB patients included in the study, 169 followed the treatment strategy in the RCT (83 in aVOT and 86 in DOT) and 478 were on DOT in operational conditions. Those in aVOT were more likely to have favourable short-term outcome than patients with DOT in operational conditions (RR 0.07; p < 0.001). TB recurrence as an indicator for the long-term outcome, was observed in group with DOT in operational conditions (40 cases, p = 0.006). This study demonstrated that the aVOT treatment strategy was associated with better adherence and both short and long-term TB treatment favourable outcomes. aVOT as a new patient-centred approach supporting TB patients on improving treatment adherence and outcomes might be recommended as an alternative to DOT strategy in the Republic of Moldova.

Co-infection With Hepatitis B in Tuberculosis Patients on Anti-tuberculosis Treatment and the Final Outcome.

BackgroundThe occurrence of both tuberculosis (TB) and concomitant hepatitis B virus (HBV) is likely to be associated with poor patient outcomes and poor treatment response.ObjectiveTo assess whether tuberculosis patients with concomitant hepatitis B virus infection were prone to poorer outcomes and treatment response.MethodologyA case-control study was undertaken at the Tuberculosis Centre, DHQ Bagh Azad Kashmir and Pulmonology Department, Lady Reading Hospital, Peshawar, between March 2020 and August 2020. All patients with diagnosed tuberculosis and coinfection with hepatitis B were labeled as the case group while those with only tuberculosis acted as the control. All patients with tuberculosis were managed on a directly observed treatment strategy (DOTS). Non-compliant patients and those without complete data were excluded from the study. All data regarding socio-demographics, laboratory investigations, and clinical characteristics were recorded in a predefined proforma. Patients were considered to have good treatment outcomes when patients completed the treatment or had a negative smear at six months of treatment. The Statistical Package for the Social Sciences (SPSS) version 26 (IBM Corp, Armonk, NY) was used for the data analysis.ResultsA total of 178 patients were enrolled in the study. It was found that patients with concomitant hepatitis B had significantly poorer outcomes as compared to patients who did not have hepatitis B (<0.001). Similarly, TB and hepatitis B patients were significantly associated with severe tuberculosis (<0.001) and required a higher frequency of retreatment (<0.001).ConclusionOur study reports a strong association between the treatment response of patients with tuberculosis with an added hepatitis B infection. Furthermore, a larger number of patients with hepatitis B had severe tuberculosis as compared to those without hepatitis B.

Ocular side effects in tuberculosis patients receiving direct observed therapy containing ethambutol

Background: India is among the largest countries to implement the revised national tuberculosis (TB) control program (RNTCP). Ocular toxicity of ethambutol has been known since 1962. It can be halted with early detection and cessation of the contributing drug. Aims and Objectives: This study aims to detect early ocular toxicity of ethambutol in TB patients under directly observed treatment strategy (DOTS). Materials and Methods: This was a prospective cross-sectional study of 30 patients getting AKT including ethambutol along with isoniazid, rifampicin, and pyrazinamide under RNTCP‑DOTS center at a tertiary care hospital. The detailed history, best-corrected visual acuity (BCVA), color vision, fundus examination, visual field, retinal nerve fiber layer (RNFL) thickness, and central subfield macular thickness were carried out in all patients pretreatment and then at the 2nd month of treatment. Results: The mean age of patient was 44.87 years. Reduced visual acuity from the baseline was noted at the second in 23.33% of the right eyes (P = 0.01) and 30% of the left eyes (P < 0.01). Mean temporal RNFL thickness was significantly reduced from baseline after 2 months of treatment (P = 0.046). No significant difference was observed with color vision and visual fields pre- and post-treatment. Conclusion: The assessment of BCVA, color vision, visual field, RNFL, and macular thickness is essential at baseline and thereafter at frequent intervals to detect early ethambutol toxicity and probable reversible visual loss.

Community Contribution to Tuberculosis Care in the Krachi West District of Ghana: A Qualitative Study.

Background Eradicating tuberculosis (TB) is one of the targets of the recently constituted Sustainable Development Goal (SDG) Three. In the light of limitations inherent in prevailing tuberculosis care and the global urgency to improve TB care, decentralising TB care beyond health facilities by harnessing the contribution of communities is essential in ensuring effective tuberculosis care. In this paper, we explored community contribution to TB care in the Krachi West District of Ghana. Methods In this qualitative study, 24 TB stakeholders made up of 7 health workers, 9 tuberculosis patients, 4 community health volunteers, 2 treatment supporters, and 2 opinion leaders were interviewed. Data collected were analysed manually, but thematically. Statements of the participants were presented as quotes to substantiate issues discussed. Results Community contribution to TB care was low. Most of the community members were not aware of any community level activity towards tuberculosis care. Though patients were mainly the ones responsible for the selection of their treatment supporters, there were instances where health workers selected supporters for them without their consent. Some treatment supporters were also not given any education concerning their roles in supporting their patients, resulting in some patients defaulting treatment and others taking their medications wrongfully. Conclusion Our study revealed low community involvement in tuberculosis care in the Krachi West District of Ghana. Community sensitisation on the World Health Organisation's Directly Observed Treatment Strategy (which Ghana adopted in 1994) to increase community involvement in tuberculosis activities is, therefore, recommended.

Multidrug-resistant tuberculosis outbreak associated with poor treatment adherence and delayed treatment: Arua District, Uganda, 2013\u20132017

BackgroundIn August 2017, the Uganda Ministry of Health was notified of increased cases of multidrug-resistant tuberculosis (MDR-TB) in Arua District, Uganda during 2017. We investigated to identify the scope of the increase and risk factors for infection, evaluate health facilities’ capacity to manage MDR-TB, and recommend evidence-based control measures.MethodsWe defined an MDR-TB case-patient as a TB patient attending Arua Regional Referral Hospital (ARRH) during 2013–2017 with a sputum sample yielding Mycobacterium tuberculosis resistant to at least rifampicin and isoniazid, confirmed by an approved drug susceptibility test. We reviewed clinical records from ARRH and compared the number of MDR-TB cases during January–August 2017 with the same months in 2013–2016. To identify risk factors specific for MDR-TB among cases with secondary infection, we conducted a case-control study using persons with drug-susceptible TB matched by sub-county of residence as controls. We observed infection prevention and control practices in health facilities and community, and assessed health facilities’ capacity to manage TB.ResultsWe identified 33 patients with MDR-TB, of whom 30 were secondary TB infection cases. The number of cases during January–August 2017 was 10, compared with 3–4 cases in January–August from 2013 to 2016 (p = 0.02). Men were more affected than women (6.5 vs 1.6/100,000, p < 0.01), as were cases ≥18 years old compared to those < 18 years (8.7 vs 0.21/100,000, p < 0.01). In the case-control study, poor adherence to first-line anti-TB treatment (aOR = 9.2, 95% CI: 2.3–37) and initiating treatment > 15 months from symptom onset (aOR = 11, 95% CI: 1.5–87) were associated with MDR-TB. All ten facilities assessed reported stockouts of TB commodities. All 15 ambulatory MDR-TB patients we observed were not wearing masks given to them to minimize community infection. The MDR-TB ward at ARRH capacity was 4 patients but there were 11 patients.ConclusionThe number of cases during January–August in 2017 was significantly higher than during the same months in 2013–2016. Poor adherence to TB drugs and delayed treatment initiation were associated with MDR-TB infection. We recommended strengthening directly-observed treatment strategy, increasing access to treatment services, and increasing the number of beds in the MDR-TB ward at ARRH.

Micronutrient levels of tuberculosis patients during the intensive phase, a prospective cohort study

The objectives of this study were to estimate the micronutrient deficiency levels of tuberculosis patients at the start and end of the intensive phase, and to identify the predictors of micronutrient deficiencies in tuberculosis patients. A prospective cohort study design was implemented. The sample size was calculated using Epi-info software. Systematic sampling technique was used. Descriptive statistics were used to estimate the micronutrient levels. The general linear model was used to predict the determinants of micronutrient level. At the start of DOTS (directly observed treatment strategy), 64% of tuberculosis patients had a serum iron level less than 60μg/dl, 41.9% of tuberculosis patients had serum zinc level less than 52μg/dl, 29.7% of tuberculosis patients had serum selenium level less than 70ng/dl, 40.5% of tuberculosis patients had serum vitamin d level less than 20ng/ml, and 60.4% of tuberculosis patients had urine iodine level of less than 60.4μg/dl. At the end of the intensive phase, 16.7% of tuberculosis patients had a serum iron level less than 60μg/dl, <1% of tuberculosis patients had serum zinc level less than 52μg/dl, <1% of tuberculosis patients had serum selenium level less than 70ng/dl, 20.4% of tuberculosis patients had serum vitamin d level less than 20ng/ml, and 53% of tuberculosis patients had urine iodine level of less than 60.4μg/dl. Serum iron level was affected by HIV infection, hookworm infection, and site of tuberculosis infection: serum vitamin d level was affected by HIV infection: and alcohol dependency affected the serum zinc level of tuberculosis patients during the course of tuberculosis treatments. Antituberculosis drugs were effective in normalizing the serum zinc and selenium level, but the serum level of iron, vitamin d and iodine were not normalized by the anti-tuberculosis drugs.

Treatment outcome in tuberculosis patients under DOTS treatment, tuberculosis unit, Nahan, Himachal Pradesh, 2013-2015: a record based descriptive study

Background: Tuberculosis (TB) has existed for millennia and remains a major global health problem. There has been significant progress in cure rates achieved in revised national tuberculosis programme (RNTCP), however concerns regarding effectiveness of RNTCP regimens, still exist. These concerns could be addressed through an assessment of treatment outcome. The present study was conducted to ascertain the treatment outcome in tuberculosis patients under DOTS treatment.Methods: A record based descriptive study was conducted in patients enrolled under directly observed treatment strategy (DOTS). The data included the summary of case findings as new smear positive, new smear negative, new extrapulmonary, new others, relapse, failure, treatment after default, category II. Treatment outcome was assessed as cured, treatment completed, died, loss to follow up, failure and transferred out. Different variables were represented as frequency distribution and percentages. Chi square test was used to observe the association of different variables with the outcome of the disease.Results: A total of 899 patients were enrolled under DOTs treatment for tuberculosis. Sputum positivity was present in 481 (72.8%) patients. Outcome showed 384 (79.8%) patients as cured, treatment completed in 414 (81.8%) patients and treatment success rate of 798 (89.7%). Treatment failure was observed 9 (1.9%) patients.Conclusions: Treatment success rate of TB patients in this study was encouraging for TB control through DOTS strategy. However, to reduce poor treatment outcome, patients should be strictly followed by health workers or ASHAs. 

Knowledge about tuberculosis among undergraduate medical students in a private college in Chennai

Background: Tuberculosis is an ancient global public health problem. In India despite of persistent government efforts in the form of revised national anti-tuberculosis programme (RNTCP) and directly observed treatment strategy (DOTS), TB still remains a major cause of mortality and morbidity in India. Multi-drug resistant TB and extensively drug resistant TB are other threats to present anti-TB strategies. Methods: Hence the present study was undertaken to assess the knowledge of undergraduate about tuberculosis under various headings of about tuberculosis, etiology, risk factors, diagnosis, complications and treatment. The present cross-sectional study was done in the private medical college in Chennai among 90 undergraduate medical students. Results: Regarding knowledge of tuberculosis, clinical features of TB, was more than 80% in interns. But the knowledge about diagnosis was only 70%. At the same time the treatment options and drugs available was known to 85% of undergraduates. Correct duration in months and schedule of giving drugs on alternate days was not known to 15% of students. Conclusions: Although awareness is created through world tuberculosis day, CMES, conferences, yet hands on training in treating tuberculosis to be given to the undergraduates as this the crucial period for learning. 

Directly Observed Treatment Strategy Still a Challenge in Tuberculosis Control: The South African Plight

The challenges in the management of tuberculosis (TB) are clearly manifested by the escalating numbers of not only the ordinary tuberculosis but also the drug resistant forms of TB, namely MDR-(Multi-Drug Resistance) and XDR-TB (Extreme Drug Resistance-Tuberculosis). The management of tuberculosis in SA and the whole world has been ranked as a priority due to its impact on health and economy. The effectiveness of Directly Observed Treatment Strategy (DOTS) as a strategy for the control of TB and its treatment is affected by a variety of socioeconomic issues around the world and particularly in the developing countries. This study was conducted to highlight the challenges faced by the country in the control tuberculosis even in the implementation of the directly observed treatment strategy.

Factors influencing knowledge on completion of treatment among TB patients under directly observed treatment strategy, in selected health facilities in Embu County, Kenya.

IntroductionThe World Health Organization (WHO) promotes the Directly Observed Treatment (DOT) strategy as the standard to increase adherence to Tuberculosis (TB) medication. However, cases of retreatment and Multi Drug Resistant continue to be reported in many parts of Kenya. This study sought to determine the factors influencing the completion of tuberculosis medication among TB patients in Embu County, Kenya.MethodsA descriptive cross-sectional study was conducted on a population of tuberculosis patients under DOT attending selected TB treatment clinics in Embu County, in Kenya. One hundred and forty TB patients interviewed within a period of 3 months. Data were analyzed using SPSS version 17.0 and included Bivariate and Multivariate Analysis. The level of significance was p≤ 0.05.ResultsThe male and female participants were 61.4% and 38.6% respectively. The mean age of the respondents was 35±31.34-39.3 years. For the majority (52%) of the participants, the highest level of education was primary education. The unemployed participants formed the highest number of the respondent in the study (73%). The majorities (91.4%0) of the respondents were under the home-based DOT strategy (91.4%, 95% C.I: 85.5-95.5). Bivariate analysis using Chi-square showed that the level of education (p=0.003), patients feeling uncomfortable during supervision (p=0.01), and knowledge regarding the frequency of taking medication (p=0.004) were all significantly associated with knowledge regarding the importance of completion of medication. However, none of these factors was significant after multivariate analysis.ConclusionMost participants did not know the importance of completion of medication. TB programs should come up with better ways to educate TB patients on the importance of supervision and treatment completion during the treatment of TB. The education programs should focus on influencing the attitudes of patients and creating awareness about the importance of treatment completion. The TB programs should be designed towards eliminating the factors influencing the completion of TB medication.

Risk factors of anti-tuberculosis drugs induced liver injury and its impact on the treatment outcome of patients treated with first line anti-tuberculosis drugs: a historic retrospective cohort study

Objective To explore the incidence and risk factors of anti-tuberculosis (TB) drugs induced liver injury (ATDILI) and to discuss its impact on the treatment outcome of patients treated with first line anti-TB drugs. Methods Among the patients who received anti-TB treatment with directly-observed treatment strategy (DOTS), 121 patients with ATDILI and 817 patients without ATDILI were included in this retrospective cohort study. Binary Logistic regression model was used to analyze the risk factors of ATDILI in univariate and multivariate analysis. The χ2 test was used to compare the treatment success rates and drug resistant rates. Kaplan-Meier analysis and Log-rank test were used to compare the sputum smear/culture conversion rates and cavity closure rates. Results The incidence of ATDILI was 12.9%(121/938) in this cohort. Multivariate Logistic regression showed that hepatitis B virus carrier with both hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) positive (OR=4.29, 95%CI: 2.15-8.58, P 0.05). The sputum smear/culture conversion rate (85.4%[41/48] vs 94.0%[298/317], χ2=38.912, P<0.01) and cavity closure rate (84.6%[22/26] vs 93.0%[198/213], χ2=20.709, P<0.01) in patients with ATDILI were both significantly lower than those in patients without ATDILI. Conclusions The incidence of ATDILI is relatively high in hospitalized patients treated with first line anti-TB drugs. ATDILI has negative effects on treatment outcome of TB patient. Hepatitis B carrier with positive HBsAg and HBeAg, systemic lupus erythematosus, albumin ≤25 g/L and alcoholism may increase the risk of developing ATDILI. Key words: Antitubercular agents; Liver injury; Risk factor; Treatment outcome; Historical cohort study

Predictors of tuberculosis treatment defaulting in informal dwellers within the eThekwini municipality, Kwazulu-Natal

Globally, tuberculosis causes more than 2-million deaths annually. Despite the implementation of the directly observed treatment strategy (DOTS) in South Africa, cure and defaulter rates have not reached World Health Organization (WHO) target rates. This causes concern as it may increase the risks of the development of multiple drug-resistant tuberculosis. Prior to commencement of this study, the eThekwini Municipality reported a defaulter rate of 18.9% in 2007 and 29% in 2009, which is higher than the WHO guideline of 5%. In 2011, eThekwini reported a defaulter rate of 24.3%. Given these statistics and the impact that these high rates may have on susceptible populations and an already overburdened health system, this study aimed to investigate predictors of defaulting in informal dwellers of eThekwini Municipality, KwaZulu-Natal. The study population comprised 102 defaulters and 102 non-defaulters from informal settlements within eThekwini. It was a cross-sectional descriptive study. The Prince Cyril Zulu Communicable Disease Centre electronic tuberculosis register was used to trace defaulters who were interviewed from informal settlements. Demographic data for non-defaulters were matched from the Prince Cyril Zulu Communicable Disease Centre electronic tuberculosis register, but were not physically traced. A questionnaire was administered to all defaulters and retrospective data were obtained from the Prince Cyril Zulu Communicable Disease Centre register for non-defaulters. Multivariate logistic analysis found smoking, alcohol use and having a family member with tuberculosis to be statistically significant predictors of defaulting. Smoking [odds ratio (OR): 2.79, 95% confidence interval (CI): 1.15, 6.77, p-value ≤ 0.005], alcohol consumption (OR: 7.04, 95% CI: 2.96, 16.71, p-value ≤ 0.005), and having a family history of tuberculosis (OR: 4.60, 95% CI: 2.34, 9.04, p-value = 0.01), were all significantly associated with defaulting in informal dwellers. Smoking, alcohol use and having a family member with tuberculosis were predictors that informal dwellers would default from their treatment. These factors should be included in tuberculosis management programmes.

Pattern of tuberculosis infection and adherence to Directly Observed Treatment Strategy at a teaching hospital in Nigeria

Background: Understanding the distribution pattern of tuberculosis infection as well as adherence to treatment guidelines could help to strengthen existing policy aimed at reducing morbidity associated with the disease. Aim: To assess the pattern of sputumsmear positive tuberculosis infection and adherence to Directly Observed Treatment Strategy (DOTS). Methods: This was a retrospective cohort study which utilized secondary data involving 210 sputum smear-positive tuberculosis patients with complete data out of 226 that underwent DOTS at LUTH from January 2008 to June 2011. Results: 66.2% of patients were HIV positive and 75.9% had pulmonary tuberculosis. The proximity of residence to the hospital was ≤25km for majority (65.7%) of the patients. 75.9% of the patients adhered to DOTS. Treatment outcomes included 72.5% cured, 8.6% dead and 12.4% defaulted. Median sputum conversion time was 67 (range: 63 ‐ 71) days. Patients who resided ≤25km to the hospital (65.7%) significantly adhered to treatment compared to those who lived >25km (31.6%). Also, patients who received family support significantly adhered to therapy (83.0%) com pared to those who did not (14.6%). Median conversion time was lower among those who adhered to treatment [58 (range: 54 ‐ 63) days] compared to those who did not [73 (range: 69 ‐ 77) days]. Conclusion: Majority of smear-positive tuberculosis infected pati ents were males and their level of adherence was high. Family support received was identified to influence adherence. Integration of family support with directly observed treatment strategy as well as location of treatment centers close to patients’ residence could enhance effectiveness of the strategy.

A study on tuberculosis treatment outcome in known diabetic patients treated under Revised National Tuberculosis Control Program in Bengaluru

Background: The rising prevalence of diabetes mellitus (DM) in high tuberculosis (TB) burden countries may adversely affect TB control. Revised National Tuberculosis Control Program (RNTCP) prescribes the same TB treatment regimen that is used for non-diabetics to the diabetics. Under the program setting, there is a need for study on successful treatment outcome of TB patients with known DM. Objective: The aim was to analyze the TB treatment outcome in patients with known DM treated under RNTCP setting in an urban area. Materials and Methods: After cluster sampling among the 9 TB Units in Bengaluru 5 were selected randomly. 75 TB-DM patients and 150 TB without Diabetes were enrolled into the study and followed-up for their treatment outcome. Results: Of the 75 TB-DM patients 72% were males, and 28% were females. >90% of the patients were of age above 40 years old. Overall treatment outcome was 81% and 87% among TB-DM and TB without DM, respectively. It was not statistically significant (Fisher's exact test P = 0.3256). Conclusion: RNTCP's directly observed treatment strategy (DOTS) regimen holds good for TB patients with and without DM. The DM co-morbidity did not significantly change the TB treatment outcome. Hence, the current DOTS regime under RNTCP can be applied to the TB-DM co-morbid patients.

Directly-Observed Treatment Strategy implementation practices in a hospital in eThekwini health district

Background: The incidence rate of tuberculosis (TB) in South Africa remains high, with the country ranked as having the 14th-highest incidence rate internationally; 646 per 100 000 people are infected with TB nationally, whilst KwaZulu-Natal has a provincial incidence of 1466 per 100 000. The Directly-Observed Treatment Strategy (DOTS) programme is intended to ensure both treatment completion and cure of TB, as well as its evaluation. Despite improved DOTS coverage – the focus of most DOTS studies – the incidence of drug-resistant TB suggests that issues of non-compliance are centrally responsible for ongoing concerns about the implementation and practices related to DOTS.Objectives: The aim of the study was to explore and describe DOTS implementation practices. The objectives of the study were to explore and describe the DOTS implementation practices of professional nurses and to describe modifiable barriers to DOTS.Method: A qualitative, descriptive, explorative study was conducted through individual interviews until saturation was reached.Results: The study revealed that DOTS implementation was not in accordance with World Health Organization prescripts. Participants reported barriers such as limited human and material resources, ineffective communication of policy and procedural guidelines, ineffective communication between service delivery institutions and lack of continuity of care, as well as a lack of recording and reporting.Conclusion: The study recommended a comprehensive recruitment process to facilitate greater training and employment of more permanent health professionals to combat TB in the community; and to re-launch the DOTS programme in underperforming facilities. This would give much needed momentum to efforts targeted at preventing treatment defaults amongst patients. Agtergrond: Die voorkomskoers van tuberkulose (TB) in Suid-Afrika bly steeds hoog, waar die land internasionaal beskou word as met die 14de hoogste voorkomskoers; 646 per 100 000 mense is nasionaal met TB besmet, terwyl KwaZulu-Natal ’n provinsiale voorkoms van 1466 per 100 000toon. Die punte program (DOTS) is bedoel om beide die voltooiing van behandeling en genesing van TB en die evaluering daarvan te verseker. Ten spyte van verbeterde DOTS-dekking, wat die fokus van die meeste DOTS studies is, dui die voorkoms van dwelm-weerstandige TB daarop dat die kwessie van nie-nakoming sentraal verantwoordelik is vir voortgesette kommer oor die implementering en praktyke wat verband hou met DOTS. Doelwitte: Die doel van die studie was om die implementering van DOTS–praktyke te ondersoek en te beskryf. Die doelwitte van die studie was om die DOTS- implementeringspraktyke van professionele verpleegkundiges te ondersoek en te beskryf asook om veranderbare hindernisse ten opsigte van DOTS te beskryf.Metode: ’n Kwalitatiewe, beskrywende, ondersoekende studie is uitgevoer deur middel van individuele onderhoude tot die versadigspunt bereik was.Resultate: Die studie het getoon dat DOTS-implementering nie in ooreenstemming is met die WHO voorskrifte nie. Deelnemers berig struikelblokke soos beperkte menslike en materiële hulpbronne, oneffektiewe kommunikasie van beleid- en prosedureriglyne, oneffektiewe kommunikasie tussen dienslewerings-instellings en die gebrek aan kontinuïteit van sorg, sowel as ‚n gebrek aan optekening en verslaggewing.Gevolgtrekking: Die studie beveel ’n omvattende werwingsproses aan wat groter opleiding en indiensneming van meer permanente gesondheidswerkers om TB te bekamp in die gemeenskap sal fasiliteer, asook om die DOTS-program in gemeenskappe met onderpresterende geriewe herbekend te stel. Dit sal broodnodige momentum gee aan pogings wat gerig is op die voorkoming van onderbreekte behandeling onder pasiënte.  

Self-administered treatment for tuberculosis among pastoralists in rural Ethiopia: how well does it work?

In the Somali Regional State, Ethiopia, where most of the population are pastoralists, conventional TB treatment strategies based on directly observed treatment (DOT) at health facilities are not adapted to the mobile pastoralist lifestyle and treatment adherence is poor. From a rural district, we report on treatment outcomes of a modified self-administered treatment (SAT) strategy for pastoralists with TB. A descriptive cohort study was carried out between May 2010 and March 2012. The modified DOT strategy comprised a shorter intensive phase at the health facility (2 weeks for new patients, 8 weeks in the event of re-treatment), followed by self-administered TB treatment. A total of 390 patients started TB treatment. The overall treatment success rate was 81.2% (317/390); the rates of death, loss-to-follow up and treatment failure were 6.7% (26/390), 9.2% (36/390) and 0.3% (1/390) respectively. A considerable proportion (10/26, 38%) of deaths occurred during the first month of treatment. In a pastoralist setting, a modified SAT strategy resulted in good treatment outcomes. If the global plan to eliminate TB by 2050 is to become a reality, it will be necessary to adapt TB services to client needs to ensure that all TB patients (including pastoralists) have access to TB treatment.