Randomized controlled trial of directly observed treatment (DOT) for patients with pulmonary tuberculosis in Thailand

Abstract

While directly observed treatment (DOT) has been recommended as the standard approach to tuberculosis control, empirical data on its feasibility and efficiency are still scarce. We conducted a controlled trial of DOT at 15 health care facilities at various levels of the government health care system in Thailand. A total of 836 patients diagnosed between August 1996 and October 1997 were randomly assigned to be treated either under DOT or self-supervised using monthly drug supplies (SS). Options for treatment supervisors were health staff, community members or members of the patients' families. Treatment outcomes were compared on the basis of cure, treatment-completion, default and death rates. In both study arms, treatment outcomes were improved compared to pre-study conditions. Cure and treatment-completion rates were significantly higher in the DOT cohort (76% and 84%) than in the SS group (67% and 76%). The benefits of DOT were more pronounced at district and provincial hospitals (DOT cure rate 81% vs. 69% in the SS group), while differences for patients treated at referral centres were non-significant (DOT cure rate 72% vs. 66% in the SS group). No significant differences in outcomes could be observed between patient groups receiving DOT under the various options for treatment supervisors. DOT appears especially suited for treatment at decentralized facilities. While a general focus on programme performance can improve outcomes, DOT provides significant additional benefits. If basic conditions are met, a DOT strategy can be tailored to country-specific conditions by exploring multiple observation options, without decreasing its effectiveness.

Assessment of the effectiveness of a home-based care program for patients coinfected with tuberculosis and human immunodeficiency virus after discharge from a reference hospital in South-Eastern Brazil

“…22 The TB cure rate achieved by this study were higher than the rates obtained by other national surveys with patients coinfected with HIV who achieved TB cure rates below 58.8%. [23][24][25] However, the success rates recorded for both groups of patients in the present study were lower than those observed in previous studies [26][27][28][29][30][31][32] of populations, containing varying percentages of HIV-infected patients, that had been treated under a directly observed therapy (DOT) Home-based care program for patients coinfected with tuberculosis and human immunodefi ciency virus program. Furthermore, the number of patients who attained a cure under either treatment program in the present survey did not reach the 85% standard set by the World Health Organization.…”

The role of polymerase chain reaction in the management of osteoarticular tuberculosis

“…Moreover, it has its economic and psychosocial implications in the developing world [9,17]. False positivity in PCR can be minimised by the adequate training of personnel in molecular methods and preventing laboratory-introduced contamination.…”

Promoting adherence to treatment for tuberculosis: the importance of direct observation

“…It is true that some small pilot projects (none of which have monitored relapse or development of drug resistance) using family observation, combined with intensive supervision and home visits, have achieved high cure rates. [12][13][14] However, other studies have reported that family observation yields lower cure rates and much higher default rates than observation by someone outside the family, 15 and results in a substantial proportion of treatment being unobserved and much higher rates of non-adherence. In practice, where family observation is allowed, patients are often merely handed medicines and told to have their spouse watch them take the pills, a practice that is inconsistent with WHO guidelines specifying that treatment observers be trained and supervised by the health-care system.…”