Directly Observed Therapy and Improved Tuberculosis Treatment Outcomes in Thailand

Abstract

BackgroundThe World Health Organization (WHO) recommends that tuberculosis (TB) patients receive directly observed therapy (DOT). Randomized controlled trials have not consistently shown that this practice improves TB treatment success rates. In Thailand, one of 22 WHO-designated high burden TB countries, patients may have TB treatment observed by a health care worker (HCW), family member, or no one. We studied whether DOT improved TB treatment outcomes in a prospective, observational cohort.Methods and FindingsWe prospectively collected epidemiologic data about TB patients treated at public and private facilities in four provinces in Thailand and the national infectious diseases hospital from 2004–2006. Public health staff recorded the type of observed therapy that patients received during the first two months of TB treatment. We limited our analysis to pulmonary TB patients never previously treated for TB and not known to have multidrug-resistant TB. We analyzed the proportion of patients still on treatment at the end of two months and with treatment success at the end of treatment according to DOT type. We used propensity score analysis to control for factors associated with DOT and treatment outcome. Of 8,031 patients eligible for analysis, 24% received HCW DOT, 59% family DOT, and 18% self-administered therapy (SAT). Smear-positive TB was diagnosed in 63%, and 21% were HIV-infected. Of patients either on treatment or that defaulted at two months, 1601/1636 (98%) patients that received HCW DOT remained on treatment at two months compared with 1096/1268 (86%) patients that received SAT (adjusted OR [aOR] 3.8; 95% confidence interval [CI] 2.4–6.0) and 3782/3987 (95%) patients that received family DOT (aOR 2.1; CI, 1.4–3.1). Of patients that had treatment success or that defaulted at the end of treatment, 1369/1477 (93%) patients that received HCW DOT completed treatment compared with 744/1074 (69%) patients that received SAT (aOR 3.3; CI, 2.4–4.5) and 3130/3529 (89%) patients that received family DOT (aOR 1.5; 1.2–1.9). The benefit of HCW DOT compared with SAT was similar, but smaller, when comparing patients with treatment success to those with death, default, or failure.ConclusionsIn Thailand, two months of DOT was associated with lower odds of default during treatment. The magnitude of benefit was greater for DOT provided by a HCW compared with a family member. Thailand should consider increasing its use of HCW DOT during TB treatment.

Factors associated with death among HIV‐uninfected TB patients in Thailand, 2004–2006

“…Chiang Rai has a severe epidemic of HIV-associated TB, but it is unclear why the death rate should be particularly high among HIV-uninfected patients in that province (Siriarayapon et al 2002). Not receiving directly observed therapy by a health care worker was of borderline significance as a risk factor for death, a finding consistent with a previous observational study in Thailand that documented a small, but significant, association between directly observed therapy and improved TB treatment outcomes (Anuwatnonthakate et al 2008). These issues and the finding that age is a strong risk factor for death highlights the greatest limitation of our study: the absence of sufficient detail about co-morbid conditions that might be strongly associated with death.…”

A Meta-Analysis of Self-Administered vs Directly Observed Therapy Effect on Microbiologic Failure, Relapse, and Acquired Drug Resistance in Tuberculosis Patients

“…DOT mandatory for noncompliant or at-risk patientsMonthly review, random urine testing and pill counts: all received FDC[28]Southern Thailand (1999)Rural/urban2HRZE 7 /4HR 7 ; 2HRZE 3 /4HR 3 4114New, smear positiveDOT supervisors not stated; various levels of DOT examined. Strict DOT referred to observers actually watching patients swallow all the drugs during the first 2 moNot strict DOT, referred to as SAT[29]San Francisco, USA (1998–2000)Urban2HRZE 3 /4HR 3 3723Culture positiveHCW at clinic, home, or workplace; enablers given: DOT mandatory for at-risk patients and noncomplianceMonthly review[30]Bangkok, Thailand (2004–2005)Urban2HRZE 7 /4HR 7 12564New, smear positiveCenter-based (HCW), family-based (FM), or hybrids of center/SAT based; or center + family DOTPatients who could not attend to be accommodated in center- or family based DOT, were assigned SAT[31]Thailand (2004–2006)Rural/urban2HRZE 7 /4HR 7 ; Other8031 (only 7070 analyzed for end-of- treatment analysis)4New, smear positive, drug susceptibleHCW observed ingest antituberculosis drugs at least 5×/week, trained FM observed patient ingest antituberculosis and record eventSelf-administered antituberculosis, reviewed monthly.Study [35] reported that 83 (7%) of the 1203 patients assigned to interventions were lost to follow-up, ie, defaulted; however, these defaulters were not reported according to their assigned interventions. Thus, this study was not included in Figure 2.…”

Directly observed therapy for treating tuberculosis

“…The debate has continued, with some even advocating for a shift of resources away from DOT programmes (Barbara 2013; Gross 2009; Moonan 2011; Pasipanodya 2013). There are also debates as to the best delivery of DOT, for example, should it be through healthcare workers or family members (Anuwatnonthakate 2008; Dick 2005).…”