1
|
Kumwichar P, Prappre T, Chongsuvivatwong V. Tuberculosis Treatment Compliance Under Smartphone-Based Video-Observed Therapy Versus Community-Based Directly Observed Therapy: Cluster Randomized Controlled Trial. JMIR Mhealth Uhealth 2024; 12:e53411. [PMID: 38830205 PMCID: PMC11184266 DOI: 10.2196/53411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Revised: 12/26/2023] [Accepted: 05/08/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND There are no recent studies comparing the compliance rates of both patients and observers in tuberculosis treatment between the video-observed therapy (VOT) and directly observed therapy (DOT) programs. OBJECTIVE This study aims to compare the average number of days that patients with pulmonary tuberculosis and their observers were compliant under VOT and DOT. In addition, this study aims to compare the sputum conversion rate of patients under VOT with that of patients under DOT. METHODS Patient and observer compliance with tuberculosis treatment between the VOT and DOT programs were compared based on the average number of VOT and DOT compliance days and sputum conversion rates in a 60-day cluster randomized controlled trial with patients with pulmonary tuberculosis (VOT: n=63 and DOT: n=65) with positive sputum acid-fast bacilli smears and 38 observers equally randomized into the VOT and DOT groups (19 observers per group and n=1-5 patients per observer). The VOT group submitted videos to observers via smartphones; the DOT group followed standard procedures. An intention-to-treat analysis assessed the compliance of both the patients and the observers. RESULTS The VOT group had higher average compliance than the DOT group (patients: mean difference 15.2 days, 95% CI 4.8-25.6; P=.005 and observers: mean difference 21.2 days, 95% CI 13.5-28.9; P<.001). The sputum conversion rates in the VOT and DOT groups were 73% and 61.5%, respectively (P=.17). CONCLUSIONS Smartphone-based VOT significantly outperformed community-based DOT in ensuring compliance with tuberculosis treatment among observers. However, the study was underpowered to confirm improved compliance among patients with pulmonary tuberculosis and to detect differences in sputum conversion rates. TRIAL REGISTRATION Thai Clinical Trials Registry (TCTR) TCTR20210624002; https://tinyurl.com/3bc2ycrh. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) RR2-10.2196/38796.
Collapse
Affiliation(s)
- Ponlagrit Kumwichar
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | - Tagoon Prappre
- Department of Epidemiology, Faculty of Medicine, Prince of Songkla University, Hat Yai, Thailand
| | | |
Collapse
|
2
|
Baye T, Kassaw AT, Gebrie D, Girmaw F, Ashagrie G. Effectiveness and cost-effectiveness of community-based directly observed treatment (DOT) versus health facility-based DOT of tuberculosis in Africa: protocol for a systematic review and meta-analysis. BMJ Open 2024; 14:e081767. [PMID: 38724061 PMCID: PMC11086473 DOI: 10.1136/bmjopen-2023-081767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 04/26/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Tuberculosis (TB) remains a significant global health challenge, especially prevalent in the WHO African region. The WHO's End TB Strategy emphasises effective treatment approaches such as directly observed therapy (DOT), yet the optimal implementation of DOT, whether through health facility-based (HF DOT) or community-based (CB DOT) approaches, remains uncertain. OBJECTIVE To conduct a systematic comparison of the effectiveness and cost-effectiveness of Community-Based Directly Observed Treatment (CB DOT) versus Health Facility-Based Directly Observed Treatment (HF DOT) for tuberculosis (TB) treatment in African settings. METHODS We will conduct a systematic review and meta-analysis following Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines. We will search PubMed, Embase, Web of Science, Scopus and the Cochrane Library for articles published up to 30 March 2023, without date restrictions. Eligible studies must be full economic evaluations conducted in African countries, comparing CB DOT to HF DOT regarding treatment outcomes and costs. Exclusion criteria include non-English, non-peer-reviewed or studies lacking caregiver involvement in CB DOT, health facility-based DOT comparison, direct comparability between CB DOT and HF DOT, significant selection bias or non-economic evaluations. Data extraction will be performed independently by reviewers, and meta-analyses will use STATA software. To pool the data, a random-effect model will be applied, and quality assessment of the studies will be conducted. ETHICS AND DISSEMINATION Ethical approval is not required as the study will use previously published articles available publicly. Findings will be presented at international and national conferences and published in open-access, peer-reviewed journals. PROSPERO REGISTRATION NUMBER CRD42023443260.
Collapse
Affiliation(s)
- Tenaw Baye
- Pharmacy, Woldia University, Woldia, Amhara, Ethiopia
| | | | - Desye Gebrie
- Pharmacy, Woldia University, Woldia, Amhara, Ethiopia
| | - Fentaw Girmaw
- Pharmacy, Woldia University, Woldia, Amhara, Ethiopia
| | | |
Collapse
|
3
|
Su Q, Liu Q, Liu J, Fu L, Liu T, Liang J, Peng H, Pan X. Study on the associations between liver damage and antituberculosis drug rifampicin and relative metabolic enzyme gene polymorphisms. Bioengineered 2021; 12:11700-11708. [PMID: 34872459 PMCID: PMC8810084 DOI: 10.1080/21655979.2021.2003930] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
The occurrence of antituberculosis drug-induced liver injury affects the effectiveness of antituberculosis treatments. Understanding the mechanism and risk factors of such liver injury may improve the outcomes of those patients who received antituberculosis treatments. In this study, 2,255 pulmonary tuberculosis patients were included. Their medical records were reviewed, questionnaire surveys, liver function tests at the end of February (including patients with uncomfortable symptoms during the intensive treatment period), and blood samples were saved. Afterward, cases of liver damage were determined using Chinese liver damage criteria. The genotype of all participants was determined using the PCR-LDR method. Finally, the association between genetic polymorphism and ATB-DILI susceptibility was assessed using the univariate Logistic regression models. Among the 2,255 tuberculosis patients who received rifampicin, 612 (27.1%) had antituberculosis drug-induced liver injury. We observed higher proportions of older age, male, and lower levels of AST, ALT, and TBil among patients with liver injury. Results of univariate of logistic regression models showed that patients with CYP2C19 were more likely to have liver injury compared with no such genotypes patients (all P < 0.05). Patients with tuberculosis with older age and genetic polymorphism of CYP3A4, CYP2C9, and CYP2C19 who received long-term rifampicin treatment were more likely to have antituberculosis drug-induced liver injury. It is important for healthcare providers to carefully evaluate and monitor rifampicin use for these patients.
Collapse
Affiliation(s)
- Qiang Su
- Department of Pharmacy, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China.,Nanchong Key Laboratory of Individualized Drug Therapy, Nanchong, P.R. China
| | - Qiao Liu
- School of Pharmacy, North Sichuan Medical College, Nanchong, P.R. China
| | - Juan Liu
- Department of Pediatrics, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China
| | - Lingyun Fu
- Department of Health Management Center, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China
| | - Tao Liu
- Nanchong Key Laboratory of Individualized Drug Therapy, Nanchong, P.R. China.,Department of Cardiology, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China
| | - Jing Liang
- Department of Pharmacy, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China.,Nanchong Key Laboratory of Individualized Drug Therapy, Nanchong, P.R. China
| | - Hong Peng
- Department of Anorectal Surgery, Nanchong Central Hospital, the Second Clinical Medical College, North Sichuan Medical College, Nanchong, P.R. China
| | - Xue Pan
- Scientific Research Department, The First Affiliated Hospital of Chongqing Medical University, Chongqing, P.R. China
| |
Collapse
|
4
|
Kumwichar P, Chongsuvivatwong V, Prappre T. Development of a Video-Observed Therapy System to Improve Monitoring of Tuberculosis Treatment in Thailand: Mixed-Methods Study. JMIR Form Res 2021; 5:e29463. [PMID: 34313602 PMCID: PMC8367133 DOI: 10.2196/29463] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 05/15/2021] [Accepted: 07/05/2021] [Indexed: 01/26/2023] Open
Abstract
Background Directly observed therapy programs for monitoring tuberculosis (TB) treatment in Thailand are unsustainable, especially during the COVID-19 pandemic. The current video-observed therapy (VOT) system, the Thai VOT (TH VOT), was developed to replace the directly observed therapy program. Objective This study aimed to describe the VOT system design and identify the potential for system improvements. Methods This pilot study was conducted in Na Yong district, a small district in Trang province, south of Thailand. The TH VOT system consists of a smartphone app for patients, a secured web-based platform for staff, items used, and standard operating procedures. There were three groups of users: observers who were TB staff, healthy volunteers as simulated patients, and patients with active TB. All participants were trained to follow the standard operating procedures. After 2-week usage, VOT session records were analyzed to measure the compliance of the patients and observers. The User Experience Questionnaire was used to lead the participant users to focus on 6 standard dimensions of usability, and was supplemented with an in-depth interview to identify potential system improvements from users’ experience. Results Only 2 of 16 patients with currently active TB had a usable smartphone. Sixty of 70 drug-taking sessions among 2 patients and 3 simulated patients in 2 weeks were recorded and uploaded. Only 37 sessions were inspected by the observers within 24 hours. All participants needed a proper notification system. An audit system was also requested. Conclusions Before upscaling, the cost of smartphone lending, audit management, and notification systems should be elucidated.
Collapse
Affiliation(s)
- Ponlagrit Kumwichar
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | | | - Tagoon Prappre
- Epidemiology Unit, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| |
Collapse
|
5
|
Pettit AC, Jenkins CA, Blevins Peratikos M, Yotebieng M, Diero L, Do CD, Ross J, Veloso VG, Hawerlander D, Marcy O, Shepherd BE, Fenner L, Sterling TR. Directly observed therapy and risk of unfavourable tuberculosis treatment outcomes among an international cohort of people living with HIV in low- and middle-income countries. J Int AIDS Soc 2019; 22:e25423. [PMID: 31814312 PMCID: PMC6900483 DOI: 10.1002/jia2.25423] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/08/2019] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Identification of persons living with human immunodeficiency virus (HIV)-associated tuberculosis (TB) at increased risk for unfavourable TB outcomes would inform efforts to improve such outcomes. We sought to identify factors associated with a decreased risk of unfavourable TB treatment outcomes among people living with HIV-infection (PLHIV) in low- and middle-income countries (LMIC), with a specific focus on directly observed therapy (DOT) compared with self-administered therapy (SAT) during the continuation phase of anti-TB therapy. METHODS We conducted a retrospective cohort study among adults diagnosed with HIV-associated TB in Africa, Asia and the Americas from 2012 to 2013; data were collected from 2012 to 2016. Unfavourable TB treatment outcomes (death during TB treatment, and TB treatment failure or recurrence) were defined according to World Health Organization criteria. Receipt of DOT was obtained at the site level and defined as ≥5 days of DOT per week. The person administering DOT and treatment location varied by site. Lack of receipt of DOT was defined as SAT. Multivariable logistic regression estimated the adjusted odds of unfavourable TB treatment outcomes. RESULTS Among 1862 adults with HIV-associated TB included, 252 (13.5%) had unfavourable TB outcomes (226 deaths, 26 recurrences/failures). Overall, 1825 (98%) received DOT in the intensive phase and 1617 (87%) received DOT in the continuation phase. DOT in the continuation phase was not significantly associated with unfavourable TB outcomes (aOR 1.43, 95% CI 0.86 to 2.38) compared to SAT. Body mass index (BMI) change during anti-TB treatment (per 2 units increase, aOR 0.74, 95% CI 0.68 to 0.82) and CD4+ count at TB diagnosis (200 vs. 50 cells/µL, aOR 0.54, 95% CI 0.39 to 0.73) were both independently associated with decreased odds of unfavourable TB treatment outcomes. CONCLUSIONS In this large, international cohort of people living with HIV-associated TB in LMIC who received intensive phase DOT, DOT during the continuation phase of anti-TB therapy was not associated with a decreased odds of unfavourable TB treatment outcomes compared to SAT. Randomized trials evaluating the effect of continuation-phase DOT on TB outcomes among PLHIV are needed.
Collapse
Affiliation(s)
- April C Pettit
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Tuberculosis CenterNashvilleTNUSA
| | - Cathy A Jenkins
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | | | | | - Lameck Diero
- Academic Model Providing Access To Healthcare (AMPATH)EldoretKenya
| | | | - Jeremy Ross
- TREAT Asia/amfAR – The Foundation for AIDS ResearchBangkokThailand
| | - Valdilea G Veloso
- Instituto Nacional de Infectologia Evandro ChagasFundação Oswaldo CruzRio de JaneiroRJBrazil
| | - Denise Hawerlander
- Centre Intégré de Recherches Biocliniques d'Abidjan CIRBAAbidjanCôte d'Ivoire
| | - Olivier Marcy
- Centre INSERM U1219Bordeaux Population HealthUniversity of BordeauxBordeauxFrance
| | - Bryan E Shepherd
- Department of BiostatisticsVanderbilt University Medical CenterNashvilleTNUSA
| | - Lukas Fenner
- Institute of Social and Preventive MedicineUniversity of BernBernSwitzerland
| | - Timothy R Sterling
- Department of MedicineVanderbilt University Medical CenterNashvilleTNUSA
- Vanderbilt Tuberculosis CenterNashvilleTNUSA
| | | |
Collapse
|
6
|
Lukman M, Ibrahim K, Yani DI, Sari SP, Juniarti N. Exploring Strategies to Improve the Performance of Community Health Volunteers for Tuberculosis Care and Prevention: A Qualitative Study. INTERNATIONAL JOURNAL OF COMMUNITY BASED NURSING AND MIDWIFERY 2019; 7:270-278. [PMID: 31641676 PMCID: PMC6779918 DOI: 10.30476/ijcbnm.2019.81353.0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Background: Community health volunteers contributed to the total Tuberculosis (TB) case findings; however, the attrition rate of these volunteers was high which reduces their optimal performance. Hence, sustainability of efforts should be explored to retain the community health volunteers in the TB program. Improvement of community health volunteers to perform community-based health education and prevent TB has not been examined consistently around the globe, including Indonesia. This study aimed to explore the strategies to improve performance of community health volunteers for TB care and prevention to reduce the incidence and stop the spread of TB in the community.
Methods: A qualitative design was adopted and we used two focus group discussions in 2017 to collect the data. The participants included village health workers as volunteers in two regencies of Bandung City, West Java Indonesia. A thematic analysis was used to analyze the data.
Results: Four major themes should be considered in developing a community-based TB health education program: (1) informing community health volunteers about the benefits and difficulties of being a TB volunteer; (2) recognizing the activities and feelings of volunteers; (3) emphasizing the Willingness to Help Others; and (4) having access to TB training.
Conclusion: To develop a community-based health education program for TB care and prevention, community nurses need to listen to the opinions of community health volunteers, and TB patients and their family members to ensure that the health education program is tailored to meet community needs.
Collapse
Affiliation(s)
- Mamat Lukman
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| | - Kusman Ibrahim
- Department of Medical Surgical Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| | - Desy Indra Yani
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| | - Sheizi Prista Sari
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| | - Neti Juniarti
- Department of Community Health Nursing, Faculty of Nursing, Universitas Padjadjaran, Bandung, Indonesia
| |
Collapse
|
7
|
McKay B, Castellanos M, Ebell M, Whalen CC, Handel A. An attempt to reproduce a previous meta-analysis and a new analysis regarding the impact of directly observed therapy on tuberculosis treatment outcomes. PLoS One 2019; 14:e0217219. [PMID: 31120965 PMCID: PMC6532908 DOI: 10.1371/journal.pone.0217219] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 05/02/2019] [Indexed: 11/18/2022] Open
Abstract
Directly observed therapy (DOT) is almost universally used for the treatment of TB. Several meta-analyses using different methods have assessed the effectiveness of DOT compared to self-administered therapy (SAT). The results of these meta-analyses often conflict with some concluding DOT is superior and others that there is little or no difference. Meta-analyses can guide policymaking, but such analyses must be reliable. To assess the validity of a previous meta-analysis, we tried to reproduce it. We encountered problems with the previous analysis that did not allow for a meaningful reproduction. We describe the issues we encountered here. We then performed a new meta-analysis comparing the treatment outcomes of adults given treatment with SAT versus DOT. Outcomes in the new analysis are loss to follow-up, treatment failure, cure, treatment completed, and all-cause mortality. All data, documentation, and code used to generate our results is provided. Our new analysis included four randomized and three observational studies with 1603 and 1626 individuals respectively. The pooled relative risks (RR) are as follows: Lost to follow-up (RR = 1.2, 95% CI 0.9, 1.7), Treatment Failure (RR = 1.1, 95% CI 0.6, 2), Cure (RR = 0.9, 95% CI 0.8, 1.1), Treatment Completion (RR = 1, 95% CI 0.9, 1.1), Mortality (RR = 0.9, 95% CI 0.6, 1.3). Based on data from our new meta-analysis, the magnitude of the difference between DOT and SAT for all reported outcomes is small, and none of the differences are statistically significant.
Collapse
Affiliation(s)
- Brian McKay
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
- * E-mail: (BM); (AH)
| | - Maria Castellanos
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Mark Ebell
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Christopher C. Whalen
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
| | - Andreas Handel
- Department of Epidemiology and Biostatistics, The University of Georgia, Athens, Georgia, United States of America
- * E-mail: (BM); (AH)
| |
Collapse
|
8
|
A systematic review of non-pharmacological interventions to improve therapeutic adherence in tuberculosis. Heart Lung 2019; 48:452-461. [PMID: 31084923 DOI: 10.1016/j.hrtlng.2019.05.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 04/30/2019] [Accepted: 05/01/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND Reviews examining non-pharmacological interventions to improve therapeutic adherence in tuberculosis have several limitations (design, quality assessment…). Consequently, for clinical practice, it is important to generate a review containing all the information to improve patient adherence, solving the previous issues. OBJECTIVES To examine non-pharmacological interventions to improve therapeutic adherence in tuberculosis through clinical trials. METHODS A systematic review in MEDLINE/EMBASE was performed. RESULTS Thirty seven papers were analysed. The disease treatment interventions were disparate, grouped into: education, psychological interventions, new technologies, directly observed treatment, incentives and improved access to health services. In the treatment of latent infection, the majority of studies were conducted in the marginal population (drug addicts, homeless individuals and prisoners) and were based mainly on the provision of incentives. Study quality was generally low. CONCLUSIONS Great variability exists in the studies comparing strategies for identifying interventions, objectives and effects. The designs carried out generally have methodological deficits.
Collapse
|
9
|
Alipanah N, Jarlsberg L, Miller C, Linh NN, Falzon D, Jaramillo E, Nahid P. Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies. PLoS Med 2018; 15:e1002595. [PMID: 29969463 PMCID: PMC6029765 DOI: 10.1371/journal.pmed.1002595] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Accepted: 05/29/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Incomplete adherence to tuberculosis (TB) treatment increases the risk of delayed culture conversion with continued transmission in the community, as well as treatment failure, relapse, and development or amplification of drug resistance. We conducted a systematic review and meta-analysis of adherence interventions, including directly observed therapy (DOT), to determine which approaches lead to improved TB treatment outcomes. METHODS AND FINDINGS We systematically reviewed Medline as well as the references of published review articles for relevant studies of adherence to multidrug treatment of both drug-susceptible and drug-resistant TB through February 3, 2018. We included randomized controlled trials (RCTs) as well as prospective and retrospective cohort studies (CSs) with an internal or external control group that evaluated any adherence intervention and conducted a meta-analysis of their impact on TB treatment outcomes. Our search identified 7,729 articles, of which 129 met the inclusion criteria for quantitative analysis. Seven adherence categories were identified, including DOT offered by different providers and at various locations, reminders and tracers, incentives and enablers, patient education, digital technologies (short message services [SMSs] via mobile phones and video-observed therapy [VOT]), staff education, and combinations of these interventions. When compared with DOT alone, self-administered therapy (SAT) was associated with lower rates of treatment success (CS: risk ratio [RR] 0.81, 95% CI 0.73-0.89; RCT: RR 0.94, 95% CI 0.89-0.98), adherence (CS: RR 0.83, 95% CI 0.75-0.93), and sputum smear conversion (RCT: RR 0.92, 95% CI 0.87-0.98) as well as higher rates of development of drug resistance (CS: RR 4.19, 95% CI 2.34-7.49). When compared to DOT provided by healthcare providers, DOT provided by family members was associated with a lower rate of adherence (CS: RR 0.86, 95% CI 0.79-0.94). DOT delivery in the community versus at the clinic was associated with a higher rate of treatment success (CS: RR 1.08, 95% CI 1.01-1.15) and sputum conversion at the end of two months (CS: RR 1.05, 95% CI 1.02-1.08) as well as lower rates of treatment failure (CS: RR 0.56, 95% CI 0.33-0.95) and loss to follow-up (CS: RR 0.63, 95% CI 0.40-0.98). Medication monitors improved adherence and treatment success and VOT was comparable with DOT. SMS reminders led to a higher treatment completion rate in one RCT and were associated with higher rates of cure and sputum conversion when used in combination with medication monitors. TB treatment outcomes improved when patient education, healthcare provider education, incentives and enablers, psychological interventions, reminders and tracers, or mobile digital technologies were employed. Our findings are limited by the heterogeneity of the included studies and lack of standardized research methodology on adherence interventions. CONCLUSION TB treatment outcomes are improved with the use of adherence interventions, such as patient education and counseling, incentives and enablers, psychological interventions, reminders and tracers, and digital health technologies. Trained healthcare providers as well as community delivery provides patient-centered DOT options that both enhance adherence and improve treatment outcomes as compared to unsupervised, SAT alone.
Collapse
Affiliation(s)
- Narges Alipanah
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
- Santa Clara Valley Medical Center, Department of Internal Medicine, San Jose, California, United States of America
| | - Leah Jarlsberg
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Cecily Miller
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| | - Nguyen Nhat Linh
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | - Dennis Falzon
- Global TB Programme, World Health Organization, Geneva, Switzerland
| | | | - Payam Nahid
- University of California San Francisco, Division of Pulmonary and Critical Care Medicine, Zuckerberg San Francisco General, San Francisco, California, United States of America
| |
Collapse
|
10
|
King E, Kinvig K, Steif J, Qiu AQ, Maan EJ, Albert AY, Pick N, Alimenti A, Kestler MH, Money DM, Lester RT, Murray MCM. Mobile Text Messaging to Improve Medication Adherence and Viral Load in a Vulnerable Canadian Population Living With Human Immunodeficiency Virus: A Repeated Measures Study. J Med Internet Res 2017; 19:e190. [PMID: 28572079 PMCID: PMC5472843 DOI: 10.2196/jmir.6631] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 03/02/2017] [Accepted: 04/11/2017] [Indexed: 02/05/2023] Open
Abstract
Background Combination antiretroviral therapy (cART) as treatment for human immunodeficiency virus (HIV) infection is effective and available, but poor medication adherence limits benefits, particularly in vulnerable populations. In a Kenyan randomized controlled trial, a weekly text-messaging intervention (WelTel) improved cART adherence and HIV viral load (VL). Despite growing evidence for short message service (SMS) text-message interventions in HIV care, there is a paucity of data utilizing these interventions in marginalized or female cohorts. Objective This study was undertaken to assess whether the standardized WelTel SMS text-message intervention applied to a vulnerable, predominantly female, population improved cART adherence and VL. Methods We conducted a repeated measures study of the WelTel intervention in high-risk HIV-positive persons by measuring change in VL, CD4 count, and self-reported adherence 12 months before and 12 months after the WelTel intervention was introduced. Inclusion criteria included VL ≥200 copies/mL, indication for treatment, and meeting vulnerability criteria. Participants were given a mobile phone with unlimited texting (where required), and weekly check-in text messages were sent for one year from the WelTel computer platform. Clinical data were collected for control and intervention years. Participants were followed by a multidisciplinary team in a clinical setting. Outcomes were assessed using Wilcoxon signed ranks tests for change in CD4 and VL from control year to study end and mixed-effects logistic regressions for change in cART adherence and appointment attendance. A secondary analysis was conducted to assess the effect of response rate on the outcome by modeling final log10 VL by number of responses while controlling for mean log10 VL in the control year. Results Eighty-five participants enrolled in the study, but 5 withdrew (final N=80). Participants were predominantly female (90%, 72/80) with a variety of vulnerabilities. Mean VL decreased from 1098 copies/mL in the control year to 439 copies/mL at study end (P=.004). Adherence to cART significantly improved (OR 1.14, IQR 1.10-1.18; P<.001), whereas appointment attendance decreased slightly with the intervention (OR 0.81, IQR 0.67-0.99; P=.03). A response was received for 46.57% (1753/3764) of messages sent and 9.62% (362/3764) of text messages sent were replied to with a problem. An outcome analysis examining relationship between reply rate and VL did not meet statistical significance (P=.07), but may be worthy of investigating further in a larger study. Conclusions WelTel may be an effective tool for improving cART adherence and reducing VLs among high-risk, vulnerable HIV-positive persons. Trial Registration Clinicaltrials.gov NCT02603536; https://clinicaltrials.gov/ct2/show/NCT02603536 (Archived by WebCite at http://www.webcitation.org/6qK57zCwv)
Collapse
Affiliation(s)
- Elizabeth King
- Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Karen Kinvig
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Jonathan Steif
- Department of Mathematics, University of British Columbia, Vancouver, BC, Canada
| | - Annie Q Qiu
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Evelyn J Maan
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Arianne Yk Albert
- Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada
| | - Neora Pick
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Ariane Alimenti
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
| | - Mary H Kestler
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Deborah M Money
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, BC, Canada
| | - Richard T Lester
- Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Melanie Caroline Margaret Murray
- Oak Tree Clinic, British Columbia Women's Hospital, Vancouver, BC, Canada.,Women's Health Research Institute, British Columbia Women's Hospital, Vancouver, BC, Canada.,Division of Infectious Diseases, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| |
Collapse
|
11
|
Berger BA, Cossio A, Saravia NG, Castro MDM, Prada S, Bartlett AH, Pho MT. Cost-effectiveness of meglumine antimoniate versus miltefosine caregiver DOT for the treatment of pediatric cutaneous leishmaniasis. PLoS Negl Trop Dis 2017; 11:e0005459. [PMID: 28384261 PMCID: PMC5404883 DOI: 10.1371/journal.pntd.0005459] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 04/25/2017] [Accepted: 03/06/2017] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Oral miltefosine has been shown to be non-inferior to first-line, injectable meglumine antimoniate (MA) for the treatment of cutaneous leishmaniasis (CL) in children. Miltefosine may be administered via in-home caregiver Directly Observed Therapy (cDOT), while patients must travel to clinics to receive MA. We performed a cost-effectiveness analysis comparing miltefosine by cDOT versus MA for pediatric CL in southwest Colombia. METHODOLOGY/PRINCIPLE FINDINGS We developed a Monte Carlo model comparing the cost-per-cure of miltefosine by cDOT compared to MA from patient, government payer, and societal perspectives (societal = sum of patient and government payer perspective costs). Drug effectiveness and adverse events were estimated from clinical trials. Healthcare utilization and costs of travel were obtained from surveys of providers and published sources. The primary outcome was cost-per-cure reported in 2015 USD. Treatment efficacy, costs, and adherence were varied in sensitivity analysis to assess robustness of results. Treatment with miltefosine resulted in substantially lower cost-per-cure from a societal and patient perspective, and slightly higher cost-per-cure from a government payer perspective compared to MA. Mean societal cost-per-cure were $531 (SD±$239) for MA and $188 (SD±$100) for miltefosine, a mean cost-per-cure difference of +$343. Mean cost-per-cure from a patient perspective were $442 (SD ±$233) for MA and $30 (SD±$16) for miltefosine, a mean difference of +$412. Mean cost-per-cure from a government perspective were $89 (SD±$55) for MA and $158 (SD±$98) for miltefosine, with a mean difference of -$69. Results were robust across a variety of assumptions in univariate and multi-way analysis. CONCLUSIONS/SIGNIFICANCE Treatment of pediatric cutaneous leishmaniasis with miltefosine via cDOT is cost saving from patient and societal perspectives, and moderately more costly from the government payer perspective compared to treatment with MA. Results were robust over a range of sensitivity analyses. Lower drug price for miltefosine could result in cost saving from a government perspective.
Collapse
Affiliation(s)
- Brandon A. Berger
- University of Chicago Pritzker School of Medicine, Chicago, Illinois, United States of America
| | - Alexandra Cossio
- Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali, Valle de Cauca, Colombia
| | - Nancy Gore Saravia
- Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali, Valle de Cauca, Colombia
| | - Maria del Mar Castro
- Centro Internacional de Entrenamiento e Investigaciones Médicas (CIDEIM), Cali, Valle de Cauca, Colombia
| | - Sergio Prada
- PROESA, Universidad Icesi, Cali, Valle de Cauca, Colombia
| | - Allison H. Bartlett
- Department of Pediatrics, Section of Infectious Diseases, University of Chicago Medicine, Chicago, Illinois, United States of America
| | - Mai T. Pho
- Department of Medicine, Section of Infectious Diseases and Global Health, University of Chicago, Chicago, Illinois, United States of America
| |
Collapse
|
12
|
Zhang H, Ehiri J, Yang H, Tang S, Li Y. Impact of Community-Based DOT on Tuberculosis Treatment Outcomes: A Systematic Review and Meta-Analysis. PLoS One 2016; 11:e0147744. [PMID: 26849656 PMCID: PMC4744041 DOI: 10.1371/journal.pone.0147744] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2015] [Accepted: 01/07/2016] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Poor adherence to tuberculosis (TB) treatment can lead to prolonged infectivity and poor treatment outcomes. Directly observed treatment (DOT) seeks to improve adherence to TB treatment by observing patients while they take their anti-TB medication. Although community-based DOT (CB-DOT) programs have been widely studied and promoted, their effectiveness has been inconsistent. The aim of this study was to critical appraise and summarize evidence of the effects of CB-DOT on TB treatment outcomes. METHODS Studies published up to the end of February 2015 were identified from three major international literature databases: Medline/PubMed, EBSCO, and EMBASE. Unpublished data from the grey literature were identified through Google and Google Scholar searches. RESULTS Seventeen studies involving 12,839 pulmonary TB patients (PTB) in eight randomized controlled trials (RCTs) and nine cohort studies from 12 countries met the criteria for inclusion in this review and 14 studies were included in meta-analysis. Compared with clinic-based DOT, pooled results of RCTs for all PTB cases (including smear-negative or -positive, new or retreated TB cases) and smear-positive PTB cases indicated that CB-DOT promoted successful treatment [pooled RRs (95%CIs): 1.11 (1.02-1.19) for all PTB cases and 1.11 (1.02-1.19) for smear-positive PTB cases], and completed treatment [pooled RRs (95%CIs): 1.74(1.05, 2.90) for all PTB cases and 2.22(1.16, 4.23) for smear-positive PTB cases], reduced death [pooled RRs (95%CIs): 0.44 (0.26-0.72) for all PTB cases and 0.39 (0.23-0.66) for smear-positive PTB cases], and transfer out [pooled RRs (95%CIs): 0.37 (0.23-0.61) for all PTB cases and 0.42 (0.25-0.70) for smear-positive PTB cases]. Pooled results of all studies (RCTs and cohort studies) with all PTB cases demonstrated that CB-DOT promoted successful treatment [pooled RR (95%CI): 1.13 (1.03-1.24)] and curative treatment [pooled RR (95%CI): 1.24 (1.04-1.48)] compared with self-administered treatment. CONCLUSIONS CB-DOT did improved TB treatment outcomes according to the pooled results of included studies in this review. Studies on strategies for implementation of patient-centered and community-centered CB-DOT deserve further attention.
Collapse
Affiliation(s)
- HaiYang Zhang
- College of Preventive Medicine, Third Military Medical University, Chongqing, China
| | - John Ehiri
- Department of Health Promotion Sciences, Mel & Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona, United States of America
| | - Huan Yang
- Department of Hygienic Toxicology, Key Lab of Medical Protection for Electromagnetic Radiation, Ministry of Education of China, Third Military Medical University, China
| | - Shenglan Tang
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
- * E-mail: (ST); (YL)
| | - Ying Li
- Department of Social Medicine and Health Service Management, College of Preventive Medicine, Third Military Medical University, Chongqing, China
- * E-mail: (ST); (YL)
| |
Collapse
|
13
|
Kasozi S, Clark J, Doi SAR. Intermittent Versus Daily Pulmonary Tuberculosis Treatment Regimens: A Meta-Analysis. Clin Med Res 2015; 13:117-38. [PMID: 26056374 PMCID: PMC4720512 DOI: 10.3121/cmr.2015.1272] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2015] [Accepted: 05/15/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several systematic reviews suggest that intermittent pulmonary tuberculosis (TB) chemotherapy is effective, but intensity (daily versus intermittent) and duration of rifampicin use (intensive phase only versus both phases) have not been distinguished. In addition, the various outcomes (success, failure, relapse, and default) have only selectively been evaluated. METHODS We conducted a meta-analysis of proportions using all four outcomes as multi-category proportions to examine the effectiveness of WHO category 1 TB treatment regimens. Database searches of studies reporting treatment outcomes of HIV negative subjects were included and stratified by intensity of therapy and duration of rifampicin therapy. Using a bias-adjusted statistical model, we pooled proportions of the four treatment outcome categories using a method that handles multi-category proportions. RESULTS A total of 27 studies comprising of 48 data sets with 10,624 participants were studied. Overall, treatment success was similar among patients treated with intermittent (I/I) (88%) (95% CI, 81-92) and daily (D/D) (90%) (95% CI, 84-95) regimens. Default was significantly less with I/I (0%) (95% CI, 0-2) compared to D/D regimens (5%) (95% CI, 1-9). Nevertheless, I/I relapse rates (7%) (95% CI, 3-11) were higher than D/D relapse rates (1%) (95% CI, 0-3). CONCLUSION Treatment regimens that are offered completely intermittently versus completely daily are associated with a trade-off between treatment relapse and treatment default. There is a possibility that I/I regimens can be improved by increasing treatment duration, and this needs to be urgently addressed by future studies.
Collapse
Affiliation(s)
- Samuel Kasozi
- National Tuberculosis and Leprosy Control Program, Ministry of Health, Wandegeya, Uganda School of Public Health, Makerere University, Uganda School of Population Health, University of Queensland, Brisbane, Australia
| | - Justin Clark
- Australian Catholic University Library, Brisbane, Australia Research School of Population Health, Australian National University, Canberra, Australia
| | - Suhail A R Doi
- School of Population Health, University of Queensland, Brisbane, Australia
| |
Collapse
|
14
|
Narayan N, Viney K, Varman S. Comparison of tuberculosis treatment outcomes by method of treatment supervision in the Fiji Islands. Public Health Action 2015; 4:174-8. [PMID: 26400806 DOI: 10.5588/pha.14.0020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/18/2014] [Indexed: 11/10/2022] Open
Abstract
SETTING The National Tuberculosis Programme (NTP) in Fiji. OBJECTIVE To determine anti-tuberculosis treatment outcomes stratified by method of treatment supervision (i.e., self-administered treatment [SAT] vs. supervision by a family member). DESIGN A retrospective descriptive study of all tuberculosis (TB) patients registered with the NTP in Fiji between January 2011 and June 2013. RESULTS Of 563 TB patients registered, information on the type of treatment supervisor was available for 470 (83%). Of these, most (n = 401, 85%) had their treatment supervised by a family member, while 69 (15%) elected SAT. SAT patients had a treatment success rate of 79.4% compared to 88.5% in those supervised by a family member; the difference was statistically significant (P = 0.0374). CONCLUSION Anti-tuberculosis treatment outcomes were more likely to be successful in patients who were supervised by a family member than in SAT patients. As this method of treatment supervision is not likely to be resource-intensive, we recommend that it continue in Fiji. Further prospective operational research could be carried out to determine patient preferences for anti-tuberculosis treatment supervision in Fiji, to promote a patient-centred approach.
Collapse
Affiliation(s)
- N Narayan
- Grant Management Unit, Ministry of Health Fiji Islands, Suva, Fiji
| | - K Viney
- Public Health Division, Secretariat of the Pacific Community, Nouméa, New Caledonia ; National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - S Varman
- College of Nursing, Medicine and Health Sciences, Fiji National University, Suva, Fiji
| |
Collapse
|
15
|
Khachadourian V, Truzyan N, Harutyunyan A, Thompson ME, Harutyunyan T, Petrosyan V. People-centered tuberculosis care versus standard directly observed therapy: study protocol for a cluster randomized controlled trial. Trials 2015; 16:281. [PMID: 26093675 PMCID: PMC4479352 DOI: 10.1186/s13063-015-0802-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2014] [Accepted: 06/08/2015] [Indexed: 11/10/2022] Open
Abstract
Background Tuberculosis is a major public health concern resulting in high rates of morbidity and mortality worldwide, particularly in low- and middle-income countries. Tuberculosis requires a long and intensive course of treatment. Thus, various approaches, including patient empowerment, education and counselling sessions, and involvement of family members and community workers, have been suggested for improving treatment adherence and outcome. The current randomized controlled trial aims to evaluate the effectiveness over usual care of an innovative multicomponent people-centered tuberculosis-care strategy in Armenia. Methods/design Innovative Approach to Tuberculosis care in Armenia is an open-label, stratified cluster randomized controlled trial with two parallel arms. Tuberculosis outpatient centers are the clusters assigned to intervention and control arms. Drug-sensitive tuberculosis patients in the continuation phase of treatment in the intervention arm and their family members participate in a short educational and counselling session to raise their knowledge, decrease tuberculosis-related stigma, and enhance treatment adherence. Patients receive the required medications for one week during the weekly visits to the tuberculosis outpatient centers. Additionally, patients receive daily Short Message Service (SMS) reminders to take their medications and daily phone calls to assure adherence and monitoring of treatment potential side effects. Control-arm patients follow the World Health Organization - recommended directly observed treatment strategy, including daily visits to tuberculosis outpatient centers for drug-intake. The primary outcome is physician-reported treatment outcome. Patients’ knowledge, depression, quality of life, within-family tuberculosis-related stigma, family social support, and self-reported adherence to tuberculosis treatment are secondary outcomes. Discussion Improved adherence and tuberculosis treatment outcomes can strengthen tuberculosis control and thereby forestall tuberculosis and multidrug resistant tuberculosis epidemics. Positive findings on effectiveness of this innovative tuberculosis treatment people-centered approach will support its adoption in countries with similar healthcare and economic profiles. Trial registration ClinicalTrials.gov registration number: NCT02082340. Date of registration: 4 March 2014.
Collapse
Affiliation(s)
- Vahe Khachadourian
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave, Yerevan, 0019, Armenia.
| | - Nune Truzyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave, Yerevan, 0019, Armenia.
| | - Arusyak Harutyunyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave, Yerevan, 0019, Armenia.
| | - Michael E Thompson
- Department of Public Health Sciences, College of Health and Human Services, University of North Carolina at Charlotte, 9201 University City Boulevard, CHHS 427D, Charlotte, NC, 28223-0001, USA.
| | - Tsovinar Harutyunyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave, Yerevan, 0019, Armenia.
| | - Varduhi Petrosyan
- School of Public Health, American University of Armenia, 40 Marshal Baghramyan Ave, Yerevan, 0019, Armenia.
| |
Collapse
|
16
|
Abstract
BACKGROUND Tuberculosis (TB) requires at least six months of treatment. If treatment is incomplete, patients may not be cured and drug resistance may develop. Directly Observed Therapy (DOT) is a specific strategy, endorsed by the World Health Organization, to improve adherence by requiring health workers, community volunteers or family members to observe and record patients taking each dose. OBJECTIVES To evaluate DOT compared to self-administered therapy in people on treatment for active TB or on prophylaxis to prevent active disease. We also compared the effects of different forms of DOT. SEARCH METHODS We searched the following databases up to 13 January 2015: the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL), published in the Cochrane Library; MEDLINE; EMBASE; LILACS and mRCT. We also checked article reference lists and contacted relevant researchers and organizations. SELECTION CRITERIA Randomized controlled trials (RCTs) and quasi-RCTs comparing DOT with routine self-administration of treatment or prophylaxis at home. DATA COLLECTION AND ANALYSIS Two review authors independently assessed risk of bias of each included trial and extracted data. We compared interventions using risk ratios (RR) with 95% confidence intervals (CI). We used a random-effects model if meta-analysis was appropriate but heterogeneity present (I(2) statistic > 50%). We assessed the quality of the evidence using the GRADE approach. MAIN RESULTS Eleven trials including 5662 participants met the inclusion criteria. DOT was performed by a range of people (nurses, community health workers, family members or former TB patients) in a variety of settings (clinic, the patient's home or the home of a community volunteer). DOT versus self-administered Six trials from South Africa, Thailand, Taiwan, Pakistan and Australia compared DOT with self-administered therapy for treatment. Trials included DOT at home by family members, community health workers (who were usually supervised); DOT at home by health staff; and DOT at health facilities. TB cure was low with self-administration across all studies (range 41% to 67%), and direct observation did not substantially improve this (RR 1.08, 95% CI 0.91 to 1.27; five trials, 1645 participants, moderate quality evidence). In a subgroup analysis stratified by the frequency of contact between health services in the self-treatment arm, daily DOT may improve TB cure when compared to self-administered treatment where patients in the self-administered group only visited the clinic every month (RR 1.15, 95% CI 1.06 to 1.25; two trials, 900 participants); but with contact in the control becoming more frequent, this small effect was not apparent (every two weeks: RR 0.96, 95% CI 0.83 to 1.12; one trial, 497 participants; every week: RR 0.90, 95% CI 0.68 to 1.21; two trials, 248 participants).Treatment completion showed a similar pattern, ranging from 59% to 78% in the self-treatment groups, and direct observation did not improve this (RR 1.07, 95% CI 0.96 to 1.19; six trials, 1839 participants, moderate quality evidence). DOT at home versus DOT at health facility In four trials that compared DOT at home by family members, or community health workers, with DOT by health workers at a health facility there was little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.88 to 1.18, four trials, 1556 participants, moderate quality evidence; treatment completion: RR 1.04, 95% CI 0.91 to 1.17, three trials, 1029 participants, moderate quality evidence). DOT by family member versus DOT by community health workerTwo trials compared DOT at home by family members with DOT at home by community health workers. There was also little or no difference in cure or treatment completion (cure: RR 1.02, 95% CI 0.86 to 1.21; two trials, 1493 participants, moderate quality evidence; completion: RR 1.05, 95% CI 0.90 to 1.22; two trials, 1493 participants, low quality evidence). Specific patient categoriesA trial of 300 intravenous drug users in the USA evaluated direct observation with no observation in TB prophylaxis to prevent active disease and showed little difference in treatment completion (RR 1.00, 95% CI 0.88 to 1.13; one trial, 300 participants, low quality evidence). AUTHORS' CONCLUSIONS From the existing trials, DOT did not provide a solution to poor adherence in TB treatment. Given the large resource and cost implications of DOT, policy makers might want to reconsider strategies that depend on direct observation. Other options might take into account financial and logistical barriers to care; approaches that motivate patients and staff; and defaulter follow-up.
Collapse
Affiliation(s)
- Jamlick Karumbi
- KEMRI‐wellcome Trust Research ProgrammeSIRCLE collaborationKenyatta National Hospital Grounds, P.O. Box 43640 ? 00100NairobiKenya
| | - Paul Garner
- Liverpool School of Tropical MedicineDepartment of Clinical SciencesPembroke PlaceLiverpoolMerseysideUKL3 5QA
| | | |
Collapse
|
17
|
Wright CM, Westerkamp L, Korver S, Dobler CC. Community-based directly observed therapy (DOT) versus clinic DOT for tuberculosis: a systematic review and meta-analysis of comparative effectiveness. BMC Infect Dis 2015; 15:210. [PMID: 25948059 PMCID: PMC4436810 DOI: 10.1186/s12879-015-0945-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2014] [Accepted: 04/29/2015] [Indexed: 07/26/2024] Open
Abstract
BACKGROUND Directly observed therapy (DOT), as recommended by the World Health Organization, is used in many countries to deliver tuberculosis (TB) treatment. The effectiveness of community-based (CB DOT) versus clinic DOT has not been adequately assessed to date. We compared TB treatment outcomes of CB DOT (delivered by community health workers or community volunteers), with those achieved through conventional clinic DOT. METHODS We performed a systematic review and meta-analysis of studies before 9 July 2014 comparing treatment outcomes of CB DOT and clinic DOT. The primary outcome was treatment success; the secondary outcome was loss to follow-up. RESULTS Eight studies were included comparing CB DOT to clinic DOT, one a randomised controlled trial. CB DOT outperformed clinic DOT treatment success (pooled odds ratio (OR) of 1.54, 95% confidence interval (CI) 1.01 - 2.36, p = 0.046, I(2) heterogeneity 84%). No statistically significant difference was found between the two DOT modalities for loss to follow-up (pooled OR 0.86, 95% CI 0.48 to 1.55, p = 0.62, I(2) 83%). CONCLUSIONS Based on this systematic review, CB DOT has a higher treatment success compared to clinic DOT. However, as only one study was a randomised controlled trial, the findings have to be interpreted with caution.
Collapse
Affiliation(s)
- Cameron M Wright
- Division of Pharmacy, School of Medicine, University of Tasmania, Hobart, TAS, Australia.
| | | | | | - Claudia C Dobler
- University of Western Sydney, Sydney, NSW, Australia. .,NHMRC Centre of Research Excellence in Tuberculosis Control, University of Sydney, Sydney, NSW, Australia.
| |
Collapse
|
18
|
Arshad A, Salam RA, Lassi ZS, Das JK, Naqvi I, Bhutta ZA. Community based interventions for the prevention and control of tuberculosis. Infect Dis Poverty 2014; 3:27. [PMID: 25136445 PMCID: PMC4136404 DOI: 10.1186/2049-9957-3-27] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2014] [Accepted: 06/06/2014] [Indexed: 01/06/2023] Open
Abstract
In 2012, an estimated 8.6 million people developed tuberculosis (TB) and 1.3 million died from the disease. With its recent resurgence with the human immunodeficiency virus (HIV); TB prevention and management has become further challenging. We systematically evaluated the effectiveness of community based interventions (CBI) for the prevention and treatment of TB and a total of 41 studies were identified for inclusion. Findings suggest that CBI for TB prevention and case detection showed significant increase in TB detection rates (RR: 3.1, 95% CI: 2.92, 3.28) with non-significant impact on TB incidence. CBI for treating patients with active TB showed an overall improvement in treatment success rates (RR: 1.09, 95% CI: 1.07, 1.11) and evidence from a single study suggests significant reduction in relapse rate (RR: 0.26, 95% CI: 0.18, 0.39). The results were consistent for various study design and delivery mechanism. Qualitative synthesis suggests that community based TB treatment delivery through community health workers (CHW) not only improved access and service utilization but also contributed to capacity building and improving the routine TB recording and reporting systems. CBI coupled with the DOTS strategy seem to be an effective approach, however there is a need to evaluate various community-based integrated delivery models for relative effectiveness.
Collapse
Affiliation(s)
- Ahmed Arshad
- Division of Women and Child Health, The Aga Khan University, 74800 Karachi, Pakistan
| | - Rehana A Salam
- Division of Women and Child Health, The Aga Khan University, 74800 Karachi, Pakistan
| | - Zohra S Lassi
- Division of Women and Child Health, The Aga Khan University, 74800 Karachi, Pakistan
| | - Jai K Das
- Division of Women and Child Health, The Aga Khan University, 74800 Karachi, Pakistan
| | - Imama Naqvi
- Division of Women and Child Health, The Aga Khan University, 74800 Karachi, Pakistan
| | - Zulfiqar A Bhutta
- Center of Excellence in Women & Child Health, The Aga Khan University, Karachi, Pakistan ; Center for Global Child Health Hospital for Sick Children, Toronto, Canada
| |
Collapse
|
19
|
|
20
|
Which urban migrants default from tuberculosis treatment in Shanghai, China? PLoS One 2013; 8:e81351. [PMID: 24312292 PMCID: PMC3842957 DOI: 10.1371/journal.pone.0081351] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 10/11/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Migration is a major challenge to tuberculosis (TB) control worldwide. TB treatment requires multiple drugs for at least six months. Some TB patients default before completing their treatment regimen, which can lead to ongoing infectiousness and drug resistance. METHODS We conducted a retrospective analysis of 29,943 active TB cases among urban migrants that were reported between 2000 to 2008 in Shanghai, China. We used logistic regression models to identify factors independently associated with treatment defaults in TB patients among urban migrants during 2005-2008. RESULTS Fifty-two percent of the total TB patients reported in Shanghai during the study period were among urban migrants. Three factors increased the odds of a treatment default: case management using self-administered therapy (OR, 5.84, 95% CI, 3.14-10.86, p<0.0005), being a retreatment case (OR, 1.47, 95% CI, 1.25-1.71, p<0.0005), and age >60 years old (OR, 1.33, 95% CI, 1.05-1.67, p=0.017). The presence of a cavity in the initial chest radiograph decreased the odds for a treatment default (OR, 0.87, 95% CI, 0.77-0.97, p=0.015), as did migration from central China (OR, 0.85, 95% CI, 0.73-0.99, p=0.042), case management by family members (OR, 0.73, 95% CI 0.66-0.81, p<0.0005), and the combination of case detection by a required physical exam and case management by health care staff (OR, 0.64, 95% CI, 0.45-0.93, p=0.019). CONCLUSION Among TB patients who were urban migrants in Shanghai, case management using self-administered therapy was the strongest modifiable risk factor that was independently associated with treatment defaults. Interventions that target retreated TB cases could also reduce treatment defaults among urban migrants. Health departments should develop effective measures to prevent treatment defaults among urban migrants, to ensure completion of therapy among urban migrants who move between cities and provinces, and to improve reporting of treatment outcomes.
Collapse
|
21
|
Moonan PK, Weis SE. Caveat emptor? Meta-analysis of studies comparing self-observed therapy and directly observed therapy for tuberculosis. Clin Infect Dis 2013; 57:1062-3. [PMID: 23811420 PMCID: PMC4589210 DOI: 10.1093/cid/cit431] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Patrick K. Moonan
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
- Department of Internal Medicine, University of North Texas Health Science Center at Fort Worth
| | - Stephen E. Weis
- Department of Internal Medicine, University of North Texas Health Science Center at Fort Worth
| |
Collapse
|
22
|
Pasipanodya JG, Gumbo T. A meta-analysis of self-administered vs directly observed therapy effect on microbiologic failure, relapse, and acquired drug resistance in tuberculosis patients. Clin Infect Dis 2013; 57:21-31. [PMID: 23487389 PMCID: PMC3669525 DOI: 10.1093/cid/cit167] [Citation(s) in RCA: 81] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Preclinical studies and Monte Carlo simulations have suggested that there is a relatively limited role of adherence in acquired drug resistance (ADR) and that very high levels of nonadherence are needed for therapy failure. We evaluated the superiority of directly observed therapy (DOT) for tuberculosis patients vs self-administered therapy (SAT) in decreasing ADR, microbiologic failure, and relapse in meta-analyses. METHODS Prospective studies performed between 1965 and 2012 in which adult patients with microbiologically proven pulmonary Mycobacterium tuberculosis were separately assigned to either DOT or SAT as part of short-course chemotherapy were chosen. Endpoints were microbiologic failure, relapse, and ADR in patients on either DOT or SAT. RESULTS Ten studies, 5 randomized and 5 observational, met selection criteria: 8774 patients were allocated to DOT and 3708 were allocated to SAT. For DOT vs SAT, the pooled risk difference for microbiologic failure was .0 (95% confidence interval [CI], -.01 to .01), for relapse .01 (95% CI, -.03 to .06), and for ADR 0.0 (95% CI, -0.01 to 0.01). The incidence rates for DOT vs SAT were 1.5% (95% CI, 1.3%-1.8%) vs 1.7% (95% CI, 1.2%-2.2%) for microbiologic failure, 3.7% (95% CI, 0.7%-17.6%) vs 2.3% (95% CI, 0.7%-7.2%) for relapse, and 1.5% (95% CI, 0.2%-9.90%) vs 0.9% (95% CI, 0.4%-2.3%) for ADR, respectively. There was no evidence of publication bias. CONCLUSIONS DOT was not significantly better than SAT in preventing microbiologic failure, relapse, or ADR, in evidence-based medicine. Resources should be shifted to identify other causes of poor microbiologic outcomes.
Collapse
Affiliation(s)
- Jotam G Pasipanodya
- Office of Global Health and Department of Medicine, The University of Texas Southwestern Medical Center, Dallas, TX 75390-8507, USA
| | | |
Collapse
|
23
|
Hunchangsith P, Barendregt JJ, Vos T, Bertram M. Cost-effectiveness of various tuberculosis control strategies in Thailand. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2012; 15:S50-S55. [PMID: 22265067 DOI: 10.1016/j.jval.2011.11.006] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of different tuberculosis control strategies in Thailand. METHODS Different tuberculosis control strategies, which included health-worker, community-member, and family-member directly observed treatment (DOT) and a mobile phone "contact-reminder" system, were compared with self-administered treatment (SAT). Cost-effectiveness analysis was undertaken by using a decision tree model. Costs (2005 international dollars [I$]) were calculated on the basis of treatment periods and treatment outcomes. Health outcomes were estimated over the lifetime of smear-positive pulmonary tuberculosis patients in disability-adjusted life years (DALYs) averted on the basis of Thai evidence on the efficacy of the selected strategies. RESULTS Cost-effectiveness results indicate no preference for any strategy. The uncertainty ranges surrounding the health benefits were wide, including a sizeable probability that SAT could lead to more health gain than DOT strategies. The health gain for family-member DOT was 9400 DALYs (95% uncertainty interval -7200 to 25,000), for community-member DOT was 13,000 DALYs (95% uncertainty interval -21,000 to 37,000), and for health-worker DOT was 7900 DALYs (95% uncertainty interval -50,000 to 43,000). There were cost savings (from less multi-drug resistant tuberculosis treatment) associated with family-member DOT (-I$9 million [95% uncertainty interval -I$12 million to -I$5 million]) because the trial treatment failure rate was significantly lower than that for SAT. The mobile phone reminder system was not cost-effective, because the mortality rate associated with it was much higher than that associated with other treatment strategies. CONCLUSIONS Because of the large uncertainty intervals around health gain for DOT strategies, it remains inconclusive whether DOT strategies are more cost-effective than SAT. It is evident, however, that family-member DOT is a cost-saving intervention.
Collapse
Affiliation(s)
- Pojjana Hunchangsith
- Institute for Population and Social Research, Mahidol University, Salaya, Phutthamonthon, Nakhon Pathom, Thailand.
| | | | | | | |
Collapse
|
24
|
Suwannakeeree W, Picheansathian W. Strategies to Promote Adherence to Treatment by Pulmonary Tuberculosis Patients: A systematic review. ACTA ACUST UNITED AC 2012; 10:615-678. [PMID: 27820545 DOI: 10.11124/jbisrir-2012-64] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND Successful tuberculosis control depends upon effective treatment of patients which requires adherence throughout the full course of medical treatment. Poor adherence to treatment is a major obstacle in the global fight against tuberculosis. Therefore, interventions that promote adherence to the tuberculosis treatment regimen should be implemented. OBJECTIVE To review and synthesise the best available research evidence that investigates the effectiveness of strategies to promote adherence to treatment by patients with pulmonary tuberculosis. INCLUSION CRITERIA This review considered all studies that included adults aged ≥ 15 years diagnosed with smear positive and smear negative pulmonary tuberculosis (regardless of HIV infection) in community settings who had never received anti-tuberculosis drugs, or had taken them for less than one month.Intervention included strategies to promote adherence to tuberculosis treatment by patients with pulmonary tuberculosis.Outcomes included measures for treatment completion rate, cure rate, and success rate.The review primarily considered any randomised controlled trials that explored different strategies to promote adherence to tuberculosis treatment of patients with pulmonary tuberculosis but also included quasi-experimental studies. SEARCH STRATEGY The search sought to find published and unpublished studies. The time period of the search covered articles published from 1990 to 2010 in English and Thai language. The database searches included: CINAHL, EMBASE, Cochrane Library, PubMed, Science Direct, Current Content Connect, Thai Nursing Research Database, Thai thesis database, Digital Library of Thailand Research Fund, Research of National Research Council of Thailand, and Database of Office of Higher Education Commission. Studies were additionally identified from reference lists of all studies retrieved. METHODOLOGICAL QUALITY Studies selected for retrieval were assessed by two independent reviewers for methodological quality using a standardised critical appraisal tool from the Joanna Briggs Institute. DATA COLLECTION Data extraction was performed using a standardised data extraction form from the Joanna Briggs Institute. DATA SYNTHESIS The quantitative study results were pooled in statistical meta-analysis using the Review Manager software (RevMan 5.0) and summarised in narrative form where statistical pooling was not appropriate or possible. RESULTS This systematic review included ten randomised controlled trials and eight quasi-experimental studies that report on the effectiveness of a number of specific interventions to improve adherence to tuberculosis treatment among newly diagnosed pulmonary tuberculosis patients. These interventions included Directly Observed Treatment coupled with alternative patient supervision options, case management with Directly Observed Treatment, Short-course, the intensive triad-model program, and an intervention package consisting of improving patients' counselling and communication, decentralisation of treatment, patient choice of Directly Observed Treatment supporter, and reinforcement of supervision activities. CONCLUSION The interventions that had the best outcomes for treatment adherence among newly diagnosed pulmonary tuberculosis patients were Directly Observed Treatment and Directly Observed Treatment, Short-course combined with case management, improving counselling and communication and decentralisation of treatment. These interventions should be implemented by health care providers and tailored to local contexts and circumstances, where appropriate.It would be beneficial to shift the treatment of all pulmonary tuberculosis patients to facilities within the primary health care structure. Directly Observed Treatment coupled with alternative patient supervision options, formalised educational programs and a tuberculosis case management team should be used to improve adherence to tuberculosis treatment among newly diagnosed pulmonary tuberculosis patients.Our review shows the need for further large-scale on adherence to treatment by newly diagnosed pulmonary tuberculosis patients. Factors that determine the usefulness of Directly Observed Treatment in various settings require further study. Further strategies, especially those that are feasible in developing countries or countries with limited resources, should be evaluated in randomised controlled trials before being introduced into routine practice.
Collapse
Affiliation(s)
- Wongduan Suwannakeeree
- 1. The Thailand Centre for Evidence-based Nursing and Midwifery: an affiliate centre of the Joanna Briggs Institute
| | | |
Collapse
|
25
|
Prado TND, Wada N, Guidoni LM, Golub JE, Dietze R, Maciel ELN. Cost-effectiveness of community health worker versus home-based guardians for directly observed treatment of tuberculosis in Vitória, Espírito Santo State, Brazil. CAD SAUDE PUBLICA 2011; 27:944-52. [PMID: 21655845 DOI: 10.1590/s0102-311x2011000500012] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Accepted: 02/28/2011] [Indexed: 11/22/2022] Open
Abstract
The objective of this study was to compare the costs and outcomes associated with guardian-supervised directly observed treatment relative to the standard of care Directly Observed Therapy, Short Course (DOTS) provided by community health workers (CHW). New cases of culture-positive pulmonary tuberculosis (TB) treated in Vitória, Espírito Santo State, Brazil, between January 2005 and December 2006 were interviewed and chose their preferred treatment strategy. Costs incurred by providers and patients (and patients' families) were estimated, and cost-effectiveness was assessed by comparing costs per successfully treated patient. 130 patients were included in the study; 84 chose CHW-supervised DOTS and 46 chose guardian-supervised DOTS. 45 of 46 (98%) patients treated with guardian-supervised DOTS were cured or completed treatment compared to 70/84 (83%) of the CHW-supervised patients (p = 0.01). Logistic regression showed only the strategy of supervision to be a significant association with treatment outcome, with guardian-supervised care strongly protective. Cost per patient treated with guardian-supervised DOTS was US$398, compared to US$548 for CHW-supervised DOTS. The guardian-supervised DOTS is an attractive option to complement CHW-supervised DOTS.
Collapse
|
26
|
Kangovi S, Mukherjee J, Bohmer R, Fitzmaurice G. A classification and meta-analysis of community-based directly observed therapy programs for tuberculosis treatment in developing countries. J Community Health 2011; 34:506-13. [PMID: 19760493 DOI: 10.1007/s10900-009-9174-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
In many developing countries, Directly Observed Therapy (DOT) for tuberculosis has been undertaken mainly in the clinic setting. However, clinic-based DOT may create a high patient load in already overburdened health facilities and increase barriers to care by requiring patients to travel to clinic frequently for therapy. Community-based DOT (CBDOT) may overcome some of these problems. This aims of this review are (a) to describe the main features of CBDOT programs, and (b) to compare features and outcomes of CBDOT programs that do and do not offer financial reward for CBDOT providers. Ten major features define CBDOT program structure and function. Programs that paid their CBDOT providers tended to differ from unpaid programs based on all of these features. CBDOT programs in which providers received financial reward had success rates of 85.7 versus 77.6% in programs without financial reward for providers. This difference was not statistically significant. CBDOT programs fall into two major archetypes, which differ in their structure and possibly in their outcomes.
Collapse
Affiliation(s)
- Shreya Kangovi
- Division of Combined Internal Medicine and Pediatrics, Hospital of the University of Pennsylvania/Children's Hospital of Philadelphia, Philadelphia, PA 19104, USA.
| | | | | | | |
Collapse
|
27
|
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. Braz J Infect Dis 2010. [DOI: 10.1016/s1413-8670(10)70117-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
|
28
|
Horne DJ, Hubbard R, Narita M, Exarchos A, Park DR, Goss CH. Factors associated with mortality in patients with tuberculosis. BMC Infect Dis 2010; 10:258. [PMID: 20799975 PMCID: PMC2936899 DOI: 10.1186/1471-2334-10-258] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 08/27/2010] [Indexed: 11/10/2022] Open
Abstract
Background Known risk factors for death following a diagnosis of tuberculosis may not be applicable to current U.S. cases. We evaluated the factors associated with all-cause mortality in patients with tuberculosis in Washington State. Methods Using data from the Tuberculosis Information Management System of Washington State, we conducted a cohort study of all residents diagnosed with tuberculosis from 1993 through 2005. Death from any cause was ascertained through the Washington State Death Certificate Data Files. Proportional hazards models were used to estimate the independent effect on all-cause mortality of demographic, clinical, and behavioral characteristics. Results During a median follow-up of 6 years in 3451 patients treated for tuberculosis, there were 417 deaths. Mortality was independently associated with increasing age, male gender, HIV-coinfection, and U.S. birth. Within 1 year of tuberculosis diagnosis, treatment by a private provider and the use of directly observed therapy were also independently associated with increased mortality. In addition, an interaction term of private provider times directly observed therapy was also significantly associated with mortality. Conclusions We identified factors independently associated with increased all-cause mortality following a diagnosis of tuberculosis. The associations between mortality and provider type should be evaluated with more thorough adjustment for severity of illness, but suggest important directions for future research.
Collapse
Affiliation(s)
- David J Horne
- Department of Medicine, University of Washington School of Medicine, Seattle, WA, USA.
| | | | | | | | | | | |
Collapse
|
29
|
Lewin S, Munabi‐Babigumira S, Glenton C, Daniels K, Bosch‐Capblanch X, van Wyk BE, Odgaard‐Jensen J, Johansen M, Aja GN, Zwarenstein M, Scheel IB. Lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. Cochrane Database Syst Rev 2010; 2010:CD004015. [PMID: 20238326 PMCID: PMC6485809 DOI: 10.1002/14651858.cd004015.pub3] [Citation(s) in RCA: 536] [Impact Index Per Article: 38.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
BACKGROUND Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. Little is known, however, about the effectiveness of LHW interventions. OBJECTIVES To assess the effects of LHW interventions in primary and community health care on maternal and child health and the management of infectious diseases. SEARCH STRATEGY For the current version of this review we searched The Cochrane Central Register of Controlled Trials (including citations uploaded from the EPOC and the CCRG registers) (The Cochrane Library 2009, Issue 1 Online) (searched 18 February 2009); MEDLINE, Ovid (1950 to February Week 1 2009) (searched 17 February 2009); MEDLINE In-Process & Other Non-Indexed Citations, Ovid (February 13 2009) (searched 17 February 2009); EMBASE, Ovid (1980 to 2009 Week 05) (searched 18 February 2009); AMED, Ovid (1985 to February 2009) (searched 19 February 2009); British Nursing Index and Archive, Ovid (1985 to February 2009) (searched 17 February 2009); CINAHL, Ebsco 1981 to present (searched 07 February 2010); POPLINE (searched 25 February 2009); WHOLIS (searched 16 April 2009); Science Citation Index and Social Sciences Citation Index (ISI Web of Science) (1975 to present) (searched 10 August 2006 and 10 February 2010). We also searched the reference lists of all included papers and relevant reviews, and contacted study authors and researchers in the field for additional papers. SELECTION CRITERIA Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to improve maternal or child health or the management of infectious diseases. A 'lay health worker' was defined as any health worker carrying out functions related to healthcare delivery, trained in some way in the context of the intervention, and having no formal professional or paraprofessional certificate or tertiary education degree. There were no restrictions on care recipients. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data using a standard form and assessed risk of bias. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the study results were combined and an overall estimate of effect obtained. MAIN RESULTS Eighty-two studies met the inclusion criteria. These showed considerable diversity in the targeted health issue and the aims, content, and outcomes of interventions. The majority were conducted in high income countries (n = 55) but many of these focused on low income and minority populations. The diversity of included studies limited meta-analysis to outcomes for four study groups. These analyses found evidence of moderate quality of the effectiveness of LHWs in promoting immunisation childhood uptake (RR 1.22, 95% CI 1.10 to 1.37; P = 0.0004); promoting initiation of breastfeeding (RR = 1.36, 95% CI 1.14 to 1.61; P < 0.00001), any breastfeeding (RR 1.24, 95% CI 1.10 to 1.39; P = 0.0004), and exclusive breastfeeding (RR 2.78, 95% CI 1.74 to 4.44; P <0.0001); and improving pulmonary TB cure rates (RR 1.22 (95% CI 1.13 to 1.31) P <0.0001), when compared to usual care. There was moderate quality evidence that LHW support had little or no effect on TB preventive treatment completion (RR 1.00, 95% CI 0.92 to 1.09; P = 0.99). There was also low quality evidence that LHWs may reduce child morbidity (RR 0.86, 95% CI 0.75 to 0.99; P = 0.03) and child (RR 0.75, 95% CI 0.55 to 1.03; P = 0.07) and neonatal (RR 0.76, 95% CI 0.57 to 1.02; P = 0.07) mortality, and increase the likelihood of seeking care for childhood illness (RR 1.33, 95% CI 0.86 to 2.05; P = 0.20). For other health issues, the evidence is insufficient to draw conclusions regarding effectiveness, or to enable the identification of specific LHW training or intervention strategies likely to be most effective. AUTHORS' CONCLUSIONS LHWs provide promising benefits in promoting immunisation uptake and breastfeeding, improving TB treatment outcomes, and reducing child morbidity and mortality when compared to usual care. For other health issues, evidence is insufficient to draw conclusions about the effects of LHWs.
Collapse
Affiliation(s)
- Simon Lewin
- Norwegian Knowledge Centre for the Health ServicesPreventive and International Health Care UnitBox 7004 St OlavsplassOsloNorwayN‐0130
| | - Susan Munabi‐Babigumira
- Norwegian Knowledge Centre for the Health ServicesPreventive and International Health Care UnitBox 7004 St OlavsplassOsloNorwayN‐0130
| | - Claire Glenton
- SINTEF Health ResearchDepartment of Global Health and WelfareP.O. Box 124 BlindernOsloNorwayN‐0314
| | - Karen Daniels
- Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Xavier Bosch‐Capblanch
- Swiss Tropical and Public Health InstituteSwiss Centre for International HealthSocinstrasse 57BaselSwitzerland4002
| | - Brian E van Wyk
- University of the Western CapeSchool of Public HealthModderdam RoadBellvilleSouth Africa7535
| | - Jan Odgaard‐Jensen
- Norwegian Knowledge Centre for the Health ServicesPO Box 7004, St. Olavs PlassOsloNorwayN‐0130
| | - Marit Johansen
- Norwegian Knowledge Centre for the Health ServicesPO Box 7004, St. Olavs PlassOsloNorwayN‐0130
| | - Godwin N Aja
- Babcock UniversityDepartment of Health SciencesIlishan‐RemoIkeja‐LagosSouth WestNigeriaPMB 21244
| | - Merrick Zwarenstein
- Sunnybrook Health Sciences CentreCombined Health Services Sciences2075 Bayview Ave., Room G1 06TorontoONCanadaM4N 3M5
| | - Inger B Scheel
- SINTEF Health ResearchDepartment of Global Health and WelfareP.O. Box 124 BlindernOsloNorwayN‐0314
| | | |
Collapse
|
30
|
Anuwatnonthakate A, Limsomboon P, Nateniyom S, Wattanaamornkiat W, Komsakorn S, Moolphate S, Chiengsorn N, Kaewsa-ard S, Sombat P, Siangphoe U, Mock PA, Varma JK. Directly observed therapy and improved tuberculosis treatment outcomes in Thailand. PLoS One 2008; 3:e3089. [PMID: 18769479 PMCID: PMC2518105 DOI: 10.1371/journal.pone.0003089] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2008] [Accepted: 08/05/2008] [Indexed: 12/22/2022] Open
Abstract
Background The 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 Findings We 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. Conclusions In 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.
Collapse
Affiliation(s)
| | | | | | | | | | | | | | | | - Potjaman Sombat
- Thailand MOPH – U.S. CDC Collaboration, Nonthaburi, Thailand
| | | | - Philip A. Mock
- Thailand MOPH – U.S. CDC Collaboration, Nonthaburi, Thailand
| | - Jay K. Varma
- Thailand MOPH – U.S. CDC Collaboration, Nonthaburi, Thailand
- U.S. Centers for Disease Control and Prevention, Atlanta, Georgia, United States of America
- * E-mail:
| |
Collapse
|
31
|
Hsieh CJ, Lin LC, Kuo BIT, Chiang CH, Su WJ, Shih JF. Exploring the efficacy of a case management model using DOTS in the adherence of patients with pulmonary tuberculosis. J Clin Nurs 2008; 17:869-75. [PMID: 17850292 DOI: 10.1111/j.1365-2702.2006.01924.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM To explore the efficacy of hospitals using case management with Directly Observed Treatment - Short course (DOTS) to monitor the adherence of patients with pulmonary tuberculosis in Taiwan. BACKGROUND Non-adherence to anti-tuberculosis chemotherapy is the major problem in treating patients with tuberculosis. Community-based case management coupled with DOTS has been applied to patients with tuberculosis and has resulted in good results in some countries. Taiwan has a high incidence of tuberculosis, and although it has implemented DOTS, the expected increased efficacy has not yet been realized. DESIGN AND METHODS The study used a quasi-experimental design. Using age and gender as matching factors, 96 subjects were randomly assigned to one of three groups in 2002-2003. Experimental group I was to receive DOTS case management comprising in-hospital education, direct daily observation in the first two months and one home visit per week. Experimental group II received traditional case management comprising in-hospital education and one home visit per month. The control group did not receive any intervention. RESULTS The adherence, the rate of completion, the treatment success, sputum conversion and chest X-ray improvement of experimental group I were significantly improved compared with experimental group II and the control group. The completion rate in experimental group I was higher than the general rate for Taiwan during the past six years and the treatment success rate met the standards of the World Health Organization. CONCLUSION Hospitals using case management with DOTS can improve the adherence of tuberculosis patients and the control of tuberculosis-epidemic situations. Relevance to clinical practice. In a rapidly changing healthcare environment, clinical nurses can make a significant contribution to healthcare delivery for tuberculosis patients. This study has provided further insight into the implementation of hospital-to-community level case management using DOTS by nurses.
Collapse
|
32
|
Abstract
Multidrug-resistant tuberculosis (MDR-TB) with bacillary resistance to at least isoniazid and rifampicin in vitro is a worldwide phenomenon. Hot spots of the disease are found scattered in different continents. Prevention of its development through good tuberculosis control programmes operating under the directly observed therapy, short-course (DOTS) strategy is of paramount importance. However, with established MDR-TB, treatment with alternative and specific chemotherapy is necessary to achieve a beneficial outcome. Such an approach on a programme basis is currently known as the 'DOTS-Plus' strategy. Second-line (reserve) drugs utilized in the treatment of MDR-TB are generally less potent and more toxic, perhaps with the notable exceptions of some fluoroquinolones and injectable agents. Surgery has a distinct adjunctive role for the management of MDR-TB in selected patients. The emergence of extensively drug-resistant tuberculosis (XDR-TB), that is, MDR-TB with additional bacillary resistance to the fluoroquinolones and injectables, has provided a very alarming challenge to global health, as the disease currently has a low cure rate and high mortality. In order to combat XDR-TB, strengthening of DOTS and DOTS-Plus programmes is mandatory, especially in the face of surging HIV infection. Furthermore, more attention needs to be focused on developing new drugs with potent bactericidal and sterilizing activities and low side-effects, and above all, drugs that are affordable for communities worldwide.
Collapse
Affiliation(s)
- Wing Wai Yew
- Tuberculosis and Chest Unit, Grantham Hospital, Hong Kong, China.
| | | |
Collapse
|
33
|
Dobler CC, Marks GB, Simpson SE, Crawford ABH. Recurrence of tuberculosis at a Sydney chest clinic between 1994 and 2006: reactivation or reinfection? Med J Aust 2008; 188:153-5. [DOI: 10.5694/j.1326-5377.2008.tb01558.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Accepted: 11/22/2007] [Indexed: 11/17/2022]
Affiliation(s)
- Claudia C Dobler
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, NSW
| | - Guy B Marks
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, NSW
| | - Sheila E Simpson
- Department of Respiratory Medicine, Liverpool Hospital, Sydney, NSW
| | | |
Collapse
|
34
|
Cardozo Gonzáles RI, Monroe AA, Arcêncio RA, Oliveira MFD, Ruffino Netto A, Villa TCS. Performance indicators of DOT at home for tuberculosis control in a large city, SP, Brazil. Rev Lat Am Enfermagem 2008; 16:95-100. [DOI: 10.1590/s0104-11692008000100015] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Accepted: 11/12/2007] [Indexed: 11/22/2022] Open
Abstract
The study had the objective to analyze the performance of the health services that implement the Directly Observed Therapy at home for tuberculosis control. This study analyzed four Tuberculosis Control Programs, referred to as A, B, C, and D, using the following indicators: Resource use; Performance quickness; Monitoring medication administration; Time spent per home visit. Data were collected during visits to 47 patients receiving DOT at home. Resource use was higher in program B (91.3%); program A showed quicker performance (5.8) and more visits during which medication administration was monitored (77.4%); program C had the longest time spent per home visit (14.7 minutes) and program A the shortest (10.4 minutes). The best or worst performance numerically expresses how resources are being used and whether the observation of medication intake is being achieved.
Collapse
|
35
|
Abstract
BACKGROUND For tuberculosis treatment, policies have been introduced to encourage adherence to treatment regimens. One such policy is directly observed therapy (DOT), which involves people directly observing patients taking their antituberculous drugs. OBJECTIVES To compare DOT with self administration of treatment or different DOT options for people requiring treatment for clinically active tuberculosis or prevention of active disease. SEARCH STRATEGY In May 2007, we searched the Cochrane Infectious Diseases Group Specialized Register, CENTRAL (The Cochrane Library 2007, Issue 2), MEDLINE, EMBASE, LILACS, and mRCT. We also checked article reference lists and contacted relevant researchers and organizations. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing a health worker, family member, or community volunteer routinely observing people taking antituberculous drugs compared with routine self administration of treatment at home. We include people requiring treatment for clinically active tuberculosis or medication for preventing active disease. DATA COLLECTION AND ANALYSIS Both authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) with 95% confidence intervals (CI) and the fixed-effect model when there was no statistically significant heterogeneity (chi square P > 0.1). Trials of drug users were analysed separately. MAIN RESULTS Eleven trials with 5609 participants met the inclusion criteria. No statistically significant difference was detected between DOT and self administration in terms of cure (RR 1.02, 95% CI 0.86 to 1.21, random-effects model; 1603 participants, 4 trials), with similar results for cure plus completion of treatment. When stratified by location, DOT provided at home compared with DOT provided at clinic suggests a possible small advantage with home-based DOT for cure (RR 1.10, 95% CI 1.02 to 1.18; 1365 participants, 3 trials). There was no significant difference detected in clinical outcomes between DOT at a clinic versus by a family member or community health worker (2 trials), or for DOT provided by a family member versus a community health worker (1326 participants, 1 trial). Two small trials of tuberculosis prophylaxis in intravenous drugs users found no statistically significant difference between DOT and self administration (199 participants, 1 trial) or a choice of location for DOT for completion of treatment (108 participants, 1 trial). AUTHORS' CONCLUSIONS The results of randomized controlled trials conducted in low-, middle-, and high-income countries provide no assurance that DOT compared with self administration of treatment has any quantitatively important effect on cure or treatment completion in people receiving treatment for tuberculosis.
Collapse
Affiliation(s)
- J Volmink
- Stellenbosch University, Faculty of Health Sciences, PO Box 19063, Tygerberg, Cape Town, South Africa, 7505.
| | | |
Collapse
|
36
|
Domínguez-Castellano A, Del Arco A, Canueto-Quintero J, Rivero-Román A, Kindelán JM, Creagh R, Díez-García F. Guía de práctica clínica de la Sociedad Andaluza de Enfermedades Infecciosas (SAEI) sobre el tratamiento de la tuberculosis. Enferm Infecc Microbiol Clin 2007; 25:519-34. [PMID: 17915111 DOI: 10.1157/13109989] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The therapeutic scheme for initial pulmonary tuberculosis recommended by the SAEI is as follows: Initial phase, isoniazid, rifampin and pyrazinamide given daily for 2 months. In HIV(+) patients and immigrants from areas with a rate of primary resistance to isoniazid > 4%, ethambutol should be added until susceptibility studies are available. Second phase (continuation phase): rifampin and isoniazid, given daily or intermittently for 4 months in the general population. HIV(+) patients (< or = 200 CD4) and culture-positive patients after 2 months of treatment should receive a 7-month continuation phase. A 6-month regimen is recommended for extrapulmonary tuberculosis, with the exception of tuberculous meningitis, which should be treated for a minimum of 12 months and bone/joint tuberculosis, treated for a minimum of 9 months. Treatment regimens for multidrug resistant tuberculosis are based on expert opinion. These would include a combination of still-useful first-line drugs, injectable agents, and alternative agents, such as quinolones. Patients who present a special risk of transmitting the disease or of non-adherence should be treated with directly observed therapy.
Collapse
|
37
|
Noyes J, Popay J. Directly observed therapy and tuberculosis: how can a systematic review of qualitative research contribute to improving services? A qualitative meta-synthesis. J Adv Nurs 2007; 57:227-43. [PMID: 17233644 DOI: 10.1111/j.1365-2648.2006.04092.x] [Citation(s) in RCA: 212] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIM This paper reports the findings from a qualitative meta-synthesis concerning people with, or at risk of, tuberculosis, service providers and policymakers and their experiences and perceptions of tuberculosis and treatment. BACKGROUND Directly observed therapy is part of a package of interventions to improve tuberculosis treatment and adherence. A Cochrane systematic review of trials showed an absence of evidence for or against directly observed therapy compared with people treating themselves. METHOD Qualitative systematic review methods were used to search, screen, appraise and extract data thematic analysis was used to synthesize data from 1990 to 2002, and an update of literature to December 2005. Two questions were addressed: 'What does qualitative research tell us about the facilitators and barriers to accessing and complying with tuberculosis treatment?' and 'What does qualitative research tell us about the diverse results and effect sizes of the randomized controlled trials included in the Cochrane review?' Findings help explain the diverse trial results in a Cochrane systematic review of directly observed therapy and tuberculosis and consider implications for research, policy and practice. FINDINGS Five themes emerged from the 1990 to 2002 synthesis: socio-economic circumstances, material resources and individual agency; explanatory models and knowledge systems in relation to tuberculosis and its treatment; the experience of stigma and public discourses around tuberculosis; sanctions, incentives and support, and the social organization and social relationships of care. Two additional themes emerged from the 2005 update. CONCLUSION The qualitative meta-synthesis improved the relevance and scope of the Cochrane review of trials. The findings make a major contribution to the development of theory concerning global WHO-branded disease control and the practicality of local delivery to people.
Collapse
Affiliation(s)
- Jane Noyes
- Cochrane Qualitative Research Methods Group University of Wales, Bangor, UK.
| | | |
Collapse
|
38
|
Khan K, Campbell A, Wallington T, Gardam M. The impact of physician training and experience on the survival of patients with active tuberculosis. CMAJ 2006; 175:749-53. [PMID: 17001055 PMCID: PMC1569931 DOI: 10.1503/cmaj.060124] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Physician training and experience may be important factors influencing treatment outcomes of patients with tuberculosis. We conducted an analysis to evaluate physician and patient characteristics and their association with the rate of death among tuberculosis patients. METHODS We retrospectively reviewed all reported cases of active tuberculosis in Toronto between July 1, 1999, and June 30, 2002. We obtained extensive clinical data on cases as well as information on the training and clinical experience of treating physicians. We subsequently identified factors associated with patient mortality in a survival analysis. RESULTS In a multivariable Cox regression analysis involving 1154 patients, factors associated with all-cause mortality included patient age (in years) (hazard ratio [HR] 1.05, 95% confidence interval [CI] 1.04-1.07, p < 0.001), use of directly observed therapy (HR 0.22, CI 0.13-0.39, p < 0.001), receipt of care from a physician experienced with tuberculosis (per case managed per year) (HR 0.98, CI 0.97-0.99; p = 0.01) and admission to hospital during the course of treatment (HR 15.44, CI 7.06-33.76, p < 0.001). Factors that were not associated with patient survival included whether the physician graduated from a foreign medical school, the physician's medical specialty and the number of years in clinical practice. INTERPRETATION Physician experience with tuberculosis and use of directly observed therapy positively influenced the survival of patients with active tuberculosis in our setting.
Collapse
Affiliation(s)
- Kamran Khan
- Centre for Research on Inner City Health and the Department of Medicine, Division of Infectious Diseases, St. Michael's Hospital, University of Toronto, Toronto, Ont
| | | | | | | |
Collapse
|
39
|
Machouf N, Lalonde RG. [Directly observed therapy (DOT): from tuberculosis to HIV]. Rev Epidemiol Sante Publique 2006; 54:73-89. [PMID: 16609639 DOI: 10.1016/s0398-7620(06)76696-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Combination antiretroviral therapy, which is the standard of care since 1996, has been demonstrated to be very effective in suppressing plasma viral load in patients infected with HIV. Optimal benefit from antiretroviral drugs, however, is obtained when the patient adheres strictly to the rigorous treatment regimen. For some patients it is difficult to obtain good adherence to antiretroviral regimens. In response to these concerns, different strategies, such as directly observed therapy, have been proposed to attempt to improve adherence to antiretroviral treatment. Directly observed therapy is a strategy that has its roots in the treatment of tuberculosis and it consists essentially of taking the medication in the presence of a health care provider or another designated person. This strategy has been recently tried in the treatment of HIV but its efficacy remains unknown. METHOD A Medline and Medscape search was performed to review all pertinent publications on the use of directly observed therapy in HIV infection. RESULTS Twenty-five papers published between 1996 and 2004 were selected. Almost all the studies were performed in industrialized countries in North America and Europe. The majority of the studies are retrospective, six of them comparing at least two strategies (directly observed therapy vs standard of care). Only one randomized trial has been found. The patients involved in the studies are intravenous drug users or particularly non-adherent patients. Almost all studies show a better rate of adherence or a better control of the viremia in patients on directly observed therapy. CONCLUSIONS The directly observed therapy seems to be a valuable and feasible way to raise the adherence rate in HIV patients with a problem of non-adherence to antiretroviral treatments. Clinical trials are needed to evaluate the efficacy of this strategy to raise the adherence rate among patients who need additional support to take their antiretrovirals.
Collapse
Affiliation(s)
- N Machouf
- Centre Hospitalier Universitaire McGill, Université McGill, Montréal, Québec, Canada.
| | | |
Collapse
|
40
|
Abstract
BACKGROUND People with tuberculosis require treatment for at least six months. As many patients do not complete their treatment, policies have been introduced to encourage adherence to treatment regimens. One such policy is directly observed therapy, which involves people directly observing patients taking their antituberculous drugs. OBJECTIVES To compare directly observed therapy (DOT) with self administration of treatment in people requiring treatment for clinically active tuberculosis or prevention of active disease. SEARCH STRATEGY We searched the Cochrane Infectious Diseases Group Specialized Register (November 2005), CENTRAL (The Cochrane Library 2005, Issue 4), MEDLINE (1966 to November 2005), EMBASE (1974 to November 2005), LILACS (1982 to November 2005), and reference lists of articles. We also contacted researchers and organizations working in the field. SELECTION CRITERIA Randomized and quasi-randomized controlled trials comparing a health worker, family member, or community volunteer routinely observing people taking antituberculous drugs compared with routine self administration of treatment at home. We include patients requiring treatment for clinically active tuberculosis or medication for preventing active disease. DATA COLLECTION AND ANALYSIS Both authors independently assessed trial methodological quality and extracted data. Data were analysed using relative risks (RR) with 95% confidence intervals (CI) and the fixed-effect model when there was no statistically significant heterogeneity (chi square P > 0.1). Trials of drug users were analysed separately. MAIN RESULTS Ten trials with 3985 participants met the inclusion criteria. There was no statistically significant difference between DOT and self administration of treatment for the number of people cured (RR 1.02, 95% CI 0.86 to 1.21, random-effects model; 1603 participants, 4 trials) or who were cured or completed treatment (RR 1.06, 95% CI 1.00 to 1.13; 1603 participants, 4 trials). Stratifying the location of the DOT by home or at a clinic suggests a possible small effect with home-based DOT (RR 1.10, 95% CI 1.02 to 1.18; 1365 participants, 3 trials). Two small trials of tuberculosis prophylaxis in intravenous drugs users found no statistically significant difference between DOT and self administration (199 participants, 1 trial), or a choice of location for DOT for completion of treatment (108 participants, 1 trial). AUTHORS' CONCLUSIONS The results of randomized controlled trials conducted in low-, middle-, and high-income countries provide no assurance that directly observed therapy compared with self-administered treatment has any quantitatively important effect on cure or treatment completion in people receiving treatment for tuberculosis.
Collapse
Affiliation(s)
- J Volmink
- Medical Research Council, South African Cochrane Centre, PO Box 19070, Tygerberg, South Africa, 7505.
| | | |
Collapse
|
41
|
Pozniak AL, Miller RF, Lipman MCI, Freedman AR, Ormerod LP, Johnson MA, Collins S, Lucas SB. BHIVA treatment guidelines for tuberculosis (TB)/HIV infection 2005. HIV Med 2005; 6 Suppl 2:62-83. [PMID: 16011537 DOI: 10.1111/j.1468-1293.2005.00293.x] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- A L Pozniak
- Chelsea and Westminster NHS Healthcare Trust, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
42
|
Wandwalo E, Makundi E, Hasler T, Morkve O. Acceptability of community and health facility-based directly observed treatment of tuberculosis in Tanzanian urban setting. Health Policy 2005; 78:284-94. [PMID: 16352370 DOI: 10.1016/j.healthpol.2005.11.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2005] [Accepted: 11/07/2005] [Indexed: 11/19/2022]
Abstract
SETTING An urban district in Dar es Salaam, Tanzania. OBJECTIVE To assess the acceptability of community and health facility-based direct observation of treatment (DOT) of tuberculosis (TB) patients in Temeke district. DESIGN Both quantitative and qualitative study methodologies were used. Eight focus group discussions were carried out with TB patients, treatment supporters, health workers and community members. Quantitative study was also carried out among TB patients and treatment supporters. RESULTS A total of 268 patients and 103 treatment supporters were enrolled in the study. The majority of the patients (75%) were satisfied with the DOT options they received. Males were more satisfied with community-based DOT (84%) than females (67%) (OR 4.96, 95% CI 1.38-17.86). The majority (81%) were willing to supervise another TB patient. The results of the qualitative study demonstrated that community-based DOT was preferred because it was found to be convenient, reduced costs, saved time of the patients and reduced workload in health services. The main challenge of community-based DOT was to ensure effective supervision and monitoring of patients and treatment supporters in the community. CONCLUSION The results from the quantitative and qualitative studies indicate that both DOT options were acceptable. The study has also identified key challenges and opportunities for effective implementation of community-based DOT interventions that are relevant, sensitive and acceptable to the population. Community-based DOT is a viable option and can complement and strengthen the existing health facility-based DOT, especially in countries like Tanzania where the health system is overwhelmed with increasing number of TB and HIV/AIDS patients.
Collapse
|
43
|
Khan MA, Walley JD, Witter SN, Shah SK, Javeed S. Tuberculosis patient adherence to direct observation: results of a social study in Pakistan. Health Policy Plan 2005; 20:354-65. [PMID: 16183735 DOI: 10.1093/heapol/czi047] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
A randomized controlled trial was carried out in Pakistan in 1999 to establish the effectiveness of the direct observation component of DOTS programmes. It found no significant differences in cure rates for patients directly observed by health facility workers, community health workers or by family members, as compared with the control group who had self-administered treatment. This paper reports on the social studies which were carried out during and after this trial, to explain these results. They consisted of a survey of all patients (64% response rate); in-depth interviews with a smaller sample of different types of patients; and focus group discussions with patients and providers. One finding was that of the 32 in-depth interview patients, 13 (mainly from the health facility observation group) failed to comply with their allocated DOT approach during the trial, citing the inconvenience of the method of observation. Another finding was that while patients found the overall TB care approach efficient and economical in general, they faced numerous barriers to regular attendance for the direct observation of drug-taking (most especially, time, travel costs, ill health and need to pursue their occupation). This may be one of the reasons why there was no overall benefit from direct observation in the trial. Provider attitudes were also poor: health facility workers expressed cynical and uncaring views; community health workers were more positive, but still arranged direct observation to suit their, rather than patients', schedules. The article concludes that direct observation, if used, should be flexible and convenient, whether at a health facility close to the patient's home or in the community. The emphasis should shift in practice from tablet watching towards treatment support, together with education and other adherence measures.
Collapse
Affiliation(s)
- M A Khan
- IMMPACT, University of Aberdeen, Aberdeen AB24 3FX, Scotland, UK
| | | | | | | | | |
Collapse
|
44
|
Jaffar S, Govender T, Garrib A, Welz T, Grosskurth H, Smith PG, Whittle H, Bennish ML. Antiretroviral treatment in resource-poor settings: public health research priorities. Trop Med Int Health 2005; 10:295-9. [PMID: 15807791 DOI: 10.1111/j.1365-3156.2005.01390.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Many countries in Africa are planning to provide highly active antiretroviral therapy (HAART) to millions of people with acquired immune deficiency syndrome. This will be a highly complex therapy programme. Physician-based models of care adapted from industrialized countries will not succeed in providing treatment to the majority of those who need it in resource-constrained settings. A high priority is to identify care models for Africa that will increase coverage of HAART safely and effectively: key issues are (i) whether nursing staff or non-clinically qualified staff can take the major role in the treatment programme and reduce the workload of physicians, (ii) whether treatment and monitoring can be delivered through peripheral health centres or through home visits and achieve better adherence and be more cost-effective than delivery at hospitals and (iii) which clinical algorithms used by nursing or non-clinically qualified staff will be effective for screening, diagnosing and managing treatment-related side-effects and medical problems being incurred. Many current ART support programmes are making little or no investment in research, but answering important questions on delivery of HAART will be essential if HAART programmes are to be successful in African nations with a high burden of human immunodeficiency virus infection.
Collapse
Affiliation(s)
- Shabbar Jaffar
- Medical Research Council Tropical Epidemiology Group, Department of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK.
| | | | | | | | | | | | | | | |
Collapse
|
45
|
Lewin SA, Dick J, Pond P, Zwarenstein M, Aja G, van Wyk B, Bosch-Capblanch X, Patrick M. Lay health workers in primary and community health care. Cochrane Database Syst Rev 2005:CD004015. [PMID: 15674924 DOI: 10.1002/14651858.cd004015.pub2] [Citation(s) in RCA: 291] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND Lay health workers (LHWs) are widely used to provide care for a broad range of health issues. However, little is known about the effectiveness of LHW interventions. OBJECTIVES To assess the effects of LHW interventions in primary and community health care on health care behaviours, patients' health and wellbeing, and patients' satisfaction with care. SEARCH STRATEGY We searched the Cochrane Effective Practice and Organisation of Care and Consumers and Communication specialised registers (to August 2001); the Cochrane Central Register of Controlled Trials (to August 2001); MEDLINE (1966- August 2001); EMBASE (1966-August 2001); Science Citations (to August 2001); CINAHL (1966-June 2001); Healthstar (1975-2000); AMED (1966-August 2001); the Leeds Health Education Effectiveness Database and the reference lists of articles. SELECTION CRITERIA Randomised controlled trials of any intervention delivered by LHWs (paid or voluntary) in primary or community health care and intended to promote health, manage illness or provide support to patients. A 'lay health worker' was defined as any health worker carrying out functions related to health care delivery; trained in some way in the context of the intervention; and having no formal professional or paraprofessional certificated or degreed tertiary education. There were no restrictions on the types of consumers. DATA COLLECTION AND ANALYSIS Two reviewers independently extracted data onto a standard form and assessed study quality. Studies that compared broadly similar types of interventions were grouped together. Where feasible, the results of included studies were combined and an estimate of effect obtained. MAIN RESULTS Forty three studies met the inclusion criteria, involving more than 210,110 consumers. These showed considerable diversity in the targeted health issue and the aims, content and outcomes of interventions. Most were conducted in high income countries (n=35), but nearly half of these focused on low income and minority populations (n=15). Study diversity limited meta-analysis to outcomes for five subgroups (n=15 studies) (LHW interventions to promote the uptake of breast cancer screening, immunisation and breastfeeding promotion [before two weeks and between two weeks and six months post partum] and to improve diagnosis and treatment for selected infectious diseases). Promising benefits in comparison with usual care were shown for LHW interventions to promote immunisation uptake in children and adults (RR=1.30 [95% CI 1.14, 1.48] p=0.0001) and LHW interventions to improve outcomes for selected infectious diseases (RR=0.74 [95% CI 0.58, 0.93) p=0.01). LHWs also appear promising for breastfeeding promotion. They appear to have a small effect in promoting breast cancer screening uptake when compared with usual care. For the remaining subgroups (n=29 studies), the outcomes were too diverse to allow statistical pooling. We can therefore draw no general conclusions on the effectiveness of these subgroups of interventions. AUTHORS' CONCLUSIONS LHWs show promising benefits in promoting immunisation uptake and improving outcomes for acute respiratory infections and malaria, when compared to usual care. For other health issues, evidence is insufficient to justify recommendations for policy and practice. There is also insufficient evidence to assess which LHW training or intervention strategies are likely to be most effective. Further research is needed in these areas.
Collapse
Affiliation(s)
- S A Lewin
- Department of Public Health and Policy, London School of Hygiene and Tropical Medicine, Keppel St, London, UK, WC1E 7HT.
| | | | | | | | | | | | | | | |
Collapse
|
46
|
|
47
|
Jasmer RM, Seaman CB, Gonzalez LC, Kawamura LM, Osmond DH, Daley CL. Tuberculosis Treatment Outcomes. Am J Respir Crit Care Med 2004; 170:561-6. [PMID: 15184210 DOI: 10.1164/rccm.200401-095oc] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Effective treatment of tuberculosis requires adherence to a minimum of 6 months treatment with multiple drugs. To improve adherence and cure rates, directly observed therapy is recommended for the treatment of pulmonary tuberculosis. We compared treatment outcomes among all culture-positive patients treated for active pulmonary tuberculosis (n = 372) in San Francisco County, California from 1998 through 2000. Patients treated by directly observed therapy at the start of therapy (n = 149) had a significantly higher cure rate compared with patients treated by self-administered therapy (n = 223) (the sum of bacteriologic cure and completion of treatment, 97.8% versus 88.6%, p < 0.002), and decreased tuberculosis-related mortality (0% vs. 5.5%, p = 0.002). Rates of treatment failure, relapse, and acquired drug resistance were similar between the two groups. Forty-four percent of patients who received self-administered therapy had risk factors for nonadherence and should have been assigned to directly observed therapy. We conclude that treatment plans that emphasize directly observed therapy from the start of therapy have the greatest success in improving tuberculosis treatment outcomes.
Collapse
Affiliation(s)
- Robert M Jasmer
- Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, Room 5K-1, 1001 Potrero Avenue, San Francisco, CA 94110, USA.
| | | | | | | | | | | |
Collapse
|
48
|
Lienhardt C, Ogden JA. Tuberculosis control in resource-poor countries: have we reached the limits of the universal paradigm? Trop Med Int Health 2004; 9:833-41. [PMID: 15228495 DOI: 10.1111/j.1365-3156.2004.01273.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The aim of TB control is to break the cycle of transmission by treating TB cases as early and efficiently as possible. In its efforts to promote a model of worldwide TB control, WHO defined specific targets and launched the 'Directly Observed Therapy, Short-course' (DOTS) strategy as the main tool to reach them. However, the diversity of patients' attitudes towards the disease and the extreme variability of access to care, especially in resource-poor countries, are amongst the many factors of social context that profoundly affect the ability of control programmes to implement this policy effectively. There are multiple reports of TB control programmes using various types of intervention to promote adherence and enhance case-holding, but most of these interventions depend on external funding, which bring into question their long-term sustainability. In this paper, we address the problems related to operational variabilities in the implementation of the DOTS strategy in resource-poor countries and question the appropriateness of a universal paradigm for global TB control. This analysis is of particular importance as programmers consider using this model in the delivery of anti-retroviral therapies for the treatment of HIV in resource-limited settings.
Collapse
|
49
|
Wright J, Walley J, Philip A, Pushpananthan S, Dlamini E, Newell J, Dlamini S. Direct observation of treatment for tuberculosis: a randomized controlled trial of community health workers versus family members. Trop Med Int Health 2004; 9:559-65. [PMID: 15117299 DOI: 10.1111/j.1365-3156.2004.01230.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We implemented community-based direct observation of treatment, short course (DOTS), including a randomized controlled trial of direct observation either by community health workers (CHWs) or family members, under operational conditions in a region of Swaziland. There was a high death rate of 15%, due to the high HIV rates in the region. There was no significant difference in the cure and completion rate between direct observation of treatment by CHWs and family members [2% difference (95% CI -3% to 7%), exact P = 0.52]. A before-and-after comparison of outcomes demonstrated that the cure and treatment completion rate improved from a baseline of 27-67% following implementation of community-based DOTS. We conclude that community-based tuberculosis DOTS can improve successful outcomes of treatment. However, direct observation can be undertaken effectively using either daily family or CHW supervision. The choice of treatment supporter should be based on access, patient preference and availability of CHW resource.
Collapse
Affiliation(s)
- John Wright
- Bradford Teaching Hospitals NHS Trust, Bradford Royal Infirmary, UK.
| | | | | | | | | | | | | |
Collapse
|
50
|
Chouaid C, Antoun F, Blanc-Jouvan F, Cormier K, Portel L, Fraisse P. L’organisation médico-sociale et administrative peut-elle améliorer la prise en charge individuelle et collective de la tuberculose en France ? Rev Mal Respir 2004; 21:S98-104. [PMID: 15344275 DOI: 10.1016/s0761-8425(04)71391-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- C Chouaid
- Service de Pneumologie, CHU Saint-Antoine, France.
| | | | | | | | | | | |
Collapse
|