Exploring the efficacy of a case management model using DOTS in the adherence of patients with pulmonary tuberculosis

Demographic Control Measure Implications of Tuberculosis Infection for Migrant Workers across Taiwan Regions

A sharp increase in migrant workers has raised concerns for TB epidemics, yet optimal TB control strategies remain unclear in Taiwan regions. This study assessed intervention efforts on reducing tuberculosis (TB) infection among migrant workers. We performed large-scale data analyses and used them to develop a control-based migrant worker-associated susceptible-latently infected-infectious-recovered (SLTR) model. We used the SLTR model to assess potential intervention strategies such as social distancing, early screening, and directly observed treatment, short-course (DOTS) for TB transmission among migrant workers and locals in three major hotspot cities from 2018 to 2023. We showed that social distancing was the best single strategy, while the best dual measure was social distancing coupled with early screening. However, the effectiveness of the triple strategy was marginally (1-3%) better than that of the dual measure. Our study provides a mechanistic framework to facilitate understanding of TB transmission dynamics between locals and migrant workers and to recommend better prevention strategies in anticipation of achieving WHO's milestones by the next decade. Our work has implications for migrant worker-associated TB infection prevention on a global scale and provides a knowledge base for exploring how outcomes can be best implemented by alternative control measure approaches.

Interventions for improving medication-taking ability and adherence in older adults prescribed multiple medications

BACKGROUND

Older people taking multiple medications represent a large and growing proportion of the population. Managing multiple medications can be challenging, and this is especially the case for older people, who have higher rates of comorbidity and physical and cognitive impairment than younger adults. Good medication-taking ability and medication adherence are necessary to ensure safe and effective use of medications.

OBJECTIVES

To evaluate the effectiveness of interventions designed to improve medication-taking ability and/or medication adherence in older community-dwelling adults prescribed multiple long-term medications.

SEARCH METHODS

We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL), PsycINFO, CINAHL Plus, and International Pharmaceutical Abstracts from inception until June 2019. We also searched grey literature, online trial registries, and reference lists of included studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs), quasi-RCTs, and cluster-RCTs. Eligible studies tested interventions aimed at improving medication-taking ability and/or medication adherence among people aged ≥ 65 years (or of mean/median age > 65 years), living in the community or being discharged from hospital back into the community, and taking four or more regular prescription medications (or with group mean/median of more than four medications). Interventions targeting carers of older people who met these criteria were also included.

DATA COLLECTION AND ANALYSIS

Two review authors independently reviewed abstracts and full texts of eligible studies, extracted data, and assessed risk of bias of included studies. We conducted meta-analyses when possible and used a random-effects model to yield summary estimates of effect, risk ratios (RRs) for dichotomous outcomes, and mean differences (MDs) or standardised mean differences (SMDs) for continuous outcomes, along with 95% confidence intervals (CIs). Narrative synthesis was performed when meta-analysis was not possible. We assessed overall certainty of evidence for each outcome using Grades of Recommendation, Assessment, Development and Evaluation (GRADE). Primary outcomes were medication-taking ability and medication adherence. Secondary outcomes included health-related quality of life (HRQoL), emergency department (ED)/hospital admissions, and mortality.

MAIN RESULTS

We identified 50 studies (14,269 participants) comprising 40 RCTs, six cluster-RCTs, and four quasi-RCTs. All included studies evaluated interventions versus usual care; six studies also reported a comparison between two interventions as part of a three-arm RCT design. Interventions were grouped on the basis of their educational and/or behavioural components: 14 involved educational components only, 7 used behavioural strategies only, and 29 provided mixed educational and behavioural interventions. Overall, our confidence in results regarding the effectiveness of interventions was low to very low due to a high degree of heterogeneity of included studies and high or unclear risk of bias across multiple domains in most studies. Five studies evaluated interventions for improving medication-taking ability, and 48 evaluated interventions for improving medication adherence (three studies evaluated both outcomes). No studies involved educational or behavioural interventions alone for improving medication-taking ability. Low-quality evidence from five studies, each using a different measure of medication-taking ability, meant that we were unable to determine the effects of mixed interventions on medication-taking ability. Low-quality evidence suggests that behavioural only interventions (RR 1.22, 95% CI 1.07 to 1.38; 4 studies) and mixed interventions (RR 1.22, 95% CI 1.08 to 1.37; 12 studies) may increase the proportions of people who are adherent compared with usual care. We could not include in the meta-analysis results from two studies involving mixed interventions: one had a positive effect on adherence, and the other had little or no effect. Very low-quality evidence means that we are uncertain of the effects of educational only interventions (5 studies) on the proportions of people who are adherent. Low-quality evidence suggests that educational only interventions (SMD 0.16, 95% CI -0.12 to 0.43; 5 studies) and mixed interventions (SMD 0.47, 95% CI -0.08 to 1.02; 7 studies) may have little or no impact on medication adherence assessed through continuous measures of adherence. We excluded 10 studies (4 educational only and 6 mixed interventions) from the meta-analysis including four studies with unclear or no available results. Very low-quality evidence means that we are uncertain of the effects of behavioural only interventions (3 studies) on medication adherence when assessed through continuous outcomes. Low-quality evidence suggests that mixed interventions may reduce the number of ED/hospital admissions (RR 0.67, 95% CI 0.50 to 0.90; 11 studies) compared with usual care, although results from six further studies that we were unable to include in meta-analyses indicate that the intervention may have a smaller, or even no, effect on these outcomes. Similarly, low-quality evidence suggests that mixed interventions may lead to little or no change in HRQoL (7 studies), and very low-quality evidence means that we are uncertain of the effects on mortality (RR 0.93, 95% CI 0.67 to 1.30; 7 studies). Moderate-quality evidence shows that educational interventions alone probably have little or no effect on HRQoL (6 studies) or on ED/hospital admissions (4 studies) when compared with usual care. Very low-quality evidence means that we are uncertain of the effects of behavioural interventions on HRQoL (1 study) or on ED/hospital admissions (2 studies). We identified no studies evaluating effects of educational or behavioural interventions alone on mortality. Six studies reported a comparison between two interventions; however due to the limited number of studies assessing the same types of interventions and comparisons, we are unable to draw firm conclusions for any outcomes.

AUTHORS' CONCLUSIONS

Behavioural only or mixed educational and behavioural interventions may improve the proportion of people who satisfactorily adhere to their prescribed medications, but we are uncertain of the effects of educational only interventions. No type of intervention was found to improve adherence when it was measured as a continuous variable, with educational only and mixed interventions having little or no impact and evidence of insufficient quality to determine the effects of behavioural only interventions. We were unable to determine the impact of interventions on medication-taking ability. The quality of evidence for these findings is low due to heterogeneity and methodological limitations of studies included in the review. Further well-designed RCTs are needed to investigate the effects of interventions for improving medication-taking ability and medication adherence in older adults prescribed multiple medications.

Tuberculosis - Present Medication and Therapeutic Prospects

BACKGROUND

Tuberculosis (TB) has been present in the history of human civilization since time immemorial and has caused more deaths than any other infectious disease. It is still considered one of the ten most common epidemiologic causes of death in the world. As a transmissible disease, it is initiated by rod-shaped (bacillus) mycobacteria. The management of tuberculosis became possible owing to several discoveries beginning in 1882 with the isolation of the TB bacillus by Robert Koch. The diagnosis of TB was enabled by finding a staining method for TB bacteria identification (1883). It was soon realized that a large-scale policy for the treatment and prevention of tuberculosis was necessary, which resulted in the foundation of International Union against Tuberculosis and Lung Diseases (1902). An antituberculosis vaccine was developed in 1921 and has been in therapeutic use since then. TB treatment regimens have changed over the decades and the latest recommendations are known as Directly Observed Treatment Short-course (DOTS, WHO 1993).

METHODS

A search of bibliographic databases was performed for peer-reviewed research literature. A focused review question and inclusion criteria were applied. Standard tools were used to assess the quality of retrieved papers.

RESULTS

A total of 112 papers were included comprising original publications and reviews. The paper overviews anti-TB drugs according to their mechanism of action. The chemical structure, metabolism and unwanted effects of such drugs have been discussed. The most recent treatment regimens and new drugs, including those in clinical trials, are also presented.

CONCLUSION

Despite a 22% decrease in the tuberculosis fatality rate observed between 2000 and 2015, the disease remains one of the ten prime causes of death worldwide. Increasing bacterial resistance and expensive, prolonged therapies are the main reasons for efforts to find effective drugs or antituberculosis regimens, especially to cure multidrug-resistant tuberculosis.

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

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.

A systematic review of non-pharmacological interventions to improve therapeutic adherence in tuberculosis

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.

Efficacy of acupressure to prevent adverse reactions to anti-tuberculosis drugs: Randomized controlled trials

AIM

To determine whether acupressure can prevent or relieve the adverse drug reactions (ADRs) of anti-tuberculosis drugs.

BACKGROUND

People receiving drug treatment for TB often experience ADRs that may cause them to stop taking their medication. Acupressure is a form of traditional Chinese medicine that can be applied to alleviate or prevent disease symptoms.

DESIGN

A double-blinded, repeated-measures clinical trial in hospitals in Taiwan was carried out from April 2015 - May 2017.

METHODS

Convenience sampling was used to select 32 people (15 for the experimental group and 17 for the control group) aged >20 years who were taking anti-tuberculosis drugs. The people were randomized to receive 4-week of true acupressure and 4-weeks of sham acupressure. Acupressure therapy was given by a researcher in all cases. Both groups received treatment once per day on weekdays, with 15 min for each acupressure session. Outcomes (gastrointestinal irritation and adverse skin reactions) were assessed according to the people feedback and the physicians' recordings during the treatment course, and during monthly follow-up visits for 6 months thereafter.

RESULTS

Both groups typically experienced gastrointestinal irritation and adverse skin reactions within 2 months of beginning anti-tuberculosis drug treatment. The 4-weeks intervention involving relevant acupressure points successfully relieved both types of side effects in both immediate and delayed manner.

CONCLUSIONS

When correctly implemented, acupressure can prevent and relieve the ADRs of anti-tuberculosis drugs, and motivate people to complete their treatment course.

Adherence interventions and outcomes of tuberculosis treatment: A systematic review and meta-analysis of trials and observational studies

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.

Role of pharmaceutical care for self-administered pulmonary tuberculosis treatment in Thailand

WHAT IS KNOWN AND OBJECTIVE

With resource constraints in Thailand, directly observed therapy (DOT) for treating tuberculosis (TB) may not be feasible to implement. To improve patients' adherence, hospitals either modify DOT or adopt different approaches: pharmaceutical care or home visit. Our objective was to assess pulmonary TB treatment success rate of pharmaceutical care compared to home visit and modified DOT in Thailand.

METHODS

We conducted a retrospective cohort study using data collected in adult pulmonary TB patients starting treatment between October 2010 and September 2013 in three hospitals in Thailand. This study was approved by the Research Ethics Board at each of the participating hospitals. We built a propensity score matching to account for differences in patient baseline characteristics.

RESULTS

Analysis included 1398 patients. Before matching, the treatment success rate for patients receiving pharmaceutical care was 94.9%, home visit 93.6% and modified DOT 90.1%. The propensity score-matched cohorts indicated that differences in the treatment success rate were not statistically significant when comparing pharmaceutical care with either home visit (success rate: 92.76% vs 94.74%, risk difference: 1.97%, 95% CI -3.64 to 7.59) or modified DOT (success rate 93.37% for both, risk difference: 0%, 95% CI -5.30 to 5.30).

WHAT IS NEW AND CONCLUSION

Pharmaceutical care, home visit and modified DOT are all associated with high success rate for pulmonary TB treatment and exceeded the WHO target, in this retrospective analysis.

Directly observed therapy for treating tuberculosis

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.

Reminder systems to improve patient adherence to tuberculosis clinic appointments for diagnosis and treatment

BACKGROUND

People with active tuberculosis (TB) require six months of treatment. Some people find it difficult to complete treatment, and there are several approaches to help ensure completion. One such system relies on reminders, where the health system prompts patients to attend for appointments on time, or re-engages people who have missed or defaulted on a scheduled appointment.

OBJECTIVES

To assess the effects of reminder systems on improving attendance at TB diagnosis, prophylaxis, and treatment clinic appointments, and their effects on TB treatment outcomes.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register, Cochrane Effective Practice and Organization of Care Group Specialized Register, CENTRAL, MEDLINE, EMBASE, LILACS, CINAHL, SCI-EXPANDED, SSCI, mRCT, and the Indian Journal of Tuberculosis without language restriction up to 29 August 2014. We also checked reference lists and contacted researchers working in the field.

SELECTION CRITERIA

Randomized controlled trials (RCTs), including cluster RCTs and quasi-RCTs, and controlled before-and-after studies comparing reminder systems with no reminders or an alternative reminder system for people with scheduled appointments for TB diagnosis, prophylaxis, or treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed the risk of bias in the included trials. We compared the effects of interventions by using risk ratios (RR) and presented RRs with 95% confidence intervals (CIs). Also we assessed the quality of evidence using the GRADE approach.

MAIN RESULTS

Nine trials, including 4654 participants, met our inclusion criteria. Five trials evaluated appointment reminders for people on treatment for active TB, two for people on prophylaxis for latent TB, and four for people undergoing TB screening using skin tests. We classified the interventions into 'pre-appointment' reminders (telephone calls or letters prior to a scheduled appointment) or 'default' reminders (telephone calls, letters, or home visits to people who had missed an appointment).For people being treated for active TB, clinic attendance and TB treatment completion were higher in people receiving pre-appointment reminder phone-calls (clinic attendance: 66% versus 50%; RR 1.32, 95% CI 1.10 to 1.59, one trial (USA), 615 participants, low quality evidence; TB treatment completion: 100% versus 88%; RR 1.14, 95% CI 1.02 to 1.27, one trial (Thailand), 92 participants, low quality evidence). Clinic attendance and TB treatment completion were also higher with default reminders (letters or home visits) (clinic attendance: 52% versus 10%; RR 5.04, 95% CI 1.61 to 15.78, one trial (India), 52 participants, low quality evidence; treatment completion: RR 1.17, 95% CI 1.11 to 1.24, two trials (Iraq and India), 680 participants, moderate quality evidence).For people on TB prophylaxis, clinic attendance was higher with a policy of pre-appointment phone-calls (63% versus 48%; RR 1.30, 95% CI 1.07 to 1.59, one trial (USA), 536 participants); and attendance at the final clinic was higher with regular three-monthly phone-calls or nurse visits (93% versus 65%, one trial (Spain), 318 participants).For people undergoing screening for TB, three trials of pre-appointment phone-calls found little or no effect on the proportion of people returning to clinic for the result of their skin test (three trials, 1189 participants, low quality evidence), and two trials found little or no effect with take home reminder cards (two trials, 711 participants). All four trials were conducted among healthy volunteers in the USA.

AUTHORS' CONCLUSIONS

Policies of sending reminders to people pre-appointment, and contacting people who miss appointments, seem sensible additions to any TB programme, and the limited evidence available suggests they have small but potentially important benefits. Future studies of modern technologies such as short message service (SMS) reminders would be useful, particularly in low-resource settings.

Perceptions and acceptability of short message services technology to improve treatment adherence amongst tuberculosis patients in Peru: a Focus Group Study

BACKGROUND

Tuberculosis (TB) is global health concern and a leading infectious cause of mortality. Reversing TB incidence and disease-related mortality is a major global health priority. Infectious disease mortality is directly linked to failure to adhere to treatments. Using technology to send reminders by short message services have been shown to improve treatment adherence. However, few studies have examined tuberculosis patient perceptions and attitudes towards using SMS technology to increase treatment adherence. In this study, we sought to investigate perceptions related to feasibility and acceptability of using text messaging to improve treatment adherence among adults who were receiving treatment for TB in Callao, Peru.

METHODS

We conducted focus group qualitative interviews with current TB positive and non-contagious participants to understand the attitudes, perceptions, and feasibility of using short message service (SMS) reminders to improve TB treatment adherence. Subjects receiving care through the National TB Program were recruited through public health centers in Ventanilla, Callao, Peru. In four focus groups, we interviewed 16 patients. All interviews were recorded and transcribed verbatim. Thematic network analysis and codebook techniques were used to analyze data.

RESULTS

Three major themes emerged from the data: limits on health literacy and information posed challenges to successful TB treatment adherence, treatment motivation at times facilitated adherence to TB treatment, and acceptability of SMS including positive perceptions of SMS to improve TB treatment adherence. The majority of patients shared considerations about how to effectively and confidentially administer an SMS intervention with TB positive participants.

CONCLUSION

The overall perceptions of the use of SMS were positive and indicated that SMS technology may be an efficient way to transmit motivational texts on treatment, health education information, and simple reminders to increase treatment adherence for low-income TB patients living in Peru.

The strategies of Japanese public health nurses in medication support for high-risk tuberculosis patients

OBJECTIVE

The purpose of this study was to describe the support provided by Japanese public health nurses (PHNs) to high-risk tuberculosis (TB) patients, focusing specifically on the support aimed at preventing interruptions in treatment.

DESIGN AND SAMPLE

A qualitative descriptive approach was used with a convenience sample of 11 PHNs in Japan who cared for TB patients at highest risk for medication adherence problems.

MEASURES

Semi-structured interviews were conducted to learn the scope and practice of PHNs with high-risk TB patients. Data were analyzed using a qualitative descriptive analysis process.

RESULTS

One main theme was identified: "Supporting the patients in overcoming tuberculosis, regaining health, and living a healthier life." Three categories with five subcategories described the nurses' activities: (1) empathetic and reliable support, (2) motivational strategies for medication adherence, and (3) developing a foundation for healthier life.

CONCLUSIONS

The nurses interviewed described creative and extraordinary strategies used to promote medication adherence and facilitate development of a healthy posttreatment lifestyle. Their approach was patient-centered and culturally congruent. Findings may be transferrable to PHN practice in other regions as care for this economically disadvantaged and marginalized population is a critical need.

Strategies to Promote Adherence to Treatment by Pulmonary Tuberculosis Patients: A systematic review

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.

Mycobacterium tuberculosis: implications for district nurses

Despite the belief of many health professionals, tuberculosis is not a disease of the past but is on the increase (Department of Health (DH), 2004) and the UK has seen a year on year increase in the number of new cases (Health Protection Agency, 2008). The DH have made a number of recommendations to combat this increase and one of those recommendations is to raise awareness among health staff (2004). This review has set out to examine district nurses' knowledge about tuberculosis and the consequences of poor knowledge. Five themes emerged from the literature search with the most prominent being the subject of adherence and how this could be addressed. The review has identified that district nurses should have a greater knowledge of tuberculosis and patient treatment could be improved by the nurse having a better understanding about tuberculosis care.

Tuberculosis: a breast-feeding challenge

A recent resurgence of tuberculosis in the world community has brought the disease into the forefront of communicable disease control. Acknowledging the proven benefits of breast-feeding infants, the question of compatibility arises regarding the safety of breast-feeding an infant in the event of active tuberculosis disease in the mother. This article will discuss the emerging trends of tuberculosis disease and review the evidence that addresses the issues of safety while breast-feeding during tuberculosis treatment.