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Chen AZ, Kumar R, Baria RK, Shridhar PK, Subbaraman R, Thies W. Impact of the 99DOTS digital adherence technology on tuberculosis treatment outcomes in North India: a pre-post study. BMC Infect Dis 2023; 23:504. [PMID: 37525114 PMCID: PMC10391893 DOI: 10.1186/s12879-023-08418-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 06/22/2023] [Indexed: 08/02/2023] Open
Abstract
BACKGROUND 99DOTS is a cellphone-based digital adherence technology. The state of Himachal Pradesh, India, made 99DOTS available to all adults being treated for drug-sensitive tuberculosis (TB) in the public sector in May 2018. While 99DOTS has engaged over 500,000 people across India, few studies have evaluated its effectiveness in improving TB treatment outcomes. METHODS We compared treatment outcomes of adults with drug-sensitive TB before and after Himachal Pradesh's 99DOTS launch using data from India's national TB database. The pre-intervention group initiated treatment between February and October 2017 (N = 7722), and the post-intervention group between July 2018 and March 2019 (N = 8322). We analyzed engagement with 99DOTS and used multivariable logistic regression to estimate impact on favorable treatment outcomes (those marked as cured or treatment complete). RESULTS In the post-intervention group, 2746 (33.0%) people called 99DOTS at least once. Those who called did so with a wide variation in frequency (< 25% of treatment days: 24.6% of callers; 25-50% of days: 15.1% of callers, 50-75% of days: 15.7% of callers; 75-100% of days: 44.6% of callers). In the pre-intervention group, 7186 (93.1%) had favorable treatment outcomes, compared to 7734 (92.9%) in the post-intervention group. This difference was not statistically significant (OR = 0.981, 95% CI [0.869, 1.108], p = 0.758), including after controlling for individual characteristics (adjusted OR = 0.970, 95% CI [0.854, 1.102]). CONCLUSIONS We found no statistically significant difference in treatment outcomes before and after a large-scale implementation of 99DOTS. Additional work could help to elucidate factors mediating site-wise variations in uptake of the intervention.
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Affiliation(s)
- Amy Z Chen
- Everwell Health Solutions, Bangalore, Karnataka, India
| | - Ravinder Kumar
- World Health Organization, Himachal Pradesh, Shimla, India
| | - R K Baria
- Directorate of Health Services, Himachal Pradesh, Shimla, India
| | - Pramod Kumar Shridhar
- Maharishi Markandeshwar Medical College & Hospital, Kumarhatti-Solan, Himachal Pradesh, India
| | - Ramnath Subbaraman
- Department of Public Health and Community Medicine and Center for Global Public Health, Tufts University School of Medicine, Boston, MA, US
| | - William Thies
- Everwell Health Solutions, Bangalore, Karnataka, India.
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Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the effects of digital devices (feature phone‐based and smartphone‐based technologies, digital pillboxes, ingestible sensors, and other devices) for improving tuberculosis treatment adherence.
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Kiwanuka N, Kityamuwesi A, Crowder R, Guzman K, Berger CA, Lamunu M, Namale C, Kunihira Tinka L, Nakate AS, Ggita J, Turimumahoro P, Babirye D, Oyuku D, Patel D, Sammann A, Turyahabwe S, Dowdy DW, Katamba A, Cattamanchi A. Implementation, feasibility, and acceptability of 99DOTS-based supervision of treatment for drug-susceptible TB in Uganda. PLOS DIGITAL HEALTH 2023; 2:e0000138. [PMID: 37390077 DOI: 10.1371/journal.pdig.0000138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 05/30/2023] [Indexed: 07/02/2023]
Abstract
99DOTS is a low-cost digital adherence technology that allows people with tuberculosis (TB) to self-report treatment adherence. There are limited data on its implementation, feasibility, and acceptability from sub-Saharan Africa. We conducted a longitudinal analysis and cross-sectional surveys nested within a stepped-wedge randomized trial at 18 health facilities in Uganda between December 2018 and January 2020. The longitudinal analysis assessed implementation of key components of a 99DOTS-based intervention, including self-reporting of TB medication adherence via toll-free phone calls, automated text message reminders and support actions by health workers monitoring adherence data. Cross-sectional surveys administered to a subset of people with TB and health workers assessed 99DOTS feasibility and acceptability. Composite scores for capability, opportunity, and motivation to use 99DOTS were estimated as mean Likert scale responses. Among 462 people with pulmonary TB enrolled on 99DOTS, median adherence was 58.4% (inter-quartile range [IQR] 38.7-75.6) as confirmed by self-reporting dosing via phone calls and 99.4% (IQR 96.4-100) when also including doses confirmed by health workers. Phone call-confirmed adherence declined over the treatment period and was lower among people with HIV (median 50.6% vs. 63.7%, p<0.001). People with TB received SMS dosing reminders on 90.5% of treatment days. Health worker support actions were documented for 261/409 (63.8%) people with TB who missed >3 consecutive doses. Surveys were completed by 83 people with TB and 22 health workers. Composite scores for capability, opportunity, and motivation were high; among people with TB, composite scores did not differ by gender or HIV status. Barriers to using 99DOTS included technical issues (phone access, charging, and network connection) and concerns regarding disclosure. 99DOTS was feasible to implement and highly acceptable to people with TB and their health workers. National TB Programs should offer 99DOTS as an option for TB treatment supervision.
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Affiliation(s)
- Noah Kiwanuka
- Department of Epidemiology & Biostatistics, School of Public Health, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Alex Kityamuwesi
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Rebecca Crowder
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Kevin Guzman
- Department of Medicine, University of California San Francisco, San Francisco, California, United States
| | - Christopher A Berger
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Maureen Lamunu
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Catherine Namale
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Lynn Kunihira Tinka
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Agnes Sanyu Nakate
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Joseph Ggita
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | | | - Diana Babirye
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Denis Oyuku
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Devika Patel
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Stavia Turyahabwe
- Uganda National Tuberculosis and Leprosy Programme, Ministry of Health, Kampala, Uganda
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Achilles Katamba
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Department of Medicine, School of Medicine, College of Health Sciences, Makerere University, Kampala, Uganda
| | - Adithya Cattamanchi
- Walimu, Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Division of Pulmonary Diseases and Critical Care Medicine, University of California Irvine, Irvine, California, United States of America
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Manyazewal T, Woldeamanuel Y, Holland DP, Fekadu A, Marconi VC. Effectiveness of a digital medication event reminder and monitor device for patients with tuberculosis (SELFTB): a multicenter randomized controlled trial. BMC Med 2022; 20:310. [PMID: 36167528 PMCID: PMC9514884 DOI: 10.1186/s12916-022-02521-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 08/09/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Tuberculosis remains the leading cause of death from a single infectious disease worldwide. Trials evaluating digital adherence technologies for tuberculosis in low- and middle-income countries are urgently needed. We aimed to assess whether a digital medication event reminder and monitor (MERM) device-observed self-administered therapy improves adherence and treatment outcomes in patients with tuberculosis compared with the standard in-person directly observed therapy (DOT). METHODS We did a two-arm, attention-controlled, effectiveness-implementation type 2 hybrid, randomized controlled trial in ten healthcare facilities in Addis Ababa, Ethiopia. We included adults with new or previously treated, bacteriologically confirmed, drug-sensitive pulmonary tuberculosis who were eligible to start anti-tuberculosis therapy. Participants were randomly assigned (1:1) to receive a 15-day tuberculosis medication supply in the evriMED500® MERM device to self-administer and return every 15 days (intervention arm) or visit the healthcare facilities each day to swallow their daily dose with DOT by healthcare providers (control arm). Both arms were followed throughout the standard two-month intensive treatment phase (2RHZE). For control participants, some provider-approved take-home doses might be allowed for extenuating circumstances in real-world practice. Data were collected on patient information (demographic, socioeconomic, behavioral, social, and clinical information), medication adherence measures (MERM vs. DOT records, IsoScreenTM urine colorimetric isoniazid test, and adherence self-report), and clinical measures (pre-post treatment sputum Xpert MTB/RIF assay or microscopy, and adverse treatment outcomes). The intention-to-treat (ITT) primary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from MERM device vs. DOT records that also considered all take-home doses as having been ingested and (2) sputum smear conversion following the standard two-month intensive phase treatment. Secondary endpoints were (1) individual-level percentage adherence over the two-month intensive phase measured by adherence records compiled from the MERM device vs. DOT records that considered all take-home doses as not ingested, (2) negative IsoScreen urine isoniazid test, (3) adverse treatment outcome (having at least one of the three events: treatment not completed; death; or loss to follow-up), and (4) self-reported adherence. The MERM device has an electronic module and a medication container that records adherence, stores medication, emits audible and visual on-board alarms to remind patients to take their medications on time and refill, and enables providers to download the data and monitor adherence. RESULTS Participants were enrolled into the study between 02 June 2020 and 15 June 2021, with the last participant completing follow-up on 15 August 2021. A total of 337 patients were screened for eligibility, of whom 114 were randomly assigned and included in the final analysis [57 control and 57 intervention participants]. Participants were 64.9% male, 15% with HIV, 10.5% retreatment, and 5.3% homeless. Adherence to TB medication was comparable between the intervention arm [geometric mean percentage (GM%) 99.01%, geometric standard deviation (GSD) 1.02] and the control arm [GM% 98.97%, GSD 1.04] and was within the prespecified margin for non-inferiority [mean ratio (MR) 1.00 (95% CI 0.99-1.01); p = 0.954]. The intervention arm was significantly superior to the control arm in the secondary analysis that considered all take-home doses in the control were not ingested [control GM% 77.71 (GSD 1.57), MR 1.27 (95% CI 1.33-1.43)]. Urine isoniazid testing was done on 443 (97%) samples from 114 participants; 13 participants had at least one negative result; a negative test was significantly more common among the control group compared with the intervention group [11/57 (19.3%) vs 2/57 (3.5%); p = 0.008]. There was no significant difference between the control and intervention arms for smear conversion [55 (98.2%) vs 52 (100%); p>0.999], adverse treatment outcomes [0 vs 1 (1.9%); p = 0.48], and self-report non-adherence [5 (8.9%) vs 1 (1.9%); p = 0.21]. CONCLUSIONS In this randomized trial of patients with drug-sensitive pulmonary tuberculosis, medication adherence among participants assigned to MERM-observed self-administered therapy was non-inferior and superior by some measures when compared with the standard in-person DOT. Further research is needed to understand whether adherence in the intervention is primarily driven by allowing self-administered therapy which reduced challenges of repeated clinic visits or by the adherence support provided by the MERM system. To avoid contributing to patient barriers with DOT, tuberculosis medical programs should consider alternatives such as medication event monitors. TRIAL REGISTRATION ClinicalTrials.gov, NCT04216420.
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Affiliation(s)
- Tsegahun Manyazewal
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - Yimtubezinash Woldeamanuel
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - David P. Holland
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia 30322 USA
| | - Abebaw Fekadu
- Addis Ababa University, College of Health Sciences, Center for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), P.O. Box 9086, Addis Ababa, Ethiopia
| | - Vincent C. Marconi
- Emory University School of Medicine and Rollins School of Public Health, Atlanta, Georgia 30322 USA
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Thompson RR, Kityamuwesi A, Kuan A, Oyuku D, Tucker A, Ferguson O, Kunihira Tinka L, Crowder R, Turyahabwe S, Cattamanchi A, Dowdy DW, Katamba A, Sohn H. Cost and Cost-Effectiveness of a Digital Adherence Technology for Tuberculosis Treatment Support in Uganda. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2022; 25:924-930. [PMID: 35667781 DOI: 10.1016/j.jval.2021.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/19/2021] [Accepted: 12/02/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Digital adherence technologies like 99DOTS are increasingly considered as an alternative to directly observed therapy for tuberculosis (TB) treatment supervision. We evaluated the cost and cost-effectiveness of 99DOTS in a high-TB-burden setting. METHODS We assessed the costs of implementing 99DOTS in Uganda through a pragmatic, stepped-wedge randomized trial. We measured costs from the health system perspective at 5 of 18 study facilities. Self-reported service activity time data were used to assess activity-based service costs; other costs were captured from budgets and key informant discussions using standardized forms. We estimated costs and effectiveness considering the 8-month study period ("trial specific") and using a 5-year time horizon ("extended activities"), the latter including a "marginal clinic" expansion scenario that ignored above-site implementation costs. Cost-effectiveness was assessed as cost per patient successfully completing treatment, using Monte Carlo simulation, cost-effectiveness acceptability curves, and sensitivity analyses to evaluate uncertainty and robustness of results. RESULTS The total cost of implementing 99DOTS in the "trial-specific" scenario was $99 554 across 18 clinics (range $3771-$6238 per clinic). The cost per treatment success in the "trial-specific" scenario was $355 (range $229-$394), falling to $59 (range $50-$70) assuming "extended activities," and $49 (range $42-$57) in the "marginal clinic" scenario. The incremental cost-effectiveness of 99DOTS in the "extended-activity" scenario was $355 per incremental treatment success. CONCLUSIONS Costs and cost-effectiveness of 99DOTS were influenced by the degree to which infrastructure is scaled over time. If sustained and scaled up, 99DOTS can be a cost-effective option for TB treatment adherence support in high-TB-burden settings like Uganda.
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Affiliation(s)
- Ryan R Thompson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Alice Kuan
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Austin Tucker
- Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, USA
| | - Olivia Ferguson
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | | | - Rebecca Crowder
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Stavia Turyahabwe
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
| | - Adithya Cattamanchi
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - David W Dowdy
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA; Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Kampala, Uganda; Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
| | - Hojoon Sohn
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
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Leddy A, Ggita J, Berger C, Kityamuwesi A, Nakate AS, Tinka LK, Crowder R, Turyahabwe S, Katamba A, Cattamanchi A. Barriers and facilitators to implementing a digital adherence technology for tuberculosis treatment supervision in Uganda: A qualitative study (Preprint). J Med Internet Res 2022; 25:e38828. [DOI: 10.2196/38828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 09/22/2022] [Accepted: 03/31/2023] [Indexed: 04/03/2023] Open
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7
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Johnson CL, Schwartz H, Greenberg A, Hernandez S, Nnamani Silva ON, Wong LE, Martins DB, Broering JM, Kumar SB, Bongiovanni T, Wick EC, Roman SA. Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic. J Surg Res 2021; 264:30-36. [PMID: 33744775 PMCID: PMC7867400 DOI: 10.1016/j.jss.2021.01.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/19/2021] [Accepted: 01/22/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.
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Affiliation(s)
- Christopher L Johnson
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California
| | - Hope Schwartz
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California
| | - Anya Greenberg
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California
| | - Sophia Hernandez
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California
| | - Ogonna N Nnamani Silva
- School of Medicine, University of California San Francisco (UCSF), San Francisco, California
| | - Laura E Wong
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California
| | - Deborah B Martins
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California
| | - Jeanette M Broering
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California
| | - Sandhya B Kumar
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California; Department of Surgery, Zuckerberg San Francisco General Hospital (ZSFGH), San Francisco, California
| | - Tasce Bongiovanni
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California; Department of Surgery, Zuckerberg San Francisco General Hospital (ZSFGH), San Francisco, California
| | - Elizabeth C Wick
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California
| | - Sanziana A Roman
- Department of Surgery, University of California San Francisco (UCSF), San Francisco, California.
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Cattamanchi A, Crowder R, Kityamuwesi A, Kiwanuka N, Lamunu M, Namale C, Tinka LK, Nakate AS, Ggita J, Turimumahoro P, Babirye D, Oyuku D, Berger C, Tucker A, Patel D, Sammann A, Turyahabwe S, Dowdy D, Katamba A. Digital adherence technology for tuberculosis treatment supervision: A stepped-wedge cluster-randomized trial in Uganda. PLoS Med 2021; 18:e1003628. [PMID: 33956802 PMCID: PMC8136841 DOI: 10.1371/journal.pmed.1003628] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/20/2021] [Accepted: 04/14/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Adherence to and completion of tuberculosis (TB) treatment remain problematic in many high-burden countries. 99DOTS is a low-cost digital adherence technology that could increase TB treatment completion. METHODS AND FINDINGS We conducted a pragmatic stepped-wedge cluster-randomized trial including all adults treated for drug-susceptible pulmonary TB at 18 health facilities across Uganda over 8 months (1 December 2018-31 July 2019). Facilities were randomized to switch from routine (control period) to 99DOTS-based (intervention period) TB treatment supervision in consecutive months. Patients were allocated to the control or intervention period based on which facility they attended and their treatment start date. Health facility staff and patients were not blinded to the intervention. The primary outcome was TB treatment completion. Due to the pragmatic nature of the trial, the primary analysis was done according to intention-to-treat (ITT) and per protocol (PP) principles. This trial is registered with the Pan African Clinical Trials Registry (PACTR201808609844917). Of 1,913 eligible patients at the 18 health facilities (1,022 and 891 during the control and intervention periods, respectively), 38.0% were women, mean (SD) age was 39.4 (14.4) years, 46.8% were HIV-infected, and most (91.4%) had newly diagnosed TB. In total, 463 (52.0%) patients were enrolled on 99DOTS during the intervention period. In the ITT analysis, the odds of treatment success were similar in the intervention and control periods (adjusted odds ratio [aOR] 1.04, 95% CI 0.68-1.58, p = 0.87). The odds of treatment success did not increase in the intervention period for either men (aOR 1.24, 95% CI 0.73-2.10) or women (aOR 0.67, 95% CI 0.35-1.29), or for either patients with HIV infection (aOR 1.51, 95% CI 0.81-2.85) or without HIV infection (aOR 0.78, 95% CI 0.46-1.32). In the PP analysis, the 99DOTS-based intervention increased the odds of treatment success (aOR 2.89, 95% CI 1.57-5.33, p = 0.001). The odds of completing the intensive phase of treatment and the odds of not being lost to follow-up were similarly improved in PP but not ITT analyses. Study limitations include the likelihood of selection bias in the PP analysis, inability to verify medication dosing in either arm, and incomplete implementation of some components of the intervention. CONCLUSIONS 99DOTS-based treatment supervision did not improve treatment outcomes in the overall study population. However, similar treatment outcomes were achieved during the control and intervention periods, and those patients enrolled on 99DOTS achieved high treatment completion. 99DOTS-based treatment supervision could be a viable alternative to directly observed therapy for a substantial proportion of patients with TB. TRIAL REGISTRATION Pan-African Clinical Trials Registry (PACTR201808609844917).
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Affiliation(s)
- Adithya Cattamanchi
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- * E-mail:
| | - Rebecca Crowder
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Alex Kityamuwesi
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Noah Kiwanuka
- Department of Epidemiology and Biostatistics, School of Public Health, Makerere University College of Health Sciences, Kampala, Uganda
| | - Maureen Lamunu
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Catherine Namale
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Lynn Kunihira Tinka
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Agnes Sanyu Nakate
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Joseph Ggita
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | | | - Diana Babirye
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Denis Oyuku
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
| | - Christopher Berger
- Center for Tuberculosis and Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Austin Tucker
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Devika Patel
- The Better Lab, Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Amanda Sammann
- The Better Lab, Department of Surgery, San Francisco General Hospital, University of California San Francisco, San Francisco, California, United States of America
| | - Stavia Turyahabwe
- National Tuberculosis and Leprosy Program, Uganda Ministry of Health, Kampala, Uganda
| | - David Dowdy
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, United States of America
| | - Achilles Katamba
- Uganda Tuberculosis Implementation Research Consortium, Walimu, Kampala, Uganda
- Clinical Epidemiology and Biostatistics Unit, Department of Medicine, Makerere University College of Health Sciences, Kampala, Uganda
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