South Africa’s Northern Cape Province has around 547 new TB cases per 100 000 population each year. It may be impossible to provide directly observed treatment (DOT) for every TB patient in high burden settings. Are there effective alternatives to DOT? Should health facilities offer patients a range of treatment options?

The World Health Organisation (WHO) advises that all TB patients should receive their treatment under direct supervision by health workers. However, health facility-based DOT is often impractical due to the distances patients have to travel. Health workers often resort to giving patients their drugs to take home with them. But patients find it difficult to stick to self-administered therapy (SAT). An alternative is for members of the community, usually volunteers, to supervise patients’ treatment at home. Researchers from the UK’s University of Oxford and the Northern Cape Department of Health compared these three options.

The study involved 769 patients at 45 primary health care facilities - almost 20 per cent of all TB patients registered in the province during this time. Patients were given three treatment options:

• Clinic-based DOT – they visit the clinic five days in every week.
• Community-based DOT – they visit a volunteer’s home five days each week.
• SAT – they receive a monthly supply of anti-TB drugs to take home.

Questionnaires and follow-up studies of participants showed that:

• 83 per cent are new patients; the rest are receiving re-treatment.
• Just over half of returning patients are successfully treated compared with 70 per cent of new patients.
• The choice of treatment delivery option does not affect the outcome for new patients. Treatment success is most likely for those who live in a rural area, have secondary education, know about the duration of treatment and do not live in a shack.
• Patients are more likely to have successful re-treatment if they are supervised. Success is not linked to TB drug side effects.
• Re-treatment patients who completed their previous treatment are just as likely as new patients to have a successful outcome.
• Re-treatment patients who opt for community-based DOT are almost ten times more likely to have a successful treatment outcome than those who receive SAT.

The successful treatment outcome reported for new patients in this study is below the WHO target of 85 per cent, but is an improvement on rates in the province before the introduction of DOT. The study shows no added benefit of direct supervision for new patients. This suggests that other elements of the strategy, such as improved convenience and accessibility of TB services, may be more important.

The researchers highlight the importance of:

• providing treatment delivery options to patients on a voluntary basis
• telling patients how long treatment will last
• targeting treatment supervision at patients most likely to benefit from it.

Source(s):
‘Tuberculosis treatment delivery in high burden settings: does patient choice of supervision matter?’, International Journal of Tuberculosis and Lung Disease 6 (7): 599-608, by S. Kironde and M. Meintjies, 2002

Funded by: Sir Halley Stewart Trust (UK); UK Department for International Development

id21 Research Highlight: 16 October 2002

Further Information:
Samson Kironde
Sandown Mews East
88 Stella Street
Sandown, Sandton
P.O.Box 652767
Benmore 2010
South Africa

Tel: +27 (0) 82 883 5450
Fax: +27 (0)11 506 9009
Contact the contributor: skironde@hotmail.com

University of Oxford

Other related links:
See id21's collection of links relevant to infectious diseases.