PHA-Exchange> Seeing pill-swallowing no TB cure

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From:<jawad at alumni.washington.edu>

Seeing pill-swallowing no TB cure
---------------------------------

Latest review of directly observed therapy paints the healthcare
policy as ineffective, stirs existing controversy

http://www.the-scientist.com/news/display/23335/
[Published 19th April 2006 04:36 PM GMT]

Directly observed therapy (DOT) -- a controversial technique in
which health care workers or community volunteers watch patients
swallow tablets -- does not have a significant impact on tuber-
culosis patients, according to a new report from The Cochrane
Library. Still, DOT remains a central tenet of international
recommendations for curbing the spread of treatment-resistant
bacteria, and experts say they are unconvinced that clinicians
should abandon the technique.

However, "at the end of the day, it's difficult to argue that
DOT would be dramatically better than self-treatment," Paul Gar-
ner, an author of the review and head of the International
Health Research Group at the Liverpool School of Tropical Medi-
cine, told The Scientist. "It's not a magical kind of approach
that is central to ensuring adherence."

Faced with a treatment regimen of at least six months, tubercu-
losis patients are particularly at risk of non-adherence, con-
tributing to the spread of treatment-resistant bacteria, accord-
ing to Dick Menzies, at McGill University in Montreal. To ad-
dress this problem, the World Health Organization (WHO) recom-
mends DOT as a central part of its five-part strategy for global
TB control, introduced in 1994. Many programs use DOT, and ex-
perts say the strategy can help caretakers form positive rela-
tionships with their patients. But others argue that DOT is not
cost-effective and demoralizes patients.

In the recent report, the authors reviewed ten randomized, con-
trolled trials with a total of 3985 participants in low-, mid-
dle-, and high-income countries that directly compared DOT to
self-administration of treatment. They found no statistically
significant difference in the number of TB patients cured or the
number of treatments completed. What's more, they reported no
evidence of DOT benefiting those who receive prophylaxis for a
latent form of the disease. DOT can be seen as paternalistic and
unnecessarily time-consuming, and clinicians should focus on
other techniques, Garner said. "[It] does tie up an awful lot of
staff time if you're directly observing every dose being taken,"
he said.

However, experts say this latest report is not the last word on
whether or not DOT works. Thomas Frieden, Commissioner of the
New York City Department of Health, told The Scientist that 22
million people have been treated with DOT, and results from
clinical trials do not match real-world data, which capture bet-
ter how well the technique works. For instance, data gathered
internationally outside clinical trials on relapse rates, death
rates, and drug resistance show that "DOT is an essential compo-
nent of scaling up an effective program," said Frieden, who has
championed the strategy in New York City. In particular, public
health programs in Texas, New York, and Baltimore have reported
that implementing DOT has made "drastic differences," Frieden
added.

Though DOT may be "important," said Garner, there likely has to
be "a whole menu of different things that are used to help en-
sure adherence, not just direct observation. For example, if
somebody defaults on an outpatient appointment, get someone to
chase the defaulter." He has penned previous reviews about DOT,
which have produced similar conclusions to the recent report.

Garner argued that by recommending DOT along with many other
strategies to control TB -- such as meal tickets for the home-
less and other incentives -- the WHO "helped contribute to the
confusion" about what DOT alone does to fight TB, perhaps caus-
ing some clinicians to overstate its importance. "In the US, DOT
programs.have loads and loads of other things they do for the
patient besides the direct observation," he said. "It's all
those other things that are terribly important."

"If it's a bad program, DOT won't be a magic bullet," Menzies
agreed. He said that he and his colleagues administer DOT on a
case-by-case basis, making decisions based on risk factors --
such as IV drug use or psychiatric illness -- that suggest that
a patient may not make his or her health a priority.

Frieden, however, said that, in his experience, adherence rarely
correlates with patient characteristics, making it impossible to
predict who needs DOT. As a result, his office continues to of-
fer DOT to all New Yorkers with TB, and he estimates about 80%
take it.

Ishani Ganguli
mailto:iganguli at the-scientist.com

Links within this article:

J. Volmink and P. Garner, "Directly observed therapy for treat-
ing tuberculosis," The Cochrane Database of Systematic Reviews,
2006 http://www.cochrane.org/

Paul Garner
http://www.liv.ac.uk/lstm/research/InternationalHealthResearch.htm

E. Russo, "Turning back the tuberculosis tide," The Scientist,
May 23, 2005.
http://www.the-scientist.com/article/display/15477/

Dick Menzies
http://www.respdiv.mcgill.ca/respepi/Menzies.htm

Thomas Frieden
http://www.nyc.gov/html/doh/html/commish/combio.shtml

J. Volmink et al., "Directly observed therapy and treatment
adherence," Lancet, 355:1345-50, April 15, 2000. PM_ID: 10776760

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