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Evidence Based Medicine Indian Pediatrics 1999;36: 1285-1286 |
Adherence to Anti-Tuberculosis Treatment |
| The pillars of an effective TB control program are to identify and effectively treat sputum smear positive cases of TB. Since the advent of TB chemotherapy, controlled clinical trials have yielded two basic principles: (i) regimens for the treatment of TB must contain multiple drugs to which the infecting organism is susceptible; and (ii) regular drug ingestion must continue for a sufficient period of time(1). In the past 20 years, regimens with varying drug combinations, efficacy, cost and duration, ranging from 4 to 24 months, have been proposed for treating new smear-positive cases of TB. The administration frequency of these regimens varied from daily to twice weekly, with or without supervision. Despite the availability of efficacious and potentially effective anti-tuberculosis drugs, the overall cure rate in most developing countries has often been below 50%(2). Directly observed treatment refers to the practice of giving patients their pills and seeing that they are swallowed(1). TB patients who do not complete a standard course of antitubercular therapy are at increased risk of treatment failure and contribute to both the emergence of drug-resistant strains of Mycobacterium tuberculosis and the further spread of TB. As a way of achieving high rates of treatment completion and of preventing drug resistance, directly observed treatment has been almost unanimously recommended for treating TB in the published literature(3-6). However, the directly observed treatment strategy for TB should ideally be based on cost effectiveness, with careful consideration of local conditions and culture. It should not be assumed that any type of directly observed treatment, under any circumstances, will do more good than harm. Due to its expensive nature, this type of approach has been offered some alternatives. A systematic review by Volmink and Garner(7) has dealt with various strategies to promote adherence to anti-tuberculosis treatment. The objective of the review was to determine the effectiveness of strategies used to promote adherence to anti-tuberculosis treatment. Using the standard search strategy for Cochrane reviews, the authors also contacted experts in the fields of TB and adherence research. Randomized or pseudo-randomized con-trolled trials of interventions to promote compliance with curative and preventive chemotherapy for TB, with at least one measure for adherence were included. Data on study methods, participants, interventions and outcomes were collected for each study and methodological quality was assessed. Estimates of effect were assessed for categorical outcomes using the Peto Odds ratio, with 95% confidence intervals. The analyses showed beneficial strategies to be: reminder cards sent to defaulters, assistance of patients by lay health workers, monetary incentives offered to patients, and increased supervision of TB clinic staff. It was not possible to determine from current trials whether health education by itself leads to better adherence to treatment. Even though directly observed therapy (DOT) is widely advocated as the most cost-effective means of ensuring completion of TB treatment, no completed trials could be found which confirm or refute this view. Thus RCT evidence exists that certain strategies improve adherence to anti-tuberculous therapy, and these should be adopted into clinical practice depending on their appropriateness to practice circumstances. Further innovations should be tested to find solutions that will be useful in low-income countries. Randomized trials evaluating the independent effects of directly-observed therapy (DOT) are awaited. Meenu Singh, References 1. American Thoracic Society/Centers for Disease Control. Treatment of tuberculosis and tuberculosis infection in adults and children. Am J Resp Crit Care Med 1994; 149: 1359-1374. 2. Leowsky J. The role of short-course chemotherapy in National Tuberculosis Control Program in developing countries. WHO Regional Office for the Western Pacific, Working Group on Short-Course Chemotherapy for Tuberculosis, Aug 22-26, 1988. 3. American Thoracic Society/Centers for Disease Control. Treatment of tuberculosis and tuberculosis infection in adults and children. Am Rev Respir Dis 1986; 134: 355-363. 4. Consensus Conference on Tuberculosis. Chest 1985; 87 (Suppl); 115S-149S. 5. WHO. Treatment of Tuberculosis: Guidelines for National Programmes. Geneva: World Health Organization, 1993. 6. Weiss ES, Slocum PC Blais FX. The effect of directly observed therapy on the rates of drug resistance and relapse in tuberculosis. N Engl J Med 1994; 330: 1179-1184. 7. Volmente J, Garner P. Promoting adherence to tuberculous treatment. The Cochrane Library 1998, Issue 2, Update Software, Oxford, UK. |
