DOTS under the microscope in the fight against Tuberculosis

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The resurgence of tuberculosis worldwide and the concern about multi-drug resistance, has fuelled the debate as to how effective Direct Observed Therapy (DOT) is ,among patients with tuberculosis. Maintaining treatment adherence for the duration of treatment is paramount in the fight to cure tuberculosis and prevent resistant strains from appearing. So far, the only strategy is DOT.

The first line treatment requires a combination of antibiotics. Taking them daily for at least a few months can be a chore that many patients may not be able to keep up with. So how effective is DOT?

This systematic review with meta analysis showed that DOT is not superior to Self Administered Therapy (SAT). There is also no statistical difference between DOT done by family members or community health workers and that done at a health facility.

Should we then throw the DOT strategy out the window?

Not so fast. There are some valid arguments against the validity of these results.

Those patients entering these trials are under quasi-supervision, even if they are in the SAT arm. They are also likely more motivated. The real value of DOT is realised where motivation to treatment is less in low- income populations. The heterogeneity of field conditions makes generalisation questionable. Perhaps more studies are needed especially in less privileged areas.

Educational background was not looked into. Illiteracy and a low socioeconomic status can promote non-adherence. The value of recognising adverse drug reactions in DOT was also not looked into.

DOT is a way of keeping track of patients to ensure adherence to therapy. Doing it right and not succumb to complacency is important to attain maximum effectiveness. Continuing education is important to ensure the community understands the perils of non-adherence to drugs. More studies are still needed to look into better and more efficient ways of attaining high medication adherence. In this era of digital technology, a solution which is cost effective, efficient and acceptable may be just round the corner.

Surendra Sharma, Saket Jha, Directly observed treatment is not the only solution for poor adherence and low cure of tuberculosis, Evid Based Med October 2015 ,volume 20, number 5 , DOI 10.1136/ebmed-2015-110247