Correspondence
Directly Observed Treatment of Tuberculosis
N Engl J Med 1993; 329:135-136July 8, 1993
- Article
To the Editor:
Iseman and colleagues (Feb. 25 issue)1 recommend that every patient with tuberculosis in the United States receive directly observed therapy. In 1984 the Mississippi State Department of Health began a pilot program in one of its nine districts. This approach was welcomed by public health nurses, who had been frustrated by frequent treatment failure and prolongation of therapy due to noncompliance. The program was surprisingly well received by patients and physicians alike. Directly observed therapy is now the standard for all patients receiving therapy for tuberculosis through the department (more than 99 percent of all patients being treated in the state). In total, 96 percent of all patients with tuberculosis are undergoing directly observed therapy. We believe that its use has contributed to the continued fall in the rates of tuberculosis in Mississippi at a time when they are rising nationally. In 1984, there were 380 newly diagnosed cases of tuberculosis in Mississippi. By comparison, in 1992 there were 281.
1 ReferencesRobert L. Hotchkiss, M.D.
Mississippi State Department of Health, Jackson, MS 392151
Iseman MD ,Cohn DL ,Sbarbaro JA . Directly observed treatment of tuberculosis -- we can't afford not to try it. N Engl J Med 1993;328:576-578
Full Text | Web of Science | Medline
To the Editor:
The proposal of Iseman et al. is predicated on conditions of health care delivery specific to Denver. Substantial modification will be needed to apply directly observed treatment elsewhere.
New York State has begun the financing and implementation of a program of directly observed treatment. Fewer than 30 percent of all patients with active tuberculosis in New York City and New York State come to local health-department clinics for their care. A successful program must therefore recruit and retain providers and establish sites of service outside the traditional sphere of public health. Such sites include centers for treating substance abuse and human immunodeficiency virus infection, shelters, soup kitchens, parole programs, community health centers, and hospitals.
The structure of directly observed therapy must also vary with site and circumstance. Some patients in methadone-maintenance programs attend a clinic five days a week, others three days a week, and others once a week. Programs of intermittent therapy should be devised around such varying schedules and use existing routines. The Denver model presumes that all 62 doses of antituberculosis medication will be provided by a registered nurse. The nursing staff will never exist to provide this level of care to the more than 4500 patients with new cases of active tuberculosis reported in 1992 in New York State. Trained nonmedical personnel can provide most of the required services, with oversight to ensure an acceptable quality of care. Community outreach workers from the populations being served can most effectively establish the trust and rapport necessary to maintain the lengthy course of treatment for drug-resistant tuberculosis. . . .
George T. DiFerdinando, Jr., M.D., M.P.H.
Susan J. Klein, M.S.
Lloyd F. Novick, M.D., M.P.H.
New York State Department of Health, Albany, NY 12237To the Editor:
The overlap of the epidemics of tuberculosis and drug use offers an opportunity to treat tuberculosis through drug-treatment facilities. Of 361 patients with tuberculosis seen at our institution over a four-year period, 165 (46 percent) had a history of using injectable drugs and 68 (19 percent) were enrolled in methadone-maintenance programs.1 The use of these programs to provide directly observed therapy to patients with chemical dependency who have tuberculosis would be an efficient means of increasing available tuberculosis-treatment services while subjecting patients to minimal additional restrictions or inconvenience. Patients enrolled in methadone-maintenance programs who are found to have tuberculosis should receive antituberculous therapy when they receive their methadone, and opiate users with tuberculosis should be fast-tracked into methadone programs. . . .
1 ReferencesDavid C. Perlman, M.D.
Nadim Salomon, M.D.
Beth Israel Medical Center, New York, NY 10003Author/Editor Response
The authors reply:
To the Editor: Although some perceive directly observed therapy as a draconian measure, we submit that its adverse effects on the individual and society are substantially less than the effects of two years of treatment of tuberculosis at a sanitarium, which was prevalent just three decades ago.
Two of us consulted with authorities in Mississippi as they were developing their program of directly observed therapy. We are most gratified to see it come to fruition. Although other elements presumably had a role in the reduction in the number of cases of tuberculosis in Mississippi, we believe that supervised treatment contributed greatly to this trend.
Dr. DiFerdinando and colleagues raise salient issues about the applicability of the Denver model to other settings. We agree wholeheartedly that there are many variations on this theme. We encourage local authorities and clinicians to devise programs and methods suited to their needs and assets1. With respect to the oversight of treatment, we calculated costs with the use of data on nurses, to produce a high-range estimate of expenses. In fact, we have employed lay community workers for much of the outreach efforts throughout the 25-year history of directly observed treatment in Denver. Not only is this approach more economical, but it is also more feasible (in terms of the number of nurses required). The use of lay community workers is potentially more effective (in terms of finding persons who have more flexibility and comfort in moving about local communities) and affords the indirect benefit of creating meaningful jobs in financially distressed areas. The recent initiation of a National Institutes of Health-sponsored nationwide trial of tuberculosis treatment that emphasizes intermittent, directly observed therapy is also helpful.
Drs. Perlman and Salomon identify a vital issue in tuberculosis treatment: the concordance of substance abuse and tuberculosis. Given the aspects of human nature that beget noncompliance with tuberculosis therapy, asking patients to visit multiple sites to receive methadone for opiate abuse or disulfiram for alcoholism, as well as medication for tuberculosis, poses a high risk that one or more programs will fail. Tuberculosis treatment should be integrated into substance-abuse programs. Some patients may be at high risk for the acquisition of tuberculosis in these settings, however. Thus, great care must be taken that patients with tuberculosis are screened carefully and their disorder is determined to be noncontagious. In addition, environmental controls2 must be in place (ventilation and ultraviolet germicidal irradiation) in case patients with infectious disease do slip through.
2 ReferencesMichael D. Iseman, M.D.
National Jewish Center for Immunology and Respiratory Medicine, Denver, CO 80206David L. Cohn, M.D.
Denver Department of Health and Hospitals, Denver, CO 80204John A. Sbarbaro, M.D., M.P.H.
University of Colorado Health Sciences Center, Denver, CO 802621
Prevention and control of tuberculosis in US. communities with at-risk minority populations and prevention and control of tuberculosis among homeless persons: recommendations of the Advisory Council for the Elimination of Tuberculosis. MMWR Morb Mortal Wkly Rep 1992;41:RR-5
2
Iseman MD . A leap of faith: what can we do to curtail intrainstitutional transmission of tuberculosis? Ann Intern Med 1992;117:251-253
Web of Science | Medline
- Citing Articles (2)
Citing Articles
1
Marcia McDonnell, Joan Turner, Michael T. Weaver. (2001) Antecedents of Adherence to Antituberculosis Therapy. Public Health Nursing 18:6, 392-400
CrossRef2
R. Bayer, D. Wilkinson, R. Bayer. (1995) Directly observed therapy for tuberculosis: history of an idea. The Lancet 345:8964, 1545-1548
CrossRef
