Direct Observational Therapy for the Treatment of Tuberculosis: A Review of Clinical Evidence and Guidelines [Internet]

Excerpt

Tuberculosis (TB) is an infectious disease caused by the bacteria Mycobacterium tuberculosis. It is transmitted between humans primarily through aerosols that are generated through the forceful expiration of air (e.g., coughing, sneezing). Infection with M. tuberculosis does not always result in active TB disease, producing instead an asymptomatic latent TB infection. People with latent TB cannot spread the disease to others, but they can develop active TB disease. Symptoms of active TB disease include a bad cough, fever, and weight loss.

The current treatment for active and latent TB involve long courses of antibiotic treatments, which often include more than one drug.^, Incomplete treatment adherence is a major challenge of TB treatment, and failing to complete the treatment can result in persistent disease or the development of drug-resistant TB. One of the strategies for improving adherence is directly observed or direct observational therapy (DOT).^– Standard DOT is conducted in person and involves directly watching the patient swallow each dose of medication. Compared to self-administered therapy, DOT has been shown to be effective, however, it is very resource intensive for both the patient and the health care service. It is unclear who should provide DOT, and whether this person needs to be a health care professional (e.g., public health nurse) or whether lay people can also provide DOT (e.g., family, community members). It is also unclear whether the location where DOT is administered is important. DOT could involve the patients returning to a health care facility every day (e.g., TB clinic, hospital), but it is also possible that DOT can occur at other locations (e.g., workplace, home). Alternatively, thanks to advances in technology, video observational therapy (VOT) is possible, where patients are observed taking their medication over video (often facilitated through a smart phone). VOT can occur in real time (i.e., synchronous VOT), or patients can record and submit videos (i.e., asynchronous VOT). VOT could help minimize resources for providing DOT, but there are some privacy concerns with VOT due to the technology.

The purpose of the current report is to summarize and critically appraise the relevant evidence regarding the provision of DOT for the treatment of TB. Additionally, evidence-based guidelines with recommendations regarding the use of DOT for the treatment of TB will be reviewed.

This report is a component of a larger CADTH Condition Level Review on TB. A condition level review is an assessment that incorporates all aspects of a condition, from prevention, detection, treatment, and management. For more information on CADTH’s Condition Level Review of TB, please visit the project page (https://www.cadth.ca/tuberculosis).