E-DRUG: Cape Town meeting on new TB drugs (2)
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Wilbert,
I meant to make a brief comment on your earlier e-mail, in which you
commented that "DOTS is presented as "the answer" by WHO, but not all
research findings support that (Jimmy Vomink of the S. Africa Cochrane
Centre actually wrote a systematic review showing DOTS made no
difference)".
Unfortunately, WHO put the label "DOTS" on the recommended TB strategy
and created a lot of confusion, since many people now identify the
whole strategy (a 5-point policy package) with "DOT"
(i.e. simply a means of verifying patient adherence to treatment).
There is little, if any, debate about the 5-point policy package as the internationally
recommended TB control strategy: political commitment, diagnosis of
infectious cases based on smear microscopy, secure drug supply,
standardised treatment regimens, and recording of cases with reporting of
treatment outcomes for programme monitoring and evaluation.
The WHO and IUATLD recommendation is to ensure adherence at least in
the initial phase of treatment by directly observed treatment. This has
generated some debate. There has been lots published on adherence to
treatment, and we understand a lot about the sort of relationship that is
necessary between a TB patient and someone (trained and supervised
health worker or community member) who can support a TB patient
throughout the extremely lengthy course of treatment. I suspect that the sort
of relationship between TB patients and their supporters that will result in
patients adhering to treatment is one which enables the supporter to
observe and document each treatment dose. Reducing the complexities of
adherence to treatment to a mechanistic approach to observing tablets go
down the gullet probably isn't very helpful. In fact, Vomink was a co-author of
a paper in Lancet which showed exactly that - observing treatment without
paying attention to any of the elements necessary to support a patient and
promote adherence, not surprisingly made no difference to treatment
outcomes.
DOT/DOTS confusion!
Dermot Maher
DFID, UK
Email: D-Maher@dfid.gov.uk
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