Community-based DOT Leads to Greater Treatment Success for Tuberculosis Compared to Clinical DOT
Why is community-based DOT for treatment of tuberculosis important?
Tuberculosis (TB) is a global health concern which kills nearly two million people per year. The World Health Organization recommends that tuberculosis treatment be delivered by directly-observed-therapy (DOT) in order to maximize patient adherence to treatment. When DOT is performed in a clinical setting, there may be barriers such as travel or cost which can prevent the patient from accessing treatment. Community-based DOT may be a method of circumventing these barriers and improving treatment outcomes.
Does community-based DOT improve treatment outcomes?
- Community-based DOT was determined to have greater treatment success (defined by the sum of cured patients and patients with completed treatment, from WHO definitions) compared to clinical DOT
- There was no difference between community-based DOT and clinical DOT for loss to follow-up (defined as a patient who did not start treatment or whose treatment was interrupted for two or more months)
Equity - Does community-based DOT work for the disadvantaged?
- The studies included in the review were conducted in low- and middle-income countries (India, Iraq, South Africa, Tanzania, Thailand, and Zambia) where TB is most prevalent. The results should be applicable in similar settings.
- Eight studies were used for the review, four of the studies were in urban areas, two in rural areas, and two in mixed areas. Overall, community-based DOT lead to greater treatment success in both urban and rural settings.
Intervention Delivery
- Conventional TB treatment regimen delivered either by Community-based DOT or clinical DOT for TB.
- Community-based DOT may involve organised community groups, peer groups, chosen members of the community, or family members acting as supervisors of the treatment. Treatment was observed daily by the community member for regimens lasting from 2 to 8 months.
Population and Setting
- TB patients (there was no restriction on the type of TB), both men and women (6 studies did not mention age of patients, 1 study was with patients ages 15 and up, and 1 study was all ages), who were receiving either community-based DOT or clinical DOT.
- Both urban and rural settings were included. Most clinical settings were health centres within the village of the patient. Several of the community-based programs involved volunteers performing the DOT at the patient’s home.
Summary of Findings [SOF] Table:
Patient or population: TB patients both men and women
Settings: low- and middle-income countries, both urban and rural settings
Intervention: Community-based DOT
Comparison: Clinical DOT
Outcomes | Anticipated percentage of patients | Odds Ratio | No of Participants | Quality of the evidence | ||
Percentage with clinical DOT (95% CI) | Percentage with community-based DOT (95% CI) | |||||
Treatment Successa | 70.94 (69.22 -72.63) | 78.44 (76.57 - 80.22) | 1.54 (1.01 - 2.36) | 8 (4,676) | + & ++ | |
Loss to Follow-Upb | 12.16 (10.91 - 13.50) | 13.59 (12.04 - 15.27) | 0.86 (0.48 - 1.55) | 7 (4,171) | + & ++ | |
About quality of evidence (GRADE) High quality (++++): Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality (+++): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality (++): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality (+): We are very uncertain about the estimate. | ||||||
a Treatment success was defined as the sum of cured patients and patients with completed treatment, using WHO definitions
b Loss to Follow-up was defined as any patient who did not start treatment or whose treatment was interrupted for two or more months
Relevance of the review for disadvantaged communities
Findings | Interpretation |
Equity – Which of the PROGRESS groups examined |
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Studies were conducted in low- and middle- income countries (India, Iraq, South Africa, Tanzania, Thailand, and Zambia)
| There is a higher prevalence of TB in low- and middle-income countries and innovative treatment approaches may decrease prevalence in these endemic areas. The study provides evidence demonstrating that community-based DOT may lead to increased treatment sucess in rural and urban seettings in both low-income and middle-income countries. The included studies were deemed low quality and thus results should be interpreted with caution. |
No other PROGRESS-plus groups were examined in the review. | |
Equity Applicability |
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The review did not analyze the effects of community-based DOT vs Clinical DOT across marginalized groups such as those who are HIV+, homeless, or street involved. In addition, the review did not discuss the intervention in children or pregnant women. | The impact of community-based DOT may differ in marginalized populations, studies should therefore target these groups and identify any variations in effect. |
Cost-equity |
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The review mentions the direct and indirect costs associated with DOT and cites several studies that indicate higher costs for clinical DOT compared to community-based DOT. | Costs play a major role in patient adherence to treatment, as such, the study and development of treatment plans should include cost-effectiveness analyses. Community-based DOT may offer a more cost-effective alternative to clinical DOT. |
Community/Stakeholder Preferences |
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Community-based DOT was shown to have increased treatment success compared to clinical DOT. | Community programs designed to supply tuberculosis treatment may have an increased impact on treatment success compared to programs outside of the community setting. The capacity of the community to provide these programs should be analysed when developing them.
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Comments on this summary? Please contact Jennifer Petkovic.
This summary was prepared by Nicholas Lebel