Family members observe TB treatment in rural Nepal

Direct observation of treatment is a key component of the DOTS strategy for tuberculosis (TB) control. Until very recently World Health Organization (WHO) guidelines have actively discouraged supervision of drug-taking by family members. But research in Nepal suggests this could be a useful strategy in remote areas.

The aim of superviseddrug-taking is to help TB patients complete treatmentand to prevent resistance to anti-TB drugs. Previous WHO guidelines recommendedthat health workers should observe treatment, but also accepted supervisionof treatment in the community. The most recent 2006 guidelines suggest thatobservation of treatment by a family member may also be considered.

Direct observation oftreatment by health workers is not suitable for areas with poorly accessiblehealth services, such as parts of Nepal, where nationwide about 60 percent of adults areinfected with TB and more than 80,000 have active disease. Observationby family members could address concerns such as the cost, inconvenience andstigma associated with visiting a health centre or community volunteer, andsupport patients to complete treatment.

Researchers from the UK'sUniversity of Leeds and Nepal's Health Research and Development Forum (HERD) comparedtwo strategies in hill and mountain districts of Nepal:

• In five districts,female community health volunteers or village health workers supervised dailydrug-taking by 549 patients and received drug supplies every month.
• In another fivedistricts, 358 patients took drugs under the daily supervision of their chosen householdmember, who received drug supplies every week.

Key results of the study are:

• Community andfamily-based DOTS have success rates (cure or completed treatment) of 85 and 89percent, respectively. The family member strategy significantly exceeds the WHOtarget of 85 percent.
• Non-completionand death rates are similar in the two groups.
• The estimatedproportion of expected new TB cases found through the community strategy is 63percent and 44 percent with family-member DOTS, substantially lower than theWHO target of 70 percent.

These results show that bothstrategies can reach international targets for treatment success underprogramme conditions. They might also be suitable in other parts of the world where directobservation of treatment by health workers is not feasible due to difficultterrain, isolated areas or conflict. However, overall HIV rates are low inNepal, so these results may not apply to areas of high HIV prevalence.

One advantage of family-memberDOTS over the community-based strategy is that it does not involve volunteers.In Nepal and many other countries, volunteers are becoming increasinglyoverloaded as many different health programmes request their help. Adisadvantage is that health workers are distanced from day-to-day contact withtheir patients, so any problems may take time to be identified. To avoid this,the researchers recommend health staff should:

• ensure that treatmentobservers record and report drug side effects to them
• encouragepatients to discuss their constraints and needs every time they see them
• periodically visit a sample of patients at home to discuss theseissues.

The researchers conclude thatimplementers of DOTS strategies should work with patients and communities toidentify and remove constraints to access to care. However, they warn that modifiedDOTS strategies should not be implemented without initial operational researchto make sure they meet international targets.