Direct Observation (DO) for Drug-Resistant Tuberculosis: Do We Really DO?
Direct Observation (DO) for Drug-Resistant Tuberculosis: Do We Really DO?
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DOI：
10.1371/journal.pone.0144936
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发表时间：
2015-12-29
期刊：
影响因子：
3.7
通讯作者：
Furin, Jennifer
中科院分区：
文献类型：
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作者：
Benbaba, Stella;Isaakidis, Petros;Furin, Jennifer
前言直接观察疗法(DOT)是耐药结核病(DR-TB)患者在整个治疗过程中推荐的治疗方法。然而，关于在现场实施直接观测(DO)的公开证据有限。这项研究旨在详细说明在印度孟买的无国界医生(MSF)结核病计划中，DR-TB患者是否遵循了DO。为了确定DO是如何实施的，来自12名患者、5名DOT提供者和5名家庭成员的有目的地选择的子集的现有定性数据被评估。2014年6月至8月期间，完成了对DR-TB患者、他们的DOT提供者和无国界医生组织工作人员的问卷调查。如果DOT提供者看到患者“每天”或“大部分时间”吞下他/她的药物，患者被定义为“遵循严格的DO”和“遵循DO”。如果没有遵循DO，也记录原因。结果纳入70名DR-TB患者、65名DOT提供者和21名MSF卫生人员。55%的患者是艾滋病毒合并感染，41%的患者对多药耐药结核病加上对氟喹诺酮类药物的额外耐药性。在所有患者中，只有14%(10/70)和20%(14/70)的患者自我报告“严格遵循DO”和“遵循DO”。在DOT提供者中，46%(30/65)的人报告他们的患者“遵循了DO”。无国界医生组织的卫生工作人员报告说，这些患者中没有一人“遵循了DO”。没有实施DOT的原因包括DOT提供者不可用、花费的时间、耻辱和治疗不良事件。定性数据还显示，严格的DO很少被遵循，并指出了缺乏实施的相同原因。结论这项混合方法研究发现，孟买大多数DR-TB患者没有遵循DO，这是患者和护理人员报告的。这些数据可能反映了在许多高负担环境中实施DO的现实情况，因为这个相对较小的队列得到了能够访问多种资源的熟练团队的支持和密切监控。这些发现引起了人们对DO作为耐药结核病治疗“支柱”的必要性的重要关注，这需要在其他环境中进一步验证。他们还建议，以患者为中心的依从性策略可能是支持患者接受治疗的更好方法。
IntroductionDirectly-observed therapy (DOT) is recommended for drug-resistant tuberculosis (DR-TB) patients during their entire treatment duration. However, there is limited published evidence on implementation of direct observation (DO) in the field. This study aims to detail whether DO was followed with DR-TB patients in a Medecins Sans Frontieres (MSF) tuberculosis program in Mumbai, India.MethodsThis was a cross-sectional, mixed-methods study. Existing qualitative data from a purposively-selected subset of 12 patients, 5 DOT-providers and 5 family members, were assessed in order to determine how DO was implemented. A questionnaire-based survey of DR-TB patients, their DOT-providers and MSF staff was completed between June and August 2014. Patients were defined as "following Strict DO" and "following DO" if a DOT-provider had seen the patient swallow his/her medications "every day" or "most of the days" respectively. If DO was not followed, reasons were also recorded. The qualitative data were analysed for theme and content and used to supplement the questionnaire-based data.ResultsA total of 70 DR-TB patients, 65 DOT-providers and 21 MSF health staff were included. Fifty-five per cent of the patients were HIV-co-infected and 41% had multidrug-resistant-TB plus additional resistance to a fluoroquinolone. Among all patients, only 14% (10/70) and 20% (14/70) self-reported "following Strict DO" and "following DO" respectively. Among DOT-providers, 46% (30/65) reported that their patients "followed DO". MSF health staff reported none of the patients "followed DO". Reasons for not implementing DO included the unavailability of DOT-provider, time spent, stigma and treatment adverse events. The qualitative data also revealed that "Strict DO" was rarely followed and noted the same reasons for lack of implementation.ConclusionThis mixed-methods study has found that a majority of patients with DR-TB in Mumbai did not follow DO, and this was reported by patients and care-providers. These data likely reflect the reality of DO implementation in many high-burden settings, since this relatively small cohort was supported and closely monitored by a skilled team with access to multiple resources. The findings raise important concerns about the necessity of DO as a "pillar" of DR-TB treatment which need further validation in other settings. They also suggest that patient-centred adherence strategies might be better approaches for supporting patients on treatment.