Promoting adherence to treatment for tuberculosis: the importance of direct observation

Since 1993, WHO has recommended a strategy through which national governments can meet their responsibility to treat patients and to prevent the spread of tuberculosis (TBI). Four of the major elements of the strategy, which came to be known as DOTS, were political commitment by governments, improved laboratory services, a continuous supply of good-quality drugs, and a reporting system to document the progress (and failure) of treatment for individual patients and of the programme. The fifth element, effective case management via direct observation of treatment by an independent and trained third party, was a response to decades of reports documenting the failure of patients to complete treatment. Put simply: direct observation of treatment is an integral and essential component of DOTS. The value of the direct observation component of DOTS has been questioned in a recent systematic review, in which it was suggested that direct observation of treatment is unnecessary and disrespectful of patients. Both self-administered treatment and treatment observation by a family member have been proposed as acceptable alternatives. This article challenges the validity of these assertions on the basis that, firstly, direct observation requires strong leadership and a lengthy commitment of human resources, which as yet is not universally employed. Secondly, it is believed that the ultimate ethical and legal responsibility for ensuring treatment completion and cure of a communicable disease belongs to the public health system and the community, and not to the individual patient. TB, this article will seek to argue, can be controlled when appropriate policies are implemented and continued, even in the absence of an outbreak or media attention. Just as patients may be tempted to change or stop an effective treatment regimen because of the long duration of treatment, public health policy-makers may be tempted to alter key elements of DOTS because of the persistence required to maintain effective programmes.