The Baltimore City Health Department program of directly observed therapy for tuberculosis

To address the vexing problem of treatment completion for tuberculosis patients, the Baltimore City Health Department (BCHD) in 1981 implemented a community outreach strategy employing directly observed therapy (DOT). By 1995, the incidence of tuberculosis in Baltimore had declined 61.7%. This BCHD program has reduced the need for patient incentives by providing nearly 90% of all DOT at either the patient's home, workplace or school; or drug treatment facility, city jail, or nursing home. Today, the proportion of all TB cases in Baltimore receiving DOT through the program approaches 90%, treatment completion rates exceed 90%, sputum-conversion rates among DOT-managed cases are nearly double the rates of privately treated cases, and drug resistant organisms remain rare (0.57% of all isolates, 1989-1993). This article describes the interworkings of this community-based program.