Treatment of tuberculosis

The importance of people taking medicines extends beyond individuals to communities when medicines are crucial for treatment of communicable diseases and prevention of transmission. In this editorial we discuss the relevance of the concept of concordance (a term introduced to emphasise patients' beliefs about treatment)¹ to the treatment of communicable disease, taking tuberculosis as an example. Tuberculosis is one of the leading causes of death due to an infectious agent, and the control of tuberculosis depends on effective treatment of the infectious patients, and therefore on people taking medicines.

The likelihood of successful treatment of tuberculosis depends on the extent to which patients complete the prescribed treatment regimen (usually called compliance with, or adherence to, treatment). Interrupted treatment of tuberculosis results in ongoing transmission of disease. Without support throughout the full course of treatment, many patients with tuberculosis adhere to treatment until symptoms have resolved and then stop, since patients may equate disease and therefore the need to continue treatment with illness (symptoms).² The consequent risks of failure of treatment, relapse, death, and drug resistance, threaten not only patients but also communities. Recognition in the 1950s of the importance of providing intensive support to patients with tuberculosis to promote adherence to treatment³ paved the way for later promotion of directly observed therapy (DOT) for adherence to treatment.⁴

Concordance refers to “the creation of an agreement between patient and healthcare provider about whether, when, and how medicines are to be taken.”¹ The applicability of concordance to treatment of a particular condition depends on the extent to which the implications of failure to take the medicines extend beyond the individual to the community. The “when” and “how” are clearly applicable to treatment of tuberculosis, but the applicability of “whether” is less clear on account of the above risks to the community of failure to take the medicines.

Approaches to control of tuberculosis need to promote the protection of individual civil liberties and of public health. Authorities have sometimes adopted authoritarian and coercive measures to ensure adherence to treatment (generally in high income countries with a low incidence of tuberculosis).⁵ In the United States, for example, New York City issued exceptional regulatory orders for compulsory treatment for 304 patients with tuberculosis (out of about 8000) over a two year period between 1993 and 1995.⁶ Of these 304 patients, 139 were detained, for varying periods up to two years (with a median of five weeks).⁶ Authoritarian and coercive approaches have been found unnecessary in some settings with a low incidence of tuberculosis⁷ and in our experience are almost unheard of in low income countries with high incidence of tuberculosis. The onus is on governments and health services to ensure adherence to treatment recommendations by health providers and to provide the resources and organisational requirements for the range of support measures necessary for patients with tuberculosis to be able to adhere to treatment without recourse to coercion.⁸,⁹

Adherence to treatment of tuberculosis is an integral part of overall patient care and of the overall framework for tuberculosis control. Thus DOT is an integral part of the WHO framework for control of tuberculosis, which constitutes the strategy known by the “brand name” DOTS (originally derived from Directly Observed Treatment, Short-course).¹⁰ The DOTS strategy consists of a five point policy package: political commitment, sputum smear microscopy for diagnosis of infectious patients, standardised short course (that is, rifampicin based) chemotherapy, secure drug supply, and a recording and reporting system. The DOTS strategy represents the basic minimum necessary for control of tuberculosis. Implementing the strategy requires flexibility, with adaptation to a broad range of contexts and community needs.¹¹

WHO recommends “standardised short-course chemotherapy... under proper case management conditions,” with the aim of adherence, completion of treatment, and therefore tuberculosis cure and prevention of drug resistance. These refer to a range of measures, including DOT, aimed at promoting treatment adherence and completion. These include placing the patient at the centre of activities for the control of tuberculosis, ensuring confidentiality and consideration of patients' needs, organising tuberculosis services so that the patient has treatment as close to home as possible, considering incentives, identifying potential problems, keeping accurate address records, and taking measures to deal with defaulters.

The long experience of promoting adherence to treatment of tuberculosis can inform the development of the concept of concordance. An agreement between a patient with tuberculosis and the healthcare provider reinforces their mutual contribution and responsibility to achieve successful treatment. Concordance is therefore a key step at the start of the dynamic process of supporting a patient with tuberculosis throughout treatment. The Bangladesh Rural Advancement Committee approach provides a good example of concordance. After signing a written agreement, the patient is supported by a community health worker throughout the full course of treatment, and the programme achieves a high cure rate (at least 85%).¹²

An enhanced concept of concordance embraces the initial agreement between patient and healthcare provider, and also measures for ongoing support for patients to enable them to complete treatment. This is relevant to successful outcomes of treatment of communicable and non-communicable disease.