Tuberculosis patients who swallow their anti-TB pills under the watchful gaze
of doctors fare just as well as patients trusted to self-medicate, according to
a new analysis.
"Do we still need to observe patients taking their pills? Our findings are
that's probably not as useful and we could direct resources to other
interventions that would be more cost-effective," said study co-author Dr
Tawanda Gumbo, associate professor of medicine at the UT Southwestern Medical
The analysis of past research included 10 studies covering 8 774 TB patients
observed to take their pills and 3 708 TB patients who took treatments on their
For both groups, the researchers examined whether the bacteria that cause
tuberculosis remained after treatment, and whether patients relapsed or
developed a drug-resistant form of TB.
The patients did as well on all three counts whether health care workers
witnessed them swallowing their anti-TB pills or they were allowed to take the
pills on their own, Gumbo's group reports in the journal Clinical Infectious
Tuberculosis killed 1.4 million people worldwide in 2011, according to
estimates from the World Health Organization.
The global target of halving tuberculosis death rates between 1990 and 2015
will likely not be reached in Africa and Europe, WHO officials warn, and the
current 630 000 cases of multi-drug resistant TB have alarmed officials.
WHO adopted a system of government-supported infrastructure to ensure
standard diagnosis and treatment for TB patients, of which one component is
Personalised TB treatments
Observing patients taking their drugs, a resource-intensive practice, is
thought to help patients adhere to their medication regimens that last a minimum
of six months. Taking medications irregularly or stopping before the full
treatment course is completed can promote the development of drug-resistant TB
Critics of the pill-watching approach say, however, that allowing TB patients
to take their own medications is just as effective and costs less, and more
attention should be paid to improving the TB treatments themselves. "Let's take
those resources watching patients take their pills and start looking at why
patients are failing therapy and drug resistance remains," Gumbo said.
Gumbo proposes personalised TB treatments that move away from a
one-pill-fits-all approach. Since people metabolise TB drugs differently, the
doses and timing of their medications should be adjusted accordingly.
His group is currently estimating the cost savings and feasibility of a
personalised system in a population in South Africa."The system would be able to
recoup its cost via treating fewer drug-resistant tuberculosis patients," Gumbo
The new pill-watching analysis contributes to an ongoing debate over whether
doctor-observed treatment is worth the resources, experts said.
Directly observed therapy is more beneficial in richer countries like the US,
where the global TB epidemic is concentrated among a relatively small number of
recalcitrant patients, according to Dr William Bishai, director of the
KwaZulu-Natal Research Institute for Tuberculosis and HIV, an independent
research institute in Durban, South Africa.
In a poorer country like South Africa, where TB rates are nearly 300 times
that in the US, watching patients take pills may divert crucial resources.
"When you withdraw services such as directly observed therapy in a rich
country, the epidemic comes back with a vengeance," Bishai said. But, he said,
"It's a worthwhile debate as to the cost-benefit ratio between (directly
observed therapy) and self-administered therapy in a resource-poor country."
As for personalising TB treatment, Bishai is doubtful. If it's not cheap and
set up so "that someone in a dusty clinic in rural Africa can get the results in
an under-resourced clinic, then it's just not going to happen with current
resources," he said.
Some health experts advocate instead community-based approaches that avoid
making patients feel untrusted and patronised. In some cases, Bishai explained,
laypeople from the affected community, who are trained to act as something akin
to midwives, see new patients through the entire process from diagnosis to
"Direct observation in and of itself is not magical, it's an opportunity to
establish a relationship between a health care provider or trained layperson and
a patient," said Carole Mitnick, assistant professor of global health and social
medicine at Harvard Medical School.
Mitnick was not involved in the current study."If that is used as a broader
support system, direct observation certainly can have benefits," Mitnick