Engaging community pharmacists in tuberculosis-directly observed treatment: a mixed-methods study

AIM

This study aimed to evaluate the feasibility of implementing community pharmacy-based tuberculosis-directly observed treatment (TB-DOT) in Malaysia.

BACKGROUND

Tuberculosis (TB) eradication is one of the top priorities in the public health agenda in Malaysia. While public-private mix (PPM) initiatives have been launched, community pharmacists remain undervalued assets in TB management.

METHODS

A two-phase mixed-methods study targeting community pharmacists was conducted in Malaysia between March and October 2021. The first phase was an online self-administered survey developed according to the Consolidated Framework for Implementation Research (CFIR). The second phase was a semi-structured interview to allow deeper understanding on the quantitative results. Quantitative data were analysed using descriptive analysis while qualitative data were analysed using thematic analysis with a semi-inductive approach. The data were triangulated to enhance comprehensiveness and credibility of the findings.

FINDINGS

The survey was completed by 388 community pharmacists, and 23 pharmacists participated in the interview. Most community pharmacists indicated their willingness to serve as TB-DOT supervisors (70.1%). Qualitative results supported the findings. Community pharmacy-based TB-DOT service was perceived as an avenue to improve TB management and outcomes and to enhance the professional role of pharmacists in TB service at primary care settings. This was also perceived as a feasible intervention with the potential to strengthen the National TB Control programme. This initiative needs be reinforced with adequate support from the public healthcare sector for a strong partnership in ensuring success.

Directly Observed Weekly Fluoxetine for Major Depressive Disorder Among Hemodialysis Patients: A Single-Arm Feasibility Trial

Rationale & Objective

Major depressive disorder (MDD) is common among hemodialysis patients, but treatment can add to their pill burden and may be limited by nonadherence. We sought to investigate the value of directly observed, once-weekly fluoxetine dosing in MDD.

Study Design

Feasibility trial of adult hemodialysis patients with untreated MDD. The diagnosis of MDD was determined using the Mini International Neuropsychiatric Interview.

Setting & Participants

16 patients at 15 hemodialysis facilities in Northeast Ohio.

Intervention

Patients were initially prescribed 20 mg of fluoxetine once daily for 2 weeks to assess their tolerance. The patients took this daily fluoxetine unobserved at home. They were then transitioned to 90 mg of fluoxetine once weekly for 10 weeks. The patients took this weekly fluoxetine during hemodialysis treatment and were observed by the study staff. The dose was increased to 180 mg once weekly among patients with an inadequate response based on the judgment of the prescribing clinician.

Outcomes

Mini International Neuropsychiatric Interview diagnosis of MDD at the end of the trial and changes in the Patient Health Questionnaire (PHQ-9) scores over 12 weeks.

Results

One patient withdrew from active treatment after 2 daily doses of 20 mg of fluoxetine because of side effects of stomach cramping, vomiting, dizziness, and lightheadedness but completed the baseline and final assessments. The remaining 15 patients received all scheduled weekly fluoxetine doses during the trial. At 12 weeks, 14 of 16 patients (87.5%) no longer met the criteria for MDD (P < 0.001). Among all participants, the mean PHQ-9 scores decreased from 11.3 to 6.6 (P = 0.002).

Limitations

Small sample size, modestly elevated baseline PHQ-9 scores, no comparison group, and short treatment duration.

Conclusions

Directly observed, once-weekly fluoxetine may be an effective and well-tolerated treatment option for hemodialysis patients. Future research should investigate longer-term health outcomes of weekly fluoxetine in this population and explore the feasibility of implementing this depression treatment model in routine clinical practice.

Trial Registration

This trial was registered at clinicaltrials.gov as NCT03390933.

Treatment Interruption Among Drug-Susceptible Pulmonary Tuberculosis Patients in Southern Ethiopia

BACKGROUND

Tuberculosis treatment interruption is a failure of attending two scheduled appointments to collect the drugs in either phase of tuberculosis treatment. Even if TB treatment is crucial to achieve a cure and avoid the emergence of drug resistance, treatment interruption is the most testing and deterring factor for successful tuberculosis treatment and one of the problems leading to the development of drug-resistant tuberculosis. TB treatment interruption is the precursor for loss to follow-up and treatment failure, but the magnitude of this problem is unknown in Ethiopia. Thus, this study was intended to identify determinants of treatment interruption among drug-susceptible pulmonary tuberculosis patients in South Ari district, Southern Ethiopia.

METHODS

An institution-based unmatched case control study was conducted from February through April 2020 using 255 samples with a ratio of 2:1 (controls to cases). Data were entered into Epi data version 4.2 and exported for analysis using STATA 14.0 statistical software. The variables having a p-value of less than 0.25 in the bivariable analysis were subjected to multivariable logistic regression analysis. In multivariable logistic regression analysis, AORs, 95% CIs, and p-values of <0.05 were used to identify significant variables.

RESULTS

The median age was 34 (IQR: 18) years in cases and 29 (IQR: 16) years in control groups. Significant factors that were associated with treatment interruption were alcohol consumption (AOR = 2.99, 95% CI; 1.41-6.36); smoking habits (AOR = 2.82, 95% CI; 1.14-6.94); use of traditional medicine (AOR = 2.35, 95% CI 1.05-5.24); co-infected with HIV (AOR=1.58, 95% CI; 1.85-4.29), and waiting time at the health facility ≥30 minutes (AOR = 2.98, 95% CI; 1.31-6.80).

CONCLUSION

Alcohol consumption, waiting time at the health facility ≥30 minutes, smoking habits, used traditional medicine, and HIV co-infected were potential determinants. Enhancing public health education, designing strategies that emphasize patients with HIV co-infection, and reducing waiting times are recommended.

Transmission and prevalence of drug-resistant tuberculosis in a Brazilian setting under a directly observed therapy short-course strategy

INTRODUCTION

We aimed to estimate the prevalence and transmission of drug-resistant tuberculosis in a high-burden Brazilian setting under directly observed therapy short-course strategy.

METHODS

Isolates of culture-confirmed pulmonary tuberculosis patients from Guarulhos, Brazil, diagnosed in October 2007-2011 were subjected to drug susceptibility and IS6110-restriction fragment length polymorphism testing.

RESULTS

The overall resistance prevalence was 11.5% and the multi-drug resistance rate was 4.2%. Twenty-six (43.3%) of 60 drug-resistant isolates were clustered. Epidemiological relationships were identified in 11 (42.3%) patients; 30.8% of the cases were transmitted in households.

CONCLUSIONS

Drug-resistant tuberculosis was relatively low and transmitted in households and the community.

Treatment on Trial: Tanzania's National Tuberculosis Program, the International Union against Tuberculosis and Lung Disease, and the Road to DOTS, 1977-1991

Tanzania's national tuberculosis control program, created in 1977, is credited with having been the main inspiration for the World Health Organization's Directly Observed Treatment, Short-Course (DOTS) strategy for the control of tuberculosis, which was implemented from 1994. The text focuses on what previously took place in Tanzanian tuberculosis control between 1977 and the early 1990s. What was it that the International Union against Tuberculosis and Lung Disease, which was central in the effort, assisted in creating? In what sense was the program innovative? How could a country whose health system was destroyed by a deepening economic crisis in the 1980s become a lighthouse of tuberculosis control? How much consideration was given to the rise of HIV/AIDS that occurred in parallel? The paper proposes answers to these questions, and suggests that we should see the creation of the Tanzanian program as a laboratory of nascent global health.

Comparison of tuberculosis treatment outcomes by method of treatment supervision in the Fiji Islands

SETTING

The National Tuberculosis Programme (NTP) in Fiji.

OBJECTIVE

To determine anti-tuberculosis treatment outcomes stratified by method of treatment supervision (i.e., self-administered treatment [SAT] vs. supervision by a family member).

DESIGN

A retrospective descriptive study of all tuberculosis (TB) patients registered with the NTP in Fiji between January 2011 and June 2013.

RESULTS

Of 563 TB patients registered, information on the type of treatment supervisor was available for 470 (83%). Of these, most (n = 401, 85%) had their treatment supervised by a family member, while 69 (15%) elected SAT. SAT patients had a treatment success rate of 79.4% compared to 88.5% in those supervised by a family member; the difference was statistically significant (P = 0.0374).

CONCLUSION

Anti-tuberculosis treatment outcomes were more likely to be successful in patients who were supervised by a family member than in SAT patients. As this method of treatment supervision is not likely to be resource-intensive, we recommend that it continue in Fiji. Further prospective operational research could be carried out to determine patient preferences for anti-tuberculosis treatment supervision in Fiji, to promote a patient-centred approach.

Ethical Issues in Tuberculosis Control

Tuberculosis (TB) remains a major global public health problem as also defined by the World Health Organization (WHO). On the other hand, the incidence of TB worldwide decreases at a lower rate than the intended targets, and it is seen that the targets set for 2015 will not be achieved at the global level. According to the WHO, failure to achieve the targets in TB control results from "resource constraints", "conflict and instability" and "generalized human immunodeficiency virus epidemics". This article is aimed to maintain an ethical debate in TB control and to investigate the WHO's TB control policy and question the reasons for failure of this policy. Within the scope of this article; the TB of TB control was problematized at macro political level within the context of philosophy, while the approach of health care staff to TB patients was analysed at micro level within the context of professional ethics.

Prevalence of Diabetes Mellitus among Tuberculosis Patients in Urban Puducherry

Background:

Diabetes and Tuberculosis often present together and complicate each other at many levels. A collaborative framework for care and control of diabetes and tuberculosis developed by World Health Organisation and International Union against Tuberculosis and Lung Diseases emphasizes routine bi-directional screening for the two diseases.

Aims:

The study was to assess the prevalence of diabetes in tuberculosis patients currently on treatment.

Materials and Methods:

This facility-based cross-sectional study was undertaken in four randomly selected peripheral health institutions providing directly observed treatment short-course, treatment for tuberculosis patients. All cases of tuberculosis, more than 18 years of age were screened for diabetes. Risk factors like age, sex, family history of diabetes, alcohol, smoking and obesity were assessed.

Results:

The prevalence of diabetes in tuberculosis patients was found to be 29% (known diabetics - 20.7%, new Diabetes cases - 8.3%). Diabetes was significantly associated with older age, family history of diabetes, consumption of alcohol and sputum positivity.

Conclusions:

Screening patients with Tuberculosis for fasting blood sugar estimation will help in early detection of diabetes

Revised National Tuberculosis Control Program regimens with and without directly observed treatment, short-course: A comparative study of therapeutic cure rate and adverse reactions

Objective:

To compare the therapeutic cure rate and adverse reactions in the regimens of the Revised National Tuberculosis Control Program (RNTCP) with directly observed treatment, short-course (DOTS) and without DOTS.

Materials and Methods:

Fifty patients in the DOTS regimen and 50 patients in the non-DOTS regimen were enrolled in the study. All the participants were asked to come regularly for 3 consecutive days for sputum collection, and the sputum samples were examined for acid-fast bacilli. If tuberculosis (TB) was confirmed, the disease status was confirmed through a chest X-ray (PA view). The participants were monitored for adverse events arising from the use of anti-TB drugs for the next 6 months.

Results:

The TB cure rates for RNTCP with DOTS and RNTCP with non-DOTS were 80% and 66%, respectively. The DOTS therapy had a better cure rate for radiologically positive, sputum-positive cases compared with the non-DOTS regimen group. The non-DOTS treatment regimen had significantly increased numbers of adverse events in the hepatic and hematinic systems.

Conclusion:

The DOTS regimen has higher cure rates and a lower incidence of adverse reactions compared with the non-DOTS regimen.

Prevalence of multidrug resistance among retreatment pulmonary tuberculosis cases in a tertiary care hospital, Hyderabad, India

Background:

India is one of the high tuberculosis (TB) burden countries in the world. India ranks second in harboring multi drug resistant (MDR)-TB cases. About 50,000 of MDR cases are recorded in retreatment pulmonary TB cases. This study was conducted in a tertiary care facility (Government General and Chest Hospital) in Hyderabad, India.

Objectives:

Toassess: Proportion of the TB patients having MDR-TB at the initiation of retreatment regimen; the prevalence of isoniazid (INH) resistance in this geographical area.

Materials and Methods:

An analytical, observational, prospective cohort study of patients attending the out-patient department from December 2010 to March 2011.

Results:

Sputum samples from 100 patients were subjected to acid fast bacilli (AFB) culture and drug sensitivity testing. Of these, 28 (28%) were MDR-TB, 42 (42%) were non-MDR-TB and 39% being INH resistance.

Conclusions:

In conclusion, one third of the retreatment pulmonary TB cases attending a tertiary care institute for TB will be MDR-TB at the initiation of treatment and there is a need to include ethambutol in the continuation phase of new TB case treatment in view of high INH resistance.

A community-based cluster randomized controlled trial of "directly observed home-based daily iron therapy" in lowering prevalence of anemia in rural women and adolescent girls

In a community-based cluster randomized controlled trial, we randomly assigned clusters of anemic women and adolescent girls to either "directly observed home-based daily iron therapy" (DOHBIT; n = 524 in 16 villages) or unsupervised self-treatment at home (n = 535 in 16 villages) for a period of 90 days. Those in the DOHBIT group, when compared with those in the unsupervised self-treatment group, had significantly lower relative risk (RR) of anemia (16.8% vs 35.3%, RR = 0.47 [95% confidence interval (CI) = 0.33-0.65]; P < .0001), higher hemoglobin (Hb) rise of ≥2 g/dL (70.2% vs 42.2%, RR = 1.56 [95% CI = 1.31-1.87]; P <.0001), and nonsignificant trend for lower side effects (3.5% vs 6.7%, RR = 0.49 [95% CI = 0.22-1.08; P < .08) on intention-to-treat analyses. On linear mixed model analysis, the subjects in the intervention group demonstrated higher mean Hb levels (13.01 vs 12.32 g/dL; P < .0001) and higher adherence to iron therapy (93% vs 60%; P < .0001). DOHBIT is effective in lowering the prevalence of anemia in rural women and adolescent girls.

Motivating health workers for the provision of directly observed treatment to TB patients in rural China: does cash incentive work? A qualitative study

As a key component of DOTS (directly observed treatment, short course) strategy, DOT is essential in the prevention of drug-resistant tuberculosis. However, DOT had very poor implementation in rural areas of China. One major reason to this problem was the lack of incentives for DOT providers. In 2005, the Chinese Minister of Health released an incentive strategy that aimed to improve the DOT performance of rural health workers by providing allowances. Our study used a qualitative method to explore the practical impact of this incentive strategy in motivating rural DOT providers, and searched for other potential incentive measures as well. A total of 16 focus group discussions were carried out among 102 rural health workers in eight counties of China. A semi-structured theme outline was used to collect the perception, attitude and experiences of health workers toward the DOT implementation as well as the cash incentive strategy. Findings showed that DOT allowance had some incentive effect to DOT providers, but its extent was circumscribed by the small amount and operational problems. Raising DOT allowance and removing existing barriers to DOT provision might result in a greater motivational impact, particularly in less developed areas of China, where health workers were more likely to encounter financial and other obstacles in delivering DOT services to TB patients in rural areas.