Family observation of antituberculosis treatment – Authors' reply
Authors: James Newell, Sushil C Baral, Shanta B Pande, Dirgh Sing Bam, Pushpa Malla
Journal: The Lancet (2006)

Our study showed that tuberculosis treatment observation by family members provided better success rates than that by community volunteers in the hill districts of Nepal. We did not claim that family-member observation is therefore appropriate everywhere in the world: different contexts require different strategies. To identify context-appropriate strategies, capacity development for operational research in national tuberculosis programmes is needed. We support Thomas Frieden and John Sbarbaro's sentiments. However, we also make a plea for realism. We should remember that strategies that cause too great a burden to patients may not serve their intended purpose of not giving patients the opportunity to fail: instead, they will merely identify when failure has occurred. Each strategy will have a capacity to recover patients who take a break in treatment, but will also cause travel, expense, or inconvenience to patients that will affect their ability and willingness to start and complete treatment. We need to weigh these pros and cons fairly rather than consistently emphasising the former while ignoring the latter. In our trial we found no evidence that people outside the family structure are more likely to provide valid information and take appropriate action when patients decline or forget treatment: quite the reverse. We believe that people outside the family often only provide observation, while families are more likely to provide support, thereby averting the need for supervisors to take action to address breaks in treatment. Observing a strategy to be ineffective in a few contexts does not mean it should never henceforth be considered: just as showing a strategy to be effective in some contexts clearly does not guarantee it will be effective in every context. Prasanta Mohapatra and Ashok Janmeja suggest that control programmes do not usually enrol patients without proof of residence. If this is so, such patients will be excluded irrespective of the type of observation provided. We would suggest that any programme that does not enrol homeless patients needs to review its strategy. We have frequently noted that health workers find it difficult to explain to patients why they must come every day to receive their drugs. If we use such strategies, we must have a credible response: otherwise we damage our relationships with patients from the outset. We declare that we have no conflict of interest. Family observation of antituberculosis treatmentJames Newell and colleagues (March 18, p 903)1 report successful outcomes of direct observation of antituberculosis treatment by family members in remote mountainous areas with limited health-care access, combined with training, patients' education, weekly supervisory visits, and visits to patients by research staff. However, they should also report cure and relapse rates and outcomes for patients who received health-centre observation. Also needed is information (eg, outpatient visits, sputum examinations, and sputum positivity) to suggest whether the lower detection rates in areas with family observation relate to lower health-sector and community awareness. Full-Text PDF Family observation of antituberculosis treatmentIn the study by James Newell and colleagues,1 the cure rate for tuberculosis was 85% in the health-worker DOTS group and 89% in the family-member DOTS group. It seems that family-member DOTS is more effective than health-worker DOTS. What is the evidence for this? Another randomised controlled study2 in the same region (southeast Asia) showed that health-worker DOTS, family-member DOTS, and self-administered treatment strategies gave very similar cure rates of 64%, 55%, and 62%, respectively. Both studies were done in similar conditions. Full-Text PDF