Three Times Weekly Anti-tuberculosis Treatment of Category 1 and Category 11 Patients of Pulmonary Tuberculosis Under Directly Observed Therapy (dots)

THREE TIMES WEEKLY ANTI-TUBERCULOSIS				2
TREATMENT OF CATEGORY 1 AND CATEGORY 11				12
PATIENTS OF PULMONARY TUBERCULOSIS UNDER				69
DIRECTLY OBSERVED THERAPY (DOTS)				65
STRATEGY IN RURAL AREAS OF SINDH,				Mean
PAKISTAN.				1.0000
AUTHORS:				2.0000
DR: BHURGRI GHULAM RASOOL				3.0000
DR: SHAMIM-UR-REHMAN				4.0000
DR: MOMINA TAKI MUHAMMAD				5.0000
DR: SHAH MURAD MASTOEE.				6.0000
DR: RAJ KUMAR CHOHAN.				Std. Error of Mean
DR: DAHRI GHULAM MUSTAFA.				.00000
DR: FAISAL KHAN.				.00000
DR: ATIF SHEIKH.				.00000
ABSTRACT:				.00000
OBJECTIVE:				.00000
The purpose of this study was to evaluate three				.00000
times weekly anti-tuberculosis treatment (ATT) for				Median
both category 1 and category 11 patients of				1.0000
pulmonary tuberculosis under directly observed				2.0000
therapy to cut the cost and time required for ATT.				3.0000
PLACE AND TIME:				4.0000
This study was conducted at TB clinic, Muhammad				5.0000
Medical College Hospital Mirpurkhas, sindh, Pakistan,				6.0000
from July 2005 to June 2007				Std. Deviation
Patients and Methods:				.00000
130 patients were enrolled for study. 70 patients of				.00000
category 1 and 60 patients of category11 pulmonary				.00000
TB who promised to come regularly for treatment				.00000
three days a week for eight months. Patients were				.00000
given antituberculosis drugs three days a week under				.00000
strict observed therapy strategy for eight months				Frequency Table
according to World Health Organization guide lines for				� category type one patients of tuberculosis
treatment of tuberculosis 2003.				Frequency
Results:				Percent
At the end of eight months in category1, out of 70				Valid Percent
patients 67 patients (96%) were cured, 3 patients				Cumulative Percent
(4%) who were sputum smear positive at the start				Validcatone
of ATT remained sputum positive. In category 11 out				70
of 60 patients, 53 patients (88%) were cured, 7				97.2
patients (12%) remained smear positive. Over all cure				100.0
rates for both categories 1 and 11 was 92%.				100.0
CONCLUSION:				Missing
Three times a week ATT is as effective as daily				System
regimen of ATT. It must be given under strict DOTS				2
strategy. It saves 65-7-% of drug cost and time as				2.8
compared to daily regimens.				Total
Key words: Anti-tuberculosis treatment ATT				72
Directly Observed Therapy Short				100.0
Course DOTS.				� categry two patients of tuberculosis
Address for correspondence:				Frequency
(2) Dr:Ghulam Rasool Bhurgari				Percent
Assistant Professor				Valid Percent
Department of Pharmacology and Therapeutics				Cumulative Percent
Muhammad Medical College				Validcattwo
Mirpurkhas, Pakistan				60
0333 2871918.				83.3
0345-3702876				100.0
E-mail INTRODUCTION:				100.0
Nearly one third of the global population i.e. two billion				Missing
people are infected with mycobacterium Tuberculosis				System
and at risk of developing the disease. More than eight				12
million people develop active tuberculosis (TB) every				16.7
year and about million die (2).This problem is worse in				Total
Pakistan. There are no reliable data on the incidence				72
and death caused by TB. It seems to be increasing				100.0
every year. Although TB affects all classes of people,				� three patients
it is more prevalent in the poor especially of the				missed
productive ages of 22-55 years, causing great				Frequency
financial burden and misery to their families.				Percent
DOTS(Directly Observed Therapy Short course) was				Valid Percent
introduced in 1993 by World Health				Cumulative Percent
Organization(WHO) DECLARED TB A GLOBAL				Validtrees
EMERGNCY IN RECOGNITION OF THE GROWING				3
IMPORTANCE AS A PUBLIC HEALTH PROBLEM.(1)				4.2
A component of case management that helps to				100.0
ensure that patients adhere to therapy is DOT.DOT				100.0
means that a health care worker or another				Missing
designated person watches the patient swallow each				System
dose of TB medication. DOT ensures an accurate				69
account of how much medication the patient really				95.8
took. DOT should be considered for all patients				Total
because clinicians are often inaccurate in predicting				72
which patient will adhere to medication regimens on				100.0
their own. DOT has been shown to be effective				� seven patients missed in cat two
when intermittent regimens are used. DOT can				Frequency
significantly reduce the frequency of development of				Percent
drug resistant and of treatment failure or relapse				Valid Percent
after the end of treatment. Treatment for drug				Cumulative Percent
susceptible TB can be given intermittently if they are				Validsvn
directly observed. Using intermittent regimens redress				7
the total number of encounters with the Health				9.7
worker, making these regimens more cost effective.				100.0
(3)				100.0
Intermittent ATT given three times a week is as				Missing
efficacious as daily therapy.Isoniazid; Rifampin,				System
Pyrazinamide, and Streptomycin are all efficacious				65
when given three times weekly as when given daily.				90.3
This finding should not be surprising, because				Total
Mycobacterium tuberculosis doubles in 18-24 hours,				72
compared with 12-20 minute for most bacteria(4).				100.0
DOTS has been employed with success UN many				FREQUENCIES
countries. We conducted this study under DOTS				VARIABLES=catone cattwo senty sixty tree svn
strategy to see the results of three days a week				/STATISTICS=STDDEV SEMEAN MEAN MEDIAN
regimens to get better results with less cost.				/PIECHART FREQ
PATIENTS AND METHODS:				/ORDER= ANALYSIS .
Criteria for enrolling the patients for study:				Pie Chart
1. Patients who fulfilled the World Health
Organization (WHO)diagnostic criteria for category
1(Patients who have never received treatment for
TB) and category 11(Retreatment of ,relapse,
treatment failure, smear positive who have taken
ATT more than one month and defaulted)pulmonary				1. Sputum smear negative for AFB on three
tuberculosis (WHO) guidelines for national				occasions.
programmed treatment of tuberculosis 2003.				2. Radiological opacities on x-ray chest had cleared or
2. Patients and their family promised to come				healed by fibrosis and calcification.
regularly thrice a week for eight months.				3. Had gained weight.
130 patients were enrolled for study.70 patients of				4. E.S.R had fallen to normal limits.
category 1 and 60 patients of category11.Out of 70				5. Hb had risen.
patients of category1, 40 patients (57%) were				6. Patient was symptoms free and doing his job.
sputum smear positive and 30 patients (43%) were				In category 1 67 (96%) patients out of 70
sputum smear negative.				cured.3 patients (4%) who were sputum positive at
In category 11 out of 60 patients, 10 patients				the start of ATT remained sputum smear positive. In
(17%)were previously treated for 8 months,6 of				category 11 53 patients (88%) out of 60 were
these patients were sputum smear positive.50				cured.7 (12%) remained sputum positive as they
patients had interrupted their treatment after more				were at the onset of ATT. Over all cure rate in both
than one month. In category 11 36 patients (60%)				categories 1and 11 was 92%.
was sputum smearing positive and 24 patients (40%)				DISCUSSION:
were sputum smear negative.				The global target for successful treatment of new
Out of the total 130 patients there were 70 male				sputum smear patients is 85% or more (5) .Average
(54%) and 60 females (46%).Their ages ranged from				treatment success among national DOTS programs is
16-65 years. 80% of the patients were between 20				82% close to the 85% global target. (6)We achieved
and 55 years of age.				the cure rate of 96% for category 1, 88% for
MANAGMENT:				category 11 pulmonary TB patients and overall cure
1. COUNCILLING:				rate in both categories 1 and 11 was 92%.
A. The patient and his family were informed about				The result is better than the global target for national
TB disease, its spread, progress and treatment.				programs set by WHO. This may be because our
Regular treatment for 8 months will cure the patient.				total number of patients was small and few
Irregular treatment or interruption of treatment				multi-drug- resistant (MDR) cases were enrolled.
before 8 months will make the disease resistant to				We think our high cure rate is due to the fact that
treatment and chances of cure will diminish.				during this trail we did not let any patient miss even a
B. Diet: Advised to eat everything available. Diet				single dose of medicine. Council ling on every visit
should increase every day some patients are given				was useful. We had to scare the patient that if, he
drugs to stimulate appetite. Few patients needed				misses even a single dose of medicine he will not be
short course of corticosteroids.				cured. He will die coughing up blood and no medicine
C. Emphasis was on regular visits and not to miss				will help.
treatment at all.				Patient’s family was told that successful
Patients and their family's contact numbers and				treatment of the patient is in their interest also
address were noted.				otherwise they will catch the disease from the
2. Drug Treatment: All the patients were given				patient.
treatment 3 days a week under DOTS strategy. The				DIET ALSO PLAYED A BIG ROLE:
drugs were given as separate drugs and doses were				On every visit the patient was weighed and advised
calculated according to weight of the patients as				to increase his daily consumption of food. Some very
recommended by WHO guidelines for treatment of				anorexic patients were given tonics and steroids.
tuberculosis 2003 for 3 days week regimen.				DOT'S strategy does not just mean giving medicines
In category 1 during initial phase months Rifamicin,				under peon's supervision. Doctor and his team
Isoniazid, Pyrazinamide and Ethambutol were given				treating the patient should win the confidence of the
and during continuation phase of six months				patient by care, sympathy, concern and politeness so
Rifampcin, Isoniazid, and Ethambutol were given.				that patient can complete his ATT without
In category 11 patients, during initial phase of two				interruption. This will increase the cure rate and
months Rifamicin, Isoniazid, Pyrazinamide,				reduce development of MDR.
Ethambutol and Streptomycin were given. In 3rd				CONCLUSION:
months initial phase Streptomycin was stopped and				3 days a week ATT for category 1 and category 11
other four drugs were continued. During continuation				pulmonary patients under a caring and strict DOTS
phase of 5 months Ionized, Rifampin, and Ethambutol				strategy is more effective and less costly than half
were continued				heartily supervised daily regimen.
.				If the total consumption of drugs for 8 months with
3. On every visit:a. Patient was attended straight				3 days a week regimen is compared with that of
away on arrival with greetings and enquired about his				daily regimen for 8 months there is a saving of
health, family and job.b. Temperature and weight				65-70% in cost and time.
recorded. Patients not gaining weight were advised to				This means that with the amount allocated by
increase the diet. Some were given drugs to				Government for TB control, as many as three times
stimulate appetite and few given corticosteroids.c. A				more patients can be treated. It also means that only
glass of water and medicine given under supervisiond.				40% sincere and dedicated personal can do better
Any co-existent illness was also treated.e. On leaving,				job than being done at present.
patient was reminded about the next visit. If he				KEY MESSAGE:a) All
cannot come then medicine were given to his family				patients of category 1 and 11 pulmonary tuberculosis
member to give the patient under his supervision.				can be treated successfully with 3 days a week ATT
The patient was made to feel that we care for him				regimen under DOTS
and want him to get better.				strategy.b) 3 days a
PROGRESS: X-RAY CHEST, ESR,Hb, and soutum				week ATT saves 65-70% money and
smear for A.F.B were repeated at 2 months, 5				time,c) DOTS strategy
months and end of treatment at 8 months.				can improve results if employed with sincerity and
RESULT:				�
After completion of eight months of ATT, the				REFERNCES:
following criteria were taken for cure.				1 Guideline for National tuberculosis programs
� Statisticscategory type				on management of tuberculosis, World Health
one patients of tuberculosiscategry two patients of				Organization 2003
tuberculosisseventy patients in cat onesixty patients				2 Dye C etal. Global burden of
in cat twothree patients missedseven patients missed				tuberculosis:estimated incidence, prevelence and
in cat two				morbidity by country. JAMA 1999, 282(7):677-678
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Valid				200 US Department of health and human services.
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70				5 An expanded DOTS framework for effective
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3				2002.297.Geneva:World Health Organization global
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				6 Global tuberculosis control,
Missing				planning,financing.WHOreport 2005. WHO/HTM/TB
2				2005.49.Geneva(Switzerland);World Heath Org.
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Three Times Weekly Anti-tuberculosis Treatment of Category 1 and Category 11 Patients of Pulmonary Tuberculosis Under Directly Observed Therapy (dots)