"The article by Cox et. al. adds an important neglected component to
the never-ending controversy over the value of directly observed
therapy (DOT) for all TB patients. They found a lack of adequate data
regarding the long-term effectiveness of DOT, and noted suggestive
evidence that intermittent regimens lead to higher relapse rates.
However, this article, like almost all articles regarding adherence
to TB treatment regimens fails to mention a potential alternative
solution to the problem".

[For a review copy of this article, you may contact the editor of
the FORUM]

Long term efficacy of DOTS regimens for tuberculosis: systematic
review

Helen S Cox, PhD scholar1, Martha Morrow, research coordinator1,
Peter W Deutschmann, executive director1 1 Australian International
Health Institute, University of Melbourne, Carlton, VIC 3010,
Melbourne, Australia. Correspondence to: H S Cox, Macfarlane Burnet
Institute for Medical Research and Public Health, Melbourne, VIC
3004, Australia hcox@...

BMJ, doi:10.1136/bmj.39463.640787.BE (published 4 February 2008)

Abstract

Objective To identify published studies assessing tuberculosis
recurrence after successful treatment with standard short course
regimens for six months to determine the strength and sufficiency of
evidence to support current guidelines.

Design Systematic review.

Data sources Medline, Embase, Cochrane clinical trials register,
specialist tuberculosis journals, and reference lists. Only English
language publications were eligible.

Review methods Studies were included irrespective of methodology or
quality. Abstracted information included inclusion and exclusion
criteria for participants, duration of follow-up, and definitions of
treatment success and disease recurrence. The primary outcome was the
proportion of successfully treated patients recorded with recurrent
tuberculosis during the follow-up period.

Results 17 study arms from 16 studies met the inclusion criteria; 10
were controlled clinical trials and six were either studies done
under programmatic conditions or observational studies from
functioning tuberculosis programmes. Although several clinical trials
supported the use of daily treatment regimens, studies reporting
tuberculosis recurrence after intermittent regimens were limited. Few
studies carried out under routine programmatic conditions reported
disease recurrence. Overall there was wide variation in recurrence
after successful treatment, ranging from 0% to 14%. Considerable
heterogeneity across studies precluded the systematic assessment of
factors contributing to tuberculosis recurrence.

Conclusions Despite DOTS (directly observed treatment, short course)
being implemented for more than 10 years and millions of patients
treated for tuberculosis, few studies have assessed the ability of
standard DOTS regimens to result in lasting cure for patients treated
under routine programmatic conditions.