By Mary Ono, Army Public Health NursingFebruary 28, 2018
HONOLULU (February 26, 2018) - At Tripler Army Medical Center, direct observation therapy, or DOT, has become a "game-changer" in the treatment of latent tuberculosis infection (LTBI), a tuberculosis-related condition that if left untreated could become tuberculosis disease, or TB, one of the most contagious diseases in the world.
The treatment for LTBI has long been nine months of a prescription medication called Isoniazid as the "gold standard." The prescription medication Rifampin has been an alternative treatment option for patients who could not tolerate Isoniazid, or if Isoniazid was contraindicated.
But a third option became available to the Army community in 2012, when the combination of prescriptions, Isoniazid and Rifapentine, administered in a 12-dose weekly regimen under DOT, was accepted into the formulary at TAMC.
Direct observation therapy is important in military populations because when a Soldier deploys, the previous medication options of daily-dosing Isoniazid or Rifampin is discontinued, since there is not a way to monitor for progress or potential adverse reaction(s). There are also limited resources to refill their monthly medication while Soldiers are "outside the wire" downrange.
Unpredictable and multiple deployment schedules can also interfere with successful treatment of LTBI with Isoniazid or Rifampin. When a Soldier returns from deployment, usually a nine-month absence, the medication must be restarted as "day one" again. A Soldier may be deployed a second or third time, and due to this "stop-start" pattern, he or she could be taking this medication for years before successfully completing months of treatment.
Treatment is the only way to remove the TB from the body. DOT has not only shortened the time required to successfully complete LTBI treatment, but also has enhanced compliance of treatment.
However, ultimately, three options remain for every patient in determining how to treat LTBI. The decision for treatment with DOT for 12 weeks, Isoniazid for nine months, or Rifampin for four months, is determined by reviewing a patient's current use of medication(s), the medical history, drug allergy history, results of baseline lab work, expectant treatment completion as foreseen by the patient's schedule, and preference of the patient and the Army Public Health nurse practitioner.
If DOT is chosen as the best treatment option, patients visit either TAMC or the Schofield Barracks Army Public Health Nursing Clinic, exclusively, to take their medication by direct observation. If a patient's schedule does not allow for attending weekly visits or the 12-dose weekly regimen, then Isoniazid or Rifampin daily dosing on their own becomes the better option.
If DOT has to be discontinued due to adverse reactions, patients must understand that their safety is paramount and that successful treatment means completing four months or nine months of treatment comfortably without side effect or injury.
DOT is not for everyone, but it is certainly a good option when available. Army Public Health Nursing has a 100 percent treatment compliance rate. Those who do not finish direct observation therapy, or those who are having adverse reactions and are switched to monotherapy are not considered compliance issues.
DOT has changed TAMC practice because the demographic that the center serves is more likely to complete 12 weeks of treatment compared to nine months. The success of the LTBI program is the direct result of having staff who are focused on the patient and patients who are engaged in their treatment.
TAMC's Army Public Health Nursing staff is committed to the success of each patient's regimen.