Watching Every Dose
Watching a patient swallow every dose became the world's standard for treating tuberculosis, but does the watching itself cure anyone? A Czech epidemiologist who caught TB in a concentration camp built the system in Tanzania, and World Bank arithmetic, a WHO emergency declaration and a four-letter brand spread it. The best randomized trials, summarized by Cochrane in 2015, did not clearly show that watching alone raised cure rates.
Who's who
- Karel StybloCzech epidemiologist who built the Tanzania program model
- Arata KochiLed the WHO's small tuberculosis unit in the early 1990s
- Kraig KlaudtWHO officer credited with the strategy's brand and slogan
- Payam NahidUCSF physician and lead author of the 2016 U.S. guideline
- C. Patrick ChaulkBaltimore physician who led community-based observed therapy
- Thomas Frieden+1 more episodeDefended direct observation in a 2007 WHO Bulletin article
- Jimmy VolminkCo-author of Cochrane reviews of observed therapy
- Paul GarnerCo-author of Cochrane reviews of observed therapy
Where it happens
- Tanzania+1 more episodeFirst country in the Union-supported national TB program model
- Mauthausen-Gusen, AustriaConcentration camp where Styblo contracted TB
- Tarrant County, TexasBegan observing nearly every patient's treatment in 1986
- Baltimore, Maryland+5 more episodesBegan community-based observed therapy in 1981
- Alaska+11 more episodesRuns observed therapy village by village with lay observers
Timeline
- 1978 to 1991The Union supports national TB programs in nine high-burden countries, beginning with Tanzania
- April 1993The WHO declares tuberculosis a global emergency
- May 21, 1993A federal advisory council recommends observed therapy be considered for all U.S. patients
- March 1995The WHO launches its branded strategy
- May 29, 2015Updated Cochrane review covers eleven trials and 5,662 participants
- August 2016Updated U.S. guideline conditionally suggests observed over self-administered therapy
Still debated
Cochrane reviews found watching alone did not clearly improve cure, while defenders say the trials implemented it poorly and did not measure relapse. Whether it prevents resistance and relapse is unsettled, and contact and case management may be the real active ingredient. Lives-saved estimates count the whole strategy.