Comparison of tuberculosis treatment outcomes by method of treatment supervision in the Fiji Islands.

In the Pacific Islands region, which covers a vast area of 22 countries and territories in the Pacific Ocean, tuberculosis (TB) remains an important health problem, resulting in a significant burden of morbidity and mortality for both individuals and populations. Approximately 16 500 cases of TB are notified in the region annually.1,2 While most patients are treated successfully, the estimated mortality rate remains unacceptably high, at an estimated 40 cases per 100 000 population.1 Fiji, a Pacific island nation in the central Pacific Ocean, is the second most populous country in the Pacific region and is currently categorised as a low TB burden country, with an estimated TB case notification rate of 24 cases/100 000 (2012 data; 95% confidence interval [CI] 21–27).1 Approximately 150 patients are notified with TB annually.1 In recent years, the TB case notification rate in Fiji has been on the increase, mainly due to the introduction of interventions aimed at actively detecting and diagnosing people with TB.2 The Fiji National Tuberculosis Programme (NTP) was established in 1951 and the World Health Organization (WHO) recommended DOTS strategy was introduced in Fiji in 1997.3 As part of the DOTS strategy, anti-tuberculosis medications are taken by patients under the direct supervision of a health care worker or family member, thereby ensuring that the correct medications are taken at the right doses, and that patients are supported throughout treatment.3,4 The goals of directly observed treatment (DOT) are to support patients throughout anti-tuberculosis treatment, ensure a successful treatment outcome and prevent drug resistance.4 The need for a strategy to enhance anti-tuberculosis treatment support has been reinforced by studies that show that, even in industrialised countries and among knowledgeable and educated individuals, at least 40% of patients do not take their medications as prescribed and may stop treatment when they feel better, before the end of the 6 months of treatment.5,6 Other studies on medication adherence predict that up to 50% of individuals do not adhere to a medication regimen as prescribed.7,8 In Fiji, the Global Fund to Fight AIDS, TB and Malaria (The Global Fund), provides support for NTP activities and the reinforcement of the health system. This grant has been in place since April 2010, with the Fiji Ministry of Health as the principal recipient. The grant provides financial support to the NTP for DOT, ensuring that selected TB patients have their treatment supervised. The revised national TB guidelines state that TB patients should be provided DOT throughout treatment if sufficient resources are available.3 Some TB patients receive treatment supervision in Fiji, while others who do not; this is largely determined by patient preference and available resources. DOT has not been evaluated in Fiji, and no information on the impact of type of supervisor on anti-tuberculosis treatment outcomes has been published. The aim of the present study is to describe and compare anti-tuberculosis treatment outcomes in TB patients on self-administered treatment (SAT) compared to those whose treatment is supervised by an immediate family member in Fiji (i.e., DOT). Findings from this study will be used by the NTP to improve patient care and to ensure that the NTP achieves acceptable treatment success rates and low levels of drug resistance.