Directly observed therapy for TB treatment, via video, gets CDC nod

Directly observed therapy — where a health professional watches someone take a medication — has been the standard of care for tuberculosis treatment in the United States since 2016. Now DOT, as it’s called, has an approved video alternative.

The Centers for Disease Control and Prevention announced Thursday it was updating its guidance to include video DOT or vDOT, saying there is enough evidence to show it is at least as effective as the in-person version.

“This update of CDC recommendations is based on evidence that vDOT is associated with a higher proportion of medication doses being observed and similar rates of TB treatment completion and microbiologic resolution [of infection] when compared with in-person DOT,” the agency said in an article published in the online journal Morbidity and Mortality Weekly Report. 

Tuberculosis treatment is onerous, lasting from four to nine months, depending on the regimen. Failure to take the drugs correctly or complete the treatment course can fuel development of drug-resistant TB, which will require still longer treatment. 

DOT has been shown to improve adherence to the medication regimen, but can be difficult to do. Enter the idea of allowing smartphones to make the process simpler.

The New York City Department of Health’s TB control program began to experiment with video DOT as early as 2014 — testing an alternative that became an imperative when the Covid-19 pandemic hit. (Other jurisdictions also use vDOT.)

“Directly observed therapy has been a backbone of our work for a long time and of course the pandemic put a lot of that under threat in restricting people’s movement and their ability to remain adherent on what can be at a minimum 6 months of treatment, if not longer,” New York City Health Commissioner Ashwin Vasan told STAT in an interview.

The city has one of the country’s highest rates of TB infections. Where the national average in 2022 was 2.5 cases per 100,000 people, in New York the figure is 6.1 per 100,000, Vasan said.

Fortunately, about five years ago the CDC asked New York to take part in a randomized controlled trial, comparing vDOT to DOT. The study is part of the evidence base for the new CDC guideline.

“In over 200 patients studied, it was found to be just as effective as traditional DOT, in addition to being more cost-effective because you obviously reduce transportation costs,” Vasan said. “You reduce delays, you reduce trade-offs and opportunity costs because these are visits that can happen over video that would otherwise cause the person to leave work, or leave school, or to leave wherever they are, and present to a clinic to pick up their medications.”

There are two video DOT options. Some people use a video call — Facetime or Zoom or some other platform — to connect to a health worker who watches them swallow their medication. The other option is to film and submit a video of oneself taking the pills.

Most people in treatment for TB prefer vDOT, said Joseph Burzynski, director of the TB Control Program at the city’s Department of Health and Mental Hygiene.

“It seems to be easier for them, and it’s less resource-intensive on our part, and it’s a cost saver. So we feel that it’s really working well for everybody,” Burzynski said. He noted that the health department provides phones for people in treatment if they do not have one.

“We do provide services in person if people request that,” he said. “But I would say the majority of people request the video DOT option. It’s just more convenient for most people, and that’s still the pattern we’re seeing.”

Philip LoBue, director of CDC’s division of TB elimination, said reducing the hurdles that get in the way of people successfully completing TB treatment is an essential component of combating the disease.

“We have these regimens that typically used to take six to nine months for people with drug-susceptible TB, and 18 to 24 months or longer for people with drug-resistant TB,” he said, noting that progress has been made in reducing those treatment times.

“Even latent TB infection treatment, which used to be a minimum of nine months, we developed a regimen that was just 12 weeks. So all really important developments, but there’s still just a lot to be done,” said LoBue. “We really need to get treatments down to much, much shorter. Two months. Less than two months. … It’s very hard on the patients and their families to go through this for such a long time.”