Directly Observed Therapy (DOT) for the Treatment of Tuberculosis

Fact sheet describing how to use DOT with TB patients.

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Directly Observed Therapy (DOT) for the Treatment of Tuberculosis (PDF)

National TB treatment guidelines strongly recommend using a patient-centered case management approach - including directly observed therapy ("DOT") - when treating persons with active TB disease. DOT is especially critical for patients with drug-resistant TB, HIV-infected patients, and those on intermittent treatment regimens (i.e., 2 or 3 times weekly).

What is DOT?

DOT means that a trained health care worker or other designated individual (excluding a family member) provides the prescribed TB drugs and watches the patient swallow every dose.

Why use DOT?

• We cannot predict who will take medications as directed, and who will not. People from all social classes, educational backgrounds, ages, genders, and ethnicities can have problems taking medications correctly.
• Studies show that 86-90% of patients receiving DOT complete therapy, compared to 61% for those on self-administered therapy.
• DOT helps patients finish TB therapy as quickly as possible, without unnecessary gaps.
• DOT helps prevent TB from spreading to others.
• DOT decreases the risk of drug-resistance resulting from erratic or incomplete treatment.
• DOT decreases the chances of treatment failure and relapse.

Who can deliver DOT?

• A nurse or supervised outreach worker from the patient's county public health department normally provides DOT.
• In some situations, it works best for clinics, home care agencies, correctional facilities, treatment centers, schools, employers, and other facilities to provide DOT, under the guidance of the local health department.
• Family members should not be used for DOT. DOT providers must remain objective.
• For complex regimens including IV/IM medications or twice daily dosing, home care agencies may provide DOT or share responsibilities with the local health department.
• If resources for providing DOT are limited, priority should be given to patients most at risk. See the MDH DOT Risk Assessment form for help identifying high-priority patients.

How is DOT administered?

• DOT includes:
  • delivering the prescribed medication
  • checking for side effects
  • watching the patient swallow the medication
  • documenting the visit
  • answering questions
• DOT should be initiated when TB treatment starts. Do not allow the patient to try self-administering medications and missing doses before providing DOT. If the patient views DOT as a punitive measure, there is less chance of successfully completing therapy.
• The prescribing physician should show support for DOT by explaining to the patient that DOT is widely used and very effective. The DOT provider should reinforce this message.
• DOT works best when used with a patient-centered case management approach, including such things as:
  • helping patients keep medical appointments
  • providing ongoing patient education
  • offering incentives and/or enablers
  • connecting patients with social services or transportation
• Patients taking daily therapy can usually self-administer their weekend doses.

For further information or assistance making referrals for DOT, contact the Minnesota Department of Health, TB Prevention and Control Program, 651-201-5414.

Adapted from materials from the Francis J. Curry National Tuberculosis Center and the New York City Department of Health.

References:
1.Treatment of Tuberculosis, American Thoracic Society, CDC and Infectious Diseases Society of America, Am J Respir Crit Care Med, Vol 167, 2003
2. Interactive Core Curriculum on Tuberculosis (Web-based), CDC, 2004
3. "DOT Essentials: A Training Curriculum for TB Control Programs", Francis J. Curry National Tuberculosis Center, 2003
4. "Management: Directly Observed Therapy", New York City Department of Health, 2001.