[Importance of monitoring the drug dosage and treatment duration for the management of tuberculosis patients at public health centers].

PURPOSE: On the basis of actual field data, we investigated the importance of monitoring the drug dosage and treatment duration for the supportive care of patients with tuberculosis who were being treated at public health centers. PATIENTS & METHODS: Data of the drug dosage of principal anti-tuberculosis drugs and the treatment duration for the registered patients with tuberculosis at the Shinjuku-ku Public Health Center were analyzed. RESULTS: The actual dosage of rifampicin and isoniazid according to the "recommended" dosage was administered to 57.3% (67/117) and 82.0% (114/139), respectively, patients with tuberculosis registered at the Shinjuku-ku Public Health Center. In contrast, in patients with tuberculosis who were treated at a highly specialized tuberculosis hospital, the rates were 81.0% (98/121) and 93.5% (86/92), respectively; for both drugs, the rates were significantly higher in this hospital than in the Shinjuku-ku Public Health Center. For the treatment duration, of 92 patients registered at the Shinjuku-ku Public Health Center who could have completed standard treatment in the standard duration, the actual treatment durations were shorter than the standard duration in 15.2% of the patients (14/92; -32 to -1 days), and longer than the standard duration in 77.2% (71/92; 2 to 146 days); the total superfluous treatment days for the latter 71 patients were 1,877 days. The treatment durations were more than 2 weeks shorter or longer than the standard duration for 31 patients, and in 71.0% (22/31) of these patients, no specific reason could be determined as to why the treatment durations were not standard. CONCLUSION: In a significant number of patients, the drug dosage and treatment duration were not according to the standard values. By using this data about the management of the drug dosage and treatment duration for the supportive care of patients with tuberculosis treated at public health centers, we may improve quality of the provided supportive care.

[On-the-street DOTS for a homeless tuberculosis patient--case report of a patient who had difficulties with TB treatment adherence].

PURPOSE: A homeless patient with tuberculosis (TB), who had often quit his TB treatment in mid-course and then gone homeless again, succeeded in completing his treatment for over 10 months through on-the-street DOTS ("Bluesky DOTS" is another expression). Based on the analysis of this case, we have discussed how to provide effective countermeasures to non-compliant TB patients. METHOD: An episode of a successful on-the-street DOTS for a 70-year-old homeless man with sputum smear positive pulmonary TB was qualitatively analyzed, with a view toward patient's empowerment. RESULT: The patient had had human-relations problems in his life, and trouble with medical and welfare service staff. During his hospital admissions, he repeatedly self-discharged or was forced to discharge due to violent behavior against staff. Public health nurses at Shinjuku public health center visited the patient frequently at the hospital, and tried to build a good relationship with the patient from the beginning of the treatment. Following a two and half month interruption of the TB treatment after he disappeared from the hospital, he was discovered staying outside at a canal side in the area, and on-the-street TB treatment was carried out, with good cooperation with the hospital and social welfare office. Directly observed TB medication was given to him by a public health nurse and another health center staff member for 293 days, at the park near his living place. The patient often rejected the medication, particularly when he was hungry, but offering lunch to him was a very effective incentive. Through comprehensive supports to the patient, he gradually changed his attitude, and on his own came to consider his health and his future. DISCUSSION: We have analyzed a successfully treated case of a homeless TB patient who had difficulties in maintaining a social life and had not been cooperative in complying with the medication. The level of independence improved during the course of on-the-street DOTS with incentive and other supports. He became receptive to TB treatment and became self-supportive during the course of DOTS, with food as an incentive. This indicates that on-the-street DOTS was successful not only for the treatment completion but also contributed to empowering the TB patient. This approach of adjusting the service to the patient's needs fostered a positive relationship with all stakeholders.

[Use of a risk assessment inventory in implementation of the community DOTS in Shinjuku, Japan].

PURPOSES: To investigate the effectiveness of a risk assessment for implementing the DOTS of outpatients in the Japanese city of Shinjuku. SUBJECTS: A total of 435 patients with tuberculosis or latent tuberculosis infection who were registered in the city of Shinjuku between 1 April 2005 and 31 December 2007. METHODS: Soon after their diagnosis or registration and again 4 months thereafter, the patients were interviewed by the public health nurse in charge using a risk assessment inventory that had 17 scales related to the risk of defaulting from the treatment. Based on the results of the risk assessment, the patients were provided with an appropriately adapted DOTS. RESULTS: Out of all patients, 386 (88.7%) were assessed twice, of whom 338 (77.7%) were those with active disease. The patients were classified into three groups according to their risk scales: high-, medium-, and low-risk groups. There was no change in the risk grouping during the 4 months in 307 (90.8%) patients. However, in 12 patients (3.6%) the risk level was increased after 4 months, because of the development of side effects and problems with regular outpatient visits. The common methods of support in drug taking were daily DOT at the health center for patients in the high-risk group, and DOT at pharmacy shops once or twice weekly with self-medication on the other days for patients in the medium-risk group. For the low-risk group, the public health nurses made interview once or twice a month. There was no significant difference in the treatment success rate, default rate, or mortality rate among these three groups. DISCUSSION: The treatment outcome suggests that the community DOTS in this area may be effective. It was important to assess possible risks in treatment for each patient in order to identify the support needs and means. Also, it is necessary to develop a good risk assessment inventory scale.