session 1: introduction to dot. dot curriculum session 1 2 worldwide tb statistics 1.approximately 8...

SESSION 1:SESSION 1:Introduction to DOTIntroduction to DOT

DOT Curriculum Session 1 2

Worldwide TB StatisticsWorldwide TB Statistics

1.1. Approximately 8 million new cases of Approximately 8 million new cases of active TB each yearactive TB each year

2.2. World Health Organization (WHO) World Health Organization (WHO) estimates 2 – 3 million deaths from estimates 2 – 3 million deaths from TB annuallyTB annually

3.3. One in every three persons is One in every three persons is infected with infected with M. tbM. tb


U.S. TB StatisticsU.S. TB Statistics

1.1. The U.S. TB epidemic peaked in the The U.S. TB epidemic peaked in the late 1800s, followed by a steady late 1800s, followed by a steady decline until 1985decline until 1985

2.2. Between 1985 and 1992, the Between 1985 and 1992, the incidence of TB increased by 20% incidence of TB increased by 20% nationwidenationwide


U.S. TB Statistics U.S. TB Statistics (2)(2)

a. Factors contributing to the a. Factors contributing to the increase:increase:

• increased immigration from increased immigration from countries with high incidence countries with high incidence of TBof TB

• HIV infectionHIV infection



a. Factors contributing to the a. Factors contributing to the increase (continued): increase (continued):

• more people living in homeless more people living in homeless shelters and correctional shelters and correctional institutionsinstitutions

• less funding for TB control less funding for TB control programsprograms



b.b. Characteristics of the Characteristics of the increase:increase:

• 92% of increase occurred in 92% of increase occurred in 5 states: NY, CA, NJ, FL, TX 5 states: NY, CA, NJ, FL, TX

• Urban case rates rose 10%; Urban case rates rose 10%; nonurban rates fell from 54% nonurban rates fell from 54% to 46% to 46%



b.b. Characteristics of the increase Characteristics of the increase (continued):(continued):

• African-American case rates African-American case rates increased 38% increased 38%

• White case rates decreased 11% White case rates decreased 11% • Foreign-born cases increased Foreign-born cases increased



b.b. Characteristics of the increase Characteristics of the increase (continued):(continued):

• Age group was young (25-45 Age group was young (25-45 years)years)



3.3. TB control from 1992 to the present TB control from 1992 to the present

a.a. 1992-2000: cases decreased by 1992-2000: cases decreased by 45%45%

b.b. 2000 was the 8 2000 was the 8thth straight year of straight year of declining numbers of cases declining numbers of cases

c.c. 2000: 16,377 cases were reported 2000: 16,377 cases were reported

(5.8 per 100,000)(5.8 per 100,000)



Factors contributing to decline:Factors contributing to decline:• Increased funding for TB controlIncreased funding for TB control • Improved laboratory methods Improved laboratory methods • Institutional infection control Institutional infection control



Factors contributing to decline Factors contributing to decline (continued):(continued):• More treatment of LTBI in high risk More treatment of LTBI in high risk

groupsgroups• Stronger efforts to ensure Stronger efforts to ensure

completion of therapy, including completion of therapy, including DOTDOT



dd. Drug resistance. Drug resistance • MDR-TB (resistance to MDR-TB (resistance to

isoniazid [INH] isoniazid [INH] andand rifampin) rifampin) remains uncommon in U.S. remains uncommon in U.S.

• INH resistance is INH resistance is approximately 8% of cases approximately 8% of cases nationwide nationwide


e.e. Race/ethnicity; U.S.-born vs. Race/ethnicity; U.S.-born vs. foreign-born foreign-born

• 1992-2000: sharp increase in % 1992-2000: sharp increase in % of cases among foreign-born of cases among foreign-born

• 2000: 75% of reported TB cases 2000: 75% of reported TB cases occurred in racial and ethnic occurred in racial and ethnic minorities minorities



e.e. Race/ethnicity; U.S.-born vs. Race/ethnicity; U.S.-born vs. foreign-born (continued) foreign-born (continued)

• 2000: U.S.-born = 54% of cases; 2000: U.S.-born = 54% of cases; foreign-born = 46%foreign-born = 46%

• African-Americans account for African-Americans account for almost 1 in every 3 casesalmost 1 in every 3 cases



e.e. Race/ethnicity; U.S.-born vs. Race/ethnicity; U.S.-born vs. foreign-born (continued) foreign-born (continued)

• 2000: most foreign-born cases 2000: most foreign-born cases came from Mexico, Philippines, came from Mexico, Philippines, Vietnam, India, China, Haiti, S. Vietnam, India, China, Haiti, S. KoreaKorea

• Half of foreign-born cases occur Half of foreign-born cases occur less than 5 years after arrival less than 5 years after arrival




ff.. Other high-risk groups (2000) Other high-risk groups (2000) • 15% of cases had excess 15% of cases had excess

alcohol use alcohol use • 2.5% of cases were injection 2.5% of cases were injection

drug usersdrug users



ff.. Other high-risk groups (2000) Other high-risk groups (2000) (continued)(continued)

• 6.1% of cases were homeless 6.1% of cases were homeless persons persons

• 56.8% of cases were 56.8% of cases were unemployed unemployed


Definition of DOT and DOT TasksDefinition of DOT and DOT Tasks

Definition of DOTDefinition of DOT

1. 1. DOT means that a health care DOT means that a health care worker or other designated worker or other designated individual (excluding a family individual (excluding a family member) watches the patient member) watches the patient swallow every dose of the swallow every dose of the prescribed TB drugs (“supervised prescribed TB drugs (“supervised swallowing”)swallowing”)


Definition of DOT and DOT Tasks Definition of DOT and DOT Tasks (2)(2)

Definition of DOT (continued)Definition of DOT (continued)

2.2. The American Thoracic The American Thoracic Society and the Centers for Society and the Centers for Disease Control and Prevention Disease Control and Prevention recommend that every TB patient recommend that every TB patient be considered for DOT be considered for DOT

3.3. Some jurisdictions mandate Some jurisdictions mandate that that all all patients be placed on DOT patients be placed on DOT



DOT tasks:DOT tasks:

1.1. Deliver medication Deliver medication

2.2. Check for side effects Check for side effects

3.3. Verify medication Verify medication

4.4. Watch patient take pills Watch patient take pills

5.5. Document the visit Document the visit



DOT staff may also assist in:DOT staff may also assist in:

1.1. Helping patients keep Helping patients keep appointments appointments

2.2. Providing patient education Providing patient education

3.3. Offering incentives and/or Offering incentives and/or enablersenablers



DOT staff may also assist in (continued):DOT staff may also assist in (continued):

4.4. Connecting patients with Connecting patients with social social services/transportation services/transportation

5.5. Drawing upon their familiarity Drawing upon their familiarity with with the client’s home environment the client’s home environment to to identify contactsidentify contacts



Who can deliver DOT?Who can deliver DOT?

1.1. Usually: TB clinic personnel Usually: TB clinic personnel

2.2. Staff at other health care Staff at other health care settingssettings

3.3. Other responsible personsOther responsible persons

4.4. NotNot family members family members



Can we predict who will be nonadherent?Can we predict who will be nonadherent?

No! Anyone can be nonadherent, No! Anyone can be nonadherent, regardless of social class, educational regardless of social class, educational background, age group, gender, or background, age group, gender, or ethnicity.ethnicity.



Some jurisdictions have successfully Some jurisdictions have successfully used DOT contracts or agreements as used DOT contracts or agreements as a method of ensuring adherence. a method of ensuring adherence.



How it works:How it works:

The DOT worker and patient The DOT worker and patient negotiate dates, places, and negotiate dates, places, and times for DOT services; both times for DOT services; both sign a document stating such sign a document stating such agreementsagreements



How it works (continued):How it works (continued):

Included in the agreement is Included in the agreement is language specifying what language specifying what consequences may result if the consequences may result if the client violates the terms of the client violates the terms of the contract contract


Review QuestionsReview Questions

1.1. Name 3 populations at risk for TB Name 3 populations at risk for TB in the U.S.in the U.S.

2.2. Name a population that is at Name a population that is at particular risk in your local particular risk in your local jurisdictionjurisdiction

3.3. What is TB case management?What is TB case management?


Review Questions Review Questions (2)(2)

4.4. What are 2 negative consequences What are 2 negative consequences that can occur if a patient is that can occur if a patient is nonadherent?nonadherent?

5.5. What is DOT?What is DOT?

6.6. What are the 4 main tasks involved What are the 4 main tasks involved in DOT?in DOT?


Review Questions Review Questions (3)(3)

7.7. What are 3 high-risk groups of What are 3 high-risk groups of patients that must receive DOT?patients that must receive DOT?

session 1: introduction to dot. dot curriculum session 1 2 worldwide tb statistics 1.approximately 8...

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