Video Directly Observed Therapy for Tuberculosis: CDC's 2023 Recommendation

Missed doses of tuberculosis (TB) medicine can lead to drug levels too low to work, drug resistance, longer treatment, treatment failure and the disease coming back. That is why U.S. clinical guidelines make directly observed therapy (DOT) the standard of care: a health care worker watches the patient take each dose, checks for side effects and offers support. In 2023, CDC updated its guidelines to say that doing this by video counts just as much as doing it in person.

Why in-person observation is hard

Under the 2016 guidelines, DOT usually meant meeting face to face, in the community or at a clinic. It also brings social support: personal connection, encouragement, advice and help with the problems illness creates. But daily appointments can clash with work, school and other routines, and getting there can be hard. A health worker arriving and leaving every day can draw unwelcome questions from neighbors or coworkers and create stigma. And in-person visits may be impossible in bad weather, natural disasters or a pandemic.

Video DOT (vDOT) lets patients use a phone, tablet or computer to connect with health workers either live (synchronous) or by recording videos of themselves taking their medicine (asynchronous).

How CDC weighed the evidence

CDC started from a published meta-analysis comparing vDOT with in-person DOT, covering studies up to January 2021, then searched PubMed, Embase and Cochrane for studies published from February 1, 2021, to May 13, 2022. It set aside studies with no comparison group, studies of text-message reminders or sensor-equipped pill containers without video, studies comparing vDOT with unsupervised self-treatment, and studies of patients in hospitals or residential institutions. It included outpatients of any age or sex with TB — including lung, other-organ and drug-resistant disease — in upper-middle- to high-income countries. The new search added a randomized controlled trial and a prospective observational study to the meta-analysis.

What the evidence showed

• Adherence was higher with vDOT in the meta-analysis and the observational study, and the trial found vDOT as effective as in-person DOT at getting doses observed. In the observational study, which counted weekday doses, patients who missed a weekday could make it up with videos at the weekend.
• Treatment completion was similar with both approaches. The trial did not measure it.
• Microbiologic resolution — the main indicator of how TB is responding to treatment — was also similar. The trial did not measure it either.

Other research has shown that vDOT can save time and money for patients and programs, improve patients' satisfaction, and allow monitoring when in-person DOT is not possible.

The recommendation

CDC continues to recommend DOT for everyone prescribed TB treatment, and now states that vDOT should be considered equivalent to in-person DOT. It can help health department TB programs meet the U.S. standard of care while using resources efficiently.

The choice should be made by patient and provider together, weighing:

• the patient's health care needs, social circumstances and preferences;
• reliable access to a video-capable device and the Internet;
• insurance coverage, where it applies;
• confidentiality and privacy; and
• the program's capacity and the provider's preferences.

In-person DOT is likely the better choice for patients receiving injectable medicines, for situations the patient and provider agree need closer monitoring, and for patients who cannot use the technology.

Gaps in the evidence

So far there have been few randomized trials and cohort studies of vDOT, and they have varied in video type and in where in-person DOT took place. Published studies were conducted with adults, in urban and suburban areas with good Internet access, so more evaluation is needed in other settings and populations. Technology has changed quickly over the past decade and will likely keep changing; CDC says it will continue to monitor new evidence and update the guidance as needed.

Sources

• Joan M. Mangan, Rachel S. Woodruff, Carla A. Winston, Scott A. Nabity, Maryam B. Haddad, Meredith G. Dixon, Farah M. Parvez, Carissa Sera-Josef, LaTweika A. T. Salmon-Trejo and Chee Kin Lam, "Recommendations for Use of Video Directly Observed Therapy During Tuberculosis Treatment — United States, 2023," Morbidity and Mortality Weekly Report, CDC: https://www.cdc.gov/mmwr/volumes/72/wr/mm7212a4.htm
• The report's promotional image is not reproduced.