1. SESSION 1: Introduction to DOT

2. DOT Curriculum Session 1 2 Worldwide TB Statistics 1.Approximately 8 million new cases of active TB each year 2.World Health Organization (WHO) estimates 2 – 3 million deaths from TB annually 3.One in every three persons is infected with M. tb

3. DOT Curriculum Session 1 3 U.S. TB Statistics 1.The U.S. TB epidemic peaked in the late 1800s, followed by a steady decline until 1985 2.Between 1985 and 1992, the incidence of TB increased by 20% nationwide

4. DOT Curriculum Session 1 4 U.S. TB Statistics (2) a. Factors contributing to the increase: increased immigration from countries with high incidence of TBincreased immigration from countries with high incidence of TB HIV infectionHIV infection

5. DOT Curriculum Session 1 5 U.S. TB Statistics (3) a. Factors contributing to the increase (continued): more people living in homeless shelters and correctional institutionsmore people living in homeless shelters and correctional institutions less funding for TB control programsless funding for TB control programs

6. DOT Curriculum Session 1 6 U.S. TB Statistics (4) b.Characteristics of the increase: 92% of increase occurred in 5 states: NY, CA, NJ, FL, TX92% of increase occurred in 5 states: NY, CA, NJ, FL, TX Urban case rates rose 10%; nonurban rates fell from 54% to 46%Urban case rates rose 10%; nonurban rates fell from 54% to 46%

7. DOT Curriculum Session 1 7 U.S. TB Statistics (5) b.Characteristics of the increase (continued): African-American case rates increased 38%African-American case rates increased 38% White case rates decreased 11%White case rates decreased 11% Foreign-born cases increasedForeign-born cases increased

8. DOT Curriculum Session 1 8 U.S. TB Statistics (6) b.Characteristics of the increase (continued): Age group was young (25-45 years)Age group was young (25-45 years)

9. DOT Curriculum Session 1 9 U.S. TB Statistics (7) 3. TB control from 1992 to the present a. 1992-2000: cases decreased by 45% b. 2000 was the 8 th straight year of declining numbers of cases c. 2000: 16,377 cases were reported (5.8 per 100,000)

10. DOT Curriculum Session 1 10 U.S. TB Statistics (8) Factors contributing to decline: Increased funding for TB controlIncreased funding for TB control Improved laboratory methodsImproved laboratory methods Institutional infection controlInstitutional infection control

11. DOT Curriculum Session 1 11 U.S. TB Statistics (9) Factors contributing to decline (continued): More treatment of LTBI in high risk groupsMore treatment of LTBI in high risk groups Stronger efforts to ensure completion of therapy, including DOTStronger efforts to ensure completion of therapy, including DOT

12. DOT Curriculum Session 1 12 U.S. TB Statistics (10) d. Drug resistance MDR-TB (resistance to isoniazid [INH] and rifampin) remains uncommon in U.S.MDR-TB (resistance to isoniazid [INH] and rifampin) remains uncommon in U.S. INH resistance is approximately 8% of cases nationwideINH resistance is approximately 8% of cases nationwide

13. DOT Curriculum Session 1 13 e. Race/ethnicity; U.S.-born vs. foreign-born 1992-2000: sharp increase in % of cases among foreign-born1992-2000: sharp increase in % of cases among foreign-born 2000: 75% of reported TB cases occurred in racial and ethnic minorities2000: 75% of reported TB cases occurred in racial and ethnic minorities U.S. TB Statistics (11)

14. DOT Curriculum Session 1 14 e. Race/ethnicity; U.S.-born vs. foreign-born (continued) 2000: U.S.-born = 54% of cases; foreign-born = 46%2000: U.S.-born = 54% of cases; foreign-born = 46% African-Americans account for almost 1 in every 3 casesAfrican-Americans account for almost 1 in every 3 cases U.S. TB Statistics (12)

15. DOT Curriculum Session 1 15 e. Race/ethnicity; U.S.-born vs. foreign-born (continued) 2000: most foreign-born cases came from Mexico, Philippines, Vietnam, India, China, Haiti, S. Korea2000: most foreign-born cases came from Mexico, Philippines, Vietnam, India, China, Haiti, S. Korea Half of foreign-born cases occur less than 5 years after arrivalHalf of foreign-born cases occur less than 5 years after arrival U.S. TB Statistics (13)

16. DOT Curriculum Session 1 16 U.S. TB Statistics (14) f.Other high-risk groups (2000) 15% of cases had excess alcohol use15% of cases had excess alcohol use 2.5% of cases were injection drug users2.5% of cases were injection drug users

17. DOT Curriculum Session 1 17 U.S. TB Statistics (15) f.Other high-risk groups (2000) (continued) 6.1% of cases were homeless persons6.1% of cases were homeless persons 56.8% of cases were unemployed56.8% of cases were unemployed

18. DOT Curriculum Session 1 18 Definition of DOT and DOT Tasks Definition of DOT 1. DOT means that a health care worker or other designated individual (excluding a family member) watches the patient swallow every dose of the prescribed TB drugs (“supervised swallowing”)

19. DOT Curriculum Session 1 19 Definition of DOT and DOT Tasks (2) Definition of DOT (continued) 2.The American Thoracic Society and the Centers for Disease Control and Prevention recommend that every TB patient be considered for DOT 3.Some jurisdictions mandate that all patients be placed on DOT

20. DOT Curriculum Session 1 20 Definition of DOT and DOT Tasks (3) DOT tasks: 1.Deliver medication 2.Check for side effects 3.Verify medication 4.Watch patient take pills 5.Document the visit

21. DOT Curriculum Session 1 21 Definition of DOT and DOT Tasks (4) DOT staff may also assist in: 1.Helping patients keep appointments 2.Providing patient education 3.Offering incentives and/or enablers

22. DOT Curriculum Session 1 22 Definition of DOT and DOT Tasks (5) DOT staff may also assist in (continued): 4.Connecting patients with social services/transportation 5.Drawing upon their familiarity with the client’s home environment to identify contacts

23. DOT Curriculum Session 1 23 Definition of DOT and DOT Tasks (6) Who can deliver DOT? 1.Usually: TB clinic personnel 2.Staff at other health care settings 3.Other responsible persons 4.Not family members

24. DOT Curriculum Session 1 24 Definition of DOT and DOT Tasks (7) Can we predict who will be nonadherent? No! Anyone can be nonadherent, regardless of social class, educational background, age group, gender, or ethnicity.

25. DOT Curriculum Session 1 25 Definition of DOT and DOT Tasks (8) Some jurisdictions have successfully used DOT contracts or agreements as a method of ensuring adherence.

26. DOT Curriculum Session 1 26 Definition of DOT and DOT Tasks (9) How it works: The DOT worker and patient negotiate dates, places, and times for DOT services; both sign a document stating such agreements

27. DOT Curriculum Session 1 27 Definition of DOT and DOT Tasks (10) How it works (continued): How it works (continued): Included in the agreement is language specifying what consequences may result if the client violates the terms of the contract

28. DOT Curriculum Session 1 28 Review Questions 1.Name 3 populations at risk for TB in the U.S. 2.Name a population that is at particular risk in your local jurisdiction 3.What is TB case management?

29. DOT Curriculum Session 1 29 Review Questions (2) 4.What are 2 negative consequences that can occur if a patient is nonadherent? 5.What is DOT? 6.What are the 4 main tasks involved in DOT?

30. DOT Curriculum Session 1 30 Review Questions (3) 7.What are 3 high-risk groups of patients that must receive DOT?