Unpaid community volunteers--effective providers of directly observed therapy (DOT) in rural South Africa.

OBJECTIVE

To illustrate successes and difficulties for the South African National Tuberculosis Programme in a rural area.

DESIGN

Prospective cohort study.

SETTING

Sekhukhuneland, Provincial Health Service Southern Region, Northern Province, South Africa.

SUBJECTS

All patients diagnosed with tuberculosis (TB) in the catchment area of four rural hospitals between January 1997 and June 1999.

MAIN OUTCOME MEASURES

Standard outcomes for TB treatment as defined by the World Health Organisation. Treatment failure, treatment interruption and death were grouped as poor outcomes.

RESULTS

One thousand four hundred and seventy-six people were diagnosed with TB. The majority (76%) had smear-positive pulmonary disease. Treatment was given by directly observed therapy (DOT) throughout in all but 15 instances. Excluding 10 subjects with known multidrug-resistant TB (MDRTB), 723 (66%) were cured, 68 (6%) completed treatment, 73 (7%) interrupted treatment, 37 (3%) failed treatment, 66 (6%) transferred out, and 134 (12%) died. Of the 920 initially smear-positive patients who survived the first 2 months to receive DOT in the community, 693 (75%) were supervised by unpaid community volunteers. Poor outcomes were no more common among patients supervised by these volunteers than among patients supervised by professional health care workers. Male gender (odds ratio 1.38, 95% confidence interval 1.02, 1.87) was significantly associated with a poor outcome.

CONCLUSION

Although there were difficulties, the national programme was successfully applied with no additional funds or facilities. Explanations for the high death rate and poor outcomes for men need to be found. Great efforts will be required to preserve the quality of the TB programme if it is devolved to primary care level.