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TB Notes 1, 2000
Where We've Been and Where We're Going: Perspectives from CDC's Partners in TB Control
Changes I've Seen
TB Control in New York City: A Recent History
Not by DOT Alone
Baltimore at the New Millennium
From Crickets to Condoms and Beyond
The Denver TB Program: Opportunity, Creativity, Persistence, and Luck
National Jewish: The 100-Year War Against TB
Earthquakes, Population Growth, and TB in Los Angeles County
TB in Alaska
CDC and the American Lung Association/ American Thoracic Society: an Enduring Public/Private Partnership
The Unusual Suspects
The Model TB Prevention and Control Centers: History and Purpose
My Perspective on TB Control over the Past Two to Three Decades
History of the IUATLD
Thoughts about the Future of TB Control in the United States
Where We've Been and Where We're Going: Perspectives from CDC
Early History of the CDC TB Division, 1944-1985
CDC Funding for TB Prevention and Control
Managed Care and TB Control - A New Era
Early Research Activities of the TB Control Division
The First TB Drug Clinical Trials
Current TB Drug Trials: The Tuberculosis Trials Consortium (TBTC)
TB Communications and Education
TB Control in the Information Age
Field Services Activities
TB's Public Health Heroes
Infection Control Issues
A Decade of Notable TB Outbreaks: A Selected Review
International Activities
The Role of CDC's Division of Quarantine in the Fight Against TB in the U.S.
The STOP TB Initiative, A Global Partnership
Seize the Moment - Personal Reflections
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TB Notes 1, 2000

Not by DOT Alone

by J. Michael Holcombe, MPPA, CPM
Mississippi TB Controller

Mississippi proved directly observed therapy (DOT) to be a great tool toward TB elimination. However, DOT is not a programmatic cure-all, a stand-alone solution, or the proverbial yellow-brick road. Not what you expected to hear from Mississippi, is it?

We know that DOT is the best way to treat TB. It might not always be the most convenient or the easiest, but with the correct drugs, dosing, monitoring, and delivery, it is unsurpassed at present. When it comes to DOT and its impact, we must remember the Chinese proverb, "Hear and forget; see and remember; do and understand."

With full implementation of universal DOT on a statewide basis in the mid-1980s, TB program performance indicators began to improve. Patients' sputum converted faster, reducing the potential period of infectiousness; a greater percentage of patients completed therapy; a greater percentage completed therapy in a timely manner; the number of patients acquiring drug resistance decreased rapidly; the number of program admissions for inpatient care dropped dramatically; the average length of an inpatient stay dropped; and the number of new TB cases began to fall. The reduction in morbidity allowed more time for contact follow-up, the expansion of targeted testing, and the implementation of directly observed preventive therapy in select high-risk populations. This increased the number of patients on preventive therapy and the percentage of patients completing preventive therapy.

To further support the strengthened efforts, laws were modified to improve our ability to protect the public from patients who fail to cooperate with treatment or isolation, and rules were changed to improve reporting. We placed emphasis on outpatient care and privatized elements of the program best and most efficiently provided by private providers radiology services, for example to expand availability, improve quality, and ameliorate cost.

Many told us universal DOT could not be done; a few said it should not be done. But we continue to truly believe DOT is the best service we can offer our patients and the public. We believe DOT offers the surest and best chance for a timely cure. Why should we treat anyone with less than what we believe is the best we can offer? Their future is our future.

True, Mississippi has made great strides in TB control. But we've made those strides not by DOT alone.

Each and every one of those great strides was made by everyday people: nurses, aides, clerks, outreach workers, doctors, disease intervention specialists, and volunteers hard working, dedicated, and passionately devoted individuals who were, and are, determined to make a difference one patient, one facility, one community at a time.

From the establishment of our sanatorium early in the century through its demise and the rise and continuing refinement of our outpatient treatment delivery system, public health nurses have made most of those great strides possible. Usually, the nurse comforts, educates, and gives hope to the distressed patient who has been notified of exposure or disease. The nurse confronts and calms the angry, hostile, and all-too-often dangerous patient who has given up and no longer cares about himself or others. The public health nurse persists through heat or snow, wind or rain, dogs, gangs, or alligators and finds the patients and persistently guides, cajoles, or bribes them through treatment. If, along the way, that means baking a few extra cookies, making an extra trip after work to deliver a home-cooked meal to a homeless or lonely patient, buying an extra can of soup or a chicken for an impoverished patient while grocery shopping, or taking the time to put a grubby little 4-year-old on the lap and reading a story in hope of making the treatment seem a little more palatable . . . that's nothing special. That's just the way DOT happens: good people doing good things. No bells, whistles, or wreaths of laurel just another great stride taken in silence and out of public view.

Public health nurses, of course, don't work in isolation or independently. Without a doubt, each stride is made easier by the clerk who greets the patient kindly and patiently, then helps expedite the visit. Each stride is made easier by the outreach worker who helps ensure each dose of medication is ingested and each appointment is kept. Physicians who take time from their busy practice to conduct regular clinics at the health department also make each stride easier, more sure, and more purposeful. And the advances in science, the effective anti-TB drugs available, and the emerging technology for more rapid and accurate diagnosis have been and are unquestionably essential to the progress we have made.

Yes, DOT has been a vital tool for ensuring progress and managing cost. We used it as the fulcrum to move Mississippi from a deepening rut and to change the direction of TB control. But, DOT was only part of the plan. Progress cannot be achieved by DOT alone. DOT requires achievement goals; community support; good legislation; adequate infrastructure and funding; a dedicated, determined public health field staff; and the strong support of administration.


Released October 2008
Centers for Disease Control and Prevention
National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention
Division of Tuberculosis Elimination -

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