Observed patient therapy

An interesting letter by Dr Brian Farrugia (The Sunday Times, February 25) apparently attempting to diminish Dr Anthony Lanfranco's legacy in Malta's past successful tuberculosis management, claimed that multi-drug-resistant TB (MDR-TB) existed among the Maltese in the past, because they were treated with single and not multi-drug regimes.

This is certainly not true for Dr Lanfranco's days. His legacy of excellence in public health delivery (with far more primitive tools than we have today) rests on the fact that 40 years ago (when some of our physicians were still in nappies) he was stressing that, without a regime for multi-drug therapy and observance of patient therapy compliance, drug-resistant TB would emerge. Hence his initiative for observed patient therapy compliance at Ruzar Briffa Ward (at St Vincent de Paul) to achieve 100 per cent therapy completion.

More recent international recognition of the importance of patient therapy compliance in dealing with this serious public health problem is now officially referred to as "directly observed therapy" (DOT). Overseas research has shown that the impact of DOT on the percentage of patients completing therapy varies with the level of DOT adopted.

So only about 78 per cent of patients complete their therapy with modified DOT (initial inpatient DOT followed by a variety of outpatient strategies, including self-administered medication).

One wonders whether this serious public health aspect has been properly audited in Malta in recent years, considering the claim that we currently have up to 20 new cases of TB annually in our indigenous population.

A recent leading article in a publication of the American College of Physicians claims that "physicians' estimates of their own patients' adherence to therapy have no better than chance accuracy, so the problem of low adherence can be almost invisible to the individual practitioner dealing with a specific patient. This is true even for patients whom physicians feel they know well".