Self-administered treatment for tuberculosis among pastoralists in rural Ethiopia: how well does it work? Mohammed Khogali a, *, Rony Zachariah a , Tony Reid a , Sweet C. Alipon b , Stuart Zimble b , Gbane Mahama b , William Etienne c , Richard Veerman c , Amine Dahmane a , Tadiwos Weyeyso d , Abdu Hassan b and Anthony Harries e,f a Me ´decins sans Frontie `res, Medical Department (Operational Research Unit/Operations), Brussels Operational Centre, MSF-Luxembourg, Luxembourg; b Me ´decins sans Frontie `res, Addis Ababa, Ethiopia; c Me ´decins sans Frontie `res, Operational Centre Brussels, Brussels, Belgium; d Ministry of Health, Jijiga, Ethiopia; e International Union against Tuberculosis and Lung Disease, Paris, France; f London School of Hygiene and Tropical Medicine, London, UK *Corresponding author: Tel:+352 3325 15; E-mail: mohammed.khogali@gmail.com Received 19 September 2013; revised 7 January 2014; accepted 10 January 2014 Objectives: In the Somali Regional State, Ethiopia, where most of the population are pastoralists, conventional TB treatment strategies based on directly observed treatment (DOT) at health facilities are not adapted to the mobile pastoralist lifestyle and treatment adherence is poor. From a rural district, we report on treatment out- comes of a modified self-administered treatment (SAT) strategy for pastoralists with TB. Methods: A descriptive cohort study was carried out between May 2010 and March 2012. The modified DOTstrat- egy comprised a shorter intensive phase at the health facility (2 weeks for new patients, 8 weeks in the event of re-treatment), followed by self-administered TB treatment. Results: A total of 390 patients started TB treatment. The overall treatment success rate was 81.2% (317/390); the rates of death, loss-to-follow up and treatment failure were 6.7% (26/390), 9.2% (36/390) and 0.3% (1/390) respectively. A considerable proportion (10/26, 38%) of deaths occurred during the first month of treatment. Conclusion: In a pastoralist setting, a modified SATstrategy resulted in good treatment outcomes. If the global plan to eliminate TB by 2050 is to become a reality, it will be necessary to adapt TB services to client needs to ensure that all TB patients (including pastoralists) have access to TB treatment. Keywords: Ethiopia, Tuberculosis, Pastoralists, SAT, Operational research Introduction Pastoralists live by a social and economic system based mainly on the raising and herding of livestock. They often move with their animals from one geographic area to another in search of fresh pastures and water. 1 Two groups of pastoralists are identified in the Somali Regional State (SRS), Ethiopia. The first group are agro- pastoralists whose basic livelihood is from livestock, but who also practise nonpastoral activities such as farming. The second group are nomadic pastoralists whose economy relies exclusively on livestock rearing. They do not practise agriculture, nor do they have any permanent places of residence. 1 Ethiopia has the world’s seventh highest TB burden, 2 and this burden is higher in the SRS, where the population is predominately pastoralist. This is most probably attributable to the region’s long history of armed conflict, which has weakened social services de- livery to most of its population. People in the region are extremely poor and bear a disproportionately high burden of TB. 3 In addition, poor health infrastructure in the areas where pastoralists live and poor compliance with treatment related to patients’ mobile life- style contribute to the spread of infection. 4 The WHO recommends direct observation of TB treatment (DOT) for all patients (including pastoralists), as it is believed that this will ensure treatment compliance and limit the develop- ment of drug resistance. 5 The DOT strategy, which relies on patients returning daily for supervised treatment (pill swallowing) to a health facility, is not adapted to the mobile lifestyle of pastor- alists 6 and poor adherence to treatment has been previously reported in such populations. 1 A study from Kenya, for example, reported a lost-to-follow-up rate of 21% among 996 new smear-positive TB patients treated in two nomadic districts. 7 Traditionally, DOT entails an intensive phase of observed treat- ment of at least 4 weeks for new patients and 12 weeks for patients requiring re-treatment. On the basis of comments from patients during counselling sessions at the Me ´decins Sans Fron- tie `res (MSF) health center in Imey, SRS, and from nursing and clinical staff administering DOT, this phase of observed treatment was considered to be too long. # The Author 2014. Published by Oxford University Press on behalf of Royal Societyof Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. ORIGINAL ARTICLE Int Health 2014; 6: 112–117 doi:10.1093/inthealth/ihu008 Advance Access publication 16 March 2014 112 Downloaded from https://academic.oup.com/inthealth/article/6/2/112/809665 by guest on 25 May 2022