DOTS
Best Way To Tackle Tuberculosis

TUBERCULOSIS (TB) persists as a global public health problem of a serious magnitude requiring urgent attention. Current global efforts to control TB have three distinct but overlapping dimensions: humanitarian, public health and economic. Alleviating the illness, suffering and death of individuals caused by TB is the major humanitarian concern and calls for a patient-centred approach to TB control. The bublic health dimension concerns proper diagnosis and treatment of TB patients to decrease disease transmission within communities. This necessitates development of well-organised TB control programmes responsive and adaptable to the reforming health sector.

Strategy

Recognising the seriousness of the problem WHO declared TB as a global emergency in 1993 and urged each National Tuberculosis Control Programme (NTP) to implement Directly Observed Treatment Short-course (DOTS) strategy, which is the most effective ever known means to control TB. Since the introduction of the DOTS strategy, considerable progress has been made in global tuberculosis control. By 2000, more than 148 countries had adopted the DOTS strategy for TB control and more than 27 per cent of the global TB cases were treated under DOTS.

Although considerable, this progress has not been enough, an estimated one third of world's population is already infected with TB. Each year an estimated 8.4 million new cases are produced from this reservoir of infection, and 1.9 million people die of the diease. The poor and marginalised in the developing world are the worst affected: 95 per cent of all cases and 98 per cent of deaths from TB occur in resource poor countries. Tuberculosis is one of the major public health problems in South Asia leading to a dramatic socio-economic impact on the SAARC countries, incurring a loss of around 4 billion dollars every year. The disease accounts for 26 per cent of avoidable deaths, 75 per cent of which occur in the 15-49 year age group, economically the most productive in the population. The SAARC region accounts for more than 31 per cent of the global burden with an estimated. 1.12 million new smear positive cases, 2.5 million all forms of new cases and 0.6 million deaths every year. India, Bangladesh, and Pakistan are occupying the 1st, 5th and 8th position respectively in the list of 22 high burden countries identified by WHO. Despite the establishment of National TB Control Programmes for over 40 years, TB has not yet been controlled in South Asia. Even within countries adopting the DOTS strategy, much needs to be done to expand the services to the whole population.
Several challenges impede sustainable implementation and expansion of TB control activities. Many of these stem from a weak political will failing to elicit the required health system and societal response to control TB. General public health services need to enhance their capacity to sustain and expand DOTS implementation without compromising the quality of case detection and treatment. Community involvement in TB care and a patient-centred approach need emphasis and promotion to improve both access to and utilisation of health services. Collaboration and synergy among the public, private, and voluntary sectors are essential to ensure accessible and quality assured TB diagnosis and treatment. The increasing impact of HIV on the incidence of TB calls for new partnership and approaches. A surge in drug- resistant forms of TB in several parts of the world requires effective implementation of the DOTS stragegy to prevent occurrence of new multi-drug-resistant (MDR-TB) cases as well as measures to cure existing MDR-TB cases. Sustaining DOTS programmes will also entail their integration into primary health care and adaptation to ongoing reforms within health sectors worldwide.

In view of the above challenges and experiences of about a decade of DOTS implementation-achievements and constraints- there is a need to update and expand the current framework of the DOTS strategy. It is now necessary to widen the scope of the DOTS control strategy and make it a comprehensive support strategy- support to all providers, patients and people to tackle the problem of TB. The expanded strategy lays equal emphasis on technical, managerial, social and political dimensions of DOTS. It acknowledges access to TB care as a human right and recognises TB control as social good with large benefits to society. It underscores the contribution TB control makes to poverty alleviation by reducing the great-economic burden that the disease inflicts on the poor.

DOTS (Directly Observed Treatment, Short-course) was developed by the International Union Against Tuberculosis and Lung Disease (IUATLD) and is recommended by WHO as a TB control stragegy worldwide.

The SAARC countries have adopted DOTS strategy to fight against TB. All member countries are implementing and expanding DOTS. As per information received from the member countries, the areas of DOTS are expanding year by year to cover more and more population under the National TB Control Programme.

DOTS in SAARC Member Countries;

BANGLADESH: adopted in 1993. DOTS population coverage 95% and smear positive cases treated successfully under DOTS (2000) 83%.

BHUTAN: adopted in 1996. DOTS population coverage 100% and smear positive cases treated successfully under DOTS (2000) 90%.

INDIA: adopted in 1993. DOTS population coverage 45% and smear positive cases treated successfully under DOTS (2000) 84%. Over the past three years, there has been a 20 -fold expansion of DOTS- one of the highest in the recent history and plans to cover 80% of the population by 2004.
MALDIVES: adopted in 1996. DOTS population coverage 100% and smear positive cases treated successfully under DOTS (2000) 95%.

NEPAL: adopted in 1996. DOTS population coverage 91% and smear positive cases treated successfully under DOTS (2000) 96% reduce mortality from 8000-11000 (2001) to 5000-7000 in the year 2002.

PAKISTAN: adopted in 1995. DOTS population coverage 10% (2001).

SRILANKA: adopted in 1994. DOTS population coverage 95% and smear positive cases treated successfully under DOTS (2000) 77%.

Success

It shows that the DOTS has proved its success in Member Countries of SAARC. Implemented DOTS areas in our region have demonstrated success rate above the target and such programmes have been appreciated all over the world. There is however clear commitment from governments within this region for achieving global targets and countrywide DOTS coverage in each country by 2005. It is expected that the SAARC region will achieve the set targets by 2006.

This article is jointly written by Dr. D. S. Bam, Dr. Md. M. Rahman, Dr. Basista Rijal and Dr. R. M. Samartunga. Dr. Bam is the director, Dr. Rahman Elldemiologist, Dr. Rijal Microbiologist and Dr. Samartunga Research Officer of SAARC TB Centre.

TB Control And Health Care

By Dr. Thir Man Shakya

TUBERCULOSIS is a disease that has made its impact felt throughout the world through many centuries. This disease was once famous by the name of "white plague". In Europe and North America this disease was the leading cause of death at one time. It increased disastrously during the industrial revolution which started from the United Kingdom in the 18th century. It gradually diminished even though there were no anti T.B. drugs in those days probably as a result of the increasing standard of living and also due to the elimination of the more susceptible members of the people.

Decline

There has been spectacular decline in tuberculosis morbidity and mortality in industrialised countries and the disease is under control. But in resource-strapped countries, the disease still remains as a major public health problem.

Despite the astonishing progress in the knowledge about the disease, tuberculosis remains as one of the widespread scourges of mankind in poor countries. About 1/3rd of the world's population are infected with mycrobacterium tuberculosis (TB germs), 8 million new cases of tuberculosis appear every year, 95 per cent of whom are in developing countries, 2.5 million are in South East Asia region only. It caused 2.9 million deaths in 1990 making the disease a largest cause of death from a single pathogen in the world. The largest number of death occurred in South Asia (940,000).

The story of tuberculosis during the past decades has been one of the triumphs and tragedies - triumph of scientists who provided the means to control and ultimately irradicate the disease and the tragedy lies in the widespread failure to exploit their discoveries. The global epidemic is getting worse which is clear by the growing number of people with active disease. There were 8.4 million new cases in 1994, up from 8 million the year before. Each year 2.5 - 3 million people die from tuberculosis more than any other single infection despite the fact that this disease in its common form is entirely curable and preventable as well.

People infected with HIV, which are increasing pandemically since it was reported in the early 1980s, are uniquely susceptible to TB. Among AIDS patients, more people are dying of tuberculosis than ever before in history.

Worse yet, years of mismanagement of this disease have created multidrug resistant strains of TB which are marginally treatable only at enormous cost and efforts for which neither the poor patients nor the government can afford. They are thus not only left to die but also to spread multidrug resistant strains of bacteria in communities.

Countries of Western Europe and North America saw an increase in incidence of TB cases mainly due to TB in immigrants. Tuberculosis cannot therefore be controlled in industrialised countries unless it is sharply reduced in developing countries.

In April 1993, WHO declared TB as global emergency. At the same time, the WHO urged its member countries to plan and implement the national programme with operational target of at least 85 per cent cure rate of diagnosed cases and detection of 70 per cent of estimated incidence each year.
Nepal is also one of the hard hit areas from tuberculosis. The gradual development of tuberculosis service in Nepal in recent years through efforts of years has been matter of satisfaction but this definitely is not a cause to be complacent and has many things to be improved on sustainable bases. The revised strategy of directly observed therapy with short course chemotherapy.-DOTS is being operated with satisfactory results.

Past efforts to control tuberculosis in various countries have a long history. Before March 24, 1882, the cause of tuberculosis was not known to anybody when a German Doctor Robert Koch announced the discovery of tubercle bacilli. Treatment of tuberculosis in those days was mainly directed towards relieving the individual patients. With the discovery of anti tuberculosis drugs in the early 1940s which are highly effacious, the efforts of TB control began to be better organised by opening of tuberculosis clinic put together as specialised programme. Later in 1960s the concepts underlying the modern national tuberculosis programme (NTP) emerged. It was enunciated in a Eighth report of WHO (1964) and elaborated in the Ninth Report of WHO expert committee on tuberculosis. NTP this came out as intervention in a planned manner in accordance with the burden of the disease, socio economic and other operational conditions relevant to the countries and knitted into general health services in order to cover the entire population on a long term basis. All the development countries are now implementing NTP. However these programmes have attained various levels of development and performance.

In 1994 His Majesty's government of Nepal on the request of the National Tuberculosis Centre undertook in-depth review of the TB programme of Nepal which led to the revised strategy, DOTS, which means that a supervisor watches the patients swallowing the tablets; the supervisor may be a health worker or a community member.

Essential

Contribution of NGOs, INGOs and donor agencies are commendable for whatever TB services have been developed in Nepal. For effectiveness of tuberculosis services, the development of primary health care services scattered throughout the country is very essential as national tuberculosis control activities are carried through them. The health workers working in them need to be properly guided, trained, supported and supervised.

Impact Of War

By Indra Adhikari

THE US attack on Iraq has begun. The world is split on the issue. However, the most affected countries of the war in the Gulf will be the developing nations.

The impact of the war will also be seen in Nepal as well. As a non-aligned nation, Nepal stresses on a peaceful solution of the problem.

One of the greatest impacts on Nepal by the war in the gulf country would be on tourism. Soon after the cease-fire between the government and the Maoists, Nepal saw some hopes of an increase in the number of tourists. The golden jubilee celebration of the first ascent of human being on top of Mount Everest this autumn has caught attention of would - be visitors. That was reason enough for tourism revival in the country.

The statistics in the last few months is seen hopeful. But the war in Iraq may see a decline in arrivals in the months to come.

The straight air routes from western countries to Nepal might be affected. There are at present a few flights from Gulf countries coming to Nepal. These flights are working as a bridge between the western countries and Nepal. The tourists from western countries especially from Europe and America use this route to Nepal. The US led attack on Iraq would affect this air route and make the route unsafe. As there are no direct air links to Europe or America, the repurcussions will be felt.

We have the experience of the economic crisis faced due to the 9/11 in America. No doubt, the attack by the USA on Iraq will also bring economic problems in Nepal.

The international trade too comes under effect. Demand for luxury goods would decline. Thus, Nepal's exports and imports would also face impact. As a cause of economic crisis in the international market, Nepal's export in particular may decline.

The government has declared the year 2003 as the year for export. But many complications may arise now. The goods exported may not find market and price for sustainability.

Nepal's foreign employment will also be affected. The government has already decided to stop allowing people to travel to Kuwait and mooting of doing the same for other Gulf countries as well. The Gulf countries are major destinations of Nepalese for foreign employment. Such a step would indirectly affect the national economy. On the other hand, it will increase unemployment. Already a few groups of Nepalese have returned because of security reasons. Others also would be returning soon. The government has said that it has prepared for the safe stay of Nepalese working in Kuwait in Saudi Arabia for another 15 days. Many companies that were employing Nepalese were reported to have given leave to them for the next six months.

Other major affect of the attack on Iraq will be the increase the price of petroleum products in the international market. It will create a shortage of petroleum products in the international market that will definitely affect Nepal market. As Nepal has to import all POL products, kerosene, diesel or petrol would become scarce.

We have seen symptoms of shortage of the petroleum producs within these two-three days. People have already started storing kerosene, diesel or petrol for future use. If the war prolongs, the availability of these petroleum products will be more difficult. But the government has declared that it would not increase the price of these products. It has also decided to fix POL quota to vehicles and introduced new system for plying vehicles.

The price rise in other commodities of daily use has also been observed.