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.

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