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 What is DOTS?
What are the Essential Elements of DOTS Strategy?
What is the Evidence that DOTS Works?
Are there "DOTS" Success Stories in Asia?
What is the Rationale Behind Directly
Observed Therapy?
What are the Benefits of New Treatment Strategy?
What is DOTS ?
DOTS
stands for directly observed Treatment, short-course. DOTS as a TI3 control
strategy was pioneered by the International Union against TI3 and Lung
Disease (IUTLD) and recommended by WHO. The DOTS
strategy takes simple technology - the successful components of TI3 control -
and packages it with good management practices for widespread use. The
strategy can be easily integrated into general health services and can
therefore be widely used. How the DOTS strategy is implemented varies from
country to country and within countries. The implementation of DOTS requires
flexibility in adapting the strategy according to local circumstances. There
are five key elements that are considered essential for the implementation of
the DOTS strategy.
What are the essential elements of DOTS strategy?
There
are five new elements that are considered essential for the implementation of
DOTS strategy. These are:
1. Government
commitment to sustained TB control;
2. Sputum-smear
microscopy to detect the infectious cases among those people attending health
care facilities with symptoms of pulmonary T13, most importantly cough of
three weeks' duration or more,
3. Standardized
short-course anti-TB treatment for at least all sputum smear-positive
pulmonary TB cases, with direct observation of treatment for at least the
initial twomonths;
4. Regular,
uninterrupted supply of anti-TB drugs and diagnostics, and
5. Monitoring
and accountability system for programme supervision
and evaluation of treatment outcome for each patient diagnosed.
What is the evidence that DOTS
works?
In
the few years since DOTS was introduced on a global scale, more than 1. 7
million infectious TB patients have received effective treatment. In areas
where DOTS was implemented, cure rates of up to 95% have been recorded, even
in very poor countries. Moreover, DOTS prevents transmission of new
infections and the development of multi-drug- resistant TB. The DOTS
strategy has been ranked by the World Bank as one of the most cost-effective
of all health interventions.
Are there "DOTS" success stories in Asia?
There
are many DOTS success stories. One of the most successful experiences is the
tuberculosis control programme in China. In April 199 1, the DOTS
strategy was implemented among two million people in five pilot counties of Hebeiprovince of China. By the end of the year, the
project was found to produce cure rates of 94%. These were among the best
results found anywhere in the world. As a result, by 1995, China had expanded DOTS to reach
nearly half the country. The number ofTB cases
detected per year increased from 835 in 1990 to over 130 000 in 1995. Nearly
91% of patients starting treatment in 1993 have been cured.
The
following are some of the success stories in the South-East Asia Region:
1. Bangladesh
adopted the DOTS strategy in 1993. Currently, it is being implemented in over
75% of the country.By 1995, as many as 80% of the
patients receivingtreatment were cured in areas of
the country where the strategy was being used. In 1997, WHO described Bangladesh's
TB control programme as a model for the entire
world.
2. In Maldives,
the DOTS strategy has been applied since1994 and has led to impressive and
consistent cure rates in excess of 85%. Maldives
is the only country in the Region which has already achieved the global
target of an 85% cure rate at the national level.
3. DOTS was introduced
in Nepal in
1995. Since then, more than 85% of patients in DOTS demonstration sites have
been cured, compared to less than 50% before the DOTS strategy was adopted.
What is the rationale behind Directly Observed Therapy?
Patients compliance is a key factor in treatment success. In
many situations, and for various reasons a
significant proportion of patients receiving self-administered treatment do
not adhere to treatment and stop treatment before completing the full course
as prescribed. With self-administered treatment, it is impossible to predict
who will not comply with treatment prescription. Directly observed therapy (DOT)
is therefore necessary at least in the initial phase to ensure adherence. DOT
is therefore only one of the five components of the DOTS strategy, i.e. the
WHO- recommended policy package for TB control.
Direct observation of treatment means that a supervisor watches the patient
swallow the tablets. This ensures that a TB patient takes the right drugs, in
the right doses, at the right intervals. Supervisors can observe patients
treatment in either inpatient or outpatient settings.
Directly Observed Treatment (DOT) vs DOTS
 Directly observed treatment (DOT) is one
element of the DOTS strategy.
An observer watches and helps the patient
swallow the tablets
Direct observation ensures treatment for the
entire course
 with the right drugs
in the right doses
at the right intervals
The
supervisors may be health workers, trained community members or NGO workers,
who are acceptable to the patients. In order to ensure that directly observed
therapy fits patients needs, Services should be organized as close to
patients homes as possible by integrating TB services into general health
services.
Directly
observed therapy is recommended in the treatment of all new smear-positive
cases at least during the initial phase of therapy. It is also recommended
that directly observed therapy should be applied in the continuation phase
particularly for patients who are using rifampicin-containing
regimens.
What are the benefits of new treatment strategy?
The
benefit for patients themselves is the increasing treatment completion
resulting in rapid cure. Furthermore, case management under DOTS strategy can
prevent death, sequelae, and relapse. Moreover,
DOTS can reduce community transmission of tuberclebacilli
as well as emergence of drug resistance strains.
Ensuring
that the patient takes treatment under observation has been highly successful
in a wide variety of settings. The costs of supervision (by treatment
observers/ supervisors) are more than offset by savings resulting from the
decreased risk of treatment failure, relapse, drug resistance, secondary
spread of the disease and case fatality.
The
strategy has been successfully demonstrated also among HIV-positive TB
patients, with increased completeness of therapy and improved patient
survival.
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