C. Directly Observed Treatment Short Course (DOTS):
WHO's strategy for curing TB patient is to use Directly Observed Treatment Short Course (DOTS). DOTS is a system where health workers watch as each patient takes the correct medication. By using DOTS one can almost be certain that TB patients will be cured.
The PHC worker will start DOTS in any patient whom the microscopy has reported smear-positive for TB bacilli. Very sick patient, or patients with frequent haemoptysis, should be sent to the hospital. The health worker must watch the patient take the entire medication during the full course of treatment.
The drugs should be distributed from the most peripheral health post, which there fore should be adequately supplied by the referral level according to the number of the patients to be diagnosed during a certain period of time. A minimum reserve for three months is indicated and it would be appropriate to test the distribution of the drugs in individual packages containing the complete number of doses necessary for treatment of each patient. Once a patient starts the treatment at any primary health care unit, his/her name is written on the individual container, in this way the drugs for the completion of the treatment are appropriately reserved.
All anti-Tuberculosis drugs produce in some few patients signs of adverse effects. Some signs are mild and can be dealt with at the primary health care level. As a general rule, when mild effects are report by the patient the drugs are stopped for three to four days and then they reinstated. If the symptoms reappear the patient should be sent to the referral level. If serious adverse effects occur, medication should be suspended immediately and the patient sent to the first referral level.
Patients under treatment will be monitored by means of periodical sputum examinations: this can be done every month or ever two or three months according to the local facilities. During the DOTS period medication taken, any adverse effects, and periodical sputum examinations should be recorded and reported to the referral level.
The training of the PHC workers in treatment includes the following operations;
･Health Workers and System-not the patient-responsible for achieving a cure;
･Observation of the patient fully taking medication;
･Ensuring the patient understands the importance of fully taking the medication as well as encouraging the patient to complete the cycle of treatment
･Informing the patient of the possibility of adverse effects due to the medication;
･Supervision and reporting of the ingestion of the oral treatment, the patient's condition, and the presence of drug related side-effects;
･Giving instructions for the following visit to the health unit;
･Obtaining reasons for failure of treatment;
･Recording and reporting of treatment activities;
･Referral of patient to the referral level
D. Monitoring of case-finding requires information on the prevalence of TB patience and the symptomatics. This information should be collected by the TB program. A comparison of the number of the cases found and that expect usually cannot be made at the community level, but is usual when made for instant at the district level. For the community level often a good estimate of the number of symptomatic, and the number of specimens collected may then be useful quantitative indicator of the case-finding activity. The proportion of specimens found positive is a useful qualitative indicator, especially when used comparatively.
Treatment is ultimately best evaluated from the number of patients cured among those detected in the previous year, but at the community level the treatment activities are best monitored by verifying the number of patient under DOTS among the patients registered.
In 1990 the rural areas of Tianjin began the integration of TB control into it's primary health care system. This integration was in accordance with the DOTS requirements and met with great success. In the rural areas the number of newly detected smear positive cases between 1990 and 1995 rose from 140 to 375 (table 1). The proportion of new smear positive cases under DOTS increased from 12% to 92.8% (table 2). The cure rate for smear positive cases under a one year period rose from 52.2% to 95% (table 3).
