What is DOTS?
A Guide to Understanding the WHO-recommended TB Control Strategy Known as DOTS
Global Tuberculosis Programme
World Health Organization, Geneva, Switzerland
Preface
This year, more people will die of TB than in any other year in history. How can this be? For over 100 years we have been able to recognize down the microscope the microbe that causes TB--Mycobacterium tuberculosis. For almost 50 years we have had effective anti-TB drugs. Why, then, are we failing to detect so many TB patients? And why are we failing to cure so many of those who are detected?
The problem has not been the lack of ways to detect and cure TB patients. The problem has been the lack of organization of services to ensure widespread detection and cure of TB patients, particularly the infectious ones. Today, however, there is a proven cost-effective TB treatment strategy known as DOTS.
A combination of technical and managerial elements, DOTS quickly makes the infectious cases non-infectious and breaks the cycle of transmission. Using DOTS also prevents the development of drug-resistant strains of TB that are often fatal and almost 100 times more expensive to cure.
The technology has been successful in large and small countries, both rich and poor. Countries achieving high cure and coverage rates include Benin Guinea, Peru, Nicaragua, China and Viet Nam. For example, in China, cure rates rose from below 50 percent to more than 95 percent in areas covered by DOTS, and about half the population of China is covered by the strategy today. In Peru, government commitment for the stategy has resulted in almost 100 percent DOTS coverage in the country and cure rates of up to 83 percent.
Several challenges, however, impede the implementation of DOTS. The worsening impact of HIV on the incidence of TB is threatening to overwhelm not only otherwise effective TB control programmes, but also primary health care services in general. After the dissolution of the centralized health system of the former Soviet republics, TB incidence and mortality are on the rise. Eastern Europe is also seeing a surge in drug-resistant forms of the disease.
The challenge in TB control today is to provide technical support to these countries by adapting the strategy to fit specific country situations. For example, in areas of high HIV prevalence, partnerships must be forged between TB and HIV programmes. In Eastern Europe, TB control must not only be introduced and reinforced, but additional programme elements should be developed to more quickly identify and treat drug-resistant cases.
Since the introduction of the strategy almost four years ago, great strides have been made in spreading the message to governments, health care workers and the public about the importance of implementing DOTS. As of 1997, 110 countries had accepted the strategy as policy and had implemented it to varying degrees. However, more must be done to ensure the implementation of DOTS more widely.
This document discusses how DOTS was developed, how it is implemented and sustained, how it differs from other control approaches, and its role within a challenging and changing health care system. This document is designed to give decision-makers with health policy and budget authority a good understanding of the strategy so that they can promote effective TB control in their countries.
Chapter 1 - What is DOTS?
DOTS is the most effective strategy available for controlling the TB epidemic today. The strategy was developed from the collective best practices, clinical trials and programmatic operations of TB control over the past two decades.
DOTS (Directly Observed Treatment, Short-course) has five key components, one of which is directly obsaved therapy, or DOT.
･ Government commitment to sustained TB control activities.
･ Case detection by sputum smear microscopy among symptomatic patients self-reporting to health services.
･ Standardized treatment regimen of six to eight months for at least all confirmed sputum smear positive cases, with direct observation of treatment for at least the initial two months.
･ A regular, uninterrupted supply of all essential anti-TB drugs.
･ A standardized recording and reporting system that allows assessment of treatment results for each patient and of the TB control programme overall.
Government commitment to sustained TB control is essential for the other four elements to be implemented and sustained. This commitment must first translate into policy fomulation, and then into the financial and human resources necessary to ensure that TB control is an essential component of health services.
Underpinning the strategy is the concept of a basic management unit--covering a population of l00,000 to 150,000--that has the staff and resources to diagnose, initiate treatment, record and report patient treatment progress, and manage supplies. This basic management unit operates successfully within existing general health services, which is critical for the full integration and survival of TB control services during this era of health sector reform.
Another underpinning of this strategy is its recording and reporting system used by health care workers to systematically monitor patient progress and TB programme performance. This system enables quality assurance of programme implementation and treatment and cure of TB patients.
