Chapter 3 - The Development of DOTS
Long-Course Drug Treatment
In the era before anti-TB drugs, treatment was intended to strengthen a patient's resistance to TB (for example through special diets and bed rest in sanitoria), and to rest the diseased part of the lung (by various techniques of collapse therapy). Treatment in a sanatorium was expensive and only available to a small number of the world's TB patients. Nevertheless, at least half of the patients with TB eventually died from the disease.
In the 1950s, the development of drugs which in combination kill off TB bacilli and cure TB revolutionized TB treatment and led to a dramatic reduction in TB case fatality--to 5 percent or less--where used correctly.
Clinical trials in India, East Africa, Singapore and Hong Kong demonstrated the effectiveness of long-course drug treatnent. One study in Chennai (then Madras), India, showed that with ample financial and human resources, long-course treatment (for one year) was effective without the need for hospitalization. Both developed and developing countries started to abandon hospitalization.
Short-course Drug Treatment
In the 1970s, the introduction of rifampicin as part of a combination of anti-TB drugs reduced treatment to six to eight months--known as short-course drug treatment. Patients feel bettet more quickly than with long-course drug treatment as the bacillary load decreases dramatically during an intensive initial two-month phase of treatment. Within these few weeks, patients are rendered non-infectious and are no longer able to spread the disease to family, friends and co-workers.
The Styblo/IUATLD Model of TB Control
In Tanzania in the 1970s, Dr Karel Styblo of the International Union Against Tuberculosis and Lung Disease (IUATLD) pioneered the development of a model of TB control based on a managerial approach to case-finding and treatment.
The use of long-course drug treatment in the first few years in Tanzania did not achieve high cure rates, and so was abandoned in favour of short-course drug treatment. The Tanzania National TB Control Programme was the first of the IUATLD model programmes with successful nation-wide coverage. Between 1978 and 1991, IUATLD supportted national TB programmes in nine high prevalence, resource-poor countries.
Dr Styblo was the fist to propose the idea of a basic management unit (usually the district) that would have the staff and resources necessary to diagnose, initiate treatment, record and report patient treatment progress, and manage supplies in a population area of 100,000 to 150,000. This basic management unit allowed the technical aspects of TB control to be integrated into the general health services.
WHO and the DOTS Strategy
In 1993, WHO's Global Tuberculosis Programme (GTB) took an unprecedented step and declared TB a global emergency. After defining the nature and size of the global TB problem through expanded monitoring and surveillance, GTB began promoting Styblo's strategy in a technical and management package known as DOTS.
The Programme developed necessary tools, such as technical guidelines and training materials, for the marketing and implementation of DOTS. At the same time, GTB embarked on intensified technical assistance to over 60 countries, focusing on big countries with the largest TB burdens.
The number of countries using DOTS expanded from only 10 in 1990 to 110 in 1997. The percent of patients treated under DOTS increased from less than 1 percent in 1990 to 15 percent in 1997.
