Letter to the Editor The Dilemma of Tuberculosis Control and the DOTS Program
Maharajgung Campus, Institute of Medicine, Nepalashokdevkota@iom.edu.np
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To the Editor -- The fear and stigma of tuberculosis is apparent both in the community and among medicos. The incidence of tuberculosis in developed countries had been declining due to improved sanitation and socioeconomic conditions long before the necessary medicines were discovered. After the discovery of anti-tubercular drugs and multi-drug regimen, the Directly Observed Treatment Scheme (DOTS) was launched in 1991 as the most effective measure in combating TB in developing nations. Today, DOTS still has many woes to share. Directly Observed Treatment for eight months often hinders complete treatment and reduces compliance due to inaccessibility of health services or time constraints. Passive case detection strategy in DOTS is only a curative strategy and only prevents the epidemic outbreak of the disease it does not eliminate it.
Despite its shortcomings, the strategy has helped to successfully treat many cases, and the results are encouraging in many countries. SAARC is a priority region that accounts for 39% of the world's tuberculosis cases and nearly 700,000 deaths annually. Moreover, tuberculosis usually kills people at a young age and has added to the social and economic burden. In Nepal, DOTS was launched in 1995/96. After nine years, it has achieved major success with a case detection rate of 70% and cure rate of 89% in 2002/03. Medicos and medical communities are also potential resources in the combat against tuberculosis, and they have worked hand-in-hand with the tuberculosis partnership program.
The Stigma of Tuberculosis
A thin and wasted patient in the medical ward listlessly sleeping and wearing a mask is enough to scare fellow students. They are afraid of approaching patients with tuberculosis. The students know that in 48 hours, anti-tuberculosis treatment kills 90% of the bacilli and renders the patient harmless, but the dreaded psychology is rooted in an incident a few years back when we lost a practicing intern due to multi-drug resistant tuberculosis.
Some of my colleagues from remote places did not get the vaccination against tuberculosis. "It was not there when I was born," they would say. "Probably my parents did not know," others would say. Most of them passed the test of time and survived tuberculosis early in childhood. With better coverage of Global Immunization Program of World Health Organization, the situation now is not as bad.
A friend of mine was apparently well until he gradually developed evening rising fever and became lethargic after a day's hard work. He often had bouts of cough. A friend insisted that he get an X-ray done. It was shocking to see a massive effusion covering the half of the right lung field. Alarmed, pleural fluid was aspirated immediately and sent for biochemistry analysis. It showed lymphocytosis. As successive smears of sputum collected in the morning were found to be negative for acid fast bacilli, my friend was diagnosed to have sputum negative extra-pulmonary tuberculosis and put on anti-tubercular treatment.
Corticosteroid did wonders. In less than a week, my friend's effusion disappeared; he had no cough and fever.
"It was hard to pursue the protracted course for eight months as my physical symptoms disappeared almost completely in a week", he said. "Treating tuberculosis is nerve-wrecking." Though we have been able to shorten the course of treatment, it's not easy to maintain the compliance for the whole eight months.
Directly Observed Treatment Scheme (DOTS)
Tuberculosis infects 100 million people each year, and 8.5 million people develop the disease. Of these, two million people die. One third of the world's population is now infected with tuberculosis (Stop TB Annual Report 2002).
Major worldwide improvement regarding tuberculosis management has resulted from the introduction of isoniazid in the early 1950s, followed by that of pyrazinamide, and the discovery of rifampin some twenty years later. The discovery of rifampin led to the development of short-course chemotherapy. Due to the introduction of chemotherapy and the socioeconomic development of the industrialized countries, the incidence of the disease declined, but not much could be achieved in developing countries. Thus, tuberculosis management was largely abandoned and neglected until the early 1990s, when the HIV/AIDS pandemic began to spread, causing a sharp increase in tuberculosis morbidity (Raviglione and Pio 2002).
In 1991, the 44th World Health Organization assembly adopted the new strategy and targets: Directly Observed Treatment Scheme (DOTS). DOTS is currently the only effective strategy to combat tuberculosis. During DOTS, a patient is treated with a multiple drugs regimen -- a combination of isoniazid, rifampin, ethambutol, pyrazinamide, and streptomycin -- normally for eight months. To increase compliance, a health worker observes the patient taking the pills.
DOTS stand on five pillars:
1. Political commitment
2. Diagnosis by microscopy
3. Directly observed treatment
4. Regular supply of drugs
DOTS has enlivened the prospect of effectively combating tuberculosis, but there are still many constrains to overcome. Though DOTS is a priority program, it may not be so for a health worker who has to work in overloaded outdoor-patient-departments.
For example, a patient visited a health center complaining of blood in his sputum. He was diagnosed with pulmonary tuberculosis and prescribed anti-tubercular treatment. He came frightened: "Doc, then I had only blood in the sputum, now I have blood in the urine as well". Rifampin stains the urine red; it is harmless.
Another story is of an alcoholic who was on anti-tubercular treatment. He missed pyridoxine doses. Pyrodixine is given to prevent neuropathy due to isoniazid, so it should not be left out. He had peripheral neuropathy. These facts have to be well explained to the patient. Adequate counseling is equally important in cases when we have to use highly hepatotoxic drugs. Because of this, health workers have to be equally committed to implement DOTS.
DOTS stands for Directly Observed Treatment Short course; it is a misnomer. Treatment therapy for eight months is not a short course'; it is only a reduced course of treatment compared to the previous regimens of even longer duration. To counteract the emergence of multi-drug resistance due to incomplete or faulty treatment, the patient is observed swallowing the drug. This creates technical difficulties for implementation. For at least two months, the patients must visit the health centers regularly. Can they afford it? It is mainly poor people, farmers, and laborers who contract disease, and it's hard for them to find the extra time to visit the health center daily. This means that they are cut off from their daily income. Also, health services are often inaccessible to some in remote districts due to the difficult topography.
Keeping the terrain barrier in mind, other approaches such as family-based supervision, community-based supervision, and use of intermittent drug regimen have been put forward, but none have been tested and implemented.
DOTS: A Curative Strategy
The DOTS program aims at controlling tuberculosis, not curing it, in sharp contrast to the well-known dictum, "Prevention is the best cure." Tuberculosis is a disease of poverty, and it's often stated as an indicator of socioeconomic condition of the community. Tuberculosis in developed countries declined long before the discovery of anti-tubercular drugs mostly due to improved sanitation and improved socioeconomic condition.
In my community, we have a reserve of tuberculosis bacilli. Tuberculosis usually presents with mild symptoms of evening rising fever and the patients are not alarmed unless they have haemoptysis or serious complications. There are also symptomatic carriers who often transmit the disease to others.
Though we are aiming to take the medical cure to the doorsteps of the people, we have not been able to do this. For decades, it is still the sick that have to come looking for the services. The DOTS strategy affects only passive case detection of only those cases reported to the health center. Active case detection is not carried out since it is expensive. Massive screening in the past with portable X-rays showed no benefit at all, and no other effective measure has been devised. Passive case detection and extensive chemotherapy only alleviate the problem; they do not eliminate it.
The DOTS strategy has completely ignored the public health approach of treating a chronic and infectious disease. No preventive strategy has been adopted in the community. Prophylaxis and containment of active cases mean primary prophylaxis for others. But this only prevents the epidemic outbreak. Achievement of the global target of detection rate of at least 70% and cure rate of at least 85% would lead to an expected decline in annual incidence of 6-7% per year (Elzina et al. 2004).
DOTS in South Asia
Seven South Asian countries, including Nepal, India, Pakistan, Bangladesh, Bhutan, Sri Lanka, and Maldives form a regional ally, the South Asian Association for Regional Cooperation (SAARC). The SAARC region accounts for 39% of the world's tuberculosis cases, with three million new cases and nearly 700,000 deaths occurring annually. Tuberculosis is the most common cause of death from infectious diseases among adults in the region; 75% of the mortality and morbidity due to the disease occur in the age group 14 - 45 years.
In areas using DOTS, the treatment success rate is nearly 80%; however, it has only 45% coverage and case detection rates are as low as 30% (SAARC TB Center 2002).
DOTS Achievements in Nepal
In 1995/96, the DOTS strategy was implemented in four of Nepal's 75 districts. Case detection rates were 46% and the cure rate was 52%. With these encouraging results from the initial implementation of the DOTS strategy, the National Tuberculosis Program expanded the program. By 2002/03, they used the DOTS method to achieve case detection rates of 70% and cure rate of 89%. More than 90% of people in these areas have access to the DOTS service. This is a significant achievement for Nepal, where 40,000 people develop active tuberculosis and 5,000 7,000 people die every year (Nepal Ministry of Health 2002).
DOTS and Medicos
While international and national organizations combating tuberculosis with DOTS are doing their job, medical communities, including medical students, are helping them in the efforts.
"Stop TB". "DOTS cured me, it will cure you too". Among medical students, these are popular slogans. Students have carried these messages not only to patients but to the community as well. Students should be well oriented on the issues of proper treatment of tuberculosis and DOTS policy to achieve conformity in treating the cases as per standard guidelines. Many student organizations have joined hands with a tuberculosis partnership program. Medical communities in South Asia are involved in combating tuberculosis by helping to implement DOTS and strengthening a partnership with the national tuberculosis program. Many medical colleges have taken the initiative and played strategic roles through technical and managerial capacity building, operational research and by monitoring progress to supplement national control efforts. They have been the eyes and ears of the national tuberculosis program and will remain so to achieve the target: a world free of tuberculosis.
Stop TB Annual Report. (2002). World Health Organization. www.stoptb.org.
Raviglione, MC and Pio, A. (2002). Evolution of WHO policies for tuberculosis control, 1948-2001. The Lancet. 359:775-80.
Elzina, G et al. (2004). Scale up: meeting targets in global tuberculosis control. The Lancet. 363:814-819.
SAARC TB Center. (2002). Involving medical colleges and Private sector in tuberculosis in tuberculosis and HIV control, Nepal.
Nepal Ministry of Health. (2002). Annual Health Report 2002/03.