Using Direct Observation Treatment (DOTS) to beat tuberculosis - A World Health Organisation strategy to address the increasing incidence of tuberculosis Case Study Click on the following links for further information about this case study: Teacher's Notes Student Activities Introduction In 1993, the World Health Organisation declared the incidence of tuberculosis (TB) as a global emergency and recommended the implementation of a treatment strategy called DOTS (Directly Observed Treatment, Short-course). The aim was firstly to identify cases of pulmonary TB in communities around the world, particularly those in developing countries, and secondly to treat victims by directly observing them take their medication for at least the first two months of treatment. The latter is to ensure that medication is taken in the right combinations and appropriate dosage in an effort to control and reduce the incidence of multi-drug resistant TB. With direct observation of treatment, it is anticipated that 80% of deaths attributed to TB worldwide will be prevented. Background to the strategy Tuberculosis is an infectious disease caused by the bacillus M. tuberculosis. Pulmonary TB is the most common form of the disease among humans, affecting the lungs. It is highly contagious as it spreads through the air when a TB infected person coughs, sneezes or spits. Each victim may infect 10-15 people each year. The TB bacillus multiply in the alveoli or air sacs in the lungs and virtually dissolves the lung tissue. The sufferer becomes very tired and breathless and will usually lose weight. In the advanced stages blood is usually coughed up. One-third of the world's population is infected with TB. However, not all those infected will develop active TB disease. For TB infection to develop into the disease, the infected person's immune system must be weakened by causes such as malnutrition, substance abuse, overall poor health, or HIV. Almost two million people die from TB each year. One million of these are women and 250,000 are children. There is currently between 16-20 million infected people around the world and approximately eight million new cases of TB each year. While TB is a growing concern in many developed countries, 98% of deaths from the disease occur in the developing world. Tuberculosis is the leading infectious killer of youth and adults in the world. While TB has been around for many years, the number of new cases arising has increased. The increasing level of poverty experienced by many countries is a contributing factor as is the emergence of HIV. Tuberculosis is the single biggest killer of people infected with HIV. HIV accelerates the progression of TB infection to active TB disease. People who are infected with TB and HIV are 30 times more likely to progress to active TB disease than people with TB infection alone. Approximately 11 million people are infected with both HIV and TB and an estimated 15% of all new cases of TB are also HIV infected. Seventy-five per cent of those affected by TB are men and women during their work productive years of 15-54. Tuberculosis therefore, has a significant economic and social cost to individuals, families and countries. When TB affects individuals, there is a loss of ability to work and to earn an income. On average, a TB patient loses three to four months work time, equivalent to 20-30% of annual household income. Developing countries seldom have social security payments for those who are sick or injured so a TB sufferer will receive no income while they are ill. In order to survive, many poor families have to sell assets such as land or livestock, pushing them further into poverty with less income for essentials such as food. Families often have to take children out of schools (especially girls) in order to help at home or to find paid work and they are unlikely to ever return to school. Unfortunately, in many countries there is a stigma that surrounds TB, often resulting from traditional beliefs about the disease, such as a punishment for past wrong doings, unhygienic habits or lifestyles, witchcraft or poisoning. This can lead to rejection of the sufferers by their wider family and the community; they may also lose their jobs or receive little or no support during treatment. Although the stigma of TB affects both men and women, its impact on women is often greater. A married woman suffering from TB is often cast aside by her husband and his family. Single women with TB are frequently deemed unmarriageable. Women who are rejected receive no support and end up alone and poor. Women are less likely to seek advice for their symptoms because they often cannot travel to a health centre; their husbands may not allow them to go or they may not have the money for travel or to meet the costs of the treatment. There may also be a fear of the stigma attached. Tuberculosis is curable. The best way to prevent the spread of TB is to identify, treat and cure people who have it with antibiotics. However, people with TB are often unaware that the condition is curable or lack access and information about available TB treatment. Another problem emerging is strains of TB resistant drugs known as multi-drug resistant TB (MDR-TB). This is caused by inconsistent or partial treatment that occurs when patients do not complete their course of medication, when the wrong drugs or the wrong combination of drugs are prescribed, or when the drug supply is unreliable. From a public health perspective, poorly supervised and incomplete treatment of TB is worse than no treatment at all. When people fail to complete their treatment or are given the wrong treatment, they may remain infectious. The bacilli in their lungs may develop resistance to anti-TB drugs. People they infect will have the same drug-resistant strain. Drug-resistant TB is more difficult and 100 times more expensive to treat, and more likely to be fatal. The DOTS strategy The majority of deaths from TB are preventable. DOTS has demonstrated high cure rates of about 80% (compared with 45% in areas that do not implement DOTS). Under DOTS, most patients can avoid costly hospital-based treatment and can be treated at home. A key principle is that every dose of treatment is observed and recorded by a health worker or trained person from the community for at least the first two months of treatment. This is a way of supporting sufferers and their families, and of ensuring that they are cured. Treatment observers can be anyone who is willing, trained, responsible, acceptable to the sufferer and accountable to the TB control services. In DOTS programs, almost twice as many patients successfully complete their treatment compared with those in non-DOTS programs. DOTS is also cost-effective to both individuals and the community. There are significantly lower costs associated to both the individual and the health system by avoiding hospital-based care. Costs will also be reduced as the number of TB cases declines. The costs of curing one TB sufferer with drugs is as little as US $7.00. An additional saving comes from the reduction of the MDR-TB which is 100 times more costly to treat. DOTS has five key components: Government commitment to sustained TB control activities - this is essential so that other components can be implemented and sustained and appropriate resources can be allocated. Detection of TB infection by the microscopic examination of sputum (spit) samples from those with symptoms reporting to a health centre. Sputum smear microscopy is an effective method of screening pulmonary TB and identifies highly infectious cases. A treatment program of six to eight months can be implemented including DOTS. A regular, uninterrupted supply of all essential anti-TB drugs. A standardised recording and reporting system that allows assessment and treatment results for each patient and of the TB control program performance over time. Where DOTS is implemented, an accurate recording and reporting system provides information needed to plan and maintain adequate drug stocks. The recording and reporting system is used to systematically evaluate patient progress and treatment outcome. Challenges Despite the World Health Organisation's declaration of TB as a global emergency in 1993, DOTS is still not widely used. As few as 21 percent of all TB patients in 1998 were thought to be treated through the DOTS strategy. This is despite the fact that most countries have adopted and are implementing DOTS - an increase from 10 countries in 1991 to 119 in 1998. Unfortunately, in many of these countries, there is no countrywide coverage so the majority of TB sufferers still do not have access to treatment. The consequences of not using DOTS more widely means that worldwide the incidence of multi-drug resistant TB is likely to rise, placing a greater economic and social burden on individuals, families and countries.   Top © Commonwealth of Australia