Medical charity criticises shortcomings of DOTS in management of tuberculosis
BMJ 2004; 328 doi: https://doi.org/10.1136/bmj.328.7443.784-a (Published 01 April 2004) Cite this as: BMJ 2004;328:784All rapid responses
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Editor- The news article: Medical charity criticizes shortcomings of
DOTS(directly observed treatment short course) in management of
tuberculosis- is misleading in that it appears to suggest that case
detection rates are equivalent to DOTS treatment rates. In your article
under the picture of the patient to be injected (with streptomycin), you
state that 'case detection rates in DOTS programmes can be as low as 5% in
children'. This has nothing to do with DOTS, but with tuberculosis in
children. The case detection rates referred to- sputum microscopy smear
positive case detection, is used by WHO as a proxy indicator to estimate
the Public Health impact of the DOTS strategy. If anything, the DOTS
strategy encourages sputum smear examinations in children and is thus
likely to lead to a higher yield of smear positive cases than in the
absence of DOTS. The article rightly states that DOTS is a strategy which
has achieved high treatment success rates in treating Tuberculosis: all
forms of Tuberculosis- whether detectable by smear microscopy or not.
According to the 2004 Global Tuberculosis Report, 2.28 million people
were treated under DOTS in the 22 high burden countries in 2002- of these
1.07 million, less than half, were smear positive cases (counted in case
detection analysis). (Case notification Table, p22)
In my view, the branding and expansion of the DOTS strategy came not a
moment too soon. It has been responsible for mobilizing global resources
and thus securing regular drug supplies, monitoring of and political
commitment to improved treatment of all forms of Tuberculosis. In many
countries it has given patients the confidence that they will receive free
TB treatment for the full 6 - 8 months course- a major achievement in
resource poor settings.
The Global Stop TB Partnership encourages the development of new drugs,
new vaccines and new tests. It is scandalous that these areas of research
into this major killer- disease of the poor have long been under-funded,
and MSF is to be commended for adding its voice to support this. Great
efforts have been made globally to increase access to DOTS. Still, there
is no case for rejoicing as less than 50% of Global Tuberculosis patients
are currently treated using this strategy. The priority for all
governments and other partners serious about TB control is to prioritize
the expansion of global access to effective TB treatment under DOTS. Thank
you for giving space to debate this in the BMJ.
Competing interests:
I have worked for MSF Holland in Darfur, and am working as WHO Medical Officer TB, Nepal
Competing interests: No competing interests
One wonders if the person who is looks so trepidaciously at the
syringe in the photograph gets royalities for the use of their image. The
same image is used for similar stories in the BMJ (2004 328(7443):784) and
the Lancet (2004 346(9415):1122) in the same week.
Isn't DOTS treatment in the form of regularly administered tablets,
not injections?
Competing interests:
None declared
Competing interests: No competing interests
Strengthen the case holding
Ganapathi Mudur's article is thought provoking for all the people
working in the field of TB in India. It raises the following points to
ponder over:
1."Urgent need for evolving new tools for diagnosis" of TB with a
high degree of sensitivity and specificity.
Though the sputum micorscopy is a very highly spcific test it is not
very sensitive and misses out on a large number of people with active TB
(both pulmonary and extra pulmonary) Pediatric TB and HIV infected people
with TB. But the situation in many parts of India is that even the 50% of
the people with semar positive TB are not detected.
2."Difficulty in implementing DOTS":
It needs a stable setting, It works better in community setting than
in a hospital as the follow up mechansm in a hospital may be inadequate or
non exixtant. The implementation of DOTS in very interior areas like deep
rural and tribal areas needs more strengthening. There is also a doubt
regarding the cure rate claimed by the national program( Jyostsna
Joshi).This shows some of the gross deficiencies in the present DOTS
program. Unless the existing DOTS program is made more effective in
addressing the situation, with better tools for diagnosis, we may end up
with a very large population who are inadequately treated for TB thereby
paving a way for emergence of a large number of MDR TB in future.
3. "Priority to public health over individual patient right":
No doubt, the DOTS focuses on the publc health issue and more so on
the communicable form than the individual patient right, but under the
existing situation, a well implemented DOTS(I emphasize " a well
implemented ") is the only answer to the present TB situation in India.
4. The effort to increase case finding with newer tools must go hand
in hand with efforts to find newer drugs to reduce the duration of
treatment. The other most important fact is the Case Holding to complete
the treatment to prevent emergence of drug resistant TB. If we cannot
complete the treatment of even the cases detected by the ancient method of
smear microscopy, will we be able to handle the large number of cases the
newer diagnostic tools will start detecting? The urgent need is to improve
the case holding in DOTS while efforts to find newer diagnostic tools and
drugs should be encouraged.
Competing interests:
None declared
Competing interests: No competing interests