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BMJ No 7120 Volume 315 Editorial Saturday 29 November 1997
Strengthening "DOTS" through community care for tuberculosisObservation alone isn't the keySee Paper (abstract only) p 1403, Paper (abstract only) p 1407World wide, more adult deaths are attributed to Mycobacterium tuberculosis than to any other infectious agent, and without improvements in control 30 million people are expected to die from tuberculosis in 1990-2000.(1) In sub-Saharan Africa alone about 1.5 million new cases arise each year. How can we care for all these patients? We have known for almost 40 years that most patients with tuberculosis can be treated in the community without increasing the risk of their infecting contacts. Indeed, the strategy of supervised outpatient therapy was developed in poor settings.(2) Nevertheless, until recently, the World Health Organisation and the International Union Against Tuberculosis and Lung Disease advocated a strategy of admission to hospital for at least the first two months of treatment, primarily as a way of ensuring adherence. Indeed hospitalisation, together with the other elements of the control programme, was highly effective.(3) However, the epidemic of tuberculosis associated with HIV in sub-Saharan Africa is such that hospital based care is no longer feasible. The caseload in Malawi increased from 5334 in 1985 to 19 195 in 1995 (Malawi National Tuberculosis Programme). Over a similar period the cure rate for smear positive cases decreased from 90% to 63% and bed occupancy reached 400% in cities.(4) The consequences of this overcrowding include nosocomial transmission of tuberculosis,(5) including multidrug resistant strains.(6) Crowded wards are also likely to deter admission and adherence. A paper in this issue provides evidence that hospital based tuberculosis treatment is also about three times more expensive for both the patient and the health system than directly observed treatment in the community (p 1407).(7) We have therefore come full circle: direct observation of treatment, not hospitalisation, is advocated to promote adherence within WHO's current global tuberculosis control strategy: directly observed treatment, short course (DOTS).(8) This is despite the fact that a systematic review, also in this issue, shows that the effect of directly observed treatment on adherence has not been evaluated in a randomised trial (p 1403).(9) Does this matter? All the interventions tested in the five trials identified improved adherence, suggesting that any serious commitment to tuberculosis care improves adherence. In New York the introduction of directly observed treatment has been associated with a sustained reduction in the number of new cases and cases of multidrug resistant disease.(6) But while cure rates exceed 90%, only about 40% of cases receive directly observed treatment. Which is more important, the observation of treatment or the concurrent strengthening of the programme? The WHO's strategy is in fact defined by three elements in addition to observation: case detection using sputum smear microscopy among symptomatic patients presenting to health services, establishment of regular supplies of essential antituberculosis drugs, and establishment of a standardised reporting system, allowing assessment of treatment results. As the implementation of these elements requires commitment to tuberculosis control, implementation of the DOTS strategy will probably be associated with improvements in adherence rates and, as a consequence, cure rates.(10) Directly observed treatment requires that a responsible observer holds the antituberculous drugs and observes each administration. At one extreme a nurse may observe the daily dosing of 100 or more hospital inpatients. At the other, the drugs may be held by a storekeeper who observes the twice weekly dosing of two or three patients who live nearby. The success of the form of observation is likely to depend on how attractive it is to the patient and the observer, not on the act of observation itself. In China it is made attractive to the observers (village doctors) through financial incentives.(11) This concept has been extended in Bangladesh through payment of a bonding incentive between patients and community healthcare workers.(12) For patients, the attraction of directly observed treatment in Hlabisa in rural South Africa probably lies partly in the fact that community treatment costs less than hospital treatment.(7) The arrangement may also be attractive to the storekeepers because it may raise their status and increase their custom. Therefore the more accessible therapy is within the community the more likely patients are to comply. Recognition of this fact has lent impetus to the current move to dehospitalise tuberculosis treatment.(13) The next question is how best to provide observation. The caseload in Hlabisa increased from about 300 in 1991 to over 1200 in 1996, and caseholding by clinic health workers fell significantly more in 1991-6 than it did among community workers or volunteers.(14) Thus it may be a mistake to rely entirely on clinics for supervision as they too risk becoming congested. The message is that we should look to the community itself to sustain DOTS but not look on it as a limitless resource.(15) Future economic analysis of provision of tuberculosis treatment could usefully extend its assessment to broader societal costs - for example, those incurred by carers. It is important not to concentrate solely on adherence but also to assess the pathways patients take to reach treatment. There is some evidence, for example, that sputum smear microscopy is not achieving its potential as a casefinding tool.(16) Also, if a significant number of cases of tuberculosis result from recent transmission and casual contact in developing countries(17,18) then we should not tolerate delays between onset of symptoms and starting treatment. We need to involve communities in casefinding as well as caseholding. If we succeed, the DOTS strategy, and community care for tuberculosis, can only be strengthened. S Bertel Squire
Senior lecturer
David Wilkinson
Specialist scientist
References
1 Dolin P J, Raviglione M C, Kochi A. Global tuberculosis
incidence and mortality during 1990-2000. Bull WHO
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2 Bayer R, Wilkinson D. Directly observed therapy for
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3 Graf P, Davies P D O, eds. Tuberculosis. London:
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4 Harries A D, Mbewe L N, Salaniponi F M L, Nyangulu D S L, Veen J,
Ringdal T, et al. Tuberculosis programme changes and treatment outcomes
in patients with smear-positive pulmonary tuberculosis in Blantyre,
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5 Harries A D, Kamenya A, Namarika D, Msolomba I, Salaniponi F M L,
Nyangulu D S, et al. Delays in diagnosis and treatment of smear-positive
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7 Floyd K, Wilkinson D, Gilks C. Comparison of cost
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Africa. BMJ 1997;315:1407-11.
8 World Health Organisation. Global tuberculosis
control. Geneva: WHO, 1997.
9 Volmink J, Garner P. Systematic review of randomised
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10 Raviglione M C, Dye C, Schmidt S, Kochi A. Assessment of
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11 China Tuberculosis Control Collaboration. Results of directly
observed short-course chemotherapy in 112,842 Chinese patients with
smear-positive tuberculosis. Lancet 1996;347:358-62.
12 Chowdhury A M R, Chowdhury S, Islam M N, Islam A, Vaughan P.
Control of tuberculosis by community health workers in Bangladesh.
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13 Maher D, Hausler H P, Raviglione M C, Kaleeba N, Aisu T, Fourie
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14 Wilkinson D, Davies G R. Coping with Africa's increasing
tuberculosis burden: are community supervisors an essential component
of the DOT strategy? Trop Med and Int Health
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15 Standing H. Gender and equity in health sector reform
programmes: a review. Health Policy and Planning
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16 Squire S B, Nyasulu I, Amali R, Kanyerere H, Salaniponi, F M L. Is
smear-microscopy functioning as a case-finding strategy for
tuberculosis in Africa? Tubercle and Lung Disease
1996;77:(2 suppl):77.
17 Wilkinson D, Pillay M, Davies G R, Lombard C, Sturm A W, Crump J.
Molecular epidemiology and transmission dynamics of Mycobacterium
tuberculosis in rural Africa. Trop Med Int Health
1997;2:747-53.
18 Gilks C F, Godfrey-Faussett P, Batchelor B I F, Ojoo J C, Ojoo S J,
Brindle R J, et al. Recent transmission of tuberculosis in a cohort of
HIV-1 infected female sex workers in Nairobi, Kenya.
AIDS 1997;11:911-8.
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