EDITOR- Farmer & Kim propose in their recent article a " DOTS-
plus" strategy to attempt controlling multidrug resistant tuberculosis
(MDRT)1. As much as I sympathize with them, after following several
patients with MDRT and watching them die, I would like to express my
concern and skepticism towards such a proposal being implemented in low
income areas.
The development of MDRT is a complex multifactorial process and the
wide distribution of new drugs will not solve the issue. Need to generate
an income, family duties, religious misconceptions, social stygma and
mismagement by health practitioners constitute only a limited list of some
of the obstacles that patients must face before achieving a successful
outcome of their treatment. Anti-tuberculosis drugs used for the treatment
of MDRT are not very effective, have frequent undesirable effects and must
be given for prolonged periods of time. Who will supervise such complex
regimens? Who will observe the prescribers?
Directly observed therapy (DOT) requires directly observed doctors (DOD)2
but DOTS-plus will make double DOD mandatory.
We must always attempt to treat and cure the individual patient but
initiating a "DOT-plus" strategy at a national level is, at present, a
dream; it risks diverting our limited resources and causing
epidemiological havoc. We should not awaken one day only to realize that
our dream has become a microbiological nightmare.
Jaime E Ollé-Goig, MD, MPH
Apartado postal 9802
Santo Domingo, Dominican Republic
References.
1. Farmer P, Kim JY. Community based approaches to the control of
multidrug resistant tuberculosis: introducing "DOTS-plus". BMJ 1998;
317:671-674.
2. Ollé-Goig JE. Non-compliance with tuberculosis treatment; patients
and physicians. Tuberc Lung Dis 1995; 76:277-278.
Rapid Response:
"DOTS-plus" strategy hard to implement
EDITOR- Farmer & Kim propose in their recent article a " DOTS-
plus" strategy to attempt controlling multidrug resistant tuberculosis
(MDRT)1. As much as I sympathize with them, after following several
patients with MDRT and watching them die, I would like to express my
concern and skepticism towards such a proposal being implemented in low
income areas.
The development of MDRT is a complex multifactorial process and the
wide distribution of new drugs will not solve the issue. Need to generate
an income, family duties, religious misconceptions, social stygma and
mismagement by health practitioners constitute only a limited list of some
of the obstacles that patients must face before achieving a successful
outcome of their treatment. Anti-tuberculosis drugs used for the treatment
of MDRT are not very effective, have frequent undesirable effects and must
be given for prolonged periods of time. Who will supervise such complex
regimens? Who will observe the prescribers?
Directly observed therapy (DOT) requires directly observed doctors (DOD)2
but DOTS-plus will make double DOD mandatory.
We must always attempt to treat and cure the individual patient but
initiating a "DOT-plus" strategy at a national level is, at present, a
dream; it risks diverting our limited resources and causing
epidemiological havoc. We should not awaken one day only to realize that
our dream has become a microbiological nightmare.
Jaime E Ollé-Goig, MD, MPH
Apartado postal 9802
Santo Domingo, Dominican Republic
References.
1. Farmer P, Kim JY. Community based approaches to the control of
multidrug resistant tuberculosis: introducing "DOTS-plus". BMJ 1998;
317:671-674.
2. Ollé-Goig JE. Non-compliance with tuberculosis treatment; patients
and physicians. Tuberc Lung Dis 1995; 76:277-278.
Competing interests: No competing interests