The Role of DOTS in Tuberculosis Treatment and Control
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CURRENT OPINION
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The Role of DOTS in Tuberculosis Treatment and Control Peter D.O. Davies Tuberculosis Research Unit, Cardiothoracic Centre, Liverpool, UK
Abstract
Directly Observed Therapy Shortcourse (DOTS) is composed of five distinct elements: political commitment; microscopy services; drug supplies; surveillance and monitoring systems and use of highly efficacious regimens; and direct observation of treatment. The difference in the way the term ‘DOTS’ as defined by WHO and interpreted by many observers has led to some misunderstanding. WHO generally uses the term to mean the five components of DOTS. But the word ‘DOTS’ is an acronym for Directly Observed Therapy Shortcourse. Many workers therefore interpret DOTS purely as direct supervision of therapy. DOTS is not an end in itself but a means to an end. In fact it has two purposes, to ensure that the patient with tuberculosis (TB) completes therapy to cure and to prevent drug resistance from developing in the community. The main criticism of DOTS rightly derives from the fact that some properly conducted randomized, controlled trials of directly observed therapy with or without the other components have shown no benefit from it. The problem is that it is impossible to design a study of modern directly observed therapy against the previous self-administered, poorly-resourced programs. As soon as a study is implemented, the attention to patients in the control (non-directly observed therapy) arm inevitably improves from the previous non-trial service situation. What is of concern is that in some trials less than 70% cure rates were achieved even in the direct observation arm. With no new drugs or adjuvant treatment available to bring the length of treatment down to substantially less than 6 months, DOTS offers the best means we have at our disposal for TB control.
1. Definition The website of the WHO[1] summarises the definition and efficacy of Directly Observed Therapy Shortcourse (DOTS) as the following: "The WHO-recommended treatment strategy for detection and cure of TB [tuberculosis] is DOTS. DOTS combines five elements: political commitment, microscopy services, drug supplies, surveillance and monitoring systems and use of highly efficacious regimes with direct observation of treatment. Once patients with infectious TB (bacilli visible in a sputum smear) have been identified using microscopy services, health and community workers and trained volunteers observe and record patients swallowing the full course of the correct dosage of anti-
TB medicines (treatment lasts six to eight months). The most common anti-TB drugs are isoniazid, rifampicin [rifampin], pyrazinamide, streptomycin and ethambutol. Sputum smear testing is repeated after two months, to check progress, and again at the end of treatment. A recording and reporting system documents the patients’ progress throughout, and the final outcome of treatment. DOTS produces cure rates of up to 95 percent even in the poorest countries. DOTS prevent
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