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  2. 2. What is DOTS? DOTS is a comprehensive strategy recommended by WHO for the detection and cure of tuberculosis. A trained health care worker or a designated individual provides the prescribed anti-tuberculous drugs and watches the patient swallow every dose.1
  3. 3. PROCEDURE: Patients with infectious tuberculosis are:  Identified using microscopy services.  Health workers then observe and record patients swallowing the full course of the correct dosage of anti-TB medicines for 6 to 8months.  Sputum smear testing is repeated after two months, to check progress, and at the end of treatment.  A recording and reporting system documents patients' progress throughout, and the final outcome of treatment.
  4. 4. HISTORY OF DOTS: During World War II : Styblo at 24 years of age, contracts tuberculosis at a concentration camp. 1980: Styblo defines IUATLD model to control TB in Tanzania2 1990: World Bank asks Styblo to create Pilot project for China 1993: WHO declares TB as a global emergency 1994: New TB control framework [Dr Arata Kochi] 1995: DOTS launched as a WHO strategy
  5. 5. Dr. Karel Styblo [1921-1998]3
  6. 6. The five components of DOTS4: 1. Effective political and administrative commitment. 2. Case finding primarily by microscopic examination of sputum of patients presenting to health facilities. 3. Short-course chemotherapy given under direct observation. 4. An effective drug supply and management system. 5. Systematic monitoring and evaluation system.
  7. 7. 1. Effective political and administrative commitment. Sustained political commitment at all levels with provision of adequate and competent resources required for the program including infrastructure as well as manpower. Local partnership and commitment. Provision of adequate funding. Recognition of TB as a public health responsibility and priority.
  8. 8. 2. Case detection through quality- assured bacteriology Bacteriology remains the recommended method of TB case detection, first using sputum smear microscopy and then culture and drug susceptibility testing. Adequate provision of high quality diagnostic laboratories, microscopes, lab workers and reporting facilities.
  9. 9. 3. Short-course chemotherapy given under direct observation. Provision of standardized treatment according to WHO which includes a 6 or 8 months regimen(2HRZE/4HR)5 Provision of treatment under supervision of a health worker or designated individual.
  10. 10. 4. An effective drug supply and management system  An uninterrupted and sustained supply of quality assured anti-TB drugs free of cost is fundamental to TB control.  Legislation related to drug regulation should be in place, and use of anti-TB drugs by all providers should be strictly monitored
  11. 11. 5. Monitoring and evaluation system Maintaining a standardized recording of individual patient data, which can be used at the facility level to monitor treatment outcomes, to identify local problems as they arise, and to evaluate the performance of each country.
  12. 12. DOTS IN PAKISTAN: Pakistan ranks 8th amongst the top 22 TB burden countries in the world. According to estimates about 300,000 new cases are added each year with Punjab having a quarter of the total disease burden.6 DOTS program was started in Pakistan in 1995, under the National TB Control Program however the non- availability of funds from regular health budget brought it to a halt. In 2000, it was revived and funds were allocated to it seeking to provide 100% TB care to its population by 2005. By 2005, DOTS had been set up all over Pakistan.
  13. 13. TARGET:  Increase cure rates to 85% and above.  Increase case detection to 70%.  100% DOTS coverage by 2005.  Reduce mortality and morbidity from TB by 50% by the year 2010.  To achieve Millennium Development Goals by 2015.
  14. 14. ACHIEVEMENTS:  DOTS coverage in Pakistan achieved in May 2005  Achievement of TB related MDG Targets by 2008  DOTS expansion to 36 districts of Punjab.  Capacity building of districts; Training of doctors and paramedics, at all levels healthcare.  Expansion of laboratories network.  Advocacy, communication and social mobilization: media, news letter, billboards.  Engaging all care providers: Private as well as public.
  15. 15. Pakistan - tuberculosis treatment success rate7: 0 10 20 30 40 50 60 70 80 90 100 1994 1995 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 SUCCESS RATE SUCCESS RATE
  16. 16. CHALLENGES:  Financial constraints.  Emergence of MDR-TB and HIV.  Capacity building constraints.  Inadequate laboratory services.  Inadequate information systems.  Unaccounted migration from high prevalence areas with inadequate DOTS coverage.
  17. 17. Why DOTS?  To ensure adherence to treatment regimen.  To check for side effects if any.  To decrease the risk of drug resistance caused by incomplete treatment.  To enforce standard protocol for the detection and treatment of tuberculosis as recommended by WHO.  For maintenance of proper recording and monitoring system.  Diagnosis is simple, and treatment cures over 95% of patients in clinical trials.
  19. 19. The Stop TB Strategy: WHO developed a new six point Stop TB Strategy in 2000 which builds on the success of DOTS while also explicitly addressing the key challenges facing TB. Vision: A world free of TB. Goal: To reduce dramatically the global burden of TB by 2015 in line with the MDGs and the Stop TB targets,to achieve major progress in the research and development for tuberculosis cure. To eliminate tb by 2050.
  20. 20. OBJECTIVES: To achieve universal access to high quality diagnosis and treatment for people with TB.  To reduce the suffering and socio- economic burden associated with TB. To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB.  To support the development of new tools and enable their timely and effective use.
  21. 21. COMPONENTS: 1. Pursue high-quality DOTS expansion and enhancement. 2. Address TB/HIV, MDR-TB and other challenges. 3. Contribute to health system strengthening. 4. Engage all care providers. 5. Empower people against tuberculosis. 6. Enable and promote research.
  22. 22. DOTS PLUS: DOTS- Plus is a new strategy that is designed to manage MDR-TB in resource limited countries. Drug-resistant TB is caused by inconsistent, partial or incorrect treatment of drug-susceptible TB. MDR-TB is a specific form of drug resistant TB that is resistant to at least Isoniazid and Rifampicin, the two most powerful first-line anti-TB drugs. Treatment regimen includes the use of 2nd line anti-TB drugs that are expensive and required to be taken for a longer time with greater side effects.
  23. 23. REFERENCES: 1. e9/ss9reading2.htm 2. 3. 4. 5. Treatment of tuberculosis 4th edition,WHO 6. 7. losis-treatment-success-rate

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