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DOTS in Pakistan

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    2. 2. What is DOTS?DOTS is a comprehensive strategy recommended byWHO for the detection and cure of tuberculosis.A trained health care worker or a designatedindividual provides the prescribed anti-tuberculousdrugs 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 patientsswallowing the full course of the correct dosage ofanti-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 documentspatients progress throughout, and the final outcomeof treatment.
    4. 4. HISTORY OF DOTS:During World War II : Styblo at 24 years of age, contractstuberculosis at a concentration camp.1980: Styblo defines IUATLD model to control TB inTanzania21990: World Bank asks Styblo to create Pilot project forChina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 examinationof sputum of patients presenting to healthfacilities.3. Short-course chemotherapy given under directobservation.4. An effective drug supply and managementsystem.5. Systematic monitoring and evaluation system.
    7. 7. 1. Effective political andadministrative commitment.Sustained political commitment at all levels withprovision of adequate and competent resourcesrequired for the program including infrastructure aswell as manpower.Local partnership and commitment.Provision of adequate funding.Recognition of TB as a public health responsibilityand priority.
    8. 8. 2. Case detection through quality-assured bacteriologyBacteriology remains the recommended method ofTB case detection, first using sputum smearmicroscopy and then culture and drug susceptibilitytesting.Adequate provision of high quality diagnosticlaboratories, microscopes, lab workers and reportingfacilities.
    9. 9. 3. Short-course chemotherapy givenunder direct observation.Provision of standardized treatment according toWHO which includes a 6 or 8 monthsregimen(2HRZE/4HR)5Provision of treatment under supervision of a healthworker or designated individual.
    10. 10. 4. An effective drug supply andmanagement system An uninterrupted and sustained supply of qualityassured anti-TB drugs free of cost is fundamental toTB control. Legislation related to drug regulation should be inplace, and use of anti-TB drugs by all providersshould be strictly monitored
    11. 11. 5. Monitoring and evaluation systemMaintaining a standardized recording of individualpatient data, which can be used at the facility level tomonitor treatment outcomes, to identify local problemsas they arise, and to evaluate the performance of eachcountry.
    12. 12. DOTS IN PAKISTAN:Pakistan ranks 8th amongst the top 22 TB burdencountries in the world. According to estimates about300,000 new cases are added each year with Punjabhaving a quarter of the total disease burden.6DOTS program was started in Pakistan in 1995, underthe National TB Control Program however the non-availability of funds from regular health budget brought itto a halt.In 2000, it was revived and funds were allocated to itseeking to provide 100% TB care to its population by2005.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% bythe year 2010. To achieve Millennium Development Goals by2015.
    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 andparamedics, at all levels healthcare. Expansion of laboratories network. Advocacy, communication and social mobilization:media, news letter, billboards. Engaging all care providers: Private as well aspublic.
    15. 15. Pakistan - tuberculosis treatmentsuccess rate7:0102030405060708090100199419951997199819992000200120022003200420052006200720082009SUCCESS RATESUCCESS 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 areaswith 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 byincomplete treatment. To enforce standard protocol for the detection andtreatment of tuberculosis as recommended byWHO. For maintenance of proper recording andmonitoring 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 in2000 which builds on the success of DOTS while alsoexplicitly addressing the key challenges facing TB.Vision: A world free of TB.Goal: To reduce dramatically the global burden of TBby 2015 in line with the MDGs and the Stop TBtargets,to achieve major progress in the research anddevelopment for tuberculosis cure.To eliminate tb by 2050.
    20. 20. OBJECTIVES:To achieve universal access to highquality diagnosis and treatment forpeople with TB. To reduce the suffering and socio-economic burden associated with TB.To protect poor and vulnerable populations fromTB, TB/HIV and MDR-TB. To support the development of new toolsand enable their timely and effective use.
    21. 21. COMPONENTS:1. Pursue high-quality DOTS expansion andenhancement.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 manageMDR-TB in resource limited countries.Drug-resistant TB is caused by inconsistent, partial orincorrect treatment of drug-susceptible TB.MDR-TB is a specific form of drug resistant TB that isresistant to at least Isoniazid and Rifampicin, the two mostpowerful first-line anti-TB drugs.Treatment regimen includes the use of 2nd line anti-TBdrugs that are expensive and required to be taken for alonger time with greater side effects.
    23. 23. REFERENCES:1. http://www.scienceheroes.com4. Treatment of tuberculosis 4th edition,WHO6.