DOTS is the WHO-recommended strategy for tuberculosis detection and treatment. It involves identifying infectious TB patients through microscopy, observing patients swallowing anti-TB drugs daily for 6-8 months, and regularly monitoring patients' progress. DOTS was launched in Pakistan in 1995 but faced challenges until being expanded nationwide by 2005. While cure rates and coverage increased under DOTS, Pakistan still faces ongoing issues with drug-resistant TB, capacity, and monitoring systems. The updated Stop TB Strategy aims to further improve TB control globally through universal access to diagnosis and treatment.

1. DOTS
DIRECTLY OBSERVED
TREATMENT SHORT
COURSE
REHMANI SAMEERAH IBTISAM
ROLL NUMBER 198

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. 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. 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. Dr. Karel Styblo [1921-1998]3

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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.

18. THE STOP TB PARTNERSHIP

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. 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. 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.

23. 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.

24. REFERENCES:
1. http://www.cdc.gov/tb/education/ssmodules/modul
e9/ss9reading2.htm
2. http://www.who.int/tb/publications
3. http://www.scienceheroes.com
4. http://www.who.int/tb/dots
5. Treatment of tuberculosis 4th edition,WHO
6. http://health.punjab.gov.pk/?q=tb_control_program
7. http://www.indexmundi.com/facts/pakistan/tubercu
losis-treatment-success-rate