INDIA AND CHINA RAPIDLY EXPAND TB CONTROL
3 June 2002
Washington/Geneva: India and China have demonstrated how the strategy promoted by WHO for control and treatment of tuberculosis known as DOTS* can be rapidly and effectively expanded, according to two studies just published in the Bulletin of the World Health Organization.
Both these countries – which account for more than a third of all TB cases in the world – have achieved high rates of case-identification and cure even where the technology and public health infrastructure are inadequate. "The benefits of large-scale DOTS expansion for the individual patient and society at large are obvious," conclude Xianyi Chen and colleagues of China's Ministry of Health.
WHO and its partners are leading the global effort against tuberculosis by expanding DOTS, which is now used in 148 countries. The Global Plan to Stop TB has set two main targets for 2005: to identify 70% of estimated new infectious TB cases, and to cure 85% of cases identified. "These studies clearly show that even in huge countries with a heavy burden of TB it is possible – with strong political commitment, adequate financial resources and sound technology – to achieve very high levels of cure," says Jong-Wook Lee, Director of WHO’s Stop-TB Programme. The DOTS expansion projects in both China and India were funded with loans from the World Bank. The progress of both countries will be discussed at the 4th World Congress on TB from 3 to 5 June in Washington, DC.
The study on China analysed the effects of the DOTS strategy 10 years after it was put into operation. It found that the health authorities had succeeded in expanding use of DOTS from 5 pilot counties in 1991 to 1208 counties, representing half of China’s population, by 1995. By the year 2000, 8 million suspected TB cases had been evaluated, 1.3 million smear-positive cases were treated under DOTS, and 90% of the treated cases were cured. In the areas where DOTS is being implemented, 30 000 deaths have been averted each year and the percentage of previously treated TB cases among all smear-positive patients has decreased.
In India, DOTS coverage expanded by more than 350 million people to nearly half of the national population over a three-year period which began in October 1998. During this period, the number of patients started on treatment under DOTS increased from 80 per day to over 1300. The quality of diagnosis is good: only 5% of districts have an unexpectedly high proportion of cases that are not confirmed in a laboratory. Cure rates exceed 80% and identification rates in DOTS areas are 55–60% of estimated new infectious cases.
By early 2002, more than a million TB patients in India had been started on DOTS. According to the Bulletin study, the rapid expansion of DOTS coverage has saved nearly 200 000 lives and more than $400 million in indirect costs.
While the two studies highlight the effectiveness of DOTS, they also underline the difficulties of implementing it. In both countries nearly half the population are not yet covered by the strategy. Case identification rates for TB in both countries remain below the global target of 70%. "This means that both programmes need to reach more TB patients in the areas they cover", says Mario Raviglione, WHO's head of TB Strategy and Operations. "For that, innovative approaches are needed, such as involving health workers in other settings in the care of TB patients, in hospitals in China, for instance, and private practices in India."
The study on India found there were 10 key ingredients for successful DOTS expansion: 1) ensuring appropriate technical excellence; 2) building commitment supported by the necessary funding with flexible utilization; 3) maintaining focus and priorities; 4) systematically appraising areas before starting service delivery; 5) ensuring uninterrupted supply of drugs; 6) strengthening existing infrastructure and staff; 7) supporting the infrastructure required in urban areas; 8) ensuring full-time independent technical support and supervision, especially during early phases of implementation; 9) monitoring intensively and giving timely feedback; and 10) continuous supervision.
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