DOTS reduces pulmonary TB cases in Peru

 

Peru set to halve new TB cases every 10 year

High-level political commitment to TB control in Peru has produced one of the most successful DOTS programmes in the world. On current trends, the number of new TB cases in Peru could be halved every 10 years. Diagnosis and treatment are provided free of charge and low-income families receive food packages to encourage compliance with treatment.

One of the world's most successful TB programmes, the nationwide programme in Peru, has provided the first evidence that widespread use of DOTS prevents new cases of TB. New research shows that the decline in the incidence of TB in Peru almost doubled between 1991 and 1999 through the implementation of DOTS -- preventing at least 70 000 cases and deaths. If this trend continues, the incidence of TB in Peru could be halved every 10 years. Peru is one of only a handful of high-burden countries to have met the WHO targets for TB control of 70% case detection rates and 85% cure rates. The country has one of the highest TB incidence rates in the Americas and is among the 22 countries accounting for 80% of the new TB cases occurring worldwide each year. Peru accounts for only 3% of the population of the Americas but has 15% of its TB cases.

Before the DOTS programme was launched in Peru in 1990, only 50% of people diagnosed with TB were able to get treatment. And of those, only half were cured. Drugs were in short supply, record systems non-existent, and health workers overworked and demoralized. Inflation was soaring and a newly elected government was negotiating to end a guerilla war that had killed thousands and destroyed much of the country's infrastructure, including many of its health centres. This was highlighted in 1991, when a three-year-old boy achieved unwanted celebrity as the last case of polio in the Americas. He caught polio after his local health centre was destroyed by guerillas --preventing childhood immunization.

Peru's incoming government recognized that TB control was a social, political, and economic priority -- increasing the TB budget from US$ 600 000 to US$ 5 million a year. With high-level political commitment, adequate funding for drugs, and dynamic leadership, the new DOTS programme in Peru had a head start. Today, TB diagnosis and treatment are provided free of charge, drug financing is sustainable, and the programme has become a model for training managerial staff from other Latin American countries. Drugs, equipment, and other supplies are purchased and distributed at the central level. Food packages are provided for low-income families as an incentive to comply with treatment and funding has been provided to establish patient and family support groups. In sparsely populated remote areas such as the Amazonas jungle and high plateaux, treatment delivery is adapted to the needs of the patient to ensure access and completion of treatment. The treatment comprises initial daily administration of drugs followed by twice-weekly drug therapy. All drug doses are directly observed to ensure compliance.

By 1997, the entire population was covered by the DOTS programme and almost 90% of patients were being cured. And by 1998, an estimated 94% of TB cases were being detected. The number of health centres participating in the programme soared from under 1000 in 1991 to over 6000 by 1999. And as efforts to detect new cases intensified, the number of laboratories capable of carrying out sputum smear tests rose from about 300 in 1989 to over 1000 by 1999. As efforts to improve diagnosis were stepped up, there was a sharp increase in the number of cases notified between 1990 and 1993. Since then, the number of new cases has steadily declined.

Peru is the first of the 22 countries with a high TB burden to systematically address the problem of multidrug-resistant TB. Since 1997, about 800 patients with chronic TB have been treated with the WHO standardized treatment, with good results. Treatment costs for chronic TB cases are far higher at about US$ 2500 a patient. However, funds have been made available as a result of overall savings in treatment costs due to the drop in TB cases nationwide. In addition, about 80 patients with multidrug-resistant TB have received specialist individualized treatment through a Harvard University project. WHO is monitoring this project so that the experience can be applied to other countries.