DOTS prevents TB deaths in China
China halves TB deaths through DOTS
The DOTS programme in China, the largest DOTS
programme in the world, prevents about 30 000 deaths a year. Over 90%
of patients treated are cured. Treatment is provided free of charge
and village health workers are paid a bonus for every TB case they identify
and for every patient they cure.
In China, the world's largest DOTS programme --serving over 700 million
people-- is today preventing an estimated 50% of all TB deaths in areas
covered by the programme. New research, based on data from the first
seven years of operation, has revealed that the programme saves about
30 000 lives a year.
The DOTS programme, funded through a US$ 58 million World Bank loan
and matching funds from the Chinese Government, is one of the most successful
DOTS programmes in the world. Among the TB patients treated, over 90%
are cured. Over the past eight years, more than half a million infectious
TB cases have been successfully treated.
Progress has been rapid and dramatic. In 1990, tuberculosis accounted
for one in two of all deaths from infectious diseases in China. A nationwide
survey found that an alarming six out of every 1000 people had some
form of TB. Of these, about 25% were infectious. Many could not afford
the treatment costs or defaulted on treatment when they could no longer
meet the cost of drugs. Of those who started treatment, less than half
were cured. The remainder continued to spread infection --each with the
potential to infect up to 15 people a year. Some developed multidrug-resistant
forms of the disease which are extremely difficult to cure and can inflate
treatment costs 100-fold.
In 1991, after a review of China's national TB programme by WHO and
the World Bank, the government launched a series of pilot projects involving
the use of DOTS. The trial involved people living in urban areas near
Beijing as well as rural areas in Hebei province. Expensive and all
too often ineffective hospital-based treatment was jettisoned. In its
place came the new DOTS programme --providing village-level treatment
through the supervised use of a cocktail of four inexpensive drugs.
Diagnosis and treatment were made available free of charge and village
health workers paid a bonus for every TB case identified and for every
patient certified to be cured. The health worker was responsible for
storing the drugs and monitoring each patient to ensure they took the
correct dose of drugs at the right time. In addition, the health worker
was responsible for organizing periodic sputum checks in a laboratory
to monitor progress and verify eventual cure.
Spurred by the success of these pilot projects, which notched up a
94% cure rate, the DOTS strategy was extended to 13 of China's 31 provinces
in 1992. Treatment involves a 6-month course of drugs to be taken under
supervision every other day. Drugs are obtained on the international
market at competitive prices --about US$ 20 for a 6-month course of
supplies are centralized, and treatment is free. However, in provinces
not covered by the DOTS programme, drugs are bought locally, quality
is often poor, prices inevitably higher. And patients are normally required
to pay for the full cost of medical treatment and drugs. It is not yet
clear how the Chinese Government will address these disparities as it
considers the future of the DOTS programme, and its possible extension
nationwide, after the World Bank funding comes to an end in mid-2001.
Despite the outstanding success of the DOTS programme in treating TB
and preventing deaths in the provinces it serves, the needs remain as
great as ever in other provinces. In this vast country of 1.2 billion
people, tuberculosis still claims more lives than any other infectious
disease. Over 400 million people have been infected with the TB bacillus.
Every year, 1.4 million people develop active TB and over a quarter
of a million people die from it. Today as China's DOTS programme enters
its final year of World Bank funding, there is a critical need to sustain
the DOTS strategy and to expand it to cover the entire country. For
the millions of people who remain infected with TB throughout China,
universal access to DOTS is long overdue.