DOTS prevents TB deaths in India
DOTS coverage and treatment success rate soars in India
In India, which accounts for 30% of the global
burden of TB, the DOTS programme is undergoing massive expansion as
treatment success rates double and death rates fall. Government commitment,
community involvement, and partnerships have all been key factors in
the success of the DOTS programme in India.
A massive expansion of TB treatment using DOTS is today under way in
India. By the end of 2000, one in four of the population -- over 250
million people -- will be covered by the strategy. By the end of 2002,
it is planned that half the country will be covered. Eventually, it
is hoped that the entire population of over one billion will have access
Up until late 1998, only 2% of the population were covered by DOTS.
By early 1999, the number had soared to over 120 million and the numbers
have been rising ever since.
The logistics involved in such rapid large-scale expansion were considerable.
Over 10 000 doctors had to be trained, 2000 laboratory technicians,
and 100 000 allied health workers. An additional 500 staff were employed.
Almost 3000 microscopes had to be purchased and enough TB drugs to treat
over 400 000 patients. Meanwhile, hundreds of thousands of technical
documents had to be finalized and printed. Any future expansion will
have to be phased to ensure that drug supplies, training, supervision,
and monitoring can all be guaranteed. The stakes are high. India accounts
for about 30% of the global burden of TB. An estimated one in two of
the adult population are infected with the TB bacterium. Every year,
two million people develop active tuberculosis -- more than in any other
country in the world. And about 450 000 die from it -- more than the
total deaths from AIDS, malaria, and tropical diseases combined.
Launched in 1993 with a series of successful small-scale pilot projects,
the DOTS programme has shown continued impressive success rates. A recent
analysis of the impact of the programme found that 80% of cases were
successfully treated -- twice as many as in the previous TB programme.
Death rates among infectious patients treated within the programme were
4%, compared with a rate over seven times higher in the non-DOTS programme.
India's DOTS programme is mainly financed through a US $ 142 million low-interest
loan from the World Bank, with an increasing proportion of the costs
already being met by the national and state governments. Treatment is
supervised by health workers, community volunteers, traditional birth
attendants, and community or religious leaders. Community workers supervise
treatment for patients with limited access to a health centre. Additional
staff are provided to serve difficult mountainous, tribal, and urban
In order to maintain the uninterrupted supply of drugs throughout the
treatment period, each patient is allocated an individual box at the
outset containing the full course of treatment. This helps ensure that
no patient has to stop treatment because drugs are not available, even
in the event of a break in the drugs supply chain.
Ironically, India was one of the seedbeds for the global DOTS strategy,
but it was many years before the idea took root there. In the 1950s,
the Tuberculosis Research Centre in Chennai (formerly Madras) demonstrated
that treatment observation is both necessary and feasible in the community,
using intermittent treatment. In the early 1960s, India demonstrated
that most TB patients did not need to be in hospital. In Madras, even
destitute people living on the streets in slum areas were successfully
treated with a regular supervised course of TB drugs. Meanwhile, the
National Tuberculosis Institute in Bangalore demonstrated that, with
minimal training and regular supervision, technicians working at the
periphery could carry out sputum smear microscopy -- enabling this to
become the primary tool for diagnosis of TB.
Today, as India establishes the second largest DOTS programme in the
world (after China), the wheel has turned full circle. But there is
still a long way to go before DOTS is available country-wide.