DOTS reduces TB deaths in Nepal

 

Preventing TB deaths in one of the world's poorest countries

In Nepal -- one of the poorest and least accessible countries in the world -- 75% of the population have access to DOTS. Treatment success rates more than doubled between 1994 and 1999 and the programme prevents thousands of TB deaths a year. This achievement is the result of government commitment, support from a wide range of partners, and the use of innovative ways of ensuring access to DOTS -- especially in remote areas.

In the mountain kingdom of Nepal -- one of the poorest countries in the world -- almost half of the over 20 million population are infected with TB. Of these, up to 90 000 people have active TB and there are 44 000 new cases of the disease every year.

Yet today, following a rapid expansion in access to DOTS, the Government of Nepal is succeeding in preventing thousands of TB deaths a year. The number of people dying from TB has plummeted from an estimated 15 000-18 000 in 1994 to about 8000-11 000 today.

Launched in 1996 with four pilot projects, the DOTS programme has been extended to reach 75% of the population today. Treatment success rates have more than doubled from 40% in 1994 to over 88% in 1999 -- a treatment success rate that was maintained throughout the four years of programme expansion. Meanwhile, case detection rates, another measure of success, have surged from 30% in 1994 to 67% in 1999, just short of the WHO target of 70% case detection.

The programme has benefited greatly from government commitment, community support, and assistance from a range of both international agencies and NGOs. In three out of the five regions covered by DOTS, NGOs provide advice and support services for government efforts, including training.

But success has not been easy and many hurdles remain before DOTS can be extended nationwide. Much of Nepal is remote mountain and hilly terrain and many areas are sparsely populated -- making drug distribution and treatment supervision extremely difficult. Drugs are distributed from the central level to regional stores and from there supplied to the district, usually by vehicle or plane. From there, the drugs have to be carried by bike or on foot to some treatment centres. In some areas, additional sub-health posts are used as DOTS-providing TB subcentres in an effort to extend coverage. Patients can be treated there and only have to go to a health centre for occasional sputum checks to monitor progress.

In eastern Nepal, hostels have been established in some districts for TB patients living in remote hill districts. People are encouraged to stay in the hostels for the first two months of treatment to ensure that the initial treatment period is supervised. Meanwhile the Government of Nepal is working with researchers to investigate the feasibility of community volunteers and family members supervising DOTS in remote hilly areas.

Efforts are also under way to encourage private sector doctors to refer TB patients for DOTS treatment or to establish DOTS centres in the private sector. The approach is flexible, the main aim being to ensure all TB patients have access to DOTS. Regular meetings are held with private practitioners to discuss the DOTS programme and encourage an exchange of information. Meanwhile, a clinical manual on DOTS treatment has been produced for use by doctors.

Other concerns include an increase in the number of people co-infected with HIV and TB (currently almost 2% of TB cases) and an increase in the incidence of multidrug-resistant forms of TB (over 1% of TB cases).

Today, efforts are continuing to expand DOTS coverage to the entire population. The aim is to ensure that for every 100 000 people in Nepal there is a DOTS treatment centre within the primary health care system, supported by a microscopy centre for diagnosis and treatment monitoring. It is estimated that almost 60 000 TB deaths will be prevented by the DOTS programme in Nepal over the next five years.