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
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
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.