Directly Observed Treatment Short course (DOTS) is the most effective strategy available today for tuberculosis control. The World Health Organization (WHO) recommended treatment strategy for detection and cure of TB. In 1994, WHO Framework for effective TB control recommended the five core elements for TB treatment and control (later known as DOTS) recommended the establishment of microscopy service and “if additional resources are made available, establish culture and susceptibility testing in order to monitor drug resistance”.

Situation of DOTS in Nepal

DOTS is one of the significant programs that has been implemented throughout the country since April 2001. National Tuberculosis Program (NTP) has rapidly expanded DOTS strategy in 1996 with 4 pilot centres. This cost effective and highly successful treatment strategy has reduced TB mortality and morbidity in Nepal.

The NTP has achieved sustain the good progress in the DOTS program and has expanded the program with the coordination of public sector, private sector, local government, I/NGOs, social workers, educational institutions and other sectors. There are 4,344 DOTS treatment centres in Nepal and the NTP has adopted the global End TB Strategy and the achievement of the SDGs as the country’s TB control strategy.

Long term goal: End the tuberculosis epidemic by 2050.

Short term goal: Reduce TB incidence by 20% by 2021 compared to 2015 and increase case notifications by a cumulative total of 20,000 from July 2016 to July 2021.

The End TB Strategy was unanimously endorsed by the World Health Assembly in 2014.

The overarching indicators of the strategy are

i) the number of TB deaths per year,

ii) TB incidence rate per year, and

iii) the percentage of TB-affected households that experience catastrophic costs as a result of TB. These indicators have related targets for 2030 and 2035.

The main principles for implementing the strategy are:

  • government stewardship and accountability, with monitoring and evaluation;
  • strong coalitions with civil society organizations and communities;
  • the protection and promotion of human rights, ethics and equity; and
  • the adaptation of the strategy and targets at country levels, with global collaboration.

The strategy’s components (three pillars) and related strategies are as follows:

  1. Integrated, patient centered care and prevention:
  • Early diagnosis of TB including universal drug-susceptibility testing, and systematic screen­ing of contacts and high-risk groups.
  • Treatment of all people with TB including drug-resistant TB.
  • Collaborative TB/HIV activities and the management of co-morbidities.
  • The preventive treatment of persons at high risk, and vaccination against TB.
  1. Bold policies and supportive systems:
  • Political commitment with adequate resources for TB care and prevention.
  • The engagement of communities, civil society organizations, and public and private care providers.
  • Universal health coverage policy and regulatory frameworks for case notification, vital registration, quality and rational use of medicines, and infection control.
  • Social protection, poverty alleviation and actions on other determinants of TB.
  1. Intensified research and innovation:
  • The discovery, development and rapid uptake of new tools, interventions and strategies.
  • Research to optimize implementation and impact, and promote innovations.

TB resistant drugs

  • Rifampicin resistant TB(RR-TB) is resistant to rifampicin (detected using rapid diagnostic tests), with or without resistance to other anti-TB drugs and covers any resistance to rifampicin.
  • Pre-extensively drug resistant TB(Pre XDRTB) is a multi-drug resistant strain of TB that is also resistant to either one of the fluoroquinolones and all the second line injectable drugs.
  • Extensively drug resistant TB (XDR-TB) is a severe form of MDR-TB that is multidrug-resistant (MDR-TB) to all the fluoroquinolones and second line injectable drugs.

Challenges

TB drug resistance is a major problem that threatens the success of DOTS in Nepal. TB Drug resistance arises due to the improper use of drugs in chemotherapy of drug-susceptible TB patients. This improper use is a result of a number of actions, including administration of improper treatment regimens by health care providers and failure to ensure that patients complete the whole course of treatment. Essentially, drug-resistance arises in areas with poor TB control programmes. The DOTS-Plus programme is developed by WHO and partners to manage Drug Resistant-TB (DR-TB) using second-line Anti-TB drugs. Based upon DOTS, DOTS-Plus is a comprehensive management strategy under development and testing that includes the five tenets of the DOTS strategy.

To improve the efficacy of DOTS programme, along with free medicine and directly observed treatment, mass awareness campaign should be designed targeting health education programme for patients, family members and community.