DOTS in Aral Sea area
This article first appeared in The Lancet Volume 358, Number 9297, Correspondence, 8 December 2001.
Reviews done by Médecins Sans Frontières (MSF) of its efforts to implement tuberculosis treatment in western Uzbekistan and northern Turkmenistan concurs with the views expressed by Dermot Maher and colleagues (Aug 4, p 421)1 that putting patients with tuberculosis in the centre of their own care is central to the success of directly observed treatment short course (DOTS) for tuberculosis.
The rapidly shrinking Aral Sea in Central Asia, resulting in loss of crop yield and fishing, has impinged negatively on the socioeconomic status of the population. Moreover, the effect on health has been substantial, and the return of tuberculosis is pathognomonic of this trend. With an incidence of tuberculosis of 100-150 per 100,000 population, by MSF's estimates, this disease is a problem in districts straddling the former Aral Sea coast on the scale of that in countries in WHO's high burden league, such as Russia and China.2 MSF began working in the region three years ago, rolling out DOTS among a target population of 3.8 million spread over huge, largely desert expanses. To date, more than 6,000 treatment episodes have been registered.
MSF has helped to equip 19 diagnostic laboratories for smearing and microscopy, to train and support health care workers to use observed treatment in 13 inpatient facilities and hundreds of ambulatory clinics, to computerise the information system for case registration and reporting, and to supply drugs and reagents at no charge to the patients and the local service. Through effective advocacy, it has helped procure external funding for medications in Uzbekistan and achieve commitment from the government of the two countries to establish national policies on tuberculosis in the near future.
Whereas the mainstay of observation in our programmes remains the health-care worker, the internal reviews noted that distances between the patients and the health-care workers continue to present a formidable obstacle, making regular observation of doses, even three times weekly, difficult to achieve.
Pete Moore3 has reiterated the need to reorient the role of health workers in DOTS, from one of passive observer to that of counsellor. However, we believe that he presents insufficient information on who the alternative observer could be. There is growing acknowledgment through the official stand of key international authorities on tuberculosis4,5 that, although the observation component is important, bringing the observer closer to the patient is more crucial than mandating a professional to watch patients swallow drugs.
In the Aral Sea area, patients' preference for observers, be it state care worker, Red Crescent nurse, family member, employer, or neighbourhood committee members, will become a priority to improve adherence to the observed methods. Health-care workers' role would be to provide backup support, to train and regularly supervise observers, and to manage arising difficulties, such as adverse reactions to medication.
J Shafer, D Falzon, I Small, D Kittle, N Ford, Médecins Sans Frontières, Aral Sea Programme, Tashkent, Uzbekistan
1 Maher D, Raviglione M, Lee JW. Direct observation for tuberculosis treatment. Lancet 2001; 358: 421
2 Global tuberculosis control: WHO report 2000. Geneva: WHO, 2000
3 Moore P. DOTS: what's in a name. Lancet 2001; 357: 940
4 Maher D, Chaulet P, Sincaci S, Harries A. Treatment of tuberculosis: guidelines for national programmes, 2nd edn. Geneva: WHO WHO/TB/97.220, 1997: 41
5 WHO International Union Against Tuberculosis and Lung Disease, Royal Netherlands Tuberculosis Association. Revised international definitions in tuberculosis control. Int J Tuberc Lung Dis 2001; 5: 21315.