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Global TB Control – DOTS & DOTS-Plus, WHO

DOTS

DOTS sign

DOTS sign

In 1994 the World Health Organisation (WHO) announced a new strategy for the worldwide control of TB. All countries with a TB problem were to provide standardized short course drug treatment to, at least, all sputum smear positive TB patients. This new strategy was packaged as “DOTS”, or Directly Observed Treatment Short course strategy. Until 2006 DOTS was to be the internationally recommended approach to global TB control.

DOTS had five components which were initially as follows.1“What is DOTS? WHO Tuberculosis Factsheet”, WHO, 2006 What is dots?

  • Sustained political and financial commitment.
  • Diagnosis of TB by quality ensured sputum smear microscopy.
  • Standardized short course anti TB treatment (SCC) given under direct and supportive observation (DOTS).
  • A regular uninterrupted supply of high quality anti TB drugs.
  • Standardized recording and reporting.
Upside down DOTS sign

Upside down DOTS sign

In 1996 the WHO claimed that “where the health system is working even moderately well, the DOTS strategy is extraordinarily effective achieving cure rates over 90%.” But where in sub-Saharan Africa were there TB programs reliably implementing all five parts of DOTS?

It became clear from several studies that treatment outcomes in some instances didn’t appear to be better under DOTS than they were without it. DOTS was not the “magic bullet” it was thought to be, and a universal solution had not been found. However, the World Bank made support of TB programs contingent on the adoption of DOTS, and the “gospel” of DOTS spread far and wide. Five years after its emergence 120 countries had at least nominally adopted DOTS.

When it was first introduced DOTS did not take any account of HIV. In a 2006 interview Arata Kochi the former director of TB programs at the WHO said:

One thing that I didn’t do well is develop an additional strategy in addition to DOTS for HIV/TB. That is my regret.

Multi drug resistant TB

DOTS also did not take any account of drug resistant TB. Where resistance already exists to first line drugs such as isoniazid and rifampin, the DOTS program reverts to a short course of pyrazinamide and ethambutol. These are at doses insufficient to treat active TB, but in doses large enough to boost resistance. Further, if a patient’s TB was not cured, DOTS also called for retreatment with rifampin and isoniazid. So in these circumstances the DOTS programme could actually cause a worsening of the MDR TB situation.

DOTS-Plus

In 1999 WHO and their partners launched DOTS-Plus. DOT-Plus was to be developed as a comprehensive initiative that was to build upon the five elements of DOTS. However it would take into account specific issues such as the use of second line anti TB drugs, that needed to be used in areas where there were significant levels of MDR TB.

One of the difficulties with the implementation of some of the DOTS-Plus pilot projects, was the need for quality second line anti TB drugs, which were normally very expensive. WHO and their partners made an arrangement with the pharmaceutical industry for preferential prices for the second line drugs used for the pilot projects. However, it was considered important that these beneficial prices were only used in projects that were organised according to certain standards. So the Green Light Committee was established to review project applications, and to decide whether they were sufficiently in accordance with the guidelines that had been established for the pilot projects.2“DOTS-Plus & the Green Light Committee”, www.who.int/tb/publications/2000/en/index.html

The Global Plan to Stop TB 2001–2005

By the year 2000 some global TB targets set in 1991 had still not been met. So further international meetings were held, and a new declaration was the Amsterdam Declaration to Stop TB. The same goals were once again set, but this time to be achieved by 2005.3“Amsterdam Declaration to Stop TB”, Amsterdam, The Netherlands, 24th March 2000 www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf

The Stop TB Partnership was set up in 2001 following the Amsterdam Conference in 2000. Initially the partnership comprised just six organisations. Three of its working groups were:

  • DOTS Expansion
  • TB/HIV
  • DOTS-Plus

and one of its first initiatives was the Global Drug Facility.

The Global Drug Facility was established in 2001 to expand access to and the availability of high quality TB drugs, in order that DOTS programs could be expanded. It was established in response to the difficulties that countries had in the 1990s in finding and funding high quality supplies of TB drugs. It was believed that patients were developing resistance as a result of poor quality drugs.4“What is the GDF?”, www.stoptb.org/gdf/

By the time the first Stop TB Partners’ Forum took place in October 2001 the partnership had grown from six to over 120 organisations. At the Forum the launch took place of the Global Plan to Stop TB 2001–2005. Its aim was to provide a “roadmap” towards a TB free world, and it was considered that the 2005 TB control targets were realistic.5“First Stop TB Partners’ Forum”, Washington, 22 October 2001, 6 www.stoptb.org/events/meetings/partners_forum/2001/

The Global Plan to Stop TB 2001–2005 made a number of commitments including that:6“First Stop TB Partners’ Forum”, Washington, 22 October 2001, 6  www.stoptb.org/events/meetings/partners_forum/2001/

  • Within the next 50 months — by the end of 2005:
  • A global DOTS case detection rate of at least 70% would have been achieved, while maintaining a treatment success rate of at least 85%
  • Effective responses to TB/HIV and MDR TB would have been developed and scaled up
  • A Global Plan to Stop TB for the period 2006–2010 would have been developed.

The Global Plan to Stop TB 2006–2015

Once again the targets set in a Global Plan to Stop TB had not been reached. This time it was the targets in the Global Plan to Stop TB 2001–2005. These targets had been considered realistic back when they were set in 2001.

In the new global plan for 2006–2015, the targets were no longer set in terms of the percentage of people reached in case detection rates, or a treatment success rate of at least 85%. Instead there were a range of targets covering specific areas such as the development of improved diagnostics and drugs, and the targets set in the Millenium Development Goals.

The Global Plan to Stop TB 2011–2015

GLobal Plan To Stop TB

Global Plan to Stop TB

In 2009 the Stop TB Partnership produced a report on the progress that had been made in global TB control between 2006 and 2008.7“The Global Plan to Stop TB 2006-2015: Progress Report 2006-2008”, WHO, 2009 www.stoptb.org/resources/publications/plans_strategies Many different areas were highlighted and in some, significant progress had been made, whereas in others, such as screening HIV positive people for TB, it was noted that much less progress had been made. It was particularly noted that the provision of funding for TB was an area of particular difficulty with a funding gap still existing of over US$1 billion per year.

The Global Plan was subsequently updated in 2010, to become the “Global Plan to Stop TB 2011–2015”.8“The Global Plan to Stop TB 2011-2015”, WHO, Geneva, 2010 www.stoptb.org/global/plan/

After 2015 — TB is still a Global Emergency

In 1993 the WHO declared TB to be a global emergency, stating that the disease would claim more than 30 million lives in the next ten years unless sufficient action was taken. Since then some action has been taken, but TB still claims one and a half million lives a year. More than 30 million people have died since the global emergency was declared. What was said by WHO in 1993 is still probably true today.

“Tuberculosis today … is out of control in many parts of the world. The disease, preventable and treatable, has been grossly neglected and no country is immune to it.”

Arati Kochi, Manager WHO Tuberculosis Program 9“WHO Calls Tuberculosis a Global Emergency”, Los Angeles Times, 1993 //articles.latimes.com/1993

References

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1. “What is DOTS? WHO Tuberculosis Factsheet”, WHO, 2006 What is dots?
2. “DOTS-Plus & the Green Light Committee”, www.who.int/tb/publications/2000/en/index.html
3. “Amsterdam Declaration to Stop TB”, Amsterdam, The Netherlands, 24th March 2000 www.stoptb.org/assets/documents/events/meetings/amsterdam_conference/decla.pdf
4. “What is the GDF?”, www.stoptb.org/gdf/
5. “First Stop TB Partners’ Forum”, Washington, 22 October 2001, 6 www.stoptb.org/events/meetings/partners_forum/2001/
6. “First Stop TB Partners’ Forum”, Washington, 22 October 2001, 6  www.stoptb.org/events/meetings/partners_forum/2001/
7. “The Global Plan to Stop TB 2006-2015: Progress Report 2006-2008”, WHO, 2009 www.stoptb.org/resources/publications/plans_strategies
8. “The Global Plan to Stop TB 2011-2015”, WHO, Geneva, 2010 www.stoptb.org/global/plan/
9. “WHO Calls Tuberculosis a Global Emergency”, Los Angeles Times, 1993 //articles.latimes.com/1993