Dr. Archie Cochrane

Case

A 45 year old man presents with persistent cough for the past 3 months, low grade fever, and abdominal pain.

Provisional Diagnosis

1. TB

2. TB

3. TB

• India has one of the highest cases reported of TB in the world

• TB is controlled in India by the DOTS(Direct Observation Therapy, Short course) programme as recommended by the WHO

What is DOTS?

• Directly observed treatment (DOT) or directly observed therapy is watching the patient take his/her medication to ensure medications are taken in the right combination and for the correct duration

Five components of DOTS

• Government commitment • Case detection by sputum smear microscopy • Standardized treatment regimen with directly

observed treatment for at least the first two months

• A regular drug supply • A standardized recording and reporting system

that allows assessment of treatment results

Facts

• The Indian Government has spent over $200 million on setting up the DOTS programme 1

• “DOTS lost track of more than 35,000 patients last year” The Telegraph

• “Nearly 70,000 people suffering from multi-drug resistant tuberculosis (MDR-TB) in India require quality second-line treatment, experts at the World Health Organization say. India needs quality second-line drugs to treat these patients ..." - The Hindu

1 www.indiatogether.com

How effective is DOTS?

[Intervention Review]

Directly observed therapy for treating tuberculosis

Jimmy Volmink1, Paul Garner2

1Faculty of Health Sciences, University of Stellenbosch, Tygerberg, South Africa

2International Health Group, Liverpool School of Tropical Medicine, Liverpool, UK

Objective

To compare DOT with self administration of treatment or different DOT options for people requiring treatment for clinically active tuberculosis or prevention of active disease.

Study Methods

• This systematic review evaluated 11 Randomized Control Trial (RCT’s) with 5906 participants from all economic strata’s of society.

• Trials of drug users were analysed separately• Data were analysed using relative risks (RR) with

95% confidence intervals (CI) and the fixed-effect model when there was no statistically significant heterogeneity (chi square P > 0.1).

Study Methods

• The control was routine self administration of treatment at home, with intermittent clinic visits for drugs with or without treatment adherence checks.

• All studies on the topic, irrespective of language of publication and origin were looked into.

• For papers that had not been published the authors were contacted to verify the validity and level of bias in the study

Result

The results of randomized controlled trials conducted in low-, middle-, and high-income countries provide NO assurance that DOT compared with self administration of treatment has any quantitatively important effect on cure or treatment completion in people receiving treatment for tuberculosis

Food for Thought

In a country like India were 900 million people survive on Rs. 80 per day, how much difference would it make to their lives if $200 million were spent on there up liftment instead of wasting it on setting up a system that is not effective.

Thank You

Thank You