Medical charity criticises shortcomings of DOTS in management of tuberculosis
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《英国医生杂志》
New Delhi
Many people with active tuberculosis miss out on effective treatment because of outdated diagnostic tools and shortcomings in the direct observed treatment short course (DOTS) programme, the medical charity Médecins Sans Frontières (MSF) has warned.
In a report released at the meeting of the Stop TB Partners' Forum in New Delhi last week, the humanitarian medical aid organisation called on governments and the World Health Organization to intensify research to find new drugs and diagnostic tools for tuberculosis to overcome the limitations of DOTS programmes.
Case detection for DOTS relies on sputum smear microscopy, but this test detects only 48% of people with tuberculosis, said the MSF report. It pointed out that the smear microscopy test worked in less than 38% of HIV infected people with tuberculosis. Its detection rate in children with pulmonary tuberculosis was only 5% because children were not able to cough up sufficient sputum sample for smear microscopy testing.
Dr Rowan Gillies, president of MSF, said: "We rely on a 19th century tool—it doesn't detect paediatric, extra pulmonary, or smear negative tuberculosis. People who get into a well managed DOTS programme do well; the problem is that DOTS excludes many people with active tuberculosis."
A patient waits to be given an injection at a DOTS centre at the Lok Nayak Hospital, New Delhi. Case detection rates in DOTS programmes can be as low as 5% in children
Credit: GURINDA ASSAN/AP
The 2004 Global Tuberculosis Control Report published recently by WHO acknowledged that tuberculosis control targets were unlikely to be achieved without improving the detection and treatment programme.
The current detection rate of infectious cases was 37%, whereas the target was to detect 70% of all infectious cases by 2005. The WHO report estimated that there were 8.8 million new cases of tuberculosis each year, with 3.9 million of these being infectious. It noted that DOTS programmes were now treating three million patients with tuberculosis every year, representing an increase of more than one million compared with two years ago.
The MSF report recognised that DOTS programmes achieved greater treatment success (82%) than treatment without DOTS (67%). But, it argued, it was difficult to implement DOTS in all but the most stable settings. Dr Leopold Blanc, coordinator of tuberculosis strategy and operations with WHO, agreed that DOTS worked better in the community than in hospitals. "Many hospitals appear to lack mechanisms to follow up patients and to ensure they take the drugs," he said.
The basic structure and functioning of DOTS programmes had not been substantiated in large clinical trials and had little empirical basis, the MSF report said. It argued that the normal scientific process of scrutinising DOTS principles was "cut short by its launch as a brand promoted by the World Health Organization." With the focus of DOTS on the detection of smear positive patients, there were also concerns about a system that seemed to prioritise public health over individual patients' rights, it said.
Earlier this year, doctors at a government designated DOTS centre in India reported a 70% cure rate in a study of 112 patients, which was lower than India's national average cure rate of 83% ( Postgraduate Medical Journal 2004;80: 97-100). The lower cure rate may mean that good microscopy can detect treatment failure better or that the cure rates claimed by the national programme are of questionable reliability, said Jyotsna Joshi, head of respiratory medicine at Topiwala National Medical College in Mumbai, India, where the study was carried out.
Delegates attending the meeting of the Stop TB Partners' Forum welcomed a call from MSF for new tests to improve diagnosis and new drugs to shorten the duration of treatment of tuberculosis. "But these are long term goals; DOTS is the best strategy for the moment," said Dr Bobby John, director of Massive Effort India, a non-government agency.(Ganapati Mudur)
Many people with active tuberculosis miss out on effective treatment because of outdated diagnostic tools and shortcomings in the direct observed treatment short course (DOTS) programme, the medical charity Médecins Sans Frontières (MSF) has warned.
In a report released at the meeting of the Stop TB Partners' Forum in New Delhi last week, the humanitarian medical aid organisation called on governments and the World Health Organization to intensify research to find new drugs and diagnostic tools for tuberculosis to overcome the limitations of DOTS programmes.
Case detection for DOTS relies on sputum smear microscopy, but this test detects only 48% of people with tuberculosis, said the MSF report. It pointed out that the smear microscopy test worked in less than 38% of HIV infected people with tuberculosis. Its detection rate in children with pulmonary tuberculosis was only 5% because children were not able to cough up sufficient sputum sample for smear microscopy testing.
Dr Rowan Gillies, president of MSF, said: "We rely on a 19th century tool—it doesn't detect paediatric, extra pulmonary, or smear negative tuberculosis. People who get into a well managed DOTS programme do well; the problem is that DOTS excludes many people with active tuberculosis."
A patient waits to be given an injection at a DOTS centre at the Lok Nayak Hospital, New Delhi. Case detection rates in DOTS programmes can be as low as 5% in children
Credit: GURINDA ASSAN/AP
The 2004 Global Tuberculosis Control Report published recently by WHO acknowledged that tuberculosis control targets were unlikely to be achieved without improving the detection and treatment programme.
The current detection rate of infectious cases was 37%, whereas the target was to detect 70% of all infectious cases by 2005. The WHO report estimated that there were 8.8 million new cases of tuberculosis each year, with 3.9 million of these being infectious. It noted that DOTS programmes were now treating three million patients with tuberculosis every year, representing an increase of more than one million compared with two years ago.
The MSF report recognised that DOTS programmes achieved greater treatment success (82%) than treatment without DOTS (67%). But, it argued, it was difficult to implement DOTS in all but the most stable settings. Dr Leopold Blanc, coordinator of tuberculosis strategy and operations with WHO, agreed that DOTS worked better in the community than in hospitals. "Many hospitals appear to lack mechanisms to follow up patients and to ensure they take the drugs," he said.
The basic structure and functioning of DOTS programmes had not been substantiated in large clinical trials and had little empirical basis, the MSF report said. It argued that the normal scientific process of scrutinising DOTS principles was "cut short by its launch as a brand promoted by the World Health Organization." With the focus of DOTS on the detection of smear positive patients, there were also concerns about a system that seemed to prioritise public health over individual patients' rights, it said.
Earlier this year, doctors at a government designated DOTS centre in India reported a 70% cure rate in a study of 112 patients, which was lower than India's national average cure rate of 83% ( Postgraduate Medical Journal 2004;80: 97-100). The lower cure rate may mean that good microscopy can detect treatment failure better or that the cure rates claimed by the national programme are of questionable reliability, said Jyotsna Joshi, head of respiratory medicine at Topiwala National Medical College in Mumbai, India, where the study was carried out.
Delegates attending the meeting of the Stop TB Partners' Forum welcomed a call from MSF for new tests to improve diagnosis and new drugs to shorten the duration of treatment of tuberculosis. "But these are long term goals; DOTS is the best strategy for the moment," said Dr Bobby John, director of Massive Effort India, a non-government agency.(Ganapati Mudur)