Tuberculosis remains a leading cause of death among adults in less-developed countries; incidence is rising in sub-Saharan Africa and countries in the former Soviet Union. A failure to provide treatment in accordance with the international standard of care can sometimes result in patients being unable to take treatment properly. This can lead to failure to cure the disease and to prevent subsequent relapse.
The tuberculosis control strategy recommended by WHO to tackle this problem is known by the "brand name" of DOTS (DirectObservations of Treatments). The whole DOTS package involves five separate aspects: improved political commitment and funding, diagnosis by a laboratory, regular supplies of essential drugs, strengthened programme supervision, and the use of standard drug treatment with at least the initial treatment being directly observed by a trained treatment supporter.
Mario C. Raviglione from WHO and colleagues discuss how, despite great progress, global targets (70% TB detection of which 85% should be treated) for tuberculosis case detection and cure might not be reached by 2005. The authors highlight the serious case-detection gap between estimated annual incident cases and those reported under the DOTS strategy.
Four key actions are outlined that could speed up progress towards reaching the targets: 1) equipping national tuberculosis programmes to have a stewardship role in engaging all health providers in implementing the DOTS strategy; 2) establishing the feasibility of national certification systems of DOTS coverage; 3) promoting community action to contribute to patient care and to voice demand for the DOTS strategy; and 4) increasing support to sub-Saharan Africa to counter HIV-1-fuelled tuberculosis through implementation of a strategy of expanded scope (comprising the DOTS strategy and additional interventions).
Dr. Raviglione comments: "We face a health workforce crisis, a failure so far to engage all health care providers and a global financial gap that stands at about US$300 million annually, with the most pressing financial needs felt in sub-Saharan Africa. Closing this financial gap and systematically applying the four approaches outlined are paramount to the achievement of the 2005 targets and, subsequently, to decrease the global burden of tuberculosis".
Contact: Dr Mario C Raviglione,Stop TB Department (STB) Communicable Diseases (CDS),World Health Organization,Avenue Appia 20,CH-1211 Geneva 27,Switzerland. T) 41-22-791-2663/3986; F) 41-22- 791-4268; E) raviglionem@who.int.
Journal
The Lancet