Tuberculosis control in Bangladesh: success of the DOTS strategy.

SETTING

Tuberculosis (TB) has been a major public-health problem in Bangladesh for many decades. National control efforts in the past have not been successful, with less than half of detected cases being cured. In 1993, a project based on the DOTS (directly observed treatment, short-course) strategy was initiated for a population of approximately one million in a rural setting. Following a 78% cure rate in the initial cohort of new smear-positive patients, the project was expanded in phases to cover a rural population of 67 million in 1996.

OBJECTIVES

Routine programme data on all new sputum smear-positive patients registered in the TB project since its inception until 1996 were analysed. Case finding results are presented until 1996, as are results of sputum smear conversion after 2 months of treatment in new smear-positive patients for the same cohort of patients. Final treatment outcome results were analysed for new smear-positive patients registered up to 1995.

RESULTS

A total of 41,525 patients were registered in the project during the 3-year period. Two-thirds of these were new smear-positive cases and 27% were new smear-negative patients. Sputum smear conversion in 26,151 new smear-positive patients at 2 months was 85%; 5% remained smear-positive, 3% had died and the rest had no sputum examination. Final treatment outcome results in 10,142 new smear-positive patients registered during 1993-1995 showed that 75% were cured, 4% completed treatment but did not have a sputum smear result, 2% remained smear-positive, 6% died, 10% defaulted and 3% were transferred out.

CONCLUSION

The DOTS strategy can be successfully implemented in phases in large countries with a high tuberculosis burden. This success is due to decentralizing sputum smear microscopy and treatment delivery services to peripheral health facilities, utilizing the existing primary health care network. High cure rates can be maintained despite rapid expansion of coverage, with proper implementation of the strategy and regular monitoring of reports on case finding, sputum smear conversion and treatment outcome. Case detection needs to be further increased by informing and involving the community in TB control efforts through social mobilization.