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Failure of Directly Observed Treatment for Tuberculosis

in Africa: A Call for New Approaches
Christopher C. Whalen
Department of Epidemiology and Biostatistics, School of Medicine, Case Western Reserve University, Cleveland, Ohio

(See the article by Lawn et al. on pages 1040–7)

The tuberculosis pandemic continues to tribute, the problem with the DOTS strat- tion census surveys 8 years apart, so
evolve. In some parts of the world, tu- egy may be even more fundamental. What disease rates could be adjusted for de-
berculosis case rates have decreased to his- is the rationale for the DOTS strategy? Is mographic changes. The community is
torically low levels, whereas, in other parts it a public health intervention designed to served by a single community health
of the world, the incidence of tuberculosis curb the spread of tuberculosis, or is it a clinic, making it likely that the means of
is increasing. In sub-Saharan Africa, tu- treatment guideline for tuberculosis? diagnosing and reporting cases of tuber-
berculosis continues to be a major threat The DOTS strategy was introduced in culosis and HIV infection were uniform,
to individual and public health as inci- 1994 as a comprehensive plan for tuber- thereby avoiding detection and reporting
dence rates surpass 1000 cases per 100,000 culosis control built around 5 strategic ac- biases. The most striking feature of the
population in some regions. In 1994, the tivities [1]. First, governments must com- design is that DOTS was implemented in
World Health Organization (WHO) de- mit to control tuberculosis and provide an optimal way in the district, and the
clared tuberculosis a global emergency and the human resources and infrastructural program achieved cures rates of ⭓80% in
introduced the directly observed treat- capacity to deliver care for persons with smear-positive cases of tuberculosis.
ment, short course (DOTS), strategy for tuberculosis. Second, case detection is per- In this setting, the authors were able to
global tuberculosis control, but the plan formed through passive case-finding, with show that the tuberculosis rates increased
has produced variable success. In the face microscopic examination of sputum sam- 2.5-fold during the study period and con-
of this intensified effort to diagnose and ples used as the diagnostic standard. tinued to increase even after the preva-
treat tuberculosis, the rates in sub-Saharan Third, treatment consists of the standard lence of HIV infection had leveled off. Tu-
short-course regimen and must be given berculosis rates increased most among
Africa continue to climb. Various experts
using directly observed therapy. Fourth, adolescents and individuals aged 20–39
have argued that the failure of the DOTS
there must be a regular supply of medi- years—the age groups most likely to be
strategy to control tuberculosis results
cation to the national tuberculosis-control affected by HIV infection in this popu-
from failed implementation, poor public
program. Fifth, a system must be in place lation. The authors conclude that the
health infrastructure, poverty, the lack of
for monitoring and tracking cases DOTS strategy alone was ineffective in this
interventions that are sensitive to personal
throughout the country. As part of the community because of the population ef-
preferences, and the HIV epidemic. Al-
strategy, the WHO also proposed a per- fects of HIV infection on tuberculosis.
though each of these reasons may con-
formance target of identifying 70% of tu- Although it is important to herald the
berculosis cases and curing 85% of them. successes of the DOTS strategy around the
Received 5 December 2005; accepted 6 December 2005;
electronically published 16 February 2006.
The article by Lawn et al. [2] is an eco- world [3, 4] and to acknowledge its role
Reprints or correspondence: Dr. Christopher C. Whalen, logic study that describes coincident tu- in preventing the emergence of multidrug-
Dept. of Epidemiology and Biostatistics, WG-37, Case
Western Reserve University, School of Medicine, 10900 Euclid
berculosis and HIV epidemics in a town- resistant stains of Mycobacterium tuber-
Ave., Cleveland, OH 44106-4945 (ccw@case.edu). ship near Cape Town, South Africa. The culosis [5], we may learn more about tu-
Clinical Infectious Diseases 2006; 42:1048–50 study is unique because it examines a pop- berculosis control from examining where
 2006 by the Infectious Diseases Society of America. All
rights reserved.
ulation in a well-defined geographic re- the DOTS strategy has failed. By under-
1058-4838/2006/4207-0026$15.00 gion that was characterized by 2 popula- standing the reasons for failure, we may

1048 • CID 2006:42 (1 April) • EDITORIAL COMMENTARY

be able to modify and improve current individual; and (3) the duration of infec- goals—that is, whether an intervention
approaches and to design new strategies. tiousness of the index case. targets primarily transmission or treat-
The study by Lawn et al. [2] offers some When one examines the elements of ment. The DOTS strategy is an excellent
insight into why the DOTS strategy failed, DOTS, only the treatment of disease di- and well-orchestrated set of treatment
at least in this small, well-studied African rectly alters one of these key epidemic pa- guidelines that provide governments,
community. Some experts have stated that rameters by reducing the duration of in- ministries of health, and health care pro-
the main reason for the DOTS strategy’s fectiousness. The DOTS strategy does not fessionals unambiguous advice on how to
failure is lack of proper implementation address the number and frequency of con- treat patients with tuberculosis. And for
[6–8]. But that is not likely here, because tacts or the likelihood of disease after in- this reason, it should remain a centerpiece
all tuberculosis care was offered through fection. For tuberculosis, it is estimated in our efforts to treat tuberculosis disease.
a single clinic that achieved WHO treat- that a single patient may infect ∼10 con- The study from Cape Town illustrates the
ment goals. Lawn and colleagues argue tacts before receiving treatment [10]. With urgent need to develop novel strategies to
that the HIV epidemic fueled the tuber- a lifetime risk of tuberculosis of ∼10% act as companions to DOTS. These novel
[11], then each case of tuberculosis will be public health strategies should have as
culosis epidemic in the township, citing
replaced by another, at some point in the their primary goal to interrupt the spread
the temporal association between the 2 ep-
future. In the presence of HIV infection, of tuberculosis. Because of the potential
idemics and its biologic plausibility as evi-
however, the dynamics are altered, because effect of HIV infection on tuberculosis
dence. As an ecologic study, however, it is
HIV infection is associated with a high risk control, these strategies must also integrate
possible that an unmeasured factor, such
for progressive primary tuberculosis [12] with the HIV prevention and treatment
as population migration, has produced the
and reactivation of disease [13]. A single programs.
results we observe. In the United States,
tuberculosis case will likely yield 11 sub-
for example, we witnessed a resurgence of Acknowledgments
sequent case, thereby accentuating an
tuberculosis from 1986 to 1993 that was
epidemic. Financial support. Tuberculosis Research
initially attributed to the “new” AIDS ep- Unit (AI-45244-95383) and an investigator-initi-
Our experience with DOTS teaches us
idemic but was later attributed to tuber- ated grant (AI51219) from the National Institutes
that treatment of tuberculosis alone is in- of Allergy and Infectious Diseases, and the AIDS
culosis in foreign-born individuals, with
effective in containing its spread in some International Training and Research Program
HIV infection playing a lesser role [9]. In (TW-00011) of the Fogarty International Center,
communities, particularly where HIV in-
this township, we find ourselves confront- National Institutes of Health.
fection is endemic. New approaches Potential conflicts of interest. C.C.W.: no
ing a similar interpretation. Detailed mo-
should be developed that interrupt the conflicts.
lecular epidemiology of tuberculosis cases
spread of M. tuberculosis in the commu-
and HIV serostatus of individuals would References
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