结核病化疗督导管理的实施和体会

由于政府对结核病防治政策的承诺,各级领导的重视,以及全体医务人员的共同努力,使本镇现代结核病控制策略（DOTS）得以实施,目前结核病治疗覆盖率已达100％。     

结核病疫情现状和控制策略

结核病是全球重大公共卫生问题。我国是全球22个结核病高负担国家之一,肺结核发病人数居全球第3位。本文一方面从结核病疾病负担、发病和死亡等情况描述了目前全球及我国结核病疫情现状;另一方面介绍了全球及我国结核病控制策略及其从现代结核病控制策略(DOTS)到遏制结核病策略,最后到终止结核病策略的演变发展历程。最后,阐述了目前结核病防控工作面临的问题和困难,并提出了未来我国结核病防控工作发展方向的几点建议。     

结核病控制及其可持续发展的思考和对策探讨

回顾分析了结核病控制现状，提出科学规划，明确责任，努力扩大实施现代结核病控制策略（DOTS）覆盖面等结核病控制对策。     

乌鲁木齐市医疗机构痰涂片检查现状分析

结核病的实验室检查是发现传染源的最主要手段,是结核病确诊、治疗方案选择、疗效考核的主要依据[1].现代结核病控制策略(DOTS策略)提出通过痰涂片检查发现肺结核主要传染源.     

2003年～2006年泗阳县不同时间新登涂阳肺结核病人分析

泗阳县是江苏省控制结核病项目县之一,通过推行现代结核病控制策略(DOTS),对肺结核病人统一归口到县疾病预防控制中心结核病防治门诊,按国家统一方案实行免费检查和免费治疗,并实施统一管理.     

浅谈县级结核病防治工作模式存在的问题和建议

肺结核病归口管理是结核病控制的一项重要措施,也是实行现代结核病控制策略（DOTS）的基础。一直以来,各级卫生部门认真履行职责,特别在近几年,加强了疾控机构（或结防机构）与综合医院的密切协作,积极开展现代结核病控制策略,结核病防治工作取得了很好的成效。然而,由于各地情况不同,发展不均衡,部分县在实际工作实践中也暴露出了不少问题,制约了结核病防治工作的深入展开。     

博白县肺结核病归口管理5年效果分析

现代结核病控制策略的核心是医务人员直接面视下的短程督导化疗 (DOTS) [1] ,对结核病实施“归口管理” ,是DOTS的基础[2 ] 。归口管理是现代结核病控制的一项主要措施 ,是实现结核病“高发现率、高治愈率”的重要保证[3] 。归口管理的效果如何直接影响现代结核病控制策略的有效实施。博白县于 1997年开始实施卫生部结核病控制项目 ,对肺结核病例实施归口管理。几年来 ,博白县结核病防治所按照项目手册要求 ,全面开展结核病例发现和化疗管理 ,现将 1997- 2 0 0 1年结果分析报告如下。1　资料和方法1 1　资料来源于博白县防疫站结防科门…     

福建省结核病控制策略扩展与应用研究

<正>当前结核病不但是公共卫生问题,而且已成为严重的社会、经济和政治问题。为了控制福建省结核病的流行,1993-1999年福建省实施了卫生部加强与促进结核病控制项目[1]全面推行现代结核病控制策略(DOTS),然而成效并不显著,项目实施到1999年结束,全省只覆盖34个县(市、区),DOTS覆盖率仅为39.5%、新发的     

舟山市结核病防治效果分析

2009年,中国在多年来实施现代结核病控制(DOTS)策略的基础上,优化资源,结合全球遏制结核病策略,实行现阶段适合我国结核病防治形势的中国结核病控制策略。浙江省舟山市从2002年起积极开展DOTS策略,实施浙江省结核病控制项目,以发现并治愈传染性肺结核病人为重点,促进全市结核病控制项目的快速健康发展。现将舟山市2002-2008年结核病防治工作效果分析如下。     

2004—2008年临海市结核病控制效果分析

临海市的结核病防治工作根据《浙江省结核病防治规划（2001--2010年）》要求,以全面实施现代结核病控制策略（DOTS）和防治规划,建立有效的医防合作机制,加强专业机构归口管理,收到了显著的成效。现将本市2004--2008年结核病控制效果分析如下。     

Resistance to implementing policy change: the case of Ukraine

Tuberculosis (TB) is a major public health problem in eastern Europe. Since 1990, the incidence rates of TB have continued to increase in Belarus, the Russian Federation, the Ukraine and the central Asian republics of Kazakhstan, Kyrgyzstan, Tajikistan and Uzbekistan. Eastern Europe, and in particular the Russian Federation and the Ukraine, also face the public health challenge of an escalating multidrug-resistant tuberculosis (MDR-TB) epidemic. Of the 17 283 global MDR-TB cases reported in 2004, over 60% (10 595) were from the European region and the vast majority of these from eastern Europe, including the Baltic states of Estonia, Latvia and Lithuania. Of particular concern is the fact that, along with Africa, treatment success for DOTS in eastern Europe is substantially below average when compared with other regions of the world, and DOTS coverage and smear-positive case detection rate remain the lowest in the world. Collectively, along with Africa, these problems in eastern Europe remain the principal obstacle to meeting the Millennium Development Goals for TB in Europe. The Ukraine has worsening epidemics of TB, MDR-TB and HIV, against a background of epidemics of sexually transmitted illness (STI) and injecting drug users (IDUs). The TB and HIV epidemics are converging. In spite of attempts, the Ukraine has failed to implement DOTS policy due to health systems organization, financing and provider payment systems that created disincentives to change while opposition by policy-makers and clinicians to DOTS strategy hindered implementation efforts.     

Cost and cost-effectiveness of PPM-DOTS for tuberculosis control: evidence from India

OBJECTIVE: To assess the cost and cost-effectiveness of the Public-Private Mix DOTS (PPM-DOTS) strategy for tuberculosis (TB) control in India. METHODS: We collected data on the costs and effects of pilot PPM-DOTS projects in Delhi and Hyderabad using documentary data and interviews. The cost of PPM-DOTS was compared with public sector DOTS (i.e. DOTS delivered through public sector facilities only) and non-DOTS treatment in the private sector. Costs for 2002 in US$ were assessed for the public sector, private practitioners, and patients/attendants. Effectiveness was measured as the number of cases successfully treated. FINDINGS: The average cost per patient treated was US$ 111-123 for PPM-DOTS and public sector DOTS, and US$ 111-172 for non-DOTS treatment in the private sector. From the public sector's perspective, the cost per patient treated was lower in PPM-DOTS projects than in public sector DOTS programmes (US$ 24-33 versus US$ 63). DOTS implementation in either the public or private sectors improved treatment outcomes and substantially lowered costs incurred by patients and their attendants, compared to non-DOTS treatment in the private sector (US$ 50-60 for DOTS compared to over US$ 100 for non-DOTS). The average cost-effectiveness of PPM-DOTS and public sector DOTS was similar, at US$ 120-140 per patient successfully treated, compared to US$ 218-338 for non-DOTS private sector treatment. Incremental cost-effectiveness analysis showed that PPM-DOTS can improve effectiveness while also lowering costs. CONCLUSION: PPM-DOTS can be an affordable and cost-effective approach to improving TB control in India, and can substantially lower the economic burden of TB for patients.     

DOTS in action

About 80,000 cases of tuberculosis (TB) are reported annually in South Africa. However, control measures have failed to check the growing numbers of TB cases and the spread of HIV is bound to exacerbate the situation. The Western Cape has almost 3 times the national notification rate (663 vs. 225 per 100,000). With only 60-70% of patients in Western Cape found to adhere to treatment, the Community Health Association of South Africa (CHASA) recommended using the DOTS strategy to control TB. The DOTS method, however, burdens both health workers and those patients who have to travel long distances to reach a health center. Such inconvenience contributes to poor treatment compliance. Any strictly medical approach to TB eradication will fail. Medical interventions must instead be set within, and supported by, a strong social and political network. A change in attitude is needed in order to ensure the success of DOTS. The creation of the Western Cape TB Alliance (TBA), TB control-related research, DOTS implementation, and project objectives and achievements are described.     

Self-determination and compliance in directly observed therapy of tuberculosis treatment in the Kingdom of Lesotho

Public health officials have created directly observed therapy, short course (DOTS) to treat tuberculosis (TB) and to guarantee that drugs are taken in the right combination and for the appropriate duration. The World Health Organization (WHO) uses supervisors (nurses, nursing assistants, and community health workers [CHWs], as well as community members and relatives), to watch the patient take his or her TB medication. This article explores the observation component of DOTS, and how DOTS supervisors enhance patients' ability to comply with TB treatment by providing enablers, education, and supportive relationships. It also explores how supervisors can achieve the balance between patients' right to self-determination and a community's need for social accountability. Social work can contribute to the efficacy of TB treatment by helping public health officials understand the importance of balancing patients' rights and society's needs in determining the allocation of program resources. The results of this study are based on data gathered from 71 researcher-administered questionnaires and 25 semi-structured interviews in seven of the Kingdom of Lesotho's 19 health service areas. It was found that by providing enablers, education, and supportive relationships, DOTS supervisors ameliorate some of the logistical problems that prevent compliance. Noncompliance for patients is often an institutional/managerial problem that denies patients access to services and resources and should not be blamed on them.     

边远山区新发肺结核患者采用家庭成员督导化疗依从性的观察

目的探讨家庭成员短程督导化疗对提高新发肺结核患者治疗依从性的效果。方法采用2006年1—12月密云县户籍新发患者为结核病防治所和社区卫生服务中心医务人员督导的（Ⅰ组）为对照组,2007年1—12月密云县户籍新发肺结核患者为家庭成员督导的为试验组（Ⅱ组）,分别在结核病防治所、社区卫生服务中心和家庭督导员督导下实施短程督导化疗,比较2组治疗依从性和治疗效果。结果2006年共登记新发肺结核128例,2007年共登记新发肺结核133例。即：对照组（Ⅰ组）128例,试验组（Ⅱ组）133例;Ⅰ组2、5、6月末随访查痰率分别为95.3%、90.6%和85.9%,Ⅱ组2、5、6月末随访查痰率分别为97.7%、94.0%和94.7%。II组6月末随访查痰率明显高于Ⅰ组（P〈0.01）。Ⅰ组和Ⅱ组规则服药率分别为93.8%和97.7%,Ⅱ组规则服药率明显高于Ⅰ组（P〈0.01）。Ⅰ组和Ⅱ组的治愈率分别为88.3%和94.7%,Ⅱ组治愈率高于Ⅰ组。结论在推广全程督导化疗有困难的边远山区和贫困农村,鼓励具有一定文化程度,经过培训的结核病患者家庭成员或志愿者担任家庭督导员,督导病人按时服药及复查,可以弥补辖区结核病防治所、社区卫生服务中心医生在部分农村地区做全程督导治疗有困难,从而提高患者治疗依从性和全程督导短程化疗（DOTS）实施质量。     

Improving detection and notification of tuberculosis cases in students in Shaanxi province, China: an intervention study

Background  

Cooperation between different public and private health institutes involved in tuberculosis (TB) control has proven to enhance TB control in different settings. In China, such a mechanism has not been set up yet between Centers for Disease Control (CDCs) and university hospitals despite an increased TB incidence among students. This study aims to improve arrival of TB suspects identified by universities at the CDCs in order to manage them under standardized, directly observed treatment-short course (DOTS) conditions according to the National Tuberculosis Programme (NTP) guidelines.     

Enhancing the private provision of care through premiums for ability: the case of tuberculosis care in the Philippines

This paper examines how premiums for ability are set and how these can enhance the quality of care provided in private markets. The specific context for this study is the market for tuberculosis (TB) care in the Philippines. While the most cost- and clinically-effective treatment method known as TB Directly Observed Treatment Short Course (TB DOTS) is increasingly being provided by the public sector, few private doctors have adopted this protocol. As findings of multivariate regression analyses of private physicians' fees suggest, this low adoption rate can be partly explained by the modest premiums private doctors receive for using TB DOTS. While the public provision of TB DOTS should be pursued in earnest, this paper argues that the complementarity between public and private provision of TB DOTS should be strengthened, especially since Filipino TB patients seem to prefer private doctors. This goal can be achieved through user fees that (i) include a sufficiently large premium for physician ability and (ii) are paid through the social insurance system.     

Reforming tuberculosis control in Ukraine: results of pilot projects and implications for the national scale-up of DOTS

The period of economic transition has had severe consequencesfor health and health systems in Ukraine. The tuberculosis (TB)situation illustrates this. The strategy recommended by theWorld Health Organization (WHO) for TB, directly observed treatmentshort-course (DOTS), has the potential to provide real improvementsin TB services, forming the basis of the response to the growingepidemic. In 2002, Ukraine, financially supported by USAID andthe European Community (EC), began to introduce DOTS throughpilot projects in Mariupol and Kyiv City. The aim of this studyis to assess the feasibility, effectiveness, health servicecost, patient cost, and the cost-effectiveness of these pilots,in order to inform the national scale-up of DOTS. The study finds that DOTS is feasible and has the potentialto be both effective and cost-effective in Ukraine. Followingthis study, Ukraine adopted DOTS as a national TB control strategyin 2005. However, the pilots also found that there are severalevidence-related concerns and perverse economic incentives toboth providers and patients that will need to be addressed ifnational scale-up is to be successful. These include concernsrelated to the treatment of MDR-TB, economic benefits to somepatients to remain hospitalized, and payments to providers andhealth facilities that support current practices. These willneed to be addressed if Ukraine is to develop an effective responseto its emerging TB epidemic.     

Provision and financial burden of TB services in a financially decentralized system: a case study from Shandong, China

Both challenges and opportunities have been created by health sector reforms for TB control programmes in developing countries. China has initiated radical economic and health reforms since the late 1970s and is among the highest TB endemic countries in the world. This paper examines the operation of TB control programmes in a decentralized financial system. A case study was conducted in four counties of Shandong Province and data were collected from document reviews, and key informant and TB patient interviews. The main findings include: direct government support to TB control weakened in poorer counties after its decentralization to township and county governments; DOTS programmes in poorer counties was not implemented as well as in more affluent ones; and TB patients, especially the low-income patients, suffered heavy financial burdens. Financial decentralization negatively affects the public health programmes and may have contributed to the more rapid increase in the number of TB cases seen over the past decade in the poorer areas of China compared with the richer ones. Establishing a financial transfer system at central and provincial levels, correcting financial incentives for health providers, and initiating pro-poor projects for the TB patients, are recommended.     

Reversing the tide of tuberculosis in India: complementing microscopy with line probe assays

Abstract

In 1993, the World Health Organisation (WHO) declared tuberculosis (TB) a global health threat, adopted the Directly Observed Therapy – Short Course (DOTS) strategy, and set two targets for control and elimination of the disease: to detect 70% of sputum smear positive cases and to successfully treat 85% of those cases. The recommended diagnostic tool under DOTS remains sputum smear microscopy, a simple, yet ineffective, technique that only detects roughly half of TB cases. In India, where TB killed 450,000 people in 2005, both WHO targets for detection and treatment were met in the smear positive population covered by DOTS. However, HIV co-infection and multidrug-resistant TB (MDR-TB) pose formidable threats to TB control: TB in HIV-positive patients is often smear-negative, and microscopy cannot detect drug resistance. Although, the reliance on DOTS has proven effective in areas where both HIV prevalence and drug resistance are low, in India, the National TB Programme should consider complementing the antiquated technique of microscopy in order to diagnose smear-negative, extrapulmonary, and MDR-TB cases. Integrating existing rapid molecular diagnostics with the Indian National TB Programme is timely, and would be extremely beneficial to address the two major threats to TB control in the country.