DOT in rural China: experience from a case study in Shandong Province, China.

SETTING: Four counties at varying levels of economic development in Shandong Province were sampled. All offered tuberculosis (TB) directly observed treatment (DOT) treatment at the County TB Dispensary (CTBD). OBJECTIVE: To empirically document how DOT and home visits were implemented in rural China and to shed light on whether DOT is one of the key elements through which China achieves its high cure rates for TB. DESIGN: A total of 404 rural smear-positive TB patients registered in the CTBDs were interviewed face-to-face with structured questionnaires. Village doctors and key informants from the CTBDs were also interviewed. RESULTS: The majority of TB patients in rural areas do not receive DOT from village doctors and rarely get support, such as visits as required, from the CTBDs or township health providers in Shandong, China. CONCLUSION: The lack of DOT in Shandong does not have a negative effect on TB treatment outcomes. Given that the DOTS strategy is still the core measure of TB control in China, implementation of other programme elements apart from DOT is necessary to ensure a successful TB treatment programme.     

Survival and health status of DOTS tuberculosis patients in rural Lao PDR

Background  

Contact tracing of tuberculosis (TB) patients is rarely performed in low-income countries. Our objective was to assess the outcome of and compliance with directly observed treatment (DOTS) of TB patients over a 3 year period in rural Lao PDR.     

福建省山区农村DOTS策略执行现状分析

目的评价福建省山区农村DOTS策略执行现状。方法采用定量与定性相结合的方法，对肺结核病人问卷调查，并对知情人员及肺结核病人深入访谈，内容包括：结核病患者发现和治疗管理过程，相关部门对结核病控制的相关策略措施等；从政府承诺、病人发现过程、督导管理落实三方面分析评价。结果调查的3个县政府承诺落实较好；在村卫生室／私人诊所首次就诊的病人占53．5％，在结防机构的首次就诊仅占6．9％；有26．4％的病人就诊延迟，且59．9％的病人存在确诊延迟；94．9％的涂阳病人治疗过程中有医生上门访视，但72．9％的涂阳病人认为没有必要由医生看着吃药。仅有47．3％的病人在医务人员直接面视督导下服药。结论政府承诺及领导重视能保证结防工作顺利开展；应引导疑似肺结核病人和可疑症状者到结防机构就诊，提高归口管理工作的效率，减少卫生服务提供方造成的确诊延迟。直接面视下的短程督导化疗是DOTS策略的关键，应加强对村卫生室／私人诊所等乡村医生培训，提高认识，并制定适合我国农村地区并且符合医学伦理的策略。     

福建省山区农村DOTS策略执行现状分析

目的评价福建省山区农村DOTS策略执行现状。方法采用定量与定性相结合的方法,对肺结核病人问卷调查,并对知情人员及肺结核病人深入访谈,内容包括:结核病患者发现和治疗管理过程,相关部门对结核病控制的相关策略措施等;从政府承诺、病人发现过程、督导管理落实三方面分析评价。结果调查的3个县政府承诺落实较好;在村卫生室/私人诊所首次就诊的病人占53.5%,在结防机构的首次就诊仅占6.9%;有26.4%的病人就诊延迟,且59.9%的病人存在确诊延迟;94.9%的涂阳病人治疗过程中有医生上门访视,但72.9%的涂阳病人认为没有必要由医生看着吃药,仅有47.3%的病人在医务人员直接面视督导下服药。结论政府承诺及领导重视能保证结防工作顺利开展;应引导疑似肺结核病人和可疑症状者到结防机构就诊,提高归口管理工作的效率,减少卫生服务提供方造成的确诊延迟。直接面视下的短程督导化疗是DOTS策略的关键,应加强对村卫生室/私人诊所等乡村医生培训,提高认识,并制定适合我国农村地区并且符合医学伦理的策略。     

结核病的性别差异:南印度某农村地区DOTS项目报告

背景:南印度 Tiruvallur 地区。目的:了解 14 岁以上成年人在结核感染和患病、就医途径、就医行为、诊断延误、接受 DOT的方便程度、疾病歧视以及治疗依从性等方面的性别差异。方法:相关数据主要来自:1)社区调查,2)在公立初级保健卫生机构(PHIS)主动就医的病人,3)转诊到 PHIS 进行痰涂片检查的可疑结核病人;4)DOTS 策略下的登记报告结核病人。并将社区调查结果与 PHIS 登记病人进行比较。结果:社区人群中 66%的男性和 57%的女性感染了结核菌;男性和女性的涂阳肺结核患病率分别为568/10 万和87/10 万。在 PHIS 就医的男性少于女性,男女之比为 68:100。女性占社区调查发现涂阳病人的 13%;占 PHIS 发现病人的 20%(P<0.05)。随着年龄的增长,男性和女性的登记率显著降低。女性感觉难于与家人讨论自己病情的比例要高于男性(21%∶14%),也更需要有人陪伴去接受 DOT(11%∶6%)。男性的治疗中断率比女性高 1 倍(19%∶8%;P<0.01)。结论:尽管女性发病后更容易遭受歧视和不便,但女性更易于利用医疗服务、接受 DOTS 策略登记以及依从治疗。而男性以及高龄病人在诊断和 DOT服务方面更需要帮助。     

蒙古1995年DOTS试点项目

目的为了在采用前苏联结核病控制模式的国家建立与WHO和IUATLD推荐相一致的结核病控制模式。前苏联用放射学方法实行主动发现病人并且长期观察和治疗病人。设计与方法DOTS策略试点项目在蒙古东部的东方省实施。在6周期间对慢性咳嗽3周及以上者用痰涂片镜检进行筛选。涂片阳性病人接受6个月(2SRHZ/4RH)方案的督导化疗。对开始治疗2,5,和6个月后的痰涂片检查结果评价效果。结果从1241名有症状者中筛选出169例涂阳肺结核病人(14％)。其中大多数(92％)通过痰菌阴转证实已被治愈。5例完成治疗但未经痰涂片检查随访,死亡和丢失各4例。结论DOTS策略被成功地引进前社会主义模式的国家,为在蒙古实施全国SOTS策略铺平了道路,并可作为其卫生服务传统相类似的独联体国家的范例     

Gender disparities in tuberculosis: report from a rural DOTS programme in south India.

SETTING: Tiruvallur District, south India. OBJECTIVES: To examine gender differences in tuberculosis among adults aged >14 years with respect to infection and disease prevalence, health care service access, care seeking behaviour, diagnostic delay, convenience of directly observed treatment (DOT), stigma and treatment adherence. METHODS: Data were collected from 1) community survey, 2) self-referred out-patients seeking care at governmental primary health institutions (PHIs), 3) tuberculosis suspects referred for sputum microscopy at PHIs, and 4) tuberculosis patients notified under DOTS. Community survey results were compared with those for patients notified at PHIs. RESULTS: In the community, 66% of males and 57% of females had tuberculosis infection. The prevalence of smear-positive tuberculosis was 568 and 87/100,000, respectively, among males and females. Fewer males than females attended PHIs (68 men for every 100 women). Females constituted 13% of all smear-positive patients detected in the community survey, and 20% of those detected at PHIs (P < 0.05). The probability of notification decreased significantly with age among both males and females. Significantly more females than males felt inhibited discussing their illness with family (21% vs. 14%) and needed to be accompanied for DOT (11% vs. 6%). Males had twice the risk of treatment default than females (19% vs. 8%; P < 0.01). CONCLUSIONS: Despite facing greater stigma and inconvenience, women were more likely than men to access health services, be notified under DOTS and adhere to treatment. Men and elderly patients need additional support to access diagnostic and DOT services.     

Access and barriers to measures targeted to prevent malaria in pregnancy in rural Kenya

Objectives To evaluate barriers preventing pregnant women from using insecticide‐treated nets (ITN) and intermittent presumptive treatment (IPT) with sulphadoxine‐pyrimethamine (SP) 5 years after the launch of the national malaria strategy promoting these measures in Kenya. Methods All women aged 15–49 years were interviewed during a community survey in four districts between December 2006 and January 2007. Women pregnant in the last 12 months were asked about their age, parity, education, use of nets, ITN, antenatal care (ANC) services and sulphadoxine‐pyrimethamine (SP) (overall and for IPT) during pregnancy. Homestead assets were recorded and used to develop a wealth index. Travel time to ANC clinics was computed using a geographic information system algorithm. Predictors of net and IPT use were defined using multivariate logistic regression. Results Overall 68% of pregnant women used a net; 52% used an ITN; 84% attended an ANC clinic at least once and 74% at least twice. Fifty‐three percent of women took at least one dose of IPT‐SP, however only 22% took two or more doses. Women from the least poor homesteads (OR = 2.53, 1.36–4.68) and those who used IPT services (OR = 1.73, 1.24–2.42) were more likely to sleep under any net. Women who used IPT were more likely to use ITNs (OR = 1.35, 1.03–1.77), while those who lived more than an hour from an ANC clinic were less likely (OR = 0.61, 0.46–0.81) to use ITN. Women with formal education (1.47, 1.01–2.17) and those who used ITN (OR: 1.68, 1.20–2.36) were more likely to have received at least one dose of IPT‐SP. Conclusion Although the use of ITN had increased 10‐fold and the use of IPT fourfold since last measured in 2001, coverage remains low. Provider practices in the delivery of protective measures against malaria must change, supported by community awareness campaigns on the importance of mothers’ use of IPT.     

山东省莒县2003-2013年登记结核病流行特征及DOTS策略实施效果的评价分析

目的 了解《莒县结核病防治规划(2001-2010年)》(简称“《莒县规划》”)实施情况,摸清区域人群的结核病发病规律,科学评价《莒县规划》实施情况和DOTS策略的执行效果,为制定完善莒县结核病控制策略及对策提供科学依据.方法 莒县2003-2013年间全县总人口为12 166 055人,以结核病管理信息系统及相关统计报表数据为来源,对莒县2003-2013年登记管理的4481例结核病患者进行登记率、流行病学特征、治疗效果进行分析,并对DOTS效果及社会效益进行评价分析.结果 2003-2013年登记率为36.83/10万(4481/12 166 055);新涂阳登记率为21.59/10万(2627/12 166 055);男∶女=2.74∶1;登记率年龄组分布前三位分别为15～岁组[21.36％ (957/4481)]、55～岁组[17.96％(805/4481)]和65～74岁组[15.53％ (696/4481)];职业分布以农民为主,占87.61％ (3926/4481);新涂阳患者强化期结束痰菌阴转率为98.82％(2596/2627);复治涂阳患者强化期结束痰菌阴转率为95.91％(211/220),涂阳患者平均治愈率为95.36％(2715/2847).避免22 460人感染结核分枝杆菌,避免新发结核病患者2246例,为社会节约医疗费用1 533 765元,为社会挽回损失总价值266 685 094元.结论 莒县积极推行现代结核病控制策略,2003-2013年结核病登记率呈逐年下降趋势,患者治愈率达到并超过了《莒县规划》要求,DOTS策略实施效果显著.     

Factors affecting patient adherence to DOTS in urban Kathmandu, Nepal.

SETTING: The urban area of Kathmandu has a population of one million, with an annual risk of tuberculosis (TB) infection of 4%. It is estimated that up to 200 people default from treatment in Kathmandu annually, giving a defaulter rate of 10%. OBJECTIVES: To identify the socio-demographic factors, availability and accessibility of DOTS services and behavioural factors affecting patient adherence to DOTS. METHODS: Structured questionnaire of a random sample of 234 new smear-positive TB patients enrolled on treatment. Analysis of socio-demographic, psychosocial factors and availability and accessibility of DOTS services. Sub-analysis of non-adherent (missed >7 consecutive treatment days) vs. adherent patients. RESULTS: Reasons given by non-adherent patients included 61% who claimed insufficient knowledge about the need to take daily treatment, especially after they felt better. Directly observed treatment, younger age, knowledge of TB and availability of daily health education were associated with increased adherence. Daily health education and knowledge of TB and its treatment were independently associated with adherence on multivariate analysis (OR 6.27, 95%CI 2.88-13.64, P < 0.001). CONCLUSION: Daily health education delivered at DOTS centres is strongly associated with improved adherence. Adherence throughout treatment needs emphasis.     

山东省日照市加强肺结核病人DOTS管理措施的效果分析

目的分析日照市结防所利用防痨网络加强对肺结核病人实施DOTS管理措施的效果。方法介绍加强DOTS管理措施的做法,并依据各种报表,对实施DOTS管理的病人进行疗效分析。结果由于加强了DOTS管理措施,使病人规则治疗率达99.1%,新发涂阳病人强化期结束痰菌阴转率达97.5%,其治愈率为96.7%。结论加强肺结核病人DOTS管理措施模式既方便了病人,又真正使DOTS管理措施落到实处,保证了访视频率,提高了督导质量和治愈率,提高了对结核病的控制能力总体水平,有力的推动了结核病防治工作的开展。     

Rapid decline in prevalence of pulmonary tuberculosis after DOTS implementation in a rural area of South India

SETTING: Tiruvallur District in Tamilnadu, South India, where the World Health Organization-recommended DOTS strategy was implemented as a tuberculosis (TB) control measure in 1999. OBJECTIVE: To assess the epidemiological impact of the DOTS strategy on the prevalence of pulmonary tuberculosis (PTB). DESIGN: Surveys of PTB were undertaken on representative population samples aged > or =15 years (n = 83000-90000), before and at 2.5 and 5 years after the implementation of the DOTS strategy. The prevalence of PTB (smear-positive/culture-positive) was estimated. RESULTS: TB prevalence declined by about 50% in 5 years, from 609 to 311 per 100000 population for culture-positive TB and from 326 to 169/100000 for smear-positive TB. The annual rate of decline was 12.6% (95%CI 11.2-14.0) for culture-positive TB and 12.3% (95%CI 8.6-15.8) for smear-positive TB. The decline was similar at all ages and for both sexes. CONCLUSION: With an efficient case detection programme and the DOTS strategy, it is feasible to bring about a substantial reduction in the burden of TB in the community.     

Investigation of anaplasmosis in Yiyuan County, Shandong Province, China

ObjectiveTo investigate the situation of anaplasmosis in Yiyuan county, Shandong Province.MethodsA total of 26 blood samples from febrile patients suspected of anaplasmosis, 48 blood samples from healthy farmers, 8 from dogs, and 10 from goats and 170 ticks were collected in the same area during 2005-2007, and detected by serological and molecular methods.ResultsEight confirmed cases and 6 probable cases were determined using serologic and molecular methods. The seroprevalence of Anaplasma phagocytophilum (A. phagocytophilum) was 26.7% in healthy cases. Nine out of 10 sheep samples and 7 out of 8 dog samples reacted positively to the A. phagocytophilum antigen. PCR amplification and sequencing of the 16SrRNA of A. phagocytophilum gene showed that some samples from patients, goats and ticks were 100% identical. The seroprevalence of Rickettsia typhi was 22.9%, Orientia tsutsugamushi 6.3%, Rickettsia sibirica 27.1%, Coxiella burnetii 18.8%, Bartonella henselae 31.3%, and Borrelia burgdorferi 41.6%.ConclusionsIt is important to make differential diagnosis of febrile patients and to apply treatment with specific antibiotics. It is needed to enforce essential prevention and control measures including tick control and to improve sanitation conditions.